Every finding on record at TLC Care Center

Based on interview, observation, and document review, the facility failed to:1) Maintain sufficient and adequate linen supplies;2) Ensure a sanitary, clean and homelike environment of resident rooms;3) Maintain the cleanliness of shower rooms and resident care areas; and4) Ensure resident equipment, including a footboard, was maintained in good repair.This deficient practice had had the potential to encourage pathogen growth, spread infection, compromise resident comfort, dignity, and hygiene, and could interfere with the provision of timely and appropriate care.Findings include: On 06/02/2026 at 9:33 AM, a tour of the 200-Hall revealed the following: -room [ROOM NUMBER]; floors and walls were soiled with dark colored splatter of brownish/reddish areas of an unknown substance throughout and multiple nails in walls with no hanging items. -room [ROOM NUMBER], 212, and 214 the privacy curtain was soiled with a large brown colored area and multiple smaller brown colored areas of an unknown substance. On 06/02/2026 at 10:48 AM, a tour of the 300-Hall revealed the privacy curtain was soiled with a large brown colored area of an unknown substance in Rooms 300, 301, 302 and 304. On 06/02/2026 at 2:08 PM, room [ROOM NUMBER] was observed with floors and walls soiled with dark colored splatter and brownish/reddish areas of an unknown substance throughout multiple areas. On 06/02/2026 at 2:09 PM, a certified nursing assistant (CNA1) explained the walls appeared dirty and soiled with possible food and/or bodily fluids and should have been cleaned by housekeeping staff. The CNA1 indicated they would typically clean something like that when observed if housekeeping staff were not in the unit. On 06/02/2026 at 2:13 PM, a housekeeping aide explained being responsible for all rooms in the 200-unit hallway and rooms were cleaned daily. The daily cleaning consisted of light switches, walls, air conditioner unit, window frame, bed rails, foot/head of bed, and wiping the closet/nightstand and bedside table. A deep cleaning of the resident rooms was done at discharge. The housekeeping aide indicated they had just cleaned the walls and floors in room [ROOM NUMBER]. The housekeeping aide confirmed room [ROOM NUMBER] still had multiple spots and areas on the walls which required more cleaning. The housekeeping aide indicated the resident who occupied room [ROOM NUMBER] was known to spit on the walls and hawk loogies. The housekeeping aide explained a lot of what was cleaned off the wall earlier was loogies or mucus globs, spit, food, and blood. On 06/04/2026 at 2:41 PM, the housekeeping assistant supervisor explained the expectation for cleaning resident rooms, shower rooms, lobby, eating areas, trash, floor sweeping/mopping was to be done daily. The housekeeping assistant supervisor explained deep cleaning for scrubbing baseboards, wiping down walls, and wiping food stains was done as needed. On 06/04/2026 at 3:13 PM, the environmental services (EVS) director explained curtains were washed/switched out as needed when soiled or stained. When a new resident was admitted , housekeeping would observe the room and curtain and notify laundry if needed to be replaced or cleaned. If the curtain was not dirty or soiled it would not be switched out on a routine basis. No log was kept. The EVS Director explained walls and bedrails in the resident rooms were cleaned daily. The facility's Homelike Environment policy (undated), documented residents would be provided with a safe, clean, comfortable and homelike environment. Characteristics of the facility that reflect a personalized, homelike setting include a) clean, sanitary and orderly environment and e) clean bed and bath linens that are in good condition. On 06/02/2026 at 7:50 AM, a tour of the 900-Hall revealed the following: - the floors were filthy with old and new dirt stains more pronounced at the corners of the wall by the base boards. A certified nursing assistant (CNA) confirmed the floors were dirty throughout the unit because the housekeeper in the 900-Hall quit. - debris such as plastic, ports and foil were observed on the floor. - shower room where floors were dirty with wheelchair tracks and discoloration built-up between tiles. - a dirty linen was found in the clean hand-washing sink inside the shower room. - broken equipment was stored in the shower room, namely, one wooden rocking chair, two gray bedside commodes, bedside table with wheelchair parts on top. - three trash bins without plastic bags. On 06/02/2026 at 8:57 AM, the CNA confirmed the shower room was cluttered which contributed to the unsanitary condition and obstructed movement of residents within the shower room. not in use. On 06/02/2026 9:23 AM, Resident 219 (R219) laid in bed alert. The foot board was detached from the bed and leaning on the wall by the air-conditioning unit. R219 indicated complaining about the broken foot board for six months and the staff members would just push the foot board back in and it would fall again. The CNA indicated the issue had been reported to maintenance staff this morning and the maintenance staff instructed the CNA to push the foot board back into bed. On 06/03/3036 at 1:10 PM, the Unit Manager confirmed the unit was not maintained in a sanitary manner, floors were dirty, and the shower room was cluttered with broken equipment. The Unit Manager could not speak to why the 900-Hall shower room was being used as storage of broken equipment. On 06/03/2026 at 1:13 PM, the Assistant Director of Nursing (ADON) explained the facility faced challenges with housekeeping services. Housekeeping staff were employed and not contracted and occasionally short-staffed. The ADON stated residents deserved to live in a clean environment and the unit and the shower rooms should have been maintained in a sanitary manner for residents. On 06/04/2026 at 1:45 PM, the housekeeping assistant supervisor confirmed being directly employed by facility and not contracted. The assistant supervisor explained the facility had nine units and there was one housekeeper assigned to each unit. The housekeeper assigned to the 900-Hall resigned and other housekeepers were helping doing their best to cover the 900-Hall. The assistant supervisor reviewed the housekeeping schedule and explained the housekeeper assigned to the 900-Hall on 06/02/2026 was also assigned to clean the lobby, front desk and nurse's station as well as 16 rooms in the 900-Hall as well as common areas. On 06/04/2026 at 1:56 PM, the housekeeping assistant supervisor explained housekeepers were responsible for routine cleaning of resident rooms in their assigned units, common areas such as showers and activity lounge and side tasks. On 06/04/2026 at 2:01 PM, the housekeeping assistant supervisor acknowledged housekeeping staff have expressed concerns regarding workload and time constraints which were difficult to meet within the 8-hour work shift. The assistant supervisor indicated there were currently two full-time housekeeping vacancies. The facility's Homelike Environment policy (undated), documented residents would be provided with a safe, clean, comfortable and homelike environment. On 06/02/2026 at 12:23 PM, observation of the Unit 500 linen closet revealed minimal stocked items, which were not adequate for the unit's needs. On 06/02/2026 at 12:26 PM, observation of the Unit 400 linen closet revealed bare minimum supplies, which were not adequate for the unit's needs. On 06/02/2026 at 8:28 AM, Resident 199 indicated the facility was always out of clean linens and chucks. The resident verbalized staff reported not having enough linen to change sheets and that his bed was changed once a week. On 06/02/2026 at 8:46 AM, Resident 132, indicated obtaining clean linen could be a concern at times and that the facility does not have enough chucks and blankets. On 06/02/2026 at 9:10 AM, Resident 249, indicated facility had a shortage of towels and blankets. On 06/02/2026 at 9:12 AM, Resident 248, voiced the facility had a shortage of towels and blankets and reported needing to obtain towels early to ensure they had one available for shower days. On 06/02/2026 at 9:20 AM, Resident 228, verbalized staff did not make the bed unless requested and there was little to no linen with an ongoing issue obtaining a blanket. On 06/02/2026 at 9:23 AM, Resident 207 indicated staff did not make the bed and the facility had a shortage of linen. The resident verbalized obtaining a blanket continued to be an ongoing issue. On 06/03/2026 at 7:32 AM, observation of the Unit 400 linen closet revealed minimal supplies, including seven towels, two sheets, two fitted sheets, one chuck, five gowns, one shower blanket, three pillowcases, and six hand towels. This inventory was insufficient for a unit housing 24 active residents. On 06/03/2026 at 7:40 AM, observation of the Unit 500 linen closet revealed linen supplies at a bare minimum, consisting of two towels, one hand towel, four fitted sheets, one shower blanket, six pillowcases, eight gowns, and no chucks. This inventory was inadequate for a unit with 23 active residents. On 06/03/2026 at 7:54 AM, observation of the laundry room revealed three functioning washers and three functioning dryers. The clean linen area contained only one three tier rack with eight gowns and lacked all other essential linens, including towels, blankets, chucks, fitted sheets, sheets, pillowcases, and hand towels. On 06/03/2026 at 7:33 AM, Licensed Practical Nurse (LPN), indicated the facility did not ensure sufficient linen availability for the unit. The LPN reported linen supplies were often below minimum and that residents experienced delays in receiving essential care needs. On 06/03/2026 at 7:34 AM, Certified Nursing Assistant (CNA), verbalized there was no linen available for resident use and that the lack of linen directly prevented staff from providing necessary and timely care. On 06/03/2026 at 7:41 AM, Certified Nursing Assistant (CNA), indicated linen supplies were consistently insufficient for the unit, resulting in delays in resident care. On 06/03/2026 at 7:42 AM, Licensed Practical Nurse (LPN), reported linen was normally unavailable, which negatively impacted residents and hindered the delivery of required care. On 06/03/2026 at 7:44 AM, Certified Nursing Assistant (CNA), reported the unit's linen supply was never fully stocked and frequently insufficient, leading to ongoing negative effects on the delivery of resident care. On 06/03/2026 at 7:57 AM, the Environmental Services (EVS) Director, stated that the facility had not received its blanket delivery and had no blankets available aside from shower blankets. On 06/03/2026 at 8:01 AM, the Environmental Services (EVS) Director, inspected the Unit 500 linen closet and acknowledged the current linen inventory was insufficient, confirming that adequate linen levels are necessary to ensure proper resident care. On 06/03/2026 at 8:05 AM, the Environmental Services (EVS) Director, inspected the Unit 400 linen closet and confirmed that the linen inventory was inadequate to support the unit's needs. The EVS Director stated that the available linen supply was not sufficient to meet resident care needs.

Based on interview, record review, and document review the facility failed to implement its Drug Diversion Risk Tool for missing narcotics, for 1 of 64 sampled residents (Resident 272). The deficient practice had the potential to put residents at risk of physical harm. Findings include:Resident 272 (R272) was admitted on [DATE] with the diagnoses including polyneuropathy, unspecified severe protein-calorie malnutrition, major depressive disorder (recurrent), other osteoporosis without current pathological fracture, and other chronic pain. R272 resided in the 300-hall. On 06/02/2026 at 9:44 AM, a Registered Nurse (RN) indicated noticing R272's Norco (hydrocodone-acetaminophen) oral tablet 10-325 milligram (MG) punch card was missing from the medication cart on 03/17/2025. The RN reported immediately notifying the past Director of Nursing (DON) the Norco punch card was missing from the medication cart and Administration immediately started an investigation The RN indicated the medication was signed for by a fellow Licensed Practical Nurse (LPN) on 03/13/2026 as having received it from the pharmacy. On 06/02/2026 at 11:07 AM, the LPN indicated working on the 200-hall on 03/13/2026 when the pharmacy delivered the medication to the nurses on the halls. The nurse from the 300-hall was not available as the nurse was on a break. The LPN indicated having had signed for both the 200-hall and 300-hall medications. The LPN also stored the the 300-hall medications in the 200-hall cart until the 300-hall nurse came back from break. The LPN expressed giving the nurse the medications for the 300-hall as soon as the nurse returned from a break. The LPN remembered the nurse putting the medications in the locked drawer of the medication cart. The LPN indicated around 03/17/2025 or 03/18/2025 Administration called them about the missing medication. The LPN verbalized Administration informed they may be required to have a drug test. The LPN was never drug tested and was unsure if the other nurse was drug tested. The LPN revealed the medication for R272 was a PRN medication which is why no medication doses were missed. The LPN was able to get the medication for R272 on the night of 03/17/2025.R272's Medication Administration Record documented no doses of Norco oral tablet 10-325 MG was given from the date the medication was received by the nurse on the 300-hall (03/13/2025) until 03/17/2025.On 06/02/2026 at 11:23 AM, the Lead Pharmacy Technician explained the Norco oral tablet 10-325 MG was available in the facility's pyxis machine (an automated, computer-controlled medication dispensing system) to dispense, so R272 could have still gotten the medication if needed.The employee file for the nurse in question documented due to a pattern of repeated issues of not following protocol and mis-handling narcotics, the facility was going to move forward with termination.On 06/02/2026 in the morning, the Human Resource (HR) Manager verified there was no documentation of the mishandling of narcotics being reported to the Board of Nursing, nor of the nurse involved being reported to the Board of Nursing. The HR Manager also verified there was no documentation of a drug test being performed on the alleged wrongdoer or an employee declining a drug test.On 06/05/2026 at 8:50 AM the Assistant Director of Nursing (ADON) confirmed if a nurse was terminated for a pattern of repeated issues of not following protocol and mis-handling narcotics, this would have been reported to the Board of Nursing. The ADON explained facility Administration would have been the ones to report the issue to the Board of Nursing.The facility provided a Drug Diversion Risk Tool for investigating possible nursing drug diversion. According to the tool, any suspicion of drug diversion was immediately reported to the Administrator, Director of Nursing, Regional [NAME] President of Operations and Regional Director of Clinical Services. The facility then notified the Department of Health, Law Enforcement and Area Agency on Aging (if applicable). The facility notified the pharmacy and reported the allegation to the Board of Nursing. Then, moved to Step One which involved removing the alleged wrongdoer from the facility and conducting a drug test. The process consisted of four total steps to reach a final determination.

Based on interview, record review and document review, the facility failed to ensure skilled services were maintained for a resident with an approved appeal for 1 of 64 Residents (Resident 276). The deficient practice had the potential for a resident not to receive the necessary skilled services to attain maximum potential and prevention from hospital readmission.Findings include:Resident 267 (R267) was admitted on [DATE], with diagnoses including cerebral infarction and cognitive communication defect.R267 Notice of Medicare Non-Coverage (NOMNC) had a last cover date (LCD) of 10/16/2025. Based on the LCD the beneficiary had a date of liability (date of discharge without accruing financial responsibility) of 10/17/2025. The NOMNC documented successful timely phone notification to R267's spouse on 10/14/2025.A Social Services R267 progress note dated 10/14/2025 NOMNC was issued on this date with the resident's spouse. NOMNC with a LCD of 10/16/2025 discharge date [DATE]. Appeal rights, financial responsibility and the deadline to file an appeal were all explained. Copy of the NOMNC was provided and uploaded in the PCC. Spouse verbalized understanding and states that she will file an appeal.A nursing progress note dated 10/17/2025 documented resident transferred to the home in community at 2:45 PM via ambulance. The resident left in safe stable condition, no evidence of distress prior to leaving. Resident transferred with all his remaining meds, and personal belongings. Left via MTC transport.An appeals determination letter dated October 16, 2027 (the day before liability date) with a successful transmittal fax cover sheet dated October 16, 2025 at 11:16 AM documented, it was determined that you require the continued services being provided by the facility.The medical records lacked documented evidence the facility had discussed with the resident or the resident representative the determination of the appeals organization and the care for R267 could be continued until a new NOMNC was provided by the resident's Managed Medicare plan.On 06/04/2026 at 3:40 PM, the case management (CM) confirmed the resident's appeal was approved and care should have been continued. The CM indicated the residents' spouse decided to discharge the resident. There was no documented evidence the resident's spouse was informed of the approved appeal and care could have been continued. There was no evidence a second NOMNC was issued. The CM agreed resident should not have been discharged and if the resident or resident's representative decided to be discharged , documentation of the conversation should have been reflected in the medical records.The facility policy titled Transfer or Discharge, Preparing a Resident for dated 10/01/2021, documented the business office and/or the social worker is responsible for informing the resident, or his of her representative of the facility's readmission, appeal rights, bed-holding policies and others as appropriate or as necessary.

