Every finding on record at Skye Canyon Post Acute

Based on observation, interview, record review and document review the facility failed to ensure infection control practices were maintained for 1 of 20 sampled residents (Resident 41). The deficient practice had the potential to increase risk of cross-contamination, spread infectious diseases, and compromise health and safety for residents. Findings include:Resident 41 (R41) was admitted on [DATE] with diagnoses including rheumatoid arthritis, type 2 diabetes mellitus with hyperglycemia, and cognitive communication deficit. A physician order dated 04/04/2026 documented strict isolation precaution via private room / alone in room and not cohort with another resident due to active infectious disease. All services will be provided inside the private room.A physician order dated 04/04/2026 documented Contact Precautions due to clostridium difficile (C. Diff- a highly contagious bacterium that causes diarrhea and colitis) until 04/17/2026.R41 had a sign posted to the right of the door which documented the following:-Contact Precautions: put on gloves and gown before room entry and discard gloves and gown before room exit. A plastic three drawer storage bin stocked with personal protective equipment (PPE) including disposable gloves and gowns was present outside R41's room.A care plan dated 04/04/2026 documented the resident required contact precautions due to C. Diff with interventions including educating the resident and visitor(s) about isolation precautions, stress hand hygiene when visiting resident, and use of personal protective equipment as recommended for type of infection. On 04/09/2026 at 2:39 PM, a visitor who identified themselves as R41's family member, was seated in chair on right side of R41's bed. R41 was lying supine in bed. The chair was positioned within one foot of R41's bed. The family member was barefoot and began applying socks to their feet. The family member was not wearing a disposable gown or gloves. The family member's dog was lying in the bed next to R41's lower right leg. The family member was aware R41 was on isolation for c-diff. and indicated the staff had explained it was optional, if they wanted, to use PPE when visiting. On 04/09/2026 at 2:47 PM, the Infection Preventionist (IP) explained the expectation was to educate and encourage visitors to adhere to use PPE when visiting residents in isolation rooms. The IP explained the use of PPE was not optional for family members.The facility policy titled Isolation- Transmission-Based Precautions and Enhanced Barrier Precautions, revised 09/2022, documented contact precautions staff and visitors wear gloves (clean, non-sterile) when entering the room. Staff and visitors wear disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown removed.

Based on observation, interview, record review, and document review, the facility failed to ensure physician orders for medication administration were followed or clarified for 1 of 12 sampled residents (Resident 8). The deficient practice had the potential to put R8 at risk of receiving medication in unapproved form. Resident 8 (R8) R8 was admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, and cognitive communication deficit. A brief interview for mental status (BIMS) was conducted on 04/02/2025 with a score of 9/15 indicating the resident had moderate cognitive impairment. The facility policy titled Crushing Medications (2001) documented medications shall be crushed only when it was appropriate and safe. The attending physician must document or provide nurses with clinically pertinent reason. The medication administration record must indicate why it was necessary to crush the medication. On 04/08/2025 at 8:37 AM, the Licensed Practical Nurse (LPN1) was conducting medication administration for R8 and crushed the following medication: - Aspirin - Plavix - Ferrous Gluconate (Iron) - Folic Acid - Multi-Vitamin A physician order dated 03/18/2025 documented Aspirin 81 milligrams (mg), give one tablet one time a day by mouth for prophylaxis. A physician order dated 03/18/2025 documented Clopidogrel Bisulfate (Plavix) 75 mg, give one tablet by mouth one time a day for deep vein thrombosis. A physician order dated 03/18/2025 documented Ferrous Gluconate (iron) 324 mg, give one tablet by mouth one time a day every other day for supplement. A physician order dated 03/18/2025 documented Folic Acid 1 mg, give one tablet by mouth one time a day for supplement. A physician order dated 03/18/2025 documented Multi-Vitamin/Minerals, give one tablet by mouth one time a day for at risk for malnutrition. R8's medical record lacked documented evidence of a physician order to crush any medications. On 04/08/25 11:06 AM, LPN1 indicated when determining what medications could be crushed the medication label would be the first place to check. The LPN indicated pharmacy would put on the label if a medication could not be crushed. The LPN explained all new admission residents would be assigned batch order for crushing medications and the nurse would use standards of practice and nursing judgement to determine if medications could be crushed. If there was a question about crushing medications the pharmacy or physician would be consulted. The LPN verified long-acting medications and extended-release medications would be inappropriate to crush as it could alter the absorption rate. LPN1 confirmed there was no physician order to crush medications and there should have been prior to nurse crushing medications. The LPN indicated a new order should be obtained or a clarification of the existing medication orders should be completed with the physician. On 04/08/2025 at 3:38 PM, the Consultant Pharmacist indicated when crushing medication, it would be essential to have physician order to clarify what medications can and cannot be crushed. On 04/09/2025 in the afternoon, the Director of Nursing (DON) verbalized nurses were allowed to crush medications when there was a physician order to ensure safety of the resident. The DON confirmed there were no physician orders to crush medication for R8 and it should have been in place prior to any administration of crushed medications. The facility policy titled Administering Medications (revised 04/2019) documented Medications were to be administered in accordance with prescriber orders.

Based on observation, interview, record review, and document review, the facility failed to ensure protected health information was not visible to residents or visitors for 1 of 12 sampled residents (Resident 42). The deficient practice had the potential for a negative psychosocial outcome for the resident of concern. Resident 42 (R42) R42 was admitted on [DATE] with diagnoses including encephalopathy, and cognitive communication deficit. On 04/07/2025 at 10:29 AM, the Licensed Practical Nurse (LPN1) for the unit was performing medication administration for the residents on the unit. The LPN parked the medication cart at the end of the unit and walked medications to R42s room. LPN1 was away from the cart for approximately 3-5 minutes, several residents ambulated past the medication cart with one stopping at front of cart during the time the nurse was away from the cart. The cart was locked, the computer screen was open and visible to anyone in the hallway with R42's medication administration record revealing all the medications taken by the resident. On 04/08/2025 at 8:11 AM, the LPN explained when passing medications the medication cart should be locked, and the computer screen should be locked or hidden so residents or visitors would not be able to see private medical information of other residents. The LPN confirmed the screen was not locked and should have been. On 04/08/2025 at 11:42 AM, the Director of Nursing (DON) indicated the expectation was to always protect private health information of all the residents. The DON verbalized when completing medication administration, the nurse should lock or hide the computer screen to protect the information when away from the cart. The facility policy titled Dignity (2001) documented staff were to protect confidential clinical information, staff promote, maintain, and protect resident privacy.

