Every finding on record at Torrey Pines Post Acute and Rehabilitation

Based on interview, record review and document review the facility failed to ensure a resident was informed in advance of the risks and benefits of psychotropic medications and ensure informed consent was obtained prior to administration of psychotropic medications for 1 of 43 sampled resident (Resident 136). The deficient practice potentially deprived the resident of the right to be informed of the medications' risks, benefits and potential side effects.Findings include:Resident 136 (R136) was admitted on [DATE] with diagnoses including unspecified mood affective disorder, unspecified dementia with agitation, anxiety disorder, violent behavior, and homicidal ideations. R136's medical record documented R136 as self-responsible. The admission Minimum Data Set (MDS) initiated on 07/08/2026 documented R136's brief interview for mental status (BIMS) score was 12 indicating R136 had moderate cognitive impairment. R136's Physician Orders for Life Sustaining Treatment (POLST) signed by the physician on 07/08/2026 documented R136 had decisional capacity. Physician orders dated 07/07/2026 documented the following:-Haloperidol 5 milligrams (MG) every four hours as needed for mood disorder manifested by agitation for 14 days.-Lorazepam 2 MG every 4 hours as needed for severe anxiety manifested by restlessness for 14 Days.-Quetiapine Fumarate 25 MG two times a day for mood disorder manifested by aggressive behavior.R136's Medication Administration Record for 07/2026 documented the following:-Haloperidol 5mg was administered on 07/07/2026-Lorazepam 2mg was administered on 07/07/2026 and 07/08/2026-Quetiapine Fumarate 25 MG was administered on 07/07/2026 through 07/09/2026R136's psychotropic consents dated 07/04/2026 documented ok to administer psychotropics per two Doctors.R136's medical record lacked documentation R136 was informed in advance of the risks and benefits of the medication, the treatment alternatives or other options and was able to choose the option R136 preferred. On 07/09/2026 at 8:16 AM, the Director of Nursing (DON) confirmed R136's BIMS score indicated R136 was capable of making decisions. On 07/09/2026 at 9:58 AM, the DON explained the expectation for residents receiving psychotropics was for the nurse to explain risk and benefits of medications to the resident or their responsible party and obtain consent prior to medications being administered. The DON confirmed staff did not document risks and benefits were explained and a consent was obtained prior to psychotropic medication administration for R136. The facility policy titled Psychotropic Drug Treatment, revised 12/2016, documented the resident or representative would be given information regarding the need for, the desired effects and potential side effects of the medication to enable the resident/representative to make an informed decision regarding the use of any psychoactive medications.

Based on interview, record review, and document review, the facility failed to ensure the physician was notified of a resident's change of condition for 1 of 43 sampled residents (Resident 114). The deficient practice had to the potential to delay treatment and contribute to the resident's decline.Findings include:Resident 114, (R114) was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation and acute and chronic respiratory failure with hypoxia. R114s last recorded blood pressures were documented as follows:On 06/18/2026 at 4:43 AM, 128/80On 06/18/2026 at 7:53 AM, 115/72On 06/18/2026 at 6:57 PM, 98/63On 07/09/2026 at 2:33 PM, the Director of Nursing (DON) explained Certified Nursing Assistants (CNAs) are instructed to report blood pressures that were not within the normal range of 120/80. The DON clarified the purpose of reporting abnormal blood pressure readings was to ensure the resident was not experiencing a decline in condition and to allow the nurse to complete an assessment and recheck the resident's blood pressure. The DON further explained the nurse would document any change in condition, including the resident was assessed and the blood pressure was retaken, and would notify the physician and the resident's power of attorney (POA) regarding the change in the condition. The DON confirmed no change in condition assessment was completed for Resident R114. The DON verified the physician was not notified, and there was no documented evidence in the medical record indicating the resident's blood pressure was rechecked. A review of the medical record revealed no evidence a change in condition assessment was completed, a nursing progress note, nursing assessment, or documentation indicating notification to the physician or Power of Attorney regarding the R114's decline in blood pressure. The weights and vitals section of the medical record lacked documented evidence of a retake of R114s blood pressure.On 07/09/2026 at 3:05 PM, a Licensed Practical Nurse (LPN) indicated when a resident's systolic blood pressure was below 100, the CNA was required to report the change to the nurse. The LPN clarified the nurse was responsible for assessing the resident, documenting the change in condition, completing a nursing assessment, notifying the physician and Power of Attorney, and retaking the resident's blood pressure. The LPN acknowledged a blood pressure reading of 98/63 was concerning and should have prompted the completion of a change in condition assessment, a nursing assessment, and notification to the physician for further instruction.On 07/09/2026 at 3:09 PM, a CNA indicated when obtaining blood pressure readings, any abnormal result must be reported to the nurse for further evaluation. The CNA clarified that any blood pressure reading below 100 indicated a potential change or decline in the resident's health status and must be reported and retaken to ensure accuracy. The CNA acknowledge a blood pressure reading of 98/63 should have been reported to the nurse. On 07/09/2026 at 3:12 PM, another CNA indicated CNAs were trained to monitor high or low blood pressure readings and to report any abnormal values that fall outside a resident's normal baseline range. The CNA clarified any systolic blood pressure below 110 or diastolic below 60 was required to be reported to the nurse for further evaluation. The CNA acknowledged that a blood pressure reading of 98/63 should have been reported. The facility policy Change in a Resident's Condition or Status, revised May 2017 required the nurse notify the resident's physician when a significant change in the resident's physical condition occurred. The policy directed the nurse to document information related to any change in the resident's medical condition or status in the resident's medical record.The facility policy dated October 2016, titled Blood Pressure, Measuring, revised October 2016 defined hypotension as a blood pressure reading below 100/60. In cases of hypotension, staff were required to notify the physician, and several blood pressure readings must be recorded throughout the day, including measurements taken before and after meals.

Based on interview and document review the facility failed to complete and electronically transmit Minimum Data Set (MDS-an assessment used to evaluate resident health, guide care planning, and determine reimbursement) data to Centers for Medicare and Medicaid Services (CMS) within the required timeframe. The deficient practice had the potential to delay accurate care planning, monitoring, and reimbursement for resident care. Findings include:A report submitted by the State MDS Coordinator documented the facility was non-compliant with timely completion and/or transmission of MDS assessments for 10/2025 and 11/2025 with a non-compliance rate of greater than 10 percent (%). On 07/09/2026 at 12:58 PM, the Director of Nursing (DON) explained the MDS completion was a collaborative process from various departments and transmission of the MDS data was the responsibility of the MDS Coordinator. On 07/09/2026 at 1:12 PM, the DON explained they had reviewed the MDS submissions and verified the facility had multiple late transmissions which occurred in 10/2025 and 11/2025. The DON explained other departments were responsible for entering information on the MDS and were not completing their perspective sections in a timely manner. On 07/09/2026 at 1:35 PM, the DON provided the facility CMS final validation reports for 10/2025 and 11/2025 which documented the following:-10/2025 the facility had 46 total transmissions with 20 late transmissions (43.48%).-11/2025 the facility had 66 total transmissions with 21 late transmissions (31.8%).The DON acknowledged the late transmissions for both 10/2025 and 11/2025. The facility policy titled MDS Completion and Submission Timeframes, revised 07/2017, documented the assessment coordinator or designee was responsible for ensuring resident assessments were submitted to CMS Internet Quality Improvement and Evaluation System (iQIES) portal system in accordance with current federal and state guidelines. Timeframes for completion and submission of assessments were based on the current requirements published in the Resident Assessment Instrument (RAI) Manual.The CMS RAI Version 3.0 Manual documented care plan completion and transmission was no later than 14 calendar days from the assessment reference date.

Based on interview, record review, and document review, the facility failed to ensure a physician discharge summary was completed within 30 days of discharge for 1 of 43 sampled residents (Resident 115). The deficient practice had the potential to result in incomplete documentation regarding the resident's condition, care, treatment at discharge, and affect continuity of care. Findings include:Resident 115 (R115) was admitted [DATE], with diagnosis including other cerebral infarction due to occlusion or stenosis of small artery, type 2 diabetes mellitus with hyperglycemia, diabetic neuropathy and acute respiratory failure with hypoxia. A Social Services Progress Note dated 06/03/2026, documented R115 planned to leave against medical advice (AMA).A Leaving Against Medical Advice form dated 06/03/2026 signed by R115 documented R115 left the facility.R115's medical record documented R115 was discharged from the facility on 06/03/2026. R115's medical record lacked documented evidence a physician discharge summary was completed. On 07/09/2026 at 8:39 AM, the Director of Nursing (DON), explained R115 chose to leave the facility against medical advice despite receiving education. The DON confirmed R115's medical record lacked a physician discharge summary and acknowledged a physician discharge summary should have been completed within 30 days of R115's discharge to ensure continuity of care if the resident returned to the facility. On 07/09/2026 at 10:07 AM, the Medical Records Director, reported R115's medical record lacked a physician discharge summary. The Medical Records Director explained the physician was noncompliant with completion of discharge summaries, the concern was addressed during the Quality Assurance and Performance Improvement (QAPI) meeting and all of the physician's residents were transferred to another physician. The Medical Records Director explained the physician discharge summary should have been completed within 30 days of R115's discharge from the facility. A facility policy titled Physician Discharge summary dated [DATE], documented the attending provider must complete the discharge summary within 30 days of the resident's discharge.

Based on observation, interview, record review, and document review the facility failed to ensure it was free of a medication error rate of less than five percent (%) for 2 of 43 sampled residents (Resident 87 and 62). The deficient practice posed a potential risk of injury or harm to the residents.Findings include: On 07/08/2026 in the morning, a medication administration pass observation was performed with 39 opportunities observed with two errors. The medication error rate was 5.13%.1) R87 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type two diabetes mellitus with diabetic chronic kidney disease, and chronic congestive heart failure.On 07/08/2026 at 7:49AM, during the medication administration pass observation a Registered Nurse (RN) prepared and administered R87's scheduled morning medications.A Physician order dated 05/28/2026 documented Ascorbic Acid 250 milligrams (mg) one tablet by mouth one time a day for supplement.The RN administered Ascorbic Acid 500mg one tablet to R87.On 07/08/2026 at 8:41 AM, the RN confirmed R87's physician order for Ascorbic Acid was 250mg daily and acknowledged the incorrect dosage of Ascorbic Acid 500mg was administered. The RN explained the physician order should have been followed. 2) R62 was admitted on [DATE] with diagnoses including idiopathic peripheral autonomic neuropathy, fibromyalgia, and hydronephrosis.On 07/08/2026 at 8:02AM, during the medication administration pass observation a Registered Nurse (RN) prepared and administered R62's scheduled morning medications.A Physician order dated 07/06/2026 documented Calcium 500mg with Vitamin D3 one tablet by mouth one time a day for supplement.The RN administered Calcium 600mg with Vitamin D3 one tablet to R62.On 07/08/2026 at 8:40 AM, the RN confirmed the physician order for R62 was Calcium 500mg with Vitamin D3 and acknowledged the wrong dosage of Calcium 600mg with Vitamin D3 was administered. The RN explained the physician order should have been followed. On 07/09/2026 at 7:33 AM, the Director of Nursing explained the expectation during medication administration was for nurses to follow the five rights of medication administration which included the following: right resident, right medication-check the medication to the physician order, ensure right route, right dose and right time. The facility policy titled Administering Medications, revised 04/2019, documented medications were administered in accordance with prescriber orders. The individual administering the medication would check the label to verify the right dosage before giving the medication.

Based on observation, interview and document review the facility failed to:- Prevent employee personal beverage items from being stored in the tray line refrigerator and in the South Hall resident nourishment refrigerator.- Ensure a thermometer was present in the kitchen's reach in freezer.- Maintain required cold holding temperatures at or below 41 F (5 C) for the nourishment room refrigerators in the South and Northwest halls. This deficient practice had the potential to risk for cross contamination, promote bacterial growth, increasing the risk of foodborne illness and compromising resident health and safety. Findings include: On 07/07/2026 at 7:43 AM, an inspection of the tray line refrigerator revealed an employee's stainless steel tumbler stored inside on the second shelf. On 07/07/2026 at 7:52 AM, an inspection of the kitchen's reach in freezer revealed no thermometer present to determine the internal temperature of the unit. A review of the freezer and cooler temperature log indicated the reach in freezer was documented as checked, with a recorded temperature of -2 F. However, at the time of inspection, no thermometer was present in the reach in freezer to verify the accuracy of the logged measurement.On 07/07/2026 at 8:00 AM, an inspection of the south hall nourishment room resident refrigerator revealed a temperature measured 50 F, which exceeded safe storage guidelines for potentially hazardous foods and stored an employee's [NAME] sparkling energy drink. On 07/07/2026 at 8:10 AM, an inspection of the Northwest Hall nourishment room resident refrigerator revealed a temperature measured 50 F, which exceeded safe storage guidelines for potentially hazardous foods. On 07/07/2026 at 7:44 AM, the Dietary Manager confirmed employee beverages were not permitted in the tray line refrigerator at any time and must be stored in the employee breakroom. The Kitchen Manager acknowledged an employee drink had been stored in the tray line refrigerator and confirmed this practice was not in accordance with facility policy.On 07/07/2026 at 7:45 AM, the dietary aide indicated employee food and beverages were not permitted in the tray line refrigerator and acknowledged storing the stainless steel tumbler in the refrigerator was not allowed. The dietary aide confirmed the stainless steel tumbler should have been stored in the employee breakroom or in the manager's office in accordance with facility policy.On 07/07/2026 at 7:52 AM, the Dietary Manager acknowledged there were no thermometer present in the reach in freezer and verified the facility's freezer and cooler temperature log documented the reach in freezer as checked, with a recorded temperature of -2 F. The Dietary Manager confirmed without a thermometer there was no way to accurately measure the freezer's temperature. The Dietary Manager verbalized kitchen personnel were responsible for checking daily to ensure required equipment was in place to assure proper food temperatures can be obtained in accordance with facility procedures. On 07/07/2026 at 8:01 AM, the Dietary Manager acknowledged a sparkling energy drink was stored in the south hall's resident nourishment refrigerator. The Dietary Manager confirmed employee beverages were not permitted to be stored in the resident nourishment refrigerator and should instead be kept in the employee breakroom in accordance with facility policy.On 07/07/2026 at 8:05 AM, the medical records staff member acknowledged a sparkling energy drink was stored in the resident nourishment refrigerator. The medical records staff member verbalized that employee food and beverages should be stored in the employee breakroom in accordance with facility policy.On 07/07/2026 at 8:10 AM, the Dietary Manager acknowledged the Northwest Hall nourishment room resident refrigerator was not maintaining the proper temperature and verified the thermostat was reading 50 F. The Dietary Manager indicated kitchen personnel were responsible for checking resident refrigerators daily to ensure proper temperatures were maintained to prevent bacterial growth.On 07/07/2026 at 8:15 AM, the Dietary Manager acknowledged the South Hall nourishment room resident refrigerator was not maintaining the proper temperature and verified the thermostat was reading 50 F. The Dietary Manager confirmed that dietary staff were responsible for checking the refrigerator temperature daily to ensure it maintains a proper temperature for the safe storage of resident food and beverages.The facility policy titled Employee Food Storage revised October 2020, documented approved storage locations for employee food and beverages included the employee breakroom refrigerator and employee lockers. The policy documented that employees were not permitted to store food or drinks in resident refrigerators or in kitchen food storage areas.The facility policy titled Food Receiving and Storage revised October 2017 documented that refrigerated foods must be stored below 41 F. The policy documented the functioning of refrigeration units and the temperatures of stored foods will be monitored throughout the day by the Food and Nutrition Services Manager or designee.

