Every finding on record at Accura HealthCare of Kenesaw

Licensure Reference Number 175 NAC 12-007.04CiBased on observation, record review, and interview the facility failed to develop and implement a plan to maintain required safe temperatures in resident rooms to prevent heat-related injury for facility residents. This affected 1 of 3 sampled residents (Resident 1). The facility census was 58.The facility Administrator was notified on 07/01/2026 at 12:45 PM of an Immediate Jeopardy (IJ) which began on 07/01/2026. The IJ was removed on 07/01/2026, as confirmed by surveyor onsite verification. Findings are:Record review of the undated facility admission Agreement revealed that the facility shall provide room, board, linens, bedding, and nursing care to the resident. The facility is dedicated to promoting the dignity, independence, and quality of life for each resident. The facility will provide care in a safe, comfortable environment. Record review of the Centers for Disease Control (CDC) document titled Heat and Older Adults (Aged 65+) dated 6/25/24 revealed that people aged 65 years or older are more prone to heat-related health problems. Record review of the Federal Emergency Management Agency (FEMA) document titled Be Prepared for Extreme Heat dated June 2018 revealed that extreme heat often results in the highest annual number of deaths among all weather-related disasters. Signs of heat exhaustion (a heat related injury) may include heavy sweating, paleness, muscle cramps, tiredness, weakness, dizziness, headache, nausea or vomiting, and fainting. Signs of heat stroke (the most severe form of heat illness) may include extremely high body temperature (above 103 degrees); red, hot, and dry skin with no sweat; rapid, strong pulse; dizziness; confusion; and unconsciousness. Record review of the National Institute on Aging (NIH) document titled Hot Weather Safety for Older Adults dated 9/2/22 revealed that too much heat is not safe for anyone. It is even riskier if you are older or have health problems. The risk of heat-related illness for older adults is raised by health problems such as cardiovascular, lung, or kidney disease; any illness that causes weakness or results in a fever; being on several prescription drugs at the same time; and living in places without air conditioning or fans. Being overheated for too long can cause many health problems including heat exhaustion (a warning that your body can no longer keep itself cool; heat exhaustion can progress to heat stroke [a medical emergency]).Record review of the facility admission Record dated 7/1/26 for Resident 1 revealed that Resident 1 admitted into the facility on 3/10/25. Diagnoses included peripheral vascular disease (a blood circulation disorder that narrows or blocks blood vessels outside of the brain or heart); Chronic Obstructive Pulmonary Disease (COPD) (an ongoing progressive lung condition that restricts air flow); and high blood pressure. Resident 1's age is greater than 65. Record review of the progress note dated 6/28/26 at 8:32 PM for Resident 1 revealed that the nurse went into Resident 1's room to administer the bedtime medications. Resident 1 was in the bathroom. The nurse noticed that the room was very warm. The window was open and hot air was blowing in. The nurse walked out of the resident's room to give Resident 1 privacy. The nurse returned to Resident 1's room. Resident 1 was still in the bathroom. The nurse knocked on the door and asked if the resident was ok. Resident 1 knocked back and the nurse waited a few more minutes. After a few minutes, the nurse informed Resident 1 that the nurse was going to open the door to ensure the resident's safety. Resident 1 was found sitting on the toilet with the resident's upper body leaning onto the left side with Resident 1's head downward against the wall. The nurse asked another nurse to assist. The two nurses assisted Resident 1 up to a sitting position. Resident 1's eyes were wide open. Resident 1 was asked if they were ok. Resident 1 had a blank look on their face and did not answer any questions. Resident 1 looked confused and was very warm. Nurse aides arrived to assist Resident 1 back to bed. The nurse called the Power of Attorney (POA) of Resident 1 and informed the POA of Resident 1's condition. The POA said that they wanted a hospice nurse to come to the facility and assess Resident 1. The nurse called hospice and spoke to the hospice on call nurse and informed the hospice nurse of Resident 1's condition. The hospice nurse stated that the triage nurse will be making a visit. Resident 1's temperature was 103.7 degrees Fahrenheit (F). Cold compresses were applied to Resident 1's forehead and abdominal area.Record review of the National Weather Service weather observation history dated 7/1/26 revealed that the high temperature on 6/28/26 was 96.1 F at 5:53 PM. The high temperature on 6/29/26 was 97 F at 4:53 PM. The high temperature on 6/30/26 was 90 F at 4:53 PM. Observation on 7/1/26 at 9:06 AM in the room of Resident 1 revealed that the resident was in bed with their eyes closed. Resident 1 wore a hospital gown and a sheet was covering the resident's groin area. Resident 1's legs and upper torso were uncovered. The air unit under the window in the room blew warm air and the temperature at that location was 76.1 F. There was no fan or other cooling devices present in the room of Resident 1.Interview on 7/1/26 at 9:12 AM with Resident 3 revealed that the resident has the room window open and stated: I always have my window open because the air conditioner doesn't work. They always say they are going to fix it but it is still broken. Supposed to get a new condenser on the roof but haven't found anyone to service it yet. I have lived here 2 years and it has never worked. I keep my door and window open all the time for cross air or it is just stuffy in here. I don't even have a fan and they haven't offered to give me one either.Observation on 7/1/26 at 9:12 AM in the room of Resident 3 revealed that the temperature was 78.4 F.Observation on 7/1/26 at 10:02 AM outside of room [ROOM NUMBER] revealed that the temperature in the hallway outside the room was 83.5 F.Observation on 7/1/26 at 10:12 AM in the room of Resident 1 revealed that the temperature was 78.0 F at the room heating/cooling unit. Interview on 7/1/26 at 10:08 AM with Nurse Aide-A (NA-A) revealed that the facility resident rooms air conditioning has not been working for quite a while. NA-A was unsure of the timeframe but revealed that it had not been not working for several weeks. NA-A revealed that portable air conditioners are provided by the facility or by the resident family if the resident air conditioner unit is not working. NA-A revealed that the facility maintenance is to blow out the air conditioner unit today to help with air conditioning. NA-A confirmed that a portable air conditioner was not placed in the room of Resident 1.Interview on 7/1/26 at 10:52 AM with the Facility Administrator (FA) confirmed that the facility is warm because the chiller for the air conditioning units in the resident rooms needs to be recharged. The FA revealed that the facility is waiting for the licensed people to come and charge it. The FA revealed that there was no definitive time for the charging of the chiller to be completed. The FA revealed that the FA asked the facility maintenance to call the company again to see when the licensed person would be at the facility. The FA revealed that the air conditioner issue started about a week or so ago. The FA revealed that the issue with the chiller was noted when the facility changed from the boiler heat to air conditioning. The FA revealed that the company that works on the facility air conditioning looked at the chiller and the facility has the chemical to charge the chiller unit but a licensed staff is only allowed to charge the chiller. The FA revealed that the facility has had the maintenance person checking resident room temperatures. The FA revealed that all resident room temperatures are all within limits. The FA confirmed that the required temperatures are to be between 71 F and 81 F. The FA was asked by this surveyor what the room temperatures had been. The FA revealed that the FA did not ask maintenance specifically what the temperatures were. The FA revealed that the facility is doing resident water passes in the morning and afternoon. The FA confirmed that the facility did not increase the number of water passes to keep residents hydrated with the high temperatures. The FA revealed that residents can be moved to the 300 or 400 halls that have air conditioning if the resident is warm or uncomfortable. The FA revealed that the facility does have portable air conditioning they can put in the windows. The FA confirmed that the facility has 4 of those units. The FA confirmed that no education was provided to staff for monitoring residents for heat injury, prevention of resident heat injury, increasing resident hydration, or what to do for residents with heat injury. The FA revealed that the staff just let the FA know if there is any problem.Interview on 7/1/26 at 11:05 AM with the facility Maintenance Supervisor (MS) revealed that air conditioner (AC) filters are checked every 3 months. The MS revealed that each year before the units are turned on, maintenance staff give each unit a good cleaning and rinse out the condensers and charge those that need to be charged. The MS revealed that the 100 and 200 halls chiller needs the condenser charged. The MS revealed that the facility just repaired and replaced the AC Unit that serves the 300/400 hall nurses' station and the medication room down there. The MS revealed that the guy is supposed to come today or tomorrow or by the end of the week to charge the chiller condenser. The MS confirmed that the 100/200 hallway chiller condenser has needed recharged since the facility needed to turn on the chiller on April 15th which is the beginning of the cooling season. The MS revealed that corporate wanted some estimates to decide whether to change the AC units, repair them, or just charge them for the time being. The MS confirmed that they haven't gotten the estimates. The MS revealed that the units in resident rooms both heat and cool depending on the time of the year. In the winter, they run on the boiler and heat with hot water and then in the spring we turn off the boiler, circulate cool water through the system to cycle out the hot water and then they are able to turn on the cooling system. The water that runs through the system is 60 degrees F or less. The MS revealed that there are 3 units that aren't working. Interview on 7/1/26 at 11:08 AM with Nurse Aide-B (NA-B) revealed that to monitor residents for heat related illness NA-B would watch residents for rosy cheeks and encourage residents to go to the activity room if their room is too hot. NA-B confirmed that water passes have not been increased with the hot weather. NA-B confirmed that the facility has not provided them with education on the hot resident rooms and preventing heat illness. Interview on 7/1/26 at 11:14 AM with Nurse Aide-C (NA-C) revealed that the lack of air conditioning in the facility has been an issue since probably April of this year. NA-C revealed that NA-C was not provided education on preventing or recognizing heat illness but would give residents water and ice. NA-C confirmed that NA-C worked the evening of 6/28/26. NA-C revealed that Resident 1 was unresponsive in the resident bathroom. NA-C revealed that they got Resident 1 to bed and NA-C put wet wash cloths on the resident's neck and abdomen. NA-C revealed that a drink of water was provided to Resident 1. NA-C revealed that Resident 1 was out of it and would not talk. NA-C revealed that NA-C returned to the room of Resident 1 about an hour later and Resident 1 was able to talk at that time. NA-C revealed that hospice was called and hospice staff came to the resident. NA-C revealed that Resident 1 toilets themselves. Observation on 7/1/26 at 2:14 PM in the room of Resident 1 revealed a temperature of 80.6 F. Resident 1 was in bed with eyes closed and sheet over their groin. Resident 1 was otherwise uncovered. No fan or other cooling devices were present in the room of Resident 1.Interview on 7/1/26 at 2:49 PM with a sibling of Resident 1 revealed that Resident 1 was independent last Wednesday when visiting and now is unable to get up. Observation on 7/1/26 at 2:52 PM at the door of room [ROOM NUMBER] revealed that the window was open. The temperature was 86.2 F. Licensed Practical Nurse-D (LPN-D) confirmed the temperature of 86.2 F.Observation on 7/1/26 at 2:53 PM in the room of Resident 1 revealed a temperature in the room of 80.7 F. Interview on 7/1/26 at 2:53 PM with Resident 1 confirmed that the resident passed out a couple of days ago in the bathroom. Resident 1 confirmed that the resident got too hot in the bathroom. Resident 1 revealed that the ribs on their right side are sore and that the resident may have bumped them when passing out. Resident 1 revealed that right now the room could be cooler than it is and that the resident is warm. Resident 1 confirmed that they were able to go to the toilet on their own but that they are now too weak and need assistance after becoming too hot. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 6/3/26 for Resident 1 revealed a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 11 indicating moderate cognitive impairment (BIMS scoring: 13-15: Cognitively intact; 8-12: Moderately impaired; 0-7: Severely impaired). Resident 1 is independent for rolling left to right, sitting to lying, lying to sitting, sit to stand, chair to bed transfers, toileting, and toileting hygiene. Record review of the Point of Care (POC) Response History for Toilet Transfer (the ability to get on and off a toilet) for Resident 1 dated 7/1/26 revealed that Resident 1 was independent and required no assistance with toilet transfers on 6/22/26, 6/23/26, 6/24/26, and 6/25/26. Resident 1 required supervision to touch assistance with toilet transfer on 6/26/26. Resident 1 was independent with toilet transfers on 6/27/26. On 6/28/26 Resident 1 required set up assistance (the staff assists only prior to and after the transfer- the resident completes the activity). On 6/29/26 Resident 1 required maximum staff assistance (the staff performs more than half of the effort) for toilet transfers. On 6/30/26 Resident 1 required maximum staff assistance for toilet transfers. On 7/1/26 Resident 1 required touch assistance with toilet transfers.Record review of the POC Response History for Sit to Stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) for Resident 1 dated 7/1/26 revealed that Resident 1 was independent and required no assistance with standing from a sitting position on 6/22/26, 6/23/26, 6/24/26, 6/25/26, 6/26/26, and 6/27/26. Resident 1 required supervision to touch assistance with standing from sitting on 6/28/26. On 6/29/26 Resident 1 required maximum staff assistance to stand from a sitting position. On 6/30/26 Resident 1 required maximum staff assistance to stand from a sitting position. On 7/1/26 Resident 1 required touch assistance to stand from a sitting position.Record review of the POC Response History for Sitting to Lying (the ability to move from sitting on the side of the bed to lying flat on the bed) for Resident 1 dated 7/1/26 revealed that Resident 1 was independent and required no assistance with sitting to lying on 6/22/26, 6/23/26, 6/24/26, 6/25/26, 6/27/26, and on 6/28/26 at 2:31 PM (prior to the heat injury incident on 6/28/26). Resident 1 required supervision to touch assistance with sitting to lying on 6/26/26. On 6/29/26 Resident 1 required moderate assistance to go from sitting to lying. On 6/30/26 Resident 1 required maximum staff assistance for sitting to lying. On 7/1/26 Resident 1 required touch assistance for sitting to lying. Record review of the POC Response History for Chair/Bed to Chair Transfer (the ability to transfer to and from a bed to a chair or wheelchair) for Resident 1 dated 7/1/26 revealed that Resident 1 was independent and required no assistance to transfer from the bed to the chair on 6/22/26, 6/26/26, 6/24/26, 6/25/26, 6/27/26, and 6/28/26 at 2:28 PM (prior to the heat injury incident on 6/28/26). Resident 1 required supervision to touch assistance on 6/26/26. On 6/29/26 Resident 1 required maximum staff assistance to transfer from the bed to the chair. On 6/30/26 Resident 1 required maximum staff assistance to transfer from the bed to the chair. On 7/1/26 Resident 1 required touch assistance with bed to chair transfer. Interview on 7/1/26 at 4:04 PM with Medication Aide-E (MA-E) confirmed that Resident 1 was able to go to the toilet by themselves prior to this week. MA-E revealed that the resident is weaker and has declined this week.Interview on 7/1/26 at 4:05 PM with Nurse Aide-F (NA-F) revealed that resident 1 has declined over the past couple of days and is now unable to transfer without assistance.Record review of the Abatement Letter for F584 Safe Environment dated 7/1/26 submitted by the Facility Administrator on 7/1/26 at 4:10 PM on 7/1/26 revealed the following:-Staff Education was initiated to ensure that all staff are aware of signs and symptoms of heat injury.-All residents will be assessed for heat injury by the charge nurse.-Education to nursing and dietary staff was initiated on increase in hydration pass to residents with room water pitchers passed out at 4:00 AM and 2:00 PM. The hydration cart will be passed at 10:00 AM and 7:00 PM daily. Ongoing education will continue until all staff have been educated prior to the next shift and new hires upon hire. -The licensed air conditioning service was contacted on 7/1/26 at 11:17 AM and reported that they would be at the facility today to charge the chiller unit. The regional maintenance director contacted the licensed air conditioning service at 1:05 PM and verified that they would be at the facility within an hour to charge the chiller.-7/1/26 at 2:11 PM the licensed air conditioning service arrived at the facility to charge the chiller.-7/1/26 at 3:00 PM facility temperature checks that facility temperatures are decreasing below the 81 degrees.-7/1/26 the Maintenance Director is checking every resident room for current temperature. The facility will continue to check resident room temperatures twice daily between 12:00 PM and 2:00 PM and then between 4:00 PM and 6:00 PM through 7/15/26.-An audit will be conducted by the facility Maintenance Director of all units in resident rooms for functionality.-Any concerns will be reported to the administrator immediately and addressed in facility Quality Assurance (QA). At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Licensure Reference Number 175 NAC 12-006.09(I)Licensure Reference Number 175 NAC 12-006.09(I)(i)(1)Licensure Reference Number 175 NAC 12-006.09(I)(i)(3)Based on observation, record review, and interview the facility failed to ensure that residents were protected from injury for 1 of 5 residents (Resident 1); failed to ensure that interventions to prevent falls were implemented for 1 of 5 residents (Resident 2); and failed to develop fall prevention interventions related to causal factors for 1 of 5 residents (Resident 6). The facility census was 66.Findings are:A. Interview on 2/17/26 at 3:37 PM with the facility Minimum Data Set Coordinator (MDSC) (a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) revealed that the facility does not currently have a policy and procedure for fall prevention and falls. The MDSC confirmed that the facility follows professional standards, Centers for Medicare and Medicaid Services regulations, and state regulations for fall prevention and falls. Record review of the facility policy titled Comprehensive Care Plans dated 12/3/25 revealed that it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives to meet a resident's medical, nursing, and mental and psychosocial needs. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will describe the resident specific interventions that reflect the resident's needs and preferences. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 1 dated 2/5/26 revealed that Resident 1 admitted into the facility on 1/18/22. The MDS revealed that Resident 1 had 1 fall with major injury since the previous MDS assessment dated [DATE]. Record review of the current care plan for Resident 1 dated 2/17/26 revealed that Resident 1 is a high risk for falls related to confusion, lack of safety awareness, history of falls with injuries, and dementia revised on 7/15/25. Fall prevention interventions included: -Anticipate and meet the resident's needs- dated 6/23/25. - Take the resident to the nurse's station and the nurse will sit with the resident for safety during busy times of nurse aides where they cannot watch as closely- dated 11/6/24. - Reiterate with staff to be in visualization and within distance to intervene when Resident 1 is attempting to self-transfer- dated 11/6/24. - The resident is to sit at the assisted table for all meals for close observation- dated 4/14/25. - Resident is to sit in the commons area when not in bed and not be left unattended while in the wheelchair- dated 11/6/24. - Resident's chair is to be reclined unless staff is sitting with the resident- dated 4/14/25. Observation on 2/17/26 at 9:55 AM in the facility west dining room revealed that Resident 1 was seated in a Broda wheelchair (a specialized, highly adjustable medical wheelchair providing the ability to tilt and recline patients for safety, advanced comfort, and support). The wheelchair was tilted back 45 degrees per visual measurement. Resident 1 had their knees bent and legs pulled up towards the resident's chest. No staff were next to or in close proximity to monitor Resident 1 while they were in their reclined wheelchair in the west dining room. Record review of the facility Incidents By Incident Type report dated 2/17/26 revealed that Resident 1 had a witnessed fall on 2/5/26 at 1:00 PM. Record review of the progress note for Resident 1 dated 2/5/26 at 3:10 PM revealed that a change in condition notification was initiated. Record review of the Change in Condition assessment for Resident 1 dated 2/5/26 at 3:10 PM revealed that this nurse (author of the progress note) was called to the dining room due to the resident falling out of their chair. The fall was witnessed by a nurse aide and a nurse. They stated that the resident leaned forward in the wheelchair and tumbled forward landing on their head. When this nurse arrived, Resident 1 was on their side next to the wheelchair. Resident 1 had blood in their hair and a 3 centimeter laceration on the front of the head. Resident 1 was sent to the hospital for a Computerized Tomography (CT) scan (a computerized x-ray imaging procedure) of the head and neck. Record review of the progress note for Resident 1 dated 2/5/26 at 11:50 PM revealed that the nurse called the hospital emergency room for an update on Resident 1. The hospital house supervisor revealed that Resident 1 was transferred to another hospital and admitted into the Intensive Care Unit for a subdural hematoma (a dangerous, often life-threatening condition where blood collects between the skull and the surface of the brain that is typically caused by a head injury). Record review of the progress note for Resident 1 dated 2/9/26 at 12:59 PM revealed that Resident 1 re-admitted into the facility from the hospital. Observation on 2/17/26 at 11:37 AM in the resident room revealed that Nurse Aide-C (NA-C) used a brush to comb the hair of Resident 1. A dark red/black scar approximately 2.5 centimeters in length was on the upper forehead just above the hairline. NA-C stated that Resident 1 had staples there that are now removed. NA-C transferred Resident 1 from the resident room into the west dining room. Interview on 2/17/26 at 1:05 PM with Nurse Aide-B (NA-B) revealed that NA-B had observed Resident 1 fall in the dining room on 2/5/26. NA-B revealed that the wheelchair was not tilted back and the resident fell forward from the chair and cut their head. NA-B confirmed that the wheelchair of Resident 1 is to be tilted back. Interview on 2/17/26 at 3:37 PM with the facility Minimum Data Set Coordinator (MDSC) confirmed that a fall intervention to have Resident 1's wheelchair tilted back to prevent falls was in place prior to Resident 1's fall on 2/5/26. The MDSC confirmed that staff failed to follow the intervention and that Resident 1 fell in the dining room and suffered an injury requiring hospitalization. B. Record review of the facility policy titled Risk Management dated 9/27/24 revealed that all accidents/incidents involving residents will be reported, investigated, and reviewed to ensure residents receive the highest quality of care. The nurse identifying an incident will be responsible for completing the incident report in the Risk Management module of the electronic health record. Incidents include witnessed or unwitnessed falls. Triggered assessments will be completed. Interview on 2/17/26 at 3:37 PM with the facility Minimum Data Set Coordinator (MDSC) (a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) revealed that the facility does not currently have a policy and procedure for resident lifts and transfers or for fall prevention and falls. The MDSC confirmed that the facility follows professional standards, Centers for Medicare and Medicaid Services regulations, and state regulations for resident transfers and fall prevention and falls. The MDSC confirmed that when a resident has a fall the facility always does the incident report in the risk management module of the electronic health record. The MDSC confirmed that a fall risk assessment, post fall data collection, and change of condition assessment are always completed for a resident fall to gather data to assist with updating fall prevention interventions. Record review of the facility policy titled Comprehensive Care Plans dated 12/3/25 revealed that it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives to meet a resident's medical, nursing, and mental and psychosocial needs. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will describe the resident specific interventions that reflect the resident's needs and preferences. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 2 dated 2/2/26 revealed that Resident 2 admitted into the facility on 1/28/26. The MDS revealed that Resident 2 was dependent on staff for chair to bed transfers, toilet transfers, and tub/shower transfers. Resident 2 had a diagnosis of hemiplegia or hemiparesis (one-sided body weakness that can affect the arm, leg, or face). Resident 2 had a major orthopedic surgery prior to admission into the facility. Record review of the admission Record dated 2/17/26 for Resident 2 revealed a diagnosis of acquired absence of the left leg below the knee (a below the knee amputation of the left lower leg). Record review of the current care plan for Resident 2 dated 2/17/26 revealed that Resident 2 had a self-care performance deficit related to weakness and below the knee amputation of the left leg. Interventions included that Resident 2 was totally dependent on 2 staff for transferring dated 2/5/26. Resident 2 requires Mechanical Hoyer Lift (a mechanical total body lift- a mechanical assistive device used to transfer a resident with difficulty standing up on their own) with 2 staff assistance for transfers dated 2/5/26. Observation on 2/17/26 at 12:58 PM in the room of Resident 2 revealed a laminated sign on the wall above the bed Resident is a FULL Hoyer lift 2A (assist) for all transfers. Record review of the facility Incidents By Incident Type report dated 2/17/26 revealed that Resident 2 had a witnessed fall on 2/5/26 at 11:45 AM. Record review of the progress note for Resident 2 dated 2/5/26 at 4:06 PM revealed that it was a fall note. All nursing staff were provided written education that Resident 2 is a 2 staff assist with the Hoyer lift for all transfers. Record review of the hospital emergency room report dated 2/5/26 for Resident 2 revealed that Resident 2 presented to the emergency room for a fall. Resident 2 was being transferred at the facility when they reportedly dropped the resident and the resident got stuck between the shower chair and the wall injuring their right chest. The report revealed that no rib fracture or pneumothorax (an abnormal collection of air in the space between the lung and the chest wall often caused by trauma to the chest) were seen on imaging (X-ray). Record review of the progress note for Resident 2 dated 2/5/26 at 6:10 PM revealed that a nurse from the hospital called and stated that Resident 2 will be discharged from the emergency room and returned to the facility. The hospital nurse revealed that Resident 2 is complaining of right rib pain and has a lidocaine patch (a topical medicated patch for pain relief) to the right rib area. Resident 2 arrived back at the facility at 7:25 PM per ambulance. Interview on 2/17/26 at 1:08 PM with Registered Nurse-E (RN-E) revealed that Resident 2 is currently in the hospital for a procedure to debride the infected left stump (the remaining area on the leg where the lower leg was removed from). RN-E confirmed that RN-E was the charge nurse on 2/5/26 when Resident 2 fell. RN-E confirmed that Resident 2 fell during transfer by 2 nurse aides without the use of a lift. RN-E revealed that it was a teachable moment on the transfer status of the resident to the staff. Interview on 2/17/26 at 1:55 PM with Nurse Aide-B (NA-B) confirmed that NA-B was transferring Resident 2 with another nurse aide on 2/5/26. NA-B confirmed that they were not using the Hoyer lift to transfer Resident 2 as required. NA-B confirmed that they were doing a pivot transfer (an assisted movement technique where the resident stands and bears weight on at least one leg and pivots (spins) their body to sit on the new surface) with Resident 2. (Resident 2 was not being transferred per the care plan intervention of 2 person assist Mechanical Hoyer Lift). NA-B revealed that Resident 2 stated that they were getting weak and fell to the floor during the pivot transfer. Interview on 2/17/26 at 3:37 PM with the facility MDSC confirmed that staff failed to follow the care planned transfer status for Resident 2 resulting in a fall on 2/5/26. The MDSC confirmed that staff were re-educated that Resident 2 is a 2 staff assist with the Hoyer lift for all transfers after the fall on 2/5/26. Record review of the Inservice Record dated 2/5/26 revealed that Resident 2 is a 2 assist Hoyer lift for all transfers. Resident 2 is not safe to pivot transfer. The Inservice Record was signed by 22 facility staff. Interview on 2/17/26 at 3:59 PM with Licensed Practical Nurse-D (LPN-D) revealed that an incident report is always completed for a resident fall. LPN-D revealed that the nurse is expected to complete the change of condition assessment, fall risk assessment, and post fall data collection for all resident falls. Interview on 2/17/26 at 4:05 PM with the Facility Administrator (FA) revealed that the resident transfer status is communicated to staff through the pocket care plan, the Kardex (a concise, and frequently updated nursing worksheet that provides a quick-reference overview of a resident's essential information and daily care needs), and the resident care plan. The FA confirmed that staff are expected to follow the care plan for the resident transfer status. The FA confirmed that a fall is any incident when a resident comes to rest on a lower surface. Record review of the medical record for Resident 2 revealed that it contained no fall risk assessment or post fall data collection for Resident 2's fall on 2/5/26. Interview on 2/17/26 at 4:18 PM with the FA confirmed that Resident 2 had a fall on 2/5/26 that was not reported to the state agency as there was no injury to the resident. The FA confirmed that the Risk Management incident report, change of condition assessment, fall risk assessment, and post fall data collection should be completed for the fall. This surveyor requested that the FA provide copies of the fall risk assessment and post fall data collection for Resident 2's fall on 2/5/26. Interview on 2/17/26 at 4:23 PM with the Regional Clinical Specialist (RCS) confirmed that the facility did not complete the fall risk assessment and post fall data collection for Resident 2's fall on 2/5/26 as required. The RCS confirmed that the assessments should have been completed as post fall interventions. C. Record review of a facility policy titled Risk Management and dated 09/27/2024 revealed all accidents and incidents involving residents will be reported and investigated. The Director of Nursing, MDS Coordinator, and Executive Director will review Monday through Friday ensuring that interventions are appropriate and care planned. Residents having 2 or more falls in a 30 day period will be reviewed for trends and need for further interventions. Record review of a facility policy titled Comprehensive Care Plans and dated 12/03/2025 revealed the residents comprehensive care plan will be person centered for each resident. The care plan will be reviewed and revised to ensure that services will be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. Record review of an admission Record revealed the facility admitted Resident 6 on 02/10/2026 with diagnosis of cerebral infarction (a stroke when the blood is cut off from part of the brain) affecting the L (left) side of the body and seizure disorder (a chronic neurological condition characterized by recurrent unprovoked seizures caused by sudden abnormal electrical activity in the brain). Review of Resident 6's comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 02/15/2026 revealed Resident 6 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15 indicating the resident was cognitively intact. The MDS was coded to reflect the resident utilized a wheelchair or walker for mobility and had functional limitations of range of motion to one side of the body upper and lower extremity. The resident required supervision or touching assistance with eating, partial to moderate assistance with bed mobility, toilet use and transfers. The resident was occasionally incontinent of bladder and continent of bowel. The MDS was coded to reflect that the resident had no falls in the last 6 months prior to admission and had suffered from falls without injury since admission to the facility. Record review of Resident 6's Care Plan on 02/17/2026 revealed a focus of the resident being at high risk for falls with a goal stated of the resident will not sustain serious injury through the review date dated 02/11/2026. An intervention dated 02/11/2026 stated to review information on past falls and attempt to determine cause of falls and possible root causes. Record review of a facility supplied document titled Incident by Incident Type and dated 02/17/2026 revealed documentation that Resident 6 had 2 witnessed falls on 02/15/2026, 1 unwitnessed fall on 02/15/2026, 1 unwitnessed fall on 02/11/2026, and 1 unwitnessed fall on 02/10/2026. Record review of a facility supplied document titled Post Fall Data Collection and dated 02/10/2026 at 5:35 PM revealed documentation that the Resident 6 was found on the floor of their room. In the section labeled potential root cause of fall the other specify box was checked and in the description of the cause of the fall it was documented that the resident was unable to use their call light do to lack of function of hands and a new/different call light was obtained for the resident. Record review of Resident 6's Care Plan on 02/17/2026 revealed a focus of the resident being at high risk for falls with a goal stated of the resident will not sustain serious injury through the review date dated 02/11/2026. An intervention dated 02/10/2026 was listed for a pressure call light that was placed due to the resident not being compliant with call light use. Record review of a facility supplied document titled Post Fall Data Collection and dated 02/11/2026 at 5:47 AM revealed that the resident (Resident 6) was found on the floor of their room. Documentation reflected that the resident had socked feet and stated that they had needed to go to the bathroom and attempted to self-transfer. In the potential root cause of fall, footwear was documented with description for the resident was attempting to self-transfer and was reminded to call for assistance, and no skid socks were place as well as lighting adjustments so the resident could see better. Record review of Resident 6's Care Plan on 02/17/2026 revealed a focus of the resident being at high risk for falls with a goal stated of the resident will not sustain serious injury through the review date dated 02/11/2026. An intervention dated 02/11/2026 revealed an intervention of side rails being placed on the bed to prevent falls was listed. There was no intervention to correlate with the documented root cause of the fall on the care plan of skid socks or to change lighting so the resident could see better. There was no intervention placed addressing the residents need to toilet being the reason they attempted to self-transfer and fell. Record review of a facility supplied document titled Post Fall Data Collection and dated 02/15/2026 at 4:30 AM revealed that the resident was found on the floor of their room. Documentation reflected that the resident had socked feet and was self-ambulating. The potential root cause of the fall was documented as toileting status and described as the resident was self-ambulating and had turned on the call light but did not wait for staff to assist the resident to go to the bathroom and the resident did not have no skid socks on. Record review of Resident 6's Care Plan on 02/17/2026 revealed a focus of the resident being at high risk for falls with a goal stated of the resident will not sustain serious injury through the review date dated 02/11/2026. An intervention dated 02/15/2026 revealed an intervention of a bed alarm being placed when the resident was in bed due to the resident being non complaint with fall precautions and self-transferring. There was not intervention to correlate with the documented root cause of the fall on the care plan of skid socks or addressing the residents need to toilet being the reason the resident self-transferred and fell. Record review of a facility supplied document titled Post Fall Data Collection and dated 02/15/2026 at 7:50 AM revealed that the resident had a fall to the floor in their room. Documentation reflected that the resident had socked feet and was attempting to self-transfer and ambulate. The potential root cause of the fall was documented as the residents medical or physical condition and the resident attempting to transfer and ambulate without assistance. Interventions were documented to review and adjust toileting schedule and to re-arranging the residents' room to improve ease of movement. Record review of Resident 6's Care Plan on 02/17/2026 revealed a focus of the resident being at high risk for falls with a goal stated of the resident will not sustain serious injury through the review date dated 02/11/2026. An intervention dated 02/15/2026 revealed an intervention of nonskid strips were placed on the exit side of the bed and bathroom to prevent falls. There was no interventions to correlate with review and adjustment of the resident's toilet schedule and that the room was rearranged to improve ease of movement. Record review of a facility supplied document titled Post Fall Data Collection and dated 02/15/2026 at 11:50 AM revealed the resident had a fall to the floor in the commons area the resident was self-transferring with their shoes on. There was no potential root cause of fall identified, or documentation of interventions placed. Record review of Resident 6's Care Plan on 02/17/2026 revealed a focus of the resident being at high risk for falls with a goal stated of the resident will not sustain serious injury through the review date dated 02/11/2026. An intervention dated 02/15/2026 revealed an intervention of anti-roll backs were placed on the residents' wheelchair to prevent falls. In an interview conducted on 02/17/2026 at 2:30 PM with Resident 6, the resident was lying awake in their bed with a pressure alarm visible underneath the hip area of the resident's bed. The resident had the white control box in their right hand. The resident states has gotten into some trouble and had some falls denied getting hurt from falls. Resident stated that when they try to get out of their bed without help the alarm will sound (holds up the white box). The resident stated that they think it is supposed to remind the resident to call for help (resident points to their call light). During conversation resident begins to scoot self on the pressure alarm to the edge of the bed. Once at the edge of the bed the resident reaches out with their right hand and grasps their wheelchair that is sitting approximately 4 feet from the edge of the bed where the resident is sitting with both foot pedals in place and in the down position. The resident is able to grasp the side of the wheelchair and turn the seat and foot pedals towards themselves. The resident uses their right leg wrapped under their left leg and their right hand to adjust their foot position placing feet on the no skid strips that are placed on the floor beside the residents bed. The resident grasps the wheelchair and pulls themselves into a standing position and rotates lowering to the seat of the wheelchair the places their socked feet onto the wheelchair pedals. The bed alarm begins sounding once the resident is in a standing position. A staff member enters the room and asks the resident what they need and observes the resident sitting in their wheelchair and the alarm sounding. The staff shut off the alarm and ask the resident why they did not turn on the call light and wait for help. The resident stated I thought that is what that (points to the bed alarm) is for so you know I need help. In an interview completed on 02/17/2026 at 3:51 PM with the MDS Coordinator (MDSC), the MDSC stated that the facility does not have a policy or procedure in regard to falls. The MDSC stated that the incidents are reviewed and interventions are placed not sure if always necessary by documentation of root cause of the incident. Reviewed Resident 6's falls with the MDSC, the MDSC confirmed that the facility had not evaluated the resident's toileting schedule or habits and toileting was identified as a root cause of 2 of the residents falls. In an interview completed on 02/17/2026 at 4:45 with the facility Director of Nursing (DON), the DON confirmed that root cause of each fall should be determined and interventions to prevent further incidents/falls should be placed using the root cause. The DON confirmed that the interventions placed for Resident 6 were not by using the root cause of the incident/fall.

