Every finding on record at Accura Healthcare of Neligh

Licensure Reference Number 175 NAC 12-006.19 Based on observation, interview, and record review, the facility failed to ensure an air conditioning system to maintain comfortable temperatures below 81 degrees F [Fahrenheit] in common areas of the facility. This has the potential to affect all 30 residents of the facility. Findings are:A review of facility temperature log revealed the following temperatures in the dining room:-7/27/26 at 2:25 PM the temperature was 86 F-7/28/26 at 3:00 PM the temperature was 81 F In an interview on 7/29/26 at 10:05 AM, Infection Control Licensed Practical Nurse (LPN)-A reported that the facility had no air conditioning in the hallways and that portable air conditioning units were used in the hallways every summer. Observations on 7/29/26 between 10:06 AM-10:24 AM revealed portable air conditioners units vented into the ceiling in the following areas:-Portable air conditioning unit located in the doorway of empty room C7 with cool air blowing into the C hallway-Portable air conditioning unit located in the alcove near room D16 with cool air blowing into the D hallway-Portable air conditioning unit in alcove near room [ROOM NUMBER] with cool air blowing into hallway-Portable air conditioning unit in [NAME] dining room with cool blowing into the dining room area-Portable air conditioning unit in doorway to empty room B49 with cool air blowing in to B hallway-Two portable air conditioning units located next to main entrance door to the facility with cool air blowing into the entrance lobby-Portable air conditioning unit in main dining room blowing into the dining room area. In an interview on 7/29/26 at 10:26 AM, Nurse Aide B reported that there were window air conditioning units in each resident room and the built-in heating/air conditioning units were used for heat only. In an interview on 7/29/26 at 10:40 AM, the Administrator reported that the air conditioning chiller went out last year. At that time, window air conditioning units were installed in resident rooms. Observations on 7/29/26 between 11:08 AM-11:31 AM revealed the following temperatures in common areas of the building as measured with facility thermometer:-West dining room [ROOM NUMBER]-80 F measured in different areas of the room-Front hallway near the main entrance to the facility 82 F-Main dining room facing East 82 F and [NAME] 82 F -Kitchen 86 F with 2 portable air conditioning units and a window air conditioning unit In an interview on 7/29/26 at 11:30 AM, the Administrator reported that the facility was looking at fixing the ceiling air conditioning unit that covered the kitchen. The Administrator reported that the window air conditioning unit in the kitchen had been adjusted, and an outside exhaust fan had been added to cool the kitchen. A review of outside temperatures on 7/29/26 at 11:37 AM utilizing Accu Weather revealed an air temperature of 87 F and a feels-like temperature of 107 F. In an interview on 7/29/26 at 2:00 PM, Regional Maintenance Director C reported that the roof unit air conditioning unit that cooled the kitchen and helped cool the dining room had gone out last week. The Regional Maintenance Director reported the air conditioning chiller went out last year and they had been trying to get quotes for mini splits air conditioning units for the common areas and hallways. Observations on 7/29/26 between 2:45-3:37 PM revealed the following temperatures in common areas of the building as measured with facility thermometer:-West dining room [ROOM NUMBER] F-Front lobby by main entrance 84.7 F-Main dining room facing North 84-Main dining room facility East 87 F In an interview on 7/29/26 between 2:45-3:37 PM, Resident 4 reported leaving the bingo activity in the main dining room as it was too hot and humid, making it hard to breathe. In interviews on 7/29/26 at 10:40 AM, between 2:45-3:37 PM, and 4:30 PM, the Administrator reported having an electrician coming out next week to have 2,220 volt outlets installed in the main dining room in order to be able to plug in larger portable air conditioning units. The Administrator acknowledged that the kitchen ceiling air unit had helped cool the dining room. In the meantime, residents could eat in their rooms, the menu would be changed to colder items, and activities would be split between the 2 dining rooms. The Administrator reported that there was a discussion of installing mini spilt air conditioning units to cover the building but was not aware of any bids being received or approved for completion of the work. The Administrator was not aware of what the delay was for getting the air conditioning fixed in the common areas of the building.

Licensure Reference Number 175 NAC 12-006.04(D) Based on record review and interview; the facility failed to ensure 8 hours of consecutive Registered Nurse (RN) coverage in a 24-hour period 7 days per week as required. This had the potential to affect all facility residents. The facility census was 30.Findings are: A. Review of the Facility Assessment with a revised date of 1/13/26 revealed the following:- The facility assessment would be used to ensure that there were sufficient number of staff with the appropriate competencies and skill sets needed to care for the residents' needs.-The facility would have one RN on day shift and one RN on evening shift. B. Review of the Nursing Staff Schedule for October 2025 revealed no documentation of 8 hours of RN coverage on 10/4, 10/5, 10/25, and 10/26. C. Review of the Nursing Staff Schedule for November 2025 revealed no documentation of 8 hours of RN coverage on 11/15 and 11/16. D. Review of the Nursing Staff Schedule for December 2025 revealed no documentation of 8 hours of RN coverage on 12/6, 12/7 and 12/27. E. Interview on 5/5/26 at 2:55 PM with the Administrator confirmed the facility did not have 8 hours of consecutive RN coverage on 10/4, 10/5, 10/25, 10/26, 11/15, 11/16, 12/7 and 12/27.

Licensure Reference Number 175 NAC 12-006.19(A)Based on observation, record review and interview; the facility failed to ensure the building was clean and in good repair. The facility census was 30.Findings are: A. Review of the facility deep clean checklist, undated, revealed that cleaning vents and light fixtures was one of the tasks on the checklist to deep clean a room. B. Observation of resident rooms on 5/4/26 at 9:00 AM revealed resident rooms B42, C12, C14, D17, D22, D26, D27 and ACU 6 vents in the bathroom had a heavy layer of gray fuzzy layer covering the vent. C. Record review of the April 2026 Calendar, Resident Rooms Deep Cleaned, revealed that room B42 was deep cleaned on 4/10/26, room C12 was deep cleaned on 4/2/26 , room C14 was deep cleaned on 4/11/26, room D17 was deep cleaned on 4/14/26, room D22 was deep cleaned on 4/21/26, room D26 was deep cleaned on 4/13/26, room D27 was deep cleaned on 4/8/26 and room ACU 6 was deep cleaned on 4/13/26. D. An interview with the Housekeeping Aide-L confirmed that cleaning the bathroom vents was not part of the deep cleaning of the room. Further interview confirmed that the bathroom vents were wiped off but not routinely cleaned. E. Review of the Facility Assessment (document used to determine needed resources necessary to care for facility residents during day to day operations and emergencies) including the physical environment, equipment, services, and other physical plan considerations necessary to care for the resident population, dated 5/15/24 revealed the facility department managers or designees, followed procedures for maintaining inventory, and assessing the condition of equipment. Preventative maintenance and cleaning schedules were in place per manufacturer recommendations. F. During the course of the survey from 5/4/26 through 5/6/26 multiple environmental concerns identified were identified including the following: -very soiled and stained baseboards that were pulling away from the drywall in areas in halls B and D.-Dry wall gouges in hall D next to rooms [ROOM NUMBERS]. -All room entry door frames had heavily chipping paint as did the bathroom door frames in halls B and D. -The floor next to an exit door in the ACU hallway was heavily soiled and a trap door/crawl space door on the floor at the same entry had sunken in, making the floor unlevel and the area was covered by a rug. -Hallway's B and D had chipping paint on the lower half of the walls throughout both halls. -Drywall corners were deteriorated and peeling away next to both nurses' stations. G. On 5/7/26 at 10:04 AM during a tour and interview with the facility Administrator the following environment concerns were observed and confirmed. Chipping/peeling paint on the lower half of the hallway walls in halls B and D, chipping and peeling paint on the entry doors and bathroom doors of the resident rooms in halls B and D, gouged and deteriorated dry wall in the hallways in both halls B and D, and on the corners of both nurses' stations. There were areas of heavily soiled flooring and a dipping crawl space door in the ACU hallway near the exit door creating a tripping hazard in need of repair. The facilities lack of repair was not creating a homelike environment.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview; the facility failed to report allegations of potential abuse of Residents 32 and 29 to the State Agency as required. The sample size was 2 and the facility census was 30. Findings are: A. Review of the facility policy Vulnerable Adult dated 12/30/2025 revealed the following:-The facility had zero tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of property. The facility reported maltreatment of vulnerable adults to protect adults who were dependent upon others for their care. -Abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.-Abuse included deprivation by an individual or caretaker of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. -Instances of abuse, included verbal, sexual, physical, and mental abuse.-All incidents deemed reportable under Nebraska statute are submitted to Adult Protective Services via the 24-hour toll-free hotline. -If the Administrator or Director of Nursing determined the internal report does not meet the criteria for reporting under either State or Federal guidelines, that decision would be noted in writing. B. Review of Resident 32's Care Plan with a revision date of 1/30/26 revealed the resident had a history of a stroke, bladder incontinence related to immobility, wore an incontinence product to protect the skin and maintain dignity, and had self-care performance deficits including dependence on staff for transfers and toileting hygiene. Review of Resident 32's Grievance Form dated 1/23-1/24/26 revealed that on Friday night (1/23) the resident requested to go to the bathroom and staff told the resident that they could not do that, so the resident messed self and the spouse of Resident 32 reported the resident felt humiliated. In addition, on Saturday (1/24) the resident sat on the toilet for 15-20 minutes waiting for assistance. Further review revealed the facility confirmed that staff members (un-named) made those comments and were given verbal warnings. There was no evidence the allegations of potential neglect and/or psychosocial well-being concerns were reported to the State Agency or Adult Protective Services. C. During an interview on 5/6/26 at 3:00 PM the facility Administrator confirmed Resident 32's spouse had filed grievances that included staff treatment of the resident including failure to toilet in a timely manner resulting in humiliation and leaving the resident to the toilet for extended periods, staff had been given verbal warnings regarding the grievance, yet the allegations of mistreatment or neglect were not reported to the State Agency. D. Review of Resident 29's MDS (Minimum Data Set (MDS-federally required comprehensive assessment used in the development of resident Care Plans) dated 2/19/26 revealed the resident was admitted to the facility on [DATE], was cognitively intact, and had dementia, anxiety and depression diagnoses. No evidence of mood or behavioral issues were noted. Review of facility grievances revealed that on 5/12/25 a grievance form was completed that Medication Aide (MA)-P yelled at Resident 29 for taking off the alarm, the resident was wanting to change sheets and go to supper. The resident stated MA-P has got a temper. On 5/13/25 the Administrator completed education with MA-P over the phone regarding resident rights and the need for MA-P to be mindful of how loud MA-P's voice can be and the tone MA-P was using when talking with residents. Review of facility grievance dated 5/20/25 revealed that Resident 29 was upset about how the night went. Resident 29 stated that the night shift staff, MA-P, were rude. Resident 29 used the light to use the restroom; staff didn't answer the call light so Resident 29 transferred self. MA-P was in the restroom cleaning up bowel movement from another resident. MA-P stated to Resident 29 do you fucking mind, you can see I am busy, do you think you're the only resident I have to help. Resident 29 stated MA-P was nasty the remaining of the night. On 5/20/25 the Administrator completed education with MA-P regarding resident rights and to pay attention to tone of voice and how things are being said. MA-P was removed from working with Resident 29. There was no evidence that the allegations of potential abuse concerns were reported to the State Agency or Adult Protective Services. During an interview on 5/6/26 at 10:45 AM the facility Administrator confirmed that Resident 29 had verbalized concerns about staff member MA-P with grievance reports filed on 5/13/25 and 5/20/25. MA-P had received education on resident rights, speaking loudly and use of tone of voice on 5/13/25 and 5/20/25. The potential allegation of verbal abuse were not reported to the State Agency.

