How many inspection deficiencies does MOUNTAIN VIEW HEALTH & REHABILITATION CENTER have?

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER has 50 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at MOUNTAIN VIEW HEALTH & REHABILITATION CENTER?

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER has a two-star staffing rating from CMS with 0.23 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MOUNTAIN VIEW HEALTH & REHABILITATION CENTER located?

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER is located in CARSON CITY, NV. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MOUNTAIN VIEW HEALTH & REHABILITATION CENTER have?

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER has 146 certified beds.

Who owns MOUNTAIN VIEW HEALTH & REHABILITATION CENTER?

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER is a for profit - corporation facility and is part of the EMPRES OPERATED BY EVERGREEN chain.

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER

Name: MOUNTAIN VIEW HEALTH & REHABILITATION CENTER
Address: 201 KOONTZ LANE, CARSON CITY, NV, 89701, US
Telephone: (775) 883-3622
Rating: 2.0

201 KOONTZ LANE, CARSON CITY, NV 89701 · (775) 883-3622

For profit - Corporation 146 Beds EMPRES OPERATED BY EVERGREEN Data: November 2025

Trust Grade

25/100

#45 of 65 in NV

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MOUNTAIN VIEW HEALTH & REHABILITATION CENTER nursing home in CARSON CITY, NV - Photo 1 of 3

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Last Inspection: November 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Mountain View Health & Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided at this facility. It ranks #45 out of 65 nursing homes in Nevada, placing it in the bottom half of facilities in the state, but it is #2 out of 4 in Carson City County, meaning there is only one other local option that performs better. While the facility is improving, with issues decreasing from 13 in 2024 to just 1 in 2025, it still has a concerning number of total deficiencies, including serious incidents such as a resident being physically harmed by another resident, which resulted in a facial fracture. Staffing is somewhat stable with a turnover rate of 44%, which is slightly below the state average, but the facility has less RN coverage than 96% of Nevada facilities, raising concerns about oversight. Additionally, fines totaling $25,675 suggest ongoing compliance issues that families should consider before making a decision.

Trust Score: F
In Nevada: #45/65
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 44% turnover. Near Nevada's 48% average. Typical for the industry.
Penalties: $25,675 in fines. Higher than 56% of Nevada facilities. Some compliance issues.
Skilled Nurses: Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Nevada. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 50 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 13 issues

2025: 1 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (44%)
4 points below Nevada average of 48%

Facility shows strength in fire safety.

The Bad

2-Star Overall Rating

Below Nevada average (3.0)

Below average - review inspection findings carefully

Staff Turnover: 44%

Near Nevada avg (46%)

Typical for the industry

Federal Fines: $25,675

Below median ($33,413)

Moderate penalties - review what triggered them

Chain: EMPRES OPERATED BY EVERGREEN

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 50 deficiencies on record

1 actual harm

Mar 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review, the facility failed to ensure the safety of a resident with wandering behaviors from elopement from the facility for 1 of 16 sampled residents (Resident #13). The deficient practice had the potential for physical and psychosocial harm to the resident. Findings include: Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including memory deficit following other cerebrovascular disease, unspecified dementia, unspecified severity, with other behavioral disturbance, and cognitive communication deficit. Elopement Risk Evaluation dated 03/04/2025, documented Resident #13 had a history of wandering, had verbalized the desire to leave the facility, and was seeking out family members placing the resident at significant risk of an unsafe situation related to the resident's diagnosis of dementia with behaviors. Care Plan dated 03/06/2025, documented Resident #13 was an elopement risk, wandered aimlessly related to impaired safety awareness, and required a secured unit. A Facility Reported Incident (FRI), documented on 03/11/2025, Resident #13 was seen walking through the main entrance of the facility from the outside. The resident resided in a secured unit and was last seen by staff at approximately 3:10 PM and not seen again until approximately 3:45 PM. The resident was wearing appropriate clothes for outside weather. On 03/13/2025 at 1:00 PM, the Executive Director confirmed Resident #13 had eloped from the facility on 03/11/2025, and was unable to determine how the resident left the facility. The Executive Director confirmed Resident #13 was in a locked unit due to the resident's diagnoses and related lack of safety awareness. The facility policy titled, Elopement/Wandering, updated February 2025, documented an elopement had occurred when a resident exited the facility without staff knowledge, and residents assessed at risk for elopement residing a locked unit were to be accompanied by a staff member while outside the facility to ensure resident safety. FRI #NV00073658

Nov 2024 13 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #104 Resident #104 was admitted to the facility on [DATE], with diagnoses including vascular dementia, unspecified severity, with other behavioral disturbance and other symptoms and signs involving cognitive functions following cerebrovascular disease. Resident #140 Resident #140 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, unspecified and other symptoms and signs involving cognitive functions following cerebral infarction. A FRI dated 10/15/2024, documented Resident #140 was observed hitting Resident #104. Resident #140 pushed Resident #104 to the ground and bit Resident #104's left ear. Resident #104 was evaluated in the emergency room and was found to have sustained scratches to the resident's left ear and a facial fracture. The following notes were documented in Resident #104's clinical record: -An Emergency Department (ED) Provider Note dated 10/15/2024, documented a computed tomography (CT) scan was completed on 10/15/2024, and indicated Resident #104 had an acute fracture of the anterior wall of the left maxillary [NAME]. -A Nursing Progress Note dated 10/15/2024, documented a nurse saw a resident pushing, punching and biting another resident. The residents were separated and sent to the hospital. -An Interdisciplinary Note dated 10/16/2024, documented Resident #104 was involved in an altercation with another resident. Resident #104 sustained the following injuries: bruising to the resident's left ear, scratches to the resident's face and nose, and a fracture. -A Social Services Note dated 10/17/2024, documented Resident #104 was tearful due to not understanding why the resident was uncomfortable following the incident. The resident had noted confusion and did not recall the incident. -A Psych Follow Up Note dated 10/21/2024, documented Resident #104 was attacked and beaten up by the resident's roommate. Staff reported the resident appeared more scared and withdrawn and was demonstrating regressive behaviors. -A Social Services Note dated 10/21/2024, documented Resident #104 was displaying regressive behaviors as evidenced by urinating in the resident's closet. -A Social Services Note dated 10/22/2024, documented Resident #104 was displaying regressive behaviors as evidenced by defecating on the floor. -A Social Services Note dated 10/25/2024, documented Resident #104 had new regressive behaviors as evidenced by peeing in public or in closets rather than the restroom. -A Social Services Note dated 11/05/2024, documented Resident #104 was displaying regressive behaviors as evidenced by urinating in the trashcan. On 11/04/2024 at 4:13 PM, during a telephone interview with Resident #104's guardian, the guardian recalled the guardian was notified of a resident-to-resident incident involving Resident #104. The guardian recalled Resident #104 was sent to the emergency room following the incident and was found to have a fracture. On 11/06/2024 at 12:21 PM, a Licensed Practical Nurse (LPN) verbalized the LPN was aware of a resident-to-resident incident involving Resident #104 and Resident #140. The LPN explained the LPN was not working the day of the incident however was informed Resident #140 had attacked Resident #104 and both residents were sent out of the facility. On 11/06/2024 at 12:30 PM, a CNA verbalized physical abuse included hitting a resident. If staff observed abuse or an allegation of abuse was reported to staff, staff were to separate the residents, assure the residents' safety, and report to the Abuse Coordinator. The CNA recalled the CNA worked the evening shift on the day of the resident-to-resident incident involving Resident #104 and Resident #140. The CNA verbalized Resident #140 started hitting Resident #104. Both residents were sent out of the facility. The CNA recalled Resident #104 seemed scared and was intermittently tearful after returning to the facility. On 11/07/2024 at 11:42 AM, the Executive Director explained abuse could be intentional or non-intentional and included physical and sexual abuse, neglect, involuntary seclusion and misappropriation of resident property. The Executive Director verbalized all allegations of abuse were to be reported to the Executive Director who was also the facility's Abuse Coordinator. The Executive Director verbalized the Executive Director was familiar with a resident-to-resident incident on 10/15/2024, involving Resident #104 and Resident #140. The initial altercation was unwitnessed, however staff heard the residents fighting and immediately tried to separate the residents. The Executive Director recalled Resident #104 sustained a significant injury, a facial fracture, during the incident. The Executive Director verbalized when Resident #104 returned to the facility, the Executive Director interviewed the resident who did not recall the incident however the resident's body language and demeanor appeared to the Executive Director the resident was fearful. Resident #104 had some difficulty chewing for one to two days after return to the facility and required soft foods. The Executive Director verbalized the facility would provide social services visits for emotional support and to monitor for mental anguish following an incident of abuse. The Executive Director reviewed Resident #104's clinical record and verbalized, since the incident on 10/15/2024, Resident #104 had been visited by the facility's social worker and a talk therapist from behavioral health services. The Executive Director verbalized the clinical record indicated Resident #104 had recently developed regressive behaviors including urinating in trash cans. The Executive Director explained the development of regressive behaviors after an incident of abuse could indicate psychosocial harm. The facility policy titled Abuse, Neglect, or Exploitation, updated November 2016, defined abuse as an act by an individual which injured, exploited, or jeopardized an individual's health, welfare, or safety. Examples included physically damaging or potentially damaging non-accidental acts and emotionally damaging verbal behavior. The facility document titled Notice of Resident Rights Under Federal Law, updated November 2016, documented residents had the right to be free from verbal, sexual, physical, or mental abuse. FRI #NV00072457 Based on observation, clinical record review, interview, and document review the facility failed to protect residents from physical abuse for 2 of 28 sampled residents (Resident #72 and #104) from resident to resident abuse. Resident #104 obtained a facial fracture resulting in actual harm. Resident #72 obtained lacerations requiring eight staples resulting in actual harm. Findings include: Resident #72 Resident #72 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease and anxiety disorder. Diagnoses added on 10/31/2024, included laceration without foreign body of scalp, subsequent encounter, and unspecified injury of the head, subsequent encounter. A Minimum Data Set 3.0 (MDS) assessment dated [DATE], Section C (Cognition), documented a Brief Interview for Mental Status (BIMS) assessment was not conducted for Resident #72 due to the resident was rarely and/or never understood. Resident #72's cognitive skills for daily decision making was severely impaired. A Nursing Progress Note dated 10/09/2024, documented Resident #72 walked past Resident #240, cutting in between Resident #240 and a staff member. Resident #240 grabbed and spun Resident #72 around and hit Resident #72 in the face and on the body with open hand and closed fist. Resident #72's Comprehensive Care Plan, initiated on 04/02/2021, documented the resident was at risk for resident to resident altercations related to dementia with behavioral disturbances. Interventions included redirecting Resident #72 away from other residents if Resident #72 became too friendly. The Comprehensive Care Plan documented throughout Resident #72's stay at the facility, there had been multiple resident to resident incidents where Resident #72 was hit, grabbed, and shoved by other residents. Resident #240 Resident #240 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including metabolic encephalopathy, schizoaffective disorder, bipolar type, borderline personality disorder, generalized anxiety disorder, personal history of traumatic brain injury, and other symptoms and signs involving cognitive functions and awareness. A final Facility Reported Incident (FRI) submitted to the State Agency (SA) on 10/09/2024, documented on 10/09/2024, Resident #240 was standing in the hallway outside of the nutrition room and a staff member was standing across from Resident #240. Resident #72 walked between Resident #240 and the staff member. Resident #240 grabbed Resident #72, spun the resident around and hit Resident #72 multiple times on the face and body with an open hand and a closed fist. Resident #240's MDS assessment dated [DATE], Section C (Cognition), documented a BIMS score of 10, indicating the resident had moderate cognitive impairment. Section E (Behavior) documented the resident had delusions and verbal behaviors directed towards others occurred daily. Resident #240's Comprehensive Care Plan documented the following: -A care plan initiated on 01/09/2024, documented Resident #240 had an escalation in behaviors and had pushed and punched another resident on 01/24/2024, hit another resident in the face with a teddy bear on 04/02/2024, punched another resident in the arm on 04/12/2024, and pulled another resident's hair on 08/08/2024. -A care plan initiated on 01/10/2024 documented Resident #240 had the potential to be physically aggressive. On 01/09/2024, Resident #240 hit a resident on the shoulder and hit another resident in the stomach with the back of Resident #240's hand. -On 07/22/2024, Resident #240 hit a resident on the back of the resident's shoulder. -On 09/20/2024, Resident #240 pushed a resident. -On 10/03/2024, Resident #240 pushed another resident in the hallway resulting in a fall. -On 10/09/2024, Resident #240 hit a resident who walked past Resident #240 on 10/09/2024. The resident had uncontrollable behaviors, destruction of property, and refused care and medications. Resident #240's Medication Administration Record (MAR) for October 2024, documented the resident refused medications as follows: -Aripiprazole oral tablet, 15 milligrams (mg), give one time per day for mania, was documented as refused by the resident each day from 10/01/2024-10/09/2024. -Lorazepam oral concentrate 2 mg/milliliter (ml), give one ml by mouth two times a day for anxiety, documented the morning dose of the medication was refused by the resident on 10/01 and 10/03-10/09/2024. The evening dose of the medication was refused by the resident on 10/02, 10/03, and 10/05 -10/09/2024. On 11/07/2024 at 1:45 PM, a Registered Nurse (RN) recalled being present when Resident #240 hit Resident #72. The RN explained Resident #72 walked between Resident #240 and a staff member. Resident #240 began hitting Resident #72. The RN confirmed Resident #240 often refused to take medications and had increased behaviors directed towards others, including on 10/09/2024. On 11/07/2024 at 1:53 PM, a Licensed Practical Nurse (LPN), verbalized the Executive Director was the Abuse Coordinator. On 11/07/2024 at 2:24 PM, the Executive Director verbalized on 10/09/2024, Resident #240 was in a common area of the Memory Care Unit when Resident #72 walked past Resident #240. The Executive Director confirmed Resident #240 hit Resident #72 several times in the face with an open hand and a fist. On 11/07/2024 at 2:28 PM, the Executive Director confirmed Resident #240 had been escalating all day and had refused medication. The Executive Director explained Resident #240 was non-ambulatory when first admitted to the facility, but now walked all over the unit and the resident was getting more difficult to handle. FRI #NV00072412 A final FRI submitted to the SA on 10/31/2024, documented on 10/30/2024, Resident #72 was wandering the halls and attempted to enter Resident #135's room. Resident #135 grabbed Resident #72 by the shoulder and pushed the resident to the floor, resulting in a laceration to the back of Resident #72's head. Both Residents resided in the Memory Care Unit. (Resident #72) An Alert Charting Note for Resident #72, dated 10/30/2024, documented at approximately 7:35 PM, Resident #72 was in the hallway near the door of Resident #135's room. A Licensed Practical Nurse (LPN) was requested to assist with Resident #72 following an altercation between Resident #72 and Resident #135. The nurse arrived to the scene and observed Resident #72 sitting on the floor. A staff member was assisting Resident #72 to a sitting position and was holding a compress on the back of Resident #72's head. The LPN visualized excessive blood pooling onto Resident #72's neck and draining onto the resident's clothing. The resident was transported to an acute care hospital for further evaluation. A Nurse Progress note dated 10/31/2024, documented Resident #72 arrived back at the facility at 9:00 AM. The resident had eight staples on the right side of the resident's head. Resident #135 Resident #135 was admitted to the facility on [DATE], with diagnoses including paranoid personality disorder, bipolar type, generalized anxiety disorder, auditory hallucinations, and restlessness and agitation. A diagnosis of schizoaffective disorder was added on 10/04/2024. An MDS assessment dated [DATE], Section C (Cognition), documented Resident #135's BIMS score was 99, indicating the resident did not participate in the assessment. Section E (Behavior) documented the resident had delusions, and verbal behaviors directed towards others daily. Resident #135's Medication Administration Record (MAR) for October 2024, documented the resident refused medications as follows: -Doxepin hydrochloride (HCL) 25 mg capsules, give four capsules by mouth one time a day for insomnia, was documented as refused by the resident each day from 10/02 - 10/07, 10/09, 10/11-10/16, 10/18, 10/19, 10/24-10/26, 10/30, and 10/31/2024. Doxepin HCl is a tricyclic antidepressant. - Quetiapine fumarate oral tablet 200 mg, give one tablet by mouth four times a day for mood. The medication had a stop date of 10/15/2024. The medication was refused by the resident during the morning on 10/01, 10/02, 10/04-10/11, and 10/13/-10/15. The medication was refused by the resident during each afternoon on 10/02 - 10/11, and 10/13 - 10/15. The medication was refused by the resident during each evening on 10/10/01- 10/06, 10/08 - 10/11, and 10/14/2024. The medication was refused by the resident each night on 10/03 - 10/07, 10/09, and 10/11 - 10/14/2024. -Quetiapine fumarate oral tablet 200 mg, give two tablets by mouth two times a day for mood. The medication had a start date of 10/15/2024 during the evening shift. The medication was refused by the resident each day shift on 10/16. 10/17, 10/19-10/21, 10/23, and 10/27-10/30/2024. The Medication was refused by the resident each evening shift on 10/15/10/16, 10/17, 10/18, 10/19, 10/22, 10/24 - 10/27, and 10/29 - 10/31/2024. -Diazepam oral tablet, 5 mg, give one tablet by mouth three times per day for generalized anxiety disorder. The medication was refused by the resident during each day shift on 10/01, 10/02, 10/04-10/11, 10/13-10/17, and 10/19-10/30/2024. The Medication was refused by the resident during each afternoon shift on 10/03-10/11, 10/13-10/17, 10/19-10/25, and 10/27-10/30. The Medication was refused by the resident during each evening shift on 10/02 -10/07, 10/09 -10/15, 10/18, 10/19, 10/22, and 10/24-10/31/2024. Resident #135's clinical record documented the following behaviors were noted throughout the day on 10/30/2024. -Was having auditory/visual hallucinations and responded to the hallucinations by yelling, growling and making statements which could not be understood. -Was noted to have had hallucinations and was known to respond to internal stimuli and would yell out in response. -Continued to respond to auditory and internal stimuli while in the resident's room and was grunting, laughing, and yelling. -Continued to have auditory/ visual hallucinations and was laughing maniacally in the resident's own room. -Was wandering the hallways and making noises with the resident's mouth in response to auditory/visual hallucinations and was wandering into different (resident) rooms. A Social Service Follow Up Note dated 10/31/2024, documented a Social Worker (SW) met with Resident #135, observed the resident and spoke with staff. Resident #135 did not appear to remember the altercation with Resident #72. Resident #135 was agitated and yelled at the SW to get out of the resident's room before the resident messed the SW up, the sentiments were expressed using profanities and Resident #135 was growling. The SW attempted to complete a room change for Resident #135 to move to another unit. However, the resident refused to change rooms and became more agitated and using profanities verbalized the resident was not moving to another room. On 11/07/2024 at 2:37 PM, the Executive Director verbalized the altercation between Resident #72 and Resident #135 occurred when Resident #72 wandered into Resident #135's room. The Executive Director verbalized Resident #135 did not push Resident #72, as documented in the FRI and explained Resident #135 grabbed Resident #72 and threw the resident to the ground. On 11/07/2024 at 2:44 PM, the Executive Director explained nurses were expected to write behavioral notes for each adverse behavior observed. The notes were then reviewed in the facility's stand up meeting the following day, or the following Monday for observations documented during the weekend. Therefore, the Interdisciplinary Team (IDT) would not have received the information to review until the next day. The Executive Director verbalized if the facility had a system to review behavioral documentation prior to the next shift, Resident #135 could have been placed on 1:1 supervision and the altercation between Resident #135 and #72 could have been prevented. The Executive Director confirmed the altercation between Resident #135 and Resident #72 occurred on 10/30/2024, and resulted in a laceration to Resident #72's head, requiring eight staples. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, dated 12/2023, documented abuse was the willful infliction of injury resulting in physical harm, pain or mental anguish and was irrespective of any mental or physical condition. Willful meant the individual acted deliberately and did not mean the individual must have intended to inflict injury or harm. FRI #NV00072575

