Every finding on record at Trellis Paradise

Based on observation, interview, record review, and document review, the facility failed to ensure the Discharge Summary was completed before obtaining a resident's signature and prescribed discharge medications were appropriately coordinated and transferred with the resident upon discharge for 1 of 36 sampled residents (Resident 118).The deficient practice had the potential to result in an incomplete medical record and discharge instructions, interruption of prescribed medication therapy, lack of continuity of care, delayed treatment, inappropriate billing and medication charges, and adverse clinical outcomes following discharge. Findings include:Resident 118 (R118) was admitted on [DATE], with diagnoses including fracture of left femur and anemia.A Case Management Progress Note dated 04/28/2026, documented R118 expressed a desire to discharge to an assisted living facility. The receiving facility accepted the transfer, scheduled discharge for 04/30/2026, and arranged wheelchair transportation.1) The Packing Slip/Proof of Delivery dated 04/30/2026, documented the facility's receipt of the prescribed medications. The record indicated Nitrofurantoin 100 mg capsules, Rx #90512785/001, quantity 14, and Oxycodone, Rx #90512388/001, quantity 30 tablets, were delivered to the facility and received by nursing staff, as evidenced by the signature on the Proof of Delivery.On 07/09/2026 at 9:50 AM, the Director of Nursing (DON) indicated R118 was discharged on 04/30/2026, with the scripts to the accepting facility. The DON confirmed the Oxycodone and Nitrofurantoin were delivered to the facility and it was returned to the pharmacy post resident's discharge.On 07/09/2026 at 10:01 AM, the Pharmacist confirmed, upon review of the medication return log, there was no documentation indicating 30 tablets of oxycodone had been returned to the pharmacy. The Pharmacist indicated being unable to determine whether the nitrofurantoin had been returned because it was a non-controlled medication and was not tracked.On 07/09/2026, in the morning, the nurse who discharged R118 confirmed the facility had ordered and received the Oxycodone containing 30 tablets before R118's discharge; however, the medication was not provided to R118. The nurse acknowledged the Nitrofurantoin was received after R118's discharge. The nurse indicated R118 was discharged on 04/30/2026 after 11:00 AM and confirmed the prescribed discharge medications had not been appropriately coordinated and transferred with R118 upon discharge.On 07/09/2026, at 1:36 PM, the DON acknowledged the facility ordered and received the Oxycodone prior to R118's discharge. The DON indicated staff were expected to clarify discharge medication orders with the physician whenever there was uncertainty regarding whether a controlled substance, such as Oxycodone, was to accompany the resident upon discharge. The DON explained the physician's discharge orders should clearly specify whether the narcotic medication was to be sent with the resident, and staff were expected to obtain clarification before discharge.The DON located and presented R118's previously delivered unopened bubble pack containing 30 tablets of Oxycodone. The DON indicated the Nitrofurantoin may have already been destroyed and acknowledged R118 may have been billed for the medication because the resident was private pay.2) On 07/09/2026, in the morning, the nurse who discharged R118 confirmed the Discharge Summary had not been completed before R118 signed the document and acknowledged the practice was not consistent with the professional standard of practice. The nurse explained the discharge information should have been completed, reviewed and explained to R118, and the resident's signature obtained to acknowledge understanding of the discharge instructions.On 07/09/2026, in the morning, the Medical Records staff confirmed R118's Discharge Summary contained blank sections despite documentation of R118's signature.On 07/09/2026, at 1:36 PM, the Director of Nursing (DON) confirmed R118's Discharge Summary had not been completed. The DON indicated nurses were expected to complete the discharge information before obtaining the resident's signature to ensure the discharge instructions were complete, appropriate, and understood by the resident.A facility policy titled, Discharge Summary and Plan, revised October 2022, documented when a resident's discharge was anticipated, a discharge summary and post-discharge plan were developed to assist the resident with discharge. The policy documented a copy of the evaluation of the resident's discharge needs, the post-discharge plan, and the discharge summary was provided to the resident and receiving facility, with a copy maintained in the resident's medical record.Complaint #3025672

Based on observation, interview, record review and document review, the facility failed to ensure documentation of care was accurate and truthful as outlined in the Documentation Guidelines of the American Nurses Association for 1 of 36 sampled residents (Resident 101). The deficient practice placed residents at risk for negative outcomes.Findings include:Resident 101 (R101) was admitted on [DATE], with diagnoses including osteomyelitis of ankle and foot. A hospital Discharge summary dated [DATE], revealed R101 underwent surgery for an infected right ankle on 06/18/2026 and a PICC line was placed on 06/19/2026 for a six-week IV antibiotic course.A nursing admission assessment dated [DATE], revealed R101 was admitted to the facility with a right upper arm PICC line.The admission minimum data set (MDS) dated [DATE], revealed R101 had intact cognition and was receiving IV medications through a PICC line.On 07/07/2026 at 9:16 AM, R101 was seated upright in bed with right lower leg in a short-leg cast (a padded surgical splint), a PICC line was observed in R101's right upper arm with transparent dressing dated 07/06/2026. R101 indicated undergoing a second surgery for right ankle after it had gotten infected and R101 was in the facility for therapy and antibiotic therapy. R101 indicated no one had changed the PICC line dressing nor measure arm circumference since admission until the director of nursing (DON) personally changed the dressing yesterday (07/06/2026).A physician order dated 06/25/2026, documented to change PICC line dressing after cleansing with PICC dressing kit, cover with waterproof transparent dressing. A physician order dated 06/25/2026, documented to assess length of external catheter and upper arm circumference three inches above insertion site every seven days during dressing changes.The Medication Administration Record (MAR) revealed a Registered Nurse (RN1) performed the PICC line dressing change and measured external catheter and arm circumference on 06/25/2026 and another nurse (RN2) performed the PICC line dressing change and measured external catheter and arm circumference on 07/02/2026.On 07/07/2026 at 9:40 AM, the DON was present when R101 indicating being familiar with RN1 and RN1 who were night shift nurses, but the resident emphasized RN1 did not perform PICC line dressing change nor measured arm circumference on 06/25/2026 and R2 did not perform dressing change not measure arm circumference on 07/02/2026. R101 pointed to the DON stating the DON was the first nurse who performed care on the resident's PICC line. On 07/07/2026 at 9:42 AM, the DON described R101 as alert, oriented and a credible historian. The DON could not speak to why RN1 and RN2 had signed for PICC line care which did not align with the residents' recollection of events. The DON indicated changing R101's dressing because it had become wet and loose with unreadable date on label.On 07/07/2026 at 9:53 AM, the DON indicated nurses were required to document the procedure in progress notes. The DON confirmed R101's medical record lacked documentation from RN1 on 06/25/2026 and from RN2 on 07/02/2026 regarding R101's PICC line dressing change and measurement of external catheter and arm circumference.On 07/08/2026 at 11:57 AM, RN1 recalled admitting R101 on the evening of 06/25/2026 and completing the resident's admission assessment and entered the resident's admission orders which included PICC line care orders. RN1 acknowledged not performing PICC line dressing change on 06/25/2026 and signing for the task was an honest mistake. RN1 indicated not knowing what the purpose was for measuring arm circumference and not being trained to do it or what measuring device to use.On 07/08/2026 at 5:18 PM, RN2 indicated being assigned to R101 on the evening of 07/02/2026 and confirmed the RN did not perform dressing change on PICC line but may have documented the service as administered by mistake. RN2 was not familiar with the purpose of measuring arm circumference and signing for the task was an oversight on the RN2's part.On 07/09/2026 11:34 AM, the DON provided the professional standards of practice from the American Nurses Association (ANA). On 07/09/2026 at 12:52 PM, the DON indicated expecting nurses to not sign for medications, services and tasks which were not provided or performed. Nurses were trained to document accurately and only after the medication, service or task was completed, administered or provided. The DON stated RN1 and RN2 did not follow professional standards of practice with regards to documentation of care.The ANA Principles of Nursing Documentation 2010 indicated documentation of nursing care must be clear, accurate and accessible and was an essential element of safe, quality evidence-based nursing practice. Nurses document their work for several reasons to include communicating within the health care team, and credentialing purposes. Documentation that is inaccurate, false or misleading can lead to undesirable outcomes.