Based on interviews, record review and document review, the facility failed to ensure residents were free from physical abuse for four sampled residents (Residents 1, 4, 5 and 10). The deficient practice placed other residents at risk of being physically abused.Findings include:Incident #1 - Residents 2 and 10Resident 10 (R10) was admitted on [DATE], with diagnoses including fibromyalgia and unspecified intracranial injury.A nurse progress note dated 11/27/2025, revealed R10 called law enforcement after getting punched in the face by R2 in the smoking area. Law enforcement arrived and spoke with both residents. The physician assistant and social services director (SSD) was made aware. The SSD was to inform Administrator.A change of condition evaluation form dated 11/27/2025, revealed R10 reported being slapped and cursed at by R2 in the smoking area. R2 had attempted to strike R10's face with a lit cigarette. Redness was noted on R10's left mandible area. An X-ray was ordered which was negative for injury.Resident 2 (R2) was admitted on [DATE] and readmitted [DATE], with diagnoses including schizophrenia and paranoid personality disorder.A nurse's progress note dated 11/27/2025, revealed R2 was in a physical altercation with R10 in the smoking area. When the writer approached R2 in the smoking area, R2 explained R10 was being annoying and deserved it. Law enforcement arrived at facility due to R10 pressing charges against R2 for battery.Incident #2 - Residents 1 and 2Resident 1 (R1) was admitted on [DATE], with diagnoses including unspecified psychosis due to a substance or unknown physiological condition, schizophrenia, and major depressive disorder.A change of condition evaluation form dated 12/19/2025, revealed R1 was found on floor with a bleeding nose, a skin tear to left forearm, and redness of left forehead. R2 started pushing and kicking R1 because R1 entered R2's room.The admission minimum data set (MDS) dated [DATE], revealed R1 had moderately impaired cognition and did not have aggressive or wandering behaviors.Resident 2 (R2) was admitted on [DATE] and readmitted [DATE], with diagnoses including schizophrenia and paranoid personality disorder.The admission minimum data set (MDS) dated [DATE], revealed R2 had intact cognition and no aggressive behaviors.A nurse's progress note dated 12/18/2025, documented a certified nursing assistant (CNA) informed the nurse R2 had a behavioral outburst and became upset when R1 entered the room. R2 reported to staff pushing R1 to the floor and kicking R1 on right lateral side. The physician was notified and ordered the nurse to send R2 to the hospital for psychiatric evaluation.A physician Discharge summary dated [DATE], revealed R2 had a significant history of schizophrenia, anxiety disorder, and homicidal ideation and was recently admitted to a psychiatric hospital for chasing a person with a knife and threatening police.Incident #3 - Residents 5 and 6Resident 6 (R6) was admitted on [DATE], with diagnoses including peripheral vascular disease, heart failure and neuropathy.An admission MDS dated [DATE], documented R6 had moderately impaired cognition.A nurse's progress note dated 03/12/2026, revealed R6 reported being punched by roommate (R5) the night before. The progress indicated noted mild elevation on forehead. R6 indicated not doing anything to R5 and did not understand why the resident hit them.A skin/wound note dated 03/12/2026, revealed the wound care team performed a head-to-toe assessment after the reported altercation and a slight swelling to mid forehead was noted.Incident #4 - Residents 4 and 5Resident 4 (R4) was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, heart failure and schizoaffective disorder.A nurse's progress note dated 03/12/2026, revealed R4 was punched by roommate (R5) very early in the morning. The nurse assessed R4 who was observed with discoloration around left eye socket with sensitivity.A skin/wound note dated 03/12/2026, revealed R4 had a head-to-toe assessment by wound team who identified a nose bridge abrasion and skin tear to left forehead.Resident 5 (R5) was admitted on [DATE] and readmitted on [DATE], with diagnoses including neuroleptic induced Parkinsonism, schizoaffective bipolar type and psychosis.A nurse's progress note dated 03/12/2026, revealed R5 was noted to be screaming violently inside the room. A CNA reported to the nurse R5 hit their roommate (R4). The note indicated R5 was hostile and physically aggressive. R4 was assisted to vacate the room and the nurse asked R5 to calm down.A social services note dated 03/12/2026, revealed the Social Services Director (SSD) attempted to speak with R5 regarding altercation with R4. The resident became agitated, started screaming and yelling and used inappropriate language toward staff. Due to the R5's behavior, the SSD could not obtain further information at this time.A nurse's progress note dated 03/12/2026, indicated R5 was showing hostile and aggressive behavior towards residents and staff, non-redirectable. The physician ordered to transfer R5 to hospital under a legal hold (an emergency involuntary hold for individuals undergoing mental health crisis). A physician Discharge summary dated [DATE], revealed R5 was transferred to this facility from a psychiatric hospital where R5 was evaluated for exacerbation of schizophrenia symptoms. R5 had been noncompliant with psychotropic medications.On 04/22/2026 at 11:39 AM, the Director of Nursing (DON) confirmed the incidents involving R1, R4, R6 and R10 met the facility's definition of willful infliction of injury. The DON indicated aggressors R2 and R5 both had intact cognition and a history of inpatient psychiatric stays - R2 due to homicidal ideations and R5 for exacerbation of schizophrenic symptoms. Injury was evident when R1 sustained a bleeding nose, skin tear to left forearm, and redness of left forehead; R4 sustained discoloration around left eye socket; R6 sustained mid forehead swelling and R10 sustained redness to mandible area. The DON indicated R2 and R5 both acted with intent.On 04/22/2026 at 11:44 AM, the SSD corroborated with the DON and indicated R2 and R5's actions were classified as abuse.On 04/22/2026 at 11:45 AM, the DSD confirmed the abuse incidents where R1, R4, R6 and R10 were harmed by R2 and R5 were all purposeful acts which caused harm and therefore considered physical abuse.On 04/23/2026 at 10:40 AM, the DSD indicated the facility had a high behavior population and the facility assessment took this into consideration specifying there was an average of 45 behavior residents at this time and the facility had increased staffing and tried to decrease admission of behavior residents.On 04/23/2026 at 10:42 AM, the Assistant Administrator there was currently a pattern with regards to resident altercations particularly physical abuse, and the inter-disciplinary team (IDT) had identified the root cause to be a lack of support from the psychiatric provider particularly the nurse practitioner (NP) who rounded in the facility and the medical director.On 04/23/2026 at 10:45 AM, the Assistant Administrator indicated being dissatisfied with the psychiatric NP who did not conduct thorough evaluations, made infrequent and delayed visits to the facility. The Assistant Administrator indicated communicating this pattern of abuse with the medical director in hopes of receiving support specifically to screen admission to ensure the level of behavioral care could be met by the facility, but the medical director did not address this request.On 04/23/2026 at 10:47 AM, the DON indicated R2 and R5 were both inpatient psychiatric patients who were both refusing to take psychotropic medications. This was reported to both psychiatry provider and the medical director. The medical director did not give much support, for example the physician did not allow administration of intramuscular (IM) psychotropics to control aggressive or crisis events. The Assistant Administrator, the DSD and DON indicated R2, R5 and residents like them should contract into a behavioral agreement wherein if they were medically noncompliant with care plan and medications this could lead to involuntary discharge for the safety of the other residents who resided at the facility.On 04/23/2026 at 2:40 PM, the Director of Staff Development (DSD) clarified the altercation between R5 and R6 occurred on 03/11/2026 at approximately 9:00 PM. After this incident R6 was removed from the room to separate both parties and R4 moved in as R5's new roommate. An altercation between R5 and R4 occurred on 03/12/2026 at 4:00 AM. R5 was ordered to be transferred for legal hold after the second physical altercation involving new roommate R4The facility's Patient Abuse and Prevention policy (undated), defined abuse as the willful infliction of injury. Physical abuse may include assault and battery. FRI 2699069FRI 2804144FRI 2806325

Based on interview, record, and document review, the facility failed to:1) provide a trauma evaluation after a physical abuse incident for 2 of 10 sampled residents (Residents 1 and 4), and2) implement meaningful interventions for 2 residents (Residents 2 and 5) with psychiatric histories, aggressive behaviors, and refusal of prescribed psychotropic medications.These failures placed residents at risk for mental and emotional harm and increased the risk of physical abuse.Findings include:1) Resident 1 (R1) was admitted on [DATE], with diagnoses including unspecified psychosis due to a substance or unknown physiological condition, schizophrenia, and major depressive disorder.A change of condition evaluation form dated 12/19/2025, revealed R1 was found on floor with bleeding nose, a skin tear to left forearm, and redness of left forehead. R2 admitted to pushing and kicking R1 because R1 entered R2's room.A psychiatry progress note dated 12/19/2025, documented R1's chief complaint was Good and revealed the psychiatric nurse practitioner (NP) saw R1 per staff request.The medical record lacked documentation the psychiatry provider discussed the altercation/physical abuse incident with R1 and addressed R1's newly identified wandering behavior.On 04/22/2026 at 10:40 AM, the social services director (SSD) explained after each resident-to-resident altercation, involved parties were separated, nurses performed a head-to-toe assessment, and a psychiatric consult would be ordered to evaluate the resident's trigger, review medication regimen, identify mental and emotional distress and other interventions as necessary.On 04/22/2026 at 10:46 AM, the director of staff development (DSD) reviewed the psychiatry progress notes on 12/19/2025 and confirmed there was no concrete documentation of purpose which should have been trauma evaluation from R1's abuse incident on 12/18/2025. The DSD stated there was no documentation of root cause of the altercation which was R1's wandering behavior.R4 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, heart failure and schizoaffective disorder.A nurse's progress note dated 03/12/2026, revealed R4 was punched by roommate (R5) very early in the morning. Nurse assessed R4 who was observed with discoloration around left eye socket with sensitivity.A skin/wound note dated 03/12/2026, revealed R4 had a head-to-toe assessment by wound team who identified a nose bridge abrasion and skin tear to left forehead.R4's care plan for emotional distress initiated on 03/12/2026, revealed R4 had the potential for emotional distress related to inappropriate behavior by another resident. Interventions included psychiatry evaluation.The medical record lacked documented evidence R4 was seen by the psychiatric provider after being punched by roommate on 03/12/2026.A text message from DSD's phone dated 03/12/2026, revealed the psychiatric NP was informed of the incident with a request to see R4.The medical record lacked documented evidence psychiatrist completed a trauma evaluation post physical abuse incident.On 04/22/2026 at 2:26 PM, the Director of Nursing (DON) confirmed R4 was not seen by psychiatry following physical abuse incident.The facility's Behavioral Assessment and Management policy revised March 2019 documented the facility would provide behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being.2)Resident 2 (R2) was admitted on [DATE] and readmitted [DATE], with diagnoses including schizophrenia and paranoid personality disorder.The admission minimum data set (MDS) dated [DATE], revealed R2 had intact cognition.A nurse's progress note dated 11/27/2025, revealed R10 called law enforcement after getting punched in the face by R2 in the smoking area. Law enforcement arrived and spoke with both residents. Physician assistant and social services director (SSD) made aware, SSD to inform Administrator.A nurse's progress note dated 12/18/2025, a certified nursing assistant (CNA) informed the nurse R2 had a behavioral outburst and became upset when R1 entered the room. R2 reported to staff pushing R1 to the floor and kicking R1 on right lateral side. The physician was notified and ordered the nurse to send R2 to the hospital for psychiatric evaluation.A physician Discharge summary dated [DATE], revealed R2 had a significant history of schizophrenia, anxiety disorder, and homicidal ideation and was recently treated in a psychiatric hospital for chasing a person with a knife and threatening police prior to admission to this facility.R2's care plan revealed the resident had a behavioral problem specifically, irritability, anger, violent behavior, homicidal ideations, mood swings and had the tendency to push and kick other residents. Interventions included attempts to identify underlying causes.A review of medical record revealed R2 routinely refused medications.Resident 5 (R5) was admitted on [DATE] and readmitted on [DATE], with diagnoses including neuroleptic induced Parkinsonism, schizoaffective bipolar type and psychosis.A nurse's progress note dated 03/12/2026, revealed R6 reported being punched by roommate (R5) the night before. Noted mild elevation on forehead. R6 indicated not doing anything to R5 and did not understand why the resident was [NAME] nurse's progress note dated 03/12/2026, revealed R5 was noted to be screaming violently inside the room. The CNA reported to nurse R5 hit their roommate (R4). R5 was hostile and physically aggressive. R4 was assisted to vacate room and the nurse asked R5 to calm down.A social services note dated 03/12/2026, revealed the SSD attempted to speak with R5 regarding altercation with R4. The resident became agitated, started screaming and yelling and used inappropriate language toward staff. Due to the R5's behavior, the SSD could not obtain further information at this time.A nurse's progress note dated 03/12/2026, indicated R5 was showing hostile and aggressive behavior towards residents and staff, non-redirectable. Physician ordered to transfer R5 to hospital under legal hold (an emergency involuntary hold for individuals undergoing mental health crisis) family notified.A physician Discharge summary dated [DATE], revealed R5 was transferred to this facility from a psychiatric hospital where R5 was evaluated for exacerbation of schizophrenia symptoms. R5 had been noncompliant with psychotropic medications.A Refusal of Treatment form dated 03/08/2026, was signed by R5 after staff explained to the resident refusal of medications could affect stabilizing mood and cause worsening behaviors.On 04/23/2026 at 10:40 AM, the DSD indicated the facility had a high behavior population and the facility assessment took this into consideration specifying there was an average of 45 behavior residents at this time and the facility had increased staffing and tried to decrease admission of behavior residents.On 04/23/2026 at 10:42 AM, the Assistant Administrator there was currently a pattern with regards to resident altercations particularly physical abuse, and the inter-disciplinary team (IDT) had identified the root cause to be a lack of support from the psychiatric provider particularly the nurse practitioner (NP) who was assigned to the facility. On 04/23/2026 at 10:45 AM, the Assistant Administrator indicated being dissatisfied with the psychiatric NP who did not conduct thorough evaluations, made infrequent and delayed visits to the facility.On 04/23/2026 at 10:47 AM, the DON indicated R2 and R5 were both inpatient psychiatric patients who were both refusing to take psychotropic medications. This was reported to both psychiatry provider and the medical director. The Assistant Administrator, the DSD and DON indicated R2, R5 and residents like them should contract into a behavioral agreement wherein if they were medically noncompliant with care plan and medications this could lead to involuntary discharge for the safety of the other residents who resided at the facility.The facility's Abuse Prevention Program revised December 2016, documented residents had the right to be free from abuse which included physical abuse. Resident abuse prevention included protecting residents from other residents.FRI 2699069FRI 2804144FRI 2806325

