**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure a resident's advanced directive was accurately documented in the medical record for 1 of 17 sampled residents (Resident 37). The deficient practice had the potential to result in administration of unwanted life-sustaining treatment against the resident's expressed wishes. Findings include: Resident 37 (R37) R37 was admitted on [DATE], with diagnosis including hydronephrosis with renal and ureteral calculous obstruction, pressure induced deep tissue damage of left heel, and malignant neoplasm of prostate. R37's electronic medical record documented Full Code, medical interventions included full treatment, long term artificial nutrition or feeding tube. A Physician order dated [DATE], documented admit to hospice with primary diagnosis of malignant neoplasm. A Care Plan initiated [DATE], documented R37 was on hospice care. Interventions included to respect resident wishes. A Physician Orders for Life-Sustaining Treatment (POLST) form signed by R37 dated [DATE], documented do not attempt resuscitation, no cardiopulmonary resuscitation (CPR), comfort focused treatment, no artificial nutrition or feeding tube, and R37 had decisional capacity. On [DATE] at 4:19 PM, a Licensed Practical Nurse (LPN), acknowledged R37's electronic medical record listed R37's code status as Full Code. The LPN confirmed the most current POLST form dated [DATE], indicated a Do Not Resuscitate status. The LPN acknowledged the electronic medical record should have been updated to reflect R37's current code status in accordance with the POLST form. The LPN explained the wrong code status in the electronic medical record could have resulted in R37 receiving medical interventions R37 did not want. On [DATE] at 4:35 PM, the Director of Nursing (DON), acknowledged R37's electronic medical record listed R37's code status incorrectly as Full Code. The DON explained R37's code status in the electronic medical record should have been updated when R37 made the change to Do Not Resuscitate on the POLST form dated [DATE]. The DON indicated consequences of a wrong code status in the electronic medical record included providing unwanted medical interventions and not honoring R37's wishes. A facility policy titled Advanced Directives documented the resident had the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The resident's wishes were communicated to the resident's direct care staff by placing the advanced directive documents in a prominent, accessible location in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to obtain a physician's order for the insertion of an intravenous (IV) line and for the care and monitoring of the IV site for one of 17 sampled residents (Resident #116). The deficient practice had the potential to significantly increase the resident's risk of serious complications such as bloodstream infection, phlebitis, infiltration, and sepsis.Findings include:Resident #116 (R116)R116 was admitted on [DATE], with diagnoses including acute post-hemorrhagic anemia, acute kidney failure, and venous insufficiency.On 06/24/2025 at 10:48 AM, an intravenous (IV) line was observed in R116's right arm. The IV line had a dressing dated 06/15/2025. R116 verbalized the IV site was painful and stated it had been used for iron administration, which had been completed two days ago. Resident 116 reported informing the nurse to remove the IV; however, it remained in place at the time of observation.Physician order dated 06/14/2025, documented Ferrlecit IV solution 12.5 milligrams per milliliter (mg/ml) to administer 125 mg IV one time a day for iron deficiency anemia for eight administrations. (Ferrlecit was an iron replacement product administered IV to treat iron deficiency anemia).Medication administration record for June 2025, revealed the medication Ferrlecit was administered as ordered from 06/15/2025 to 06/22/2025. On 06/26/2025 at 9:00 AM, the Charge Nurse explained R109 had been receiving IV iron therapy for anemia. The course of medication had been completed on June 22, 2025; however, the physician requested follow-up lab work to confirm acceptable iron levels before authorizing the removal of the IV line.The medical record lacked documented evidence a physician's order was obtained for the insertion of the IV line, as well as for the ongoing care and monitoring of the IV site to reduce potential risks of preventable complications, including infection, phlebitis, or IV-line dislocation.On 06/26/2025 at 11:00 AM, the Charge Nurse confirmed orders for the insertion on the IV line and for the care and monitoring of the IV insertion site were not obtained. The Charge Nurse acknowledged the IV insertion site should have been routinely assessed for signs of infection, bleeding, or dislocation to prevent potential complications, and the assessment documented in the medical record.The facility policy titled Peripheral and Midline IV Catheter Flushing and Locking, last updated in October 2024, revealed staff should document IV care in the treatment administration record. Documentation should include the location of the catheter, the condition of the IV insertion site, and the status of the dressing. The policy also specified that any complications must be recorded and reported to the supervisor and the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure an air intake cabinet filter was installed in an oxygen concentrator prior to being used for 1 of 17 sampled residents (Resident #102). The deficient practice had the potential to affect the quality of the oxygen delivered, placing the resident at risk for exacerbation of preexisting respiratory conditions or exposing the resident to environment contaminants.Findings included:Resident #102 (R102) R102 was admitted on [DATE], with diagnoses including hypertension, hyperlipidemia, diabetes mellitus type 2, chronic kidney disease, recurrent UTIs, history of obstructive uropathy.A physician order dated June 14, 2025 at 6:00 PM, documented the administration of oxygen at 3 liters per minute via nasal cannula every shift for the treatment of hypoxia.06/25/25 at 11:00 AM, R102 was receiving oxygen via nasal cannula from an oxygen concentrator (a medical device that provides supplemental oxygen). The concentrator did not have installed an air intake cabinet filter (a filter that removes dust and particles from the air, protecting the machine and ensuring the oxygen remains clean).A physician order dated 06/14/2025, documented oxygen tubing and humidifier should be changed at bedtime every Saturday to support management of shortness of breath (SOB). The order did not mention when and how often the air intake cabinet filter should be replaced.On 06/26/2025 at 3:20 PM, the oxygen concentrator was still missing the intake air filter. A Certified Nursing Assistant (CNA) verified this observation and explained the intake filter, humidifier, and tubing were typically replaced weekly by the night shift nursing staff.On 06/26/2025 at 3:40 PM, the Charge Nurse stated the oxygen concentrator should have been equipped with an air intake filter to prevent the resident from being exposed to dust and contaminants. The Charge Nurse acknowledged the absence of this filter posed a potential health risk, as the device may not have delivered adequately purified oxygen to the resident.The oxygen concentrator manufacturer's user manual, dated November 2009, documented a cautionary directive stating the concentrator should not be operated without the filter installed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and document review, the facility failed to obtain consents for the administration of psychoactive medications, develop a care plan, and monitor target behaviors and side effects related to the administration of psychoactive medications for 1 of 17 sampled residents (Resident #101). The deficient practice had the potential to adversely affect the resident's health, safety, and well-being by failing to identify possible adverse drug reactions, behavioral deterioration, or ineffective treatment. Findings include: Resident #101 (R101) R101 was admitted on [DATE], with diagnoses including metabolic encephalopathy secondary to urinary tract infection, short-term memory loss and cognitive impairment. The Minimum