Based on interview, record review and document review, the facility failed to provide the documented evidence showers were provided to a resident for 1 of 64 sampled resident (Resident 228). The deficient practice had the potential to prevent resident from skin infections and exposing unhygienic conditions which can affect a resident's mental health, dignity, and overall immune response. Findings include: Resident 228 (R228) had an initial admission date of 03/23/2026, with diagnoses including malignant neoplasm of the colon and difficulty in walking. R228's point of care (POC) task charting documented a scheduled shower/bathe every Wednesday and Saturday on the 2:00PM to10:00 PM shift and as needed (PRN), entered on 03/23/2026. R228's POC showers encoded the following on the assigned shower days: 04/03/2026 – shower, supervision or touching assistance 04/07/2026 – NA 04/10/2026 - shower, supervision or touching assistance 04/13/2026 – Shower sheet 04/14/2026 – NA 04/17/2026 – NA 04/21/2026 – NA 04/24/2026 – Resident Refused (RR) 04/28/2026 – NA 05/01/2026 – Blank 05/04/2026 – Blank 05/08/2026 – RR 05/12/2026 – RR 05/15/2026 – RR 05/18/2026 – Blank 05/22/2026 – RR 05/25/2026 – Blank 05/26/2026 – Shower (PRN) 05/29/2026 - RR On 06/02/2026 at 3:00 PM, a certified nursing aide (CNA) indicated if a resident refused a shower. The nurse would be informed and attempts made to encourage the shower to be taken. The CNA would complete the shower form and give it to the nurse to complete. On 06/02/2026 at 3:20 PM, a license practical nurse (LPN) indicated they would attempt to encourage the resident to take the shower. If the attempt was not successful, the shower sheet would be completed and filed. The nurse would also document on to the progress notes on the resident's refusal and attempts were made to encourage the resident to receive the shower. On 06/03/2026 at 8:50 AM, an LPN indicated a shower sheet would be generated per shower. The assistant director of nursing (ADON) would pick up the shower sheets and filed separately. On 06/03/2026 at 9:00 AM, the ADON confirmed the shower sheets would be compiled and expectation a sheet generated per shower day regardless if the shower was given or refused. The ADON indicated the shower sheets was initiated not just a tool to track the residents shower but also to monitor assessments of skin conditions during shower days. On 06/03/2026 at 9:10 AM, the director of nursing (DON) indicated shower sheets were initiated due to the electronic healthcare record (EHR) not charting appropriately and recording it as NA. The facility had reverted to paper documentation due to the system not recording showers or the attempts accordingly. The expectation was shower sheets were generated per shower day. Review of R228's shower sheets revealed the resident only had one shower sheet (dated 04/13/2026) completed for the months of April 2026 and May 2026. The POC charting only documented a shower on 04/03/2026 and 04/10/2026 as Type of Bath: 1) Shower and 04) Supervision or touching assistance. The rest of the shower days were NA or RR. On 06/03/2026 at 2:45 PM, the director of nursing (DON) reviewed the resident shower sheets and POC charting. The DON agreed the NA documentation did not reflect the type of care provided or if the residents refused. The DON acknowledged the lack of shower sheets for the residents which should have been generated for each shower day. The DON indicated progress note should have been entered by the nurse if the resident had refused and the attempts to encourage. The DON acknowledged the lack of shower sheets or inconsistent entries at the EHR reflects the resident was not provided any shower attempts. The facility policy titled Shower/Tub Bath (undated), documented to notify the licensed nurse if the resident refused the shower/tub bath. If the resident refused the shower/tub bath, document the reasons why and the interventions taken. Complaint 2991411 Resident 108 (R108) was admitted on [DATE], with diagnoses including cerebral palsy and profound intellectual disability. The annual minimum data set (MDS) dated [DATE], revealed R108 had impaired cognition and was dependent on staff for personal hygiene. On 06/02/2026 at 9:53 AM, a thick bandage dated 05/05/2026 was wrapped around R108's right forearm. The Licensed Practical Nurse (LPN) assigned to R108 indicated not knowing if R108 had scratching behaviors to right forearm. The LPN described R108's fingernails as thickened, about one-fourth inch above nail bed long, and yellowish. The LPN indicated R108 was special needs residents and would require podiatry services. On 06/03/2026 at 2:02 PM, the Unit Manager indicated R108 was not a diabetic and did not have complicated hands and/or fingernails and any certified nursing assistant (CNA) or nurse could cut R108's fingernails when observed to be long. The Unit Manager indicated a licensed nurse may be better for R108's fingernail trimming due to R108's uncontrolled movements related to cerebral palsy. On 06/03/2026 at 2:07 PM, the Assistant Director of Nursing (ADON) explained R108 was developmentally delayed and was not aware of behaviors such as scratching so nails must be kept short to prevent injury. The facility's ADL policy (undated), residents unable to carry out ADLs independently would receive all services necessary to maintain grooming, personal and oral hygiene. Resident 194 (R194) was admitted [DATE], readmitted [DATE], with diagnosis including encounter for attention to gastrostomy, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, and polyneuropathy. On 06/03/2026 at 2:30 PM, R194's fingernails were observed extending greater than 0.25 inch beyond fingertips on both hands. The right middle fingernail was observed significantly shorter than the remaining fingernails and extended only to the end of the nail bed. Multiple fingernails contained dark-colored matter beneath the nails. R194 stated wanted nails trimmed and confirmed had previously requested the nails to be trimmed. A minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13. R194 was cognitively intact. R194 was dependent on staff to maintain personal hygiene, including grooming activities. A Care Plan dated 05/18/2026, documented R194 required assistance with activities of daily living related to hemiplegia of the left side and limitations in range of motion and left upper extremity. On 06/03/2026 at 2:38 PM, a Registered Nurse (RN), confirmed R194's nails were excessively long. The RN explained certified nursing assistants (CNAs) were supposed to trim resident's fingernails. The RN acknowledged R194's fingernails were over 0.25 inch long and had not been trimmed recently. The RN acknowledged fingernails should have been trimmed to prevent R194 from scratching self with long nails. On 06/03/2026 at 3:00 PM, a Unit Manager, confirmed the length of R194's fingernails exceeded 0.25 inch and dark matter was present beneath multiple fingernails. The Unit Manager explained it was R194's choice to have the fingernails trimmed. The Unit Manager explained Certified Nursing Assistants (CNAs) where to check resident's fingernails during care and report to nurse if nails needed to be trimmed. The Unit Manager verbalized perhaps CNAs were not trimming R194's fingernails because they thought the podiatrist would do it. The Unit Manager acknowledged R194's right middle fingernail was much shorter than the rest and explained it was possible the nail broke off. The Unit Manager acknowledged nail care including trimming and cleaning underneath the fingernails should have been provided to R194. A facility policy titled Fingernails/Toenails, undated, documented the purpose of the procedure was to clean the nail bed, to keep nails trimmed, and to prevent infections. Routine nail care may be performed by nursing staff and/or qualified activity team members. Nial care included daily cleaning and regular trimming.

Based on observation, interview, record review and document review, the facility failed to ensure 1) enteral feeding bottle and hydration bag were labeled in accordance with facility policy for 1 of 64 sampled residents (Resident 245), and 2) a physician order was obtained for an enteral feeding tube de-clogging procedure for 1 of 64 sampled patients (Resident 5). The deficient practice placed the resident at risk for complications and for the resident's physician not to be aware of the enteral feeding tube clogging event and providing clinical oversight of the medical situation. Findings include: Resident 245 (R245) was admitted on [DATE] and readmitted on [DATE], with diagnoses including traumatic brain injury, encephalopathy, and attention for gastrostomy. The annual minimum data set (MDS) dated [DATE], revealed R245 received nutrition by enteral feeding. On 06/02/2026 at 9:42 AM, R245 laid supine in bed and was nonverbal. A tube feeding pump was infusing Peptamen 1.5 formula at 65 cubic centimeters (cc) per/hour (hr.). A Licensed Practical Nurse (LPN) confirmed the enteral formula was not labeled with the resident's name, date and time initiated, and the tubing and hydration bag was not labeled with date and time as well. The LPN indicated enteral formula, tubing and hydration bags must be labeled with date and time along with initials of the person who hung the set up. On 06/03/2026 at 1:33 PM, the Unit Manager indicated speaking with the night nurse who hung 245's enteral formula on the evening of 06/01/2026. According to the Unit Manager, the night nurse had intended to label and date the tube feeding set up after attending to another resident but had forgotten to do so. On 06/03/2026 at 1:39 PM, the Assistant Director of Nursing (ADON) confirmed the facility policy required enteral formulas to be labeled with resident's name, date and time started. The ADON indicated R245's formula was a closed system and was good for 24 hours once accessed. The facility's Enteral Feedings policy dated 10/01/2021, instructed to check the enteral nutrition against the order prior to administration. On the formula container, document initials, date and time the formula was hung. Practice strict adherence to maximum hang times, open systems have a maximum hang time of eight hours while closed systems have a maximum hang time of 24 hours. Resident 5 (R5) was initially admitted at the facility on 05/17/2022 with diagnoses including chronic respiratory failure and dysphagia oropharyngeal phase. On 06/04/2026 at 2:15 PM, observed R5 receiving tube feeding (TF) via an enteral feeding pump. The TF was connected to R5's gastrostomy (GT) tube. The nurse caring for R5 was at the bedside and confirmed having used a declogger device on R5's GT in the past. The nurse confirmed R5 has a tendency to clog up the GT wherein a declogger device had to be used to free up the clogged section of the GT. The nurse indicated seeing several sizes of the declogger device stocked by the facility. The nurse was not aware a physician order had to be obtained prior to performing a declogging GT procedure. On 06/05/2026 at 10:50AM, observed R5 bedside table had an opened cover sleeve of a declogger device. The nurse caring for R5 was not sure as to why the declogger device was there and stated the night nurse might have used it to unclog R5's GT. The nurse confirmed not being aware a physician order was needed to perform a GT declogging procedure. The nurse indicated training for the declogging procedure was obtained through other nurses. R5's physician orders lacked documented evidence of an order to declog the GT. On 06/04/2026 at 2:45 PM, the director of nursing (DON) was not aware the declogger device was being used in the facility. The DON indicated they would check if the facility had a policy and procedure for any enteral feeding tube declogging procedure. On 06/05/2026 at 11:00AM, the director of staff development (DSD) was not aware of nursing staff obtaining orders for declogging enteral feeding tubes. The DSD agreed there could have been risk in the procedure (examples included damage of the GT wall or perforation of the stomach lining). The DSD acknowledged all procedures for a resident, especially with potential risk should have a physician order. On 06/05/2026 at 11:10, the DON confirmed the facility did not have a policy and procedure for the enteral feeding declogging process. The DON confirmed orders should have been obtained and staff training should be offered to ensure resident safety during the procedure. Complaint 303420