Based on interviews and document review, the facility failed to ensure allegations of physical abuse were reported to the state agency in a timely manner for four sampled residents (Residents 1, 4, 6 and 10). The deficient practice had the potential to place residents at risk from abuse.Findings include:A facility investigation report of alleged physical abuse between Resident 1 and Resident 2 reportedly occurred on 12/18/2025 at 6:26 PM. According to the report, Resident 2 pushed Resident 1 to the ground and started kicking Resident 1. Resident 1 was found with a bleeding nose, skin tear on arm and redness to left forehead.The report was submitted to the state agency on 12/19/2025 at 5:04 PM.A facility investigation report of alleged physical abuse between Resident 2 and Resident 10 reportedly occurred on 11/27/2025 during the day in the smoking area. R10 was noted to have redness on mandible area after being hit on the face by Resident 2.The report had not been submitted to the state agency.A facility investigation report of alleged physical abuse between Resident 4 and Resident 5 reportedly occurred on 03/12/2026 at 4:00 AM. Resident 4 was observed to have discoloration around left eye socket after being punched by Resident 5.The report was submitted to the state agency on 03/13/2026 at 3:05 PM.A facility investigation report of alleged physical abuse between Resident 5 and Resident 6 reportedly occurred on 03/11/2026 at approximately 9:00 PM. Resident 6 was found to have swelling on forehead after being hit on the head by Resident 5.The report was submitted to the state agency on 03/13/2026 at 3:51 PM.On 04/22/2026 at 3:25 PM, the Director of Nursing (DON), Director of Staff Development (DSD) and the Assistant Administrator indicated the four incidents of physical abuse which were confirmed to be true physical abuse resulting in bodily injury should have been reported to state agency within two hours and all were submitted late to the state agency.The facility's Abuse Investigation and Reporting policy revised July 2017, documented an alleged violation of abuse would be reported immediately but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury.FRI 2699069FRI 2804144FRI 2806325

Based on interview, record review, and document review, the facility failed to investigate an incident of physical abuse for 1 of 10 sampled residents (Resident 10). The deficient practice placed other residents at risk for abuse.Findings include:Resident 10 (R10) was admitted on [DATE], with diagnoses including fibromyalgia and unspecified intracranial injury.A nurse's progress note dated 11/27/2025, revealed R10 called law enforcement after getting punched in the face by R2 in the smoking area. Law enforcement arrived and spoke with both residents. The physician assistant and social services director (SSD) was made aware. The SSD was to inform the Administrator.A change of condition evaluation form dated 11/27/2025, revealed R10 reported being slapped and cursed at by R2 in the smoking area. R2 had attempted to strike R10's face with a lit cigarette. Redness was noted on R10's left mandible area. An X-ray was ordered which was negative for injury.Resident 2 (R2) was admitted on [DATE] and readmitted [DATE], with diagnoses including schizophrenia and paranoid personality disorder.A nurse's progress note dated 11/27/2025, revealed R2 was in a physical altercation with R10 in the smoking area. When the writer approached R2 in the smoking area, R2 explained R10 was being annoying and deserved it. Law enforcement arrived at facility due to R10 pressing charges against R2 for battery.A physician Discharge summary dated [DATE], revealed R2 had a significant history of schizophrenia, anxiety disorder, and homicidal ideation and was recently admitted to a psychiatric hospital for chasing a person with a knife and threatening police.A The facility did not report this incident to the state agency. On 04/22/2025 at 11:18 AM, the Director of Nursing (DON) indicated working in the facility at this time but was not the DON yet. The DON indicated hearing about the incident but was not well-versed due to being busy with unit assignment.On 04/22/2026 at 11:20 AM, the Director of Staff Development (DSD) indicated based on review of R10 and R2's medical records there was a physical abuse incident on 11/27/2025 but this was not investigated nor reported. The DSD could not speak to the efforts made by the former DON who had more knowledge on the incident.On 04/22/2026 at 11:29 AM, the social services director (SSD) recalled informing the Administrator regarding this incident but could not speak to why the incident was not investigated or reported. The SSD indicated the Administrator was on leave and was not available for interview.On 04/22/2026 at 11:33 AM, the DSD indicated when alleged abuse occurred the facility was to report to state agency within two hours if abuse led to serious bodily harm and 24 hours if it does not involve abuse or serious injury. This was an abuse incident and should have been reported within two hours and complete investigation submitted within five working days.The faciity's Abuse Investigation and Reporting policy revised July 2017, revealed an incident or suspected resident abuse would be reported to the Administrator who will assign the investigation to the appropriate individual. The individual conducting the investigation will review documentation forms, interview the persons reporting the incident, residents and witnesses, and review all events leading up to the alleged incident.FRI 2699069

Based on interview, record review and document review, the facility failed to ensure a resident's care plan was developed for a newly identified wandering behavior for 1 of 10 sampled residents (Resident 1). The deficient practice placed the resident at risk for a repeat resident to resident altercation.Findings include:Resident 1 (R1) was admitted on [DATE], with diagnoses including unspecified psychosis due to a substance or unknown physiological condition, schizophrenia, and major depressive disorder.The admission minimum data set (MDS) dated [DATE], revealed R1 had moderately impaired cognition, no wandering behaviors.A change of condition evaluation form dated 12/19/2025, revealed R1 was found on floor with bleeding nose, a skin tear to left forearm, and redness of left forehead. R1 wandered into another resident's room and was pushed to the ground and kicked by the resident in the room.The medical record lacked documented evidence a care plan for R1's newly identified wandering behavior was developed following the incident on 12/18/2025.On 04/22/2026 at 10:35 AM, the Director of Nursing (DON) indicated R1 was admitted with no wandering behaviors but wandered into R2's room on 12/18/2025. At this point, the nurse assigned to R1 was responsible for developing a care plan for wandering which was considered a new behavior. According to the DON, typical interventions for wandering behaviors included close monitoring, transferring resident near nurse's station, activities involvement to keep busy and one-one-one sitter when needed.The facility's Comprehensive Person-Centered Care Plan policy revised December 2016 revealed assessments were ongoing and revised as information about the residents and conditions changed.FRI 2699069

Based on interview, record review, and document review, the facility failed to ensure a resident was safely discharged to a facility which could meet the care needs of the resident for 1 of 5 sampled residents (Resident 2). The deficient practice had the potential to result in the resident's care needs not being met. Findings include:Resident 2 (R2) was admitted [DATE], readmitted [DATE], with diagnosis including schizoaffective disorder bipolar type, psychosis not due to a substance or known physiological condition, and manic episode.A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three (severe cognitive impairment). Disorganized thinking behavior was present, fluctuated, changed in severity.A Care Plan revised 06/17/2025, documented R2 had a behavior problem related to, among others, irritability and anger, impulsiveness, emotional liability, violent behavior, restlessness, agitation, auditory hallucinations, bizarre behaviors, paranoid, labile, racing thoughts, uncooperative, anxious delusion, erratic behavior, dysmorphic mania, anger outburst, tendency to spit, kick, and bite. Interventions included providing 1:1 supervision.An MDS assessment dated [DATE], Section GG, Functional Abilities, documented R2 needed partial assistance from another person to complete any activities. R2 was dependent for indoor mobility, a helper completed all the activities for the resident. Functional cognition stated R2 needed partial assistance from another person to complete any activities. R2 was dependent for eating, and toileting hygiene was substantial/maximal assistance. An Interdisciplinary Discharge summary dated [DATE], documented resident was discharged to a group home. The Activities section documented R2 exhibited behaviors and required a one-on-one sitter.A Social Service Note dated 07/11/2025, documented a placement coordinator/owner assessed R2, accepted the resident, and provided the facility address. R2 was discharged to the accepting facility. Approximately 30 minutes after discharge, the placement coordinator/owner informed the facility that upon arrival, under one-on-one supervision, the resident became agitated, yelling and broke the television.On 11/18/2025 at 12:15 PM, the Social Service Assistant/Discharge Coordinator stated R2 was discharged to an independent living facility. The Social Service Assistant/Discharge Coordinator acknowledged R2's discharge was an unsafe discharge because R2 was sent to an independent living facility and R2 was dependent on others for care.On 11/18/2025 at 12:20 PM, the Assistant Administrator stated R2's discharge was inappropriate based on R2's needs and R2 was not appropriate for an independent living facility. The Director of Nursing was present during the interview and concurred with the statement made by the Assistant Administrator.On 11/18/2025 at 1:45 PM, the owner of the independent living facility indicated the facility could accommodate five residents. There was a caregiver who was expected to provide supervision but not expected to provide assistance with activities of daily living (ADLs). The facility owner recalled R2 was admitted to the facility on [DATE]. The owner denied coming to the facility to assess if R2 was suited for independent living but rather, R2 was accepted based on the trust relationship the owner had with the discharging facility. The owner indicated the independent facility did not admit residents who required assistance with ADLs or behavior monitoring. R2 displayed disruptive behaviors during the stay, was throwing stuff and hitting others so the owner had to call 911 and R2 was transferred to a hospital because the level of care R2 needed could not be provided by the independent living facility. The owner stated R2's discharge by the facility to the home (independent living) was inappropriate. A facility policy titled Discharge Process undated, stated information provided to the receiving provider must include at a minimum all necessary information, and any other documentation to ensure a safe and effective transition of care.Complaint 2573776

Based on interview, record review, and document review, the facility failed to ensure a resident with severe cognitive impairment received a competency assessment to determine decision-making capacity and the need for a guardian or representative for 1 of 5 sampled residents (Resident 2). The deficient practice had the potential for a severely cognitive impaired resident to not understand or make an informed decision on the care and treatment being provided.Findings include:Resident 2 (R2) was admitted [DATE], readmitted [DATE], with diagnosis including schizoaffective disorder bipolar type, psychosis not due to a substance or known physiological condition, and manic episode.A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three (severe cognitive impairment). Disorganized thinking behavior was present, fluctuated, changed in severity.R2's profile in the electronic medical record documented R2 was responsible party.A Psycho-Social Assessment Form dated 06/25/2025, Admission, documented possible discharge plan to another facility, anticipated long term care, responsible party self, no advanced directives, severely impaired decision making skills regarding tasks of daily life. Additional comments included no relative resources available, no regional psychiatric facility placement available. R2's medical record lacked documented evidence of a Power of Attorney (POA) or guardianship documentation.A Social Services Note dated 06/24/2025, documented the regional psychiatric facility was not able to take R2 back. A suggestion was made to contact a service coordinator to look for an appropriate placement for R2. An Interdisciplinary Discharge summary dated [DATE], documented resident was discharged to a group home.A Resident Notice of Transfer or discharge date d 07/01/2025, documented resident would be discharged from the facility on 07/11/2025. The reason for the transfer or discharge was marked: as per you/and your family request. The signature line of the form read verbal consent from R2, dated 07/11/2025.On 11/18/2025 at 12:15 PM, the Social Service Assistant/Discharge Coordinator explained the discharge process included to ensure resident's needs would be met at the new facility. The Social Service Assistant/Discharge Coordinator stated R2 was followed by a regional psychiatric facility which dropped R2 and was no longer involved or returning phone calls. The Social Service Assistant/Discharge Coordinator acknowledged, due to R2's cognitive impairment R2 needed a legal representative and did not have one. The Social Service Assistant/Discharge Coordinator stated R2 could not make their own decisions and acknowledged R2 was discharged to an independent living facility. The Social Service Assistant/Discharge Coordinator acknowledged a competency assessment should have been completed for R2 to assess the need for a guardian and explained did not have knowledge of the process for guardianship, for residents with severe cognitive impairment.On 11/18/2025 at 12:20 PM, the Assistant Administrator explained a competency evaluation for a resident with a BIMS score of three and no familial support should have been completed for R2, and acknowledged the facility failed to do a competency evaluation for R2.On 11/18/2025 at 12:38 PM, a Physician Assistant (PA), recalled the R2 was admitted with psychosis, mainly had schizoaffective issues and was referred to a psychiatrist. The PA reported R2 was stable some days, but it was back and forth. R2's behavior was unpredictable. The PA confirmed R2 could not make their own decisions and therefore needed a POA, guardianship or representative.A facility policy titled Assessing Resident's Mental Capacity undated, documented if a resident was identified having diagnosis of dementia or impaired cognition, the resident would be referred to the psychiatrist to determine if the resident had the capacity to make informed decisions regarding medical care, financial matters, and daily living activities. In the absence of surrogate or responsible party, the facility would follow state specific laws on guardianship and consent.Complaint 2573776

