Every finding on record at Silver Ridge Healthcare Center

Based on interview and document review, the facility failed to permit a resident to return to the facility for one of two sampled residents (Resident 1). The deficient practice had the potential to disrupt the resident's care, safety and recovery leading to a cascade of negative outcomes.Findings Include:Resident 1 (R1) was admitted on [DATE] with diagnoses including convulsions, depression, and mood disorder. R1 had a Public Guardian. A Brief Interview for Mental Status (BIMS) indicated R1 had intact cognitive function.On 08/27/2026 at 1:10 PM, a Certified Nursing Assistant (CNA) verbalized on the day of the incident R1 became angry after a request was denied, blocked the Licensed Practical Nurse (LPN) supervisor from entering the room, and argued with the LPN supervisor. Paramedics were called, and R1 was transported to the hospital.On 08/27/2026 at 1:50 PM, the Director of Nursing (DON), who was the charge nurse during the incident, reported R1 trapped the LPN supervisor in the room and later used threatening language in the hallway. Police were contacted, and R1 was admitted to the hospital. The DON was not aware of any referral received for R1 to return to the facility.On 08/27/2026 in the afternoon, the Admissions Director revealed the facility did not receive a referral to accept R1 back from the hospital. The Admissions Director explained the facility's hospital liaison was responsible for following residents during hospitalization.On 08/27/2026 in the afternoon, the Public Guardian indicated being told by the facility's Social Worker R1 could not return to the facility. The Public Guardian provided an email from the Social Worker documenting R1 was denied readmission and any further discussion should be with administration.On 08/27/2026 in the afternoon, the Marketing Liaison indicated being aware R1 was hospitalized but did not follow R1 during the hospital stay. The Marketing Liaison confirmed no referral to accept R1 back was received and believed R1 may have told the hospital they did not wish to return. The Marketing Liaison reported notes from this timeframe had been purged.On 08/27/2026 in the afternoon, the Social Worker explained R1 was verbally abusive to staff and other residents. and The Social Worker indicated being in contact with the Public Guardian for months regarding group home placement. The Social Worker revealed the Public Guardian had been informed the previous DON decided R1 would not be permitted to return to the facility.The facility's Transfer or Discharge policy (dated 2001) documented if a resident or representative appealed a discharge while the resident was in the hospital, the resident would be permitted to return pending the appeal unless there was evidence the facility could not meet the resident's needs or the resident's return would pose a danger to the health or safety of the resident or others. The policy further documented determinations would not be based on the resident's condition at the time of the initial transfer to the hospital.The facility was unable to provide documentation supporting they could not meet R1's needs or R1's condition at the hospital posed a danger to the resident or others.

Based on observation, interview, record review, and document review, the facility failed to implement Enhanced Barrier Precautions (EBP) and the required use of personal protective equipment (PPE) in accordance with current infection prevention and control guidance for 1 of 29 sampled residents (Resident #22). This deficient practice had the potential to increase the risk of transmission of multidrug-resistant organisms (MDROs), expose residents and staff to infectious pathogens, and contribute to preventable healthcare-associated infections.Findings include:Resident 22 (22) was admitted on [DATE] with diagnoses including sequelae of cerebral infarction, syncope and collapse, urinary tract infection, and hypothyroidismOn 04/22/2025 at 2:15 PM, it was noted R22 had a feeding tube in place. There were no Enhanced Barrier Precautions (EBP), personal protective equipment (PPE) such as gowns, at the resident's door for staff to obtain.physician order dated 02/23/2026 documented implementation of Enhanced Barrier Precautions (EBP) for all high-contact resident care involving the G-tube. Staff must do appropriate personal protective equipment (PPE), including gowns and gloves, before performing any high contact tasks such as stoma care, dressing changes, tube manipulation, or assistance with activities of daily living that involved potential exposure to bodily fluids.On 04/22/2026 at 11:00 AM, a Licensed Practical Nurse (LPN), explained when a resident was on Enhanced Barrier Precautions, the nurse must wear a gown and gloves when providing high contact care, such as replacing a G tube or cleaning the tube stoma site. The LPN confirmed personal protective equipment (PPE) supplies should be available the residents' door so staff can have the required protective equipment before entering the room to provide high contact resident care.On 04/22/2026 at 11:14 AM, a Registered Nurse (RN) Manager indicated any resident receiving tube feeding, Enhanced Barrier Precautions supplies such as gowns, masks, and gloves should be at the resident's door. The RN Manager explained nurses were required to wear gloves and a gown before providing high contact care to a resident with a feeding tube. The RN Manager acknowledged this was not the ideal practice; however, the standard expectation was PPE supplies should be available at each resident's room when Enhanced Barrier Precautions were required.On 04/22/2026 at 11:34 AM, a Registered Nurse (RN) verbalized when a resident was placed on Enhanced Barrier Precautions, it was typically due to the residents receiving tube feeding or wound care from the nursing staff. The RN explained the nurse must perform hand hygiene before and after providing care and must wear a gown and gloves when delivering direct, high contact care, such as replacing tube feeding equipment or cleaning the resident's G tube. The RN indicated any room displaying an Enhanced Barrier Precautions sign must have PPE supplies available at the resident's door or inside the room to ensure staff can do appropriate protective equipment before entering.On 04/22/2026 at 11:45 AM, a Registered Nurse (RN) indicated when a resident was placed on Enhanced Barrier Precautions, staff must wear a gown and gloves before providing any high contact care, including care related to tube feeding or wound treatment. The RN explained the ideal standard practice was for each resident room requiring Enhanced Barrier Precautions to have PPE supplies readily available at the room entrance or inside the room, ensuring staff can provide appropriate protective equipment before entering.On 04/22/2026 at 11:56 AM, the Central Supply Clerk confirmed each resident room with an Enhanced Barrier Precautions sign posted at the door should have PPE supplies readily available at the entrance.The facility policy titled Enhanced Barrier Precautions, revised December 2024, documented outside the resident's room, signs are posted on the door or wall outside the residents' rooms which communicate the types of precautions and PPE required.

Based on observation, interview, record review and document review, the facility failed to ensure a safe environment was provided to residents and staff when an unauthorized male intruder entered the facility and stole the personal belongings of 1 of 29 sampled residents (Resident 94) and a staff member. The deficient practice had the potential to cause physical harm to residents and staff members.Findings include:Resident 94 (R94) was admitted on [DATE], with diagnoses including anxiety disorder, major depressive disorder, and pain in left knee.On 04/24/2026 at 9:41 AM, R94 was lying in bed, alert, and oriented. R94 revealed around 5:00 AM, sometime in December 2025, seeing a guy inside the resident's room and took a cellphone with a phone case containing R94's driver's license, debit card, health insurance card, and RTC (Regional Transportation Commission) bus card. R94 indicated the guy said being a kitchen staff and just checking the resident's table to be ready for breakfast. R94 explained not knowing the guy and had not seen him before. The guy had a backpack.R94 confirmed the door alarms did not go off when the guy entered the building (facility). R94 indicated they would usually hear the door alarms if somebody had entered the building and did not press the correct code. R94 acknowledged the staff called the police and the resident was interviewed. R94 revealed there were two unauthorized charges from the debit card after the incident. The bank reimbursed the resident for the two unauthorized charges and the facility replaced R94's cellphone.R94 acknowledged the same incident did not happen again and they had not heard from other residents about their belongings being stolen by the same guy. R94 indicated feeling safe now.On 04/24/2026 at 10:03 AM, a Licensed Practical Nurse (LPN) revealed in December 2025, R94 reported there was a man who went inside the resident's room and introduced self as a kitchen staff when asked by the resident who he was. The guy (man) took the resident's cellphone according to the resident. The LPN explained the alleged incident was discussed by the Interdisciplinary Team (IDT) on the same day it was reported by the resident. The LPN was thinking R94 could have a delusional episode due to having a history of seeing a person. During the IDT meeting, the other nurse reported that the day prior to the alleged incident reported by R94, a stranger came into the kitchen and stole the iPhone of a dietary staff which happened about 5:30 PM. The same guy was seen from the camera entering the door by the kitchen by following somebody from behind. The incident happened the day before R94 reported about the guy entering the resident's room. The picture of the guy was posted throughout the building after the incidents.The LPN indicated a month later or in January 2026, the same guy climbed through the window to enter the facility. The purse, house key, and car key of a night shift nurse were stolen. The same guy was involved in these three incidents. The LPN revealed in between these three incidents, the same guy was seen twice in the parking lot and staff called the police immediately.The LPN confirmed it was only R94 and the night shift nurse who reported about missing belongings due to these incidents. The LPN acknowledged the same incident did not happen again. The facility put locks on the windows of the resident rooms and pictures of the intruder were posted throughout the facility. The police and detectives came. All visitors were required to check in at the front and wear a visitor's badge while at the facility.On 04/24/2026 at 12:44 PM, a Certified Nursing Assistant (CNA) indicated hearing about an intruder who was able to get inside the building. The CNA recalled about this guy who indicated having to pick up the belongings of a discharged resident. The guy asked for the Wi-Fi which the CNA provided. During the investigation of a security breach, the CNA indicated that the same guy was the one who was in the video camera and broke into the building. After the incident and corrective actions in place, there were no more intruders. The visitors were required to have a visitor badge while inside the building.On 04/24/2026 at 2:21 PM, the Administrator explained and read through the investigation report and final conclusion about the incident which happened 01/24/2026 - 01/25/2026 when an unauthorized individual gained access to the facility. The report documented the following:- Location: South Side Case Management Office/300 Hall Egress- Description of Event: During the night shift, an unauthorized individual gained access to the facility by bypassing a window on the south side of the building. The window was not fully seated in the locked position, allowing the intruder to shimmy the frame open and enter an unoccupied administrative office. The individual exited the office into the hallway and proceeded to the nurse station where a wallet and set of keys belonging to a nurse were misappropriated. As the individual attempted to exit through the west doors near the end of 300 Hall, the door alarm was triggered. Staff responded immediately to the alarm, but the individual had already reached a getaway vehicle parked on the south paved access road and fled the premises. The Administrator met with the nurse to discuss findings and the incident that occurred. The police report was discussed as well as the interventions taken to ensure the staff and residents' safety.- Investigative Findings including a full internal investigation and calling the Las Vegas Metro Police Department (LVMPD). Security footage was reviewed and handed over to LVMPD who was in pursuit of the suspect. A floor-wide check was conducted immediately, and it was determined the individual did not enter a resident room or come into physical contact with any residents. No staff members were physically harmed during the encounter, though a theft of personal property occurred.- Corrective and Preventative Measures:1) Hardware Upgrades: The facility had installed new and State-approved secondary locks on windows. These locks would prevent a window from being shimmied or forced open from the exterior even if the primary latch was not full engaged. 2) Environmental Audit: Maintenance staff conducted a full sweep of the south side of the building to ensure all windows were fully functional and that no exterior landscaping would provide cover for unauthorized access and all lights and camera were fully functional.3) Law Enforcement Collaboration: LVMPD was working directly with the nurse to recover the stolen personal property. The Administrator had requested and secured an increase Active Patrols from Metro during the night shift hours for the next two to three weeks.4) Alarm System Review: The west door alarm functioned as intended, providing the immediate alert that led to the staff members' rapid response and the identification of the getaway vehicle.- Conclusion: The investigation concluded that while a theft of staff property occurred, no residents or staff were in immediate harm's way. The swift response of the nursing team and the subsequent physical interventions, specifically the addition of window locks and increased Metro presence, had successfully secured the facility against future breaches of this nature.The report included a staff in-service titled All Staff Meeting Agenda: Night Shift Security and Window Safety which was conducted on 01/26/2026, with sign-in sheets.The Administrator indicated there were no similar incidents which occurred after the January incident. The police found out the guy was driving a stolen vehicle. The guy exited the door by the wound care team office in 300 Hall. There was no physical contact with the residents. The guy could have entered the kitchen door or the employee entrance.When asked if a similar incident had occurred prior to the January 2026 incident, the Administrator responded there was an incident in December 2025 where an intruder had entered the room of R94. The Administrator indicated the need to get and refer to the investigation report related to this incident.On 04/24/2026 at 2:47 PM, the Administrator revealed there an incident on 12/24/2025 about a security breach involving an unauthorized male intruder. The individual made his way into the room of R94. The incident was investigated and the Administrator read through the report which documented the following:- Date of Incident:12/24/2025- Location: Name of the Facility/Resident Room/Facility Perimeter- Findings: On 12/24/2025, the Administrator was notified of a security breach involving an unauthorized male intruder. It was reported that an individual bypassed the front lobby visitor kiosk and entered the facility. The individual made his way into the room of R94. The intruder removed a cellphone and personal items attached to the device from the resident's bedside. Upon staff becoming aware of an unrecognized individual, the male was immediately challenged, at which point he exited the building. A full facility sweep was conducted instantly to ensure no other unauthorized persons were present and to confirm the safety of all other residents. It was determined that no other resident rooms were entered and no physical contact or verbal threats were made toward any resident. Investigation included a review of the visitor kiosk logs, staff interviews, and a physical inspection of all egress points. Findings showed the individual was not an authorized visitor, family member, or vendor. LVMPD was notified immediately and arrived onsite to conduct an official report. LVMPD interviewed R94. During the interview, R94 remained alert and oriented. R94 did not wish to press criminal charges against the individual but expressed a desire to have the personal property restored. Clinical staff assessed theR94 for any signs of psychosocial distress, none were noted. R94 reported feeling safe once seeing the increased staff and police presence. The facility provided prompt reimbursement and replaced the cellphone and all attached items to the resident's satisfaction.- New Intervention and Systemic Measures including visual identification, mechanical hardware audit, access control update, law enforcement partnership and staff re-education.- Conclusion: The facility took aggressive and immediate measures to ensure R94 was supported and that the building was secured. R94 expressed full satisfaction with the resolution. The facility continued to monitor door security and kiosk compliance daily to ensure incidents of this nature would not happen again.The report included a staff in-service titled All Staff Meeting Agenda: Facility Security and Safety which was conducted on 12/29/2025, with sign-in sheets.The Administrator explained not being aware of an incident prior to the 12/24/2025 incident where an intruder entered the kitchen and stole the cellphone of the dietary staff.On 04/24/2026 at 3:01 PM, a night shift LPN indicated having heard about a guy who came through the window of the case management office during the night shift when the LPN was working. There were no residents harmed and no stolen items/belongings from the residents during this incident. The cellphone and keys of the other LPN were stolen. After the incident, locks were placed on all windows including the resident rooms and the code in the employee entrance was changed. The night shift LPN acknowledged feeling safer now.On 04/24/2026 at 3:22 PM, the Director of Nursing (DON) indicated R94's report about a stolen cellphone was treated and addressed as a grievance and it was resolved. The DON explained there were no IDT notes related to the incident.During the onsite investigation on 04/21/2026 through 04/24/2026, verification of the facility's correction of the past non-compliance related to the security breach and an intruder entering the facility occurred as evidenced by:- A tour of the facility on 04/22/2026 revealed the windows, including the resident rooms' window, had thumb screw clamp in place. An observation of the window to resident room [ROOM NUMBER] from the exterior revealed the window was intact, open approximately four inches, and the thumb screw clamp lock was in place. Allegedly, the intruder entered into room [ROOM NUMBER] during the 01/25/2026 incident. The room was next to the case management office. The egress doors were locked from the exterior and door alarms were functioning.- An observation of the window to resident room [ROOM NUMBER] (R94's room) from the interior revealed the window was intact and the thumb screw clamp lock was in place. This window led to an interior courtyard.- During the screening of the residents on 04/21/2026 and resident council meeting on 04/23/2026, the residents indicated they felt safe at the facility and there were no intruders or random guys entering their rooms.- A staff in-service titled All Staff Meeting Agenda: Facility Security and Safety was conducted on 12/29/2025, with sign-in sheets.- A staff in-service titled All Staff Meeting Agenda: Night Shift Security and Window Safety was conducted on 01/26/2026, with sign-in sheets.- The facility had investigated the incidents and implemented the corrective actions. Complaint 2730077