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review the facility failed to ensure a resident's right to self determination was respected when the facility failed to inform a new Certified Nursing Assistant (CNA) of the resident's wishes not to be disturbed for care during the night. The CNA continued to attempt to turn the resident after the resident had asked the CNA to stop, resulting in bruising to the resident's thigh for 1 of 28 sampled residents (Resident #23). Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including other specified arthritis, unspecified site, essential primary hypertension, and chronic obstructive pulmonary disease. An initial Facility Reported Incident (FRI) submitted to the State Agency (SA) on 10/29/2024, documented Resident #23 complained of being provided rough care by a CNA on 10/26/2024. The CNA was identified, and the date of the incident was determined to be 10/27/2024. Resident #23's Comprehensive Care Plan included a care plan with a revision date of 08/19/2024 related to grooming and personal hygiene. The care plan documented the resident did not want to be awakened for rounds and would use the call light if the resident needed assistance. On 11/04/2024 at 10:42 AM, Resident #23 verbalized the resident was provided rough care by a CNA and had bruises on the resident's thigh. The distal portion of Resident #23's thigh had three oblong purple marks measuring approximately 7-8 centimeters (cm) x 1.5 cm. Adjacent to the three oblong purple marks was a round purple mark approximately 1.5 -2.0 cm in diameter. The resident explained the CNA entered the resident's room in the middle of the night, woke the resident, ripped the sheets off of the resident, and started pulling on the resident. Resident #23 verbalized the resident told the CNA to stop, but the CNA would not listen and did not stop. Resident #23 verbalized the CNA spoke very rudely to the resident and told Resident #23 the resident had to be changed, and added do you just want to get bedsores?. A Social Services note dated 10/29/2024, documented Resident #23 had made an allegation of abuse from a staff member. The incident was reported to the Executive Director and an investigation was pending. On 11/07/2024 at 2:55 PM, the Executive Director confirmed Resident #23 had correctly identified the CNA. The Executive Director explained on the night of the incident, the CNA informed the Registered Nurse (RN) Resident #23 had complained about the CNA being too rough with care. The Executive Director further explained the CNA was not informed of the resident's wishes not to be disturbed during the middle of the night unless the resident called for assistance. The facility policy titled Notice of Resident Rights Under Federal Law, updated 11/2016, documented residents had the right to a dignified existence and self-determination. Residents had the right to be treated with respect and dignity. Residents had the right to reasonable accommodation of individual needs or preferences, except where the health or safety of the resident or other residents was endangered. FRI #NV00072571

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review, the facility failed to ensure a comfortable, homelike environment when staff were reported as being loud and disruptive to a resident's sleep during the night shift for 1 of 28 sampled residents (Resident #112). Findings include: Resident #112 Resident #112 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including generalized anxiety disorder and insomnia, unspecified. On 11/04/2024 at 2:03 PM, Resident #112 verbalized the resident was concerned about staff waking the resident up in the middle of the night. Resident #112 explained night shift staff were loud, and the resident often heard staff talking in the hallway about staff's personal lives and other residents' care. The resident had been offered to move rooms as the resident was previously near the nurses' station however the resident reported the noise level on the night shift had not improved since the resident moved to another room. The resident verbalized being frustrated as the resident could not sleep due to staff being loud. A Psych Evaluation Note dated 08/13/2024, documented Resident #112 yelled out toward the hallway for people to be quiet. Resident #112 reported being tired of the noise in the facility. The facility's grievance log from January 2024 through November 2024 documented the following: -On 01/16/2024, the facility received a grievance from resident council indicating Certified Nursing Assistants (CNAs) were loud and yelled down the hall on the night (NOC) shift. The concern was documented as confirmed and resolved on 01/16/2024. Action taken documented CNAs would approach the nurse on shift to relay a message and would not yell down the hall. -On 02/13/2024, the facility received a grievance from resident council indicating CNAs on the NOC shift were loud and would yell in the hallways while residents tried to sleep. The concern was documented as confirmed and resolved on 02/15/2024. Staff were coached on being respectful of residents' space. -On 04/10/2024, the facility received a grievance from resident council indicating NOC shift CNAs were loud in the hallways while residents were sleeping. The concern was documented as confirmed and resolved on 04/11/2024. Action taken included an in-person discussion with CNAs and the addition of a full-time charge nurse. Recommended actions included spot checks from management. -On 08/13/2024, the facility received a grievance from resident council indicating staff were loud on the NOC shift in the hallways. The concern was documented as confirmed and resolved on 08/15/2024. Staff were reminded to talk quietly even when at the nurses' station as residents in nearby rooms could hear the staff's conversations. -On 09/17/2024, the facility received a grievance from resident council indicating CNAs on the NOC shift were yelling in the hallways. The concern was documented as confirmed and resolved on 09/19/2024. Staff were educated and provided an in-service. On 11/07/2024 at 3:22 PM, the Executive Director explained the facility reviewed grievances during clinical meetings, facility leadership would ensure follow up was completed with the person filing the grievance, and grievances were tracked for trends. The Executive Director verbalized the facility had received several grievances related to noise levels at night, it was a known issue in the facility, and had been consistent over the last few months. Staff had been re-educated regarding appropriate noise levels on the NOC shift. To monitor the effectiveness of implemented interventions in response to grievances, the facility conducted rounds with residents to ask about any concerns or complaints the residents had. The Executive Director explained the facility had last completed rounds in August and September and had not received any feedback regarding noise at night. However, the Executive Director had recently met with a member of the facility's resident council who reported the noise on the NOC shift was increasing. The Executive Director explained the facility could have conducted a root cause analysis to help determine what the noises were and how to better address resident concerns of excessive noise at night however the facility had not yet conducted a root cause analysis. The Executive Director verbalized excessive noise at night would cause the facility to not feel homelike for residents. The facility document titled Notice of Resident Rights Under Federal Law, updated November 2016, documented residents had the right to a safe, clean, comfortable, and homelike environment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 28 sampled residents (Resident #27). This deficient practice had the potential to deprive the resident of a person-centered care plan relative to their current health management needs. Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of other low back pain. Resident #27's quarterly MDS assessment dated [DATE], section J1900 (Health Conditions-Number of Falls Since Prior Assessment) documented Resident #27 had two falls with no injury, one fall with injury, and two falls with major injury since the last assessment. Resident #27's progress notes documented the resident fell once on 09/14/2024 but lacked documented evidence any other falls occurred in 2024. On 11/07/2024 at 12:01 PM, the MDS Coordinator Licensed Practical Nurse (LPN)verbalized using the Resident Assessment Instrument (RAI) Manual to guide MDS activities. The MDS Coordinator verbalized Resident #27 had one fall with no injury on 09/14/2024, however the MDS assessment reflected five falls. The MDS Coordinator confirmed Resident #27's quarterly MDS assessment was inaccurate.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and document review the facility failed to provide showers for 1 of 28 sampled residents (Resident #108). The deficient practice had the potential to negatively impact the resident's overall well-being. Findings include: Resident #108 Resident #108 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including spinal stenosis, cervical region, chronic pain syndrome, and difficulty in walking. On 11/04/2024 at 4:07 PM, Resident #108 verbalized the resident did not get showers or bed baths. Resident #108's Comprehensive Care Plan dated 09/09/2024, documented shower two times weekly. On 11/06/2024 at 2:11 PM, a Certified Nursing Assistant (CNA)/Shower Aid verbalized residents should receive two showers a week, but the CNA was aware the Resident #108 preferred showers more often. Resident #108 only received showers once a week, although the resident's preference was three times a week. The resident did not refuse showers when offered. On 11/06/2024 at 2:13 PM, the Director of Nursing Services (DNS) verbalized all residents received showers twice a week. The DNS explained shower documentation was kept in a shower book. The Shower Book documented the following showers for Resident #108: -10/04/2024 -10/08/2024, four days between offered showers/bed bath. -10/15/2024, seven days between offered showers/bed bath. -10/29/2024, 14 days between offered showers/bed bath. -11/05/2024, six days between offered showers/bed bath. On 11/06/2024 at 2:16 PM, the Shower Aid verbalized to the DNS the resident was only showered once a week due to time constraints. The Shower Aid explained they gave shower priority to residents with skin issues. On 11/06/2024 at 4:37 PM, the DNS verbalized residents should be showered twice a week and per their preference. The DNS explained there was not a facility policy followed related to showering and/or bathing however the facility followed their standard of practice. The facility's Standard of Practice was [NAME]. The DNS did not provide the Standard of Practice for activities of daily living, to include showers.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review, the facility failed to ensure 1) a resident's significant surgical wounds were evaluated weekly for 1 of 28 sampled residents (Resident #67), 2) a resident's change in condition was reported timely to a physician for 2 of 28 sampled residents (Resident #36 and #62) and 3) ensure a resident's blood sugar levels were checked according to a physician's order for 1 of 28 sampled residents (Resident #52). The deficient practices had the potential to result in 1) overlooked skin integrity decline, 2) a change in condition going unmonitored, placing residents at risk for infection to spread and for poor clinical outcomes, and 3) a resident experiencing hyperglycemia (elevated blood sugar) or hypoglycemia (low blood sugar) without adequate monitoring and intervention. Findings include: Wound Evaluations Resident #67 Resident #67 was admitted to the facility on [DATE], with a diagnosis of unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, subsequent encounter. Resident #67's care plan revised 09/25/2024, documented a problem of potential for skin integrity impairment related to fragile skin to include chronic abdominal midline surgical wounds. Interventions included following facility protocols for treatment of injury and documenting weekly treatment with measurement of each area of skin breakdown, width, length, depth, type of tissue and other notable changes. Resident #67's clinical record lacked documented evidence of weekly wound evaluations. On 11/06/2024 at 2:41 PM, a Licensed Practical Nurse (LPN) verbalized Resident #67 had surgical wounds on the resident's abdomen. The LPN verbalized wound evaluations were useful in detecting signs of infection, fever and pain; however, weekly wound evaluations were not completed for Resident #67. On 11/07/2024 at 8:33 AM, the Director of Nursing Services (DNS) verbalized Resident #67's abdominal wounds would be considered significant surgical wounds because they were chronic and nonhealing. The DNS verbalized the DNS completed weekly wound evaluations for residents with pressure ulcers but did not do weekly wound evaluations for residents with surgical wounds to include Resident #67. The DNS confirmed this practice did not follow the facility policy. The facility policy titled, Skin Integrity, updated October 2022, documented wounds were evaluated weekly by center clinicians and significant surgical wounds were evaluated, measured, and findings documented in the medical record. Change in condition Resident #36 Resident #36 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified and unspecified dementia, severe, with agitation. Section C0200 of a Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented Resident #36 had a Brief Interview for Mental Status (BIMS) score of 12. A score of 12 indicated moderate cognitive impairment. The BIMS evaluation was completed by the MDS Coordinator LPN. Section C0200 of an MDS assessment dated [DATE], documented Resident #36 had a BIMS score of four. A score of 4 indicated severe cognitive impairment. The BIMS evaluation was completed by the Social Worker. On 11/07/2024 at 1:47 PM, during an interview with the MDS Coordinator LPN and the Social Worker, the MDS Coordinator LPN explained the facility's Social Worker typically completed the BIMS evaluation for the MDS assessments. The MDS Coordinator LPN reviewed the MDS assessments completed for Resident #36 and confirmed the assessments documented the resident had a BIMS score of 12 on 07/12/2024, and a score of four on 10/03/2024. The Social Worker recalled Resident #36 was not wanting to answer questions during the BIMS evaluation completed on 10/03/2024. The MDS Coordinator LPN explained the process when a resident experience a decline in BIMS score would be to determine if there was a medical reason for the change, perform a repeat BIMS evaluation to determine if the first one was accurate, and notify the physician. The Social Worker verbalized the BIMS score of four on 10/03/2024 was accurate at the time the evaluation was completed. The Social Worker denied the Social Worker performed a repeat BIMS evaluation or notified the physician of the decline in score. On 11/07/2024 at 2:31 PM, the DNS verbalized a BIMS evaluation checked a resident's mental status and cognition. The DNS verbalized a decline in BIMS score from 12 to four would be considered a significant change. The DNS explained the DNS's expectation of staff, if there was a significant change in BIMS score, was to repeat the BIMS to ensure the score was accurate and report to the physician. Resident #62 Resident #62 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including Alzheimer's disease, unspecified and type two diabetes mellitus without complications. On 11/04/2024 at 1:35 PM, Resident #62 was ambulating in the hallway. A clean, dry dressing was noted on the resident's left elbow. Resident #62 recalled staff placed the dressing after a recent fall. On 11/06/2024 at 11:06 AM, an LPN verbalized Resident #62 had an abrasion on the resident's left elbow related to a fall. On 11/06/2024 at 2:09 PM, the LPN explained signs and symptoms of a wound infection included swelling, redness, pain, and drainage. The LPN verbalized Resident #62 had recently completed antibiotics for cellulitis in the resident's left elbow. The LPN recalled the LPN had called the physician the week prior as Resident #62's left elbow had become swollen and red. A Nursing Progress Note dated 10/25/2024, documented Resident #62 had a low-grade fever. An Orders Administration Note dated 10/25/2024, documented Resident #62's left elbow had a large circular red area. An Orders Administration Note dated 10/26/2024, documented Resident #62's left elbow remained red. A Nursing Progress Note dated 10/30/2024, documented Resident #62's left elbow was red, swollen, and painful. The physician was contacted and prescribed Augmentin for seven days. On 11/06/2024 at 2:23 PM, the DNS verbalized wounds included open skin, skin tears, abrasions and lacerations. Signs and symptoms of a wound infection included redness, warmth, drainage, pain and odor. If there was a change in a wound, the DNS expected staff to notify the DNS and the physician. On 11/06/2024 at 4:44 PM, during an interview with the DNS and the MDS Coordinator LPN, the DNS verbalized a low-grade fever and a large circular red area, as noted in the progress notes dated 10/25/2024, were signs and symptoms of infection and should have been reported to the physician immediately. The MDS Coordinator and the DNS reviewed Resident #62's record and denied the physician was notified of any signs or symptoms of infection prior to the documented notification on 10/30/2024. The facility policy titled Change in Condition: When to report to the physician, undated, documented immediate notification of the physician was required when any symptom, sign or apparent discomfort was acute or sudden in onset and a marked change in relation to usual signs/symptoms or was unrelieved by measures already prescribed. Non-immediate notification of the physician was required when new or worsening symptoms were present and did not meet the above criteria. Blood glucose monitoring Resident #52 Resident #52 was admitted to the facility on [DATE], with a diagnosis of type two diabetes mellitus with diabetic neuropathy, unspecified. A physician's order dated 06/04/2024, documented Humalog injection solution 100 units/ milliliter (ml), inject per sliding scale: -If blood sugar 200-250, give two units. -If blood sugar 251-300, give four units. -If blood sugar 301-350, give six units. -If blood sugar 351-400, give eight units. Subcutaneously before meals and at bedtime for diabetes mellitus type two. If blood sugar less than 80 or greater than 400, call physician. The October 2024 Medication Administration Record (MAR) for Resident #52 documented Humalog injection solution 100 units/ ml. The scheduled administration times were 9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The 10/31/2024 9:00 PM blood sugar reading was documented as Not Applicable (NA) and the Humalog administration was documented as 4 - vitals outside of parameters for administration. The November 2024 MAR for Resident #52 documented Humalog injection solution 100 units/ ml. The scheduled administration times were 9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM. The 11/01/2024 and 11/02/2024 9:00 PM blood sugar readings were documented as Not Applicable (NA) and the Humalog administration was documented as 4 - vitals outside of parameters for administration. On 11/06/2024 at 8:54 AM, an LPN explained blood sugars were to be checked per physician orders. The frequency and documentation of blood sugar monitoring for residents could be seen on the resident's MAR. The LPN verbalized Resident #52 had an order to check the resident's blood sugar four times per day, at meals and at bedtime. On 11/06/2024 at 2:39 PM, the DNS explained the frequency of blood sugar monitoring depended on the physician's order. The DNS verbalized Resident #52 had an order to check blood sugar levels four times per day, before meals and at bedtime. The DNS reviewed the October and November MARs for Resident #52 and confirmed the blood sugar readings for 10/31/2024, 11/01/2024, and 11/02/2024 were documented as NA and the Humalog administration was documented as 4. The DNS verbalized the portion of the MAR documented as NA should have included the resident's bedtime blood sugar reading. The DNS explained NA indicated the nurse did not check the resident's blood sugar and confirmed failure to check Resident #52's blood sugar at bedtime was not following the physician's order. The facility policy titled Blood Glucose Monitoring Protocol, updated October 2017, documented the nurse would conduct blood glucose testing as ordered by the physician. Diabetic guidelines for residents prescribed sliding scale insulin included blood glucose testing routinely prior to meals and at bedtime.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review the facility failed to ensure oxygen was administered according to a physician's order for 1 of 28 sampled residents (Resident #80). This deficient practice had the potential to cause worsening of the resident's diagnosed chronic obstructive pulmonary disease. Findings include: Resident #80 Resident #80 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified bacterial pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease with acute exacerbation. On 11/04/2024 at 8:44 AM, Resident #80 was lying in bed and receiving Oxygen via nasal cannula (NC). The resident's Oxygen concentrator was set at three liters per minute (LPM). Resident #80 verbalized Resident #80 wore Oxygen continuously and was supposed to be receiving two LPM. On 11/05/2024 at 4:04 PM, Resident #80 was lying in bed and receiving Oxygen via NC. The resident's Oxygen concentrator was set at three LPM. A physician's order dated 06/16/2023, documented Oxygen two LPM per cannula to keep saturations (sats) greater than 90 percent (%). Resident #80's Care Plan included pneumonia. Interventions included Oxygen, two liters per NC to keep sats greater than 90%. The initiated and revision date was 09/13/2024. On 11/05/2024 at 4:06 PM, a Licensed Practical Nurse (LPN) verbalized licensed nurses were able to administer Oxygen to residents with a physician's order. The LPN explained the physician's order would specify the liter flow the resident's Oxygen concentrator should be set at. The LPN confirmed Resident #80 had a physician's order for Oxygen to be administered via NC at two LPM. On 11/05/2024 at 4:10 PM, the LPN entered Resident #80's room. The LPN verbalized the Oxygen concentrator was set at three LPM and adjusted the flow rate down to two LPM. The LPN confirmed three LPM did not match the physician's order. On 11/05/2024 at 4:51 PM, the Director of Nursing Services (DNS) verbalized the DNS's expectation of nursing staff when administering Oxygen to residents was to follow the physician's order. The DNS explained a physician's order for Oxygen would include how many LPM the resident was to receive. The DNS reviewed Resident #80's clinical record and verbalized Resident #80 had a physician's order for Oxygen to be administered at two LPM via NC. The DNS confirmed administering oxygen to Resident #80 at three LPM was not following the physician's order. The facility policy titled Respiratory Care; Oxygen Administration, published December 2017, documented Oxygen was to be administered per physician order. Oxygen liter flow was to be set by a licensed nurse in accordance with physician's orders.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review the facility failed to identify triggers for a resident diagnosed with post-traumatic stress disorder (PTSD) for 1 of 28 sampled residents (Resident #52). This deficient practice placed the resident at risk for re-traumatization. Findings include: Resident #52 Resident #52 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder, chronic and paranoid schizophrenia. Resident #52's Care Plan documented Resident #52 was at risk for feelings of trauma or re-traumatization due to a diagnosis of PTSD. Goals included Resident #52 would be free of feelings of trauma or re-traumatization and would be safe and supported. Interventions included assisting Resident #52 with obtaining mental health or other services to support the resident as indicated and displaying warmth, compassion, and non-judgmental approach. On 11/06/2024 at 11:30 AM, a Licensed Practical Nurse (LPN) verbalized residents' behaviors were monitored every shift and if a resident's behavior changed staff would notify the physician. The LPN explained staff would know a resident's baseline behaviors because staff knew the residents. The LPN was not able to verbalize where a resident's baseline behaviors were documented. On 11/07/2024 at 12:10 PM, the Director of Nursing Services (DNS) explained the facility's interdisciplinary team would identify triggers for residents diagnosed with PTSD and the triggers would be added to the resident's care plan. Staff were informed through the care plan of how to eliminate or mitigate triggers which may cause residents diagnosed with PTSD to feel re-traumatized. The DNS verbalized the DNS had no idea what Resident #52's PTSD was related to or what may trigger the resident to feel re-traumatized. The DNS reviewed Resident #52's clinical record and denied the resident's care plan identified the resident's triggers and the interventions included on the care plan were not specific to the resident's experiences or preferences. The facility policy titled Trauma-Informed Care, updated October 2022, documented the facility wanted to guarantee residents who were trauma survivors received trauma-informed care and account for residents' experiences and preferences to eliminate or mitigate triggers which may cause re-traumatization.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #62 Resident #62 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including Alzheimer's disease, unspecified and type two diabetes mellitus without complications. Resident #62's October 2024 Treatment Administration Record (TAR) documented abrasion to left elbow related to fall. Cleanse with wound cleanser (WC), pat dry, apply triple antibiotic ointment and cover with Band-Aid, monitor for signs and symptoms (s/s) of infection and notify provider, every day shift. Negative (-) for s/s of infection, positive (+) for s/s of infection. The start date was 09/07/2024. There were no positive (+) responses documented in the month of October 2024. On 11/06/2024 at 2:09 PM, the LPN explained signs and symptoms of a wound infection included swelling, redness, pain, and drainage. The LPN verbalized Resident #62 had recently completed antibiotics for cellulitis at the site of an abrasion on the resident's left elbow. The LPN recalled the LPN had called the physician the previous week, on 10/30/2024, due to Resident #62's left elbow being swollen and red. The LPN explained a dash (-) on Resident #62's TAR indicated no s/s of infection and a positive (+) would indicate s/s of infection were present. The LPN reviewed Resident #62's progress notes and confirmed the date the LPN noted swelling and redness on the resident's left elbow was 10/30/2024. The LPN verbalized the documentation on the Resident #62's TAR indicated no s/s of infection were present and was inaccurate. A Nursing Progress Note dated 10/30/2024 documented Resident #62's left elbow was red, swollen, and painful. The physician was contacted and prescribed Augmentin for seven days. An Alert Charting Infection Note dated 11/02/2024 documented Resident #62's left elbow remained red and tender. On 11/06/2024 at 2:23 PM, the DNS verbalized s/s of a wound infection included redness, warmth, swelling, drainage, pain and odor. The DNS confirmed Resident #62 had a wound on the resident's left elbow. The facility policy titled Skin Integrity, updated October 2022, documented in an effort to maintain residents' optimal level of skin integrity the facility had a systematic approach and monitoring process for evaluating and documenting skin integrity. Significant abrasions were to be evaluated weekly and documented in the medical record. The licensed nurse was to remove dressings two times per week. The licensed nurse would examine the skin underneath and document the findings on the TAR. Based on observation, interview, clinical record review and document review, the facility failed to ensure 1) resident information was not visible on an unattended computer screen, and 2) records were accurate for 1 of 28 sampled residents (Resident #62). Findings include: On 11/03/2024 at 12:24 PM, a computer screen on an unattended medication cart in the 100 hall displayed resident information. On 11/03/2024 at 12:25 PM, a Licensed Practical Nurse (LPN) returned to the medication cart and verbalized the computer screen should not display resident information. The LPN confirmed the computer screen was unlocked and unattended with resident information on display. On 11/06/2024 at 4:35 PM, a computer screen on an unattended medication cart in the 100 hall displayed resident information. On 11/06/2024 at 4:36 PM, a Registered Nurse (RN) returned to the cart and verbalized computer screens should be locked when not attended and confirmed the computer screen displayed resident medical records. On 11/07/2024 at 9:14 AM, the Director of Nursing Services (DNS) verbalized medication carts and computer screens should be secure when not in use. On 11/07/2024 at 10:24 AM, a computer screen on an unattended medication cart in the 100 hall displayed resident information. A resident was standing next to the medication cart with the computer displaying resident information. On 11/07/2024 at 10:27 AM, an RN returned to the unsecured medication cart and verbalized the computer screen displayed resident information, and the medication cart was unlocked. The RN confirmed a resident was standing next to the medication cart and could have accessed resident information. The facility policy titled Privacy - HIPAA Health Insurance Portability and Accountability Act, updated 05/2023, documented the facility was required to protect the privacy of health information of residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure ordered Enhanced Barrier Precautions (EBP) were implemented for a resident with chronic pressure ulcers for 1 of 28 sampled residents (Resident #60). The deficient practice had the potential for spreading infectious illnesses to the vulnerable resident. Findings include: Resident #60 Resident #60 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus with hyperglycemia and pressure ulcer of right heel, stage three. A physician's order dated 02/20/2024, documented Enhanced Barrier Precautions (EBP) every shift for wounds. Resident #60's care plan revised 10/30/2024, documented a potential and actual impairment to skin integrity to include a healing stage three pressure ulcer to right heel. An intervention documented EBP due to wounds. On 11/03/2024 at 10:45 AM, EBP signage was not posted at the entrance of Resident #60's room. On 11/07/2024 at 9:27 AM, EBP signage was not posted at the entrance of Resident #60's room. On 11/07/2024 at 9:41 AM, a Certified Nursing Assistant (CNA) verbalized the CNA used gloves when providing care to all residents. The CNA explained EBP required glove use but was unsure what other personal protective equipment was used, when EBP was warranted, or which residents were on EBP. The CNA verbalized Resident #60 had a wound on their right leg, but the CNA did not do anything different or special when providing care to the resident. The CNA confirmed there was no EBP signage outside Resident #60's room. On 11/07/2024 at 9:51 AM, a Licensed Practical Nurse (LPN) entered Resident #60's room wearing gloves, greeted Resident #60 by name, and informed the resident the LPN was going to look at the resident's heel. On 11/07/2024 at 10:32 AM, the LPN verbalized Standard Precautions required the use of gloves during care while EBP required the use of gloves during care except during wound care when the LPN was required to wear gloves and a gown. The LPN verbalized Resident #60 was not on EBP, so the LPN has not been wearing personal protective equipment when providing wound care. The LPN confirmed Resident #60 did have an order for EBP. On 11/07/2024 at 10:45 AM, the Director of Nursing Services (DNS) verbalized staff were expected to follow EBP orders and EBP signage should be posted outside corresponding resident rooms. The DNS confirmed Resident #60 was on EBP. On 11/07/2024 at 11:24 AM, the Infection Preventionist (IP) verbalized the intent of EBP was to prevent residents from getting infections. The IP confirmed staff were expected to wear gowns and gloves when providing high contact care to residents on EBP. The facility policy titled, Enhanced Barrier Precautions, revised 03/26/2024, documented EBP was indicated for residents with chronic wounds including pressure ulcers. EBP expanded the use of personal protective equipment to donning of gown and gloves during high contact resident care activities. High-contact resident care activities included dressing, bathing, transferring, providing hygiene, changing linens, toileting, and wound care. When EBP was implemented, the IP or designee posts the appropriate notice on the room entrance door, so personnel were aware of precautions.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure 1 of 5 residents (Resident #392) reviewed for vaccinations, including influenza vaccines (Resident #392) was adminitstered the vaccine after the resident's guardian had consented for the vaccine to be administered. The deficient practice had the potential to place the resident at risk for not being protected against serious illness. Findings include: Resident #392 Resident #392 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, type II diabetes mellitus, and adult failure to thrive. Resident #392's State Immunization Record documented the resident last received an influenza vaccine on 12/27/2023. Resident #392's clinical record included a Resident Multi-Vaccine Consent Form. The form was signed and dated by the resident's guardian on 10/29/2024, giving consent for the resident to receive an influenza vaccine. The form documented the resident was eligible to recieve the vaccine and education regarding the vaccine was provided to the resident's guardian. A form titled Standing Vaccine Consent and Administration, revised on 10/13/2023, was signed by Resident #392's guardian on 10/29/2024. The form documented the guardian was provided a copy of the Vaccine Information Sheet (VIS) and understood the information/education related to the vaccine. Resident #392's clinical record lacked documented evidence the resident was administered an influenza vaccine. On 11/06/2024 at 4:08 PM, the Infection Preventionist (IP) verbalized Resident #392's guardian consented for the resident to receive an influenza vaccine on 10/29/2024. The IP confirmed the resident had not been administered the vaccine and should have been administered the vaccine on the day of consent, but it was missed. The facility policy titled Influenza and Pneumococcal Vaccine Administration, updated October 2024, documented influenza vaccination was provided to residents annually.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 26 opportunities and 14 medication errors. The medication error rate was 53.85%. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 11/07/2024 at 8:07 AM, a Licensed Practical Nurse (LPN) began preparing to administer medications to Resident #4. Among the medications prepared were the following: -Cholecalciferol (Vitamin D) 1000 units, two tablets. -Loratadine 10 milligrams (mg), one tablet. -Fish Oil 1000 mg, one capsule. -Multivitamin, one tablet. -Fluticasone 50 micrograms (mcg) per spray. -Vitamin B1 (Thiamine) 100 mg, one tablet. -Lisinopril 10 mg, one tablet. On 11/07/2024 at 8:15 AM, the LPN administered the prepared medications to Resident #4. The November 2024 Medication Administration Record (MAR) and Order Summary Report for Resident #4 documented the following: -Cholecalciferol (Vitamin D) tablet 1000 units, give two tablets by mouth one time a day for supplement. The scheduled administration time was 7:00 AM. -Loratadine tablet 10 mg, give 10 mg by mouth one time a day for allergies. The scheduled administration time was 7:00 AM. -Fish Oil capsule, give one capsule by mouth one time a day for supplement. The scheduled administration time was 7:00 AM. -Multivitamin tablet, give one tablet by mouth one time a day for supplement. The scheduled administration time was 7:00 AM. -Fluticasone Propionate Suspension 50 mcg/ actuation (act), one spray in each nostril one time a day for allergic rhinitis. The scheduled administration time was 7:00 AM. -Thiamine (Vitamin B1) tablet 100 mg, give one tablet by mouth one time a day for supplement. The scheduled administration time was 7:00 AM. -Lisinopril oral tablet 10 mg, give one tablet by mouth one time per day for hypertension. The scheduled administration time was 7:00 AM. Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of allergic rhinitis, unspecified. On 11/07/2024 at 8:17 AM, the LPN administered one spray of Fluticasone Propionate 50 mcg/act into Resident #12's left nostril. Resident #12 then requested to self-administer the remainder of the medication. Resident #12 took the bottle of Fluticasone Propionate and administered two sprays into the resident's right nostril. A physician's order dated 08/03/2024, documented Flonase Allergy Relief nasal suspension 50 mcg/act (Fluticasone Propionate), one spray in both nostrils one time a day for allergies. Resident #46 Resident #46 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. On 11/07/2024 at 8:29 AM, the LPN began preparing to administer medications to Resident #46. Among the prepared medications were the following: -Baclofen 10 mg, one tablet. -Sertraline 100 mg, one tablet. -Docusate Sodium 100 mg, one capsule. -Gabapentin 100 mg, one capsule. -Quetiapine Fumarate (Seroquel) 50 mg, one tablet. On 11/07/2024 at 8:34 AM, the LPN administered the prepared medications to Resident #46. The November 2024 MAR and Order Summary Report for Resident #46 documented the following: -Baclofen oral tablet 10 mg, give one tablet by mouth three times a day for muscle spasms. The scheduled administration time was 7:00 AM. -Sertraline Hydrochloride (HCl) tablet 100 mg, give one tablet by mouth one time a day for depression. The scheduled administration time was 7:00 AM. -Docusate Sodium capsule 100 mg, give 100 mg by mouth two times a day for constipation, hold for loose stool. The scheduled administration time was 7:00 AM. -Gabapentin capsule 100 mg, give 100 mg by mouth three times a day for anxiety, hold for sedation. The scheduled administration time was 7:00 AM. -Quetiapine Fumarate (Seroquel) tablet 50 mg, give 50 mg by mouth two times a day for psychosis. The scheduled administration time was 7:00 AM. Resident #111 Resident #111 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of heart disease, unspecified. On 11/07/2024 at 8:36 AM, the LPN began preparing to administer medications to Resident #111. Among the prepared medications was two tablets of Cyanocobalamin (Vitamin B12) 500 mcg. On 11/07/2024 at 8:40 AM, the LPN administered the prepared medication to Resident #111. The November 2024 MAR and Order Summary Report for Resident #111 documented the following: -Cyanocobalamin oral tablet 1000 mcg, give one tablet by mouth one time a day for nutritional support. The scheduled administration time was 7:00 AM. On 11/07/2024 at 9:16 AM, the Director of Nursing Services (DNS) verbalized the DNS's expectation of nursing staff when administering medications to residents was to first review physician orders and ensure the nurse was administering the correct dose to the correct resident. The DNS explained medications were to be administered within one hour before and one hour after the scheduled administration time reflected on the resident's MAR. The DNS confirmed if a medication was scheduled for 7:00 AM and administered after 8:00 AM the medication was considered late. The DNS explained residents could be allowed to self-administer medications if the resident was evaluated for safety and the facility obtained a physician's order. The DNS verbalized documentation would be in the evaluations section of the resident's electronic clinical record. Resident #12's clinical record lacked documentation of a physician's order and an evaluation for safety to self-administer medications. On 11/07/2024 at 11:37 AM, the LPN verbalized medications were to be administered to residents within one hour before and one hour after the scheduled administration time on the resident's MAR. The LPN confirmed the medications administered to resident #4, #46, and #111 during the AM medication pass, with a 7:00 AM scheduled administration time, were given late. The LPN explained the LPN had been running behind during the AM medication pass. The LPN explained residents were allowed to self-administer medications only after the resident was evaluated for safety. The evaluation included assuring the resident knew what medications were prescribed to the resident, the correct dose and the correct time. The LPN denied Resident #12 had an evaluation for self-administration of medications and should not have self-administered the Fluticasone Propionate nasal spray. The LPN verbalized the resident should have received one spray in each nostril. On 11/07/2024 at 4:25 PM, the Executive Director verbalized the facility did not have a policy defining what a medication error was. The Executive Director explained medication errors included administering a medication at the wrong time and the wrong dose. The facility policy titled Medication Administration, General Guidelines, dated January 2024, documented medications were to be administered according to written orders of the prescriber. Medications were to be administered within 60 minutes of the scheduled time. Residents were allowed to self-administer medications when specifically authorized by the prescriber, the interdisciplinary team, and in accordance with procedures for self-administration. The facility policy titled Medication Administration, Self-Administration by Resident, dated January 2023, documented residents who desired to self-administer medications were permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team had determined the practice would be safe.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