Based on observation, interview, record review and document review, the facility failed to ensure consents for psychotropic medications were not obtained from a resident who was assessed to have severely impaired cognition for 1 of 19 sampled residents (Resident 79). The deficient practice potentially deprived the resident and the resident's representative the right to be informed of the medications' purpose, risks, benefits and potential side effects. Findings include: Resident 79 (R79) R79 was admitted on [DATE], with diagnoses including Parkinsonism, schizophrenia and anxiety disorder. The admission minimum data set (MDS) dated [DATE], documented R79 had a brief interview of mental status of 06 (severely impaired cognition). Review of medical record revealed R79's family member was R79's responsible party. A physician's order dated 04/10/2025, documented to give Quetiapine Fumarate (Seroquel an anti-psychotic) tablet 100 milligrams (mg) four tablets by mouth in the evening for Schizophrenia manifested by hearing voices. A consent for psychoactive medication use dated 04/09/2025, revealed a staff member completed the consent form for Seroquel and the risk, benefits, potential side effects of the medication were discussed with R79. The document had the physical signatures of a staff member and R79. A physician's order dated 04/09/2025, documented to give Trazadone (anti-depressant) tablet 100 mg one tablet by mouth at bedtime for insomnia manifested by inability to sleep. A consent for psychoactive medication use dated 04/09/2025, revealed a staff member completed the consent form for Trazadone and the risk, benefits, potential side effects of the medication were discussed with R79. The document had the physical signatures of a staff member and R79. On 06/25/25 at 12:10 PM, R79 was ambulating around the bed and appeared pleasant and cooperative. R79 reviewed consents for Trazadone and Seroquel and confirmed they were the actual signature of the resident. The resident indicated not knowing what Seroquel or Trazadone were for and verbalized just trusting the doctors. On 06/25/2025 at 12:11 PM, the Registered Nurse (RN) indicated being familiar with R79 whom the RN described as often confused with disorganized thinking, The RN explained R79 had a family member who was involved in care and staff obtained consents from R79's family member. The RN reviewed the consents for Seroquel and Trazadone and confirmed they appeared to be signature of R79 and not of the family member. The RN indicated R79 was not capable of understanding or retaining information regarding medications or treatments and the staff member who obtained consents for R79's psychoactive medications should have obtained consent from R79's family member and not the resident who had severely impaired cognition. On 06/25/2025 at 12:33 PM, the Director of Nursing (DON) confirmed R79 had severely impaired cognition and should not be signing own consents. The DON indicated R79 had a family member who was involved in the resident's care and signed R79's treatment consents except for the consent to use Seroquel and Trazadone. The DON indicated not being able to recognize whose signature the staff member belonged to, but the staff member could have called R79's family member by phone and obtain verbal consent. The Psychotropic Drug Treatment revised December 2016, documented the resident and/or resident representative would be given information regarding the need for, the desired effects and the potential side effects of the medication. This enabled the resident or the resident representative to make an informed decision regarding use of psychoactive medication. The resident representative should be involved in the medication management process and aware of the benefits and risks of medications and goals of treatment.

Based on observation, interview, record review, and document review, the facility failed to ensure enteral feeding and water flush orders administered through the gastrostomy tube (GT) were followed as ordered, and the total volume delivered was monitored and documented for 1 of 26 sampled residents (Resident 34). This deficient practice had the potential to result in inadequate nutritional and fluid intake, leading to malnutrition, dehydration, electrolyte imbalances, delayed wound healing, and increased susceptibility to infections. Findings include: Resident 71 (R71) R71 was admitted on [DATE] and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), diabetes mellitus, and gastrostomy. On 06/24/2025 at 10:42 AM, R71 was not in the room. A Certified Nursing Assistant (CNA) indicated the resident was in the activity area. Glucerna 1.2 (a liquid therapeutic nutritional supplement specifically designed to help meet nutritional needs) was hung on a pole and turned off at the time of observation. The bag was labeled with the date, time, and resident's last name. The feeding volume was marked at 900 milliliters (mL) and the water volume at 1000 mL. On 06/24/2025 in the afternoon, R71 was not in the room; the TF remained off at this time. A Physician order dated 04/22/2025, documented enteral feeding Glucerna 1.2 at 65 ml per hour, turn off at 8:00 AM, and turn on at 12:00 noon for dysphagia. A Care plan dated 02/19/2025, documented R71 required enteral nutrition feeding related to dysphagia. R71 was at risk for dehydration, weight fluctuation, weight changes, intolerance to feeding, and infection at the gastrostomy site. R71 was dependent on tube feeding (TF) and water flushes and to provide TF and water flushes as ordered. The Quarterly Minimum Data Set, dated [DATE], documented the brief interview of mental status as incomplete. R71 had a feeding tube and had unknown weight changes. The Medication Administration Record (MAR) for the month of June lacked documented evidence the total TF volume dose delivered was consistently monitored or documented. On 06/25/2025 at 1:57 PM, the tube feeding (TF) was infusing at 65 mL/hour. A Registered Nurse (RN) indicated R41's TF was ordered to administer from 12:00 PM to 8:00 AM, delivering Glucerna 1.2 at 65 mL/hour. At the time of observation, approximately 600 mL of formula and 800 mL of water remained in the feeding bag. The RN verified and confirmed the history readings of the feeding pump, which recorded the total dose delivered for both tube feeding and water flush over the review period. A review of the previous 72-hour period revealed the following discrepancies between the ordered and delivered volumes: 24-hour period: Ordered formula: 1,300 mL (65 mL/hour × 20 hours) Delivered: 912 mL Shortage: 388 mL Ordered water flush: 900 mL/day Delivered: 622 mL Shortage: 278 mL 48-hour period: Ordered formula: 2,600 mL Delivered: 1,706 mL Shortage: 894 mL Ordered water flush: 1,800 mL Delivered: 1,131 mL Shortage: 669 mL 72-hour period: Ordered formula: 4,680 mL Delivered: 2,960 mL Shortage: 1,720 mL Ordered water flush: 2,700 mL Delivered: 1,764 mL Shortage: 936 mL The feeding pump in use had a calibration label dated February 2026. On 06/25/2025 at 3:30 PM, a Licensed Practical Nurse (LPN) indicated the tube feeding should have been administered over 20 hours or until the total volume dose was completely delivered. The LPN acknowledged there was no documented evidence of the actual volume administered per shift. The LPN indicated monitoring was typically based on the bag label and enteral pump history, and the total volume delivered was not recorded each shift. The LPN indicated the documentation involved signing off on the paper MAR, without any verification of the total amount administered during each shift. On 06/25/2025 at 4:35 PM, the Director of Staff Development (DSD) indicated the facility used feeding pumps capable of displaying total volumes of formula and water infused. The pump was designated to R71 and had not been changed. For orders specifying 20 hours at 65 mL/hour, nursing staff were expected to program the pump per physician orders, monitor the infusion, and verify completion. The DSD explained the facility did not maintain a log for documenting tube feeding volumes delivered. Compliance was based on pump initiation, shift monitoring, and sign-off of scheduled flushes and tube placement verification. The RD acknowledged the potential benefits of structured shift-level volume tracking. The DSD indicated implementing a shift-based tracking system could improve accountability and ensure complete and consistent delivery. The DSD indicated failure to follow enteral feeding orders posed risks of inadequate nutrition and hydration, impairing wound healing and overall health, particularly for residents dependent on tube feeding. Continuous water flushes were administered concurrently to support hydration goals. On 06/26/2025 at 8:41 AM, the Registered Dietitian (RD) indicated R71's tube feeding (TF) order was for Glucerna 1.2 to run at 65 mL/hour for 20 hours per day, along with water flushes of 150 mL every 4 hours, totaling 900 mL per day. The RD acknowledged that a review of TF delivery over a 72-hour period revealed multiple deficits in prescribed nutrition and hydration. The Registered Dietitian (RD) indicated R71 received 2,960 mL of formula out of the expected 4,680 mL over 72 hours, resulting in a deficit of 1,720 mL of nutrition and 936 mL of water, which was described as significant. The RD explained continued missed feedings and hydration could place R71 at risk for weight loss, dehydration, and nutritional decline, particularly due to a prior risk for malnutrition. The RD verbalized uncorrected deficits could compromise wound healing, immune function, and overall clinical stability. The RD indicated R71's weight and body mass index remained stable and noted R71 was the only resident in the facility receiving continuous tube feeding via pump. The RD acknowledged missed doses of tube feeding or water flushes posed a risk for harm and emphasized the importance of accurately documenting volumes delivered. The RD expressed concern that current practice relied on MAR signoffs without consistent recording of actual volumes infused, which hindered accountability and effective monitoring. On 06/26/2025 at 11:48 AM, the Director of Nursing (DON), indicated the enteral pump was assigned solely to R71 and had not been changed. The DON indicated education had been provided to the licensed nurses, who were expected to allow the tube feeding (TF) to continue until the total prescribed dose was delivered. The DON indicated the nurses were expected to verify TF orders and monitor and document the start-of-shift volume infused in the Medication Administration Record (MAR) to ensure accurate tracking of the total TF amount delivered each shift and to support continuity of care. A facility policy titled Enteral Nutrition revised November 2018, documented adequate nutritional support through enteral nutrition was provided to residents as ordered. A facility policy titled Physician Orders, dated October 2014, documented to provide care and services to residents in accordance with physician orders, including dietary orders such as tube feeding.

Based on observation, interview, and document review, the facility failed to ensure staff foods were stored properly and frozen meat was thawed correctly. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and placed residents at risk of foodborne illness. Findings include: On 06/25/2025 at 12:03 PM, a follow-up tour and walk through of the kitchen was completed. An open and undated bottle of Gatorade was found stored in the reach in freezer. The facility policy titled Food Preparation and Service/ Food Preparation Area, revised April 2019, documented food preparation staff adhered to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Personal items will not be stored in food preparation or storage areas. On 06/25/2025 at 12:13 PM, a follow-up tour and walk through of the kitchen was completed. In a sink compartment in the dirty dish area, tubes of meat were being thawed in a still water bath. This still water bath was located under a hose leading to a concentrated detergent delivery system. The facility policy titled Food Preparation and Service/ Thawing Frozen Food, Revised April 2019, documented foods would not be thawed at room temperature. Thawing procedures included completely submerging the item in cold running water which would run fast enough to agitate and remove loose ice particles. On 06/25/2025 at 12:17 PM Dietary Manager (DM) acknowledged the thawing of meat should occur by submerging the item under cold running water. The DM also acknowledged staff food and drinks should not be kept in facility food preparation or food storage areas.

Based on interview and document review, the facility failed to ensure dementia training was provided for 3 of 11 employee files reviewed (Employees 4, 5, and 8) as outlined in Nevada Administrative Code (NAC) 449.74522 Findings include: NAC 449.74522 documented: 1. Except as otherwise provided in subsection 4, each person who is employed by a facility for skilled nursing which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer's disease, who has direct contact with and provides care to persons with any form of dementia and who is licensed or certified by an occupational licensing board must complete the following number of hours of continuing education specifically related to dementia: (a) In his or her first year of employment with a facility for skilled nursing, 8 hours which must be completed within the first 30 days after the employee begins employment; and (b) For every year after the first year of employment, 3 hours which must be completed on or before the anniversary date of the first day of employment. 2. The hours of continuing education required to be completed pursuant to this section: (a) Must be approved by the occupational licensing board which licensed or certified the person completing the continuing education; and (b) May be used to satisfy any continuing education requirements of an occupational licensing board and do not constitute additional hours or units of required continuing education. 3. Each facility for skilled nursing shall maintain proof of completion of the hours of continuing education required pursuant to this section in the personnel file of each employee of the facility who is required to complete continuing education pursuant to this section. 4. A person employed by a facility for skilled nursing which provides care to persons with any form of dementia, including, without limitation, dementia caused by Alzheimer's disease, is not required to complete the hours of continuing education specifically related to dementia required pursuant to subsection 1 if he or she has completed that training within the previous 12 months. 5. As used in this section, continuing education specifically related to dementia includes, without limitation, instruction regarding: (a) An overview of the disease of dementia, including, without limitation, dementia caused by Alzheimer's disease, which includes instruction on the symptoms, prognosis and treatment of the disease; (b) Communicating with a person with dementia; (c) Providing personal care to a person with dementia; (d) Recreational and social activities for a person with dementia; (e) Aggressive and other difficult behaviors of a person with dementia; and (f) Advising family members of a person with dementia concerning interaction with the person with dementia. On 06/26/25 at 09:23 AM, the Director of Staff Development (DSD) indicated dementia training was required to be completed upon hire and annually on or before the employee's hire anniversary date. The personnel file of Employee 4 revealed the employee was hired as the Social Services Director (SSD) on 03/16/2024. The last recorded dementia training was dated 05/16/2024. The DSD confirmed that Employee 4's dementia training was overdue. The personnel file of Employee 5 revealed the employee was hired as the Registered Dietitian on 05/06/2019. The last recorded dementia training was dated 05/16/2019. The DSD confirmed that Employee 5's dementia training was overdue. The personnel file of Employee 8 revealed the employee was hired as a Certified Nursing Assistant (CNA) on 09/12/2023. The last record of dementia training was dated 05/06/2024. The DSD confirmed that Employee 8's dementia training was overdue. On 06/26/25 at 09:41 AM, the DSD explained dementia training was provided at the time of hire and annually, using a combination of learning methods such as face-to-face instruction, printed materials, and a Learning Management System (LMS). Employees signed an in-service sheet as evidence of completing the mandatory training. The DSD was responsible for tracking providing and tracking all mandatory training and stated dementia training which were past due for Employees 4, 5, and 8 was an oversight. The Facility Assessment document reviewed on 03/17/2023, documented dementia training was to be provided upon hire, annually and as needed. The facility policy titled Compliance with Federal, State, and Local Laws and Professional Standards revised April 2021, documented the facility was expected to conform with to all applicable federal, state, and local laws, regulations, and codes, as well as accepted professional standards and principles that apply to professionals providing services in the facility.

