Every finding on record at Accura Healthcare of O'Neill

Licensure Reference Number 175 NAC 12-006.09Based on record review and interview; the facility failed to implement physicians' orders for Residents 3, 4,12, and 50. The sample size was 12 and the facility census was 45. Findings are: A. Review of the facility policy Provision of Quality Care dated 12/3/25 revealed the facility ensured resident's received treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans and the resident's choices. Qualified persons provided care and treatment in accordance with professional standards of practice, the residents' care plan, and the residents' choice. B. Review of Resident 12's History and Physical dated 12/12/25 revealed the resident's condition had worsened over the past 4-5 days. The resident presented to the provider with fever, chills, sore throat, cough, and a weight change. The resident was subsequently admitted to the hospital. Review of Resident 12's Hospital Discharge Information dated 12/24/25 and provided to the nursing facility at the time of admission revealed the resident was discharged from the hospital on [DATE]. Diagnoses included Pulmonary Hypertension (type of high blood pressure that can damage the blood vessels in the lungs and lead to heart failure), Peptic Ulcer, Weakness, and Chronic Kidney Disease (stage 4-severe). Review of the included laboratory findings for BUN and Creatinine (tests used to determine overall kidney function) dated 12/24/24 revealed an elevated BUN of 38 (normal 7-25) and an elevated Creatinine of 1.9 (normal 0.6 to 1.2). Review of Resident 12's New admission Diagnosis information for the nursing facility dated 12/24/26 and signed by the medical provider revealed a primary diagnosis of Weakness and Chronic Kidney Disease. Review of Resident 12's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated 4/23/25 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Clinically Complex medical conditions, and Renal (kidney) Insufficiency. Review of Resident 12's Care Plan initiated on 12/26/25 revealed the resident had chronic kidney disease (stage 4-severe), and chronic lung disease. A revision on 12/31/25 indicated the resident did not want to be resuscitated. The resident had cognitive impairment and the resident's family chose long term placement in the nursing facility. Review of Resident 12's Progress Notes revealed the following: -on 12/24/26 the resident arrived at the facility in the facility van from the local hospital. The resident was admitted for pneumonia and chronic lung disease and was receiving oxygen. The resident was to receive skilled therapy for strengthening. At 12:21 PM the admission paperwork was completed with family, and the resident chose to not be resuscitated. The hospital nurse report included a report that the resident had declined and weakened over the last few days. -On 1/3/26 at 1:34 AM the resident awoke at midnight and complained of can't breathe. The resident's oxygen saturation was 59% and with repositioning increased to 74-76% (low as normal is 90-100%). The resident was transferred by ambulance to the local hospital at 1:45 AM. -On 1/4/26 at 1:07 PM the hospital reported the resident would not be returning for 4-7 days and had tested positive for Influenza-A. -On 1/8/26 at 11:45 AM the resident returned from the hospital. -On 1/8/26 at 1:24 AM an evaluation revealed the resident had an indwelling catheter in the urinary bladder. -On 1/9/26 at 10:05 PM the resident's doctor was in the facility and ordered oxygen use of 1 liter during the day and 3 liters at night. The resident had reportedly been refusing to get out of bed, refusing therapy and having hallucinations. -On 1/12/26 at 2:40 PM the facility attempted 3 times to get the resident out of bed, however the resident refused. The resident continued to have a urinary catheter and was receiving oxygen. -On 1/13/26 at 1:40 AM the resident continued to refuse therapy. -On 1/13/26 at 5:48 PM the resident's catheter was noted to be blood tinged. -On 1/14/26 at 2:12 PM the resident left the facility for an appointment. -On 1/14/26 at 6:03 PM the facility received an order to stop Lasix (diuretic) and Potassium Chloride (supplement used to replace potassium often depleted by the use of diuretics) and the check a BMP (Basic Metabolic Profile- standard laboratory test to check things including kidney function, fluid balance, and blood glucose levels) in 2 days.-On 1/16/26 at 12:49 PM the resident returned from a urology (medical specialty that treats disorders of the genitourinary (involving the reproduction and urinary) systems) appointment. The orders received were to conduct a voiding trial (urinary catheter removal and assessment of the ability to void effectively after removal). The facility called the urology clinic and requested clarification. There was no evidence ordered lab for the BMP was completed at the facility or the urology clinic. -On 1/19/26 at 8:29 AM the urology clinic called and reported they would fax clarification orders for the voiding trial.-On 1/19/26 at 11:36 PM the note indicated the urinary catheter had been removed at 3:00 PM. -On 1/20/26 at 8:47 AM the resident had not urinated through the night thus the urinary catheter was re-inserted at 6:15 AM and urology was notified. -On 1/21/26 at 9:04 AM the facility noted that after a follow up appointment the facility identified the BMP had not been obtained on 1/16/26 as ordered by urology. In addition, the resident had not received 1 liter of LR (lactated ringers) IV (Intravenous-administered through an intravenous catheter directly into the blood stream) solution used to replace lost fluids and essential electrolytes) also ordered on 1/14/26 and scheduled to be given on 1/15/26 at a 10:00 AM appointment. -On 1/21/26 at 11:03 PM the BMP laboratory findings were reviewed by the physician with a critical high Creatinine of 6.1 thus the resident was transferred to the emergency room (ER). Review of the hospital Resident 12's History and Physical report dated 1/3/26 Assessment included Acute Kidney injury superimposed on chronic kidney disease stage 4. This report was generated from the ER Visit and subsequent hospitalization. Laboratory values revealed the BUN had increased to 52 and the Creatinine had increased to 2.4. In addition, the potassium level was low at 2.9 and the Hemoglobin (blood oxygen carrying capacity) was low at 9.9 with evidence of acute kidney injury. Review of Resident 12's urology appointment and patient plan dated 1/14/26 revealed orders to discontinue the resident's Lasix, and Potassium, and to complete a BMP in 2 days. In addition, the report stated the resident needed 1 liter of LR in the ER treatment room over 4 hours for acute renal failure on 1/15/26 at 10:00 AM. The resident's current creatinine was 3.7 which was well above the usual baseline. Review of Resident 12's History and Physical dated 1/21/26 revealed the resident presented to the ER from the nursing home due to an elevated Creatinine. The resident had been seen by urology on 1/14/26 and had labs drawn, on January 15 the resident was to present to the treatment room for IV fluids but that was not completed. The facility had held the residents' Lasix and Potassium as ordered. Redraw of the resident's blood revealed worsening Creatinine and thus was instructed to present to the ER for evaluation. The resident presented awake and alert and in no acute distress. During an interview on 6/3/26 at 12:49 PM the consultant Registered Nurse (RN) revealed the facility had not completed the ordered lab and/or facilitated the appointment for IV