Every finding on record at Silver Hills Health Care Center

Based on observation, interview, and document review, the facility failed to ensure residents were free from abuse for 2 of 54 residents (Resident 173 and Resident 174). The deficient practice had the potential to place residents at risk for physical and psychosocial injury.Findings include:Resident 173 (R173) was admitted on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder and anxiety disorder.A minimum data set (MDS) comprehensive assessment dated [DATE] documented a brief interview for mental status (BIMS) was conducted and R173 received a score of 15/15 indicating intact cognition. Resident 174 (R174) was admitted on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia, epilepsy.A brief interview for mental status (BIMS) assessment was conducted by the facility on 03/10/2026 and R174 received a score of 14/15 indicating intact cognition. The state agency received a facility report 04/14/2026 regarding a resident-to-resident physical altercation which occurred on 04/13/2026. The report detailed two residents (R173 and R174) were in the smoking area for residents and a verbal altercation started. The altercation escalated to multiple punches from both residents before another resident attempted to de-escalate the situation and staff arrived to separate R173 and R174.On 08/06/2026 at 9:01 AM, one resident was observed smoking independently without supervision.On 08/06/2026 at 9:01 AM, the Activities Director reported the 200-hall patio was the only approved smoking area at the facility and explained there was no direct supervision of residents while smoking.On 08/06/2026 12:47 PM, a Physical therapist indicated having observed two residents engaged in verbal altercation which appeared to be escalating toward a physical confrontation. The Therapist contacted a nearby nurse and requested assistance in separating residents. On 08/06/2026 12:49 PM, a Licensed Practical Nurse verbalized two male residents were arguing, one of the residents used a racial slur and was punched and returned punch and was punched again. On 08/06/2026 at 12:55 PM, The Activities Director explained the facility did not have designated smoking times or schedules in the smoking patio. Residents independently accessed the patio to smoke, and supervision was not provided by the facility during smoking. The Activities Director reported only residents able to smoke independently could go outside to smoke, if residents were not independent, they could not smoke because there was no supervision for smoking.On 08/06/2026 at 1:57 PM, the Director of Nursing (DON) and Administrator indicated being familiar with the incident and verbalized a staff member walking by and witnessed the verbal altercation. notified nurse and, by the time staff arrived a third resident had stepped in to break up the fight. R173 and R174 struck each other, both assessed. residents did not require medical care. The DON explained there was no supervision during smoking and emphasized the smoking assessment important to ensure safety. The DON and Administrator acknowledged the incident could be described as resident-to-resident abuse. The facility policy tilted Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, documented the policy interpretation and implementation included to protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including facility staff, other residents, and family members.Facility Reported Incident 2984395

Based on interview, document review, and record review the facility failed to ensure an elopement incident was thoroughly investigated for 1 of 45 sampled residents (Resident 172). The deficient practice resulted in the facility being unable to fully determine the root cause of the elopement and whether additional interventions were necessary to ensure safety and prevent recurrence.Findings include:Resident 172 (R172) was admitted on [DATE] with diagnoses including dementia, anxiety, and mood disorder.A final report was sent to the State Agency 04/20/2026 regarding a resident elopement at the facility. Per the timeline reported by facility R172 was noted to be missing from the building at 8:08 AM after conducting rounds in search of the resident. Law enforcement was contacted and the facility was not aware of the location or exact time the resident left the facility. At approximately 11:37 AM the facility received a phone call from R172s public guardian who notified the facility the resident was at the social security office approximately 5 miles from the facility.On 08/03/2026 at 7:30 AM, the survey team attempted to enter the building and on arrival the doors were locked and there was no staff in the reception area. After approximately a five-minute wait and ringing the bell a staff member appeared and pushed on door for approximately 10-15 seconds and doors unlocked with audible alarm sounding.On 08/06/2026 at 10:17 AM, the receptionist indicated the front doors are locked until 7:00 AM when the receptionist started and the front lobby was not monitored from 9:30 PM until 7:00 AM. The receptionist explained residents were aware to leave the building once the doors were locked, the residents would push on the door for 15 seconds and doors would open and audible alarm would sound.On 08/06/2026 at 12:48 PM, a Licensed Practical Nurse (LPN) indicated being familiar with R172 and recounted passing by front lobby on 04/16/2026 early in the morning around 7:00AM (when receptionist arrives). The LPN indicated noticing a walker in the front lobby and realized it belonged to Resident 172 who couldn't be without the walker. The LPN informed the receptionist at approximately 7:15 AM and a code pink was initiated at 8:08 AM. The receptionist told the LPN the walker was observed by the front door, and the receptionist moved it towards the couch. The LPN went to R172's room and R172 was not there. No one in the perimeter noticed the resident and the roommate was confused. On 08/06/2026 at 12:55 PM, the Director of Staff Development (DSD) recounted being the charge nurse on 04/16/2026 and was notified by the LPN Supervisor regarding R172 missing. A search was initiated which included inside of the building as well as outer perimeter. Once the initial search was completed, but R172 was nowhere to be found. A 911 call was made to involve metro and emergency personnel. Public guardian was notified as well. On 08/06/2026 at 12:58 PM the DSD indicated receiving a call from social security at around 11:30 AM because social security called the public guardian and the public guardian notified the facility. R172 returned accompanied by Metro. No hospitalization and no injuries no sign of heat exhaustion. Physician was updated.On 08/06/2026 at 1:01 PM the DSD reviewed the elopement care plan and explained it was developed after the first elopement in September 2025 and revised after the second on 04/16/2026. R172 was on 1:1 until discharged to another facility. The DSD could not speak to why the resident was transferred to another facility. On 08/06/2026 at 1:14 PM, the Director of Maintenance explained the front door was in lock mode before operating hours at 7:00AM when the receptionist arrived. If someone tried to open it in lock mode, the door would alarm after 15 seconds and eventually open. It was the expectation staff would go to the door to investigate why it opened. On 08/06/2026 at 1:29 PM the Director of Nursing (DON) indicated expecting staff to respond to the alarm, and the DON could not recall census or staffing levels on night or morning in question. The DON confirmed there were no notes in the facility investigation file regarding testing alarms to ensure they were in working order or to discover why no staff members responded to alarms.On 08/06/2026 at 1:34 PM the Administrator indicated the 15-second alarm on the door served the purpose of alerting staff that someone was opening the door during visiting hours when there was a receptionist out front. The Administrator indicated expecting staff to respond to the alarm to see who was accessing the door during locked mode. On 08/06/2026 at 1:42 PM the DON confirmed asking staff who were present at the time of elopement regarding hearing or responding to the alarm was an important part of the investigation. The DON explained questions regarding the alarm were not documented in the facility investigation report. The facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating (revised April 2021) documented all allegations would be thoroughly investigated. Facility Reported Incident 2986672

Based on interview, record review, and document review, the facility failed to ensure a baseline care plan was developed and implemented including instructions for peripheral intravenous (IV) catheter identified during the initial assessment for 1 of 54 sampled residents (Resident 168). The deficient practice placed the resident at risk of neglect and complications to insertion site.Findings include:Resident 168 (R168) was admitted on [DATE] with diagnoses including surgical aftercare following surgery on the genitourinary system, elevated white blood cell count, and adult failure to thrive.A nursing admission note dated 05/02/2026 documented R168 was admitted to facility with peripheral IV in place to right antecubital (AC), 22 gauge, not currently receiving IV medications.A nursing skin/wound note dated 05/02/2026 documented R172 was admitted with peripheral IV to upper right arm.The medical record lacked documented evidence of an order for the IV. The medical record lacked documented evidence of any further assessment of peripheral IV. The baseline care plan dated 05/02/2026 documented in notes section the presence of peripheral IV. There was no further information regarding the care or needs of peripheral IV in the interventions and goals section of the baseline care plan.On 08/06/2026 at 8:30 AM, a Licensed Practical Nurse (LPN) indicated when a resident was admitted the nurse assigned to the specific unit would provide the initial assessment and would begin to document the needs of the resident to include in the baseline care plan. The LPN explained when a resident was admitted with or had new IV line during stay it would be documented in the baseline care plan, comprehensive care plan, and added to orders to ensure care was provided.On 08/06/2026 at 8:39 AM, the Director of Nursing (DON) verbalized during the initial assessment the nurse would identify any skin concerns, devices, including IV or any other intravenous lines. The nurse would enter batch orders for IV care or possibly request order for removal. The DON indicated generally a peripheral IV would be changed or removed every 72 hours. The DON confirmed R172 was admitted on [DATE] with peripheral IV in place and there were no orders associated with the care or follow up with IV. The resident discharged on 05/05/2026 with IV still in place.The facility policy titled Care Plans -Baseline dated 2001 documented the baseline care plan includes instructions needed to provide effective, person-centered care of residents to meet professional standards of quality care.Complaint 3008186