Based on observation, interview, record review, and document review, the facility failed to ensure visitors and staff wore appropriate personal protective equipment (PPE) and hand hygiene had been performed when cleaning a room under transmission-based precautions (TBP). These deficient practices had the potential to expose residents, staff, and visitors to infectious agents and compromise the facility's infection prevention and control measures. Findings include: Resident 140 (R140) R140 was admitted on [DATE], with diagnoses including diabetes mellitus and osteomyelitis, left ankle and foot. On 06/24/2025 at 11:54 AM, a contact precaution sign was posted on R140's room door, instructing staff to perform hand hygiene before room entry and exit, and to wear a gown and gloves. PPE was available. R140 had a left foot infection and was on contact isolation for a methicillin-resistant Staphylococcus aureus (MRSA). R140's spouse was observed seated in bed assisting the resident, who was lying in bed, without wearing PPE. Staff observed the spouse without PPE but failed to provide education. A physician order dated 06/03/2025 documented R140 had been placed on contact isolation for MRSA in the wound. The History and Physical dated 06/04/2025, documented R140 had been diagnosed with osteomyelitis of the left foot and had a wound culture positive for MRSA. A care plan revised on 06/07/2025 documented instructions for visitors to wear disposable gloves and a gown when in the resident's room and to wash hands before leaving the room. The admission Minimum Data Set, dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R140's cognitive status was intact. R140 had intravenous access and was receiving antibiotic treatment to treat the wound infection. On 06/26/2025 at 10:22 AM, R140 acknowledged the spouse had visited the room without wearing PPE and stated the couple remained close. R140 recognized the spouse should have worn gloves and a gown while staying at the bedside to prevent contamination. R140 was aware of being on contact precautions due to a MRSA wound infection and indicated staff had not provided education that visitors should have worn PPE. On 06/26/2025 at 2:40 PM, a housekeeper was observed cleaning R140's room wearing gloves, without a gown. The housekeeper wiped down the bed, table, intravenous pole, restroom, and mopped the floor. After cleaning, the housekeeper exited the room with used gloves on, then removed and discarded the gloves in the housekeeping cart located in the hallway. The housekeeper explained awareness of the contact precautions in place and acknowledged the transmission-based precautions (TBP) protocol had not been followed. On 06/27/2025 at 9:12 AM, a Registered Nurse (RN) indicated R140 was on contact precautions for MRSA in the left foot wound. The RN acknowledged staff were expected to perform hand hygiene, wear a gown and gloves upon entry, and perform hand hygiene again before exiting the room. The RN verbalized staff and visitors were expected to follow TBP protocol, including use of PPE to prevent transmission of infection to self and others. On 06/27/2025, the Infection Preventionist (IP) explained staff were expected to perform hand hygiene when entering and exiting a contact precaution room. The IP indicated if no direct resident care was provided (e.g., answering a call light), staff could enter the room without donning a gown, provided no physical contact occurred and hand hygiene was performed upon entry and exit. The IP stated R140's MRSA-infected wound was covered and not draining, and precautions were maintained. The IP confirmed R140 was permitted to ambulate within the facility as long as the wound remained covered. The IP indicated staff were required to wear a gown and gloves when performing tasks such as changing linens or engaging with the resident's immediate environment like cleaning. The IP acknowledged housekeeping staff were expected to wear PPE when cleaning rooms under contact precautions. The IP indicated staff were advised to clean non-isolation rooms first, then TBP rooms last, and to follow infection control procedures including proper PPE use and sequencing. The IP explained R140's spouse had been instructed to remain seated in a designated chair during visits to avoid contact with R140's bed. The IP indicated staff and visitors required reminders to perform hand hygiene upon entry and exit of the room. A facility policy titled Personal Protective Equipment dated September 2024, documented employees performing tasks involving potential exposure to blood or body fluids were required to wear appropriate protective clothing and equipment.

Based on interview and document review, the facility failed to ensure abuse training was provided in accordance with the facility assessment and facility policy for 3 of the 11 employee files reviewed (Employees 4, 5, and 8). The deficient practice had the potential to allow unqualified employees to provide care for residents. Findings include: On 06/26/25 at 09:23 AM, the Director of Staff Development (DSD) indicated abuse training was required to be completed upon hire and annually, on or before the employee's hire anniversary date. The personnel file of Employee 4 revealed the employee was hired as the Social Services Director (SSD) on 03/16/2024. The last recorded abuse training was dated 03/25/2024. The DSD confirmed that Employee 4's abuse training was overdue. The personnel file of Employee 5 revealed the employee was hired as the Registered Dietitian on 05/06/2019. The last recorded abuse training was dated 05/16/2019. The DSD confirmed that Employee 5's abuse training was overdue. The personnel file for Employee 8 revealed the employee was hired as a Certified Nursing Assistant (CNA) on 09/12/2023. The last recorded abuse training was on 05/21/2024. The DSD confirmed that Employee 8's abuse training was overdue. On 06/26/25 at 09:41 AM, the DSD explained abuse training was provided upon hire and annually, using a combination of learning methods such as face-to-face instruction, printed materials, and a Learning Management System (LMS). Employees signed an in-service sheet as evidence of completing the mandatory training. The DSD was responsible for providing abuse training, while the Assistant DSD was responsible for tracking all initial and annual mandatory training. The DSD stated the abuse training for Employees 4, 5, and 8 were overdue due to an oversight. The Facility Assessment document last reviewed on 03/17/2023, documented abuse training was required to be provided upon hire, annually and as needed. The facility policy titled Abuse Prevention Program Policy revised in December 2016, documented the facility required staff training and orientation programs covering topics such as abuse prevention, identification, and reporting of abuse.

Based on interview, record review and document review, the facility failed to ensure a resident was kept safe from physical abuse for 1 of 5 sampled residents (Resident 2) and a resident was protected from abuse by another resident with increasingly aggressive behaviors for 1 of 5 sampled residents (Resident 4). The deficient practice had the potential for the residents to experience emotional and physical harm. Findings include: Resident 2 (R2) R2 was admitted on [DATE] with diagnoses including other specified disorders of bone density and structure of left ankle and foot, type 2 diabetes, and chronic obstructive pulmonary disease. Resident 3 (R3) R3 was admitted on [DATE] and discharged on [DATE] with diagnoses including unspecified psychosis, schizophrenia, and unspecified dementia. The facility reported incident (FRI) dated 09/24/2024 documented the following: -On 09/18/2024 at approximately 7:00 PM, R3 was observed being physically aggressive with R2 and striking R2's body. - R2 and R3 were immediately separated by a Certified Nurse Assistant (CNA) and R3 was placed on one-to-one supervision. -Conclusion: The incident was verified and R3 was transferred to an acute care hospital for psychiatric evaluation. A Psychiatry consultation note dated 09/20/2024 documented R2 was pleasant and stated being more comfortable that R3 was taken to an acute hospital for inpatient management of disrupted behaviors. R2 denied feeling depressed or anxious and stated feeling safe in the facility. Social Service notes documented the following: -09/19/2024 R2 stated everything was fine, feels safe, aware R3 is gone, no problems. -09/20/2024 R2 smiled and stated everything was still fine, no problems and feels safe. -09/22/2024 R2 stated everything is fine and feels safe. On 03/12/2025 at 10:25 AM, R2 stated gets along well with residents and has not had any negative interactions with anyone. R2 stated feels safe in the facility. During the onsite investigation on 03/12/2025, the facility's correction of the past non-compliance related to the incident occurred as evidenced by: -Observation of resident-to-resident interactions were polite and courteous. - R3 was discharged from the facility on 09/18/2024 and had not returned. - Staff indicated the facility provided continuing education regarding Resident-to-Resident altercations. -Review of the facility's training records corroborated the staff interviews regarding training. Facility Reported Incident #NV00072264 Resident 4 (R4) R4 was admitted on [DATE] and discharged on [DATE] with diagnoses including low back pain, idiopathic peripheral autonomic neuropathy, and type 2 diabetes with hyperglycemia. Resident 5 (R5) R5 was admitted on [DATE] and discharged on [DATE] with diagnoses including schizoaffective bipolar type disorder, anxiety disorder, and abnormalities of gait. The FRI dated 11/04/2024 documented the following: -On 11/03/2024 at 10:30 PM, R5 struck R4's face causing a fall to the floor and bleeding nose. The residents were immediately separated and R5 placed on one-to-one monitoring. -R5 was placed on legal hold, transferred to an acute hospital, and metro police were notified. - R4 was sent to the hospital for evaluation. -Conclusion: The incident was verified. R4 returned to the facility with psychiatry and social services to follow. R4 reported feeling safe in the facility. R5 was transferred to an acute hospital. A care plan dated 11/05/2024 documented R4 had potential for emotional distress related to altercation with interventions to monitor R4 for verbalizing fear or not being safe. A Psychiatry progress note dated 11/05/2024 documented R4 feels safe and denied negative thoughts. Social Service notes documented the following: -11/05/2024, R4 stated feeling fine and safe, not afraid of anyone. -11/06/2024, R4 walking down hallway stated being fine, no problem with face or nose and feels safe. -11/07/2024, R4 stated feels safe and not afraid of anyone. A Radiology Interpretation of nasal bones x-ray dated 11/11/2024 documented no displaced facial fracture detected. On 03/12/2025 at 3:38 PM, the Director of Nursing (DON) stated the expectation of staff when a resident was aggressive, and another resident was attempting to approach was for staff to intervene and separate them for safety. During the onsite investigation on 03/12/2025, the facility's correction of the past non-compliance related to the incident occurred as evidenced by: -Observation of resident-to-resident interactions were polite and courteous. - Staff indicated the facility provided continuing education regarding Resident-to-Resident altercations. -Review of the facility's training records corroborated the staff interviews regarding training. Facility Reported Incident #NV00072620

Based on observation, interview, record review and document review, the facility failed to prevent a resident fall when it failed to ensure the resident's wheelchair was securely latched to the transportation van prior to transit for 1 of 25 sampled residents (Resident 8). Findings include: Resident 8 (R8) was admitted on [DATE], with diagnoses including [CONDITION(S)] and dementia. A Licensed Progress Note dated 08/10/2020, revealed R8 had a fall incident in the transportation van while being transported back to the facility from a medical appointment. Upon return to facility, the resident was assessed for injuries, physician and responsible party were notified and the resident was transferred to the hospital. An Incident Narrative report dated 08/10/2020, documented the fall incident occurred inside the transportation van, the wheelchair fell backwards when the driver accelerated. On 08/25/2021 at 10:56 AM, the transportation driver recounted the resident of concern's fall incident on 08/10/2020. The transportation driver described the facility van was equipped with latches on the floor intended to secure the resident's wheelchair during transit. There were two latches to secure both sides of the wheelchair from the front and two latches to secure both sides of the wheelchair from the back. The transportation driver indicated being fully responsible in securing all four latches but sometimes the transportation aides helped. On the day of the incident while the driver was securing the resident's wheelchair from the back the transportation aide was observed bent down on the front of the resident. The driver assumed the transportation aide was taking care of the front latches. The driver started the vehicle and while approaching an uphill road the driver heard a loud thump followed by the resident's scream. The resident had fallen backwards hitting the head. The driver parked the van in an emergency lane while the transportation aide received direction from facility staff. On 08/25/2021 at 11:05 AM, the transportation driver should not have assumed the transportation aide secured the front part of the resident's wheelchair but instead should have physically checked all four latches were secured. The driver indicated the fall incident which resulted in injury to the resident was preventable if safety measures were employed. On 08/25/2021 at 11:16 AM, the Director of Staff Development (DSD) indicated the transportation driver was fully responsible in ensuring all passengers were secured by latches, hooks, or seatbelts prior to starting the vehicle. The DSD reported the transportation driver admitted to facility leadership the back floor straps were secured but the driver failed to ensure the front straps were latched prior to transit. The facility conducted a full investigation into the incident which revealed the resident's fall incident inside the transportation vehicle was due to human error and not a hook malfunction within the vehicle. On 08/25/2021 at 12:00 PM, an unsampled resident was wheeled into the facility van by the transportation driver. The driver secured the resident's wheelchair using two latches from the back and two latches from the front. The driver walked behind the wheelchair and pulled the wheelchair with force three times to check if the wheelchair was secured for transit. The wheelchair appeared secured to the base of the van. The driver indicated pulling on the resident's wheelchair from behind became a practice after the resident of concern's fall incident in August 2020. On 08/25/2021 at 12:10 PM, the Administrator and Assistant Administrator recalled the incident which was fully investigated after the resident's fall resulted in an injury requiring hospitalization . The facility assumed full responsibility for the oversight of the transportation driver when the driver failed to ensure the resident's wheelchair was latched securely on all four corners of the wheelchair. On 08/25/2021 at 2:52 PM, the transportation aide who accompanied the resident of concern on 08/10/2020 recalled trying to break the resident's fall when the wheelchair started tilting backwards when the van went uphill but the seatbelt prevented the transportation aide from getting to the resident timely. The transportation aide indicated the fall was not loud and hard and the transportation aide assisted the resident up while still on the wheelchair and the resident verbalized being okay. The transportation aide phoned the nurse supervisor at the facility who directed the transportation aide and driver to return to the facility with the resident for a full assessment. The transportation aide indicated while the driver was ultimately responsible for securing the safety latches on the base of the van, the transportation aide should have done a visual inspection to ensure the resident's wheelchair was safe and secure prior to transit. A History and Physical dated 08/10/2020, revealed Resident #8 presented to the emergency department with complaints of pain to back of head status post fall. The back of the resident's head hit the floor of the vehicle during transport. A computed tomography (CT) of the head demonstrated a 7 millimeter (mm) thick acute subdural hematoma in the left cerebral convexity, 2.7 mm thick acute parafalcine subdural hematoma, 6 mm acute cerebral hematoma along the tentorium and trace amount of subdural hematoma in the right tentorium. The resident was transferred to the intensive care unit for further management, no surgical intervention was recommended. The Driver 10-Point Safety Inspection Checklist (undated), documented to make sure the four bottom seat belts of the resident's wheelchair were secured. The Safety Transportation policy revised August 2020, documented before transport, the transport aide will ensure the resident is secured to wheelchair and the wheelchair was anchored and secured to the latches on the floor of the vehicle. Following the 08/10/2020 fall incident on the bus, the facility implemented the following corrective actions: -the old 16-seater bus was replaced with two transportation vans, -Safety Transportation policy was revised August 2020 to ensure safety, -the 10-point driver safety checklist was revised and implemented, -continuous training was provided to the driver and transportation aides regarding the revised policies and safety checklist prior to transit, -a transportation coordinator has been designated to oversee the maintenance and periodic checklist for the transportation vans.