Based on observation, interview, record review and document review, the facility failed to ensure residents received necessary Activities of Daily Living (ADL) services to maintain the highest practicable physical, mental, and psychosocial well being for 1 of 36 sampled residents (Resident 35). The deficient practice placed the resident at risk not receiving needed services to support daily functioning. Findings include:Resident 35 (R35) was admitted on [DATE] with diagnoses including surgical aftercare following surgery on the circulatory system, presence of cardiac pacemaker, acute chronic diastolic (congestive) heart failure, and cellulitis of left lower limb.On 07/07/2026 at 9:35 AM, R35's feet were noted to be dry, with visible flaking and shedding of the skin. The dryness was generalized across both feet, and the peeling skin.On 07/07/2026 at 9:35 AM, R35 acknowledged their feet were dry and indicated staff were supposed to apply lotion. R35 expressed staff had not applied lotion to the feet as needed.On 07/08/2026 at 10:59 AM the Licensed Practice Nurse (LPN), indicated R35's feet were very dry, and the Certified Nursing Assistant (CNAs) should have applied lotion during daily Activities of Daily Living (ADLs). The LPN confirmed the Certified Nursing Assistant CNAs were responsible for providing showers, baths, ADLs, and should have applied lotion on R35's feet before putting on socks to keep the skin moisturized and help prevent skin breakdown.On 07/08/2026 at 11:04 AM, R35 expressed staff should soak their feet to help reduce the dryness and to assist with the effective application of lotion. The resident expressed soaking feet would help to improve comfort and reduce the dryness.On 07/08/2026 at 11:56 AM, the Wound Care Nurse indicated after the resident's shower, CNAs were to apply lotion before putting on the socks. The wound care nurse indicated when providing ADLs, staff should apply lotion with extremely dry skin, especially on the feet. The wound care nurse reported always educating staff on the importance of applying lotion to residents with dry skin to prevent skin breakdown.On 07/08/2026 at 12:06 PM, the Certified Nursing Assistant (CNA) indicated while providing activities of daily living (ADLs), staff should ensure the resident's skin is properly cleansed and lotion is applied if any areas are observed to be dry. The CNA explained particular attention should be given to the residents' feet, which included applied A&D ointment and regular lotion daily to help maintain adequate moisture. The CNA acknowledged A&D ointment should have been applied to R35's feet before putting on socks due to the resident's extremely dry skin. The CNA indicated applying A&D ointment will help keep the feet moisturized and would assist in preventing skin irritation or potential bruising.The admission Minimum Data Set (MDS) dated [DATE], Personal Hygiene (Section GG) documented R35's ability to maintain personal hygiene was supervision or touching assistance, meaning the resident required oversight, encouragement, or light physical guidance to complete personal hygiene tasks safely and effectively. Cognitive Patterns (Section C), documented R35's cognitive function was intact.The facility policy titled Prevention of Pressure Injuries, revised April 2020, documented staff should moisturize dry skin daily, and ensure the skin remains clean and well-hydrated.

Based on observation, interview, record review and document review, the facility failed to ensure perineal care was performed on a routine basis for a resident with an indwelling catheter for 1 of 36 sampled residents (Resident 45). The deficient practice placed residents at risk for urinary tract infection (UTI).Findings include:R45 was admitted on [DATE] with diagnoses including malignant neoplasm of the rectum and attention to colostomy.A nursing admission assessment dated [DATE], documented R45 was admitted with a 16 French (diameter size)/10 milliliter balloon Foley catheter and had a rectal mass. A physician's order dated 07/06/2026, documented to provide Indwelling Urinary (Foley) Catheter Care every shift, cleanse with soap and water.The medical record lacked documented evidence physician's order to provide catheter care, cleanse perineal (area between anus and genitalia) with soap and water was transcribed and performed from admission on [DATE] through 07/06/2026.On 07/07/2026 at 9:04 AM, R45 laid on specialty mattress, awake and alert. R45 indicated being admitted on [DATE] after rectal surgery and required a Foley catheter to void. R45 indicated staff do not routinely wash catheter insertion site with soap and water. R45 indicated not receiving a shower or bed bath for two weeks and some CNAs would do a quick wipe down of the resident's quickly cleaning penal area with wipes and the resident was unsure if it counted as a bed bath.A perineal care observation was performed by a CNA using soap, warm water and washcloths. The CNA carefully and thoroughly cleaned the resident's genitalia and the catheter tubing. The CNA was present when R45 stated not all staff cleansed the resident's catheter insertion site this thoroughly and oftentimes do not perform the task at all.On 07/09/2026 at 9:14 AM, the Director of Nursing (DON) indicated the facility protocol was to use soap and water for perineal care once every shift for all residents who have an indwelling catheter. The DON indicated performing an audit and identified an order for perineal care was missing from R45's orders so the DON transcribed the order themselves. The DON explained because the order was not entered on admission, there was no documentation perineal care was provided to R45 from 06/03/2026 through 07/06/2026.On 07/09/2026 at 9:23 AM, the DON indicated and when an order was not entered it may not trigger staff to perform the task. The DON indicated not performing perineal care placed the resident at risk for UTI.The facility's Urinary Catheter Care policy revised August 2022, documented catheter care was provided to prevent urinary tract infections. Use soap and water for routine daily hygiene. Document date, time, assessment data, urine characteristics, and any problems noted at the catheter-urethral junction during perineal care.