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Multi-dose vial On 11/05/2024 at 10:08 AM, during a review of the station one medication storage room and in the presence of a Licensed Practical Nurse 1 (LPN), an open vial of Tubersol 5 units/0.1 milliliters (ml) was found in the medication fridge. The vial did not have the date opened or the initials of the first person to use the vial written on it. On 11/05/2024 at 10:20 AM, the Director of Nursing Services (DNS) verbalized a multi-dose vial was required to have the date opened and the initials of the staff member opening the vial written on it. The DNS confirmed the vial of Tubersol was open and lacked the date opened or initials of the first person to use it. The facility policy titled Medication Administration, Injectable Vials and Ampules, dated January 2024, documented the date opened and the initials of the first person to use the vial were to be recorded on multi-dose vials. Outdated medications On 11/05/2024 at 10:27 AM, during a review of the station two medication cart and in the presence of an LPN2, the following medications were found: -Albuterol Sulfate inhaler 90 micrograms (mcg) per actuation (act). The discard after date printed on the pharmacy label was 06/06/2024. -Albuterol Sulfate Inhaler 90 mcg/act. The discard after date printed on the pharmacy label was 01/31/2024. -Tramadol 50 milligram (mg) tablet, 56 tablets remaining in the bubble pack. The discard after date printed on the pharmacy label was 10/26/2024. The LPN2 verbalized the discard after dates printed on the pharmacy labels for the two Albuterol Sulfate inhalers and the Tramadol tablets had passed and the medications should have been removed from the medication cart. On 11/05/2024 at 10:59 AM, during a review of the station three medication storage room and in the presence of an LPN3, a tube of Diclofenac Gel one percent was found. The discard after date printed on the pharmacy label was 08/06/2024. The LPN3 confirmed the discard after date printed on the pharmacy label for the Diclofenac Gel had passed and the medication should have been removed from stock in the medication storage room. On 11/05/2024 at 11:13 AM, during a review of the station three medication cart and in the presence of an LPN3, the following medications were found: -Hyosciamine 0.125 mg. The discard after date printed on the pharmacy label was 09/28/2024. -Liquid Pain Relief (Acetaminophen) 160 mg/5 ml. The expiration date printed on the bottle was April 2024. -Geri-Tussin (Guaifenesin) 200 mg/10 ml. The expiration date printed on the bottle was October 2024. -Cetirizine, ten mg tablets. The expiration date printed on the bottle was September 2024. -Acetaminophen suppositories, 650 mg. The expiration date printed on the box was June 2024. -Bisacodyl suppositories, 10 mg. The expiration date printed on the box was April 2024. The LPN3 confirmed the discard after date and the expiration dates for the medications had passed and the medications should have been removed from the medication cart. On 11/05/2024 at 3:35 PM, during a review of the station one medication cart, and in the presence of an LPN4, an Albuterol inhaler was found. The discard after date printed on the pharmacy label was 06/18/2024. The LPN4 verbalized the LPN4 could not read the discard after date as the print was too small. On 11/05/2024 at 3:43 PM, an LPN1 viewed the Albuterol inhaler and verbalized the discard after date printed on the Albuterol inhaler's pharmacy label was 06/18/2024. The DNS explained medications were to be removed from stock in medication carts and medication storage rooms on or before the expiration/discard after date printed on the medication. The DNS verbalized the facility abided by the discard after date printed on the pharmacy label for medications delivered from the pharmacy. The facility policy titled Medication Storage, Storage of Medications, dated January 2024, documented medications were stored according to manufacturer or provider pharmacy recommendations. Outdated medications were to be immediately removed from stock and disposed of. Based on observation, interview, and document review, the facility failed to ensure 1) a medication cart containing resident medications was secure, 2) an open multi-dose vial had the date opened and initials of the first person to use the vial written on it in 1 of 2 medication storage rooms reviewed and 3) outdated medications were removed from 3 of 3 medication carts reviewed and 1 of 2 medication storage rooms reviewed. The deficient practice could have facilitated unauthorized access to medications in the cart and had the potential for outdated/expired medications to be administered to residents. Findings include: Unsecured Medications On 11/07/2024 at 9:14 AM, the Director of Nursing Services (DNS) verbalized medication carts should be secure when not in use. On 11/07/2024 at 10:24 AM, an unattended medication cart in the 100 hall was unlocked. A resident was standing next to the unlocked medication cart. On 11/07/2024 at 10:27 AM, a Registered Nurse (RN) returned to the unsecured medication cart and confirmed the medication cart was unlocked. The RN confirmed a resident was standing next to the medication cart and could have accessed resident medications. The facility policy titled Storage of Medication, revised 01/2024, documented in order to limit access to prescription medications, only license nurses and those authorized to administer medications were allowed to access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access.

Nov 2023 20 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and document review, the facility failed to prevent resident to resident physical abuse for 1 of 12 Facility Reported Incidents (FRI) (Resident #5). Findings include: A FRI final report, dated 10/27/23, documented on 10/25/23, Resident #115 had punched Resident #5 in the stomach when attempting to exit the common room. Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia and major depressive disorder. Resident #115 Resident #115 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including psychotic disorder with delusions, unspecified mood disorder and unspecified psychosis. Resident #5's Interdisciplinary Note dated 10/26/23, documented on 10/25/23, Resident #5 was involved in a resident-to-resident altercation. A Certified Nursing Assistant (CNA) notified the nurse, Resident #5 was witnessed getting hit by Resident #115 with a closed fist when Resident #115 was attempting to exit the dining room. On 11/16/23 at 11:02 AM, a Licensed Practical Nurse (LPN) explained Resident #115 had been physical with other residents and had punched Resident #5 in the stomach in attempt to get Resident #5 out of the dining room doorway. On 11/16/23 at 1:54 PM, the Director of Nursing (DON) explained Resident #115 would get frustrated with other residents due to not being able to understand other residents. The DON verbalized Resident #115 had been physical with Resident #5 when attempting to get Resident #5 out of the dining room doorway to exit the dining room. The DON explained both residents reside in a locked dementia unit, and staff was to provide safety to the residents and understand each residents' triggers. The DON verbalized neither resident recalled the incident during the investigation. On 11/16/23 at 1:56 PM, the Administrator explained the incident occurred on 10/25/23, when Resident #115 was trying to go through the dining doorway and punch Resident #5 in the stomach to get the resident to move. After the incident occurred, both residents were separated, and appropriate agencies notified. The care plans were updated for both residents with new interventions and concerns for staff to watch for. Both Resident #115 and Resident #5 received support visits from behavioral health services, the DON, and the Social Worker. Resident #115 had a full work up completed to rule out any medical conditions because of the physical behavior. The interdisciplinary team (IDT) meets within the five days to see what interventions were beneficial to the resident. The IDT monitors the new interventions to see if the interventions were effective or not. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property and Exploitation, updated 10/2022 documented each resident had the right to be free from abuse including physical abuse. The center implements policies and processes, so residents were not subjected to abuse by other residents. FRI #NV00069720