Licensure Reference Number 175 NAC 12-006.05(S)Based on record review, observation, and interview the facility failed to promote resident dignity by ensuring that resident body parts were not exposed to public view for 1 resident (Resident 7) and not knocking and announcing entry to residents' room for 1 resident (Resident 5). The facility census was 66.Findings are:Record review of a document titled Residents' Rights of a Long-Term Care Facility and not dated the resident has the right to confidentiality and privacy during treatment and care and to be treated with consideration, respect, and dignity.A.Record review of a document titled admission Record revealed the facility admitted Resident 7 on 08/13/2021 with diagnosis of Type 2 Diabetes (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia {high blood sugar} resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), and Spinal Stenosis (a narrowing of spaces in the spine causing pressure on the spinal cord and nerves).The Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 02/12/2026 revealed Resident 7 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15 indicating the resident was cognitively intact. The MDS was coded to reflect the resident required substantial or maximal assistance with upper body dressing and utilized a wheelchair for mobility throughout the facility.In an observation completed on 02/17/2025 from 12:30 PM through 12:45 PM Resident 7 was observed to be sitting in the main dining area of the facility. The resident was observed to be sitting in their wheelchair in a sideways position so that the right side of the residents' body was closest to the edge of the table and left side of the body was away from the table. The resident's gray sweatshirt was observed to be pulled up exposing the resident's abdomen to public view. This observation occurred at mealtime and there were other residents sitting at their tables facing this resident and eating their meals. Staff were present in the dining area and walking around serving meals and passing drinks to residents. At 12:45 PM Resident 7 indicated to a staff member that they wanted to return to their room. The staff member removed the resident from the table and pushed the resident in their wheelchair down the hallway to their room. The staff member did not attempt to pull down the residents' shirt or other intervention to cover the resident's abdomen exposed body part.In an interview conducted on 02/17/2026 at 12:45 PM with Nurse Aide G (NA-G), NA-G confirmed that residents body parts should not be exposed to public view and this was a dignity issue for the resident. In an interview conducted on 02/17/2026 at 12:50 PM with Resident 7, Resident 7 confirmed that their abdomen was exposed in the dining room and while they were being assisted in their wheelchair down the hall to their room. The resident confirmed that they cannot pull their shirt down to cover their abdomen and need assistance with ensuring that their shirt is pulled down and their abdomen is not exposed.In an interview conducted on 02/17/2026 at 4:45 PM with the facility Director of Nursing (DON), the DON confirmed that residents body parts should not be exposed for public view and this was a dignity issue for the resident. B.Record review of a facility document titled Basic Nursing Skills the Beginning 4 are dated 1995 from the Nebraska Health Care Association Basic Nursing Assistant Training Manual revealed the first of the beginning 4 is to knock prior to entering the room and request permission to enter the room.Record review of a admission Record revealed that the facility admitted Resident 5 on 09/22/2025 with diagnosis of schizoaffective disorder (a chronic mental health condition combining symptoms of hallucinations, delusions, disorganized speech with major mood disorder such as depression or mania) and morbid obesity (a chronic disease defined by a body mass index of 40 or higher typically representing 100 pounds or greater over ideal weight).The Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 12/04/2025 revealed Resident 5 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15, indicating the resident was cognitively intact. The MDS was coded to reflect the required set up or clean up assistance with eating, partial to moderate assistance with bed mobility, and substantial or maximal assistance with transfers and toilet use.In an observation completed on 02/17/2026 at 11:30 AM Medication Aide A (MA-A) was entering Resident 7 room to administer their medications. The residents' door to their room was cracked open and the MA just pushed the door open and entered the room. Other staff were in the room providing personal care for the residents' roommate and the roommates' legs and lower half of their body was exposed when opening the door and entering the room. While the MA was assisting the resident with their medications a laundry staff member opened the door to the room and entered the room to place linen items in the resident's closet. The resident's roommate continued to receive cares and lower half of their body was exposed when the laundry staff member opened the door.In an interview completed on 02/17/2026 at 12:15 PM with Resident 5, Resident 5 states not sure if staff always knock prior to entering their room stated will wake up sometimes and staff will be in the room and will tell what they are there doing but does not recall them always knocking.In an interview completed on 02/17/2026 at 11:36 AM with MA-A, MA-A confirmed that they should always knock and announce themselves when entering a resident's room. The MA confirmed that they did not do this when entering Resident 5's room to administer their medications.In an interview completed on 02/17/2026 at 4:45 PM with the facility DON, the DON confirmed that staff should knock on the resident's door prior to entering the residents room.