fluids for Resident 12, on 1/15/26 and 1/16/26 and when the labs were completed on 1/21/26 the residents BUN and Creatinine were identified as critically high and the resident required evaluation in the ER. During an interview on 6/3/26 at 1:21 PM regarding Resident 12 RN-K revealed the facility identified through investigation that the order for the IV LR was not put in the computer by an agency nurse. The agency nurse received the order and discontinued the Lasix and Potassium but did not put it in the lab and IV fluid orders in computer. By the time the error was identified the agency nurse was no longer working in the facility. In response the facility re-evaluated the orientation process for agency nurses which included a quick reference for documentation and education that required a triple noting process for new orders. In addition, the Documentation Quick Reference guide for charting included appointment documentation that included documenting where the resident went, who transferred the resident, and new orders and skin conditions. C. Review of Resident 3's Minimum Data Set (MDS-a federally mandated assessment tool used in Care Planning) dated 2/18/26 revealed the resident was admitted [DATE]; was cognitively intact; had diagnoses of Dementia, Anxiety, Depression, Psychotic Disorder, Schizophrenia and Post-Traumatic Stress Disorder; and was independent with dressing, transfers, and hygiene. Review of Resident 3's Care Plan last revised 6/1/26 revealed the resident was independent with dressing, eating, toileting, transfers and personal hygiene; had diagnoses of delusional disorder, anxiety, depression, and schizophrenia; was independent with dressing, toileting, transfers and hygiene; and was able to make needs known. Review of the facility form Pharmacist Recommendation History Report from 6/1/25 through 6/1/26 regarding Resident 3 revealed the following notes: -on 11/6/25 the following laboratory blood tests (labs) were ordered to start on 9/15/25, but there were no results on the chart: Complete Blood Count (CBC-a standard blood test that measures the types and numbers of cells in your blood of [NAME] and Red blood cells, Platelets and Hemoglobin), Comprehensive Metabolic Panel (CMP-a routine blood test that measures kidney and liver function, blood sugar and protein levels), Thyroid Stimulating Hormone (TSH- a blood test to measure thyroid function), and a Vitamin D level (a blood test that measures the amount of Vitamin D in your blood stream); -on 12/3/25 the following lab was ordered on 9/12/26 to be drawn 9/15/26, but no results were on the chart: CBC, CMP, TSH, Vitamin D; and -on 5/5/26 the following lab was ordered September 2025 to be drawn every 6 months, but there were no results on the chart: CBC, CMP, TSH, Vitamin D. Review of the facility form Order Summary Report with active orders dated 6/3/26 revealed Resident 3 had orders for CBC, CMP, TSH, and a Vitamin D level to be drawn every 6 months starting on 9/15/25. Review of Resident 3's Medical Record revealed on 3/3/26 the Resident had a CBC drawn. There was no evidence any of the other labs had been drawn in the resident's Medical Record. Further review revealed no evidence the labs were drawn in September of 2025 or in March of 2026 when they were due. Interview on 6/3/26 at 11:55 AM with the Director of Nursing confirmed the CBC, CMP, TSH, and Vitamin D levels were not drawn in September of 2025 and the CMP, TSH and Vitamin D levels were not drawn in March of 2026 when they were due. D. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of heart failure, Multi-Drug Resistant Organism (MDRO-microorganism which is resistant to multiple antibiotics), anxiety, heart failure, high blood pressure, and depression. Review of a Recommendation History Report for Resident 4 with Monthly Medication Regimen Reviews from 6/25 to 6/26 revealed the Consultant Pharmacist identified on 12/3/25 the resident had an order dated 10/2/25 to have a CMP and a CBC which was to be drawn on 11/1/25. Review of a Pharmacist's Report to Nursing revealed the resident's Primary Care Practitioner (PCP) was notified on 12/18/25 that the CMP and the CBC had not been completed. Further review revealed a new order dated 2/16/26 (4 months since the testing was first ordered) to draw the lab this week. Review of a Nursing Progress Note dated 2/18/26 at 9:37 AM revealed the CBC and the CMP were drawn for Resident 4. During an interview on 6/2/26 at 9:13 AM, the Interim DON confirmed the resident had an order dated 10/1/25 for a CMP and a CBC which was not drawn until 2/18/26. The Pharmacist identified the lab was not drawn with monthly review on 12/3/25. The PCP was notified about the missed lab on 12/18/25 but the missed lab was not addressed and/or drawn until 2/16/26. E. Review of Resident 50's Progress Notes revealed the following: -On 12/3/25 at 10:35 AM a verbal order was received to collect a urinalysis (UA) (a diagnostic lab test that evaluates the urine for an infection) due to altered mental status. -On 12/11/25 at 11:30 AM a UA was obtained and taken to the hospital laboratory (lab). -On 12/16/25 at 11:32 AM a call was placed to the lab to obtain results of the UA. Further review of Resident 50's progress note dated 12/16/2025 revealed addition that was for annual CBC and CMP were drawn and taken to the lab. -On 12/16/25 at 2:36 PM lab results were received from the CBC, CMP, and UA and faxed to the physician. -On 12/16/25 at 6:14 PM a new order was received for an antibiotic, Levaquin 250 mg, for 7 days for a Urinary Tract Infection (UTI). -On 12/17/25 at 8:23 AM the facility was waiting to receive Levaquin 250 mg from the pharmacy. -On 12/18/25 at 1:01 PM the primary care physician was in-house for recertification, no new orders received. -On 12/18/25 at 2:21 PM the physician replied to CBC and CMP results stating no new orders. -On 12/18/25 at 6:32 PM the nurse was notified that the resident was feeling faint and shaking. Blood pressure initially was 212/178, recheck was 148/104. Emergency department was called and updated on the residents' condition. Order was received to transfer the resident by ambulance to the ER. -12/19/25 at 10:55 AM Report received that resident would be returning from the hospital after being treated with IV antibiotic, Levaquin, for pneumonia and UTI. -12/19/25 at 11:45 AM Resident returned to the facility. Review of resident's Treatment Administration Record (TAR) dated 12/25 revealed that a UA was to be obtained on 12/4/25, review of documentation revealed that this was not completed. Review of UA lab results from 12/11/25, (8 days after physician's order was received), revealed a physician's order was received on 12/16/25 for Levaquin 250 mg for 7 days. Review of resident's Medication Administration Record (MAR) dated 12/25 revealed that the resident received one dose of Levaquin 250 mg on 12/18/25, the order was received on 12/16/25. Review of the physician's progress note from 12/18/25 at 3:38 PM revealed that the resident was evaluated by the physician with no new orders received. Review of History and Physical updated 12/18/25 revealed that the resident does have a history of UTI's. Review of the resident's Hospital Discharge Information dated 12/19/25 provided to the nursing facility revealed the resident's diagnosis for treatment was a UTI and Parainfluenza virus pneumonia (respiratory virus). An interview with the DON on 6/3/26 at 11:30 AM confirmed that the UA ordered on 12/3/25 should have been completed within 48 hours of receiving the order, the UA was not collected until 12/11/25, 8 days after the order was received.