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review the facility failed to document an investigation of alleged abuse for 1 of 25 sampled residents (Resident #114). Findings include: Resident #114 Resident #114 was admitted to the facility on [DATE], with diagnoses including spinal stenosis, chronic obstructive pulmonary disease, unspecified, generalized anxiety disorder, and major depressive disorder, recurrent severe without psychotic features. On 11/13/23 at 3:15 PM, Resident #114 verbalized a facility staff member had thrown water on the resident a couple of days prior. Resident #114 verbalized they threw the water back at the staff member and had been frustrated due to waiting 45 minutes for a response to the call light. The resident recalled the staff member was not a nurse. On 11/14/23 at 9:54 AM, Resident #114 recalled telling a nurse on the day of the incident about the staff member throwing water at them but did not file a grievance. On 11/15/23 at 4:09 PM, a Registered Nurse (RN) verbalized if a resident alleged abuse, the staff member receiving the allegation was to ensure the resident was safe and report immediately to the Abuse Coordinator. The RN verbalized the Abuse Coordinator was the facility Administrator. Resident #114's clinical record lacked documented evidence of the allegation. On 11/15/23 at 5:04 PM, the Administrator verbalized they were aware of the allegation involving Resident #114 and a Certified Nursing Assistant (CNA). The Administrator recalled being notified the morning of the incident and verbalized they had forgotten to follow up, place a note in the resident's record, or update the care plan. The allegation was reported by a nurse. The Administrator explained the reporting nurse informed them, upon being notified of the incident, they immediately went into Resident 114's room to investigate. The nurse verbalized there was no evidence of water in the resident's room, nothing in the room was found to be wet, no evidence of water was noted on linens or floor. On 11/16/23 at 7:37 AM, the Administrator verbalized follow up with Resident #114 and the involved CNA had been completed and the resident's care plan had now been updated. Two progress notes dated 11/15/23, documented the Social Services Director and the Administrator met with Resident #114 to follow up on the incident alleging water was thrown on the resident on 11/05/23. A progress note dated 11/16/23 documented an Interdisciplinary Team review of the incident occurred on 11/16/23. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property and Exploitation documented physical abuse included but was not limited to throwing objects. The center conducts a thorough investigation of allegations of abuse in accordance with state and federal regulations.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) for 1 of 25 sampled residents (Resident #114). Findings include: Resident #114 Resident #114 was admitted to the facility on [DATE], with diagnoses including spinal stenosis, chronic obstructive pulmonary disease, unspecified, generalized anxiety disorder, and major depressive disorder, recurrent severe without psychotic features. On 11/13/23 at 3:24 PM, Resident #114 verbalized their dentures were broken the second day in the facility. The resident recalled the facility informed them a dental appointment would be made but no one had followed up. A Care Conference note dated 08/08/23, documented the resident had upper and lower dentures in need of repair. A Social Service admission and History Evaluation note dated 08/08/23, documented the resident had broken dentures - (upper and bottom) dental to follow. Resident #114's MDS Sectiom L0200 Oral/Dental Status, dated 08/14/23, lacked documentation the resident had broken or loosely fitting full or partial dentures. On 11/15/23 at 3:48 PM, the MDS Coordinator confirmed the Care Conference dated 08/08/23, documented the resident's dentures were damaged. The MDS Coordinator confirmed the MDS assessment dated [DATE], did not accurately document the damaged dentures. Cross Reference tag F790.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident requiring assistance with nail care had the need care planned and a resident's care planned interventions for chronic pain were implemented for 2 of 25 sampled residents (Resident #29 and #16). Findings include: Resident #29 Resident #29 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, contracture, left hand, and muscle weakness (generalized). On 11/13/23 at 8:46 AM, the resident was sitting on the side of the resident's bed and was not wearing shoes or socks. The resident's toenails were very overgrown. The resident's clinical record lacked documentation of a care plan to address the resident's need for assistance with nail care. On 11/15/23 at 10:19 AM, Resident #29 was standing at the nurse's station. The resident had no shoes or socks on, and the resident's toenails appeared long, thick, and yellowed. On 11/15/23 at 10:41 AM, the Licensed Practical Nurse (LPN) for Resident #29 verbalized the LPN had not noticed how bad the resident's toenails were until the resident was standing at the nurse's station because the resident was never on the LPN's list to assess. On 11/15/23 at 3:19 PM, the Director of Nursing confirmed the resident lacked a care plan for nail care. Resident #16 Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pressure ulcer of sacral region, stage four, diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter, and major depressive disorder, recurrent, unspecified. On 11/13/23 at 9:10 AM, the resident verbalized the resident had a wound on the resident's back and the dressing changes frequently caused the resident pain. A care plan for Resident #16, revised 09/20/23, documented the resident had chronic pain and received Tylenol as needed. Analgesia would be administered one half hour before treatments or care. An Order Summary Report for Resident #16 documented the following: - acetaminophen (Tylenol) suppository 650 milligrams (mg), insert 650 mg rectally every four hours as needed for pain. The order start date was 11/09/18. - Tylenol tablet 325 mg, give 650 mg by mouth every four hours as needed for general pain. The order start date was 11/09/18. - cleanse coccyx pressure ulcer daily. The order start date was 11/09/23. On 11/15/23 at 11:36 AM, the Director of Nursing (DON) performed wound care for Resident #16. The November 2023 Medication Administration Record for Resident #16 did not have any administrations documented for the as needed pain medications (Tylenol). On 11/15/23 at 3:33 PM, the DON verbalized the DON did not realize the resident had a care plan with the intervention to medicate the resident for pain prior to providing care. The DON confirmed the DON did not medicate the resident prior to the dressing change. The facility policy titled admission - Person Centered Plan of Care, dated 11/2016, documented the resident's goals would be reviewed and developed on admission. Cross reference with tag F 677 and F 697

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to offer a non-English speaking resident translation services as care planned for 1 of 25 sampled residents (Resident #97). Findings include: Resident #97 Resident #97 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, dementia unspecified, and adult failure to thrive. Resident #97's Comprehensive Care Plan documented Resident #97 had a communication problem related to a language barrier as Resident #97 speaks Spanish and interventions included use of a language (phone) line. On 11/15/23 at 10:07 AM, a Certified Nursing Assistant (CNA) verbalized there were two residents who were Spanish speaking only. The CNA explained there was always a staff member on the hall who speaks Spanish. The CNA verbalized sometimes having to provide translation with assessments for the nurses. The CNA confirmed not using the translation service as the CNA was fluent in Spanish. On 11/15/23 at 10:25 AM, a Registered Nurse (RN) verbalized using staff to provide translation with assessments. The RN confirmed not using the translation service as there was always a staff member who was fluent in Spanish on the hall. On 11/15/23 at 4:49 PM, the Director of Nursing (DON) explained the resident was Spanish speaking and most of the staff spoke Spanish on the hall. The CNA should not have been translating assessments and nursing staff should have been using the language line to complete assessments. A facility policy titled Communication with Persons with Limited English Proficiency (LEP), updated 04/2015, documented the purpose of the LEP was to ensure meaningful communication with the LEP resident and their authorized representatives involving medical condition and treatment. Cross reference with tag F838.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident requiring assistance with nail care was provided with care to prevent the resident's toe nails from becoming overgrown for 1 of 25 sampled residents (Resident #29). Findings include: Resident #29 Resident #29 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, contracture, left hand, and muscle weakness (generalized). On 11/13/23 at 8:46 AM, the resident was sitting on the side of the resident's bed and was not wearing shoes or socks. The resident's toenails were very overgrown. The resident's clinical record lacked documentation of an assessment of the resident's nails or a care plan to address the resident's need for assistance with nail care. On 11/15/23 at 10:19 AM, Resident #29 was standing at the nurse's station. The resident had no shoes or socks on, and the resident's toenails appeared long, thick, and yellowed. On 11/15/23 at 10:41 AM, the Licensed Practical Nurse (LPN) for Resident #29 verbalized the facility did not have a Podiatrist who visited residents in the facility when needed. The LPN verbalized residents would be assessed for nail care needs weekly and the provider would be notified if staff had concerns about a resident refusing nail care. The LPN verbalized the LPN had not noticed how bad the resident's toenails were until the resident was standing at the nurse's station because the resident was never on the LPN's list to assess. On 11/15/23 at 3:19 PM, the Director of Nursing (DON) verbalized the need for nail care would be assessed when the resident was showered. The DON verbalized the facility no longer had a Podiatrist visit the facility. The DON verbalized the DON would expect staff to address a resident's need for nail care if the nails were getting long and thick. The DON confirmed the resident lacked a care plan for nail care. The facility document titled Mosby's Textbook for Nursing Assistants, Ninth Edition: Nail and Foot Care, documented nail and foot care prevented infection, injury, and odors. Hangnails, ingrown nails, and nails torn away from the skin caused skin breaks. These breaks were portals of entry for microbes. Long or broken nails would scratch skin and snag clothing. The feet were easily injured and infected. Cross reference with tag F 656.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0678 (Tag F0678)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, personnel record review and document review, the facility failed to ensure Cardio-Pulmonary Resuscitation (CPR) with First Aid training was completed for 1 of 5 sampled Licensed Nurses (Employee #2). Findings include: Employee #2 Employee #2 was hired on [DATE], as the Director of Nursing (DON). The DON's personnel record documented evidence of CPR with First Aid training was last completed on [DATE], and had expired [DATE]. The DON's personnel record lacked documented evidence of CPR with First Aid training for [DATE]. On [DATE] at 10:52 AM, the Human Resources Manager verbalized CPR was required to be taken by all licensed nurses upon hire and again upon the expiration date. The facility policy titled Cardiopulmonary Resuscitation (CPR), last updated 09/2017, documented all licensed nurses employed by the center were required to have current CPR certification.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #54 Resident #54 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including aftercare following joint replacement surgery, dysphagia following cerebral infarction, unspecified dementia, mild, with other behavioral disturbance, and Alzheimer's disease, unspecified. A Skin/Wound Note dated 11/02/23 documented an open area on right side buttock was noted during skin check. Director of Nursing Services and Nurse Practitioner were notified. A physician order dated 11/02/23, documented wound care as follows: cleanse right sacral stage II pressure ulcer (PU) with normal saline daily and pat dry. Apply skin prep to periphery and collagen powder to wound bed and cover with an adhesive edged foam dressing every day shift for wound healing. On 11/16/23 at 9:01 AM, a LPN verbalized the following interventions were ordered for Resident #54 for PU care and prevention: turns every 2 hours, hydration, wound care every shift. The LPN verbalized orders for wound care were on the resident's TAR. Resident #54's clinical record lacked documented evidence of wound care having been completed for the resident's right sacral PU on 11/04/23 and 11/05/23. On 11/16/23 at 11:44 AM, the DON confirmed documentation was missing from the resident's TAR for wound care for 11/04/23 and 11/05/23. The DON confirmed wound care did not occur as ordered on 11/04/23 and 11/05/23. The facility policy titled Skin Integrity, last updated 10/2022, documents in the event a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds. The licensed nurse implements new interventions as needed. Documents on the resident's care plan and care directive. Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a history of a pressure ulcer and determined to be at risk for the development of a pressure ulcer received wound care per physician and the facility policy for 2 of 25 sampled residents (Resident #64 and #54). Findings include: Resident #64 Resident #64 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter, pressure ulcer of left heel, unstageable, pressure ulcer of other site, stage two, pressure ulcer of right hip, stage three, and pressure ulcer of sacral region, stage four. A Weekly Skin Evaluations dated 10/25/23, documented three different pressure ulcers. An unstageable pressure ulcer on the left heel, a stage two pressure ulcer on the left outer ankle, and a stage four pressure ulcer on the sacrum. A care plan for Resident #64, initiated on 11/02/23, documented the resident had an infection to the sacral ulcer. A care plan for Resident #64, initiated on 09/05/23, documented the resident had a left heel pressure ulcer or potential for pressure ulcer development related to disease process, history of ulcers, and immobility. A physician's order dated 11/09/23, documented to cleanse left heel stage two pressure ulcer daily with wound cleanser or normal saline, pat dry and skin prep to periphery. Apply collagen sprinkles to wound bed and cover with a foam dressing every night shift for wound healing. A physician's order dated 09/15/23, documented to cleanse right trochanter pressure ulcer with wound cleanser. Pat dry. Apply skin prep to peri wound tissue. Apply anasept and collagen powder to wound bed. Cover with super absorbent dressing daily every night shift for stage three pressure ulcer. A physician's order dated 11/09/23, documented to cleanse sacral pressure ulcer with antimicrobial wound cleanser, pat dry, and apply silver calcium alginate to wound bed. Skin prep to periphery and to deep tissue injury (DTI) areas and cover with sacral wound dressing daily every night shift for pressure ulcer. Resident #64's Treatment Administration Record (TAR) dated November 2023, lacked documented evidence wound care was provided for any of the resident's pressure ulcers on 11/11/23, during the night shift. On 11/15/23 at 1:59 PM, a Licensed Practical Nurse (LPN) explained Resident #64 had three pressure ulcers in which the cleansing and changing of the dressings were physician ordered to be done each night, during the night shift. On 11/15/23 at 2:10 PM, the Director of Nursing (DON) verbalized Resident #64 had pressure ulcers requiring cleaning and changing of the dressing daily, on the night shift. A nurse would be required to follow the physician's orders for cleaning and changing the dressings on the pressure ulcers to avoid the pressure ulcers worsening, draining or causing an infection. The DON explained there were times when nursing staff would also notate the dressing changes in the nursing progress notes. The DON confirmed the dressing changes and cleansing of the resident's pressure ulcers were not completed on 11/11/23, nor was it noted by a nurse in the nursing progress notes. Cross referenced with tag F725

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to ensure a bed was in the low position per physician's orders and followed after a resident was identified as a high risk for falls and had a history of actual falls, in an attempt to prevent future falls for 1 of 25 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including other sequalae of other cerebrovascular disease, conversion disorder with seizures or convulsions and vascular dementia, severe, with psychotic disturbance. On 11/13/23 at 9:41 AM, Resident #1 was sleeping in bed and the bed was in the highest position. A Care Plan initiated on 01/19/21, and revised on 09/20/22, documented the resident was at risk for falls related to confusion, gait and balance problems, incontinence, psychoactive drug use, unaware of safety needs and wondering. The resident's last actual fall was documented on 09/20/22. Fall interventions included keeping the bed in a low position. A Fall Risk assessment dated [DATE], documented the resident was a high risk for falls. A physician's order dated 09/21/22, documented low bed for safety. On 11/16/23 at 9:20 AM, a Licensed Practical Nurse (LPN) verbalized if a resident was considered a high fall risk, interventions would include keeping the bed in the lowest position while the resident was in bed. On 11/16/23 at 9:23 AM, the Director of Nursing (DON) verbalized Resident #1 was non-verbal and non-ambulatory, requiring staff to use a Hoyer lift to get the resident out of bed. The resident was also known to have seizures and could cause the resident to fall. The resident was completely dependent on staff which automatically made the resident a fall risk. The DON acknowledged Resident #1 was not to be sleeping in bed while the bed was in the highest position and if the resident fell from the bed, the resident would not know how to use the call light provided. On 11/16/23 at 9:23 AM, the Administrator expressed frustration with the resident's bed in the highest position while the resident was sleeping and verbalized fall interventions were discussed frequently concerning Resident #1 and still the Administrator discovered fall interventions, such as the bed in the low position while the resident was in bed were frequently not being followed by staff. The facility policy titled Fall Evaluation (Morse Scale) and Management, last updated 03/2018, documented the center implemented fall management plans based on medical history reviews and resident evaluations. Potential interventions for falls would include low beds and frequent observation of the resident and interventions placed for falls.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure an attempt was made to schedule a timely follow up appointment with a Urologist for a resident with a urinary catheter for 1 of 25 sampled residents (Resident #113). Findings include: Resident #113 Resident #113 was admitted to the facility on [DATE], with diagnoses including overactive bladder, unspecified urinary incontinence, and major depressive disorder, single episode, unspecified. On 11/13/23 at 8:43 AM, Resident #113 was sitting up on the side of the resident's bed. The resident held up the resident's catheter bag and became tearful. The resident asked if the resident could take it out. On 11/13/23 at 10:10 AM, the representative for Resident #113 verbalized the resident had gone to the Emergency Department (ED) and had the catheter inserted for a blockage. The representative verbalized the facility was supposed to schedule an appointment with a Urologist for Resident #113 to determine the necessity of the catheter. The representative verbalized the representative was going to follow up with the facility because the representative had not yet been notified about the appointment. An ED After Visit Summary for Resident #113, dated 11/05/23, documented the resident had a referral to Urology with instructions to call the Urology office to schedule an appointment in one day (11/06/23). An order for Resident #113, dated 11/05/23, documented indwelling catheter for urinary retention, leave foley catheter in until seen by Urologist. A care plan for Resident #113, revised on 11/05/23, documented the resident had a potential for infection related to indwelling catheter. The indwelling catheter would be left in until seen by the Urologist. On 11/15/23 at 10:43 AM, the Licensed Practical Nurse (LPN) for Resident #113 verbalized the LPN was unable to find a follow up Urology appointment documented for Resident #113. On 11/15/23 at 3:27 PM, the Director of Nursing (DON) verbalized the resident's catheter could not be removed until after the resident had been seen by the Urologist. The DON verbalized the appointment was not documented in the clinical record and would have been made by the Transporter. On 11/15/23 at 3:30 PM, the Transporter verbalized the Transporter had been made aware of the need to schedule the appointment earlier in the day and had left a message for the Urologist's office. The Transporter verbalized nursing staff would notify the Transporter when a resident needed an appointment to be scheduled. On 11/15/23 at 3:32 PM, the DON verbalized the appointment with the Urologist to determine the necessity of the catheter should have been scheduled the next business day. The facility standard of practice titled Lippincott Manual of Nursing Practice: 10th edition, documented catheters would be changed according to the needs of the resident. Female, older, and debilitated residents, and those with obstructed bladders were at risk for infection.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was medicated for pain prior to procedures as care planned for 1 of 25 sampled residents (Resident #16). Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pressure ulcer of sacral region, stage four, diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter, and major depressive disorder, recurrent, unspecified. On 11/13/23 at 9:10 AM, the resident verbalized the resident had a wound on the resident's back and the dressing changes frequently caused the resident pain. A care plan for Resident #16, revised 09/20/23, documented the resident had chronic pain and received Tylenol as needed. Analgesia would be administered one half hour before treatments or care. An Order Summary Report for Resident #16 documented the following: - acetaminophen (Tylenol) suppository 650 milligrams (mg), insert 650 mg rectally every four hours as needed for pain. The order start date was 11/09/18. - Tylenol tablet 325 mg, give 650 mg by mouth every four hours as needed for general pain. The order start date was 11/09/18. - cleanse coccyx pressure ulcer daily. The order start date was 11/09/23. On 11/15/23 at 11:36 AM, the Director of Nursing (DON) performed wound care for Resident #16. The November 2023 Medication Administration Record for Resident #16 did not have any administrations documented for the as needed pain medications (Tylenol). On 11/15/23 at 3:33 PM, the DON verbalized the DON did not realize the resident had a care plan with the intervention to medicate the resident for pain prior to providing care. The DON confirmed the DON did not medicate the resident prior to the dressing change. The DON verbalized the resident should have been assessed and the as needed pain medication should have been offered prior to performing the dressing change. The facility policy titled Pain Management, updated 08/2023, documented the facility evaluated for, and attempted to manage/minimize, pain in residents. Cross reference with tag F 656