Based on interview, record review and document review, the facility failed to ensure residents did not feel like their privacy rights were violated related to an unauthorized video recording and subsequent social media release by a resident's family member for 10 of 21 sampled residents (Resident 1, 2, 3, 7, 10, 11, 15, 18, 19, and 21). The deficient practice placed residents and/or representatives at risk for exploitation.Findings include: On 03/20/2026 at 8:30 AM, the Director of Nursing (DON) indicated a fire occurred on 03/08/2026 which came from the ceiling in the dining room. The DON explained the Code Red was called during lunch service, and residents were assisted to the outdoor courtyard. The doors remained closed during activation of the fire protocol which caused a resident's family member to be upset over not being allowed to enter the facility from the courtyard. The resident's family member started video recording the incident which captured multiple residents without consent and uploaded the video to social media. A review of the 45 second social media posting showed multiple residents, staff members and visitors which included minors. The resident's family member who uploaded the video included a long narrative, stating We gonna go internet viral let's do it! Yes, all these people just sitting in here with the AC. They are talking about there is a fire here, but they are just chilling. (Camera moves to courtyard towards residents) While these old people are outside, disabilities, they try to come in and they shoo-ing them away like dogs. Check this out. Ridiculous!As of 03/20/2026 at 8:49 AM, the social media post viewed alongside the DON garnered 1,020 comments, 12,800 likes, 841 shares, and 754 shared collections with friends.The DON provided a list of residents who were identified to be in the courtyard at the time of the incident.Resident 1 (R1)R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including acute on chronic respiratory failure and chronic obstructive pulmonary disease (COPD).An incident summary for resident/family notification of unauthorized recording and social media posting dated 03/18/2026, revealed R1 felt upset and stated the individual should have warned everyone.Resident 2 (R2)R2 was admitted on [DATE], with diagnoses including cerebral infarction and encephalopathy, gastrostomy status and tracheostomy status.An incident summary for resident/family notification of unauthorized recording and social media posting signed by R2's family member on 03/18/2026, documented the family member did not want to be in the video and would have wanted to be able to give consent. R2 and this family member were in the video.Resident 3 (R3)R3 was admitted on [DATE], with diagnoses including protein-calorie malnutrition and absence of right leg above knee and left leg above knee.On 03/20/2026 at 10:22 AM, R3 confirmed being evacuated into the courtyard during the fire incident indicated viewing the social media post where R3 identified self in the footage. R3 indicated witnessing a staff member telling the person who was filming to stop filming, but the person continued to film which R3 found inappropriate. R3 indicated the facility should take legal action against the perpetrator.Resident 7 (R7)R7 was admitted on [DATE], with diagnoses including cerebral palsy and other seizures.On 03/20/2026 at 10:52 AM, R7 confirmed being evacuated to the courtyard during the fire incident. R7 indicated taking offense to the person who filmed the incident without consent and would be satisfied if the facility took legal action towards this person.Resident 10 (R10)R10 was admitted on [DATE], with diagnoses including schizoaffective disorder.On 03/20/2026 at 10:35 AM, R10 confirmed being one of the residents evacuated one Sunday. R10 indicated being informed by the facility that a visitor filmed the incident and posted the video on social media. R10 indicated feeling the individual violated R10's privacy. R10 indicated being satisfied if the facility took legal action against the perpetrator.Resident 11 (R11)R11 was admitted on [DATE], with diagnoses including Parkinson's disease.On 03/20/2026 at 10:41 AM, R11 indicated if someone took a video of them without consent and posted on social media they would take offense. R11 indicated being content if the facility took legal action against this person.Resident 15 (R15)R15 was admitted on [DATE], with diagnoses including pleural effusion and bipolar disorder.On 03/20/2026 at 10:03 AM, R15 confirmed being evacuated by staff from the dining room to the courtyard a while ago. R15 indicated social services informed R15 a visitor filmed the incident and posted the video on social media. R15 stated, that was uncool and indicated feeling violated but at the same time was not surprised as it was the age of social media. R15 stated they would be satisfied if the facility pursued legal action against the perpetrator.Resident 18 (R18)R18 was admitted on [DATE], with diagnoses including atrial fibrillation.On 03/20/2026 at 9:35 AM, R18 indicated being one of the residents who were evacuated to the courtyard during a fire a few weeks ago. R18 indicated feeling their privacy was violated when informed of unauthorized recording posted on social media. R18 indicated the facility should take legal action against the individual on behalf of the residents.Resident 19 (R19)R19 was admitted on [DATE] with diagnoses including polyneuropathy and unspecified dementia.On 03/20/2026 at 11:09 AM, the social services director (SSD) indicated R19 who was under public guardianship was in the courtyard on 03/08/2026. The SSD reached out to the public guardian who expressed not liking a video of R19 being taken without consent. The guardian emphasized not wanting any more incidents of residents recorded without consent and posted on social media.Resident 21 (R21)R21 was admitted on [DATE], with diagnoses including schizophrenia and unspecified dementia.On 03/20/2026 at 11:15 AM, the SSD indicated reaching out to R21's responsible party since R21 had dementia. According to the SSD, R21's family member expressed not liking R21 being in the video without the family member's consent and did not like R21 to be used by the individual for a social media video.On 03/20/2026 at 11:16 AM, the SSD indicated there were about 20 residents involved in the unauthorized recording on 03/08/2026 and subsequent social media release of the footage. The SSD indicated interviewing the residents and/or their responsible parties, four of whom were public guardians. The SSD indicated completing a form titled Resident/Family Notification Documentation of Unauthorized Recording/Social Media Posting after the incident all residents who appeared in the video and forwarded findings to the Assistant Administrator who was in charge of submitting incident reports to state agency.On 03/20/2026 at 11:37 AM, the Administrator indicated resident interviews resulted in a decision the incident was reportable due to its potential for privacy violation or construed as mental abuse related to privacy.The facility's Videotaping, Photographing, and other Imaging of Residents policy dated 10/01/2021, documented transmitting unauthorized images of any resident through email, internet, or social media was considered a violation of resident's rights. Any image or recording taken may be construed as humiliating or demeaning to a resident or residents was considered resident abuse and should be reported and investigated as such. The facility took the following corrective actions since the incident on 03/08/2026:-A letter to families dated 03/112026, documented the Administrator released a letter to residents and families regarding the incident of unauthorized footage circulating on social media involving residents during a fire evacuation incident and made clarifications to inaccurate information circulating in social media and wanted to ensure residents were informed 1) a mechanical issue with an AC unit belt caused a small amount of smoke to enter the dining room, 2) an evacuation occurred where residents were assisted to courtyard, 3) water was offered to residents who were not allowed to re-enter until fire dept cleared code, 4) professional clearance was obtained, 5) the privacy and safety of residents were highest priority.-Staff training on HIPAA and Management and Protection of protected health information (PHI) was provided to staff and corroborated by in-service sign-in sheets- Signages were posted in high visibility areas Due to patient privacy, no photography or video- The Administrator, under the guidance of the corporation's legal team has contacted two law offices to initiate filing a lawsuit against the person who filmed the video without consent and posted the video on social media-The person who filmed the video without permission was no longer allowed to visit the resident of concern. This was the request of the resident of concern's responsible party who was also related to the alleged individual.FRI 2959459

Based on observation, interview, record review and document review, the facility failed to ensure a 1) fire incident and 2) an incident of unauthorized video recording and social media release of multiple residents by a resident's family member were reported timely to the state agency. The deficient practice placed residents at risk for delayed emergency response and potential violation of privacy. Findings include: Fire incidentOn 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke from a ceiling vent in the facility's main dining room and a burning electrical odor. The assistant activated the fire alarm, and additional staff evacuated residents to the courtyard. The fire department responded and identified the source as a seized heating, ventilation and air conditioning (HVAC) fan blower motor, the belt generated smoke briefly until failure. The Fire Department confirmed there was no fire or heat, and no injuries or suppression activity occurred. Power to the unit has been secured and replacement was pending.During the investigation, the surveyor observed the 3,363 square feet main dining room is only protected by a single photoelectric smoke detector at the entrance (egress coverage). The remainder of the space in its entirety, including the tray ceiling, lacked detection. This suggested the absence of a performance-based design assessment, resulting in inadequate coverage under a spot detection approach.This condition appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1, and the space should be reevaluated to ensure compliant and adequate smoke detection coverage.The facility submitted report of this incident to the state agency on 03/19/2026 (11 days after the incident).Unauthorized recording and social media releaseA facility report dated 03/19/2026, revealed a code red was called 03/08/2026 for unidentified smoke in the dining room. The residents were immediately evacuated to the outdoor courtyard. While waiting for clearance from the fire department, a resident's family member began recording unauthorized video footage containing faces of residents without their consent.On 03/20/2026 in the morning, staff and resident interviews, review of social media footage and documents provided by the facility confirmed there was unauthorized videotaping of multiple residents without consent and subsequent social media release.The facility submitted a report of the incident on 03/19/2026 (11 days after the incident).The facility's Videotaping, Photographing, and other images of resident's policy dated 10/01/2021, documented transmitting unauthorized images of any resident through email, internet or social media was considered violation of resident rights. Any images, recordings taken may be construed as humiliating or demeaning to a resident or residents, was considered abuse and should be reported and investigated as such.The facility's Abuse policy defined exploitation as taking advantage of a resident for personal gain. Incidences of abuse should be reported to the state survey agency no later than 24 hours if the events which caused the suspicion did not result in serious bodily harm. FRI 2959459

Based on interview, record review, and document review, the governing body of the facility failed to oversee services performed by a contracted vendor, including ensuring the accuracy of documentation of resident behaviors, for 2 of 13 sampled residents (Resident 4 and 6). This deficient practice had the potential to result in inappropriate tiering and state payments for residents in the Medicaid Behaviorally Complex Care Program.Findings include:The investigation included a review of a document titled Behavior Frequency Documentation Data Sheet, consisting of four pages used for tracking resident behaviors:Page 1 contained columns for the date, tracked behaviors, Other, and staff initials, along with a grid for days 1-31 and instructions directing staff to check applicable behaviors daily. Pages 2 and 3 contained sections listing behaviors and a table with columns for the date, time, behaviors, interventions, and signature.Resident #4 (R4) was admitted on [DATE], with diagnoses including schizophrenia, dementia, major depressive disorder, and generalized anxiety disorder. R4 was discharged on 10/18/2025.R4's Behavior Frequency Documentation Data Sheets for September 2025 revealed staff checked off behaviors which occurred each day and initialed the entries. Review of the document revealed initials were recorded by two different staff members. Fourteen of these entries, marked as AB were associated with a staff member whose identity could not be verified.R4's Behavior Frequency Documentation Data Sheets for October 2025 revealed staff checked off behaviors which occurred each day and initialed the entries. Review of the document revealed initials were recorded by two different staff members. Eight of these entries, marked as AB were associated with a staff member whose identity could not be verified.Interventions documented for R4 included those noted as effective, such as loss of privileges, time-out, detention, parent teacher conferences, suspension, student-teacher conferences, expulsion, and seclusion; those noted as successful, such as a calm-down corner; those noted as failed, such as expulsion and corporal punishment; and those noted as ineffective, such as detention and corporal punishment. All these interventions were unapproved for R4.R6's Behavior Frequency Documentation Data Sheets for August 2025 revealed staff checked off behaviors which occurred each day and initialed the entries. Review of the document revealed initials were recorded by two different staff members. Fifteen of the entries, marked as AB were associated with a staff member whose identity could not be verified.R6's Behavior Frequency Documentation Data Sheets for September 2025 revealed staff checked off behaviors which occurred each day and initialed the entries. Review of the document revealed initials were recorded by two different staff members. Nine of the entries, marked as AB were associated with a staff member whose identity could not be verified.On 12/31/2025 at 11:45 AM, a Unit Manager explained contracted behavioral health staff came to the facility to visit residents who had behavioral issues and were contracted to provide treatment and interventions for residents who were enrolled in the behaviorally complex care program. The Unit Manager indicated the facility typically held interdisciplinary team (IDT) meetings with contracted behavioral health staff to discuss each resident's progress.The Unit Manager indicated the facility had never used terms such as loss of privileges, time-out, detention, parent-teacher conferences, suspension, expulsion, or seclusion when addressing resident behaviors.The Unit Manager explained none of the facility staff documented on the Behavior Frequency Documentation Data Sheets because facility staff did not have access to these sheets. The Unit Manager verified the interventions documented on the sheets did not come from R4's care plan, as the facility had not used any of the listed interventions for behaviors.On 12/30/2025 at 10:30 AM, the Assistant Administrator indicated an outside vendor was contracted by the facility to provide services for residents with behavioral issues. The vendor had its own behavioral health staff who came to the facility to provide treatment and interventions. The Assistant Administrator stated behavioral health staff and facility staff participated in interdisciplinary team (IDT) meetings; however, all treatment and documentation were completed by behavioral health staff. On 12/30/2025 at 2:45 PM, the Administrator explained none of the facility staff documented on the Behavior Frequency Documentation Data Sheets because facility staff did not have access to these sheets. The Administrator stated contracted behavioral health staff were solely responsible for submitting all documents to Medicaid. The Administrator further indicated the facility and contracted behavioral health staff met during IDT meetings to discuss and review residents, and BHS brought its own staff to provide the services.On 12/31/2026, an email communication from the Chief Clinical Officer with the contracted vendor, indicated after reviewing the documents, the issue was determined to be isolated to a single employee who had documented interventions which were not actually implemented at the facility. The employee signed a statement confirming they had never witnessed any inappropriate interventions.The Chief Clinical Officer explained when documenting behavioral interventions, the employee was expected to obtain source information directly from facility staff regarding the real-time interventions being used in response to specific behaviors. Instead, the employee used an AI tool to generate interventions and entered this information into the documentation. On 12/31/2025 in the morning, during a telephone interview, a Lead Behavior Coordinator, with the contracted agency explained that prior to October, each coordinator submitted their data sheets directly to the office staff, who gathered the sheets and submitted them with the application packet to the physician for final review and submission to the State.After October, a new process was implemented: each coordinator placed the completed data sheets in a designated folder. The Lead Behavior Coordinator reviewed the sheets for accuracy and then moved them to a Management Review folder. Once management reviewed the sheets, they were forwarded to the office staff, who compiled them with the application packet for physician review and submission to the State.The Lead Behavior Coordinator admitted instructing the Behavior Coordinator to stop using spanking and corporal punishment as interventions after noticing those terms on the sheets and explained where to find the correct information. The Lead Behavior Coordinator acknowledged being aware that the Behavior Coordinator was using other initials to sign off on paperwork but had not reported it. The Lead Behavior Coordinator stated they were not aware the Behavior Coordinator was using AI to generate interventions.The Lead Behavior Coordinator also reported a supervisor held a meeting one week prior to the State survey, instructing staff to discontinue using templates and showed them where to locate the required information.The facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership (undated) documented the governing body was responsible for ensuring the QAPI focused on problems and opportunities reflecting processes, functions and services provided to the residents. The facility provided a copy of the Consulting Agreement, effective September 1, 2022, which documented during the term of the agreement, the consultants shall render the following services on behalf of the company: recommend best practices for maintaining adequate and accurate documentation of patient behavioral symptoms and conditions, and verify that patient data is correctly labeled and identified to ensure that claims are properly submitted.Complaint NV0002655916

Based on interview, record review, and document review, the facility failed to ensure target behaviors and side effects were monitored with regards to use of an anti-psychotic medication for 1 of 7 sampled residents (Resident 1). The deficient practice had the potential to place the residents at risk for receiving unnecessary medications.Findings include:The Anti-psychotic Medication Use policy (undated), documented residents admitted already receiving anti-psychotics would have been evaluated for its appropriateness and indication for use. The inter-disciplinary team (IDT) assessed the residents' symptoms and overall situation, and the physician determined whether to continue, adjust, or stop the antipsychotic medication.Resident 1 (R1) was admitted on [DATE], with diagnoses including metabolic encephalopathy, malignant neoplasm of the colon and non-traumatic subarachnoid hemorrhage.The admission minimum data set (MDS) dated [DATE], revealed R1 was cognitively intact, had verbally aggressive behaviors and was receiving an anti-psychotic medication.A physician order dated 04/15 /2025, documented to give Quetiapine Fumarate (anti-psychotic) oral Tablet 25 milligrams (mg) one tablet by mouth at bedtime for bipolar disorder as manifested by (AMB) mood swings.A physician order dated 04/29/2025, documented to monitor behavior of mood swings for anti-psychotic medication Quetiapine. Use non-pharmacological intervention codes: (1) redirect; (2) one-on-one 1:1; (3) activities; (4) toilet; (5) give food or fluids; (6) reposition; (7) back rub; (8) other chart in progress notes. Outcome Code: (+) effective (-) ineffective every shift.A physician order dated 04/29/2025, documented to monitor for side effects of anti-psychotic medication Quetiapine: dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling, extra pyramidal symptoms (EPS) symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue), every shift for bipolar disorder manifested by mood swings.The medical record lacked documented evidence target behaviors and side effects were monitored from 04/15/2025 to 04/28/2025.On 03/04/2026 at 9:34 AM, a Licensed Practical Nurse (LPN) assigned to R1's unit indicated not being familiar with R1 due to being newly hired at the facility. The LPN explained all psychoactive medication orders were entered with specific target behaviors and side effect monitoring for the purpose of guiding providers on whether the medication and dosage continued to be appropriate for the resident. The LPN reviewed R1's medical record and confirmed R1 started receiving Quetiapine on 04/15/2025 but behavior monitoring and side effect monitoring were not initiated until 04/29/2025. The LPN confirmed physician orders to monitor target behaviors such as mood swings and side effects such as dry mouth and blurry vision were not entered until 04/29/2025 but the LPN could not speak to why this was the case.On 03/04/2026 at 10:18 AM, a charge nurse vaguely recalled R1 who was at the facility briefly a year ago. The charge nurse reviewed R1's medical record and stated the admitting nurse who entered R1's Quetiapine order on 04/15/2025 may have forgotten to enter orders for behavior and side effect monitoring. The charge nurse indicated the medication administration record (MAR) reflected R1 started receiving Quetiapine on 04/15/2025 but target behavior of mood swings and potential side effects were not monitored until 04/29/2025 which may have been due to monitoring orders being entered only on 04/29/2025. The charge nurse clarified orders which were not entered into the electronic health record (EHR) would not prompt the floor nurses to view a medication or task which as due.On 03/04/2026 at 10:30 AM, the charge nurse explained residents receiving psychoactive medications were monitored for target behaviors and potential side effects for the purpose guiding the clinician on whether the medication, frequency and dosage were appropriate or whether a dose reduction was appropriate.On 03/04/2026 at 1:55 PM, the Director of Nursing (DON) indicated having reviewed R1's record and confirmed R1 was not monitored for target behaviors and potential side effects from 04/15/2025 (first dose of Quetiapine) until 04/29/2025 due to monitoring orders being entered two weeks late.On 03/04/2026 at 2:00 PM, the DON indicated the purpose of monitoring behaviors and side effects for residents receiving any psychoactive medications were to ensure the medication, dosage and frequency were still appropriate for the residents. This also served as a guide for pharmacy and providers with regards to gradual dose reductions (GDRs) or changes to the medicationsThe facility's Tapering medications and Gradual Dose Reduction policy (undated), documented tapering applicable to anti-psychotic medications shall be referred to as GDR. The attending physician identified target symptoms for which the resident was receiving the medication. The staff monitored the improvement of target symptoms and provided the physician with the information. The physician in collaboration with nursing and pharmacy would periodically review whether the medications were still necessary in their current doses.Facility Reported Incident 2646420

