Every finding on record at Saint Joseph Transitional Rehabilitation Center

Based on interview, record review and document review, the facility failed to ensure a significant change in status Minimum Data Set (MDS) assessment was completed within the required time frame for 1 of 32 sampled residents (Resident 50). The deficient practice had the potential to delay the development and implementation of a person-centered care plan for residents.Findings include:Resident 50 (R50) was admitted on [DATE], with diagnoses including fracture of unspecified part of neck of left femur, displaced fracture of base of neck of right femur, and major depressive disorder.R50's medical record contained the list of MDS assessments including a significant change in status MDS with an assessment reference date (ARD/the end date of an observation or look-back period for an MDS assessment) of 05/09/2025.The Centers for Medicare and Medicaid Services (CMS) Final Validation Report (a system-generated document which detailed the processing status of submitted data such as MDS) for the significant change in status MDS dated [DATE], documented the MDS was submitted to CMS on 05/27/2025 and a message the assessment was completed late (more than 14 days after the ARD).On 09/12/2025 at 9:57 AM, the MDS Director revealed the MDS assessments such as admission, quarterly, annual, and significant change in status were transmitted (submitted) to CMS upon completion of the assessments. On 09/12/2025 at 10:30 AM, the MDS Director indicated that R50's significant change in status MDS was completed and transmitted to CMS on 05/27/2025. The MDS Director confirmed R50's significant change in status MDS should have been completed on 05/23/2025, or 14 days after the ARD of 05/09/2025, when the significant change in the resident's status was identified. The MDS Director acknowledged R50's significant change in status MDS was not completed on time.The MDS Director was the only person in the department (MDS). The MDS Director indicated being a licensed practical nurse and had to wait for a registered nurse to sign the MDS assessments for its completion.The CMS Resident Assessment Instrument (RAI) Omnibus Budget Reconciliation Act (OBRA)- required Assessment Summary (assessment conducted using the RAI and the MDS to develop standardized care plans, ensuring residents would receive appropriate and quality care in long-term care facilities) dated October 2017, documented the significant change in status MDS should have been completed no later than determination date plus 14 calendar days (14th calendar day after determination that significant change in resident's status had occurred).The facility's policy titled Resident Assessments, revised in October 2023, documented that the resident assessment coordinator was responsible for ensuring that the interdisciplinary team would conduct timely and appropriate resident assessments.

Based on observation, interview, record review, and document review, the facility failed to ensure the care planning process included feedback and information from a resident for 1 of 32 sampled residents (Resident 5). The deficient practice had the potential to result in care which did not reflect the resident's preferences, goals, and choices, diminishing the resident autonomy and person-centered care. Findings include: Resident 5 (R5) was admitted on [DATE] with diagnoses including acute and chronic respiratory failure, neuromuscular dysfunction of bladder, and urinary tract infection. A Brief Interview for Mental Status (BIMS) assessment revealed a score of 13/15 indicating R5 was cognitively intact.On 09/09/2025 at 10:31 AM, R5 revealed the facility was not allowing R5 to participate in care planning for use of ventilator and care regarding tracheostomy. The medical record revealed a care conference was conducted on 09/09/2025 regarding skin alterations included the Director of Nursing, Social Worker, Rehab, and treatment nurse. A care conference was conducted on the following dates:08/05/2025, R5 was not identified as participating in the care conference.08/12/2025, R5 was not identified as participating in the care conference.08/21/2025, R5 was not identified as participating in the care conference.08/29/2025, R5 was not identified as participating in the care conference.The medical record revealed only facility staff members were present at the care conferences held for R5. On 09/11/2025 at 9:56 AM, a Respiratory Therapist (RT) explained respiratory therapists did not participate in the resident care conferences however the director would sometimes attend. On 09/11/2025 at 10:29 AM, a Licensed Practical Nurse (LPN) indicated, when possible, that the resident or representative would be included in the care planning process. The LPN indicated R5 was cognitively intact and would be able to participate in care planning as well as family who were involved in R5's care.On 09/11/2025 in the afternoon, the Respiratory Therapy Director indicated it would be appropriate for a resident with a BIMS of 13 to be involved in the care planning process.On 09/12/2025 at 11:05 AM, the Director of Nursing (DON) indicated it would be appropriate to invite a resident or resident representative to care plan conference and verbalized there was no documented evidence R5 was included in the care plan conferences.The facility policy titled Care Plan Comprehensive dated August 2021, documented the facility Interdisciplinary Team in coordination with the resident and/or representative must develop and implement a comprehensive person-centered care plan. The comprehensive care plan includes the resident's expressed wishes regarding care and treatment goals.

Based on interview, record review and document review, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for 3 of 32 sampled residents (Resident 21, 50, and 58). The deficient practice had the potential to delay the development and implementation of a person-centered care plan for the residents.Findings include:1) Resident 21 (R21) was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, tracheostomy status, gastrostomy status, and dependence on respirator (ventilator) status.R21's medical record contained the list of quarterly MDS with assessment reference date (ARD/the end date of an observation or look-back period for an MDS assessment) of 05/09/2025 and 08/07/2025.The Centers for Medicare and Medicaid Services (CMS) Final Validation Report (a system-generated document which detailed the processing status of submitted data such as MDS) documented the following:- R21's quarterly MDS with an ARD of 05/09/2025 was submitted to CMS on 05/27/2025 and a message (report feedback) the assessment was completed late (more than 14 days after the ARD).- R21's quarterly MDS with an ARD of 08/07/2025 was submitted to CMS on 09/09/2025 and a message the assessment was completed late (more than 14 days after the ARD).On 09/12/2025 at 9:57 AM, the MDS Director confirmed R21's quarterly MDS assessments were not completed on time or were completed more than 14 days after the ARD.The MDS Director revealed that the MDS assessments such as admission, quarterly, annual, and significant change in status were transmitted (submitted) to CMS upon completion of the assessments.2) Resident 50 (R50) was admitted on [DATE], with diagnoses including fracture of unspecified part of neck of left femur, displaced fracture of base of neck of right femur, and major depressive disorder.R50's medical record contained the list of MDS assessments including a quarterly MDS with an ARD of 08/06/2025.The CMS Final Validation Report for the quarterly MDS dated [DATE], documented the MDS was submitted to CMS on 09/09/2025 and a message the assessment was completed late (more than 14 days after the ARD).On 09/12/2025 at 10:30 AM, the MDS Director indicated R50's quarterly MDS was completed on 09/08/2025 and transmitted to CMS on 09/09/2025. The MDS Director confirmed R50's quarterly MDS should have been completed on 08/20/2025, or 14 days after the ARD of 08/06/2025. The MDS Director acknowledged R50's quarterly MDS was not completed on time.3) Resident 58 (R58) was initially admitted on [DATE], readmitted on [DATE], and discharged on 08/28/2025, with diagnoses including lower leg osteomyelitis, dehiscence of amputation stump, and depression.R58's medical record contained the list of MDS assessments including a quarterly MDS with an ARD of 08/06/2025.The CMS Final Validation Report for the quarterly MDS dated [DATE], documented the MDS was submitted to CMS on 09/09/2025 and a message the assessment was completed late (more than 14 days after the ARD). On 09/12/2025 at 10:36 AM, the MDS Director revealed R58's quarterly MDS was completed on 09/08/2025 and transmitted to CMS on 09/09/2025. The MDS Director confirmed R58's quarterly MDS should have been completed on 08/20/2025, or 14 days after the ARD of 08/06/2025. The MDS Director acknowledged R58's quarterly MDS was not completed on time.The MDS Director was the only person in the department (MDS). The MDS Director indicated being a licensed practical nurse and had to wait for a registered nurse to sign the MDS assessments for its completion.The CMS Resident Assessment Instrument (RAI) Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary (assessment conducted using the RAI and the MDS to develop standardized care plans, ensuring residents would receive appropriate and quality care in long-term care facilities) dated October 2017, documented the quarterly MDS should have been completed no later than ARD plus 14 calendar days. The facility's policy titled Resident Assessments, revised in October 2023, documented that the resident assessment coordinator was responsible for ensuring that the interdisciplinary team would conduct timely and appropriate resident assessments.

Based on interviews, record review, and document review, the facility failed to ensure comprehensive, resident-centered care plans were developed and implemented for ventilator use and tracheostomy care for 3 of 32 sampled residents (Residents 1, 4, and 10). The deficient practice had the potential to result in unmet respiratory care needs, inadequate staff direction, and compromised resident safety. Findings include: 1) Resident 1 (R1) was admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure, and protein-calorie malnutrition. On 09/09/2025 at 10:20 AM, the resident was lying in bed ventilator dependent and receiving tube feeding, eyes closed. On 09/10/2025 at 9:15 AM, the resident was lying in bed ventilator dependent and receiving tube feeding, eyes closed.09/11/2025 10:35 AM, the resident was lying in bed ventilator dependent and receiving tube feeding, eyes closed. The medical record lacked documented evidence of a care plan for management of ventilator and tracheostomy. 2) Resident 4 (R4) was admitted on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure, and dependence on respirator.The medical record revealed the care plan included enhanced barrier precautions due to the use of a ventilator and tracheostomy, no other care plan regarding the management was included. 3) Resident 10 (R10) was admitted on [DATE] with diagnoses including anoxic brain damage and chronic respiratory failure. On 09/09/2025 at 8:20 AM, R10 was lying in bed ventilator dependent and receiving tube feeding, eyes closed. On 09/10/2025 at 10: 15 AM, R10 was lying in bed ventilator dependent and receiving tube feeding, eyes closed.On 09/11/2025 at 10:35 AM, R10 was lying in bed ventilator dependent and receiving tube feeding, eyes closed. The medical record revealed there was no care plan in place for the care and management of tracheostomy and ventilator. On 09/10/2025 at 12:37 PM, a Respiratory Therapist (RT) indicated the care plan was developed based on the comprehensive assessment completed and should include the care and management of ventilator and tracheostomy.On 09/12/2025 at 8:45 AM, the Minimum Data Set Coordinator (MDS) explained that all disciplines were involved in completing the MDS which was a comprehensive assessment. The MDS was one tool used to help develop the overall care plan for each resident. The MDS Coordinator indicated that if a resident was identified as having a ventilator or tracheostomy it should be in the care plan as the care plan was a comprehensive plan for each resident. The MDS Coordinator acknowledged there was no care plan for the care and management of ventilators and tracheostomy for the residents of concern.On 09/12/2025 at 8:57 AM, the RT Director, was not directly involved in the MDS assessment. The RT Director explained being involved in the development of a care plan and would ensure the ventilator dependent residents had a care plan for the care and management of the ventilator and tracheostomy. Each care plan should be resident specific including ventilator setting and respiratory needs for residents with a ventilator and tracheostomy. The RT Director confirmed there was no care plan for the residents of concern and there should be. On 09/12/2025 at 1:10 PM, the Director of Nursing acknowledged there were no care plans specific to ventilators and tracheostomy for the residents of concern. Care plans should be resident centered which would include the care and management of the ventilator and tracheostomy for the residents of concern to ensure there was adequate direction of care for staff.The facility policy titled Care Plan Comprehensive dated August 2021, documented an individualized comprehensive care plan would include measurable objectives and timetable to meet the resident's medical, physical, mental and psychosocial needs and would be developed for each resident. The care plan should incorporate identified problem areas and identify professional services responsible for each element of care.