License Reference Number 175 NAC 12-006.09(J)(i)(1)Based on observation, record review and interview; the facility failed to implement nutrition measures to prevent ongoing weight loss for Residents 1 and 14. The sample size was 3 and the facility census was 45. Findings are:A. Review of the facility policy Weight and Height Measurement last updated 10/25/21 revealed if a resident gained or lost three or more pounds the resident needed to be reweighed with nurse supervision. If the nurse verified the weight change, then the nurse would notify the physician and nursing leadership. B. Review of Resident 14's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 3/12/26 revealed the resident was admitted on [DATE]; diagnoses included Non-Traumatic Brain Dysfunction, Schizophrenia (a serious mental health condition that affects how people think, feel and behave), Disorder, and Stroke; had severe cognitive impairment; required assistance with setup for eating, and was dependent with oral hygiene, toileting, dressing, and personal hygiene; consumed a mechanically altered diet; and had a weight loss and was not a prescribed weight-loss regimen. Review of Resident 14's Care Plan last revised 6/4/26 revealed the resident had a severe cognitive impairment due to a traumatic brain injury, had behaviors of wandering and staff were to cue the resident to places such as the dining room; was dependent on staff for dressing, grooming, oral cares, and toileting; required set-up assistance with eating; received a mechanical soft diet with thickened liquids and had the potential for altered nutrition and was to receive supplements per the physician orders. Review of the facility form Weights and Vital Summary dated 6/4/26 revealed Resident 14's weights: -12/2/25 (day of admission) 142.3 pounds (lbs); -12/23/25 142.3lbs.; -1/22/26 134.4lbs. (loss of 7.9lbs or 5.55% in 30 days); Record review of Resident 14's practitioners ordered, progress notes, faxes, Registered Dietician assessments revealed there was no indications Resident 14's significant weight loss had been evaluated and interventions implemented to prevent further weight loss. Further review of the facility form Weights and Vital Summary dated 6/4/26 revealed Resident 14's weights: -2/24/26 130.6lbs.; -3/25/26 126.2 lbs. (loss of 16.1lbs or 11.31% in 92 days); -4/22/26 122.4 lbs.; -5/13/26 119.8lbs -5/27/26 (176 days after admission) 120.4lbs (loss of 21.9lbs or 15.39% since admission). Review of Resident 14's Mini Nutritional assessment dated [DATE] revealed a score of 7 which indicated the resident was malnourished. There were no nutritional interventions documented in the assessment. Review of the facility form RD (Registered Dietician) report dated 3/11/26 revealed Resident 14 had a weight loss of 5.4% at 30 days and 12.8% at 90 days after admission with recommendations to start Ensure 4 ounces (oz) every day and the resident's physician was updated through a fax. Review of the RD reports until 6/4/26 revealed no further documentation or follow up for Resident 14's weight loss. There was no documentation that the effectiveness of the Magic Cup had been evaluated. Review of Resident 14's Medication Administration Record (MAR's) for March, April, and May in 2026 revealed an order for a Magic Cup twice a day at noon and 7:00 PM with a start date of 1/31/26. There was no documentation to show the resident was to receive an Ensure supplement. Review of Resident 14's Progress Notes from March 1, 2026 through June 4, 2026 revealed an entry on 3/12/26 at 11:35 AM by the RD that included a recommendation for Ensure 4 oz daily. There was no further documentation by the RD, Dietary Manager, or the Nursing Department related to the ongoing weight loss, Ensure supplementation, or an evaluation of the effect of the Magic Cup supplement. The following observations were made regarding Resident 14: -On 6/1/26 at 12:05 PM the resident was in the sitting room in the front lobby next to the dining room sitting in a recliner. The resident left the area at 12:10 PM. The resident re-entered the dining room at 12:20 PM and went directly to their seat. The resident was served lunch right away and the resident ate most of the meal and drank 1/2 of their thickened juice. There was no evidence that a magic cup or ensure was given to the resident. At 12:25 PM the resident left the dining room again and at 12:30 PM a staff member re-directed the resident back to the dining room table. The resident left the dining room as soon as the staff member walked away. -On 6/1/26 at 12:35 PM The resident was in the resident room resting in the resident bed. There was no evidence of Ensure or a Magic Cup in the resident's room. -On 6/2/26 from 8:05 AM to 8:25 AM The resident was wandering in and out of the dining room, to their room and back to the dining room. Numerous staff redirected the resident back to the dining room and encouraged the resident to eat. The resident did eat all of the breakfast meal during this time period. There were no observations of Ensure or a Magic Cup to have been served to the resident. -On 6/2/26 at 8:35 AM The resident was in their room lying in the resident bed. There were no observations of a Magic Cup or Ensure in the resident room. -On 6/2/26 from 12:10 PM to 12:30 PM The resident ambulated out of the dining room to the sitting room next to the dining room and sat in a recliner. At 12:12 PM the resident left and ambulated towards the resident room. Staff were able to redirect the resident back to the dining room to finish eating several times. No Magic Cup or Ensure were observed to be served to the resident. -On 6/3/26 at 8:00 AM The resident was observed to be ambulating away from the dining room independently. The resident had drank a glass of thickened juice. Staff were observed to redirect the resident back to the table. The resident was served their meal right away. The resident ate 100%. There were no observations of a Magic Cup or Ensure served to the resident. -On 6/3/26 at 12:05 PM the Magic Cup was already signed off in the MAR. At 12:10 PM The resident was ambulating independently towards the dining room and a staff member stopped to ambulate with the resident. The same staff member served the resident their meal right away. No Magic Cup or Ensure were observed to be served. The resident ate all of their meal, got up and ambulated to their room. The resident was lying on the resident bed at 12:15 PM. There were no observations made of a Magic Cup or Ensure in the resident's room. Interview on 6/4/26 at 9:05 AM with Licensed Practical Nurse (LPN)-Q revealed the dietary department was responsible for administering a Magic Cup to Resident 14 with their meals. The nurse was to ensure it was administered and sign it off on the MAR. LPN-Q stated a Magic Cup was the only supplement for the resident. Further interview with LPN-Q revealed the resident was active and wandered to and from meals several times for one meal and required a lot of redirection. Interview on 6/4/26 at 9:25 AM with Cook-D and Dietary Aide (DA)-P revealed the dietary department was responsible for administering the supplements to residents. They were to administer the Magic Cup at breakfast and noon meals (the MAR order was for 12:00 PM and 7:00 PM). DA-P revealed someone else served Resident 14 breakfast on this day and they were unsure if Resident 14 had a Magic Cup administered. Interview on 6/4/26 at 10:10 AM with the Dietary Manager (DM) revealed Resident 14 did have a significant weight loss. Further interview revealed the facility was not holding a weight meeting to review weight losses and interventions. The DM was unaware that the Nursing Department was signing that the Magic Cup was given at 12:00 PM and 7:00 PM but an interview with the [NAME] and Dietary Aide revealed they were giving it at the breakfast and noon meals, the DM was unaware of the recommendation made on 3/12/26 by the RD for Ensure 4oz daily, the DM confirmed interventions were not put into place when the significant weight loss of 12.8% was identified by the RD 90 days after admission, and the DM confirmed the resident continued to lose weight. Interview on 6/4/26 at 10:40 AM with the Registered Nurse (RN) Consultant confirmed Resident 14 did have a significant weight loss of 15.39% and further interview confirmed the facility did not implement interventions to prevent further weight loss. C. Review of Resident 1's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of end stage renal disease, diabetes, and non-Alzheimer's dementia. The assessment identified Resident 1 was receiving dialysis (treatment which removes waste, extra fluids, and toxins from the blood when the kidneys are not working properly); required assistance with eating/drinking; weight was 143 lbs. and the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months. The resident was not on a prescribed weight-loss regimen. Review of Resident 1's current Care Plan last revised on 1/14/26 revealed the resident was at risk for altered nutrition related to diagnosis of Myasthenia Gravis (chronic disorder which affects communication between nerves and muscles leading to muscle weakness and difficulty swallowing), chronic kidney disease/end stage renal disease and diabetes. The following interventions were identified: -1/14/26 initiated fortified food/drink at meals for additional calories. -alert the RD of any changes to skin integrity, significant health changes or decrease