Based on observation, record review, interview and document review the facility failed to provide bathing as scheduled for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to negatively impact the resident's overall well-being. Findings include:Based on observation, record review, interview and document review the facility failed to provide bathing as scheduled for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for skin breakdown, rashes, and overall poor hygiene. Findings include:Resident 1 (R1) was admitted on [DATE] with diagnoses including dysphagia following cerebral infarction, type 2 diabetes mellitus, and essential hypertension.On 12/30/2025 at 9:30 AM, R1 explained they had a rash, experienced itching, and staff did not bathe or shower them regularly.On 12/30/2025 at 9:40 AM, a Certified Nurse Assistant (CNA) explained that resident bathing was scheduled according to room numbers, with residents bathed twice weekly and as needed. Bathing was documented in the medical record. After reviewing the schedule, the CNA confirmed that R1's baths were assigned to the evening shift on Wednesdays and Saturdays.The Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 was dependent on staff for showering and bathing, including washing, rinsing, and drying (excluding washing of the back and hair). This did not include assistance with transferring in or out of the tub/shower. R1's shower/bathing tasks documented the following bathing activity:-Tuesday, 09/30/2025 a bed bath-Saturday, 10/11/2025 a shower-Wednesday, 10/22/2025 a bed bath-Wednesday, 10/29/2025 a bed bath-Wednesday, 11/19/2025 a bed bath-Wednesday, 12/10/2025 a shower-Wednesday, 12/17/2025 a bed bath-Saturday, 12/20/2205 a bed bath-Sunday, 12/21/2025 a showerOn 12/30/2025 at 10:31 AM, the Director of Nursing (DON) explained resident showers or bed baths were to be performed as scheduled. After reviewing R1's bathing schedule and documentation, the DON confirmed showers were scheduled for Wednesday and Saturday evening but were not provided as scheduled. The DON explained when a resident did not receive routing bathing, they were at risk for skin breakdown, rashes, and overall poor hygiene. The facility policy titled Shower/Tub Bath, undated, documented qualified nursing staff would provide a bed bath to the resident as needed, at a minimum, the resident would be offered at least two full baths or shower per week. Complaint #2651495

Based on record review and staff interviews, the facility failed to ensure physician orders for monthly weights were followed for 1 of 6 sample residents (Resident 6). This deficient had the potential to impact monitoring of the resident's changes in weight (loss or gain), nutritional assessment, and delay dietary interventions. Findings Include: Resident 6 (R6) was admitted to the facility on [DATE] with diagnoses including Parkinson's disease without dyskinesia, dementia, and major depressive disorder.A physician order summary dated 07/03/2025, documented monthly weight one time a day starting on the 1st and ending on the 7th every month for monitoring.A physician/nurse practitioner progress note dated 12/11/2025 documented R6 had an eight-pound weight loss from August of 2025.R6's weight record documented the following:12/10/2025- 92.3 pounds (weight chair) 08/07/2025 -100.00 pounds (weight chair)The medical record lacked documented evidence of weights for September 2025, October 2025 and November 2025. On 12/30/2025 at 1:25 PM, the Director of Nursing (DON) stated obtaining resident weights had been an ongoing issue. Certified Nurse Assistants (CNA) had not consistently obtained monthly weights, which could have resulted in inaccurate care planning and delayed or inappropriate interventions for residents who experienced weight loss.On 12/30/2025 at 2:30 PM, the Unit Manager stated that CNAs were expected to obtain resident weights monthly. The Unit Manager acknowledged ongoing challenges in obtaining consistent and accurate measurements and indicated that missing or inaccurate weights had negatively impacted care planning and delayed timely interventions for residents experiencing weight loss or significant changes.On 12/30/2025 at 2:45 PM, the Assistant Director of Nursing (ADON), revealed obtaining accurate weights by CNAs had been challenging. Weights were obtained upon admission, monthly, and as needed. Inconsistent weight measurements could have negatively impacted resident care plans and overall health outcomes.On 12/30/2025 at 3:15 PM, the Registered Dietitian (RD) acknowledged ongoing challenges in obtaining accurate and consistent weight measurements, noting missing or inconsistent data made it difficult to track true weight changes. The RD stated that consistent weight monitoring would have allowed timely dietary interventions and more effective nutritional planning, ensuring better alignment of R6's dietary needs with the care plan.The facility's policy titled Weight Assessment and Intervention, dated 10/01/2021, stated the nursing staff or designee will measure resident weight as ordered by the physician/practitioner and weights will be measured monthly. Complaint #2675657

Based on observation, interview, record review and document review the facility failed to ensure an orthopedic consult was obtained as per physician order for 1of 5 sampled residents (Resident 1). The deficient practice had the potential to delay treatment and healing of a fracture. Findings include: Resident 1 (R1) R1 was readmitted on [DATE] with diagnoses including fracture of left wrist and hand, dementia without behavioral disturbance and major depressive disorder. A Change of Condition Note dated 02/22/2025 at 5:32 AM, documented R1 was noted calling for help. Immediately staff responded to R1's room and R1 was noted lying on the floor next to wheelchair holding left wrist. R1 moaned in pain. R1's left wrist had a small skin tear, swollen and painful to touch. R1 was assisted back to wheelchair. Supervisor and family were notified. R1 was sent to the emergency room for further evaluation. A Progress Note dated 02/22/2025, documented R1 returned from hospital via stretcher transport at 2:30 PM with a splint/cast on left arm. Diagnosis from hospital was a left wrist fracture. Left arm elevated above heart level to help decrease swelling. R1 was given Tylenol for pain. A Physician/Nurse Practitioner Progress note dated 02/23/2025, documented Left wrist fracture status post fall. With left upper extremity cast. Requested emergency room notes. Orthopedic follow-up. A Physician Order dated 03/03/2025, documented arrange Orthopedic follow-up status post fall with left wrist fracture. A Physician Order dated 04/01/2025, documented left wrist x-ray two views. Radiology Results dated 04/01/2025, documented findings: fracture of distal ulna (lower end of the forearm) and distal radius (end of forearm that forms the wrist joint). On 04/24/2025 at 1:37 PM, R1 was lying on right side in bed with left arm draped across abdomen R1's left arm had a pink and black cast extending from thumb area of hand to just below elbow. R1 explained had fell about a month ago and denied any discomfort or pain. R1 was unable to explain when the cast was applied. On 04/24/2025 at 1:40 PM, a Licensed Practical Nurse (LPN) explained R1 had the cast applied on 04/23/2025 at an orthopedic appointment. The LPN stated R1 had a fall in February 2025 and returned from the emergency room with a splint and ace wrap. The LPN explained being told there were issues with R1's insurance and being able to get an appointment. On 04/24/2025 at 1:55 PM, the Unit Manager (UM) explained R1 had a fall on 02/22/2025 and returned from the emergency room the same day with a soft half cast with a plaster bottom and ace wrap. The UM explained being unsure of why there was a delay in obtaining an orthopedic appointment and stated it could have been due to an insurance issue. On 04/24/2025 at 2:08 PM, the Transportation Coordinator explained the process for arranging appointments was for the provider to give the consultation order, nurses input the order and complete an appointment slip for transportation. The appointment slip was given to the transportation coordinator. If transportation was unable to schedule the appointment due to a resident needing insurance authorization the Case Manager was notified and provided a copy of the appointment slip to obtain authorization. Records would be sent to insurance company for the approval which generally takes about a week. Once authorization was received the appointment would be made. The Transportation Coordinator explained having asked multiple times about R1's insurance approval and was told authorization had not been received. On 04/24/2025 at 2:18 PM, the Case Manager (CM) explained when orders were obtained a transportation slip was completed and the CM would contact the insurance company to obtain authorization. Once the authorization was given the Transportation Coordinator would schedule the appointment. The time frame for approval depended on the insurance company and would fluctuate. The CM reviewed the physician orders for R1 and confirmed R1 had an order dated 03/03/2025 for an orthopedic consult. The CM explained being unaware of R1's consult order and a request was not made. The CM explained leaving for medical leave on 3/14/2025 and not returning until 4/17/2025 and was unaware if anyone else in the facility had the capability to request authorization. On 04/24/2025 at 3:05 PM, the UM confirmed R1had an order for an orthopedic consult on 03/03/2025 explaining being aware some residents require insurance approval and was informed this caused delay for obtaining R1's appointment. The UM explained having only communicated with transportation regarding the delay and had not spoken to the CM. The UM explained being unaware of who had access to request insurance approval and the time frame for obtaining R1's appointment was unacceptable due to the fracture. The facility provided documentation confirming insurance authorization for Orthopedic consult was not requested until 04/11/2025. An Orthopedic Progress Note dated 04/23/2025 documented R1 was seen for initial evaluation of left wrist injury. Will continue closed management of left wrist fractures using left upper extremity short arm cast versus left upper extremity removable wrist brace. On 04/24/2025 at 4:43 PM, R1's Nurse Practitioner (NP) explained the expectation of staff to carry out an order for consults would be to obtain a visit within 2 weeks. The NP acknowledged the order for an Orthopedic consult was placed on 03/03/2025 and explained waiting until 04/11/2025 to request authorization was not an acceptable time frame. The facility policy titled Resident Rights, undated, documented the Resident has a right to a dignified existence, self-determination, communications with and access to persons and services inside and outside the facility.

Based on observation, interview, record review and document review, the facility failed to ensure: 1. The plan of care was followed regarding transfers and the staff was provided with transfer training after a resident fall for 1 of 35 sampled residents (Resident 25) and, 2. An Oxygen tank was secured for 1 of 35 sampled residents (Resident 98). The deficient practice led to a resident's fall with injury and had the potential to cause a resident injury due to an unsecured Oxygen tank. Findings include: Resident 25 (R25) R25 was admitted on [DATE], discharged on [DATE], and readmitted [DATE] with diagnoses including displaced bicondylar (upper and lower parts) fracture of right tibia. The Annual Comprehensive Minimum Data Set (MDS) dated [DATE], documented R25 had lower extremity (hip, knee, ankle, foot) impairment on one side of the body. R25's Care Plan documented the following: -Resident at risk for spontaneous pathologic fracture, injury, and trauma secondary to osteoporosis. The interventions identified included two persons assist when providing care. -Resident had Activities of Daily Living (ADL) self-care performance deficit as evidenced by impaired mobility, limited range of motion right lower extremity, and activity intolerance. -Resident had limited physical mobility as evidenced by weakness, impaired range of motion right lower extremity, and activity intolerance. Resident utilizes a Hoyer lift (device that helps transfer residents with limited mobility). A Physical Therapy Evaluation and Plan of Treatment dated 07/04/2024, documented R25 had physical impairments and associated functional deficits. The resident was at risk for falls and required a Hoyer lift with transfers. A Nursing Progress Note dated 09/18/2024, documented a Certified Nurse Assistant (CNA) reported an assisted fall with R25 during a transfer from the bed to shower chair. R25's knee buckled and started to lean toward the CNA which resulted in R25 being assisted down to the floor. R25 complained of severe right knee and right ankle pain. An order was obtained for a right knee and ankle x-ray. Radiology results dated 09/18/2024 documented a right knee view impression: nondisplaced fracture of the proximal (situated nearer to the center of the body or the point of attachment) tibia. The Hospital Course of the Discharge Summary dated 09/27/2024, documented R25 experienced a ground level fall while attempting to transfer to a shower chair while utilizing R25's less efficient right foot to balance and an X-ray suggested right tibial plateau (a break at the top of the tibia bone) fracture. On 03/25/2025 at 9:24 AM, R25 was lying in bed alert and oriented and stated, a CNA pulled the leg, picked them up and threw them to the floor. On 03/26/2025 at 12:54 PM, Certified Nurse Assistant 1 (CNA 1) described the attempted transfer of R25 to a shower chair but was unable to locate a sling for the transfer in September 2024. The CNA expressed the nurse stated R25 transferred with the Restorative Nurse Assistant (RNA) check with them regarding abilities. The CNA explained not speaking to the RNA and returning to R25's room. The CNA attempted the transfer independently, when pivoting, R25's feet buckled, and the CNA fell with R25 to the floor. The CNA explained had recently started working the hall where R25 resided and always asked the nurse about a resident's transfer abilities. The CNA stated R25 required a sling and lift with transfers. On 03/27/2025 at 10:24 AM, the MDS Director explained the CNAs would check the Kardex (a care plan used by CNAs) to obtain information regarding a resident level of assistance. The Kardex would indicate how much assistance was required and if a Hoyer lift was needed. On 03/27/2025 at 10:29 AM, the MDS Director confirmed in September of 2024 R25 was dependent and required a Hoyer lift for transfers. On 03/27/2025 at 1:51 PM, Certified Nurse Assistant 2 (CNA 2) explained a Hoyer lift required two staff members or more depending on the resident. Staff needed to check with the resident's assigned nurse or the plan of care to know the method of transfer for a resident. On 03/27/2025 at 2:20 PM, the Therapy Director confirmed R25 was evaluated in July 2024 by physical therapy prior to the fall event in September. At the time of the evaluation, R25 required a Hoyer lift for transfers and the CNAs were to utilize a Hoyer lift for R25's transfers. On 03/28/2025 at 11:25 AM, the Unit Manager stated an investigation for the fall event should have been documented in the progress notes. The Unit Manager confirmed the medical record lacked documentation the investigation occurred and the 9/18/2024 nurse notes for R25 had no indication of what new fall prevention interventions were implemented after the fall event. The Unit Manager confirmed R25 was a Hoyer lift transfer prior to the September 2024 fall. The Unit Manager stated education and counseling occurred with the CNA involved with the incident. On 03/28/2025 at 11:31 AM, the Unit Manager confirmed the CNA should have checked R25's ADLs to determine how to transfer the resident and the CNA should have implemented the use of the Hoyer lift. The root cause was the CNA not utilizing the Hoyer lift and the fall could have been prevented. The Unit Manager explained education needed to be conducted for the CNA staff that work R25's unit and education to all CNA's regarding how to check the plan of care and ADLs for residents prior to performing care, and ensure new interventions were in place related to the fall event. On 03/28/2025 at 11:39 AM, the Unit Manager explained the expectation was to ensure new interventions were in place related to the fall event and education to be conducted for the CNA staff who worked R25's unit. Education should have been provided to all CNA's on where to locate information regarding a residents ADL's prior to performing care. CNA1's employee file, lacked documented evidence education or counseling had occurred as a result of the 09/18/2024 fall event. On 03/28/2025 at 11:54 AM, the Unit Manager confirmed there was no record of education or counseling in the employee file for the CNA involved. The CNA had not completed ADL training after the fall event and there was no record of other CNAs having been trained. Throughout the week of the survey a skills competency for the CNA involved in the fall was requested and documentation was not provided, as of the last onsite date of survey 03/28/2025. On 03/28/25 at 1:01 PM, Certified Nurse Assistant 3 (CNA 3) verbalized R25 would require two staff and a Hoyer lift for transfers. The CNA explained looking at the resident care plan to determine a resident's ADLs and level of assistance. CNA 3 stated knowing another CNA had transferred R25 resulting in an injury. On 03/28/2025 at 3:18 PM, the Assistant Director of Nursing (ADON) verbalized when fall events occur a discussion is held to determine a root cause of the fall incident and ensure interventions are implemented. The facility policy titled Fall Protocols, undated, documented staff would conduct a comprehensive investigation to implement change in the care or system to minimize recurrence. Resident 98 (R98) R98 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, Type 2 diabetes mellitus, and dependence on supplemental Oxygen. A physician order dated 03/19/2025 documented to administer Oxygen at two liters per minute (LPM) via nasal cannula continuously every shift for shortness of breath. On 03/25/25 at 11:15 AM, an Oxygen cylinder tank was noted to be unsecured in R98s room beside the bed. R98 stated the staff change the Oxygen out when needed and the tanks are normally placed on the floor without support. On 03/25/25 at 11:19 AM, a CNA verified the Oxygen cylinder tank was not secured in an Oxygen holder. The CNA explained the tank was half full and it should be placed in a holder so it cannot fall. The CNA stated a holder was needed for safety. On 03/28/25 at 3:19 PM, the ADON confirmed Oxygen cylinder tanks were to be secured in a holder when in resident rooms to prevent them from falling and potentially causing injury. The facility policy titled Fire Safety and Prevention, dated 10/01/2021, Oxygen Safety section, documented to store Oxygen cylinders in sturdy portable carts or approved stands. Never leave Oxygen cylinders free-standing.