Based on observation, interview, and record review, the facility failed to revise a comprehensive person-centered care plan after a new skin condition was identified for 1 of 32 sampled residents (Resident 89). The deficient practice had the potential to place the resident at risk for delayed treatment, infection, and discomfort.Findings include:Resident 89 (R89) was admitted [DATE], with diagnosis including type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and major depressive disorder recurrent severe with psychotic symptoms. On 09/09/2025 at 10:16 AM, R89 was observed in bed with both legs exposed from the knees down. Multiple skin lesions (abnormal or damaged areas of skin) were present on both legs, greater in number on the left leg than the right leg. The lesions included scabbed areas and multiple linear scratch marks, some appeared bright red and fresh, some were darker red and scabbed. R89 reported both legs itched very much and R89 could not help but scratch them. R89 stated staff were not applying any treatment, creams, or other interventions to the affected skin and reported nothing was being done for R89's legs.A Body Check dated 03/04/2025, documented multiple scratches on left knee.A Body Check dated 03/14/2025, documented scabbing bilateral lower extremities.A review of R89's medical record revealed Body Checks, from initial identification of skin issues on 03/04/2025 and 03/14/2025, consistently documented the resident's existing skin condition through Body Check dated 08/25/2025. The description of the skin condition found in the Body Checks included multiple scratches, scabbing, dry skin, knee scabs, and old scabs. R89's medical record lacked documented evidence of physician orders for current treatment, medication, or topical interventions to treat R89's skin condition.A Care Plan dated 06/19/2025, lacked documented evidence R89's current skin condition was identified, care planned, including goals and interventions. On 09/10/2025 at 1:11 PM, a Licensed Practical Nurse (LPN), explained R89's care plan should have been updated when the first signs of the wounds and scratches on the legs were identified.On 09/10/2025 at 1:37 PM, the Director of Nursing (DON), confirmed R89's care plan was not updated to include the existing skin condition. The DON acknowledged R89's care plan should have been revised and updated to reflect the existing skin condition, goals and interventions.A facility policy titled Care Plan Comprehensive effective 08/25/2025, documented each resident's comprehensive care plan was designed to incorporate identified problem areas. The Interdisciplinary Team was responsible for evaluating and updating the care plans.

Based on interview, record review and document review, the facility failed to ensure a resident was assisted with meals in accordance with the assessment and care plan for 1 of 32 residents (R111). The deficient practice had the potential for residents not to maintain good nutrition.Findings include:Resident 111 (R111) was admitted on [DATE] and discharged on 09/27/2024, with diagnoses including dysphagia, cerebrovascular disease, and muscle weakness.R111's admission Minimum Data Set (MDS) assessment dated [DATE], documented the resident required supervision or touching assistance with eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident). The coding for supervision or touching assistance was 04, where the staff would provide verbal cues and/or touching/steadying and/or contact guard assistance as resident completed the activity (eating). R111's care plan documented the interventions/assistance for activities of daily living (ADL) which included providing the resident with supervision assist of one person for eating.The Documentation Survey Report (ADL charting) for September 2024, lacked documented evidence that R111 was provided with meal assistance on the following dates:- 09/05/2024 for breakfast and lunch- 09/08/2024 for breakfast and lunch- 09/11/2024 for breakfast and lunch- 09/12/2024 for breakfast and lunch- 09/13/2024 for lunch- 09/15/2024 for breakfast and lunch- 09/16/2024 for breakfast- 09/18/2024 for breakfast and lunch- 09/21/2024 for breakfast and lunchThe Documentation Survey Report for August 2024 and September 2024, documented the coding for R111's meal (eating) was mostly 5 (Set up or clean-up assistance. The staff would set up or clean up; the resident completed the activity. The staff assisted only prior to or following the activity.)On 09/12/2025 at 11:13 AM, the MDS Director indicated R111's admission MDS dated [DATE], documented the resident required supervision or touching assistance with eating, and the code was 04. The MDS Director explained that the certified nursing assistants (CNA), or licensed nurses should have been in the room with the resident to supervise the resident while eating. The CNAs should have been coding the level of assistance provided to the resident during meals. The MDS Director revealed the CNAs were expected to document in the ADL charting every meal.The MDS Director explained R111's care plan documented to provide the resident with supervision assistance of one person for eating. The MDS Director acknowledged the coding for R111's meal or eating in the ADL charting should have been 04. The MDS Director confirmed the CNAs had documented the code 5 in R111's ADL charting with meal which meant set up or clean-up assistance was provided and not supervision ( 04) per the resident's care plan. The MDS Director acknowledged the care plan was not followed.The MDS Director confirmed there was no documentation of the meal assistance provided to R111 during the above-mentioned dates for the month of September 2024. The MDS Director explained the boxes corresponding to those dates were left blank, and the other dates had a coding of 5 most of the time. The MDS Director indicated there was no documentation the resident had refused meals which could have been coded as 07.On 09/12/2025 at 11:44 AM, a CNA indicated being informed of the required level of assistance with meals for each resident through the hand off report from the previous shift. The required meal assistance was documented in the point-of-care (POC) charting in the kiosk (electronic charting) where the CNAs documented the ADL charting for each resident. The CNA explained verifying in the POC charting the level of meal assistance required for each resident such as supervision, set up help only, or 1:1 meal assistance. The CNA indicated the level of meal assistance provided to each resident should have been documented every meal. The CNA confirmed R111's ADL charting for eating was incomplete because some dates were left blank.On 09/12/2025 at 1:58 PM, the Director of Nursing (DON) explained the CNAs were expected to follow the ADL level of assistance including eating indicated in the POC such as moderate assistance, supervision, set-up help only, or dependent and document in the ADL charting every meal. The DON confirmed R111's ADL documentation for eating, including meal percentage, was incomplete.The facility's policy titled Activities of Daily Living (ADLs), Supporting revised in March 2018, documented the residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with dining (meals and snacks).Complaint 2282565

Based on observation, interview, and document review, the facility failed to ensure treatment was provided for a resident with an identified skin condition for 1 of 32 sampled residents (Resident 89). The deficient practice had the potential to place the resident at risk for delayed healing, worsening of the skin condition, and infection.Findings include:Resident 89 (R89) was admitted [DATE], with diagnosis including type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and major depressive disorder recurrent severe with psychotic symptoms. On 09/09/2025 at 10:16 AM, R89 was observed in bed with both legs exposed from the knees down. Multiple skin lesions (abnormal or damaged areas of the skin) were present on both legs, greater in number on the left leg than the right leg. The lesions included scabbed areas and multiple linear scratch marks, some appeared bright red and fresh, some were darker red and scabbed. R89 reported both legs itched very much and R89 could not help but scratch them. R89 stated staff were not applying any treatment, creams, or other interventions to the affected skin and reported nothing was being done for R89's legs.A review of R89's medical record revealed Body Checks, from initial identification of skin issues on 03/04/2025 and 03/14/2025, consistently documented the resident's existing skin condition through Body Check dated 08/25/2025. The description of the skin condition found in the Body Checks included multiple scratches, scabbing, dry skin, knee scabs, and old scabs.A Quarterly Interdisciplinary Care Conference dated 09/04/2025, lacked documented evidence that the resident's skin condition was discussed. The pressure injury/skin problem status section of the form was left blank. R89's medical record lacked documented evidence of physician orders for current treatment, medication, or topical interventions to treat R89's skin condition. R89's medical record lacked documented evidence that the resident was assessed or treated by the wound care team from 02/24/2025 through 09/09/2025. R89's Progress Notes lacked documented evidence treatment was provided for the existing skin condition.On 09/10/2025 at 11:39 AM, a Wound Care Nurse reported R89 had previous skin issues which were resolved in February 2025. The Wound Care Nurse reported did not receive any prompts or notification of R89's existing skin condition from February 2025 through 09/10/2025. The Wound Care Nurse explained when nursing identified R89's skin condition, a change of condition assessment should have been initiated which included notifying the physician and the wound care team. The Wound Care Nurse confirmed R89 had not received treatment from the wound care team for the existing skin condition. On 09/10/2025 at 11:54 AM, a Wound Treatment Nurse explained the expectation was on initial identification of R89's skin condition, nurses should have notified the wound care team to complete an evaluation. The Wound Treatment Nurse denied receiving notification of R89's skin condition. The Wound Treatment Nurse explained that the wound care team depended on communication from nursing to identify concerns. The Wound Treatment Nurse explained the consequences of not treating R89's skin condition included R89 continued to itch and scratch, possible infection and worsening of condition. On 09/10/2025 at 1:08 PM, a Certified Nursing Assistant (CNA), reported R89 complained of itching. The CNA had reported R89's complaint about itchy skin to a nurse. On 09/10/2025 at 1:11 PM, a Licensed Practical Nurse (LPN), explained R89 had an ongoing issue of itchy skin. The LPN confirmed R89 did not have any physician orders for treatment or medication for the existing skin condition. The LPN acknowledged new wounds and scratches should have been reported to the treatment or wound care nurse when the first signs of the skin condition were identified. On 09/10/2025 at 1:37 PM, the Director of Nursing (DON), explained R89's skin condition should have been reported immediately when identified to the physician for a treatment order, and the wound care nurse for a consult. The DON acknowledged notification was not done. The DON confirmed R89 did not have a physician order for treatment or medication to treat the skin condition.A facility policy titled Skin Integrity Management effective 05/26/2025, documented the purpose was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continuously observe and monitor patients for changes and implement revisions to the care plan. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information.