Data Set (MDS) assessment (a standardized, federally mandated tool used in nursing homes and long-term care facilities to evaluate the clinical, functional, and psychosocial status of residents) dated 06/11/2025, revealed a Brief Interview for Mental Status (a short, structured tool used primarily in nursing homes to assess a resident's cognitive function) score of 12, indicating a moderate cognitive impairment. A psychiatric evaluation dated 05/27/2025, documented R101 and the facility's staff reported intermittent periods of depressed mood and agitation. At that point pharmacological interventions were discussed with R101's spouse who deferred the medication for two weeks. The psychiatric evaluation indicated changes in mood and behaviors as well as changes in symptoms of psychosis, depression, anxiety and mania would be continuously monitored. A physician order dated 06/03/2025, documented Mirtazapine 7.5 milligram (mg) by mouth at bedtime for depression. A physician progress note dated 06/05/2025, revealed R101's mentation improved but was experiencing anxiety and irritability. The physician reported the initiation of Hydroxyzine 10 mg twice daily for anxiety management. A physician order dated 06/06/2025, indicated Hydroxyzine 10 mg, twice daily for anxiety management. The medication administration record (MAR) for June 2025, revealed Mirtazapine 7.5 mg was administered as ordered on 06/04/2025 and from 06/06/2025 through 06/24/2025, and Hydroxyzine 10 mg was administered from 06/07/2025 through 06/19/2025. The medical record lacked documentation indicating staff monitored anxiety-related behaviors and potential side effects of Hydroxyzine from 06/07/2025 to 06/18/2025. Additionally, there was no evidence depression-related behaviors, and the side effects of Mirtazapine were monitored from 06/04/2025 to 06/18/2025, during which time R101 was receiving both medications. The medical record revealed the orders to monitor target behaviors related to the administration of Hydroxyzine and Mirtazapine, and side effects of these drugs were not obtained until 06/19/2025. The orders directed staff to monitor and document R101's behaviors each shift for signs of depression and anxiety. The order required staff to record the number of behavioral episodes, the interventions used, and their effectiveness, and to observe for side effects of antidepressant and anti-anxiety medications. Additionally, the medical record revealed the informed consents for the use of Hydroxyzine and Mirtazapine psychoactive medication were not obtained prior to start the administration of these drugs. The medical record lacked documented evidence a care plan was developed and implemented for the use of Mirtazapine and Hydroxyzine when the medications were initially ordered on 06/03/2025 and 06/06/2025 respectively. On 06/25/2025 at 3:00 PM, the Charge Nurse confirmed consents for the administration of Hydroxyzine and Mirtazapine had not been obtained, and behaviors and side effects were not monitored until 06/19/2025. The Charge Nurse acknowledged the importance of developing a care plan and monitoring the behaviors and side effects to ensure effectiveness of the therapeutic efforts. The facility policy titled Psychotropic Medication Use last revised July 2022, documented drugs such as anti-depressants and antianxiety were subject to monitoring, and residents and family members were involved in the medication management process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and document review, the facility failed to ensure an insulin pen was not left unattended in a resident's room and failed to maintain a medication storage room free of expired medication. The deficient practice had the potential to compromise resident safety by exposing the residents to the risk of using expired or improperly stored medications and allowing for possible misuse of unattended insulin pens.Findings included:On [DATE] at 3:20 PM, a Glargine insulin pen containing medication was discovered on the overbed meal table in room [ROOM NUMBER]. A Certified Nursing Assistant (CNA) confirmed the observation and acknowledged the insulin pen had been left unattended, posing a potential safety risk to the resident and others in the unit. On [DATE], at 3:40 PM, the Charge Nurse was notified about the Glargine insulin pen found in room [ROOM NUMBER]. The Charge Nurse confirmed the medication belonged to the resident assigned to room [ROOM NUMBER] (Resident #102) and acknowledged the insulin pen should not have been left unattended, citing it as a potential safety concern. Resident #102 (R102) R102 was admitted on [DATE], with diagnoses including hypertension, hyperlipidemia, diabetes mellitus type 2, chronic kidney disease, recurrent UTIs, history of obstructive uropathy. A physician order dated [DATE], documented Insulin Glargine Solution 100 units per milliliter to be administered to R102 at a dose of 15 units subcutaneously daily at 9:00 AM for the management of diabetes. On [DATE] at 4:50 PM, the nurse who administered the medications to R102 confirmed the insulin Glargine was administered in the morning as ordered and acknowledged had left the insulin pen in the resident's room. On [DATE] at 2:09 PM, the Director of Nursing (DON), explained medications should not be left unattended for resident safety due to the risk of medication misuse and to ensure resident received medication as ordered. Expired Medication:On [DATE] at 12:44 PM, an inspection was conducted on the first-floor medication room with an Admissions Registered Nurse (RN) present. The following medication was found to be expired:Two intravenous (IV) bags labelled Daptomycin 575 milligram (MG)/100 milliliter (ML) Normal Saline (NS), use by date [DATE]. On [DATE] at 12:44 PM, the Admissions RN, confirmed the medication was expired. The Admissions RN acknowledged the two IV bags should have been discarded. The Admissions RN explained the expired medication should have been discarded to avoid confusion with the resident's medication and for resident safety. On [DATE] at 2:09 PM, the Director of Nursing (DON), explained expired medication should have been separated and discarded. The DON confirmed expired medication was not to be kept in the medication storage room.A facility policy titled Medication Labeling and Storage revised February 2023, documented all medications and biologicals should be stored in locked compartments. The policy indicated if the facility had discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy was to be contacted for instructions regrading returning or destroying the items.Complaint #NV00074207

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and document review, the facility failed to ensure staff followed appropriate infection control practices by wearing required personal protective equipment (PPE) while providing care to 1 of 17 sampled residents (Resident 32). The deficient practice had the potential to contribute to the transmission of infections to other residents. Findings include: Resident 32 (R32) R32 was admitted on [DATE], and readmitted [DATE], with diagnosis including acute embolism and thrombosis of right popliteal vein, acute embolism and thrombosis of right tibial vein, and urinary tract infection. A Physician order dated 06/20/2025, documented contact isolation precautions for Extended-Spectrum Beta-Lactamase (ESBL) (an enzyme produced by certain bacteria) Klebsiella Urinary Tract Infection (UTI). On 06/24/2025 at 8:44 AM, a contact precautions sign was observed posted next to R32's room door. The contact precautions sign indicated providers, and staff must wear PPE including a gown before entering the room. On 06/24/2025 at 8:49 AM, a Speech Therapist (ST), was observed in R32's room, standing next to R32's bed, holding a conversation with the resident. The ST was not wearing a gown. The ST acknowledged did not put on a gown prior to entering the room to provide care to R32. The ST confirmed the contact precautions sign indicated a gown was to be donned prior to entering the room. The ST confirmed R32 was under contact precautions and explained the ST did know the reason why. The ST stated should have worn a gown while inside the room to prevent becoming infected and passing on the infection to