Based on interview, record review, and document review the facility failed to ensure a resident was free from a significant medication error involving the administration of insulin for 1 of 19 sampled residents (Resident #12). Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #12 was alert, oriented and able to verbalize his needs. The admission orders [REDACTED] - Humalog ten units SQ (subcutaneous) before each meal (scheduled at 7:00 AM, 11:00 AM, and 4:00 PM) - [MEDICATION NAME] 25 units SQ in the morning and at night (scheduled at 8:00 AM and 9:00 PM) - Accucheck (blood sugar monitoring) before each meal and at night no coverage (scheduled at 6:30 AM. 11:00 AM, 4:00 PM, and 8:00 PM) The Physician's Progress Notes dated 5/19/15 at 10:00 PM, documented: "...sugar (blood sugar) 42 (milligrams per deciliter) usually under good control..." The physician's orders [REDACTED]. On 5/20/15, the resident reported the incident to the Administrator. The resident indicated he was concerned with the medication errors and the nurse did not check the contents of the syringe prior to medication administration. The resident verbalized the Administrator told him the incident would be investigated. On 5/27/15 at 10:30 AM, during the Resident Group Meeting, Resident #12 reported about the incident when he was given two insulin shots instead of one which resulted to the resident's low blood sugar level. Then the nurse gave the resident a shot of [MEDICATION NAME] and was told later on by the nurse that he was given a wrong shot. The Nurse's Notes dated 5/27/15 at 2100 (9:00 PM), documented: "On 5/19/15 pt's (resident's) blood sugar was 42 (42 mg/dL), pt claimed he was given Humalog insulin twice. I was orienting (name) (new hired RN) on SW (Southwest Unit), we were helping each other passing meds (medications) 8 pm (8:00 PM) meds. For some reason (name) (orientee) gave the Humalog insulin at 2000 (8:00 PM), when she took the BS (blood sugar level) for pm. I gave the [MEDICATION NAME] right away when BS was 42... Also, when I gave the [MEDICATION NAME], the first box that I opened was just a syringe of sterile water, I thought that was the [MEDICATION NAME] already, but after giving it, I realized that there was no vial, so I opened up another box, and given (sic) the complete set of [MEDICATION NAME]. Explained to pt and showed him the first syringe was just sterile water." On 5/28/15 at 12:28 PM, the Administrator verbalized on 5/20/15, Resident #12 reported the Licensed Practical Nurse (LPN) gave Humalog at 4:00 PM and the RN (Registered Nurse) Trainee gave another dose of Humalog at 8:00 PM. The resident's physician was at the facility when the incident happened. On 5/28/15 at 1:08 PM, Resident #12 verbalized he received Humalog ten units on 5/19/15 before 5:00 PM. The resident received [MEDICATION NAME] 25 units at 8:00 PM, then two minutes later a new nurse gave the resident Humalog ten units. The resident revealed he asked the nurse after several minutes to check his blood sugar because he felt bad, was jittery, and had blurred vision. The blood sugar level was down to 42 mg/dL. The nurse gave the resident [MEDICATION NAME] but after ten to 15 minutes the nurse came back and told the resident saline was given and not [MEDICATION NAME]. The resident received another shot and was told it was [MEDICATION NAME]. On 5/29/15 at 7:20 AM, the LPN verbalized an RN orientee worked with the LPN on 5/19/15. The LPN confirmed on 5/19/15, Resident #12 received Humalog ten units at 4:00 PM and [MEDICATION NAME] 25 units at 8:00 PM. The RN orientee administered Humalog ten units to the resident around 8:30 PM. Then the resident asked the LPN to check his blood sugar and the result was 42 mg/dL. The LPN indicated the resident was given [MEDICATION NAME] IM (intramuscular) but after a few minutes the LPN realized sterile water was administered and not [MEDICATION NAME]. The LPN verbalized she thought the syringe already contained the medication. The LPN failed to read the label of the first injectable syringe. The LPN took another box of [MEDICATION NAME], prepared and mixed the medication into a sterile water syringe, and gave another shot to the resident. The LPN indicated the first box of [MEDICATION NAME] did not have a vial which contained the medication and the box was sealed when the LPN took it from the medication room. The LPN acknowledged the administration of Humalog ten units around 8:30 PM and the administration of sterile water instead of [MEDICATION NAME] to the resident were considered medication errors. The LPN verbalized the incident was not documented during the shift because they were busy. On 5/29/15 at 7:20 AM, the LPN indicated a late entry was documented in the nurse's notes on 5/27/15 because she was assigned in other units. The LPN acknowledged the physician's orders [REDACTED]. On 5/29/15 at 11:20 AM, the Director of Staff Development (DSD) verbalized the RN orientee was employed at the facility from 5/16/15 to 5/20/15. The DSD confirmed the RN orientee did not receive the usual classroom orientation prior to working on the floor with a Trainer per the instructions of the former DON. The facility's policy titled "Administering Medications" revised 12/12, documented: "...Policy Interpretation and Implementation ...3. Medications must be administered in accordance with the orders, including any required time frame. ...18. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility." The facility's policy titled "Medication Orders" revised 2/14, documented: "...Recording Orders 1. Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered..." The facility's policy titled "Insulin Administration" revised 10/10, documented: "...Preparation ...2. Only the person who draws up the insulin for injection can inject it. 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders [REDACTED]. The facility's policy titled "Adverse Consequences and Medication Errors" revised 2/14, documented: Policy Interpretation and Implementation ...3. A "medication error" is defined as the preparation or administration of drugs or biologicals which is not in accordance with the physician's orders [REDACTED]. 4. Examples of medication errors include: Failure to follow manufacturer instructions and/or accepted professional standards... ...10. The incident is described on the shift change report to alert staff of the need to the following information is documented in an incident report and in the resident's clinical record: a. Factual description of the error or adverse consequence; b. Name of physician and time notified; c. Physician's subsequent orders; and d. Resident's condition for 24 to 72 hours or as directed." A copy of the manufacturer's instructions for the administration of [MEDICATION NAME] provided by the facility documented: "...Instructions for Use: To Prepare [MEDICATION NAME] ([MEDICATION NAME]) For Injection: [MEDICATION NAME] HypoKit includes: 1 (one) vial containing 1 mg [MEDICATION NAME] powder... 1 prefilled disposable syringe with attached needle containing 1 mL (milliliter) solvent (sterile water) for reconstitution. The vial with [MEDICATION NAME] in it has a protective plastic cap. You must remove the plastic cap to inject the water and mix the [MEDICATION NAME]. If the cap is loose or missing when you buy the package, return it to your local pharmacy. Use the prefilled disposable syringe that comes in [MEDICATION NAME] HypoKit, with the attached needle, to mix the [MEDICATION NAME] and sterile water before giving the injection..."

Based on interview, record review, and policy review, the facility failed to ensure 3 of 14 sampled residents were discharged safely and appropriately (Resident #1, #5, #14). Findings include: Resident #1 Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1 was discharged to home on [DATE]. The Post-Discharge Plan of Care indicated Resident #1 was ordered home health and should follow up with the primary care physician within 3 days. There was no information (i.e., name and telephone number of the physician and the home health agency) listed on the form. The Post-Discharge Plan of Care was blank regarding Equipment Needs (commode, wheelchair, special bed), and Special Training / Instructions (injections, dressing change, Foley catheter care, meal preparations / special diet, and pain management). Resident #5 Resident #5 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #5 was discharged to home on [DATE]. There was no documentation of the time the resident was discharged . The Discharge Instructions sheet lacked documentation of the name and contact information of the home health agency, the physical therapy agency, and the vendor for the durable medical equipment. The sections on this form "Next Doctor's Appt (appointment)" and "Current Physical Status of Resident" were blank. The Discharge Instructions lacked documentation regarding: 1) how many liters of oxygen were to be administered; and 2) clear instructions on how to administer the oxygen were explained with the family. There was no documented evidence of any durable medical equipment sent home with the resident. There was no documented evidence on the Discharge Instructions sheet the facility provided any oxygen equipment for Resident #5 to take home, or that the oxygen equipment had been delivered and set up at the home. The Certificate of Death indicated Resident #5 died on [DATE] at the Emergency Department at an Acute Care Facility, with acute cardiopulmonary arrest listed as the cause of death. The following discharge summaries by Physician #2 indicated there was lack of communication with the family and confusion upon discharge regarding the oxygen administration for Resident #5: -Discharge Summary dated [DATE]: "The patient is an [AGE] year old gentleman with very advanced [MEDICAL CONDITION] - stage 4, 02 dependent and chronically hypoxic..." -Discharge Summary dated [DATE]: "...02 saturations 96% on 3 liters of 02, which he is constantly on..." (Note: The Vital Signs Records showed Resident #5 was on 2 liters of 02 on [DATE].) -Discharge Summary Addendum dated [DATE]: "...Please note that I did discuss during the whole hospitalization with him and his wife the importance of wearing his oxygen because of his severe, advanced [MEDICAL CONDITION] biggest concern right now is that I got a call, being told this morning that the patient had apparently passed away, possibly of a [MEDICAL CONDITION] when he got home yesterday. One of the nurses, who was able to speak with one of his daughters, had clearly heard the daughter say that when the patient was taken into the house, he was asking his wife for his oxygen and as per something that the daughter said, they were working on the tubing or wiring for the oxygen. This is very concerning to me. This is a patient where again I discussed with the patient as well as his wife and as well his daughter (name), that the [MEDICAL CONDITION] or [MEDICAL CONDITION] is extremely advanced and that therefore he needs to be on oxygen at all times. I am concerned as to whether the patient was off oxygen for even a brief period of time, which could have endangered him and this is very concerning. I am not aware of what the facts (sic), as I was not there to see it when he went home...Please note again my bigger concern and I am documenting this because of what the nurse told me, is I am trying to figure out why the patient had a [MEDICAL CONDITION] when he went home, when he was perfectly stable when he left (facility) and this was as per the nurse saying he was stable at the time that he went home. He was very stable when I saw him in the morning. My question therefore becomes was the patient off oxygen for even a brief period of time, which indeed could have caused him a high risk of going into [MEDICAL CONDITION]." -Discharge Summary dated [DATE]: "The patient expired, most likely due to a [MEDICAL CONDITION] on [DATE] after going home...I did call the family back today and I was able to speak to their daughter who is a pediatrician...I was very concerned because the nurse, who was quite sharp and understood very clearly what she was told made it clear to me that she was told that he was asking for oxygen and they were apparently fumbling with tubes and it was (the nurse's) understanding that he was either not on oxygen or not on enough oxygen at the time that he was sent home, but what she understood is that he was not on oxygen. This was very clear to her. Clearly, there was a mistake in communication from what the family is telling us, where they said this was never communicated with (nurse)...but again the family claims this is not what they ever told (nurse). The daughter who I spoke to explained to me that he was always on oxygen, that he was saying he could not breathe and somehow I am not sure, I am presuming they wanted to give him more oxygen. I am not sure what they tried to do..." The Resident Progress Notes (written by Licensed Nurse - Employee #13 on [DATE] at 11:45 AM ("Late Entry")) indicated, "This nurse received a telephone call from one of (Resident #5's) daughters...Daughter also stated that her father had expired the night before upon returning home from discharge. This nurse offered condolences and asked daughter what happened. Daughter stated that, 'My father went into [MEDICAL CONDITION].' This nurse asked again what had happened. Daughter was sobbing at this time and stated, 'My mom helped my father into the room, (she then stated something about her father asking for oxygen (between sobs)), Mother had briefly left room was 'fiddling' with tubing, came right back into room and my father had died '..." The Resident Progress Notes dated [DATE] / 5:00 PM ("Late entry for [DATE]") indicated Resident #5 had a "Travel 02 machine" and the nasal cannula was on upon discharge. There was no documented evidence regarding whether a portable oxygen tank was sent home with Resident #5, or if the oxygen machine was an oxygen concentrator. There was no documented evidence on the Resident Progress Notes indicating whether oxygen equipment had already been delivered to the home and was set up. On [DATE] in the afternoon, the Regional Nurse Consultant could not identify from the Resident Progress Notes what a "Travel 02 machine" was, and whether a portable oxygen tank was sent home with the resident for the ride home. On [DATE] in the afternoon, the chart was reviewed with the Director of Nursing (DON) and the Regional Nurse Consultant, who verified there was no documentation of the DME, names and contact information of the home health agency, physical therapy agency, and vendor information for the oxygen equipment. The Regional Nurse Consultant further verified there were no orders or discharge instructions for the oxygen, no evidence the family member was instructed specifically regarding administration of the oxygen, and no evidence the oxygen equipment was delivered and set up at the home. On [DATE] in the afternoon, the Regional Nurse Consultant and the DON indicated there should have been clear documentation contained in the chart indicating the specific oxygen orders, type of oxygen equipment, and confirmation the vendor had delivered and set up the oxygen equipment at the home. Resident #14 Resident #14 was admitted [DATE] with [DIAGNOSES REDACTED]. The facility failed to ensure a resident with unsafe smoking behavior who had a lighter in her possession and required one-on-one supervision was discharged safely. Nurse's Notes dated [DATE] @ 3:30 PM indicated Resident #14 was found behind the kitchen smoking in a non-designated smoking area, and a fire was started. Nurse's Notes dated [DATE] @ 8:00 PM indicated, "Pt strongly refuses to give cigarettes & lighter to staff despite explanation of her safety & everyone else's safety in the hospital..." There was no documented evidence the cigarettes and lighter were removed from Resident #14's possession following the fire incident on [DATE] until the time of discharge on [DATE]. There was no documented evidence the person from the Independent Living Facility who picked up Resident #14 was informed of Resident #14's history of unsafe smoking, the need for supervision, and that the resident was in possession of a lighter. Nurse's Notes dated [DATE] @ 4:00 PM indicated, "Discharge note: Pt discharged to independent living. Alert and oriented x3..." physician's orders [REDACTED]. [DATE]: "Pt will be a 1:1 staff monitoring for safety precautions until further notice." The Post Discharge Plan of Care indicated Resident #14 was discharged on [DATE] to an independent living facility. The Policy and Procedure, "Discharging the Resident", revised [DATE] indicated, in part: "The purpose of this procedure is to provide guidelines for the discharge process...5. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions." Complaint #NV 891 Complaint #NV 651