in appetite/intakes. -monitor for changes in acceptance of diet and meals. -monitor weight as ordered. Review of the Weights and Vital Summary Form for Resident 1 revealed the following weights: -12/1/25 156 lbs. -1/5/26 144 lbs. (down 12 lbs. or a loss of 8% in 1 month). -1/22/26 140 lbs. (down an additional 4 lbs. in 17 days). Review of a Provider Communication Form from the RD to the resident's Primary Care Provider (PCP) dated 1/28/26 revealed a new recommendation for Glucerna (nutritional supplement with added protein and calories) to be given twice a day until the resident's weight stabilized. The form also indicated the resident was already receiving fortified food/drinks at meals. Review of the residents' MAR dated 2/2026 revealed the resident was to receive the Glucerna at 10:00 AM and at 2:00 PM for weight loss. Further review of the MAR revealed at 10:00 AM the resident refused or was out of the facility and was not offered the supplement 26 out of 28 days. The resident was documented as receiving the supplement on 2/7 and on 2/19 but there was no documentation as to how much supplement was offered and how much the resident had consumed. Review of the documentation for the 2:00 PM administration revealed the resident did not receive or was not available for administration of the supplement 26 out of 28 days. The supplement was provided on 2/6 and on 2/19 but there was no documentation as to how much supplement was offered and how much the resident had consumed. Review of Consulting Dietician Activity Reports for 2/2026 revealed the RD was at the facility on 2/2/26, 2/11/26, and on 2/25/26. Further review revealed no evidence the RD evaluated Resident 1's weight loss or the effectiveness of the weight loss interventions developed. Review of the residents' MAR for 3/2026 revealed at 10:00 AM the resident refused or was unavailable for administration of the nutritional supplement on 23 out of 31 days. The resident received the supplement on 3/8, 3/13, 3/14, 3/15, 3/27, 3/28, 3/29 and on 3/31 but there is no documentation as to how much of the supplement the resident received/consumed. Documentation of the 2:00 PM administration revealed the resident refused or was not available on 23 out of 31 days. The resident received the supplement on 3/8, 3/13, 3/14, 3/15, 3/27, 3/28, 3/29 and on 3/31 but there is no documentation as to how much of the supplement the resident received/consumed. Review of Resident 1's medical record revealed no evidence the resident was assessed by the RD from 3/1/26 to 3/20/26. Review of a Progress Note by the RD on 4/2/26 at 3:43 PM revealed the resident's current body weight was 143 lbs. and the resident had a significant weight loss of 12.3% at 180 days. The RD identified the resident was routinely refusing the Glucerna which was to be provided twice a day. A new recommendation was made to discontinue the Glucerna and to start nutritional supplements Boost Breeze or Ensure Clear 240 cc twice a day. Review of the residents' MAR dated 4/2026 revealed the resident continued to receive the Glucerna nutritional supplement. At 10:00 AM and at 2:00 PM the resident was unavailable or the resident refused the nutritional supplement on 29 out of 30 days. The resident accepted the supplement at 10:00 AM and at 2:00 PM on 4/24 but there is no documentation as to how much of the supplement the resident received/consumed. Review of the residents' MAR dated 5/2026 revealed the resident continued to receive the Glucerna twice a day. The resident refused or was not available at 10:00 AM on 28 out of 31 days. The resident received the supplement on 5/8, 5/16 and on 5/22 but there was no documentation as to the amount of the nutritional supplement the resident was provided and/or consumed. In addition, the resident refused or was not available at 2:00 PM for 28 out of 31 days. The resident received the supplement on 5/8, 5/16 and on 5/21 but there was no documentation as to the amount of the nutritional supplement the resident was provided and/or consumed. Review of the resident's medical record from 4/3/26 to 6/2/26 revealed no evidence the RD assessed the resident's ongoing weight loss or that the RD's recommendation on 4/2/26 to discontinue the Glucerna and to start a different nutritional supplement was ever implemented. Review of Resident 1's Weights and Vitals Summary Form revealed the resident's weight on 6/1/26 was 148 lbs. Review of a list dated 6/4/26 of residents who were to receive fortified food/fluids revealed no evidence Resident 1 was identified on the list. During an interview on 6/2/26 at 2:42 PM, the Nurse Consultant and the Administrator indicated the RD was to assess residents with a weight loss on a monthly basis and ensure recommendations were followed and that they were effective. In addition, they indicated it was difficult to determine the resident's weight status due to the resident receiving dialysis three times a week. Interview with the DM on 6/4/26 at 10:15 AM confirmed the following regarding Resident 1: -a history of ongoing weight loss. -the RD had made a recommendation on 1/28/26 to start the resident on Glucerna twice a day and for the resident to receive fortified foods/drinks. -refused the supplement or did not receive as the resident was not available on multiple occasions throughout 2/2026, and 3/2026. -no evidence the RD assessed the resident from 1/28/26 to 4/2/26. -4/2/26 the RD recommended the Glucerna be discontinued due to multiple refusals and to start Boost Breeze or Ensure Clear. -there was no evidence the RD's recommendations were followed and the resident continued to be offered the Glucerna. -the RD had not assessed the resident since 4/2/26. -there was no evidence the facility had been providing the resident with fortified food/drinks.

Licensure Reference Number 175 NAC 12-006.02(I)Based on record review and interview; the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) plan was effective in addressing recently identified deficient practice and preventing repeat deficient practice with similar concerns. This had the potential to affect all facility residents. The facility census was 45. Findings are: Review of the facility policy Quality Assurance and Performance Improvement Plan (QAPI)/ and Assurance (QAA) dated 5/23/23 revealed the facility developed a process for conducting quality activity and identification and correction of deficiencies as well as opportunities for improvement through continuous attention to quality of care, quality of life, and resident safety. -Principles of the system included outcomes of quality of life and quality of care, accountability for professional performance and practice, identification of process and system gaps, identification of root cause of concerns, timely and clinically sounds services, and a culture that supported performance accountability. -The program encompassed all segments of care and services and aimed for safety and high quality with all clinical interventions, while emphasizing resident autonomy and choices. -Opportunities for improvement identification included but was not limited to the use of regulatory requirements to define and measure goals.-The facility Administrator and DON were designated as the governing body of the QAPI/QAA program and developed a culture that involved staff, resident, and family input, assured adequate resources, developed and completed training as needed, created an atmosphere of comfort that promoted comfort in identifying and reporting problems and opportunities for improvement. -Opportunities for improvement were continuously identified and addressed through monitoring of survey results, complaint investigations, self-reports, identified clinical care concerns, staff competency, errors related to medications, hospitalizations, resident satisfaction, quality measures, and adverse events. -The facility goal was to provide the highest practicable resident services, identification of strengths and weaknesses through consistent monitoring and evaluations. Evaluations were completed with a goal of addressing and improving quality of services provided. Review of the most recent standard survey conducted for the facility dated 5/6/25 revealed citations for resident rights, changes in resident conditions, restraints (chemical/psychotropic medications), quality of care, medication storage, infection control and antibiotic stewardship. During an interview on 6/4/26 at 10:00 AM Registered Nurse (RN)-K who routinely attends the facility QAPI meetings, confirmed the QAPI team discussed previous survey citations through the Plan of Correction (POC) dates and if further concerns were identified, however RN-K was unsure if those concerns had continued to be monitored. During an interview on 6/8/26 at 12:20 PM the facility Administrator confirmed the facility had not employed a long-range QAPI process to ensure that deficient practices identified at the last standard survey on 5/6/25 continued to be monitored through the facility QAPI program. The Administrator further confirmed that concerns related to the previously cited deficient practice (resident rights concerns for comprehensive informed consent for psychotropic medications, quality of care concerns, concerns with gradual dose reductions or documented contraindications for reductions of psychotropic medications/chemical restraints, drug storage concerns, infection control concerns, and antibiotic stewardship) concerns remained.

Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview; the facility failed to obtain the required comprehensive (including an appropriate diagnosis for use, potential affects, adverse effects and alternate treatment options) informed consent for the use of psychotropic (substance that affects how the brain works, altering a person's mood, thoughts, feelings, or behavior) medications for Residents 2, 3, 4, 14, and 29. The sample size was 5 and the facility census was 45. Findings are: A. Review of the facility Resident's Rights undated policy revealed the facility residents had the right to be fully informed, the right to complain, the right to participate in one's own care, the right to make independent choices, the right to privacy and confidentiality, the right to transfer and discharge, the right to respect, dignity, and freedom, and the right to visits. B. Review of the facility policy Use of Psychotropic Medication(s) with a revision date of 4/21/25 revealed the following: -The facility ensured residents only receive psychotropic medications when other nonpharmacological interventions were clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. -Psychotropic medications were used only when a practitioner determined that the medication was appropriate to treat specific, diagnosed, and documented conditions and the medication was beneficial to the resident, as demonstrated by monitoring and documentation or the resident's response. -Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative were informed in advance of the risks and benefits or the proposed care, including any 'black box (warning indicating a particular medication may have severe reactions, the potential for preventable harm, and/or strict usage restrictions) warnings in advance, and treatment alternatives.-Resident had the opportunity to accept or decline the initiation or increase of a psychotropic medication. -The facility documented the resident or resident representative was informed of the risks and benefits, and other treatment options. C. Review of Resident 29's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated5/14/26 revealed the resident had taken antipsychotic and antidepressant medication. There were no documented behaviors. The resident had diagnoses including Alzheimer's dementia, anxiety, depression, and a psychotic disorder. Review of Resident 29's Care Plan dated 12/27/25 revealed the resident had a mood problem related to dementia, anxiety, delusions, and bipolar disorders. The resident took antidepressant and antipsychotic medications, and staff were to observe/document/report adverse effects. Review of Resident 29's Informed Consent for Psychopharmacological (scientific study of how medications and psychoactive drugs affect the mind, brain, and behavior) Medications dated 7/25/24 revealed the resident's current medications included Seroquel (antipsychotic medication), and Lexapro (antidepressant medication). However, there were no indications for what diagnoses or symptoms the resident was receiving the medication, no evidence of potential effects or adverse effects, and/or alternate non-pharmacological treatment options. During an interview on 6/4/26 at 2:00 PM the DON (Director of Nursing) confirmed the facility consents for use of psychotropic medications were not comprehensive and did not include the following: 1). for which symptoms and/or diagnosis/conditions the residents were being treated, 2). potential effects, 3). potential adverse effects, and/or 4). alternate non-pharmacological treatment options. D. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of heart failure, Multi-Drug Resistant Organism (MDRO-microorganism which is resistant to multiple antibiotics), anxiety, and depression. The following was assessed regarding the resident: -cognitively intact. -no behaviors exhibited. -received antipsychotic, antidepressant, anti-anxiety, and opioid medications. Review of Resident 4's undated Informed Consent for Psychopharmacological Medications revealed the resident's medications included Abilify (antipsychotic medication) 5 milligrams (mg) daily, Lexapro (antidepressant medication) 20 mg daily and Klonopin (used to treat anxiety) 0.25 mg twice a day. However, there were no indications for what diagnoses or symptoms the resident was receiving the medications, evidence of potential effects or adverse effects, and/or alternate non-pharmacological treatment options. Review of the facility form Order Summary Report with active orders as of 6/3/26 revealed the resident received Abilify 1 mg daily with a start date of 5/31/25, Klonopin 0.25 mg twice a day with a start date of 4/3/24 and Lexapro 20 mg daily with a start date of 3/26/20. During an interview on 6/3/26 at 3:00 PM, the Registered Nurse (RN) Consultant confirmed that Resident 4's Informed Consent for Psychopharmacological Medications was undated and did not correctly identify the current dosages of the medications the resident was receiving. In addition, the form did not include for which symptoms and/or diagnosis/conditions the resident was being treated, potential effects, potential adverse effects, and/or alternate treatment options. E. Review of Resident 2's MDS dated [DATE] revealed the resident was admitted [DATE]; was cognitively intact; had delusional (having false or unrealistic beliefs or opinions) behaviors; diagnoses included: Non-Traumatic Brain Dysfunction, Anxiety, Bipolar Disorder, and Schizophrenia (a serious mental health condition that affects how people think, feel and behave); and received Antipsychotic, Antianxiety and Antidepressant medications. Review of Resident 2's Care Plan with a revision date of 3/20/26 revealed the resident had a mood disorder and received antidepressant, antianxiety, and antipsychotic medications related to schizophrenia, anxiety disorder, and bipolar disorder. Staff were to monitor, document and report adverse effects. Review of the facility forms Informed Consent for Psychopharmacological Medications dated 10/31/24 revealed the resident's current medications included Haldol (antipsychotic medication), Seroquel, Venlafaxine (antidepressant medication, Klonopin (antianxiety medication) and Ativan (antianxiety medication). There was no evidence of documentation for which diagnoses the medications were given, potential side effects or alternative non-pharmacological treatment options. Interview on 6/4/26 at 12:30 PM with the Registered Nurse (RN) Consultant confirmed the psychotropic medication consents did not have symptoms, behaviors or diagnoses included for which the facility was administering the medications, potential side effects and/or alternative non-pharmacological treatment options. F. Review of Resident 3's MDS dated [DATE] revealed the resident was admitted [DATE]; was cognitively intact; did not exhibit any behaviors; was independent with dressing, toileting and hygiene; had diagnoses of Dementia, Anxiety, Psychotic Disorder, Schizophrenia, and Post-Traumatic Stress Disorder; and received antipsychotic, antianxiety and antidepressant medications. Review of Resident 3's Care Plan last revised 6/1/26 revealed the resident had a mood disorder and received psychotropic medications related to anxiety, delusional disorder and schizophrenia. Staff were to observe and report any adverse side effects. Review of the facility form Order Summary Report with active orders as of 6/3/26 revealed the resident received the following psychotropic medications: -Celexa (an antidepressant medication); -Lorazepam (an antianxiety medication); and -Loxapine (an antipsychotic medication). Review of the facility form Informed Consent Psychopharmacological Medications dated 3/24/25 revealed no evidence of documentation for which diagnoses the medications were given, potential side effects or alternative non-pharmacological treatment options. G. Review of Resident 14's MDS dated [DATE] revealed the resident was admitted [DATE]; had severe cognitive impairment; had behaviors of rejection of care, wandering, and other behaviors not directed towards others; required staff assistance with oral hygiene, toileting, and dressing; diagnoses included: Non-Traumatic Brain Dysfunction, Schizophrenia, and Stroke; and received Antipsychotic, Antianxiety, and Antidepressant medications. Review of Resident 14's Care Plan last revised 6/4/26 revealed the resident had a mood disorder and received psychotropic drugs related to schizophrenia, depression and anxiety. Staff were to observe, document and report adverse effects. Review of the facility form Order Summary Report with active orders as of 6/3/26 revealed the resident received the following psychotropic medications: -Buspirone (anti-anxiety) with a start date of 12/2/25; -Mirtazapine (anti-depressant) with a start date of 2/27/26; and -Olanzapine (anti-psychotic) with a start date of 2/27/26. Review of Resident 14's Medical Record revealed no evidence the facility obtained informed consent for psychotropic medications prior to administration. Interview on 6/4/26 at 12:30 PM with the RN Consultant confirmed staff were to obtain informed consent prior to the administration of antipsychotic medications. Further interview confirmed the facility did not have any evidence of documentation that informed consent was obtained prior to the administration of antipsychotic medications for Resident 14.