Based on interview and document review, the facility failed to ensure an annual appraisal for 1 of 4 sampled Certified Nursing Assistants (CNA3) was completed. The deficient practice could potentially impact the quality of care provided to residents. Findings include: The personnel records checklist completed on 04/08/2025, revealed CNA3 was hired on 03/26/2024 as a CNA. A review of CNA3's employee file lacked documented evidence of a completed CNA Clinical Performance Evaluation form. On 04/08/25 10:11 AM, the Human Services (HR) Director explained the Director of Nursing (DON) was responsible for completing annual performance evaluation forms for CNAs. The HR Director indicated CNA3's annual evaluation was due on or before 03/26/2025 but was not completed due to an oversight. On 04/08/2025 at 11:51 AM, the DON indicated being responsible for completing annual performance evaluation forms for CNAs and confirmed CNA3's annual evaluation was not completed due to an oversight. The DON explained the purpose of completing annual performance evaluation forms was to identify and discuss areas which the employee needed to improve to provide better care to residents. The Performance Evaluations policy revised July 2010, revealed a performance evaluation would be completed on each employee at the conclusion of the 90-day probationary period and at least annually thereafter. Performance evaluations would be completed by the employee's department director and may be used to determine wage increases, transfers, promotion or demotion to improve the quality of the employee's work performance.

Based on observation, interview, and document review, the facility failed to ensure multi-dose vaccine (MDV) vials were discarded after expiration date and labeled with open date once accessed for 1 of 2 medication refrigerators. The deficient practice placed residents at risk for receiving ineffective vaccine protection and yielding inaccurate Tuberculosis (TB) test results. Findings include: On [DATE] at 9:07 AM, the Station One medication refrigerator revealed two opened MDVs with contents of the following: - one Afluria MDV Formula ,d+[DATE] expiration date [DATE] - one Aplisol TB MDV no opened date On [DATE] at 9:11 AM, the Director of Nursing (DON) confirmed the observation and indicated the expired flu vaccine should have been discarded because it was expired, and the formula was for flu season 2020 to 2021. The DON indicated the TB MDV should have been labeled with open date because the vial must be discarded 30 days from the date it was opened. The Aplisol product insert (undated), documented once entered vial should be discarded after 30 days due to possible oxidation which may affect potency. The Medication Labeling and Storage policy revised February 2023, documented when the facility has discontinued and outdated drugs or biologicals the pharmacy must be contacted for instructions regarding returning or discarding these items.

Based on observation, interview, record review and document review, the facility failed to ensure a self-administration of medication assessment was completed for 1 of 15 sampled residents (Resident 66). The deficient practice had a potential for a resident not to be properly evaluated if able to safely self-administer a nasal spray medication. Findings include: Resident 66 (R66) R66 was admitted on [DATE], with diagnoses including chronic kidney disease and osteoporosis. On 04/09/2024 at 10:55 AM, observed on R66's nightstand was a Fluticasone Nasal spray. R66 indicated the nasal medication was sent from the hospital together with belongings upon discharge. R66 indicated continues to use the medication while at the facility. R66 confirmed self-administering nasal medication on a daily basis. On 04/09/2024 at 11:33 AM, the Licensed Practical Nurse (LPN) confirmed not aware the facility had a process to assess a resident for safe administration of medications. The LPN confirmed resident administers own nasal spray, and at times in front of the nurse. R66's medical records lacked documented evidence a safe administration assessment was completed. R66's progress notes lacked documented evidence an assessment or notations for self-administration on medication was completed. On 04/11/2024 at 8:35 AM, the nurse caring for R66 confirmed for every resident who prefers to self-administer medications, would require a self-administer evaluation completed. The evaluation ensures the resident was taking the medication correctly. On 04/11/2024 at 3:06 PM, the Director of Nursing confirmed a self-administration assessment should have been completed. The facility policy titled Resident Self-Administration of Medication revised 06/2023, documented each resident who self-administers medications will have an assessment completed.

Based on observation, interview, record review and document review the facility failed to ensure an intravenous (IV) medication was completely administered for 1 of 15 sampled residents (Resident 6). The deficient practice had the potential for a resident not to receive a full dose of medication affecting therapeutic effect. Finding include: Resident 6 (R6) R6 was admitted on [DATE], with diagnoses including infective myositis and extended spectrum beta lactamase (ESBL) resistance infection. On 04/09/2024 at 10:37 AM, observed at R6's bedside was an IV pole. On the IV pole was an IV piggyback (IVPB) medication bag. The IVPB had a dial-a-flow tubing where the end tip was looped at the Y connector creating a closed system. Observed inside the IVPB medication bag was left over medication which was not infused to the resident. On 04/09/2024 at 11:16 AM, a Licensed Practical Nurse (LPN) indicated an IVPB should be completely infused to be considered as a full dose. The LPN confirmed the IVPB medication had 10 to 15 percent of the medication left in the bag. The LPN acknowledged the full bag should have been infused. R6's physician's orders documented Piperacillin-Tazobactam in Dextrose Intravenous Solution 4 - 0.5 gram (GM)/100 milliliter (ML), use 4.5 gram intravenously every 8 hours for Pelvic Osteomyelitis, start date 04/01/2024 until 04/23/2024. R6's medication administration record (MAR) documented on 04/09/2024 at 8:00 AM, a dose was signed off as given with no other administration codes entered. R6's medical records lacked any documented evidence as to why the IVPB medication was not completely infused for the 04/09/2024, 8:00 dose. On 04/11/24 at 3:55 PM, the Director of Nursing (DON) confirmed a fully emptied bag would only have fluids at the drip chamber not in the actual IVPB medication bag. The DON acknowledged the medication bag should have been completely infused to be considered as a full dose. The facility policy Medication Administration - General Guidelines revised January 2018; documented medications are administered in accordance with the written orders of the provider.