Licensure Reference Number 175 NAC 12-006.18(A)Based on record review and interview; the facility failed to offer Resident 29 the recommended Pneumococcal vaccines in accordance with facility policy and Center for Disease Control (CDC) guidelines. The sample size was 5 and the facility census was 30.Findings are:Review of the facility policy Pneumococcal Vaccinations with a revision date of 11/13/24 revealed that all residents would be provided the opportunity and encouraged to receive pneumococcal vaccinations. On admission each resident would be questioned regarding history of receiving the pneumococcal vaccinations. Each resident would be educated and offered the pneumococcal vaccine if they have never had the vaccine. The Director of Nursing would be responsible for following up with the Physician's office when questions arise as to whether the resident has had vaccine in the past. Review of Resident 29's MDS (Minimum Data Set (MDS- federally required comprehensive assessment used in the development of resident Care Plans) dated 2/19/26 revealed the resident was admitted to the facility on [DATE], was cognitively intact, and had a dementia, anxiety and depression diagnoses. The Pneumococcal vaccine was offered and declined.Review of Resident 29's Immunization Consent Forms revealed that there was no Pneumococcal Informed Consent Form refusal or acceptance signed by the resident.Review of Resident 29's Medical Record, Immunization Report, revealed no documentation of the Pneumococcal Vaccine being administered or refused. During an interview on 5/7/26 at 11:20 AM the Director of Nursing confirmed the facility did not have evidence of consent from the resident or family to administer or decline the pneumococcal vaccination. Further interview confirmed that the facility was unable to determine if the resident was up to date on pneumococcal vaccination.

Licensure Reference Number 175 NAC 12-006.18(A)Based on record review and interview; the facility failed to offer Resident 10 the recommended Covid-19 vaccines in accordance with facility policy and Center for Disease Control (CDC) guidelines. The sample size was 5 and the facility census was 30.Findings are:Review of the facility policy COVID-19 Vaccination with a revision date of 11/13/24 revealed all residents would be provided with the opportunity and encouraged to receive the Covid-19 vaccination. On admission each resident would be questioned regarding the history of receiving the Covid-19 vaccination. Each resident would be educated and offered the Covid-19 vaccine if they had never received the vaccine. During the admission Assessment, each resident/family would be questioned regarding if the resident had a current Covid-19 vaccine injection. When it was determined that the resident would like to be up to date on the Covid-19 vaccine, the primary physician would be contacted and an order received if not contraindicated. Review of Resident 10's MDS (Minimum Data Set (MDS- federally required comprehensive assessment used in the development of resident Care Plans) dated 3/13/26 revealed the resident was admitted to the facility on [DATE], was cognitively impaired and had a diagnosis of anxiety. The Covid 19 vaccination was not up to date.Review of Resident 10's Personal Immunization History revealed the Covid-19 vaccination was recommended now.Review of Resident 10's Vaccination Consent for Influenza, Pneumovax, Shingles, RSV and Covid revealed the facility did not receive a declination or acceptance for the Cov-19 vaccination signed by the residents family on 12/10/25.Review of Resident 10's Medical Record, Immunization Report, revealed no documentation of the Covid-19 Vaccine being administered or refused.During an interview on 5/7/26 at 11:20 AM the Director of Nursing confirmed the facility did not have evidence of consent from the resident or family to administer or decline the Covid-19 vaccination. Further interview confirmed that the resident was not up to date on Covid-19 vaccination.

Licensure Reference Number 175 NAC 12-006.05(S)Based on record review and interview; the facility failed to ensure Resident 32 received dignified care when staff did not respond in a timely manner to a request for assistance with toileting. The sample size was 22 and the facility census was 30.Findings are: A. Review of the facility policy Vulnerable Adult dated 12/30/2025 revealed the following:-The facility had zero tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of property. The facility reported maltreatment of vulnerable adults to protect adults who were dependent upon others for their care. -Abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.-Abuse included deprivation by an individual or caretaker of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. -Instances of abuse, included verbal, sexual, physical, and mental abuse.B. Review of Resident 32's Care Plan with a revision date of 1/30/26 revealed the resident had a history of a stroke, bladder incontinence related to immobility, wore an incontinence product to protect the skin and maintain dignity, and had self-care performance deficits including dependence on staff for transfers and toileting hygiene. Review of Resident 32's Grievance Form dated 1/23-1/24/26 revealed that on Friday night (1/23) the resident requested to go to the bathroom and staff (un-named) told the resident that they could not do that, so the resident messed self and the spouse of Resident 32 reported the resident felt humiliated. In addition, on Saturday (1/24) the resident sat on the toilet for 15-20 minutes waiting for assistance. Further review revealed the facility confirmed that staff members (un-named) made those comments and were given verbal warnings. During an interview on 5/6/26 at 3:00 PM the facility Administrator confirmed that a resident reporting feeling humiliated was a dignity concern, and staff were to treat residents with dignity at all times. Staff education including Residents Rights, was completed at the time of hire and annually. Further interview confirmed that Resident 32's concern that involved lack of staff response to a request for assistance with toileting resulting in unnecessary incontinence was a dignity concern.

Licensure Reference Number 175 NAC 12-006.19 Based on observations, record review and interview; the facility failed to ensure mechanical lifts were maintained in a manner to promote resident safety. This has the potential to affect all residents who utilized mechanical lifts. In addition, the facility failed to ensure the wall, curtain, light cover and bathroom door frame were maintained in good repair in room C11, maintain the cleanliness of the bathroom ceiling ventilation covers, maintain the door frames to the resident's room and bathrooms to be free of chipped paint to 29 rooms ( C5 to C14, D15 to D27, B30 to B530) and maintain the cleanliness and condition of bathroom floors in room C11 and D25. The sample size was 19 and the facility census was 33. Findings are: A. Review of the Facility Assessment Tool with a revision date of 1/27/25 revealed the facility conducted an annual review of their resident population and the resources the facility needed to care for their residents. The purpose of the assessment was to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The facility ensured equipment was maintained to protect and promote the health and safety of residents including lifts (lifting devices). Equipment and/or devices were inspected annually or replaced/repaired if they presented a hazard. The maintenance and nursing staff ensured adequate supplies or equipment for resident care. Maintenance staff were to perform inspections of the property and building. B. Review of the facility policy Safe Resident Handling/Transfers dated 12/5/23 revealed the following: -It was the policy of the facility to ensure that residents were handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. -All residents required safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. -Mechanical lifting equipment or other approved transferring aides were used based on resident need. -Staff inspected equipment prior to use to ensure functionality and alerted maintenance or designee if the equipment was not functioning properly. -Damaged, broken, or improperly functioning lift equipment was not used and tagged out according to facility policy. C. Review of the facility policy Preventative Maintenance Program dated September 2024 revealed the following: -The Maintenance Director was to develop and maintain a schedule of services to ensure that the building and equipment were maintained in a safe and operable manner. -The Maintenance Director was to assess all areas of the building to determine if maintenance was required. -If maintenance was required, the Maintenance Director should decide what tasks need to be completed and how often to complete them. -Tasks completed would be documented on a calendar. -Documentation should be completed for all tasks and kept in the Maintenance Director's office for at least 3 years. D. During an interview on 3/18/25 at 10:15 AM with responsible party of Resident 15, a concern was brought up in regard to the wall in room C11 being gouged, scraped and missing paint and the curtain liner hanging lower the curtain. Observation of resident rooms during the initial pool on 3/18/25 from 10:30 AM to 2:30 PM revealed the following: -Resident room C11 had a 21 centimeter (cm) by 16 cm area with paint peeled away with scrapes and gouges in the drywall. The curtain in the room had the inner lining hanging lower than the curtain and there was a large hole in the light cover over the resident bed. -Ventilation covers were coated with a collection of a dark fuzzy substance which resembled dust in bathrooms of rooms C5 to C14, D15 to D27, and B38 to B53. -Door frames to the resident rooms and bathrooms had chipped and peeling paint to the bottom 1/3 of the doors, rooms C5 to C14, D15 to D27 and B38 to B53. -The bathroom in room D25 had cracked flooring around the toilet and the tile was stained a dark brown color. -The bathroom in room C9/C11 had stained tile, black in color, surrounding the toilet, the threshold going into the bathroom from room C9 and C11 was missing chunks of tile. The lower 1/3rd of the door frame to room C11 was the color of a brown substance with a rust like appearance, the base of the door frame was missing a piece of the door frame with a sharp splintered edge measuring 8cm by 2.5 cm. During an interview on 3/20/25 at 1:30 PM the Housekeeping Supervisor confirmed that the ventilation covers in the resident bathrooms are not being cleaned. During an interview on 3/20/25 at 2:30 PM the facility Maintenance Director and the interim Director of Nursing (DON) confirmed that they were unaware of the condition to the wall, curtain and bathroom in room C11 and the bathroom in room D25. The Maintenance Director and the interim DON confirm that the wall, light cover, curtain and bathroom in room C9/C11 need to be fixed, the bathroom floor in room D23 needs to be fixed and the door frames to the rooms and bathroom need to be painted. E. During an observation of the provision of care for Resident 3 on 3/20/25 at 11:24 AM Nurse Aides (NA)'s J and N entered the resident room to assist the resident to the commode. Both NA's put on gowns and gloves, placed a lifting sling under the resident and proceeded to transfer the resident to the commode using a full body mechanical lift. During the lifting process the mechanical lift stopped abruptly, and the NA's had to utilize the emergency switch to lower the lift. The NAs were unable to get the lift to function even after retrieving a fresh battery. During an interview on 3/20/25 at 11:51 AM NA -N confirmed having routinely struggled with the mechanical lifts used in the facility. NA-N further reported staff have to routinely stop in the middle of a task and replace a battery, and sometimes that doesn't even work. During an interview on 3/20/25 11:55 AM Resident 3 confirmed staff daily have to try multiple things just to get the facility lifts to work as intended when they are completing cares. During an interview on 3/20/25 at 12:00 PM the interim DON confirmed nursing staff had reported problems with the facility mechanical lifts working consistently, and/or the batteries working consistently, however was not aware of a long-term solution to ensure the facility lifts were being maintained to ensure care delivery was safe and consistent. During an interview on 3/25/25 at 9:50 PM the facility Maintenance Director confirmed being aware of the facility mechanical lifts were not consistently functioning despite the facility replacing the removable lift batteries, however the lifts also have attached power boxes that the batteries hook to and a request to replace those had not been approved.

Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interviews; the facility failed to follow the consultant pharmacist's recommendations to address irregularities in the medication regimen for Resident 16. The sample size was 6 and the facility census was 33. Findings are: A. Review of the facility policy Medication Regimen Review (MRR) dated September 2024 revealed the following: -The MRR was a thorough process of review and assessment conducted by a Consultant Pharmacist of the medications ordered for each resident, with a goal of promoting positive outcomes and minimizing adverse consequences associated with medications. -The MRR occurred monthly for each resident and recommendations were reported to the Administrator, Director of Nursing, attending physicians, and the Medical Director as it applied. -The Consultant Pharmacist utilized federally mandated standards of care, in addition to other applicable standards. -The Consultant Pharmacist provided reporting each month including documented concerns, irregularities, clinically significant risks, adverse consequences that resulted from of could be associated with medications. -The reports included nursing issues as well as communication to attending physicians. -Letters were provided to attending physicians regarding any significant potential or actual medication concerns. -Facility staff notified the attending physicians and obtained responses within a timely manner. B. Review of Resident 16's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of the resident care plan) dated 1/9/25 revealed the resident received an antidepressant medication. Review of Resident 16's Order Summary Report sheet dated 1-31-2025 revealed that resident had an order for Mirtazapine (Remeron) (antidepressant) 7.5 milligrams (mg) by mouth at bedtime for appetite also related to insomnia. Review of Consultant Pharmacist's MRR for Resident 16 revealed the following: 8/14/2024-Need a consent for the following medication: Remeron. 12/09/2024-Need a consent for the following medication: Remeron. 01/15/2025-Need a consent for the following medication: Remeron. 02/10/2025-Need a consent for the following medication: Remeron. Informed consent for Remeron was signed by responsible party on 3/18/25, 7 months after the pharmacist made their initial recommendation. An interview on 03/20/25 at 1:55 PM with the Director of Nursing, Registered Nurse (RN-L) and Social Services Director confirmed that the facility had not addressed the Consultant Pharmacist MRR request in a timely manner or in accordance with facility policy.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 (b) Based on observations, interviews, and record review; the facility failed to implement fall interventions, and to develop and/or revise fall interventions for the prevention of ongoing falls for Residents 5, 15 and 19. The sample size was 4 and the facility census was 33. Findings are: A. Review of the facility policies Fall Prevention Program and Fall Risk Assessment with revision dates of 9/24 revealed at the time of admission, a Fall Risk Assessment was to be completed to determine a resident's risk for falls. The Fall Risk Assessment was then to be completed quarterly, annually and with any significant change in condition. If the resident were determined to be at risk for falls, a care plan would be created to address each item identified on the risk assessment and updated accordingly. The at-risk care plan would include interventions, including adequate interventions consistent with the resident's needs and goals to reduce the risk of an accident. The staff were to monitor the effectiveness of the care plan interventions and modify the interventions, as necessary. B. Review of Resident 5's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/6/25 revealed the resident was admitted [DATE] with diagnoses of pneumonia, atrial fibrillation, heart failure, arthritis, non-Alzheimer's dementia, Parkinson's disease, anxiety, depression, bipolar disorder and morbid obesity. The following was assessed for the resident: -cognition was moderately impairment. -frequently incontinent of bladder. -dependent for personal hygiene, dressing, transfers, toileting hygiene and bed mobility. -functional limitation of range of motion to bilateral lower extremities. -use of chair alarm daily. Review of the Resident 5's current Care Plan dated 9/5/24 revealed the resident was at risk for falls related to poor balance and the need for assistance with transfers. Nursing interventions with development dates included the following: -9/5/24 allow the resident privacy but do not leave unattended and alone on the commode or in the bathroom. -9/6/24 resident to wear non-skid footwear when up and out of bed. -9/6/24 do not leave the resident unattended and alone while seated in the wheelchair in the resident's room. Assist to the recliner or into bed before leaving the room. -9/9/24 Tabs alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When the resident attempts to rise, the pull string magnet is pulled away from the alarm which causes the alarm to sound) to alert staff when the resident attempts to transfer without assistance. Staff to check placement and function each shift. -9/10/24 Dycem (non-slip material) pad to the seat of the resident's recliner. -10/4/24 each time staff walks by the resident's room to check and to monitor for safety in positioning in bed and chair. -10/14/24 the evening shift to toilet the resident before they leave at 10:00 PM. Review of an Incident Report dated 1/9/25 at 6:00 AM revealed the resident was found on the floor next to the resident's bed. The resident's bed was in the lowered position, but the resident's Tabs alarm was not in place. Review of a staff meeting held 1/9/25 revealed the nursing staff were educated on ensuring all resident's fall alarms were functional and in place before leaving the resident rooms. Review of an Incident Report dated 1/20/25 at 4:00 AM revealed the resident was observed on the floor next to the resident's bed. An intervention was identified to make sure the bed controls were not in reach for the resident as the resident was unable to utilize safely. Review of an Incident Report dated 1/22/25 at 2:22 PM revealed the resident was transferred to the bath chair by the bath-aide. The staff failed to secure the bath chair safety belt and started to undress the resident. The resident leaned forward and then fell out of the bathchair. Staff were educated to secure the seat belt on the bathchair before starting to work with the resident. Further review revealed no documentation as to the education provided or to the staff who received the education. No further interventions were developed and current interventions were not reviewed and/or revised. Review of an Incident Report dated 2/14/25 at 6:45 AM revealed the resident was found seated on the floor next to the resident's bed. The bed was in the lowered position and the resident identified sliding off the edge of the bed. Review of a Post Fall Evaluation dated 2/14/25 at 10:31 AM revealed the resident's Tabs alarm was not sounding when the resident was found on the floor. An intervention was developed for non-slip strips to be placed on the floor next to the resident's bed. Further review of the assessment revealed no evidence staff addressed the resident's fall alarm not functioning. Review of an Incident Report dated 2/23/25 at 2:25 AM revealed the resident's fall alarm was sounding and the resident was found on the floor in the resident's room next to the bed. At the time of the fall the resident was wearing gripper socks. An intervention was identified for a fall mat next to the resident's bed to prevent or to lessen injuries related to a fall. Observations of Resident 5 revealed the following: -3/18/25 at 11:20 AM the resident was seated in the wheelchair in the corridor outside of the dining room. The resident had a Tabs alarm box attached to the back of the chair, however, the pull string and garment clip was hanging down the back of the chair and was not attached to the resident and/or their clothing. -3/18/25 Nurse Aide (NA)-G approached the resident from behind and clipped the string of the fall alarm to the back of the resident's clothing. NA-G stated, I guess I forgot to attach your alarm. -3/18/25 from 1:45 PM to 2:15 PM the resident was seated in the wheelchair alone and unsupervised in the resident's room. -3/20/25 at 9:25 AM the resident's bathroom call light was activated. NA-G opened the bathroom door and revealed the resident was attached to the mechanical lift and was alone and unsupervised, seated on the toilet. -3/20/25 from 9:37 AM to 11:40 AM the resident remained in the resident's room while seated in the wheelchair. The resident was alone and unsupervised throughout this time. Interview with NA-G on 3/20/25 at 11:45 AM revealed the resident was at risk for falls and was to always have a Tabs alarm on when up in the wheelchair. NA-G was unaware of interventions for the resident to be supervised when alone in the wheelchair in the resident's room or when in the bathroom but confirmed most of the resident's falls occurred when the resident was attempting to self-transfer. During an interview on 3/20/25 at 2:49 PM, the Interim Director of Nursing (DON) confirmed the resident's Care Plan identified the resident was not to be left alone and unsupervised in the resident's room when seated in the wheelchair or when in the bathroom. The resident was a high risk for falls and continued to self-transfer despite repeated directions to use the call light and to call for staff assistance. The following was also confirmed: -Tabs alarm was to always be on the resident when up in the wheelchair and/or recliner. -the Charge Nurses were to complete an Incident Report at the time of each fall with identified causal factors and a new intervention. The fall interventions should be related to the causal factors to prevent further falls. Reports should include implementation of current interventions in place at the time of the falls. -staff re-education should be documented as to when it occurred, what education was provided and which staff received if this was identified as a fall intervention. C. Review of Resident 19's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of Alzheimer's disease, non-Alzheimer's dementia, depression, and osteoporosis. The following was assessed for the resident: -cognition was moderately impairment. -frequently incontinent of bowel and bladder. -substantial for dressing, transfers, and toileting hygiene. -use of a motion sensor alarm daily. Review of the resident's current Care Plan dated 9/18/24 revealed the resident was at risk for falls related to Alzheimer's disease, impaired safety awareness and need for assistance with transfers. Nursing interventions with dates the interventions were developed included the following: -9/18/24 make sure the resident's room was free of clutter and the resident's bedspread was not touching the floor. -9/18/24 make sure the resident's bed was always in the normal position except during active cares. -9/18/24 to wear non-skid footwear unless wearing shoes. -9/18/24 Make sure the resident's walker was always safely within reach. Review of an Incident Report dated 12/1/24 at 10: 40 PM revealed the resident was found on the floor of the resident's room in front of the electric lift recliner. The recliner was in the highest position. The resident identified trying to fix the lights on a nearby Christmas tree. The resident was encouraged to use the call light to seek staff assistance when needed. An intervention was identified to speak to the staff tomorrow to see of the resident's room could be rearranged so the Christmas tree was less accessible to the resident. In addition, a video camera was placed in the room with the monitor positioned at the Nurse's Station so the staff would be able to observe the resident more closely. Review of a Progress Note dated 12/2/24 at 3:40 AM revealed the resident had an unwitnessed fall in the resident's room when reaching for a box of Kleenex. The staff rearranged the resident's room to ensure the resident could reach frequently used items. Review of a Progress Note dated 12/19/24 at 1:31 PM revealed the resident was reaching for an item in the closet, lost balance and fell . The resident's fall alarm was sounding at the time of the fall. The assessment indicated the staff were provided re-education regarding leaving the resident alone in the room when positioned in the wheelchair. Review of an Incident Report dated 12/26/24 at 5:40 PM revealed the resident was found on the floor of the resident's room by the bathroom door. The resident identified trying to take self to the bathroom. A new intervention was identified to toilet the resident before and after meals. Review of an Incident Report dated 1/4/25 at 7:05 PM revealed the resident was found on the floor next to the resident's bed. The resident identified getting ready for bed, stumbled and fell backwards. An intervention was identified to assist the resident with getting ready for bed after the evening meal. Review of an Incident Report dated 1/5/25 at 5:05 PM revealed the staff heard the resident's fall alarm sounding and found the resident on the floor of the bathroom. The resident was incontinent of urine. A new intervention was listed to take the resident to the bathroom every 2 hours when awake. Observations of Resident 19 revealed the following: -3/20/25 from 7:43 AM to 9:03 AM the resident was seated in the dining room in a regular chair. No fall alarm was in place to the resident's chair. -3/20/25 from 10:11 AM to 11:24 AM the resident was alone in the resident's room, and unsupervised. The video camera was faced away from the resident and did not allow staff to visualize the resident from the Nurse's Station. During an interview on 3/24/25 at 11:55 AM the DON confirmed the following regarding Resident 19: -the resident had a video camera in the resident's room which was attached to a monitor at the Nurse's Station. Staff were to point the camera at the resident when in the recliner or in bed so the resident could be monitored more closely. -fall alarms were to always be on the resident. -12/19/24 the staff were re-educated regarding leaving the resident alone and unsupervised in the resident's room. The DON verified there was no evidence as to when the staff were re-educated, and which staff received the education. In addition, no other interventions were developed. 51391 D. Review of Resident 15's MDS dated [DATE] revealed the resident had a diagnosis of Non-Traumatic Brain Dysfunction, Alzheimer's Disease and Paranoid Personality Disorder. The following was assessed regarding the resident: -cognitive skills for daily decision making was severely impaired. - inattention and disorganized thinking continuously. - dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing and personal hygiene. - dependent on staff for repositioning in bed and transferring from bed to chair and tub. - dependent on staff for wheelchair mobility. - always incontinent of bowel and bladder. - 2 or more falls, 1 with injury and 1 without injury since previous assessment. Review of Resident 15's Care Plan dated 10/8/24 revealed the resident was at risk for falls related to poor balance, confusion and the need for assistance with transfers. Nursing interventions with development dates included the following: -10/8/24 Do not leave resident unattended alone in room when in the wheelchair. Assist to the recliner or to bed before leaving the room. -10/8/24 Make sure that the bed is in the normal low position at all times except during cares. -10/8/24 Resident does not remember to pull the call light to ask for assistance when the resident wants to get up. Each time a staff member walks by the room, take the time to get eyes on the resident to ensure safety -10/8/24 Transfer with 2 assist and mechanical lift. Make sure the sling fits properly prior to lifting. -2/6/25 Ensure residents bed in a locked position before leaving the room -3/13/25 Hourly checks done on resident at all times. Review of Nursing Progress Note dated 3/13/25 at 6:00 PM revealed the resident was laying on the floor on their stomach beside the bed, had reddened area to left check with no other injuries noted. A new intervention was identified for hourly checks at all times. An observation on 3/18/25 at 9:49 AM revealed the resident was sitting in a wheelchair in room alone, rocking back and forth, eyes were open, and resident was moaning. An observation on 3/20/25 at 7:15 AM revealed the resident was sitting in a wheelchair in room alone with eyes shut. An observation on 3/20/25 at 8:00 AM revealed the resident was sitting in a wheelchair in room alone, eyes were shut, and resident was moaning. An interview on 3/20/25 at 10:40 AM with NA-G and MA-H confirmed that the resident was at risk for falls, was to be on hourly checks at all times, staff confirm that hourly checks were not being completed. Staff were unaware of intervention for the resident to be supervised when alone in the wheelchair in the resident's room. An interview on 3/20/25 at 2:55 PM with the interim DON confirmed that the resident was at risk for falls. The fall prevention care planned intervention of hourly checks at all times and do not leave resident unattended alone in room when in wheelchair were not being implemented. An observation on 3/24/25 at 2:20 PM revealed the resident was lying in bed, awake, trying to sit up, bed was in highest position, no staff were in the room. An interview on 3/24/25 at 2:30 PM with NA-K confirmed that the bed was in the highest position when resident was in the bed and resident was alone in the room.