Based on observation, interview, record review, and document review, the facility failed to ensure 1) a physician-ordered antibiotic was available for administration resulting in a delay of over five hours for 1 of 54 sampled residents (Resident 158), 2) scheduled medications were not given late for 1 of 45 sampled residents (Resident 97) and 3) medications for multiple residents were not prepared at the same time prior to administration for 2 unsampled residents. The deficient practice had the potential to negatively impact the effectiveness of treatment and placed residents at risk for medication error. Findings include: Resident 158 (R158) was admitted [DATE], with diagnosis including acute osteomyelitis (an infection in the bone) of right ankle and foot, a local infection of the skin and subcutaneous tissue, and cellulitis (a bacterial infection of the skin) of the right lower limb. On 08/03/2026 at 10:57 AM, R158 explained having a wound infection of the foot. R158 reported being concerned because the facility was out of his prescribed antibiotic for the infection for the 8:00 PM administration on 08/02/2026. R158 reported not receiving the antibiotic dose scheduled for 8:00 PM and receiving the medication at a later time. An admission Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15. R158 was cognitively intact. A Care Plan dated 07/23/2026, documented R158 had osteomyelitis in the right foot. R158 had impaired skin integrity present on admission as evidenced by an infection of the foot. Goals indicated R158 would be free from complications related to infection. Interventions included to administer antibiotic as per physician orders. A physician order dated 07/23/2026, documented Oxacillin (an antibiotic) Sodium Injection Solution Reconstituted 2 grams (GM). Use 2 grams intravenously every 4 hours for cellulitis until 08/28/2026. Start date 07/23/2026, to be administered at 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. The Medication Administration Record (MAR) for August 2026, documented Oxacillin Sodium Injection 2 GM, was not administered on 08/02/2026, at 8:00 PM with a reason code of 9, which indicated other/see nurses notes. A Medication Administration note dated 08/02/2026 at 8:00 PM, documented Oxacillin Sodium Injection Solution Reconstituted 2 GM was not available. Per the day Registered Nurse, followed up with pharmacy and the medication should be delivered by 11:00 PM. A Medication Administration note dated 08/03/2026 at 1:42 AM, documented Oxacillin Sodium Injection Solution Reconstituted 2 GM arrived at this time and was administered. R158's medical record documented the 8:00 PM dose of 08/02/2026 was administered 08/03/2026 at 1:42 AM, a delay of 5 hours and 42 minutes after the scheduled administration time. On 08/04/2026 at 1:09 PM, the Registered Nurse (RN1), reported on 08/02/2026, the day R158 did not receive the 8:00 PM antibiotic dose as scheduled, there was a mishap while the charge nurse was removing excess medications from the medication room. RN1 explained the charge nurse had prepared a container of medications to be returned to the pharmacy and may have returned R158's antibiotic to the pharmacy in error. RN1 reported calling the pharmacy directly to reorder the medication, rather than submitting the request electronically, in an effort to expedite receipt of the medication. RN1 acknowledged antibiotics should have been administered at the times ordered by the physician and administering the antibiotic at different times could have caused the treatment to be ineffective. On 08/04/2026 at 1:15 PM, a Registered Nurse (RN2), reported cleaning the medication rooms and explained checking the medications against the computer to determine whether the residents had been discharged or remained at the facility. RN2 did not recall coming across R158's antibiotic while cleaning the medication rooms. Later that day, when R158's antibiotic was due to be administered, it was identified that the medication was not in the medication room. RN2 reported there was a possibility RN2 had returned R158's antibiotic to the pharmacy in error. RN2 acknowledged R158 experienced a delay in receiving the antibiotic and antibiotics needed to be administered as ordered to maintain a therapeutic level of the medication in the blood. On 08/05/2026 at 10:01 AM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) reported staff should have been more careful to read labels prior discarding medication. The ADON/IP explained the results of not administering antibiotics as ordered could have included a delay in care and a worsening infection. The ADON/IP explained the expectation was for antibiotics to be administered on time. A facility policy titled Administering Medications revised April 2019, documented medications were administered in accordance with prescriber orders, including any required time frame. Based on observation, interview, record review and document review, the facility failed to ensure 1) scheduled medications were not given late for 1 of 45 sampled residents (Resident 97) and 2) medications for multiple residents were not prepared at the same time prior to administration for 2 unsampled residents. The deficient practice had the potential to negatively impact the effectiveness of treatment and placed residents at risk for medication error. Late Medications Resident 97 (R97) was admitted on [DATE], with diagnoses including pneumonia and cystitis. On 08/03/2026 in the morning, R97 was observed self-propelling wheelchair towards room. R97 indicated being in the facility for two weeks and had issues with medications being administered late almost all of the time by night shift staff. The Administering Medications policy revised April 2019, documented medications were administered within one hour of their prescribed time. A review of the R97's Medication Admin Audit Report from 07/19/2026 until 08/04/2026, revealed the resident's routine medications were administered more than one hour of the prescribed time on 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026, 07/25/2026, 07/28/2026, 07/29/2026, 07/30/2026, 07/31/2026, 08/01/2026, 08/02/2026, and 08/04/2026. On 08/05/2026 at 12:40 PM, the Director of Nursing (DON) indicated routine medications at night were typically scheduled for 8:00 PM and medications administered more than one hour before or after the scheduled time were considered late. On 08/05/2026 at 3:22 PM, the DON reviewed the R97's Medication Administration Audit Report and confirmed routine medications were given more than one hour past the prescribed time on 07/20/2026, 07/21/2026, 07/22/2026, 07/23/2026, 07/25/2026, 07/28/2026, 07/29/2026, 07/30/2026, 07/31/2026, 08/01/2026, 08/02/2026 and 08/04/2026. The DON could not speak to the practices of night shift nurses and why R97's routine medications were being administered late during night shift. Medication Preparation On 08/04/2026 at 9:35 AM, a Licensed Practical Nurse (LPN) was observed doing medication pass in the 200-Hall. There were two unlabeled medication cups containing multiple pills on top of the medication cart. The LPN explained the medications were for two different residents who were roommates in room [ROOM NUMBER]. The LPN indicated the resident in bed A would be administered Depakote, Keppra, Zoloft and Vitamin B1 while the resident in bed B would be administered Aspirin, Vitamin C and Multivitamins and minerals. On 08/04/2026 at 9:37 AM, the LPN indicated having no intentions of entering the room with both medication cups in hand but rather the LPN had intended to lock one of the medication cups inside the cart while the LPN administered medications to one of the residents inside room [ROOM NUMBER]. On 08/04/2026 at 9:39 AM, the LPN stated there was nothing wrong with preparing medication for multiple residents as long as the LPN administered one resident at time. The LPN indicated the facility allowed for medication preparation for multiple residents at the same time versus preparing, administering, documenting one at a time. On 08/05/2026 at 12:51 PM, the Director of Nursing (DON) indicated preparing for multiple residents went against facility policy and the LPN's practice of preparing medications for multiple residents who were roommates placed those residents at risk for medication errors. The Lippincott Nursing Center published 05/09/2016, documented administration errors were one of the most common mistakes made by nurses and could result in hospitalization, increased costs, and implications on life and death. To safely administer medications, start with the basics of preparing medications one patient at a time. Follow the eight rights of medication administration: right patient, drug, does, route, time, documentation, reason and education. Complaint 3070010

Based on interview and record review, the facility failed to ensure a thorough investigation was completed and failed to report an allegation of misappropriation involving a certified nursing assistant to the State Board of Nursing. The deficient practice had the potential to place all residents at risk for unreported financial exploitation.Findings include:Resident 12 (R12) was admitted on [DATE] with diagnoses including Alzheimer's disease and dementia.A Nursing Progress Note dated 07/27/2025, documented a nurse had been asked by R12 for change for the vending machine. Having noticed the resident had multiple twenty dollar bills the nurse asked R12 about the cash. R12 explained asking a friend to get cash from the automated teller machine using R12's bank card.R12 was roomed with wife and upon further questioning by the nurse it was discovered the friend was a staff member assigned to provide care for both residents. The nurse documented information collected and entered into the electronic health record on 07/27/2025 for the social worker to address the following day.On 07/28/2025 the Social Services Director filed a grievance on behalf of R12 and notified the administrator.On 11/20/2025 at 2:05 PM, the Social Services Director (SSD) indicated being aware of incident which was reported to the social services department on 07/28/2025. The SSD verbalized that a nurse had an encounter with the resident of concern asking the nurse for change to get something from the vending machine. The nurse questioned where the money came from and was told the resident gave debit card to a friend, who was a staff member, to get cash for the resident and wife. The cash was returned however the debit card was not. The nurse kept the cash locked in the medication cart and completed a note for social work to follow up the following day.The SSD indicated after receiving information and talking with residents, Adult Protective Services (APS) were notified as R12 had an active case worker for unrelated concern. The Administrator was notified, and police were contacted for report. The SSD revealed the police had contacted the staff member in question and told the staff member to return items as soon as possible and indicated a garage remote control and keys were also missing. The other items were returned or found in the resident's room. The SSD indicated helping the residents to cancel the debit card with issuing bank.An email from the SSD to the Administrator dated 08/12/2025 documented information from the APS worker advising the facility the staff member who took the ATM card had wiped out the bank account. On 07/28/2025 there were two additional withdrawals of over $1000 each and a pizza [NAME] expense and rental care expense. APS was filing an updated police report.On 11/20/2025 at 2:58 PM, the Director of Nursing (DON) confirmed the incident and explained the staff member of concern was identified through description provided by residents and cross referenced with the schedule. The staff member was identified as a current certified nursing assistant (CNA1). The DON added it was confirmed by video evidence from the ATM and at the entrance of facility. The DON indicated the employee of concern was terminated for violation of policy, specifically for misappropriation of resident property and financial exploitation. The DON acknowledged the staff member should have been reported to the State Board of Nursing but was not at the time of termination. On 11/20/2025 at 3:30 PM, the Director of Staff Development (DSD) explained having been involved in human resource duties when CNA1 employment was terminated and indicated CNA1 was suspended on 07/28/2025 while investigation was conducted. The DSD verbalized, ultimately CNA1 was terminated for misappropriation of resident property, financial abuse.The investigation file provided by facility lacked documented evidence of interviews with CNA1, identification of CNA1 as the resident's friend, or determination by facility of outcome of in-house investigation.The investigation file provided by the facility lacked documented evidence that CNA1 was reported to the State Board of Nursing.The facility policy titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating (2001) documented all abuse, neglect, exploitation or misappropriation of resident property allegations would be thoroughly investigated, and all relevant professional and licensing boards would be notified when an employee was found to have committed abuse.Incident 2575106