Licensure Reference Number 175 NAC 12-006.05(H)Based on record reviews and interviews, the facility failed to ensure that a resident was free from physical abuse for 1 resident (Resident 3). The facility census was 66. Findings are: A record review of a facility policy titled, Vulnerable Adult updated on 12/30/2025 revealed its purpose as a facility is to support a zero tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of resident property.The policy identifies a vulnerable adult as every adult residing in the facility.The policy identifies neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Resident to resident altercations; including physical, mental, or verbal abuse are reportable to the state agency. The facility should have systems in place to identify residents whose personal history render them at risk for abusing other residents.Adverse Event: An adverse event is an untoward, undesirable and usually unanticipated event that causes death or serious injury. Prevention: Employees will identify, intervene and correct situations in which abuse, neglect, mistreatment and/or misappropriation of resident property may occur. This includes assessment of the resident's environment, adequate staffing to meet resident needs and supervision of staff to identify inappropriate behaviors.Residents will be continually assessed, care planned and monitored in order to identify needs and behaviors which might lead to conflict or neglect.The facility will evaluate the individual's susceptibility of abuse and also evaluate the individual's risk of abusing other vulnerable adults. The plan will also include the measures to be taken to protect that individual from abuse and to minimize the risk of abuse to other vulnerable adults. A record review of Resident 3's progress notes dated 11/01/2025 revealed Resident 3 was observed wandering in and out of other resident rooms. Another resident alerted staff that Resident 3 would not leave their room resulting in Resident 3 being pushed out of their room, landing on the floor face down sustaining a hematoma above the left eye. A record review of Resident 3's Care Plan dated 2/9/2026 revealed interventions to place Resident 3 on 15-minute checks starting on 11/1/2025 ending on 11/3/2025. Additional interventions dated 11/3/2025 revealed to provide calming environment through playing resident's music, hand massage and 1:1 time. A record review of Resident 3's progress notes dated 11/09/2025 through 12/15/2025 revealed:11/9/2025: Resident 3 wandering into other resident rooms, redirected and going back into other resident rooms.12/7/2025: Resident 3 wandering into other resident rooms, touching residents on the chest and head.12/9/2025: Resident 3 wandering into other resident rooms, being invasive. Interventions used, snacks, toileting, 1:1, music therapy, PRN psychotropic medication.12/12/2025: Resident 3 wandering into other resident rooms, Resident 3 agitated and physically aggressive towards staff. A record review of Resident 3's progress notes dated 12/16/2025 revealed Resident 3 was found by staff after being instructed to check on residents screaming for help in a room on 400 hall. The staff member removed Resident 3 from another resident's room revealing the resident residing in the room stating, Resident 3 hit and choked them while sitting in their wheelchair. The resident was directed by staff to and an activity area with no visible injuries. A record review of Resident 3's Care Plan dated 2/9/2026 revealing interventions to the assault on 12/16/2025 to place Resident 3 on checks, 32x's a shift for 72 hours discontinue when resident was placed on 1:1 checks. A record review of Resident 3's progress notes dated 12/18/2025 revealed Resident 3 was in the activity room watching a movie when Resident 3 walked over and hit another resident on the top of the head. Staff member moved Resident 3 to check on the resident assaulted, when Resident 3 pursued another resident, hitting them in the face. Resident 3 was assigned a 1:1 staff member. A record review of Resident 3's Care Plan dated 2/9/2026 revealed interventions for the assault on 12/18/2025 revealed the facility attempted to refer Resident 3 to another facility. Resident 3 then placed on 1:1 checks until discharge to a Mental Health inpatient facility. A record review of Resident 3's census list revealed Resident 3 went to the hospital from [DATE] and returned on 12/29/2025. An interview with Facility Administrator (FA) on 2/17/2026 at 3:45 PM revealed not recalling about specific interventions or incidents regarding Resident 3, needing to confer with the Minimum Data Set Coordinator (MDSC; a person who completes a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems). An interview with MDSC on 2/17/2026 at 4:10 PM revealed that Resident 3 wandered throughout the facility and at times 1:1 did occur, but not always. Temporary interventions listed for incidents occurring with Resident 3, revealed redirection, music, food, medications, closing some resident room doors, referrals to other facilities and inpatient psychiatric, however no long-term interventions were initiated. MDSC revealed, Resident 3 needed continuous 1:1 and the facility's inability to provide that type of care was evident only after Resident 3 was admitted to the facility. MDSC further revealed long-term interventions such as continuous 1:1's were not implemented for keeping Resident 3 and others safe from the related adverse behaviors.

Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of 5% or less with an actual observed medication error rate of 90%. This had the potential to affect all the residents residing and receiving medications administered by the facility. The facility census was 66.Findings are:Record review of a facility policy titled Medication Administration and dated 12/03/2025 revealed medication is administered by licensed nurses or other staff who are legally authorized to do so in the state and as ordered by the physician and in accordance with professional standards of practice. With compliance guidelines listed as to ensure that the six rights of medication administration are followed including the right dose, right time, and right documentation and to sign out the medication as administered after observing the resident consume the medication.Record review of a document titled Nursing Rights of Medication Administration and dated 01/2025 by the National Library of Medicine stated the five rights of medication administration are the right patient (ensuring the medication is being administered to the recipient it is prescribed for), the right drug (ensuring the medication being administered is identical to what is being prescribed), the right route (ensuring the medication is administered in the correct way as prescribed), the right time (ensuring the medication is administered at the correct time intervals ensuring therapeutic dosing), and the right dose (ensuring the medication is administered at the prescribed dose).In an observation completed on 02/17/2026 from 11:05 AM through 11:35 AM of Medication Aide A (MA-A) administering medication to Resident 5 the following was observed:-MA-A opened the computer screen to Resident 5's medication administration page. Resident 5's medication listed were all observed to be highlighted in red. All of the medication listed had an administration time listed to be administered between 0630AM - 1100AM.-MA-A removed the cardboard bubble pack packaged medications from the medication cart and placed them on top of the medication cart. The MA compared the label on the bubble pack to the computer and then removed the medication from the bubble pack placing it into a clear plastic medication cup. The MA then signed out (clicked on the Y button) in the computer for each medication after placing it in the medication cup. The MA did not wait until the resident had consumed the medication to sign out the medication in the electronic medication administration record.-MA-A informed Resident 5 that they had their nasal spray medication for the resident. The MA placed the tip of the white bottle labeled Azelastine 0.1% into the residents left nostril and depressed the applicator twice and then into the resident's right nostril and depressed the applicator twice.-MA-A poured a white granular powder from a white bottle labeled Polyethylene Glycol 3350 into a 30 milliliter (ml) clear plastic cup approximately 1/2 full. The MA stated the dosage for the medication was to administer 17 grams. The MA confirmed that grams were not a measurement on the 30ml plastic cup and would need to ask the nurse how to measure the dosage appropriately. The MA then placed the clear plastic cup with the white granular substance in it into the trash can located on the side of the medication cart. The MA did not dispose of the medication/white granular medication per facility policy or professional guidelines.Record review of Resident 5's Medication Administration Record (MAR) for the month of February 2026 revealed Resident 5 had orders for the following medications to be administered in the AM (0630 AM-1100 AM): Calcium Citrrate (a mineral supplement medication) 950 milligrams(mg), Cholecalciferol (a vitamin supplement medication) 25 micrograms(Mcg), Cyanocobalamin (a vitamin supplement medication) 1000 Mcg, Docusate Sodium (a laxative medication) 100 mg, Escitalopram (an antidepressant medication) 10 mg, Escitalopram 20 mg, Ferrous Sulfate (a mineral supplement medication) 325 mg, Folic Acid (a vitamin supplement medication) 1 mg, Polyethylene Glycol (a laxative medication) 350 17 grams, Omeprazole (a stomach acid reduction medication) 40 mg, Trelegy Ellipta Inhalation (an inhaled medication to improve breathing), Vraylar (an antipsychotic medication) 1.5 mg capsule, Azelastine (an inhaled allergy relief medication) 0.1% nasal spray with direction for 1 spray to each nostril, Calcitrol (a vitamin supplement medication) 0.25 Mcg capsule, Geri-Lanta (a laxative medication), Oxcarbazepine (an antispasmodic medication) 150 mg, Pregabalin (a nerve pain medication) 100 mg, Topiramate (an antispasmodic medication) 50 mg, UTI-Stat (a liquid supplement medication) 30 milliliters, and Midodrine (a blood pressure medication) 5 mg.In an interview completed on 02/17/2027 at 11:36 AM with MA-A, MA-A confirmed that all of Resident 5's medications were administered late and late administering of medications was a medication error. MA-A confirmed that Resident 5's Azelastine 0.1% ordered dose was for 1 spray each nostril and they administered 2 sprays to each nostril. The MA confirmed that this was a medication error. The MA confirmed that they signed out each medication prior to the medication being consumed by the resident and they should not have. The MA stated that the white granular powder was a medication and should have been destroyed and not placed in the trash can.In an interview completed on 02/17/2026 at 12:25 PM with Resident 5, Resident 5 confirmed that all their morning medications were administered late. The resident confirmed that they are to receive only 1 spray in each nostril and the MA gave them 2 sprays in each nostril.In an interview completed on 02/17/2026 at 12:30 PM with Licensed Practical Nurse D (LPN-D) LPN-D confirmed that all of Resident 5's medications were administered late and that they would notify the provider of the late medication administration.In an interview completed on 02/17/2026 at 12:40 AM with the facility Director of Nursing (DON), the DON confirmed that Resident 5's medications were administered late, and the late administration of medications were medication errors. The DON confirmed that the facility utilized medication destroyer for medication destruction and the MA should have destroyed the medication using this method and not placed the medication in the trash can. The DON confirmed that MA-A administered the wrong dose of the nasal spray to Resident 5 and this was a medication error and that the MA-A should not have signed out the medications as administered until after the resident consumed the medications. The DON confirmed that the MA-A did not administer Resident 5's medications using the 5 rights of medication administration.

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2)Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to complete nurse aide registry checks prior to staff having possible/probable contact with residents for 3 of 6 sampled staff and failed to report an adverse event to the designated agencies as stated in facility policy for 1 resident (Resident 59) of 1 sampled residents. The facility census was 67.Findings Are:A.Review of a facility policy titled Pre-Employment Background Screening and dated 02/01/2024 revealed applicants for employment will receive job offers contingent upon the satisfactory completion of a background screening. A record review of a facility document titled General Orientation Check List dated 08/15/2025 revealed a date of hire for Nurse Aide (NA)-F of 07/30/2025. A record review of a facility document titled Timecard for 07/27/2025 through 08/02/2025 revealed that NA-F worked on 07/30/2025, 07/31/2025 and 08/02/2025. A record review of a facility document titled Public Health Licensure Unit Certification of Licensure and included NA-F full name was dated 08/08/2025. The registry check was completed 10 days after NA-F was hired and began working in the facility. A record review of a facility document titled General Orientation Check List dated 06/12/2025 revealed a date of hire for the Business Office Manager (BOM) of 06/12/2025. A record review of a facility document titled Timecard for 06/08/2025 through 06/14/2025 revealed that the BOM worked on 06/12/2025. A record review of a facility document titled Public Health Licensure Unit Certification of Licensure and included the BOM full name was dated 06/24/2025. The registry check was completed 12 days after BOM was hired and began working in the facility. A record review of a facility document titled General Orientation Check List dated 06/27/2025 revealed a date of hire for Housekeeper (HSK)-J of 06/09/2025. A record review of a facility document titled Timecard for 06/08/2025 through 06/14/2025 revealed that the HSK-J worked on 06/09/2025, 06/10/2025, 06/12/2025, 06/13/2025, and 06/14/2025. A record review of HSK-J's employee records revealed no evidence of the Nurse Aide registry check being completed. In an interview completed on 08/25/2025 at 2:15 PM with the Facility Administrator (FA), the FA confirmed that NA-F and the BOM worked prior to the date listed on the registry check document indicating the registry check was not completed prior to the individuals working in the facility. The FA confirmed that no registry check was completed for HSK-J prior to working in the facility. B.Review of a facility policy titled Vulnerable Adult and dated 10/19/2022 revealed the facility shall report abuse, neglect, and mistreatment of an vulnerable adult as soon as possible after the discovery of the incident. In the section labeled identifying maltreatment, it revealed an adverse event was an untoward, undesirable, and usually unanticipated event that caused death or serious injury, or the risk thereof. A record review of a Resident Dashboard revealed the facility admitted Resident 59 on 08/13/2021 with a diagnosis of spinal stenosis (a condition where the spinal canal or the bony tunnel that protects the spinal cord becomes narrowed causing pain, numbness, and weakness). In an interview completed on 08/20/2025 at 11:18 AM with Resident 59 the resident stated they had suffered from a recent fall. The resident stated that during a transfer from their wheelchair to their bed in the full body lift they fell out of the lift and landed half on their bed and half on the floor. The resident stated that they only suffered some soreness and bruises from the incident. A record review of a facility supplied document titled Witnessed Fall and dated 06/16/2025 revealed that Resident 59 was observed lying on the floor and staff stated the strap on the sling for the full body list broke causing the resident to fall from the lift to the floor. The report listed a predisposing environmental factor of the incident was malfunctioning equipment and the resident was observed to have no injuries from the incident. In an interview completed on 08/21/2025 at 2:30 PM with the facility Director of Nursing (DON), the DON confirmed that this event was an unusual unanticipated event that had the potential to cause serious injury. The DON confirmed that this incident was not reported to the appropriate agencies as outlined in the facility policy.

Licensure Reference Number 175 NAC 12-006.04(A)(ii)Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview, and record review the facility failed to ensure employee health screens were reviewed prior to the start of employment for 4 of 5 sampled employees and failed to complete hand hygiene per professional standards. These had the potential to affect all residents residing within the facility. The facility census was 67. Findings are:A.A record review of a facility supplied document titled Employee Health History Screen and dated 06/12/2025 was signed as completed by the Business Office Manager (BOM) on 06/12/2025. There was no signature indicating a facility staff member or nurse had reviewed the document prior to the Business Office Manager working in the facility. A record review of a facility supplied document titled Employee Health History Screen and dated 07/30/2025 was signed as completed by Nurses Aide (NA)-F on 07/30/2025. There was no signature indicating a facility staff member or nurse had reviewed the document prior to the Business Office Manager working in the facility. A record review of a facility supplied document titled Employee Health History Screen and dated 07/18/2025 was signed as completed by Nurses Aide (NA)-K on 07/18/2025. There was no signature indicating a facility staff member or nurse had reviewed the document prior to the Business Office Manager working in the facility. A record review of a facility supplied document titled Employee Health History Screen and dated 06/09/2025 was signed as completed by Housekeeper (HSK)-J on 06/09/2025. There was no signature indicating a facility staff member or nurse had reviewed the document prior to the Business Office Manager working in the facility. In an interview completed on 08/25/2025 at 1:35 PM with the facility MDS Coordinator (MDSC) who acts as the facility infection preventionist, the MDSC stated they did not review employee health screens for new employees prior to their start of employment. In an interview completed on 08/25/2025 at 2:50 PM with the Facility Director of Nursing (DON), the DON stated either themselves or the infection preventionist nurse was to review the employee health screens prior to the employee starting employment at the facility. The DON confirmed that the BOM, NA-F, NA-K or HSK-J health history screens were not reviewed and signed by themselves or the infection preventionist nurse prior to those individuals' start of employment at the facility. B.A record review of a facility policy titled Hand Hygiene and dated 11/13/2024 revealed hand washing should be performed by all employees to prevent cross contamination. Hand Hygiene (HH) using soap and water should include rubbing hands together vigorously for at least 20 seconds and the water should be turned off by using a clean paper towel to prevent recontamination. In an observation completed on 08/25/2025 at 10:50 AM of medication administration by Medication Aide (MA)-G it was observed that after applying a topical medication to a resident's ankles with gloved hands, MA-G removed their gloves. The MA then performed hand hygiene with soap and water rubbing their hands together for 11 seconds. The MA then obtained paper towels and dried both of their hands with the paper towels. The MA then used the used paper towels to turn off the water. In an interview completed on 08/25/2025 at 11:05 AM with MA-G, MA-G confirmed that hands are to be washed for a minimum of 20 seconds and that a clean paper towel should be used to turn off the water. In an observation completed on 08/25/2025 at 11:29 AM Licensed Practical Nurse (LPN)-L, LPN-L prepared to obtain a resident's blood glucose reading by a finger stick. The LPN placed the needed supplies on a clean paper towel on the resident's over bed table. The LPN then went to the sink and completed hand hygiene with soap and water rubbing their hands together for 6 seconds. The LPN obtained paper towels and dried off their hands, then used the used paper towels to turn off the water. In an interview completed on 08/25/2025 at 11:35 AM with LPN-L, LPN-L confirmed that they did not rub their hands for at least 20 seconds and did not use a clean paper towel to shut off the sink. In an observation completed on 08/25/2025 at 4:12 PM LPN-B administered eye drops to a resident using gloved hands. The LPN then removed their gloves and completed hand hygiene with soap and water, rubbing their hands together for 5 seconds. The LPN obtained paper towels and dried off their hands, threw the used paper towels away, and used a clean paper towel to shut off the sink. In an interview completed on 08/25/2025 at 4:15 PM with LPN-B, LPN-B confirmed that they did not rub hands for at least 20 seconds during HH and should have. In an interview completed on 08/25/2025 at 4:30 PM with the MDS Coordinator (MDSC) who also acts as the Facility Infection Preventionist, the MDSC confirmed that when using soap and water hands should be rubbed for at least 20 seconds and that a clean paper towel should be used to shut off the water. The MDSC confirmed that hand hygiene under 20 seconds and using the same paper towels to dry hands and shut off the water was not the proper procedure for hand hygiene.

License Reference Number 175 NAC 1-005.06(C) Based on record review and interview, the facility failed to follow Antibiotic Stewardship standards for antibiotic surveillance and monitoring for 1 (Resident 10) of 2 sampled residents. The facility census was 67. Findings are:A record review of a facility policy titled antibiotic Stewardship Program and dated 11/13/2024 revealed the antibiotic stewardship program will optimize the treatment of infections by ensuring the residents who require an antibiotic are prescribed the appropriate antibiotic, reducing the risk for adverse side effects, including the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use to improve resident out comes. The nurse will utilize the appropriate infection criteria protocol based upon signs and symptoms to determine if it is necessary to treat antibiotics or if adjustments in therapy needed to be made. In the event the prescribing practitioner orders an antibiotic without identification of infection criteria, the provider will be requested to identify the rationale for the ordered antibiotic and document in the medical record. The nurse will observe and document in the nurse's notes the effectiveness of the antibiotic, side effects, and potential adverse consequences. A record review of Resident 10's Resident Dashboard revealed that the facility admitted Resident 10 with a diagnosis of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior). A record review of Resident 10's comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 06/20/2025 revealed that the resident was at risk for alterations in skin integrity and had none present at the time of the assessments. A record review of Resident 10's Progress Notes revealed that on 07/15/2025 the resident was seen in the facility by the provider. The provider prescribed an oral antibiotic for a diagnosis of cellulitis of the second toe on the left foot. A progress note was also entered that the antibiotic that was prescribed was outside of the recommended dose and frequency. A record review of Resident 10's assessments revealed no assessment indicating the infection criteria protocol was completed or reviewed by the provider prior to prescribing the antibiotic or after prescribing the antibiotic. In an interview conducted on 08/26/2025 at 4:12 PM with the facility MDS Coordinator (MDSC) who also is the facility Infection Preventionist, the MDSC stated that an antibiotic time out was to be completed 24-48 hours after the start of an antibiotic. This check was to review the appropriateness of the antibiotic and to update the provider that prescribed it, if necessary, about the use and appropriateness of the antibiotic prescribed. The MDSC confirmed that this process was not followed for Resident 10's antibiotic. The MDSC also confirmed that an assessment indicating the appropriate infection criteria was met or not met was not completed and communicated to the prescribing provider indicating the provider was made aware of the infection meeting or not meeting criteria. The MDSC also confirmed that the provider was not notified about the antibiotic that was being prescribed was outside of the recommended dose and frequency for the medication being prescribed. The MDSC confirmed that antibiotic stewardship standards were not being followed.

Based on interviews and record reviews, the facility failed to notify 1 resident in writing before the resident's room in the facility changed. This affected 1 of 1 sampled resident (Resident 32). The facility census was 67. Findings are:A record review of an electronic form titled, Census dated 8/21/2025 for Resident 42 revealed an admission date of 08/03/2023. The form further revealed Resident 42 had a room change entered on the census as of 08/20/2025. A record review of Resident 42's electronic medical record (EMR, digital collection of medical information about a person that is stored on a computer) titled Progress Notes revealed on 08/19/2025 an IDT note stating Resident 42 was being monitored for room change and new roommate, resident moved to a new room to prevent falls. The record also revealed on 08/20/2025 a Brief Interview for Mental Status (BIMS; a brief screener that aids in detecting cognitive impairment) score of 10/15. A score of 8-12: reveals a moderate impairment. On 08/20/2025 at 1:05 PM, Resident 42 was interviewed which revealed the facility had recently packed up their belongings and moved their items to another room. Resident 42 further revealed no knowledge of the move or reasoning for the move. The Social Services Director (SSD) was interviewed on 08/21/2025 at 11:00 AM. The SSD stated they were typically involved in room moves, however was not familiar on the room move for Resident 42. The SSD further revealed that the Director of Nursing (DON) was involved and could clarify details on Resident 42's room move. The DON was interviewed on 08/21/2025 at 11:26 AM. The DON stated they and the Interdisciplinary Team (IDT; a group of professionals from various healthcare disciplines who collaborate to provide comprehensive care to a patient) decided to move Resident 42 due to increased falls the resident was having. The DON was then interviewed about notifying Resident 42 on the room move request, to which the DON revealed Resident 42 was spoken to regarding reasons for the move and stated the resident had agreed to it, and the room move occurred on Monday 08/18/2025. The DON then revealed that Resident 42 was not alert and oriented to place or person and displays hallucinations, delusions and is unable to make those decisions. When asked if the Power of Attorney (POA; someone to make decisions on their behalf regarding finances or healthcare) was notified, the DON revealed that the POA cannot be gotten ahold of. The DON confirmed they had not provided written notification of the room change to Resident 42 or their POA. An interview with SSD on 8/21/2025 at 12:44 PM revealed there was a form that was supposed to be provided to the resident or the resident representative when a room change is considered. This form provided notification and an ability to appeal if necessary.