Based on observation, interview, and document review, the facility failed to maintain the kitchen floor's cleanliness, and 1 of 2 nourishment refrigerator temperatures (Nurse Station One). The deficient practice posed a potential risk to safety and health standards as it could lead to contamination or place the residents at risk for foodborne illness. Findings include: On 04/09/2024 at 7:59 AM, an initial kitchen tour was conducted with the Director of Culinary Services. The following floor areas were observed with grease buildup, dust buildup, and/or food particles: -under the food preparation table -under storage racks in the dry storage room -under dish washing machine area The nurse station one nourishment refrigerator internal temperature read 50 degrees Fahrenheit. Potential perishable items inside the nourishment refrigerator were ten individual servings of yogurt, two in-house nutritional shakes, and two individual servings of chocolate milk flavored protein shake belonging to a resident. A single serve yogurt was temped at 51.8 degrees Fahrenheit. The nurse station one nourishment refrigerator temperature log for April 2024, documented daily temperatures within the range of 48 to 50 degrees Fahrenheit. The temperature log form indicated refrigerator temperature range should have been 36 to 41 degrees Fahrenheit and to report abnormal temperatures to the dietary manager immediately. The form lacked documentation under the section for action taken for abnormal temperature. On 04/09/2024 during the initial kitchen tour, the Director of Culinary Services confirmed the above noted concerns. The Director of Culinary Services revealed the kitchen staff were responsible for documenting the nourishment refrigerator temperatures and the temperature should be 40 degrees Fahrenheit or below. On 04/11/2024 at 9:40 AM, a Chef revealed all kitchen staff were responsible for cleaning the kitchen floors and would initial their name on the Daily Cleaning/Task form, which indicated the task was completed. The form was reviewed with the chef, who indicated the listed areas of mop the office/prep area and empty the drain in the dish machine included cleaning the floors. The Chef revealed all kitchen staff were responsible for documenting the temperature logs for refrigerators in the facility. The temperature should be 41 degrees Fahrenheit or below. On 04/11/2024 at 10:16 AM, the Director of Culinary Services revealed various kitchen staff were responsible for cleaning their perspective work floor areas after lunch and dinner services. It was important to keep the floor areas clean as to not leave food particles, prevent potential work hazards, and prevent bug infestations. The Director of Culinary Services indicated the facility did not have a policy specific to the kitchen floor, but followed the facility's general floor care policy. The Director of Culinary Services indicated it was important to monitor refrigerator temperature to ensure the temperature was within appropriate range and avoid food spoilage to prevent residents from getting sick. If the refrigerator temperature was out of range, all items inside the refrigerator should have been discarded. The Director of Culinary Services confirmed the documentation of the nourishment refrigerator temperature log lacked documentation in the section for actions taken for abnormal temperature and the temperatures documented were not within the acceptable temperature range. The Director of Culinary Services indicated the food danger zone temperature was between 40 to 140 degrees Fahrenheit. On 04/11/2024 in the morning, the Daily Cleaning/Tasks form was reviewed and staff initials were documented as task completed on 04/07/2024 through 04/10/2024 for the listed areas of mop the office/prep area and empty the drain in the dish machine. A facility policy titled Floor Care, date 01/11/2021, documented floors to be dry swept, dust mopped, and damp mopped daily. A facility policy titled Refrigerator and Freezer Temperature Monitoring, last revised 01/05/2021, documented the facility would ensure safe refrigerator temperatures to maintain food handling and minimize the risk of food borne illness. Acceptable temperature should be 35 to 41 degrees Fahrenheit for refrigerators, the dietary manager or designated employees will check and record temperatures, and the monthly log would include an action taken section to be completed if the temperatures were not acceptable.

Based on observation, interview, record review, and document review, the facility failed to complete an Interdisciplinary Team (IDT) meeting post fall incident for 1 of 15 residents (Resident 124). The deficient practice had the potential for inaccurate assessment and monitoring following the incident, which may impact the safety of the resident. Findings include: Resident 124 (R124) R124 was admitted on [DATE] with diagnosis including acute and chronic respiratory failure with hypoxia, acute or chronic congestive heart failure (diastolic and systolic), acute kidney failure, and abnormalities of gait and mobility. An Admission Minimum Data Set, dated dated dated [DATE], documented R124's Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate impairment. A Facility Reported Incident dated 10/12/2023, revealed R124 exited the facility through the service door and was found on the parking lot ground on 10/12/2023 at 1:30 AM. R124 reported they dropped something on the ground and as the resident bent over to pick it up, fell to the ground and was unable to get back up. R124 sustained an abrasion on the right elbow; no other injury was noted. A progress noted dated 10/12/2023 at 2:39 AM, documented R124 was found outside in the front parking lot lying on ground. R124 was utilizing a front wheeled walker and wore nonskid socks at the time. R124 was able to move all extremities and stand holding their own weight when assisted up off the ground without complaints of pain or discomfort. A physician progress note dated 10/12/2023, documented R124 may have suffered from sundowning at around 1:00 AM and left the facility. R124's medical record lacked documented evidence an IDT discussion occurred post fall as indicated per facility policy. On 04/10/2024 at 3:10 PM, a Unit Manager reviewed R124's medical record and confirmed the medical record lacked documented evidence a conference was held by an IDT post fall to evaluate need for additional interventions. On 04/10/2024 at 3:53 PM, the DON reviewed R124's medical record and confirmed it lacked documented evidence a discussion was held by an IDT post fall. On 04/11/2024 at 9:47 AM, the Health Information Director confirmed R124's medical record lacked documentation of an IDT post fall discussion. A facility policy titled Fall Reduction Policy, last revised 04/2023, documented to review the event as an IDT when any resident experienced a fall. Facility Reported Incident NV00069674