Based on interview, record review, and document review, the facility failed to ensure wound care treatments were implemented as ordered for 1 of 32 sampled residents (Resident 1). The deficient practice had the potential to result in delayed healing, infection, and other negative outcomes for a resident with identified wound care needs. Findings include: Resident 1 (R1) was admitted on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcers, osteomyelitis, and protein-calorie malnutrition. On 09/09/2025 at 10:20 AM, R1 was lying in bed ventilator dependent and receiving tube feeding, eyes closed and wound dressing saturated.On 09/10/2025 at 9: 15 AM, R1 was lying in bed ventilator dependent and receiving tube feeding, eyes closed and wound dressing saturated.On 09/11/2025 at 10:35 AM, R1 was lying in bed ventilator dependent and receiving tube feeding, eyes closed and wound dressing saturated.A Physician Order dated 09/08/2025 documented to give protein oral liquid 30 milliliters (mL) enterally every 12 hours for skin healing. A Physician Order dated 09/08/2025 documented wound culture right hip wound. A Physician Order dated 08/26/2025 documented to provide wound care to left buttock. Cleanse with Dakins solution, apply silver alginate and then cover with foam dressing three times a week and as needed. Every Monday, Wednesday, and Friday. A Physician Order dated 08/25/2025 documented to provide wound care to the lower right leg. Cleanse site with normal saline solution, pat dry, apply Medi-honey and cover with foam dressing. Every day shift every Monday, Wednesday, and Friday and as needed. A Physician Order dated 08/25/2025 documented to provide wound care to right buttock. Cleanse with Dankins solution, apply calcium alginate, cover with foam dressing three times a week and as needed when soiled or saturated. Every day shift every Monday, Wednesday, Friday and as needed. A Physician Order dated 08/19/2025 documented to provide wound care to right lateral leg. Cleanse site with normal saline solution pat dry, apply xeroform and cover with dry dressing. Every day for skin tear. A Physician Order dated 08/19/2025 documented to provide wound care to left medial leg. Cleanse site with normal saline solution, pat dry, apply xeroform and cover with dry dressing. Every day for skin tear.A Physician Order dated 07/28/2025 documented to provide wound care to right lateral ankle. Cleanse site with normal saline solution, pat dry, apply Medi-honey and cover with foam dressing. Every Monday, Wednesday, Friday, and as needed. A Physician Order dated 07/08/2025 documented to provide wound care to right heel. Cleanse site with normal saline solution, pat dry, apply silver alginate and cover with foam dressing three times a week and as needed. Every day shift every Monday, Wednesday, and Friday for a stage three pressure ulcer. A Nursing Order dated 05/09/2025 documented to apply bilateral heel protectors when in bed for wound management. A review of the medical record revealed no documentation wound care treatment was provided on the following dates: 08/15/2025, 08/21/2025, 08/25/2025, 08/28/2025, 08/30/2025, 09/03/2025, 09/06/2025, 09/07/2025On 09/12/2025 at 9:13 AM, the wound care Licensed Practical Nurse (LPN) indicated wound care was provided 7 days a week between two wound care nurses with overlapping coverage. One nurse would work Monday - Friday and another works Wednesday - Sunday. The floor nurses would be responsible for as needed wound care changes after 3 PM when the wound nurses were out of the building. The wound care nurse explained that the wound team provided care for residents in the vent unit as well. These residents were vulnerable and missing wound care dressing changes could result in additional complications such as additional wounds or infections. The wound care nurse acknowledged the missing dates in the treatment administration record and indicated it was most likely due to documentation errors. The wound care nurse could not provide any further documentation to confirm wound care treatments were performed on the dates in question.On 09/12/2025 at 11:31 AM, the Director of Nursing (DON) indicated a blank box in the treatment administration record would mean the ordered care was not provided and documented in the electronic health record. The DON explained the expectation was staff accurately record completed treatments in the medical record. The facility policy titled Skin Integrity Management dated May 2021revealed to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Perform daily monitoring of wounds or dressings for presence of complications or declines and document.

Based on observation, interview, and record review, the facility failed to ensure all required sections of the Provider Order for Life-Sustaining Treatment (POLST) form were completed for 4 of 32 residents (Resident 5, 50, 74, and 89), and failed to ensure resident's Power of Attorney (POA) documentation was present in the medical record for 3 of 32 sampled residents (Resident 1, 4, and 5). The deficient practice had the potential to result in the resident's treatment preferences and decision-making authority not being known or honored. Findings include:1) Resident 1 (R1) was admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure, pressure ulcers, osteomyelitis, and protein-calorie malnutrition. The medical record revealed the resident had a Provider Order for Life Sustaining Treatment (POLST) which indicated the resident wanted full treatment in case of emergency which was signed by the physician. In the section to be signed by the durable power of attorney and/or guardian a family member signed. The form indicated the resident lacked decisional capacity to sign. The medical record lacked documented evidence R1 had a legal guardian, durable power of attorney, or healthcare surrogate to sign and make decisions for R1. 2) Resident 4 (R4) was admitted on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure, and dependence on respirator. The medical record revealed the resident had a Provider Order for Life Sustaining Treatment (POLST) which indicated the resident wanted full treatment in case of emergency which was signed by the physician. In the section to be signed by the healthcare surrogate a family member signed. The form indicated the resident lacked decisional capacity to sign. The medical record lacked documented evidence that R4 had a legal guardian, durable power of attorney, or healthcare surrogate to sign and make decisions for R4. 3) Resident 5 (R5) was admitted on [DATE] with diagnoses including acute and chronic respiratory failure, neuromuscular dysfunction of bladder, and urinary tract infection. A Brief Interview for Mental Status (BIMS) assessment indicated R5 had a BIMS of 13/15 indicating the resident was cognitively intact. The medical record revealed the resident had a Provider Order for Life Sustaining Treatment (POLST) which indicated the resident wanted full treatment in case of emergency which was signed by the physician. In the section to be signed by the durable power of attorney and/or guardian a family member signed. The form did not indicate if R5 lacked decisional capacity to sign. The medical record lacked documented evidence that R5 had a legal guardian, durable power of attorney, or healthcare surrogate to sign and make decisions for R5. On [DATE] at 9:05 AM, the Social Services Director explained advanced directives include a living will and allows caregivers to know what the resident's wishes were if the resident was unable to express on their own. Nevada POLST was one example of advanced directives, however if it was not accurate it would be considered null and void. The Social Services Director indicated there was no documentation to verify if the residents of concern had a durable power of attorney or legal guardianship and should not be signed as such without providing the correlating documents. 4) Resident 50 (R50) was admitted [DATE], readmitted [DATE], with diagnosis including fracture of part of the neck of the left femur, rheumatoid arthritis, and age-related cognitive decline. R50's electronic medical record documented Code Status: Attempt Resuscitation/Cardiopulmonary Resuscitation (CPR), Full Treatment. A Provider Order for Life-Sustaining Treatment (POLST) form, documented attempt cardiopulmonary resuscitation (CPR). R50's POLST form did not have the required section completed to indicate whether the resident had the decisional capacity to understand and communicate their health care preferences for the treatment options listed on the medical order, did not have a physician signature and information, the printed resident's name and date resident signed. 5) Resident 74 (R74) was admitted [DATE], readmitted [DATE], with diagnosis including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic pain syndrome. R74's electronic medical record documented Code Status: Do not Resuscitate (DNR).A Provider Order for Life-Sustaining Treatment signed by R74 on [DATE] documented do not resuscitate (allow natural death). R74's POLST form did not have the required section completed to indicate whether the resident had the decisional capacity to understand and communicate their health care preferences for the treatment options listed on the medical order. 6) Resident 89 (R89) was admitted [DATE], with diagnosis including type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and major depressive disorder recurrent severe with psychotic symptoms. R89's electronic medical record documented Code Status: Full Code. A Provider Order for Life-Sustaining Treatment (POLST) form dated [DATE] documented to attempt cardiopulmonary resuscitation (CPR). R89's POLST form did not have the required section completed to indicate whether the resident had the decisional capacity to understand and communicate their health care preferences for the treatment options listed on the medical order, and did not have a resident or representative signature, printed name, or date of signature. On [DATE] in the afternoon, the Director of Nursing acknowledged POLST forms for R50, R74, and R89 were incomplete and missing the required information listed above. The DON explained POLST forms should have been completed with all required information to ensure residents' wishes were known and honored. A facility policy titled Health Care Decision Making effective [DATE], documented the purpose was to provide patients with the opportunity and knowledge necessary to make his/her health care decisions known. To ensure that patient's wishes concerning health care decisions were communicated to all staff so that patient's rights would be honored, and their wishes would be executed at the appropriate time.

Based on interview and record review, the facility failed to ensure the Water Management Plan was completed and implemented.Findings include: The facility's Water Management Plan (WMP) was reviewed and lacked information regarding the validation process which establishes procedures to confirm the water management program effectively controls the hazardous conditions throughout the building's water system.On 09/10/2025, the Maintenance Director indicated the hot water temperatures were tested at the water heaters to ensure the temperatures were above 113 degrees Fahrenheit, but did not document the temperature results. The Maintenance Director revealed the facility did not test residual disinfectant levels.