Based on observation, interview, record review, and document review, the facility failed to ensure the prescribed enteral or tube feeding (TF) was administered timely as ordered for 1 of 36 sampled residents (Resident 109).The deficient practice had the potential to compromise the resident's nutritional and hydration status, and an increased risk of malnutrition and dehydration.Findings include:Resident 109 (R109) was admitted on [DATE] and readmitted on [DATE], with diagnoses including gastrostomy and dysphagia (difficulty swallowing).A care plan dated 05/26/2026, documented R109 was at risk for complications related to enteral nutrition. Interventions included administering the prescribed tube feeding formula as ordered. The goal was for R109 to maintain adequate nutritional and hydration status without signs or symptoms of malnutrition or dehydration.On 07/07/2026 at 10:04 AM, R109 was in bed, non-verbal, and unable to respond to questions. A Kangaroo enteral feeding pump was at the bedside; however, no tube feeding (TF) formula was infusing at the time of the observation. The percutaneous endoscopic gastrostomy (PEG) tube insertion site was covered with a dressing dated 07/06/2026.A physician order dated 05/21/2026, documented nothing by mouth (NPO) diet, with NPO texture and NPO consistency.A physician order dated 07/07/2026 documented changing the current enteral feeding to Jevity 1.5 at 50 milliliters (mL) per hour for 20 hours daily to provide a total volume of 1,000 mL, 1,500 kilocalories (27 kilocalories per kilogram (kg)), 64 grams of protein (1.2 grams of protein per kg), and 760 milliliters (mL) of water via the gastrostomy tube (GT). The TF was scheduled to be infused from 2:00 PM until 10:00 AM the following day, or until the total prescribed volume was infused.On 07/07/2026 at 2:07 PM, R109 was seated in a wheelchair in the dining room. No enteral feeding was being administered despite the physician order for continuous tube feeding to start at 2:00 PM.On 07/07/2026 at 4:30 PM, R109 remained seated in a wheelchair in the dining room. No tube feeding (TF) formula was being administered. Observation of the resident's room revealed the enteral feeding pole was at bedside; however, no feeding had been prepared and initiated.On 07/07/2026, at 4:37 PM, a Licensed Practical Nurse (LPN) confirmed R109's prescribed enteral feeding had not been initiated as ordered. The LPN acknowledged the physician changed the enteral feeding earlier that morning and confirmed the new order. The LPN reviewed the feeding pump history and acknowledged the previous physician order directed at 35 milliliters (mL) per hour for 20 hours daily, for a total of 700 mL of enteral formula and 700 mL of water flushes through GT. The LPN confirmed R109 received 1,766 mL of enteral formula and 1,867 mL of water during the previous 72 hours. The LPN confirmed cumulative deficits of 334 mL of enteral formula and 233 mL of water.The LPN indicated the TF should have been initiated at 2:00 PM and acknowledged R109 was dependent on TF to meet nutritional and hydration needs. The LPN explained R109 remained seated in a wheelchair awaiting assistance to return to bed before the feeding could be initiated. The LPN acknowledged the prescribed enteral feeding formula was not administered timely and confirmed R109 had not received any enteral feeding since the morning, resulting in an approximately seven-hour gap in enteral feeding because the feeding was not initiated at the scheduled time of 2:00 PM.On 07/08/2026, at 12:35 PM, the Registered Dietitian (RD) confirmed R109's enteral feeding formula was changed on the morning of 07/07/2026, due to low sodium and low potassium levels. The RD acknowledged cumulative deficits of 334 mL of enteral formula and 233 mL of water during the previous 72 hours. The RD indicated the expectation was for the prescribed enteral feeding formula to be administered as ordered and initiated at 2:00 PM to meet R109's nutritional and hydration needs, prevent weight loss, and support correction of the electrolyte abnormalities. The RD indicated delaying the initiation of the prescribed tube feeding could compromise the resident's nutritional status and delay improvement of the electrolyte imbalance.On 07/08/2026 at 1:30 PM, the Director of Nursing (DON) indicated staff were expected to administer the prescribed tube feeding (TF) exactly as ordered. The DON explained the

Based on observation, interview, record review and document review, the facility failed to ensure dressing changes were performed for a peripherally inserted central catheter (PICC) line per facility protocol for 1 of 36 sampled residents (Resident 101) and a peripheral intravenous (IV) line was labeled with date and time for 1 of 36 sampled residents (Resident 113). The deficient practice placed the residents at risk of infection and IV-related complications.Findings include: Resident 101 (R101) was admitted on [DATE], with diagnoses including osteomyelitis of ankle and foot. A hospital Discharge summary dated [DATE], revealed R101 underwent surgery for an infected right ankle on 06/18/2026 and a PICC line was placed on 06/19/2026 for a six-week IV antibiotic course.A nursing admission assessment dated [DATE], revealed R101 was admitted to the facility with a right upper arm PICC line.The admission minimum data set (MDS) dated [DATE], revealed R101 had intact cognition and was receiving IV medications through a PICC line.On 07/07/2026 at 9:16 AM, R101 was seated upright in bed with right lower leg in a short-leg cast (a padded surgical splint), a PICC line was observed in R101's right upper arm with transparent dressing dated 07/06/2026. R101 indicated undergoing a second surgery for right ankle after it had gotten infected and R101 was in the facility for therapy and antibiotic therapy. R101 indicated no one had changed the PICC line dressing nor measure arm circumference since admission until the director of nursing (DON) personally changed the dressing yesterday (07/06/2026).A physician order dated 06/25/2026, documented to change PICC line dressing after cleansing with PICC dressing kit, cover with waterproof transparent dressing. A physician order dated 06/25/2026, documented to assess length of external catheter and upper arm circumference three inches above insertion site every seven days during dressing changes.The Medication Administration Record (MAR) revealed a Registered Nurse (RN1) performed the PICC line dressing change and measured external catheter and arm circumference on 06/25/2026 and another nurse (RN2) performed the PICC line dressing change and measured external catheter and arm circumference on 07/02/2026.On 07/07/2026 at 9:40 AM, the DON was present when R101 indicating being familiar with RN1 and RN2 who were night shift nurses, but the resident emphasized RN1 did not perform PICC line dressing change nor measured arm circumference on 06/25/2026 and R2 did not perform dressing change not measure arm circumference on 07/02/2026. R101 pointed to the DON stating the DON was the first nurse who performed care on the resident's PICC line. On 07/07/2026 at 9:42 AM, the DON described R101 as alert, oriented and a credible historian. The DON could not speak to why RN1 and RN2 had signed for PICC line care which did not align with the residents' recollection of events. The DON indicated changing R101's dressing because it had become wet and loose with unreadable date on label.On 07/07/2026 at 9:53 AM, the DON indicated nurses were required to document the procedure in progress notes. The DON confirmed R101's medical record lacked documentation from RN1 on 06/25/2026 and from RN2 on 07/02/2026 regarding R101's PICC line dressing change and measurement of external catheter and arm circumference.On 07/08/2026 at 11:57 AM, RN1 recalled admitting R101 on the evening of 06/25/2026 and completing the resident's admission assessment and entered the resident's admission orders which included PICC line care orders. RN1 acknowledged not performing PICC line dressing change on 06/25/2026 and signing for the task was an honest mistake. RN1 indicated not knowing what the purpose was for measuring arm circumference and reported not being trained to measure the arm circumference or what measuring device to use.On 07/08/2026 at 5:18 PM, RN2 indicated being assigned to R101 on the evening of 07/02/2026 and confirmed dressing [NAME] was not completed but may have documented the service as administered by mistake. RN2 was not familiar with the purpose of measuring arm circumference and signing for the task was an oversight.On 07/08/2026 at 3:35 PM, the DON indicated expecting RN1 and RN2 to perform the PICC line dressing change and measurement of arm circumference prior to signing for the task. The DON explained measuring arm circumference was to monitor for edema around insertion site and not performing PICC line cleansing and dressing change every seven days placed the resident at risk for infection and other IV-related complications.The Central Venous Catheter Dressing Change policy dated 2001, instructed to change dressing when it becomes damp or loose or every day when using transparent dressing. Label with initials and date. Document date and time of dressing change, and complications, as well as any resident statement and education given. Resident 113 (R113) was admitted on [DATE], with diagnoses including gangrene to left great toe. On 07/07/2026 at 12:19 PM, R113 laid awake in bed with IV pole on left side of the bed. A peripheral IV was observed on left hand, undated and bleeding at insertion site. On 07/07/2026 at 12:22 PM, a certified nursing assistant (CNA) and a Licensed Practical Nurse (LPN) confirmed the resident's left hand peripheral line was not labeled with date and time and bleeding was present at insertion site.A physician order dated 07/03/2026, documented to insert short peripheral IV catheter one time only. Rotate IV Site as needed when clinically indicated as needed.A physician order dated 07/03/2026, documented to give Zosyn Intravenous Solution 3-0.375 grams/50 milliliter (Piperacillin Sodium-Tazobactam Sodium in Dextrose), intravenously three times a day for urinary tract infection for seven days. On 07/08/2026 at 3:47 PM, the DON indicated the policy was not followed when R113's peripheral IV was not labeled with date and time. According to the DON, peripheral IVs were meant for short term use and should be labeled with date and time upon insertion to monitor the 72-hour time frame. The facility's peripheral IV Catheter Insertion policy dated 2001, documented to place label on one side of the catheter not covering insertion site with date and time of insertion.

