Every finding on record at Sunset Ridge Post Acute

Based on observation, interview and document review, the facility failed to comply or establish compliance with all applicable Federal, State, and local laws, regulations, and codes, specifically concerning:(1) not being properly permitted for construction/electrical change activities within the building with the local building department;(2) not completing the change of ownership license application with the State Survey Agency;(3) by not completing the change of ownership license application with the State Survey Agency, the facility has prevented their Centers for Medicare Medicaid Services (CMS) certification change of ownership from proceeding to completion; and(4) not timely notifying the State Survey Agency with all Administrator changes at this facility. Findings include: On [DATE] the census was 147 out of 160 licensed beds. A subsequent site visit on [DATE] the census was 128 out of 160 licensed beds. The facility failed to:1) Obtain the proper local building department permit related to the electrical wiring;2) Complete the state licensing application for the change of ownership;3) Complete the federal certification application process for the change of ownership; and4) Establish that there was an Administrator at the facility at all times or that the listed Administrator was present and available at this facility at all times. 1) On [DATE], a call was placed to the [NAME] County Building Department to enquire about electrical permits. Spoke with a Manager of Code Enforcement who was available to answer my questions. Our recent complaint investigation revealed the temporary installation of two Spider Boxes, these devices are generally used at construction sites to add electrical capacity to the project. In this case the Spider Boxes were used to add capacity for the use of portable air conditioning units in resident rooms and hallways while a new heating, ventilation, and air conditioning (HVAC) system was being installed. The two devices were hard wired into electrical panels in an electrical room on the first and second floor of the north housing section (half of the beds). The question of an electrical permit issued by the county was brought up but could not be answered by the facility. According to the telephone conversation with the Manager of the local county building department, an electrical permit would be required for this type of work of modifying the electrical panels connections to the spider boxes. The Manager indicated that a permit is required whether or not the electrical changes are code compliant or not. The Manager then looked up the facility's permit status and found one permit (for the HVAC system), and no permit was on record for the electrical panels modifications with the Spider Boxes. The facility would need to provide evidence of a permit issued by the County building department for the electrical modifications with the connected Spider Boxes installations. 2) The facility's proposed new owners submitted a Change of Ownership (CHOW) state licensing application on [DATE]. The [NAME] of Sale date was [DATE]. As of the date of this writing of [DATE], the CHOW license application has not been completed. Note: The license is still under the previous licensee until the license application is completed and approved. The previous licensee is exposed to the new owner's actions past the CHOW license completion date. 3) The facility's proposed new owners submitted a Change of Ownership (CHOW) federal certification application on [DATE]. The [NAME] of Sale date was [DATE]. As of the date of this writing of [DATE], the CHOW federal certification cannot be completed pending the completion of the state licensing application. 4) Interview with Administrator B on the afternoon of [DATE], revealed that Administrator B was currently an acting Administrator for the absent Administrator C, prior to the arrival of Administrator D that started on Monday [DATE]. Subsequent contact with Nevada Administrator Board, and this Board provided Administrator licenses for this facility's Administrators which were found in violation with the facility licensing regulations (Nevada Administrative Code (NAC) 449.0114) and not accurate with the Board of Administrators (NAC 654) for this facility as described below: a) The previous and current facility (Sandstone Spring Valley) had an Administrator Change on [DATE], wherein a new administrator, Administrator A, was in charge at the time when the state CHOW application was filed on [DATE]. What is not known is when Administrator A had actually left the facility. The [NAME] of Sale date was [DATE]. On [DATE] the State Survey Agency (SSA) was investigating a temperature related complaint at the facility and Administrator A had left Sandstone Spring Valley at an undetermined date prior to the SSA arrival. Administrator A's departure was made known to this SSA. There was no 10-day notification that Administrator A had left and that a new Administrator (Administrator B) was now at the facility (See NAC 449.0114(4)). However, on [DATE], Administrator B was at the facility on [DATE] complaint investigation. Administrator B was covering both his facility and temporarily covering this facility (which is allowed per NAC 654), but Administrator B's temporary license for this facility did not go into effect until [DATE], (per his temporary license) while being in charge at Sandstone Spring Valley during the [DATE] complaint investigation. Administrator B temporary Administrator License at this facility was issued [DATE] and an expiration date of [DATE]. Administrator C was not present and Administrator C's where abouts were unknown at the time of the hot ambient air temperature survey that was conducted on dates of [DATE] and 15, 2026, even though Administrator C was the Administrator of record for the facility at that time. However, Administrator B was at the facility on those dates even though Administrator B's temporary facility (Sandstone) Administrator's license had expired on [DATE]. Administrator C's Administrator's license issued [DATE], with the new name of the unlicensed facility (Sunset Ridge Post Acute) had the expiration date of [DATE]. Administrator D's first workday was [DATE]. Administrator D's Administrator license was issued [DATE], with the new name of the unlicensed facility (Sunset Ridge Post Acute) and had the expiration date of [DATE]. Administrator D was onsite with the subsequent survey date of [DATE]. Note: Administrator D license indicated 168 beds, which was a typo. There were only 160 licensed beds for this facility. A review summary of the above concerning this facility's noncompliance includes:i)The facility not pulling proper building permits;ii) the new owners of the new facility not being licensed;iii) the new owners of the new facility not being certified;iv) the facility not reporting Administrator changes timely to this State Survey Agency (SSA). NOTE: It is important to keep this SSA informed of the current Administrators so that when emergent events occur the SSA can get ahold of the proper person to mitigate problems. Since the CHOW application has not been closed, the new owner must ensure that all Administrator associated documentation has been included in the application, along with dates of service.

Based on observation, interview, record review and document review, the facility failed to maintain a safe and comfortable room temperature for 1 of 8 sampled residents (Resident 1). The deficient practice had the potential to cause discomfort, dehydration, heat-related illness, and reduce the quality of life for the residents. Findings include: On 05/15/2026 at approximately 1:30 PM - 2:00 PM, observations and temperature measurements were conducted on the first-floor resident rooms located within the Lake [NAME] and Mt. [NAME] residential hallways. Room temperature measurements were obtained using a battery-operated temperature gun. Temperatures were taken along the forward-facing wall directly in front of the resident's bed in each room. Great care was taken to avoid obtaining temperature readings from windows, exterior walls exposed to direct sunlight, reflective surfaces, or other heat-producing sources in order to maintain a consistent and reliable method for assessing room temperatures. The observations and temperature measurements were conducted in the presence of facility maintenance staff, who acknowledged the conditions observed. The following resident room temperatures were recorded: room [ROOM NUMBER] – 81.6 degrees F room [ROOM NUMBER] – 84.9 degrees F room [ROOM NUMBER] – 85.4 degrees F room [ROOM NUMBER] – 86.1 degrees F room [ROOM NUMBER] – 81 degrees F room [ROOM NUMBER] – 81. degrees F room [ROOM NUMBER] – 85.1 degrees F During an interview, the Maintenance Director (MD) stated that portions of the facility's aged HVAC system were not operational. The MD further indicated that fans and portable interior air-conditioning units were being deployed throughout the facility in an attempt to mitigate elevated temperatures. During an additional interview, the facility's newly contracted HVAC vendor stated that the facility's HVAC system was aged out and was under contract for complete replacement. The vendor stated that the replacement project would be completed in four phases, with each phase expected to last approximately one to one-and-one-half months. The vendor further stated that phases one and two would focus on areas of the facility with HVAC systems that were completely inoperable, with subsequent phases addressing the remaining units until full replacement of the HVAC system was completed. A resident complaint involved the air conditioning system not keeping the residents comfortable. The acceptable temperature range was 71 degrees to 81 degrees. At the time of the survey the resident of concern room temperature was measured at 85 degrees, which is four degrees greater than the maximum 81 degrees. The building has a first floor and a second floor, and each floor is divided into three major building sections. The three sections of the building were (1) Housing South; (2) Housing North; and (3) Central Middle for support services. Each of the housing sections further divided into three smoke compartments and are the same on both levels: North housing, three smoke compartments for each level to include: North (1200 & 2200) with 12 single resident rooms, nurse station and dining room. East (1300 & 2300) with 12 single resident rooms. South (1100 & 2100) with 4 single resident rooms and 6 double resident rooms (16 total residents). South housing North (1400 & 2400) with 4 single resident rooms and 6 double resident rooms (16 total residents). West (1600 & 2600) with 16 single resident rooms. South (1500 & 2500) with 12 resident rooms, nurse station and dining space Central support first floor. Large smoke compartment: lobby, multiple business offices, PT and OT, resident activity spaces, medical records storage spaces and dietary department. Small smoke compartment: stairs wand east elevators and storage rooms. Central support second floor Large smoke compartment with [NAME] elevators and stairs, Northeast freight. elevators and stairs, long corridor open to the lower floor, and mechanical rooms. Small smoke compartment for East stairs and elevators, plus storage rooms. 05/14/2026 Thursday High outside temperature (95 degrees ) First floor: Central smoke compartment, Lobby was hot (82 degrees ) Delivery hall (82.5 degrees ) North housing, East 1302 (82 degrees ), 1311 (84 degrees ) Nurse station (82.4 degrees ) South 1108 (85 degrees ), 1102-1108 corridor (84 degrees ); re-temp 1108 (83.5 degrees AVG) Second floor: South housing, South 2508 (81.5 degrees ), 2502 (86.5 degrees ), West Dining (83.8 degrees ) nurse station (81.5 degrees ) North housing, South 2102 (87.9 degrees ) East Nurse station (83.1 degrees ), 2302 (84.9 degrees ), 2304 (89.2 degrees ), 2311 (89.6 degrees ) 05/15/2026 Friday High outside temperature (99 degrees ) First floor: North housing, East smoke compartment 1304 (85.1 degrees ), 1311 (85.4 degrees ) South housing South smoke compartment 1507 (81.6 degrees ), 1508 (85 degrees ) Second floor: North housing East smoke compartment 2-303 (87 degrees ), 2304 (96 degrees ) empty room, 2-306 (98 degrees ) empty room, 2-308 (85 degrees ), 2-309 (87 degrees ), 2-310 (91 degrees ), 2-311 (92 degrees ), 2-312 (88 degrees ) 05/21/2026 Thursday High outside temperature (97 degrees ) South housing, South smoke compartment 1508 (82.9 degrees ) The facility had eight air handling unit systems, one roughly for each resident smoke compartment (6) for both the first and second floor; and one for each half of the central support smoke compartment upstairs and downstairs. On the roof, each air handling system had a bank of three units, and each unit required some level of attention for repair. Interview with the heating, ventilation, and air conditioning (HVAC) vendor Field Supervisor occurred over all three days, revealed the HVAC system needed to be redesigned to function properly. All HVAC system components needed to be custom built for this facility. A mechanical engineer was involved in generating the necessary data to update the mechanical plan set in order to begin the installation of the new upgraded HVAC equipment. The HVAC contractor indicated repairs and replacement efforts are currently underway and are projected to occur in four phases over an estimated six-month period. Each phase is anticipated to take approximately 1 to 1.5 months. The contractor reports they will first address units that are completely inoperable and then transition into replacement of aging rooftop units. Resident 1 (R1) was admitted on [DATE] with diagnoses including acute osteomyelitis right ankle and foot, type 2 diabetes mellitus with hyperglycemia, hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease. R1 resided on the 1100 hallway of the facility. On 05/14/2026 at 2:20 PM, upon entry into the facility a white 8x11 paper with black typed lettering was taped on the door entering the facility and at the reception desk in lobby and documented the following: Attention! We apologize for any inconvenience. Upgrades to the AC system are currently in progress. If you have any concerns, please feel free to communicate with Management. Thank you for your patience and understanding. A portable air conditioning (AC) unit was located in the front lobby adjacent to the reception desk. Ambient temperature throughout the facility in hallways, common areas and resident rooms fluctuated from comfortable to stuffy and warm. The facility utilized a multiple variety of portable AC units, industrial floor fans, and household oscillating fans throughout the hallways and in individual resident rooms. On 05/14/2026 at 2:26 PM, upon entering the 1100 hallway three fans were noted to be on and in use within the hallway. On 05/14/2025 at 2:28 PM, the Director of Maintenance explained the facility was in the process of replacing the existing air conditioning units and temperature checks were conducted every four hours. On 05/14/2026 at 2:30 PM, R1 was lying in bed with a sheet covering R1's abdomen and R1's legs were out from under sheet. A portable fan was located in the corner of R1's room by the door upon entry into R1's room. A small fan was sitting on R1's overbed table. R1 explained had been in the facility for a few weeks, and stated it's hot in here, had to bring the fans in to help. R1 explained the room had been hot for a few days. On 05/14/2025 at 2:32PM, a Life Safety surveyor and the Director of Maintenance obtained the room temperature of R1's room which registered at 85 degrees Fahrenheit ( ). On 05/14/2026 at 4:06PM, the Administrator 1 (A1) and Director of Maintenance explained periodic temperature checks were initiated when temperatures outside began to rise approximately two weeks ago. Temperature checks were conducted every four hours 24 hours a day seven days a week. The nursing staff assisted with obtaining temperature checks in the evening/night shift hours. On 05/14/2026 at 4:34PM, the A1 explained the facility Emergency Plan would be if unable to keep room temperatures below 81 , staff would relocate residents to alternate facilities. The trigger or determination of the relocation would be if temperatures were not able to be reduced below 81 within two hours of placing portable air conditioners/fans then measures would be taken. On 08/14/2026 in the afternoon, review of the facility temperature logs lacked documentation regarding specific areas where the temperatures were obtained. On 05/14/2026 at 5:15PM, R1's room temperature was 83.8 ; a portable AC unit had been installed and was turned on operating. The facility policy titled Homelike Environment, revised 02/2021, documented Residents were provided with a safe, clean, comfortable, and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics included a comfortable and safe temperature (71 - 81 ). Complaint #3014048