Based on observation, interview, and record review the facility failed to ensure a post-discharge plan of care was completed for 2 of 17 sampled residents. (Resident #10 and Resident # 3). Findings include: Resident#10 Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. A physician's orders [REDACTED]. Resident #10's Medication Administration Record [REDACTED] -[MEDICATION NAME] 25 milligrams (mg) by mouth daily -[MEDICATION NAME] 10 mg by mouth daily -[MEDICATION NAME] 40 mg by mouth daily -Folic Acid 1 mg by mouth daily -[MEDICATION NAME] 100 mg by mouth daily -Multivitamin 1 tab by mouth daily -[MEDICATION NAME] 5 mg by mouth daily A prescription dated 4/14/14, was in the clinical record that documented Resident #10's discharge medication as follows: -[MEDICATION NAME] 5 (mg) by mouth daily -[MEDICATION NAME] 10 mg by mouth daily -[MEDICATION NAME] 25 mg by mouth daily -[MEDICATION NAME] HFA 2 puffs every four hours as needed The nurses' notes dated 4/18/14, documented Resident #10 was alert and oriented x 2-3. Resident #10 was given discharge instructions, and discharged with medications. The clinical record did not indicate what discharge instructions were given or what medications and quantity of medications were discharged with Resident #10. The clinical record lacked documented evidence the instructions were given in writing. The post discharge plan of care form dated 4/17/2014 and 4/18/2014 lacked documented evidence Resident #10 was instructed on the name of the medication, the frequency of the medication, any special instructions for the medications, or the amount of medication released. The form did not have an appointment scheduled with the community physician or a phone number/address where the physician could be reached. On 4/23/14 in the morning, a Nurse Practitioner (NP) reported the prescription should have been sent with Resident #10 to fill his medications. The NP verbalized if home health was ordered it was expected the facility would make a referral for home health and follow up as appropriate. The facility lacked documented evidence a referral was made for home health as ordered. On 4/23/14 at 3:00 PM, the Social Worker (SW) expressed Resident #10 was discharged to the shelter and the shelter did not accept home health. The SW further indicated the resident did not need home health services and that was the reason a referral was not made. The SW agreed there was not any further documentation for this discharge. A Social Services note dated 03/25/14, indicated the resident was homeless and had "no source of income". The note indicated Resident #10's family was back east and that could be an option for discharge. The clinical record lacked documented evidence of any further follow up for this option. On 4/23/14 at 3:15 PM, the Director of Nursing acknowledged this was not a completed discharge. The policy titled "Transfer or Discharge Documentation" (undated) indicated: "...Documentation from the care planning team concerning all transfers or discharges must include...a summary of the resident's overall medical, physical, and mental condition...disposition of medications...other as appropriate or necessary..." Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician discharge order dated 3/19/14, documented the resident should be discharged home the following day with all medication from the medication cart including narcotics and at least a one month supply of [MEDICAL CONDITION] bags. The "Post Discharge Pan of Care" dated 3/26/14, did not document medications from the medication cart or [MEDICAL CONDITION] bags were provided. The facility provided a Physician Prescription for medication only. On 4/24/14 at 12:30 PM, Resident #3's father indicated he picked up the resident from the facility and did not receive medications or [MEDICAL CONDITION] bags. The resident's father expressed frustration the facility social worker would not allow the discharge until a discharge care conference could be completed on 3/16/14.

Based on interview, clinical record review and document review the facility failed to ensure preventative measures were put into place for one of 21 sampled residents (Resident #20); failed to turn and reposition two of 21 sampled residents (Resident #20 and #10); failed to ensure a resident's physician and responsible party were notified when a pressure ulcer had been identified for 3 of 21 sampled residents (Resident #20, #10, and # 6); failed to ensure a resident's wound was re-assessed in accordance with their policy for one of 21 sampled residents (Resident #10). Findings include: The facility's policy entitled Pressure Ulcer Care dated 5/28/08, documented "A resident who has a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection to the extent possible and prevent new pressure ulcers from developing". #1. If skin breakdown should occur or was identified upon admission, document the area in resident medical record. #2. Consult with attending physician and obtain an appropriate treatment and document in the medical record. #4. Appropriate physician's order for cleansing to minimize colonization and enhance pressure ulcer healing by effective cleansing. #10. Completion of pressure ulcer treatments was to be documented on the resident's Treatment Record. The facility's policy entitled, Pressure Ulcer Prevention dated 5/28/08, documented "A resident who enters the center without pressure ulcers and/or non-pressure ulcers does not develop pressure ulcers and/or non pressure ulcers, unless the individual's clinical condition demonstrates that they were unavoidable." The facility's policy entitled, Change in a resident's Condition or Status dated 4/11, documented the facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition and/or status. Resident #20 Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #20's History and Physical dated 4/12/13, documented over the last 2-3 weeks the resident had been quite weak and debilitated, not eating or drinking. The only thing the resident ate was noodle soup and according to the family was the only thing the resident could "keep down". Otherwise, any other food would make him nauseous, throw up and have diarrhea. The History and Physical dated 4/12/13, lacked documented evidence the resident had a pressure ulcer upon admission to the facility. On 4/12/13, Resident #20's admission orders [REDACTED]. Pressure relief mattress and wheelchair cushion. The admission orders [REDACTED]. Documentation entitled Patient Nursing Evaluation dated 4/12/13 documented Resident #20 required a turning schedule and functional limitation of range of motion. The resident was alert and orientated to place, time, others and self. The documentation indicated the resident had a rash on his back, chest, neck, bilateral upper limbs, perineal area and a scalp rash. The documentation indicated the resident had multiple bruises on both arms. The documentation revealed Resident #20 was a low risk for pressure ulcers. The Patient Nursing Evaluation form did not indicate Resident #20 had an open area upon admission to the facility. The Medical Nutrition Therapy Assessment Form dated 4/15/13 documented Resident #20's skin had no open areas. laboratory results dated [DATE] documented Resident #20's [MEDICATION NAME] level was 2.2 (low- the range was documented as 3.5-5.7 g/dl (gram/deciliter). laboratory results dated [DATE] documented Resident #20's [MEDICATION NAME] level was 2.7 g/dl (low). laboratory results dated [DATE] documented Resident #20's [MEDICATION NAME] level was 2.3 g/dl (low). Documentation entitled, Weekly Skin Integrity Data Collection dated 4/25/13, documented Resident #20 had a new open area on the right buttocks "4 times 1". A Nurses note dated 4/25/13 at 11:30 AM, documented Resident #20 had an open area to the right buttock "4 times 1". The Nurse note on 4/26/13, lacked documented evidence Resident #20's physician and the resident's family were notified about the new open area on the right buttocks. The clinical record lacked documentation a physician's order had been received to treat the open area on the right buttocks or a comprehensive care plan had been developed for the open area on the resident's right buttocks. Documentation from the Wound Consultant dated 4/26/13, documented Resident #20 was a direct admit from the physician's office secondary to weakness, muscle pain and deconditioning which had been worsening over the past 3 weeks. The documentation from the Wound Consultant revealed the resident had a stage 2 pressure ulcer on the right buttocks that was pink and very tender. The pressure ulcer measured "4 times 1" with scant drainage, the color of the wound was red. The Wound Consultant's documented recommendations included: [MEDICATION NAME] gel daily to the ulcer on the right buttocks, the physician to address the pain, continue current treatment plan, RD (Registered Dietician) to evaluate for supplements secondary to poor intake. The clinical record lacked documented evidence Resident #20's physician, the RD and resident's family were notified about the new open area or the recommendations from the Wound Consultant's report on 4/26/13. The clinical record lacked documentation a physician's order had been received to treat the new open area. The clinical record lacked documented evidence of a treatment record for Resident #20 or a comprehensive care plan for the pressure ulcer. The clinical record lacked documented evidence Resident #20 had been turned every 2 hours in accordance with the physicians order from 4/12/13 through 4/26/13. The Physician's progress notes dated 4/25/13 and the physician's discharge summary dated 4/29/13 lacked documentation from the physician about the resident having a stage 2 pressure ulcer. laboratory results dated [DATE] documented Resident #20's [MEDICATION NAME] level was 2.2 g/dl (low). On 5/21/13 at 10:00 AM, the Director of Nursing (DON) verbalized Resident #20's History and Physical revealed the resident was pretty sick, just drinking and eating soup. The DON revealed the admission note and the Registered Dietician's (RD) note both revealed Resident #20 did not have a pressure sore. The DON verbalized on 4/25/13, after the pressure ulcer was identified the physician should have been notified, treatment orders received and a care plan developed. The DON verbalized this had not been done. The DON revealed the nurses notes lacked documentation the physician and the resident's family had been notified of the pressure ulcer. The DON revealed the low [MEDICATION NAME] on 4/18/13 meant the resident had low protein and would not be able to heal. The DON verbalized the laboratory results were signed and had been reviewed by the physician. During the interview the DON verbalized the documentation on the Medication Administration Record (MAR) for turning the resident every 2 hours documented FYI (for your information). The DON revealed this did not provide documentation the resident had been turned every 2 hours in accordance with the physician's order. On 5/21/13, the DON revealed the clinical record lacked documentation a treatment order from the physician had been received for Resident #20's pressure ulcer or evidence a care plan had been developed for the pressure ulcer. The DON verbalized there was no documentation the recommendations from the Wound Consultant visit on 4/26/13 had been followed. The DON revealed after a resident developed a pressure ulcer she would expect documentation in the clinical record from the Registered Dietician (RD). The DON confirmed the clinical record lacked documentation from the RD after the initial assessment had been completed. The DON confirmed the clinical record lacked documentation the physician had addressed the resident's pressure ulcer in the progress notes or discharge summary. The DON verbalized the facility's policy for pressure ulcers had not been followed. On 5/21/13 at 10:45 AM, the Wound Care Nurse and a Registered Nurse (RN) indicated the resident had no pressure ulcer upon admission. The Nurses verbalized if a resident was turned and repositioned it was usually documented on the MAR and in the nurses notes. The Nurses were not able to locate the documentation Resident #20 had been turned and repositioned every 2 hours in accordance with the physician's order. The Wound Care Nurse revealed she had documented the new open area on the resident's right buttocks. The Wound Care Nurse revealed there was no documentation of when the Wound Consultant had been contacted. The Nurses verbalized a pressure ulcer was a change in a resident's condition and the resident's family and physician should be notified. The Nurses were not able to locate documentation the resident's family or physician had been notified about the pressure ulcer. The Nurses confirmed the clinical record lacked a care plan for the pressure ulcer. The RN verbalized [MEDICATION NAME] levels were checked for liver function and healing. During the interview the RN verbalized if a resident was not turned they could develop a pressure ulcer and the pressure ulcer could get worse. The Nurses revealed the clinical record lacked documentation the RD or physician had been contacted after the Wound Consultants report was received. The Wound Care Nurse verbalized she had received a physician's order for the [MEDICATION NAME] gel and completed the treatments daily. The Wound Care Nurse was not able to locate a signed physician's order for the [MEDICATION NAME] gel or the treatment records for Resident #20 to confirm this. On 5/21/13 at 11:10 AM, the DON confirmed the admission orders [REDACTED]. The DON confirmed there was no documentation in the nurses notes a new order had been received from the physician for the pressure ulcer. The DON confirmed Resident #20's clinical record did not contain treatment sheets which documented a treatment order or documentation a treatment had been done. On 5/21/13 at 11:40 AM, a staff member from Medical records revealed they were not able to locate any thinned records for Resident #20. Resident #6 Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's record revealed an admission skin assessment was done on 5/4/13, indicating the resident had a deep tissue injury wound on the heel measuring 0.8 x 1.2 and a coccyx wound measuring 1.5 x 1.4 x 0.1. Review of Resident #6's admission orders [REDACTED]. There was an order to cleanse the deep tissue injury on the right heel with wound cleanser, pat dry, apply [MEDICATION NAME] daily for 30 days. The nurse signature was the wound nurse, licensed practical nurse (LPN, Employee # 7) who completed the admission skin assessment. The orders had not been signed by a physician as of 5/23/13. Review of Resident #6's treatment administration records (TARs) revealed the treatment on the coccyx was done from 5/4/13 through 5/16/13. A second care wound nurse (LPN, Employee #2) made the following entry on 5/17/13 in Resident #6's record, "Patient has developed slough over entire wound bed and pressure ulcer has increased in size and deteriorated. New measurements are 3 x 8 with small/moderate purulent drainage. Patient is completely bed bound and can't reposition self. Patient is frequently turned and heel protectors have been in place since admission assessment.... New orders written to be followed daily." Review of Resident #6's record revealed on 5/17/13, there was a telephone order written to cleanse the wound with wound cleanser, pat dry, and apply Santyl and skin prep, clean dry dressing daily for 30 days. The wound care nurses were interviewed regarding the deterioration of Resident #6's wound. LPN, Employee #7 reported she had no additional documentation for the 5/11/13 wound assessment. LPN, Employee #7 reported she was not staging pressure ulcers yet, as she had not been trained to do so. LPN, Employee #2 indicated the wound had been incorrectly measured on admission. Review of Resident #6's skin inspections revealed an assessment was done on 5/4/13. There were no additional skin assessments in the resident's record. The wound nurses were unable to provide additional documentation regarding when Resident #6's wound began to deteriorate. The wound care nurses were unable to provide evidence the physician had been notified of the deterioration of the wound prior to 5/17/13. On 5/22/13, at approximately 1:00 PM, the Director of Nursing was interviewed and confirmed the facility policy was for weekly skin assessments to be completed on all the residents. The DON confirmed the wound measurements were to be recorded in centimeters (CM). Review of the facility's policy POL 614-02 Pressure Ulcer Care, with an effective date of 5/28/08, revealed under compliance guidelines: "2. Consult with attending physician and obtain an appropriate treatment and document in medical record. 4. Appropriate Physician's order for cleansing to minimize colonization and enhance pressure ulcer healing by effective cleansing. 8. Monitor pressure ulcer and document observations of the pressure ulcer's condition on a daily basis including pain and discomfort. 10. Completion of pressure ulcer treatments is documented on the resident's TAR. 11. Assess pressure ulcer at least weekly for effectiveness of treatment and other pressure ulcer reduction/prevention interventions until pressure ulcer is documented as healed. a. Size - using clock face method 1. Length in cm from ulcer edge to ulcer edge... 2. Width in cm.... 3. Depth in cm is measured from the visible surface to the deepest point in the ulcer. 16. Document in resident medical record identified pressure ulcer complications, notification of physician and any new physician orders. 18. Update care plan as necessary." Review of Resident #6's Braden scale for predicting pressure sore risk revealed it had been completed on 5/4/13, 5/10/13, and 5/17/13. Each time the resident was rated as a 13, or moderate risk. Review of Resident #6's lab values from 5/4/13 revealed an [MEDICATION NAME] level of 2.4 (normal reference range is 3.5 - 5.7) and a total protein level of 4.9 (normal reference range of 6.4 - 8.9). The nurse completing the scale indicated the resident's nutrition was adequate. The resident was on a tube feeding and took nothing by mouth. On 5/22/13, the nurse (LPN, Employee #7) completing the assessment was interviewed and reported the adequate entry included "is on tube feeding, which probably meets most nutritional needs." The nurse had rated the resident's nutrition as adequate on 5/4/13, 5/10/13, and 5/17/13. The nurse had not considered Resident #6's compromised nutritional status when completing the form. The physician saw Resident #6 on 5/6/13 and 5/17/13. Review of the physician progress notes [REDACTED]. Resident #10 Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #10's wound assessment dated [DATE], revealed he had a coccyx wound measuring "9 x 5, red with blanching present." The resident's left great toe had "necrosis measuring 2.5 x 3". Multiple bruises were noted on the right and left arms. admission orders [REDACTED] Monitor bruising to right arm q (every) day x 30 days Monitor bruising to left arm q day x 30 days Cleanse wound to coccyx with wound cleanser, pat dry, apply [MEDICATION NAME]/CDD (Clean Dry Dressing) q day Apply [MEDICATION NAME] to left great toe q day x 30 days Monitor right foot amputation site q day x 30 days The wound care orders written on the form were not identified as verbal orders. As of 5/20/13, ten days after wound care was initiated, the orders were not signed by a physician and no evidence was found to indicate the physician ever issued or approved the wound care orders. Record review revealed Resident #10's wounds were measured by the wound care nurse, Employee #7, on 5/10/13, the day after admission. No evidence was found to indicate the wounds were reassessed and remeasured by the wound care nurse since 5/10/13. Record review revealed Resident #10 saw a wound consultant. Review of the wound consultants reports dated 5/13/13 and 5/17/13, recommended "off loading as ordered" but no evidence was found to indicate off loading was ever written as a physician's order. Review of Resident #10's nursing care plan revealed Resident #10 was to be frequently turned and repositioned. The care plan did not specifically identify the frequency of repositioning and turning required by the resident and no documented evidence was found to indicate the resident was turned on a scheduled basis. The Director of Nursing (DON) was interviewed on 5/23/13, and reported it was the facility's practice not to identify the frequency of turning required by a resident. The wound care nurse, Employee # 2, was a Licensed Practical Nurse (LPN). The nurse was interviewed on 5/21/13 and reported the wound care nurses assessed the wounds the day or day after a resident's admission. The nurse reported she sometimes did talk to the physician before writing out wound orders but did not do so consistently. The nurse reported she would write the wound orders on the admission form and place the form in the resident's chart for the physician to sign. The nurse reported most physician's would sign the wound orders the day of admission or the next day. The nurse reported some physician's came into the facility on ly a few days a week and would not sign the wound orders for almost a week. The nurse reported she did not consistently speak to a physician or obtain a verbal order/telephone order from the physician before initiating wound care. She was not aware Resident #10's physician did not verified/authorize the wound care orders. The nurse confirmed the facility did not identify the frequency of repositioning required by a resident. The nurse reported she was not responsible for documenting the condition of Resident #10's wounds since she was not assigned to the resident for documentation. On 5/22/13, wound care nurse, Employee #7, was interviewed. The nurse reported she was an LPN. The nurse reported she would assess a wound and determine the treatment the would require. The nurse reported she would write the treatment on an admission order form for the physician to sign and leave the form on the chart. The nurse confirmed verbal/telephone orders for wound care were not usually obtained upon admission of a resident and that it may take days for the physician to sign the orders. The wound care nurse reported she did not recall why she did not complete the reassessment of Resident #10's wound following the initial 5/10/13 assessment. Review of the facility policy and procedure entitled "Pressure Ulcer Care" dated 5/28/08 revealed the physician was to be consulted to obtain an appropriate treatment for [REDACTED]. The policy and procedure revealed pressure ulcers were to be assessed at least weekly for effectiveness of treatment and other pressure reduction/prevention interventions.