others. On 06/26/2025 at 4:35 PM, the Director of Nursing (DON), explained staff was to wear required PPE when entering rooms with contact precautions. The DON acknowledged consequences of not wearing required PPE included staff becoming sick and spreading disease. The DON indicated staff was expected to adhere to facility infection control and prevention policies by wearing required PPE. A facility policy titled Isolation - Categories of Transmission-Based Precautions revised September 2022, documented Contact Precautions were implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Staff and visitors wore a disposable gown upon entering the room, removed it before leaving the room and avoided touching potentially contaminated surfaces with clothing after gown was removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a self-administration medication assessment, care plan, physician's orders, and a safe storage area was completed for 1 of 3 sampled residents (Resident 3). The deficient practice had a potential for a resident not to be properly evaluated if able to safely self-administer a nasal spray medication. Findings include: Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including anxiety disorder, chronic obstructive pulmonary disease (COPD), and age-related osteoporosis. On 01/02/2025 at 8:49 AM, a container of saline nasal spray was on R3's overbed tray table. R3 confirmed self-administered the saline nasal spray for when their nose was dry from the oxygen cannula. R3 indicated the saline nasal spray was on overbed tray table to self-administer as needed. On 01/02/2025 at 9:04 AM, the Licensed Practical Nurse (LPN) confirmed resident had a Saline Nasal spray, and there was no physician's order for the Saline Nasal spray or for R3 to self-administer the saline nasal spray. The medical record lacked documented evidence of the following: -A self-administration assessment -A care plan for self-administration had been completed -A physician's order had been obtained for R3 to self-administer medication -A physician's order for R3 to receive the saline nasal spray On 01/03/2025 at 9:30 AM, a Registered Nurse (RN) confirmed every resident who wanted to self-administer medication would require a self-administration assessment, a care plan, a physician's order to self-administer, a physician's order for the medication, and must be provided a safe area to store the medication. The self-administration assessment ensured the resident was able to administer the medication correctly and safely. On 01/03/2025 at 10:08 AM, the Director of Nursing (DON) reviewed R3's medical record. The DON confirmed the medical record lacked documented evidence of the following: -A self-administration assessment -A care plan for self-administration had been completed -A physician's order had been obtained for R3 to self-administer medication -A physician's order for the R3 to receive the saline nasal spray The Director of Nursing verbalized the resident should not have had the medications in the room or self-administered the Saline Nasal spray. The facility policy titled Resident Self-Administration of Medication revised 02/2021, documented each resident who self-administers medication will have an assessment completed in the medical records, a care plan, and a safe and secure place not accessible by other residents to store the medication. Any medications found at the bedside not authorized for self-administration would be turned over to the nurse in charge and returned to the family or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a resident was provided supervision during medication administration for 1 of 3 sampled residents (Resident 3). The deficient practice had the potential to place a resident at risk of an accident. Findings include: Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including anxiety disorder, chronic obstructive pulmonary disease (COPD), and age-related osteoporosis. On 01/02/2025 at 8:49 AM, the following was on R3's overbed tray table: - a clear plastic medication cup with one white oval tablet - a clear plastic medication cup of 9 various tablets R3 verbalized the nurse had left the oral medications with the resident to take at 9:00 AM. On 01/02/2025 at 9:04 AM, the Licensed Practical Nurse (LPN) verbalized R3 was given their 9:00 AM medications, and the LPN had stepped out of the resident's room to get something from the medication cart before returning to observe the resident take the medication. The LPN revealed should have stayed with R3 until all the medications had been taken. On 01/03/2025 at 9:30 AM, a Registered Nurse (RN) verbalized during medication pass; the nurse must remain at the resident's side to ensure medication was properly taken according to the physician's orders. The RN explained if the resident was not observed taking the medication, the resident could potentially choke or forget to take the medication. The RN revealed a confused resident could potentially wander into the room and take the medication since it was left unsecured in the resident's room. On 01/03/2025 at 10:08 AM, the Director of Nursing verbalized the LPN should have remained by the resident's side until all medication was taken. The facility policy titled Administering Oral Medications revised on 10/2010, documented the facility procedure for medication administration included remaining with the resident until all medications have been taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure medications were secured in; 1) 1 of 2 central supply rooms on the first floor which contained wound care supplies and 2) 1 of 3 sampled resident's room (Resident 3). The deficient practice had the potential risk of unauthorized access to medications, medication errors, theft, or misuse of medication within the facility. Findings include: 1. Unsecured Wound care Supplies in a Supply Room On 01/02/2025 at 7:40 AM, the central supply room door was open, the lights were on, and no staff members were in the supply room. The supply room contained wound care supplies. On 01/02/2025 at 8:17 AM, the central supply room door was open, the lights were on and no staff members in the supply room. The following unsecured wound care supplies were located on the shelves in the central supply room: -16-ounce bottles of Dakin's solution (a topical antiseptic) -16-ounce bottles of Hydrogen Peroxide (a topical antiseptic) -Petroleum jelly dressings and other medicated wound care dressings -Spray bottle of wound cleanser On 01/02/2025 at 8:18 AM, the Central Supply Clerk entered the room and stated the central supply rooms were never locked so staff can have access to supplies, including wound care supplies. The Central Supply Clerk confirmed the room should have been locked. On 01/02/2025 in the afternoon, the Administrator acknowledged the supply rooms were left opened. On 01/03/2025 at 9:49 AM, the Transport Coordinator stated their desk was located in the Central Supply room with the wound care supplies. The Transport Coordinator advised the door to the room did not have a lock due to staff constantly going in and out of the supply room to obtain needed supplies. The central supply room was supposed to remain open even if the Transport Coordinator or the Central Supply Clerk were not present. The Transport Coordinator verbalized the facility just installed a lock on the door during the night and guidance was given to lock the central supply room door moving forward. On 01/03/2025 at 10:23 AM, the Director of Nursing confirmed the Central Supply room should have been locked because it contained wound care medications. 