Based on interview, record review, and document review, the facility failed to respond to each resident's grievance about their trust account statements for 1 of 19 sampled residents (Resident 72) and 2 unsampled residents (Residents 30 and 31). The deficient practice caused residents to feel slighted, angry, or suspicious of financial mismanagement by the facility. Findings included: Resident 30 (R30) R30 was admitted on [DATE] with diagnoses including stroke. The record indicated the resident was responsible for their finances. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R30 had normal memory function. On 09/19/2024, at 12:16 PM, R30 verbalized keeping a trust account with the facility. R30 revealed being furnished with a trust account statement monthly in the past. R30 reported not having received a trust account statement for a long time. R30 reported submitting a grievance to the facility about four months ago regarding the lack of the monthly trust account statement. R30 verbalized despite filing the grievance, the resident was still not being furnished with a monthly trust account statement. R30 revealed not knowing how much money was in the trust account. The Grievance/Complaint Resolution Report, dated 05/08/2024, documented R30 request Trust Account Statement for 2024. The employee assigned to address the concern was Business Office. No date was provided. Department Findings documented Accts to be audited, statements first week in June. Pt reports wanting to be kept informed of .allowance. The Resolution and Action plan area of the form was left blank. The Grievance/Complaint Resolution Report lacked documentation the resident had received the statement. Resident 31 (R31) R31 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease. The record indicated the resident was responsible for their finances. The MDS assessment dated [DATE] indicated R31 had normal memory function. On 09/19/2024, in the afternoon, R31 stated they had a trust account with the facility. The resident verbalized they had not received a trust account statement despite filing a grievance with the facility. The resident felt frustrated and disregarded by the lack of response from the facility. The Grievance/Complaint Resolution Report, dated 05/14/2024, documented R31 requests Trust Account Statement. The employee assigned to address the concern was not documented. No date was provided. Department Findings documented Pt has not been given a statement since admission. The Resolution and Action plan area of the form documented Accounts to be audited 1st then statement will be forwarded. The Grievance/Complaint Resolution Report lacked documentation the resident had received the statement. Resident 72 (R72) R72 was admitted on [DATE] with diagnoses included congestive heart failure. The record indicated the resident was responsible for their finances. The Quarterly MDS dated [DATE] documented R72 had normal memory function. On 09/19/2024, in the afternoon, R72 stated they had a trust account with the facility. The resident verbalized they had received one trust account statement after filing a grievance with the facility and getting the Ombudsman involved. R72 felt frustrated and angry at having had to go to great lengths to get a statement. R72 verbalized statement still were not furnished monthly as they should be. The Grievance/Complaint Resolution Report, dated 05/16/2024, documented R72 concern as Pt request Trust Account Statement. The employee assigned to address the concern was not documented. No date was provided. Department Findings documented Business Office reports acct will be audited and then statement forwarded. The Resolution and Action plan area of the form documented Pt .OK with acct to audited and then will provide a trust Acct Statement The Grievance/Complaint Resolution Report lacked documentation the resident had received the statement. On 09/18/2024 at 2:15 PM the retired Social Worker (SW) verbalized had worked at the facility from 05/01/2024 until around 08/01/2024. The SW reported in accordance with the facility process, a completed grievance must include documentation of resolution of the resident's concern, or a rationale as to why the grievance was not resolved. The SW verbalized a grievance should be resolved as quickly as feasible, usually within 30 days. The SW verbalized the resident must be notified of the outcome in writing. The SW remembered R30, R31, and R72. The SW verbalized having taken grievances down for all three of these residents, with the concern of not being furnished with their trust account statements each month. The SW recalled forwarding the grievances to the Business Office Manager (BOM) for resolution. The SW verbalized being unable to recall if each or any of the grievances had been acted upon or resolved. On 09/18/2024, in the morning, the Business Office Manager (BOM) verbalized being responsible for managing the resident Trust Accounts and billing. The BOM verbalized starting this position on 06/12/2024. The BOM verbalized R30, R31, and R72 had Medicaid funding, and all had trust accounts with the facility. The resident's social security checks came directly to the facility and were credited to the trust account. Any and all transactions must be documented in the trust account. The facility process was each resident with a trust account should receive a statement monthly, or the person who pays the bills for the resident. The statements were hand delivered to the resident rooms or mailed to persons who were responsible for the resident's finances. The BOM verbalized being new to the position, getting organized and learning the ropes, and had not distributed the monthly statements since beginning work. The BOM was not aware of the grievances which had been filed by R30, R31, and R72. On 09/18/2024, in the morning, the Administrator (ADM) reported starting in the position recently. The ADM stated there had been recent changes in management. The ADM reviewed the Grievance/Complaint Resolution Reports for R30, R31, and R72. The ADM verbalized the reports lacked evidence the grievances were resolved. The ADM verbalized the grievance process had lacked follow-through and evidence of resolution. The ADM had been aware of the grievance filed by R72 and the involvement of the Ombudsman. The ADM verbalized and had also talked with R31 frequently and the resident had not mentioned the concern. The ADM verbalized not having been made aware of R30s concern. The policy and procedure titled Grievance/Concern, dated 08/25/2021, indicated upon receipt of the grievance, the Administrator and appropriate department manager would be notified, and immediate action would be taken. The department manager would investigate the grievance and corrective actions would be taken as needed. The department manager would notify the person filing the grievance of resolution and/or status within 72 hours.

Based on interview, record review and document review, the facility failed to ensure restorative nursing services were provided as ordered and scheduled for 1 of 19 sampled residents (Resident 16). The deficient practice had the potential for the resident's further decline in mobility and physical functioning. Findings include: Resident 16 (R16) R16 was admitted on [DATE], with diagnoses including quadriplegia, age-related osteoporosis, muscle wasting and atrophy, and polyneuropathy. The Rehab Restorative Transition Program form for R16 documented the following: - Restorative Program(s): Standing frame - Measurable Goal(s): Resident would maintain ability to tolerate static standing using a standing frame. - Restorative Program Instructions: Standing frame activity as tolerated. - The Physical Therapist (PT) designed R16's restorative nursing program. - The PT signed the form on 08/27/2024. The physician's order dated 08/27/2024, documented restorative nursing program (RNP) one time weekly for standing frame activity as tolerated every day shift. On 09/15/2024 at 10:05 AM, R16 revealed having spinal cord injury. R16 indicated restorative nursing services for standing frame activity were scheduled every Thursday. R16 confirmed not receiving restorative nursing services on Thursday, 09/12/2024, because the staff had a meeting. R16 indicated the session (standing frame activity) was not rescheduled to cover for the missed restorative nursing services on 09/12/2024. R16 explained the facility should have more restorative nurse assistants (RNA) and the resident needed more RNA sessions. On 09/17/2024 at 1:52 PM, an RNA explained there were three RNAs employed at the facility. The RNA indicated R16's RNP included standing frame activity which was scheduled every Thursday. The RNA confirmed R16 missed the standing frame activity on 09/12/2024 because all nursing staff had a meeting at 10:30 AM. The RNA revealed the session was not rescheduled to compensate for the missed restorative nursing services on 09/12/2024. The RNA explained they could not accommodate R16's standing frame activity on 09/12/2024 due to their workload and the two RNAs were scheduled to leave at 3:00 PM. The other RNA (3rd RNA) worked on 09/12/2024 from 10:00 AM to 5:00 PM. The RNA explained two RNAs were required to perform R16's standing frame activity. The RNA revealed a total of two hours was spent in providing R16's standing frame activity including a half hour for the preparation, like dressing up the resident and getting up from bed. The actual standing frame activity lasted for one hour and a half. The RNA provided a copy of R16's Restorative Nursing Record for September 2024. A handwritten note documented R16's standing frame activity was withheld today (09/12/2024) due to the staff having a meeting at 10:30 AM. On 09/18/2024 at 12:02 PM, the PT explained R16 wanted to work on lower extremity weight bearing activity, so the standing frame activity was recommended. The PT indicated once a week standing frame activity for R16 was the minimum recommended for the meantime because of staffing requirement, and to be able to perform the activity safely with the resident since it required two RNAs. On 09/18/2024 at 3:13 PM, the Director of Nursing (DON) acknowledged the RNAs should have reported to the DON or the Assistant DON (ADON) about R16 not receiving the standing frame activity on 09/12/2024, as scheduled, due to the staff meeting held on the same day. The DON explained the session could have been rescheduled to accommodate the resident's standing frame activity. The facility's policy titled Restorative Nursing Services dated July 2017, documented residents would receive restorative nursing care as needed to help promote optimal safety and independence.

Based on interview, record review, and document review, the facility failed to consistently provide residents with a quarterly trust account statement for 1 of 19 sampled residents (Resident 72) and 2 unsampled residents (Residents 30 and 31). The deficient practice caused residents to lack peace of mind about their trust account balances. Findings include: Resident 30 (R30) R30 was admitted on [DATE] with diagnoses including stroke. The record indicated the resident was responsible for their finances. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R30 had normal memory function. On 09/19/2024, at 12:16 PM, R30 verbalized keeping a trust account with the facility. R30 revealed being furnished with a trust account statement monthly in the past. R30 reported not having received a trust account statement for a long time. R30 reported submitting a grievance to the facility about four months ago regarding the lack of the monthly trust account statement. R30 verbalized despite filing the grievance, the resident was still not being furnished with a monthly trust account statement. R30 revealed not knowing how much money was in the trust account. The resident verbalized a plan to buy a new I-pad, because the one currently being used by the resident was not holding a battery charge. R30 reported feeling curious about the lack of a facility response to the grievance even after months had elapsed. Resident 31 (R31) R31 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease. The record indicated the resident was responsible for their finances. The MDS assessment dated [DATE] indicated R31 had normal memory function. On 09/19/2024, in the afternoon, R31 stated they had a trust account with the facility. The resident verbalized had not received a trust account statement despite filing a grievance with the facility. The resident felt frustrated and disregarded by the lack of response from the facility. The resident reported being handed today a facility bill showing they owed about $5000.00 to the facility, past due. The resident verbalized not knowing how this could have happened and felt shocked and concerned as to how to pay this large bill. Resident 72 (R72) R72 was admitted on [DATE] with diagnoses included congestive heart failure. The record indicated the resident was responsible for their finances. The Quarterly MDS dated [DATE] documented R72 had normal memory function. On 09/19/2024, in the afternoon, R72 stated they had a trust account with the facility. The resident verbalized they had received one trust account statement after filing a grievance with the facility and getting the Ombudsman involved. R72 felt frustrated and angry at having had to go to great lengths to get a statement. R72 verbalized statements still were not furnished monthly as they should be. The resident reported not knowing the state of finances and did not like that feeling. The resident verbalized feeling suspicious the facility might be defrauding the resident. R72 verbalized we may be old but we are not asinine. On 09/18/2024, in the morning, the Business Office Manager (BOM) verbalized being responsible for managing the resident Trust Accounts and billing. The BOM verbalized starting this position on 06/12/2024. The BOM verbalized R30, R31, and R72 had Medicaid funding, and all had trust accounts with the facility. The resident's social security checks came directly to the facility and were credited to the trust account. Any and all transactions must be documented in the trust account. The facility process was each resident with a trust account should receive a statement monthly, or the person who pays the bills for the resident. The statements were hand delivered to the resident rooms or mailed to persons who were responsible for the resident's finances. The BOM verbalized being new to the position, getting organized and learning the ropes, and had not distributed the monthly statements since beginning work. The BOM was not aware of the grievances which had been filed by R30, R31, and R72. The BOM verified R31 owed the facility over $5,000 dollars. The BOM verbalized R31 had withdrawn too much money from the trust account by asking the front desk clerk for $50 cash every day for many months. The BOM acknowledged the facility should not have given cash to R31 without checking the trust account balance first to see if the funds were available. On 09/18/2024, in the morning, the Regional BOM verbalized R31 actually had not paid the share of cost in three months, for unknown reasons, in addition to overdrawing petty cash. The Regional BOM verbalized these findings were not in accordance with how resident funds should be managed and was currently in the process of sorting things out in the business office. On 09/18/2024, in the morning, the Administrator (ADM) reported starting in the position recently. The ADM stated there had been recent changes in management. The ADM verbalized the former BOM had quit, and then another BOM had been hired and then quit, and then the current BOM had been hired. The ADM verbalized a corporate consultant Regional BOM was currently helping the BOM get up to speed on the facility procedures for trust accounts and billing. The ADM reported this was a work in progress. The policy and procedure titled Management of Residents' Personal Funds, revised 04/2017, indicated the resident may have the facility manage their personal funds. The facility would account for the resident funds.