Licensure Reference Number 175 NAC 12-006.09(D) Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) for 2 (Residents 7 and 59) of 17 sampled residents. The facility census was 67. Findings are:A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated 10/2023 revealed coding instructions for N0350A to enter the number of days during the 7-day look back period that insulin injections were received. A.A record review of Resident 7's Annual MDS with an Assessment Reference Date of 07/10/2025 revealed Section N0350A to be coded as 1, indicating that the resident had received insulin (an injectable medication) during the assessment look back period. A record review of Resident 7's Medication Administration Record (MAR) for the month of July 2025 revealed that Resident 7 had no documented administrations of insulin. The documentation present reflected that Resident 7 had received Trulicity (an injectable medication used to treat Type 2 Diabetes that is not insulin) 0.75 milligrams on 07/08/2025, which was during the assessment look back period. B.A record review of Resident 59's Quarterly MDS with an Assessment Reference Date of 07/10/2025 revealed Section N0350A to be coded as 1, indicating that the resident had received insulin during the assessment look back period. A record review of Resident 59's MAR for the month of July 2025 revealed that Resident 59 had no documented administrations of insulin. The documentation present reflected that Resident 59 had received Ozempic (an injectable medication used to treat Type 2 Diabetes that is not insulin) 2 milligrams on 07/09/2025, which was during the assessment look back period. In an interview completed on 08/26/2025 at 2:40 PM with the facility Minimum Data Set Coordinator (MDSC), the MDSC stated the facility followed the RAI instructions for the coding of MDSs. The MDSC confirmed that Resident 7 and Resident 59 did not receive insulin during the look back period. The MDSC confirmed that Section N0350A should be coded 0 and not 1 for both residents and this was a coding error.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review the facility failed to prevent accidents and or incidents from occurring for 1 resident (Resident 62) of 1 sampled residents. The facility census was 67. Findings are:A record review of a facility policy titled Vulnerable Adult and dated 10/19/2022 revealed the facility shall take ongoing steps to identify each resident at risk for accidents and adequately plan care and implement procedures to prevent accidents. A record review of Resident 62's Resident Dashboard revealed the facility admitted Resident 62 on 12/03/2024 with diagnoses of schizophrenia (a chronic mental illness characterized by a combination of positive, negative, and cognitive symptoms that significantly impair daily functioning), and bipolar with psychotic features (a severe form of bipolar disorder characterized by the presence of psychotic symptoms, such as delusions and hallucinations, in addition to mood swings). A record review of Resident 62's Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 06/19/2025 revealed Resident 62 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14/15 indicating the resident was cognitively intact. The resident was documented to have delusions but no other behavioral problems, including wandering. The resident was independent with their activities of daily living and was independently ambulatory throughout the facility without an assistive device. A record review of a facility supplied document titled Risk Assessment: Elopement and dated 06/17/2025 revealed Resident 62 had a score of 4, placing them in the high-risk category for elopement. The assessment stated a total score of 3 or greater is high level of risk and precautions were to be initiated. The assessment stated the resident was independently mobile without an assistive device, had a previous history of wandering, had episodes of disorientation and confusion. In the comments area, documentation was present that the resident was only a moderate risk of elopement and that their wander guard had been removed. A record review of a facility document titled Incidents by Incident Type and dated 08/06/2024 through 08/20/2025 revealed Resident 62 had 1 incident during this period of time described as a witnessed fall. No other incidents or accidents were listed for Resident 62. A record review of Resident 62's physician orders on 08/26/2025 revealed the resident had an order for a wander guard to be in place and functioning on their left ankle. Staff were directed to check for placement and function of the wander guard every shift with a start date of 08/21/2025. A record review of Resident 62's Progress Notes revealed documentation on 08/18/2025 at 9:17 PM that the resident was having aggressive behaviors towards staff and was brought back inside the facility. Additional documentation on 08/19/2025 at 5:53 AM revealed the resident was having aggressive behaviors towards staff and was brought back inside the facility from the courtyard. A record review of a facility supplied document titled Rehab Communication and dated 08/20/2028 revealed documentation that Resident 62 was found outside of the facility and the therapy staff had assisted the resident back into the facility and reported the incident to the charge nurse. There was no other documentation in Resident 62's medical health record about this event. A record review of Resident 62's Progress Notes on 08/21/2024 revealed documentation that on 08/21/2025 a wander guard had been placed to the resident's left ankle due to the resident's exit seeking. In an observation completed on 08/25/2025 at 11:29 AM, a resident in a wheelchair entered the code to the secured front door of the facility, releasing the security device and wheeled themself out the front double doors. Resident 62 walked behind this resident and exited the building onto the unsecured front patio of the building. The resident in the wheelchair that entered the code to the door un-securing it, did not know Resident 62 had exited the building behind them. Resident 62 was outside the building on the patio and had started walking to the sidewalk that leads to a busy street. Licensed Practical Nurse (LPN)-B exited the building approximately 1 minute later, saw Resident 62 and assisted the resident back into the building. In an interview completed on 08/25/2025 at 4:45 PM with the facility Director of Nursing (DON), the DON confirmed that no new or changes to interventions to prevent Resident 62 from exiting the building without staff knowledge had been placed. The DON confirmed that the resident had exited the building without staff knowledge on 08/18/2025 and 08/19/2025 and no incident reports had been completed for these incidents and no changes to interventions to prevent the resident from exiting the building without staff knowledge had been placed on these dates. The DON confirmed a wander guard had been placed on Resident 62 on 08/21/2025 due to the resident's increased exit seeking, and confirmed that no incident reports or interventions were placed from 08/18/2025 through 08/21/2025 to prevent the resident from exiting the building without staff knowledge, ensuring the resident's safety.

Based on record review and interview the facility failed to ensure that residents were provided their required 30-day physician visit for 2 (Residents 47 and 63) of 4 sampled residents. This prevented the residents from receiving a thorough physician assessment of the resident for developing the resident's comprehensive care plan (a written interdisciplinary comprehensive plan to meet the resident's needs), including verifying initial orders and prescribing medication and treatments for the residents. The facility census was 67. Findings are:Record review of the facility policy titled Physician Visits and Physician Delegation dated 3/2025 revealed that it is the policy of the facility to ensure that the physician takes an active role in supervising the care of residents. The physician should see the resident within 30 days of initial admission to the facility. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by the physician or physician delegate. A. Record review of the admission Record dated 8/26/25 for Resident 47 revealed that Resident 47 admitted into the facility on 6/20/25. Resident 47 had diagnoses of Alzheimer's dementia, anxiety, dyskinesia of the esophagus (a condition where the esophagus, the tube that carries food from the throat to the stomach, experiences abnormal or uncoordinated muscle contractions that can lead to difficulty swallowing, chest pain, and other related symptoms), and high blood pressure. Record review of the Progress Note dated 7/8/25 at 1:27 PM for Resident 47 revealed that the interdisciplinary team discussed Resident 47's 5% weight loss since admission to the facility. Record review of the Medical Record for Resident 47 revealed an admission weight of 126 pounds. Resident 47 weighed 117 pounds on 7/14/25 which was a 7.14% weight loss. Record review of the Progress Note dated 8/19/25 at 8:59 AM for Resident 47 revealed that Resident 47 left the facility with the transportation coordinator for their follow up appointment with the resident's physician. (This was 60 days after the admission date of 6/20/25). Record review of the Physician's Visit Record dated 8/19/25 for Resident 47 revealed that Resident 47 had a 10:00 AM appointment with the resident's physician on 8/19/25. The physician provided a new order for Ensure (a nutritional drink designed to provide essential nutrients and calories to individuals who may not be able to consume adequate nutrition through their diet) or Boost (a drink used to supplement a person's diet with extra nutrients, especially protein and calories, when they are unable to get enough from their regular meals) chocolate with meals and as needed for hunger. The physician signed the order and dated the order 8/19/25. Record review of the Medical Record of Resident 47 revealed no documentation of a required 30 day physician visit for Resident 47. Interview on 8/26/25 at 5:28 PM with the facility Director of Nursing (DON) confirmed that facility residents were required to have a physician visit within 30 days after admission to the facility. The DON confirmed that the facility did not have documentation of an initial 30 day physician visit for Resident 47. Interview on 8/26/25 at 5:37 PM with the Regional Nurse Consultant (RNC) confirmed that the facility had no documentation of an initial 30 day physician visit for Resident 47. The RNC confirmed that a 30 day physician visit was not completed for Resident 47 as required. B. Record review of Resident 63's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 7/10/2025 revealed an admission date of 3/10/2025. Record review of Resident 63's Physician Visit record dated 4/11/2025 revealed an admission date to the facility on 3/10/2025. The physician visit reviewed a history, a current physical and an overview of medications, treatments and reasoning for the visit, which revealed a new admission to a facility and a 30-day review from admission. The physician visit also requested on the provider communication record stating: return visit in 30 days. Record review of Resident 63's Physician Visit record dated 6/10/2025 revealed the order summary report that was printed from the facility on 6/09/2025 and sent with the resident for review with the physician. The order summary report was signed on 6/10/2025 at the end of the report. The physician visit also requested on the provider communication record stating: check labs at next visit, continue current medications and follow up in 60-days. Record review of Resident 63's Physician Visit record dated 8/12/2025 revealed the physician reviewed a history, a current physical and an overview of medications, treatments and reasoning for the visit, which was a 60-day visit. The physician visit requested, under instructions, to return in about 2 months. An interview on 8/26/2025 at 5:15 PM with the Director of Nursing (DON) confirmed that facility residents are required to have a physician visit after admission to the facility every 30 days for the first 90 days, then every 60 days thereafter. Interview on 8/26/25 at 5:45 PM with the Regional Nurse Consultant (RNC) confirmed that the facility had no documentation of a 30-day physician visit for Resident 63 after the initial visit on 4/11/2025 was completed. The RNC confirmed that a 30-day physician visit was completed, however the following physician visit 30 days later was not completed for Resident 63 as required.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview the facility failed to ensure a medication error rate of 5% or less with an actual observed medication error rate of 12%. This affected 1 (Resident 4) of 5 sampled residents. The facility census was 67. Findings are: Record review of a document titled Diclofenac Sodium (a topically applied non-steroidal anti-inflammatory medication) Gel Dosage dated 08/22/2025 revealed the proper amount of gel should be measured using the dosing card supplied. The dosing card should be used for each application of the product. Record review of a document titled Instructions for use Trelegy Ellipta (an inhaled medication) and dated 12/2022 revealed to rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water. Record review of a facility document titled Competency for Inhaler Administration dated 05/11/2021 revealed to instruct the resident to rinse their mouth with water after inhalation of the medication. A record review of Resident 4's Medication Administration Record for the Month of August 2025 revealed that Resident 4 had orders for Trelegy AER 200 micrograms with directions to inhale 1 puff into the lungs once daily and Diclofenac Sodium External Gel 1% with directions to apply 1 gram to both ankles topically twice daily for pain. In an observation of medication administration completed on 08/25/2025 at 10:54 AM by Medication Aide (MA)-G administering medication to Resident 4 the following was observed:-MA-G handed the resident a gray plastic oblong device and informed the resident that it was their inhaler. The resident took 2 deep breaths then on the exhale placed the mouthpiece to their mouth and inhaled. The resident then removed the device from their mouth and gave it back to the MA. The medication aide then applied gloves to both of their hands. The MA used a finger to scoop out an opaque white gel from a clear medication cup. The MA then applied the gel to the residents right ankle. The MA then repeated this process and applied the gel to the right ankle. The medication aide removed their gloves, completed hand hygiene. The MA did not instruct the resident to rinse their mouth after using the inhaler and did not use the measuring device for administration of the topical gel to the resident's ankles to ensure they received the proper dose of the medication. The resident requested an as needed pain medication from the MA voicing a headache rated a 4 on a 1-10 scale. The MA returned to the medication cart, signed out the administered medications and then obtained Acetaminophen (a pain-relieving medication) 1500 milligram tablet and placed it into a clear plastic medication cup. The MA then took the cup to the resident's room and handed the medication to the resident. The resident ingested the medication. The MA then returned to the medication cart. The MA did not obtain the nurses' permission prior to the administration of the as needed medication. In an interview completed on 08/25/2025 at 10:52 AM with MA-G the MA confirmed that they did not have the resident rinse their mouth after use of the inhaler and did not use the dosing card/measuring device to measure out the correct dose of the topically applied medication. The MA also confirmed they did not notify or request the nurse's permission prior to the administration of the as needed medication and should have. In an interview completed on 08/25/2025 at 11:05 AM with Licensed Practical Nurse (LPN)-A, LPN-A confirmed the MA should have informed or gained permission from them as the nurse for the administration of the as needed medication to Resident 4. The LPN confirmed that the MA informed them of the resident's pain level and the administration of the as needed pain medication after they had administered the medication and not before.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on record review, observations, and interviews, the facility failed to identify causal factors for falls and failed to implement interventions for the prevention of new falls following each new incident. This affected 3 (Residents 3,7, and 11) of 3 sampled residents. The facility census was reported to be 60. The facility Administrator was notified on 3/17/2025 at 5:44 PM of an Immediate Jeopardy (IJ) which began on 12/01/2024. The IJ was removed on 3/17/2025, as confirmed by surveyor onsite verification. Findings are: Record review of the facility policy Fall Risk and Prevention Guidelines revised October 2024 revealed that a resident's fall risk begins pre-admission. Upon admission, the plan of care should be ready to incorporate the fall prevention measures based on information gathered. The Morse Fall Scale is completed with each admission, readmission and with quarterly, annual and significant changes when completing the minimum data set (MDS, a standardized assessment tool used in Medicare and Medicaid certified nursing homes to collect comprehensive, standardized data on residents' health status and functional capabilities). Intervention and prevention measures of falls were to include use of: 1.) the resident care plan to identify history, risks, and resistance or refusal of interventions, 2.) incident analysis to identify trends and patterns for prevention. 3.) customer service rounds (nursing rounds), 4.) resident information sheets or the use of a [NAME], 5.) information gathered post fall, 6.) use of the reference Suggested Interventions to Manage Falls, 7.) immediate assessment and treatment of any injuries, 8.) complete set of vital signs, 9.) make appropriate notifications to Director of Nursing, hospital, family, etc. At this point the root cause analysis could be conducted by: 1.) interviewing any witnesses, 2.) making notes of the resident's surroundings, 3.) interviewing staff about the last time cares were provided to the individual, 4.) recording reviews of the medications and any recent lab work and revisit the plan of care, and 5.) nursing reviews of the post data collected and initiating a plan of care. Record review of the facility policy Risk Management updated on 09/27/2025 revealed all accidents/incidents involving residents must be reported, investigated, and reviewed through the facility's quality improvement program to ensure residents are receiving the highest quality of care. Each nurse who identified an incident would be responsible for completing the incident report. The incidents reportable included witnessed and unwitnessed falls, new skin issues, elopements, medication errors, abuse, resident to resident interactions, any unusual event, and smoking or burn injuries. The completed report would include details and descriptions of the incident as well as any immediate action taken; list any injuries, pain level, mobility and any confusion: identify predisposing factors for the incident including environmental, physiological, situation, or other causative factors; list any witnesses; describe actions taken (called family, director of nursing, ER), document in the electronic medical record; and finally, the nurse's signature. Neurological assessments were to take place if there were any unwitnessed falls or head injuries and to continue assessing for potential or further injuries. Record review of the facility policy Person Centered Care Plan revised January 2024 revealed the care plans are developed within 7 days after the completion of the comprehensive MDS assessment, and reviewed annually, quarterly and with significant changes as needed. The comprehensive person centered care plan contains measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that are identified. The overall person centered care plan should be oriented towards 1.) preventing avoidable declines, 2.) managing risk factors, 3.) preserving and building on the resident's strengths, 4.) respecting personal preferences and the right to decline treatments, 5.) include specific goals, treatment preferences and desired outcomes of care, and 6.) Include resident strengths and care needs. The care plans should be clear and concise, include personal strengths, include refusals of care, and show the risk versus the benefits. A. Record review of the annual MDS assessment dated [DATE] revealed Resident 7 had a Brief Interview for Mental Status (BIMS score-a 15-point cognitive screening tool used in long-term care facilities to assess a resident's cognitive function) score of 9 indicating the resident is moderately cognitively impaired, used a walker, needed standby assistance with dressing but substantial assistance when toileting or bathing, was occasionally incontinent of bowel and/or bladder, had no skin conditions, used a pressure reducing device in her chair, had diagnoses of arthritis, hypertension, and non-Alzheimer's dementia as well as other diagnoses. Resident 7's medications included the use of anti-psychotics, diuretics, antiplatelets, a hypoglycemic, and anticonvulsants. Resident 7 did not receive any physical therapy or occupational therapy in the 7 days used to prepare the annual MDS assessment. Record review of the working Care Plan (a structured approach to address an individual's healthcare and personal care needs) for Resident 7, printed and reviewed on 03/17/2025, revealed Resident 7 used an anticoagulant with a goal to remain free of complications and injuries (bleeding, bruising, swelling, hypotension and hospitalizations) through the next review of date of 07/06/2025. Resident 7's Protime/INR (a test that measures how quickly ones blood clots, helping to assess the effectiveness of blood-thinning medications like Warfarin) was to be checked per the physician orders. Resident 7 was at high risk of falling related to gait and balance problems, incontinence, and hypotension. New care plan interventions were initiated on 02/26/2025 for the following: -call light within reach and encourage use, -educate resident, staff, and family about safety reminders, -ensure proper footwear, -fax meds to physician for review, -follow facility fall protocol, -review information on past falls and attempt to determine cause of falls, -record possible root causes. -Alter remove any potential causes if possible. Educate resident/family/caregivers/Interdisciplinary team as to causes. Care plan interventions were also updated on 03/03/2025 when staff were to request a physical therapy and occupational therapy evaluation and obtain a urine analysis (UA) due to recent falls report and send results to provider. The resident started an antibiotic for a urinary tract infection. The last update was initiated on 03/10/2025 which stated the resident needs a safe environment with, even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items within reach. Record review of the facility incidents by incident types for the month of February 2025 revealed eight witnessed falls, eight unwitnessed falls, two unusual event incidents, and two observed on the floor incidents of which Resident 7 had two unwitnessed falls (02/23/2025 and 02/26/2025). Record review of the facility incidents by incident types for March 1 to March 17, 2025, revealed five witnessed falls, nine unwitnessed falls, and one unusual event incidents of which Resident 7 had one witnessed fall (03/08/2025) and 3 unwitnessed falls (03/01/2025, 03/02/2025, and 03/10/2025). Record review of the post Fall Report from 02/26/2025 at 7:10 AM revealed Resident 7 was alert and oriented to person, place, and thing and had fallen in the hallway on the way back to the resident's room. Resident 7 stated they had fallen in the hallway when they lost their balance. Vital signs were reported to be stable. The resident reported dizzy feeling prior to falling. Interventions put into place by facility included need to tighten the laces on the shoes when tied, possible need for new shoes, and need to change pull-up when getting dressed in the morning. No injuries noted. Record review of the post Fall Report from 03/01/2025 at 6:55 AM revealed Resident 7 had been found on the floor of the resident's room with no apparent injuries noted. Resident 7 was alert and oriented to person, place and thing, but was found to be incontinent of both bowel and bladder. Interventions on the fall report but not the care plan stated to keep the call light within reach of Resident 7. No injuries noted. Record review of the post Fall Report from 03/02/2025 at 11:30 PM revealed Resident 7 was found on the floor of the resident's bathroom. Resident 7 reportedly lost balance and fell due to weakness and being alone. Resident 7 was reported to be alert and oriented to person, place and thing, wore only socks without grippers, and had changes in gait and balance over the last 2 weeks. When found Resident 7 was incontinent of urine. Resident 7 had started a new medication for a urinary tract infection the same date. Interventions put into place were to obtain a physical therapy and occupational therapy referral. No injuries noted. Record review of the post Fall Report from 03/08/2025 at 6:45 PM revealed Resident 7 tried to get out of the wheelchair without assistance and fell in the presence of a roommate. Neurological checks were initiated because it was unknown if Resident 7 hit (gender) head. Resident 7 was moved near the nurses station until it was time for bed for that single evening episode. There was no update to Resident 7's care plan. No injuries noted. Record review of the post Fall Report from 03/10/2025 at 4:03 PM revealed Resident 7 lost (gender) balance when getting out of the wheelchair, was disoriented x 2, had changes in gait, mobility, and balance over the past 2 weeks, and had a change in mental condition. At the time of the fall, Resident 7 wasn't using the walker for ambulation and had not used the call light. No injuries noted. Record review on 03/17/2025 of the Progress Notes of Resident 7 revealed that the Healthcare Power of Attorney (HPOA) had been contacted by nursing staff about the fall that occurred on 03/10/2025 at 3:15 PM. The HPOA asked that the resident be sent to the emergency room for further evaluation. This was further ordered by Resident 7's primary healthcare physician as noted in the progress notes. Interview on 03/17/2025 at 1:20 PM with the MDS, revealed that since Resident 7 had been placed in the hospital on [DATE]. The MDS had not gotten any updates about Resident 7 but did know the hospital admission diagnosis included a diagnosis of urinary tract infection. The MDS, further revealed that generally, the next day the care plans are updated with the new interventions because there must be a new intervention with each incident. The nurses and charge nurses may come to me or to the DON to ask about adding something to the care plan and then the DON and I meet to add what is needed. The DON and I have weekly meetings. We also have monthly meetings to discuss the high fall risk residents and make sure there are interventions in place. Interview on 03/17/2025 at 1:25 with the DON in the office of the DON, revealed that there is a Performance Improvement Project (PIP) in place for falls. We have seen some trends and made some improvements. After an incident, the MDS, the Assistant Director of Nursing (ADON), and I all meet to discuss what staff put into place in the fall report at the time of the incident. We let the staff know right away by going out to the floors and visiting with the staff when we have changed the care plan. We also use a white board to share updates. I think the staff use a small binder at the nurses' station to track these changes as well. But a lot of the updates are done by word of mouth at the time of report. Interview on 03/17/2025 at 3:45 PM with the DON confirmed that not all information identified for care plan interventions, found on the fall reports, get added to the care plans after each incident. DON confirmed that some of the updates to care plan interventions did not show on the care plans until a few days after the incidents and at times another incident had already taken place. DON further confirmed some interventions are not appropriate because staff cannot assist with interventions such as physical therapy and occupational therapy referrals, asking physician for orders for biopsies, and single occurrence interventions. The DON also confirmed the fall reports are used to identify issues and follow trends, but the root cause of many of the fall issues is not found. B. Record review of the Resident 11 quarterly MDS dated [DATE] revealed this resident had a BIMS Score of 12 indicating the resident was moderately cognitively impaired, did not wander or refuse cares, used a walker and wheelchair, is independent in activities of daily living except for supervision at bathing time, is occasionally incontinent of urine, and had diagnoses of hypertension, hypokalemia, diabetes, and seizure disorder. Resident 11 also took the following types of medications: Antipsychotics, antidepressants, hypnotics, and anticonvulsant's. Record review of the care plan for Resident 7 revealed the resident had idiopathic epilepsy and was a high risk for falls. The care plans were updated for falls on 12/13/2024, 01/06/2025, 01/30/2025, 3/7/2025, and 3/10/2025. The care plan update on 3/7/2025 stated staff were to rearrange the room. The update on 3/10/2025 occurred while the resident was in the hospital and revealed the facility had added siderail's to Resident 11's bed to promote independence with transfers and repositioning, and to promote safety. Record review of the facility incidents by incident types for the month of January 2025 revealed Resident 11 had two unwitnessed falls (1/1 and 1/28/2025). Record review of the facility incidents by incident types for the month of February 2025 revealed Resident 11 had one witnessed fall (2/21/2025) Record review of the facility incidents by incident types for March 1 to March 17, 2025, revealed Resident 11 had 2 unwitnessed falls (3/5 and 3/7/2025). Record review of the Progress notes reviewed on 03/17/2025 revealed a health status note written on 03/07/2025 at 5:09 AM revealed Resident 11 was having urgency and frequency with urination and when asked about the symptoms denied burning or pain with urination. Resident 11 was assisted to the bathroom and voided small amounts and was having incontinence issues post voiding with no strong odors or cloudiness observed while voiding but needed to have assistance to the bathroom every hour through the night. The resident remained on Neuro checks from a fall that occurred on 03/05/2025. On 03/07/2025 at 5:34 AM a change of condition notification was faxed to the Resident 7's doctor and staff awaited a response. On 03/07/2025 at 6:33 AM the staff found Resident 7 on the floor in the bathroom with back resting against the wall. Resident 11 was confused and after a quick assessment by staff was ambulated and found to be unsteady and shaky. Resident 11's primary care physician sent an order to have to have Resident 11 sent to the emergency room for evaluation and treatment. Record review of the Hospital Discharge paperwork for Resident 11 dated 03/13/2025 revealed that upon admission to the emergency room the resident had chills, an altered mental status changes. His blood work revealed a white count of 20,000 (Normal is 3000 to 11,000) which indicated a bacterial infection, a lactic acid of 2.0 and procal of 5.5 (Both lactic acid and procalcitonin are indicators used to determine whether a patient has sepsis of the blood). Resident 11's urine was positive for bacteria that was positive for nitrates, 3+ leukocyte esterase, cloudy, many bacteria, and a white count that was too numerous to mention (nitrates, leukocyte esterase, cloudiness, bacteria and white counts are all used to determine if there is an infection in the urine). Prior to discharge Resident 11 was diagnosed with a urinary tract infection and sepsis due to E.coli (a bacteria) without acute organ dysfunction. The reason for his referral to the hospital had been weakness. Interview with MDS Coordinator on 03/17/2025 at 3:45 PM who revealed that updates to the care plan did not occur with each incident and were not added immediately after the incidents that occurred. Interview with the DON on 03/17/2025 at 3:45 PM who confirmed that updates to the care plan did not flow over from the progress notes and were not added to the care plan. C. Record Review of the MDS dated [DATE] for Resident 3 revealed the BIMS had not been conducted for this resident as Resident 3 is rarely understood or never understood. Resident 3 does have behavioral issues 1 to 3 times per week, and occasional rejects cares, is unable to ambulate 10 feet, and uses a motorized electric wheelchair. Resident 3 needs assistance with eating and toileting, and is dependent with cares related to dressing and bathing. Resident 3 is occasionally incontinent of urine, frequently incontinent of bowel, and has ongoing pain. Resident 3's diagnoses include atrial fibrillation (abnormal beating of the heart), osteoporosis (weakened bones), anxiety, depression, schizophrenia, and a fractured right patella. Resident 3 takes medications for anxiety, depression, opioid for pain, and an anticonvulsant. Record review of the Care Plan printed on 3/17/2025 for Resident 3 revealed this resident was at high potential for falls. There were no updates to the care plan for falls during the month of December 2024. During the month of January 2025, there were updates to the care plan on 01/06, 01/08, 01/10, 01/28 and 01/29/2025. During the month of February 2025 there was a single update to the care plan pertaining to falls on 2/26/2025. There were no updates to the fall area of the care plan during the month of March 2025. Record review of the Progress Notes for Resident 3 which revealed falls occurred on 12/01/2024 at 10:16 PM, 12/22/2024 at 11:45 AM, and 12/28/2024 at 5:39 PM during the month of December 2025. The progress notes further revealed that Resident 3 was educated about carrying too many things at one time. This was not included in the care plan. Record review of Resident 3's progress notes also revealed that on 12/23/2024 the resident was given gripper socks, educated about wearing proper footwear, and to not wash things in the sink. This was not added to the care plan. Resident 3 did have pain in the right knee following the accident on 12/28/2024 at 5:39 PM. A change of condition report was called to the Primary care provider and the resident was sent to the emergency room at 11:45 PM. The resident returned to the facility on [DATE] at 1:30 AM diagnoses with a right patellar fracture of the right knee, wearing an ace wrap and an immobilizer to the right knee. Record review of the facility incidents by incident types for the month of January 2025 revealed Resident 3 had four unwitnessed falls (1/12, 1/17, 1/26 and 1/27/2025) and one observed on the floor incident (1/2/2025). Record review of the facility incidents by incident types for the month of February 2025 revealed Resident 3 had one witnessed fall (2/26/2025). Record review of the facility incidents by incident types for March 1 to March 17, 2025, revealed Resident 3 had one unwitnessed fall (3/13/2025). Interview with the MDS Coordinator on 03/17/2025 at 3:45 PM revealed that Resident 3 is able to get out the wheelchair to sit on the floor for prayers. We encourage Resident 3 to ask for assistance, but oftentimes (gender) doesn't remember to use the call light. Resident 3 is a High Potential Fall Risk per (gender) care plan but we really didn't have any issues until December. There were no care plan updates added to Resident 3's care plan until that fractured patella occurred. MDS Coordinator confirmed that new interventions should have been added with each incident. Interview with the DON on 03/17/2025 at 3:34 PM confirmed no new updates to the care plan concerning fall risks were added until January. Also confirmed that some of the interventions need to be revised so that they are pertinent to the staff. D. Interview on 03/17/2025 at 1:15 PM with the charge nurse Licensed Practical Nurse (LPN-C) who has worked at the facility for the past 3 years, explained that the current process following incidents in the facility is to call the Director of Nursing (DON) and family as well as sending a change of condition report to the physician to let them know about the occurrences. The DON will then update the care plan and let us as staff know right away what changes have been added. LPN-C admitted to not reviewing the care plan itself and just gets the care plans by word of mouth from the DON or the MDS. Charge nurses do not update the care plans. Charge nurses will fill out the fall reports and do the neuro checks when needed such as unwitnessed falls and when a resident hits their head. Interview on 03/17/2025 at 1:20 PM with the MDS in the office of the MDS, revealed that generally, the next day the care plans are updated with the new interventions because there must be a new intervention with each incident. The nurses and charge nurses may come to me or to the DON to ask about adding something to the care plan and then the DON and I meet to add what is needed. The DON and I have weekly meetings. We also have monthly meetings to discuss the high fall risk residents and make sure there are interventions in place. Interview on 03/17/2025 at 1:25 with the DON in the office of the DON, revealed that there is a Performance Improvement Project (PIP) in place for falls. We have seen some trends and made some improvements. After an incident, the MDS, the Assistant Director of Nursing (ADON), and I all meet to discuss what staff put into place in the fall report at the time of the incident. We let the staff know right away by going out to the floors and visiting with the staff when we have changed the care plan. We also use a white board to share updates. I think the staff use a small binder at the nurses' station to track these changes as well. But a lot of the updates are done by word of mouth at the time of report. Interview on 03/17/2025 at 3:25 PM with Nurse Aide (NA-A) revealed the nurses will tell the nurse aides at the beginning of the shift if there are any changes to the way care is provided for residents. Or there is a book we can look in at the desk too. NA-A revealed [gender] does not review the care plans for any residents and instead relies on word of mouth. Interview on 03/17/2025 at 3:28 PM with NA-B revealed to have no knowledge of a book at the front desk to obtain updates. NA-B stated the nursing staff let the nurse aides know about changes at the beginning of the shift about care changes. NA-B does not review the care plans for any residents. Interview on 03/17/2025 at 3:30 PM with LPN-C who confirmed that most staff including LPN-C rely on the word of mouth to get the information about care updates on residents in house. Interview on 03/17/2025 at 3:45 PM with the MDS Coordinator in office of the DON who stated that the care plans are updated with each incident, however, MDS was unable to identify the updates for each incident on the care plans for sampled residents after incidents in question. MDSC also identified the care plan interventions that do not actually assist the residents at the time of the incidents. MDS did identify that some residents are non-compliant with interventions and so these are just not added to the care plans. Interview on 03/17/2025 at 3:45 PM with the DON confirmed that not all information identified for care plan interventions, found on the fall reports, get added to the care plans after each incident. DON confirmed that some of the updates to care plan interventions did not show on the care plans until a few days after the incidents and at times another incident had already taken place. DON further confirmed some interventions are not appropriate because staff cannot assist with interventions such as physical therapy and occupational therapy referrals, asking physician for orders for biopsies, and single occurrence interventions. The DON also confirmed the fall reports are used to identify issues and follow trends, but the root cause of many of the fall issues is not found. E. An abatement statement was presented and approved on 03/17/2025 at 9:34 PM by the Administrator. The Abatement statement read as follows: -On 3/17/2025, Administrator, Director of Nursing and MDS were educated on the Accura Risk Management process by Chief Clinical Officer. -On 3/17/2025, staff education was initiated to ensure all licensed staff understand the Accura risk management process. Any licensed staff not currently working will be educated prior to the start of their next shift. -On 3/17/2025. All NA's through evening shift into night shift were educated on the communication plan for care plan changes and intervention updates. -On 3/17/2025, Care Plan updates were initiated on Resident 3 and Resident 11. Resident 7 remains out of the facility and the care plan will be updated upon return. Audit: All residents who have had two or more galls within 30 days in the last 60 days will have care plan reviews for causative factors and appropriate interventions. The communication board will be audited daily for the next 4 days to ensure all updated care plan changes and new interventions are communicated to the NAs. We will move to auditing 3x weekly starting 3.24.2025. Any concerns will be reported to the administrator immediately and addressed in facility Quality Assurance. After consideration, it was determined that the facility put the facility residents in a situation of immediate jeopardy by not assessing the fall situations, identifying the causal factors for the fall incidents, and for failing to add interventions that staffing knew about immediately following the incidents, and to make changes to care plans using a process that was known to all staff members. The Immediate Jeopardy started with the fall that took place on 12/01/2024 at 10:16 PM. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on Observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. After receiving the abatement statement, the severity was changed to a D.