Based on interview and record review, the facility failed to ensure an allegation of misappropriation involving a certified nursing assistant was reported to the State Agency within the required timeframe for 1 of 1 allegation reviewed. The deficient practice had the potential to place all residents at risk for unreported financial exploitation.Findings include:Resident 12 (R12) was admitted on [DATE] with diagnoses including Alzheimer's disease and dementia.A Nursing Progress Note dated 07/27/2025 documented an allegation of misappropriation of resident property/funds.The facility reported the allegation of misappropriation of resident property to the State Survey Agency on 07/29/2025.On 11/20/2025 at 2:20 PM, a Licensed Practical Nurse (LPN) indicated being familiar with the abuse reporting policy and indicated the administrator was the abuse coordinator. The LPN verbalized abuse allegations including allegations of misappropriation were to be reported immediately by phone or in person. The LPN indicated abuse allegations were to be reported immediately and the facility had two to 24 hours to report to the state agency depending on the specific allegation. The LPN explained it would not be appropriate to consider an allegation of misappropriation to have been reported through electronic health record documentation.On 11/20/2025 at 2:58 PM, the Director of Nursing (DON) verified the timeline for reporting abuse to the state agency was within two hours if the allegation of abuse involved physical harm or within 24 hours for all other allegations, including allegations of misappropriation.On 11/20/2025 at 2:58 PM, the Administrator confirmed being the abuse coordinator and indicated all allegations of abuse were to be reported to the abuse coordinator immediately. The Administrator explained that the nurse notified the abuse coordinator by entering information into the electronic health record causing an alert for the next time a user logged into the system. The Abuse Coordinator confirmed the Social Services Director initiated an investigation the following day and acknowledged the initial report was sent on 07/29/2025.The facility policy titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating (2001) documented the administrator or individual making the allegation immediately reports suspicion to the state licensing/certification agency, local/state ombudsman, resident representative, adult protective services, law enforcement officials, attending physician, and the medical director. Immediately was defined as within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation which does not involve abuse or result in serious bodily injury.Incident 2575106

Based on observation, interview, and document review, the facility did not ensure that dishware was sanitized according to food safety protocols in the three-compartment sink area of the main kitchen. This deficient practice had the potential to cause cross-contamination and foodborne illness, affecting all residents who receive meals from the kitchen.Findings include: On 08/12/2025 at 7:45 AM, the Assistant Director of Dietary Services was observed performing a sink sanitizer strip test. The Assistant Director dipped the test strip into the sink with the sanitizer solution for 5 seconds. After 10 seconds, the Assistant Director compared the color of the strip with the color chart on the test strip canister; however, no color change was observed. The test was repeated, but the strip showed no color change, indicating the sanitizer was ineffective.On 08/12/2025 at 8:48 AM, the Director of Dietary Services observed performing the sink sanitizer strip test. The Director dipped the test strip into the sink with the sanitizer solution for 5 seconds. After 10 seconds, when the Director compared the color of the strip with the colors on the test strip canister, it showed a faded brown color. The test was repeated and showed a faded brown color. This result did not meet the minimum manufacturer-required color, indicating a sanitizer concentration of less than 150 parts per million (ppm), whereas the required range is between 200-400 ppm.On 08/12/2025 at 7:51 AM, the Assistant Director was not sure why the test strip was not reading. On 08/12/2025 at 8:50 AM, the Director was not sure why the solution in the sink and test strip was not accurate. The Director confirmed the testing strip measured below the required concentration of the solution in the sink. The facility policy titled Manual Cleaning and Sanitizing, effective February 2017, documented immersion for at least 30 seconds in a sanitizing solution of 220 ppm of quaternary ammonia at 75 degrees Fahrenheit or hotter.

Based on interview, record review, and document review, the facility failed to ensure psychotropic medication consent forms were obtained and/or updated for 3 out of 39 sampled residents (Resident 12, 14, and 15). The deficient practice had the potential to deny residents the right to be fully informed and to participate in decisions regarding care and treatment.Findings include:1) Resident 12 (R12) was admitted on [DATE] with diagnoses of major depressive disorder, unspecified dementia, unspecified psychosis and traumatic brain injury. A Physician Note dated 06/11/2025 documented to perform a gradual dose reduction for psychotropic medication Quetiapine (an antipsychotic medication) from 400 milligrams (mg) to 300 mg.A Physician Order dated 06/11/2025 documented Quetiapine 300 mg oral tablet give at bedtime for major depressive disorder.The medical record revealed a psychotropic informed consent for Quetiapine 400 mg dated 04/01/2025.The medical record lacked documented evidence informed consent was obtained for the new medication dosage.2) Resident 14 (R14) R14 was admitted on [DATE] with diagnoses including unspecified dementia, anxiety, and schizoaffective disorder. A Psychotropic Informed Consent was signed on 07/07/2025 for Quetiapine 50 mg twice daily for schizoaffective disorder.A Physician Order dated 07/17/2025 documented Quetiapine 100 mg oral tablet twice daily for schizoaffective disorder.The medical record lacked documented evidence a new informed consent was obtained prior to the change in dose.3) Resident 15 (R15) was admitted on [DATE] with diagnoses including schizoaffective disorder, depression, anxiety, and bipolar disorder. A Physician Order dated 08/30/2024 documented Risperdal (an antipsychotic medication) oral tablet 2 mg, give one tablet by mouth at bedtime for schizophrenia. The medical record lacked documented evidence of an informed consent for Risperdal. On 08/19/2025 at 2:00 PM, Licensed Practical Nurse (LPN)1 indicated the nurse would obtain consent for psychotropic medication if the resident was alert and oriented and would explain the risks and benefits of the medication.On 08/19/2025 at 2:15 PM, LPN2 stated there would be a physician order for any psychotropic, if the resident was able to understand the consent form would have the resident sign the form. LPN2 indicated any changes in medication would require a new consent form.On 08/19/2025 at 3:00 PM, the Director of Nursing (DON) indicated any nurse would be able to obtain order and consent for psychotropic medication. The DON verbalized when the medication dose changed a new consent would be obtained. The DON confirmed the changes in dosage for R12 and R14 and a new consent form should have been obtained but was not. The DON confirmed there was no informed consent for the use of Risperdal for R15.The facility policy titled Use of Psychotropic Medication (revised 08/2024) documented residents and/or representatives would be educated on the risks and benefits of psychotropic drug use as well as alternative treatments. Facilities and prescribers should comply with State and Federal requirements pertaining to informed consent.

Based on interview, record review, and document review, the facility failed to ensure a comprehensive care plan was revised to reflect interventions following a fall incident for 1 of 39 sampled residents (Resident 9). The deficient practice had the potential to result in unmet care needs and to increase the risk of additional falls.Findings include: Resident 9 (R9) was originally admitted in 2003, re-admitted on [DATE] with diagnoses including distal tibial impacted fracture and multiple sclerosis.On 08/12/2025 at 1:42 PM, R9 indicated being dependent on staff for care. The resident had fall in January 2025 with fractures. R9 was sitting in a wheelchair and verbalized staff assist resident out of bed and sit in wheelchair during day.The medical record revealed R9 was sent to hospital on [DATE], returned 01/10/2025. The medical record revealed a report was completed for a change in condition (CIC) on 01/05/2025: The CIC evaluation indicated there was a change in skin condition due to swelling and pain in left thigh, left knee, and left foot.The physician was contacted and recommended x-ray and non-weight bearing with left leg.A Progress Note dated 01/05/2025 documented at 10:30 AM, a Certified Nursing Assistant (CNA) called nurse to room to report R9 had complaint of pain to left thigh. Noted left knee and left foot swollen. R9 reported fall from chair on 01/01/2025.The medical record revealed R9 had a care plan for fall risk and included intervention of following facility fall protocol.The medical record lacked documented evidence the care plan was updated with information regarding an actual fall which occurred on 01/01/2025.On 08/14/2025 at 10:19 AM, a Licensed Practical Nurse (LPN) indicated the charge nurse generally updated the care plan when changes or new events occur. The LPN indicated nursing had the ability to update the care plan. The LPN verbalized the care plan should have been updated after fall however it was not completed.On 08/19/2025 at 2:48 PM, the Director of Nursing (DON) verbalized several different disciplines have ability to change or update care plans. Any nurse could update, or any discipline involved could update the care plan. After a change or fall the care plan should be updated to reflect a person-centered approach to care.The facility policy titled Care Plan, Comprehensive (revised [DATE]) documented the purpose was to support and guide resident and interdisciplinary team collaboration to achieve and maintain optimal resident health, function and quality of life. Resident progress was regularly evaluated, and approaches revised or updated as appropriate.

Based on observation, interview, record review and document review the facility failed to ensure there were physician orders for the care and maintenance of a central line (a long, flexible tube inserted in a large vein, usually the superior vena cava near the heart) and a peripheral line (a small plastic tube inserted through the skin into a vein of the arm or hand) for 1 of 30 sampled residents (Resident 153). This deficient practice had the potential for an increased risk of infection and to compromise resident health.Findings include: Resident 153 (R153) was admitted on [DATE] and discharged on 08/13/2025 with diagnoses including acute respiratory failure with hypoxia, acute post hemorrhagic anemia, and atherosclerotic heart disease.On 08/12/2025 at 1:21 PM, R153 had a peripheral line located on the back of right hand. The dressing was peeling away and was not dated.On 08/13/2025 at 3:10 PM, R153 was lying in bed with a family member at bedside. The family member explained was unaware why R153 had the peripheral line on the back of the right hand. The family member was aware of a central line located on R153's upper chest. The family member unpinned R153's gown and revealed a central line port to right upper chest intact with sutures and a brownish red stained dressing peeled halfway back from the tubing with an illegible date written in black ink.On 08/13/2025 at 3:15 PM, a Registered Nurse (RN) entered R153's room and stated, I didn't even know [R153] had a central line. The RN was unaware resident had a peripheral line. The RN confirmed the dressing for the peripheral line was peeling off and was undated.On 08/13/2025 at 3:28 PM, the RN confirmed was unable to determine the date written on the dressing for the central line.On 08/13/2025 at 3:40 PM, the RN reviewed R153's medical record and confirmed there were no orders for maintaining the central line and peripheral line such as flushing, dressing change, and observation.On 08/13/2025 at 3:45 PM, the RN explained the process for residents with peripheral or central lines would be to obtain orders for maintenance of the line to include monitoring, flushing, and dressing changes. The RN explained dressings for a peripheral line were changed every three days and the dressing for a central line were to change every seven days. A Physician Order dated 08/13/2025 documented Cefdinir (an antibiotic) 300 milligrams (mg) one tablet twice daily by mouth for 7 days, Lactobacillus twice a day for 10 days, DuoNeb 3 milliliters (ml) every four hours for shortness of breath, and Oxygen at 2 Liters per minute (LPM) via nasal cannula (NC) for Oxygen saturation less than 89%.A Physician Order dated 08/13/2025 documented send resident to emergency room for failure to thrive and pneumonia. A Radiology Report dated 08/13/2025 documented small right basal infiltrate. On 08/14/2025 at 2:34 PM, the Director of Nursing (DON) explained the process for new admissions were when a resident arrived notify the physician, review and verify order with the physician. assess and welcome the residents, complete admission forms, and initiate the care plan. The DON explained the expectation was for licensed nurse to complete daily skilled charting for residents with skilled services. On 08/14/2025 at 2:37 PM, the DON reviewed R153's medical record and confirmed there were no orders for maintenance and daily assessment of the central line or peripheral line. The DON explained the expectation would be for staff to perform a complete assessment and describe the site and status of the dressing. On 08/14/2025 at 2:56 PM, the DON explained not having orders in place could lead to an infection, a central line infection, an embolism, clots, sepsis, or multiple things.On 08/15/2025 at 8:16 AM, R153's Nurse Practitioner (NP) explained when a resident had a central line or peripheral line the expectation for staff was to perform cleaning, flushes, dressing changes and monitoring of the site. The NP explained by not maintaining a central or peripheral line could lead to phlebitis or infections. The NP was aware R153 had a central line and peripheral line but was unaware there were no orders for maintaining the line. The NP confirmed R153 was diagnosed with pneumonia, started on oral antibiotics and discharged .The facility policy titled Catheter Insertion and Care, revised November 2016, documented peripheral intravenous (IV) dressings were changed when needed to prevent catheter related infections associated with contaminated, loosened or soiled catheter site dressings.