Based on observation, interview and record review, the facility failed to ensure the physician ordered medications were available for 2 of 19 sampled residents (Resident 72 and 16) and one unsampled resident (Resident 29). The deficient practice had the potential for the residents to have adverse events. Findings include: Resident 29 (R29) R29 was admitted on [DATE] with diagnoses including epilepsy. On 09/17/24 at 09:05 AM, the Licensed Practical Nurse (LPN) gave R29 oral medications. The resident swallowed the medications with water. On 09/17/24 at 09:20 AM, the LPN verbalized R29 had Keppra, (an anti-seizure medication), and was supposed to be given during the morning medication pass, but Keppra had not been given to R29 because the supply had run out and the Keppra was not available. The LPN verbalized the medication needed to be ordered for delivery. R29's medical record indicated a physician order dated 05/09/2024, to give Keppra 750 milligrams (mg) by mouth two times a day for seizure, at 8:00 AM and at 8:00 PM. A progress note documented by the Nurse Practitioner (NP), dated 09/18/2024 at 10:30 AM, indicated the NP was aware the resident missed the morning dose of Keppra the previous day. The September 2024 Medication Administration Record (MAR) for the resident documented NN for the 8:00 AM dose of Keppra on 09/17/2024, indicating the medication had not been given. On 09/18/24 at 1:02 PM, the Corporate Consultant verified the AM dose of Keppra had not been given on 09/17/2024 due to not being available. 33980 Resident 72 (R72) R72 was admitted on [DATE], with diagnoses including gastro-esophageal reflux disease (GERD) without esophagitis and hypothyroidism. The physician's order dated 05/09/2024, documented Protonix Oral Tablet Delayed Release 40 milligram (mg) by mouth one time a day for GERD. R72's Medication Administration Record (MAR) for September 2024, documented Protonix was scheduled to be given at 9:00 AM. On 09/17/2024 at 8:13 AM, during the Medication Administration Pass observation, a Licensed Practical Nurse (LPN) prepared the following medications for R72: - Aspirin 81 mg one tablet by mouth - Cyclobenzaprine Hydrochloride (HCl) 5 mg one tablet by mouth - Lisinopril 2.5 mg one tablet by mouth On 09/17/2024 at 8:17 AM, the LPN indicated R72's Protonix 40 mg was not available and would be reordered electronically from pharmacy. Resident 16 (R16) R16 was admitted on [DATE], with diagnoses including quadriplegia, age-related osteoporosis, muscle wasting and atrophy, and polyneuropathy. The physician's order dated 08/05/2024, documented Alendronate Sodium Oral Tablet 70 mg by mouth one time a day every seven days for osteoporosis prevention. R16's MAR for September 2024, documented Alendronate Sodium was scheduled to be given every Tuesday at 9:00 AM. The MAR lacked documented evidence R16 received the medication on 09/10/2024. On 09/17/2024 at 8:24 AM, during the Medication Administration Pass observation, the LPN prepared the following medications for R16: - Active Liquid Protein 30 milliliter (ml) by mouth - Vitamin C 500 mg by mouth - Cranberry Oral Tablet 450 mg by mouth - Magnesium Oxide 400 mg by mouth - Multivitamin Oral Tablet by mouth - Vitamin E 180 mg by mouth The LPN revealed R16's Alendronate Sodium 70 mg was not available and would be reordered electronically from pharmacy. On 09/17/2024 at 8:44 AM, the LPN acknowledged the medications should have been reordered when there were four remaining doses left to ensure the medications were available for the residents. On 09/17/2024 at 9:40 AM, the LPN indicated there was no documentation why R16's Alendronate Sodium was held on 09/10/2024. The LPN confirmed R16 did not receive Alendronate Sodium on 09/10/2024 and 09/17/2024 and there was no documentation the resident refused the medication on 09/10/2024. On 09/18/2024 at 3:06 PM, the Director of Nursing (DON) explained the nurses were expected to reorder the medications at least within 72 hours prior to the supply of the medications being utilized or ran out.

Based on observation, interview, record review and document review, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater for 1 of 19 sampled residents (Resident 16). Failure to administer medications as prescribed could have delayed the therapeutic treatment for the resident. Findings include: On 09/17/2024 in the morning, a Medication Administration Pass observation was performed with 27 opportunities observed and revealed two errors. The medication error rate was 7.41%. Resident 16 (R16) R16 was admitted on [DATE], with diagnoses including quadriplegia, age-related osteoporosis, muscle wasting and atrophy, and polyneuropathy. On 09/17/2024 at 8:24 AM, during the Medication Administration Pass observation, the LPN prepared the following medications for R16: - Active Liquid Protein 30 milliliter (ml) by mouth - Vitamin C 500 milligram (mg) by mouth - Cranberry Oral Tablet 450 mg by mouth - Magnesium Oxide 400 mg by mouth - Multivitamin Oral Tablet by mouth - Vitamin E 180 mg by mouth On 09/17/2024 at 8:42 AM, the LPN confirmed there was a total of five tablets to be given to the resident as listed above (Vitamin C, Cranberry Oral Tablet, Magnesium Oxide, Multivitamin, and Vitamin E). The LPN administered the five tablets and the Active Liquid Protein to R16. The physician's order dated 08/22/2024, documented Cranberry Tablet 300 mg by mouth two times a day, scheduled at 9:00 AM and 5:00 PM. The physician's order dated 08/29/2024, documented Fish Oil Oral Capsule (Omega-3 Fatty Acids) 3,000 mg by mouth three times a day, scheduled at 9:00 AM, 1:00 PM, and 5:00 PM. On 09/17/2024 at 9:40 AM, the LPN confirmed Cranberry Oral Tablet 450 mg was given to R16, but the physician's order was Cranberry Oral Tablet 300 mg. The LPN explained the order should have been clarified because Cranberry Oral Tablet 450 mg was the house stock and the one given to the resident. The LPN acknowledged the physician's order was not followed. The LPN confirmed Fish Oil Capsule 3,000 mg was not given to R16. The LPN explained the Fish Oil Capsule and the Vitamin E 180 mg given to the resident were the same. On 09/17/2024 at 2:02 PM, the LPN confirmed Fish Oil Capsule 3,000 mg was available in the medication cart and should have been given to R16 during the Medication Administration Pass observation. The LPN acknowledged being confused with the Fish Oil Capsule and Vitamin E and thought both medications were the same. On 09/18/2024 at 3:06 PM, the Director of Nursing (DON) indicated the nurses were expected to verify the physician's order, right medication, right dose, and right resident prior to medication administration. The facility's policy titled Administering Medications dated April 2019, documented medications were administered in accordance with prescriber orders, including any required time frame. The individual administering the medications would check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation and interview, the facility failed to ensure raw chicken stored inside the walk-in refrigerator was labeled with the date and time the chicken had been placed in the refrigerator. The deficient practice had the potential to allow bacteria to proliferate in raw poultry, a high-risk food. Findings include: On 09/16/24 at 08:14 AM, a tour of the kitchen was conducted with Dietary Regional Director. A metal pan full of cut-up chicken, weighing about 10 pounds, was stored in the walk-in refrigerator. The chicken was covered with plastic wrap. The chicken lacked a label as to the date and time the chicken had been placed in the refrigerator. The Dietary Regional Director verbalized the facility policy and procedure required staff to affix a label to all refrigerated products listing the name of the product, and the date and time the product was placed in the refrigerator. The Dietary Regional Director verbalized the chicken lacked a label. The Dietary Regional Director verbalized not knowing when the chicken had been placed in the refrigerator.

Based on observation, interview, and document review, the facility failed to ensure: 1) food items were labeled and not expired in 3 of 4 nourishment refrigerators, and 2) 1 of the 4 nourishment refrigerators was within the recommended temperature to keep cold foods cold. The deficient practice had the potential to impact the well-being of the residents through potential consumption of hazardous food items and breaches in infection control. 1) On [DATE] in the morning, three of the four nourishment refrigerators contained both unlabeled and/or expired food items. One refrigerator located in the 100 unit contained the following unlabeled and/or expired food items: - One unlabeled bottle of dipping cheese with an expiration date of [DATE] - One unlabeled Rockstar Energy drink with a glove wrapped over the mouthpiece Second refrigerator located in the 100 unit contained the following unlabeled and/or expired food items: - Two unlabeled yogurts with an expiration date of [DATE] - Two unlabeled microwavable meat loaf meals - Two unlabeled packages of raw pork sausages The refrigerator located in the 300 unit contained the following unlabeled and/or expired food items: - One rotten red apple - Three expired milk cartons with expiration dates of ,d+[DATE], [DATE], [DATE] - One chocolate shake with an expiration date of [DATE] - One unlabeled chicken alfredo microwavable meal - One unlabeled plastic cup filled with chocolate kisses - One unlabeled zip lock bag with chocolate truffles - Two unlabeled Chinese food take out containers - One unlabeled bottle of mayonnaise - One unlabeled, opened bag of microwavable burritos with ice buildup. A Certified Nursing Assistant (CNA) confirmed the unlabeled and expired food items in the 100 and 300 unit. The CNA indicated the nourishment refrigerators were designated for residents only. The CNA explained resident food items needed to be labeled with the resident's name, room number, and date. The CNA verbalized all staff members were responsible for labeling resident food items and ensuring food items were not expired. 2) On [DATE] at approximately 8:00 AM, one of the nourishment refrigerators in the 100 unit had an internal temperature of 48 degrees Fahrenheit. On [DATE] at approximately 8:15 AM, the same refrigerator in the 100 unit had an internal temperature of 52 degrees Fahrenheit. The CNA confirmed the internal refrigerator temperature. On [DATE] at approximately 2:30 PM, the District Manager indicated nourishment refrigerators needed to be maintained at 41 degrees Fahrenheit or less to keep cold foods cold. The District Manager and the Dietary Manager indicated it was important to ensure food items were not expired because of the potential of resident's getting sick due to food illness. On [DATE] at 11:35 AM, the Director of Nursing (DON) indicated nursing staff and CNAs were responsible for ensuring nourishment refrigerators were within the recommended temperature and resident food items were labeled and not expired. The facility's policy titled Food: Safe Handling for Foods from Visitors revealed resident specific food items were labeled with the resident's name and current date. The policy indicated refrigerator temperatures were monitored daily and kept at a temperature of 41 degrees Fahrenheit or less. The policy explained food items stored for greater than seven days were discarded.