Based on record review and interivews, the facility failed to ensure that all residents were seen by a physician every 30 to 60 days. This had the potential to affect 5 of 5 sampled residents (Residents 3,7,11,13, and 15.) The facility census was 60. Findings are: Review of the policy Physician Visits and Physician Delegation dated 03/2025 revealed it is the policy of this facility to ensure the physician takes an active role in supervising the care of the residents. The physician should: -See the resident within 30 days of initial admission to the facility. -The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by a physician or physician delegate. A. Record review of the Minimum Data Set Assessment (MDS) completed with a significant change and Assessment Reference Date (ARD) of 01/02/2025 revealed Resident 3 did not have a Brief Interview for Mental Status score due to inability to understand, was admitted on [DATE], had diagnoses of osteoporosis, atrial fibrillation, fractured right patella, and frequent pain. Interview with the Director of Nursing (DON) on 03/18/2025 at 11:25 AM. The DON was asked to provide copies of the physician face to face primary care visits for Resident 3 and stated those visits would be brought in for review. Interview with the DON on 03/18/2025 at 1:10 who revealed all of the face-to-face primary care visits for Resident 3 were presented for review. There were documented primary care visits with Resident 3 for the following dates: -03/19/2024, -06/04/2024, -08/20/2024, -11/05/2024, -01/05/2025, -01/07/2025, -02/14/2025, -03/14/2025. In an interview with the Director of Nursing (DON) on 03/18/2025 at 2:45 PM revealed that a copy of all primary care visits had been made available for review. In an interview with the Administrator (ADM) on 03/18/2025 at 2:50 PM confirmed that the dates did not cover all the mandated physician visits. B. Record review of the Annual MDS with an ARD of 01/16/2025 revealed Resident 7 had a Brief Interview for Mental Status score of 9 (moderate cognitive impairment), was admitted on [DATE], had diagnoses of non-Alzheimer's dementia, hypertension, diabetes, arthritis, depression, and chronic kidney disease. In an innterview with the DON on 03/18/2025 at 1:10 PM who revealed all of the face-to-face primary care visits for Resident 7 were presented for review. There were documented primary care visits with Resident 7 for the following dates: -05/09/2024, -08/22/2025, -10/31/2024. In an interview with the DON on 03/18/2025 at 2:45 PM who stated that a copy of all primary care visits had been made available for review. In an interview with the ADM on 03/18/2025 at 2:50PM confirmed that the dates did not cover all the mandated physician visits. C. Record review of the quarterly MDS with an ARD of 01/16/2025 revealed Resident 11 had a Brief Interview for Mental Status score of 12 (moderate cognitive impairment), was admitted on [DATE], had diagnoses of seizure disorder, diabetes, chronic kidney disease, hypertension, and depression. In an interview with the DON on 03/18/2025 at 1:10 PM revealed all of the face-to-face primary care visits for Resident 11 were presented for review. There were documented primary care visits with Resident11 for the following dates: -05/15/2024, -12/17/2024, -01/21/2025, -03/05/2025, -03/07/2025. In an interview with the DON on 03/18/2025 at 2:45 PM who stated that a copy of all primary care visits had been made available for review. Interview with the ADM on 03/18/2025 at 2:50 PM confirmed that the dates did not cover all the mandated physician visits. D. Record review of the quarterly MDS completed and ARD of 02/27/2025 revealed Resident 13 had a Brief Interview for Mental Status score of 15 (cognitively intact), was admitted on [DATE], and had diagnoses of status post stroke, hypertension, chronic obstructive pulmonary disease, history of falling, long term use of anticoagulants, anxiety, bipolar disorder, schizophrenia, and hemiplegia. Interview with the Director of Nursing (DON) on 03/18/2025 at 11:25 AM. The DON was asked to provide copies of the physician face to face primary care visits for Resident 15 and stated those visits would be brought in for review. Interview with the DON on 03/18/2025 at 1:10 who revealed all the face-to-face primary care visits for Resident 15 were presented for review. There were documented primary care visits with Resident 13 for the following dates: -04/16/2024, -07/02/2024, -08/21/2024, -09/12/2024, -11/19/2024, -01/21/2024, -03/11/2024. In an interview with the DON on 03/18/2025 at 2:45 PM who stated that a copy of all primary care visits had been made available for review. In an interview with the ADM on 03/18/2025 at 2:50 PM confirmed that the dates did not cover all the mandated physician visits. E. Record review of the MDS completed with an ARD of 02/27/2025 revealed Resident 15 had a Brief Interview for Mental Status score of 12 (Moderate cognitive impairment), was admitted on [DATE], and had diagnoses of hypertension, long term use of anticoagulants, and end stage renal disease. In an interview with the DON on 03/18/2025 at 1:10 PMwho revealed all the face-to-face primary care visits for Resident 15 were presented for review. There were documented primary care visits with Resident 15 for the following dates: -08/20/2024, -10/09/2024, -11/20/2024, -01/28/2025. In an interview with the DON on 03/18/2025 at 2:45 PM who stated that a copy of all primary care visits had been made available for review. In an interview with the ADM on 03/18/2025 at 2:50 PM confirmed that the dates did not cover all the mandated physician visits.

LICENSURE REFERENCE NUMBER NAC 175 ,d+[DATE].11(E) The facility failed to ensure foods were not outdated and were labeled to prevent the potential for food-borne illness for all 62 residents served out of the kitchen. The facility identified a census of 62. An observation on [DATE] from 8:35 AM to 9:15 AM during the initial kitchen tour revealed the following: - 5 bags of opened cereal on a metal cart that with no label or date on them. - The upright refrigerator with 12 half chicken salad sandwiches with no label or date, and Med Pass nutritional shake open without a date with the manufacturers label instructing to use within 4 days of opening. -The dry storage room with 1 can of dented mandarin oranges on the shelf for use, a large bag of taco seasoning open with no date, 1 container of chicken bouillon cubes with best by date of ,d+[DATE], and 1 bag of semi-sweet chocolate chips open with no date. -The walk in refrigerator with 1 plastic container of pears with a use by date of [DATE],and 1 plastic container of sliced jalapeno labeled with an open date of [DATE] and no use by date. An interview with the Dietary Supervisor (DS) on [DATE] at 9:10 AM confirmed the 12 half chicken salad sandwiches had not label or date, the can of mandarin oranges was dented and available for use, the taco seasoning had no open date, the chicken bouillon cubes were expired, the bag of chocolate chips had no open date, and the plastic containers of pears and jalapeno were expired. Record review of the Nutrition services manual: Sanitation: Storage- Dry Storage revealed: Number 8 states: Pour contents of open canned goods into plastic container with label and date and place into refrigerator storage. Dry goods may be placed in plastic bags and sealed or placed in plastic containers. Number 9 states: Follow expiration date for all packaged goods.

Licensure Reference Number 175 NAC 12-006.09B Based on observation, record review and interview the facility failed to ensure accuracy of the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) assessment for 2 (Residents 33 and 16) of 6 sampled residents related to Stage 2 pressure injury wounds (loss of partial thickness of the skin including epidermis and part of the superficial dermis) for (Resident 33) and for hospice services for (Resident 16). The facility census was 62. Findings are: A. A review of Resident 33's Admission Record revealed an admitted to the facility of 11/20/2020. A review of Resident 33's MDS dated [DATE] revealed that in Section C a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15 which suggests the resident is cognitively intact. In an interview on 07/29/24 at 2:17 PM with Resident 33 revealed Resident 33 reported having a sore on (gender) bottom and the sore had been there for a few months. A review of Resident 33's Comprehensive Careplan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed: -Focus area date initiated 4/19/2021 and last revision date of 7/25/2024 revealed right lower posterior pressure injury area. An observation on 07/31/2024 at 8:35 AM of Resident 3's wound care to the left buttock with Licensed Practical Nurse (LPN)-C revealed a red opened area to left buttocks that was bleeding. In an interview on 7/31/2024 at 8:39 AM LPN-C reported that the sore was a pressure wound and that Resident 33 had the wound for a while. A review of Resident 33's MDS dated [DATE] revealed in Section M: - Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device not indicated. - Does this resident have one or more unhealed pressure ulcers/injuries? Answered as no. A review of Resident 33's Weekly Skin assessment dated [DATE] revealed two Stage 2 Pressure areas to the resident's left buttock. A review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual v1.18.11 dated October 2023 revealed: -if the medical record reflects the presence of a Stage 2 pressure injury, it should be coded on the MDS as a Stage 2 pressure ulcer. -code 1, yes if the resident had any pressure ulcer/injury -pressure ulcer/injury should continue to be classified at the higher numerical stage until healed. In an interview on 07/31/24 at 4:05 PM the Administrator confirmed that Resident 33's Stage 2 pressure ulcer was not coded on the MDS dated [DATE] and should have been. 51122 B. A review of Resident 16's Admission Record revealed an admitted to the facility of 1/18/2022. Record review of Resident 16's Annual MDS dated [DATE] Section O, hospice was marked No. An interview on 7/31/2024 at 10:39 AM with the Hospice RN revealed the resident was admitted to their services on 7/19/2022. Review of Resident 16's physician orders revealed an order dated 7/19/2022 to admit resident to Hospice services. An interview on 7/31/2024 at 9:19 AM with the Director of Nursing (DON) confirmed the resident is on hospice. The DON stated the discrepancy was due to changes in MDS staffing during that time.