Based on interviews, record review, and document review, the facility failed to maintain professional boundaries and protect a resident from verbal abuse for 1 of 3 sampled residents (Resident 1). This deficient practice had the potential for residents to experience emotional and physical harm.Findings include:Resident 1 (R1) was admitted on [DATE] and discharged on 03/13/2026 with diagnoses of quadriplegia, immunodeficiencies, protein-calorie malnutrition, and difficulty walking.The Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a BIMS score of 15 indicating R1 was cognitively intact.A nurse's progress note dated 01/16/2026, documenting events from 01/15/2026, indicated R1 went to the Director of Nursing's (DON) office with the Director of Staff Development and a certified nursing assistant (CNA) present. R1 expressed concerns regarding an argument with CNA1. R1 reported becoming frustrated due to waiting times and began yelling and using foul language toward CNA1. CNA1 responded in a similar manner and then exited the room.A physical therapy assistant (PTA) present during the incident was interviewed. R1 was informed an investigation would be initiated and that appropriate reporting procedures would be followed. R1 apologized for the behavior and indicated they were simply frustrated.The DON offered a psychiatric consultation, which R1 accepted. The primary provider was notified and ordered a psychiatric referral. A psychiatric nurse practitioner who was on-site evaluated R1. R1 expressed appreciation for the facility's response.A physician encounter note dated 01/17/2026 documented the nurse reported R1 had a verbal altercation with CNA1. The incident was reported to DON and Assistant Director of Nursing (ADON). The physician noted R1 had a history of behavioral issues and a pattern of being non-cooperative with nursing staff.On 04/02/2026 at 9:25 AM, a Licensed Practical Nurse (LPN) reported R1, did not want to be at the facility, frequently became upset and used profane language toward staff. The LPN recalled an incident in which the resident was yelling at a staff member. When the LPN entered the room to assess the situation, the resident yelled, I have gotten one staff fired; do you want to get fired also? The LPN noted the resident later apologized for the behavior.On 04/02/2026 at 10:45 AM, a Physical Therapy Assistant (PTA) recalled going to R1's room to determine whether the resident was ready for their scheduled therapy session. The PTA indicated, upon entering the room, R1 appeared agitated. CNA1, whose name was unknown, entered the room shortly afterward, and R1 began exchanging words with staff, using profane language, including repeated use of the F word.The PTA immediately reported the incident to the DON. The PTA observed R1 had gone to the DON to report the issue as well.On 04/02/2026 at 11:50 AM, CNA2 reported hearing noise coming from R1's room and went to check what was happening. Upon entering, CNA2 observed R1 yelling, CNA1 then entered the room, and a verbal exchange occurred between the R1 and CNA1. During this exchange, both R1 and the CNA1 used profane language. CNA1 subsequently exited the room.On 04/02/2026 at 12:45 PM, the Director of Nursing (DON) explained the facility's procedures when an allegation of abuse was reported. The DON explained upon receiving an allegation, the facility immediately initiated an investigation. This process included interviewing the residents involved, followed by interviews with other residents and staff members who might have had relevant information.The DON explained team meeting would be held, which included the Assistant Director of Nursing (ADON) and Social Services, to develop appropriate, tailored to the individual needs and goals of each resident.If the allegation involved staff-to-resident abuse, the employee would be suspended pending the outcome of the investigation. If the allegation was not substantiated, the staff member would be permitted to return to work but required to complete one-on-one retraining regarding abuse prevention and appropriate conduct. If the allegation was substantiated, the employee would be terminated, and the incident reported to the Board of Nursing.The DON indicated being informed of an incident between R1 and CNA1 in which profane language was exchanged by both parties. The DON interviewed CNA1 involving in the incident, and CNA1 admitted responding to the resident using profanity out of frustration. The DON suspended the CNA1 pending further investigation.The DON indicated other staff members, who were present during the incident, were interviewed and confirmed the verbal exchange between R1 and the CNA1 had occurred. After gathering all interviews from staff, residents, and the CNA1 involved, the Interdisciplinary Team (IDT) concluded the incident was verified. Based on the findings, CNA1 was terminated on and reported to the State Board of Nursing. Education and training on abuse prevention and reporting policies and procedures were provided for all staff, and the family members and physician were notified.During the onsite investigation on 04/02/2026, the facility's correction of the past non-compliance as evidenced by:Observation of staff and resident interactions were professional and courteous.The DON interviewed the staff who were present during the incident and verified that the incident had occurred between Resident 1 (R1) and the Certified Nursing Assistant (CNA1).ADON interviewed alert and oriented residents in the area where the CNA had worked; no additional complaints were noted or observed.R1 was seen by the psychiatric nurse practitioner following the incident to assess psychosocial well-being.R1 remained stable, and no acute changes were observed.Documentation of education was provided to the CNA1 on 01/15/2026 including training on abuse and prior customer service, termination was carried out on 01/21/2026, and the CNA was reported to the State Board of Nursing regarding the incident. Documentation of staff in-services and education on abuse and neglect were provided from 01/16/2026 through 01/20/2026.FRI #2720791

Based on observation, interview and document review, the facility failed to ensure fingernail care was provided for 4 of 40 sampled residents (Resident 10, 13, 12 and 9). The deficient practice had the potential for residents not to receive nail care. Findings include:1) Resident 10 (R10) was admitted on [DATE], with diagnoses including cerebral infarction and dependence on a respirator.On 08/19/2025 at 10:51 AM, R10 was observed lying in bed and noted to have bilateral hand contractures. The fingernails on both hands were approximately more than a quarter of an inch long. Two wound care nurses confirmed the long fingernails. The two wound care nurses indicated certified nursing assistants (CNAs) were responsible for providing fingernail care. 2) Resident 13 (R13) was admitted on [DATE], with diagnoses including chronic respiratory failure and tracheostomy.On 08/19/2025 at 11:33 AM, R13 was observed lying in bed and noted to have bilateral hand contractures. The fingernails on both hands were approximately more than a quarter of an inch long. Two wound care nurses confirmed the long fingernails.3) Resident 12 (R12) was admitted on [DATE], with diagnoses including urinary tract infection and infection/inflammation reaction due to other urinary catheter.On 08/19/2025 at 11:42 AM, R12 was observed lying in bed and noted to have bilateral hand contractures. The fingernails on both hands were approximately a quarter of an inch long. The nursing supervisor came to assess R12's fingernails and agreed that the resident needs nail care. The nursing supervisor indicated fingernail care could be provided by both nurses and CNAs. Fingernail length and the need for trimming should be assessed during shower days.4) Resident 9 (R9) was admitted on [DATE], with diagnoses including anoxic brain damage and dependence on a respirator.On 08/19/2025 at 11:31 AM, R9 was observed lying in bed and noted to have bilateral hand contractures. The fingernails on both hands were approximately a quarter of an inch long. Two wound care nurses confirmed the long fingernails.On 08/21/2025 at 3:15 PM, a Registered Nurse (RN) indicated CNAs were responsible for fingernail care and stated nail care should be provided during shower days. The RN acknowledged long nails could pose a risk for digging into skin causing a wound for a resident with hand contractures.On 08/21/2025 at 3:31 PM, the Assistant Director of Nursing (ADON) inspected the hands of R12 and confirmed fingernails were long and could use trimming. The ADON indicated nursing, and CNAs should be providing routine nail care for vulnerable residents. On 08/22/2025 at 11:05 AM, the Infection Preventionist (IP) indicated nail care for residents was important for proper hygiene. Long nails could harbor microorganisms and pose an infection risk.The facility policy titled Nail Care adopted 05/01/2024, documented it was the policy of the facility to promote cleanliness, safety, and neat appearance of our residents.