Based on observation, interviews, record reviews, and document reviews, the facility failed to ensure a resident was protected from physical abuse for 1 of 29 sampled residents (Resident 13). The deficient practice had the potential to cause emotional and physical harm to the residents.Findings include: Resident 13 (R13) was admitted on [DATE] with diagnoses including local infection of the skin and subcutaneous tissue, extended-spectrum beta-lactamase (ESBL) resistance, and neuromuscular dysfunction of the bladder.A facility document verified on 04/10/2026 at approximately 7:00 PM, R13's roommate pushed a bedside table into R13 around 7:00 PM, while in the resident's shared room. The police department was contacted and responded to the incident. The roommate was moved to a separate room.On 04/24/2026 at 3:30 PM, during a telephone interview, the Supervisor indicated the charge nurse had called them regarding an altercation between two residents. When asked what occurred, R13 reported the roommate slammed the bedside table toward their face because the roommate had been upset about the television volume being too loud. The roommate attempted to move the bedside table out of the way, and it fell over onto R13.The R13 was observed with bleeding from the lip and reported having a loose tooth. The blood on R13's face and lip were cleaned, and the loose tooth was noted. R13 had a scheduled appointment with a dentist for further evaluation. The resident refused to transfer to the hospital. Law enforcement was notified, and both R13 and the roommate provided statements to the responding officer. R13 declined to press charges. Roommate was relocated to a separate room following the incident.On 04/23/2026 at 11:45 AM, R13, reported the roommate had pushed the bedside table and struck them in the face. R13 sustained a cut lip and a loose tooth because of the incident. R13 explained the roommate became angry because the television volume was too loud. R13 indicated the facility contacted the police, who obtained statements from both residents. R13 reported the facility was planning to arrange a dental evaluation for the loose tooth. On 04/23/2026 at 12:12 PM, the Social Worker reported the incident occurred on the evening of 04/10/2026. Since the event, the Social Worker regularly checked to ensure the residents continued to feel safe and everything remained stable and satisfactory with the residents' wellbeing.On 04/23/2026 at 12:40 PM, R78 (R13's former roommate) reported the bedside table had been positioned on the side of the bed. R78 indicated pushing the bedside table back toward the roommate's side, they were simply returning the bedside table to its proper place.A progress note dated 04/10/2026 documented an assessment of R13's face and face was done to determine if the resident required to be sent out for treatment. A Social Service visit note dated 04/13/2026 documented the Social Services Director and Administrator visited R13 regarding the report. R13 was provided with emotional support. Since the event, the Social Worker had been regularly checking on the resident to ensure they continued to feel safe and everything remained stable and satisfactory with the resident's well-being.A Care Plan dated 04/14/2026 documented R13 was involved in an altercation with a roommate. Interventions included the following:-Provide a safe environment for R13.-Monitor for coping strategies and respect resident's wishes.-Assist with conflict resolution as needed.-Notify MD (Medical Doctor) for any changes.During the onsite investigation on 04/21/2026, the facility demonstrated correction of past non-compliance related to the incident, as evidenced by the following:-Observation of resident-to-resident interactions. -Interviews with residents revealed the residents were happy with their fellow residents and felt they were treated politely.-Interviews with Certified Nursing Assistants and Licensed Nurses indicated the facility provided continuing education regarding Abuse and Neglect.-Review of the facility's staff in-service sign-in sheets dated 04/13/2026 pertaining to elder abuse recognizing, prevention and reporting. FRI 2981818

Based on observation, interview, and document review, the facility failed to ensure food was stored in a sanitary manner when perishable items in the walk-in refrigerator were not stored within the safe temperature range of 35-41 degrees Fahrenheit (F). The deficient practice had the potential to cause food-borne illness in all residents. Findings include: On 04/08/2025, in the morning, a tour of the kitchen was conducted with the Dietary Manager (DM). The walk-in refrigerator in the kitchen had heavy ice build-up on the back of two evaporator fans. The internal thermometer inside the walk-in registered 53 degrees F. - Sliced ham inside the refrigerator was at 53.2 degrees F - Chicken salad was at 52.9 degrees F. - Other perishable items in the walk-in included whole peeled eggs, liquid eggs in cartons, and mayonnaise. The DM verbalized the acceptable range for refrigerated foods was 35-41 degrees F and variance from this temperature range could cause food to spoil. The Refrigerator/Freezer Temperature Log (Form 603a), dated April 2025, indicated temperatures had been checked in the AM and the PM daily. The form documented the temperatures in the walk-in refrigerator in degrees F as follows: 04/04/2025 - AM: 45 PM: 53 04/05/2025 - AM: 45 PM: 51 04/06/2025 - AM: 35 PM: 53 04/07/2025 - AM: 51 PM: 35 04/08/2025 - AM: 55 On 04/08/2025, in the morning, the DM verbalized the temperature log documented a pattern of temperature readings over 41 degrees F starting on 04/04/2025 until present. The DM reported the temperature log indicated the walk-in refrigerator had not been holding food in the safe range for about four days. On 04/10/2025 at 9:35 AM, the Dietary Manager (DM) revealed all of the refrigerators in the kitchen were equipped with thermometers. The DM reported refrigerator temperatures were checked by cooks and documented twice daily, in the AM and in the PM. The DM stated temperatures above 41 degrees should have been reported to the Maintenance Director immediately. The DM reported having worked in the kitchen during these time frames but had been very busy and had failed to check the temperature log posted on the front of the walk-in refrigerator. On 04/10/25 at 9:41 AM, the [NAME] reported upon arrival to work on Friday morning, 04/04/2025, the walk-in refrigerator had a temperature of 45 degrees F. The [NAME] recalled reporting the out-of-range temperature to the Assistant Dietary Director. The [NAME] stated had returned to work the next morning, 04/05/2025, and the walk-in temperature was again 45 degrees. The [NAME] verbalized had also noted a temperature of 53 degrees F taken the prior evening. The [NAME] reported asking someone if maintenance had been notified of the PM high temp of 53, and someone said they had. The [NAME] did not remember who made the statement. The [NAME] recalled being very busy trying to get out two meals and did not think further on the matter. The [NAME] stated had next two days off, and upon returning to work on Tuesday, 04/04/2025, the AM temperature was 55 degrees F, which the [NAME] documented on the temperature log. On 04/10/25 at 09:50 AM, the Assistant Dietary Manager recalled on Friday, 04/04/2025, being notified by the [NAME] about the walk-in refrigerator being 45 degrees F. The Assistant Dietary Manager revealed had reported the concern to the Maintenance Assistant. The Assistant Dietary Manager verbalized the Maintenance Assistant checked the walk-in refrigerator. The Assistant Dietary Manager verbalized being not certain if the issue was resolved. On 04/10/25 at 09:55 AM, the Registered Dietician (RD) revealed storing food above 41 degrees F could allow harmful bacteria to grow in perishable items. The RD revealed residents ingesting spoiled food items which contained bacteria could experience nausea, vomiting, and diarrhea. On 04/10/25 at 10:44 AM, the Maintenance Assistant verbalized not recalling being notified by kitchen staff regarding an issue with the walk-in refrigerator. The Maintenance Assistant indicated not having examined the walk-in refrigerator. The Maintenance Assistant stated not being aware of any issues with the walk-in. 04/10/25 at 4:49 PM, the Maintenance Director verbalized on 04/08/2025, in the morning, having been alerted the walk-in refrigerator was not functioning properly. The Maintenance Director verbalized had called a service company to come out and check the walk-in. The Maintenance Director stated the service technician had found ice around the evaporation fans, and a small coolant leak in part of the walk-in cooling system located on the roof of the facility. The Maintenance Director verbalized having not been notified of the walk-in refrigerator issue prior to 04/08/2025. The Maintenance Director reported not knowing if the Maintenance Assistant had been notified of the issue. The Maintenance Director explained ideally we would both be notified. A Refrigerator Service Invoice dated 04/08/2025, indicated receipt of a service request from the Maintenance Director on 04/08/2025 at 8:11 AM, regarding the walk-in refrigerator frozen up and too warm. The service invoice documented frozen evaporation coils and a coolant leak were identified and addressed. The policy and procedure titled Food Safety in Receiving and Storage, dated 02/2009 indicated food was stored by methods to minimize contamination by bacterial growth. Refrigerator temperatures would be checked and recorded daily. Temperatures not in the appropriate range should be reported to the Dietary Manager, or maintenance, immediately. The temperature of refrigerators would be maintained to hold cold foods at 41 degrees F or below. The policy and procedure titled Safe Food Temperatures, dated 02/2009, indicated the time the food was in the temperature danger zone (between 41 to 135 degrees F) should not exceed six hours.

Based on interview and document review, the facility failed to ensure mandatory training which included abuse, fire, disaster, and dementia training was provided to 1 of 2 sampled Certified Nursing Assistants (Employee 10). The deficient practice placed residents at risk for inappropriate care. Findings include: Employee 10 (E10) E10 was hired as a Certified Nursing Assistant (CNA) on 03/04/2003. Employee file reviews revealed E10 had not completed Abuse, Fire and Disaster training. The employee file also lacked documentation of initial or annual dementia training. On 04/11/2025 in the afternoon, the Human Resource/ Payroll Clerk (HR) confirmed E10 had no record of abuse, fire, disaster, or dementia training in this employee's files. The HR indicated abuse, fire, disaster and dementia training were mandatory trainings which were expected to be completed by all new hires and refreshed annually. On 04/11/2025 in the afternoon, the Staff Development Assistant verbalized the facility was expected to abide by state and local laws which would include state-required training such as care of dementia residents, abuse, fire and disaster training. The Covenant Care Employee Training Requirements updated 12/2022, outlined new hire and annual compliance-related training for all employees which would include but was not limited to, abuse and neglect, safety-related training and training required by federal and state requirements and conditions of participation specific for Nevada. The State Operations Manual for Long Term Care Facilities documents required in-service training for nurse aides must include but are not limited to dementia management training and resident abuse prevention training.

Based on observation, interview, record review, and document review, the facility failed to comply with the prescribed meal consistency and dietary preferences for 1 of 28 sampled residents (Resident #13). The deficient practice had the potential to disregard resident autonomy and preference, negatively impacting meal satisfaction, leading to reduced appetite, and increase meal refusal that could have affected the resident's nutritional intake and quality of life. Findings include: Resident #13 (R13) R13 was admitted on [DATE], with diagnoses including hypertension, chronic debility, hypothyroidism, atrial fibrillation, type 2 diabetes, and chronic obstructive pulmonary disease. Physician order dated 03/21/2025, documented R13 had a consistent, constant, or controlled carbohydrate diet (a diet used to manage blood sugar levels, particularly for individuals with diabetes), minced and moist texture, and regular thin consistency. On 04/08/2025 at 12:15 PM, Resident R13 was observed in their room during lunch. The resident did not eat the provided meal and expressed no longer required a pureed diet. R13 stated had already been removed from the pureed diet and did not understand why meals continued to be served in that consistency. On 04/09/2025 at 12:00 PM, R13 was in the dining room when a Certified Nursing Assistant (CNA) served their lunch, which consisted of a pureed diet including ham, bread, and mashed potatoes. The resident refused the meal due to its pureed consistency. The meal ticket, which provided essential details regarding the resident's dietary needs, preferences, and restrictions, indicated a minced moist consistency diet. Additionally, the meal ticket documented allergies and dislikes, including pork. R13 was upset because the facility continued serving puree diet and meals resident disliked such as pork (ham). On 04/09/2025 at 12:15, the kitchen manager confirmed the observation and inquired with the cook responsible for the tray line regarding the meal consistency served to R13. The cook stated a pureed diet was provided since pureed and minced/moist consistencies were considered the same. The cook confirmed that R13 was served a pureed diet that included ham, bread, and mashed potatoes. The kitchen manager clarified a minced/moist diet consists of soft, moist, and finely minced foods that require minimal chewing, whereas a pureed diet includes foods blended into a smooth, pudding-like consistency, eliminating the need for chewing. Additionally, the kitchen manager acknowledged R13's documented food preference, specifically the dislike of pork, was not honored, as ham was included in the meal served for lunch. The nutritional care plan for R13 identified a risk of altered nutrition and hydration due to diabetes, depression, and gastroesophageal reflux disease (GERD). The care plan indicated R13 had multiple food preferences and experienced fluctuations in weight. The care plan interventions included encouraging a meal intake of more than 50% through the review date, ensuring the resident exhibits no signs or symptoms of altered hydration, and preventing significant weight change. The facility policy titled Resident Food Preferences dated November 2016, documented all food and dinning staff would be made aware of resident food preferences and allergies to prevent serving foods that could contribute to food allergies, and to meet resident's food preferences. The Resident [NAME] of Rights provided to the residents at the time of admission, listed the recognition of their individualities as part of their rights.

Based on interview, record review and document review, the facility failed to notify the physician regarding resident post fall behavior and refusal of care for 1 of 28 sampled residents (Resident 126). The deficient practice had the potential for not exploring other physician interventions for resident care needs. Findings include: Resident 126 (R126) R126 was admitted on [DATE] and discharged on [DATE] with diagnoses including chronic obstructive pulmonary disease, pleural effusion, and chronic pulmonary edema. A Change in Condition dated [DATE] at 1:47 PM, documented R126 had a fall and complaints of back pain and pain in the back of head. Recommendation of physician was to send R126 to the hospital to be checked. The hospital after-visit summary dated [DATE], documented diagnoses of closed head injury, with education of certain problems the caregiver should watch for and to call for an ambulance if acting confused or disoriented, sudden, and persistent change in behavior, have trouble speaking or slurred speech. Skilled evaluation notes documented the following: -[DATE] at 11:28 PM, mood is pleasant, no unwanted behaviors witnessed. -[DATE] at 8:33 AM, mood is pleasant, no unwanted behaviors witnessed. -[DATE] at 6:42 PM, mood is pleasant, no unwanted behaviors witnessed. A Nursing note dated [DATE] documented the following: - 6:30 AM, the Supervising Nurse got a report from night nurse the resident was agitated the whole night after came back from the hospital from getting a CT scan. The night nurse reported there were no new orders. R126 was really confused and combative with transport. R126 was cursing and kicking and continued to do so when transferred to room. R126 refused to receive care and for vitals to be taken. R126 scratched, hit, and kicked staff if nearby. R126 also repeatedly tried to throw themselves on the floor the whole night shift. -6:40 AM, the dayshift Certified Nurse Assistant (CNA) and night shift CNA helped R126 to change clothes due to taking clothes off and trying to get out of bed. -7:20 AM, a CNA went to R126's room to give resident a water pitcher and R126 was talking to themselves. -7:35 AM, a CNA reported to the Supervising Nurse R126 was unresponsive. The Supervising Nurse checked R126 to confirm and immediately paged code blue and called 911 right after the page. The Supervising Nurse and other staff started Cardiopulmonary Resuscitation (CPR) Protocol. - 7:40 AM, 911 came and started working with R126. - 8:08 AM, 911 pronounced the R126 expired. R126's medical record lacked documented evidence the physician was notified of R126's behaviors and refusal of care, post fall. On [DATE] at 9:42 AM, a Licensed Practical Nurse 1 (LPN1) explained when a fall event occurs the resident would be assessed with notification made to family and physician. If the resident was sent to the hospital and returns the staff would continue monitoring the resident for 72 hours. If the resident was refusing treatment or vitals the staff would notify the physician and the family and document in the resident's clinical record. On [DATE] at 10:41 AM, a Supervising Nurse explained when a fall event occurs staff will assess the resident and call the doctor to notify and obtain orders. Staff would send resident to the hospital for a CT scan if it was a suspected head injury. When the resident returns staff would continue monitoring vitals. Staff would notify the doctor if the resident was refusing care, and this would be documented in the medical record. On [DATE] at 10:45 AM, the Supervising Nurse reviewed R126's medical record and confirmed R126 was refusing care, and the physician was not notified. On [DATE] at 12:04 PM, a Licensed Practical Nurse 2 (LPN 2) confirmed being familiar with R126's fall event. LPN 2 explained receiving report from the night shift nurse indicating R126 had returned from the hospital and was aggressive, throwing a urinal, fighting, and kicking and staff did a one on one with R126. The LPN explained staff would need to notify the physician if a resident was exhibiting behaviors and refusing care after a fall event. On [DATE] at 11:43 AM, the Director of Nursing (DON) explained if a resident was refusing care the expectation would be for staff to notify the physician. The facility policy titled Change of Condition, undated, documented the Licensed Nurse was to appropriately assess, document and communicate changes of condition including diagnostic results to the primary care provider.