Based on observation, interview, and document review, the facility failed to ensure the temperature in a resident's personal refrigerator was monitored for 1 of 30 sampled residents (Resident 97). The deficient practice had the potential for foods to be stored at temperatures which could lead to food borne illness. Findings include:Resident 97 (R97) was admitted on [DATE], with diagnoses including moderate persistent Asthma, chronic obstructive pulmonary disease, hypertensive heart disease, and anemia.On 08/12/2025 in the morning, R97 reported having a mini fridge like machine with yogurt inside for taking medication. R97 disclosed the machine did not keep items cold like a traditional refrigerator.On 08/19/2025 at 12:45 PM, the Assistant Director of Nursing (ADON) went to R97's room and was not able to find a temperature log for the refrigerator. The ADON was not able to locate a thermometer inside the refrigerator. The ADON checked the temperature of the refrigerator which read 64 degrees Fahrenheit. The ADON checked the temperature of the yogurt inside the refrigerator which was 60 degrees Fahrenheit. The facility policy titled Personal Food Storage, effective 09/2014, documented all refrigeration units would have internal thermometers to monitor for safe food and storage temperatures. All units must have maintained safe internal temperature in accordance with state and federal standards for safe food handling. Staff would monitor and document individual room storage and refrigeration units.On 08/19/2025 in the afternoon, the Administrator and the Director of Nursing acknowledged yogurt, at a prolonged temperature greater than 41 degrees Fahrenheit, was not safe for consumption according to state and federal standards for safe food handling.

Based on interview and record review, the facility failed to ensure the medical records were complete and accurate for 3 of 30 sampled residents (Residents 153, 156, and 157). The deficient practice had the potential for residents not to receive timely interventions needed and for the facility missing the opportunity to identify care issues. Findings include: 1) Resident 156 (R156) was admitted on [DATE]. A review of R156's hard chart medical record revealed the following items were missing face sheet, medication administration record (MAR), advanced directives, order summary, and facility history and physical. Only limited laboratory and diagnostic information was available in the hard chart.2) Resident 157 (R157) was admitted on [DATE].The medical record for R157 revealed the following items were missing face sheet, medication administration record (MAR), advanced directives, order summary, and facility history and physical. Only limited laboratory and diagnostic information was available in the hard chart.On 08/13/2025 in the morning, the Medical Records Supervisor confirmed the items missing were required to be included in the hard chart binder. The Medical Records Supervisor verbalized there were no records for the residents of concern stored in the Medical Records Department.On 08/13/2025 at 10:34 AM, a Registered Nurse (RN) indicated if R157 needed to be sent to the hospital, the face sheet, order summary, MAR, advanced directive, facility history and physical, recent and relevant laboratory and diagnostic information along with the hospital discharge summary would be sent with the resident to the hospital. The RN expressed if it were an emergency, the RN would need to call the hospital and provide a verbal report. The RN would inform the hospital additional information would be provided when it was collected since the information was not available in the medical record chart. The RN would have to go to medical records to get the information, but if medical records did not have the information, did not know how to get the information.3) Resident 153 (R153) admitted on [DATE]. On 08/13/2025 at 3:15 PM, an RN was unaware R153 had a central line. The RN reviewed the medical record and confirmed there were no orders for treatments, no face sheet, no advanced directive, no facility history and physical, and limited laboratory and diagnostic information were completed and filed in the resident's paper medical record hard chart.On 08/14/2025 in the afternoon, the Director of Nursing (DON) confirmed the findings and revealed there were no face sheets, no medication administration records (MARs), no advanced directives, no order summaries, no facility history and physicals. The DON explained that the MARs were located on each nurse's medication cart, but the expectation would be for staff to perform resident assessments and file the documentation in the resident's paper medical record hard chart.The facility policy titled Charting and Documentation and Abstract of Medical Records dated 2001, documented the contents of a resident's medical record should contain a history and physical, current diagnosis, treatment records, medication records, nursing notes, dietary notes, care plans, advanced directives, preadmission screen and resident review (PASARR) screenings, and other information as appropriate. Documentation in the medical record would be objective, complete, and accurate so as to facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on interview and document review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was in place. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life.Findings include:On 08/19/2025 at 2:08 PM, the Administrator acknowledged the facility did not have a QAPI plan. The Administrator explained the facility was using their QAPI policy as their plan.The facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised in February 2020, noted the QAPI committee oversees implementation of the QAPI plan. The QAPI plan described the specifics of the QAPI program, how the facility conducted QAPI functions, and the activities of the QAPI committee. The QAPI plan described the process for identifying and correcting quality deficiencies. The QAPI committee met monthly to review reports, evaluate data, and monitor QAPI-related activities and adjusted the QAPI plan. The QAPI plan was to be presented to the state survey agency annually during the recertification survey.On 08/19/2025 in the afternoon, the Administrator confirmed the facility did not have a specific QAPI plan. The Administrator provided a Quality Assurance & Performance Improvement (QAPI) PowerPoint Presentation which documented the nursing home would have a QAPI Plan which adhered to the core principles of the QAPI Program. The Administrator acknowledged the QAPI policy could be part of the plan, but the plan should be tailored to reflect the specific units, programs, departments, and unique population the facility serves, as identified in the facility assessment.

Based on observation, interview, record review, and document review, the facility failed to ensure 1) enhanced barrier precautions were in place for 2 of 39 sampled residents (Resident 60, and 114); 2) staff observed infection control protocols during resident care; and 3) infection prevention and control policies and procedures were reviewed and updated annually. The deficient practice had the potential to result in increased risk of transmission of infectious organisms to residents, staff, and visitors.Findings include: 1) Resident 60 (R60) was admitted to the facility on [DATE] with diagnoses of gastrostomy and cerebral infarction affecting the left non-dominant side. On 08/13/2025 at 3:15 PM, R60 had a feeding tube. There were no signs on or around the resident's door indicating Enhanced Barrier Precautions (EBP). Staff were observed providing care without wearing Personal Protective Equipment (PPE). On 08/13/2025 at 3:54 PM, a Registered Nurse (RN) acknowledged EBP signage should have been posted on the door to inform staff R60 had feeding tube. The RN emphasized that when providing care related to the feeding tube, it was important for staff to wear gowns and gloves due to the potential for liquid splashing, to ensure proper protection. On 08/13/2025 at 4:09 PM, the Director of Nursing (DON) indicated when a resident had an enteral access site for a feeding tube Enhanced Barrier Precautions (EBP) sign should be posted on the resident's door. The DON acknowledged staff were required to wear a gown and gloves when providing care for residents with a feeding tube, as part of infection control protocols. On 08/18/2025 at 4:22 PM, the Infection Preventionist (IP) stated R60 should have had an EBP sign posted on the door. The IP confirmed awareness of the EBP requirements and explained the facility was currently evaluating all residents on contact precautions due to recent staff changes. The IP acknowledged staff were required to wear gloves and a gown when providing care to residents receiving enteral nutrition via gastrotomy tube, to ensure protection for both staff and residents. Resident 114 (R114) was admitted to the facility on [DATE] with diagnoses of hypertensive chronic kidney disease and Type 2 diabetes mellitus. On 08/13/2025 at 10:50 AM, R114 was observed to have a dialysis shunt in the chest. There was no signage on the resident's door indicating Enhanced Barrier Precautions (EBP). Staff were observed providing care without wearing PPE. On 08/15/2025 at 8:48 AM, a Licensed Practical Nurse (LPN) was observed wearing gloves to access R114's dialysis site. The LPN removed the dressing covering the dialysis line (right subclavian), then removed gloves without performing hand hygiene. The LPN exited the room to retrieve a new dressing, re-entered, put on new gloves, applied the dressing, and removed gloves without performing hand hygiene. The LPN did not wear a gown during the procedure. The LPN confirmed hand hygiene had not been performed when changing gloves while applying the new dressing. The nurse acknowledged the importance of hand hygiene in preventing infection and maintaining cleanliness. The LPN did not cleanse the site before applying the new dressing. The LPN stated failure to perform proper hand hygiene presents a significant risk for infection. On 08/15/2025 at 10:23 AM, the Infection Preventionist (IP) stated Enhanced Barrier Precautions (EBP) signage should have been posted on the doors of residents receiving dialysis care. The IP confirmed that when nurses were checking a resident's dialysis access site, the nurse was required to wear a gown and gloves. The IP acknowledged after completing care, nurses would remove the gloves and gown and perform hand hygiene using either soap and water or an alcohol-based hand sanitizer. The IP emphasized failure to perform hand hygiene after providing care increases the risk of infection. On 08/15/2025 at 1:20 PM, the Director of Nursing (DON) stated residents with a dialysis access site must have Enhanced Barrier Precautions (EBP) signage posted at the door. The DON indicated that when staff were providing care, they must wear a gown and gloves. The DON confirmed after completing care, staff must perform hand hygiene following the removal of gloves and gown either by washing hands with soap and water or using hand sanitizer gel. The DON acknowledged performing proper hand hygiene was essential in preventing infection. The facility policy titled Infection Prevention Manual for Long-Term Care (Enhanced Barrier Precautions), revised in May 2024, documented an order for Enhanced Barrier Precautions should be obtained for residents with indwelling medical devices such as central lines or feeding tubes even if the resident had not been known to be infected or colonized with a multidrug-resistant organism (MDRO). The policy documented that implementation of Enhanced Barrier Precautions included making gowns and gloves immediately available near or outside of the resident's room. The facility policy titled Hemodialysis, implemented on December 2022, stated staff would ensure appropriate PPE was worn and follow current infection control practices when assessing dialysis access site. 2. On 08/14/2025 at 10:24 AM, room [ROOM NUMBER] had a contact precaution sign on door, housekeeping staff in room mopping the floor with mask and gloves as the only personal protective equipment (PPE). The housekeeping staff member explained the sign indicated when staff had contact with residents the staff would be required to have a gown as well as the other personal protective equipment. On 08/14/2025 at 10:45 AM, room [ROOM NUMBER] had a contact precaution sign on the door. Housekeeping staff were outside the room, staff member entered the room without putting on a gown, gloves were the only PPE worn. The staff member entered the resident bathroom and exited approximately one minute later and went to cart in hallway. The staff member retrieved an item from the cart and returned to the resident room without removing gloves or performing hand hygiene. On 08/14/2025 at 10:46 AM, Housekeeper2 indicated the resident in B bed was on precautions and indicated gown, gloves should be used and Houskeeper2 forgot to put on proper PPE. On 08/14/2025 at 10:50 AM, room [ROOM NUMBER] had a contact precaution sign on door. A resident in the room was talking with a staff member who was not wearing any PPE. The staff member was identified as the Laundry Supervisor and verbalized the contact precaution sign indicated that any person entering the room should put on gloves and gown. The Laundry Supervisor explained the contact precaution sign was updated from enhanced barrier precaution on the previous day and verbalized it was the staff responsibility to read the sign. On 08/15/2025 at 1:02 PM, the Infection Preventionist (IP) indicated starting position approximately one week ago and was updating protocols and providing education as needed to staff regarding the use of PPE and difference between contact precautions and enhanced barrier precautions. The IP indicated contact precautions required all staff regardless of resident contact to wear PPE. Enhanced barrier precautions required staff wear PPE if performing a high-risk procedure such as changing catheter or providing wound care. Observations of staff in contact isolation rooms were shared, and the IP indicated the staff did not meet the expectations of proper infection control practices. The facility policy titled Companion Guidance and Resources (revised May 2024) documented resources for staff when encountering contact precautions or enhanced barrier precautions. The document included information on proper use of PPE and handwashing. 3. The infection prevention manual documented the last review, or update was May of 2024. On 08/15/2025 at 1:02 PM, the Infection Preventionist (IP) provided the Infection Prevention Manual for Long Term Care. The IP indicated it was used to formulate policy, procedures, and protocols for all infection control practices at the facility. The IP acknowledged the revision date on the documents was May of 2024. The IP confirmed it was what the facility was currently using. The Director of Nursing was not able to provide any further information on the latest update to the infection control policies and procedures.