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review the facility failed to ensure an informed consent was obtained prior to installation of grab bars for 1 of 25 sampled residents (Resident #69). Findings include: Resident #69 Resident #69 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other specified fracture of right pubis, subsequent encounter for fracture with routine healing, traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, unspecified dementia, mild, without behavioral disturbance, and muscle weakness (generalized). On 11/14/23 at 7:57 AM, Resident #69's bed had grab bars on both sides. A Device Informed Consent, dated 07/12/23, documented the resident was informed of the risks and benefits of right-side grab bar use and device did not restrict movement. A bed rail evaluation dated 08/17/23, documented bilateral grab bars were recommended. Resident #69's care plan documented the resident was at risk for falls related to confusion, gait/balance problems, dementia and required assists with mobility and transfers. Interventions included bilateral grab assist bars for bed mobility initiated 08/17/23. Resident #69's clinical record lacked documented evidence of a signed informed consent for grab bars on both sides of the bed. On 11/15/23 at 12:13 PM, the Director of Nursing (DON) confirmed the resident had previously used a grab bar on the right side only and current order was for bilateral grab bars. The DON confirmed an updated consent for the bilateral grab bars should have been obtained and the DON was not able to locate it in the resident's electronic or paper record. The facility policy titled Bed Rails, published 09/2017, documented physician orders were received for all types of bed rails which include the following: side rails, bedside rails, safety rails, grab bars, assist bars, bed canes. Bed rails were only implemented after consent was obtained. An individual consent was obtained for each device.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review the facility failed to obtain informed consent prior to administration of a psychotropic medication, ensure psychotropic medications were ordered and administered to treat a specific, diagnosed condition for 1 of 25 sampled residents (Resident #54) and ensure a resident on a psychotropic medication had a gradual dose reduction (GDR) for 1 of 25 sampled residents (Resident #22). Findings include: Resident #54 Resident #54 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including aftercare following joint replacement surgery, dysphagia following cerebral infarction, unspecified dementia, mild, with other behavioral disturbance, and Alzheimer's disease, unspecified. Resident #54's Medication Administration Record (MAR) documented: - Start date of 04/18/23, hydroxyzine hydrochloride (HCl) Oral Tablet 25 milligrams (mg) (Hydroxyzine HCl) Give 1 tablet by mouth every eight hours as needed for Agitation - Getting out of bed/post hip replacement for seven days. - Hydroxyzine HCl 25 mg was administered to the resident on the following dates: 04/18/23, 04/19/23, 04/20/23, 04/23/23, 04/24/23. Resident #54's clinical record lacked documented evidence of a completed informed consent for psychotropic drugs prior to administration of hydroxyzine HCl 25 mg. On 11/15/23 at 10:00 AM, the Director of Nursing (DON) confirmed agitation was not an acceptable indication for use of hydroxyzine HCl. On 11/15/23 at 10:56 AM, the DON confirmed the hydroxyzine HCl was administered to the resident and a consent was not obtained prior to administration. Resident #54's order documented: - Start date of 08/15/23, Quetiapine Fumarate Oral Tablet (Quetiapine Fumarate), give 50 mg by mouth one time a day for psychosis/agitation. On 11/15/23 at 12:24 PM, the DON confirmed the indication of psychosis/agitation was insufficient and the clinical record lacked documented evidence of a specific diagnosis being treated with quetiapine. The DON verbalized the expectation was the provider would document an acceptable diagnosis in their note prior to use of a psychotropic medication. The DON verbalized the DON should have asked for clarification of the resident's diagnosis for quetiapine at the facility's weekly meeting with the provider. The facility policy titled Informed Consent for Psychotropic Drugs, last updated 09/2017, documented when the physician ordered the use of anti-psychotic, anti-depressant, and/or hypnotic drug, the center obtains, per federal and state regulations and center policy, informed consent from the resident or resident representative. An informed consent is obtained before the drug prescribed is administered. The facility policy titled Psychotropic Drugs, last updated 10/2022, documented in anti-psychotic medications were not used unless the medical record contained documentation the resident had one or more of the following specific conditions: schizophrenia, schizo-affective disorder, delusional disorder, psychotic mood disorder, brief psychotic disorder, schizophreniform disorder, psychosis not otherwise specified (NOS), atypical psychosis, Tourette's disorder, Huntington's disease. Dementia or dementia with behavioral disturbance itself was not an approved diagnosis for the use of antipsychotic medications. Resident #22 Resident #22 was admitted to the facility on [DATE], with a diagnoses of anxiety disorder, unspecified. Resident #22's physician's orders for Sertraline HCI were as follows: - Start date of 06/11/23, give 100 mg by mouth one time a day for anxiety, -Start date of 01/28/23, give 100 mg by mouth one time a day for anxiety, discontinued 06/11/23. -Start date of 01/19/22, give 100 mg by mouth one time a day for anxiety, discontinued 01/28/23. On 11/15/23 at 10:00 AM, the DON confirmed the facility lacked evidence an annual Gradual Dose Reduction (GDR) was conducted or a clinical rationale for continued use was documented by a physician for Resident #22's Sertraline. The facility policy titled Psychotropic Drugs, last updated 10/2022, documented a gradual dose reduction was to be attempted annually, unless contraindicated, if the psychotropic was initiated more than one year ago.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review the facility failed to ensure a dental consult was scheduled for damaged dentures for 1 of 25 sampled residents (Resident #114). Findings include: Resident #114 Resident #114 was admitted to the facility on [DATE], with diagnoses including spinal stenosis, chronic obstructive pulmonary disease, unspecified, generalized anxiety disorder, and major depressive disorder, recurrent severe without psychotic features. On 11/13/23 at 3:24 PM, Resident #114 verbalized their dentures had broke the second day in the facility. The resident recalled the facility informed them a dental appointment would be made but no one had followed up with the resident. A Care Conference note dated 08/08/23, documented the resident had upper and lower dentures in need of repair. A Social Service admission and History Evaluation note dated 08/08/23, documented the resident had broken dentures - (upper and bottom) dental to follow. Resident #114's care plan reflected resident had oral/dental problems related to poor oral health. Interventions included coordinate arrangements for dental care, transportation as needed/as ordered. On 11/15/23 at 12:44 PM, the Social Services Director verbalized resident needs for outside services were to be coordinated with the Social Services Director, Director of Nursing (DON) and resident transport. The Social Services Director verbalized Resident #114 had not been scheduled a dental appointment because the resident had been admitted to the facility for therapy (rehabilitation). On 11/16/23 at 11:49 AM, during an interview with the DON and the Administrator, the DON confirmed the Care Conference note dated 08/08/23, documented the resident's dentures needed repair. The DON verbalized a referral to outside dental services should have been made as soon as a problem was identified. The DON and Administrator confirmed the process or timing for referral to outside services would not change based on why a resident was admitted to the facility. The Administrator verbalized the facility had a standing order which allowed staff to begin the referral process without having to obtain an additional physician order. The DON and Administrator confirmed Resident #114 should have been referred on 08/08/23, to outside dental care for the resident's damaged dentures. Cross Reference tag F641

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, clinical record review, and document review, the facility failed to provide meals based on resident's allergies for 1 of 25 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and re-admitted [DATE], with diagnoses including schizoaffective disorder, bipolar type, generalized anxiety disorder and metabolic encephalopathy. The diagnosis of celiac disease was added on 10/20/23. Food Preferences Record, dated 04/17/23, lacked documented evidence of celiac disease for Resident #3. Resident #3's behavioral health solutions psych progress notes from 04/25/23 to 09/25/23 documented Resident #3's gluten allergy. On 11/15/23 at 2:38 PM, the Registered Dietician (RD) explained all nutritional assessments were completed by the RD. The RD confirmed the facility was not aware of a gluten allergy prior to Resident #3's re-admission on [DATE]. On 11/15/23 at 4:16 PM, the Director of Nursing (DON) verbalized medical records was responsible for inputting allergies. The DON explained when the resident admitted there was no documentation on the admission paperwork of a gluten allergy or celiac disease. The DON confirmed the behavioral health solutions psych progress notes located in the facilities electronic medical record for Residnet #3 from 04/25/23 to 09/25/23 documented a gluten allergy and the facility did not provide the resident a gluten free diet from 04/10/23 to 09/26/23. The facility document titled Food Preference Record, updated 03/2016, documented the diet order and food allergies/intolerance was to be gathered from the medical record prior to the interview. The Food and Nutrition Services Manager or designee verifies allergies and intolerances during the interview.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure transmission-based precautions (TBP) were initiated and discontinued per facility policy and staff were able to explain the reason a resident was on TBP for 1 of 25 sampled residents (Resident #31). Findings include: Resident #31 Resident #31 was admitted to the facility on [DATE], with diagnoses including non-ST elevation (NSTEMI) myocardial infarction, type two diabetes mellitus without complications, and personal history of COVID-19. On the mornings of [DATE], [DATE], and [DATE], a sign was posted on the outside of the resident's door documenting the following: - Contact Precautions (in addition to Standard Precautions). Visitors: Report to nurse before entering. An order dated [DATE], documented droplet precautions were necessary when a patient infected with a pathogen, such as influenza, pertussis, mumps, and respiratory illnesses, such as those caused by coronavirus infections. (Extended spectrum beta-lactamase [ESBL] in urine - use bedside commode). On [DATE] at 10:40 AM, the Licensed Practical Nurse (LPN) verbalized Resident #31 was on contact precautions because the resident would get rashes on the resident's right leg. The LPN then clarified the LPN needed to figure out why the resident needed contact precautions. On [DATE] at 3:14 PM, the Director of Nursing (DON) verbalized Resident #31 had been placed on contact precautions for ESBL in the urine, but the resident should not have still been on TBP as the order had expired on [DATE]. The DON verbalized the order was incorrectly entered as droplet precautions. The DON verbalized the DON's expectation was for staff working with the resident to be able to explain why a TBP sign was posted on a resident's door. The facility policy titled Transmission-Based Precautions (Isolation), dated 05/2015, documented the facility would use the least restrictive approach to managing individuals with potentially communicable infections. TBPs were only used when transmission could not be reasonably prevented by less restrictive measures. The facility would implement a signage system to alert staff to the type of precaution residents required.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Excessively Low Weekend Staffing The Centers for Medicare and Medicaid Services, Payroll-Based Journal (PBJ) Staffing Data Report, dated 04/01/23 through 06/30/23, documented the facility had one star staffing rating and excessively low weekend staffing. The Facility Assessment, reviewed 06/13/23, documented the facility was in need of six nurses and 14 Certified Nursing Assistants (CNA). Multiple staff members were cross-trained and assisted in filling needed shifts. On 11/13/23 at 10:02 AM, Resident #43 verbalized facility staff told the residents they were shorthanded. On 11/13/23 in the afternoon, Resident #114 verbalized staff were overwhelmed. On 11/14/23 at 3:00 PM, during the Resident Council Interview, the following statements were made by residents: -Weekends were the worst and there were a lot of staff no-shows including CNAs and nurses. -Staff did not come in (to fill empty shifts) when they were on call. -When State was in the building, everyone passed food trays, but this was the only time it happened. Management was supposed to come in on the weekends to pass food trays and it did not happen. -Call lights took 45 minutes to one hour for response on night shift (NOC) and CNAs were responsible for 43 residents each. -I just cringe when I hear a weekend is coming up. On 11/16/23 at 1:58 PM, an LPN verbalized the LPN sometimes had to stay until 7:30 PM when their shift ended at 6:00 PM, due to not having enough time to complete required assignments each day. On 11/16/23 at 2:13 PM, the Resident Care Manager (RCM) verbalized the number of residents they were responsible for depended on the shift they were working. The RCM verbalized at night they were responsible for 80 residents per one nurse. During night shift there was one nurse for station two and three combined. The RCM verbalized there were times they did not have enough time during their shift to complete their required assignments and communication would be given to the next shift to complete it. On 11/16/23 at 2:28 PM, a CNA verbalized they were typically responsible for 25 residents per two CNAs but not always. The CNA verbalized they were sometimes responsible for more residents on the weekends. The CNA verbalized required tasks for their shift were sometimes delayed due to not having enough time. The CNA denied being included by administration in determining staffing needs. The CNA verbalized feeling short staffed and it was a problem because there were no state regulations for staffing ratios. The CNA verbalized they did communicate to residents when they were short staffed. On 11/16/23 at 3:37 PM, the Administrator and DON verbalized staffing was not based on a matrix, staffing was based on acuity of the residents in the facility. When staff called out an on-call phone was used and all staff were called who were not already scheduled, to ask if they would pick up an extra shift. Nurses' schedules were recently changed due to not all nurses working weekends. The Administrator verbalized a nurse manager was filling in, working many weekend shifts. The Administrator verbalized the facility had been staffing two nurses overnight and had an agency nurse who started orientation on 11/15/23 for night shift. The Administrator verbalized three nurses were ideal for night shift and nursing leadership was currently rotating coverage for each night shift. Monthly nursing schedules for April, May and June 2023 (same quarter as the PBJ Staffing Data Report) documented the NOC shift to need three nurses. Review of Daily Schedules documented the following for NOC shift: On 04/02/23 - two licensed nurses On 04/08/23 - two licensed nurses On 04/09/23 - two licensed nurses On 05/14/23 - two licensed nurses On 05/21/23 - one licensed nurse On 06/03/23 - two licensed nurses On 06/04/23 - two licensed nurses Based on observation, clinical record review, interview, and document review the facility failed to ensure staffing in the 300 hall memory care was sufficient to ensure timely administration of medications resulting in the failure to ensure a medication error rate of less than 5 percent (%) and the facility did not experience excessively low weekend staffing. Findings include: Timely Administration of Medications On 11/16/23 between 9:05 AM and 9:46 AM, during observation of the 300 hall memory care unit's medication administration pass, a Registered Nurse (RN) administering medications, prepared resident medications in the enclosed nurse's station to ensure resident safety. The RN explained due to the residents' cognitive deficits items on top of the medication administration cart, such as pitchers of water, juice, and pudding put the residents at increased risk of harm related to falls. There was not another staff member present at the nurse's station to assist the RN when residents came to the nurse's station for assistance. The RN had to make frequent delays in the medication administration process to attend to the residents' needs at the desk. During the medication administration pass, Certified Nursing Assistants (CNAs) were not available in the units hallways to ensure residents were kept safe if the medication cart was taken into the hallway or to assist the RN with locating residents for medication administration. There were 25 rooms and 34 residents in the 300 hall memory care unit. During the medication administration observation two residents were not in their rooms or in the units common areas and the RN had to search for the residents by looking in each resident room until the resident could be located hindering the RNs ability to be administer medications to the unit's residents in a timely manner. On 11/16/23 at 1:32 PM, a Licensed Practical Nurse (LPN) verbalized when other staff were not available to assist with residents, when the LPN was preparing resident medications for administration, the LPN had to stop mediation preparation, lock the cart and delay medication preparation and administration to assist the resident. The LPN verbalized resident behaviors and searching for residents during medication administration was very time consuming and made timely administration of medications in the unit very difficult. The LPN confirmed there were not always enough staff members to assist in the unit and this contributed to late medication administration. On 11/16/23 at 2:16 PM, the Director of Nursing (DON) confirmed medications could be administered one hour prior to the scheduled administration time and were required to be administered no later than one hour after the scheduled administration time. The DON verbalized timely administration of medications in the 300 hall memory care unit could be difficult when an incident involving the residents occurred. The DON confirmed searching for residents, interruptions related to resident care, and measures to ensure resident safety made the timely administration of medications in the 300 hall difficult and acknowledged additional staffing or retraining of support staff could help ensure timely administration of medications. Cross reference with tag F759

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected most or all residents

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Based on observation, interview and document review, the facility failed to accurately document the amount of a controlled substance in 2 of 2 sampled controlled substance logs and failed to ensure the discrepancies were reported to the Director of Nursing (DON). Findings include: On 11/14/23 at 2:03 PM, a controlled substance reconciliation count was completed for the 300 hall medication cart's controlled substance log with the DON and the following inaccuracies were identified. The controlled substance log documented the following: -On 11/09/23 at 8:00 AM, a 0.25 milliliter (ml) dose of morphine sulfate concentrate (morphine) was documented as administered, and 4.0 ml of the medication remained in the bottle. -On 11/09/23 at 8:00 PM, a 0.25 ml dose of morphine was documented as administered and the remaining amount was documented as 3.5 ml and should have been documented as 3.75 ml. -On 11/13/23 at 8:00 PM, documented 1.5 ml of morphine remained in the bottle. There were no additional entries in the log. A 0.25 ml dose of morphine was documented as given twice daily on 11/10, 11/11, 11/12, and 11/13/2023, indicating a total of 1.5 ml of morphine was administered during these dates and the remainder of the medication should have been documented as 1.75 ml. On 11/14/23 at 2:24 PM, the DON confirmed the bottle of morphine contained a scant amount of the medication and should have contained 1.75 ml of morphine. On 11/14/23 at 3:25 PM, a controlled substance reconciliation count was completed for the 100 hall medication cart's controlled substance log with the DON and the following inaccuracies were identified: -The controlled substance log documented on 11/14/23 at 7:30 AM, 21.25 ml of morphine remained in the medication bottle. On 11/14/23 at 3:27 PM, the bottle of morphine 20 milligrams (mg)/ml located in the 100 hall medication cart contained approximately 19 ml of morphine. On 11/14/23 at 3:27 PM, a Licensed Practical Nurse (LPN) verbalized the LPN had noted the count inaccurate on the morning of 11/14/23, and confirmed the nurse did not discuss the discrepancy with the off going nurse and did not report the inaccuracy to the DON. The DON confirmed the bottle of morphine contained 19.0 ml of morphine and should have contained the 21.25 ml documented in the controlled substance log. The facility policy titled Medication Storage - Controlled Medication Storage, dated 01/2023, documented at each shift change a physical inventory of all schedule II medications was conducted by two licensed nurses and documented in the controlled substance log. Any discrepancy in controlled substance medication counts was reported to the DON immediately. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, last updated 10/2022, documented misappropriation of resident property to include missing prescription medication or diversion of a resident's medication including but not limited to, controlled substances.

MINOR (C)

Minor Issue - procedural, no safety impact

Menu Adequacy (Tag F0803)

Minor procedural issue · This affected most or all residents

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Based on observation, interview, and document review the facility failed to ensure the menu was followed or updated for a lunch service. Findings include: On 11/14/23 at 3:00 PM, during the Resident Council Interview, residents complained food changes to the menu occurred often. The menu was frequently not posted at Station 1 and if it was posted, it did not always match the menu served. The residents verbalized the concern with not posting accurate menus resulted in residents not knowing if they wanted an alternate meal. A resident could request the alternate if they did not want what was served but then they have to wait for their meal and could be more than 45 minutes. On occasion, the alternate requested, was forgotten and the resident would have to wait for the next meal. On 11/15/23 at 11:41 AM, residents were served honey mustard pork loin, au gratin potatoes, savory cabbage, and apple pie. The dining room menu posted documented lunch on 11/15/23, was to be honey mustard pork loin, au gratin potatoes, savory cabbage, and cream cheese cherry square. On 11/15/23 at 3:38 PM, the Food and Nutrition Services Manager confirmed the lunch served was to have cream cheese cherry square. The Food and Nutrition Services Manager verbalized the facility did not have the ingredients to make the cream cheese cherry square and served apple pie instead. The Food and Nutrition Services Manager explained the kitchen staff was to notify the front staff or activities aides of any changes to the menu. The facility policy titled, Menus, updated 10/2017, documented if any meal served varied from the planned menu, the change was to be posted for the residents and on the posted menu in the kitchen.