Based on observation, interview, record review, and document review, the facility failed to ensure a change in the resident's respiratory distress was assessed and documented, a physician's order was obtained and transcribed including the care and management for Oxygen (O2) use for 1 of 36 sampled residents (Resident 8). The deficient practice had the potential to result in the unauthorized administration of O2, worsening change in condition, delayed physician intervention and treatment, progression of respiratory compromise, respiratory failure and hospitalization. Findings include:Resident 8 (R8) was admitted on [DATE], with diagnoses including obesity, diabetes mellitus, and cirrhosis of liver.The Nursing admission Evaluation, dated 06/12/2026, documented R118's respiratory assessment indicated no shortness of breath, and no respiratory equipment was in use. The Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R8's cognitive status was intact. The Respiratory Treatments section contained no indication R8 required or received Oxygen (O ) therapy.On 07/07/2026 at 10:28 AM, R8 was in bed with eyes closed. O2 was on and flowing at four (4) liters per minute (LPM) through a nasal cannula. A portable O2 concentrator was also observed attached to R8's wheelchair. No signs of respiratory distress or difficulty breathing were observed.On 07/07/2026 at 2:00 PM, R8 remained in bed with eyes closed. O2 continued to be flowing via O2 concentrator at 4 LPM through a nasal cannula. A humidification water container dated 07/07/2026, attached to the O2 concentrator. No signs of respiratory distress were observed.On 07/07/2026, in the morning, R8 remained in bed with eyes closed. O2 continued flowing at 4 LPM through a nasal cannula. The LPN indicated O2 was being administered as needed to maintain R8's O2 saturation. On 07/09/2026 at 10:45 AM, R8 was in bed, awake, alert, and oriented. R8 indicated O2 was administered after saturation levels became low and shortness of breath developed approximately one week after admission to the facility. R8 indicated O2 had been administered during a previous hospitalization and indicated the O2 therapy helped make breathing easier.R8's medical records lacked documented evidence of a physician order for O2 therapy, a respiratory assessment, and initiation of a care plan to address the resident's change in condition.On 07/09/2026, at 11:00 AM, the assigned Licensed Practical Nurse (LPN) verified and confirmed there was no physician's order authorizing O therapy for R8 and no documented diagnosis supporting its use. The LPN indicated not being the admitting nurse and explained R8 had recently been transferred to the room currently occupied. The LPN was unable to identify an admission assessment or subsequent nursing assessment documenting the onset of R8's respiratory symptoms, the initiation of O therapy, or the clinical indication for the therapy.The LPN further indicated a physician order was required before initiating O therapy and the resident's response to the therapy should have been assessed and monitored. The LPN acknowledged there was no documented evidence supporting the initiation of O therapy, the resident's assessment, or ongoing monitoring. The LPN further indicated inappropriate administration of O therapy could place a resident at risk for complications, including carbon dioxide retention.On 07/09/2026, at 2:30 PM, the Director of Nursing (DON) indicated the facility's process required a physician's order before initiating O therapy. The DON explained a change in condition required completion of a Situation, Background, Assessment, and Recommendation (SBAR), physician notification, a nursing assessment, and initiation of a care plan. The DON confirmed R8's medical record lacked documented evidence of a physician's order for O therapy, a nursing assessment, SBAR, and a care plan addressing the resident's change in condition.On 07/09/2026, in the afternoon, Nurse Practitioner (NP) was unable to recall whether notification had been received regarding R8's respiratory distress. The NP explained the facility's process for a change in condition included notifying the provider, obtaining and implementing physician orders, assessing and monitoring the resident's condition and the care provided. The NP indicated initiation of O therapy required a physician's order, monitoring of R8's response, and ongoing care and management.A facility policy titled Oxygen Administration, revised October 2010, indicated staff were to verify a physician's order before initiating oxygen administration, review the resident's care plan for any special needs, and assess the resident before and during O therapy for signs and symptoms of cyanosis, hypoxia, oxygen toxicity, changes in vital signs, lung sounds, oxygen saturation, and other pertinent clinical indicators, as applicable.

Based on interview, record review, and document review nursing staff failed to document physician notification, change in condition, nursing interventions or attempts to obtain a physician order to manage a resident's high temperature (fever) as documented in facility policy for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for harm or adverse outcomes due to delayed medical evaluation and treatment. Findings include:Resident 1 (R1) was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and pneumonia.On 08/14/2025 at 8:54 PM, R1 had an oral temperature of 102.9 degrees Fahrenheit (F) documented on the Weights and Vitals Summary. The next documented temperature was an oral temperature of 98.6 degrees (F) taken on 08/15/2025 at 12:39 PM.The Nursing - daily skilled charting form dated 08/14/2025 at 11:44 PM documented an oral temperature of 102.9 on 08/14/2025 at 8:54 PM. The document was electronically signed by a licensed practical nurse on 08/15/2025.R1's medical record lacked documented evidence of a change in condition, that staff contacted the family, or a physician order was obtained for interventions related to the high temperature. The temperature was not retaken until the following day, and there was no documented evidence of what occurred during the more than 15 hours between the first and second readings.A physician progress note dated 08/15/2025 documented a high temperature of 102.9 degrees (F) and noted patient with temperature signed by physician on 08/17/2025 at 7:49 PM. This note also revealed the chest x-ray on 07/30/2025 showed slight left lower lobe pneumonia treated with combination therapy of Augmentin and Doxycycline antibiotics both for 5 days, follow up chest x-ray on 08/12/2025 showed persistent left lower lung bronchopneumonia, infectious disease was consulted and escalation to intravenous antibiotic therapy may be required. Fever, monitor closely, repeat labs if persistent, Tylenol as needed. On 11/18/2025 at 1:00 PM, a Licensed Practical Nurse (LPN), explained a temperature above 100.3 degrees (F) was considered high and interventions such as lowering the room temperature, offering water, using a cool towel, and wiping down the resident's face and neck done prior to receiving physician orders. A change of condition assessment would have been completed, the charge nurse alerted, the physician notified for orders, and the resident's family contacted. The LPN stated a possible physician's order might have been Tylenol 325 milligrams give, one to two tablets, and confirmed an order was required to give Tylenol. The LPN indicated all interventions would have been documented and the temperature rechecked within the hour to report back to the physician.On 11/18/2025 at 1:10 PM, a Certified Nursing Aide (CNA 1), explained vital signs were taken at the beginning of shift or when a nurse requested them. The CNA would have notified a nurse if the resident's temperature was above 99 degrees (F). The CNA would have continued to monitor the resident and rechecked the temperature in 30 minutes to an hour and reported the findings back to the nurse.On 11/18/2025 at 1:16 PM, Certified Nursing Aide (CNA 2), a nurse would have notified if the resident's temperature was above 99 degrees (F)and the temperature rechecked within 15 minutes and reported the findings back to the nurse.On 11/18/2025 at 1:20 PM, a Registered Nurse (RN), explained that vital signs were checked in the morning and again later in the day if needed before medications were administered. A temperature above 100.3 F was considered high, and interventions would have been done, including giving Tylenol, applying a cold compress, wiping the resident down, providing hydration, removing blankets, lowering the room temperature, and rechecking the temperature in one hour. The physician would have been notified initially, and if the interventions did not work, the nurse would have contacted the physician again for further orders such as Tylenol or laboratory bloodwork. The situation would have been documented as a change of condition, the resident's family notified, and the temperature rechecked within the hour. The RN added that a high temperature raised concern for infection and possible sepsis, which was why laboratory bloodwork would be needed.On 11/18/2025 at 2:55 PM, the Director of Nursing (DON) explained a temperature above 99.1 degrees (F) was considered high, and a physician would have been notified. A change of condition would be completed, and the facility would get a physician order and place it in the system. The resident's family would have been notified but if the resident was alert and oriented the resident would be told to contact the family with their information. While waiting on the physician's order, interventions and cooling measures would have been done. The temperature would be rechecked within the hour. The DON stated there was no facility standing order for temperature medications.On 11/18/2025 at 3:43 PM, a Physician explained, documenting Tylenol as needed in a physician progress note should not be considered a Tylenol order, because an order must include the type, route, dosage, frequency and strength of the medication. The physician stated the facility nurses called directly or contacted the answering service after hours to make physician notifications for changes in conditions. Physicians would have given verbal orders over the phone or placed the orders themselves. In a change-of-condition event, the expectation was to document the fever and the nursing interventions, and the temperature rechecked.On 11/18/2025 at 4:08 PM, the DON confirmed R1's medical record lacked a change of condition for the high temperature, nursing progress notes regarding interventions, and physician notification.The facility's Change in a Resident's Condition or Status policy dated 02/2021 documented the facility promptly notified the resident, the attending physician, and the resident representative of any changes in the resident's medical or mental condition. The nurse notified the physician or on-call physician when there was a significant change in the resident's physical condition or a need to significantly alter medical treatment. The policy indicated nurses made detailed observations, gathered relevant information for the provider, and, except in emergencies, made notifications within 24 hours of the change. Regardless of the residents' condition, staff informed the resident of changes in care and documented all related information in the medical record. Complaint #2591137