Based on observation, interview, record review and document review, the facility failed to ensure an assessment was completed for the self-administration of medication for 1 of 6 sampled residents (Resident 6). The deficient practice had the potential for the resident's unsafe administration of medication. Findings include: Resident 6 (R6) was admitted on [DATE], with diagnoses including gout, Type 2 diabetes and generalized muscle weakness. On 02/04/2025 at 8:50 AM, observed on R6's bedside table was a purple bottle of Vicks ZzzQuil Pure Zzzs Sleep Aid Melatonin Gummies, 1 milligram for sleep support. R6 indicated the resident's family brought the bottle of melatonin two days ago, 02/02/2025. R6 verbalized taking two gummies last night. On 02/04/2025 at 2:01 PM, a Registered Nurse (RN) confirmed the observations and was unaware the resident had the medication at bedside. The RN indicated the resident's family should have notified the nurses if a medication was brought to the facility. The RN explained a physician's order should have been obtained for self-administration of the medication. R6's medical record lacked documented evidence of an assessment for the self-administration of medication and a physician's order. On 02/04/2025 at 3:03 PM, the Director of Nursing (DON) verified there was no evidence of a physician's order for self-administration of medication. The DON indicated the resident did not have a self- administration of medication assessment. The medication should have been kept in a secured bedside storage. The facility's policy titled Self-Administration of Medication from Covenant Care Resident Care Procedures dated 2008, documented the actions needed for any resident to self-administer medication within the facility. Prior to allowing any resident to self-administer medication the following items must be in place: - The resident's evaluation of self-medication from the nurse - The interdisciplinary team's assessment and outcome of the resident - Physician's approval - Bedside storage that prevents other residents from accessing the medication

Based on interview, record review, and document review, the facility failed to ensure an allegation of physical and verbal abuse were thoroughly investigated for 1 of the 6 sampled residents (Resident 3). This deficient practice could potentially compromise the safety and well-being of other residents. Findings include: Resident 3 (R3) was readmitted to the facility on [DATE], with diagnoses including urinary tract infection, chronic obstructive pulmonary disease, atherosclerotic heart disease, and personal history of transient ischemic attack. A facility Grievance/Complaint Resolution Report dated 01/10/2025, documented possible physical and verbal abuse which had occurred over the weekend. R3 reported two staff came into the room at night to take care of R3. While performing the care, R3 complained the staff were too rough when moving R3 and spoke rudely to R3. R3 remembered one staff had a beard on the side of their face. On 02/04/2025 at 2:12 PM, the Social Services Assistant (SSA explained the date of the incident was not correct on the form and the date should have been 01/13/2025. The SSA expressed R3 was not able to elaborate on how the staff person spoke to R3 rudely. The SSA stated was trying to determine whether it was the tone the staff person used or whether it was what the staff person said. The SSA said R3 stated it was both but could not elaborate because this happened in the middle of the night and R3 could not remember exactly what was said. The SSA was able to surmise from what staff was working who the staff person was based on the description provided by the resident. The information was passed on to the Director of Nursing (DON) who agreed with the SSA to remove the staff person from the resident's care. The facility Grievance/Complaint Resolution Report dated 01/10/2025, documented the grievance was confirmed. The facility adjusted the schedule to remove the staff from the room and educated staff members to be conscientious of conversations and tones and handling residents during care. The facility notified the resident of the adjustment in the nursing schedule. On 02/04/2025 at 3:53 PM, the Director of Staff Development (DSD) affirmed a grievance like this would go to Social Services. Social Services would talk to the resident who filed the grievance, talk to other residents around the resident, and talk to the staff. Social Services would request the DSD to provide education. The DSD confirmed there was no documentation interviews were conducted with staff or residents regarding the allegation of abuse. On 02/04/2025 at 4:06 PM, the Administrator confirmed being the Abuse Coordinator. The Administrator explained if a grievance were to come in where a staff person was rude and rough with a resident, the following would occur: - the resident would be checked to make sure they feel safe - the resident would be interviewed to obtain more detailed information about the incident - the resident would be assessed for any bruises and/or injuries - Interviews with the roommate and/or other residents in close by rooms cared for by the same staff would be conducted. - management would check the schedules to see what staff member was working on these days which might match the description given. - an interview with the alleged staff members would be conducted. - the alleged staff member would be suspended, and the facility would continue with the investigation. The Administrator confirmed there was no other documentation for this incident. and other residents and the alleged staff members were no interviewed and an investigation was not completed. A facility policy titled Alleged or Suspected Abuse and Crime Reporting revised on 10/2022, indicated it was the responsibility of all employees to immediately report to the facility administrator any incident of suspected or alleged abuse. All reports are timely and thoroughly investigated. All alleged victims and perpetrators, as well as others which may have direct knowledge of the incident should be interviewed. Staff members believed to be involved, would be suspended pending the outcome of the investigation. The facility would protect all residents and staff from harm or retaliation when the incident was being investigated.