2. Unsecured Medication in a Resident Room Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including anxiety disorder, chronic obstructive pulmonary disease (COPD), and age-related osteoporosis. On 01/02/2025 at 8:49 AM, the following was on R3's overbed tray table: - a container of Saline Nasal spray - a clear plastic medication cup with one white oval tablet - a clear plastic medication cup of 9 various tablets The following over the counter medications were on a storage rack in the resident's bathroom and contained the following: - a tube of topical analgesic cream - three 15 milliliter containers of lubricant eye drops On 01/02/2025 at 9:04 AM, the Licensed Practical Nurse (LPN) revealed were not aware the resident had the above medications in R3's bathroom storage rack. The LPN acknowledged the saline nasal spray was left unsecured on the resident's bedside tray table. On 01/03/2025 at 9:30 AM, a Registered Nurse (RN) stated medication should never be left out, as it was considered unsecured. The RN stated it was dangerous not only for the resident, but another confused resident could potentially wander into the room and take the medication. The facility policy titled Medication Labeling and Storage revised on 02/2023, documented all medications and biologicals, including antiseptics and disinfectants, must be stored in locked compartments with only authorized personnel having access to keys.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure the resident and/or resident's family were informed about the resident being placed on isolation (transmission-based precautions) upon admission for 1 of 15 sampled residents (Resident 46). The deficient practice had the potential for the facility not respecting the rights of the resident to be fully informed about their treatment. Findings include: Resident 46 (R46) R46 was admitted on [DATE], with diagnoses including epilepsy and abnormal findings of blood chemistry. On 07/09/2024 at 12:17 PM, R46's family member indicated nobody explained to the resident and resident's family about R46 being on isolation upon admission. The family member revealed nobody from the facility explained why the resident was on isolation. The family member confirmed R46 had tested negative for COVID-19. R46's Face Sheet (demographics) documented the family member was the resident's emergency contact and next of kin. R46's medical record lacked documented evidence the resident and/or resident's family was notified about the resident being placed on isolation upon admission. On 07/10/2024 at 12:56 PM, the Infection Preventionist (IP) Nurse confirmed the findings and revealed R46 was admitted on [DATE] at night and was placed on isolation upon admission due to loose stools. The IP Nurse indicated R46 had tested negative for COVID-19. The IP Nurse explained the nurses were expected to notify the resident or resident's family/responsible party (RP) if isolation was warranted. During admission, the charge nurse or admitting nurse was responsible to inform the resident or resident's family/RP in real time and document such notification in the progress notes. The IP Nurse revealed R46 was placed on contact/droplet precautions (transmission-based precautions) upon admission on [DATE] and the isolation was discontinued on 06/19/2024. The IP Nurse provided the line listing form (infection surveillance) which corroborated the interview. The IP Nurse confirmed the Progress Notes dated 06/19/2024 (when the isolation was discontinued), documented the admission Nurse explained to R46 and resident's family member about the contact/droplet precautions. The IP Nurse acknowledged the notification should have been done on 06/17/2024 upon R46's admission and when the resident was placed on isolation. On 07/10/2024 at 2:31 PM, R46 was sitting in a wheelchair inside the resident's room. R46 indicated being placed on isolation upon admission but nobody explained the reason for the isolation. R46 revealed being scared when people were coming inside the room wearing a gown and with mask and gloves on. The resident was told there was an isolation sign by the door. R46 indicated coming from the hospital prior to admission and the resident was aware of having no infection and negative for COVID-19. On 07/10/2024 at 2:34 PM, the admission Nurse indicated would have informed the resident or the resident's family within the shift when a resident was placed on isolation upon admission. The admission Nurse explained the notification would have been documented in the progress notes. On 07/11/2024 at 8:02 AM, the Director of Nursing (DON) indicated the nurse who determined to put a resident on isolation should have informed the resident about the reason for the isolation and the necessary precautions to be taken. The notification should have been done in real time or when it was determined the resident needed to be on isolation. Either the admission nurse, charge nurse, medication nurse, or nursing management could have talked to the resident as long as they were the one who determined the resident should be placed on isolation. The facility's policy titled Resident Rights dated February 2021, documented the residents had the right to be notified of their medical condition and of any changes in their condition. The residents had the right be informed of and participate in their care planning and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to follow the resident's choice for comfort-focused treatment for 1 of 3 sampled closed records (Resident 159). The failed practice resulted in a non-emergent hospital transfer which potentially caused the resident discomfort and distress. Findings include: Resident 159 (R159) R159 was admitted on [DATE], with diagnoses including malignant neoplasm of lungs and cachexia (wasting syndrome). A Provider Order for Life-Sustaining Treatment (POLST) dated 07/02/2024, documented in the event of a cardiopulmonary arrest, R159 elected not be resuscitated (DNR), allow natural death. The document revealed R159 desired comfort-focused treatment with a goal of maximizing comfort through symptom management. Transfer to hospital only if comfort needs cannot be met in current location. A physician's order (undated), documented do not transfer R159 to acute hospital per family member request. A nursing progress note dated 07/04/2023, revealed a certified nursing assistant (CNA) found R159 unresponsive at 7:00 PM and notified the nurse. The nurse assessed R159 who was found to have a blood pressure (BP) of 110 millimeters of mercury mmHg/52 mmHg, heart rate (HR) of 83, Oxygen saturation (O2Sat) of 94% on two liter of Oxygen via nasal cannula and temperature of 98.4 degrees Fahrenheit. Charge nurse was notified, 911 called. Paramedics arrived at 7:10 PM and left with R159 at 7:30 PM. Physician and family member made aware of the situation. A nursing progress note dated 07/04/2023, documented an emergency department nurse called to inform the facility R159 was going to be transported back to the facility. R159's family member arrived at the hospital, spoke with physician and no interventions were done due to R159's DNR status. A nursing progress note dated 07/04/2023, documented R159 arrived at facility at 10:46 PM with transport staff and a family member. Resident still unresponsive. A provider progress soap note dated 07/05/2024, revealed R159's family member was very upset due to the facility transferring R159 to the hospital on [DATE] due to unresponsiveness. R159 was sent to the hospital where no interventions were done and was sent back to the facility. R159's family member emphasized to the nurse practitioner (NP) R159 was a DNR and wanted comfort measures only and no aggressive treatment. R159's family member agreed to a hospice evaluation. A hospice nurse came to evaluate R159 on 07/05/2023. A nursing progress note dated 07/05/2023, revealed R159 was pronounced at 8:29 PM. NP and family member notified. Coroner approved release of body to mortuary. On 07/10/2024 at 10:45 AM, the NP reviewed R159's POLST and indicated if R159 was found unresponsive, with stable vital signs and there were no signs and symptoms of discomfort or distress, the NP would have told the nurse to contact the family member who should make the decision on whether to transfer the resident to the hospital. The NP reviewed R159's medical record and indicated it appeared the Registered Nurse (RN) seemed to have called 911, transferred R159 to the hospital and notified the NP and the family member after the fact. The NP emphasized residents who elected DNR on their POLST may still be sent out to the hospital if they were in acute distress such as unrelieved pain, respiratory distress, or bleeding but if R159 was not showing signs of distress and was just unresponsive, the NP repeated the RN would have been instructed to ask the family member to decide as long as the RN notified the NP first. On 07/10/2024 at 2:27 PM, the RN who