Based on record review, interview and document review, the facility failed to ensure medical record documentation was complete and accessible for 1 of 5 residents (Resident #1).Findings Include:Resident 1 (R1) was admitted on [DATE], with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and pneumonia.A Licensed Practical Nurse completed a daily skilled charting form on [DATE] at 11:44 PM, which showed an oral temperature of 102.9 Fahrenheit. The nurse entered the temperature at 8:54 PM.An oral temperature of 98.6 Fahrenheit was entered on [DATE] at 12:39 PM, according to the weights and vitals summary.On an effective date of service progress note dated [DATE], a physician documented acknowledging the resident's fever with recommendations to continue to monitor closely, repeat labs if persistent and Tylenol as needed. The above note was e-signed at 6:49 PM on [DATE]. The resident expired on [DATE]. The above note was not transferred to the facility's software until late [DATE]. On [DATE] in the afternoon, the Director of Nursing (DON) was unable to provide information, despite attempting to get an answer, regarding whether the creation date in the facility's software (of late [DATE]) was the date the facility's software accepted the transferred note, dated [DATE], from the physician or not. When a copy was requested, the DON refused to provide one, saying a copy could not be provided because of HIPAA privacy. Section #7 of the Electronic Medical Records policy provided revealed authorized federal and state survey agents as outlined may be granted access to electronic medical records. On [DATE] at 1:00 PM, a Licensed Practical Nurse indicated a temperature of 100.3 Fahrenheit constituted a change in condition, requiring provider notification, intervention(s) to address the increased temperature, follow-up monitoring and change in condition documentation. All actions were documented.On [DATE] at 1:20 PM, a Registered Nurse indicated a temperature of 100.3 Fahrenheit constituted a change in condition, requiring provider notification, intervention(s) to address the increased temperature, follow-up monitoring and change in condition documentation. All actions were documented.On [DATE] at 2:55 PM, the DON indicated a temperature of 99.1 Fahrenheit constituted a change in condition, requiring provider notification, intervention(s) to address the increased temperature, follow-up monitoring and change in condition documentation. All actions were documented.On [DATE] at 3:43 PM, R1's Physician verbalized it was expected there would have been documentation on the fever or interventions from facility nursing staff. The Physician expected the temperature to be rechecked, and interventions documented. The Physician did not recall any update from the covering physician regarding addressing an elevated temperature. The Physician did not know what 00:00 meant next to the effective date referenced in the progress note or why a visit time was not specified. Physicians had up to 48 hours after opening an electronic progress note to finish it. The covering physician did not specify labs to order, so a verbal order over the phone or put in an order himself for labs or Tylenol would have had to be given. On [DATE] at 4:08 PM, the DON claimed the [DATE] date of service progress note inferred the physician was notified. The medical record lacked documented evidence of physician orders and/or nursing interventions to address the increased temperature and follow-up monitoring and change in condition documentation. R1's medical record lacked documented evidence of any nursing interventions and/or monitoring related to the change of condition. The medical record and aforementioned physician progress note lacked documented evidence of visit time. The Change in a Resident's Condition or Status policy dated 02/2021 revealed a nurse notified a physician when there was a significant change in the resident's condition. Prior to notifying a physician, the nurse made detailed observations and gathered pertinent information for the provider. The nurse notified the resident and/or resident representative within 24 hours. The nurse documented in the resident's medical record information relative to changes in the resident's medical condition or status.R1's medical record lacked documented evidence, a nurse notified a provider and documented information relative to changes in the resident's medical condition or status. The Physician Services policy dated 2001 revealed physician orders and progress notes were maintained in accordance with facility policy.The aforementioned policy lacked documented evidence for holding physicians accountable for electronic entries or their software transfers accountable for timely transfer documentation, such as progress notes. Complaint #2591137

Based on observation, interview, and document review, the facility failed to ensure syringes filled with normal saline used to flush intravenous (IV) catheters were left unattended in two different resident rooms. The deficient practice had the potential to compromise residents' safety and infection control standards since the unsecured items could have been inadvertently misused or contaminated.Findings included:On 07/22/2025 at 11:08 AM, Resident 11 was observed with a peripheral intravenous (IV) line placed in the left hand and was receiving IV antibiotic therapy. An open 10 milliliter (ml) prefilled syringe labeled Sodium Chloride 0.9% (Normal Saline Solution), containing a clear liquid was attached to the antibiotic bag and left unsecured in the resident's room. A Licensed Practical Nurse (LPN) confirmed the observation and stated the syringe was used to flush the IV line and should have been discarded after being used. The LPN verbalized the presence of the open syringe posed a potential infection control concern.On 07/22/2025 at 11:20 AM, Resident 88 was observed with a Peripherally Inserted Central Catheter (PICC) in the right upper arm. Two unopened 10 ml prefilled syringes labeled Sodium Chloride 0.9% containing a clear liquid, were found on top of a sharp disposal container in the resident's room. An LPN verified the observation and acknowledged the syringes should not have been left in the room unattended due to safety and infection control concern. The LPN indicated syringes used to flush IV lines should be stored in a medication cart or medication room.On 07/25/2025, the Assistant Director of Nursing (ADON) acknowledged syringes containing Normal Saline Solution used to flush IV lines should not have been left in resident rooms. The ADON emphasized that this practice poses risks to patient safety. The facility's policy titled Storage of Medications, last revised in November 2020, stipulated drugs and biologicals used in the facility must be stored in locked compartments and accessed only by authorized personnel.