Based on interview, record review and document review, the facility failed to provide documented evidence wound care treatments were provided per the physician's order for 1 of 28 sampled residents (Resident 42). The deficient practice had the potential to place the resident at risk for delayed healing of a wound. Findings include: Resident 42 (R42) R42 was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with other circulatory complications, pressure ulcer of sacral region stage 3, and atrial fibrillation. A Physician order dated 03/25/2025 documented cleanse wound to coccyx with normal saline and pat dry. Apply Medihoney & Triad cream topically to site and cover with 2x2 and secure with border gauze every day shift for pressure wound. R42's Treatment Administration Record (TAR) for the pressure wound of the coccyx lacked documented evidence wound care treatments were completed 03/25/2025 through 03/31/2025. On 04/11/2025 at 08:10 AM, a Wound Care Nurse explained the Admission Nurse was to complete the residents initial skin assessment. The wound care staff was to perform an additional assessment, obtain wound care treatment orders, and add residents to the wound care case load. The Wound Care Nurse reviewed the physician orders and TAR and confirmed R42's medical record lacked documented evidence wound care treatments were completed as per physician orders for 03/25/2025 through 03/31/2025. On 04/11/2025 at 08:55 AM, the Wound Care Nurse explained by not performing treatments as per physician orders could result in the wound not healing. On 04/11/2025 at 11:33 AM, the Director of Nursing (DON) explained the expectation was for the staff to document treatments performed on the TAR. The facility policy titled Pressure Ulcer, Prevention of, undated, documented if a pressure ulcer was present, the licensed nurse was responsible to record condition of the skin including stage, size, site, depth, color, drainage, and odor as well as the treatment provided.

Based on observations, interviews, and document review, the facility failed to remove expired medications from two of three medication rooms and one of five medication carts. This deficient practice had the potential to compromise patient safety by contributing to the risk of medication errors. Findings include: On the morning of April 10, 2025, inspections were conducted on four medication carts and two medication rooms. The following concerns were identified: Medication cart 200 Hall: 04/10/2025 at 8:28 AM, during a medication administration observation, a Licensed Practical Nurse (LPN) attempted to administer a 250-milligram tablet of Vitamin C to an unsampled resident (Resident #16). The LPN retrieved the tablet from a bottle in the medication cart and placed it in a cup in preparation for administration. The inspector advised the LPN not to administer the Vitamin C after noting the supplement had expired in December 2024. The LPN confirmed the observation and acknowledged that the expiration date should have been verified before placing the medication in the cup. Medication Rooms: Medication room [ROOM NUMBER] Hall: A bottle of Vitamin C 250 mg had expired in December 2024. A Licensed Practical Nurse (LPN) had confirmed this observation. Medication room [ROOM NUMBER] Hall: An opened vial of Insulin Lispro had been dated February 14, 2025. According to the label, the medication had been required to be discarded within 28 days of opening. A Licensed Practical Nurse (LPN) confirmed this observation and had acknowledged the medication should have been discarded after the designated period. The facility policy titled Medication Storage I, dated November 2011, indicated nurses should check the expiration date of each medication before administering. The policy revealed all expired medications should be removed from active supply and destroyed in the facility. The policy documented the expiration date of vial would be 30 days after being initiated.

Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure the water bag used for gastrostomy feeding hydration and the tubing system were properly dated upon initiation of use for 2 of 28 sampled residents (Resident #68 and #70). This deficient practice had the potential to compromise patient safety by increasing the risk of contamination and infections, and improper hydration management, potentially leading to adverse health outcomes. Findings include: Resident #68 (R68) R68 was originally admitted on [DATE], and readmitted on [DATE], with diagnoses including history of pneumonia, history of CVA with left side weakness, diabetes mellitus, atrial fibrillation, chronic kidney disease, and congestive heart failure. On 04/08/2025 at 4:42 PM, a gastrostomy tube (G-tube) feeding infusion pump was noted with a hanging bottle of feeding formula of Glucerna 1.2 dated 04/08/2025. However, the time of initiation for the bottle was not documented. The pump was turned off, and the tubing was undated and disconnected from the G-tube. Approximately 400 ml of formula remained in the bottle. Additionally, a bag of water was present, though it was undated and untimed, with around 700 ml remaining. On 04/08/2025 at 4:44 PM, a Licensed Practical Nurse (LPN) confirmed the observation and explained the feeding tubing, and the water bag should have been dated when initiated to ensure changed every 48 hours. A physician's order, dated February 22, 2025, documented the administration of Glucerna 1.2 via an enteral pump. The order specified an infusion rate of 65 milliliters (ml) per hour for a duration of 20 hours, with feedings commencing at 2:00 PM and continuing until the prescribed dose is fully delivered. A physician order dated 01/28/2025, indicated to change enteral feeding tubing every 48 hours and/or with each bottle or bag. Resident #70 (R70) R70 was originally admitted on [DATE], and readmitted on [DATE], with diagnoses including Parkinson's disease, hypertension, seizure disorder, and history of cerebral vascular accident (CVA). The resident was receiving nutrition via gastrostomy tube. The physician's order, dated 11/30/2024, had documented the administration of Jevity 1.5 via a gastrostomy tube (G-tube) at a rate of 50 ml per hour, totaling 1,000 ml. The order indicated feedings had been scheduled to begin at 2:00 PM and to continue until the prescribed dose had been fully delivered. A physician order dated 11/05/2024, indicated to change enteral feeding tubing every 48 hours and/or with each bottle or bag. On 04/08/2025 at 1:36 PM, a gastrostomy tube (G-tube) feeding infusion pump was noted with a hanging bottle of feeding formula of Jevity 1.5 dated 04/08/2025. However, the time of initiation for the bottle was not documented. The pump was turned off, and the undated tubing was disconnected from the G-tube. There was no bag of water attached to the infusion pump. On 04/08/2025 at 1:45 PM, an LPN explained the feeding was stopped after the prescribed amount was delivered and should have been restarted at 2 PM. The LPN confirmed the feeding formula did not document the time the bottle of formula was initiated, and the tubing was not dated. On 04/09/2025, at 7:40 AM, R70 was receiving feeding formula Jevity 1.5 via G-tube at a rate of 50 ml per minute. A Licensed Practical Nurse confirmed the feeding tubing was not dated. On 04/09/2025 at 12:00 PM, R70 was receiving the feeding at 50 ml per minute. At the time of observation, approximately 700 mL remained in the bottle. A bag of water was present, though it was undated and untimed, as well as the infusing tubing. On 04/10/2025 at 7:25 AM during med pass, R70 was receiving the feeding via G-tube. A water bag was present. The water bag was undated and untimed, the bottle of formula was dated 04/09/2025 but not timed. Additionally, tubing system was not dated. An LPN confirmed the observation and indicated bottles of formula, water bags and tubing should have been dated and timed. The LPN emphasized the importance of labeling the tube feeding items since formula should be discarded within 24 hours upon initiated. The facility policy titled Enteral Nutritional Therapy (Tube Feeding) dated 2006, indicated prefilled formula container and tubing should be changed every 48 hours or per manufacturer guidelines.

Based on interview, record review and document review, the facility failed to ensure weekly skin assessments were not missed or late for a resident who was assessed to be at risk for developing pressure ulcers for 1 of 4 sampled residents (Resident 1). The deficient practice potentially contributed to the resident's facility-acquired pressure ulcer and a delay in necessary interventions to prevent and treat the resident's pressure sore. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including left toe cellulitis of left lower limb, acquired absence of right leg, peripheral vascular disease and diabetes mellitus. A Clinical Admission note dated 04/23/2024, documented R1 was admitted with a right above the knee amputation (AKA) with no skin other issues. A Skin/Wound Evaluation dated 04/23/2024, revealed R1 was seen by a treatment nurse and was noted to have a healed right AKA, scarring to left shin and right hip, with no other skin issues identified. A Braden scale (a formal tool used in assessing a patient's risk for developing pressure ulcers) dated 04/23/2024, revealed R1 was at risk for developing pressure ulcers due to skin often being exposed to moisture, limited mobility, and chairfast status. On 01/16/2025 at 2:18 PM, the treatment nurse explained the admission nurse was responsible for conducting the initial head-to-toe skin assessment which was followed by an in-depth skin evaluation by the wound team. According to the treatment nurse, when a skin impairment was identified, the treatment nurse would include the resident on the wound team's case load for monitoring and treatment of wounds. The treatment nurse indicated weekly skin checks were performed by floor nurses and documented in the electronic health record (EHR) under skin inspection assessments. The medical record lacked documented evidence weekly skin checks were completed on 04/30/2024, 05/07/2024, and 05/14/2024. On 01/16/2025 at 2:20 PM, the treatment nurse reviewed R1's medical record and confirmed weekly skin checks were missed on 04/30/2024, 05/07/2024 and 05/14/2024. The treatment nurse explained weekly skin assessments were necessary for timely identification and interventions for any new skin impairments. A general note dated 05/18/2024, revealed a Certified Nursing Assistant (CNA) noticed a wound on R1's left hip while changing R1, a nurse assessed R1. A Skin/Wound Evaluation dated 05/19/2024, revealed R1 was identified to have a pressure wound, deep tissue injury on the front left trochanter (a bony prominence toward the end of the thigh bone or femur) which was in-house acquired and measuring 11.4 centimeters (cm) in length, 10.5 cm in width and 0.1 cm in depth. The wound was noted to be sanguinous (bloody). A physician's order dated 05/19/2024, documented to cleanse left buttock with normal saline, pat dry and apply dressing. A physician's order dated 05/19/2024, documented to provide R1 with a low air loss mattress for wound management. A physician's order dated 05/19/2024, documented to do weekly skin assessments every Tuesday on day shift. On 01/16/2025 at 2:25 PM, the treatment nurse confirmed R1 was not on the wound team's case load because admission assessments revealed R1 had no skin issues. The treatment nurse indicated meeting R1 for the first time on 05/19/2024 after multiple areas of skin breakdown were communicated by the floor nurse on 05/18/2024. The treatment nurse confirmed physician orders for wound management were obtained on 05/19/2024 but were unable to get carried out because R1 was transferred to the hospital on 05/20/2024. On 01/16/2024 at 2:30 PM, the treatment nurse indicated the purpose of conducting weekly skin checks was to identify areas of skin breakdown in a timely manner and to prevent a delay in appropriate interventions. The treatment nurse indicated the missed weekly skin checks may possibly have caused a delay in identification, prevention interventions such as use of an air loss mattress and treatment orders to R1's wounds. On 01/16/2025 at 3:10 PM, the Director of Nursing (DON) confirmed the facility's practice for nurses to document weekly skin inspections in the EHR. The DON confirmed R1's weekly skin check was missed on 04/30/2024 and were completed late 05/10/2024 (due 05/07/2024) and 05/18/2024 (due 05/14/2024). The DON confirmed weekly skin checks were done by licensed nurses per facility policy for the purpose of identifying new skin impairments and ensure timely interventions. The Discharge Summary dated 05/20/2024, revealed R1's family requested a hospital transfer for further evaluation and management. The Skin Integrity policy dated December 2016, revealed residents at risk for skin breakdown (pressure ulcers) would have a routine assessment to maintain and/or improve skin integrity. The objective was to create an on-going process to identify and actively manage risk and skin integrity issues to prevent infections and determine appropriate referrals or interventions to achieve positive clinical outcomes. Licensed nurses would perform weekly head to toe assessments. Complaint #NV00071274

Based on interview, record review, and document review, the facility failed to ensure a baseline care plan was developed for a resident who was admitted with an infected left foot and was assessed to be at risk for developing pressure ulcers and other skin impairments for 1 of 4 sampled residents (Resident 1). The deficient practice potentially resulted in delayed interventions for the resident's skin impairments. Findings include: Resident 1 (R1) was admitted on [DATE], with diagnoses including left toe cellulitis of left lower limb, acquired absence of right leg, peripheral vascular disease and diabetes mellitus. A Braden scale (a formal tool used to assess a patient's risk for developing pressure ulcers) dated 04/23/2024, revealed R1 was at risk for developing pressure ulcers due to skin often being exposed to moisture, limited mobility, and chairfast status. The medical record lacked documented evidence a baseline care plan was developed for R1 for pressure ulcer prevention and maintaining skin integrity. A change of condition document dated 05/18/2024, documented R1 was identified with bilateral groin and excoriation, skin tear on left buttock half dollar size, right knee scab and left foot discoloration to foot and toes. On 01/16/2025 at 12:33 PM, the treatment nurse reviewed R1's medical record and confirmed R1 was admitted with left foot cellulitis and was assessed to be at risk for developing pressure ulcer but no care plan was initiated for R1. The treatment nurse indicated a care plan for pressure ulcer prevention and maintaining skin integrity typically included interventions such as: 1) floating heels, 2) monitoring incontinence and providing perineal care timely, 3) performing weekly skin checks and reporting new impairments immediately, and 4) use of an air loss mattress. The treatment nurse explained the admission nurse, minimum data set (MDS) nurse or any nurse assigned to the resident in the first 48 hours were jointly responsible for completing the baseline care plan. On 01/16/2025 in the afternoon, the treatment nurse indicated being involved in R1's care on 05/19/2024 after a nurse reported R1's multiple skin issues to the wound team. The treatment nurse indicated review of medical record revealed a potential delay in identification and necessary interventions for the resident of concern which resulted in development of a pressure ulcer, groin rash and complications to left foot and toes. On 01/16/2025 at 3:34 PM, the Director of Nursing (DON) confirmed a pressure ulcer and skin integrity care plan was not included in the resident's baseline care plan but should have been. The DON clarified the admission nurse, or any nurse assigned to the resident during the first 48 hours were responsible for development of the baseline care plan. The Baseline Care Plan policy dated October 2022, documented the baseline care plan would be developed in the first 48 hours of the resident's admission and include instructions needed to provide effective and person-centered care for each resident. Complaint #NV00071274

Based on interview, record review and document review, the facility failed to ensure a care plan was developed and implemented for a resident who was assessed to be at risk for developing pressure ulcers for 1 of 4 sampled residents (Resident 1). The deficient practice potentially resulted in delayed identification and interventions resulting in multiple areas of skin breakdown. Findings include: Resident 1 (R1) was admitted on [DATE], with diagnoses including left toe cellulitis of left lower limb, acquired absence of right leg, peripheral vascular disease and diabetes mellitus. A Braden scale (a formal tool used for assessing a patient's risk for developing pressure ulcer) dated 04/23/2024, revealed R1 was at risk for developing pressure ulcers due to skin often being exposed to moisture, limited mobility, and chairfast status. The admission minimum data set (MDS) dated [DATE], revealed R1 was at risk for developing pressure injuries, and was not admitted with any pressure injuries. R1 had an infection of the foot. The care area assessment summary (Section V) revealed pressure ulcer was a triggered care area for Resident 1. The medical record lacked documented evidence a care plan was developed for R1 for pressure ulcer prevention and maintaining skin integrity. A change of condition document dated 05/18/2024, documented R1 was identified with bilateral groin and excoriation, skin tear on left buttock half dollar size, right knee scab and left foot discoloration to foot and toes. On 01/16/2025 at 1:32 PM, the MDS Director reviewed R1's medical record and confirmed the admission nurse recorded no skin issues apart from R1's healed right leg amputation and the treatment nurse recorded no other skin issues apart from scarring to hip and shin upon admission on 04/23/2024. The MDS Director confirmed the pressure ulcer care area was triggered due to R1 being incontinent and requiring assistance for bed mobility. The MDS Director explained the admission nurse, treatment nurse or any nurse assigned to the resident was responsible for developing a care plan for preventing pressure ulcers or maintaining skin integrity. On 01/16/2025 in the afternoon, the Director of Nursing (DON) clarified if the admission nurse or any nurse assigned to R1 failed to initiate a care plan for pressure ulcer prevention and maintaining skin integrity, the MDS Director who completed the comprehensive assessment should have identified the care plan was missed and the MDS Director had time to include the pressure ulcer care plan in the resident's comprehensive care plan. The Baseline Care plan policy dated October 2022, documented the baseline care plan would be used until the inter-disciplinary team could conduct the comprehensive assessment and develop the comprehensive care plan within seven days of comprehensive assessment completion. The Pressure Ulcer Prevention policy dated 2006, documented residents would be assessed for risk of pressure ulcer development and a care plan would be developed Complaint #NV00071274