was assigned to R159 on the night of the incident recalled being notified by a CNA regarding R159 being found unresponsive. The RN went inside the room and assessed R159 who was found to be unresponsive with stable vital signs and no signs of discomfort. The RN indicated not checking R159's code status but assumed the charge nurse who was notified of the incident may have confirmed R159's code status. The RN indicated it was difficult to recall the sequence of events but based on the RN's documentation, the RN indicated being the one to call 911, and contacting the NP and R159's family member after the resident had already left. The RN recalled R159's family member was very upset upon learning R159 was transferred to the hospital and told the nurse R159 should not be sent to the hospital unless the resident was in actual distress. The RN emphasized R159 was not in any distress or discomfort during this time but was merely unresponsive. On 07/10/2024 at 2:52 PM, the charge RN who was on duty on the night of the incident indicated not being able to recall whether the RN notified the charge RN regarding R159's condition, or asked the charge RN to confirm R159's code status. The charge nurse indicated expecting the RN to assess the resident and when the resident was assessed to be unresponsive with stable vital signs and not in acute distress, the correct thing to do next would be for the RN to call the provider. The charge nurse indicated nurses can transfer residents to the hospital prior to physician notification only in emergent situations such as hypoxia, traumatic injury, bleeding episodes, etc. R159's situation was not considered emergent and so the physician should have been notified first before the transfer to the hospital. On 07/10/2024 at 2:55 PM, the Director of Nursing (DON) indicated when the RN assessed R159 to be unresponsive with stable vital signs, the RN should have confirmed the resident's code status and contact the physician once all pertinent information has been gathered. The DON indicated based on the RN's documentation, it appeared the RN called 911 and sent R159 to the hospital prior to notifying the physician. The DON stated because the RN did not notify the NP prior to R159's hospital transfer, there may have been missed opportunity in involving the resident's family member in the decision-making process to ensure the resident's treatment wishes were honored. The Change in Condition policy revised February 2021, documented the facility would promptly notify the resident, the attending physician, and the resident representative of changes in the resident's condition or status. Prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider including information prompted by the SBAR (situation, background, assessment, recommendation) communication form. The Advanced Directives policy revised September 2022, documented the physician order for life-sustaining treatment (POLST) recorded a resident's treatment wishes and were communicated to direct care staff and physician by placing the document in a prominent, accessible location. Facility staff were not required to provide care which conflicts with the resident's advanced directives. Complaint #NV00069770

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a physician's order for an indwelling urinary catheter (Foley catheter) included the medical justification and the physician's orders were obtained to include all components of a Foley catheter care for 1 of 15 sampled residents (Resident 26). The deficient practice had the potential for the resident to acquire infection and unnecessary use of a Foley catheter. Findings include: Resident 26 (R26) R26 was admitted on [DATE], with diagnoses including aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and functional quadriplegia. On 07/09/2024 at 9:25 AM, R26 was lying in bed and was observed to have an indwelling urinary catheter in place. The physician's orders dated 06/15/2024, included the following: - Urinary Catheter: 16 French (catheter size) 10 bulb indwelling catheter - Urinary Catheter Care: Cleanse with soap and water every shift. Empty Foley bag every shift for urinary retention. R26's medical record lacked documented evidence of a physician's order which included the medical justification for the use of the Foley catheter and physician's orders were obtained on when to change the Foley catheter and the urinary catheter bag. On 07/11/2024 at 2:22 PM, the Infection Preventionist (IP) Nurse explained the nurses were expected to obtain physician's orders for the Foley catheter use with a medical diagnosis (justification) to support the use of the Foley catheter, for monitoring the output, and for changing the Foley catheter as needed (PRN) or when clogged. The IP Nurse confirmed there was no medical diagnosis written in the physician's order for R26's Foley catheter. The IP Nurse indicated the need to check the order set for Foley catheter care and the facility's policy. On 07/11/2024 at 2:33 PM, a Registered Nurse (RN) revealed the nurses should have obtained the physician's orders for Foley catheter use which included the size of the Foley and the medical justification for the use of Foley such as urinary retention. The RN indicated the physician's orders for Foley catheter care should have been obtained which included to clean with soap and water every shift, empty Foley bag every shift, monitor and document output every shift, change the Foley bag every month and PRN, and change Foley catheter PRN. On 07/11/2024 at 2:43 PM, the IP Nurse explained the order set for Foley catheter care included to change the Foley catheter and the urinary drainage bag PRN. The IP Nurse indicated the physician's order should have included the medical diagnosis to support the use of the Foley catheter. The IP Nurse confirmed there were no physician's orders obtained to change the urinary drainage bag and the Foley catheter as needed for R26.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a physician's order was obtained for an insertion of a peripheral intravenous (IV) access and care orders were entered and documented for the IV access for 1 of 15 sampled residents (Resident 161). The deficient practice placed the resident at risk for phlebitis (site infection). Findings include: Resident # 161 was admitted on [DATE], with diagnoses including right femur fracture with routine healing. On 07/09/2024 at 10:18 AM, R161 was seated in wheelchair watching television. A single lumen peripheral IV access was observed in R161's left forearm. The IV insertion site was covered with transparent dressing with white paper tape on each side. The dressing was not signed and dated and red drainage was observed around the insertion site. An IV pump was observed on the left side of the resident's bed. On 07/09/2024 at 10:20 AM, R161 indicated sustaining a fall-related fracture which required surgery and R161 was receiving antibiotics to prevent an infection since the surgical site still had drainage. R161 indicated the IV access was inserted at this facility a few days ago for IV antibiotic administration. A physician's order dated 07/03/2024, documented to give Cefepime hydrochloride IV solution two grams per 100 milliliter solution every 12 hours for right hip surgical drainage for seven days from 07/03/2024 until 07/10/2024. The medical record lacked documented evidence a physician's order to insert a peripheral IV access and care orders were entered and carried out for the IV access such as site monitoring and flushing. On 07/09/2024 at 10:29 AM, a Licensed Practical Nurse (LPN 1) confirmed by direct observation R161's IV access was unsigned, undated and had bloody drainage around the insertion site. The LPN indicated the facility policy was for peripheral lines to be replaced every 72 hours, so it was important to know when the peripheral line was inserted. On 07/11/2024 at 7:42 AM, LPN 2 indicated being assigned to R161 on 07/03/2024 but the LPN indicated not being the nurse who inserted R161's IV access and the line may have been inserted by night shift. LPN 2 explained a peripheral IV insertion required a physician's order and the nurse who inserted the IV access was responsible for entering care orders such as flushing and site monitoring every