Based on observation, interview, and document review, the facility failed to ensure 1) expired food products were discarded; 2) food was labeled, 3) dented cans were removed from use; and 4) perishable food products were properly stored in the walk-in refrigerator. The deficient practices had the potential to increase the risk of bacterial growth and cross-contamination that could cause foodborne illness and jeopardize the health and safety of the residents.Findings included:On 07/22/2025 at 7:41 AM, an inspection of the kitchen was conducted with a cook and the following deficiencies were observed:Food Preparation Area:- Countertop oven cavity floor tray was visibly soiled with food remains; three baking trays inside were also dirty.- One mobile ingredient bin was empty but unclean.- Another bin containing an unlabeled white powder (identified by the cook as dry milk) was contaminated with black debris and plastic cups. The cook acknowledged the bin should have been labeled with the product name and use-by date.Walk-In Refrigerator: - Two unlabeled 4-quart cheese containers.- One 5-pound container of cottage cheese expired on 07/13/2025.- One container of egg salad expired on 07/09/2025.- Unlabeled containers observed:- Two with gravy- One with beef patties- One with corn kernels- One with cooked chicken- One with chicken soup- One open gallon of mayonnaise- One open gallon of sweet pickle relish- One open packet of sliced Swiss cheeseWalk-In Freezer:- A packet of green peas was placed directly on the freezer floor.Dry Storage:- One 1-pound bottle of caramel topping opened on 11/01/2024 and expired 01/30/2025.- Two dented 6-pound cans of Mandarin oranges- Two dented 6-pound cans of country-style gravyThe cook confirmed the findings and acknowledged several food items had been improperly stored or inadequately labeled. The cook stated expired products should have been discarded. The cook explained the countertop oven had not been used recently and admitted it should have been cleaned after its last use.The facility policy titled Food Receiving and Storage last revised in November 2022, documented dry foods were removed from the original packing and stored in bins labeled and dated. The policy indicated that all foods stored in the refrigerator or freezer should be labeled and dated.

Based on observations, document review and staff interview, the facility failed to secure 2 of 4 medication carts and 1 of 2 treatment carts. This deficient practice had the potential to compromise residents' safety and cause harm from unauthorized access to controlled substances. Findings include: On 03/26/2025 at 8:21 AM, a treatment cart was left outside of the nourishment room across from the clean linen room, unlocked and unattended. The drawers were easily accessible to a resident or visitor walking by the cart. The contents inside the treatment cart were scissors, various ointments, creams and various sized dressings. On 03/26/2025 at 10:33 AM, a medication cart was left unattended and unsecured in front of room [ROOM NUMBER] with a 50 milliliter (ml) intravenous bag of Saline with a 1mg of Meropenem (an antibiotic medication) laying on the counter of the cart. The Registered Nurse (RN) was inside of room [ROOM NUMBER] without view of the medication cart. The RN indicated this is only the employees fourth day and is in training. On 03/26/2025 at 12:00 PM, in front of room [ROOM NUMBER], an unattended medication cart was open. A Registered Nurse (RN) confirmed the medication cart was unlocked and verbalized the lock system to the medication cart could potentially be broken. The RN indicated the medication cart should be locked so residents don't come around and take the medications. On 03/26/2025 at 8:23 AM, a Certified Nursing Assistant (CNA), verified the treatment cart was unlocked and stated the cart belonged to wound care and it should not be unlocked because of the safety concerns for the residents due to the cart containing ointments, scissors and gauze. On 03/26/2025 at 8:30 AM, a Registered Nurse (RN), verbalized the treatment cart was unsecured and indicated the cart stays unlocked for treatment needs and supplies. The RN voiced the key was lost and the cart should be locked because residents could have unauthorized access to the cart. On 03/26/2025 at 12:01 PM, the wound care nurse confirmed the treatment cart contains medications. On 03/26/2025 at 12:02 PM, the Assistant Director of Nursing (ADON), confirmed the medication cart in front of room [ROOM NUMBER] should have been locked. The ADON was unaware a treatment cart and medication cart located in the south hallway could not be locked. The facility policy titled Security of Medication Cart revised in April 2007, documented the cart must be securely locked at all times when out of the nurse's view. The cart must be parked against a wall with all doors and drawers facing the wall and locked before the nurse enters a resident's room.

Based on record review, interview, and document review, the facility failed to ensure coordination of care was maintained with the referred home health agency for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for an unsafe discharge. Findings include: Resident 1 (R1) was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, muscle weakness, multiple sclerosis, difficulty walking, chronic pain and scoliosis. On 03/21/2025 at 3:53 PM via telephone, R1 denied being contacted by the home health agency within 24 to 48 hours as indicated by the facility's case manager upon discharge, and did not receive any form of care by the referred home health agency. The Discharge summary dated [DATE], documented the resident was referred to a home health agency for physical therapy, occupational therapy, and nursing services. The agency's name and phone number were recorded in the note. On 03/26/2025 at 12:27 PM, the Licensed Practical Nurse who identified as the Case Manager Director indicated the role of a case manager entailed discharge planning and coordination of care with different organizations such as home health agencies. On 03/26/2025 at 1:20 PM, the Registered Nurse who identified as the Case Manager (CM) conveyed the home health agency would typically contact the resident within 24 to 48 hours after discharge. The CM would follow-up with the home health agency within the next four weeks post discharge to ensure care was being undertaken by the home health agency. The CM indicated the follow-up phone call with home health agency was not charted in the medical record. On 03/26/2025 at 1:32 PM, the CM explained the home health care agency informed the CM the resident was seen for one week but did not open the door for a subsequent visit. The CM could not provide the time period of the visit from today's conversation with the referred home health agency. On 03/26/2025 at 4:15 PM via telephone, the Office Manager from the referred home health agency conveyed R1 was never under the agency's care. On 03/26/2025 at 4:23 PM, the CM confirmed the referred home health agency name and phone number documented in the Discharge summary dated [DATE] was correct. The CM acknowledged preexisting issues with the home health agency regarding another resident's care prior to R1's coordination of care. The CM admitted a follow-up phone call to the agency and the resident should have been made to ensure services were provided. The CM confirmed there was a breakdown in continuity of care between the facility and the home health care agency. On 03/26/2025 at 4:47 PM, the Director of Nursing (DON) confirmed a follow-up phone call to the resident and home health care agency was crucial to sustaining continued care due to the home health agency's past performance. The facility policy titled, Discharge Summary and Plan revised 10/2022 documented the post discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and includes arrangements that have been made for follow-up care and services. Residents who are discharged to a home health agency are assisted in selecting a post-acute care provider relevant and applicable to the resident's goals of care and treatment preferences. Complaint #NV00073111

Based on observation and staff interview, the facility failed to protect a residents protected health information. This deficient practice had the potential to cause unauthorized disclosure or misuse of protected health information (PHI). Findings Include: On 03/26/2025 at 10:33 AM, a medication cart was left unattended and unsecured in front of room [ROOM NUMBER] with a 50 milliliter (ml) intravenous bag of Saline with one milligram (mg) of Meropenem (an antibiotic medication) laying on the counter of the cart. The Registered Nurse (RN) responsible for the cart, was in room [ROOM NUMBER] and had left the laptop computer screen on the cart open with the resident name, medication profile and diagnoses of room [ROOM NUMBER]'s resident exposed to the public or other residents walking by. The RN returned to the medication cart from room [ROOM NUMBER], and indicated this is only the employees fourth day and is in training. The RN explained the computer screen should have been locked to protect the residents' medical information. On 03/26/2025 in the afternoon, a Licensed Practical Nurse (LPN), stated nurses are trained to close the laptops or to place the screen on lock before walking away from a medication cart to ensure no one could view resident information. On 03/26/2025 in the afternoon, a Registered Nurse (RN), stated the nurses were trained to protect protected health information (PHI) by ensuring laptops were locked or closed to prevent others from viewing. The facility policy titled Confidentiality of Information and Personal Privacy revised in October 2017, documented the facility would protect and safeguard the confidentiality and personal privacy of all residents' personal and medical records.