Based on observation, interview, record review and document review, the facility failed to ensure food preferences for a resident was followed for 1 of 23 sampled residents (Resident 74). The deficient practice prevented a resident to exercise the right of choice. Findings include: Resident 74 (R74) R74 was admitted on [DATE] with diagnoses including aftercare for joint replacement surgery and complication of internal fixation device of left femur. On 09/20/2023 at 8:47 AM, observed R74 breakfast tray with an untouched orange juice. R74 indicated speaking with dietary services and conveyed not wanting orange juice due to the acidity. R74 verbalized getting orange juice every breakfast. R74 did not have a meal ticket on the food tray. On 09/21/2023 at 8:30 AM, a visit to R74 indicated the resident received orange juice with the breakfast tray. The breakfast meal ticket indicated Juice and R74 confirmed receiving orange juice at all breakfast trays. The meal ticket documented Allergy: onions. On 09/21/2023 at 11:30 AM, a list of R74's Allergies, Likes and Dislikes list was provided by the Dietary Manager. The manager indicated items listed on the list should be reflected on the resident's meal ticket. On 09/22/2023 at 8:50 AM, R74 indicated receiving an orange juice for breakfast. R74 had to ask certified nursing aide (CNA) for another juice and apple juice was provided. 09/22/23 09:50 AM - the Dietary Manager confirmed R74's meal ticket did not indicate the resident's dislikes. The manager shared the dislike list on the electronic Health record (EHR) and the kitchen's master list reflected the dislike for orange juice. The manager confirmed the error could have been a glitch in the system where the list doesn't cross over. The manager mentioned CNAs should have told the kitchen staff the resident continuously receives orange juice on the breakfast tray and should be replaced with an alternative juice. Review of the kitchen's master list of dislikes for all residents revealed R74 had orange juice as one of the dislike. The manager confirmed kitchen staff should follow the dislike list when preparing residents' trays. On 09/22/2023 at 10:31 AM, the CNA caring for R74 confirmed resident received orange juice with the breakfast tray and the resident requested it to be changed to apple juice. On 09/22/23 at 11:07 AM, the director of nursing (DON) confirmed kitchen and CNA staff should be vigilant when preparing a resident trays to provide the right of choice and resident's food safety. The facility policy titled resident food preferences revised July 2017, documented individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet and preferences will only be ordered with the resident or representative's consent.

Based on observation, interview, record review and document review, the facility failed to ensure residents restraints needs were assessed and evaluated; and nurses document the resident's need to have restraints for 1 of 23 sampled residents (Resident 34). The deficient practice prevented a resident's quality of life free from any restraint device. Findings include: Resident 34 (R34) R34 had a re-admitted [DATE] with diagnoses including acute respiratory failure and dependence on ventilator. On 09/20/2023 at 10:19 AM, R34 was observed wearing bilateral hand mitts. R34 was observed to be alert and calm. R34 was not restless or pulling any life sustaining devices (feeding tube or tracheostomy). A physician's order dated 06/10/2023, documented apply hand mittens for risk of decannulation, remove every two hours and check for skin integrity. Nursing progress notes last documented need for the bilateral mitts was 06/13/2023, for pulling life support devices. R34's Restraint Evaluation/Reduction was last assessed on 02/27/23 and 02/13/22. Physician's progress notes lacked documented evidence for the need for bilateral mittens. On 09/22/2023 at 8:38 AM, a license practical nurse (LPN) confirmed R34 had been wearing the mittens for a while now. The LPN indicated the resident's behavioral needs for the mittens should be documented on the progress notes. On 09/22/2023 at 10:31 AM, the CNA caring for R34 confirmed resident had been calm and cooperative with care for quite some time. On 09/22/23 at 11:07 AM, the director of nursing (DON) confirmed mittens were a form of restraints. The DON indicated the need for documenting resident behaviors was important to continuously assess the resident's need for the restraint. The DON confirmed a quarterly restraint assessment were to be completed on any mitten restraint. The facility policy titled Use of Restraint revised April 2017, documented restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they were candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination.

Based on observation, interview and record review, the facility failed to ensure showers and/or bed baths were provided for 4 out of 28 sampled residents (Residents 2, 51, 148, and 149). The deficient practice had the potential for residents to be uncleaned and at risk for skin issues and breakdown. Findings include: Resident #148 (R148) was admitted on [DATE] and discharged on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertensive heart and chronic kidney disease without heart failure, gastrostomy tube, generalized muscle weakness, dependence on respirator (ventilator), and cognitive communication deficit. A review of the 100-hall shower schedule revealed the resident was scheduled for a bath/shower on Wednesday and Saturday during the evening shift. The Weekly Bath and Skin Report dated 06/14/2023, documented the resident had a bed bath and there were no reported skin issues. A review of the Certified Nursing Assistant Electronic Activities of Daily Living Record for June 2023 revealed the resident had received a bed bath on 06/24/2023 and 06/26/2023. The documentation revealed the resident was totally dependent on staff for bathing. A review of the Certified Nursing Assistant Electronic Activities of Daily Living Record for July 2023 revealed the resident had received a shower on 07/01/2023, a bed bath on 07/05/2023, 07/22/2023, and 07/25/2023. The resident should have received 13 showers/bed baths during the resident's admission to the facility. The medical record lacked documented evidence that the resident received 6 out of the 13 scheduled showers/bed baths. Resident #149 (R149) was admitted on [DATE] and discharged on [DATE] with diagnoses including quadriplegia, chronic respiratory failure with hypoxia, epilepsy, dependence on respirator, gastrostomy tube, and generalized muscle weakness. The Admission Minimum Data Set (MDS) dated [DATE] documented the resident was severely cognitively impaired. The activity of bathing did not occur during the lookback period. The Quarterly MDS dated [DATE] documented the resident was dependent upon staff for the activity of bathing. On 09/22/2023 at 8:53 AM, a Licensed Practical Nurse (LPN) on the 100-hall revealed the body check form was completed with each shower. The resident's scheduled shower was for Tuesday and Friday in the morning. The resident should have received 24 showers/bed baths during the resident's admission. The medical record lacked documented evidence that the resident received 12 of the 24 scheduled showers/bed baths. On 09/22/2023 at 9:41 AM, a Certified Nursing Assistant (CNA) revealed each unit had a shower book with skin check forms to be competed for each shower, this would include if the resident had a bed bath, shower, refused or had a partial bed bath. If the resident received a partial bed bath to document what was done such as washing face, under the arms, etc. If the resident refused the shower or bed bath to report to the nurse, ask the resident at different times during the shift if they want a shower, encourage the resident on the importance of getting a shower and to document the refusals. During the shower/bed bath the CNA should document any skin issues observed. The facility Clinic Bath, Shower/Tub Policy (undated) documented the purpose of the procedures are to promote cleanliness, provide comfort for the resident and to observe the condition of the resident's skin. Documentation included the date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower/tub bath, all assessment data (e.g., any reddened areas, sores, etc. on the resident's skin) obtained during the shower/tub bath, how the resident tolerated the shower/tub bath, if the resident refused the shower/tub bath, the reason(s) why and the interventions taken, and the signature and title of the person recording the data. 37718 Resident 2 (R2) was readmitted on [DATE], with diagnoses including schizophrenia and right sided hemiplegia. Physician orders included nothing by mouth, and enteral feeding via a gastrostomy tube. The 06/23/2023 Quarterly MDS indicated the resident was unable to speak, had severe cognitive impairment, and was totally dependent in activities of daily living including requiring two person assist for hygiene and bathing. The MDS indicated the resident was incontinent of bowel and bladder. The current care plan indicated the resident needed assist with ADLs, was resistive to care due to traumatic brain injury, risk for dehydration, and incontinence. 09/21/2023 12:20 PM The resident was non-verbal but smiled in response to questions. The resident had disheveled, greasy looking hair with loosely attached or completely detached whitish flakes noted dusting the right temporal scalp consistent with dandruff. The resident's mouth was dry, and the lips were crusted with dried white secretions. A review of the 200-hall shower schedule revealed the resident was scheduled for a bath/shower every Tuesday and Friday during the evening shift. A review of the Weekly Bath and Skin Reports for the month of September 2023 to date, indicated one bed bath had been given. The Weekly Bath and Skin Report dated 09/09/2023, documented the resident had a bed bath and there had been redness (butt area) noted. The resident should have received 6 showers/bed baths from 09/01/2023 - 09/20/2023. The shower record lacked documented evidence that the resident received 5 out of the 6 scheduled showers/bed baths scheduled during that time period. The resident's medical record lacked documented evidence of a rationale as to why a bed bath had been given rather than a shower. Resident 51 (R51) was admitted on ,d+[DATE] with diagnoses including history of fracture of the right femur, cerebral infarction without residual, and muscle weakness. The Annual MDS dated [DATE] indicated the resident's memory function was not measured, and the resident required extensive assistance of one person for bed mobility, transfers, and hygiene, and total dependence on two persons for bathing. On 09/20/2023 at 11:06 AM, R51 was in bed wearing a gown and answered questions appropriately. The resident had long, unkempt greasy looking hair. The resident verbalized they would like to get their hair washed. R51 verbalized their hair had not been washed for an extended period of time. On 09/21/2023 at 12:15 PM, R51 was in bed. The resident's hair was long and greasy as seen the prior day. The resident verbalized they would still like to get their hair washed. A review of the 200-hall shower schedule revealed the resident was scheduled for a bath/shower on Wednesday and Saturday during the morning shift. A review of the Weekly Bath and Skin Reports for the month of September 2023 to date indicated three bed baths had been given in total. The Weekly Bath and Skin Report dated 09/06/2023, documented the resident had a bed bath and there was redness and bruising to the skin noted. The Weekly Bath and Skin Report dated 09/13/2023, documented the resident had a bed bath and there were no skin issues. The Weekly Bath and Skin Report dated 09/20/2023, documented the resident had a bed bath and there were no skin issues. The resident should have received 6 showers/bed baths from 09/01/2023 up until 09/20/2023. The bathing record lacked documented evidence that the resident received 3 out of the 6 scheduled showers/bed baths scheduled during that time period. On 09/22/2023 at 10:05 AM, the Assistant Director of Nursing (ADON) toured the 200 hall and visited R2 and R54 at bedside. The ADON verbalized the oral hygiene for R2 and the unkempt and greasy condition of the hair for both R2 and R54, did not meet facility expectations for acceptable hygiene care. The ADON verbalized the standard would be what a reasonable person would want in the way of oral hygiene and clean and neat hair. On 09/22/2023 at 10:15 AM, the Director of Nursing (DON) explained a lack of documentation for baths and showers given was an issue that had been identified. The DON verbalized action should be taken to address the lack of baths and showers documented as given. The DON verbalized bathing should be performed in accordance with the bath/shower schedule and these along with skin checks, should be documented on the Weekly Bath and Skin report. The DON verbalized showers were preferred and should be given whenever practical. The DON verbalized the facility had sufficient shower rooms and equipment to accommodate showers. On 09/22/23 at 01:01 PM, the CNA verbalized their assigned group of 14 residents were all dependent in ADL's. The CNA reported bed baths were used when there was insufficient time or staff to accommodate the full shower, which took an average of 30 minutes to provide using two CNAs for each dependent resident. The CNA verbalized a shower was better at cleaning the resident than the bed bath. The CNA revealed that many residents refused to have their hair touched or washed during a bed bath, whereas during a shower they would allow staff to wash their hair. The CNA indicated residents often refused to have water poured on their hair while in a horizontal position in bed during the bed bath. The CNA indicated having to prioritize daily work load; incontinent care took priority over bathing and sometimes baths/showers would have to be omitted if the work load did not allow time. The facility policy and procedure titled Activities of Daily Living (ADLs), Supporting, revised March 2018, indicated residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good grooming, and personal and oral hygiene, including bathing, grooming, and oral care. The policy indicated resident's response to interventions would be monitored, evaluated, and revised as appropriate. Complaints NV00069460 and NV00069157, and FRI NV00069446