shift and replace every 72 hours or as needed when soiled, leaking and loose dressing. LPN 2 reviewed R161's medical record and confirmed there was no documentation a physician's order was obtained to insert an IV line and there were no care orders such as site monitoring and flushing every shift and remove and replace the IV access every 72 hours or as needed. On 07/11/2024 at 9:00 AM, the Director of Nursing (DON) indicated a physician's order was required for insertion of a peripheral line. According to the DON, the nurse who inserted the IV access was responsible for entering care orders such as site monitoring and flushing every shift. The DON stated the facility protocol was for nurses to sign and date all IV dressings so other nurses may know when the peripheral line was due to be replaced since peripheral IVs were meant for short term use and should be replaced every 72 hours. The DON reviewed R161's medical record and confirmed there were no orders to place R161's IV access and there were no care orders such as flushing, site assessment and replacing every 72 hours and as needed. The DON indicated consequences to not following the facility policy on IV site care was potential infection. The Peripheral IV Catheter Insertion policy revised February 2022, documented a physician's order was necessary for this procedure. Once inserted, label the dressing with date and initials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and document review, the facility failed to ensure the medication error rate was below five (5) percent (%) when three errors were identified with 40 opportunities observed, calculating an error rate of 7.5 %. The deficient practice posed a potential risk of injury or harm to the resident. Findings include: The facility policy titled Administering Medications (2001) documented medications were administered in accordance with prescriber orders. The individual administering the medication would check the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. On 07/10/2024 in the morning, a medication administration pass observation was performed with 40 opportunities observed and revealed three errors. The medication error rate was 7.5%. Resident 46 (R46) R46 was admitted on [DATE] with diagnoses including epilepsy, hyperlipidemia, and osteoporosis. 1. On 07/10/2024 in the morning, during the medication administration pass observation, a Registered Nurse (RN1) administered medications to R46 including Psyllium Husk Powder (Metamucil). RN1 used small plastic teaspoon to scoop powder into a five-ounce cup and filled with water and mixed. 2. RN1 appeared to be ready to take medications to R46 and the surveyor questioned the amount of liquid mixed with the powder. RN1 revealed thinking the cup being used was eight ounces and transferred medication to larger cup and mixed in an additional three ounces of water. A physician order dated 06/26/2024 documented Psyllium Husk Powder give one tablespoon by mouth one time a day for bowel management. The product information label documented to mix powder with eight ounces of liquid. RN1 indicated all medications and supplements require a physician order and should be followed along with the product information label for powder mixtures. On 07/11/24 at 8:05 AM, the Director of Nursing (DON) indicated when administering medication or supplements which require mixing with water staff should follow the product guidelines unless a physician order specifies a different amount of water. Resident 4 (R4) R4 was admitted on [DATE] with diagnoses including legal blindness and hypertension. 3. On 07/10/2024 in the morning, during medication administration pass observation, a Registered Nurse (RN2) administered R4's medication including PreserVision AREDS 2, giving R4 two capsules. A physician order dated 08/29/2023 documented PreserVision AREDS 2 oral capsule, give one capsule by mouth one time a day for eye supplement. On 07/10/2024 at 2:34 PM, RN2 revealed thinking RN2 only gave one pill however all medications should be given based on physician orders and would need to be clarified if given outside of the orders and any errors documented. On 07/11/2024 in the afternoon the Assistant Director of Nursing and Director of Staff Development indicated all medications should have a physician order and nursing staff were expected to follow order or clarify medication order as needed.

Based on observation, interview and document review, the facility failed to maintain sanitary condition in the kitchen and failed to ensure 1 of 2 refrigerated juice dispensers was holding the juice cold in the storage chamber. The deficient practice could potentially result to cross-contamination in food preparation and posed a potential risk to safety and health standards. Findings include: Unsanitary condition in the kitchen On 07/09/2024 at 8:48 AM, the following were observed during the initial tour of the kitchen: - The cook's line ventilation hood filters were heavily soiled with gross build-up above the grill. - There was grease build-up on the underside of the griddle. - There was dust build-up in the crevices of the range (stove). The Director of Dining Services was present during the observations and acknowledged the surfaces and equipment in the kitchen should have been maintained in a sanitary condition. The Director of Dining Services explained the kitchen staff were responsible in cleaning the surfaces and equipment in the kitchen. The facility's policy titled Area and Equipment Cleaning revised in January 2023, documented the Maintenance Department was scheduled to clean equipment which required special training and equipment such as the ice maker, refrigeration coils and exhaust hood. Written procedures were available, detailing daily and weekly (as needed) cleaning for all areas and equipment in the department. Juice Dispenser On 07/09/2024 at 8:57 AM, the refrigerated juice dispenser (juice machine) in the second floor satellite kitchen, was not holding the juice cold in the storage chamber. Juice was dispensed at 69.2 degrees Fahrenheit. The Director of Dining Services confirmed the observation and acknowledged the temperature of the juice dispensed from the machine should have been in the 40's (degrees Fahrenheit). The Director of Dining Services explained the juice dispenser should have been repaired. On 07/11/2024 at 12:33 PM, the Director of Dining Services confirmed the best quality of the juice dispensed in the juice machine should have been at a temperature of 45 degrees Fahrenheit and below. The facility's policy titled Equipment Maintenance Program revised in January 2023, documented the Director of Food and Nutrition Services, jointly with the Maintenance Department, would plan in writing a program of preventive maintenance for all Food/Nutrition equipment requiring regular maintenance. The program included the regular inspection/maintenance by the Maintenance Department, and periodic servicing by service companies contracted through the Maintenance Department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the Lidocaine patch was applied and removed as ordered for 2 of 16 sampled residents (Residents 59 and 1). This deficient practice could lead to compromised treatment efficacy, skin irritation, and compromised overall quality of care for these residents. Findings include: Resident 59 (R59) R59 was admitted on [DATE], with diagnoses including sprain ligament of right ankle and contusion of right ankle. The Brief Interview of Mental Status (undated), documented a score of 13/15 which indicated R59's cognitive status was intact. A Physician order dated 08/04/2023, documented Lidocaine 4 % (percent) topical patch, medicated adhesive patch, to be applied topically daily at 9:00 AM for right ankle pain. The patch removal scheduled at 9:00 PM after 12 hours. The application directions for the Lidocaine pain relief patch were to apply and remove the patch from the skin after a maximum of 12 hours of application. On 08/22/2023 at 12:35 PM, R59 lay in bed, verbally alert, and R59's family was at bedside. A Lidocaine patch was in place on R59's right ankle, undated. R59's family removed the patch. R59 indicated the patch was applied the previous day and most of the time the patch was not taken off after 12 hours