Based on interview and document review, the facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life. Findings include: On 03/28/2025 in the afternoon, the administrator acknowledged the facility was not able to produce documentation providing evidence the facility had developed, implemented, and maintained an effective, comprehensive QAPI program. The Administrator provided evidence the facility had a QAPI meeting on 02/27/2025, 09/24/2024, and 07/30/2024. The administrator stated had been the administrator at this facility for a short time and was not able find where the electronic documents were filed or if they were filed. A facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, undated, documented the facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. The State Operations Manual documented, the facility must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must also maintain documentation and demonstrate evidence of its ongoing QAPI program along with documentation and evidence of its ongoing QAPI program's implementation. The governing body and/or executive leadership is responsible and accountable for ensuring that the QAPI program is sustained during transitions in leadership and staffing.

Based on interview and document review, the facility failed to maintain documented evidence of maintaining a Quality Assurance and Performance Improvement (QAPI) Committee consisting at a minimum of: the Director of Nursing services; the Medical Director or his/her designee; at least three other members of the facility's staff, at least one of who must be the administrator, owner, or board member; and the infection preventionist. The facility also failed to maintain documentation of evidence of the committee meeting at least quarterly. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life. Findings include: On 03/28/2025 in the afternoon, the Administrator acknowledged the facility was unable to provide documented evidence the facility had a QAPI Committee meeting on 02/27/2025, 09/24/2024, and 07/30/2024. The Administrator acknowledged the 02/27/2025 QAPI Committee meeting was missing the Director of Nursing and the Administrator, Owner, or Board Member. The Administrator acknowledged the 09/24/2024 QAPI Committee meeting was missing the Medical Director or his/her designee and the Administrator, Owner, or Board Member. The Administrator acknowledged the 07/30/2024 QAPI Committee meeting was missing the Medical Director or his/her designee. The Administrator also acknowledged the facility was not in compliance with the requirement to hold a QAPI Committee meeting at least quarterly. The administrator stated had been the administrator at this facility for a short time and was not able find where the electronic documents were filed or if they were filed. A facility policy titled, Quality Assurance and Performance Improvement (QAPI) Committee, undated, documented the facility will maintain a (QAPI) Committee consisting at a minimum of the Director of Nursing services; the Medical Director or his/her designee; at least three other members of the facility's staff, at least one of who must be the administrator, owner, or board member; and the infection preventionist. The policy also documented the committee will meet at least regularly and as needed to coordinate and evaluate activities under the QAPI program. The state operations manual documented, the facility must have maintained a quality assurance and performance improvement committee consisting at a minimum: the director of nursing services; the Medical Director or his/her designee; at least three other members of the facility's staff, at least one of who must be the administrator, owner, or a board member; and the infection preventionist. It also documented the QAPI committee meetings must be held at least quarterly or more often as necessary to fulfill the committee's responsibilities to identify and correct quality deficiencies effectively.

Based on observation, interview, record review and document review, the facility failed to ensure a physician's order was obtained, an assessment was completed, and care plan was developed for the self-administration of medication for one unsampled resident (Resident 38). The deficient practice had the potential for the resident's unsafe administration of medication or adverse reactions to medication. Findings include: Resident 38 (R38) R38 was admitted on [DATE], with diagnoses including peripheral vascular disease and age-related physical debility. The physician's order dated 10/18/2023, documented Ketotifen Fumarate Ophthalmic Solution 0.035% (eye drops), instill two drops in both eyes two times a day for itching. R38's Medication Administration Record (MAR) for March 2025, documented the medication was scheduled to be given at 8:00 AM and 8:00 PM. On 03/28/2025 at 8:44 AM, during the medication administration pass observation, a Licensed Practical Nurse (LPN) prepared R38's oral medications scheduled for 8:00 AM. The LPN indicated R38 kept and self-administered the eye drops. On 03/28/2025 at 8:56 AM, the LPN administered R38's medications except for the eye drops. On 03/28/2025 at 8:58 AM, R38 confirmed self-administering the eye drops as needed and kept the eye drops on bedside. R38 took the eye drops from a purse kept at the resident's bedside and showed the medication to the LPN. R38 refused to have the eye drops administered. The label of the eye drops documented Eye Itch Relief 0.035%. On 03/28/2025 at 8:59 AM, the LPN revealed a physician's order for the resident's self-administration of medication and keeping the medication on bedside should have been obtained, an assessment should have been completed to determine if the resident could self-administer the medication, and care plan for self-administration of medication should have been developed. The LPN confirmed there was no physician's order obtained for R38's self-administration of the eye drops and for the resident to keep the eye drops on bedside, no assessment was completed and no care plan developed for the resident's self-administration of the medication (eye drops). The LPN acknowledged the medication should have been kept in a secured and locked storage and not in the resident's purse. On 03/28/2025 at 12:29 PM, the Regional Director of Clinical Services confirmed there were no physician's orders for R38's self-administration of the eye drops and keeping the eye drops at bedside, no assessment had been completed and no care plan developed for R38's self-administration of the medication. On 03/28/2025 at 2:01 PM, the Assistant Director of Nursing (ADON) indicated a physician's order should have been obtained for a resident's self-administration of medication and allowing the resident to keep the medication on bedside. The ADON revealed an assessment for self-administration of medication should have been completed and care plan should have been developed. The ADON explained the medication should have been kept in a secured and locked storage and not in the resident's purse. The facility's policy titled Self-Administration of Medications and Treatments (undated), documented the residents had the right to self-administer medications/treatments if the interdisciplinary team had determined it was clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff and practitioner would assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treatments was clinically appropriate for the resident. In addition to general evaluation of decision-making capacity, the staff and practitioner would perform a more specific skill assessment, which might include (but not limited to) the resident's: - Ability to read and understand medication labels/treatment instructions - Comprehension of the purpose and proper administration of the medications/treatments - Ability to remove medications and/or treatment supplies from a container - Ability to recognize risks and major adverse consequences of the medications/treatments Self-administered medications and/or treatment supplies would be stored in a safe and secure place. If safe storage was not possible in the resident's room, the medications of residents permitted to self-administer would be stored on a central medication cart or in the medication room.

Based on observation, interview, and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which are significant to the resident for 1 of 35 sampled residents (Resident 102). The failure to accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents. Findings include: Resident 102 (R102) was admitted to the facility with diagnoses of nontraumatic intracerebral hemorrhage and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R102 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. On 03/26/2025 in the morning, R102 stated do not get enough showers and two showers a week was not enough. R102 stated would like more showers because if the resident missed a shower for any reason, then the resident won't get another shower until the next week. R102 stated having to wait this long is too much. R102 complained about sweating in bed, hair becoming greasy, and body odor occurs when resident don't get enough showers. On 03/28/2025 at 3:41 PM the Administrator-In-Training (AIT) stated R102's shower days were Tuesday and Thursday, and the facility had added on Sunday for R102. However, on Tuesday, 03/25/2025, the facility did not have a Hoyer (mechanical resident lift) sling available to complete the shower transfer to get the resident from the bed to the shower chair/gurney. The AIT stated each resident should have their own sling for the Hoyer, but R102 did not have a sling at this time. The AIT also reported there was no documentation a shower had been given on 03/27/2025. On 03/28/2025 in the afternoon, the Assistant Director of Nursing (ADON) verified R102's shower days were Tuesday and Thursday, and the facility had added on Sunday for this resident. The ADON also verified on Tuesday, 03/25/2025, the facility did not have a Hoyer sling available to complete the shower transfer to get the resident from the bed to the shower chair/gurney and there was a lack of documentation whether a shower had been given on 03/27/2025. Facility policy titled Shower/Tub Baths (undated), documented the baths would promote resident cleanliness and provide comfort to the resident and the resident would, at a minimum, be offered at least two full baths per week and resident preferences for type and frequency of baths would be honored.

Based on interview and document review, the facility failed to document a written response including rationale to address complaints brought forth in the resident council. The deficient practice had the potential to cause resident concerns to remain unresolved. Findings include: Resident council meeting minutes dated 02/19/2025 revealed residents complained of call lights were not answered in a timely manner, and staff were on their phones more than paying attention to residents. Resident council meeting minutes dated 03/19/2025 revealed a resident complained nurses were slow to answer their call light, resulting in waiting up to 45 minutes for assistance. A different resident complained had not had a shower in three months. Resident 57 (R57) R57 was admitted on [DATE]. The 02/04/2025 Quarterly Minimum Data Set (MDS) assessment indicated R57 had normal memory function. On 03/27/25 at 1:34 PM, R57 reported serving as the Resident Council President for greater than the prior four months. R57 reported resident council meetings were conducted on the third Wednesday of each month and eight or nine residents typically attended each meeting. R57 reported a staff member recorded the meeting minutes. R57 reported sometimes the facility did not make a response to concerns raised in the resident council. R57 verbalized residents in several recent council meetings had verbalized a complaint about delay in assistance from staff after putting on the call bell. R57 verbalized as of yet, no facility response to this concern had been received. R57 verbalized feeling frustrated by the lack of response to the ongoing issue. R57 verbalized other residents had also expressed frustration regarding the issue. On 03/27/25 at 1:34 PM, a group interview was conducted with R57 and seven other alert residents. Five of the residents verbalized their call lights could be on for 45 minutes before staff responded. The five residents stated the call light issue had been ongoing for several months. One resident reported staff were constantly on their phones. The facility was unable to provide any written documentation of corrective actions taken in response to the complaints from the meetings. On 03/28/25 at 2:18 PM, the Activities Assistant verbalized council notes were taken by activities staff and were furnished to department heads for response, but these were not consistently returned to the activities department for reply to the residents. Call light response time was an ongoing issue, and the complaints had been furnished to nursing, but no response had been returned to the Activity Assistant regarding what was being done. On 03/28/25 at 8:43 AM, the Administrator (ADM) reviewed the resident council meeting minutes from the 02/19/2025 and 03/19/2025 meetings. The ADM verbalized there should have been written responses to the complaints regarding call light delay, staff using personal phones, and lack of shower provided. The ADM verbalized having checked, but written responses to the concerns could not be located. The ADM verbalized not being sure of the reason. The ADM verbalized having commenced employment at the facility on 03/23/2025, and the former ADM had left employment with no briefing provided on the status of complaints. On 03/28/25 at 1:01 PM, the Regional Director of Clinical Services verbalized concerns from the resident council should be forwarded to the appropriate department and an investigation/response should have been documented. The policy and procedure titled Resident/Family Council, undated, indicated resident council meetings were scheduled monthly or as requested by residents. The policy indicated the purpose was to provide a forum for concerns or suggestions for improvement. The policy indicated documentation of the resident council meeting would be utilized to track issues and their resolution. The facility department related to any issues would be responsible for addressing the item(s) of concern. The policy and procedure titled Grievances/Complaints, dated 01/2018, indicated all grievances, complaints, or recommendations stemming from resident or family groups would be considered. Actions on such issues would be responded to in writing, including a rationale for the response.