Based on observation, interview, record review and document review, the facility failed to ensure falls resulting in injury were prevented for 2 of 43 sampled residents (Residents #247 and #40) and Vehicle Safety Competency training was provided to 3 of 3 transportation drivers. Findings include: Resident #247 (R247) R247 was admitted on [DATE] and readmitted on [DATE], with diagnoses including [CONDITION(S)], dependence on ventilator and gastrostomy status. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had functional impairment on bilateral upper and lower extremities, was totally dependent for care, and required two staff assistance for bed mobility and toileting. The activities of daily living (ADL) care plan initiated 04/05/2021, documented an intervention to provide the totally dependent resident with two staff assistance for bed mobility and toileting. An INTERACT transfer form dated 06/27/2021, documented R247 rolled off the bed onto the floor during care. Contusion to left side of the head noted, resident transferred to hospital for further evaluation. Refer to Certified Nursing Assistant (CNA) written statement. A written statement by the Certified Nursing Assistant (CNA) indicated the CNA provided incontinent care to the resident by themselves. While the resident was turned to the right side, the resident rolled off the bed onto the floor. The resident sustained a contusion on the upper left eye and was transferred to the hospital. On 08/10/2022 at 3:16 PM, the Assistant Director of Nursing (ADON) confirmed R247 fell from bed during ADL care on 06/27/2021 when a CNA performed the task without seeking assistance from another staff member. According to the ADON, the resident was bedfast, totally dependent for care and was well known to staff to require two persons for ADL care. As a result, R247 rolled off the bed when the CNA turned the resident to the right side to clean the resident's bottom. The resident fell on the ground hitting the head. On 08/10/2022 at 3:27 PM, the former Administrator recalled speaking with the CNA of concern following the incident. The CNA told the former Administrator the CNA was aware the resident of concern required two staff members to perform incontinent care and tried to look for other staff but everyone else was busy with other residents. According to the former Administrator, the CNA of concern resigned shortly after the incident. An Individual Performance Plan document dated 06/28/2021, revealed the Director of Nursing (DON) took disciplinary action towards the CNA of concern due to unsatisfactory job performance and failing to comply with safety measures. The CNA was providing care to R247 on 06/27/2021 when the resident fell and sustained a head contusion. On 08/11/2022 at 9:13 AM, the DON confirmed the R247's fall incident on 06/27/2021 was preventable and should not have happened. According to the DON, the CNA of concern admitted providing the resident's ADL care alone because no other staff members were available. On 08/11/2022 at 9:30 AM, the DON verbalized the resident of concern was bedfast, totally dependent, used a low air-loss mattress and was assessed to require two persons for bed mobility and toileting. The DON indicated it was unacceptable and considered a neglect of duty when the CNA performed the ADL task on the resident by themselves. If no staff members were available, the CNA should have waited until someone was available to assist to ensure safe delivery of care. As a result, the resident fell off the bed during provision of care which resulted in injury and hospitalization . A Hospital History and Physical report dated 06/27/2021, revealed the resident presented to the emergency department on 06/27/2021 following a fall from bed when the patient rolled off the bed while being cleaned. Left periorbital swelling was noted. The resident was admitted for acute fall head contusion. A Computed Tomography (CT) scan of head or brain without contrast dated 06/27/2021, revealed a left forehead, frontal scout and periorbital [CONDITION(S)] and hematoma. A Discharge Summary dated 07/06/2021, revealed the resident was discharged after being treated for a closed head injury following mechanical fall. The facility policy titled Activities of Daily Living revised 05/04/2015, documented residents would be evaluated and a program of assistance and instruction in ADL skills would be implemented as appropriate. Complaint #NV 400 Resident #40 R40 was admitted on [DATE] and readmitted on [DATE], with diagnoses including [CONDITION(S)] and dependence on renal [CONDITION(S)]. A Nursing note dated 11/19/2021, revealed R40 fell from wheelchair in the van coming back from [CONDITION(S)] and sustained abrasions to both knees. Physician ordered X-ray of bilateral knees. A Nursing note dated 11/20/2021, revealed the night shift nurse communicated to the day shift nurse R40 was screaming due to pain to bilateral lower extremity. X-ray of bilateral knees showed mild [CONDITION(S)] with no acute fracture. Physician ordered STAT (immediately) X-ray of bilateral hip/pelvis due to complaints of pain and left knee swelling and showed modest [CONDITION(S)] with no acute fracture. On 08/09/2022 at 11:45 AM, the transportation driver indicated the facility owned two vans and employed two drivers for the purpose of transporting residents to medical appointments. The driver who was employed in January 2022, was familiar with R40 since the resident was transported to the [CONDITION(S)] clinic three times a week prior to R40's recent hospitalization . The driver described the resident as alert and oriented, able to communicate and was not the type to unlatch a seatbelt during transit. According to the transportation driver, the driver involved in R40's incident was no longer employed at the facility. On 08/09/2022 at 11:55 AM, a Certified Nursing Assistant (CNA) who was steadily assigned to the R40's care indicated after the fall incident on 11/19/2021, the CNA had been escorting the resident to [CONDITION(S)] and described the resident as alert, oriented, verbal and was not the type to unlatch own seatbelt during transit. On 08/09/2022 at 12:00 PM, using an empty wheelchair the transportation driver demonstrated how a wheelchair and its occupant would be secured during transport. Four tie-down mechanisms were observed on the van floor. The wheelchair was maneuvered into the correct position and two front straps, and two rear straps were latched to the wheelchair's metal frames. The driver shook the chair vigorously to check for stability. Once the wheelchair was secured, two seatbelts, one across the pelvic area and one across the shoulder and chest would be strapped across the resident. The seatbelt would be adjusted accordingly for the resident's safety. After completing the demonstration, the transportation driver verbalized, if the wheelchair and the resident were properly secured, it would be impossible for a resident to slip off the wheelchair and take a frontal fall. On 08/10/2022 at 8:00 AM, a repeat demonstration was conducted by another driver in the presence of the former Administrator, the Rehabilitation Corporate Consultant, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). Transportation driver #2 repeated the steps in the procedure performed by transportation driver #1 on 08/09/2022 which resulted in the wheelchair being secured by two frontal straps and two rear straps hooked to the van's tie-down mechanisms. Two seatbelts were latched across the empty wheelchair, one intended for the occupant's pelvic area and the other one for occupant's left shoulder and chest. On 08/10/2022 in the morning, transportation driver #2 shook the wheelchair vigorously and verbalized even if the driver stepped on the brakes, a frontal fall would be highly unlikely if the wheelchair and its occupant were secured properly. On 08/10/2022 in the morning, the Rehabilitation Corporate Consultant who was inside the van during the demonstration verbalized even if the driver stepped on the brakes, a frontal fall would be impossible if the wheelchair and its occupant were secured properly. On 08/10/2022 in the morning, the former Administrator, ADON and DON who observed the demonstration from outside the van verbalized even if the driver stepped on the brakes, a frontal fall would be impossible if the wheelchair and its occupant were secured properly. On 08/10/2022 in the morning, the former Administrator, the ADON and the DON indicated being familiar with R40's fall in the van on 11/19/2021. During the investigation of the incident, it was determined the resident's wheelchair stayed in place when the resident slipped off the wheelchair and landed on knees when the driver hit the brakes. The former Administrator recalled the driver's involved in the incident explained the resident had put the shoulder strap under the left arm and the pelvic strap may have loosened causing the resident to take a frontal fall. The former Administrator indicated the fall was unwitnessed so there was no one to corroborate the driver's report and the facility failed to interview the resident of concern during the investigation. On 08/10/2022 in the morning, the transportation driver #2, the Rehabilitation Corporate Consultant, the former Administrator, ADON and DON indicated the only logical explanation for the resident's fall on 11/19/2021 was if the resident was not properly secured for example, one or both seatbelts may not have been engaged or if there was a malfunction on one or both seatbelts. On 08/10/2022 at 9:56 AM, the ADON recalled the resident's orthopedic appointment was scheduled for 12/06/2021. During the consult, the orthopedic doctor called the facility to recommend the resident's transfer to the hospital for further evaluation due to persistent pain despite negative X-rays. A Hospital History and Physical dated 12/06/2021, revealed the patient had a left femur fracture, apparent distal femoral fracture with angulation. Exam significantly limited by patient positioning. Fracture in the proximal femur could not be excluded on these images. An X-ray single and double views of the left knee revealed acute distal femur fracture and marked knee flexion contracture. An X-ray of left tibia fibula revealed distal femoral fracture. An X-ray of left knee without contrast revealed flexion deformity of the knee suggests underlying contracture, no acute or displaced fracture is seen and diffuse vascular calcification. A Hospital Physician Progress note dated 12/06/2021, revealed the patient had been reporting pain on left knee since a fall two weeks prior. X-rays performed at skilled nursing facility revealed no acute fractures however patient was transferred on 12/06/2021 to ED for further evaluation. CT of left knee revealed no acute fractures and no further surgical orthopedic intervention was recommended. Recommendation was to continue PT focusing on bilateral lower extremity strengthening as tolerated by patient. The facility policy titled Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs (undated) revealed the wheelchair tie down and occupant restraint (WTORS) system was utilized which included a step-by-step procedure on securing the wheelchair and its occupant during transportation. Driver Competency On 08/09/2022 at 11:45 AM, the transportation driver indicated the facility owned two transportation vans and employed two drivers. The transportation driver explained being employed by the facility since January 2022 while the other driver started in May 2022. The driver indicated receiving informal training from a former driver who was no longer employed at the facility. The transportation driver indicated no formal training or competency checklist was provided by the facility. On 08/10/2022 at 10:39 AM, the former Administrator indicated during the investigation of the incident the Administrator checked for the training and competency checklist for the driver of concern, but none could be found. The transportation driver of concern informed the former Administrator having only received informal instruction from another driver regarding securing and transporting residents. On 08/10/2022 at 10:50 AM, the former Administrator and current Administrator verbalized when transportation drivers were hired, they must be trained in accordance with the facility's procedure to transport residents in wheelchairs. The training included hands-on training and successful return demonstration and there must be documented evidence the training occurred. On 08/10/2022 at 11:16 AM, the Administrator explained the driver of concern was a Certified Nursing Assistant who doubled as a transportation driver. The Administrator indicated the driver of concern resigned in December 2021. The Administrator indicated the driver's employee file was reviewed which did not contain a signed job description for transportation drivers nor a competency checklist for securing and transporting residents. On 08/10/2022 at 11:20 AM, the Administrator confirmed there was no documented evidence the Vehicle Safety Competency training was provided to the driver who was involved in R40's fall incident on 11/19/2021. The Administrator acknowledged there were no Vehicle Safety Competencies for the two drivers currently employed by the facility prior to the start of survey on 08/09/2021. The Vehicle Safety Competency document (undated), revealed driver training included steps in safely transporting patients in a wheelchair and critical elements included operation of the wheelchair van lift, securing the wheelchair with tie-down mechanisms, proper placing of seatbelts to secure the patient and being mindful of precautions and safety issue while transporting residents in wheelchair. Complaint #NV 405