Aug 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and document review, the facility failed to prevent resident to resident abuse for 7 of 28 sampled residents (Resident #15, #16, #17, #19, #21, #22, and #28), and failed to prevent employee to resident neglect for 1 of 28 sampled residents (Resident #13). Findings include: A Facility Reported Incident (FRI) final report, dated 05/01/23, documented on 04/24/23, Resident #13 had an unwitnessed fall resulting in a fractured left hip. Resident #13 was not assessed by a nurse or given medical attention until 04/26/23 due to a Hospitality Aide and Certified Nursing Assistant (CNA) not reporting the fall. Resident #13 Resident #13 was admitted on [DATE], with diagnoses including low back pain, unspecified; age-related osteoporosis without current pathological fracture; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; muscle weakness (Generalized); unspecified abnormalities of gait and mobility; repeated falls; and difficulty in walking, not elsewhere specified. A Nursing Progress Note dated 04/26/23, documented Resident #13 complained of left leg pain on 04/26/23, and had an in-house x-ray ordered. The x-ray revealed Resident #13 had a left femoral neck fracture and was transported via Emergency Medical Services (EMS) to the hospital. Resident #13 was hospitalized from [DATE] to 04/29/23. A nursing Progress Note dated 05/01/23, documented Resident #13 had a history of placing themselves on the floor to pray. Staff observed Resident #13 sitting on the floor on 04/24/23. A Care Plan dated 01/25/23, documented Resident #13 had a behavior of placing themselves on the floor to pray or lay down and in the event Resident #13 was on the floor, a nurse was to assess Resident #13 prior to getting up. The Pain Level Chart of Resident #13 from 04/24/23 to 04/26/23, when they received medical attention was as follows: On 04/24/23, Resident #13 had a pain level of 2 out of 10. On 04/25/23, Resident #13 had a pain level of 0 out of 10. On 04/26/23, Resident #13 had a pain level of 5 out of 10. On 05/30/23 at 2:01 pm, the Administrator verbalized Resident #13 had recently broken their left hip due to an unwitnessed fall. The Administrator verbalized they did not know Resident #13 had fallen until the facility started their own investigation due to Resident #13 having a left broken hip with unknown origin. The Administrator verbalized a Hospitality Aide and CNA assisted Resident #13 off the floor after the resident had fallen from their bed on 04/24/23. The Hospitality Aide found Resident #13 on the floor and asked a CNA on the unit to assist them with getting Resident #13 back into bed. The Administrator verbalized the Hospitality Aide and CNA did not report the fall to a nurse or any other staff as they believed Resident #13 had put themselves on the floor. Resident #13 had a behavior care planned for placing themselves on the floor and the Administrator verbalized the Hospitality Aide and CNA believed this was what happened. The Administrator verbalized all staff were coached on falls and the process for reporting them. The facility policy titled Resident Fall Response, updated 05/2016, documented residents who have fallen should not be moved and should be assessed by a Licensed Nurse whether there is an obvious injury or not. The facility policy titled Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation, updated 09/17, documented residents have the right to receive services necessary to avoid physical harm, pain, mental anguish, or emotional distress. FRI #NV00068460 FRI #NV00068706 documented Resident #14 yelled a profanity and pushed Resident #15 causing the resident to land on the floor. Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis, psychotic disorder with delusions, mental disorder, and mood disorder. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including cerebral palsy and autistic disorder. A Nursing Progress Note dated 06/02/23, documented Resident #14 was standing by the dining room door when Resident #15 walked up and jiggled the dining room door handle. Resident #14 then yelled a profanity at Resident #15 and with two hands pushed Resident #15 on the shoulder and upper chest area causing Resident #15 to fall to the floor. Resident #15 was assessed for injury with none noted. On 08/30/23 at 4:48 PM, the Director of Nursing (DON) confirmed Resident #14 had pushed Resident #15 causing the resident to fall to the floor without injury. FRI #NV00068728 documented Resident #16 hit Resident #17 after Resident #17 grabbed the back of Resident #16's wheelchair, then Resident #17 hit Resident #16 in the back. Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder, bi-polar type and unspecified intellectually disabilities. Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including dementia, psychotic disturbance and mood disturbance. A Nursing Progress Note dated 06/05/23, documented Resident #17 grabbed Resident #16's wheelchair to propel forward and Resident #16 became agitated and hit Resident #17 on the left shoulder. Then Resident #17 hit Resident #16 with an open hand on the back. The residents were separated and both assessed with no injuries noted. On 08/30/23 at 4:51 PM, the DON confirmed Resident #16 hit Resident #17 in a reaction to grabbing the wheelchair and Resident #17 hit Resident #16 in the back. FRI #NV00068736 documented Resident #18 hit Resident #19 on the cheek and mouth with a closed fist. Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia and unspecified psychosis. Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including dementia, psychotic disturbance and mood disturbance. A Nursing Progress Note dated 06/05/23, documented both residents were attending activities in the dining room when Resident #19 attempted to assist Resident #18. Then Resident #18 became agitated and hit Resident #19 with a closed fist to the left side of the cheek and mouth area. Residents were separated immediately. Resident #19 was assessed with no injuries noted. On 08/30/23 at 4:54 PM, the DON confirmed Resident #18 hit Resident #19 on the cheek and mouth area. The DON verbalized Resident #19 could sometimes agitate other residents and was to be paired with a staff member during activities. FRI #NV00068757 documented Resident #20 swatted Resident #21's hand away and threw a coffee cup containing coffee at Resident #21's chest. Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including dementia, dysphagia and restlessness and agitation. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including dementia, unspecified psychosis and cognitive communication deficit. An Interdisciplinary Note dated 06/08/23, documented Resident #20 and Resident #21 were holding hands while sitting down when Resident #20 became agitated and swatted Resident #21's hand away. Then Resident #20 picked up a cup containing lukewarm coffee and threw it at Resident #21's chest area. Residents were immediately separated. Resident #21 was assessed for injury or pain with none noted or expressed. On 08/30/23 at 4:57 PM, the DON confirmed Resident #20 swatted Resident #21's hand away and then threw a cup of coffee at Resident #21. FRI #NV00068775 documented Resident #14 yelled at Resident #22 and hit Resident #22 on the arm twice. Resident #14 Resident #14 admitted to the facility on [DATE], with diagnoses including unspecified psychosis, psychotic disorder with delusions, mental disorder, and mood disorder. Resident #22 Resident #22 admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia and mood disorder. A Nursing Progress Note dated 06/09/23, documented Resident #14 was yelling at Resident #22. Resident #14 continued to follow and make comments towards Resident #22 when Resident #14 reached out and slapped Resident #22's arm twice. No injuries were noted. On 08/30/23 at 5:01 PM, the DON confirmed Resident #14 was yelling at Resident #22 and continued to follow and make comments towards Resident #22. Then Resident #14 slapped Resident #22 on the arm twice. FRI #NV00069075 documented Resident #28 was attempting to take Resident #16's food tray. When Resident #16 tried to take the tray back, Resident #16 pushed Resident #28 causing the resident to fall to the floor resulting in a small abrasion to the back. Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder, bi-polar type and unspecified intellectually disabilities. Resident #28 Resident #28 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease and unspecified psychosis. A Social Services Note dated 07/27/23, documented Resident #28 was attempting to take Resident #16's food tray while in the dining room. When Resident #16 tried to take the tray back, Resident #16 pushed Resident #28 causing the resident to fall to the floor resulting in a small abrasion to the back. A room change will be done as these residents were roommates. On 08/30/23 at 5:07 PM, the DON confirmed Resident #16 became agitated when Resident #28 tried to take the resident's food tray. Resident #16's reaction was to push Resident #28 causing the resident to fall to the floor. Resident #28 had a small abrasion to the back. The facility policy titled Abuse Prohibition Notification, and Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation, dated September 2017, documented residents had the right to be free from abuse, including verbal and physical abuse and the facilities policies and processes were to be implemented so residents were not subjected to abuse by other residents.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to ensure post fall interventions were implemented and followed after a fall in an attempt to prevent future falls for1 of 28 sampled residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter, epilepsy, unspecified, not intractable, without status epilepticus, anoxic brain damage, not elsewhere classified, and conversion disorder with seizures or convulsions. On 05/30/23 at 9:30 AM, a Licensed Practical Nurse (LPN) explained residents who were identified as a fall risk would have fall interventions put in place in an attempt to prevent injuries if a resident had fallen. The interventions could include fall mats on each side of the resident's bed and the resident would be under close supervision to ensure all precautions had been taken. The LPN verbalized Resident #8 was to be on fall precautions after a recent fall. The LPN verbalized Resident #8 had recently slid out of bed and the mattress to the bed was also on the floor alongside the resident. The LPN explained staff could not determine how the resident fell out of bed because the resident could not move on their own and the resident was nonverbal and could not communicate falling out of bed. The LPN verbalized the resident was assessed for injury and sent to the hospital for further evaluation. The hospital had determined Resident #8 had fractured parts of the legs. Nursing Progress Notes dated 04/11/23, documented Resident #8 was found lying on the floor with the mattress from the bed. The resident was assessed and showed no apparent injury. An Interdisciplinary Team (IDT) Fall Review Note dated 04/12/23, documented Resident #8's mattress seemed to be the cause of the fall because the mattress would dip toward the sides, instead of the middle of the bed. As a result, interventions to include a bariatric low air loss mattress with bolsters was put on the resident's bed. A Care Plan initiated on 02/23/20, documented the resident was a high risk for falls and fall mats were to be at the resident's bedside to ensure the resident would be free from injury. On 05/30/23 at 9:52 AM, Resident #8 was sleeping in bed. The resident's bed was placed in the lowest position, however there were no fall mats placed on either side of the bed. On 05/30/23 at 10:43 AM, the Administrator explained Resident #8 was bed bound and needed assistance with all needs to include fall precautions as a result of a recent fall in the facility. The resident was found on the ground with the mattress by staff. The resident was assessed and determined the resident would need to go to the hospital for further evaluation, a month after the fall. The Administrator verbalized the resident did not show any signs of discomfort, bruising or injuries and was sent to the hospital for a blister on the resident's knee. Once the resident was at the hospital, it was determined the resident had leg fractures. As a precaution, the resident was put on fall precautions to include the bed in the lowest position and fall mats on each side of the bed. The Administrator observed Resident #8 lying in bed and confirmed the resident did not have fall mats on either side of the bed and verbalized if the resident had fallen again, the fall may cause another serious injury as a result of no bed mats next to the bed. On 05/30/23 at 2:29 PM, the Nurse Supervisor verbalized Resident #8 was discovered on the ground by staff, however the assessment of the resident did not determine any injuries sustained by the resident. As a result, fall mats were placed on each side of the bed as a fall precaution. The Nurse Supervisor explained staff read the care plan for Resident #8's roommate and mistakenly put Resident #8's fall mat by the roommate's bed. A facility policy titled Resident Fall Response, last updated December 2016, documented the facility would provide proper interventions after a resident had fallen and staff would observe every shift to ensure fall interventions were actively in place. Complaint #NV00068655

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a Licensed Nurse provided care for a resident post fall when a Certified Nursing Assistant (CNA) and Hospitality Aide did not notify a Licensed Nurse of a resident's fall to complete an assessment of the resident for 1 of 15 residents (Resident #13). Findings include: A Facility Reported Incident (FRI) final report, dated 05/01/23, documented on 04/24/23, Resident #13 had an unwitnessed fall resulting in a fractured left hip. Resident #13 was not assessed by a nurse or given medical attention until 04/26/23 due to a Hospitality Aide and Certified Nursing Assistant (CNA) not reporting the fall. Resident #13 Resident #13 was admitted on [DATE], with diagnoses including low back pain, unspecified; age-related osteoporosis without current pathological fracture; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; muscle weakness (Generalized); unspecified abnormalities of gait and mobility; repeated falls; and difficulty in walking, not elsewhere specified. A Nursing Progress Note dated 04/26/23, documented Resident #13 complained of left leg pain on 04/26/23, and had an in-house x-ray ordered. The x-ray revealed Resident #13 had a left femoral neck fracture and was transported via Emergency Medical Services (EMS) to the hospital. Resident #13 was hospitalized from [DATE] to 04/29/23. An Education/Coaching Form was completed for the Hospitality Aide on 05/01/23. The form explained all resident falls were to be reported to a nurse so they can assess the resident as the Hospitality Aid cannot physically assist any resident. An Education/Coaching Form was completed for the CNA and explained all resident falls were to be reported to a nurse prior to assisting the resident back into bed. A job description for the Hospitality Aide was reviewed with the Hospitality Aide on 05/01/23. The job description explained the Hospitality Aide reports to the Licensed Nurse on the unit and was responsible for: -Answering call lights to assess resident needs, -Providing snacks and fluids to residents, -Serving food to residents during mealtimes, -Cleaning, disinfecting, and changing linens. On 05/30/23 at 2:01 pm, the facility Administrator verbalized a Hospitality Aide and CNA assisted Resident #13 off the floor after they had fallen from their bed on 04/24/23. The Hospitality Aide found Resident #13 on the floor and asked a CNA on the unit to assist them with getting Resident #13 back into bed. The Administrator verbalized the Hospitality Aide and CNA did not report the fall to a nurse or any other staff. The Administrator also verbalized is was out of the Hospitality Aide's scope of practice to be assisting a resident back into bed. The facility policy titled Resident Fall Response, updated 05/2016, documented residents who have fallen should not be moved and should be assessed by a Licensed Nurse whether there is an obvious injury or not. FRI #NV00068460

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including delusional disorders, vascular dementia, unspecified severity, with other behavioral disturbance, and restlessness and agitation. Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, dementia in other disease classified elsewhere, severe, with agitation, age-related cognitive decline, and cognitive communication deficit. A Progress Note dated 02/23/23, documented Resident #3 was seen in Resident #1's room. Resident #3 was holding the privacy curtain in the left hand and had the right hand in a fist like position. Resident #3 punched Resident #1 in the left eye. An abrasion was noted on Resident #1's left eye. An Alert Charting Behavior note dated 02/23/23, documented Resident #3 had an altercation with another resident when Resident #3 entered Resident #1's room and was witnessed punching Resident #1 in the eye. On 04/11/23 at 11:57 AM, a Registered Nurse explained Resident #3 was often possessive of the resident's room and belongings. On 04/11/23 at 12:57 PM, the Administrator confirmed Resident #3 entered Resident #1's room and punched Resident #1 in the left eye. The Administrator verbalized Resident #1 sustained an abrasion to the left eye as a result of the altercation. Resident #2 Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including traumatic subdural hemorrhage without loss of consciousness, sequela, schizoaffective disorder, bipolar type, unspecified mood (affective) disorder, and legal blindness, as defined in USA. A Progress Note dated 02/26/23, documented Resident #1 was noted to squeeze Resident #2's right forearm and slapped the back of Resident #2's hand before staff could intervene. An Interdisciplinary note dated 02/27/23, documented Resident #2 was sitting near the nurse's station when the resident was heard yelling. Resident #1 was seated next to Resident #2 and was holding onto and squeezing Resident #2's right forearm. Resident #1 then slapped the back of Resident #2's right hand before staff could separate the residents. Resident #2's care plan initiated on 02/27/23, documented Resident #2's right forearm was squeezed and right hand was slapped in a resident to resident altercation on 02/26/23. On 04/11/23 at 11:43 AM, a Certified Nursing Assistant (CNA) communicated the CNA heard Resident #2 say Ouch, he hit me, while providing care to the resident in the next room. The CNA explained Resident #1 had Resident #2's right hand and was slapping the back of the hand. On 04/11/23 at 12:53 PM, the Administrator confirmed Resident #1 was seated next to Resident #2 when Resident #2's right forearm was squeezed and right hand was slapped by Resident #1. The Administrator explained the residents should not have been seated together as Resident #1 did not like other people to get too close and could become agitated. The facility policy titled Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation, updated 09/2017, documented each resident had the right to be free from abuse, including physical abuse. The facility would implement policies and processes so residents were not subjected to abuse by other residents. Physical abuse included, but was not limited to, hitting, slapping, punching, biting, and kicking. FRI #NV00068009 FRI #NV00068054 FRI #NV00068047 Based on interview, clinical record review, and document review, the facility failed to prevent resident to resident physical abuse for 3 of 13 sampled residents (Resident #9, #1, and #2). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including schizophrenia, unspecified, anxiety disorder, unspecified, and mental disorder, not otherwise specified. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, difficulty in walking, not elsewhere classified, and cognitive communication deficit. A facility reported incident final report, documented on 02/17/23, Resident #8 was trying to exit the multi-purpose room and Resident #9 was standing in the doorway. Resident #8 yelled at Resident #9 and then used both hands to push Resident #9 out of the doorway. Resident #9 then stumbled forward several steps before the resident was able to stop. A Progress Note for Resident #8, dated 02/17/23, documented Resident #8 was exiting the activity room and Resident #9 was standing in the doorway to the activity room. Resident #8 had screamed at Resident #9 and then pushed Resident #9 with both hands, causing Resident #9 to take several stumbling steps forward. On 04/11/23 at 11:28 AM, a Licensed Practical Nurse for Residents #8 and #9 verbalized Resident #8 had a history of verbal aggression and agitation. On 04/11/23 at 12:26 PM, the Administrator verbalized when the incident occurred Resident #8 was exiting a room and Resident #9 was standing in the doorway to the room. Resident #8 pushed Resident #9 forcefully.

Jan 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and document review, the facility failed to prevent resident to resident physical abuse for 10 of 19 sampled residents (Resident #1, #3, #6, #7, #9, #11, #12, #4, #15, and #19). Findings include: FRI #NV00061813 documented on 08/15/20, a resident grabbed and punched another resident's arm. Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including dementia with behavioral disturbance, unspecified psychosis and anxiety. An Alert Charting Behavior Progress Note dated 08/15/20, documented Resident #2 was heard yelling for help from the resident's room. Resident #1 was found standing above Resident #2 next to the bed. Resident #2 verbalized having been attacked, grabbed and punched in the arm. Resident #1 was removed from the room. Resident #2's left arm was red, scratched, and covered with grab marks. Resident #2's had no complaints of pain. The nursing staff would continue to monitor the resident. Resident #1's Care Plan dated 06/02/20, documented the resident had a history of resident to resident physical altercation. The resident was to be redirected away from other residents who would yell or holler due to agitating the resident. Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including dementia with psychotic disturbance, psychotic disorder with delusions and anxiety. Resident #2's Care Plan dated 03/18/19, documented the resident had the potential to be verbally aggressive as exhibited by name calling, shouting and yelling. On 01/31/23 at 1:44 PM, the Director of Nursing Services (DNS) verbalized Resident #1 had a history of aggression towards other residents if the resident was not kept busy. Staff had continued to try and keep the resident occupied but was unable to intervene in this incident. FRI #NV00063494 documented on 03/26/21, a resident hit another resident in the mouth with a fist. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis, schizoaffective disorder and anxiety. A Nursing Progress Note dated 03/26/21, documented Resident #3 had reported the resident's roommate (Resident #4) had hit the resident in mouth with a fist. No injury was noted. The resident denied any pain. The roommate was removed from the room. Resident #3's Care Plan dated 03/26/21, documented a resident to resident altercation. The resident reported the roommate hit the resident. The resident was to be monitor for discomfort and treated as needed. Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including psychotic disorder with delusions, unspecified psychosis and anxiety. Resident #4's Care Plan dated 03/26/21, documented a resident to resident altercation. The resident's roommate reported being hit the resident. Resident #4 as moved to another room. On 01/31/23 at 1:50 PM, the DNS verbalized Resident #4 had knocked Resident #3's belongings off the table. Resident #3 had yelled at Resident #4 to get out of the room. Resident #4 then hit Resident #3 in the mouth. The resident was immediately removed and moved to a different room. FRI #NV00067486 documented on 11/25/22, a resident pushed another resident while walking in the hallway causing the resident who was pushed to throw water on a third resident. Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including dementia with mood disturbance, psychotic disorder with delusions and major depressive disorder. An Alert Charting Behavior Progress Note dated 11/25/22, documented Resident #6 was walking in the hallway when two different residents had an altercation. One of the residents threw water which landed on Resident #6's back. There was no noted distress or injuries from incident. Resident #6's Care Plan dated 11/25/22, documented the resident had water thrown on the back after two other residents had an altercation. The resident was to be monitored for distress or changes in mood or behavior. Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia and agitation and anxiety. An Alert Charting Behavior Progress Note dated 11/25/22, documented Resident #8 pushed Resident #7 in the hallway. Resident #6 was walking by, and Resident #7 threw water on Resident #6. Resident #7 had thought Resident #6 was the one who pushed. All residents were redirected. Resident #7's Care Plan dated 11/25/22, documented the resident had a history of physical aggression as exhibited by hitting and punching. Resident #7 threw water at a resident after being pushed by a third resident. The resident was to be redirected when appearing to become agitated towards other residents. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia with mood disturbance and major depressive disorder. Resident #8's Care Plan dated 11/25/22, documented the resident had the potential to be physically aggressive towards other residents. The resident had pushed another resident in the hallway. The resident was to be redirected and offered diversions and activities. On 01/31/23 at 1:59 PM, the DNS verbalized Resident #8 could be physically aggressive had pushed Resident #7 in the hallway. Resident #7 did not mean to throw water on Resident #6 but had only reacted to being pushed. The residents were separated and monitored. FRI #NV00067536 documented on 12/03/22, a resident hit the back of another resident's head with a closed fist. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis, dementia with agitation and anxiety. A Nursing Progress Note dated 12/03/22, documented Resident #10 hit Resident #9 in the back of the head with a closed fist. Both residents were separated. Resident #10 was assessed, and no redness or injuries were noted. Resident #9's Care Plan dated 12/03/22, documented the resident was hit in the back of the head by another resident. The resident was to be monitored for adverse reactions or changes in mood or behavior. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, unspecified psychosis, dementia with agitation and anxiety. A Nursing Progress Note dated 12/03/22, documented Resident #10 had walked by another resident in a wheelchair when Resident #10 proceeded to hit the resident in the back of the head with a closed fist, unprovoked. The staff had redirected Resident #10 away from the resident and into the hall. Resident #10's Care Plan dated 12/03/22, documented the resident had the potential to be physically aggressive towards other residents. The resident had hit another resident in the back of the head. The resident was to be monitored for behaviors and agitation. On 01/31/23 at 2:05 PM, the DNS verbalized Resident #10 had a behavior of grabbing the handles of other residents' wheelchairs. The DNS confirmed Resident #10 had hit the back of Resident #9's head after Resident #9 tried to get Resident #10 to let go of the wheelchair. FRI #NV00067537 documented on 12/03/22, a resident hit another resident in the shoulder blade with a closed fist. Resident #11 Resident #11 was admitted to the facility on [DATE], with diagnoses including dementia, psychotic disturbance and anxiety. A Nursing Progress Note dated 12/03/22, documented Resident #10 had grabbed the handles of Resident #11's wheelchair, while the resident was in the wheelchair. When staff was redirecting Resident #10 from the wheelchair, Resident #10 hit Resident #11 in the shoulder blade with a closed fist. Resident #10 was immediately redirected. Resident #11 had slight redness noted on the resident's shoulder blade. The resident did not complain of pain. Resident #11's Care Plan dated 12/03/22, documented the resident was hit in the shoulder blade by another resident. The resident was to be monitored for adverse reactions or changes in mood or behavior. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, unspecified psychosis, dementia with agitation and anxiety. Resident #10's Care Plan dated 12/03/22, documented the resident had the potential to be physically aggressive towards other residents. The resident had hit another resident in the shoulder blade. The resident was to be monitored for behaviors and agitation. On 01/31/23 at 2:08 PM, the DNS verbalized Resident #10 lashed out after attempting to be redirected. The resident was still getting adjusted to living in a nursing home. The DNS verbalized Resident #10 had a behavior of grabbing the handles of other residents' wheelchairs. FRI #NV00067680 documented on 12/28/22, a resident hit another resident in the face with a closed fist. Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease and dementia with agitation. A Nursing Progress Note dated 12/28/22, documented Resident #12 was sitting at a table in the dining room. Resident #13 wandered up to the table and attempted to grab Resident #12's food. Resident #12's became upset and hit Resident #13 in the face with a closed fist. Both residents were then separated. Resident #12's Care Plan dated 12/28/22, documented the resident had the potential to be physically aggressive towards other residents. Resident #12 had hit another resident in the face after an altercation in the dining room. The resident was to be monitored for behaviors and interventions attempted. Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including cerebral palsy, autistic disorder and Lennox-Gastaut Syndrome. Resident #13's Care Plan dated 12/28/22, documented the resident had been hit in the face by another resident. The resident was to be monitored for adverse reactions. Staff were to engage resident in activities during mealtimes when resident was not eating. On 01/31/23 at 2:14 PM, the DNS confirmed Resident #13 had grabbed food off Resident #12's tray. Resident #12 then reacted by hitting Resident #13 in the face. The residents were separated. FRI #NV00067746 documented on 01/09/23, a resident grabbed the wrist and bit the hand of another resident. Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia with psychotic disturbance, panic disorder, and anxiety. A Nursing Progress Note dated 01/09/23, documented Resident #10 grabbed Resident #14 by the wrist and bit the resident's finger. Resident #14 was noted to have bleeding coming from the right index finger. Upon assessment, a small piece of flesh was noted to be missing. The residents were immediately separated. Resident #14's Care Plan dated 01/09/23, documented a resident had bit Resident #14 on the finger. Administer treatment as ordered. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, unspecified psychosis, dementia with agitation and anxiety. Resident #10's Care Plan dated 12/03/22, documented the resident had the potential to be physically aggressive towards other residents. The resident had bit another resident on the finger. The resident was to be monitored for behaviors and agitation. On 01/31/23 at 2:11 PM, the DNS confirmed Resident #10 had grabbed Resident #14's wrist and bit a finger after Resident #14 tried to get Resident #10 to let go of the resident's wheelchair. The DNS verbalized Resident #10 had a behavior of grabbing the handles of other residents' wheelchairs. FRI #NV00067767 documented on 01/11/23, a female resident pulled a male resident's shirt causing the male resident to hit the female resident in the shoulder with a closed fist. Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia and agitation and anxiety. A Nursing Progress Note dated 01/11/23, documented a resident grabbed Resident #7's shirt and attempted to pull the resident down to the floor. Resident #7 became aggressive and retaliated by hitting Resident #15 in the shoulder multiple times with a closed fist. The residents were separated immediately. No injuries noted to Resident #15. Resident #7's Care Plan dated 01/11/23, documented the resident had a history of physical aggression as exhibited by hitting and punching. Resident #7 hit another resident in the shoulder multiple times with a closed fist. The resident was to be redirected when appearing to become agitated towards other residents. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, schizoaffective disorder, post-traumatic stress disorder ad anxiety. Previous interventions included redirection and separation from other residents. Resident #15's Care Plan dated 01/11/23, documented the resident attempted to pull to floor another resident by the shirt. Staff were to ensure the resident had meaningful activities and engagement and attempted to maintain safe distances between Resident #15 and other residents. On 01/31/23 at 2:25 PM, the DNS verbalized Resident #15 had a behavior of sitting on the floor and trying to pull other residents down to the floor. Resident #15 was still holding Resident #7's shirt when Resident #7 hit the residents shoulder trying to get the resident to let go. FRI #NV00067830 documented on 01/24/23, a resident hit another resident four times in the left thigh. Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including dementia with mood disturbance, psychotic disorder with delusions and major depressive disorder. A Nursing Progress Note dated 01/24/23, documented Resident #6 sat next to Resident #17 in the dining room. Resident #17 had become agitated and hit Resident #6's left thigh four times with an opened hand. Both residents were immediately separated, and no injuries were noted on assessment. Resident #6's Care Plan dated 01/24/23, documented the resident was slapped on the left thigh four times by another resident. No injuries were noted. The resident was to be monitor for distress or changes in mood or behavior. Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis and dementia with psychotic disturbance. Resident #17's Care Plan dated 01/24/23, documented the resident hit another resident on the thigh after becoming agitated when the other resident sat down next to the resident. The resident was to be monitored for adverse reactions or changes in mood or behavior. On 01/31/23 at 2:32 PM, the DNS verbalized Resident #17 did not like other residents sitting next to the resident. The DNS confirmed Resident #17 had become agitated and reacted by hitting Resident #6 on the thigh after Resident #6 sat down next to the resident. FRI #NV00067842 documented on 01/25/23, a resident kicked another resident's lower left leg. Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, unspecified psychosis, dementia with agitation and anxiety. A Nursing Progress Note dated 01/25/23, documented staff heard screaming and found Resident #18 in Resident #19's room. Resident #19 verbalized when the resident asked Resident #18 to leave, Resident #18 kicked Resident #19 on the left foreleg causing bruising and skin tears. Both residents were redirected and monitored closely. Resident #18's Care Plan dated 01/25/23, documented Resident #18 kicked another resident on the foreleg. Staff were to provide meaningful activities as needed and to closely monitor and intervene with wandering and increased irritability. Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including unspecified dementia with mood disturbance and adult failure to thrive. Resident #19's Care Plan dated 01/25/23, documented the resident was kicked by another resident on the left foreleg. The resident was to be monitored for adverse reactions. On 01/31/23 at 2:41 PM, the DNS verbalized Resident #18 had not exhibited kicked behaviors before. The DNS confirmed Resident #18 did kick Resident #19 after wandering into the resident's room. Staff tried to keep Resident #18 from wandering into other residents' rooms. Staff were not able to redirect the resident prior to this incident. FRI #NV00067843 documented on 01/25/23, a female resident grabbed a male resident by the ankle causing the male resident to slap the female resident on the head with an open hand. Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, dementia and agitation and anxiety. A Nursing Progress Note dated 01/25/23, documented another resident grabbed Resident #7 by the ankle. Resident #7 became agitated and slapped the other resident on the head. Both residents immediately separated. Resident #7's Care Plan dated 01/25/23, documented the resident had a history of physical aggression as exhibited by hitting and punching. Resident #7 hit another resident with an opened hand on the head after being grabbed on the ankle by the resident. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, schizoaffective disorder, post-traumatic stress disorder and anxiety. Resident #15's Care Plan dated 01/25/23, documented the resident grabbed another resident by the ankle causing that resident to hit the head of Resident #15. Staff were to ensure the resident had meaningful activities and engagement and attempt to maintain safe distances between Resident #15 and other residents. On 01/31/23 at 2:47 PM, the DNS verbalized Resident #15 liked to get on the floor and would pull other residents down to the floor with the resident. This incident the resident grabbed Resident #7's ankle and Resident #7 reacted by slapping the back of the resident's head. The facility policy titled, Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation, updated September 2017, documented physical abuse included but was not limited to hitting, slapping, or biting, residents had the right to be free from abuse, including verbal and physical abuse, sexual abuse was non-consensual if the resident lacked the cognitive ability to consent, and residents would not be subjected to abuse by staff or other residents. FRI #NV00061813, NV00063494, NV00063529, NV00067486, NV00067536, NV00067537, NV00067680, NV00067746, NV00067767, NV00067781, NV00067828, NV00067830, NV00067842, NV00067843