Based on observation, interview and record review, the facility failed to ensure a physician order for Pressure Relief Ankle Foot Orthosis (PROFO - a specialized medical device used to relieve pressure and support the ankle and foot) boots were implemented as ordered for 2 of 40 sampled residents (Resident 10 and 9). The deficient practice had the potential for not limiting the progression of contractures of limited mobility residents and heel protection. Findings include: 1) Resident 10 (R10) was admitted on [DATE], with diagnoses including cerebral infarction and dependence on a respirator.2) Resident 9 (R9) was admitted on [DATE], with diagnoses including anoxic brain damage and dependence on a respirator.A review of the medical record for R10 and R9 revealed a physician order dated 08/13/2025, for the residents to wear bilateral lower extremity (BLE) PRAFO boots as needed for contracture management, every shift.On 08/19/2025 at 10:58 AM, observed R10 and R9 were not wearing PRAFO boots. On 08/20/2025 at 3:31 PM, observed R10 and R9 were not wearing PRAFO boots.On 08/21/2025 at 9:31 AM, observed R10 and R9 were not wearing PRAFO boots.On 08/21/2025 at 10:33 AM, observed R10 and R9 were not wearing PRAFO boots. On 08/21/2025 at 12:46 PM, observed R10 and R9 were not wearing PRAFO boots. On 08/22/2025 at 9:38 AM, observed R10 and R9 were not wearing PRAFO boots. On 08/21/2025 at 11:25 AM, the Director of Rehabilitation indicated PRAFO boots were typically applied daily or as tolerated. The boots were intended to prevent heel ulcers and foot drop. PRAFO boots application was handled by nursing staff and the rehabilitation department would educate nursing if needed with the application. The PRAFO boots were entered in the medical record as a physician order.On 08/21/2025 at 12:43 PM, a physical therapist (PT) indicated PRAFO boots were to keep alignment of the lower extremity and for the device to attain its purpose the application had to be daily.On 08/22/2025 at 9:10 AM, a certified Nursing aide (CNA) indicated PRAFO boots could be applied by both CNA and nurses. Most of the time the resident would request the boots to be put on, or the nurse would inform the CNA to ensure the boots were applied.On 08/22/2025 at 9:16 AM, a registered nurse (RN), indicated orders for PRAFO boots were transcribed onto the medication administration record (MAR) and nursing would then sign off the boots were applied as ordered. The RN indicated nursing, or CNAs could apply the boots.On 08/22/2025 at 9:37 AM, an RN reviewed the R10's and R9's MAR and confirmed the licensed nurse did not sign off the PRAFO boots were applied as ordered. The RN indicated entry of the PRAFO boots application orders in the MAR usually served as a reminder to nursing to assure the application of the device. On 08/22/2025 at 12:30 PM, the assistant director of nursing (ADON) reviewed R10's and R9's medical record and confirmed no documentation for application of the PRAFO boots were present. The ADON acknowledged the PRAFO boots should have been ordered as tolerated and not written as needed because a resident with lower extremity contractures would need the positioning device to prevent the progression of contractures. ADON indicated the orders should have been visible on the MAR to ensure its application.On 08/22/2025 at 2:30 PM, the director of nursing (DON) indicated the facility would follow a physician order for managing a resident's splint or positioning device. The DON reviewed R10's and R9's orders/ MAR and confirmed the physician order was not transcribed to the MAR.

Based on observation, interview, and document review, the facility failed to ensure a physician order for monthly urinary catheter change was completed for 1 of 40 sampled residents (Resident 12). The deficient practice had the potential for a resident to develop a urinary tract infection.Findings include: Resident 12 (R12) was admitted on [DATE], with diagnoses including urinary tract infection and infection/inflammation reaction due to other urinary catheter.On 08/19/2025 at 10:15 AM, R12 was observed in bed with a urinary tubing and collection bag hanging on the side of the bed.A Physician Order dated 05/01/2025, documented change indwelling Foley catheter or suprapubic catheter every 30 days on the 1st day of the month. One time a day starting on the 1st and ending on the 1st every month for Foley catheter care/maintenance. May change Foley catheter or suprapubic catheter if not contraindicated.The Comprehensive Care Plan revised 08/07/2025, documented the resident utilized an indwelling catheter and was at risk for trauma and infection and other complications of indwelling catheter use related to obstructive uropathy.R12's Medication Administration Record (MAR) lacked documented evidence that R12's urinary catheter was changed for the month of June and July of 2025.On 08/22/2025 at 9:16 AM, a Registered Nurse (RN) indicated an order to change a urinary catheter was transcribed to the MAR. The order was signed off by the nurse to signify the change had been completed. If the urinary catheter change was not completed, the nurse should notify the physician and document in the progress note as to why the change was not performed.On 08/22/2025 at 9:37 AM, an RN reviewed R12's MAR and confirmed the June and July order to change the urinary catheter were not signed off as completed. The RN indicated the nurse assigned should have documented in the progress notes. On 08/22/2025 at 12:30 PM, the Assistant Director of Nursing (ADON) reviewed R12's medical record and confirmed the June and July urinary catheter change was not signed off as completed. ADON was not able to provide documented evidence from nursing as to why the urinary catheter change was not completed as ordered. The ADON indicated if a resident had refused or for any reason the catheter was not changed the nurse should have entered a progress note.On 08/22/2025 at 2:30 PM, the Director of Nursing (DON) indicated the facility would follow the physician order for managing a urinary catheter. The DON reviewed R12's orders/ MAR and confirmed the entered order for the catheter change was not signed off as completed.

Based on observation, interview and record review, the facility failed to ensure a physician order was obtained for a Peripherally Inserted Central Catheter (PICC - a long, flexible tube inserted into a vein in the upper arm and threaded to a large vein in the chest near the heart) line and heparin lock (Heplock - a small, flexible tube inserted into a vein to maintain access for intermittent intravenous (IV) infusions) care, maintenance, and the dressing change per facility standards for 1 of 40 sampled residents (Resident 1). The deficient practice had a potential for placing a resident at risk for IV insertion site infections.Findings Include: Resident 1 (R1) was re-admitted on [DATE], with diagnoses including urinary tract infection and chronic respiratory failure.On 08/19/2025 at 10:00 AM, R1 was observed with two IV lines. A right upper arm IV access with two ports and a left mid arm IV access with one port. The medical record lacked documented evidence that a physician order was obtained for the care and maintenance of the IV accesses. On 08/20/2025 at 4:08 PM, both IV lines were present. The left arm heplock was not dated and the right arm PICC line had a dressing date of 08/03/2025. On 08/20/2025 at 4:25 PM, a Licensed Practical Nursed caring for R1 confirmed the presence of the 2 IV lines and verified from the electronic medical records (EMR) the lack of physician orders for both IV lines. The nurse confirmed the PICC line dressing was dated 08/03/2025 and should have been replaced when the resident was readmitted to the facility. The nurse indicated orders to maintain the IV accesses should have been initiated upon return from the hospital. On 08/22/2025 at 2:30 PM, the Director of Nursing (DON) indicated the facility would follow physician orders when managing IV access. The DON reviewed R1's orders and confirmed the entered orders for the IV access were dated 08/20/2025. The DON agreed that the orders should have been placed once the IV access was identified during the readmission nursing assessment to ensure proper management of the IV lines.

Based on interview, record review, and document review, the facility failed to provide medication for glaucoma (abnormal high pressure in the eye) as ordered by a physician for 1 of 40 sampled resident (Resident 185). The deficient practice could result in poor control of glaucoma and potential loss of vision. Findings include: The facility policy titled Medications, Provision of Routine or Emergency, indicated the facility provided medications to meet the needs of each resident. The policy indicated that prescribed medications were administered in a timely manner. Resident 185 (R185) was admitted on [DATE] with diagnoses including abscess of the liver. The resident was responsible for self and making medical decisions. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had good memory function. On 08/22/2025, in the morning, R185 verbalized routine home medications included a prescription eye drop to each eye daily at bedtime to control glaucoma. R185 verbalized requesting the facility to furnish the prescription eye drop. R185 reported the facility staff verbalized they would order the prescription eye drop. R185 reported to date not having received the eye drop. R185 expressed a concern about being at risk of visual loss if the medication was not used consistently. A Physician Order dated 08/08/2025 indicated Bimatoprost Ophthalmic Solution 0.01 %, instill 1 drop in both eyes at bedtime for increased ocular pressure.On 08/22/2025 8:39 AM, the order audit report indicated the medication had been ordered on 08/08/2025 and then reordered on 08/13/2025. On 08/22/2025 the medication was listed as on order. The audit lacked documented evidence that the medication had been delivered.On 08/22/2025 in the morning, the Assistant Director of Nursing (ADON) was unable to locate the Bimatoprost eye drop on the unit. The ADON verbalized staff had attempted to order the medication, but it had not been delivered. The ADON spoke to a pharmacist who verbalized the medication request had not been filled as a prescription was needed and had not been provided. The ADON verbalized 14 days had elapsed since the order was received on 08/08/2025 until today, 08/22/2025. The ADON verbalized that the lack of the medication should have been addressed by nursing staff within a day or two after receiving the order. ADON did not know why nursing staff did not call the pharmacy to clarify what was needed to obtain the medication before now.On 08/22/2025, at 11:05 AM, the Director of Nursing (DON) verified the medication had been ordered by the physician on 08/08/2025, but the facility had not obtained the medication. The DON reported that the Bimatoprost eye drop was used to prevent raised intraocular pressure, which could damage the retina of the eye. The DON verbalized it was important to give the Bimatoprost consistently.

Based on observation, interview, record review and document review, the facility failed to ensure 1) enhanced barrier precaution (EBP - a set of infection control practices designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) was maintained during care for 1 of 40 sampled residents (Resident 1), and 2) provisions in the water management program was implemented. The deficient practice had potential for microbial infection to develop and spread within the facility.Findings Include: 1) Resident 1(R1) was re-admitted on [DATE], with diagnoses including urinary tract infection and pneumonia gram negative bacteria. R1's physician's order dated 08/17/2025, documented Enhance Barrier Precaution: Tracheostomy, ventilator, Gastrostomy tube and indwelling foley catheter. On 08/20/2025 at 4:05 PM, observed a certified nursing aide (CNA) emptying R1's Foley catheter bag with gloves donned. The CNA was not wearing a gown. On 08/20/2025 at 4:18 PM, the CNA indicated a gown should have been worn when emptying a Foley catheter bag for a resident on EBP. The CNA acknowledged the risk of splatters when emptying a urine bag and potential cross contamination between residents and other staff. On 08/22/2025 at 11:05 AM, the Infection Preventionist (IP) indicated staff were educated on transmission-based precautions (TBP) and the appropriate personal protective equipment (PPE) to be used during care activities. The IP indicated TBP signage should be followed. The IP acknowledged not following TBP poses a risk of cross contamination for the resident population and other staff members. The facility policy titled TBP (Isolation), Enhanced Barrier Precautions adopted 05/01/2024, documented residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO. The use of gowns and gloves for high-contact resident care activities is indicated. 2) On 8/21/2025, the Administrator indicated the Maintenance Director was responsible for the water management plan. The Maintenance Director explained the facility had a water management plan but did not think the plan addressed the prevention of Legionella, however, the facility intended to include Legionella in the plan next month. On 8/21/2025, the Infection Preventionist was not familiar with the facility's water management plan. The facility, Water Management Program for Prevention of Legionella Growth, revised 6/27/2023, was provided on 8/22/2025. The resources cited in the facility's Water Management Program (WMP) was the Center for Disease Control (CDC) Toolkit Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, a nationally accepted standard. However, many components of this standard were not included in the facility's WMP. The WMP did not explain the water flow in the building in both text and diagram. The WMP listed areas of potential risk but included risks that were not applicable to the facility. These included hot tubs and cooling towers. The list of areas of potential risk included risks that were applicable to the building but did not define the location or number of the risks. These included showerheads, ice machines, water heaters and eyewash stations. The WMP stated the preventative maintenance included verification and documentation at least once weekly to ensure the domestic hot water boiler/storage tanks were set between 140-160 degrees Fahrenheit, and the temperature of water entering the circulating system at the mixing valve set at 120 degrees Fahrenheit or above. The facility failed to provide documentation the temperature measures were completed. The WMP stated the preventative maintenance included ice machines inspections for leaks and contamination at least monthly. The WMP did not state the number and location for the ice machines. During a telephonic interview on 8/22/2025 at 12:20 PM, the Maintenance Director explained there were five ice machines, and a vendor cleaned the ice machines monthly. The facility failed to provide documentation, the ice machines were cleaned monthly. The WMP stated the preventative maintenance included weekly sanitizing of medical devices such as continuous positive airway pressure (CPAP), hydrotherapy, etc. The Administrator indicated on 8/21/2025 that the facility had 25 ventilator-dependent residents. The facility failed to provide documentation ventilator maintenance and cleaning was completed weekly. The WMP stated the elements of the water management program should be reviewed at least once per year. The WMP indicated the effective date was 6/30/2017, and the revisions occurred on 12/28/2017, 7/19/2019, and 6/27/2023. There was no evidence provided to indicate the WMP had been reviewed within the past year.