Based on interview, record review and document review, the facility failed to ensure a resident's left foot which was being treated for cellulitis (infection) was assessed and monitored in a timely manner for 1 of 4 sampled residents (Resident 1). The deficient practice potentially resulted in complications to the resident's left foot resulting in hospitalization . Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including cellulitis of left lower limb, acquired absence of right leg, peripheral vascular disease (PVD) and diabetes mellitus. A hospital discharge summary dated 04/22/2024, revealed R1 was admitted for left foot pain, swelling and cellulitis. R1 injured left foot 10 days ago after a mechanical fall at home. R1's problem list included diabetes mellitus type two, peripheral vascular disease (PVD) and history of above the knee amputation (AKA) and hypotension leukocytosis (low blood pressure and elevated white blood cells due to infection) most likely evolving sepsis. The discharge plan included physical therapy, completion of oral antibiotics, and discharge with a CAM (controlled ankle motion) boot device. A Clinical Admission note dated 04/23/2024, documented R1 was admitted with a healed right AKA with no other skin issues. A Skin/Wound Evaluation dated 04/23/2024, revealed R1 was seen by a treatment nurse and was noted to have a healed right AKA, scarring to left shin and right hip, with no other skin issues. The medical record lacked documented evidence R1's left foot condition or the presence/absence of a CAM boot device was documented in the admission skin assessments dated 04/23/2024 and a subsequent skin inspection on 05/10/2024. A skin inspection assessment dated [DATE], revealed R1's left foot had discoloration to foot and toes. A Skin/Wound Evaluation dated 05/18/2024, documented R1 had an arterial wound to left dorsum foot measuring 19.8 centimeters (cm) in length, 5.2 cm in width for a total area of 83.2 square cm. The wound was described to have eschar (black, dry necrotic tissue) to 100 percent (%) of the wound, surrounding tissue was dark reddish brown. A Skin/Wound note dated 05/19/2024, revealed the treatment nurse noted left dorsal foot and toes to be black, hard and cool to touch. The provider was informed and an arterial doppler ultrasound (a non-invasive test which could assess blood flow in arteries) was ordered and carried out. An arterial doppler of left extremity arteries performed 05/19/2024, revealed severe inflow stenosis (narrowing). Intermediate segment occlusion middle to distal femoral artery. Limited Outflow. Suggest CT (computed tomography) angiogram. The discharge summary dated 05/20/2024, revealed R1's provider discussed results of R1's arterial doppler with R1's family members who were present in the resident's room. R1 expressed being in a lot of pain, staff reported R1's left leg was discolored, cool to touch with unappreciated pulses. Family requested R1 be transferred to the hospital for further evaluation and management. On 01/16/2025 in the afternoon, the treatment nurse reviewed R1's medical record and indicated the status or condition of R1's left foot should have been documented in the admission skin assessments which were completed by the charge nurse and the other treatment nurse, because the resident was admitted with primary diagnosis of left foot cellulitis. The treatment nurse confirmed weekly skin checks were missed on 04/30/2024, 05/07/2024 and 05/14/2024 could have identified any issues with R1's left foot much earlier. The treatment nurse emphasized being involved in R1's care on 05/19/2024 after a nurse reported R1's multiple skin issues on 05/18/2024 to include abnormalities to R1's left foot. On 01/16/2025 at 3:10 PM, the Director of Nursing (DON) confirmed the facility's practice for nurses to document weekly skin inspections in the electronic health record. The DON confirmed R1's weekly skin check was missed on 04/30/2024 and were completed late on 05/10/2024 (due 05/07/2024) and 05/18/2024 (due 05/10/2024). The DON confirmed weekly skin checks were done by licensed nurses per facility policy for the purpose of identifying new skin impairments and timely interventions. The DON indicated the admission skin assessment should have documented the appearance of R1's left foot due to the fact R1 was admitted with a primary diagnosis of left foot cellulitis. The Skin Integrity policy dated December 2016, documented skin integrity issues were identified post-admission to the facility and the following documented information was required: location and size of wound, description of wound bed, drainage if present, odor, signs and symptoms of infection, description of surrounding tissue and notation of the 24-hour report indicating the skin condition. Complaint #NV00071274

Based on observation, interview, record review and document review, the facility failed to ensure 1) elopement measures were effectively executed for 2 of 5 sampled residents (Resident 1 and 2), and 2) elopement risk assessment tool intervention recommendations were implemented for 1 of 5 sampled residents (Resident 2). The deficient practice had a potential for residents to elope from the facility that could lead to resident's harm. Findings include: 1. Elopement Measures Resident 1 (R1): R1 was admitted on [DATE] with diagnoses including bipolar disorder and psychosis. R1's Psychiatric Follow Up Notes dated 1/4/2024 and 5/9/2024, both documented: Staff Report: confusion, self-talk noted at times, wanders, and dysphoric mood. A physician Progress Note dated 03/25/2024, documented resident was confused and has wondering behaviors. Resident is on frequent monitoring. R1's Physician Order dated 04/21/2024, documented Wanderguard - check placement right arm every shift. R1's comprehensive care plan with a date initiated 09/30/2022, documented the following identified problems and interventions: - Behavior of wandering/ exit seeking related to diagnosis of dementia. Putting resident at risk of getting into unsafe situations. Wander Guard in place. - Resident will have no psychosocial distress related to wandering/exit seeking. Resident will adhere to kind redirection daily as needed. - Administer medications as ordered. Monitor/document for side effects and effectiveness. - Anticipate and meet the resident's needs. - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. - Provide reassurance to help resident feel safe. Ensure Wander Guard is operating properly. Change batteries in Wander Guard as needed. Check device placement. Evaluate effectiveness. - Potential Risk for Elopement Cognitive Deficit, exit seeking behavior (with purpose to leave). History of wandering. - 1 to 1 monitoring due to the risk of elopement. - Monitor the resident interactions with peers to identify escalating tension, frustration, or aggression. - Monitor whereabouts regularly. Recognize unsafe conditions or escalating patterns. - Respond to alarm promptly. On 06/05/2024 at 7:10 PM, R1 was discovered by a certified nursing aide (CNA) missing and could not be found inside the facility. An elopement search was initiated with no discovery of R1 within the facility or the external grounds. The last reported visualization of R1 was at 6:15 PM near the front entry by the receptionist. An Alert Note: Nursing, dated 06/06/2024 at 7:00 PM documented: Addendum to note: Prior to CNA stating could not find R1, the following staff members saw R1 at these times: Night shift nurse on-coming 5:00 PM, saw resident in the 300 Hall. At 5:30PM, the charge nurse on 100 Hall gave R1 ice cream. At 6:00 PM, on-coming CNA, saw resident in the lobby speaking with the receptionist. At 6:15 PM, the receptionist confirmed talking with R1 in the lobby. This was the last time any staff members had seen the resident. On 6/6/2024 at 2:51 PM, the facility was notified R1 had been found and was at a local homeless shelter. R1 was picked up and taken to the hospital for evaluation. Shelter personnel indicated R1 spent the night at the shelter but was unsure as to how R1 got to the shelter. On 06/07/2024 in the afternoon, three license practical nurses (LPNs), an activity staff, a wound care nurse and two CNAs indicated not hearing or responding to any door alarm prior to or around the time R1 was discovered missing. Resident 2 (R2): R2 was admitted on [DATE], with diagnoses including altered mental status and homelessness. Review of R2's progress notes revealed the following occurrences: On 06/4/2024 at 8:20 PM, a nurse Alert Note documented: R2's roommate told a nurse R2 had taken all belongings and left the facility. The nurse assigned to R2 questioned the Resident's roommate regarding this incident in which the roommate agreed R2 had given this information to the Nurse. R2 was found in the dining area fully dressed carrying all belongings counting pennies at the table. R2 stated was trying to buy a soda and wanted to work the puzzle. The nurse asked R2 if everything was okay, R2 stated yes. The nurse asked R2 if the resident was upset or trying to leave the facility for any reason? R2 stated I can't leave all the doors were locked I just want to get a soda. The nurse purchased a soda for R2 and stayed for a few minutes to make sure the resident was fine. R2's CNA arrived and stayed until the resident was ready to go back to room. On 06/05/2024 at 12:00 PM, a General Note documented: CNA was looking for the resident for lunch tray. CNA reported to nurse the resident couldn't be found anywhere inside the building. The nurse informed the charge nurse and called code pink (Missing Resident). R2 was found outside a few meters away from the building. R2 was assisted back inside the facility. Offered water and the lunch tray. The primary physician was notified. On 06/07/2024 at 2:00 PM, a tour of the facility revealed all exit doors were equipped with a door alarm. The door would alarm if opened without entering a code at the panel prior to opening the door. As demonstrated by staff, all door alarms could only be disarmed to the specific alarming door. Staff were to look around the exterior vicinity of the exit door to ensure no resident was able to exit before disarming the alarm. A wanderguard sensor was in place for the main door which would alarm when a resident with a wanderguard came close to the exit door. The facility main entrance had a receptionist present during the hours of 8:00 AM to 7:30 PM. Main doors were kept closed during the hours when there was no receptionist. During the initial tour two LPNs and two CNAs indicated if a resident would have left through the doors, staff would easily have seen them once they looked around the vicinity of the exit door. The receptionist indicated residents who were identified as an elopement risk would be redirected when exiting thru the main door. Review of the surveillance cameras during the time of the elopement revealed no footage was captured. The exterior cameras were limited in numbers and limited to the scope of view with other exit doors not being viewed. There were several identified dead spots not being viewed by the cameras. On 06/07/2024 at 3:15 PM, the Administrator indicated the facility has not had any elopement incidents for a while and was confident the facility had a good elopement measure in place. The Administrator was puzzled as to how the two residents were able to leave the campus and could not tell as to how exactly the residents left the building. The facility policy titled Elopement and Missing Resident dated December 2017, documented review resident identified at risk during the initial walking rounds process, annually and with significant change of condition to ensure ongoing evaluation and adequate plan of care. Initiate interventions to address resident's elopement risk, which may include implementing an electronic alert system such as wanderguard bracelet. 2. Elopement Risk Assessment: On 06/04/2024 at 8:55 PM, the nurse caring for R2 after identifying the new possible elopement behavior entered a Nursing Advanced - Elopement Evaluation: Elopement Evaluation: Recently admitted or readmitted (within past 30 days) and has not accepted the situation: Yes. Elopement Score: 3.0 Actioned clinical suggestions: Nursing - Yes Assessment: Resident at Risk of Elopement - Score 3.0 (Score value of 1 or higher indicates Risk of Elopement). The Care Plan and the Clinical Suggestions section of the Evaluation were not completed. The incomplete evaluation prevented elopement interventions to be implemented. R2's medical record lacked documented evidence a care plan with interventions to prevent elopement were put into place after R2's elopement evaluation had determined the resident was a risk for elopement. On 06/07/2024 in the morning, the Director of Staff Development explained indications of elopement should have a corresponding assessment completed with a care plan intervention initiated. A floor nurse indicated if a resident was noticed to have signs and symptoms of exiting behavior, interventions should have been put into place. Example, every Q15 minutes checks. An LPN indicated triggers for an elopement evaluation would be exit seeking behaviors. If elopement risk score indicates risk, the interventions should be implemented. A corresponding care plan should have been initiated. A Unit Charge Nurse indicated Elopement Evaluations were completed on admission, for at risk patients and change of conditions (ex. exit seeking). The charge nurse reviewed R3's 06/04/2024 elopement assessment and verified a 1 plus or more Elopement Assessment score indicates a risk and interventions should have been in place and a care plan generated, update the staff during staff meetings, picture taken and provided at the main desk. On 06/08/2024 at 12:05 PM, reviewed R2's medical record with the director of nursing (DON) and the assistant DON (ADON). The DON and the ADON indicated any signs of exit seeking would require an elopement assessment. The ADON confirmed the care plan interventions for R2 were implemented on 06/05/2024 (day of the elopement incident) not on 06/04/2024 (day the elopement assessment tool was completed) wherein R2 was flagged as a risk for elopement. The DON acknowledged assessment tools should be coordinated with a care plan and interventions. The DON expressed assessment tools were there to be utilized by nurses to facilitate better care for the residents. The facility policy titled Elopement and Missing Resident dated December 2017, documented if wandering or exit seeking behaviors is identified for any resident who previously had not exhibited this behavior, a change of condition Interdisciplinary Team (IDT) Walking Rounds should be completed. The IDT is responsible for identifying residents at risk for elopement, implementing measures to reduce the risk, and providing a process for action.

Based on observation, interview, and document review, the facility failed to ensure handwashing stations were properly controlled to provide hot water, food items were labeled and dated after opening, and maintain a clean and sanitary environment in the kitchen. The 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. On [DATE] at 8:05 AM, the initial tour of the kitchen was completed with the following findings: - temperature of handwashing stations were measured at 68 degrees Fahrenheit. - there was a black tarry build up under the shelf on the stove. - food and debris were found under the preparation table. - in the dry storage area there were four containers of thickened apple juice which expired on [DATE]. - in the walk-in refrigerator there was an undated, partially used package of ground beef. - by the dishwasher there was a sanitizer station which was continuously leaking onto the counter. On [DATE] at 8:30 AM, the dietitian verbalized maintenance was responsible for adjusting the temperature control for the handwashing stations. The dietitian indicated staff was responsible for ensuring daily cleaning and would complete log once completed. The Dietitian explained it was part of the storage policy to label and date all perishable items in the refrigerator, freezer, and dry storage. On [DATE] at 8:35 AM, the maintenance director indicated monthly logs were completed to verify temperatures in kitchen, the maintenance director completed adjustment of water temperatures while surveyors completed walk through of kitchen. The maintenance director explained when the temperature was low or high the kitchen staff would normally contact maintenance and make a report to have it fixed. On [DATE] at 8:45 AM, in the nourishment rooms the following concerns were identified: - the nourishment room on the 200 unit had expired items in the refrigerator for resident use and several items did not have name or use by date. - the nourishment room on the 300 unit had a container of soup or noodles in a bag which was not labeled or dated, and dietitian believed items belonged to staff. - under the sink the bottom board of cabinet was warped and broken and had orange-brown residue. On [DATE] at 10:56 AM, the Dietary Manager verbalized the appropriate procedure for storage of food items was to label and date all food items in the refrigerator, freezer, and dry storage. Items in the refrigerator and freezer should be labeled with delivery date, opened date, and use by date. The Dietary Manager indicated it was important to label and date items in order to protect against foodborne illness and spoilage of food. The Dietary Manager verbalized the nourishment rooms monitored by both the kitchen staff and nursing staff on the specific unit. The dietary aides would label and date food and snack items while in kitchen and will restock the nourishment rooms. The Dietary Manager explained part of the responsibility while restocking was to also check the expiration dates of items in the refrigerator in the nourishment rooms. The facility policy titled Food Safety in Receiving and Storage (,d+[DATE]), documented expiration dates and use-by dates would be checked to ensure dates were within acceptable parameters. Repackaged food would be placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. The container would be labeled with the name of the contents and dated with the date it was transferred to the new container.