Based on interview, record review and document review, the facility failed to ensure a resident was kept safe from physical abuse for 1 of 35 sampled residents (Resident #43). The deficient practice had the potential for the resident to experience emotional and physical harm. Findings include: Resident #43 (R43) Resident #43 (R43) was admitted to the facility 01/02/2025 with diagnoses including encephalopathy, urinary tract infection, hypothyroidism, and hypertension. The facility reported incident (FRI) dated 02/27/2025 documented the following: -On 02/25/2025, R43 was in a wheelchair in the 700 hall and was arguing with Employee 20 (E20). R43 was trying to wheel the wheelchair back to the room R43 had just been transferred from. E20 got in front of R43 and blocked the ability of R43 to move forward in the wheelchair. R43 became agitated and started yelling at E20 to get their hands off R43. - Employee 14 (E14) stepped outside their office and witnessed E20 holding R43's arms down against the wheelchair. R43 began to kick at E20. E20 then told R43 if R43 kicks E20, E20 would kick R43 back. Throughout 02/25/2025 and the following day E14 witnessed E20 leading R43 past the office of E14 holding R43's hands down against the wheelchair and R43 yelling to be let go of. -Conclusion: The allegation of physical abuse by E20 against R43 was substantiated. Subsequently E20 was suspended pending investigation and then terminated. The nursing board was notified on 03/25/2025 of the incident. R20 had been previously trained on abuse on 03/25/2024. A behavior note dated 02/25/2025 written by E20 documented R43 was kicking at staff and becoming more verbally and physically aggressive when not allowed to enter other resident rooms. R43 was yelling and using profanity. R43's medical record lacked documented evidence of social services involvement with this situation other than a Social Services note for a referral to psych services for agitation dated 02/26/2025. An email from the Director of Social Services (DSS) to the Administrator-in-Training on 02/27/2025 at 11:36 AM documented the incident between E20 and R43 had been brought to attention on this day and the DSS had the nurses write statements. The AIT acknowledged receipt of the email's information on 02/27/2025 at 11:48 AM. R43's care plans lacked evidence of an update or revision related to the incident involving the altercation with the staff member. On 03/26/2025 in the afternoon, R43 stated the current staff was very nice. R43 said there was a staff member which tried to kidnap the resident, but R43 has not seen this person since the other staff members stopped this person from kidnapping. R43 also stated the facility is run very well, and would not change a thing. During the onsite investigation on 03/26/2025, the facility's correction of the past non-compliance related to the incident occurred as evidenced by: -Observation of staff and resident interactions were professional and courteous. -Interviews with residents revealed they were happy with staff and were treated in a polite manner. - CNA's and Licensed Nurses indicated the facility provided continuing education regarding Abuse and Neglect. -Review of the facility's employee file for E20 revealed reference and background checks were completed. -Review of the facility's training records corroborated the staff interviews regarding training. Facility Reported Incident #NV00073562 Complaint #NV00073745

Based on observations, record reviews, staff interviews, and facility policy reviews, the facility failed to ensure 1 of 35 sampled residents (Resident 168) remained free from restraints not needed to treat a medical symptom, identify the use of lower bed rails as a restraint, and follow policies and procedures in assessing the use of a physical restraint or alternatives considered prior to implementing a physical restraint. The deficient practice could have resulted in a decline in activities of daily living, loss of dignity, and physical and psychosocial harm to the resident. Findings include: Resident 168 (R168) R168 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, lack of coordination, major depressive disorder, anxiety disorder, chronic post-traumatic stress disorder, and a fracture of the base of the neck of the right femur. On 03/27/25 at 10:03 AM, R168 was observed sleeping in bed. The bed was in the lowest position with bilateral floor mats and full rails (two upper and two lower rails) raised. On 03/27/25 at 10:06 AM, a Certified Nursing Assistant (CNA) explained floor mats, bed rails, and lowering the bed were used for the safety of fall-risk residents. On 03/27/25 at 10:09 AM, a Licensed Practical Nurse (LPN) explained floor mats were placed beside beds to relieve pressure on staff's lower backs during care provision. The LPN also explained lower bed rails could be used for safety only if physician orders the rails and bed rail assessments were conducted but stated lower bed rails were typically considered restraints. The LPN confirmed R168 had both upper and lower rails raised and acknowledged the lower rails were physical restraints. The LPN was unable to recall how long the lower rails had been in place. R168's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/25 documented a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Under Section P0100, Physical Restraints Used in Bed was documented as Not used. Section GG0115, Functional Limitation in Range of Motion, documented no impairment of the upper extremities and impairment on both sides of the lower extremities. The Physician's Orders lacked documented evidence of orders for bilateral floor mats, upper side rails, lower side rails, or full side rails. The Comprehensive Care Plan, initiated on 11/23/24, documented R168 was at risk for falls due to cognitive impairment, functional impairments, muscle weakness, and unsteady gait. The interventions lacked documented evidence of the use of bilateral floor mats, upper bed rails, lower bed rails, or full bed rails. R168's medical record revealed The Side Rail and Entrapment Risk Assessment, completed on 05/04/2024, documented the resident was not dependent in bed mobility but had altered safety awareness due to cognitive decline and poor decision-making. The assessment identified periods of confusion and unsafe behaviors placing the resident at risk. The recommendations section lacked documented evidence of alternatives considered or trialed before implementing side rails. The use of both upper half-rails was recommended for independent bed mobility. The interventions section documented full/half rails up per physician's order for safety during care provision, to assist with bed mobility, and to observe for injury or entrapment related to side rail use. The clinical record lacked documented evidence of another Side Rail and Entrapment Risk Assessment completed after the resident's readmission on 11/23/24 to a different room. R168's medical record revealed a document titled Siderail Consent, which documented Full Rails on both sides to assist the resident in turning and positioning while in bed, transferring to and from bed, stabilizing while sitting on the side of the bed, and promoting safety while receiving care in bed. However, the document lacked the resident's name, signature, or the signature of a resident representative. A facility representative had signed and dated the document on 01/31/25. On 03/27/25 at 10:38 AM, an Assistant Director of Nursing (ADON) explained the facility did not have beds with full side rails. The ADON confirmed side rails used as enablers required a side rail assessment and bilateral fall mats and upper rails required a physician's order. The ADON verified R168's bed had bilateral fall mats and both full upper and full lower rails raised. The ADON acknowledged the lower rails were considered a restraint. The ADON was unaware of when the full rails had been installed. On 03/27/25 at 11:01 AM, the Regional Director of Clinical Services verified R168 had both upper and lower rails raised. The consultant explained whether lower rails could be used depended on the care plan, physician orders, assessments, and family requests. After reviewing R168's medical records, the Regional Director of Clinical Services confirmed there were no physician orders, care plan documentation, or family requests for the rails. The Regional Director of Clinical Services stated the lower bed rails were considered a restraint and should not have been in place. On 03/28/25 at 9:15 AM, the Director of Maintenance (DOM) explained the facility did not track when bed rails were installed because all beds had upper rails as enablers. The DOM stated unaware lower rails could not be installed until the survey team identified R168's bed. The DOM reported walking through the facility and finding three additional beds with lower rails. The DOM explained the maintenance team secured all lower rails in the lowered position with zip ties until proper removal could be arranged. On 03/28/25 at 3:09 PM, the ADON acknowledged no in-service training had been conducted on bed rail guidelines. The ADON explained full side rails should not have been used as restraints and stated the facility could not determine when the rails had been installed. The ADON indicated side rails could have contributed to R168's past falls and stated an investigation should have been conducted, but no documented evidence of such an investigation was found. On 03/28/25 at 3:25 PM, a Registered Nurse Unit Manager explained full bed rails could result in injuries, particularly if residents attempted to self-transfer and became trapped between rails. The nurse stated a root cause analysis should always be conducted and reviewed by a supervisor, but no such analysis was found for R168. The facility policy titled Physical Restraints, undated, documented a physical restraint as a physical or mechanical device, equipment, or material which meets all the following criteria: -is attached or adjacent to the resident's body; -cannot be removed easily by the resident; and -restricts the resident's freedom of movement or normal access to the resident's body. The restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of fall. When the use of the restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need of restraints will be documented. The restraint will only be used upon the written order of a physician and after obtaining consent from the resident or representative. The facility policy titled Fall Protocol, undated, documented an investigation of the fall will be conducted to identify reason, contributing factors and/or root cause of the fall. The staff would conduct a comprehensive investigation to understand the how and why the fall occurred, protect the resident involved and other potential residents, and implement change in the care of system to minimize recurrence.