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on observation, record review and interview; the facility staff failed to provide care and management of Resident 6's urinary catheter (tube placed into the bladder to drain urine) to prevent the potential for infections and/or complications. The sample size was 1 and the facility census was 33. Findings are: A. Review of the facility policy Catheter Cares dated 9/2024 revealed it was the policy of this facility to ensure residents with indwelling catheters received appropriate catheter care and maintained their dignity and privacy when indwelling catheters were in use. The following was indicated: -catheter care was be performed every shift and as needed by nursing personnel. -privacy bags were to be available and catheter drainage bags were to be always covered while in use. -privacy bags were to be switched out when soiled, and with a catheter change was needed. -empty drainage bags when the bag was half-full or every 3 to 6 hours. -ensure the catheter drainage bag was located below the level of the bladder to discourage backflow of urine. The following guidelines were identified for completion of catheter cares: -perform hand hygiene and place on gloves. -gently grasp penis and draw foreskin back if applicable. -using circular motion, cleanse the meatus. -starting at the meatus, move down and cleanse the shaft of the penis. -with a clean cloth, start at the urinary meatus and move outward, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter. B. Minimum Data Set Date: 3/6/25 Type: Quarterly BIMS: 15 out of 15 Resident mood interview conducted and the resident identified the following: -feeling down, depressed or hopeless 12-14 days -trouble falling asleep or staying asleep or sleeping too much 7-11 days. -feeling tired or having little energy 12-14 days -moving or speaking slowly 2-6 days. Behaviors: None Functional limitation of ROM: no impairment Self-Care Status: Set-up or clean up assistance with eating/drinking, and oral hygiene. Dependent with toileting hygiene, toileting bathing, dressing, and personal hygiene. Substantial/maximal assistance with bed mobility and transfers. Bowel and bladder: indwelling catheter and ostomy. Active diagnoses: diabetes, HTN, PVD, hyperlipidemia,, depression, pressure ulcer stage 3, obstructive sleep apnea, and osteoarthritis. Pain: denied the presence of pain. Prognosis does the resident have a condition or a chronic disease that may result in a life expectancy of less than 6 months. No Falls: None Weight: 252 pounds, no weight loss//gain. Unhealed pressure/venous ulcers: one stage 3 pressure ulcer which was present on admission and a diabetic foot ulcer. Resident has a PRD for chair and bed, nutrition/hydration interventions to manage skin problems, pressure ulcer care, application of nonsurgical dressings, applications of ointments/medications and application of dressings. Observation of wound care for Resident 6 on 3/20/25 from 10:12 AM to 10:45 AM revealed Licensed Practical Nurse (LPN)-D washed hands and placed on a disposable gown and gloves. LPN-D prepared items to complete the dressing change and placed on a bedside table. LPN-D used the bed controls to lower the bed so that staff could more easily access the resident's wounds. However, once the bed was lowered the urinary catheter drainage bag which was hanging from the bedframe was now positioned directly on the floor underneath of the resident's bed. The catheter drainage bag remained on the floor throughout the completion of wound care. During an interview with LPN-D on 3/20/25 at 11:30 AM, the LPN confirmed the resident's catheter drainage bag should not have been positioned on the floor during the wound care. During an observation of catheter cares and a transfer on 3/20/25 at 11:40 AM the following was observed: -Nurse Aide (NA)-H and NA-G entered the resident's room, washed hands, and placed on gowns and gloves. The resident remained in bed and lying on back. NA-H removed the bed linens and adjusted the resident's clothing to expose the catheter insertion site. The resident was observed to have feces to bilateral groin and lower abdomen. -NA-G used pre-moistened cleansing cloths to remove feces. NA-G removed soiled gloves but failed to complete hand hygiene before placing on clean gloves. -NA-G completed catheter cares and removed soiled gloves. -without performing hand hygiene, NA-G placed on clean gloves and removed the catheter drainage bag from the bed frame and placed directly on the resident's bed linens. The drainage bag contained approximated 700 cubic centimeters (cc) of yellow urine. -the catheter drainage bag remained on the resident's bed while the staff removed the PRAFO devices to bilateral feet and changed the resident's clothing. -NA-G removed the catheter drainage bag from the bed and placed the bag on the resident's lap. The resident was assisted to sit on the side of the bed. -the catheter drainage bag was then removed from the resident's lap and NA-G held the bag against NA-G's uniform as staff placed the resident on the mechanical lift and transferred the resident into the wheelchair. -the resident was positioned into the wheelchair and the catheter drainage bag was placed into a privacy bag underneath of the wheelchair. During an interview with NA-G on 3/20/25 at 12:00 PM the following was confirmed: -the resident's urinary catheter drainage bag was to remain below the level of the resident's bladder with any cares. -the catheter drainage bag should not have been placed directly on the bed linens or on the resident's lap. -after cleansing the feces from the resident's groin areas and lower abdomen, and after completion of catheter cares, staff should have removed soiled gloves and performed hand hygiene before placing on clean gloves and continuing cares.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview; the facility failed to prevent the potential for cross contamination as the staff failed to utilize the required Personal Protective Equipment (PPE) when performing direct cares for Resident 6 who was on Enhanced Barrier Precautions and to change gloves and perform hand hygiene at appropriate intervals when providing wound care for Residents 5 and 6. The total sample size was 19 and the census was 33. Findings are: A. Review of the facility policy Infection Prevention and Control Program with a revision date of 5/16/23 revealed the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. B. Review of the facility policy Hand Hygiene dated 9/2024 revealed all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene was the general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub also known as alcohol-based hand rub. (ABHR). The use of gloves would not replace hand hygiene. If gloves were required, staff were to perform hand hygiene prior to donning and immediately after removing gloves. C. Review of the Clean Dressing Change Policy dated 9/24 revealed it was the policy of this facility to provide wound care in a manner to decrease the potential for infection and/or cross contamination. The following guidelines were identified: -each wound will be treated individually. -when multiple wounds were being dressed, the dressings would be changed in order of least contaminated to most contaminated. Dressings of infected wounds should be changed last. -set-up a clean filed on the overbed table with the needed supplies for wound cleansing and dressing application. -establish an area for soiled products to be placed. -perform hand hygiene and place on clean gloves. -remove the existing dressing. -remove gloves, discard, complete hand hygiene and put on clean gloves. -cleanse the wound and pat dry with gauze. -measure wound using a disposable measuring guide. -remove soiled gloves, discard, perform hand hygiene and place on clean gloves. -dress wound as ordered and secure dressing. -discard disposable items including gloves and wash hands. D. Review of the Enhanced Barrier Precautions (EBP) Policy with a revision date of 5/24 revealed it was the policy of this facility to implement EBP for the prevention of the transmission of multidrug resistant organisms. EBP refers an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employed a targeted gown, and gloves use during high contact resident care activities. EBP were to be used for residents with any of the following; chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, chronic venous stasis ulcers and/or indwelling medical devices such as urinary catheters, central lines, feeding tubes, and tracheostomy/ventilator tubes. The use of PPE for residents on EBP was necessary when performing high-contact care activities such as the following: -dressing. -bathing/showering. -transferring. -providing hygiene. -changing linens. -changing briefs or assisting with toileting. -device care or use. -wound care. E. Review of Resident 6's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/6/25 revealed the resident was admitted [DATE] with diagnoses of diabetes, peripheral vascular disease, depression and a stage 3 (staging system is a method of summarizing characteristics of pressure ulcers including the extent of tissue damage. A stage 3 ulcer is a full thickness tissue loss. The subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss) pressure ulcer. The stage 3 pressure ulcer and a diabetic foot ulcer were both present with the resident's admission. Observation of wound care for Resident 6's right foot pressure ulcer and left foot diabetic ulcer on 3/20/25 at 10:12 AM revealed the following: -Licensed Practical Nurse (LPN)-D entered the resident's room, washed hands, and placed on a disposable gown and gloves. LPN-D positioned a barrier on a bedside table and placed items needed for the dressing changes on the barrier. -LPN-D removed the Coban and the gauze wraps which had been used to keep the dressing in place to the sole of the resident's right foot. LPN-D sprayed saline wound wash onto the dressing, which had a small amount of brown shadow drainage until the dressing was no longer adhered to the wound bed and removed the dressing. -after removal of the soiled dressing, LPN-D did not remove gloves but proceeded to cleanse the wound bed and then to pat dry. The resident's wound was covered with black eschar (dead tissue) and the perimeter of the wound had a deep pink color with dry and flakey skin. -while still wearing the same gloves, LPN-D applied a clean dressing to the wound and re-wrapped with gauze and Coban. -after completing the dressing change to the resident's right foot, LPN- removed soiled gloves but failed to complete hand hygiene before putting on a clean pair of gloves. -LPN-D removed the dressing to the wound site on the side of the resident's left foot. -without removing soiled gloves, LPN-D cleansed the wound with saline wound wash and completed the dressing change. -after completion of the dressing change, and without removing soiled gloves, LPN-D placed a heel protector on the resident's left foot, positioned the resident for comfort and adjusted the resident's bed linens. -LPN-D removed disposable gown and gloves and exited the resident's room still without performing hand hygiene. During an interview with LPN-D on 3/20/25 at 11:30 AM the following was confirmed: -the resident was currently on EBP related to a diabetic ulcer and pressure ulcers. -when completing wound care, should have removed gloves, and performed hand hygiene after removing the soiled dressings and then placed on clean gloves. -should have performed hand hygiene each time clean gloves were donned and when removing soiled gloves. During an interview with NA-G on 3/20/25 at 12:00 PM the following was confirmed: -the resident's urinary catheter drainage bag was to remain below the level of the resident's bladder with any cares. -the catheter drainage bag should not have been placed directly on the bed linens or on the resident's lap. -after cleansing the feces from the resident's groin areas and lower abdomen, and after completion of catheter cares, staff should have removed soiled gloves and performed hand hygiene before placing on clean gloves and continuing cares. F. Review of Resident 5's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of pneumonia, heart failure, non-Alzheimer's dementia, Parkinson's disease, bipolar disorder, and morbid obesity. The resident was identified as having one unstageable (the stage is not clear; the base of the wound is covered by a layer of dead tissue and are unable to see the base of the wound to determine a stage) pressure ulcer which was not present on admission. During an observation of toileting cares for Resident 5 on 3/20/25 at 9:25 AM the following was observed: -the resident's bathroom call light was activated. NA-G and NA-H entered the resident's room, performed hand hygiene, and placed on clean gloves. Staff did not place on gowns and no gowns were visible in the resident's room. -the resident was in the bathroom and was attached to the mechanical lift. Staff assisted the resident per the mechanical lift into a standing position and NA-G performed hygiene cares with pre-moistened cleansing cloths. -the resident was transferred out of the bathroom with the lift and was transferred into a wheelchair. -staff removed gloves and washed hands before leaving the resident's room. During an interview on 3/20/25 at 11:45 AM, NA-G confirmed the resident had a pressure ulcer which was not resolved and continued to receive treatment. However, the wound vac treatment (uses a device to apply negative pressure to a wound to promote healing by removing fluid and debris and encouraging blood flow) had been discontinued so NA-G thought the resident was no longer on EBP. The following was observed during wound care for Resident 5 on 3/20/25 at 1:40 PM: -without performing hand hygiene, LPN-D placed on a disposable gown and gloves. -the dressing was removed from the right buttock area which had a small area of brownish drainage. -LPN-D removed gloves and without performing hand hygiene placed on a new pair of gloves. -the wound was cleansed with wound wash and was patted dry. -a barrier cream was applied to the area surrounding the wound bed with LPN-D's gloved hand. -LPN-D removed gloves but failed to complete hygiene before putting on a clean pair of gloves and applying a dressing to the wound. -with completion of wound care, LPN-D removed gloves and gown but failed to perform hand hygiene before exiting the resident's room. An interview was conducted with LPN-D on 3/20/25 at 2:00 PM and the following was confirmed: -the resident's pressure ulcer had improved but was not healed and the resident was still on EBP. -should have performed hand hygiene each time clean gloves were donned and when removing soiled gloves.