Based on observation, interviews, record review, and document review, the facility failed to ensure a baseline care plan was developed within 48 hours for the use of a leg brace following admission for 1 of 29 sampled residents (Resident 189). This deficient practice could have the potential to result in further injury, delayed recovery, or increased risk of falls, compromising the resident's overall safety and well-being. Findings include: Resident 189 (R189) R189 was admitted on [DATE], with diagnoses including presence of left artificial knee joint, cellulitis of left lower limb, left knee pain and unsteadiness of feet. On 04/23/2024 at 9:10 AM, R189 was seated on the edge of the bed, the left leg was wrapped with a kerlix/ace wrap (elastic bandage) and on top was a black full length knee brace or immobilizer. R189 indicated the brace was applied by the wound care treatment nurse (WCTN) after the completion of the treatment. R189 indicated the hospital provided the brace and was admitted with it. The hospital Transfer/Discharge Summary dated 04/19/2024, documented to maintain knee brace in full extension at all times. The History and Physical dated 04/20/2024, documented to maintain knee brace in full extension at all times. R189's medical records lacked documented evidence the knee brace was assessed and care plan was completed for the use of a knee brace were implemented following R189's admission. On 04/24/2024 at 1:15 PM, a Registered Nurse (RN) indicated upon R189's admission the knee brace should have been assessed and care planned. The RN verified the knee brace had not been identified in the admission assessment and not care planned. The RN indicated there should have been a person-centered care plan within 48 hours which included the goals and care instructions necessary for the use of the full length knee brace. On 04/24/2024 at 2:47 PM, the Charge Nurse in 100 hall indicated upon resident's admission there should have been an assessment, matched with the transfer summary and care planned. The CN indicated the hospital transfer summary should have been reviewed and R189 should have been assessed appropriately, orders obtained, and care planned. On 04/25/2024 at 3:07 PM, the Director of Rehabilitation Services (DORS) indicated R189 was admitted with knee brace to immobilize the left leg post knee surgery. The DORS indicated R189's knee brace was mentioned in the transfer summary. The nursing department was responsible in developing the care plan following R189's admission. On 04/26/2024 at 11:30 AM, the Assistant Director of Nursing (ADON) indicated the admission nurse or the charge nurse was responsible in developing a baseline care plan within 48 hours following R189's admission and the person-centered care instructions orders should have been in place and implemented. A facility policy titled Baseline Care Plan dated 10/2022, documented the facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan would be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission order.

Based on observation, interview, record review and document review, the facility failed to ensure a care plan for range of motion was updated to include a physician's order for a cervical collar for 1 of 29 residents (Resident 82). The deficient practice may have resulted in a delay in the use of the cervical collar potentially causing increased discomfort to the resident due to poor alignment and positioning of the head and neck. Findings include: R82 was admitted on [DATE], with diagnoses including Parkinson's disease and gastrostomy status. A restorative note dated 03/26/2024, revealed R82 had a tendency to lean on one side and would benefit from having a soft collar for repositioning of neck while in bed. Restorative nurse aide (RNA) to obtain order for cervical collar. A physician's order dated 04/17/2024, documented soft cervical collar for repositioning and alignment, on every day shift (AM) and off every night shift (PM). A care plan for range of motion (ROM) initiated 02/07/2024, lacked documented evidence the care plan was revised to include use of a soft collar device on 04/17/2024. On 04/24/2024 at 11:33 AM, the Assistant Director of Nursing (ADON) reviewed R82's care plan and confirmed the care plan was not but should have been updated to include use of the soft collar device which was initially recommended by therapy on 03/26/2024 and ordered by the physician on 04/17/2024. The ADON stated R82's range of motion care plan was not updated due to an oversight. The Comprehensive Care Plan policy (undated), documented the care plan was directed towards achieving and maintaining optimal status of health, functional ability, and quality of life. The care plan was reviewed and revised when there were changes.

Based on observation, interview, record review, and document review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 29 sampled residents (Resident 67). The deficient practice had the potential to deprive the resident of concern and other residents of necessary behavioral health services. Findings include: Resident 67 (R67) R67 was admitted on [DATE], with primary diagnoses including bipolar disorder, new schizophrenia and schizoaffective disorder and a secondary diagnosis of unspecified dementia. On 04/23/2024 in the morning, R67 laid in bed with eyes on television. R67 appeared lethargic with flat affect and spoke softly stating R67 had been in the facility for a long time. On 04/25/24 in the morning, R67 laid in bed with eyes on television and appeared lethargic with flat affect. A PASSAR level one document dated 08/17/2021, revealed R67 did not have dementia, mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility placement. The admission minimum data set (MDS) dated [DATE], documented R67 had a negative PASSAR one (no MI, MR, ID, or RC), impaired cognition, had a diagnosis of bipolar disorder but did not have schizophrenia, schizoaffective disorder, psychotic disorder, or dementia. The quarterly MDS dated [DATE], documented R67 had new diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia. A review of psychiatry notes revealed R67's schizophrenia had an onset date of 03/05/2022, schizoaffective disorder on 12/01/2022 and unspecified dementia on 03/14/2024 and R67 was prescribed Bupropion 75 milligrams (mg) (anti-depressant) and Olanzapine 2.5 mg (anti-psychotic.). The Resident Assessment - Coordination with PASARR program policy dated October 2022, documented any resident who exhibited a newly evident or possible serious mental disorder, intellectual disability and, or a related condition would be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASSAR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority. The medical record lacked documented evidence R67 was referred for a PASSAR level two. On 04/26/2024 at 12:10 PM, the MDS Director confirmed R67 had a negative PASSAR one when first admitted on [DATE] but had new diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia by the completion of the resident's quarterly MDS on 09/15/2022. The MDS Director stated the purpose of PASSAR was to ensure residents were appropriately placed and the facility could meet the needs of the residents. The MDS Director indicated MDS nurses were not involved in the process of identifying and referring residents who met criteria for a new level of care (LOC) assessment or a PASSAR level two referral. The MDS Director deferred to the social services department for information on PASSAR two. On 04/26/2024 at 12:28 PM, the Admission Director indicated being responsible for ensuring all newly admitted residents had a PASSAR level one or two in place. The Admissions Director indicated not being involved in the process of identifying and referring residents who met criteria for a PASSAR two referral after new behaviors and psychiatric diagnoses were identified during their stay in the facility. On 04/26/2024 at 1:20 PM, the Social Services Director (SSD) explained being employed three months ago and was informed the SSD was responsible for completing a form which would be provided to the state PASSAR representatives who came to audit PASSAR two residents during quarterly visits. The SSD indicated not being informed nor trained regarding social services' involvement with identifying and referring residents who met criteria for PASARR two referral. On 04/26/2024 at 1:53 PM, the Director of Nursing (DON) and the Assistant DON were present when the charge nurse verbalized being responsible for monitoring residents who were on psychotropic medications and worked closely with the psychiatrist regarding behavior residents. The charge nurse, DON and ADON indicated the facility currently did not have a process for identifying and referring residents for a new LOC or PASSAR two because the former SSD who used to perform this task was no longer employed at the facility.

Based on interviews, record review, and document review, the facility failed to ensure the resident environment was free of accident hazards and there was adequate supervision to prevent accidents for two sampled residents (Resident 4, and Resident 9). The deficient practice resulted in injury to the residents. Findings include: Resident 4 (R4) R4 was admitted on [DATE] with medical diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or inability to move one side of the body) following cerebral infarction affecting left side and dependence on wheelchair. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed R4 was cognitively intact with a Brief Interview for Mental Status of 14. The MDS documented R4 required extensive, two-person physical assistance for bed mobility, transfers, and toilet use. A Care Plan, undated, documented R4 required assistance to turn and reposition every two hours in bed and wheelchair. The Care Plan indicated R4 required two-person physical assistance for transfers and toilet use. A Quarterly Fall assessment dated [DATE] revealed R4 was a low risk for falls. On 11/07/2023 in the morning, Licensed Practical Nurse 1 (LPN1) indicated had provided care for R4. LPN1 explained R4 was incontinent and wore a brief, did not get out of bed, and required repositioning every two hours. A facility Complaint Referral Intake dated 08/08/2023, documented R4 had explained a staff member was holding the resident from the side and then pushed them to the left which led to a fall. The Complaint Referral Intake revealed R4 reported they were transferred to the hospital where they had a broken clavicle and underwent hip surgery. A facility document dated 06/08/2023, documented Certified Nursing Assistant 1 (CNA1) was changing R4's roommate, heard a thump, and realized R4 was on the floor. On 11/07/2023 at approximately 10:50 AM, LPN1 was the nurse assigned to R4 on 06/08/2023. LPN1 explained CNA1 initially reported they rolled R4 to the side during brief change and pushed R4 too far, R4 started slipping off the bed and they assisted R4 to the floor. LPN1 verbalized CNA1 then explained they were assisting R4's roommate when R4 rolled out of bed. LPN1 indicated when they went into the room of R4, the bed was high, there was urine on the floor, and the brief was off. LPN1 explained CNA1 was attempting to lift R4 from the floor to get R4 back in bed. LPN1 verbalized R4 had a bump on their head and complained of shoulder pain. LPN1 indicated R4 was transferred to the hospital. LPN1 explained prior to CNA1 reporting the fall to them, CNA1 found Certified Nursing Assistant 2 (CNA2) and asked CNA2 to assist them with getting R4 back to bed. LPN1 explained CNA2 refused to assist CNA1 and instructed CNA1 to inform LPN1 so R4 could be assessed. On 11/07/2023 at 11:22 AM, CNA2 explained they were walking down the hall to grab their resident a snack when they observed CNA1 walking out of R4's room looking up and down the hall. CNA1 then started calling CNA2 to come help them get R4 back in bed. CNA2 indicated when they entered the room of R4, R4 was on the floor, urine on the floor, and the bed was a little high. CNA2 explained they told CNA1 they needed to notify R4's nurse first before putting R4 back in bed because the nurse needed to assess R4. CNA2 refused to help CNA1 until R4's nurse was informed. CNA2 explained CNA1 did not tell them what occurred and once R4's nurse arrived to the room CNA2 walked out. On 11/07/2023 in the morning, the Director of Nursing (DON) indicated the fall was unwitnessed. The DON explained CNA1 reported care was provided to R4 and then proceeded to provide care to R4's roommate. The DON indicated as CNA1 was leaving the room they heard R4 fall off the bed. The DON explained CNA1 asked another CNA to assist them with getting R4 back into bed versus reporting the fall to R4's nurse. The DON indicated CNA1 did not follow protocol and had endangered R4. The DON explained R4 was found on the floor, urine and brief were on the floor. A review of records revealed R4 did not return to the facility after being transferred to the hospital. A Hospital History and Physical dated 06/30/2023, documented R4 was admitted to the hospital on 06/08/2023 after falling out of bed. The History and Physical revealed R4 reported falling out of bed when they were rolled over, while their sheets were changed. The History and Physical revealed R4 had a right clavicle fracture, right hip fracture, and underwent right partial hip arthroplasty on 06/11/2023. The facility's policy titled Resident Rights revised on 10/23/2023 indicated the resident has a right to a safe environment, including but not limited to receiving treatment and support for daily living safely. Complaint #NV00069166 46265 Resident 9 (R9) R9 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and flaccid hemiplegia affecting right dominant side. A Brief Interview for Mental Status (BIMS) score of 99 indicated the resident was not able to complete the interview. A Comprehensive MDS dated [DATE] documented R9 was extensive, two-person assist with bed mobility and transfer. A Care Plan dated 05/03/2023 documented R9 was one-person physical assist for bed mobility and transfers. A fall assessment note dated 11/03/2023, documented the CNA reported resident fell out of bed while brief was being changed. The CNA indicated R9 was at the edge of the bed and CNA went to the other side to pull R9 close to the middle of the bed, the CNA grabbed the draw sheet and started to pull and R9 fell to the floor with head striking the floor causing a laceration. The nurse arrived in the room and noted the bed was in high position and R9 was on the floor bleeding from the head. A progress note dated 11/03/2023 documented R9 was received in room being transported back to facility after visit from emergency room . R9 was received with four staple wire sutures on laceration on right side of head. On 11/07/20 23 at 2:07 PM, CNA3 explained during turning and repositioning the CNA should ensure the resident was positioned in the middle of the mattress, use pillow to assist at back or legs of resident, and keep head slightly elevated. CNA3 indicated it was not standard practice to position or leave a resident at the edge of the bed due to concern of resident falling. The CNA verbalized for a resident at the edge of the bed the CNA would remain on same side and reposition resident towards the middle of the mattress or request assistance if needed. CNA3 was familiar with R9 but was not aware of the resident fall or a history of falls. CNA3 reported the nurses would document in the electronic medical record of fall precautions for a resident and verbally inform the CNAs of fall precautions and care for resident. If a resident was a total care resident or a new resident that was not yet assessed, CNAs always utilized two staff members to assist with care. 11/7/23 at 2:18 PM, CNA4 was familiar with R9 and verbalized the CNA often requested another staff member to assist with turning and repositioning of R9. CNA4 advised it would not be appropriate to push a resident, instead pull on the sheets under the resident towards the CNA's body to avoid a resident from rolling or falling. The CNA would position a resident in the middle of the mattress and use pillows as needed under the resident. The CNA would not leave the resident on the edge of the bed at any time due to being afraid a resident may fall. If a resident was on the edge of the bed, the CNA would stand on the same side of the bed and call out for help from another staff member. In addition, the CNA described they would remain on the same side of the bed as the resident, reach over the resident, and pull the sheets under the resident to reposition them towards the middle of the mattress. The CNA indicated it was not appropriate to leave a resident on the edge of the bed to go to the opposite side/edge of the bed to reposition the resident due to the concern of the resident potentially falling. On 11/07/2023 in the afternoon, an RN indicated being very familiar with R9 who was totally dependent on staff for care. The RN indicated R9 was on an air-loss mattress and was occasionally combative during ADL care and in the RN's professional opinion R9 required two persons during ADL care. The RN reviewed R9's medical record and confirmed R9's MDS assessment and care plan did not match, and it should. The RN confirmed the MDS assessment documented R9 required two persons for bed mobility and toileting and the care plan reflected one person assistance was sufficient. On 11/7/23 at 2:27 PM, the Assistant Director of Staff Development explained CNA staff learned how to reposition/turn a resident during their course of education. The facility does not provide formal training on how to reposition/turn a resident. New CNA staff would orient with existing CNAs who may show them how to reposition and turn a resident. The Assistant Director of Staff Development was not on the floor with the new staff to confirm how they were shown to reposition/turn a resident. On 11/07/2023 in the afternoon, an Assistant Director of nursing indicated being a former MDS nurse and indicated the MDS assessment drove the resident's plan of care. The ADON indicated R9's quarterly MDS assessment revealed R9 required extensive assistance by two persons for bed mobility and toileting. R9's care plan dated 04/27/2023 and revised 11/02/2023 indicated R9 required one person to bed mobility and toileting. The ADON confirmed R9's MDS assessment did not align with the ADL care plan. On 11/07/2023 at 3:00 PM, the DON indicated if the MDS assessment revealed R9 required two persons for bed mobility and toileting, then the care plan must also reflect two persons were required to provide R9's ADL care. Complaint NV00069760