Licensure Reference Number 175 NAC 12-006.12 (D)(i)Based on observation, record review and interview; the facility failed to provide safe storage of drugs as: 1) Medications were left on top of the medication cart and unattended, 2) The medication cart was left unlocked with no staff in attendance. This had the potential to affect any mobile resident passing by the medication cart. The facility census was 45.Finding are:A. Review of the facility policy Medication Storage in the Facility with a revised date 11/18 revealed the following:-Medication and biologicals were stored safely, securely, and properly. The medication supply would be accessible only to licensed facility personnel, pharmacy personnel or facility personnel lawfully authorized to administer medications.-Medication rooms, carts, and medication supplies were locked when not attended by people with authorized access. B. An observation on 6/3/26 at 8:00 AM revealed the following:-The medication cart was parked in the hall by the activity room door unlocked and unsupervised with residents ambulating or pushing self in a wheelchair by the medication cart. The following medications were on top of the medication cart:-Preservision (eye vitamin) pills (18 pills).-Iron pills (8 pills).-Multivitamin tablets (15 tablets).-Folic Acid (treats anemia) pills (10 pills).-Senna (laxative) tablets (18 tablets).-Colace (stool softener) capsules (24 capsules).-Aleve (relieves minor aches and pains) (11 pills).-Loratadine (antihistamine) 10 milligram (mg) tablets (5 tablets).-Fish Oil (supports heart health) 500 mg capsules (21 capsules).-Tylenol 325 mg tablets (50 tablets).-Tylenol 650 mg tablets (38 tablets).-Half a bottle of Miralax (laxative).-Acetaminophen 500 mg tablets (42 tablets). -At 8:15 AM (the medication cart was unlocked, unsupervised with medications on top of the cart for 15 minutes) Registered Nurse (RN)-K walked up to the cart to administer medications to residents.-At 8:45 AM RN-K confirmed that when completing the medication pass RN-K would keep the stock medications on top of the medication cart. An interview with RN-K completed on 6/3/26 at 12:40 PM confirmed the following:1) Medications were to be locked when not in the view of a nurse.2) The medication cart was to be locked when not in the view of the nurse administering medications.

Licensure Reference Number 175 NAC 006.11 (E)Based on observation, record review and interview; the facility staff failed to store, prepare and serve food in a manner to prevent the potential for cross contamination and/or food borne illness. These practices had the potential to affect all residents who were served meals from the kitchen. The facility census was 45.Findings are:A. Review of the facility policy Food Storage reviewed 2021 revealed the following:-Leftover food must be used within 7 days or discarded per the 2017 Federal Food Code. -All refrigerated foods would be covered, labeled, dated and routinely monitored to ensure that leftovers would be consumed by their safe use by dates or discarded. Review of the facility policy Cleaning and Sanitation of Dining and Food Service Areas reviewed 2021 revealed the following:-The food and nutrition service staff would maintain the cleanliness and sanitation of the dining and food service areas through compliance with written and comprehensive cleaning schedule.-A cleaning schedule would be posted for all cleaning tasks and staff would initial the tasks when completed. Review of the undated facility Daily Cleaning Checklist revealed staff were to clean the exterior and handles of the walk-in cooler, walk-in freezer and drink refrigerator. Discard expired items. Review of the undated facility Weekly Cleaning Checklist revealed staff were to wipe off shelves weekly. Review of the 2022 version of the Food Code revealed the following:2-402.11 Food employees should wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair that were designed and worn to effectively keep hair from contacting exposed food, clean equipment, utensils, linens and unwrapped single service and single use articles.4-601.11 Nonfood contact surfaces equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. B. An observation conducted during the initial kitchen tour on 6/1/26 from 8:15 AM to 9:15 AM revealed the following prepared outdated food items in the walk-in refrigerator:-A container of chicken salad dated 5/16/26, (16 days between 5/16/26 to 6/1/26).-A container of tuna salad dated 5/19/26, (13 days between 5/19/26 to 6/1/26).-A container of lemon meringue pudding dated 5/20/26, (12 days between 5/20/26 to 6/1/26).-A container of banana pudding dated 5/24/26, (8 days between 5/24/26 to 6/1/26).- At 8:15 AM the Dietary Manager (DM) was in the kitchen preparing sandwiches for the noon meal and did not have a beard restraint on.-At 11:45 AM on 6/1/26 the window blind covering the window across from the grill area had a thick layer of brown particles covering the blinds. The window was open blowing air through the blind; hamburgers were being cooked on the grill area. The DM did not have a beard restraint on when preparing a lettuce salad.-At 12:20 PM a silver-colored wire shelf that was above an open loaf of white bread, an open container of 1) peanut butter, 2) lettuce and 3) tomatoes, was covered with a thick layer of brown particles. Observations completed during the follow-up kitchen sanitation tour on 6/2/26 from 8:05 AM to 8:30 AM revealed the following:-The DM did not have a beard restraint on when serving the breakfast meal.-A large trash can lid was leaning against clean pans. C. An interview on 6/1/26 at 9:30 AM with the DM confirmed that leftover foods were to be disposed of after 7 days of being prepared or opened. An interview with the DM on 6/1/26 at 1:30 PM confirmed that the kitchen staff had a daily, weekly and monthly cleaning list. The daily and weekly cleaning checklist had not been completed for March, April, May and June 2026. The window blinds and shelves should be cleaned weekly. An interview on 6/2/26 at 9:00 AM with the Administrator confirmed that dietary staff were to wear hair restraints including beard and mustache and the trash can lid should not be touching clean items.