Based on observation, interview and document review, the facility failed to ensure it stored, prepared, distributed, and served food in a sanitary manner as evidenced by an infestation of German cockroaches, poor kitchen sanitation and poor equipment and facility maintenance. The failure of the facility to maintain the kitchen in a clean and sanitary manner had the potential to impact 179 residents who received meals from the kitchen. Findings include: On 06/04/2021 at 10:15 AM, an Environmental Health Inspector (EHI) initiated a state licensure complaint investigation and conducted a walk-through inspection of the kitchen with the contracted Dietary Manager and Administrator. The following was observed by the EHI: An infestation of German cockroaches was observed throughout the kitchen. Live cockroaches were observed under the steam table, under equipment on the cook's line, covering tiles on the cook's line, in the ice machine, in the dishwash area and in the janitor's closet. Dead cockroaches were observed under the steam table, cook's line, prep tables, shelving in the dry storage, in a deli refrigerator, on top of the dishwasher, at the door of the walk-in freezer and under the sink of the 100 hall nourishment room. Food was not protected based on observation of cockroaches on prep tables, around prepared food, within refrigeration units and on equipment. There was spillage of food products on other food containers/shelving in dry storage. The following food contact surfaces and non-food contact surfaces of equipment were soiled with food debris and grease: inside of refrigeration units in the kitchen and nourishment rooms, external and internal components of the cook's line equipment, ventilation hoods, food storage bins, clean ware, on top of the dishwasher, transport carts, prep tables and the inside of cabinets in nourishment rooms. On 06/04/21 at 10:05 AM, during the EHI's kitchen inspection, the dietary manager indicated the kitchen was deep cleaned three times per week. There were no cleaning logs available for review. The Dietary Manager and Administrator acknowledged the violations throughout the kitchen as they were observed and pointed out by the EHI. The Dietary Manager indicated the presence of cockroaches in the kitchen had increased over the past couple of months. The Dietary Manager reported they have put in multiple complaints with Environmental Services (EVS) to address the pest problem. The Dietary Manager indicated they never see when the pest control service comes to the facility and had requested service reports from EVS, however had not received any copies of reports that pest service was being provided. The EVS Director reported pest service was provided multiple times per month. The EVS Director acknowledged the pest problem had worsened since the last kitchen inspection in March of 2021. The Dietary Manager, EVS Director and Administrator could not explain why the pest control problem and sanitation in the kitchen had fallen out of compliance. On 06/04/21 at 11:00 AM, a conference call was conducted with the bureau's Environmental Health Services (EHS) Supervisor, the EHI, Facility Administrator, Dietary Manager, Regional Director of Operations (Ops), Director of Nursing, Dietitian and EVS Director. The kitchen was ordered to cease operations on 06/04/2021 after dinner service until further notice. The facility was directed to provide a list of residents on special diets and create a plan of action to feed the residents, deep clean the kitchen and contract with a pest control company to eradicate the cockroaches. On 06/04/2021, Health Facility Investigators arrived at the facility at 1:00 PM to assist with the complaint investigations. Observations in the kitchen revealed numerous multigenerational cockroaches crawling across the floors, behind equipment on the cook's line, underneath the steam table, adjacent to most walls along the decrepit tile throughout the kitchen, on the walls, and in the dish room. Numerous dead cockroaches were observed on a prep counter, by the ice machine, at entrances to coolers/freezer, and in corners. The Administrator stepped on several live roaches during the inspection. Dried, loose, and liquefied food debris and/or spillage was observed in multiple open areas on the floors throughout the kitchen and storage areas. Dry storage racks were coated with cooking oils, food additives and supplement spillage which had transformed into grease and grime. Loose sugar was spilled over multiple bins and on the floor. The fiberglass reinforced plastic (FRP) was falling off the walls in the dish room. A large area of dry wall was missing from a lower corner behind the dish machine. Tiled areas displayed a multitude of cracks and crevices where caulking or grout was missing. Fifty residents were identified as requiring specialty diets (example: pureed, chopped, renal or calorie/carbohydrate-controlled diets). The remaining residents were receiving regular diets. On 06/04/2021 at 4:20 PM, the facility was notified an Immediate Jeopardy situation had been identified. A removal plan was provided by the facility at 6:00 PM on 06/04/2021 and included the following components: - A food service contractor would provide all meals for the residents requiring altered or specialty diets through 06/11/2021 or until the kitchen reopened. - A different health facility would provide breakfast for the regular meals through 06/11/2021. - Lunch and dinner for the regular meals would be provided from local restaurants on a day to day basis until the kitchen reopened. The Administrator, Regional Director of Operations for the facility's dietary service, Director of Nursing and Dietary Manager were instructed by the EHI that a temporary tray line must be set up in a sanitary area of the facility with hot holding and cold holding capabilities. Only disposable ware would be allowed to be used during the closure of the kitchen. The Administrator revealed the plan would be to set up the temporary food service in the dining room using disposable chaffing dishes, sternos for heat and a refrigerator from a nourishment room would be relocated to the dining room for cold holding. Insulated food transport containers would be used to transport food from the outside locations into the facility and would transport cold food product on ice. The EVS Director reported the Pest Control company, which had provided the routine service at the facility, was called to fumigate the kitchen the night of 06/04/2021. The Dining Service Agreement (the contract between the third-party kitchen service and the facility) documented the following: - Third Party Contractor Responsibilities include procuring, handling, inventorying, and storing food and related supplies on hand; cooking, staging and/or transporting meals; cleaning dishes and utensils used in the preparation of the food; and cleaning and sanitizing kitchen equipment at each facility. - The facility will be responsible for routine cleaning of grease traps and all food prep and service areas that are not readily and conveniently accessible, such as under and behind appliances and equipment. In addition, the facility shall be responsible for trash and garbage removal and extermination services. The Pest Control Service Contract documented the following: Section IV, Customer Responsibilities, maintain good sanitation practices. Kitchens should be kept neat and clean at all times. Section VII, Pest Audit Guidelines, there should be no tolerance for roaches in any indoor area of the facility. They may carry several pathogens that can cause health problems under certain circumstances. To determine response times and threshold levels, response to a pest problem MUST be both timely and effective. The facility must recognize that some pest problems are more serious than others. Roaches are a potential medical harm to the public, tenants, and staff because of the potential for food contamination. One working day is a recommended response. A cockroach in a cafeteria would require a very careful inspection to find out if other cockroaches were present, and probably some kind of pest management action. An action threshold is the point at which the risk of injury to individuals, the risk to public health, or the potential disruption of business activity demands that pest management measures be implemented. Review of pest control service invoices and deep cleaning invoices revealed the following documentation/entries: 03/09/2020: Mild German roach infestations in employee lounge and kitchen. 04/13/2020: Recommend deep cleaning, steam clean all carts, countertops, underneath countertops, mop floors, throw away empty boxes. 05/11/2020: German roaches in employee lounge and kitchen. 06/08/2020: German roaches in employee lounge and kitchen, mild infestation. 06/16/2020: German roaches, cracks/crevices in kitchen. 09/07/2020: German roaches, cracks/crevices in kitchen. 10/12/2020: Service kitchen. German roaches noted, moderate infestation. Kitchen needs a deep cleaning. Recommend fogging (fumigation). 11/09/2020: German roaches noted in kitchen. Kitchen needs to BE cleaned. 12/09/2020 and 12/11/2020: Deep clean of kitchen including walls, appliances, and floors (third party contractor). 01/11/2021: Mild German roach activity in kitchen. 02/08/2021: Moderate infestation of multigenerational German roaches in kitchen. Recommend fogging treatment (fumigation). 02/23/2021: Roach bait used in cracks and crevices in kitchen. 02/24/2021: Decreased number of German roaches. 02/26/2021: Moderate multigenerational German roaches. Kitchen dirty. 03/05/2021: Roach bait used in kitchen. Noticeable decrease in number of multigenerational German roaches. 03/08/2021: Roach bait used in kitchen. Mild to moderate infestation of German roaches present in kitchen. Follow up with crack and crevice treatment. 03/23/2021: Noticeable decrease in German roach numbers. Mild multigenerational infestation noted. 04/12/2021: Roach bait used around ice machine, employee lounge and kitchen. 05/10/2021: Kitchen area with multigenerational German roaches noted. Kitchen cleanliness and sanitation needs to be improved. Recommend clean out service for kitchen. 05/25/2021: Roach bait used in kitchen. 06/04/2021: Multigenerational German roaches in kitchen. Crack and crevice application. Recommend kitchen fogging (fumigation). Review of District Manager Unit Inspection Reports documented the following: 03/09/2020: Cleaning Schedule (Daily and Deep Clean) posted and adequate. Pest problem in dish room due to water leak. 04/29/2020: Cleaning Schedule (Daily and Deep Clean) posted and adequate. Roaches in dish room. 05/28/2020: Cleaning Schedule (Daily and Deep Clean) posted and adequate. Roach problem. 06/29/2020: Cleaning Schedule (Daily and Deep Clean) posted and adequate. Not currently posted. Have been revised and adjusted to needs. 08/30/2020: Cleaning Schedule (Daily and Deep Clean) posted and adequate. This is corrected and will be updated weekly. 09/25/2020: Cleaning Schedule (Daily and Deep Clean) posted and adequate. Not posted. Maintenance increased frequency of pest control. 10/31/2020: Cleaning Schedule (Daily and Deep Clean) posted and adequate. Not posted. Pests visible in kitchen and communal dining area. Increased pest control service. Insect seen in kitchen prep area. 11/23/2020: Cleaning Schedule (Daily and Deep Clean) posted and adequate. November not posted. Team using October schedule. Observed pest issue, discussed with Maintenance Manager (EVS Director). 12/23/2020: Cleaning Schedule (Daily and Deep Clean) posted and adequate. Being revised so not posted. Visible pests seen. Hired outside vendor for deep cleaning. Increased pest control frequency. 01/26/2021: Upgraded frequency of pest control service. 02/27/2021: Everyone is aware of pest issue and working to rectify issue. Increased pest control spray; changed food storage method. 03/30/2021: Pests found. 04/28/2021: Pest control still an issue. Facility is aware. Deep cleaning intensified and increased frequency of pest service. 05/27/2021: Water damage under dishwasher. The following Work Order Requests were submitted by the dietary aides: 03/30/2021: Roaches in ice machine and found frozen in an ice cube. 04/04/2021: Roaches in kitchen. 05/07/2021: Cracks/holes in the wall in dish-scraping area and wash/rinse area, manifesting cockroaches. The following Work Order Request was submitted by the facility's dietitian: 02/02/2021: Live cockroach found in resident food cart. Request pest control for the kitchen. The following Work Order Requests were submitted by the District Manager of the contracted kitchen provider: 01/08/2021: Ceilings/vents need to be cleaned. 01/08/2021: Need to schedule pest control. A lot of activity in kitchen. 04/04/2021: FRP is coming off the walls allowing pests to freely enter the kitchen. 05/07/2021: Clean the dust from around the vents throughout the kitchen. Daily Cleaning/Deep Cleaning Schedule highlighting various cleaning assignments were provided by the kitchen contractor's District Manager. The District Manager indicated the schedules were not utilized, dated, and initialed for the cleaning tasks highlighted for the period of March 2020 through June 2021. Food Service Contractor policies documented the following: 027 Equipment: All foodservice equipment will be clean, sanitary, and in proper working order. 028 Environment: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. - Procedure 1 The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. - Procedure 2 The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. - Procedure 3 All food contact surfaces will be cleaned and sanitized after each use. - Procedure 4 The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. 029 Pest Control: A program will be established for the control of insects and rodents for the dining services department. - Procedure 1 The Dining Services Director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed. - Procedure 2 All food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin. The center staff will be notified immediately of any concerns. Monthly reports from the Kitchen Manager documented the following: November 2020: Drains backing up. January 2021: Drains backing up. Pest control needed. April 2021: Cracks in tile behind equipment on cook's line; damaged wall in dish room; pest control schedule requested. The Administrator's kitchen audits documented the following information: 11/30/2020: Kitchen sanitation poor. 12/16/2020: Kitchen sanitation poor. 01/14/2021: Kitchen sanitation poor. 02/03/2021: Kitchen sanitation below average. 03/02/2021: Kitchen sanitation poor, considerable concerns. 04/13/2021: Kitchen sanitation below average, up and down. 05/14/2021: Kitchen sanitation poor, still seeing pests. 06/02/2021: Kitchen sanitation poor, still some major pest and sanitation concern. On 06/08/2021 at 1:00 PM, the Environmental Services Director indicated being responsible for Plant Operations, Maintenance, and Housekeeping. The Director indicated the facility was aware of the roach problem, but the kitchen did not cooperate and sent the pest control away when they came during meals. Cleaning and sanitation were an ongoing issue in the kitchen. The facility had extra cleaning and pest treatments done and routine monthly invoices were received from the facility on 06/09/2021. The Director advised the Kitchen Manager had an issue with the Director, so a technician was appointed to do walk-throughs which lasted a few weeks. The Director indicated the Kitchen Manager stopped doing the walk-throughs but did not indicate why there was no follow-up. On 06/09/2021 at 11:30 AM, the Environmental Services Director had no explanation for 1) why the dish room was allowed to get out of hand, 2) why the FRP was peeling off the wall, 3) the missing dry wall which was exposing hiding places for pests or 4) the uncaulked/ungrouted tile. The Director had involved the Administrator at one point because the Director felt the Kitchen personnel did not cooperate with sanitation practices. In the afternoon of 06/09/2021, the Director of Environmental Services supplied the pest control and cleaning invoices for January and April 2021, but there were no extra treatments or outside cleaning provided. On 06/14/2021, the Environmental Health Inspector received the December 9th and 11th invoice for deep cleaning. There were no additional fumigation or treatment invoices provided. On 06/09/2021 at 3:00 PM, the Administrator acknowledged awareness of the ongoing roach and sanitation issues in the kitchen but explained the facility had improved at one point a few months ago. The Administrator felt communication was an issue between the kitchen, the Director and administration. The Administrator verbalized responsibility and a failure to realize how quickly things had deteriorated in the last few months. On 06/04/2021 at 1:28 PM, a cook indicated the cockroaches in the kitchen had been present for a while but started getting very noticeable last month. The cook revealed reporting the issue to maintenance and the sous chef. The cook indicated being told pest control would come at night when staff left. The cook indicated little improvement had been made regarding the cockroaches. The cook verbalized the cockroaches would come up on food preparation tables and that was not good for sanitation. On 06/04/2021 at 1:35 PM, the dietary manager reported being employed by a contracted foodservice company and began working in the facility in September 2020. The dietary manager indicated the cockroaches were present in the kitchen at the time of hire. The dietary manager revealed discussing the presence of cockroaches consistently with the facility management and with management from the dietary manager's employer. The dietary manager reported being told pest control came once per month. The dietary manager indicated being so concerned regarding the cockroaches in the kitchen, the contracted food service company initiated a second pest control service in addition to the facility's pest control services. The additional pest control service was scheduled to begin on 06/07/2021. The dietary manager indicated the kitchen was not sanitary enough to serve out of. On 06/04/2021 at 1:28 PM, the Assistant Dietary Manager indicated the cockroaches were present in the kitchen since starting employment at the facility in March of 2021. The Assistant Account Manager indicated the kitchen staff had reported the cockroaches to the Dietary Manager and work orders were entered. The kitchen staff were to clean and sanitize the counter tops before and after use due to the cockroaches in the kitchen. The Assistant Dietary Manager expected the kitchen to be clean and in sanitary conditions free from pests. On 06/04/2021 at 1:35 PM, a Dietary Aide indicated there were cockroaches in the kitchen since starting in September 2020. The Dietary Aide explained the pest control company fumigated the kitchen for the cockroaches, however it was not effective as there were cockroaches in the kitchen afterwards. The cockroach problem did not improve after fumigation. On 06/04/2021 at 1:45 PM, a Dietary Aide indicated the cockroaches in the kitchen were reported to the Dietary Manager. The Dietary Aide indicated pest control sprayed the kitchen and there were more cockroaches afterwards, than prior to spraying. The Dietary Aide explained the cockroaches were inside the walls and crawling out from the cracks. The Dietary Aide indicated that the cockroaches would fall onto the food preparation tables while preparing sandwiches for the residents. The Dietary Aide explained the cockroaches were everywhere in the kitchen from the dry storage room, dish room, steam table area and inside the meal carts. The Dietary Aide indicated the kitchen staff would need to check the meal cart during tray line service to ensure there were no cockroaches inside before putting the food for the residents into the cart. 06/04/2021 at 1:55 PM, a Cook indicated there were cockroaches in the kitchen since early 2020. The Cook indicated cockroach infestation started to get increase in August of 2020 and the Dietary Manager was notified. Pest control did fumigate the kitchen a few times and the cockroach problem got worse after the fumigation in the kitchen. The cook indicated a cockroach crawled into the juice pitcher during tray line service and the staff had to dispose of the juice for the residents. The Cook indicated the kitchen was infested with cockroaches and expects the kitchen to be sanitary in order to serve food for the residents. On 06/04/2021 at 2:32 PM, the Environmental Services Director (EVS) and the Director of Operations for the contracted food service company indicated the facility had an outside company do the pest control services for the facility. The kitchen staff conducted the deep cleaning in the kitchen. The EVS Director explained the exterminator was at the facility a month ago and conducted the fumigation three times a week for three weeks during the night in the kitchen. On 06/04/2021 at 3:08 PM, the District Manager for the contracted food service company, the Dietary Manager, and the Registered Dietitian (RD) indicated there was a cleaning schedule for the kitchen. There was a weekly and bi-weekly cleaning schedule for the staff to follow. The kitchen management would coordinate with the maintenance staff to address kitchen issues during a daily morning walk through. The Dietary Manager and District Managed had brought up to EVS regarding the cockroaches in the kitchen.

Based on interview, record review, and document review, the facility did not ensure proper timely treatment of [REDACTED].#1), and did not follow the facility's falls policy for 2 of 8 sampled residents (Resident: #5 & #8). Findings include: Resident #1: On [DATE], the facility provided the document titled, "Policy for [MEDICAL CONDITION] Infection" (no date). The policy stated in part, "It is the policy of this facility to institute contact precautions for residents with known [MEDICAL CONDITION] infection, pseudomembranous [MEDICAL CONDITION], or antibiotic-associated [MEDICAL CONDITION] who are exhibiting diarrhea stools due to the infection in the following situations: When the resident is incontinent and soiling of the environment with stool is likely". Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE], the Licensed Practical Nurse that cared for Resident #1, documented the physician was "called about continuous bowel movements & changing of (the dressing to the coccyx) multiple times a day". Resident #1's physician ordered [MEDICATION NAME] 30 milliliters by mouth to be given twice per day. [MEDICATION NAME] was an anti-diarrheal medication. [MEDICATION NAME] Drug Facts information written by Chattem, the manufacturer of the medication, was reviewed on [DATE]. The drugs directions stated in part, "use until diarrhea stops but not more than 2 days". A "Weekly - Physical Therapy Progress Note", dated [DATE], stated in part, "declines gait and (illegible) training frequently (secondary) to various (complaints) rectum pain or fear of bowel movements". Resident #1's "Nurses Medication Notes" indicated that on [DATE], [MEDICATION NAME] (an antidiarrheal medication) was given twice for "loose stools". The resident also received [MEDICATION NAME] twice daily. The nurse noted the resident also refused his dietary supplement and stated "I think that's been causing my loose stools". On [DATE] at 8:50 AM, Resident #1 was medicated with [MEDICATION NAME] for loose stools. The resident also received [MEDICATION NAME] twice daily. On [DATE] at 4:00 PM, Resident #1 was medicated with [MEDICATION NAME] for loose stools. At 8:30 PM, the resident refused [MEDICATION NAME] and dietary supplement, and stated, "I'm not taking anything" until his physician addressed his "loose stools". The resident also received [MEDICATION NAME] twice daily. On [DATE], a "Weekly - Physical Therapy Progress Note", stated in part, (patient demonstrated "limited progress this report period (secondary to complaints of) frequent bowel movements". On [DATE] at 9:00 PM, the nurse documented in the Nurse's Notes, the resident "states he is not taking pills until he knows that they don't have diarrhea as a side effect, that [MEDICATION NAME] is not working and he wants his MD to address this".On [DATE] at 3:20 PM, the resident was medicated with [MEDICATION NAME] for loose stools, and that evening again refused [MEDICATION NAME] and dietary supplement. The resident also received [MEDICATION NAME] twice daily. On [DATE] at 7:45 AM, Resident #1 was medicated with [MEDICATION NAME] for loose stools. The resident also received [MEDICATION NAME] twice daily. On [DATE] at 8:30 AM and 4:30 PM, Resident #1 was medicated with [MEDICATION NAME] for loose stools. The resident also received [MEDICATION NAME] twice daily. On [DATE] at 9:30 AM, Resident #1 was medicated with [MEDICATION NAME] for loose stools. The resident also received [MEDICATION NAME] twice daily. On [DATE] at 4:00 PM, Resident #1 was medicated with [MEDICATION NAME] for loose stools. The resident also received [MEDICATION NAME] twice daily. On [DATE] at 10:00 PM, Resident #1 was medicated with [MEDICATION NAME] for loose stools. The resident also received [MEDICATION NAME] twice daily. On [DATE], Resident #1's physician ordered "stool for [DIAGNOSES REDACTED] X2" to be cultured.On [DATE], Resident #1's [DIAGNOSES REDACTED]icile results were received by the facility. The cultures were both positive. On [DATE] at 11:00 AM, Resident #1 was placed on contact isolation. The physician ordered the antibiotic [MEDICATION NAME] 250 milligrams to be given by mouth four times per day for two weeks. On [DATE] at 1:00 PM, Resident #1's nurse documented in the Nurse's Notes, "Stools X3 loose to soft in consistency (small)... strong foul odor". At 2:15 PM, the nurse documented, that she had contacted the physician to report loose stools and vomiting once by the resident. The resident was given an anti-nausea medication ([MEDICATION NAME]) and the physician ordered two liters of fluid to be given intravenously (IV). On [DATE] at 11:00 AM, Resident #1's physician discontinued the IV access and contact precautions. The resident was sent home with home health on [DATE] at 11:30 AM. An interview was conducted with the Director of Nursing (DON), on [DATE]. The DON indicated that a side effect of [MEDICATION NAME] could be constipation.A review of Resident #1's clinical record at an acute care facility indicated that after the resident was discharged from this facility he went home and experienced nausea and abdominal pain. The resident was taken by ambulance to the acute facility at 5:25 PM on [DATE]. On [DATE] at 6:15 PM, a computerized tomography scan of the abdomen indicated the resident had a fecal impaction. Resident #1's Admit emergency room Report, dated [DATE] at 7:32 PM, stated the [DIAGNOSES REDACTED]. Resident #1 was admitted to the acute facility. The resident expired on [DATE].Resident #5: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE], the policy "Fall Prevention Program", dated [DATE], was reviewed. The policy stated in part, "Interdisciplinary care plans will be established revised and/or reviewed each time a resident falls to ensure that all appropriate interventions to maintain a resident's safety have been included...The nurse on duty will notify the physician and family members at the time a resident falls". Resident #5's Plan of Care, dated [DATE], addressed falls. The "Problem" was identified: "(Resident #5) has a potential for falls or injury from falls due to confusion, severe cognitive deficits, very poor safety awareness, debility, advanced age, attempts to rise out of (wheelchair) unassisted, and [MEDICAL CONDITION] drug use". The Plan of Care listed reasonable interventions to achieve the goal of "(Resident #5) will have no falls or injury from falls daily throughout next review". The Plan of Care noted on [DATE], Resident #5 had "Fall (without) injury". No new interventions were listed. The Nurse's Notes documented Resident #5 fell on [DATE], this fall was not addressed in the Plan of Care, and no new interventions were added to prevent further falls. The Nurse's Notes documented Resident #5 fell on [DATE], this fall was not addressed in the Plan of Care, and no new interventions were added to prevent further falls. On [DATE], Resident #5's physician ordered "sensor pad @ all times in bed & (wheelchair)". This order was not noted as an intervention on the Plan of Care. On [DATE], Employee #1, the Director of Nursing indicated the Plan of Care should be updated after each fall. Resident #8: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8's Plan of Care was reviewed. The documentation indicated the resident was at risk for falls, and interventions were identified to meet the stated goal of "(Resident #8) will have no falls or injury from falls daily through next review. The Plan of Care indicated that the resident fell on [DATE]. The intervention "low bed (with) mats on both sides" was added as an intervention. The Plan of Care indicated Resident fell on [DATE]. The intervention "therapy as ordered" was added as an intervention. On [DATE] at 3:00 PM, the Nurse's Notes indicated that Resident #8 was found with the tab alarm and sensor pad alarming when the resident was attempting to get out of bed. The resident was assisted to the wheelchair. [DATE] at 3:15 PM, the resident was found in her wheelchair with her bedside table turned over. The resident was assisted to the POD area, where she stated she wanted to go to bed. The resident was assisted to bed. The note stated, "Tab alarm (and) sensor pad continued to ring (due to) resident attempting to get out of bed". On [DATE] at 4:10 PM, Resident #8 was found on the floor in her room by the door. Resident lying in a prone position favoring (R) side (with) (R) hand suppporting (R) side of face. Tab alarm (and) sensor pad alarming. Small (amount) of blood draining from resident's nose". The resident was put to bed with tab alarm and sensor in place and floor mats applied. The physician and family were notified of the fall via voicemail. On [DATE] at 4:45 PM, Resident #8 ate dinner and was put back to bed with the tab alarm and sensor in place. At 5:30 PM, a family member of her roomate notified the staff that the resident was on the floor. She was found on the floor, lying on her back, she was assessed as having knee pain. The physician was sent a message and her family was notified. At 8:00 PM, she was sent to the hospital for evaluation. The Plan of Care indicated there were three falls that occurred on [DATE]. "#1 fall - (no) injury... #2 fall - (with injury)... #3 fall (complains of ) pain (right) knee". No new interventions were added. Complaint #NV 653