Licensure Reference Number 175 NAC 12-006.09(H)(v) Based on record review, interview and observation the facility failed to provide restorative therapy and an assistance device for contractures (abnormal shortening of muscle tissue making it highly resistant to stretching and eventually causing permanent disability) for 1 (Resident 58) of 3 sampled residents. The facility census was 62. Findings are: Record review of Resident 58's Admission Record revealed resident admitted to the facility on [DATE] with a diagnosis of Muscle Wasting and Atrophy, not elsewhere classified, unspecified site, Generalized Muscle Weakness, Hemiplegia (paralysis of one side of the body) and Hemiparesis (one-sided muscle weakness) following other nontraumatic intracranial hemorrhage (bleeding on the brain causing a stroke) affecting unspecified side. Record review of Resident 58's care plan with admitted [DATE] printed on 07/29/2024 revealed the following: -The resident had deficits in Activities of Daily Living related to Hemiplegia and Hemiparesis and needed one staff assistance for bathing, bed mobility, dressing, eating, mobility, and transfers. -Resident wears right hand splint, assisted by staff to apply daily and off at hour of sleep for contracted hand. An observation and interview with Resident 58 on 07/30/2024 at 2:32 PM revealed that they are unable to open contracted fingers on right hand, unable to move right wrist, and can extend elbow approximately 30 degrees. Resident 58 denied ever having any brace for right hand. An interview with COTA (Certified Occupational Therapy Assistant) on 07/31/2024 at 2:25 PM confirmed Resident 58 was not receiving any restorative therapy and that the therapy department was not aware of Resident 58's contractures. An interview with DON on 08/01/2024 at 9:01 AM confirmed that Resident 58 had limited range of motion to the right arm and had a contracture to the right hand and that an orthotic device was not provided to help reduce contractures. An interview with DON on 08/01/2024 at 10:42 AM confirmed that the facility does not have a restorative program for Resident 58. A record review of facility policy Restorative Nursing- Contracture Prevention and Management Program Original dated 5/14/2014 revealed: -Assisting a resident/patient to attain and/or maintain joint mobility promotes independence, prevents or reduces contractures, preserves range of motion for use of prostheses, stimulated circulation and enhances muscle strengthening. A resident/patient requiring passive range of motion, active range of motion and/or splint/brace application and removal are considered for this restorative program. Restorative programs including range of motion and splint/brace application are provided by trained nursing assistants or licensed nurses. -Procedures #4. Review any recommendations from therapy on providing range of motion or splint/brace application. #5. Complete the nursing evaluation, Range of Motion Data Collection. #6. Develop the Restorative Program Plan and Summary with recommendations from the interdisciplinary team and the resident/patient and family responsible party.

Licensure Reference Number 175 NAC 12-006.09(l) Based on observations, interviews, and record review, the facility failed to evaluate a Broda chair (a specialty wheelchair that can be used for positioning and can be placed in a reclining position with the foot rest up) for safety prior to use for 1( Resident 16) of 1 sampled resident. The facility staff identified a census of 62. Findings are: Record review of Resident 16's admission record revealed the resident was admitted to this facility on 1/18/22. Record review of Resident 16's physician orders dated 07/19/22 revealed the resident was placed on Hospice on 7/19/22 with a diagnosis of senile degeneration. Record review of Resident 16's annual Minimum Data Set (MDS) (a federally mandated assessment used to identify a resident's functional capabilities and health needs) with an Assessment Reference Date (ARD) of 7/9/2024, revealed under Section C, Resident 16's Cognitive Skills for Daily Decision Making are Moderately impaired. Section GG revealed the following: use of a wheelchair, transfers including bed to chair and toilet scored at a 2 which indicates substantial assistance. Section P under Restraints and Devices revealed no devices were marked for restraints or alarms. The quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 4/8/24, also revealed Resident 16's Cognitive Skills for Daily Decision Making are Moderately impaired. Record review of Resident 16's care plan with a last target date of 7/8/2024 revealed under the Focus problem: Resident has potential for falls related to ( r/t) confusion, gait/balance problems, incontinence, unaware of safety needs as evidenced by history of falls with injuries. Gets out of bed at different times and is unsteady when first getting out of bed. Interventions are: -Anticipate and meet the resident's needs. Keep needed items, water, etc., in reach. Date initiated 01/26/2022. - Broda chair per Hospice due to unstable core daily. Date Initiated: 10/25/2023. An observation on 7/29/24 at 10:30 AM revealed Resident 16 was trying to climb out of a reclined Broda chair and calling out for help. Further observation on 7/29/2024 at 10:30 AM revealed facility staff at a desk did not intervene. A continuous observation from 07/29/24 at 2:09 PM until 2:44 PM revealed Resident 16 sitting in a Broda chair in the west dining room with several other residents gathered for a group activity at the table. The resident sat back several feet from the table, attempting to sit up but both legs were elevated due the wheelchair being reclined. Further observation on 7/29/2024 revealed the following: -At 2:11 PM the resident called out the daughter's name, also asking for someone to move the stuff out of the way so the resident could get up. The resident continued trying to sit up more in the chair, talking to the back of the person sitting in front of the resident. -At 2:15 PM the resident had both legs over the left side of the reclined Broda chair, still attempting to get someone's attention by talking. -At 2:18 PM the resident had both feet extenders of the wheelchair folded up, still talking loudly with no staff responding. -At 2:44 PM the resident yells, I can't go anywhere, and was still trying to get up out of the Broda chair. Resident then yelled, Does anyone want to help me? without staff responding. An observation on 07/29/24 at 3:50 PM revealed Resident 16 sitting in the Broda chair in an upright position and was pushed up to a table in the west dining room, the brakes were engaged on the Broda chair. Resident 16 was talking to them self and calling out. There were no staff in dining area to monitor Resident 16. An observation on 7/31/24 11:00 AM of Nurse Aide/Medication Aide F (NA/MA F) and Nurse Aide E (NA E) revealed Resident 16 was transferred from bed to the Broda chair to the toilet and then place back into the Broda chair. An interview on 7/31/2024 at 11:10 AM with NA E revealed Resident 16 had previously used a regular wheelchair but Resident 16 kept falling because (gender) frequently stood up from wheelchair. A continuous observation on 07/31/2024 from 1:34 PM until 1:54 PM revealed Resident 16 sitting in a reclined Broda chair in the [NAME] dining room calling out, Somebody help me. Further observation on 7/31/2024 at 1:34 PM revealed Resident 16's leg was extended up in the air, talking to self and was holding on to a foot. An observation on 7/31/24 at 3:02 PM revealed Resident 16 was in the [NAME] dining room trying to sit up in the reclined Broda chair. Staff sitting beside the resident did not set Resident 16 up in the Broda chair up to visit. An interview on 7/31/24 at 9:14 AM with the Registered Nurse with Hospice (Hospice RN) revealed that Resident 16 was admitted to their services on 7/19/22. Hospice RN reported when Resident 16 is in the Broda chair the recommendations are supervision, redirection and if needed antianxiety medications. Hospice RN also stated, If the resident had a regular wheelchair, (the resident) would try to get up. An interview with Licensed Practical Nurse (LPN) C on 7/31/24 at 12:20 PM revealed when asked about Resident 16's previous level of functioning, LPN C stated the resident used to walk with a walker. When the facility tried a wheelchair, the resident was falling out of it, so the facility had to go to the Broda chair right away. An interview on 07/31/24 at 1:46 PM was conducted with Resident 16's Family Member (FM). During the interview Resident 16's FM reported seeing Resident 16 flip around in the Broda chair with the residents head at the foot pedals and feet at the head area. An interview on 7/31/24 at 12:32 PM with the Director of Nursing (DON) revealed the following the Broda chair is being used to prevent falls and because Resident 16 has a weak core. The DON confirmed the facility had not evaluated Resident 16 for the use of the Broda chair. During the interview with the DON on 7/31/24 at 12:35 PM the Corporate Registered Nurse verbalized that maybe there should be an assessment by occupational therapy for the Broda chair.

Licensure Reference Number 175 NAC 12-0006.09(H) Based on interviews and record reviews the facility failed to ensure non-pharmacological interventions were provided prior to administering the PRN (as needed) Xanax (a medication used to treat anxiety) for one (Resident 53) of 5 sampled residents. The facility identified a census of 62. Findings Are: A record review of the Admission Record ran on 7/30/24 revealed Resident 53 had been accepted into the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of Sepsis (an infection trigger inflammation throughout the body) and Pulmonary Embolism with Acute Cor Pulmonale (a blood clot gets stuck in an artery in the lung). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) dated 7/5/24, Section C, revealed Resident 53 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function, while scores of 00 or 99 indicate total confusion) score of 15. A record review of current orders list ran on 07/30/24 at 02:20 PM revealed Resident 53 had the following orders; Alprazolam 0.5mg (milligrams) give 1 tab by mouth (po) twice (BID) daily as needed for anxiety or sleep (Related Diagnoses: Anxiety Disorder, Unspecified) Alprazolam 0.5mg 1 tab po three (TID) times daily as needed for sleep (Indications for Use: Anxiety/Insomnia) (Additional Directions: DNE (do not exceed): 3 tablets in 24 hour period) A record review of the running Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 53 revealed the following goal and interventions related to anxiety; -Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/13/2024. -Monitor/record/report to MD prn mood patterns s/sx (signs/symptoms) of depression, anxiety, sad mood as per facility behavior monitoring protocols. Date Initiated: 06/13/2024. A record review of the MAR (Medication Administration Record) dated July 2024 revealed Resident 53 had been given the PRN Xanax 54 times between 7/1/24 and 7/30/24 with no non-pharmacological interventions documented. A record review of the Progress Notes dated 7/1/24 through 7/30/24 revealed no documentation of non-pharmacological interventions surrounding the PRN Xanax administration. An interview on 8/1/24 at 9:10 AM with the facility Administrator, after review of the MAR dated July 2024 for Resident 53, confirmed that the facility expectation was to attempt non-pharmacological interventions prior to administering the PRN Xanax and that no indications of non-pharmacological interventions existed for Resident 53 and should have. A record review of the facility policy titled Behavior Management, dated 5/2014, revealed the following guidance related to non-pharmacological interventions; -Non-pharmacological interventions are the first choice in management of behavioral symptoms, when possible.