Licensure Reference Number 175 NAC 12-006.17 Based on observations, interviews, and record review the facility staff failed to: 1). utilize Personal Protective Equipment (PPE) in a manor to prevent the potential spread of COVID-19; 2) administer medication in a manner to prevent the potential for cross contamination; and 3) develop/implement a water management program which identified a risk assessment and control measures to address potential hazards. This had the potential to affect all residents. The total sample size was 21 and the facility census was 33. Findings are: A. Review of the facility Water Management Program with a revision dated of 9/2022 revealed the Water Management Plan referred to the documents that contained all the information pertaining to the development and implementation of the facility's water management activities for reducing the risk of Legionella (bacterium which causes Legionnaires' disease, a serious type of pneumonia. The bacteria can be found in human-made building water systems such as sinks, shower heads, decorative fountains, hot tubs, or large complex plumbing systems). The document indicated the facility was to develop a risk assessment to identify where Legionella and/or other opportunistic pathogens could grow and spread in the facility's water system. In addition, the facility was to develop/implement control measures to address potential hazards and was to conduct an annual evaluation of the water management program. B. Review of the Water Management Program revealed no evidence the facility had developed a risk assessment to include use of a water system schematic description and environmental assessment. In addition, there was no evidence the facility had developed/implemented specified control measures to address potential hazards. An interview with the facility Administrator on 3/19/24 at 10:22 AM confirmed no risk assessment had been completed and the facility did not have a plan to prevent the growth of waterborne bacteria in the facility water system. The Administrator indicated the policy was developed in 2022 and there was no evidence there had been any further evaluation of the program. C. Review of a facility policy titled Personal Protective Equipment with a revision date of 7/2020 revealed the facility promoted the appropriate use of PPE to prevent the transmission of pathogens to residents, visitors, and other staff. Staff were to wear a mask to protect the face from contamination with blood, body fluids and other potentially infectious materials during tasks that generate splashes or sprays. The policy further indicated when wearing a face mask, don't do the following: -don't wear under your nose or mouth, -don't allow a strap to hang down and don't cross the strings, -don't touch or adjust the face mask without hand hygiene before and after, -don't wear your facemask on the head, -don't wear your facemask around the neck, and -don't wear your facemask around your wrist. D. Observations of staff wearing face masks throughout the facility on 3/14/24 revealed the following: -7:14 AM to 7:35 AM Licensed Practical Nurse (LPN)-A was administering medications to Resident 18 through the resident's gastrointestinal feeding tube (tube inserted into the stomach that brings nutrition directly to the stomach). LPN-A was wearing a face mask which was positioned below the staff's nose and exposed the nares. LPN-A used gloved hands repeatedly to reposition mask on staff's face but never secured the mask over staff's nose, and -10:55 AM to 11:25 AM Medication Aide (MA)-D provided Resident 27 assistance with transferring, toileting, and personal hygiene. MA-D then ambulated the resident out to the dining room for the noon meal. MA-D was wearing a facemask, but the mask was positioned below staff's nose. MA-D was standing close to the resident throughout much of the observation and Resident 27 was not wearing a mask. An interview with the Infection Preventionist on 03/18/24 at 9:43 AM revealed the facility had been in an outbreak status on 3/13/24 and 3/14/24 due to recent COVID positive residents. All staff were to wear surgical masks when in resident care areas. Masks were to be worn over the staff's nose and mouth and the nose should not be left exposed. 42360 E. During observations of facility staff wearing their required surgical masks to protect the residents from the potential spread of COVID-19 in the facility the following was observed; -on 3/13/23 at 8:30 AM MA-D was observed walking in the resident hallway with a surgical mask on, but not covering the nose/nostrils. -on 3/13/23 at 9:15 AM MA-D was observed walking in the hallway and turning to address a resident with a surgical mask on but pulled well below the nose and was pulled down even further when addressing the resident. -on 3/14/23 at 12:00 PM MA-D was observed in the dining room delivering meal trays to the resident wearing a surgical mask that was on but not covering the nose/nostrils. -on 3/14/23 at 12:00 PM Dietary Aide (DA)-Z was observed in the dining room delivering meal trays to resident wearing a surgical mask that was on but not covering the nose/nostrils. During an interview on 3/13/24 at 8:33 AM RN-AA revealed that all staff were to be wearing masks in the facility due to one resident still on isolation for COVID exposure, and a recent COVID-19 outbreak. 45739 F. Review of the facility policy Administering Medication, undated, revealed the following: -only licensed persons were to administer and document the administration of medications, -the Director of Nursing (DON) supervised and directed all personnel who administered medications, -medications were administered in accordance with prescriber orders, and -staff were to follow established facility infection control procedures for the administration of medications. G. Observation on 3/18/24 at 8:10 AM revealed MA-G performed hand hygiene, obtained Resident 4's medication cards from the medication cart, compared each medication card to the Medication Administration Record (MAR), MA-G pushed the medication out of the window of the medication card into MA-G's bare hand, then MA-G placed the medication into the medication cup. MA-G repeated this process for a total of 12 medications. MA-G then administered all 12 medications to the resident. Interview on 3/18/24 at 3:20 PM with the DON confirmed that staff should not be touching the medications they are administering to residents with their bare hands.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, record review and interview, the facility failed to develop and/or implement interventions to prevent ongoing elopements for Resident 236 and falls for Residents 27 and 5. The sample size was 6 and the facility census was 33. Findings are: A. Review of the facility Elopement and Wandering Residents policy with a revised date of 5/2020 revealed the facility would ensure residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision. The following interventions were identified for managing residents at risk for elopement or unsafe wandering: -residents were to be assessed for risk of elopement upon admission and throughout their stay, -the resident would be evaluated to determine the unique factors contributing to risk to develop a person-centered care plan, -interventions to increase staff awareness of the resident's risk, modify the resident's behaviors or minimize risks associated with hazards was to be added to the resident's care plan and communicated to staff, -adequate supervision was to be provided to help prevent accidents or elopements, -charge nurses were to monitor the implementation of interventions, response to interventions and document accordingly, and -the effectiveness of interventions to be evaluated, changes made as needed, and changes communicated to relevant staff. The following Post-Elopement Procedure was identified: -licensed nurse to perform a physical assessment and document findings, -social service designee to re-assess the resident and make referrals for counseling or consults as needed, and -implement any new physician orders and communicate to staff, resident, and resident representative. B. Review of Resident 236's Face Sheet revealed the resident was admitted [DATE] with diagnoses of unspecified dementia, psychotic/mood disturbance, anxiety, depression, and vascular dementia. Review of an Elopement Risk assessment dated [DATE] at 3:07 PM revealed the resident had a history of elopement while living at home and wandering behaviors. The wandering placed the resident at risk and affected the safety and well-being of the resident and others. The resident was identified as high risk for elopement. A wander guard bracelet (a device attached to the resident that sets off an alarm at facility exits that are equipped with sensor devices activated by the bracelet) was placed on the resident. Review of the resident's current Care Plan dated 11/3/22 revealed the resident was at risk for Elopement related to a history of elopement while living at home. The following interventions were indicated with a date of 11/1/22 for development/implementation: -clearly identify the resident's room and bathroom, -encourage participation in activity program, -engage in purposeful activity, -monitor and report behaviors especially exit seeking, -monitor for whereabouts in the facility, -picture identification at the front desk, -redirect resident when wander guard sounds and attempting to leave the facility, and -test wander guard alarm to make sure it is working properly and check for placement. Review of a Nursing Progress Note dated 4/27/23 at 9:09 PM revealed the door alarm was activated by the employee entrance/exit door. Resident 236's walker was positioned near the door. The resident was found outside walking in the trees on the other side of the employee parking lot. The resident was assisted back into the facility and to the resident's room. 15-minute checks were immediately initiated and were to be completed for 12 hours. No injuries were identified. Review of the resident's medical record which included the resident's current Care Plan, Nursing Progress Notes, assessments, and physician orders revealed no new interventions were developed and/or implement after the resident's 15-minute checks were discontinued on 4/28/23 to prevent further potential elopements. Review of a Care Plan Note dated 5/1/23 at 2:18 PM revealed the resident was displaying increased non-compliance. The resident had been going into other resident's rooms and taking naps on open beds, using other resident's bathrooms, had been more outspoken and irritable. In addition, the resident had increased exit seeking behaviors. Review of a Nursing Progress Note dated 5/1/23 at 8:00 PM revealed the wander guard alarm and the door alarm were sounding. The resident's walker was observed outside of the alarming exit door and staff were able to visualize the resident outside. The staff witnessed the resident step off the sidewalk and onto the grass falling forward onto knees. Interview with the Director of Nursing (DON) on 3/18/24 at 10:02 AM confirmed the following regarding Resident 236: -the resident had an elopement on 4/27/23 at 9:09 PM, -staff completed 15-minute checks on the resident for 12 hours after the resident's elopement, -no additional interventions were developed/implemented after the resident's 15- minute checks were discontinued, -continued to have exit seeking behaviors, and -the resident had another elopement 5/1/23 at 8:00 PM. C. Review of the facility Fall Prevention and Fall Leaf Program with a revision date of 2/2023 revealed the purpose of the policy was to ensure fall risks were identified and interventions were developed to prevent falls, when possible and to maintain a safe environment for each resident. At the time of admission, each resident's risk for falls was to be evaluated. If the resident's score was 10 or greater, the resident was identified as high risk for falls. The following procedure was indicated after a resident fall: -staff to complete a post fall evaluation, and -staff to review the evaluation to determine the need for revision of current interventions or development of new interventions. D. Review of Resident 27's MDS dated [DATE] revealed diagnoses of non-traumatic brain dysfunction, dementia, anxiety, depression, and Alzheimer's dementia. The following was assessed for Resident 27: -short- and long-term memory loss with moderately impaired decision-making skills, -incontinent of bowel and bladder, -required assistance with transfers, bed mobility, toilet use, dressing and personal hygiene, and -1 fall without injury since previous assessment. Review of the resident's current Care Plan dated 6/27/23 revealed the resident was at risk for falls due to poor safety awareness, unsteady gait, and history of falls. The following interventions and dates of implementation were identified: -6/27/23 make sure resident wearing non-skid footwear when up and about, -7/29/23 video monitor, -8/23/23 bed and chair alarms always, and -8/23/23 ambulate resident with gait belt and walker from meals and to the resident's room, toilet the resident and transfer into wheelchair, recliner, or bed. Review of a Post Fall Evaluation dated 10/2/23 revealed the resident had a fall on 10/1/23 at 8:44 PM. The evaluation indicated the resident had been found on the floor of the resident's room, the resident had been wearing socks and the resident's fall alarm was not sounding. Further review of the evaluation revealed a new intervention to ensure the resident was wearing tennis shoes or gripper socks (intervention already identified after a fall on 6/27/23). Further review revealed no evidence the facility addressed the resident's fall alarm which had not been alarming when the resident fell . Review of a Post Fall Evaluation dated 10/25/23 revealed the resident had a fall at 11:15 PM. The fall occurred in the resident's room when the resident had attempted to self-transfer from the wheelchair to the bed. The resident's fall alarm had not sounded as the staff had left it attached to the resident's recliner and had not been placed on the wheelchair. The evaluation indicated staff received re-education regarding use of the resident's fall alarms. Review of a Post Fall Evaluation dated 11/29/23 revealed the resident had a fall on 11/26/23 at 1:30 PM. The resident was found on the floor of the resident's room after attempting to self-transfer from the recliner to the wheelchair. Further review revealed the resident's fall alarm had not been activated. Staff were again re-educated regarding the use of Resident 27's fall alarms. Observations of Resident 27 on 3/18/24 revealed the following: -7:34 AM the resident was seated in a wheelchair in the resident's room. The wheelchair was positioned between the foot of the resident's bed and the recliner. The video camera positioned on a dresser at the foot of the resident's bed was pointed toward the head