Based on interview, record review and document review the facility failed to provide and document sufficient preparation and orientation prior to notification of discharge for 2 of 6 sampled residents (Resident 3 and 5). This deficient practice had the potential to place the resident at risk for an unsafe discharge. Findings include: 1.) Resident 3 (R3) was readmitted to the facility on [DATE], with diagnoses including urinary tract infection, chronic obstructive pulmonary disease, atherosclerotic heart disease, and personal history of transient ischemic attack. A Notice of Medicare Non-Coverage document was issued to R3 on 01/07/2025. The resident's family helped R3 file an appeal to the discharge. R3 won the appeal. A Notice of Medicare Non-Coverage document was issued to R3 on 01/14/2025. The resident's family helped R3 file an appeal to the discharge. R3 won the appeal. A Notice of Medicare Non-Coverage document was issued to R3 on 01/16/2025 with a discharge date of [DATE]. R3 did not file an appeal this time. On 02/04/2025 at 10:00 AM the Social Services Director (SSD) stated the Case Managers (CM) were responsible for resident discharges. The SSD stated Social Services did get involved with this discharge after the family of R3 and the CM were not able to work together amicably. The Social Services progress notes documented the SSD became involved in the discharge planning process for R3 on 01/17/2025. The medical record lacked documented evidence discharge planning had taken place prior to issuing the Notice of Medicare Non-Coverage document to R3. The first CM discharge note was on 01/07/2025 documenting the equipment needed for R3 and discussing hospice options with the family. On 02/04/2025 at 10:16 AM, CM1 stated the facility had a weekly inter-disciplinary meeting with the insurance company to determine which residents would be issued a Notice of Medicare Non-Coverage document. The CM would start discharge planning when the notice was issued. The CM stated discharge planning did not start prior to the Notice of Medicare Non-Coverage document being given to the resident. The CM contacted R3's family on 01/07/2025 to begin discharge planning and discuss the Notice of Medicare Non-Coverage document. The CM stated the SSD became involved with the discharge planning with R3 as the family was condescending, rude, and insulting to the CM. On 02/04/2025 at 11:28 AM, CM2 stated discharge planning began on admission. CM2 affirmed meeting the resident within 24 hours after being admitted was expected to get the pertinent discharge information like the resident's current living situation and if the resident could return to this place, any medical equipment the resident had at home, whether the resident had any family/friends which would be able to assist them at home with any care they may need. On 02/04/2025, the SSD confirmed it was best practice and expected that discharge planning began when the resident was admitted to the facility. 51396 2.) Resident 5 (R5) was admitted to the facility on [DATE], with diagnoses including partial left side paralysis due to stroke. The resident's insurance coverage ended on 01/01/2025 and the resident's discharge was to be effective 01/02/2025. The resident's medical record lacked documented evidence the facility provided discharge planning prior to the resident's discharge on 01/02/2025. On 02/6/2025 at 9:00 AM, Case Manager 1 (CM) indicated the discharge planning began when the insurance submits an intent to discharge. Upon admission, the CM would conduct a discharge assessment of the resident and annotate the notes from the assessment on a personal paper tracker. The notes would be kept on the CM's personal tracker until the resident's discharge which it would then be shredded. The CM indicated the notes were not scanned into the electronic medical record. The CM confirmed there were no CM notes within the medical record to determine what discharge planning was done for R5. On 02/06/2025 at 9:21 AM, Case Manager 2 (CM2), conveyed being the only CM working in the facility in the beginning of December 2024. CM2 did not participate in the interdisciplinary team (IDT) meetings during this time. The CM indicated discharge assessments were performed on all residents on admission. The assessments were not charted in the electronic health record. CM2 would make an internal note from the encounter to determine the resident's needs at discharge. CM2 explained having conversations with R5 and R5's family regarding discharge plans but admitted to not charting the conversations in the electronic medical record. CM2 indicted it should have been documented in the medical record. On 02/06/2025 at 2:15 PM, the Director of Nursing (DON) explained the expectations of the case manager. The case manager's duties included coordinating with the IDT and the insurance companies to create a discharge plan. Any conversations conducted with the resident or family from admission to discharge should be documented in the electronic medical record. The DON verified the medical record lacked documented evidence discharge planning was done for the resident. The job description for the case manager revised on 11/13/2017 documented the case manager would coordinate communication of IDT to accurately assess and manage resident clinical progress to attain goal necessary for discharge. The case manager would provide accurate and complete documentation. The facility did not have a policy for Discharge Planning. The facility provided a Discharge Planning Positive [best] Practice document revealing to facilitate effective discharge planning, it was imperative to have a clear picture of how the resident was functioning prior to the facility admission. Complaint NV00073123 Complaint NV00073228

Based on interview, record review and document review the facility failed to provide bathing as scheduled for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to negatively impact the resident's overall well-being. Findings include: Resident 1 (R1) was admitted on [DATE] and discharged on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, muscle weakness, and difficulty walking. The Admission Minimum Data Set (MDS) dated [DATE] documented R1 required maximal assistance to shower/bathe self, including washing, rinsing, and drying self (excludes washing of the back and hair). R1's shower day skin inspection sheets documented the following bathing activity: - Wednesday, 05/01/2024 a bed bath. - Sunday, 05/05/2024 a bed bath. - Sunday, 05/19/2024 a shower. - Sunday, 05/26/2024 a shower. A Progress note dated 5/10/2024 at 4:53 PM by the Director of Nursing (DON) documented the Restorative Nurse Assistant (RNA) gave R1 a shower that afternoon. On 02/204/2025 at 3:00PM, a Registered Nurse confirmed the bathing schedule for R1's assigned room was every Wednesday and Sunday on the day shift. R1's medical record and shower day skin inspection sheets lacked documentation of bathing for scheduled days of: - Wednesday, 05/08/2024 - Sunday, 05/12/2024 - Wednesday, 05/15/2024 - Wednesday, 05/22/2024 - Wednesday, 05/29/2024 On 02/04/2025 at 10:52 AM, an RNA verbalized residents had showers scheduled twice a week. The showers were documented on a shower sheet. On 02/04/2025 at 1:20 PM, a CNA stated residents had showers twice a week. On 02/04/2025 at 1:30 PM, the DON confirmed the resident showers were documented under the CNA Activities of Daily Living task section of the electronic medical record and shower day skin inspection sheets were also to be filled out. Complaint NV00073143

Based on observation, interview, and document review, the facility failed to ensure stored foods and cleaning agents were labeled, dated, and were stored properly and ice machines were properly cleaned in 2 of 4 ice makers in the facility. This deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness. Findings include: On 09/04/2024 in the morning, a walkthrough of the kitchen was completed. The following was observed: 1. A box containing some thickened liquid lemon flavored water cartons in the walk-in cooler with an expiration date of 09/03/2024. The Dietary Manager explained the water cartons should have been discarded. The Dietary Manager had a staff member dispose of the cartons during the survey. 2. A spray bottle with some type of liquid stored in the utility room in the kitchen. The Dietary Manager explained the spray bottle contained a de-[NAME] and would have it labeled and restored. On 09/04/2024 in the morning, a walkthrough of the kitchen and the nursing unit nourishment rooms was completed. The following was observed: 1. A water/ice machine in the kitchen with a wet brownish debris buildup on the ice spout side of the machine. 2. An ice machine in the 200-hall nourishment room with a wet brownish debris buildup on the ice spout of the machine. The Dietary Manager explained the ice machines are cleaned periodically and were recently cleaned. A document titled Safe Employee Work Practices, effective 02/2016 revealed chemicals will not be transferred to spray bottles or other containers unless the new container is clearly identified with chemical name, appropriate hazard warnings, and the name and address of the manufacturer. A document titled Ice Machine Sanitation effective 02/2009 revealed the facility shall maintain sanitary and clean ice machines to ensure proper service of ice.