Based on interview, clinical record review, and document review the facility failed to ensure a resident's physician was notified of a change in a resident's condition for 2 of 5 sampled residents (Resident #1 and # 4). The facility failed to ensure their policy for the refusal of medication was followed for 1 of 5 sampled residents (Resident #3). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was transferred to an acute care hospital on [DATE]. 1) The computer generated Activity of Daily Living (ADL) sheets dated [DATE], indicated Resident #1 had a medium stool on the evening shift and a large watery stool on [DATE] on the night shift. On [DATE] during the night shift, the resident had a medium stool and two medium watery stools. On [DATE] on the day shift, the resident had a medium stool, a small watery stool on the evening shift and a small stool on the night shift. On [DATE] on the day shift, the resident had 2 large stools, a large watery stool on the evening shift, and 2 large watery stools on the night shift. On [DATE], a large watery stool on the day shift. The clinical record lacked documentation a Change of Condition form had been completed or the resident's physician notified of the watery stools on [DATE], [DATE], [DATE] and [DATE]. Physician's Progress Notes dated [DATE] and [DATE], lacked documentation the physician was aware of the resident's loose watery stools. 2) The physician's orders [REDACTED]. The area on the form under fluid/medication orders/stop date documented Na Cl 0.9 % (Sodium Chloride) times 1 liter at 55 ml per hour. The Medicare Skilled Documentation notes dated [DATE] indicated the resident's vitals were: temperature 98.0, pulse rate 76 and respirations 20. Orientation times 2, lungs clear, skin turgor fair, oral membranes moist. The date of last bowel movement [DATE]. The Ohio State University Medical Center website documented the normal body temperature can range from 97.8? F (or Fahrenheit, equivalent to 36.5? C, or Celsius) to 99? F (37.2? C) for a healthy adult. The normal pulse for healthy adults ranges from 60 to 100 beats per minute. Normal respiration rates for an adult person at rest range from 15 to 20 breaths per minute. The normal blood pressure as follows: Less than 120 mm Hg (millimeters of mercury) and systolic pressure and Less than 80 mm Hg diastolic pressure. The Narrative Nurse's Noted dated [DATE] at 11:00 AM, documented asleep, opens eyes with touch, all morning medications given via [DEVICE]. Alert noted agitation. Vital signs at 9:00 AM, blood pressure ,[DATE], pulse rate 103, respiratory rate 30 and temperature 98.4. The physician was notified. Received new orders for Chest x-ray, Electrocardiogram (EKG) and NS (Normal Saline) 1 liter at 55 milliliters (ml) per hour. The Narrative note lacked documentation the resident had nausea or vomiting. Documentation entitled, Infusion Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The form documented NS (Normal Saline) 55 ml/hr. The Infusion Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Change of Condition form indicated on [DATE] at 3:50 PM, the resident was unresponsive, the resident was a full code, and current blood sugar level was 361. The resident was "comatose", lung assessment with rhonchi, irregular heart rate-thready, dyspnea at rest, cool extremities. The gastrointestinal status was documented as nausea and vomiting. The form lacked documentation to indicate the resident had been having watery stools on [DATE] through [DATE]. The Narrative Nurse's Notes dated [DATE] at 4:00 PM documented Patient sent to the acute care hospital due to unresponsiveness and labored breathing. Oxygen saturation 58%. "MD (physician) made aware." The Narrative notes lacked documentation the resident had nausea or vomiting. The web site www.mayoclinic.com/health/hypoxemia/MY , documented normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. The clinical record lacked documentation Resident #1 had received the Na Cl 0.9 % times 1 liter at 55 ml per hour in accordance with the physician's orders [REDACTED]. The Acute Hospital Transfer Record dated [DATE] documented the resident's vitals were temperature 98.0, pulse ,[DATE], respiration 42 and blood pressure ,[DATE]. Oxygen saturation was 58%. The resident was orientated to person and place and had a catheter in place. The reason for the transfer was documented as non-responsive, lethargic, rapid respirations, hypertensive, nausea and vomiting and thready pulse rate. The resident was transferred to an acute care hospital on [DATE] at 4:00 PM. The Acute Hospital Transfer form lacked documentation the resident had watery stools on [DATE] through [DATE]. On [DATE] at 1:00 PM, the Assistant Director of Nursing (ADON) stated if a Certified Nursing Assistant (CNA) told a nurse a resident had ,[DATE] watery stools the physician would be called, an order obtained for stool for [MEDICAL CONDITION] Toxin (C- diff) times 3 and depending upon the physician Intravenous Therapy Fluid (IVF), [MEDICATION NAME] antibiotic's given and the resident placed on isolation. The ADON stated this would be considered a change in a resident's condition. During the interview the ADON stated if a resident was found unresponsive she would call their name, check Airway, Breathing and Circulation (ABC's) call for help, start IV line, other staff would check the chart for code status and call the physician, call 911, if required perform Cardiopulmonary resuscitation (CPR), notify the family and await 911. When 911 arrived provide them with resident's diagnoses, the condition prior to the event, a current medications list and the History and Physical (H&P). On [DATE] at 11:00 AM, a Licensed Nurse (LN) verbalized diarrhea, a fall, a temperature or watery eyes could indicate a change in a resident's condition, anything different for the resident. The LN stated when there was a change in condition the physician would be contacted and a change of condition form completed. The LN indicated the care plan for the loose/watery stools would be on the back of the change of condition form. The LN reviewed the ADL sheets and confirmed the resident had watery stools on [DATE], [DATE], [DATE] and [DATE]. The LN indicated a change of condition form should have been completed and the physician called. The LN was not able to locate documentation a change of condition form had been completed or the physician had been notified regarding the resident's watery stools. The LN was not able to locate documentation in the nurse's notes regarding the watery stools. The LN stated it was the Registered Nurse/Licensed Practical Nurse's responsibility to know what was going on with the resident. The LN stated after 3 watery stools the physician should be notified and a stool specimen obtained. The LN indicated the loose/watery stool should be care planned. During the interview on [DATE] the LN was not able to locate documentation Resident #1 had received the IVF as ordered on [DATE]. The LN stated the resident was admitted to the facility with a PICC line in his right upper arm. The LN was asked what warranted the physician's orders [REDACTED]. The LN stated "Probably the diarrhea." The LN stated she was not able to tell from the clinical record what prompted the nurse to call the physician. The LN stated she was not able to locate documentation in the clinical record the IVF had been given in accordance with the physician's orders [REDACTED]. There was not a clear picture of why the resident needed the IVF. The LN was asked if the documentation gave a clear picture of what happened before, during or after the event. The LN stated "No". On [DATE] at 2:30 PM a Licensed Nurse (LN) stated the signs and symptoms of dehydration included, dry cracked lips and tongue, the vital signs would be low with dehydration depending upon the state of dehydration. The pulse rate would be thready and irregular and dehydration can cause the respiratory rate to increase. The LN indicated the laboratory work would show increase in Blood Urea Nitrogen (BUN), [MEDICATION NAME], Potassium, Sodium. The LN was asked if a resident had watery stools times 3 days could this cause dehydration. The LN stated, Of coarse", it was symptomatic of [MEDICAL CONDITION], a definite sign something was not right. The LN verbalized the resident would need to be isolated, a stool specimen obtained per a physician's orders [REDACTED]. On [DATE] at 12:50 PM a Registered Nurse (RN) verbalized the signs and symptoms of dehydration were dry, sunken eyes, dry mouth, dry skin, low blood pressure and increased heart rate due to the body trying to compensate. The RN indicated the pulse rate could be thready. The RN was asked if a resident had watery stools times 3 days can this cause dehydration. The RN stated, "Yes", the change of condition form would be completed and the physician called. The situation would be explained to the physician and await physician's orders [REDACTED]. The RN stated the facility had Normal Saline IVF available in stock at the facility. If the physician had ordered IVF it should be started right away. The IVF was documented on the IV sheet. The initials of the nurse on the form documented the time the IVF bag was hung. The clinical record form the Acute Care Hospital contained a Comprehensive Metabolic Panel dated [DATE] at 5:00 PM. The laboratory results were as follows: Sodium 165 critical (normal reference range ,[DATE] MMOL Millimole/Liter) Potassium 5.7 high (normal reference range 35.-5.1 MMOL/L) Chloride 128 high (normal reference range ,[DATE] MMOL/L) Glucose 326 high (normal reference range ,[DATE] Milligrams/Deciliter MG/DL) BUN 161 high (normal reference range ,[DATE] milligrams/deciliter, mg/dl) [MEDICATION NAME] 9.5 high (normal reference range 0.6- 1.5 mg/dl) The Complete Blood Count dated [DATE] at 5:00 PM, documented the following: WBC 2.60 low ( reference range 4.30- 12.00 Kilograms MilliMoles Cubed, K/MM3) RCB 3.58 low (reference range 4.50 - 6.00 K/MM3) HCT 34.2 low (reference range 39XXX,[DATE].0 percentage) HGB 10.9 low (reference range 13XXX,[DATE].0 Grams/Deciliter) Immunochemistry Serology test dated [DATE] documented positive for [MEDICAL CONDITION] Toxin. Reference range negative. The Emergency Department Admit note dated [DATE], documented the patient was found unresponsive at a skilled nursing facility by staff member who called 911. According to the Emergency Medical Service (EMS) the patient was down and unresponsive for approximately 1 hour prior to the phone call. EMS stated that when they arrived they found an unresponsive patient lying on the floor. They assessed the patient and found that he was not responding verbally or in any other way to their stimuli. They intubated him immediately. EMS indicated the patient was hypotensive and had an accu-check blood sugar of 330's. Initial vital signs temperature 99.6, respirations 25, heart rate 115, blood pressure ,[DATE]. A Foley catheter was in place. PEG tube in place. The patient had a PICC line in place in the right upper extremity. Peripheral pulses were difficult to palpate. The patient's extremities were cool to the touch. The skin was cool and dry. Clinical Impression included: Septic shock, Altered mental status, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Hospital History and Physical dated [DATE] documented the patient was brought to the hospital by EMS. Temperature 101, pulse 115, respiratory rate 29, blood pressure ,[DATE]. The patient was intubated and was not following commands. Sodium 164, potassium 5.7, chloride 128,. EKG showed [MEDICAL CONDITION] The documentation indicated in part "he looks dehydrated..." "The patient had [MEDICAL CONDITION] most likely secondary to dehydration."... On [DATE] from 10:00 AM to 10:20 AM, a Physician from the Acute Care Hospital stated Resident #1 had a respiration rate of 30 times a minute inidcated the patient was breathing very abnormally. The Physician verbalized the resident was hypotensive when he saw him along with dehydrated and septic. The Physician verbalized the clinical signs and symptoms of dehydration would be: -[MEDICAL CONDITION] -confusion -decrease urinary out put -dry mucous membranes The Physician indicated if the dehydration was bad enough the patient/resident could be hypotensive. The facility's policy entitled, Managing Change of Condition updated ,[DATE], documented Objective: To appropriately assess, document and communicate Change of Condition (COC) to the primary care provider. To provide treatment and services to address changes in accordance with resident needs and existing Advance Directives. The documentation indicated if the change in condition does not appear life-threatening to notify the physician and responsible party of the assessment findings and to document the assessment findings and communications. Resident #4 Resident #4 was admitted to the facility on [DATE] and transferred to the Acute Care Hospital on [DATE] with [DIAGNOSES REDACTED]. The computerized ADL sheets dated [DATE] documented the following bowel movements: On [DATE], a large watery stool. On [DATE], 3 medium stools On [DATE], 2 medium watery stool, medium stool and small stools. On [DATE], a medium stool, large watery stool and a medium watery stool. The Nurse's notes dated [DATE] through [DATE] lacked documentation the resident had watery stools or the physician had been contacted regarding the watery stools. The Post-Fall Documentation Flow Sheet dated [DATE] documented at 2:45 AM, the resident was resting, no shortness of breath noted. No change in level of consciousness noted. Vitals stable. No complaint of pain/ discomfort. No nausea or vomiting noted. Neurological checks with in normal limits. Call light in reach. Orientated times 3 and the resident was alert. Will continue to monitor. The resident's vitals signs were documented as temperature 96.4, pulse rate 100, respirations 16 and Blood pressure ,[DATE]. The Medicare/HMO Skilled Documentation Flow Sheet dated [DATE] at 11:55 AM, documented patient "is lethargic" pain medication held due to decreased blood pressure and lethargy. Vital signs: temperature 97.0, Blood pressure ,[DATE], pulse rate 105 and respirations 20. Orientated to person, place and time, lungs clear, bowel sounds normal times 4, skin turgor fair. The Medicare/HMO Skilled Documentation Flow Sheet dated [DATE] at 11:55 AM, lacked documented the resident's physician had been notified the resident's orientation changed from alert to lethargic. The Flow Sheet lacked documentation the resident had watery stools [DATE], [DATE] and [DATE] per the computerized ADL sheets. The Post-Fall Documentation Flow Sheet dated [DATE] at 3:50 PM, documented patient in bed resting- "lethargic". Denies hitting head. Decreased blood pressure, "all meds (medication) held". Blood pressure ,[DATE], pulse 105, respiratory rate 20 and temperature 97.0. Oriented to person and place, lethargic and no nausea or vomiting. The form lacked documentation the resident's physician had been notified the resident was lethargic or had watery stools on [DATE], [DATE] and [DATE]. The Medicare/HMO Skilled Documentation Flow Sheet Narrative Notes dated [DATE] at 3:30 PM, documented the resident was unresponsive. BP was at ,[DATE]. Placed on oxygen at 2 liters via nasal cannula. "Tried to put in IV access, but no veins could hold it since they're very small and constricted." Called 911. Resident discharged and sent to (name of hospital). Doctor notified. Family as well. The Post- Fall Documentation Flow Sheet dated [DATE] at 3:55 PM, indicated sent to (name of hospital). Patient unresponsive with Blood pressure of ,[DATE]. The Change of Condition form dated [DATE] documented at 3:30 PM the resident's Blood Pressure (BP) was ,[DATE], temperature 97.8, pulse 120, respiratory rate 26. The resident was lethargic, lungs clear and heart rhythm irregular. the documentation on the form indicated the physician was notified on [DATE] at 5:35 PM. Documentation on the Nurse's Progress Note indicated on [DATE] at 3:30 PM, "patient is found with BP: ,[DATE] pulse 120- lethargic-called MD (physician)-send to 911." The Change of Condition form dated [DATE] lacked documentation the resident had watery stools on [DATE], [DATE] and [DATE]. On [DATE] at 9:30 AM, the Assistant Director of Nursing (ADON) stated the nurse's note dated [DATE] at 11:55 AM documented the patient was lethargic. The ADON stated if a resident's condition changed from alert to lethargic this was a change in condition. The ADON was not able to locate documentation the physician had been contacted. The ADON stated I do not see anything in the note. The ADON was not able to locate documentation a Change of Condition form had been completed per the facility's policy. The ADON was asked to review the computerized ADL sheets for [DATE]. The ADON was asked if the physician should have been contacted for loose stools 5 times in 3 days. The ADON stated "yes, It's a change in condition." The ADON was not able to locate documentation the physician had been contacted regarding the watery stools or a Change of Condition form had been completed per the facility's policy. The Emergency Department (ED) Admit Note dated [DATE] documented the patient was found to have vitals of ,[DATE], pulse 120, tachypneic at 26, and much less responsive, rapid respirations. Paramedics found the patient unresponsive and intubated the patient. The daughter said she actually told them that she felt a little confused last night like she was not thinking clearly and though she might have Alzheimer's, but had otherwise been doing fine. According to the nursing notes the patient had diabetes, gout, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. The ED note documented Physical Examination: A Foley catheter was placed. The staff removed her diaper and she had "a bunch of bloody diarrhea". The patient's glucose was around 57. The documented Impression: [MEDICAL CONDITION], Hypothermia, Leukocytosis, Bloody diarrhea and [DIAGNOSES REDACTED]. The documentation indicated the patient received fluids and "she is still not urinating". Documentation from the Acute Care Hospital dated [DATE] Comprehensive Metabolic Panel indicated the following at 4:29 PM. Sodium 138 normal Potassium 4.2 normal Chloride 105 normal Glucose 37 low (reference range ,[DATE] MG/DL) BUN 52 high (reference range ,[DATE] MG/DL) [MEDICATION NAME] 3.9 high reference range 0XXX,[DATE].5 MG/DL) Calcium 7.5 low (reference range 8XXX,[DATE].2 MG/DL) A Urinalysis report dated [DATE] at 9:40 PM, documented urine color yellow, appearance turbid, blood 3+ (normal range negative), protein 1+ ( normal range negative). The physician's orders [REDACTED]. The Adult Critical Care Flow Sheet dated [DATE] at AM Assessment documented the resident's last bowel movement was [DATE], color bloody and the was consistency liquid. The Adult Critical Care Flow Sheet dated [DATE] at PM Assessment documented the resident's last bowel movement was [DATE] and bowel sounds were hypoactive. Documentation from the Acute care Hospital indicated on [DATE] at 1552 the patient was asystole at 1550. No heart ones, pulse or respiration. Pronounced at 1552. On [DATE] from 10:00 AM to 10:20 AM, a Physician from the Acute Care Hospital indicated BUN and [MEDICATION NAME] were "pretty" elevated from the Complete Metabolic Pannel, and the Glucose was very low. The Physician stated the patient's/ resident's immune system was decreased and she was very susceptible to infection. The Physician stated the patient could have been septic from [MEDICAL CONDITION]. The Physician indicated watery stools can cause a patient/resident to be dehydrated. The Physician stated the patient/resident "looked clinically dry" (mild dehydration) based on the laboratory results. Resident #3 Resident #3 was admitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. On [DATE] at 4:00 PM, a Registered Nurse (RN) confirmed the clinical record lacked documentation the resident's physician had been notified for the refusal of the [MEDICATION NAME] and [MEDICATION NAME] from [DATE] through [DATE]. The RN stated the physician should have been notified. On [DATE] at 11:00 AM, a LN stated [MEDICATION NAME] was a form of [MEDICATION NAME]. The LN stated the physician should have been called regarding the resident's refusal of the medication. The LN confirmed the clinical record lacked documentation the physician had been notified the resident refused the [MEDICATION NAME] from [DATE] through [DATE]. The LN stated per the facility policy after a resident refused medication for 3 days the physician needed to be told. The LN it would be important the physician knew a resident had been refusing insulin. The LN stated the policy had not been followed. The facility's policy entitled, Resident Medication Rights dated revised ,[DATE], documented the facility should notify the physician/Prescriber of a resident's refusal of medications/treatment for [REDACTED]. The facility should notify the physician/prescriber immediately if the refused medication could affect the health or safety of the resident. Complaint #NV 167