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and document review, the facility failed to provide supervision to prevent a resident from elopement from the facility for 1 of 19 sampled residents (Resident #5). Findings include: FRI #NV00063529 documented on 04/02/21, a resident was found walking on the sidewalk outside the facility. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder and dementia with behavioral disturbance. A Nursing Progress Note dated 04/02/21, documented Resident #5 was seen by staff walking outside down the sidewalk on the 200 unit side of the facility. Staff redirected the resident back into the facility and was assessed by the charge nurse. Staff had been with the resident 15 minutes before being seen outside. The exit door on the 200 unit was checked by maintenance immediately after the incident. An Elopement/Exit-Seeking Evaluation dated 01/03/21, documented the resident had a history of wandering and was a risk for elopement. Resident #5's Care Plan dated 06/21/19, documented the resident was at risk for elopement and wandering related to dementia. Interventions included staff were to identify patterns of wandering and provide structured activities, reorient resident as needed and intervene to prevent elopement as appropriate. Resident #5's Care Plan dated 04/02/21, documented the resident had eloped from the facility exiting the 200 unit door. Staff were to redirect the resident from exit doors. On 01/31/23 at 1:55 PM, the DNS confirmed Resident #5 had pushed open the exit door to the 200 unit and was found walking on the sidewalk on the side of the facility. The resident was outside the facility for approximately 15 minutes and was assessed for any injuries upon return. No injuries were found. The facility policy titled, Elopement/Wandering, updated March 2018, documented if a resident had been assessed for the risk of wandering and/or elopement, the resident specific interventions identified were to be initiated and implemented. FRI #NV00063529

Dec 2022 10 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, document review, and interview, the facility failed to provide a functional call light device for a resident with a diagnosis of cerebral atherosclerosis for 1 of 24 sampled residents (Resident #81). Findings include: Resident #81 Resident #81 was admitted to the facility on [DATE], with diagnoses including cerebral atherosclerosis, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, unspecified psychosis not due to a substance or known physiological condition, and schizoaffective disorder, bipolar type. On 11/28/22 at 12:45 PM, a Certified Nursing Assistant (CNA) was feeding the resident and verbalized Resident #81 was non-verbal and was dependent for all Activities of Daily Living (ADL). The CNA verbalized Resident #81 yelled out to get the attention of staff when the resident needed assistance and could not use the call light device. The room call light device was a standard call light with a red button at the end of a cord, in which the button needed to be pressed to be activated. The call light device was placed on the bed next to the resident's left upper arm. On 11/30/22 at 8:10 AM, a Licensed Practical Nurse (LPN) confirmed Resident #81 was not capable of using the push button on the call light device and would yell out to get staff's attention. The call light was laying on the floor and the LPN clipped it to the bed proximate to the resident's upper left arm. Resident #81's admission Clinical Functional Abilities Performance dated 11/09/20, documented the resident had maximal assistance for ADLs. Resident #81's comprehensive care plan dated 11/10/20, documented the resident was dependent on staff for meeting physical needs related to physical limitations and to ensure adaptive equipment the resident needed was provided and present and functional. On 11/30/22 at 9:21 AM, the Director of Nursing Services (DNS) verbalized the facility lacked a formal evaluation for determining a resident's ability to use the call light device. Staff would have to communicate a change in condition or contracture, the communication would be reviewed by the Interdisciplinary Team, and a referral would be made to therapy for a resident assessment. On 11/30/22 at 9:26 AM, the DNS confirmed Resident #81 had not been assessed for the resident's ability to use the call light device and occupational therapy should have assessed the resident's abilities. The DNS verbalized the facility lacked a policy covering call lights. The DNS verbalized all residents needed the ability to contact staff and confirmed Resident #81 did not have an ability to contact staff other than yelling out. The facility's standard of practice titled Lippincott Manual of Nursing Practice, 11th Edition, copyright 2019 by Wolters Kluwer documented nursing would assess the resident for deficits in a resident with a neurologic disorder and adjust the resident's environment, including call light, to meet the resident's needs.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0559 (Tag F0559)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to provide written notice of a room or roommate change for 4 of 4 residents affected by a room change (Residents #39, #21, #16, and #119). Findings include: Resident #39 Resident #39 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified and unspecified dementia, severe, with psychotic disturbance. Resident #21 Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including schizoaffective disorder, unspecified and bipolar disorder, current episode manic severe with psychotic features. Resident #16 Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, severe, with agitation and chronic obstructive pulmonary disease, unspecified. Resident #119 Resident #119 was admitted to the facility on [DATE], with diagnoses including unspecified psychosis not due to a substance or known physiological condition and anxiety disorder, unspecified. On 11/29/22 at 1:58 PM, Resident #119 was sitting in the hallway in between rooms [ROOM NUMBERS]. An Activities Assistant and a Certified Nursing Assistant (CNA) were moving resident belongings between the rooms. On 11/29/22 at 2:00 PM, the CNA and the Licensed Practical Nurse for the residents verbalized Resident #119 and Resident #39 were switching rooms because Resident #39 yelled out a lot and would throw things in the room with Resident #21. Resident #39 was being moved to a room with Resident #16 because Resident #16 also tended to yell out and would be less bothered by the behaviors of Resident #39. A Room Change Note for Resident #39, dated 11/29/22, documented the resident was moved to room [ROOM NUMBER] and the resident's guardian was aware. A Social Services Note for Resident #21, dated 11/29/22, documented roommate change, resident was aware. A Social Services Note for Resident #16, dated 11/29/22, documented roommate change, guardian aware. A Room Change Note for Resident #119, dated 11/29/22, documented the resident was aware the resident would be moving to room [ROOM NUMBER]. On 11/30/22 at 10:46 AM, Resident #119 verbalized the facility had not provided the resident with a written notification prior to the room change. On 11/30/22 at 12:52 PM, the Executive Director and the Licensed Social Worker verbalized the facility did not provide a written notice of room or roommate change to residents or their representative and instead notified them verbally. The facility policy titled Room Changes/New Roommate, updated 11/2016, documented the Interdisciplinary Team would evaluate the impact of a room change on the resident before making changes by determining the desire to move, roommate compatibility, and psychosocial well-being. The facility would seek the resident's preference from the available options as appropriate. The facility would notify the resident and/or resident representative of the new room change or roommate (prior to the change).

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0576 (Tag F0576)

Could have caused harm · This affected 1 resident

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Based on interview and document review, the facility failed to ensure residents were receiving mail, packages and other materials delivered to the facility, including on Saturdays. Findings include: On 11/29/22 at 11:04 AM, during the Resident Council interview, six of six residents reported not receiving mail for weeks at a time, as residents would observe the mail having been delivered to the facility on a daily basis. The residents reported on Saturdays and Sundays, the days when there was no receptionist at the front entrance, mail would be left out on a table, undistributed, until the following Monday. On 11/30/22 at 8:31 AM, the Receptionist verbalized not having been responsible to sort or distribute mail, only to collect it together and place it in the Business Office Manager's (BOM) office. The BOM would sort it for distribution, and it was the Activities Department responsibility to distribute to residents. The Receptionist verbalized having recently seen resident mail collect in the Activities Director's mailbox, for a couple of weeks. The Receptionist verbalized seeing delivered mail on the Receptionist's desk, the following Monday after Thanksgiving (of 2022). The mail had not been distributed to the residents over the holiday weekend. On 11/30/22 at 8:37 AM, the BOM confirmed having been responsible to sort and place resident mail in the Activities Director mailbox for distribution. The BOM verbalized not having been aware how long mail was left in the mailbox before the Activities Director collected the mail. The BOM verbalized the Activities Assistants were responsible for sorting and distributing resident mail on the weekends. On 11/30/22 at 11:23 AM, the Activities Director verbalized having checked for resident mail, every morning, and sorted it by section for the Activities Assistants to distribute. The Activities Director verbalized having seen delivered mail on the table, at the front entrance, on the Monday following Thanksgiving, and placed it on the Receptionist's desk. On 11/30/22 at 11:36 AM, the Executive Director (ED) confirmed the facility had been receiving mail six days a week. The ED verbalized having recently been made aware the Activities Director had not been retrieving mail on a daily basis from the Activities Director's mailbox which included resident mail. The ED confirmed the mail delivered after Thanksgiving should have been delivered to the residents within 24 hours of delivery, and the Activities Department was responsible to sort and distribute mail to residents, per the facility policy. The facility policy titled, Resident Mail, updated July 2015, documented mail would be distributed to the residents within 24 hours of delivery, except when there was no scheduled delivery service.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, document review, and clinical record review the facility failed to 1) protect 1 of 24 sampled residents from sexual abuse (Resident #114), 2) prevent resident to resident physical abuse for 2 of 24 sampled residents (Resident #37 and #100), and 3) prevent employee to resident physical and verbal abuse for 2 of 24 sampled residents (Resident #57 and #91). Findings include: FRI#NV00067420 documented on 11/14/22, Resident #37 was in the hallway in a wheelchair when Resident #126 began to push Resident #37 in the wheelchair. Staff intervened and separated Resident #37 and Resident #126 when Resident #126 became agitated and hit the back of Resident #37's head. Resident #37 Resident #37 was admitted on [DATE], with diagnoses to include unspecified dementia, unspecified severity, and major depressive disorder, recurrent unspecified. Resident #126 Resident #126 was admitted on [DATE], with diagnoses to include unspecified dementia, unspecified severity, with agitation, and mental disorder, not otherwise specified. A Nursing Progress note dated 11/14/22, documented Resident #37 was involved in a resident-to-resident altercation at 10:00 AM. Resident #37 was wandering the halls in a wheelchair and Resident #126 attempted to push Resident #37's wheelchair. When the Registered Nurse (RN) went to redirect Resident #126, Resident #126 hit Resident #37 on the back of the head. Resident #37 was assessed and some redness at the site of the hit. On 11/30/22 at 9:22 AM, an Licensed Practical Nurse (LPN) explained Resident #37 did not like anyone pushing their wheelchair and Resident #126 was new, at the time of the incident, to the facility. The LPN verbalized Resident #126 was attempting to push Resident #37 in their wheelchair when staff intervened and Resident #126 became agitated and hit Resident #37 on the back of the head. On 11/30/22 at 10:46 AM, the Director of Nursing Services (DNS) confirmed Resident #126 had hit Resident #37 on the back of the head when staff attempted to redirect Resident #126. The DNS explained staff was aware Resident #37 did not like having their wheelchair pushed and staff failed to ensure other residents did not attempt to push Resident #37's wheelchair. On 12/01/22 at 8:59 AM, the Executive Director (ED) confirmed Resident #126 had hit Resident #37 on the back of the head when staff attempted to redirect Resident #126. FRI#NV00066956 documented on 09/05/22 at approximately 2:00 PM, Resident #28 and Resident #114 were found by staff laying in Resident #114's bed and Resident #28 was rubbing Resident #114's privates over the brief. A Nursing Progress note dated 09/06/22, documented on 09/05/22 at approximately 2:00 PM, Resident #114 was lying in bed with a brief on and Resident #28 was in the room and was rubbing Resident #114 brief in the vaginal area. Resident #28 was re-directed from the room. Upon being notified of the situation, the [NAME] Department was notified. Resident #114 Resident #114 was admitted on [DATE], with diagnoses to include unspecified dementia with behavioral disturbance, and unspecified psychosis not due to substance or known physiological condition. Resident #28 Resident #28 was admitted on [DATE], and re-admitted on [DATE], with diagnoses to include unspecified dementia with behavioral disturbance, and unspecified psychosis. On 11/30/22 at 10:54 AM, the DNS confirmed Residents #114 and #28 were found laying in Resident #114's bed and Resident #28 was rubbing Resident #114's privates over the brief. The DNS explained staff was supposed to be redirecting and supervising residents to keep them busy, to avoid sexual encounters. On 12/01/22 at 8:43 AM, the Executive Director confirmed Resident #114 was lying in bed with a brief on and Resident #28 was in the room and was rubbing Resident #114's brief in the vaginal area. Resident #28 was re-directed from the room. The residents were immediately separated and neither of the residents recalled the incident. FRI #NV00066911 documented on 08/26/22, staff heard a noise then came out into the hallway and witnessed Resident #100 up against the wall and Resident #95 punching Resident #100 in the back. Resident #100 Resident #100 was admitted to the facility on [DATE], with diagnoses including paranoid schizophrenia and unspecified psychosis not due to a substance or known physiological condition. A Nursing Progress Note dated 08/27/22 at 8:07 AM, documented Resident #100 was involved in a physical altercation yesterday at 3:45 PM, where another resident was witnessed pinning the resident against the wall and hitting the resident in the back. Resident #100 was assessed by the charge nurse and the DNS. No noted injury to the resident's back and pain was denied. A care plan was in place and was on alert charting. So far, the resident had not exhibited sign or symptoms of adverse effects from altercation. Staff continued to monitor. Resident #100's Care Plan dated 08/26/22, documented the resident was punched in the back by another resident. Monitored for adverse effects such as change in mood, fear, distress, etc. Monitored for injury and discomfort and was treated as needed. Resident #95 Resident #95 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder, bipolar type, dementia with agitation and post-traumatic stress disorder. Resident #95's Care Plan dated 08/26/22, documented the resident had pinned another resident against the wall and punched the resident in the back. Resident was on one to one staff observation for 48 hours then was reevaluated. Consultation with psychiatric services. Increased Thorazine and monitored for side effects. On 12/01/22 at 10:09 AM, the DNS verbalized Resident #95 had not been aggressive to other residents before but had displayed aggressive behaviors towards staff previously. Previous interventions included redirection and separation from other residents. Resident #95 was placed on one to one staff observation for 48 hours after the incident. On 12/01/22 at 12:04 PM, the ED confirmed the allegation was substantiated for resident to resident physical abuse based on the abuse having been witnessed by staff members and the previous aggressive behaviors of Resident #95. FRI #NV00067139 documented on 10/03/22, staff members heard a Certified Nursing Assistant (CNA) tell Resident #91 to shut up after the resident had asked for assistance. Resident #91 Resident #91 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder, major depressive disorder and anxiety disorder. A Communication with Resident Note dated 10/03/22 at 11:03 AM, documented the ED met with Resident #91 to follow up on the allegation of verbal abuse by a CNA. The resident did not recall the incident. The resident was placed on alert charting and monitored for adverse effects from the incident. The CNA's employee record documented a start date of 09/04/22, and abuse training completed on 09/10/22, six days late. On 12/01/22 at 10:27 AM, the DNS confirmed the incident was substantiated based on multiple staff members reporting having heard the CNA tell Resident #91 to shut up. The CNA's contract was then terminated. On 12/01/22 at 12:16 PM, the ED confirmed the allegation was substantiated for employee to resident verbal abuse based on the abuse having been heard by staff. FRI #NV00067416 documented on 11/10/22, a hospice CNA reported hearing Resident #57 yelling for help. The hospice CNA entered the resident's room and witnessed the resident in bed, a CNA had one hand over Resident #57's mouth and the other hand on the resident's neck. Resident #57 Resident #57 was admitted to the facility on [DATE], with diagnoses including schizophrenia and unspecified psychosis not due to a substance or known physiological condition. A Skin/Wound Progress Note dated 11/11/22 at 10:08 AM, documented a purple discoloration (bruise) to the right cheek area one inch from the right side of the resident's mouth measuring one by two centimeters with the skin intact. The resident denied pain or discomfort to the area. The care plan was updated, and the resident was placed on alert charting. A Skin/Wound Progress Note dated 11/14/22 at 8:58 AM, documented the DNS assessed the bruise to Resident #57's right cheek near the resident's mouth. The bruise remained intact and was light purple in color. The resident denied pain and displayed no discomfort to the area. Resident #57's Care Plan dated 11/10/22, documented an allegation of physical abuse against the resident. Nursing completed a head to toe skin assessment. The resident was placed on alert charting and monitored for mood changes or behaviors. Provided Social Services support visits. A small bruise to the right side of the resident's cheek one inch from the lips was noted. Nursing was to monitor for further injury. The CNA's employee record documented a start date of 06/09/21, and abuse training completed on 02/23/22. On 12/01/22 at 10:22 AM, the DNS confirmed the incident was substantiated and the CNA was terminated based on the witnessed physical abuse. On 12/01/22 at 12:18 PM, the ED confirmed this allegation was substantiated for employee to resident physical abuse based on the abuse having been witnessed by a hospice CNA and the discoloration on the resident's right cheek. The facility policy titled, Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation, updated September 2017, documented physical abuse included but was not limited to hitting, slapping, or biting, residents had the right to be free from abuse, including verbal and physical abuse, sexual abuse was non-consensual if the resident lacked the cognitive ability to consent, and residents would not be subjected to abuse by staff or other residents. FRI #NV00067420, NV00066956, NV00066911, NV00067139, and NV00067416.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II determination was submitted for determination for 1 of 24 sampled residents (Resident #22). Findings include: Resident #22 Resident #22 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including major depressive disorder, recurrent, other sequelae of cerebral infarction, and post-traumatic stress disorder (PTSD), chronic. The clinical record for Resident #22 documented a PASARR level I determination dated 10/02/14, and lacked documented evidence of a PASARR level II screening. On 12/01/22 at 8:19 AM, the LSW confirmed Resident #22's diagnosis of PTSD was added in July 2019, would trigger the submission of a PASARR level II screening review, and the PASARR level II screening had not been submitted. A Behavioral Services note dated 11/17/22, documented the resident was receiving routine behavioral health services and talk therapy visits. A physician order dated 07/12/22, documented Mirtazapine tablet 45 milligrams, give one tablet by mouth one time a day for insomnia. A physician order dated 02/12/21, documented anti-depressant side effect monitoring every shift for adverse reactions and special concerns of possible increased risk of suicidal thinking or ideations and behavior. On 12/01/22 at 9:21 AM, the Director of Nursing Services confirmed Resident #22 did not have a PASARR II screening submitted for evaluation and should have based on the resident's diagnosis. The facility policy titled Resident Assessments - PASARR Screening, updated 07/2015, documented the facility would coordinate assessments with the pre-admission screening and resident review (PASARR) program. The coordination was to include referring level II residents and residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a Comprehensive Care Plan was updated to include comfort care measures for 1 of 3 residents reviewed for closed records (Resident #104) and to ensure a Comprehensive Care Plan was updated to include a resident's behaviors associated with oxygen administration for 1 of 24 sampled residents (Resident #84). Findings include: Resident #104 Resident #104 was admitted to the facility on [DATE], with diagnoses including personal history of leukemia and personal history of COVID-19. Resident #104 expired on [DATE]. A Physician's Order for Resident #104, dated [DATE], documented comfort care measures, discontinue all by mouth medications, eye drops, finger sticks, and insulin. The Comprehensive Care Plan for Resident #104 lacked a care plan to address the comfort care measures. On [DATE] at 3:38 PM, the Director of Nursing Services (DNS) verbalized a resident on comfort care should have had a care plan to address comfort care measures. The care plan would be necessary to address the change in the resident's condition and the new plan for managing the resident's symptoms. Resident #84 Resident #84 was admitted to the facility on [DATE], with diagnoses including mild cognitive impairment of uncertain or unknown etiology, chronic obstructive pulmonary disease (COPD), unspecified and cognitive communication deficit. On [DATE] at 10:17 AM, Resident #84 was sitting in a wheelchair on continuous oxygen administration via nasal canula from an oxygen concentrator at 3.5 liters (L) per minute. A Certified Nursing Assistant (CNA) confirmed the setting and verbalized the CNA would inform the nurse. A physician order dated [DATE], documented oxygen: 4L per minute, delivery: (cannula) to keep oxygen saturation greater than 90% (O2) every shift for shortness of breath and COPD. A comprehensive care plan dated [DATE], documented the resident had oxygen therapy related to COPD. Oxygen settings: O2 via nasal cannula at 4L continuous. On [DATE] at 1:33 PM, Resident #84's oxygen concentrator was set at 3.5 L. On [DATE] at 1:35 PM, an LPN verbalized the oxygen flow should be at 4L per physician order. The LPN adjusted the flow rate. The LPN verbalized when the resident got stressed in movement or had shortness of breath, the resident adjusted the oxygen level. The LPN verbalized staff were routinely resetting the flow rate. The LPN confirmed Resident #84's comprehensive care plan did not address the resident's behavior associated with oxygen administration. On [DATE] at 3:20 PM, the DNS verbalized if a resident was exhibiting behaviors of changing the resident's oxygen flow rate, the DNS would expect the behaviors to be care planned for the resident. On [DATE] at 7:56 AM, Resident #84's oxygen concentrator was set slightly below 4L. On [DATE] at 8:05 AM, an LPN confirmed Resident #84's oxygen flow rate should be 4L and the current rate was below 4L. The LPN verbalized the oxygen flow rate would be checked every time the LPN was in the resident's room. On [DATE] at 9:10 AM, the DNS verbalized Resident #84 did not always tell the truth and believed the resident had changed the oxygen flow rate settings previously. The DNS verbalized the resident's oxygen administration behavior should be care planned based on the resident's previous behavior of deniability. On [DATE] at 11:43 AM, the Administrator verbalized nursing used the Resident Assessment Instrument for a reference for Comprehensive Care Plans. The facility policy titled Respiratory Care: Oxygen Administration, published [DATE], documented oxygen was administered per physician order, oxygen liter flow was set by a licensed nurse in accordance with physician orders. The facility policy titled Minimum Data Set 3.0 Resident Assessment Instrument Manual, dated 10/2019, documented the facility was responsible for assessing and addressing all care issues relevant to individual residents, regardless of whether or not they were covered by the Resident Assessment Instrument, including monitoring each resident's condition and responding with appropriate interventions (page 4-7).