Based on interview, record review and document review, the facility failed to ensure assistance with activities of daily living (ADLs) were provided to 3 of 29 sampled residents (R225, 226, and 229). The deficient practice had the potential for the residents' further decline and compromised the residents' skin integrity. Findings include: Resident 225 (R225) R225 was admitted on [DATE], with diagnoses including muscle wasting and atrophy, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. R225's Care Plan documented the resident had self-care deficit as evidenced by needing assistance with ADLs related to pain. The following interventions/tasks were identified in the resident's care plan: - Bed Mobility - One person physical assist required. - Transfer - One person physical assistance required. - Toilet Use - One person physical assist required. On 09/04/2024 at 9:17 AM, R225 was lying in bed, alert, and oriented. R225 indicated the staff did not check the resident during night shift which made the resident felt insecure. R225 revealed being dependent, could not move, and had been lying in the same position for a long time. On 09/06/2024 at 9:20 AM, the Minimum Data Set (MDS) Director explained the certified nursing assistants (CNAs) would document in the electronic charting (point of care/POC) the assistance with ADLs provided to each resident at least every shift. The MDS Director revealed repositioning in bed or bed mobility could be documented on the following interventions/tasks in the ADL Flowsheet: - Lying to Sitting on Side of Bed: Move from lying on the back to sitting on side of bed with no back support. - Roll Left and Right: Roll from lying on back to left and right side and return to lying on back on the bed. - Sit to Lying: Move from sitting on side of bed to lying flat on the bed. The MDS Director indicated R225 required a one person physical assist with bed mobility. R225's ADL Flowsheet for September 2024 was reviewed with the MDS Director. There was no documented evidence the resident was repositioned or provided assistance with bed mobility during the night shift on 09/02/2024 and 09/03/2024. The MDS Director confirmed the findings and indicated there was no documentation R225 had refused to be repositioned on the said dates and shift. The MDS Director explained when a resident refused to be repositioned, the CNA would document the refusal in the ADL Flowsheet and report to the nurse about the resident's refusal. On 09/06/2024 at 11:09 AM, a CNA revealed working on a 12-hour shift. The CNA explained the ADL documentation would be completed every shift using a tablet (electronic device). The CNA indicated the ADL assistance provided to each resident should be documented every time the care was given. When a resident refused the ADL assistance, the CNA would document the refusal in the ADL Flowsheet and would report to the nurse. The CNA confirmed R225 required maximum assistance with repositioning. The CNA revealed R225 should be repositioned every two hours and the resident could develop bed sores if not repositioned. The CNA indicated R225 had not refused to be repositioned. On 09/06/2024 at 1:13 PM, the Director of Nursing (DON) explained the CNAs were expected to provide personal care and hygiene to the residents upon request or should anticipate the residents' needs. The CNAs should document in the electronic charting the care or ADL assistance provided to the residents. The DON confirmed R225 was not using a low air loss mattress (LAL/provides airflow to help skin dry, as well as to relieve pressure) which could provide offloading or repositioning for the resident. Resident 226 (R226) R226 was admitted on [DATE], with diagnoses including muscle weakness, need for assistance with personal care, and chronic pain. The Admission MDS dated [DATE], documented R226 required substantial/maximal assistance with toileting hygiene. (The ability to maintain perineal hygiene, adjust clothes before and after urinating or having a bowel movement.) R226's Care Plan documented the following: - Resident had self-care deficit as evidenced by needing assistance with ADLs related to pain and weakness. The interventions/tasks identified in the resident's care plan included one person physical assistance with transfer, toilet use, and personal hygiene. - Resident was incontinent of bowel/bladder related to functional, congestive heart failure, diuretics, and narcotics. The interventions/tasks identified in the resident's care plan included to check and change during personal care and to assist with toileting. On 09/04/2024 at 9:36 AM, R226 was lying in bed with a family member at bedside. R226's family member stated the resident was lying in urine for hours quite often. On 09/06/2024 at 9:40 AM, R226's ADL Flowsheet for August 2024 and September 2024 were reviewed with the MDS Director. There was no documented evidence the resident was provided with toileting hygiene during the night shift on 08/23/2024, 08/25/2024, 08/29/2024, 08/30/2024, 08/31/2024, and 09/02/2024. The MDS Director confirmed the findings and indicated R226 required substantial/maximal assistance with ADLs. The MDS Director revealed R226 needed help from staff with toileting hygiene which included changing the resident's adult briefs. Resident 229 (R229) R229 was admitted on [DATE], with diagnoses including lumbago with sciatica (left side), muscle weakness, need for assistance with personal care, and chronic pain. The Admission MDS dated [DATE], documented R229 had a Brief Interview for Mental Status (BIMS) score of 15 which could be interpreted as cognitively intact. The resident required substantial/maximal assistance with toileting hygiene, partial/moderate assistance with roll left and right, dependent with sit to lying and lying to sitting on side of bed. R229's Care Plan documented the following: - Resident had self-care deficit as evidenced by needing assistance with ADLs related to pain and weakness. The interventions/tasks identified in the resident's care plan included one person physical assistance with bed mobility, transfer, toilet use, and personal hygiene. - Resident was incontinent of bowel/bladder related to functional, narcotics, anti-psychotic, and anti-depressant. The interventions/tasks identified in the resident's care plan included to assist with toileting and clean perineal area with each incontinence episode. On 09/04/2024 at 12:05 PM, R229 was lying in bed, alert, and oriented. The resident revealed not being checked by staff for an hour and a half or longer which happened more at night shift. The resident stated feeling trapped and could not get up. The resident indicated having to wait for five hours not being changed at night even with bowel movement. On 09/06/2024 at 9:55 AM, R229's ADL Flowsheet for August 2024 and September 2024 were reviewed with the MDS Director. There was no documented evidence the resident was repositioned or provided assistance with bed mobility and toileting hygiene during the night shift on 08/23/2024. The MDS Director confirmed the findings and indicated R229 required a one person physical assist with bed mobility and toileting hygiene. On 09/06/2024 at 10:11 AM, R229 indicated during night shift the resident needed assistance with changing the adult briefs and repositioning. On 09/06/2024 at 1:19 PM, the DON confirmed R229 was not using a low air loss mattress. The facility's policy titled Activities of Daily Living (ADLs) dated 10/22/2022, documented care and services would be provided for the following ADLs: - Bathing, dressing, grooming, and oral care - Transfer and ambulation - Toileting - Eating to include meals and snacks - Using speech, language or other functional communication systems A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interviews, record reviews, and document reviews, the facility failed to ensure: 1) fall interventions and management had been implemented when a resident's risk factors were identified upon admission and categorized as high risk for falls for 1 of 14 sampled residents (Resident 1), 2) the post-fall incident had been thoroughly investigated when documentation indicated a resident had fallen during peri-care, the fall circumstances and root cause analysis had been determined and approaches or interventions based on actual causal factor had been implemented per policy for 1 of 14 sampled residents (Resident 1), 3) the physician and family had been timely notified following a post-fall incident per policy for 1 of 14 sampled residents (Resident 1), and 4) an assessment had been completed upon the resident's return from the hospital following a fall in the facility, care orders had been obtained to manage the resident's cast and appropriate care had been implemented to monitor the cast to treat a fractured wrist for 1 of 14 sampled residents (Resident 1). These deficient practices resulted in a fracture and inadequate management of existing fall-related injuries. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and discharged on [DATE], with diagnoses including Parkinson's disease, muscle wasting and atrophy, weakness, obesity, a history of falling, and muscle weakness. The Brief Interview of Mental Status dated 04/19/2024, documented a score of 8/15, which indicated R1's cognitive status was moderately impaired. R1's Fall Risk assessment dated [DATE], documented a score of 75, which indicated a high risk of falling. R1's gait was weak, impaired, and had fallen within the last three months. The Morse Fall Scoring system classifies falls into three categories: high risk (45 and higher), moderate risk (25-44), and low risk (0-24). 1) R1's medical records lacked documented evidence R1's fall precautions and management had been implemented when R1's risk factors were identified upon admission and categorized as high-risk for falls. On 06/14/2024 at 7:40 AM, an LPN who had been assigned to R1 on the night of the fall incident indicated on 04/11/2024 at 1:15 PM, a CNA reported finding R1 on the floor. The LPN responded immediately and found R1 on the floor, without a fall mat present, and the bed approximately at waist level. The LPN explained R1 had not been considered a fall risk upon admission, so no fall prevention measures had been implemented. On 06/14/2024 at 8:42 AM, the Assistant Director of Nursing (ADON) confirmed R1 was admitted as high risk for falls due to a history of falling at home and the reason for hospitalization . The Morse Fall Risk assessment dated [DATE] indicated a score of 75, signifying R1 was at very high risk for falls. The ADON confirmed no documented interventions were in place for R1. When the ADON started to work at the facility, the ADON observed no fall precautions were implemented for residents identified as high-risk. No fall indicators by the door or fall risk bracelets were in use. The ADON indicated that the facility was just beginning to implement precautions upon residents' admission, and staff members would receive training. The ADON indicated R1 had Parkinson's disease and was identified as high risk for falls. The ADON explained interventions could have been implemented, such as low bed positioning and the provision of fall mats since R1 was non-ambulatory. The ADON confirmed R1 had a fall incident on 04/11/2024, at the facility and during the time, no interventions were in place. On 06/14/2024 at 2:14 PM, the DSD indicated the facility had never implemented the fall indicators to signify precautions for the high fall risk residents. A facility policy titled Fall Prevention and Response revised August 2023, documented each resident would be assessed for fall risk factors and would receive care and services in accordance with an individualized level of risk to minimize the likelihood of falls. For residents with identified fall risk factors upon admission, the facility would implement bed in lowest position if a resident could not transfer. Providing supervision and physical assistance in accordance with assessed needs. 2) R2's medical records lacked documented evidence the post-fall incident had been thoroughly investigated when documentation indicated a resident had fallen during peri-care, the fall circumstances and root cause analysis had been determined and approaches or interventions based on actual causal factor had been implemented per policy. The e-interact dated 04/11/2024, documented by the Charge Registered Nurse (CRN), documented R1 was dependent on activities of daily living, was alert and oriented times 3-4, and was able to verbalize needs. R1 was incontinent due to immobility. The CRN documented R1 had fallen out of bed in the facility during pericare/brief change the night prior; R1 hit head. PCP ordered neurochecks, but no abnormal results were noted until early evening. R1 appeared groggier and complained of pain in the posterior R scalp & R anterior face (near nose). R1 complained of pain in the left hand, thumb, and first two fingers. Orders received to send to the emergency room for computed tomography (CT) of the brain and an X-ray of the left hand. A Care Plan dated 04/11/2024, documented R1 had an actual fall. The intervention consisted of monitoring neurochecks and vital signs. No fall precautions or management were indicated after the fall incident to prevent a recurrence. The Post Fall Notes dated 04/18/2024, documented by the ADON revealed, R1 rolled from bed to the floor, unwitnessed. R1 had a left arm injury on 04/11/2024, complained of pain in the back of R1's head and neck and the right side of R1's face, bump on the back of the head was observed. This writer was notified by the Licensed Practical Nurse (LPN) R1 had a fall. The LPN reported finding R1 on the floor, lying on the left side of the bed. Reports indicated R1 had rolled out of bed and slightly hit R1's head. On 06/13/2024 at 3:00 PM, the Director of Nursing (DON) indicated was aware of R1's fall from bed on 04/11/2023, and sustained a suspected fracture on the left wrist based on the X-ray conducted in the hospital. The DON indicated the Charge Registered Nurse (CRN) who documented R1 fell out of bed in the facility during pericare no longer worked at the facility. The DON indicated the ADON was responsible with fall incidents. On 06/14/2024 at 8:42 AM, the ADON acknowledged the post-fall report was completed by the ADON. The ADON acknowledged the e-interact information was a transfer document handed to the paramedics when R1 was picked up to transport R1 to the hospital. The ADON expressed unawareness R1 fell during pericare, as documented. The ADON indicated was responsible for following through on the fall incident investigation but had missed further investigating R1's fall incident during pericare or a brief change as documented. The ADON indicated the CRN, who no longer worked at the facility, completed the report. The ADON explained that the fall incident was being reviewed but had not been discussed with the Interdisciplinary Team (IDT). The ADON stated that stand-up meetings were conducted daily, but R1's fall incident on 04/11/2024 had not been discussed because the meetings focused on other matters. The ADON confirmed there was no documented evidence of attempts to determine the root cause of R1's fall incident, nor were any interventions implemented based on actual factors. A facility policy titled Fall Prevention and Response revised in August 2023, documented when a resident experienced a fall, the IDT should review the underlying circumstances and establish fall prevention interventions accordingly: a) meet as soon as practically possible following the incident; b) review fall circumstances and attempt to determine the root cause; c) customize interventions or approaches based on actual or suspected causal factors; d) coordinate appropriate care and referrals to address underlying circumstances; e) review any applicable accident trends and risk factors; and f) review and update the care plan/Kardex as indicated. 3) R2's medical records lacked documented evidence the physician and family had been timely notified following a post-fall incident per policy. The situation, background, assessment, and recommendation (SBAR) dated 04/11/2024, documented R1 had a fall on 04/11/2024 at 1:15 AM. R1 slid from the bed, and a CNA found R1 on the floor on the left side of R1's bed, lying on the left side of the body. The SBAR lacked documented evidence the family or representative was notified. A Physician Progress Note dated 04/12/2024 documented, nursing's report of a fall and left wrist pain on the prior evening, was sent to the emergency room , and R1 returned to the facility the previous night. The attending physician documented being informed about the initial fall only after R1's arrival from the hospital. On 06/14/2024 at 7:40 AM, an LPN who was assigned to the care of R1 on the night of the fall confirmed the SBAR was completed but could not remember if the physician or the family was notified. On 06/14/2024 at 8:42 AM, the Director of Nursing (DON) verified and confirmed there was no documentation the family had been notified. The ADON confirmed the SBAR documented as self, referring to R1 as self-responsible as indicated in the face sheet. The DON indicated for any change of condition, like a fall incident the physician should have been notified immediately, and the family should have been involved if the resident was alert or self-responsible. A facility policy titled Fall Prevention and Response revised August 2023, documented when any resident experienced a fall, the Licensed Nurse should notify the physician and responsible party. A facility policy titled Change of Condition (undated), documented the Licensed Nurses should notify the physician as soon as practical and notify the responsible party. 4) R1's medical records lacked documented evidence an assessment had been completed upon the resident's return from the hospital following a fall in the facility, and care orders had been obtained to manage the resident's cast and appropriate care had been implemented to monitor the cast to treat a fractured wrist. The hospital Radiology Report dated 04/11/2024, documented the impression of a suspected acute nondisplaced fracture of the distal radius extending to the articular surface. A Physician Progress Note dated 04/12/2024 documented nursing's report of a fall and left wrist pain on the prior evening. R1 was sent to the emergency room , and an X-ray showed an acute, nondisplaced left wrist fracture, leading to the application of a splint or cast. R1 returned to the facility the previous night. On 06/13/2024 at 2:25 PM, a Registered Nurse (RN) explained being off when the fall incident occurred, but upon returning to work, a cast on R1's left wrist was observed. The family was at the bedside, and R1 reported the fall to the RN, stating R1 told the CNA, I'm falling. I'm falling, but the CNA did not believe it. The RN indicated R1 was fully dependent on ADLs and bed-bound, requiring two-person assistance due to bed mobility dependence and obesity. The RN confirmed there were no orders in place to manage or monitor R1's cast to treat the fractured wrist. On 06/14/2024 at 7:40 AM, an LPN who had been assigned to R1 on the night of the fall incident on 04/11/2024, indicated had returned to work the next night. The LPN was advised by the CRN R1 had been transferred to the hospital due to pain and swelling in the left wrist. An X-ray had revealed a wrist fracture, and R1 had returned to the facility with a cast applied in the hospital. The LPN indicated went to check on R1 and observed a cast on R1's left wrist and a sling on. The LPN conveyed the Licensed Nurse who admitted R1 upon return to the facility was responsible for assessing R1 and obtaining orders. On 06/14/2024 in the morning, the Director of Rehabilitation (DOR) indicated R1 was seen upon return to the facility with a cast or splint in the left wrist, as documented. The DOR indicated R1's left wrist was non-weight-bearing and was not included in the treatment plan. The DOR indicated nursing was responsible for the assessment and obtaining orders. On 06/14/2024 at 12:35 PM, the attending physician reviewed and verified R1's fall incident in the facility on 04/11/2023, which resulted in a fractured wrist. The Physician indicated the facility did not mention the reason of R1's fall. The physician indicated R1 was transferred to the hospital due to complaints of pain and swelling in the left wrist following the fall. The physician indicated a CT and X-ray were performed in the hospital, and the X-ray revealed a non-displaced fracture to R1's left wrist. R1 returned to the facility with a cast to left wrist to treat the fracture. Although the hospital X-ray indicated a suspected acute nondisplaced fracture of the distal radius, the physician determined it was still a fracture. The physician further explained the X-ray impression would remain suspected until an MRI was performed, but it was most likely a fracture. R1 was referred to an orthopedic specialist. The physician confirmed R1 had a fall in the facility which resulted in nondisplaced left distal radial fracture. The Physician indicated assessment and appropriate interventions were expected. A facility policy titled Fall Prevention and Response, revised in August 2023, documented each resident would be assessed for fall risk factors and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of a fall. The facility would assess each resident's individual fall risk factors and implement comprehensive, resident-centered fall prevention plans for those with a recent history of falls. When a resident falls, the IDT should review the underlying circumstances and establish person-centered fall prevention interventions, including customizing interventions or approaches based on actual or suspected causal factors, coordinating appropriate care, and reviewing and updating the care plan or Kardex as indicated. Complaint #NV00071056