Based on observation, interview, record review, and document review, the facility failed to ensure necessary care and services were provided for 7 of 32 sampled residents (Resident #8, #11, #14, #22, #5, #6, and #7) and for 1 unsampled resident (Resident #34). Findings include: Resident #8 Resident #8 was a [AGE] year-old admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's Telephone Orders for 12/6/10, revealed an order for [REDACTED]. Further review of the resident's record revealed no documented evidence as of 1/25/11, a dental consult had occurred. Weight records maintained in the facility's electronic charting indicated the resident had lost weight following the re-admission on 11/14/10. On 1/27/11 at 2:40 PM, the Unit Manager indicated Resident #8 was on Medicare and Medicare does not pay for dental assessments. She indicated the resident was recently accepted for Medicaid on 1/11/11. Resident #11 Resident #11 was a [AGE] year-old admitted to the facility 1/13/11, with [DIAGNOSES REDACTED]. The initial physician's orders [REDACTED]. An entry noted in the Medicare/HMO (Health Maintenance Organization) Skilled Documentation Flow Sheet for 1/26/11, revealed the resident had an indwelling catheter still in-place, 13 days following the resident's admission. It was noted that the elimination mode for the resident's bladder was a catheter and the resident had received catheter care. There was no documented evidence of new orders for the continued use of the indwelling catheter. Resident #34 Resident #34 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #34's Telephone Orders dated 12/31/2010, documented: -"...change diet consistency to mech (mechanical) soft c\ (with) nectar thick liquids..." On 1/25/2011, in the morning, Resident #34 was sitting up at the bedside eating breakfast. A sign on the wall above the head of the bed for Resident #34 posted, nectar thick liquids. On the resident's tray were thickened water and thickened coffee. Beside the tray within the resident's reach was a pitcher of (regular) water and a cup half-filled with (regular) water. The surveyor interviewed the Minimum Data Set (MDS) Coordinator (Employee #20) regarding the clear liquids at the resident's bedside. The MDS Coordinator then removed the pitcher and cup that contained (regular) water. Resident #34's Comprehensive Plan of Care, dated 12/14/2010, documented the problem of decreased safe swallowing skills. The goals section of the form documented the resident will tolerate thin liquids. The 12/14/2010, the comprehensive plan of care was not updated to reflect the change to nectar thick liquids. There was no new comprehensive plan of care initiated regarding the change to nectar thick liquids. Resident #22 Resident #22 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 1/25/2011, in the morning, the resident's left side of the bed was located next to the wall and the foot of the bed faced the door opening of the room. The privacy curtain was located at the foot of the bed, and when fully extended, no one could see the bed or the resident when standing outside the room. That morning the door was closed and the curtain was fully extended, hiding the resident. The resident's bed was in a low position and the cushioned floor mat was folded with a corner portion of the pad leaning against the top right edge of the mattress. The position of the floor mat exposed the entire floor and presented a safety hazard for the resident if the resident fell . The MDS Coordinator indicated the resident sometimes moves the floor mat herself. On 1/26/2010, in the afternoon, Resident #22 was asleep in bed with the floor mat folded and leaning against the wall. Resident #22's Telephone Orders form, dated 11/8/2010, documented: -"...low bed c\ (with) mat on floor for safety..." Resident #22's Fall Risk Care Plan, dated 10/22/2010, did not reflect the new order made on 11/8/2010, for a low bed with a mat on the floor for safety. Care plans regarding falls, dated 11/20/2010 and 12/13/2010, did not document interventions for a low bed and mat on the floor for safety. Resident #14 Resident #14 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #14's January 2011 physician's orders [REDACTED]. -"...Diet: Puree, Large portions @(at) all meals..." On 1/26/2011, in the afternoon, Resident #14 was being fed by the certified nursing assistant (CNA). Resident #14 had moderate amounts of food around her mouth and on her bib due to her drooling when the CNA was feeding her. Resident #14's IDT (interdisciplinary team) Care Plan was initially dated 1/9/2006. The last evaluation date was on 12/2010. (The next re-evaluation date was 3/2011.) The form documented: -"...Problem...(Resident #14) is at risk for aspiration D/T (due to) dysphagia." -"...Approach 1) Assess respiratory status for S/S (signs and symptoms) of possible aspiration - diminished breath sounds - cough - increased resp (respiratory) rate - sputum production. 2) Monitor V/S (vital signs) as ordered. 3) Encourage resident to cough to clear secretions. 4) Have (Resident #14) at 90 degrees for all meals. 6) Thickened liquids as ordered. 7) Give small bites/sips - alternating liquids with solids. 8) No straws. 9) Give good oral care AM & PM and prn (as needed). 10) Diet as ordered. 11) Report pocketing of food. 12) ST (speech therapist) eval (evaluation) & approaches." On 1/28/2011, in the morning, the Director of Activities in charge of the volunteer program indicated that volunteers were not allowed to feed residents. The Director of Activities was not aware who was the female visitor for Resident #14, since the volunteer did not fill out a volunteer application. The Director of Activities was not aware that a group of people were coming into the facility to assist with feeding some residents. On 1/27/2011, in the evening, an unknown female was seen entering Resident #14's room waiting for dinner trays to be passed out. On 1/27/2011, in the evening, the licensed practical nurse (LPN) was asked who entered Resident #14's room. The LPN did not know who entered Resident #14's room, but she indicated that the person may have been a volunteer to assist with feeding the resident. On 1/28/2011, in the morning, a day shift CNA indicated the facility uses volunteers, usually in the assisted dining room. The CNA indicated the volunteers help feed the residents. On 1/27/2011, in the evening, the female volunteer was observed feeding Resident #14 in the resident's room. The volunteer indicated the following: -She was a volunteer who had assisted with Resident #14's feeding for the past 3 years. -Sometimes the receptionist had the volunteers sign in when they come in, but usually they would just walk into the facility without checking in with anyone and go right to the residents' rooms. The nurses who were passing out trays were aware that they were helping feed the residents. -She (the volunteer) was given an application by the facility, but had not filled out the application yet. -She (the volunteer) has not received training, but would like to receive training related to care and feeding. -A large group of volunteers had come at times to visit and assisted with the feeding of the residents. -Resident #14 usually takes more than an hour to eat her dinner meal. -Resident #14 would sometimes spit out her food or pockets the food in the side of her mouth. If the resident started to choke, the volunteer would feed the resident slower. If the resident was to choke, she wouldn't know what to do other than just push the call button. On 2/1/11 at approximately 5:30 PM, the Dietitian indicated she was not aware that Resident #14 was being fed by a volunteer. She further indicated she was not aware of any volunteers coming into the facility to feed any residents. (IMMEDIATE JEOPARDY) Resident #5 Resident #5 was originally admitted [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. On 1/26/11, there was no documented evidence on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 1/26/11 at 3:45 PM, the Unit Charge Nurse verified the [MEDICATION NAME] had not been administered to Resident #5 as ordered by the physician. Resident #6 Resident #6 was admitted [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. On 1/25/11, Resident #6 was observed to be sitting in the wheelchair with her feet below and behind the foot rests. Interview with the Charge Nurse as why the resident was sitting in that position, the Charge Nurse indicated the resident was unable to bend her feet to adjust to the foot rests due to contractures. On 1/27/11, the Restorative Therapy Aide was observed assessing the range of motion for Resident #6 while the resident was laying in bed. The Aide verified Resident #6 had bilateral foot contractures, was receiving passive range of motion by the Restorative Department, was not receiving active range of motion (AROM), and was not using splints. The Aide further indicated it would be the Physical Therapy's role to recommend splints for the feet to prevent further decline of range of motion/contractures. The Aide indicated the Physical Therapy Department was not involved with Resident #6's care, as the resident was only evaluated for Physical Therapy services and was no longer considered a candidate for physical therapy. The Aide was unable to indicate whether the bilateral foot contractures had worsened since the resident's admission, indicating that the Restorative Department does not do any measurements. The Physician's Recaps (Recapitulations) indicated, "8/4/10: RNA Program for AROM/PROM and bed mobility." There was no documentation the facility had provided AROM for Resident #6 as ordered by the physician. The MDS Assessments for Assessment Reference Dates (ARD's) 2/8/11, 2/11/10, 3/3/10, 3/31/10, 4/30/10, 7/28/10, 8/28/10, and 11/24/10, indicated 0/0 coding for Function Limitations/Range of Motion. Note: 0/0 represents No Limitations in Range of Motion and No Loss in Voluntary Movement. On 2/1/11, the MDS Coordinator (Employee #20) verified that the 0/0 coding on the above MDS assessments were erroneous. The MDS Coordinator also confirmed there was no Plan of Care generated and implemented for the contractures due to the erroneous 0/0 coding. Summary for Resident #6: The facility failed to ensure accurate assessment of the contractures, continued monitoring and intervention by the rehabilitation department to prevent further decline of range of motion and provide AROM as ordered by the physician. Resident #7 Resident #7 was admitted [DATE], with [DIAGNOSES REDACTED]. On 1/25/11 through 2/2/11, Resident #7 was observed with multiple contractures. On 2/1/11 at 5:30 PM, it was confirmed by observation during the MDS (Minimum Data Set) Coordinator's (Employee #21) assessment that the resident had contractures to the left elbow, left hand, left fingers, right hand, right elbow, bilateral toes, bilateral knees, bilateral feet, and bilateral ankles. The left hand and fingers were severely contracted, and close proximity to each other. The bilateral knees were severely contracted above the bed in a bent position. The Nursing Admission Assessment, dated 6/4/10, indicated contracture sites as bilateral feet, bilateral hands and fingers and further stated: "Doing full passive ROM (range of motion) on UE (upper extremities)/uarm (upper arm), unable to do ROM on LE (lower extremities)." The Nursing Assessment did not include the contractures to the bilateral knees, bilateral ankles, bilateral toes, left elbow, and right elbow. The MDS Assessments indicated the following (MDS - Functional Limitation in Range of Motion (sections for a. neck; b. arm; c. hand; d. leg; e. foot; f. other limitation or less) and (0/0 represents No Limitation in range of motion and no loss in voluntary movement.)): 6/14/10: 0/0 7/2/10: 0/0 7/30/10: 0/0 8/9/10: 0/0 8/31/10: 0/0 12/17/10: 2=Impairment both sides; 2=Upper Extremity (shoulder, elbow, wrist, hand); and 2=Lower Extremity (hip, knee, ankle, foot) The Interdisciplinary (IDT) Care Conference Notes/Walking Rounds (signed off by the DON (Director of Nursing) indicated the following inconsistent documentation regarding Resident #7's functional limitation/ROM: 6/15/10: No ROM limitations listed (section is blank); 8/18/10: No ROM limitations listed (section is blank); 8/26/10: "Functional Limitation: None UE/LE" 10/21/10: "Functional Limitation: None UE/LE" 11/22/10: "Functional Limitation: Both Sides UE/LE" 12/1/10: "Functional Limitation: One Side U/E, Both Sides L/E" 1/17/11: "Functional Limitation: One Side U/E, One Side L/E". On 2/1/11 in the late afternoon, in response to questions of how the facility was aware of, and tracked, how many residents were with contractures, the MDS Coordinator (Employee #21) indicated there was no system for nursing to track the number of residents with contractures (including the number of resident who obtained the contractures after admission to the facility), and that the only way was to review the MDS reports. On 1/26/11, the other MDS Coordinator (Employee #20) indicated it was the process to assess range of motion by observing and attempting to move each limb of the resident in order to demonstrate limits of range of motion of residents with contractures. The MDS Coordinator indicated the resident probably did have contractures in bilateral upper and bilateral lower extremities upon admission, and that the 0/0 coding was erroneous. The MDS Coordinator also confirmed there was no Plan of Care generated and implemented for the contractures due to the erroneous 0/0 coding. The Procedure (undated) provided by the DON regarding the completion of the MDS indicated as follows: "1. The appropriate sections of the Minimum Data Set are completed by the Nutrition Services Manager, Dietitian or Nursing (Section K of MDS is at least completed, others may be assigned as facility designates interdisciplinary team responsibilities.) 2. The MDS, trigger legend and RAP (Resident Assessment Protocol) summary are completed by day fourteen from admission day or by day 5 for Medicare. 3. The appropriate care plan content is completed within 14 days of admission by the Nutrition Services Manager, Dietitian or Nursing identifying problems/needs, setting measurable, realistic goals and utilizing feasible approaches. Interdisciplinary team approaches must be evident for integrated care plans. 4. Care plans are updated at least quarterly and as needed when goals and approaches change based on resident improvement or deterioration." The Policy and Procedure titled, "Therapy Initial Evaluation" (undated) / Procedures For Completion of the CMS (Centers for Medicare/Medicaid) 700 Form, indicated as follows: "POLICY: Any resident requiring active treatment will have an initial evaluation completed detailing baseline information, goals, and a plan of care... PURPOSE: The initial evaluation is used to establish baseline data as well as provide a forum to report the information accurately, objectively, and succinctly. PROCEDURES: 1. Upon receipt of each discipline's physician order [REDACTED]...20. Initial Assessment: Enter current relevant history from records or resident interview pertinent to this claim. Enter the pertinent functional limitations stated in objective and measurable terms. Include pertinent baseline tests and measurements to establish baseline data to measure future progress." An attachment (undated) to this Policy and Procedure provided by the Director of Rehabilitation indicated as follows: "Licensed Nurses contribute to the Nursing Rehab/Restorative Care Program in the following ways: -Provide the restorative services and/or activities as identified in the Plan of Care and/or directed by the Rehab/Restorative Care Nurse Coordinator. -Provide assessment and observational information relative to the resident's progress toward goals, as identified in the Plan of Care. -Actively participate in evaluation and planning discussions with other disciplines. -Document information on appropriate forms in the medical record. -Assist in the resident's transition from and to programs or services within the Continuum of Care. -Participate in the general orientation of new staff and in the training programs for staff preparing to provide restorative services. -Be aware of opportunities to improve restorative services and participate in developmental activities that are directed at enhancement of the program. Therapists contribute to the Nursing Rehab/Restorative Care Program in the following ways: -Work collaboratively with nurses and other IDT members to identify and develop a plan to meet the needs of the resident. -Participate with other disciplines to identify residents who should have a screening or formal evaluation for skilled rehabilitation services. -Work with nurses to plan for a resident's transition form and to skilled rehabilitation services. -Assist in the training of nurses and CNA's (Certified Nursing Assistants) who are to assume responsibility for providing Nursing Rehab/Restorative Care services. -Observe those who are providing Nursing Rehab/Restorative Care services, provide feedback regarding their performance and correct them when appropriate. -Participate in activities that enhance the resident's functionality. -Provide consultation to the IDT and Nursing Rehab/Restorative Care staff." An additional form attached to the Policy and Procedure was the "Therapy Referral to Restorative Nursing Program," which included the following information for the therapist to complete upon the resident's transition/referral to Restorative Therapy. This form included an area "Specific Instructions: (blank spaces for the Physical Therapy to fill out) ROM (active, passive, U/E, L/E, all extremities...Orthotics (Splint, Brace)." A review of the Occupational Therapist's notes (Start of Care 6/6/10) did not include any baseline measurements for any of the contractures of the upper and lower extremities and only included the following measurements: 6/16/10: "Pt tolerates soft splint to left wrist 10 min (minutes) to decrease risk of further contractures. Measurements as follows: - (negative) 86 degrees of left extension can passively move it to -60 degrees of extension. Passive range thumb into 20 degrees of abduction/10 degrees of left." Service period 6/6/10 - 6/12/10: "Patient's progress is as follows: Previous: ROM Shoulder PROM Left: The patient demonstrates wrist PROM (passive range of motion of L (left) UE (upper extremity) wrist extension from -30 to -20 degrees due to severe flexion contracture. Current: Same as previous week. Service period 6/13/10 - 6/19/10: ROM Shoulder PROM Left: Previous: Same as previous week; Current: The patient demonstrates PROM of left shoulder to 110 degrees to decrease tone and risk of contractures. Service period 6/20/10 - 6/26/10: Previous: The patient demonstrates PROM of left shoulder to 110 degrees to decrease tone and risk of contractures. Current: Same as previous week. Plan of Treatment (Start of Care 6/6/10): Current Level of Function at SOC (Start of Care): 5. ROM: Shoulder PROM Left: The Patient demonstrates PROM of left shoulder flexion from 0 to 85 degrees. 6. ROM: UE - Wrist - The patient demonstrates wrist PROM of L UE wrist extension from -30 to -20 degrees due to severe flexion contractures. Plan of Treatment (Start of Care 9/20/10): 3. ROM: General - The patient tolerates PROM left UE to negative 90 degrees elbow extension. Pt displays maximal contractures left shoulder/wrist/elbow. Plan of Treatment Functional Goals: 3. ROM Shoulder PROM Left - The patient will improve PROM of left shoulder flexion to 0 to 100 degrees in order to decrease contractures for ease of ADL (Activities of Daily Living) care. ROM UE - wrist - The patient will improve PROM of left wrist to -10 degrees extension in order to tolerate a resting hand splint. A review of the Physical Therapy notes (Start of Care 6/6/10) revealed the following: Progress Report service period 6/21/10 - 6/28/10: "Patient's progress is as follows: Previous (also documented on 6/14/10 - 6/20/10 service period report) ROM: General: L knee minus 28 degrees extension post prolonged static stretching; R -35 degrees extension. Current: R knee minus 50 degrees extension. L knee minus 30 degrees to full extension." The Therapy Department's records did not provide consistent documentation of the baseline measurements of the contractures. There was no documented evidence of a Therapy Referral to Restorative Therapy in Resident #7's chart. There was no documented evidence the Therapy Department continued to monitor and communicate with nursing staff and the Restorative Therapy Department to follow up on Resident #7's contractures to ensure the contractures did not further worsen. The facility failed to provide: - RNA Services, - continued monitoring and interventions by the Rehabilitation Department, and - accurate assessment of the contractures.