Based on interviews, clinical record reviews and document reviews, the facility failed to provide a safe environment and adequate supervision for one resident (Resident #16) during a transfer by a Certified Nurse's Assistant (CNA) from a Hoyer Lift to a shower chair which resulted in a fall and a traumatic head injury Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. On 11/16/11 at 1:45 PM, Employee #4 (date of hire 8/22/11) described the incident that occurred with Resident #16. - Employee #4 indicated the incident occurred on Saturday 10/22/11 at approximately 5:00 PM. - Employee #4 indicated Resident #16's shower days were Tuesday and Saturday. - Employee #4 indicated Resident #16 needed a shower because she, "smelled". - Employee #4 indicated she and the other CNA had 15 residents each. - Employee #4 indicated she and another CNA each had five residents to get up and ready for dinner. - Employee #4 indicated the other CNA was very busy and Employee #5 (Licensed Nurse on hall 200) was busy with the physician. - Employee #4 indicated she would get Resident #16 up by herself using the Hoyer lift. - Employee #4 drew a diagram of Resident #16's room. The shower chair was located several feet from the head of the bed and perpendicular to the Hoyer lift. - Employee #4 indicated when she tried to transfer Resident #16 herself from the Hoyer lift to the shower chair the Hoyer lift moved and the resident moved forward. - Employee #4 indicated she put the base of the Hoyer under the resident's bed. Employee #4 then hung the sling under the Hoyer lift. When Employee #4 moved the Hoyer lift Resident #16, "jerked" forward. - Employee #4 indicated, that she tried to hold Resident #16 back as she fell forward. - Employee #4 indicated the resident was too heavy. - Employee #4 indicated, Resident #16 fell forward, face down and hit her head on the floor. - Employee #4 then indicated she turned Resident #16 on her back. - Employee #4 indicated she left Resident #16 on the floor in her room and went to find Employee #5. - Employee #4 indicated she had not done a one person assist with Resident #16 before. - Employee #4 indicated Resident #16 was a very heavy person and smelled bad if not given a shower. - Employee #4 indicated even if she asked for staff to help transfer Resident #16 they were all too busy. - Employee #4 stated, "They (the facility) never trained me on transfers when I was hired. There was no training when I got here. They never told me you need two people to transfer with a Hoyer lift. I had all my training done after the accident." - Employee #4 indicated that she was really concerned with Resident #16 "smelling so bad" and the resident really needed a shower. - Employee #4 indicated it was always hard to find people to help. - Employee #4 indicated she did not have training or orientation until 11/07/11. - Employee #4 stated, "They (referring to the facility) made me sign that I had all my orientation on 8/22/2011. I did not have any orientation on 8/22/11." - Employee #4 indicated she started on the floor on 8/22/11 without any training by the facility. On 11/16/11 at 11:00 AM, Employee #5 indicated she was charting at the nurse's station on the 200 hall on 10/22/11 at about 5:00 PM, when Employee #4 told her Resident #16 fell . - When Employee #5 entered the room she observed Resident #16 on her back. - Employee #5 indicated Employee #4 said she was putting the resident back into bed from the shower chair. - Employee #5 indicated she did not know Employee #4 was giving Resident #16 a shower on that day. - Employee #5 indicated the other CNA was getting residents ready for dinner. - Employee #5 indicated the wheels on the Hoyer were locked. - There were no other witnesses to the fall. - Employee #5 indicated she had no idea how Resident #16 landed on her back. - Employee #5 indicated Employee #4 told her the resident moved, the sling tilted over and she fell face down on her head. - Employee #5 was asked to draw a diagram of how Resident #16's room looked when she entered on 10/22/2011. The diagram was the same as the one Employee #4 drew. - Employee #5 indicated the resident was a very large person and her upper and lower extremities were very contracted. - Employee #5 indicated it took five staff members to put the Resident #16 back to bed after the fall. - Employee #5 indicated the Resident #16 had a large swelling over her right eye with discoloration. - Employee #5 indicated she assessed Resident #16, started neurochecks and called the physician's assistant (PA). The PA ordered Resident #16 to be transferred to the acute hospital on [DATE] at approximately 6:00 PM. On 11/15/11 at 1:15 PM, Employee #2 (DON) indicated as a clinical professional the CNA should have had a two person assist with a totally dependent person. The DON indicated the staff was taught Hoyer lift transfers should always be done with a two person assist. The DON indicated, Employee #4 should have called for help. On 11/15/2011 in the morning, six CNAs from three units were interviewed on how a Hoyer lift transfer should be conducted. Each CNA interviewed indicated at the least a two person transfer. The quarterly Minimum Data Set ((MDS) dated [DATE], for Resident #16 documented under Section G Functional Status Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Under Self Performance "4" was documented in the box which was defined as: total dependence. Next to the Self Performance was Support "3" was documented in the box and was defined as: Two persons plus for physical assist. The Activities of Living form for Resident #16 for the month of October 2011 documented the resident was not transferred on all shifts from 10/16/11 through 10/21/11. On 10/22/11 the column for day shift documented an "8" defined as (no transfer occurred), for the evening shift when the resident fell , the columns were blank. From 10/01/11 through 10/15/2011 each time the Hoyer lift was used for transfer it was documented 2 person assist. The facility staffing schedule for 10/22/11 on the 3 PM to 11 PM shift indicated there were two CNAs for the 200 hall scheduled to work (Employee #4 and another CNA). The Care Plan for Resident #16 dated 8/29/2011, did not document Resident #16 required transfer by use of a Hoyer lift with a two person assist. The Care Plan for Resident #16 was revised on 10/23/2011. The form documented, "When resident returns, PT (physical therapy) will evaluate resident on use of Hoyer lift." The facility policy on Lifting and Transferring of Residents 2.5.20 (not dated) documented the following: Policy: "All members of the nursing staff, nurses and nursing assistants are responsible for using good body mechanics, knowing the proper procedures and properly operating assistive devices." Procedures: "5. The designated method of lifting and transferring of a resident is indicated in the plan of care and MDS." A sign in sheet, provided by the Staff Coordinator documented a date of 11/07/2011, and the following: "INFORMATION PRESENTED General Orientation 5.75 hrs. (hours)." Employee #4's name appeared on the sign in sheet. The Emergency Record for Resident #16 dated 10/22/11, indicated the physician's clinical impression was intracranial hemorrhage in the subarachnoid of the brain. A Neurological Consultation completed on Resident #16 dated 10/22/2011 documented the following: 1. Patient required 2 units of fresh frozen plasma in the emergency room 2. A CAT (computerized tomography) scan was performed without contrast and showed a large right frontal supraorbital scalp hematoma, acute right frontal lobe, intraparenchymal bleed 2 by 2 cm (centimeters) associated with subarachnoid hemorrhage (traumatic). Resident #16's discharge summary dated 11/01/2011, documented the following: "...long standing resident of (facility name) with past medical history of [REDACTED]. The patient subsequently had a CT of the brain, which showed intracranial bleed. The patient was subsequently seen by neurosurgery. At this time the patient was a category 2, and was seen by neurology as well as neurosurgery. The patient subsequently passed away on 10/31/2011." Complaint #NV 831