Licensure Reference Number 175 NAC 12-006.09.18Based on observations, interview, and record review the facility failed to ensure the facility infection control program was implemented including the use of Enhanced Barrier Precautions ((EBP) -infection control measure in which the use of Personal Protective Equipment (PPE)-specialized gear, clothing, or barrier worn by individuals to protect themselves from hazards such as infection and prevent the spread of infection to others) and Hand Hygiene during the provision of care for Residents 1,4,2,7, and 12. The sample size was 12 and the facility census was 45. Findings are: A. Review of the facility policy Hand Hygiene dated 11/13/24 revealed the facility used proper hand-washing techniques to protect against the spread of infection. Cleaning hands reduced the spread of potentially deadly germs to the resident and reduced the risk of healthcare provider infection. Hand hygiene occurred multiple times during a single care episode following indications, before care or touching of a resident, before putting on and taking off gloves, after contact with body fluids or contaminated surfaces, when hands were visibly soiled, and before moving from a soiled body site to a clean site. B. Review of the facility policy Enhanced Barrier Precautions dated 11/13/24 revealed the policy of the facility was to implement EBP for the prevention of transmission of Multidrug-Resistant Organisms (MDRO's-organisms that over time have become resistant to medications/antibiotics/antifungals that previous were effective in killing that bacteria/fungi). EBP was an infection control intervention designed to reduce the transmission of MDRO's through targeted gown and glove use during high contact resident care. PPE use was followed for residents with chronic wounds, indwelling medical devices, or for those residents infected or colonized (bacteria that are present but not causing harm or illness) with a Center for Disease Control (CDC)-targeted MDRO's. High contact resident care activities included, dressing, bathing, transferring, providing hygiene, changing linens, toileting assistance, device care, and wound care. EBP were used for the duration of a resident's stay in the facility, or until resolution of the wound, or discontinuation of the device that placed the resident at increased risk. C. Review of Resident 12's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 4/23/26 revealed the resident's bladder function was not assessed due to the presence of an indwelling bladder catheter. Review of Resident 12's Care plan dated 2/4/26 revealed the resident had an indwelling urinary catheter for a diagnosis of urinary retention and EBP was to be used during care of the catheter. During an observation of the provision of care for Resident 12 on 6/2/26 at 1:00 AM Nurse Aid (NA)-H and Registered Nurse (RN)-I (Hospice provider) donned gloves but no gowns and then repositioned the resident from the left side to the right side, then checked the resident's skin under an incontinence brief and noted an irregular rash that appeared to be healing on the right hip and thigh area that extended upward toward the resident's mid-lower back. No open areas were observed. The resident was also noted to have a urinary catheter with a drainage bag secured to the resident's left leg. A sign on the residents' door indicated the resident was to be on Enhanced Barrier Precautions. During an interview on 6/2/2026 11:10 AM Interview with Nurse Aide (NA)-G confirmed the NA was aware Resident 12 was on EBP which included the use of gowns and gloves during high contact care episodes including repositioning the resident in bed, however NA-G confirmed not wearing a gown as required. Further interview confirmed despite being aware of EBP the NA rarely had time to put on a gown and had not been monitored by supervising staff to ensure gown use was being implemented. During an interview on 6/4/26 at 2:30 PM Register Nurse (RN)-K confirmed staff were to wear both gown and gloves during catheter and other high contact care provision for Resident 12. D. Review of Resident 2's MDS dated [DATE] revealed the resident was admitted [DATE]; was cognitively intact; was independent with oral hygiene, dressing, and toileting; diagnoses included renal disease, anemia, diabetes, anxiety, bipolar disorder and schizophrenia; received 51% or more of nutrition by feeding tube and received 501 cubic centimeters (cc) of fluids by feeding tube. Review of Resident 2's Care Plan last revised 3/20/26 revealed the resident required a feeding tube for nutrition and hydration related to esophageal strictures; the resident was dependent on staff for the tube feedings, medications, and water flushes; and the resident was on enhanced barrier precautions and staff were to use PPE during cares with the feeding tube. The following observations were made regarding Resident 2: -On 6/1/26 at 10:30 AM The resident was resting in bed with their eyes closed. There was an EBP sign on the residents door, a caddy with PPE was on the residents bathroom door and trash cans to place used PPE in were next to the door on the inside of the room. -On 6/2/26 at 8:30 AM The EBP sign remained on the resident's door, caddy with supplies and trash cans remained inside of the resident's room. -On 6/3/26 at 8:00 AM The EBP sign was noted on the resident's door to the room, a caddy with PPE supplies and the trash cans remained in the resident's room. -On 6/3/26 at 12:00 PM with Licensed Practical Nurse (LPN)-O revealed LPN-O performed hand hygiene, obtained supplies and entered Resident 2's room. LPN-O placed a barrier on the resident's bedside table then placed the supplies on the table. LPN-O performed hand hygiene and applied gloves. No gown was observed to be worn. The resident pulled their feeding tube out from under their shirt and handed it to LPN-O. LPN-O's pants and scrub top were touching the residents bed linens. LPN-O, still not wearing a gown, administered the residents nutrition, water and medications. LPN-O's clothing continued to be touching the residents bed linens throughout the entire treatment. When finished, LPN-O cleaned up their supplies and removed their gloves then exited the resident room. Interview on 6/4/26 at 12:30 PM with the RN Consultant confirmed the resident was supposed to be on EBP and PPE should have been worn during cares with the feeding tube. E. Review of Resident 7's MDS dated [DATE] revealed the resident was admitted on [DATE]; was cognitively intact; was independent with dressing, transfers, and hygiene and was dependent with toileting; had an indwelling catheter; and had diagnoses of renal disease, anxiety, depression, psychotic disorder and respiratory failure. Review of Resident 7's Care Plan last revised 4/2/26 revealed the resident had an indwelling catheter; was independent with dressing, eating, grooming, oral cares, and transfers and was dependent with toileting; and had diagnoses of anxiety, depression, urinary incontinence, weakness and pain. Review of the facility form Order Summary Report with active orders as of 6/3/26 revealed Resident 7 had the following orders: -change the foley catheter monthly with a start date of 2/23/26; -enhanced barrier precautions due to the indwelling foley catheter dated 12/23/26; -ensure catheter cares were completed every shift dated 12/17/26; and -monitor foley catheter output every shift. The following observations were made of Resident 7: -On 6/1/26 at 2:15 PM the resident was sitting in the resident room in a wheelchair with eyes closed. The resident had an EBP sign on the door. An empty supply caddy was noted to be hanging off the bathroom door and there was a trash can right outside of the bathroom with a yellow hazardous bag inside. -On 6/2/26 at 8:25 AM An EBP sign was noted on the resident's door and the PPE caddy on the bathroom door was still empty. -On 6/3/26 at 9:40 AM observation with NA-C. The EBP sign remained on the residents door. The resident was lying in bed. NA-C performed hand hygiene and put on gloves. NA-C did not put a gown on. NA-C still not wearing a gown assisted the resident to roll from their back to the right side to pull their pants down. NA-C's clothing was touching the resident's bed linens. NA-C still not wearing a gown performed catheter cares with appropriate glove changes. When finished, NA-C removed their gloves, performed hand hygiene, applied new gloves then proceeded to empty Resident 7's catheter while still not wearing a gown. NA-C completed appropriate glove changes and hand hygiene throughout the observation. When finished, NA-C cleaned up their supplies and performed hand hygiene upon exiting the resident room. Interview on 6/4/26 at 12:30 PM with the RN Consultant confirmed PPE should be worn with all cares including catheter cares and emptying of the catheter bag for Resident 7. F. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of heart failure, Multi-Drug Resistant Organism (MDRO-microorganism which is resistant to multiple antibiotics), anxiety, heart failure, high blood pressure, and depression. Review of Resident 4's current Care Plan with a revision date of 4/24/26 revealed the resident was on EPB due to an indwelling urinary catheter. Interventions included notifying the physician of any signs of an active infection and using EBP during cares with the catheter. Observations of Resident 4 included the following: -6/1/26 at 9:59 AM, the resident was observed seated in a wheelchair in the resident's room. A privacy bag which contained a urinary catheter drainage bag was hanging from a brace underneath the seat of the wheelchair. A sign had been placed on the outer doorframe of the resident's room which indicated the resident was on EBP. A storage caddy was hanging from the bathroom door which contained disposable gloves and gowns. -6/2/26 at 10:07 AM, the resident was seated in a wheelchair in the resident's room. Bath Aide (BA)-F without completing hand hygiene and without use of gloves or an isolation gown, positioned a walker in front of the wheelchair and placed a gait belt on the resident. A privacy bag with the urinary catheter drainage bag was tied to a brace under the seat of the wheelchair. BA-F removed the privacy bag from the wheelchair and tied the bag to a lower brace of the walker. Resident 4 stood and then ambulated from the resident's room to the bath house. Still without use of disposable gown or gloves, BA-F lowered the resident's slacks and removed an incontinence brief from the resident. A shower chair was behind the resident and the resident was lowered onto the chair. Without performing hand hygiene, NA placed on clean gloves but still did not utilize a gown, removed the drainage bag from the privacy bag, and removed the edema wear/leg wraps to the resident's bilateral lower legs. BA-F removed gloves and still without completing hand hygiene placed on clean gloves then positioned the resident to begin the shower. BA-F failed to utilize a disposable gown throughout the observation. During an interview on 6/2/26 at 11:02 AM, BA-F confirmed the resident had an indwelling urinary catheter and was to be on EBP. BA-F further confirmed failure to use the required PPE when giving the resident a shower/handling the resident's catheter and to perform hand hygiene before beginning cares with the resident, before putting on clean gloves and when removing soiled gloves.