Based on observation, interview, and document review, the facility failed to ensure the air conditioning unit in 2 of 12 resident room halls (1300 Hall and 2300 Hall) was maintained in good working condition. The deficient practice had the potential for the temperature to be at an uncomfortable level. Findings include: The Resident Council Meeting Minutes dated 06/10/2025, with ten residents in attendance, documented the residents had complained the air conditioning was not working in the Valley of Fire Unit and Mount [NAME] Unit. There were cooling fans throughout the building, but it did not alleviate the situation.Review of the facility map revealed the Valley of Fire Unit (located on the first floor of the building) consisted of resident rooms in 1100 Hall, 1200 Hall, and 1300 Hall. Mount [NAME] Unit (located on the second floor of the building) had the residents' rooms in 2100 Hall, 2200 Hall, and 2300 Hall.On 08/21/2025 at 12:15 PM, a Certified Nursing Assistant (CNA) revealed in June 2025 the air conditioning in some of the rooms on the first and second floor of the building was shut down and not working. The CNA indicated it was hot in the affected resident rooms. The CNA confirmed the residents were complaining about the hot room temperature.On 08/21/2025 at 2:44 PM, the Director of Nursing (DON) indicated Resident 181 (R181) was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 05/28/2025 at 2:10 PM due to complaint of warm temperature in the room.R181 was admitted on [DATE] and discharged on 06/07/2025. The Nurse's Notes dated 05/28/2025 at 2:11 PM, documented room change to 2608 from 2201.On 08/22/2025 at 11:07 AM, the Administrator indicated in June 2025 an electric power surge in the building which shutdown the air conditioning unit in 1300 Hall and 2300 Hall. There were 12 private rooms in each hall or a total of 24 private rooms for the two halls. The facility called the contracted Heating, Ventilation, and Air Conditioning (HVAC) company immediately. The HVAC company came out servicing the air conditioning and was able to reset the system to make the air conditioning worked. The Administrator revealed after the repair, the system (air conditioning unit) was shutting down and needed to reset again. The Administrator explained the Maintenance Director kept on resetting the system every two hours to have the air conditioning work.The Administrator indicated electric fans and portable air conditioning units were provided to mitigate the situation. The Administrator confirmed the 1300 Hall, and 2300 Hall were closed on 07/12/2025 and had not been used since then.The Administrator acknowledged the temperature in the resident rooms should have been between 72 to 82 degrees Fahrenheit. The Administrator indicated the temperature in the resident rooms was 83 to 84 degrees Fahrenheit when the air conditioning was shut down.The Administrator explained the facility provided portable swamp coolers (evaporative coolers) in all affected rooms. The Administrator indicated it was an ongoing process and the needed parts for the repair of the air conditioning arrived yesterday (08/21/2025). The Administrator confirmed the contracted HVAC company was currently at the facility today and working to install the parts.On 08/22/2025 at 11:44 AM, the Maintenance Director indicated the residents remained in the affected rooms no longer than three days in June 2025 when the air conditioning was shut down and not working.On 08/22/2025 at 2:30 PM, the DON confirmed R181's room upon admission (room [ROOM NUMBER]) was affected by the air conditioning being shut down. The DON indicated there were individual rooms aside from the rooms in 1300 Hall and 2300 Hall which were affected.On 08/22/2025 at 2:48 PM, the Administrator indicated around 17 residents in 1300 Hall and 2300 Hall could have been affected by the hot room temperature when the air conditioning was not working and shut down in June 2025. The Administrator explained five residents opted to stay in the unit. The Administrator revealed 1300 Hall, and 2300 Hall had 12 private rooms each, or a total of 24 rooms, with 90-95% occupancy rate.The Administrator provided a timeline of events regarding the issue with the air conditioning unit which documented the following:- On approximately 06/01/2025, the facility experienced a power surge which damaged one indoor air unit. The contracted HVAC company was notified and was onsite the same day to review and provide repairs.- While repairing the individual unit, a communication error occurred causing one of six hallways on the first floor and one of six hallways on the second floor to experience intermittent outages.- System was able to be reset same day. The system worked for approximately ten days before a wiring issue caused the system to shut down.- Facility maintenance staff were on site and able to manually reset the air conditioning unit in question. This corrected the issue but only temporarily. The air conditioning system continued to shut down approximately every two hours. Maintenance staff stayed onsite and would manually reset the system as needed.- Approximately 06/10/2025, the contracted HVAC company identified a wiring issue in one of six hallways on the first floor and one of six hallways on the second floor. The wiring issue affected 12 rooms in 2300 Hall and seven rooms in 1300 Hall. 2300 Hall was closed at this time to allow for the air conditioning repairs to be completed without resident disruption. The air conditioning in rooms 1301 to 1305 continued to function and the residents remained in the rooms, while the remainder of 1300 hall was closed.- On 07/12/2025. all remaining rooms in 1300 Hall were closed to allow for HVAC wiring repairs to be completed.- One of six hallways on the first floor and one of six hallways on the second floor had remained closed since 07/12/2025 while HVAC repairs were being completed.During the onsite investigation on 08/19/2025 through 08/22/2025, the facility's correction of the past non-compliance related to the air conditioning not in good working condition occurred as evidenced by:- A tour of the facility revealed the resident rooms were not visibly hot. The room temperature ranged from 70.2 degrees Fahrenheit to79.0 degrees Fahrenheit. There were three portable air conditioning units on the first floor and two portable air conditioning units on the second floor.- The affected halls (1300 Hall and 2300 Hall) were closed.- During the onsite investigation, there were no residents who complained about the hot room temperature.- A CNA confirmed the resident room temperatures were okay now and the CNA had not received any complaints from the residents about the hot room temperature.- On 08/21/2025 at 1:57 PM, during the resident council meeting, the residents had no complaints about the room temperatures. Complaint 2289515

Based on interview, record review and document review the facility failed to ensure a resident was kept safe from abuse for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential for the resident to experience emotional distress and physical harm. Findings include: Resident 1 (R1) R1 was re-admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure. The facility reported incident (FRI) dated 02/03/2024 documented the following: -On 02/01/2025 in the PM, R1 reported to the Nurse that on Saturday 2/1/2025, a Certified Nursing Assistant (CNA) took R1's room phone away because the resident kept calling the desk. - Employee 1 (E1) was interviewed and admitted to taking the phone away from the resident because the resident had kept calling the front desk. -Conclusion: The allegation of abuse by E1 against R1 was substantiated. The facility investigation documented R1 was upset with E1 due to E1 unplugging the phone in the room and putting it on the dresser across the room where R1 could not get to it and telling R1 to stop calling downstairs. E1 was suspended pending the investigation results. E1 was terminated on 02/06/2025 for abuse as the facility documented the employee willfully inflicted punishment to the resident which resulted in R1's mental anguish. The facility also reported E1 to the Board of Nursing on 02/06/2025. The Social Services Coordinator's (SSC) investigative notes documented R1 thought E1 was upset with R1. R1 also stated E1 had been bossy and had given R1 attitude because E1 said R1 was putting the call light on too much and was calling downstairs constantly asking for things. R1 stated E1 unplugged the phone in the room and put it on the dresser across the room where R1 could not get to it and told R1 to stop calling downstairs. The SSC also documented R1 still had their cell phone and call light with them during this event. A behavioral Care Plan revised 02/28/2025 documented R1 was demonstrating behavioral distress related to feeling powerless or out of control and utilizing ineffective coping mechanisms. Interventions included praising calm communication, walking to quiet areas, and staff to professionally and calmly communicate to the resident. A behavioral Care Plan implemented on 02/28/2025 documented R1 was displaying behavioral symptoms of yelling and screaming out due to difficulty in adjusting to life in a Long-Term Care facility due to ineffective coping skills. Interventions were updated to include staff intervening when inappropriate behaviors were observed by using creative refocusing to alter the resident's behavior patterns. On 06/05/2025 at 10:45 AM, R1 stated this incident happened a while ago. R1 said nothing like this had happened before or after this incident. R1 reported no psychosocial harm from the incident and reported also not experiencing any emotional distress from the incident. R1 stated felt safe and fine at this facility. The facility policy titled Resident Rights, Abuse and Neglect, adopted 05/01/2024, documented it is the policy of this facility to provide professional care and services in an environment free from any type of abuse, corporal punishment, involuntary seclusion, and misappropriation of property, exploitation, neglect, or mistreatment. During the onsite investigation on 06/05/2025, the facility's correction of the past non-compliance related to the incident occurred as evidenced by: -Observation of resident interactions were respectful and courteous. -Interviews with residents revealed they were happy with staff and were treated in a polite manner. -E1 was terminated and reported to the Board of Nursing on 02/06/2025. Facility Reported Incident #NV00073489 Complaint #NV00073457

Based on interviews, record review, and document review the facility failed to ensure abuse policies and procedures were implemented for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to put residents at risk of physical or psychosocial harm. Findings include: Resident 1 (R1) R1 was re-admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, end stage renal disease, and heart failure. The facility reported incident (FRI) dated 02/03/2024 documented the following: -On 02/01/2025 in the PM, R1 reported to the nurse that on Saturday 2/1/2025, a Certified Nursing Assistant (CNA) took the resident's room phone away because the resident kept calling the desk. - Employee 1 (E1) was interviewed and admitted to taking the phone away from the resident because the resident had kept calling the front desk. The facility investigation documented the allegation of abuse by E1 against R1 was substantiated. The investigation also documented R1 was upset with E1 due to E1 unplugging the phone in the room and putting it on the dresser across the room where R1 could not get to it and telling R1 to stop calling downstairs. E1 was suspended pending the results of the investigation. E1 was terminated on 02/06/2025 for abuse as the facility documented the employee willfully inflicted punishment to the resident which resulted in R1's mental anguish. The facility also reported E1 to the Board of Nursing on 02/06/2025. On 06/05/2025 at 1:37 PM, a CNA indicated staff have their trainings on the computer. The CNA stated thought had completed the Abuse and Neglect Annual Training last week. On 06/05/2025 at 10:15 AM, a Licensed Practical Nurse (LPN) verbalized could not remember the last time the facility had training on resident abuse and neglect. On 06/05/2025 in the afternoon, the Director of Nursing (DON) indicated ongoing abuse training should occur with an abuse allegation event. The DON stated would have expected staff education on abuse like they provide at hire and annually. Employee training records indicated staff had not received additional abuse training related to the abuse event. The facility policy titled Resident Rights, Abuse and Neglect, adopted 05/01/2024, documented ongoing training sessions were one of the seven steps for the prevention of abuse. On 06/05/2025 at 3:07 PM, the Administrator acknowledged their policy and procedures bullet pointed steps which should be taken to prevent a future occurrence of the abuse. The administrator indicated abuse training related to the identified abuse, which was investigated, should have been a part of their action steps taken to prevent future occurrences. The Administrator stated an allegation of abuse should have initiated this type of ongoing abuse training. FRI #NV00073349