of the resident's bed and the doorway of the resident's room, and -2:34 PM the resident was seated in the recliner of the resident's room with the footrest elevated. The video camera remained pointed toward the door of the resident's room and the head of the resident's bed. Observation of the monitor linked to the camera and positioned on the Nurse's Station confirmed the resident was not visible on the monitor. Interview with the DON on 3/18/24 at 3:16 PM confirmed the following: -staff were to develop a new intervention or were to revise current interventions with each resident fall to prevent further falls and potential injuries, -there was no documentation as to which staff received education or what education was provided after the resident's falls on 10/25/23 at 11:15 PM and on 11/26/23 at 1:30 PM, and -use of the video monitor was not an effective fall intervention if the camera did not capture the resident on the video monitor. E. Review of Resident 5's MDS dated [DATE] revealed diagnoses of non-traumatic brain dysfunction, dementia, anxiety, and depression. The following was assessed for the resident: -cognition was severely impaired, -required substantial assistance with bed mobility, transfers, dressing, toileting use and personal hygiene, -incontinent of bowel and bladder, and -behaviors which included wandering and rejection of cares. Review of the resident's current Care Plan with a revision date of 5/23/23 revealed the resident was at risk for falls related to poor safety awareness, refusal to call for assistance, poor positioning in wheelchair and unaware of physical limitations. The following interventions were identified: -staff to assist with toileting after the evening meal, -bathroom door alarm, -keep resident's bedside table clean and water within reach, -anti-rollback brakes on wheelchair, -video monitor, and -fall alarm with alarm attached to the resident's lower back and out of reach of the resident. Review of a Post Fall Evaluation dated 12/5/23 at 5:00 PM revealed the resident was found on the floor of the resident's room. The resident had been leaning forward to reach something from the floor. Further review of the evaluation revealed no evidence a new intervention was developed to prevent further falls. Review of a Nursing Progress Note dated 12/18/23 at 12:05 AM revealed the resident was found on the floor of the resident's room in front of the wheelchair. The resident was fully dressed, with shoes on and the fall alarm sounding. Review of the resident's medical record revealed no evidence current interventions were revised or additional interventions were developed. Review of a Post Fall Evaluation dated 12/23/23 at 7:00 AM revealed the resident was found on the floor of the resident's room The resident indicated trying to self-transfer from the bed to the wheelchair, brakes were not locked, and the resident slid to the floor. Review of the resident's Post Fall Evaluation revealed no change in the resident's fall prevention interventions. Observations of Resident 5 on 3/18/24 revealed the following: -7:08 AM the resident was seated in a wheelchair in the resident's room. The resident's fall alarm was pinned to the resident's upper left shoulder and the video camera in the resident's room was faced toward the head of the resident's bed and the entrance of the resident's room. The resident's wheelchair was behind the camera and the video monitor at the nurse's station revealed no image of the resident, and -10:20 AM the fall alarm remained to upper left shoulder and video camera remained facing the head of the bed and the doorway of the room. The resident had an opened bag of candy and several pieces had spilled onto the floor. The resident was leaning forward to pick the candy up from the floor. During an interview with the DON on 3/18/24 at 10:30 AM, the DON confirmed the following: -the resident's fall alarm was to be pinned to the resident's lower back to prevent the resident from removing, and -the video camera in the resident's room should be positioned on the resident so staff could monitor from the nursing station to prevent further falls for Resident 5.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(8) Based on observations, record review and interview; the facility staff failed to evaluate the use of a seatbelt as a restraint for 1 (Resident 30) of 1 sampled resident. The facility identified a census of 33. Findings are: Review of Resident 30's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 1/19/24 revealed diagnoses of non-traumatic brain dysfunction, malignant neoplasm of cerebral meninges (tumor formed in the layers of the tissue that covers the brain and the spinal cord), cancer, diabetes, paraplegia (inability to voluntarily move the lower parts of the body), seizure disorder, and depression. The facility staff assessed the following about the resident: -cognitively intact, -dependent with bed mobility, transfers, dressing, toilet use and personal hygiene, and -no restraints were in place. Review of the resident's current Care Plan dated 1/26/24 revealed the resident had paralysis, was unable to self-propel a regular wheelchair and had limited ability to perform gross motor skills. The resident was identified as using a motorized wheelchair with an intervention for Physical Therapy (PT) and Occupational Therapy (OT) to assess and determine the resident's ability to use the motorized wheelchair. The Care Plan further identified a seat belt was placed on the resident when in the motorized wheelchair. The following interventions were indicated: -ensure the resident was positioned correctly while restrained, and -monitor/document/report any changes regarding effectiveness of restraint, less restrictive device if appropriate, and any negative or adverse effects. Review of Resident 30's medical record that included progress notes, assessments and practitioner orders revealed there was no evidence the facility had evaluated the seatbelt as a restraint or how the seatbelt was being used to treat a medical condition. During an interview on 3/13/24 at 11:00 AM, Resident 30 reported the resident had lower extremity paralysis and was using an electric wheelchair. The resident identified the following: -independent with mobility when using the electric wheelchair, -use of a seatbelt when positioned in the electric wheelchair, and -uncertain if would be able to remove the seat belt independently but had never been asked to demonstrate. Observations of Resident 30 on 3/13/24 at 11:00 AM and on 3/14/24 at 11:08 AM and at 12:20 PM, revealed the resident was seated in an electric wheelchair with a connected seat belt. During an interview on 3/14/24 at 2:59 PM, the Director of Nursing (DON) and Register Nurse (RN) Consultant-P, staff confirmed there was no evaluation of the seatbelt as a potential restraint. In addition, the DON was unable to produce a policy regarding potential restraint use and monitoring for the facility. Observations on 3/18/24 at 12:26 PM and on 3/19/24 at 8:49 AM revealed Resident 30 was seated in the motorized wheelchair and the seatbelt was always buckled across the resident's lap when positioned in the chair.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to accurately code Resident 25's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) to reflect the resident's current urinary and nutritional interventions. The sample size was 18 and the facility census was 33. Findings are: Review of Resident 25's MDS dated [DATE] revealed the following: -diagnoses of spinal cord injury, orthostatic hypotension (low blood pressure that happens when changing positions), neurogenic bladder (lack of control of the bladder due to neurological injury), quadriplegia (paralysis of all 4 limbs), -required set up assistance with eating and was dependent with toileting and dressing, -did not use any appliances for bladder elimination (such as an indwelling catheter), -urinary incontinence was not rated (the resident had a catheter), -did not receive parenteral (administration in a way not involving the intestines or digestive tract) or Intravenous (Into the Vein [IV]) feedings, -did not have a feeding tube, -received 25% or less of total calories through parenteral or IV feedings, and -received 500 cubic centimeters (cc) per day or less of fluids through IV or tube feedings. Review of Resident 25's Care Plan revised 2/22/24 revealed the following: -was able to feed self with staff set up, -had adaptive equipment for eating utensils, -staff were to keep the resident's hydration system filled with water, -required total assistance with catheter cares, and -had an indwelling suprapubic catheter (a tube inserted through the abdomen into the bladder to drain urine). Interview on 3/14/24 at 9:40 AM with Resident 25 revealed the resident had an indwelling catheter, did not receive any nutrition or fluids through an artificial route, and was able to feed themself since the resident was admitted to the facility in October of 2023. Interview on 3/18/24 at 7:30 AM with the MDS Coordinator confirmed the resident had an indwelling catheter. Further interview on 3/18/24 at 2:58 PM confirmed the resident had the urinary catheter upon admit to the facility, the resident did not receive nutrition or fluids through parenteral, IV, or TF, and the resident was able to feed self with set-up assistance. The MDS Coordinator confirmed the MDS dated [DATE] had not been completed accurately. Interview on 3/18/24 at 3:20 PM with the Director of Nursing (DON) and the Consulting RN confirmed the facility did not have a policy on completing assessments and the facility followed the Resident Assessment Instrument (RAI) manual for guidance. Further interview confirmed the MDS dated [DATE] had not been accurately coded.

Licensure Reference Number: 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure that routine assessments were completed to monitor for adverse side effects of anti-psychotic medications (medication used to treat psychosis) for 1 (Resident 2) of 5 sampled residents. The facility census was 33. Findings include: A. Review of a form titled Clinical Management dated 10/2021 revealed it was the policy of the facility to complete assessments per the outlined time frames to ensure monitoring of individual resident's current medical status. Staff were to complete an Abnormal Involuntary Movement Scale (AIMS- assessment used to monitor for extrapyramidal symptoms (EPS-involuntary movements and tremors that could be permanent) for residents receiving an antipsychotic medication. B. Review of Resident 2's Minimum Data Set (MDS-a federally mandated assessment) dated 12/7/23 revealed diagnoses of progressive neurological condition, dementia, anxiety, depression, and psychotic disorder. The assessment indicated the resident's cognition was intact and the resident had poor appetite and sleeping habits. The resident had physical and verbal behaviors directed at others and received antianxiety, antidepressant and an antipsychotic medication all on a routine basis. Review of Resident 2's physician orders revealed the resident had an order dated 12/22/23 for Risperidone (antipsychotic medication) 0.25 milligrams (mg) twice a day for diagnosis of severe depressive disorder with psychotic symptoms. Review of the resident's current Care Plan with revision date of 12/29/23 revealed the resident was started on the Risperidone due to behavioral disturbances; inappropriateness in common areas, yelling, delusions, demanding and irritability. Review of the resident's medical record revealed no evidence the facility had completed an AIMs assessment when the resident was started on the Risperidone 12/22/23. Further review of the resident's medical record revealed no evidence the facility was monitoring the resident's use of the Risperidone for potential side effects of the medication. During an interview on 3/19/24 at 7:57 AM, the Director of Nursing (DON) confirmed the resident had taken Risperidone 0.25 mg twice a day since 12/22/23. Facility staff should have completed an initial AIMS assessment when the resident was started on the antipsychotic and assessments should then be completed quarterly or with a re-admission/change of condition to monitor for potential EPS. The DON further confirmed there was no evidence in the resident's medical record to indicate staff were monitoring for potential side effects from use of the antipsychotic medication.

Licensure Reference Number 175 NAC 12-006. 04B Based on record review and interview; the facility failed to provide the required abuse training for new and existing staff. The sample size was 8 and the facility census was 33. Findings are: Review of the facility policy Abuse, Neglect, Misappropriation and Exploitation dated 10/2019 revealed the following; -Residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. -Resident were not subject to abuse by anyone including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. -The facility reported allegation of suspected abuse, neglect, or exploitation immediately to the facility Administrator, Other officials in accordance with State Law, and the State Survey and Certification Agency. -The facility would not employ otherwise engage individuals who had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. -Background, reference, and credential checks would be conducted on employees prior to or at the time of employment, by facility administration, in accordance with applicable State and Federal regulations. -New employees would be educated on abuse, neglect, and exploitation during initial orientation, and -Annual education and training were provided to all existing employees. Review of the facility undated Relias Official Transcripts (computer generated training modules) revealed the following; -Nurse Aide (NA)-R (new staff) had not completed Abuse and Neglect training. -Housekeeper-S (new staff) had not completed Abuse and Neglect training. -NA-T (new staff) had not completed Abuse and Neglect training. -Medication Aide (MA)-P (existing staff) had completed Understanding Abuse and Neglect on 8/4/22, but there was no evidence abuse and neglect training was completed in 2023 or 2024. -NA-Q (existing staff) had not completed Abuse and Neglect training. Review of the Nursing Staff Meeting Sign-In's dated August 2023, and September 2023 with content including Abuse/Neglect revealed the following existing staff were not in attendance; -NA-U -MA-P -NA-Q During an interview on 3/19/24 at 12:18 PM The Director of Nursing confirmed the facility had no evidence that all new and existing staff had completed the required initial and yearly training on abuse. During an interview on 3/9/24 at 1:08 PM Registered Nurse Consultant confirmed the facility had no evidence of the required initial training for abuse and neglect for NA-R, Housekeeper-S, and NA-T, and had no evidence the required ongoing abuse and neglect training for MA-P, NA-Q, and NA-U had been completed.