of administration. A Licensed Practical Nurse (LPN) confirmed the patch still on and should have been removed last night. The Medication Administration Record dated 08/21/2023, documented patch had been applied and removed as scheduled. R59's Lidocaine patch was not removed as it was documented. An LPN indicated a new patch should be placed daily in the morning, but the patch was not yet administered. An LPN confirmed there was a delay of administration. An LPN indicated the medication should have been administered one (1) hour before and 1 hour after of the scheduled time. On 08/23/2023 at 9:22 AM, no patch was in place on R59's ankle. R59's family was at bedside. On 08/23/2023 at 11:39 AM, a Registered Nurse (RN) indicated the Lidocaine pain relief patch was not yet applied and acknowledged it was late. An RN indicated the Lidoderm patch was house supply, and the medication direction documented removing the patch from the skin after at most, a 12-hour application. On 08/23/2023 in the morning, the Director of Nursing (DON) indicated the Lidocaine patch would be contingent upon the physician's orders. The DON indicated the nursing staff was expected to adhere to both the orders provided by the physician and the medication instructions outlined by the manufacturer. The DON indicated in cases of uncertainty; clarification of the orders should have been sought. Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including chronic kidney disease and partial intestinal obstruction. A Physician order dated 06/21/2023, documented Lidocaine 5 percent (%) topical patch for hip pain daily at 9:00 AM and to remove the patch at 9:00 PM. The application directions for the Lidocaine pain relief patch were to remove the patch from the skin after a maximum of 12 hours of application. On 08/23/2023 at 10:30 AM, during the inspection of the medication cart in 200 hall, a Lidocaine Patch was noted inside the cart, removed from the wrapper, and dated 08/23/2023. An LPN explained R1 was not ready yet for patch application. The LPN explained the old Lidocaine patch had just been removed and that it had been applied a few days ago. The Medication Administration Record dated 08/23/2023, documented the Lidocaine patch was applied at 9:03 AM, when it was not actually applied. The LPN indicated R1's Lidocaine patch should have been applied in the morning and removed at night time as ordered. An LPN indicated the Lidocaine was not administered consistently due to R1's refusal. An LPN confirmed there was no documented evidence a physician was notified when the Lidocaine patch was not administered as ordered. On 08/23/2023 at 10:35 AM, R1 indicated the Lidocaine patch was not received for four days and the staff were not consistently removing the patch at night and the patch had stayed on R1 for few days. R1's medical records lacked documented evidence a physician was notified when the Lidocaine Patch was not administered as ordered or there was a delay of administration. On 08/23/2023 at 10:40 AM, a Registered Nurse (RN) explained any medication should have been applied 1 hour before or 1 hour after the scheduled time. The RN indicated the Lidocaine patch should have been removed as scheduled to prevent the medication tolerance. On 08/23/2023 at 11:24 AM, a physician indicated the staff were expected to follow the physician orders and to notify if there was a delay of the medication administration. A facility policy titled Administering Medications revised 04/2019, documented medications were administered in a safe and timely manner, and as prescribed. Medications were administered in accordance with prescriber orders, including any required time frame. Medications were administered within one hour of the prescribed time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure safety techniques were implemented to prevent a fall for 1 of 16 sampled residents (Resident 148). This deficient practice led to a resident fall, compromised resident well-being, and risk for potential harm. Findings include: Resident 148 (R148) R148 was admitted on [DATE], with diagnoses including the presence of a left artificial hip joint and obesity. The Brief Interview Mental Status dated 04/04/2023, documented a score of 14/15, which indicated R148's cognitive status was intact. The Discharge summary dated [DATE], documented a fall incident on 04/03/2023, resulting in a right knee injury and bruising. Documentation included X-ray of the right knee, hips, and left arm; bed in the lowest position at all times; strict fall precautions; neurocheck protocol. The Clinical Notes Report dated 04/03/2023, documented while providing pericare for R148, R148 was sliding and falling from the bed. The CNAs grabbed the patient and lowered R148 to the ground. R148 was noted with a bruise measuring 2 centimeters (cm) by 1 cm at the right knee. The family was at the bedside and aware. Vital signs were stable, x-rays and laboratory tests were ordered. The Fall Risk Evaluation dated 04/03/2023, documented a score of 15. The total score of 10 or above, indicated R148 was at risk for falling and to initiate precautions. A Care Plan dated 03/28/2023, documented R148 was at risk for falling. The Clinical Notes Report dated 04/04/2023, documented the fall IDT committee review recommendations: R148 should have two-person assistance at all times during transfers and ADL care. On 08/24/2023 at 10:33 AM, the Director of Nursing (DON) indicated R148 was admitted on [DATE] and was discharged on 04/05/2023 due to hypotension. The DON indicated Certified Nursing Assistant 2 (CNA2), who was involved in the fall incident, no longer works at the facility. On 08/24/2023 at 11:24 AM, a Certified Nursing Assistant 1 (CNA1) who was assigned to R148, explained at the time of the incident, was on break and CNA2 had covered CNA1's assignment. CNA1 indicated upon returning to the floor, R148's call light was activated, so CNA1 went in to check R148, and observed R148's body was out of the bed with one knee on the floor, while R148's hands grabbed the half siderail, and R148's body was facing the room door. CNA2, who had attempted to change the incontinence brief of R148, was on the opposite side of the bed (window side) and was grabbing R148's shoulder. CNA1 indicated R148's fall was preventable. CNA1 explained R148 was inappropriately turned away from CNA2, which could have possibly caused the fall on the other side of the bed. This happened because R148 was on a low-air-loss mattress, and R148 was floating on a soft cushion of air to distribute the pressure. CNA2 demonstrated the proper way to handle the situation, which involved pulling the resident closer to the caregiver and repositioning the resident's extremities before turning them, to ensure R148 would remain in the center of the bed upon turning. CNA1 indicated that R148 was obese and dependent in bed mobility due to hip surgery, which necessitated the involvement of two persons in the care process. On 08/24/2023 at 12:08 PM, a Registered Nurse (RN) explained when a resident needed assistance, would first determine if additional help was required. The RN explained during R148's brief change, the resident would be pulled towards the staff before turning to the other side, ensuring not to push resident away when no other staff were available on the other side of the bed to prevent a fall. The RN indicated the fall incident involving R148 could have been prevented with proper techniques. The RN indicated the facility provided education on proper positioning guidelines upon hire. On 08/24/2023, at 12:59 PM, the Director of Rehabilitation (DOR) indicated R148 had been evaluated and received care on 03/27/2023. The DOR indicated R148 had undergone left hip joint replacement on 02/27/2023 and had also experienced a stroke, which had left R148 bedridden and wheelchair-bound, resulting in immobility. The DOR indicated R148 was obese and had limited abilities, with a baseline level of requiring moderate to maximum assistance with bed mobility and transfers. The DOR explained when considering the circumstances of the resident's fall, factors such as age, sex, and history of falls should be taken into account. R148 exhibited core weakness, general weakness, mobility concerns, and stability concerns due to the total hip replacement surgery. During a brief change, it was expected for staff to seek assistance to stabilize the hip, and a safe technique for hip stabilization should have been used. The DOR verbalized R148 required the assistance of two persons for safety, and R148's fall was considered preventable, and all fall incidents could have been avoided with the proper approach and safety techniques. On 08/24/2023 at 02:24 PM, during a telephone interview, an RN who was assigned to R148 on the day of the fall incident indicated R148 was dependent with Activities of Daily Living (ADL), bedbound, alert, oriented, and calm. An RN indicated had received a report regarding R148's fall but did not witness the actual fall. CNA2 was aware R148 required the extensive assistance of 1-2 persons due to total hip replacement and weighed approximately 180 or 200 pounds. The RN indicated R148's fall could have been prevented if safe techniques were implemented. 