Based on interview, record review, and document review, the facility failed to ensure to communicate with the physician before holding blood pressure medication for 1 of 8 sampled resident's (Resident 4). The deficient practice had the potential to result in adverse change in condition. Findings include: Resident 4 (R4) R4 was admitted on [DATE], with diagnosis including chronic respiratory failure, pulmonary edema, acute systolic heart failure, type 2 diabetes mellitus, and asthma. A physician order initiated on [DATE] and discontinued on [DATE] for the following: -Carvedilol 3.125 milligrams (mg) (high blood pressure medication) 1 tablet by mouth two times a day for BETA Blockers (a type of high blood pressure medication). No parameters noted for when to hold the medication. -Lisinopril 5 mg 1 tablet by mouth one time a day for high blood pressure. No parameters noted for when to hold the medication. -Midodrine 5 mg 2 tablets by mouth three times a day for Vasopressors (used to treat low blood pressure). No parameters noted for when to hold the medication. A review of the Progress Notes on [DATE] revealed no documented evidence to indicate blood pressure was low or communication with physician was made. A review of the Progress Notes on [DATE] revealed no documented evidence to indicate blood pressure was low or communication with physician was made. A Nursing Progress Note dated [DATE] at 5:15 AM revealed R4 was found unresponsive, CPR started, and 911 called. Medication Administration Records reviewed for [DATE] revealed a chart code 11 for Carvedilol, which was not administered due to blood pressure out of parameters. On [DATE] in the afternoon, a Register Nurse (RN) explained blood pressure parameters were based on resident care plan and history. The RN would use judgement and knowledge of resident and would communicate with physician through phone call or text for instructions on medication hold or administer, and a physician order was needed for staff to follow. On [DATE] at 1:20 PM, the Unit Manager indicated blood pressure not within parameters were to be communicated to physician for instructions on medication administration or hold and noted in the resident's chart. On [DATE] at 3:03 PM, the Director of Nursing (DON) indicated blood pressure ranges outside of parameters were to be communicated to the physician and documented in the resident's medical record. The DON reviewed the medical record and confirmed there was no documentation of physician contact on [DATE] communicating low blood pressure and order to hold medication. An undated document titled Change of Condition and Physician notification indicated the physician is notified of blood pressure for BP that is significantly higher or less than residents normal. The facility Change in Condition Policy dated ,d+[DATE] and revised on ,d+[DATE] stated the facility will consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status. Physical symptoms to report to physician include systolic blood pressure change of 20 millimeters of mercury (mmHG) (or more) and non-responsiveness. FRI #NV00068216

Based on interview and document review, the facility failed provide timely call light response for 2 of 8 sampled residents (Residents 5 and 8). The deficient practice had the potential to lead to a loss of dignity and psychosocial harm. Findings include: Resident 5 (R5) R5 was admitted on [DATE] and discharged on [DATE], with diagnoses including compression fracture of the fourth lumbar vertebra, need for assistance with personal care. Review of R5's call light history report from 04/04/2023 to 04/22/2023 revealed a wait time exceeding 30 minutes on the following dates: -A wait time of 50 minutes on 04/08/2023 at 10:59 AM -A wait time of 41 minutes on 04/08/2023 at 6:53 PM -A wait time of 52 minutes on 04/09/2023 at 12:40 PM -A wait time of 55 minutes on 04/11/2023 at 1:06 PM -A wait time of 32 minutes on 04/12/2023 at 7:50 PM -A wait time of 55 minutes on 04/13/2023 at 7:17 PM -A wait time of 42 minutes on 04/19/2023 at 10:53 AM Resident 8 (R8) R8 was admitted on [DATE] and discharged on [DATE], with diagnoses including fracture of the hip, osteoarthritis of the knee, and abnormalities of gait and mobility. On 08/08/2023 at 8:35 AM, R8 indicated it sometimes took staff 30 minutes or longer to answer call light. The resident revealed this delay resulted in incontinence while at the facility and reported feeling a loss of dignity. Review of R8's call light history report from 07/27/2023 to 08/08/2023 revealed a wait time exceeding 30 minutes on the following dates: -A wait time of 34 minutes on 07/27/2023 at 9:33 AM -A wait time of 37 minutes on 07/29/2023 at 5:36 AM -A wait time of 39 minutes on 07/29/2023 at 10:33 PM -A wait time of 1 hour on 08/04/2023 at 6:06 AM -A wait time of 31 minutes on 08/04/2023 at 9:34 PM -A wait time of 35 minutes on 08/05/2023 at 5:43 PM -A wait time of 48 minutes on 08/07/2023 at 9:40 AM On 08/09/2023 at 8:57 AM, a Registered Nurse (RN) revealed the facility did not have a visual or audible call light system. Certified Nursing Assistants (CNA) were alerted via pager when a resident pressed their call light. The RN reported call light information was visible at the nurses' station. All clinical staff were responsible for answering call lights. On 08/09/2023 at 3:03 PM, the Director of Nursing (DON) revealed the expectation for call lights to be answered was within 15 minutes. The DON indicated the expectation was not documented in the facility's policy. The DON confirmed it was not acceptable for residents to experience incontinence as a result of delayed call light response. Residents should live in dignity and be respected. Review of the March 2023 grievance log revealed resident concerns regarding long call light wait times. There was no documentation of grievance resolution. FRI # NV00068866, FRI #NV00068923 and Complaint #NV00069162