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review and clinical record review the facility failed to reassess the resident for new interventions after a fall with major injury and ensure a resident with a bed pushed up close to the window and wall was assessed for the risk of entrapment for 2 of 24 sampled residents (Resident #36 and #77). Findings include: Resident #36 Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including repeated falls, muscle weakness (generalized), and Alzheimer's disease. Nursing Progress Note dated 10/05/22, documented Resident #36 had an unwitnessed fall with major injury on 10/05/22. Resident #36's clinical record lacked documentation a Fall Assessment was completed after the fall on 10/05/22. On 11/30/22 at 11:04 AM, the Director of Nursing Services (DNS) verbalized the resident was a high risk for falls, had impaired cognition, and impulsive behaviors. On 11/30/22 at 4:11 PM, the DNS confirmed there was not a Fall Assessment in Resident #36's clinical record completed after the fall on 10/05/22. The DNS explained the Interdisciplinary Team was relying on Physical Therapy for more direction to determine what additional interventions were required to enable the facility to keep the resident safe from falls with appropriate interventions. The facility policy titled Fall Evaluation (Morse Scale) and Management, updated 03/2018, documented after the resident had been evaluated post-fall, the licensed nurse would review newly identified interventions. Resident #77 Resident #77 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, and muscle weakness (generalized). On 11/28/22 at 1:19 PM, Resident #77 was in bed and the right side of the resident's bed was pushed up against the air conditioning unit with approximately six to eight inches between the upper right side of the resident's mattress and the window and wall. On 11/30/22 at 3:00 PM, the bed of Resident #77 was still in the same position with the lower part of the right side of the bed pushed up against the air conditioning unit and a gap of approximately six to eight inches between the upper right side of the mattress and window and wall. On 11/30/22 at 3:09 PM, the Licensed Practical Nurse (LPN) for Resident #77 verbalized the resident's bed was pushed up closer to the wall because of the resident's weakness on one side of the resident's body and it was the resident's preference. The LPN was unsure if the resident had been assessed to determine the resident's risk for entrapment. The Comprehensive Care Plan for Resident #77 documented on 04/03/22, the resident had poor safety awareness and on 01/17/22, the resident was unaware of safety needs. The clinical record for Resident #77 lacked an assessment to determine the resident was not an entrapment risk. The Minimum Data Set 3.0 (MDS) Assessment, dated 09/21/22, documented the resident's ability to make decisions regarding task of daily life was severely impaired. On 11/30/22 at 3:42 PM, the DNS verbalized the resident was a high risk for falls, had impaired cognition, and impulsive behaviors. The DNS confirmed the resident did not have an entrapment risk assessment and the proximity of the resident's bed to the wall and window created a potential danger of the resident's head becoming trapped and could lead to strangulation. The facility's standard of practice titled Lippincott Manual of Nursing Practice, 11th Edition, copyright 2019 by Wolters Kluwer documented nursing would assess for the risk for injury related to neurologic deficits in a resident with a neurologic disorder.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's gastric contents were checked for residual feeding prior to administration of enteral feeding via the resident's gastric tube for 1 of 24 sampled residents (Resident #74). Findings include: Resident #74 Resident #74 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including dysphagia, oropharyngeal phase, pneumonitis due to inhalation of food and vomit, and gastrointestinal hemorrhage, unspecified. A physician's order for Resident #74, dated 02/22/22, documented enteral feeding: check residuals prior to each feeding one time a day for enteral feeding volume less than 500 milliliters (ml) return residual to feeding tube if no abnormal distention, nausea, or vomiting. Residual volume greater than 500 ml or displaying gastric intolerance, hold feeding and contact physician. A care plan for Resident #74, dated 02/22/22, documented the resident required tube feeding related to dysphagia. Nursing would check for tube placement and gastric contents/residual volume per facility protocol and record. On 11/29/22 at 2:03 PM, the Licensed Practical Nurse (LPN) for Resident #74 started the resident's tube feeding. The LPN did not check for residual prior to administering the tube feeding. On 11/29/22 at 2:10 PM, the LPN confirmed the LPN had not checked for residual prior to administering the tube feeding and should have checked the residual prior to the administration of the tube feeding. On 11/30/22 at 3:41 PM, the Director of Nursing Services verbalized residual should have been checked prior to starting the tube feeding to prevent aspiration and to check for correct placement. The facility policy titled Enteral Tubes, dated 01/2020, documented gastric contents would be checked for residual feeding and residuals above 100 ml would be reported.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a diagnosis of dementia and a history of behavioral disturbances had behavior monitoring completed for 1 of 24 sampled residents (Resident #39). Findings include: Resident #39 Resident #39 was admitted to the facility 09/04/15, and readmitted on [DATE], with diagnoses including unspecified dementia, severe, with psychotic disturbance, senile degeneration of brain, not elsewhere classified, and alcohol dependence with alcohol-induced persisting dementia. On 11/28/22 at 2:14 PM, Resident #39 was in the resident's room and was yelling out. The resident's roommate and the residents in a neighboring room complained the resident yelled out frequently and was often confrontational at night. On 11/29/22 at 1:58 PM, Resident #39 had been moved to a new room and was yelling the resident had been carved up and now would never be able to have children, the resident then yelled for help because the resident believed someone was under the resident's bed. On 11/29/22 at 2:00 PM, the Certified Nursing Assistant and the Licensed Practical Nurse (LPN) for Resident #39 verbalized the resident had been moved to a new room because the resident was yelling out frequently and would throw things in the room bothering the resident's roommate. On 11/30/22 at 3:02 PM, the Licensed Practical Nurse (LPN) for Resident #39 verbalized the resident's behaviors were becoming progressively worse due to the resident's dementia diagnosis. The LPN verbalized the behavior monitoring was documented on the Medication Administration Record (MAR). A Physician's Order for Resident #39, dated 04/20/21, documented behavior monitoring would be completed every shift and would document associated triggers, behaviors observed, non-pharmaceutical interventions, and outcomes. The November 2022 MAR for Resident #39 did not have behavior monitoring completed for 53 of 58 shifts from 11/01/22 through 11/29/22. On 11/30/22 at 3:26 PM, the Director of Nursing Services (DNS) verbalized the nurses were not documenting regularly on the MAR because the behavior monitoring documentation was very time consuming. The DNS confirmed there was not another tool besides the behavior monitoring on the MAR to track the resident's behaviors, interventions attempted to manage the behaviors, and outcomes of the interventions. A care plan for Resident #39, dated 03/18/19, documented the resident had the potential to be verbally aggressive as evidenced by name calling and shouting at others related to dementia and ineffective coping skills. Nursing would monitor behaviors continuously and document observed behavior and attempted interventions. The facility policy titled Behavior Management, updated 10/2022, documented the behavior monitoring flowsheet would be completed as the indicated behaviors were exhibited. This included documenting the number of behaviors, triggers, interventions, and outcomes.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #71 Resident #71 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses of acute on chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, and unspecified dementia, severe, with agitation. A hospice physician order form dated 09/07/22, documented Resident #71 to be admitted to the Long-Term Care (LTC) facility, on hospice, with a diagnosis of senile degeneration of the brain. The hospice order documented regular diet as tolerated, activity as tolerated, standing up as tolerated and a list of medications. The form did not include the services the hospice would provide. Resident #71's clinical record lacked documented evidence of a hospice comprehensive assessment, a Plan of Care, the frequency of hospice visits, nurse visits progress notes, and an integrated care plan with the facility. The facility care plan for Resident #71, dated 09/07/22, documented the resident's comfort would be maintained and Social Services would consult with hospice care for the resident in the facility. The facility care plan lacked documentation of the frequency and type of hospice visits. On 11/29/22 at 2:50 PM, a Licensed Practical Nurse (LPN) confirmed the resident was on hospice. The facility lacked documented evidence of the care provided by the hospice, the hospice staff visits progress notes, and the care coordination between the contracted hospice agency and the facility. On 11/29/22 at 3:02 PM, the CNA explained hospice CNAs and RNs came in two to three times a week. The CNA explained being unaware of the hospice staff schedule. The CNA verbalized the facility staff would assist with all activities of daily living care when hospice was not able to. On 11/29/22 at 3:35 PM, the LSW verbalized hospice coordination was handled by the LSW and hospice would complete an evaluation and the LSW would complete the coordination of care. The LSW explained the importance of communication between the facility and hospice was to ensure the continuity of care for the resident. The LSW confirmed the facility lacked documented evidence of the care provided by the hospice, the hospice staff visits progress notes, and the care coordination between the contracted hospice agency and the facility. On 11/29/22 at 4:13 PM, the DNS confirmed the facility lacked documented evidence of the care provided by the hospice, the hospice staff visits progress notes, and the care coordination between the contracted hospice agency and the facility. The DNS verbalized the facility should have requested and the hospice should have provided the documentation of the hospice staff visits in 24-48 hours after the visit, for facility staff to coordinate their care. A hospice agreement with the facility dated 11/27/18, documented the facility will designate one or more liaisons to facilitate cooperation and communication between the parties to assure resident needs are met. Based on clinical record review, interview and document review, the facility failed to coordinate a resident's care with the hospice provider for 2 of 24 sampled residents (Resident #63 and #71). Findings include: Resident #63 Resident #63 was admitted to the facility on [DATE], with diagnoses including dementia, senile degeneration of brain, dysphagia, epilepsy, and adult failure to thrive. A physician's order dated 03/05/20, documented hospice services related to adult failure to thrive. Resident #63's Care Plan dated 03/17/20 and revised on 05/12/20, documented the resident was on hospice, to work cooperatively with the hospice team, and hospice was to provide a physician, a Certified Nursing Assistant (CNA), and a nurse to assist with medication management. On 11/29/22 at 11:10 AM, the CNA verbalized both hospice nurses and hospice CNAs would provide care to Resident #63 two or three times per week but could not verbalize what services and care had been provided. The CNA verbalized the CNA would provide to Resident #63, Activities of Daily Living assistance to include personal hygiene, dressing, grooming, eating, transferring, and toileting, when hospice staff where not in the facility to do so. On 11/29/22 at 12:40 PM, a binder labeled Hospice for Resident #63 was located at the nurse's station. The binder included a Hospice Plan of Care dated for the period of 03/31/21 to 05/11/21, and a Visit Summary sheet dated 03/25/21. The binder lacked documented evidence of a current Hospice Care Plan and of hospice communication forms from 03/25/21 to current. On 11/29/22 at 12:41 PM, the Registered Nurse (RN) verbalized hospice nurses and hospice CNAs would provide care to Resident #63 twice a week. The RN confirmed the lack of documented evidence of a current Hospice Care Plan and of hospice communication forms for Resident #63. The RN verbalized not having been familiar with the services or care the hospice nurses and CNAs provided to Resident #63 and would only receive verbal changes to orders from the hospice nurse as needed. On 11/29/22 at 3:20 PM, the Director of Nursing Services (DNS) confirmed the facility did not have a current Hospice Care Plan or hospice communication forms since 03/25/21, for Resident #63. The DNS verbalized the facility should have requested the communication form after each visit and the importance of the communication between the facility and the hospice was to know what care the resident was provided. On 11/29/22 at 4:13 PM, the Licensed Social Worker (LSW) verbalized having been the facility's Hospice Coordinator. The LSW confirmed Resident #63 had been receiving hospice services since 03/05/20. The LSW confirmed the last Hospice Care Plan completed for Resident #63 was for the period of 03/31/21 to 05/11/21, and the facility did not have documented evidence of hospice communication forms as of 03/25/21. The LSW verbalized not having been aware how often or what hospice services and care had been provided to Resident #63. The LSW verbalized the facility should have conducted, with the hospice provider, the resident and resident's family, a hospice care conference every three months to develop a Hospice Care Plan and should have ensured a communication form was completed after each visit to document what care had been provided and any changes to the resident's orders. A hospice agreement with the facility dated 03/02/20, documented the nursing facility would maintain responsibility for the hospice resident and ensure services were rendered in accordance with governing rules and regulations. The agreement documented the facility would maintain communication with the hospice provider to address the needs of the resident and all communications would be documented in the resident's record. The facility policy titled, Hospice-Provision of Care by Outside Providers, updated September 2017, documented the facility would establish communication between the facility and the hospice provider to ensure the needs of the resident were met based on the established plan of care. The facility would maintain a plan of care to be reviewed and updated no less then quarterly.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 44% turnover. Below Nevada's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s), $25,675 in fines. Review inspection reports carefully.
• 50 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• $25,675 in fines. Higher than 94% of Nevada facilities, suggesting repeated compliance issues.
• Grade F (25/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Mountain View Health & Rehabilitation Center's CMS Rating?

CMS assigns MOUNTAIN VIEW HEALTH & REHABILITATION CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Nevada, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Mountain View Health & Rehabilitation Center Staffed?

CMS rates MOUNTAIN VIEW HEALTH & REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 44%, compared to the Nevada average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Mountain View Health & Rehabilitation Center?

State health inspectors documented 50 deficiencies at MOUNTAIN VIEW HEALTH & REHABILITATION CENTER during 2022 to 2025. These included: 1 that caused actual resident harm, 48 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Mountain View Health & Rehabilitation Center?

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by EMPRES OPERATED BY EVERGREEN, a chain that manages multiple nursing homes. With 146 certified beds and approximately 136 residents (about 93% occupancy), it is a mid-sized facility located in CARSON CITY, Nevada.

How Does Mountain View Health & Rehabilitation Center Compare to Other Nevada Nursing Homes?

Compared to the 100 nursing homes in Nevada, MOUNTAIN VIEW HEALTH & REHABILITATION CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Mountain View Health & Rehabilitation Center?

Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the substantiated abuse finding on record and the below-average staffing rating.

Is Mountain View Health & Rehabilitation Center Safe?

Based on CMS inspection data, MOUNTAIN VIEW HEALTH & REHABILITATION CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Nevada. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Mountain View Health & Rehabilitation Center Stick Around?

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER has a staff turnover rate of 44%, which is about average for Nevada nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Mountain View Health & Rehabilitation Center Ever Fined?

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER has been fined $25,675 across 1 penalty action. This is below the Nevada average of $33,336. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Mountain View Health & Rehabilitation Center on Any Federal Watch List?

MOUNTAIN VIEW HEALTH & REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 146
Avg. Residents: 136
Occupancy: 93.4%
Ownership: For profit - Corporation
Chain: EMPRES OPERATED BY EVERGREEN
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
1 Actual Harm citation: -5
50 Deficiencies: -10
Fines ($25,675): -5
Abuse Finding: -15
Final Score: 25/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 295079