Licensure Reference Number 175 NAC 12-006. 04B Based on record review and interview; the facility failed to provide the required abuse training for new and existing staff. The sample size was 8 and the facility census was 33. Findings are: Review of the facility policy Abuse, Neglect, Misappropriation and Exploitation dated 10/2019 revealed the following; -Residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. -Resident were not subject to abuse by anyone including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. -The facility reported allegation of suspected abuse, neglect, or exploitation immediately to the facility Administrator, Other officials in accordance with State Law, and the State Survey and Certification Agency. -The facility would not employ otherwise engage individuals who had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. -Background, reference, and credential checks would be conducted on employees prior to or at the time of employment, by facility administration, in accordance with applicable State and Federal regulations. -New employees would be educated on abuse, neglect, and exploitation during initial orientation, and -Annual education and training were provided to all existing employees. Review of the facility undated Relias Official Transcripts (computer generated training modules) revealed the following; -Nurse Aide (NA)-R (new staff) had not completed Abuse and Neglect training. -Housekeeper-S (new staff) had not completed Abuse and Neglect training. -NA-T (new staff) had not completed Abuse and Neglect training. -Medication Aide (MA)-P (existing staff) had completed Understanding Abuse and Neglect on 8/4/22, but there was no evidence abuse and neglect training was completed in 2023 or 2024. -NA-Q (existing staff) had not completed Abuse and Neglect training. Review of the Nursing Staff Meeting Sign-In's dated August 2023, and September 2023 with content including Abuse/Neglect revealed the following existing staff were not in attendance; -NA-U -MA-P -NA-Q During an interview on 3/19/24 at 12:18 PM The Director of Nursing confirmed the facility had no evidence that all new and existing staff had completed the required initial and yearly training on abuse. During an interview on 3/9/24 at 1:08 PM Registered Nurse Consultant confirmed the facility had no evidence of the required initial training for abuse and neglect for NA-R, Housekeeper-S, and NA-T, and had no evidence the required ongoing abuse and neglect training for MA-P, NA-Q, and NA-U had been completed.

Licensure Reference Number 175 NAC 12-006.04C3a Based on record review and interview, the facility failed to notify the Resident 9's responsible party and the physician of a change in condition related to multiple vomiting episodes. The total sample size was 18. The facility census was 36. Findings are: A. Review of the facility's policy Change in Condition Notification last reviewed 10/2019 revealed the purpose of the policy was to monitor residents for changes in their condition, respond appropriately and to notify the physician and responsible party/family member of the changes. B. Review of Resident 9's Minimum Data Set (MDS - a federally mandated comprehensive assessment tool used for care planning) dated 1/5/23 revealed diagnoses of schizophrenia, anemia, seizure disorder, dysphagia (difficulty swallowing), and gastroesophageal reflux disorder (GERD- a condition where stomach acids flow from the stomach back into the esophagus). The assessment also revealed the resident's cognition was severely impaired and required extensive assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. Review of Resident 9's Nursing Progress Notes revealed the following: -10/12/22 at 04:01 AM, the resident was removed from the dining room after vomiting a large amount of liquid, had an episode of diarrhea and was tested for Covid-19; -11/4/22 at 09:31 AM, the resident vomited a large amount of undigested food after breakfast; -11/23/22 at 4:05 PM, the resident was lethargic (feeling sluggish or lacking energy) and leaning more; and -11/30/22 at 12:00 PM, the resident vomited several times after breakfast. Review of the resident's medical record revealed no evidence the physician or the resident's representative/family member was notified regarding the resident's changes in condition. During an interview with Licensed Practical Nurse (LPN)-N on 2/16/23 at 09:25 AM, LPN-N confirmed the physician and the resident's representative should have been notified of the following episodes: -10/12/22 the resident vomited and had diarrhea; -11/4/22 the resident vomited a large amount of undigested food after breakfast; -11/23/22 the resident was lethargic (feeling sluggish or lacking energy) and leaning more; and -11/30/22 the resident vomited several times after breakfast. In addition, LPN-N confirmed there was no evidence in Resident 9's medical record the physician and representative/family member had been notified regarding the resident's condition changes.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17(17B) (17D) Based on observation, interview, and record review; the facility failed to 1) prevent potential cross-contamination of blood borne pathogens related to the use of a glucometer for Residents 3 and 7, 2) wash hands and change gloves at appropriate intervals during the provision of catheter cares for Resident 14 and incontinence cares for Resident 33, and 3) store respiratory equipment in a sanitary manner for Residents 14, 25, 32, and 21. The sample size was 7 and the facility census was 36. Findings are: A. Review of the undated Blood Glucose Monitoring Competency provided by the facility revealed the following procedure: - Wash hands and apply gloves, - set up a clean field for the glucometer supplies, - turn on the glucometer, - disinfect the resident's finger with an alcohol swab, - insert the test strip into the meter, - puncture the skin with a lancet, - wipe the first drop of blood with a cotton ball, - apply pressure to the finger to collect the blood sample with the glucometer, - clean the resident's finger with a cotton ball and apply pressure until the bleeding stops, - remove the test strip and dispose of it and the lancet into a biohazard container, - remove gloves and wash hands, and - disinfect the glucometer according to manufacturer's instructions. Review of the undated Assure Platinum Blood Glucose Monitoring System User Instruction Manual provided by the facility revealed the following: - Option 1 was to clean and disinfect the glucometer at one time using an EPA-registered disinfectant detergent or germicidal wipe. - To use a wipe, remove it from the container and follow the product label instructions to disinfect the glucometer. - Option 2 was to clean the glucometer first with soapy water or [MEDICATION NAME] alcohol and then disinfect it with a diluted bleach solution or a bleach wipe with a 1:10 concentration. B. Review of Resident 3's current Care Plan with a review date of 12/14/18 revealed the resident had liver disease related to a [DIAGNOSES REDACTED]. It is spread by contaminated blood and may have no visible symptoms). Interventions included: - Dietary consult for recommendations and teaching, - give medications for nausea and vomiting, - provide medications as ordered, - notify the physician of any abnormal vital signs, - monitor for jaundice, - monitor for signs of internal bleeding, - monitor for signs of infection, - weigh weekly, - monitor for signs of complications, and - obtain lab as ordered. A blood glucose monitoring observation was completed on 3/7/19 at 11:30 AM. Licensed Practical Nurse (LPN) -E gathered supplies, washed hands, and applied gloves. LPN-E then entered Resident 3's room and placed the supplies on a paper towel on the resident's bed. LPN-E cleaned the resident's finger with an alcohol prep pad and then pricked the resident's finger with the lancet. LPN-E put pressure on Resident 3's finger to express enough blood for testing and placed the blood on the glucometer test strip. The resident's blood sugar was noted to be 230, the test strip was removed and discarded. The blood on the resident's finger was cleaned off and LPN-E (prior to changing gloves) carried the glucometer and the lancet out of the room. The glucometer was set on a paper towel on the medication cart and the lancet was disposed of in the sharps container. LPN-E's gloves were then removed and hands washed. LPN-E took an alcohol prep pad and wiped the outside of the glucometer (the alcohol dried immediately on contact) and with bare hands placed the glucometer inside the medication cart ready to be used by this or another resident. During an interview with LPN-E on 3/7/19 at 11:35 AM, LPN-E confirmed the glucometer was cleaned using an alcohol wipe. LPN-E stated Clorox wipes were normally used but they didn't have any available at that time. During an interview with the Director of Nursing (DON) on 3/7/19 at 1:45 PM, the DON revealed each unit had 1 glucometer to share among the residents on that unit. Review of a list provided by the facility Accuchecks by Hall (undated) revealed the BC hallways had 2 residents (Residents 3 and 7) that shared a glucometer. Review of Resident 3's Medication Administration Record [REDACTED]. Review of Resident 7's MAR indicated [REDACTED]. During an interview with LPN-G on 3/7/19 at 1:57 PM, LPN-G stated the glucometers should be cleaned with Clorox wipes. Interviews with LPN-H on 3/7/19 from 2:03 PM to 2:10 PM revealed the wipes that were normally used for the glucometers hadn't been available for about a week. LPN-H stated that until the normal glucometer wipes are available they were to use the Clorox wipes. LPN-H then showed the Clorox wipes being used and they were the Clorox Disinfecting Wipes. LPN-H was unaware of the amount of contact time that the glucometer should remain wet to ensure it was disinfected. During an interview with the DON on 3/7/19 at 2:08 PM, the DON confirmed Resident 3 had [MEDICAL CONDITION] and was unaware of any treatment the resident had received for this (which indicated the resident was still contagious). The DON confirmed the facility ran out of the proper glucometer cleaning wipes and the staff were told to use Clorox wipes in the meantime. Further interview confirmed alcohol wipes should not be used to disinfect the glucometer. The immediate jeopardy was abated to an [NAME] level on 3/7/19 at 4:30 PM when: 1) The facility found the proper cleaning wipes (Sani-Cloth Germicidal Disposable Wipes) in the supply room and placed them in the medication carts. 2) All available nurses and medication aides were trained on the proper cleaning of glucometers. For those staff that hadn't been trained yet there was a plan in place to ensure they were trained prior to working again. 3) A bulk order for Sani-Cloth Germicidal Disposable Wipes cleaning wipes was placed to ensure the facility didn't run out again. 4) A plan to get each resident their own glucometer was developed. 5) A plan was developed for audits to ensure continued compliance. C. Review of the facility policy titled Hand-Washing/Hand Hygiene with revision date 8/14, revealed the facility considered hand-washing/hand hygiene the primary method of preventing the spread of infections included [REDACTED]. -before and after direct contact with residents; -when hands are visibly soiled or dirty (with soap and water); -before and after assisting a resident with personal cares; -before and after assisting a resident with toileting; -before handling soiled equipment; and -before putting on clean gloves and after removing soiled gloves. D. During observation of nursing care on 3/5/19 at 1:31 PM, Nursing Assistant (NA)-C and NA-B provided incontinence cares for Resident 33. NA-C provided perineal hygiene, but without removing soiled gloves, placed a clean urinary incontinence brief on the resident, adjusted the resident's clothing, assisted the resident to position on the resident's right side, placed a pillow between the resident's legs and another pillow beneath the resident's head, removed the resident's shoes, covered the resident with a blanket, gave the resident a call light cord and used the bed controls to lower the resident's bed. NA-C finally removed soiled gloves and washed hands in the resident's bathroom. E. During observation of catheter cares for Resident 14 on 3/6/19 at 8:01 AM, NA-L and LPN-G washed hands and donned clean gloves. LPN-G completed urinary catheter cares and then removed soiled gloves. Without washing or sanitizing hands, LPN-G proceeded to reposition Resident 14 in bed, adjusted the resident's clothing and covered the resident with a blanket. LPN-G then returned to the resident's bathroom to wash hands F. Observations of Resident 14's room throughout the survey revealed the following: -3/5/19 from 8:36 AM to 12:36 PM, an oxygen concentrator was positioned next to the resident's bed. Oxygen tubing connected to the concentrator was positioned directly on the floor and draped on the side of the concentrator with the end of the tubing and a nasal cannula coiled on top of the concentrator. The oxygen tubing and nasal cannula were uncovered. In addition, a gallon jug of distilled water was stored directly on the floor next to the concentrator. -3/6/19 at 8:20 AM, the oxygen concentrator remained next to the resident's bed. The oxygen tubing was lying directly on the floor between the concentrator and the resident's bed. The end of the oxygen tubing and the oxygen cannula were draped across the resident's bed linens and pillow. G. Observations of Resident 21's room throughout the survey revealed the following: -3/4/19 at 11:25 AM, a nebulizer machine (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) was positioned on top of the bedside dresser. The mask for the nebulizer was connected to the machine and there were droplets of moisture visible on the inside surface. The mask was uncovered and had been wedged in an upright position in the top drawer of the dresser. -3/5/19 at 2:12 PM, the nebulizer machine remained on top of the bedside dresser. The mask remained uncovered and was hanging down the side of the dresser. -3/6/19 at 8:36 AM, the nebulizer machine continued to be stored on the top of the bedside dresser. The nebulizer mask was uncovered and was also stored directly on top of the dresser as well. The mask had been placed in a face down position so the surface of the mask which would come in contact with the resident's face was lying directly on the surface of the dresser. During interview on 3/11/19 at 9:20 AM, the DON verified the facility policy was to rinse the nebulizer mask after each treatment, allow it to dry, then store it in a plastic bag and the oxygen tubing and nasal cannula should always be stored in a plastic bag. In addition, the DON confirmed staff members were expected to remove soiled gloves and wash/sanitize hands following provision of resident cares. H. During observations on 3/5/19 from 7:44 AM until 1:45 PM, the following were observed: -there was a shelf located immediately to the right of the handwashing sink shared by Residents 32 and 25 that had a nebulizer mask and medication receptacle stored uncovered on a washcloth laid on top of the shelf; and -there was a nebulizer mask and medication receptacle stored uncovered on a washcloth laid on the ledge between the window glass pane and the blinds that were drawn closed in Resident 25's room. This practice caused potential contamination of the residents' nebulizer equipment from water spatter and/or other debris.