Based on observations and interview, the facility failed to ensure a resident was treated with dignity and respect by facility staff directing the resident to urinate in their incontinence brief for 1 of 16 sampled residents (Resident 3). The deficient practice had the potential to negatively impact the resident's well-being. Findings include: Resident 3 (R3) R3 was admitted on [DATE] with diagnoses including hypertension, end stage renal disease with hemodialysis, and congestive heart failure. On 01/07/2025 at 9:22 AM, a Certified Nursing Assistant (CNA) verbalized the staff are not supposed to tell incontinent residents to go to the bathroom in their briefs, however it does occur. On 01/07/2025 at 9:32 AM, Resident 5 (R5) verbalized having been told to urinate on themselves in the past. R5 verbalized feeling upset about it and has heard other residents have been told the same but cannot speak for them. On 01/07/2025 at 3:52 PM, R3 verbalized one CNA on the night shift told the resident if had to wait for the CNA, then just go in the brief, that is why briefs are worn. R3 verbalized this makes the resident want to cry at night and makes the stay at the facility difficult. On 01/07/2025 at 4:08 PM, the Director of Nursing (DON) verified it would not be appropriate for staff to direct a resident to urinate or defecate in their brief and staff would need to assist the resident to the bathroom as needed. The DON verbalized by directing a resident in this manner would result in dignity issues. Complaint #NV00073092

Based on record review and interview, the facility failed to clarify discrepancies in the appeal decision resulting in a resident being discharged and lacked documented evidence of well-coordinated discharge planning for 1 of 16 sampled residents (Resident 4). The deficient practice had the potential for a resident not to receive the necessary skilled therapy to improve functional ability and provide the necessary provisions for continuation of care. Findings include: Resident 4 (R4) R4 was admitted on [DATE] and discharged on [DATE] with diagnoses including difficulty in walking, chronic osteomyelitis of right ankle and foot, contracture of muscle right lower leg, and limitations of activities due to disability. The Admission Minimum Data Set (MDS) dated [DATE] documented R4 had lower extremity (hip, knee, ankle, foot) functional limitations in range of motion with impairment on both sides. The Physical Therapy Evaluation and Plan of Treatment dated 08/23/2024 documented 100+ degrees flexion contracture (knee is bent at a fixed angle preventing it to be straightened fully) of right and left knees with right side greater than left. The Detailed Explanation of Non-coverage dated 11/09/2024 documented R4 was able to walk 100 feet without an assistive device, with one person watching the resident. A Beneficiary and Family Centered - Quality Improvement Organization (BFCC-QIO) Determination letter dated 11/09/2024 documented a review of the medical records showed the resident is walking 100 feet without an assistive device with supervision. The documentation does not support the need for daily skilled therapy services. Continued Skilled Nursing Facility coverage is not needed because the resident does not require daily skilled therapies. The Physician Discharge Summary dated 11/21/2024 documented gait (pattern of how a person walks) instability and continue physical therapy for gait training. The Interdisciplinary Team (IDT) Functional Abilities Discharge document dated 11/25/2024 documented R4's discharge performance for ability to walk ten feet: once standing, the ability to walk at least ten feet in a room, corridor, or similar space as not attempted due to medical condition or safety concerns. On 01/09/2025 at 9:24 AM, the Director of Rehabilitation (DOR) verbalized upon admission R4 was unable to walk due to bilateral lower extremity contractures, upon discharge R4 was still unable to walk. The DOR stated being unsure why the appeal decision would state R4 was able to walk 100 feet. On 01/09/2025 at 9:37 AM, the Case Manager stated the facility process when a resident makes an appeal to the discharge decision, was as follows: 1) Submit the required records electronically to the insurance provider. 2) When the insurance determination was received, staff would review the decision and provide the resident with the information. The Case Manager verified for R4 this review did not occur. The case manager verbalized providing R4 with the letter without reviewing the explanation for the decision. On 01/09/2025 at 9:58AM, the Case Manager recalled discussing discharge with R4 and their spouse stating the spouse was concerned due to not being able to provide care for R4 resulting in a decision for hospice services. The Case Manager acknowledged the discharge discussion was not documented, and care giver training did not occur. On 01/09/2025 at 12:00 PM, the Case Manager verbalized R4 was financially overqualified for Medicaid services and R4 declined additional placement options such as a group home. The Case Manager stated R4 was provided with care giver services information and agreed to discharge home with hospice services. The Case Manager acknowledged the medical record lacked documentation of the discussion. On 01/09/2025 at 12:15 PM, the DOR verbalized upon admission R4 stated their spouse was able to provide care. However, when therapy contacted the spouse, the spouse indicated were not able to provide care therefore caregiver training did not occur. The DOR acknowledged the medical record lacked documentation regarding the discussion.

Based on observation, interview, record review and document review, the facility failed to ensure showers were provided as scheduled for 1 of 16 sampled residents (Resident 14). The deficient practice had the potential to increase skin breakdown, infections, odor and bacteria buildup. Findings include: Resident 14 (R14) R14 was admitted on [DATE], with diagnoses of major vascular neurocognitive disorder- dementia. A Therapy to Nursing communication form dated 01/06/2024, documented the resident is front weight bearing with transfer and the resident had an assessed device of a rolling walker. The resident needed supervision for grooming, oral care, upper body dressing and footwear, moderate assistance with toileting, minimal assistance with showering and lower body dressing. The resident is independent with communication, vison and feeding. On 01/07/2025 at 4:50 PM, Director of Medical records provided two shower sheets which documented on 01/08/2024, the resident had a bed bath and on 01/16/2024 the resident had a shower. On 01/07/2025 at 2:38 PM, Employees 16 and Employee 17 (E16 and E 17) clarified if a resident would refuse a shower or bed bath, the CNAs would notify the nurse and document the event. E16 provided the shower schedule for R14's unit which documented showers are scheduled for morning and evening shift. E16 voiced resident showers are two days a week. E16 voiced if a resident had an accident after ADL care and the family requested for incontinent care the care would be completed immediately. On 01/09/2025 at 8:31 AM, an observation of the shower schedule on the unit where the resident was housed indicated showers are designated twice a week, which are on Mondays and Thursdays. On 01/09/2025 at 8:50 AM, review of January 2024 calendar revealed R14 did not receive a shower or bed bath on the scheduled shower days. R14 had missed scheduled showers for the week of 01/11/24 through 01/15/24, a shower for 01/18/2024 and 01/22/2024. The documents, which were provided by the Director of Medical Records, indicated the resident received a bed bath on 01/08/2024, a shower on 01/16/2024, and a skin assessment on 01/22/2024. On 01/09/2025 at 10:22 AM, Employee 18 (E18) clarified residents on the Mount [NAME] Unit receives showers twice a week. E18 stated the shower schedule is arranged between morning shift and evening shift. E18 expressed if a resident refused a shower or a bed bath the nurse would be notified and documentation on a shower sheet must be present, E18 expressed the resident would sign the shower sheet along with the CNA. E18 confirmed if the resident is unable to sign the shower sheet the assigned nurse would sign the shower sheet. On 01/09/2025 at 12:20 PM, the Director of Nursing (DON), stated the expectation for resident's personal hygiene and showers are important and has scheduled shower days. The DON confirmed the facility does expect the staff to accommodate the resident's preferences if requested for a later shower or bed bath. The DON voiced the staff can provide bed baths if the residents refuse a shower on the scheduled day. On 01/09/2025, facility policy titled Quality of life activities of daily living (ADL's) maintain abilities dated 11/2017, documented the facility provides the necessary care and services to support the resident's care needs. The policy clarified that residents are given the appropriate treatment and services to maintain the ability to carry out activities of daily living, including hygiene care of bathing, grooming, dressing and oral care. The policy also indicated if a resident is unable to carry out activities of daily living receives the necessary services to maintain good grooming, personal hygiene and oral hygiene. On 01/09/2025, facility policy titled Bed and Shower, adopted on 05/01/2024, documented the facility policy is to promote cleanliness, stimulate circulation and assist in relaxation. Complaint #NV00071075

Based on observation, interview and document review, the facility failed to ensure two free standing portable oxygen cylinders were safely stored. The deficient practice had the potential to prevent avoidable accidents and increase concerns of potential harm to residents and the facility overall. Findings include: On 01/07/2025 at 8:42 AM in resident room [ROOM NUMBER], two free standing portable oxygen cylinders were left unattended. On 01/07/2025 at 8:45 AM, the resident stated was not sure why the oxygen cylinders are in the resident's room. One oxygen cylinder was empty, and the other cylinder was half full. On 01/07/2025 at 8:45 AM, a Certified Nursing Assistant (CNA) explained was not sure why the oxygen cylinders were inside the room. The CNA confirmed the oxygen cylinders were placed correctly but the oxygen cylinders should be placed in the closet with other oxygen cylinders. The CNA stated was not aware if the oxygen cylinders were empty. On 01/07/2025 at 8:48 AM, a Registered Nurse (RN) expressed the oxygen cylinders should be on a stand or Respiratory Therapy (RT) would take the tanks to be stored in the closet with empty oxygen cylinders. On 01/07/2025 at 9:00 AM, an RN explained oxygen cylinders are left in the oxygen storage room unless the resident is being transported. If the oxygen cylinder is kept in the resident's room for any reason the oxygen cylinder is placed on a stand for storage. On 01/07/2025 at 8:59 AM, in resident room [ROOM NUMBER] an oxygen cylinder was stored on a stand with wheels in the corner of the resident's room. On 01/07/2025 at 9:35 AM, in resident room [ROOM NUMBER] oxygen cylinders were not removed or stored in the oxygen storage room. On 01/09/2025 at 11:20 AM, facility policy titled Oxygen Handling and Storage last revised 05/01/2024, documented oxygen cylinders must be stored in a safe manner. The policy clarified oxygen cylinders must be secured to a wall with a chain or cable or is in a stationary rack specifically for holding oxygen cylinders. On 01/09/2025 at 12:20 PM, the Director of Nursing (DON), confirmed oxygen cylinders must be stored in a stationary rack, in an oxygen storage closet, or in a [NAME] with wheels. The DON stated that oxygen cylinders should never be left free standing inside a resident's room or hallway without the proper storage rack, contained rack or a [NAME]. The DON clarified if an oxygen tank must be stored in a resident's room it has to be on a [NAME].