08/24/23 02:57 PM, the DON acknowledged the safe technique was not implemented during the brief change to prevent a fall. A facility policy titled Falls-Clinical Protocol, dated 03/2018, documented the staff and physician's identification of pertinent interventions to address the risks of clinically significant consequences of falling. If underlying causes could not be readily identified or corrected, staff would try various relevant interventions based on their assessment of the nature or category of fall. Complaint #NV00068770

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a Lidocaine patch was applied as ordered for pain management for 2 of 16 sampled residents (Residents 59 and 1). This deficient practice had the potential to lead to inadequate pain relief, compromised treatment efficacy, and potential discomfort for the affected residents. Findings include: A facility policy titled Pain Assessment and Management revised 03/2020, documented to identify the pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying cause of pain. The pain management was based on a facility-wide commitment to appropriate assessment and treatment of pain based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Resident 59 (R59) R59 was admitted on [DATE], with diagnoses including a sprain of the right ankle and a contusion of the right ankle. The Brief Interview of Mental Status (undated), documented a score of 13/15, which indicated R59's cognitive status was intact. The History and Physical dated 08/03/2023, documented a fall while transferring from a car seat to a wheelchair and a complaint of right ankle and right foot pain. A Care Plan with R59's pain management dated 08/16/2023, documented to assess and monitor pain medications were adequately managing pain and signs and symptoms of complications. A Physician order dated 08/04/2023, documented a Lidocaine 4% topical patch and medicated adhesive patch to apply topically daily at 9:00 AM, for the right ankle. The patch was to be removed at 9:00 PM after 12 hours. The Medication Administration Record dated 08/21/2023, documented the Lidocaine patch was applied and removed as ordered. The Lidocaine patch was not removed as documented. On 08/22/2023 at 12:35 PM, R59 lay in bed, verbally alert, and R59's family was at the bedside. A Lidocaine patch was in place on R59's right ankle, undated. R59's family removed the patch. R59 indicated the patch was applied the previous day, and most of the time the patch was not removed after 12 hours of administration. A Licensed Practical Nurse (LPN) confirmed the Lidocaine patch was still on and should have been removed last night. An LPN indicated a new patch should be placed daily in the morning, but the patch was not yet administered. An LPN indicated the medication should have been administered one hour before and one hour after the scheduled time to manage R59's pain. On 08/23/2023 at 11:39 AM, a Registered Nurse (RN) indicated the Lidocaine pain relief patch was not yet applied and acknowledged it was late. On 08/23/2023 in the morning, the Director of Nursing (DON) indicated the Lidocaine patch would be contingent upon the physician's orders and should have been followed to manage the resident's pain. Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including chronic kidney disease and partial intestinal obstruction. A Physician order dated 06/21/2023, documented the application of a Lidocaine 5 percent (%) topical patch for hip pain daily at 9:00 AM, and the removal of the patch at 9:00 PM. A Care Plan with R59's pain management dated 08/16/2023, documented to assess and monitor pain medications were adequately managing pain and signs and symptoms of complications. On 08/23/2023 at 10:30 AM, during the inspection of the medication cart in 200 Hall, a Lidocaine Patch was taken out of the wrapper and dated 08/23/2023. A Licensed Practical Nurse (LPN) explained R1's Lidocaine was to manage the pain, but R1 was not ready for the patch to be applied yet, as to why the Lidocaine patch was not yet administered. The LPN indicated the old Lidocaine patch was applied a few days ago and had just been removed. The LPN indicated R1's Lidocaine patch should have been applied in the morning and removed at night, as ordered. An LPN indicated the Lidocaine was not administered daily due to R1's refusal. 08/23/23 10:35 AM, R1 indicated the Lidocaine patch was not received for four days and the staff were not consistently removing the patch at night, and it stayed on for a few days. R168 indicated had a history of hip surgery and did not refuse the Lidocaine patch because it was helping ease the pain. 08/23/23 at 10:40 AM, a Registered Nurse (RN) explained the Lidocaine patch was a medication for pain management and it should have been applied as scheduled. On 08/23/2023 at 11:39 AM, another Registered Nurse (RN) indicated the Lidocaine pain relief patch was to be applied for 12 hours and removed after 12 hours. An RN indicated the physician orders should have been followed as ordered to manage the resident's pain. On 08/23/2023 at 11:24 AM, a physician indicated the Lidocaine patch should have been removed twelve hours after its application to ensure the desired therapeutic effect. The physician verbalized the failure to adhere to this timeframe could potentially compromise the medication's efficacy and result in skin irritation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure expired medication was taken out of the active supply and the resident's discontinued IV fluids were returned to the pharmacy or destroyed. This deficient practice could potentially lead to medication errors and compromise resident safety. Findings include: On [DATE] at 9:50 AM, during observation in the 200 hall medication room, expired medication, and resident's discontinued intravenous (IV) fluids were stored together in the active supply as follows: -Stomahesive 1 ounce, expired [DATE] -5 % Dextrose 1000 milliliters (ml) expired on [DATE] (the label was partly ripped off). -0.9 % Sodium Chloride, 1000 ml (the label named Resident 100, which was discontinued) -0.9 percent (%) Sodium Chloride 1000 ml (the label was ripped off) A Registered Nurse (RN) confirmed the IV fluid for Resident 100 was discontinued and should have been taken out of the active supply and discarded. The RN indicated the nurses were responsible for checking the expiration dates of the medication and supplies in the medication room weekly. The RN explained the expired and discontinued medications should not have been stored in the active supply. On [DATE] at 9:56 AM, a Licensed Practical Nurse (LPN) confirmed the Stomahesive supply was expired and should have been removed from the active supply and discarded. The LPN indicated the risk of reusing the expired and discontinued medication if not taken out promptly. On [DATE] in the morning, the Director of Nursing acknowledged the expired and discontinued IV fluids were stored in the active supply. The DON conveyed the nurses were expected to follow the facility policies. A facility policy titled Storage of Medications dated 11/2020, documented the facility stored all drugs and biologicals in a safe, secure, and orderly manner. Discontinued, outdated, or deteriorated drugs or biologicals were returned to the dispensing pharmacy or destroyed.