Based on interview, record review, and document review, the facility failed to ensure a resident was safe from abuse for 1 of 8 sampled resident's (Resident 1). The deficient practice had the potential to expose residents to potential abuse. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnosis including orthopedic aftercare, hypertension, hypothyroidism, and hyperlipidemia. A Facility Reported Incident (FRI) investigation dated 09/13/2022, documented R1's spouse struck R1 in the face during a visit on 09/13/2022. The spouse was not allowed to return to the facility, Law Enforcement and Adult Protective Services (APS) were notified of the event. A hospital discharge summary provided to the facility documented the resident had fallen, then reported the spouse had caused the injury for the hospital admission. APS was notified of the possible abuse. The Hospital Discharge Summary dated 08/29/2022 revealed resident's spouse was escorted from the hospital during resident visit for erratic behavior in resident room on 08/26/2022. A facility pre-admission note, undated and handwritten was uploaded to R1's electronic health record on 08/29/2022 documented the resident was abused by the spouse and a report was made to APS. Facility progress note dated 08/29/2022, revealed resident reported the injury was due to physical abuse by the spouse and not a fall. The Admission/Readmission assessment dated [DATE] lacked documented evidence of interventions to protect R1 from abuse during spouse visitation. A progress note dated 09/13/2022, documented the physician was notified of the resident being struck in the face by the resident's spouse. A progress note dated 09/14/2022, documented communication made by a Social Worker (SW) with the resident addressing concerns of discharge and recommendation made to stay with other family members. The resident declined the Childrens involvement and requested to go home with the spouse. On 08/09/2023 at 1:20 PM, the SW initially did not recall the incident or have awareness of the documented abuse by R1's spouse. The SW indicated there was an expectation of chart notes for alerts to be communicated between staff. These communications would be discussed about the newly admitted resident the next day during the stand-up meeting. Any concerns about a resident would be discussed and a plan put together to protect the resident. There was no discussion about the abuse during the stand up. Due to APS not having an active case, there was no confirmed allegation of abuse. APS was not able to provide guidance in the matter. The SW indicated having concerns of spouse visiting and addressed to R1, however the R1 insisted on having their spouse over for visitation. Prior to the 09/13/2022 incident, the SW walked down unit hall during those visits as measure of supervision. R1's door was kept open about 12. The spouse did not allow the door to be open anymore. SW stated the visitor was prohibited to enter facility after the incident on 09/13/2022. Requests were then made by R1 to be discharged home to be with the spouse. On 08/09/2023 at 11:37 AM, a Licensed Practical Nurse (LPN), indicated after a resident was accepted for admission the admitting nurse would set alerts in the resident chart based on documents provided from the transferring facility. Any alerts would be communicated through an electronic communication log in the resident's chart for 14 days. There was no way to know what alerts, if any were in the system to alert staff of abuse by the spouse. The facility policy on Abuse, Neglect and Exploitation dated 1/28/2002 and revised on 06/2023, documented the facility was to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility policy on Referral Management dated 07/2019 and revised on 12/2020, documented it was the facility policy to review the clinical and social needs of all patients referenced for care, prior to admission, to ensure that patients are admitted in the most expeditious manner to facilities and programs that are clinically and operationally prepared to adequately meet their needs. FRI # NV00066996

Based on interview, record review, and document review, the facility failed to ensure professional standards were followed for an unresponsive resident by administering cardiopulmonary resuscitation (CPR) and following the facility code blue process for 1 of 8 sampled residents (Resident 4). The deficient practice had the potential to impact the well-being of its residents. Findings include: Resident 4 (R4) Resident 4 was admitted on [DATE], with diagnosis including chronic respiratory failure, pulmonary edema, acute systolic heart failure, type 2 diabetes mellitus, and asthma. R4 was designated full code for all resuscitation procedures to be provided to keep the resident alive. A Facility Reported Incident investigation on [DATE] at 6:00 PM, documented a License Practical Nurse (LPN) assigned to the resident at the time of the incident, indicated being informed of the unresponsive resident. The LPN located the Ambu bag and discovered no mask was available. The LPN left a Certified Nursing Assistant (CNA) in the resident's room to provide CPR while the LPN called 911 and printed the resident's face sheet. The LPN confirmed not beginning chest compressions and did not provide directions to the CNA to provide chest compressions or return to assist the CNA. A nursing progress note dated [DATE] by an LPN documented the resident was found unresponsive and CPR started. On [DATE] at 2:18 PM, a CNA recalled the resident of concern. That evening, there were two nurses assigned to each of the two units and three CNA's working the floor. The CNA checked on R4 and indicated the resident was observed unresponsive during rounds between 3:00 AM to 4:00 AM. The CNA checked the resident's chest for movement and breathing. When breathing was not observed during the check, the CNA stepped outside of the resident's room to inform the LPN the resident was not responsive. The LPN entered the room with the crash cart and directed the CNA to start CPR and left shortly after. The CNA maintained CPR alone and called out to a CNA passing by the room to assist. The two CNAs provided CPR to R4 until the second CNA had to leave to respond to a resident call light. The CNA indicated continuing CPR until approximately 5 to 10 minutes prior to emergency medical services (EMS) arrival. After EMS arrived, the CNA stated EMS asked why CPR was not being performed, the CNA responded the resident was deceased . The CNA explained to EMS the LPN left the CNA alone to perform CPR. The LPN returned to the room around the time EMS pronounced the resident deceased . The CNA indicated no code blue in service was conducted prior to the incident. After the incident, in-service training was provided to staff for a change of condition, code blue, CPR and a code blue drill was conducted. Since the incident, the facility purchased walkie talkies and started training staff on the use them for better communication. In addition, an overhead speaker was recently installed and when completed, code blue will be announced. On [DATE] in the morning and afternoon, two Registered Nurses (RN), indicated they had received an in-service training for code blue, CPR and code blue drills were conducted in April/ May for both shifts. The facility started using walkie talkie for better communication. Soon the newly installed overhead speaker system will be complete and utilized to announce code blue, where resident care is needed, and fire drills. A minimum of at least three staff are required for a code blue, 2 staff with the resident, one providing CPR until EMS arrives and the other documenting what is occurring. The third person gets the crash cart, and calls 911, the doctor, responsible party, and the administrator. On [DATE] at 3:03 PM, the Director of Nursing recalled the incident regarding resident R4, and stated there were issues regarding CPR and staff involvement during the incident. The DON indicated CPR was to be performed continuously until EMS arrived. The crash cart was checked for verification of equipment nightly and logged by staff. The facility conducted a root cause analysis to determine the breakdown. During a code blue, there should have been an all-hands-on deck response, however there was no way for the other unit nurse to know a code blue was occurring. There needed to be better communication. The CNAs had beepers to receive notification a resident requires care. The analysis revealed walkie talkie and overhead speakers would help with better communication between staff. Facility utilizes/follows the professional standards of nursing published by [NAME] and [NAME]. On [DATE] at 4:40 PM, the Administrator indicated the nurse failed to provide guidance to the CNA on what to do. The CNA was not aware why CPR was to be continued when R4 was unresponsive. The nurse did not explain and left the CNA alone to figure out what to do. Since the incident, all new hires receive code blue training and participate in the drill in accordance with the expectation of city fire. On [DATE] at 9:15 AM, observed a crash cart near nursing station 1 with an ambu bag and mask. Facility policy dated ,d+[DATE] and revised ,d+[DATE] and ,d+[DATE] documented CPR will be initiated on all residents with the Advanced Directive 'CPR full resuscitation' .a Basic Life Support (BLS) staff will immediately start chest compressions and direct a staff member to retrieve the crash cart, chest compressions and rescue respirations will be continuously administered per the American Heart Association recommendations (CPR will be maintained until a definitive treatment can be given), direct a staff member to call 911 immediately; direct a team member to contact the physician, responsible party and complete the hospital transfer and identify a staff to document interventions and response. FRI #NV00068216