Based on observation, interview, and record review, the facility failed to ensure medications were secured for 1 of 6 sampled residents (Resident #19). This deficient practice had the potential to result in other residents having access to the medication. Findings include: Resident 19 Resident 19 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with diabetic neuropathy, surgery on the digestive system, dehydration, elevated white blood count, hypertension, hyperlipidemia, unspecified, acute kidney failure unspecified, chronic kidney disease stage three unspecified, and acute cholecystitis. On 1/07/2025 at 9:00 AM, a white/pink cream in a medication cup was left on Resident 19's dresser, unattended. On 1/07/2025 at 9:03 AM, the Registered Nurse verbalized the medication cup with the cream medication, should not have been placed and left in the resident's room. On 1/09/2025 at 10:23 AM, the Registered Nurse verbalized Resident #19 had an order for Moisture Barrier cream with Zinc10%. The RN stated the Wound care nurse is the only staff member who would apply the Moisture Barrier Cream. On 1/09/2025 at 12:10 PM, the Wound Care Nurse verbalized Resident 19 had moisture barrier cream with Zinc. The Wound Care Nurse stated only the wound care nurse can apply the moisture barrier cream for Resident 19 and the cream cannot be left in Resident 19's room. Resident 19's treatment administration record revealed the Moisture barrier with Zinc 10% was applied on the coccyx after cleaning at 7:00am by the wound care nurse.

Based on observation, interview, and document review, the facility failed to ensure the menu was followed for a breakfast service. This deficient practice had the potential to affect all residents in the facility. Findings include: On 09/26/2024 at 8:31 PM, breakfast was delivered to residents in the Valley of Fire Unit to include cereal, fruit, pancakes and sausage. The Week At a Glance menu documented breakfast for Thursday would include assorted juice, choice of hot or cold cereal, cheesy eggs, hashbrowns, banana, toast, margarine or jelly, and milk or another beverage. The breakfast for Friday would include assorted juice, choice of hot or cold cereal, pancakes, sausage, fresh fruit cup, margarin or syrup, and milk or another beverage. On 09/26/2024 at 2:18 PM, the Dietary Manager (DM) verbalized breakfast on Thursday 09/26/2024 was swapped with the breakfast for Friday 09/27/2024 because the cook looked at the wrong day on the menu and began preparing for the breakfast for Friday instead of the breakfast for Thursday. The DM verbalized residents would be notified of this change by changing the menus in each unit hallway. The facility policy titled Honoring Resident Choice and Self-Directed Living at Meals, undated, documented residents would be offered all food and beverage components planned in the approved menu.

Based on observation, interview, and document review, the facility failed to ensure 1) a dietary aide's purse was not being stored with resident food in the dry storage area of the kitchen, 2) a hairnet was donned prior to entering the kitchen, 3) hand washing was performed when entering the kitchen or prior to donning gloves, 4) beverages were covered when traveling down hallways, 5) food was stored at safe temperatures, and 6) thermometers were properly sanitized between foods during the taking of temperatures. This deficient practice placed residents at risk for food-borne infectious illnesses. Findings include: 1. Storage of personal items: On 09/23/2024 at 12:56 PM, located on a shelf containing food for residents, was a staff members purse. On 09/23/2024 at 1:00 PM, the Dietary Aid confirmed the purse belonged to them and verbalized the Dietary Manager had previously spoke to the Dietary Aid on a few occasions about leaving the Dietary Aid's purse next to resident food. The Dietary Aid explained the purse was not to be stored with resident food because the food can get contaminants causing illnesses. On 09/24/2024 at 10:38 AM, the Dietary Manager explained the Dietary Manager had previously warned the Dietary Aid about storing the purse with resident food and the Dietary Aid continued to place the purse with resident food. The Dietary Manager verbalized personal items were not to be stored with resident food because it could cause a bacteria outbreak should the residents consume the food. On 09/25/2024 at 8:39 AM, the Administrator verbalized personal items were not to be stored with resident food to protect the resident's health and safety. The Administrator explained there were personal lockers available to the dietary staff to store the personal belongings. The Administrator verbalized the facility did not have a policy regarding the storage of personal items in the kitchen and the facility followed best practices. The facility policy titled Food Receiving and Storage, adopted 05/01/2024, documented the facility would store food in a manner that complied with safe food handling practices. The facility policy titled Preventing Foodborne Illness-Food Handling, adopted 05/01/2024, documented food would be stored in a way to prevent the risk of foodborne illnesses and staff would handle food with practices of safe food handling to prevent foodborne illnesses. 49557 2. Hair covering: On 09/25/2024 at 12:38 PM, during an observation of the satellite kitchen on the Mount [NAME] unit, a Licensed Practical Nurse (LPN) entered the satellite kitchen. The LPN opened the refrigerator, removed a tray of desserts, set the tray aside and retrieved a yogurt. The LPN was not wearing a hairnet and did not perform hand washing upon entering the kitchen. On 09/25/2024 at 12:40 PM, the LPN confirmed the LPN was not wearing a hairnet and did not perform hand washing upon entering the kitchen. The LPN confirmed staff were required to don a hairnet and hands were to be washed when entering the kitchen. The facility policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, adopted 05/01/2024, documented employees must wash their hands whenever entering or re-entering the kitchen. Hair nets or caps must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. 50210 3. Hand Hygiene On 09/25/2024 at 12:57 PM, the Dietary Aide entered the kitchen and donned gloves. The Dietary Aide did not wash hands prior to donning the gloves. On 09/25/2024 at 12:57 PM, the Dietary Aide confirmed the Dietary Aide did not wash hands upon entering the kitchen and prior to donning gloves. On 09/25/2024 at 12:59 PM, the DM confirmed the Dietary Aide did not was hands prior to donning gloves and should have. 4. Uncovered Beverages On 09/24/2024 at 8:02 AM during a dining observation of meal service, the following occurred: -Beverages were poured in the dining area, outside the satellite kitchen in the Valley of Fire Unit. -Beverages were set on meal trays on an open meal cart. -Four trays were transported down the hall and delivered to resident bedrooms. -Process was repeated three times for the 1100 hallway with 18 uncovered beverages, and twice in the 1200 hallway with 13 uncovered beverages. On 09/24/2024 at 8:40 AM, a Certified Nursing Assistant (CNA) confirmed the beverages were uncovered while being transported down the hallways. The CNA confirmed the open beverages risked the spread of bacteria between residents and staff. On 09/24/2024 at 10:38 AM, the Dietary Manager (DM) verbalized food and beverages should be covered in the hallways because it presented a sanitation issue with people coughing in the hallways and bacteria being spread. The DM confirmed beverages were being served uncovered in the Vally of Fire Unit and should not have been. 5. Food Storage On 09/25/2024 at 12:05 PM, the Dietary Aide entered the satellite kitchen in the Valley of Fire Unit and transferred beverages, pudding, and vanilla shakes into the refrigerator. The refrigerator's built-in thermometer was flashing between C46 and 88.8. On 09/25/2024 at 12:21 PM, the Dietary Aide verbalized the Dietary Aide observed the refrigerator's temperature every shift and after each meal. The Dietary Aide confirmed the refrigerator's built-in thermometer was flashing and verbalized being unsure why but may be due to the refrigerator door being open. The Dietary Aide removed beverage pitchers from the refrigerator and put them in the dining room to be served to residents. After closing the door, the Dietary Aide confirmed the built-in thermometer was still flashing and verbalized the built-in thermometer may be flashing because the refrigerator was on defrost mode. The Dietary Aide verbalized there was a thermometer inside the refrigerator reading at 55 degrees Fahrenheit (F). The Dietary Aide verbalized food should be stored at 40 F. On 09/25/2024 at 12:40 PM, the DM verbalized food should be stored at or below 41 F. The DM confirmed the refrigerator stored milk, cottage cheese, chocolate pudding, individual size yogurts, vanilla shakes, oatmeal, salads, and resident items to include tortillas, cheese slices, cooked ravioli, ham, smoothies, grapes, jelly jars, Greek yogurt and whipped cream. On 09/25/2024 at 12:40 PM, the following items were assessed to be above 41 F and confirmed by the DM: -Milk at 47.6 F. -Cottage cheese at 50 F. -Chocolate pudding at 50.1 F. -Yogurt at 41.6 F. -Vanilla pudding desserts at 54.5 F. The facility policy titled Serving Temperatures for Hot and Cold Foods, undated, documented foods would be served to ensure a safe and appetizing dining experience at 41 F or below for cold beverages, fruits, desserts, salads, and dairy products. 6.Thermometer Sanitation On 09/25/2024 at 12:51 PM, during lunch tray line observation, the Dietary Aide took the temperature of the chopped pork, wiped the thermometer with an alcohol swab, then wiped the thermometer with a stained, dirty appearing rag. The Dietary Aide used the same thermometer to take the temperature of the minced and moist pork, wiped the thermometer with a new alcohol swab, then wiped the thermometer with the stained, dirty appearing rag. The Dietary Aide took the same thermometer and took the temperature of the chopped pork, wiped the thermometer with an alcohol swab, and wiped the thermometer with the stained rag. On 09/25/2024 at 12:59 PM, the DM confirmed the Dietary Aide used the rag to wipe the thermometer before taking the temperature of the other foods. The DM verbalized the Dietary Aide should have use the alcohol swab and let the thermometer air dry without using the rag because it contaminated the other foods the thermometer was placed in. The DM asked if the DM could reheat the food to kill bacteria or if the DM would need to serve all new food to the residents. The facility policy titled Monitoring Food Temperatures for Meal Service, undated, documented alcohol swabs may be used to sanitize between uses while taking temperatures or if contamination of the thermometer occurs. If applicable, the manufacturer's recommendations for cleaning and sanitizing thermometers may be followed. The facility policy titled Preventing Foodborne Illness-Food Handling, adopted 05/01/2024, documented food would be stored in a way to prevent the risk of foodborne illnesses and staff would handle food with practices of safe food handling to prevent foodborne illnesses. CPT #NV00070408