Based on observation, interview and document review, the facility failed to maintain proper linen handling procedures. This deficient practice placed patients at risk for exposure to infections. On 3/26/2025 at 8:48 AM, Certified Nursing Assistant (CNA1) was observed walking into room [ROOM NUMBER] with clean linen held beneath the CNA's left arm and up against the staff member's uniform. On 03/26/2025 at 10:40 AM, two CNAs were observed walking out of the linen room while holding clean linen against their chest and uniform. Both CNAs confirmed they were transporting the clean linen to resident rooms. CNA2 acknowledged staff should hold clean linen away from their body or place clean linen in a plastic bag during transport to prevent contamination. The Assistant Director of Nursing (ADON) who had observed the incident from the nurse's station, indicated the CNAs should have transported the clean linen away from their body to prevent infection or contamination from the clean linen being against their uniform, which may not be clean. The facility policy titled Soiled Laundry and Bedding revised on 09/2022, documented clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.

Based on observation, interview, document review, and record review, the facility failed to honor resident rights related to the use of incontinence brief and repositioning for 1 of 26 sampled residents (R252). The deficient practice placed the resident at risk for negative psychosocial outcomes and diminished comfort. Findings include: Resident 252 (R252) Repositioning: R252 was admitted on [DATE] with diagnoses including muscle weakness. Review of R252's care plan revised on 09/09/2024, identified the resident at risk for pain related to a recent back surgery. Care plan Goals included: - The resident will be comfortable using non-pharmaceutical methods to control pain daily. Care Plan interventions: - Reposition as needed for position and comfort. - The care plan indicated R252 had the potential for skin integrity impairment and required the resident to be turned and repositioned every two hours when dependent. On 09/17/24 at 9:06 AM, R252 was observed awake lying on back in bed. R252 stated they did not get up as instructed by the medical doctor (MD) following their back surgery. R252 complained they were not repositioned and stayed in the same position all day. On 09/19/24 at 12:45 PM, R252 was observed lying in bed on their back. R252 stated the incontinent brief they were wearing was wet. On 09/19/24 at 1:48 PM, a Certified Nursing Assistant who was taking care of R252, stated R252 was total max assist (Staff Dependent) and unable to reposition or toilet self. The CNA stated the resident was alert and was able to communicate needs. The CNA stated when they needed to know resident preferences, it was communicated at shift report but did not know how to check resident preferences on the computer. On 09/20/24 at 3:37 PM, the Director of Nursing (DON) stated all residents were on a pressure relieving mattress but still required repositioning. DON was notified R252 had expressed not being turned or repositioned and stated they would investigate. On 09/19/24 at 4:53 PM, R252 was observed lying in bed on back with head of bed up thirty degrees. R252's family was at the bedside and stated were concerned R252 was not being repositioned frequently. Review of the Turn and Reposition daily log from 09/06/2024 to 09/18/2024 revealed the following regarding R252's repositioning: 09/06/2024- Not repositioned on the AM and night shifts 09/07/2024- Not repositioned on PM and night shifts. 09/08/2024- Not repositioned on night shift. 09/09/2024- Not repositioned on night shift. 09/10/2024- Not repositioned on night shift. 09/11/2024- Not repositioned on PM and night shift. 09/13/2024- Not repositioned on night shift. 09/14/2024- Not repositioned on night shift. 09/15/2024- Not repositioned on night shift. 09/16/2024- Not repositioned on PM and night shift. 09/18/2024- Not repositioned on night shift. On 09/20/24 at 4:49 PM, the DON was notified R252 did not like lying on back continuously. When asked if repositioning was attempted, DON did not answer. DON agreed R252 could have been repositioned for comfort as requested by the resident. Review of the policy titled Repositioning dated May 2013, documented: 1. The purpose of the procedure was to provide guidelines for the evaluation of resident repositioning needs. 2. To aid in the development of an individualized care plan for repositioning. 3. To promote comfort for all bed or chair bound residents. 4. Repositioning was critical for a resident who was immobile or dependent upon staff for repositioning. Incontinent Brief: On 09/17/24 at 9:06 AM, R252 stated did not get up as instructed by the medical doctor (MD) following their back surgery. R252 stated toileted using an incontinent brief while in bed. R252 stated had used a bedpan while in the hospital and were ok using the incontinent brief, if it made it easier for the nurses, but added would rather not. On 09/19/24 at 1:48 PM, a Certified Nursing Assistant who was taking care of R252, stated the resident was alert and was able to communicate needs. The CNA stated R252 was incontinent and needed to wear an incontinent brief. The CNA stated did not know if R252 chose to wear the incontinent brief. The CNA stated when needed to know resident preferences, it was communicated at shift report but did not know how to check resident preferences on the computer. Review of the care plan did not identify the R252's use of incontinent brief with goals and interventions. On 09/20/24 at 4:49 PM, the DON was asked who made the decision for the resident to wear an incontinent brief, DON stated it was done if the resident was incontinent. The DON did not give an answer when asked if R252 was asked if the resident wanted to wear an incontinent brief. Review of the policy titled Urinary Incontinence dated April 2018, lacked documentation to address resident use of incontinent briefs.

Based on observation, record review, interview and document review, the facility failed to safeguard the privacy of a resident by posting the body weight on a room's board visible from the hallway for 1 of 26 sampled residents (Resident #203). The deficient practice had the potential to violate the rights of the resident to maintain health information in a private manner. Findings include Resident #203 (R203) R203 was admitted on [DATE], with diagnoses including COPD, acute hypoxic respiratory failure, and prediabetes with steroid induced hyperglycemia, sleep apnea. R203's medical record revealed R203 was alert and oriented and able to make their own decisions. On 09/17/2024 at 9:00 AM, a board in R203's room revealed the following information that was visible from the hallway: 268.4 LB (pound) 9/10/24. When R203 was asked about the weight information posted on the board, R203 conveyed it should not be visible to everyone since it was a privacy issue. On 09/18/2024 in the afternoon, a Registered Nurse confirmed the observation and proceeded to delete the weight information from the board. On 09/19/2024 in the afternoon, the Director of Nursing indicated a family member of R203 requested to document the weight on the board. The DON acknowledged posting weight information in a visible place could be considered a dignity and privacy issue. The medical record lacked documented evidence a family requested to post R203's weight information on the board. The facility policy, undated titled Dignity, documented signs indicating the resident's clinical status or care needs were not openly posted in the resident's room unless requested by the resident or family member.

Based on interview, record review, and document review, the facility failed to ensure a total parenteral nutrition TPN (a medical method to directly deliver essential nutrients into the bloodstream to individuals with medical conditions that prevent normal food digestion) was administered by qualified Registered Nurses for 1 of 26 sampled residents (Resident #29). The deficient practice had the potential to expose the resident to medication errors that could cause health complications. Findings include: Resident #29 (R29) R29 was admitted on [DATE], and readmitted on [DATE], with diagnoses including severe protein-calorie malnutrition, dementia, dysphagia, and history of venous thrombosis and embolism. A physician's order dated 08/24/2024, documented an order for the TPN intravenous solution (Clinimix [trade mark]) 5 % amino acids electrolyte with calcium in 20% dextrose to be infused at 65 milliliter per hour (ml/h) for 16 hours intravenously. one time a day for malnourishment and poor oral intake. A new physician order dated 09/14/2024, documented TPN 5 % amino acids electrolyte with calcium in 15 % dextrose to be infused at 65 milliliter per hour (ml/h) for 20 hours intravenously. The medication administration record (MAR) for August 2024 and September 2024, revealed TPN was documented as administered by licensed practical nurses (LPNs) on 08/23/2024, 08/28/2024, 09/13/2024, 09/14/2024, and 09/16/2024. On 09/18/2024 at 10:00 AM, a licensed practical nurse (LPN) explained the check marks with numeric code initials documented in the MAR on the TPN orders meant the signing nurse administered the infusion. The LPN confirmed having documented with their initials in the TPN administration on 09/14/2024 but denied having administered the infusion and only monitored the infusion. The LPN verbalized only RNs could administer TPN. On 09/20/2024 in the morning, an LPN charge nurse explained LPNs had limited privilege for the intravenous administration of medications. The LPN verbalized only RNs were allowed to administer TPN. On 09/17/2024 in the afternoon, the Director of Nursing (DON) indicated LPNs were trained in TPN administration and had IV certification. The DON confirmed by reviewing the MAR that at least 5 LPNs documented in the MAR having administered TPN to R29. The DON was not aware LPN could not administer TPN per the Nevada Nursing Practice Act that specified LPN were not delegable for the administration of TPN. The review of personnel records for five LPNs (Employees #1, #2, #3, #4, #5, and #6), revealed the administration of TPN was not a task described in the LPN's job description; drug administration function.