Licensure reference number 175 NAC 12-006.09D6 Based on record review and interview, the facility failed to provide comfort cares to include oxygen for one resident (Resident 4). The facility sample size was 4. The facility identified a census of 41. Findings are: A record review of the Progress Notes dated 09/18/20 through 10/5/20 revealed that Resident 4 had received a Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus) test with a negative result on 9/19/20. The record review revealed that Resident 4 had been tested for Covid-19 again on 9/23/20 with positive results. The record review of the Progress Notes revealed an order for [REDACTED]. A record review of the assessments titled Covid-19 Observation dated 9/24/20 through 10/4/20 revealed Resident 4 had voiced being short of breath on 9/24/20, 9/26/20, 9/28/20, 9/29/20, 10/1/20, 10/2/20, 10/3/20 and 10/4/20. The record review of the assessments also noted intermittent symptoms to include a non-productive cough, labored respirations, abnormal lung sounds and cyanotic (a bluish or purplish discoloration due to deficient oxygenation of the blood) nail beds. A record review of the vital signs documented from 9/6/20 through 10/5/20 revealed Resident 4 had SaO2 (Oxygen saturation which is a measurement of the percentage of how much oxygenation is in the blood, The normal level is 95-100% on room air. Older adults typically have lower oxygen saturation levels than younger adults. For example, someone older than [AGE] years of age may have an oxygen saturation level of about 90-95%, which is an acceptable level) levels below 90% daily with the lowest documented level being 80% on 10/4/20. A record review of the active orders list for Resident 4 as of 10/5/20 revealed Resident 4 had not been given any supplemental oxygen to aide in maintaining comfort. An interview on 10/7/20 at 01:10 PM with LPN-A revealed hospitalization had been discussed with Resident 4 and the guardian and declined. The interview confirmed no oxygen order had been obtained for Resident 4 during the illness or time of comfort cares.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (9) Based on observation, interview, and record review; the facility failed to protect the residents from neglect by failing to ensure staff had the supplies needed to care for residents. This had the potential to affect all of the facility residents. The facility identified a census of 52 at the time of survey. Findings are: Interview with MA-O (Medication Aide) on 9/08/19 at 6:18 PM revealed the facility did not have any disposable wipes so they were using paper towels to provide perineal care to the residents as they had been directed. Observation of the facility nursing supply store room on 9/09/19 at 2:38 PM with NA-U (Nurse Aide) and NA-V revealed there were no disposable wipes. NA-U and NA-V both reported this was the storeroom they were directed to retrieve nursing supplies. NA-V revealed they had asked one of the facility staff about the wipes and they were told they had backordered. Interview with NA-U on 9/9/2019 at 2:38 PM revealed the facility never had enough disposable wipes as they frequently ran out of them. NA-U revealed they were told to use wash cloths to provide perineal care but NA-U was uncomfortable doing this as there were no wash cloths designated specifically for perineal cleansing use and NA-U felt they should not be using the same wash cloths for perineal care that the staff used to wash the residents' faces, etc. Interview with HS (Housekeeping Supervisor) on 9/11/19 at 2:27 PM revealed they were responsible for ordering nursing supplies. HS revealed there was one case of disposable wipes located in the facility. Someone had put them in the wrong storeroom. HS did not confirm or deny the facility ran out of supplies or if the storeroom was being checked regularly to ensure there were ample supplies. Review of the facility policy Central Supply issued (MONTH) 20, 2019 revealed the following: The purpose of the central supply system is to: Maintain Inventory Control. B. Observation of the facility on 9/12/19 at 12:26 PM revealed none of the residents had any hand towels or washcloths. Interview with MA-D on 9/12/19 at 12:31 PM revealed the nursing staff were supposed to pass linen at least once a shift. MA-D revealed they did not know why the residents did not have towels and washcloths. MA-D revealed they knew the facility had been low on them and they have been trying to get some more ordered. C. Interview with Resident 1 on 09/09/19 at 1:53 PM revealed it had been hot in the facility most of the summer. Interview with the MS on 9/11/2019 at 2:27 PM confirmed the AC (Air Conditioner) had not been working during the first part of the summer. It took 3 years to get fixed. The MS revealed 4 AC units had been down at one time. D. Interview on 9/09/19 at 10:07 AM with Resident 42 revealed the resident had not had a bath in the past year at times for weeks at a time. Right now the thing that really concerned the resident was during the whirlpool baths the staff were not turning on the whirlpool jets because they could not clean the jets properly because the facility was out of the proper disinfectant they needed to clean the jets in the tub. Interview on 9/10/19 at an unspecified time with Anonymous revealed the facility had been out of Penner whirlpool disinfectant for about 1 month and the staff had not been able to clean the whirlpool jets. Anonymous revealed the staff had been told in the past to never use any disinfectant in the whirlpool jets except for the Penner disinfectant or it would ruin the jets. When the facility ran out of the Penner disinfectant about 1 month ago, the facility instructed the staff to use a disinfectant from Housekeeping that was supposed to still be able to kill the germs but was not a Penner product. The staff had been cleaning the tub but not the jets so as not to ruin the jets, yet the staff were still providing baths to the residents in the whirlpools but not turning the jets on. Anonymous confirmed when giving the baths the water line was above the jet holes in the tub. Anonymous confirmed residents with catheters and wounds had been receiving baths during the time frame of the jets not being cleansed. Observation on 9/10/19 at 8:43 PM revealed NA-N performed a bath in the whirlpool on Resident 8. When done with the bath, observed NA-N cleanse the whirlpool tub and used A456II disinfectant. NA-N took the whirlpool chair seat apart and cleaned it while inside the tub and scrubbed the tub chair and the tub thoroughly. NA-N did not spray disinfectant into the jets. When done scrubbing, NA-N sprayed everything again then let it sit wet for 10 minutes. Interview with NA-N revealed the whirlpool tubs were cleansed between each resident use and there was one more bath to be given that night. NA-N confirmed the facility had been out of the Penner disinfectant that was supposed to be used to clean the whirlpool and jets and it had been approximately 1-2 weeks that they had been out. Instead the staff had been using the disinfectant A- and NA-N confirmed the staff did not put A- into the jets. NA-N revealed with the Penner disinfectant the staff sprayed it into the jets and let the jets run for 2 minutes, but now they do not disinfect the jets. They continue to bathe in the whirlpool but do not turn on the jets. Interview on 9/10/19 at 8:50 PM with the DON revealed the DON had been aware the facility had been out of the Penner disinfectant at one point but knew the facility had tried re-ordering more and thought the re-order had come in. The DON revealed the DON was never aware the staff were not cleaning the whirlpool jets. The DON revealed during the time when the DON knew the facility was out of the Penner disinfectant, the DON had checked the A disinfectant specs before using it to ensure it was approved to kill the same type of germs and could be used in regular tubs. The DON ceased any further whirlpools to be given in the facility until the facility could investigate, re-educate staff and ensure the whirlpools were cleansed appropriately before any more baths were given. The DON revealed showers would be given instead. Interview on 9/11/19 at 7:55 AM with RN-B revealed the Infection Control reports reviewed the facility had no infections in Sept or Aug of UTI's (urinary tract infection) or wound infections. RN-B provided a report which showed the only infections for the 2 months was an URI (upper respiratory infection). Review of the Product Specification Document for A- Disinfectant Cleaner revealed it was a one-step disinfectant cleaner, fungicide, virucide, mildewstat, and deodorizer to be used and then let set 10 minutes It [MEDICAL CONDITION](human immunodeficiency virus), HBV([MEDICAL CONDITION] virus), and HCV ([MEDICAL CONDITION] virus) and was a hospital use disinfectant bactericidal and had an entire list of bacteria it killed. Review of a list provided by the DON on 09/11/19 at 1:59 PM revealed 47 residents had a tub bath in the whirlpool. The residents were Residents 7, 27, 21, 4, 9, 14, 25, 44, 39, 34, 37, 53, 49, 48, 16, 33, 5, 2, 3, 38, 10, 26, 15, 11, 36, 51, 1, 8, 41, 18, 46, 6, 40, 32, 47, 45, 30, 28, 31, 43, 17, 20, 13, 50, 24, 23, and 35. Review of the facility matrix and by observation of these residents revealed out of the list provided by the DON, the following residents had a urinary catheters: Resident 53. The following residents had open wounds and received a bath in the whirlpool: Resident 5 with a pressure ulcer on the right buttocks measured on 8-19-19 at 0.5 x 0.3 x 0.4 cm (centimeters) and Resident 16 with pressure area on the ear.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility staff failed to implement interventions to ensure resident nutritional status was maintained for Resident 35 and Resident 52. This affected 2 of 5 residents evaluated for nutrition. The facility identified a census of 52 at the time of survey. Findings are: Review of Resident 35's annual MDS dated [DATE] revealed an admission date of [DATE]. Resident 35 required set up and supervision with eating. Resident 35 had unplanned weight loss and was not on a prescribed weight loss regimen. Review of Resident 35's Nutrition Data Collection Tool dated 7/24/2019 revealed Resident 35 was to receive a Mighty Shake 4 oz. (ounces) once daily. Resident 35's meal intake was difficult to determine due to spilling of food. Resident 35's usual body weigh was 150# (pounds). Age-adjusted estimated IBW (Ideal Body Weight) was 159 / 142 to 176#. Resident 35's admission weight on 7/19/16 was 172#. Resident 35's weight in (MONTH) (YEAR) was 155#. Resident 35's weight was down. Summary: ANNUAL NUTRITIONAL REVIEW: Resident is on a Regular diet w/ Mechanical Soft texture, Regular liquids. Is not to eat chips, peanuts, popcorn, peanut butter, crackers r/t (related to [MEDICAL CONDITION]'s. Is served double protein at breakfast, is on Mighty Shake 4 oz. once daily. Weighs below age-adjusted estimated IBW range. Weight is down over the past year. Was started on Mighty Shake supplement 4 oz. once daily 6/3/19. Will now request to increase supplement to BID. No known skin concerns at this time. Review of Resident 35's Progress Notes revealed the following: 8/7/2019 15:19 Weight Change Note Note Text: WEIGHT WARNING: Value: 136.0. Resident is on a Regular diet w/ Mechanical Soft texture, Regular liquids. Meal intakes are usually recorded as 100% however, resident feeds self - does not allow assistance - and spills/drops a portion of food on the floor. Continues to be on Mighty Shake supplement 4 oz. po (by mouth) once daily; will again fax provider to see if supplement can be increased to BID (twice a day). Resident has now maintained weight from 137.5# to 140# since 5/20/19 (excluding one questionable weight of 7/17/19 - 132#). Review of Resident 35's Care Plan dated 7/25/2016 revealed the following: resident has nutritional problem with a goal of resident will have no significant change thru next review date. House supplement 4 oz at HS (bedtime) with a date Initiated: 06/11/2019 Review of Resident 35's MAR (Medication Administration Record) for (MONTH) and (MONTH) 2019 revealed no documentation of how much supplement Resident 35 was taking. Review of Resident 35's weights revealed the following: On 07/24/2019, the resident weighed 139 lbs. On 08/24/2019, the resident weighed 131 pounds which is a -5.76 % Loss. On 05/28/2019, the resident weighed 138 lbs. On 08/24/2019, the resident weighed 131 pounds which is a -5.07 % Loss. On 02/24/2019, the resident weighed 148 lbs. On 08/24/2019, the resident weighed 131 pounds which is a -11.49 % Loss. Interview with the RD (Registered Dietitian) on 9/11/19 at 4:08 PM revealed the nursing staff should be documenting how much of the supplement Resident 35 was taking; they could not be sure how much of the supplement Resident 35 was taking without the documentation. Interview with Resident 35's responsible party on 9/09/19 at 5:20 PM revealed Resident 35 had lost some weight so they had restarted the power shakes. B. Review of Resident 52's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 52 had a BIMS score of 8 which indicated cognitive impairment. Resident 52 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable device. Resident 52 had unhealed pressure ulcers present; 1 stage 3 pressure ulcer (Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). 2 un-stageable pressure ulcers presenting as DTI (Deep Tissue Injury). 0 of these were present upon admission/entry or reentry indicating they were facility acquired. Interventions included nutrition or hydration intervention to manage skin problems. Review of Resident 52's weights revealed the following: On 05/31/2019, the resident weighed 253 lbs. On 09/04/2019, the resident weighed 201 pounds which is a -20.55 % Loss. Review of Resident 52's Care Plan dated 6/21/2019 revealed a goal to avoid weight loss and interventions for the presence of pressure ulcers. Resident 52 required set up assistance for eating. Observation of Resident 52 on 9/10/19 at 10:20 AM revealed Resident 52 was asleep in bed. Resident 52's HOB (Head of Bed) was elevated about 20 degrees and they were slid down in bed. There was a breakfast tray with food and drinks that was covered on an OTB (Over the Bed) table over their bed but Resident 52 was slid down and could not reach the food. The tray was also not set up as nothing was uncovered on the tray including the food and drinks Observation of Resident 52's room on 9/10/19 at 12:06 PM a tray of food on the OTB (Over the Bed table) by their bed. Resident 52 was resting in the bed. Interview with LPN-S (Licensed Practical Nurse) on 9/10/2019 at 12:06 PM the tray of food sitting by Resident 52 was not their lunch tray, it was their breakfast tray. Observation of Resident 52 on 9/10/19 at 12:48 PM revealed they were in bed. No lunch tray had been provided. Observation of Resident 52 on 9/10/19 at 1:00 PM revealed they were in bed. There was a tray of food on the OTB table that is over the bed. The food is covered and the plastic wrap was on the drinks. Resident 52 was flat in bed and not able to reach the food. Observation of Resident 52 on 9/10/19 at 6:45 PM revealed they did not eat any of their supper. It was sitting on the OTB table out of reach. Review of Resident 52's Progress Notes revealed the following: 9/11/2019 18:53 Weight Change Note Text: WEIGHT WARNING: Value: 201.0 Resident is on an RCS (Reduced Concentrated Sweets) diet w/ Regular texture, Regular liquids. Meal intakes vary from 0 - 100%. Stays in own room for some meals, comes out to dining room for some meals. Is on House supplement 4 oz. BID (Twice a Day); will re-request order to increase supplement to TID (Three Times a Day). 7/31/2019: Weight Change Note Text: WEIGHT WARNING: Value: 212.0. Resident is on an RCS diet w/ Regular texture, Regular liquids. Comes out to the dining for meals occasionally, otherwise stays in own room for meals. Meal intakes vary from 0 - 100%. Staff encourage resident to eat. Is on House supplement 4 oz. po BID for wound healing - will notify provider of significant weight loss and request an order to increase supplement to TID. Observation of Resident 52 on 9/10/19 at 2:02 PM revealed the left ring finger was black. Resident 52's bottom was unopened; there was evidence it had been excoriated as there were blotches of unblanchable (pink areas that do not change back to normal color once pressure is relieved-a risk factor for pressure ulcers) areas. Interview with LPN-S (Licensed Practical Nurse) on 9/10/2019 at 2:02 PM revealed Resident 52 had a hard splint on their left hand which caused some DTI to their fingers. Resident 52 still had a DTI on the ring finger. Interview with the RD (Registered Dietitian) on 9/11/19 at 4:29 PM revealed Resident 52 flagged for a weight change so the RD would be looking at Resident 52's nutritional status today. The RD revealed that even though weight loss would be ideal for Resident 52 due to being overweight, it would only be ideal if Resident 52 was eating well. The RD revealed Resident 52's intakes were erratic and varied between 0-100 percent. Interview with the DON (Director of Nursing) on 9/12/19 at 3:45 PM revealed the expectation was that the facility nursing staff make sure residents are set up and ready to eat and their tray is accessible.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on interview and record reviews, the facility failed to implement a QA (Quality Assurance) and QAPI (Quality Assurance and Performance Improvement) plan to prevent repeat deficiencies in the areas of and failed to have a QA program in place to ensure the provision of resident care to avoid substandard quality of care. This had the potential to affect all of the facility residents. The facility identified a census of 52 at the time of survey. Findings are: Results from the facilities last survey certification date of 8/2/2018 revealed the following deficiencies which the facility was found to have current deficient practice from the present survey: F578 formulate advance directive-repeat; F582 Medicaid/Medicare Coverage/liability notice-repeat F625 notice of bed hold policy/before/upon transfer-repeat; F656 develop/implement comprehensive care plan-repeat; F657 Care plan timing and revision-repeat; F806 resident allergies [REDACTED].>F812 Food procurement, store/prepare/serve sanitary-repeat F880 infection prevention & control-repeat; Interview with RN-B (Registered Nurse) on 9/12/19 on 5:25 PM revealed the facility QA Committee did not have current action plans in place to ensure the deficient practice was corrected and maintained to avoid further deficient practice. Citations from the current survey which resulted in SQC (Substandard Quality of Care): F584 Safe/Clean, Comfortable/Homelike Environment; F600 Free from Abuse and Neglect; F606 Not employ/engage staff with adverse actions; F607 Develop/implement abuse/neglect policy Review of the facility policy Risk Management/Quality Assurance Process Improvement Program dated 09/14 revealed the following: The Risk Management/Quality Assurance Process Improvement (QAPI) Program is directed by the Administrator. The program is focused on minimizing risk and improving resident/patient care by implementing a process for root cause analysis and the utilization of Quality Improvement teams. The following quality indicators will be reviewed/addressed: Grievance report, incident/accident trends, infection control report, outstanding regulatory citations, pharmacy reports. Identify additional facility specific quality issues that will be routinely addressed. Indicators may include but are not limit to: department process/systems/action plan, medication issues, organizational functions, quality control activities, resident/patient care, resident/patient/family satisfaction, risk management concerns, staff performance.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on observation, record review and interview the facility failed to protect residents from abuse. This affected 1 of 3 sampled residents (Resident 1). The facility census at the time of the survey was 52. Findings are: On 8/29/19 at 2:05 PM an Interview with ADM stated this is a nightmare upon my arrival. One of my nurses called the police and I informed her she should have waited until I investigated things before they were called. ADM stated ADM was very upset and disappointed in staff because ADM kept asking staff what happened and everyone would tell ADM, We don't know. No one would say anything and just walked away. One of the nurses called the police and ADM wished the nurse would have waited until ADM could investigate things further. ADM did talk to NA-D (Nurse Aide) and asked NA-D if NA-D had lost NA-Ds' temper and hit the resident to which NA-D said no. I never suspected abuse had occurred. ADM was in the process of calling support staff when the Police and Adult Protective Services walked in. When asked when that was ADM stated around 9:00 AM. ADM did ask the resident's roommate, (Resident 2) when ADM came in what had happened and if anyone had hit Resident 1 to which Resident 2 replied no but Resident 2 does have a BIMS (Brief Interview of Mental Status, a brief screening tool that aides in detecting cognitive impairment), score of 06. Resident 1 was not able to be interviewed. Resident 1 was very confused and does get upset easily. Resident 1 cries also when staff are providing care for Resident 1. ADM stated ADM didn't think of abuse at all. On 8/29/19 at 2:30 PM Observation of Resident 1 was with (gender) sitting in the recliner in Resident 1's room. Resident 1 was alert and confused. Resident 1 had a red bruises on the tops of both hands and a large red bruise on the left side of Resident 1's face. Was unable to measure the bruises on the tops of the hands as they were wide spread. The bruise on the side of the face was approximately 8.5 cm x 2.8 cm. at the widest part. Staff reported that Resident 1 received the bruise around 7:00 AM. On 8/29/19 at 2:20 PM an interview with [NAME] County Sheriff Officer revealed the Officer and Adult Protective Services had arrived around 9 A.M. and interviewed NA-D involved in the abuse allegation and other staff. The Office stated that after interviewing everyone charges of assault would be filed against NA-D. On 8/29/18 at 2:30 PM an interview with MDS-C (Minimum Data Set, a federally mandated comprehensive assessment tool used in care planning, Coordinator) revealed that when MDS-C arrived, at the facility, MDS-C was informed of what had happened with NA-D being in the room with Resident 1 and that Resident 1 came from the room crying and had a bruise to the left side of Resident 1's face. MDS-C also stated NA-D was in the facility taking care of residents and pushing residents to the dining room for lunch. NA-D was spoken to by the Office and then NA-D walked out with NA-D's belongings. Review of the admitted under the census tab revealed 7/16/13 as the admitted for Resident 1. On 8/29/19 at 2:40 PM Attempt to interview Resident 1 revealed that (gender) was unable to be interviewed. Resident 1 was alert but confused and was unable to answer test questions of what Resident 1 had eaten for lunch and what Resident 1's name was. Review of Progress Notes revealed a progress note dated 8/29/19 stated resident sitting in recliner chair in commons TV area, resident was crying and cowering. Noted 3 cm x 2 cm dark purple bruise as well as 2 cm x 1 cm dark purple bruise with reddened area present around bruising from upper eyelid to temple area. Neurological checks performed, area measure and will continue to monitor per facility protocol. On 8/29/19 at 3:15 PM an interview with LPN-A (Licensed Practical Nurse) revealed that the LPN-A was at the end of the 300-400 hallway by the nurse's station and saw Resident 1 come from Resident 1's room crying and was acting as if Resident 1 wanted to get away from the staff that was taking care of Resident 1. This was not normal behavior for Resident 1. LPN-A then asked RN-B (Registered Nurse) working to check on the Resident 1. The NA-D said to the LPN-A Resident 1 did it to Resident 1's self. When asked how long NA-D continued to provide care to the residents it was revealed that NA-D provided care until residents were in the dining room for lunch. NA-D quit working when the Officer and Adult Protective Services Arrived. Review of Weekly Skin Assessments for Resident 1 dated 8/26/19, 8/20/19, 8/11/19, 8/5/19, 7/25/19, 7/21/19, and 7/14/19 revealed no bruising on the hands and face. Review of the undated Care Plan for Resident 1 revealed that Resident 1 has impaired skin integrity due to thinning of skin. There were guidelines for monitoring injuries to skin but no bruising was noted on the care plan. There were mood and behavior interventions on Resident 1's Care Plan but no documentation on the care plan to alert staff to resident leaving room and crying as a normal behavior. On 8/29/19 3:35 PM an interview with RN-B (Registered Nurse) revealed that RN-B was at the end of the 300 hallway and could not see what was happening but was asked by the LPN-A to check on the Resident 1 because something was wrong with Resident 1. RN-B found Resident 1 crying with tears running down Resident 1's cheeks and cowering in the chair in the Television area. RN-B did vital signs and check the bruise that RN-B noted on the left side of the Resident 1's face by Resident 1's temple area. The bruise was about the size of a nickel with a bigger patch of redness noted. RN-B stated that RN-B was the Charge Nurse for the day. RN-B and the LPN-A called the ADM together at around 7:09 AM to inform the ADM of what had happened. RN-B and LPN-A were not given any instructions as to what to do except that the ADM would investigate when ADM arrived. NA-D who had been working with Resident 1 continued to take care of other residents. According to RN-B there were no instructions to relieve NA-D of any duties providing care to the residents. Review of the MAR (Medication Administration Record) revealed that Resident 1 had been on [MEDICATION(S)] (a steroid) since 5/1/19 with no bruising of the face and arms listed as a side effect. Review of the Risk Management Abuse Prevention Program & Reporting Policy revealed under page 5 Identification: #2 Injuries of unknown source-classified as injuries of unknown source when both the following conditions are met: -The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and -The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time. Protection: NOTE: In the case of a direct caregiver being suspected of allegedly abusing, neglecting, or mistreating a resident/patient, the Administrator (in their absence the Director of Nursing, Assistant Director of Nursing, Charge Nurse, in that order) must immediately relieve the individual of their duties without pay (suspend) until the investigation is complete. Reporting: Report the incident immediately to the Administrator, and Director of Nursing Notify the appropriate State Agency(s) immediately by fax or telephone after identification of alleged/suspected incident. Initiate process according to State -specified regulations. The Facility Administrator is responsible to initiate contact with local law enforcement, immediately, when warranted, as required by State law. Consult with management consulting company as needed for additional support. Special reporting requirements for suspected criminal conduct: Report MUST be made within 2 hours: if the suspected criminal activity resulted in significant/serious bodily injury, it must be reported immediately, but no later than 2 hours after the suspicion of criminal activity is formed. On 8/29/19 at 5:30 PM an interview with the DON (Director of Nursing) revealed DON had not been informed of anything out of the ordinary when she arrived to the facility. DON then saw the Officer was in the facility and Adult Protective Services and asked the staff what was happening. DON stated DON arrived to work around 9:00 AM due to having a sick child at home. DON confirmed DON had seen the Resident 1 at 7:30 PM sitting in the Television are the night before 8/28/19 when DON left for home. Resident 1 had no bruising on Resident 1's face but DON did observe bruising on the Resident 1's arms. DON had not observed what had happened but stated NA-D was still providing cares for other residents and brought some of them to the dining room for lunch. Review of the Assignment sheet revealed NA-D had been back to work for 2 days after an absence. NA-D was a float aide on 8/27/19 working with other staff. NA-D was assigned on the 300/400 hallways as a caregiver working independently (alone). Review of 2 other residents' records and doing observations identified no concerns with these residents. On 8/29/19 at 5:49 PM Interview with ADM revealed upon ADM's arrival an investigation was started and ADM spoke with NA-D the staff directly caring for the Resident 1. No abuse was suspected on ADM's behalf and none of the staff expressed concerns. ADM revealed the NA-D had been absent from work for approximately 3 weeks and conversation between them at that time revealed NA-D stating, NA-D was have things NA-D needed to work out: Upon NA-D's return the ADM stated ADM had seen no changes in NA-D's behavior and no indications of being upset or any concerns. NA-D was joking and pleasant with staff and resident's Plan of Action It had always been the practice when staff are witnessed becoming short with coworkers or easily upset to bring staff in for a visit with ADM and find out what is causing them problems When asked what had been done in the past with NA-D because NA-D had other reports of problems with residents it was revealed that NA-D worked with another staff person and was working well with them and then something happened and they were not getting along. NA-D had left for those 3 weeks and before NA-D would come back NA-D asked if a particular staff person was working and NA-D was informed no the staff was no longer there. NA-D was gone for personal reasons and was having marital issues. NA-D had been back for 2 days since NA-D's absence. NA-D had replied ok if that staff is not there then NA-D will come back to work. When ADM was asked how long NA-D was in the facility after the incident that morning was reported, ADM replied, NA-D was here until about noon when NA-D was questioned by the Officer and then NA-D just got NA-D's things and walked out. When asked if ADM suspended NA-D? ADM replied, No. Plan was to increase staff awareness on abuse protocol and go through more education on the abuse protocol. Inform staff that it will not be tolerated by anyone. Also if staff come to ADM with a problems between staff it will be handled but can't be discussed with staff what the consequences or corrections actions were. The ADM stated that if staff would have told ADM what happened or if staff suspected that NA-D had done something ADM would have suspended NA-D immediately. Based on the following, the facility has removed the immediacy of the situation: 1) The staff person involved in the allegation was no longer in the facility 2) Education will be implemented to staff letting them know Abuse will not be tolerated 3) Reporting of suspected violations will be changed to occur and report immediately. The immediacy has been removed, however, the deficient practice has not been totally corrected. Therefore, the scope and severity has been lowered to G.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 (8) Based on observations, record reviews and interviews the facility failed to immediately report potential abuse for residents. This affected 1 of 3 sampled residents (Resident 1). The facility census at the time of the survey was 52. Findings Are: On 8/29/19 at 2:05 PM an interview with Administrator (ADM) stated this is a nightmare upon my arrival. One of my nurses called the police and I informed her that she should have waited until I investigated things before they were called. ADM stated ADM was very upset and disappointed in staff because ADM kept asking staff what happened and everyone would tell ADM, We don't know. No one would say anything and just walked away. One of the nurses called the police and ADM wished the nurse would have waited until ADM could investigate things further. ADM did talk to NA-D (Nurse Aide) and asked NA-D if NA-D had lost NA-Ds' temper and hit the resident to which NA-D said no. I never suspected abuse had occurred. ADM was in the process of calling support staff when the Police and Adult Protective Services walked in. When asked when that was ADM stated around 9:00 AM. ADM did ask the resident's roommate, (Resident 2) when ADM came in what had happened and if anyone had hit Resident 1 to which Resident 2 replied no but Resident 2 does have a BIMS (Brief Interview of Mental Status, a brief screening tool that aides in detecting cognitive impairment), score of 06. Resident 1 was not able to be interviewed. Resident 1 was very confused and does get upset easily. Resident 1 cries also when staff are providing care for Resident 1. ADM stated ADM didn't think of abuse at all. On 8/29/19 at 2:30 PM observation of Resident 1 was with (gender) sitting in the recliner in Resident 1's room. Resident 1 was alert and confused. Resident 1 had a red bruises on the tops of both hands and a large red bruise on the left side of Resident 1's face. Was unable to measure the bruises on the tops of the hands as they were wide spread. The bruise on the side of the face was approximately 8.5 cm x 2.8 cm. at the widest part. Staff reported that Resident 1 received the bruise around 7:00 AM. On 8/29/19 at 2:20 PM an interview with [NAME] County Sheriff Officer revealed the Officer and Adult Protective Services had arrived around 9 A.M. and interviewed NA-D involved in the abuse allegation and other staff. The Officer stated that after interviewing everyone charges of assault would be filed against NA-D. On 8/29/18 at 2:30 PM an interview with MDS-C (Minimum Data Set, a federally mandated comprehensive assessment tool used in care planning, Coordinator) revealed that when MDS-C arrived, at the facility, MDS-C was informed of what had happened with NA-D being in the room with Resident 1 and that Resident 1 came from the room crying and had a bruise to the left side of Resident 1's face. MDS-C also stated NA-D was in the facility taking care of residents and pushing residents to the dining room for lunch. NA-D was spoken to by the Office and then NA-D walked out with NA-D's belongings. Review of the admitted under the census tab revealed 7/16/13 as the admitted for Resident 1. On 8/29/19 at 2:40 PM Attempt to interview Resident 1 revealed (gender) was unable to be interviewed. Resident 1 was alert but confused and was unable to answer test questions of what Resident 1 had eaten for lunch and what Resident 1's name was. Review of Progress Notes revealed a progress note dated 8/29/19 stated resident sitting in recliner chair in commons TV area, resident was crying and cowering. Noted 3 cm x 2 cm dark purple bruise as well as 2 cm x 1 cm dark purple bruise with reddened area present around bruising from upper eyelid to temple area. Neurological checks performed, area measure and will continue to monitor per facility protocol. On 8/29/19 at 3:15 PM an interview with LPN-A (Licensed Practical Nurse) revealed the LPN-A was at the end of the 300-400 hallway by the nurse's station and saw Resident 1 come from Resident 1's room crying and was acting as if Resident 1 wanted to get away from the staff that was taking care of Resident 1. This was not normal behavior for Resident 1. LPN-A then asked RN-B (Registered Nurse) working to check on the Resident 1. The NA-D said to the LPN-A Resident 1 did it to Resident 1's self. When asked how long NA-D continued to provide care to the residents it was revealed that NA-D provided care until residents were in the dining room for lunch. NA-D quit working when the Office and Adult Protective Services Arrived. Review of Weekly Skin Assessments for Resident 1 dated 8/26/19, 8/20/19, 8/11/19, 8/5/19, 7/25/19, 7/21/19, and 7/14/19 revealed no bruising on the hands and face. Review of the undated Care Plan for Resident 1 revealed that Resident 1 has impaired skin integrity due to thinning of skin. There were guidelines for monitoring injuries to skin but no bruising was noted on the care plan. There were mood and behavior interventions on Resident 1's Care Plan but no documentation on the care plan to alert staff to resident leaving room and crying as a normal behavior. On 8/29/19 3:35 PM an interview with RN-B (Registered Nurse) revealed RN-B was at the end of the 300 hallway and could not see what was happening but was asked by the LPN-A to check on the Resident 1 because something was wrong with Resident 1. RN-B found Resident 1 crying with tears running down Resident 1's cheeks and cowering in the chair in the Television area. RN-B did vital signs and check the bruise that RN-B noted on the left side of the Resident 1's face by Resident 1's temple area. The bruise was about the size of a nickel with a bigger patch of redness noted. RN-B stated that RN-B was the Charge Nurse for the day. RN-B and the LPN-A called the ADM together at around 7:09 AM to inform the ADM of what had happened. RN-B and LPN-A were not given any instructions as to what to do except that the ADM would investigate when ADM arrived. NA-D who had been working with Resident 1 continued to take care of other residents. According to RN-B there were no instructions to relieve NA-D of any duties providing care to the residents. Review of the MAR (Medication Administration Record) revealed that Resident 1 had been on [MEDICATION(S)] (a steroid) since 5/1/19 with no bruising of the face and arms listed as a side effect. Review of the Risk Management Abuse Prevention Program & Reporting Policy revealed under page 5 Identification: #2 Injuries of unknown source-classified as injuries of unknown source when both the following conditions are met: -The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and -The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time. Protection: NOTE: In the case of a direct caregiver being suspected of allegedly abusing, neglecting, or mistreating a resident/patient, the Administrator (in their absence the Director of Nursing, Assistant Director of Nursing, Charge Nurse, in that order) must immediately relieve the individual of their duties without pay (suspend) until the investigation is complete. Reporting: Report the incident immediately to the Administrator, and Director of Nursing Notify the appropriate State Agency(s) immediately by fax or telephone after identification of alleged/suspected incident. Initiate process according to State -specified regulations. The Facility Administrator is responsible to initiate contact with local law enforcement, immediately, when warranted, as required by State law. Consult with management consulting company as needed for additional support. Special reporting requirements for suspected criminal conduct: Report MUST be made within 2 hours: if the suspected criminal activity resulted in significant/serious bodily injury, it must be reported immediately, but no later than 2 hours after the suspicion of criminal activity is formed. On 8/29/19 at 5:30 PM an interview with the DON (Director of Nursing) revealed DON had not been informed of anything out of the ordinary when she arrived to the facility. DON then saw the Officer was in the facility and Adult Protective Services and asked the staff what was happening. DON stated DON arrived to work around 9:00 AM due to having a sick child at home. DON confirmed DON had seen the Resident 1 at 7:30 PM sitting in the Television are the night before 8/28/19 when DON left for home. Resident 1 had no bruising on Resident 1's face but DON did observe bruising on the Resident 1's arms. DON had not observed what had happened but stated that NA-D was still providing cares for other residents and brought some of them to the dining room for lunch. Review of the Assignment sheet revealed NA-D had been back to work for 2 days after an absence. NA-D was a float aide on 8/27/19 working with other staff. NA-D was assigned on the 300/400 hallways as a caregiver working independently (alone). Review of 2 other residents' records and doing observations identified no concerns with these residents. 5:49 PM Interview with ADM revealed upon ADM's arrival an investigation was started and ADM spoke with NA-D the staff directly caring for the Resident 1. No abuse was suspected on ADM's behalf and none of the staff expressed concerns. ADM revealed the NA-D had been absent from work for approximately 3 weeks and conversation between them at that time revealed NA-D stating, NA-D was have things NA-D needed to work out: Upon NA-D's return the ADM stated ADM had seen no changes in NA-D's behavior and no indications of being upset or any concerns. NA-D was joking and pleasant with staff and resident's Plan of Action It had always been the practice when staff are witnessed becoming short with coworkers or easily upset to bring staff in for a visit with ADM and find out what is causing them problems When asked what had been done in the past with NA-D because NA-D had other reports of problems with residents it was revealed NA-D worked with another staff person and was working well with them and then something happened and they were not getting along. NA-D had left for those 3 weeks and before NA-D would come back NA-D asked if a particular staff person was working and NA-D was informed no the staff was no longer there. NA-D was gone for personal reasons and was having marital issues. NA-D had been back for 2 days since NA-D's absence. NA-D had replied ok if that staff is not there then NA-D will come back to work. When ADM was asked how long NA-D was in the facility after the incident that morning was reported, ADM replied, NA-D was here until about noon when NA-D was questioned by the Officer and then NA-D just got NA-D's things and walked out. When asked if ADM suspended NA-D? ADM replied, No. Plan was to increase staff awareness on abuse protocol and go through more education on the abuse protocol. Inform staff that it will not be tolerated by anyone. Also if staff come to ADM with a problems between staff it will be handled but can't be discussed with staff what the consequences or corrections actions were. The ADM stated that if staff could have told ADM what happened or if staff suspected that NA-D had done something ADM would have suspended ADM immediately. Based on the following, the facility has removed the immediacy of the situation: 1) The staff person involved in the allegation was no longer in the facility 2) Education will be implemented to staff letting them know Abuse will not be tolerated 3) Reporting of suspected violations will be changed to occur and report immediately. The immediacy has been removed, however, the deficient practice has not been totally corrected. Therefore, the scope and severity has been lowered to G.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility staff failed to transport Resident 1 in a manner to prevent an accident with serious injury. This affected 1 of 4 sampled residents. The facility identified a census of 51 at the time of survey. Findings are: Review of Resident 1's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/5/ revealed an admitted [DATE]. Resident 1 had a BIMS (Brief Interview for Mental Status) score of 13 which indicated Resident 1 was cognitively intact. Resident 1 required extensive assistance of one staff person for locomotion on the unit and was dependent upon staff for locomotion off the unit. A wheelchair was used for a mobility device. Review of Resident 1's MDS Schedule revealed Resident 1 was discharged from the facility on 5/27/2019. Review of Resident 1's Progress Notes dated 5/27/2019 revealed Resident 1's wheelchair tipped over the curb outside and Resident 1 had active red drainage from the head. Resident 1 had a large laceration above the left eye with a copious amount of red drainage and wound was unable to be measured due to drainage. A pressure dressing was applied to the laceration above Resident 1's left eye and within minutes the pressure dressing was saturated and a second pressure dressing was applied. Resident 1 was transported to the hospital emergency room per EMS ambulance. Resident 1 also had the following injuries documented: 2 cm by 2 cm abrasion with red drainage present to right arm stump, 2 cm by 1 cm abrasion with raised purple bruise to the left wrist, 5 cm by 4 cm and 5 cm by 1 cm abrasions to the left forearm, 2 cm by 1 cm abrasion left first knuckle, 2 cm by 2 cm abrasion left palm. LPN-B (Licensed Practical Nurse) documented that further skin assessment was not completed to due the arrival of the ambulance. After Resident 1 was taken to the hospital Resident 1 was diagnosed with a brain bleed and went to surgery. Review of Resident 1's Progress Notes dated 5/28/2019 revealed Resident 1 was in the hospital with a brain bleed. Review of Resident 1's Progress Notes dated 5/29/2019 revealed Resident 1 was in the hospital displaying a gradual decline and was to have a repeat CT (Computed Tomography-a type of specialized x-ray) scan. Interview with the facility Administrator on 6/4/2019 at 1:53 PM revealed that on 5/27/2019, Van Driver-C had pushed Resident 1 out the back door of the facility and failed to secure the wheelchair brakes causing Resident 1 to roll off the curb onto the concrete between the concrete wheelchair ramp and the facility van that was parked by the ramp and the curb causing injury to Resident 1. Resident 1 landed on the concrete and their wheelchair landed on top of them. The Administrator revealed Van Driver-C was attempting to take 2 residents out to the facility van to be transported to appointments and the accident occurred as Van Driver-C let go of Resident 1 and did not lock their wheelchair brakes prior to Van Driver-C turning their attention away from Resident 1 to retrieve another resident. The Administrator further revealed Resident 1 could not control their own wheelchair due to a right arm amputation and that facility staff were to lock the wheelchair brakes on the wheelchair when residents could not control their own wheelchairs when facility staff did not have a hold of the wheelchair. Interview with the facility MS (Maintenance Supervisor) on 6/4/2019 at 1:56 PM revealed facility staff were not supposed to take 2 residents out of the facility at a time and the wheelchair brakes for a resident who was unable to manage their own wheelchair were to be locked if the facility staff did not have control of the wheelchair. Based on the following the facility had removed the immediacy of the situation: 1) Van Driver-C was immediately suspended then terminated. 2) Facility staff educated on making sure wheelchairs are locked when not being pushed by staff, residents to be assisted from the facility and secured in the van one at a time, and 2 staff to assist with securing residents in the van during bad weather. 3) Weather proof cover installed over key pad lock to protect from rain and other weather elements. With the above interventions initiated, the scope and severity of the deficiency was lowered to a G.