Based on observation, interview and document review, the facility failed to ensure 4 of 4 dining rooms maintained a comfortable home-like environment by storing medical equipment in the dining areas. The deficient practice had the potential to affect all residents who wish to eat in the dining areas. Findings include: On 09/24/2024 at 7:54 AM, in the Lake [NAME] dining room, the following medical equipment was being stored: -One hoyer lift, -One vitals sign monitor, and; -One wheelchair scale. On 09/24/2024 at 8:06 AM, there was a resident eating breakfast in the Lake [NAME] dining room. The resident explained the medical equipment was always in the dining area, however, did not know how long the equipment had been there. On 09/24/2024 at 8:11 AM, a Certified Nursing Assistant (CNA) explained the medical equipment was supposed to be put away in the cubbies, located in each hallway, however staff would put the equipment in the dining area after use. The CNA confirmed the medical equipment was stored in the dining room and verbalized the dining room was not a comfortable homelike environment for the residents who wished to eat in the dining room. On 09/24/2024 at 9:15 AM, in the Red Rock dining room, the following medical equipment was being stored: -One geri chair, -One IV drip post, -Three vital sign monitors, -One IV hanger; and, -One wheelchair scale. On 09/24/2024 at 9:19 AM, a Registered Nurse (RN) explained the medical equipment was always stored in the dining room and the equipment should be stored somewhere other than the dining room. The RN verbalized there were residents who ate in the dining room with each meal and one resident who had family visit at every meal. On 09/24/2024 at 9:21 AM, the Respiratory Therapist confirmed the dining room was being used to store medical equipment and explained there was an area available to store the equipment. The room was located next to the dining room and was large enough to accommodate all medical equipment stored in the dining room. The Respiratory Therapist confirmed the Red Rock dining room was being used to store the medical equipment and verbalized the dining room was not a comfortable, homelike environment. On 09/25/2024 at 7:33 AM, in the Valley of Fire dining room, the following medical equipment was being stored: -One wheelchair scale, -One oxygen concentrator, -One sliding weight scale, -One shower chair, -Two hoyer lifts, -One vitals sign monitor; and, _One three foot tall fan. On 09/25/2024 at 7:42 AM, a CNA confirmed the Valley of Fire dining room was being used to store medical equipment and verbalized the dining room was not a safe, comfortable homelike environment for residents. The CNA explained working at the facility for the last three years and the medical equipment had always been stored in the dining room and staff was using the dining room to store the medical equipment for staff convenience. On 09/25/2024 at 7:46 AM, located in the Mount [NAME] dining room, the following medical equipment was being stored: -Two food carts, -One wheelchair scale, -One hoyer lift, -One sliding weight scale; and, -Three vital sign monitors, On 09/25/2024 at 7:50 AM, the Director of Nursing (DON) confirmed the Mount [NAME] dining room was being used to store medical equipment and verbalized the dining room was not a comfortable homelike environment for residents wishing to eat in the dining room. The DON explained there were various other areas to store the equipment, such as the nurses' stations and verbalized the dining room was for resident use and residents were not to be staring a medical equipment while eating a meal. On 09/25/2024 at 8:39 AM, the Administrator explained storing of medical equipment in each dining room was a common practice for the facility and there were cubbies in each hallway designed to store medical equipment. The Administrator admitted not thinking anything about storing the medical equipment in dining areas was not conducive to a homelike environment for the residents. The facility policy titled Resident Rights, adopted 05/01/2024, documented residents had the right to an environment that maintained and enhanced each resident's dignity and respect. The facility policy titled Physical Environment: Space and Equipment, dated 07/2018, documented the facility would provide sufficient space and equipment in dining areas and storage of supplies elsewhere. The dining space would not restrict a resident's functional movement. The facility policy titled Physical Environment: Dining and Resident Activity Rooms, dated 07/2018, documented the facility would provide comfortable areas for residents to engage in dining activities.

Based on record review, interview, and document review, the facility failed to ensure a resident (victim of an alleged sexual abuse) was protected after the allegation was known by the facility's staff and, an allegation of sexual abuse was reported and investigated for 1 of 17 sample residents (Resident #10). Findings include: R10 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section G Functional Status of the Minimum Data Set (MDS) admission assessment dated [DATE], the quarterly assessments dated 08/04/2020, 11/03/2020, 02/03/2021, and the annual assessment dated [DATE], revealed R10 was totally dependent and unable to participate in any bathing activities, requiring two or more persons to support the activity. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated a physical exam was done per protocol. A facility report documented an incident occurred on 05/24/2021, when R10 reported to Employee 16 (E16) the resident had been inappropriately touched by a male Certified Nursing Assistant (CNA), E17. The documentation indicated a similar incident had occurred a few months previously. On 11/16/2021 at 11:30 AM, the Facility Administrator explained an interview was conducted with the alleged victim (Resident #10) who verbalized the alleged perpetrator emphasized the cleaning of the resident's private areas during showers. This additional attention made the resident uncomfortable. The incidents were not reported because the resident felt embarrassed. The Facility Administrator was not aware of a previous report made by Employee 16 (E16) since the former Director of Nursing (DON) never reported the incident to the Facility Administrator, who is also the Facility's Abuse Coordinator. The Facility Administrator indicated there was no documentation related to the specific time of the previous report since the former DON did not document the incident. However, E16 reported the initial incident could have happened in December 2020. The Facility Administrator confirmed E17 continued to provide care to R10 several times after December 2020, including showering the resident. The Facility Administrator acknowledged that E17 should have been removed from the R10's care since the concern was initially reported in December 2020. Staff assignment sheets from March 2021 through May 2021 documented E17 was assigned to provide care to R10 at least 17 times, including three shower assignments. The assignment sheets revealed E17 was always assigned to Red Rock unit where R10 resided. A review of shower sheets from 11/20/2020 through 05/28/2021 indicated E17 provided a shower to R10 at least one time after December 2020, when the allegations of sexual abuse became known by the former DON. The Facility Administrator confirmed shower sheet data was incomplete since showers were not documented as per policy, A review of E17's personnel record revealed a hire date 06/05/2020. The record lacked documented evidence E17 was suspended pending investigations of sexual abuse allegations, disciplined, or re-educated after the shower concerns were first reported in December 2020. On 11/17/2021 at 7:16 AM, a phone interview was conducted with E18 who indicated an employee had reported dignity concerns had been observed when E17 provided a shower to R10. E18 explained the report was managed as a dignity issue since R10 did not verbalize concerns related to being exposed during the shower. E18 stated the incident was not reported or investigated since the sexual abuse was ruled out after interviewing the resident. The facility policy titled Abuse Prohibition and Prevention dated 02/2020 and last reviewed on 10/2021, documented the facility would take measures to prevent mistreatment while an abuse investigation was underway. The policy indicated that the employee accused of abuse, neglect, or mistreatment would be immediately suspended until the investigation results had been reviewed by the Administrator or designee and could not complete the shift as a direct care provider to the resident. The Facility policy titled Resident Rights revised in December 2016, indicated the residents had rights including to be free from abuse, neglect, exploitation, and misappropriation of property. The policy documented all incidents related to allegations of abuse would be documented, whether or not abuse occurred, was alleged or suspected, and an investigation conducted. The policy indicated the Administrator would appoint a person to collect data prior making a determination to conduct an investigation for incidents involving reasonable cause to suspect abuse. The policy revealed that any allegation of abuse would be reported to the Administrator, the State Department of Health and the resident's representative immediately but not later than 2 hours in the violation involved abuse. Complaint #NV 182