Based on interview and document review, the facility failed to provide 3 of 5 scheduled bed baths for 1 of 8 sampled residents (Resident 5). The deficient practice had the potential for residents to experience poor hygiene which could exacerbate skin conditions. Findings include: Resident 5 (R5) R5 was admitted on [DATE] and discharged on [DATE], with diagnoses including compression fracture of the fourth lumbar vertebra and need for assistance with personal care. Review of R5's medical record revealed the resident received two documented bed baths on 04/19/2023 and on 04/21/2023. There was no documented evidence of the resident's refusal to bathe. On 08/08/2023 at 11:35 AM, a Certified Nursing Assistant (CNA) indicated residents had scheduled days for showering or bathing based upon room number. Residents were bathed every Tuesday and Thursday or Wednesday and Friday. The CNA reported resident refusals for bathing were documented in the medical record. On 08/09/2023 at 3:03 PM, the Director of Nursing (DON) reported the expectation for resident bathing was to be completed twice a week. If a resident refused to be bathed it must be documented on the electronic health record. On 08/09/2023 at 4:46 PM, the Administrator confirmed the facility's internal investigation revealed R5 received two documented bed baths while at the facility. FRI #NV00068866

Based on interview and document review, the facility failed to implement interventions to prevent a resident at risk for elopement from leaving the facility. The deficient practice had the potential for psychosocial and physical harm for the resident. Findings include: Resident 6 (R6) R6 was admitted on [DATE] and discharged on [DATE], with diagnoses including dementia without behavioral disturbance, sepsis, and urinary tract infection (UTI). The admission assessment dated [DATE] indicated R6 was an elopement risk. A care plan was generated indicating frequent checks were to be conducted. Review of the resident's medical record revealed frequent checks were not completed on 06/06/2023 or 06/07/2023. A nursing note dated 06/07/2023 revealed R6 was observed outside the facility at 8:30 PM knocking on the northeast door holding a urinary catheter bag, attempting to enter the facility. On 08/09/2023 at 8:45 AM, a Certified Nursing Assistant (CNA) revealed frequent checks were to be performed by CNA staff every 15 minutes following the resident's elopement. On 08/09/2023 at 1:00 PM, a Licensed Practical Nurse (LPN) reported while on shift the night of 06/07/2023 the LPN heard banging on the door. The LPN looked to the door and saw the resident standing outside attempting to enter the facility. The resident was brought into the facility and assessed. The LPN confirmed frequent checks were not completed on the resident prior to the elopement. On 08/09/2023 at 3:03 PM, the Director of Nursing (DON) revealed care plans created during the admissions process were automatically generated in each resident's electronic health record. The expectation was that care plan tasks were carried out upon the initial care plan's completion. The facility Elopements and Wandering Residents policy dated 03/2008, revised 04/2023, documented the facility was to establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering. This approach included identification and assessment risk, evaluation and analysis of hazards and risks, implementation of interventions to reduce hazards and risks, and monitoring for effectiveness, modifying interventions when necessary. FRI #NV00068766