LICENSURE REFERENCE: 175 NAC 12-006.09D7, 12-006.09D7a Based on observation, record review and interview; the facility failed to: 1) assess a resident with history of falls for causal factors and implement care interventions to protect the resident from falls with injury for Resident 18; and evaluate the placement of a side rail to ensure the environment was free of potential accident hazards for Resident 9. The facility had a census of 45. Findings are: A. According to the 3/16/12 FACE SHEET Resident 18 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Blood gathers within the outermost meningeal layer, between the dura mater, which adheres to the skull, and the arachnoid mater, which envelops the brain) and Frequent Falls. Interview on 1/3/13 at 1:46 PM with the Minimum Data Set Coordinator Registered Nurse (MDS-RN) confirmed that Resident 18 had falls on the following dates in the previous 30 days - 12/28/12, 12/30/12 and two falls on 1/1/13. Review of the INTERDISCIPLINARY POST FALL REVIEW for Resident 18 revealed; Date of Fall- 12/28/12; Time- 9:15 PM Description of Fall- the resident was found on the floor beside the bathroom door. The resident reported getting up from the bed and falling to the floor then scooting to the bathroom to use the call light for assistance. There were no injuries noted. Summary of Interdisciplinary Team- The resident has a urinary tract infection. Facility will make sure the motion pad is working, instruct resident to call for help and instruct staff to provide assistance with getting ready for bed. Review of the FAX notification sent to the physician regarding the 12/28/12 fall confirmed that the physician ordered "observe fall precautions". Interview on 1/14/13 at 10:46 AM with the Director of Nursing (DON) confirmed that the staff were aware of the resident having an infection and medication that could affect the resident's mental status. The DON reported that the resident probably needed more supervision and assistance, but the facility failed to plan for it. The DON reported not investigating why the motion pad failed to alarm. The DON confirmed there were no new interventions added in response to the doctor order for observing fall precautions. Review of the INTERDISCIPLINARY POST FALL REVIEW for Resident 18 revealed; Date of Fall- 12/30/12; Time- 8:20 PM Description of Fall- the resident reported bending over to put on shoes and losing balance causing the resident to fall backwards and bump the back of the resident's head on the night stand. The resident received a 1 centimeter cut on the back of the head. Summary of Interdisciplinary Team- The resident continued to be treated for [REDACTED]. Review of the FAX notification sent to the physician regarding the 12/30/12 fall confirmed that the physician ordered "fall precautions". Interview on 1/14/13 at 10:46 AM with the DON confirmed that the staff were aware of the resident having dementia and that educating the resident on use of the call light would not be an effective intervention. The DON reported that the resident was supposed to be getting more assistance while getting ready for bed, but the facility failed to implement it. The DON confirmed there were no new interventions added in response to the second doctor order for fall precautions. Review of the INTERDISCIPLINARY POST FALL REVIEW for Resident 18 revealed; Date of Fall- 1/1/13; Time- 00:30 AM Description of Fall- the resident was found on the floor in the bathroom. The resident got up to use the bathroom unassisted and fell . The resident refuses to use the call light. Summary of Interdisciplinary Team- The resident continued to be treated for [REDACTED]. Resident did not call for assist, lost balance and fell in bathroom. The facility will put up signs in the room to remind to call for assist. Interview on 1/14/13 at 10:46 AM with the DON confirmed that the staff knew the resident had been sick with gastro-intestinal flu and recent urinary tract infection. The DON reported both illnesses affected the resident's strength and mental status but the facility failed to plan for/implement closer supervision during that time. Review of the INTERDISCIPLINARY POST FALL REVIEW for Resident 18 revealed; Date of Fall- 1/1/13; Time- 11:15 PM Description of Fall- the resident reported falling on the bedside mat in the resident's room. The resident scooted to the doorway to get help. The resident reported not hitting the head. Summary of Interdisciplinary Team- The resident continued to be treated for [REDACTED]. Resident fell to floor when trying to sit on bed. The facility will order Occupational Therapy (OT) and Physical Therapy (PT) for strengthening and safety. Interview on 1/14/13 at 10:46 AM with the DON confirmed that the staff knew Resident 18 had been sick with gastro-intestinal flu and recent urinary tract infection. The DON reported both illnesses affected the resident's strength and mental status but the facility failed to plan for/implement closer supervision until OT/PT could evaluate and make recommendations. Interview on 1/14/13 at 9:47 AM with the Physical Therapist (PT) regarding the evaluation revealed that the PT was going to evaluate Resident 18 on 1/14/13 (13days after the two falls on 1/1/13) but the resident had another fall and was having too much pain to be evaluated. Review of the OCCUPATIONAL THERAPY EVALUATION signed on 1/11/13 (10days after the two falls on 1/1/13) confirmed that Resident 18 was referred for evaluation for "frequent falls in the facility". Review of the INTERDISCIPLINARY POST FALL REVIEW for Resident 18 revealed; Date of Fall- 1/13/13; Time- 10:00 PM Description of Fall- the resident was found on the floor by the fall mat. The resident had "tripped over the mat" and fell on to the floor on the right hip. The resident was asked by staff why the resident didn't use the call light to get assistance. The resident reported back to staff, "I don't know. I've never been hurt when I fell before. I knew I would fall because my hip was already hurting. I just had that feeling." Summary of Interdisciplinary Team- (Left blank on the form.) Observation on 1/14/13 confirmed the resident was out of the facility starting at 10:30 AM. Interview on 1/14/13 at 10:46 AM with the DON confirmed that the resident was being taken to the doctor due to the increased pain Resident 18 was having after the 1/13/13 fall. Review of the results of the Computed Tomography Scan (CT) done on Resident 18 on 1/14/13 confirmed that Resident 18 had a fracture in the right superior pubic ramus. The fracture was new since the CT scan in July 2012. Review of a FACE SHEET dated 8/4/12 revealed Resident 09 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident 09's Care Plan revealed hand written documentation dated 12/7/12 to "encourage to use siderail during repositioning et (and) transfers". Observation on 1/7/13 at 2:26 PM revealed Resident 09's bed had quarter side rails that were positioned approximately 4 inches away from the mattress. During an interview on 1/14/13 at 12:21 PM, the Maintenance Supervisor (MS) revealed no knowledge if the facility had guidelines that included how close side rails should be placed to the mattress. MS stated the side rails should hold the mattress in place. In Resident 09's room, observation revealed one side rail present on the bed, opposite the wall. Without resistance, MS pushed the mattress against the wall, which left approximately a 6 inch gap between the mattress and the side rail, as well as exposed the bed frame underneath. MS commented "that could be a problem", if the resident's arm got positioned between the side rail and the mattress or the bed frame. Observation on 1/14/13 at 1:26 PM revealed Resident 09's mattress could easily be moved away from the side rail and MDS-RN (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning-Registered Nurse) confirmed the gap produced the potential for Resident 09 to get an arm caught between the mattress and the side rail. During an interview on 1/14/13 at 1: 26 PM, Resident 09 stated sometimes the mattress moved and wasn't sure whether or not the resident had caused it. A Safety Alert entitled "Entrapment Hazards with Hospital Bed Side Rails" issued by the Food and Drug Administration in 1995 revealed residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as confusion, pain, uncontrolled body movement, etc. that may cause them to move about the bed or try to exit from the bed. The Safety Alert stated entrapment may occur when a resident is caught between the mattress and side rail or in the side rail itself. Technical issues, such as the proper sizing of mattresses, fit and integrity of side rails or other design elements can also affect the risk of resident entrapment. Mattress compression widens the space between the mattress and rail.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.07 Based on observation, record review, and interviews conducted during the compliance survey; the facility's Quality Assessment and Assurance (QA&A) Committee failed to identify issues of deficient practice. The QA&A Committee also failed to develop and implement plans of action to correct multiple issues of deficient practice relevant to resident care and services. The facility failed to implement plans of action to maintain correction for previously cited area of deficient practice identified during surveys completed on 6/18/12, 4/19/12, 8/23/11, 5/9/11, 3/9/10, and 5/11/09. The facility census was 45. Findings are: A. Review of the facility's June 2012 policy "Quality Assurance & Performance Improvement (QAPI) Committee revealed: - Responsibilities - "The QAPI Committee oversees and identifies all efforts that improve quality in the faciity by monitoring performance measures, identifying OFIs (opportunities for improvement) and determining their root cause, directing performance improvement plans, and evaluating the effectiveness of quality management activities". "The duties of the QAPI Committee include, but are not limited to: --Routine monitoring of the following for all residents: Nursing care, including medication administration; Prevention of pressure ulcer, dehydration and [MEDICAL CONDITION]; Nutritional status and weight loss or gain; Accidents and injuries; Unexpected deaths; Changes in mental or psychological status; and Unplanned hospitalization s". -- "Overseeing the activities of the Infection Prevention Sub-Committee, (Infection Prevention Manual) and pharmacy services". -- "Reviewing Safety Team Committee data and coordinating improvement measures with the Safety Team Committee". -- "Reviewing the Medication Management Advisory Committee summary and recommendations and implementing improvement efforts as necessary". -- "Analyzing survey results and verifying correction of deficiencies". -- "Directing the investigation of alleged incidents of abuse or neglect in accordance with approved policies". -- "Preparing, implementing, and monitoring the progress of performance improvement plans that address identified opportunities for improvement". B. The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the survey were completed. The facility failed to maintain correction for the regulations identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the areas identified below. Please refer to the Tag citations for specific detailed findings: - F156 Failed to post information how to file a complaint with the state agency; how to apply for Medicare and Medicaid, and failed to post the agencies contact information. - F225 Failed to report to the state survey and certification agency and failed to investigate allegations of abuse and/or neglect. Previously cited on 5/9/11. - F241 Failed to respect and promote residents' dignity. Previously cited on 5/9/11. - F242 Failed to honor the residents' right to choose their bathing schedule. - F272 Failed complete comprehensive assessments of the residents' needs. - F279 Failed to develop comprehensive care plans that addressed residents' needs. Previously cited on 6/18/12. - F280 Failed to revise the comprehensive care plan to reflect the actual care provided to residents. Previously cited on 6/18/12 and 5/11/09. - F323 Failed to establish and implement interventions to prevent resident falls and accidents. Previously cited during 5 of 6 surveys on 6/18/12, 4/19/12, 8/23/11, 3/9/10, and 5/11/09. - F329 Failed to ensure residents were free from unnecessary medications. Previously cited on 6/18/12 and 5/9/11. - F332 Failed to ensure the medication administration error rate was 5% or less. Previously cited on 5/9/11. - F333 Failed to ensure residents were free of significant medication errors. - F371 Failed to ensure food was stored to prevent cross contamination. Previously cited on 6/18/12, 5/9/11, 3/9/10, and 5/11/09. - F428 Failed to ensure pharmacy reviews identfied the completion of laboratory tests ordered by residents' physicians. - F441 Failed to follow the infection control program related to hand hygiene and the tracking and trending of infections. Previously cited on 6/18/12, 5/9/11, and 5/11/09. During an interview on 1/14/13 at 1:57 PM, the Administrator revealed the incident that had occurred between Residents 36 and 49 had been reviewed, but no one had identified that it should have been reported as an allegation of abuse. The Administrator revealed the QA&A committee had not looked at documentation in residents' medical records, on a routine basis for accuracy. The Administrator stated resident choices had been discussed when brought to the committee's attention through concerns and the "Ambassador" form, but don't remember ever discussing resident bathing choices. The Administrator revealed during "Ambassador" (staff assigned to residents as an advocate) visits, Ambassadors should ask residents if staff knock on doors before entering. The Administrator stated the issue had not been brought to the attention of the QA&A committee, but the Administrator didn't know if residents were being asked. The Administrator revealed the QA&A committee hadn't reviewed any copies of the pharmacist's observations of medication administration. The Administrator revealed the Director of Nursing and the Director of Nursing and the former Assistant Director of Nursing observed medication administration possibly 2-3 times a month, but the QA&A committee had not reviewed the medication administration audits. The Administrator revealed side rail safety was reviewed quarterly, by the Interdisciplinary Team committee or the MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) coordinator, but would not be reviewed by the QA&A committee unless a skin issue had been caused by a side rail. The Administrator stated resident care plans were not reviewed by the QA&A committee to ensure they reflected the needs of residents.