Based on observation, interview, record review and document review, the facility failed to ensure the correct diet order was entered in the resident's medical record to prevent the resident from choking for 1 of 6 sampled residents (Resident #32) and failed to ensure the nursing staff checked food brought in by family members and resident representatives prior to being given to the residents who were on specialized/modified diets for 2 of 6 sampled residents (Resident #33 and #58). Findings include: 1) Resident 32 (R32) R32 was admitted on [DATE], with diagnoses including acute and chronic [CONDITION(S)] with hypercapnia, pneumonia, and chronic obstructive pulmonary disease. The Hospital Medical Record Physician Progress Note dated [DATE], documented R32 was on an Orogastric Tube and a Nasogastric Tube formula. The Hospital Medical Record Speech Therapy Form dated [DATE], documented the Speech Therapist conducted trials with the resident using ice chips and pureed food. The documentation revealed the resident showed significant signs and symptoms of aspiration. The trial was discontinued as the resident had wet coughs. R32 was suspected to have severe pharyngeal dysphagia per the Speech Therapist notes. The Speech Therapist recommended a Modified [MEDICATION(S)] Swallow (MBS) to determine swallow safety and most appropriate diet consistency for the resident. The Hospital Medical Record Physician Progress Note dated [DATE], documented there were concerns for aspiration as the resident failed swallowing MBS and to restart the diet per speech therapy recommendations. The Hospital Medical Record Speech Therapy Forms dated [DATE], documented recommendation of International Dysphagia Diet Standardization Initiative (IDDSI) 6 Soft and Bite sized diet consistency with thin liquid viscosity after the MBS test was conducted. The Physician Order dated [DATE], documented R32 was on a controlled carbohydrate, no added salt diet, regular texture with thin consistency. The Admit/Readmit Evaluation Screener dated [DATE], documented R32 was on a regular diet. A Physician Order dated [DATE], documented evaluation of speech, language, voice communication and/or auditory processing. The Baseline Care Plan dated [DATE], documented R32 was on a controlled carbohydrate, no added salt diet, regular texture, and thin consistency. The Admission Summary Progress note dated [DATE], documented there were concerns of aspiration as the resident failed a swallow evaluation. Controlled carbohydrate, cardiac diet with pureed texture until further evaluation. The Admission Summary progress note of pureed texture did not match the physician order on [DATE] reflecting a regular texture diet. The medical record lacked documented evidence a speech evaluation was conducted per the physician's order. The SBAR (Situation, Background, Assessment, Recommendation) Communication note dated [DATE], documented R32 had aspirated during lunch time and was not able to breath due to choking. R32 was slumped over due to aspiration and when the staff side swiped the resident's mouth, macaroni & cheese smear was noted. The [MEDICATION(S)] maneuver was done, and Cardiopulmonary Resuscitation (CPR) was initiated. The resident was unresponsive. The resident was transferred to the hospital via 911. The Nursing Home to Hospital Transfer Form dated [DATE], documented the Certified Nursing Assistant (CNA) responded to a resident's call for help. The CNA observed the resident with difficulty breathing and asked if the resident was choking. The resident nodded yes and initiated the [MEDICATION(S)] maneuver. The nurse was called, and the resident became unresponsive. Rapid response was called, and no pulse and respiration noted. CPR was initiated and 911 was called. On [DATE] at 9:25 AM, CNA #1 indicated providing care for R32 during the day shift on [DATE] and [DATE]. CNA #1 indicated R32 was independent with meals, required the staff members to set up before meals and was on a regular texture diet. CNA #1 indicated R32 was doing fine in the morning on [DATE] while taking the resident's vitals. CNA #1 indicated communicating with R32 and exchanged good mornings. On [DATE] at 2:20 PM, CNA #2 indicated sitting on the bench near the nurse's station during lunch time on [DATE]. CNA #2 heard a person coughing and yelling for help. CNA #2 was able to locate the resident and the resident appeared to be choking on food. CNA #2 asked R32 if they were choking and R32 nodded their head up and down indicating yes. CNA #2 tried to help R32 get the food out of the resident's throat and performed the [MEDICATION(S)] maneuver but was unsuccessful. CNA #2 called for the nurse on duty to assist with the choking resident. CNA #2 indicated macaroni & cheese residue was removed from R32's mouth by the nurse. CNA #2 explained R32 was served a regular texture diet and had macaroni & cheese and a fish sandwich on the lunch tray as indicated on the meal ticket. On [DATE] at 2:26 PM, the Licensed Practical Nurse (LPN) caring for R32 on [DATE] explained R32 was in bed waiting for lunch around 11:00 AM when checking the resident's blood sugar levels. The LPN indicated taking R32's vitals after 11:00 AM per the Physician Assistant's (PA) request. The LPN indicated the resident's vitals were normal and the information was relayed to the PA. The LPN indicated taking R32's meal tray during lunch into the room and helped the resident put tartar sauce on the fish sandwich and cut the sandwich in half. The LPN explained CNA #2 called for help shortly after lunch trays were served. The LPN rushed into R32's room and the resident was wheezing and choking on something. The LPN tried to do the [MEDICATION(S)] maneuver but was not able to get the item in the throat out and ended up doing a side sweep in the resident's mouth. The LPN removed macaroni & cheese creamy sauce which was served at lunch. The LPN indicated R32 lost consciousness and CPR was initiated while waiting for the paramedics to arrive. On [DATE] at 8:00 AM, the Admission Nurse/Licensed Practical Nurse (LPN) indicated the facility would follow the hospital discharge orders unless the physician changes the orders at the time of admission. The LPN indicated the hospital record for R32 documented the resident was on a tube feed, failed an MBS test and was to be on a soft bite size diet. The LPN verbalized communicating the information to the physician at the time of admission and was given orders to have R32 be on a pureed diet until Speech Therapy evaluated the resident. The LPN indicated the admission information including the pureed diet was relayed to the floor nurse who was caring for the resident the night of the admission after the orders were entered in the electronic medical record. The LPN was not aware Speech Therapy did not evaluate the resident the following day since the evaluation order by the physician was entered. The LPN was not aware the wrong diet texture was entered in the electronic medical record until R32 was sent to the hospital on [DATE].The LPN indicated R32 should have been on pureed texture and may have clicked on the regular texture in the computer accidently. The LPN confirmed the resident was ordered to receive a pureed diet until the Speech Therapist evaluated the resident. The LPN verbalized it was important to carry out the correct diet orders as ordered by the physician so the kitchen staff would provide the correct diet to the resident and to avoid accidents such as choking to occur. On [DATE] at 1:20 PM, the Registered Nurse (RN) indicated assisting the admission nurse with R32's admission the night of [DATE] since the resident was in their hall. The RN verbalized the admission nurse communicated R32 was to be on a pureed diet until speech evaluation. The RN assumed all physician orders were entered by the admission nurse and the Speech Therapist would evaluate the resident the following day. On [DATE] at 9:37 AM, the Director of Therapy explained the facility had a Speech Therapist in the facility seven days a week and any requests for evaluations would be conducted the day of admission or the following day. The Speech Therapists would receive a hardcopy document for an evaluation, text messages or verbal requests for evaluations. The Director of Therapy explained the Speech Therapist did not evaluate R32 because the resident was on a regular texture with thin liquid diet in the electronic medical record. The Speech Therapist did not look further in the physician orders to see there was a Speech Therapy evaluation ordered for the resident at the time of admission. The Director of Therapy indicated the Speech Therapist would normally review the admission orders to see if there was an evaluation ordered. The Director of Therapy confirmed the resident was not evaluated by the Speech Therapist and the hospital discharge records indicated the resident was to be on a bite size thin liquid diet. On [DATE] at 2:30 PM, the Executive Chef indicated R32 was on a controlled carbohydrate, no added salt diet, regular texture with thin consistency. The Executive Chef indicated the kitchen generates daily meal tickets based on the diet order entered by nursing in the electronic medical record. On [DATE] at 3:15 PM, the Physician Assistant (PA) indicated the admission nurse would contact the physician for newly admitted residents for orders. The PA indicated the nurses would review the medications with them and the physician would approve the orders or make changes prior to approval. The PA expected physician orders to be carried out correctly by the nurses. The PA indicated the nurse informed the PA R32 was eating lunch and started to choke on the food. R32 lost consciousness and CPR was initiated before sending the resident to the hospital. On [DATE] at 9:30 AM, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator indicated R32's hospital records revealed the resident was to have soft bite size texture with thin liquids. The DON indicated the facility followed the hospital discharge records and verified the orders with the physician unless the physician changes the orders. The DON confirmed the Speech Therapist did not evaluate R32 per the physician's order on [DATE]. The DON indicated the facility provided R32 a regular texture diet which was different from the hospital diet orders. The DON and ADON indicated the risk of not following the prescribed diet by the physician may cause the resident to choke or aspirate. The DON expected the nursing staff to carry out the correct physician orders as requested by the physician. The facility policy titled Admission Notes revised [DATE], documented the admitting nurse must notify the attending physician of the resident's admission, would receive, and verify the physician orders, and the Dietary Department of the resident's diet order. Complaint #NV 738 2) Resident 33 (R33) R33 was admitted on [DATE], with diagnoses including Type 2 Diabetes Mellitus and [CONDITION(S)]. The Nutritional Risk assessment dated [DATE], documented R33 was on a regular diet, pureed texture, thin consistency. The Physician Order dated [DATE], documented R33 was on a regular diet, pureed texture with thin consistency. The Physician Order dated [DATE], documented R33 was on a regular diet, mechanical soft ground texture with thin consistency. The Speech Therapy Plan of Care dated [DATE], documented R33 was on a mechanical soft diet with thin liquids. R33 may have pureed texture upon request. On [DATE] at 8:37 AM, R33 was observed in bed eating breakfast. R33's breakfast tray included pancakes and ground meat. The meal ticket indicated R33 was on a regular diet, mechanical soft ground texture, and thin consistency. R33 had a bag of opened cheese puffs on the bedside table next to breakfast tray. On [DATE] at 8:50 AM, a Registered Nurse (RN) indicated the residents or family would deliver food to the front desk. The receptionist or any facility staff would deliver the food to the resident's room. The food does not need to go through the nurse on duty. On [DATE] in the morning, the Inspector informed the Registered Nurse (RN) there was a bag of opened cheese puffs in R33's room. The RN verified R33 was on a mechanical soft ground texture with thin liquids. The RN confirmed R33 was not allowed to have the bag of cheese puffs on the bedside table and would need to be removed. The RN indicated mechanical soft ground texture was not allowed to have the cheese puffs which may cause the resident to choke or aspirate. On [DATE] at 8:55 AM, a Certified Nursing Assistant indicated food brought by a family member would be left at the front desk and any staff member could deliver the food to the resident. On [DATE] at 10:00 AM, the Screener was observed entering the Mt. [NAME] Unit through the double doors and proceeded to the 2200 Hall. The Screener donned a gown and a pair of gloves before entering a resident room in the 2200 Hall. On [DATE] at 10:03 AM, the Screener indicated delivering food for a resident. The Screener indicated the food was still hot and wanted to ensure the food got to the resident immediately. The Screener indicated going straight from the main entrance to the resident room. The Screener indicated the staff did not have to check with the nurse before delivering food to the residents. On [DATE] at 11:20 AM, the Registered Dietitian (RD) indicated residents on pureed textures and mechanical soft ground textures were not allowed to have cheese puffs. The RD verbalized the cheese puffs may cause the resident to choke. On [DATE] at 11:45 AM, R33 indicated having swallowing issues for many years because food would be stuck in the throat causing the resident to cough and choke. R33 indicated a family member brought the bag of cheese puffs, bottles of Ensure drinks, and cans of tomato juice two days ago. The resident indicated the staff member at the front desk delivered the snacks and beverages to the resident's room shortly after the family member dropped off the items. Resident #58 (R58) R58 was admitted on [DATE] and readmitted on [DATE], with diagnoses including COVID-19 and diabetes. A Physician Extender Note dated [DATE], documented R58 indicated losing sense of taste since going to the hospital, possibly related to recent COVID-19 infection. R58 stated when eating solid food without water, it felt like the food was getting stuck in the throat. Speech Therapy was requested to evaluate R58. A Physician Order dated [DATE], documented to provide regular diet, pureed texture, and thin consistency to R58. A Physician Order dated [DATE], documented a bedside swallow evaluation was completed. Diet was downgraded to pureed diet per resident request. A Physician Extender Note dated [DATE], documented R58 expressed a family member would bring soup which the resident ate. On [DATE] at 8:39 AM, R58 was in bed and had a breakfast tray on the bedside table which consisted of a pureed meal of regular cream of wheat, coffee, ice cream, and apple juice. The resident also had a half-full container of wonton soup with a couple of pieces of wonton balls, several pieces of bananas and a whole bunch of green grapes. R58 indicated a family member brought the wonton soup, the bananas, and the grapes last night. A half-eaten banana was observed on top of the bedside table. R58 indicated having to eat the banana during breakfast. R58 indicated while eating the banana, the resident had to drink large amounts of fluids to push the banana down because it was getting stuck in the throat. R58 indicated since getting COVID-19 infection, the resident has had no sense of taste and increased difficulty to swallow solid foods. On [DATE] at 8:45 AM, the Inspector informed the Licensed Practical Nurse (LPN) R58 had food at bedside not consistent with the resident's diet orders. The LPN indicated the food needed to be removed from the resident's room because R58 was on a pureed diet and should not be eating bananas, wonton balls and grapes. On [DATE] at 8:50 AM, the LPN indicated family members were allowed to bring food in the facility. If a family member consented to a COVID-19 test upon arrival and tested negative, they would be allowed to visit the resident and bring food to the resident's room after checking with the nursing staff to ensure the food was appropriate for the resident. If a family member drops off food for a resident, the Receptionist, the Screener, or the Unit Clerk would bring the food to the Nursing Station for the nursing staff to check if the food was appropriate for the resident, after checking the resident's diet orders. The Receptionist, the Screener or the Unit Clerk would bring the food to the resident's room after checking in with the nursing staff. On [DATE] at 8:55 AM, a Receptionist explained if a family member dropped off food for a resident, the Receptionist would label the food with the resident's name and take it to the resident's room immediately so the resident could enjoy the food while it was still warm. The Receptionist indicated the food brought by the family member would not need to be checked by the nursing staff because it did not have to be listed in the resident's inventory sheet and the food would be consumed eventually. The Receptionist explained personal belongings excluding food brought to the facility by a family member would be given to the nursing staff so they could update the resident's inventory sheet. The Receptionist indicated not being aware if residents they were delivering the food to were on specialized or modified diets. The Receptionist relied on the family members should know what diets the residents were supposed to be on and brought food consistent with the residents' diet orders. On [DATE] at 9:00 AM, a Screener explained if the Receptionist or the Unit Clerk was busy with other tasks, the food brought by family members would be handed to the Screener for delivery to the resident's room. The Screener indicated the food would be delivered directly to the resident without informing the nursing staff. The Screener stated, we hope the family members know what the residents can and cannot have because we do not know what diets they were on; we just deliver the food. On [DATE] at 9:10 AM, R58's family member indicated bringing the wonton soup, a dish containing eggplants, bananas and grapes yesterday for the resident. The family member had been allowed to bring the food directly to the resident after COVID-19 screening. The family member indicated not being told by staff the food would need to be checked at the Nursing station. The family member indicated the facility informed them R58 was on a pureed diet but was not given information on what type of foods were restricted for R58. On [DATE] at 9:15 AM, the Registered Dietitian (RD) indicated residents on pureed diets were not allowed to have a whole banana. The banana would need to be pureed into applesauce consistency. The RD indicated the resident would be at risk for choking if the food was not pureed to the correct consistency. On [DATE] at 12:29 PM, the Administrator indicated when residents order food to be delivered in the facility or when family members bring food for the residents, the Screeners or Receptionist would call the Unit Clerks to pick up the food at the Front Desk. The Administrator indicated they have had residents who had gotten upset when the nursing staff could not come down quickly to get the food. The Screener would assist in taking the food to the residents if the nursing staff were occupied and could not come down to get the food. The Director of Nursing, Assistant Director of Nursing and the Administrator indicated the nursing staff would check the food before giving the food to the residents. The Administrator indicated the family members were aware of the resident's diet before bringing in food. The facility policy Foods Brought by Family/Visitors revised [DATE], documented food which presented a potential choking hazard for residents would be taken from the residents and returned to the family/visitor.