Based on observation, interview, record review and document review, the facility failed to ensure there were sufficient staff to meet the needs of the residents. The deficient practice placed the residents at risk for receiving inappropriate and delayed care. Findings include: The Facility Assessment reviewed 01/18/2023, indicated the staffing plan would be based on the resident population and needs for care and support. The staffing plan was based on an average daily census of 28 residents where the facility required five licensed nurses per day, 10 Certified Nursing Assistants (CNAs) per day and other nursing personnel with administrative duties such as the Case Manager, the Director of Nursing (DON), Unit Manager and the Director of Staff Development (DSD). A handwritten note dated 01/18/2023 read, staffing evaluated daily to adjust for census and acuity of patients. On 04/26/2023 in the morning, eight residents expressed concerns regarding the facility being short-staffed. The residents' concerns included long call bell response times, delayed incontinence care, missed showers, medication issues, hydration, and inaccurate meal tickets. The facility matrix (Form-802) revealed the facility currently had a census of 29 residents. Eight residents had an indwelling catheter, five residents had an existing pressure ulcer, five residents were on intravenous (IV) therapy, eleven residents were being treated for infections with two residents on transmission-based precautions (TBP), three dialysis residents and three residents with Alzheimer's dementia. On 04/27/2023 at 10:44 AM, a Certified Nursing Assistant (CNA) indicated being assigned nine to 10 residents a shift which was a manageable but challenging load. The CNA indicated the current census was 31 residents and there were three CNAs scheduled to work the day shift, but one CNA called off which resulted in the CNA being assigned 15 to 16 residents during morning care. According to the CNA, call-offs happened frequently, which led to some staff members quitting. The CNA recounted there was one day a few weeks ago when two CNAs called off and the CNA had more than 20 residents assigned, which caused the CNA to prioritize essential care and therefore no showers were provided. The CNA indicated when the units were short-staffed, quality of care was compromised, for example, instead of giving residents a thorough shower, the CNA would just clean residents as quickly as possible. On 04/27/2023 at 2:59 PM, a Licensed Practical Nurse (LPN) indicated being assigned 15 to 16 residents which was a manageable load provided there were no call-offs. The LPN indicated for an average census of 28 residents, there would be two licensed nurses and three CNAs scheduled. According to the LPN, even when the units were fully staffed there were many difficult days due to residents' acuity as some residents required a higher level of care than others. The LPN indicated when the units were short-staffed, the quality of care was compromised which impacted activities of daily living (ADLs) such as showers, bed baths, incontinence care, call light response, hydration, and meals, and placed the nurses at risk for late administration of medications. On 04/27/2023 at 3:13 PM, the DON indicated being employed in January 2023 and was informed the facility was undergoing staffing challenges, but the DON did not fully comprehend the severity of the staffing issue until assuming the role of DON. On 04/27/2023 at 3:15 PM, the DON indicated being responsible for nursing oversight, providing in-services, reviewing physician's orders, quality assurance performance improvement (QAPI) duties, conducting daily meetings, hiring, disciplinary actions, and making daily staff assignments which included attempting to get coverage when a nurse called off. The DON indicated working seven days a week because call offs happened frequently, and the DON worked the units when coverage could not be found. The DON would end up working weekends and some nights to cover for a nurse in addition to DON responsibilities. On 04/28/2023 at 10:12 AM, the Administrator indicated being employed in February 2023 and was in the process of making modifications to the existing facility assessment due to a change of ownership and changes in key leadership roles. The Administrator indicated being new to the role and had not gotten the chance to review the staffing plan and did not have a plan in place for handling staff call-offs. The Administrator reviewed the facility assessment tool and indicated the former Administrator made a handwritten note on the staffing plan which read, staffing evaluated daily to adjust for census and acuity of patients. The Administrator indicated not being aware if the DON based the daily staffing assignment on census, acuity, or both. On 04/28/2023 at 11:38 AM, the Administrator and Inspector reviewed the daily staffing assignments from 04/01/2023 through 04/28/2023, which was cross-referenced against the facility's staffing plan. After the review was completed, the Administrator indicated the facility's daily nursing assignments were not in accordance with the facility's staffing plan, specifically, there were four licensed nurses (target: five) working on 26 out of 28 days and there were six to nine CNAs (target: 10) working on 27 out of 28 days during the look back period. The Administrator indicated the DON was pulled to work the units on 04/12/23, 04/16/2023, 04/19/2023 and 04/26/2023. The Administrator indicated the DON was responsible for evaluating patient acuity and was responsible for the daily staffing schedule. According to the Administrator, when the DON got pulled to work the floor, DON duties to include staffing coverage and acuity review could be compromised. On 04/28/2023 at 11:58 PM, the DON defined census as the number of patients by count and defined acuity as the level of care a patient required (for example: Foley catheters, IV therapy, TBP, ADL assistance, fall risks, wound care, behaviors). The DON indicated being responsible for daily staffing schedules which was currently based solely on census versus acuity because this was the practice which was in place when the DON was hired in January 2023. The DON indicated being trained by the former Administrator who instructed the DON to staff the units according to census and not acuity. Specifically, the former Administrator taught the DON to staff the units with two licensed nurses and three CNAs when the census fell below 35 residents. The DON reviewed the facility assessment tool which included the staffing plan with a handwritten note, staffing evaluated daily to adjust for census and acuity of patients. The DON verbalized not being trained to incorporate acuity when making daily staffing assignments. The DON indicated this was the first time the DON saw the facility assessment tool and staffing plan and acknowledged daily nursing assignments were solely based on census, not acuity. The DON indicated not being aware current staffing practices were not in accordance with the facility assessment and staffing goals. The facility assessment policy revised December 2020, documented the facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its resident competently during both day-to-day operations and emergencies. The facility assessment would include facility capacity, staffing needs and competencies necessary to provide the level and type of care needed for the resident population and all personnel. The Facility Assessment will be reviewed and updated whenever the facility planned for any change that would require a substantial modification to any part of the assessment or at minimum annually. Complaint #NV00067839 Complaint #NV00068275 Complaint #NV00067041

Based on observation, interview, and document review the facility failed to ensure food items were labeled and dated in the freezer, there were no expired items in the refrigerator, and items were not damaged in the dry storage area. The deficient practice had the potential to allow for use of expired or damaged food products. On [DATE] at 8:30 AM, during initial kitchen tour the following were identified: - Two containers of apple juice concentrate expired on [DATE]. - Bread in freezer was not dated with freeze date. - One can of fruit cocktail was dented and in rotation for product use. - Milk for resident use was stored in a water bottle [NAME]. On [DATE] at 8:45 AM, the Director of Nutrition Services (DNS) verified items were in the freezer, refrigerator, and dry storage area. The DNS indicated all expired items should be discarded if not used by expiration date and damaged items should be taken out of use rotation and discarded. The DNS verbalized they were not aware of needing both use by and freeze date for bread in the freezer and will implement immediately. The policy titled food storage (revised ,d+[DATE]) documented food stored outside of original package shall be labeled, dated, and monitored so it is used by the use by date, frozen, or discarded. Food stored in freezer will have a receive date, or a date when the item was placed in the freezer. Dented cans will be stored in a designated area for future manufacturer pick up.