Based on observation, interview, record review, and document review, the facility failed to 1) Ensure 1 resident with a high elopement risk was provided with protective supervision as needed (Resident #1); and 2) Provide a safe and reliably secured locked unit for residents in the Memory Care Unit (MCU). Findings include: 1) Resident #1 Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. -The facility submitted a self-report on 3/12/12 to the Bureau of Healthcare Quality and Compliance indicating Resident #1 eloped from the facility on the morning of 3/12/12 and stated, "This is initial notice that at 7:45 AM this morning we discovered that one of our residents was missing...The resident had been last seen at approximately 6:00 AM by two of the unit staff. Of note, the resident had been exit seeking at approximately 3:00 AM, but was redirected to his room without difficulty. The resident is housed on our memory care unit and had a history of [REDACTED]. The entire building was searched as well as the facility grounds. At this point the (police) were notified. At that time we discovered that the resident had disabled the sliding lock on his room window and kicked out the window screen. It is assumed that this is the method he used to leave the facility..." -The Psychiatric Consultation dated 12/5/11 indicated Resident #1 was admitted with a [DIAGNOSES REDACTED]. -The Nurse's Notes indicated the following: 3/8/12 at 2100 (9:00 PM): "Res (resident) has been exit seeking most of the day..." 3/12/12 at 0300 (3:00 AM): "Resident was noted by staff getting out of his room with some personal belongings in green bag carried by resident. Staff tried to re-direct resident but ignored staff just kept walking towards exit area by nurses station. Resident started pushing buttons on keypad. Staff followed resident and convinced resident that it's too early. Resident stated 'I need some money. I have to go to the bank.' Staff explained that banks don't open till 10 AM...Resident allowed staff to assist him back to his room...Noc (nocturnal) supervisor notified of resident's behavior. Will continue to monitor." 3/12/12 at 0620 (6:20 AM): "Walking rounds made et (and) all res accounted for in their rooms et (and) beds." 3/12/12 at 0745 (7:45 AM): CNA (Certified Nursing Assistant) went to check on res et he was not in his room or bathroom. There were 2 plastic bags of clothes on his bed under the blankets to look as if there was a person in the bed. Room to room search conducted et was not able to find res. RN (Registered Nurse) supervisor notified et code MR (Missing Resident) paged overhead. 3/12/12 at 2100 (9:00 PM): "Daughter (name) called at 2040 (8:40 PM) and informed me that resident had been found on CAT (Citizens Area Transportation) bus heading to (name of casino). Notified nursing supervisor who notified administrator...Per administrator we will take resident back but will conduct frequent checks of him." 3/12/12 at 2125 (9:25 PM): "(Name of daughter) called and stated she would not be taking resident to hospital but instead would bring him back here, as there didn't seem to be anything wrong with him. Notified nursing supervisor who emphasized that CNA's should make frequent checks." 3/13/12 at 2210 (10:10 PM): "Resident was brought back by daughter. Resident in good spirits, smiling, laughing when resident saw staff members...1:1 initiated for resident's safety." The Plan of Care for Resident #1 indicated, 11/22/11, 2/12/12: "Problems/Strengths: Episodes of wandering, as shown by, wandering throughout the memory care unit. Interventions: Engage patient with a calm, patient demeanor. Attempt to redirect patient as needed. Encourage activities of interest. Encourage family and friends to visit as soon as possible. Assess patient's needs, physical or emotional." There were 2 additional handwritten notes which stated, "3/8: Exit seeking most of the day. 3/12: Exit seeking." However, there were no additional interventions with increased supervision following more severe and increased exit-seeking behaviors identified on 3/8/12 and 3/12/12. -On 3/13/12, the following interviews were conducted: Administrator (Employee #1): On 3/13/12 at approximately 8:30 AM, an interview was conducted with the Administrator regarding Resident #1, who stated as follows: "-The resident went missing at approximately 6:00 AM on 3/12/12. -He had been on the locked unit. He has exhibited wandering behaviors before, last Thursday and last Sunday. -On Monday (3/12/12) he was found very early in the morning loitering near the door in the locked unit. He asked staff if it was time to go to the bank. -The resident put clothing in bags under his bed sheets, disabled the slider on his window, opened the window, kicked out the screen, and eloped. -He was found on the bus headed to a casino close to where his daughter lives. -I was here at the facility when he returned at approximately 9:00 PM. -I told staff I wanted him on 1:1 supervision. -1:1 supervision meant 1 staff member who was just delegated to watch him at all times. -Yes, we did put him right back in the same room that he eloped from. The window was still disabled and the screen was still on the ground outside the window because I did not want to move any evidence." On 3/13/12 at approximately 9:15 AM, interviews were conducted with staff members who worked the day shift on the MCU as follows: Employee #5: Employee #5 (Day Shift CNA) indicated the following regarding Resident #1: "-The reason we keep the door to (Resident #1's) room closed is because he likes to sleep with no clothes on. -He always shuts his door. He did not want to be bothered. -This morning I got here at 6:00 and got report by Employee #3, who was telling us she was watching him. -No I did not document 1 on 1 checks or 15 minute checks because we are so busy. This morning when I got here after 6:00 I was going to check on him right away but there was another resident who was holding up her soiled diaper so I had to take care of her. I did not see him because I went right to the other lady. -We only have 2 of us to get all the residents up out of bed and to the dining room for breakfast. There are some residents on this unit that need 2 of us to transfer. We just did not have enough time to do the 15 minute checks for (Resident #1)." Employee #6: Employee #6 (Day Shift CNA) indicated Resident #1 was trying to elope 2 days before the incident. Employee #6 further indicated the following occurred on the early morning of 3/12/12 prior to Resident #1's elopement episode: -"Employee #3 said (Resident #1) was trying to escape around 3:00 to go to the bank but then he wanted to go back to bed. -He always sleeps with his door closed because he likes to sleep in the nude. He does not like us to bother him in the morning. -I saw a shape in the bed when I put clean towels in his bathroom at about 6:15 or so. I assumed he was there. -I usually do not wake him up until 7:30. -At 7:30 I pulled the covers up and I saw only the clothes." Employee #6 stated (regarding the nocturnal shift after the resident's return to the facility), "(Name of Employee #3) was the night nurse. They said they were doing 15 minute checks on him on the night shift, but this morning there was nobody who was watching him and checking him every 15 minutes. This morning after 6:00 I looked into the room and saw him in bed. The next time I saw him was when I went in and got him up and ready for breakfast at about 7:30 AM." Employee #3: Employee #3 (Nocturnal shift CNA) indicated the following via telephone interview on 3/13/12 at approximately 11:30 AM regarding Resident #1: The CNA indicated the following occurred on the early morning of 3/12/12: "-At 3:00 AM he woke up. He went straight to the exit door going to the dining room. -The other CNA took him back to his room. He (Resident #1) wanted to go to the bank but the other nurse told him the bank opened at 6:00. (Resident #1) went back to bed and closed the door. -He always sleeps in the nude, so we always keep his door closed. -At about 5:40 he was there. I did not see his head, but I think I saw him move. -When the 2 CNA's came on shift in the morning I told them to watch him. The CNA indicated Resident #1 returned to the facility late on the evening of 3/12/12, and was put back into the same room that he had eloped from. The CNA verified the window lock was not repaired, and the screen was still outside on the ground where Resident #1 had kicked it out earlier that morning. The CNA stated as follows: "-He was very excited when he got back to the facility on [DATE] in the evening. -He went to bed about 11:00 PM. He wanted to close his door but we said to keep it open a little bit. -We tried to check on him every 15 minutes or so. He was snoring. There was not a staff member available to do 1 on 1 supervision for him." 2) On 3/13/12 on the 400 Unit, there was a potential for residents to leave the memory care unit without triggering an audible alarm and electronic alarm through the following areas: -The door leading from the 400 Unit to the Nurse's Station had a visible typewritten code on the upper right hand corner. The Administrator verified this was the code to be entered to access the Nurse's Station. -There was a second door leading from the Nurse's Station to the 500 Unit, which was vacant. There was no audible alarm which sounded when the door leading from the Nurse's Station to the 500 Unit was opened. Upon walking through the unit, there were 2 containers of industrial cleaners and 1 sharp grouting tool located in the hallway. -On 3/13/12 beginning at approximately 9:15 AM, the door leading from the 400 Unit Dining Room to the Courtyard was tested several times. Upon standing directly in front of the door with a test Accutech wristband worn by the Director of Maintenance (Employee #9), there was an approximate 3 1/2 minute delay to trigger the audible and the computer alarm located in the Nurse's Station. The Director of Maintenance verified the door leading from the Dining Room to the Courtyard had been reset to a 3 minute delay because so many of the residents would walk by the door. Following the second test of the Accutech wristband, the computer in the Nurse's Station "froze" and was not operational for approximately 12 minutes, until after rebooting. Upon questioning how often the computer "freezes", a Lead CNA indicated it happens every couple of weeks or so. The Director of Maintenance indicated he was only aware that the computer froze once within the last month, and stated, "If it happens every 2 weeks they did not report it to me". Upon asking whether he was aware of how the system worked and what the system's specific operations were, the Director of Maintenance pointed to a binder on the Nurse's Station and stated, "I looked it over but I don't know how it works exactly, like how much time it takes to set off and stuff." After exiting from the 400 Unit Dining Room into the Courtyard, the door slightly overlapped the adjacent door frame, and did not close completely, latch, and re-lock. (It was necessary for a staff member to physically pull the door close with significant force in order for the door to latch and re-lock.) The Alarm Journal provided by the facility for the period of 3/11/12 through 3/13/12 indicated Resident #1 triggered a Loiter Alarm on 3/11/12 at 12:19 (12:19 PM), 13:49 (1:49 PM), 15:48 (3:48 PM), and 17:41 (5:41 PM). The Alarm Journal did not indicate Resident #1 triggered a loiter alarm by one of the exits around the time period of 3:00 AM on 3/12/12, as indicated by staff interview and nurse's notes. The facility's Policies and Procedures indicated the following: Subject: Watcher Program, Policy # MCU013, effective date 4/1/10: "Purpose: To ensure that all residents on the Memory Care Unit are kept safe and secure. Policy: A Watcher Program will be instituted on the 500 Hall of MCU (Memory Care Unit) during the day and evening shifts. Guidelines: 1. At the beginning of the day and evening shifts the charge nurse will assign a CNA 'watcher'. 2. The designated CNA watcher's sole responsibility will be to observe the 500 Hall residents with the purpose of preventing resident to resident altercations, falls and other unsafe behaviors. 3. The CNA watcher will not be assigned any nursing care duties (e.g. (such as) bathing)." On 3/13/12 in the afternoon, the ADON (Assistant Director of Nursing) and the Administrator provided staffing schedules and verified the normal staffing available for each shift in the MCU included 1 LPN (licensed practical nurse) and 2 CNA's, and there was no staff member assigned as a "watcher" available in the MCU. The facility failed to maintain adequate supervision and staffing for 1 resident prior to 1 resident's elopement. The facility failed to maintain adequate supervision, staffing, and environmental protective measures for 1 resident after his return to the facility. The facility failed to maintain a safe and secure environment for residents with high risk of elopement. The facility failed to adhere to its policy of having a "watcher" staff available. Complaint #NV 062