Based on observation, interview, clinical record review and document review the facility failed to ensure a resident with weight loss was evaluated, assessed, and approaches implemented to optimize the resident's nutritional status for 1 of 24 sampled residents (Resident #14). Findings include: The facility's policy entitled Weight Management dated 8/14, documented in part 6) Weekly weight monitoring maybe appropriate for new admissions for one month, significant unplanned weigh loss/gain and clinical conditions which may require more frequent monitoring. 7) The process for documentation of weigh variance in the medical record was completed in the electronic system by the designated person and included communication to Licensed Nurses via Accu Nurse (computer system). 8) Dietary Service manager/designee will complete weight review and determine significant weight changes. 9) Physician and responsible party will be notified of significant weight changes. 10) Licensed Nurse, Interdisciplinary team and/or RD (Registered Dietician) complete as assessment which may include a review of meal intake records, medication changes, physical assessment for declines, special equipment needs (utensils), pain and psych-social issues. Resident #14 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. The documentation indicated Resident #14 had 1+ (plus) [MEDICAL CONDITION]. The Discharge/Transfer documentation dated 9/18/14, lacked documented evidence the resident had one plus [MEDICAL CONDITION]. Resident #14's clinical record contained a physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented Resident #14's height as 61 inches and weight 127 pounds. No loss or gain of 5 percent (%) or more in the last month or 10% or more in the last 6 months. The clinical record contained a care plan dated 9/25/14, at risk for alerted nutritional status and hydration related to [MEDICAL CONDITION] and wounds. Expected weight fluctuation due to [MEDICAL CONDITION]. The documented goal was encourage greater than 75% meal intake times 3 months. The documented approaches included diet as ordered regular mechanical soft diet, monitor weight, multivitamin with minerals, laboratory tests as ordered and Occupational Therapy evaluation. The care plan dated 9/25/14, lacked documented evidence regarding the amount and location of the [MEDICAL CONDITION] or the weigh loss of 13 pounds on 9/27/14. The clinical record documented Promod one ounce dissolved in 6 ounces of fluid orally three times a day with medication pass was started on 9/26/14. Multivitamin with minerals one tablet orally daily with food for wound healing was started on 9/26/14. A Weight Log dated 9/19/14, revealed the Resident #14's weight was 127 pounds. On 9/27/14, the resident's weight was 114 pounds (a 13 pound or 10% weight loss). On 10/3/14, the resident's weight was 111 pounds. The clinical record lacked documented evidence of the following: a. Resident #14's physician had been notified of the 13 pound weight loss. b. The resident had been assessed for the cause of the weight loss. c. Interventions were put in place to stop or slow down the weight loss. d. The care plan had been updated to reflect the weight and the plan to stop or slow down the weight loss. e. Resident #14 had [MEDICAL CONDITION] after the initial note dated 9/18/14. The clinical record lacked documented evidence the RD had been aware of the resident's 13 pound weight loss, and assessed the resident after the weight loss or implemented a plan to stop or slow down the resident's weight loss. On 10/9/14 at 11:35 AM, a Licensed Nurse (LN) confirmed Resident #14's admission weight was 127 pounds and the resident had 1+ [MEDICAL CONDITION]. The LN confirmed there was no documentation in the clinical record regarding the residents [MEDICAL CONDITION] in the nurse's notes or physician's progress notes after 9/18/14. The LN confirmed there was no documented evidence the resident's physician had been notified about the 13 pound weight loss. The LN verbalized we would have completed an SBAR form and there was no SBAR found in the clinical record. The LN confirmed the clinical record and computer system lacked documented evidence the RD had been aware of or had addressed the weight loss. The LN confirmed the care plan had not been updated to reflect the 13 pound weight loss or interventions to stop or slow down the weight loss. The LN revealed Promod and a multivitamin with minerals were ordered prior to the time the RD would have known about the weight loss and would not have helped to prevent the weight loss On 10/9/14 at 11:55 AM, the Dietary Manager (DM) confirmed a 13 pound weigh loss was a significant weight loss. The DM was not able to locate documentation the RD had assessed the resident or put any interventions into place. The DM and LN indicated if a resident had weight loss the facility would have put something into place such as restorative dining or health shakes. The intervention would have been individualized for the resident and "usually" the Dietary Technician would have assessed the resident. The DM verbalized they would try to note on it in the clinical record, but was not sure if the facility's policy required a note to be completed after a weight loss. According to the DM and LN when weekly weights were completed they were documented into the Accu-Nurse and the dietary department received both the weekly and monthly weights. The DM and LN were not sure who was responsible to review the weekly weights. The LN verbalized nursing only received the monthly weights and it was nursing's responsibility to call the physician regarding a resident's weight loss. The LN verbalized 1+ [MEDICAL CONDITION] would not cause a 13 pound weight loss. During the interview of 10/9/14, the DM verbalized Resident #14's oral intake was "pretty good". The DM indicated the meal percentages were mostly 75 % to 100 % with some meals 50%. The DM revealed the care plan should have been updated with dated entries to show a weight loss and the interventions put in place. On 10/9/14 at 12:20 PM, Resident #14 was in her room with her lunch tray at bedside. The resident's meal tray contained mechanically ground meat. Resident #14 verbalized,"I don't know why they grind the meat. I have teeth and can chew." Resident #14 revealed a young lady came into her room and asked a whole bunch of questions. The resident verbalized she had told the young lady she like Soy milk and used the Soy milk at home, because regular milk went through her (diarrhea). Resident #14 verbalized she had not received the Soy milk until 2 days ago. The resident revealed she was not aware she had lost 13 pounds, but knew the swelling was decreased from the "saline" she received in the hospital. On 10/9/14 at 12:30 PM, a LN revealed the resident's tray card, Registered Dietician's notes documented the resident's diet was regular diet mechanical, but the physician's orders [REDACTED]. On 10/9/14 at 12:38 PM, a LN communicated she had spoken with Resident #14's physician and the physician was aware of the resident's weight loss, and weight loss would be expected. The LN verbalized there was no documentation in the computer or clinical record to indicated the resident's physician expected the weight loss or the physician was aware of the 13 pound weight loss. On 10/9/14 at 12:50 PM, the DM verbalized the RD came into the facility on ce a week or if the facility's census was high maybe twice a week. The DM verbalized the RD had not been at the facility and would be in on Friday or Saturday to review the monthly weights. The RD would then address the weight loss for Resident #14. On 10/9/14 at 3:55 PM, the RD verbalized 1+ plus [MEDICAL CONDITION] could cause a couple of pounds for weight loss, but he did not believe it could account for a 13 pound weight loss in one week. The RD verbalized he was not aware Resident #14 had a 13 pound weight loss or he would have done something about it. The RD revealed the last time he was at the facility was 9/30/14. The RD indicated the DM or Dietary technician would tell him if there was a weekly weight loss. The RD confirmed a 13 pound weigh loss was a significant weight loss.