Based on observation, interview, record review and document review the facility failed to ensure a communication board was utilized for a hearing-impaired resident (resident 120). The deficient practice had the potential to cause psychosocial harm to the resident. Findings include: Resident 120 (R120) R120 was admitted on [DATE] with diagnoses including unspecified hearing loss. The medical record revealed R120 had Minimum Data Set (MDS) evaluation completed on 04/19/2023 with hearing impairment noted without assistive hearing device. The medical record revealed R120 had a care plan to use a communication board with staff and visitors. On 04/26/2023 at 8:35 AM, R120 had a communication board in room with multiple pages of writing for communication. R120 was able to verbalize answers after reading the question or inquiry written on the paper. On 04/26/2023 at 9:15 AM, R120 entered hallway from room and staff member was walking by and asked if they could help. Resident indicated they could not hear and directed the staff member to the communication board. The staff member kept raising voice louder and louder. R120 requested they use the communication board, and the staff member left the room after verbalizing to resident they would get assistance. On 04/27/2023 at 9:18 AM, an Intravenous (IV) administration was observed for R120. The Registered Nurse (RN) was familiar with the resident and advised they would lower their mask so the resident could read their lips. Resident appeared to comprehend information presented. Resident acknowledged and gave consent for IV medication administration. On 04/27/2023 at 9:24 AM, the RN verbalized staff was aware of resident communication concern and would write on communication board or temporarily drop mask while in room with R120, so they were able to read lips and communicate effectively. The RN indicated it would be inappropriate for staff members to continue to raise their voice as it would not help the situation and would serve to frustrate R120. On 04/28/2023 at 8:55 AM, the Director of Nursing (DON) verbalized social services would provide assessment for resident with hearing impairment and plan of care would be implemented by nursing staff for resident requiring communication board. The DON verbalized they would expect all staff to honor the needs of residents including using the communication board. The DON explained if staff members were observed not honoring a resident's right, they would talk to staff member and explain expectation and provide in-service to correct behavior. The policy titled Resident Rights (revised 08/2021) documented the resident had the right to be treated with respect and dignity. The resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.

Based on observation, interview, record review and document review, the facility failed to ensure a comprehensive care plan was revised to include behavior monitoring for 1 of 30 sampled residents (Resident #11). The deficient practice had the potential for the resident to not receive the proper care. Findings include: Resident 11 (R11) R11 was admitted on [DATE] with diagnoses including cellulitis of the right lower limb and depression. A medication regimen review dated 03/14/2023 documented a recommendation to provide non-pharmacological interventions and behavior monitoring for depression medication. The medical record lacked documented evidence of any non-pharmacological interventions for depression. The medical record lacked documented evidence of any behavior monitoring for depression. On 04/27/2023 at 9:24 AM, a Registered Nurse (RN) verbalized the comprehensive assessment was an ongoing process and should be updated with changes in the resident condition, medications, and orders. The RN indicated when a resident was on medications for anxiety or depression it would be standard practice to include interventions to monitor behavior. On 04/28/2023 at 9:30 AM, the Director of Nursing (DON) acknowledged the medical record lacked behavior monitoring and non-pharmacological interventions. The DON indicated when recommendations include behavior monitoring for a specific medication it should be entered in the electronic medical record so the nurse assigned can see the order and document specific behaviors and effectiveness of medication regimen. The DON explained some of the behaviors to monitor would be agitation, facial expression, and insomnia. Care Planning policy revised February 2022, documented in the event the comprehensive assessment identified a change in the resident's goals, physical, mental, or psychosocial functioning which was otherwise not present in the baseline care plan, those changes will be incorporated into an updated summary provided to the resident or his/her representative.

Based on interview, record review, and document review, the facility failed to ensure a resident's debit card was not misappropriated by a facility staff member for 1 of 30 sampled residents (Resident #174). The deficient practice had the potential to place other residents at risk for financial exploitation. Findings include: Resident #174 (R174) Resident #174 was admitted on [DATE], with medical diagnoses including anxiety disorder and respiratory failure. The facility policy titled Residents Rights, last revised on 04/09/2017, revealed the resident had the right to be free from misappropriation of property. A facility reported incident dated 11/18/2022 documented a resident had reported a staff member was seen at the bedside holding the resident's phone. The staff member asked the resident for the passcode to view pictures. The next day, the resident received a call from their bank advising of unusual activity in their account. The resident's bank card was not located where it was normally kept. The facility completed an investigation into the incident, an employee was terminated, appropriate notification was made and training to staff and residents was provided. On 04/27/2023 at 2:29 PM, the Social Services Manager explained residents who come to the facility with money or other valuable personal belongings are offered to have them locked in the facility safe. If residents decline, the facility can provide a locked cabinet in their rooms upon request. On 04/27/23 at 02:33 PM, the Administrator explained the process of initiating an internal investigation for misappropriation of property and provided the facility's investigation report for review. The facility was under new management and was not conducting impromptu training to the staff members after incidents at the time but would like to incorporate them in the future. The facility policies titled Abuse, Neglect, and Exploitation policy, last revised on 04/2023, and Lost or Damage of Personal Property, last revised 12/2020, revealed the facility followed their policy. Facility Reported Incident #NV00067460