Based on observation, interview, record review, and document review, the facility failed to ensure 3 of 32 residents with contractures received appropriate treatment to prevent further decrease in range of motion (Residents #1, #6, and #7). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Nursing Admission Assessment, dated 2/5/10, indicated the resident had a right hand contracture. Review of the resident's record revealed an order on 3/1/10, for an Occupational Therapist (OT) to evaluate and develop a plan of treatment for [REDACTED]. The first documented evidence of an assessment and intervention by the facility for Resident #1's hand contracture was on 6/4/10, when a referral was made for OT services. On 6/4/10, an OT developed a goal which read, "Pt (patient) will tolerate splint to the right hand three hours daily to decrease the risk of contractures and pain with PROM (passive range of motion). Resident #1 received OT services for four weeks, and it was documented during this period that the resident "can open right hand into functional position but patient cannot maintain position." The OT further noted, "Patient is tolerating rx (therapy prescription) well...she was discharged to RNA (Restorative Nursing Assistant)." The first care plan developed by the facility for the resident's hand contracture was dated 6/29/10. The care plan included the intervention, "Rt hand splint 4-6 hours daily; review/revise on 10/10." Review of the Restorative Program Flow Sheet revealed RNAs assisted Resident #1 with the use of a hand splint from 7/8/10 through 8/5/10. The goal on the Flow Sheet read, "(Resident) will be able to tolerate right hand splint 4-6 hours per day x (times) 30 days 6 x weekly." There was no documentation as to how long the resident had the splint on each day during this 30-day period. Resident #1's record did not contain any evidence the resident used a splint or received any further treatment for [REDACTED]. This was confirmed by the MDS Coordinator (Employee #21) on 2/1/11 at 5:00 PM. On 1/19/11, the OT Department conducted RNA training pertaining to Resident #1 "for right hand splint wearing schedule 3 hours daily to prevent further contractures and decrease pain." The Director of Rehabilitation Services (Employee #14) indicated on 2/2/11 at 8:00 AM, the use of splints for hand contractures was important for preventing the decline of range of motion. Employee #14 reported residents with contractures should be assessed upon admission and have an ongoing plan of treatment developed at that time. Employee #14 acknowledged Resident #1's care plan for the use of hand splints should have been initiated in February 2010, and incorporated into the resident's daily regimen. As to why the order for splints was discontinued after the four-week RNA intervention from 7/8/10 to 8/5/10, Employee #14 stated, "I can't explain why the nurse did not make a referral." The facility did not have a policy addressing how the Rehabilitation/Therapy Department and Nursing Department would communicate with each other to ensure rehabilitation services for residents were obtained and continued if needed. Resident #7 Resident #7 was admitted [DATE], with [DIAGNOSES REDACTED]. On 1/25/11 through 2/2/11, Resident #7 was observed with multiple contractures. On 2/1/11 at 5:30 PM, it was confirmed by observation during the MDS (Minimum Data Set) Coordinator's (Employee #21) assessment that the resident had contractures to the left elbow, left hand, left fingers, right hand, right elbow, bilateral toes, bilateral knees, bilateral feet, and bilateral ankles. The left hand and fingers were severely contracted, and close proximity to each other. The bilateral knees were severely contracted above the bed in a bent position. The Nursing Admission Assessment, dated 6/4/10, indicated contracture sites as bilateral feet, bilateral hands and fingers and further stated: "Doing full passive ROM (range of motion) on UE (upper extremities)/uarm (upper arm), unable to do ROM on LE (lower extremities)." The Nursing Assessment did not include the contractures to the bilateral knees, bilateral ankles, bilateral toes, left elbow, and right elbow. The MDS Assessments indicated the following (MDS - Functional Limitation in Range of Motion (sections for a. neck; b. arm; c. hand; d. leg; e. foot; f. other limitation or less) and (0/0 represents No Limitation in range of motion and no loss in voluntary movement.)): 6/14/10: 0/0 7/2/10: 0/0 7/30/10: 0/0 8/9/10: 0/0 8/31/10: 0/0 12/17/10: 2=Impairment both sides; 2=Upper Extremity (shoulder, elbow, wrist, hand); and 2=Lower Extremity (hip, knee, ankle, foot) The Interdisciplinary (IDT) Care Conference Notes/Walking Rounds (signed off by the DON (Director of Nursing) indicated the following inconsistent documentation regarding Resident #7's functional limitation/ROM: 6/15/10: No ROM limitations listed (section is blank); 8/18/10: No ROM limitations listed (section is blank); 8/26/10: "Functional Limitation: None UE/LE" 10/21/10: "Functional Limitation: None UE/LE" 11/22/10: "Functional Limitation: Both Sides UE/LE" 12/1/10: "Functional Limitation: One Side U/E, Both Sides L/E" 1/17/11: "Functional Limitation: One Side U/E, One Side L/E" On 2/1/11 in the late afternoon, in response to questions of how the facility was aware of, and tracked, how many residents were with contractures, the MDS Coordinator (Employee #21) indicated there was no system for nursing to track the number of residents with contractures (including the number of resident who obtained the contractures after admission to the facility), and that the only way was to review the MDS reports. On 1/26/11, the MDS Coordinator (Employee #20) indicated it was the process to assess range of motion by observing and attempting to move each limb of the resident in order to demonstrate limits of range of motion of residents with contractures. The MDS Coordinator indicated the resident probably did have contractures in bilateral upper and bilateral lower extremities upon admission, and that the 0/0 coding was erroneous. The MDS Coordinator also confirmed there was no Plan of Care generated and implemented for the contractures due to the erroneous 0/0 coding. The Procedure (undated) provided by the DON regarding the completion of the MDS indicated as follows: "1. The appropriate sections of the Minimum Data Set are completed by the Nutrition Services Manager, Dietitian or Nursing (Section K of MDS is at least completed, others may be assigned as facility designates interdisciplinary team responsibilities.) 2. The MDS, trigger legend and RAP (Resident Assessment Protocol) summary are completed by day fourteen from admission day or by day 5 for Medicare. 3. The appropriate care plan content is completed within 14 days of admission by the Nutrition Services Manager, Dietitian or Nursing identifying problems/needs, setting measurable, realistic goals and utilizing feasible approaches. Interdisciplinary team approaches must be evident for integrated care plans. 4. Care plans are updated at least quarterly and as needed when goals and approaches change based on resident improvement or deterioration." The Policy and Procedure titled, "Therapy Initial Evaluation" (undated) / Procedures For Completion of the CMS (Centers for Medicare/Medicaid) 700 Form, indicated as follows: "POLICY: Any resident requiring active treatment will have an initial evaluation completed detailing baseline information, goals, and a plan of care... PURPOSE: The initial evaluation is used to establish baseline data as well as provide a forum to report the information accurately, objectively, and succinctly. PROCEDURES: 1. Upon receipt of each discipline's physician order [REDACTED]...20. Initial Assessment: Enter current relevant history from records or resident interview pertinent to this claim. Enter the pertinent functional limitations stated in objective and measurable terms. Include pertinent baseline tests and measurements to establish baseline data to measure future progress." An attachment (undated) to this Policy and Procedure provided by the Director of Rehabilitation indicated as follows: "Licensed Nurses contribute to the Nursing Rehab/Restorative Care Program in the following ways: -Provide the restorative services and/or activities as identified in the Plan of Care and/or directed by the Rehab/Restorative Care Nurse Coordinator. -Provide assessment and observational information relative to the resident's progress toward goals, as identified in the Plan of Care. -Actively participate in evaluation and planning discussions with other disciplines. -Document information on appropriate forms in the medical record. -Assist in the resident's transition from and to programs or services within the Continuum of Care. -Participate in the general orientation of new staff and in the training programs for staff preparing to provide restorative services. -Be aware of opportunities to improve restorative services and participate in developmental activities that are directed at enhancement of the program. Therapists contribute to the Nursing Rehab/Restorative Care Program in the following ways: -Work collaboratively with nurses and other IDT members to identify and develop a plan to meet the needs of the resident. -Participate with other disciplines to identify residents who should have a screening or formal evaluation for skilled rehabilitation services. -Work with nurses to plan for a resident's transition form and to skilled rehabilitation services. -Assist in the training of nurses and CNA's (Certified Nursing Assistants) who are to assume responsibility for providing Nursing Rehab/Restorative Care services. -Observe those who are providing Nursing Rehab/Restorative Care services, provide feedback regarding their performance and correct them when appropriate. -Participate in activities that enhance the resident's functionality. -Provide consultation to the IDT and Nursing Rehab/Restorative Care staff." An additional form attached to the Policy and Procedure was the, "Therapy Referral to Restorative Nursing Program," which included the following information for the therapist to complete upon the resident's transition/referral to Restorative Therapy. This form included an area "Specific Instructions: (blank spaces for the Physical Therapy to fill out) ROM (active, passive, U/E, L/E, all extremities...Orthotics (Splint, Brace)." A review of the Occupational Therapist's notes (Start of Care 6/6/10) did not include any baseline measurements for any of the contractures of the upper and lower extremities and only included the following measurements: 6/16/10: "Pt tolerates soft splint to left wrist 10 min (minutes) to decrease risk of further contractures. Measurements as follows: - (negative) 86 degrees of left extension can passively move it to -60 degrees of extension. Passive range thumb into 20 degrees of abduction/10 degrees of left." Service period 6/6/10 - 6/12/10: "Patient's progress is as follows: Previous: ROM Shoulder PROM Left: The patient demonstrates wrist PROM (passive range of motion of L (left) UE wrist extension from -30 to -20 degrees due to severe flexion contracture. Current: Same as previous week. Service period 6/13/10 - 6/19/10: ROM Shoulder PROM Left: Previous: Same as previous week; Current: The patient demonstrates PROM of left shoulder to 110 degrees to decrease tone and risk of contractures. Service period 6/20/10 - 6/26/10: Previous: The patient demonstrates PROM of left shoulder to 110 degrees to decrease tone and risk of contractures. Current: Same as previous week. Plan of Treatment (Start of Care 6/6/10): Current Level of Function at SOC (Start of Care): 5. ROM: Shoulder PROM Left: The Patient demonstrates PROM of left shoulder flexion from 0 to 85 degrees. 6. ROM: UE - Wrist - The patient demonstrates wrist PROM of L UE wrist extension from -30 to -20 degrees due to severe flexion contractures. Plan of Treatment (Start of Care 9/20/10): 3. ROM: General - The patient tolerates PROM left UE to negative 90 degrees elbow extension. Pt displays maximal contractures left shoulder/wrist/elbow. Plan of Treatment Functional Goals: 3. ROM Shoulder PROM Left - The patient will improve PROM of left shoulder flexion to 0 to 100 degrees in order to decrease contractures for ease of ADL (Activities of Daily Living) care. ROM UE - wrist - The patient will improve PROM of left wrist to -10 degrees extension in order to tolerate a resting hand splint. A review of the Physical Therapy notes (Start of Care 6/6/10) revealed the following: Progress Report service period 6/21/10 - 6/28/10: "Patient's progress is as follows: Previous (also documented on 6/14/10 - 6/20/10 service period report) ROM: General: L knee minus 28 degrees extension post prolonged static stretching; R -35 degrees extension. Current: R knee minus 50 degrees extension. L knee minus 30 degrees to full extension." The Therapy Department's records did not provide consistent documentation of the baseline measurements of the contractures. There was no documented evidence of a Therapy Referral to Restorative Therapy in Resident #7's chart. There was no documented evidence the Therapy Department continued to monitor and communicate with nursing staff and the Restorative Therapy Department to follow up on Resident #7's contractures to ensure the contractures did not further worsen. The facility failed to provide: - RNA Services, - continued monitoring and interventions by the Rehabilitation Department, and - accurate assessment of the contractures. Resident #6 Resident #6 was admitted [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. On 1/25/11, Resident #6 was observed to be sitting in the wheelchair with her feet below and behind the foot rests. Interview with the Charge Nurse as why the resident was sitting in that position, the Charge Nurse indicated the resident was unable to bend her feet to adjust to the foot rests due to contractures. On 1/27/11, the Restorative Therapy Aide was observed assessing the range of motion for Resident #6 while the resident was laying in bed. The Aide verified Resident #6 had bilateral foot contractures, was receiving passive range of motion by the Restorative Department, was not receiving active range of motion (AROM), and was not using splints. The Aide further indicated it would be the Physical Therapy's role to recommend splints for the feet to prevent further decline of range of motion/contractures. The Aide indicated the Physical Therapy Department was not involved with Resident #6's care, as the resident was only evaluated for Physical Therapy services and was no longer considered a candidate for physical therapy. The Aide was unable to indicate whether the bilateral foot contractures had worsened since the resident's admission, indicating that the Restorative Department does not do any measurements. The Physician's Recaps (Recapitulations) indicated, "8/4/10: RNA Program for AROM/PROM and bed mobility." There was no documentation the facility had provided AROM for Resident #6 as ordered by the physician. The MDS Assessments for Assessment Reference Dates (ARD's) 2/8/11, 2/11/10, 3/3/10, 3/31/10, 4/30/10, 7/28/10, 8/28/10, and 11/24/10, indicated 0/0 coding for Function Limitations/Range of Motion. On 2/1/11, The MDS Coordinator (Employee #20) verified that the 0/0 coding on the above MDS assessments were erroneous. The MDS Coordinator also confirmed there was no Plan of Care generated and implemented for the contractures due to the erroneous 0/0 coding. The facility failed to ensure accurate assessment of the contractures, continued monitoring and intervention by the rehabilitation department to prevent further decline of range of motion, and AROM as ordered by the physician was provided.