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observation, record review and interview; the facility failed to assess causal factors and/or to develop and implement interventions for the prevention of falls for Residents 62 and 66 who had a history of [REDACTED]. Facility census was 50. Findings are: A. Review of Resident 66's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/15/15 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairments; required extensive assistance with transfers and limited assistance with ambulation; and had no history of falls within 6 months prior to admission. Review of Resident 66's Immediate Plan of Care dated 10/9/15 indicated the resident was at risk for falls related to wandering. Nursing interventions included: -to assist in transfers as needed; -call light available; -assist with mobility, ambulate with walker and remind to use walker; -encourage rest periods daily to avoid overtiring; -use gait belt (a belt placed around a resident's waist to provide a secure and safe hand hold for caregivers to support residents during transfers); - personal alarm (a device that sounds an alarm when the resident stands or changes positions, thus alerting staff to the resident's movements) when in bed or recliner; and -assist to the bathroom every 2 hours. Review of Nursing Progress Notes revealed the following: -10/9/15 at 3:09 PM; resident stands and ambulates short distances in room and rearranges bedding and blankets; reminded to wait for assistance with ambulation; sensor alarm (a type of personal alarm) in place; and -10/10/15 at 3:48 AM; heard chair alarm (a type of personal alarm) go off; resident sitting on the floor in front of the recliner. Review of the Verification of Investigation (VOI) dated 10/10/15 at 3:15 AM indicated Resident 66 was getting up out of the recliner, didn't put the foot rest down, and fell . Documentation further indicated chair alarm applied. Review of the Post Fall Analysis/Plan dated 10/10/15 at 3:15 AM revealed the Possible Causal/Contributing Factors and Observations included New environment, Different chair and used to being up and down and ambulating at home. Documentation further indicated the recommended intervention for prevention of further falls was a chair alarm (already in use prior to the fall). Review of Resident 66's Nursing Progress Notes revealed the following: -10/11/15 at 3:13 AM; slept from 7:30 PM until 9:30 PM; has been in recliner, out in hallway in wheelchair, and in other resident rooms; -10/11/15 at 4:13 AM; became angry and threatening; did not want to be here; went to front door to leave; threatened nurse with cane and attempted to hit nurse with fist; yelling and swearing; pushed wheelchair up and down hallways with all of things in it; refusing to sit in recliner; and -10/11/15 at 1:48 PM; moved today to the West wing (ACU-Alzheimer's Care Unit-a locked area of the facility with the purpose to provide special programming for residents with dementia.); and -10/17/15 at 4:11 PM; at 3:45 PM the resident was heard hollering, the alarm was sounding, the resident's feet were sticking out of the doorway, and the resident was sitting on the floor with blankets in hand and near the recliner; the resident sustained [REDACTED]. Review of the Post Fall Analysis/Plan dated 10/17/15 at 3:45 PM indicated the Possible Causal/Contributing Factors and Observations were dementia, agitation, carrying a heavy quilt and blankets as was going home, and not using the walker for ambulation. Recommendations/Interventions taken to prevent recurrence included New order received for antianxiety medication (used to treat symptoms of anxiety) today and will have physician review medications and behaviors on visit 10/20/15. Review of the Medication Administration Record (MAR) dated 10/2015 indicated a physician's orders [REDACTED]. Documentation on the MAR indicated Resident 66 received Ativan prn at the following times: -10/17/15 at 11:51 AM, 6:03 PM and 11:53 PM. -10/18/15 at 8:06 AM and 9:49 PM. -10/1915 at 2:27 PM and 8:18 PM. -10/20/15 at 8:30 AM and 6:40 PM. Review of Resident 66's Nursing Progress Notes revealed the following: -10/20/15 at 10:11 PM; up and down from wheelchair numerous times, attempted to ambulate and was very unsteady; -10/20/15 at 10:13 PM; stood by the bed and straightening the covers, turned and staggered backward and fell , hitting right arm on the TV stand; sustained a skin tear to the right forearm measuring 5 centimeters (cm) wide x (by) 4 cm long, and right ear had a 1 cm skin tear to the outer edge; complained of pain in the right arm, wrist area, and was sent to the hospital for x-rays; and -10/20/15 at 11:23 PM; returned from the hospital with a fracture of the right wrist and with a splint and sling in place. Review of the VOI dated 10/20/15 at 8:40 PM revealed a detailed description of event/allegation that indicated a staff member was with Resident 66 in the restroom to obtain urine for a urinalysis (a laboratory test of the urine for signs of infection). Documentation further indicated that after the urine specimen was received, the resident was ambulating out of the restroom, lost balance and hit the left ear on the dresser and the right elbow on the door. (This description varied from the description of the same incident documented in the Nursing Progress Notes 10/20/15 at 10:13 PM.) The resident was sent to the emergency room for x-rays and returned with a fractured wrist. Review of the Post Fall Analysis/Plan dated 10/20/15 at 8:40 PM revealed Causal/Contributing Factors and Observations included that the resident was unaware of safety issues, gait was very unsteady, and the resident ambulated with knees bent and was unable to straighten them. Recommendations/Interventions taken to prevent recurrence was Need staff in unit past 2000 (8:00 PM) with charge nurse. During interview with the Interim Director of Nursing (DON) on 10/21/15 the following was revealed: -12:49 PM; reported Resident 66's fall and fracture and presented the completed VOI and Post Fall Analysis/Plan. The DON verified the investigation of Resident 66's fall was complete. -1:39 PM; discussed the discrepancy between the description of Resident 66's fall in the Nursing Progress Notes and the description in the VOI. The DON verified the VOI description was taken entirely from the telephone conversation the DON had with the staff person that reported the fall at the time it occurred, and the Nursing Progress Notes were not reviewed. During observations of Resident 66 the following were noted: -10/21/15 at 2:10 PM; sleeping in bed with bed in the low position, a defined edge mattress, and an alarm device attached; -10/22/15 at 7:11 AM; seated in a wheelchair outside the ACU dining room. The right arm was in a sling and the right hand had dark purple bruising. The resident was confused as to what happened to injure the hand. B. Review of Resident 62's MDS dated [DATE] indicated [DIAGNOSES REDACTED]. The resident displayed the following behaviors: physical behaviors (e.g., hitting, kicking, pushing, scratching, grabbing) directed toward others that occurred 2-4 days, verbal behaviors (e.g., threatening others, screaming at others, cursing at others) that occurred 1-3 days and wandering which occurred 4-6 days. The resident required extensive staff assistance with toileting, transfers and personal cares and was frequently incontinent of bowel and bladder. The assessment identified Resident 62 had no scheduled pain medication regime and the resident received no non-medication interventions for pain. Resident 62 had 2 falls without injury since the previous assessment Review of Resident 62's current Care Plan dated 7/23/15 revealed the resident was at risk for falls related to dementia, agitation and unsteady gait with complaints of knee pain. The resident was identified as easily frustrated and does not like being told what to do. The Care Plan identified the use of personal alarms increased the resident's behaviors. Nursing interventions included the following: -Observe the resident for discomfort and provide with analgesics as ordered for pain management. -Keep environment consistent and room uncluttered. -Monitor the residents whereabouts and for potential safety hazards. -If resident becomes unsteady when walking, hold the resident's hand and help the resident to find a chair to sit in and rest. The resident's Care Plan identified the following falls and interventions: -9/14/15 at 11:30 PM; fall without injury. New interventions to leave a night light on in the resident's bathroom and room and to have Consultant Pharmacist review the resident's current medications. -9/18/15 (no time documented); resident found sitting on the floor by the resident's bed. New interventions included; bed in low position, change current mattress for a scoop mattress (multi-layer foam mattress with raised side bolsters used to help prevent resident from rolling out of bed). -9/19/15 (no time documented); resident found lying on floor by the resident's bed. New intervention for floor mat alarm (mat placed on the floor next to the resident's bed with sensor which alarms when resident places weight on the mat) during the night. Review of Nursing Progress Notes revealed on 8/25/15 at 11:38 PM, Resident 62 was found on the floor next to the resident's bed. The resident indicated the resident was fixing the plumbing. Review of Resident 62's medical record revealed no evidence a Post Fall Analysis/Plan was completed. There was no evidence that causal factors and/or current fall prevention interventions were assessed and no documentation to indicate new interventions were implemented to prevent the reoccurrence of falls. Review of Nursing Progress Notes revealed on 9/14/15 at 11:10 PM, the resident was found lying on the floor of the residents' room. Review of Post Fall Analysis/Plan dated 9/14/15 at 11:30 PM revealed the Possible Causal/Contributing Factors and observations included [DIAGNOSES REDACTED]. Documentation further indicated the recommended intervention for prevention of further falls was a nightlight in the resident's room and bathroom and to have the Pharmacist review the resident's medications. Review of Nursing Progress Notes on 9/18/15 at 9:10 PM, revealed Resident 62 was found sitting on the floor next to the resident's bed. Review of Post Fall Analysis/Plan dated 9/18/15 at 9:30 PM revealed the Possible Causal/Contributing Factors and observations included the resident needed to use the bathroom and the resident was lying in bed, too close to the edge of the bed. Documentation further indicated the recommended intervention for prevention of further falls was for a scoop mattress to the resident's bed and the bed to be kept in the low position. Review of Nursing Progress Notes on 9/19/15 at 10:19 PM, revealed the resident was lying on the floor of the resident's room. Review of Post Fall Analysis/Plan dated 9/19/15 at 10:30 PM revealed the Possible Causal/Contributing Factors and observations included impaired safety awareness and the resident decided to change position. Documentation further indicated the recommendation for a floor mat alarm to be placed next to the resident's bed at night. Review of Nursing Progress Note dated 9/22/15 at 9:46 PM revealed the resident was wandering and was going in and out of other resident's rooms. The resident wandered into another resident's room, attempted to sit on the side of the bed and sat on the floor instead. No injuries were noted. Review of Resident 62's medical record revealed no evidence a Post Fall Analysis/Plan was completed. There was no evidence that causal factors and/or current fall prevention interventions were assessed and no documentation to indicate new interventions were implemented to prevent the reoccurrence of falls. Review of Nursing Progress Note dated 10/5/15 at 10:11 PM revealed staff opened the door to the resident's room and the resident was found lying on the floor. The resident indicated the resident was looking for wrenches. No injuries were noted. Review of Resident 62's medical record revealed no evidence a Post Fall Analysis/Plan was completed. There was no evidence that causal factors and/or current fall prevention interventions were assessed and no documentation to indicate new interventions were implemented to prevent the reoccurrence of falls. During an interview on 10/19/15 from 8:50 AM to 9:00 AM, Licensed Practical Nurse (LPN)-I identified the following responsibilities for a Charge Nurse after a resident falls: -Assess the resident for any injuries -Provide resident with care as needed if any injuries observed -Notification of the resident's physician, family and/or power of attorney of the fall and any potential injuries. Director of Nursing and Administrator also notified depending on the time of day. -Documentation of incident in Nursing Progress Notes and completion of a Post Fall Analysis/Plan. Post Fall Analysis/Plan to be completed by the end of the Charge Nurse's shift and to include causal factors related to why and how the fall occurred and implementation of new interventions to prevent reoccurrence. -Resident's Care Plan to be updated with new interventions for fall prevention and new interventions to be included in report to the next shift. During an interview on 10/20/15 from 2:00 PM to 2:20 PM, the Interim DON confirmed the Charge Nurse was responsible for completion of a Post Fall Analysis/Plan after each resident's fall. The Charge Nurse was to determine potential casual factors for fall and to assess current interventions, then to develop and implement new interventions. The DON verified no Post Fall Analysis was completed after Resident 62's falls on 8/25/15, 9/22/15 and 10/5/15, no causal factors were determined and no new interventions were developed or put into place to prevent ongoing falls.