Based on record review and interview, the facility failed to ensure wound care was provided in a timely manner and as ordered by the physician for 3 of 14 sampled residents (Resident #7, #8, #9). Findings include: Resident #7 Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's medical record on 8/15/13 at 2:30 PM, revealed a Skin Integrity Form which was used to document the resident's skin status and to document the care plan developed to address the resident's skin care issues. The form was blank. There were no physician orders in the medical record for the treatment of [REDACTED]. On 8/15/13 at 3:45 PM, the facility provided a completed Skin Integrity sheet dated 8/7/13 which included the problem - Open [MEDICAL CONDITION] - Stage III sacrum and Interventions including Wound care as ordered. Two additional physician orders were provided, one dated 8/7/13, and one dated 8/10/13. Both orders were telephone orders written by the wound care nurse, not signed by the physician. The telephone orders were written on two separate physician order for [REDACTED]. The telephone order dated 8/7/13, indicated "Wound Consult with Dr (name), Wet to dry dressing to sacral wound qd (every day). The telephone order dated 8/10/13, indicated "Cleanse Stage III to sacrum with wound cleanser, pat dry, apply Santyl and [MEDICATION NAME]. Cover with CDD (Clean, dry, dressing) qd." Resident #7's treatment record (TAR) dated August 2013 documented - "Cleanse Stage III to sacrum with wound cleanser, pat dry, apply santyl and [MEDICATION NAME]. Cover with CDD (Clean, dry, dressing) qd." The date of the order on the TAR was 8/7/13. The treatment was signed as completed by the nurse from 8/7/13 through 8/14/13. Resident # 8 Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's nurse's notes dated 8/11/13 documented "Upon skin assessment, one small open wound noted at coccyx. Put note in wound care chart..." Review of Resident #8's medical record revealed there was no additional wound care assessment done by the wound care nurse, and no documentation wound care was being provided to the resident's coccyx wound. On 8/15/13 in the afternoon, the wound care nurse (WCN) was asked if Resident #8 was receiving wound care to the coccyx, and if the WCN had received a referral from the nurse. The WCN verbalized Resident #8 did not have a wound on the coccyx and was not aware of any referral. The Inspector then asked the Director of Nursing (DON) to have Resident #8's skin assessed and to provide the report. On 8/16/13, received the Skin Integrity Form and care plan dated 8/16/13. The assessment documented two problems. 1) Sheer - Location 2.5 cm (centimeters) above coccyx; 2) Dry patches (no location) A physician's telephone order dated 8/15/13 indicated "Cleanse dry, patchy skin above coccyx with Wound Cleanser, pat dry, apply [MEDICATION NAME] and leave open to air QD (every day)." Resident #9 Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #9's initial nursing evaluation documented the resident had an open area on the R (right) lower extremity (LE) and open areas on the buttocks. There was no additional information documented including the measurements of the wounds, or if there was any drainage. Review of Resident #9's medical record on 8/15/13 at 3:00 PM, revealed a Skin Integrity Form which was used to document the resident's skin status and to document the care plan developed to address the resident's skin care issues. The form was blank. There were no physician orders in the medical record for the treatment of [REDACTED]. On 8/15/13 at 3:45 PM, the facility provided a completed Skin Integrity sheet dated 8/7/13 which included the problem - Open [MEDICAL CONDITION] - RLE, R Buttock, Stage III, L Buttock, Stage III. Interventions included Wound care as ordered. On 8/15/13 at 3:45 PM, the facility provided a physician's order dated 8/10/13, which documented "Cleanse VSU (vascular stasis ulcer) with wound cleanser, pat dry, cover with silver alginate and CDD (clean, dry, dressing) QD (every day). Cleanse Stage III to R Buttock and L Buttock with wound cleanser, pat dry, apply, santyl and [MEDICATION NAME], cover with CDD QD." Resident #9's treatment record (TAR) indicated "Cleanse all wounds with wound cleanser, pat dry, apply TAO (Triple Antibiotic Ointment) cover with CDD", order dated 8/7/13. Documentation on the TAR indicated this order was changed on 8/10/13. The new orders dated 8/10/13 included "Cleanse VSU with wound cleanser, pat dry, cover with Silver Alginate and CDD QD. Cleanse Stage III to R Buttock and L Buttock with wound cleanser, pat dry, apply, Santyl and [MEDICATION NAME], cover with CDD QD." There was no documentation on the TAR that wound care was provided on Resident #9's RLE as ordered. On 8/15/13 in the afternoon, the wound care nurse, Employee #2, verbalized the physician orders, wound care plan and TAR were kept in the wound care office in a separate binder. The WCN verbalized he called the attending physician for the initial wound care orders. On a weekly basis, the WCN made rounds with the wound care physician and wrote all wound care orders as telephone orders based on the physician's recommendations. The employee added there had recently been a problem with ceiling tiles in the office and he was unable to locate the binders which included the physician orders and care plans. On 8/15/13 in the afternoon, the medical records staff was asked to locate the physician orders. The medical records staff verbalized all orders should remain in the medical record. The facility policy titled Pressure Risk assessment dated [DATE], documented "Assessment - 1. Risk Assessment. A pressure ulcer risk assessment will be completed upon admission...Documentation ... 6. The condition of the resident's skin (i.e. (such as), the size and location of any red or tender areas..." The facility policy titled "Wound Care dated October 2010, documented "1. Verify that there is a physician's order for this procedure."

Based on interview and review of documentation, the facility failed to ensure a resident received adequate supervision and assistance devices to prevent a fall for 1 of 4 cases. (Resident #4) Findings include: Resident #4 Resident #4 was admitted on [DATE] with the following Diagnoses: [REDACTED]. On 1/20/12, the resident had a S/P (status [REDACTED]. The resident had a fall at home. On 1/28/12, the interim plan of care for Resident #4 identified: under #5. a Foley catheter in place and was continent of bowel.; #12 mobility: Assist with ambulation and transfers; #18 cognitive status identified as alert, confused and forgetful. On 1/28/12, the Interdisciplinary (ID) Resident Care Plan identified under the column Need/ Concern/ Problems: Potential for Fall/Accident/Injury: mobility impaired; impaired safety awareness; impaired cognitive ability and under other: dementia and Parkinson's were checked in the boxes under this heading. The goals were identified as the resident would have no falls; would have no significant injury related to falls; would have no occult bleeding. The column under the Approach/Interventions: assist with transfers and ambulation as needed; encourage resident to await assistance; ensure call-light within reach of resident; provide with increased supervision as needed; anticipate needs as possible and monitor to ensure frequently used items were easily accessible; notify physician of noted signs and symptoms of bleeding. The Patient Nursing Evaluation, dated 1/28/12, completed by the nurse identified the resident was assessed with [REDACTED]. The nurse identified the resident was considered a high risk for falls with a score of 50 using the Morse Fall Risk Scale. On 1/28/12, the nurse documented on the Admit Nursing Note: "admitted this ___(age noted) male from _____ (name of hospital) via gurney assisted by 2 male _____ (unable to read) staff. Alert but confused with noted shaking of upper extremities. Pt (patient) noted to be agitated at this time. Initiated low bed, tab alarm placed. Frequent monitoring will be done. Mattress on side of bed. Monitored." The history and physical, dated 1/29/12 completed by the resident's attending physician indicated "They mentioned mild dementia. I would assess this as moderate dementia at this point. It will impair his therapy I believe, but we will reassess." The discharge summary, dated 1/31/12 completed by the attending physician indicated "He was here for rehabilitation. This morning, the patient was on the toilet. It is not clear to me whether he had asked for assistance to get off the toilet or not. He was on fall precautions, but he came off the toilet falling to his right side. He is complaining of right arm pain, and nurse noted on evaluation that he was bleeding from the right side of his ear. On my examination, he appears lethargic. EMS (emergency medical services) is here now and arranging to transfer the patient to the hospital. " On 2/3/12 Elder Protective Services (EPS) received a report from the Director of Nursing (DON) at the facility. The report indicated that on 1/31/12, _______(name of resident) was placed on the toilet by a nurse's aide. The resident attempted to get up and fell on his side, hitting his head. The resident has a history of falls and was admitted to the facility on [DATE] after having a craniotomy. The resident was assessed by his physician and then transported to the hospital. On 2/6/12 the assigned EPS social worker contacted the DON. The DON reported the client had a history of [REDACTED]. The DON commented it was well known to staff the client was a fall risk. According to the DON, the nurse's aide took the client to the restroom and assisted him to the toilet. She then left him in the bathroom, told another nurse's aide that she was going on break. The reporter (DON) stated to social worker "He was being neglected and then he fell ." On 2/7/12 the social worker completed a facility visit at the Hospital. The client was not alert and oriented and not able to be interviewed. He again underwent a craniotomy. According to the client's family, the resident's brother and sister, clients prognosis was not good. The sister stated to the EPS social worker that family had informed staff that client could not be left alone. According to the nurse on duty at the hospital, the client was not expected to be alert and oriented again. On 2/8/12, the social worker spoke to the administrator of the facility, stated the nurse aide was currently suspended and the plan was for termination. On 3/14/12 an interview with the Director of Nurisng indicated resident was known as fall risk by staff. The CNA assisted the resident to the toilet and left the resident unattended on the toilet and took her break. Before the CNA left to take her break, she informed another CNA that she was taking her break. The DON at the skilled nursing facility reported to the Nevada State Board of Nursing (not dated). "This is to inform you that on 01/31/12 a pt. (patient) in our facility with a s/p (status [REDACTED]. The nurses' aide left the patient unattended and proceeded to take her break. The patient consequently fell and was sent to the hospital for evaluation and treatment. This nurse aide was suspended during the investigation. The investigation was substantiated for neglect on the part of the nurses' aide for using poor judgement resulting in actual harm. The nurse's aide no longer is employed at ____ (name of the skilled nursing facility)." The facility failed to ensure the CNA monitored the resident when resident was placed on the toilet. The resident had a fall from the toilet which caused actual harm. The facility did not ensure the resident received adequate supervision. Complaint #NV 651