Based on interview, record review, and document review, the facility failed to ensure a resident was discharged to a licensed group home per physician order for 1 of 26 samples residents (Resident 161). The deficient practice had the potential to place a resident in an inappropriate care setting. Findings include: Resident 161 Resident 161 (R161) was admitted to the facility on [DATE] and discharged on [DATE], with diagnoses including restless leg syndrome, generalized muscle weakness, diabetes mellitus, unspecified protein-calorie malnutrition, legal blindness, and adult failure to thrive. The facility Initial History and Physical dated 02/07/2024, documented the resident presented to the hospital after being discharged from the Emergency Department (ED) to home on 02/04/2024 with plans to get help vs placement but went back for uncontrolled muscle spasm. Resident reported stopping Pramipexole for restless leg syndrome and whole body felt numb. Resident reported not having any food at home and could not go back home. Resident had leg tremors and anxiety when the resident arrived to the ED. Resident was recommended to be discharged to a skilled nursing facility and would need help with placement. The Assessment and Plan included the following: - Weakness debility - physical and occupational therapy - Chronic low back pain/muscle spasm - Cyclobenzaprine (muscle relaxant), discontinue Ibuprofen per resident request and restart Percocet 5-325 milligrams every 4 hours as needed - Restless Leg Syndrome - Pramipexole - Chronic hyponatremia, hypomagnesemia - monitor electrolytes and replace as needed - Failure to thrive - Hypertension - not on blood pressure medications Discharge Plan: lives alone with no stairs, resident had not been eating well because the resident had no access to meals and unable to cook for self. Resident would like assistance with placement. A Physician Progress note dated 02/08/2024, documented resident reported decreased vision that had been ongoing. Resident was alert, oriented to person, place, time. Resident calm, cooperative, appropriate mood and affect. Therapy levels as of 02/07/2024 - bed: caregiver assist, transfers: moderate assist, gait: 5 feet front wheeled walker with moderate assist, lower body dressing: maximum assist, toileting: moderate assist. A Care Conference note dated 02/09/2024, documented an interdisciplinary team (IDT) meeting with resident. Resident reported having no place to discharge to at this time. Case management provided options. Resident desired a group home in a specific area of town. Resident was currently receiving physical therapy (PT)/occupational therapy (OT) services. Bed mobility Minimum assist, Transfer Moderate assist at this time. No issues or concerns at this time in regard to care at facility, IDT would continue to monitor provider support and assist as needed. A Physician Progress note dated 02/09/2024, documented a request for the facility social worker and the insurance social worker to assist the resident with placement options. A Physician Progress note dated 02/13/2024, documented insurance social worker referral placed as the resident reported not finding a group home and had paid this month's rent for the resident's apartment. Resident was engaged in conversations about discharge and agreed the skilled nursing facility was not the correct place for the resident. The resident was concerned about a safe discharge location. This information had been forwarded to the insurance social worker. Anticipated discharge on 02/16/2024. Discharge medication list sent to the pharmacy for discharge reconciliation. A Physician Progress note dated 02/14/2024, documented discussed discharge planning with the resident. Resident was agreeable with discharge to a group home with hospice services. Social worker/case manager at the facility had participated in discharge planning. A Physician Progress note dated 02/15/2024, documented the resident was admitted to the facility for rehabilitation services and pain management. Resident had participated in therapy services and was cleared for discharge with 24/7 assistance at a group home. The resident was agreeable moving into a group home. The resident's family was able to assist with the group home expenses for the next two weeks. The resident was evaluated and accepted to a group home. Hospice services were requested by the resident, and the resident would be discharged to a group home on hospice services. Therapy levels as of 02/14/2024 were bed mobility: supervised, transfers: standby assist, gait: 40 feet front wheel walker standby assist, upper/lower body dressing: contact-guard assist/standby assist, toileting: moderate assistance. Resident was discharging to a group home with hospice services. Good family support. The resident had adequate access to a safe home environment. The resident was aware the home health nurse, home physical therapy, case management and social worker will be in contact once discharged . Resident verbalized an understanding of all discharge instructions and questions answered. A Case Management note dated 02/16/2024, documented resident would be discharged to a group home with hospice per resident and family request. No other questions and concerns at this time. The Discharge Summary dated 02/16/2024, documented the resident was discharged to a home (address was documented). A review of the Bureau of Health Care Quality and Compliance Health Facility Locater website revealed there was no licensed group home located at the address the resident was discharged . On 09/20/2024 in midmorning, the facility Case Manager indicated the resident was alert and oriented and chose to go the discharge address. The Case Manager did not check to determine if the home the resident was discharged to, was a licensed group home and left it up to the insurance social worker to ensure the resident was discharging to a licensed group home. The medical record lacked documented evidence the resident was discharged to a licensed group home per physician order or the discharge plan was altered based on the resident not wanting to go to a group home and instead wanted to go to a private residence with hospice services. Complaint NV00071314

Based on observation, record review, interview and document review, the facility failed to ensure an arm brace and sling were placed for a resident with arm fracture for 1 of 26 sampled residents (Resident #98). The deficient practice could lead to complications such as improper healing, increased pain, reduced mobility, increased risk of further injury, and nerve damage. Fundings include: Resident #98 (R98) R98 was admitted on [DATE], with diagnoses including right humerus fracture. On 09/17/24 in the morning, R98 was lying in bed with a visible bandage on the right upper arm. R98 indicated had suffered a fracture and was experiencing significant pain. R98 was holding the right arm with the left hand and explained should have been wearing a brace to immobilize the fracture but had been removed the previous night by a staff member and could not locate it. R98 verbalized the brace helped to improve the pain caused by the fracture. A physician order dated 09/05/2024, indicated right arm [NAME] brace and a sling with abduction pillow to be used at all times for a right humeral fracture. (A [NAME] brace is a plastic brace used to stabilize humeral shaft fractures, allowing elbow freedom and movement of forearm and hand). Care plan dated 08/30/2024, revealed R98 had fracture of the right arm. Approaches included [NAME] brace and sling with abduction pillow on at all times. Physician progress noted dated 09/12/2024, revealed R98 was seen and examined by an orthopedist who placed a [NAME] brace and abduction pillow to R98. After the placement of the brace, R98 reported improvement in pain. On 09/18/2024 at 2:45 PM, the Physical Therapy (PT) Director indicated an order for a [NAME] brace and sling was obtained from orthopedist and should be placed all the time until 10/14/2024. The PT Director confirmed the brace should have been placed all the time. The facility undated policy titled Assistive Devices and Equipment, documented the facility should maintain and supervise the use of assistive devices following recommendations dictated by the resident's care plan.