Licensure Reference Number 175 NAC 12-006.18 Based on record review and interview; the facility failed to implement their Antibiotic Stewardship Plan to ensure antibiotics had a defined duration of use to prevent potential adverse consequences for Residents 28, 29, and 48. The sample size was 12 and the facility census was 45. Findings are: A. Review of the facility Antibiotic Stewardship Plan dated 11/13/24 revealed the facility plan optimized the treatment of infections by ensuring that residents who required antibiotics, were prescribed the appropriate antibiotic, reducing the risk of adverse effects, including the development of antibiotic resistance organisms, from unnecessary or inappropriate antibiotic use, and to improve resident outcomes. This included surveillance, monitoring and preventative measures to improve outcomes. Antibiotics were prescribed for the correct indication, dose and duration to appropriately treat the resident while also attempting to reduce the development of resistive organisms. B. Review of Resident 29's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated 5/14/26 revealed medication taken included antibiotics. The resident was frequently incontinent of bladder, involuntary of bowel and was dependent for toileting hygiene. Review of Resident 29's Care Plan with a revision date of 2/25/26 revealed no evidence that the resident was being treated with an antibiotic for any active infection. Review of Resident 29's Order Summary Report dated 6/3/26 revealed the resident had an order for the antibiotic Cephalexin 500mg daily for prophylaxis for Urinary Tract Infections (UTI's) started on 4/29/26, however there was no defined duration for use or scheduled review date. Review of Resident 29's Medication Administration Record (MAR) dated June 2026, revealed the resident received the antibiotic Cephalexin 500mg daily starting 4/29/26. During an interview on 6/4/26 at 2:10 PM the DON (Director of Nursing) confirmed Resident 29's Cephalexin was an antibiotic ordered for prophylaxis (prevention of infection) due to the resident's chronic UTI's, however there was no stop or review date in accordance with the facility Antibiotic Stewardship Program. C. Review of Resident 28's Order Summary Report dated 6/4/26 revealed the resident had an order for the antibiotic Trimethoprim 100 mg daily for prophylactic initiated 9/3/25, however there was no defined duration for use. Review of Resident 28's MAR dated 6/1/26 revealed the resident received the antibiotic Trimethoprim 100 mg daily starting 9/3/25. Review of Resident 28's Care Plan with a revision date of 3/12/26 revealed no evidence that the resident was being treated with an antibiotic for an active infection. D. Review of Resident 48's Order Summary Report dated 6/4/26 revealed that the resident received the antibiotic Minocycline Hydrochloride 100 mg by mouth two times a day for osteomyelitis (painful infection and inflammation of the bone) initiated 6/1/26, however there was no defined duration for use. Review of Resident 48's MAR dated 6/1/26 revealed that the resident received the antibiotic Minocycline Hydrochloride 100 mg by mouth two times a day starting 6/1/26. Review of Resident 48's Care Plan revealed that the resident was admitted on [DATE] with the diagnosis of Alzheimer's disease. No evidence was found that the resident was being treated for an active infection. An interview with the DON on 6/4/26 at 10:55 AM confirmed that Resident 28's Trimethoprim was an antibiotic ordered for prophylaxis and Resident 48 received the antibiotic Minocycline Hydrochloride for osteomyelitis, however there was not stop date for the antibiotics. The antibiotic orders did not meet the facilities Antibiotic Stewardship program.

Licensure Reference Number 175 NAC 12-006.09ABased on record review and interview; the facility failed to complete an updated Preadmission Screening and Resident Review (PASRR-federally mandated screen used to ensure persons with SMI (Serious Mental Illness), DD (Developmental Disability), or Related Conditions (RC) are appropriately placed in facilities that are able to provide needed specialized services) when Resident 5 was diagnosed with Bipolar Disorder and Schizophrenia. The sample size was 12 and the facility census was 45.Findings are: Review of Resident 5's Level 1 PASARR screen dated 1/29/25 revealed the resident had trouble concentrating, persistence and pacing such as serious difficulty maintaining sustained focus or attention for a long period of time to permit task completion or structures activity. In addition, the resident had a diagnosis of Dementia/Neurocognitive Disorder, Alzheimer's Disease, or an Organic Disorder. There was no indication the resident had signs of a SMI, DD, or RC. Review of Resident 5's Care Plan with a revision date of 2/5/25 revealed the resident had a traumatic response to seeing self in the mirror. In addition, the resident had a history of a Traumatic Brain Injury (TBI), Alzheimer's Dementia with agitation, Depression, Bipolar Disorder and Schizophrenia. There was no evidence the resident had a PASARR level 2 (further assessment conducted to determine if the resident was appropriately placed in the facility and if the resident required any additional specialized services) screen.Review of a Note to the Attending Physician/Prescriber for Resident 5 dated 2/25/25 requested a diagnosis for the use of the antipsychotic medication Risperdal had a documented response that the resident had a diagnosis of Schizophrenia, and agitation/aggression associated with Schizophrenia and/or Bipolar Mania. Review of a Note to the Attending Physician/Prescriber for Resident 5 dated 4/10/25 requested a diagnosis for the use of the antipsychotic medication Risperdal had a documented response that the resident had a diagnosis of Bipolar, agitation/aggression associated with Schizophrenia or Bipolar Mania and a Delusional Disorder. Review of Resident 5's Medication Administration Record (MAR) dated June of 2026 revealed the resident took the antipsychotic medication Risperidone to treat agitation and aggression related to Bipolar Disorder, the antidepressant medication Sertraline to treat depression, and the antianxiety medication lorazepam to treat restlessness.During an interview on 6/2/26 at 12:55 PM the Social Services Director (SSD) confirmed Resident 5's PASARR was not reviewed when the resident was diagnosed with Schizophrenia and/or Bipolar Disorder to determine if the resident required a Level 2 assessment. During an interview on 6/4/26 at 2:15 PM the Register Nurse (RN) Consultant confirmed the facility did not have a written policy for PASARR assessments, however the facility followed Federal regulations and guidelines and should have completed a new assessment when Resident 5 was diagnosed with Schizophrenia and Bipolar Disorder.

Based on observation, record review and interview; the facility failed to administer immunizations as requested to 1 of 5 sampled residents. The facility census was 45.Findings are:Review of Resident 14's Acknowledgement of Vaccination Consent for Influenza, Pneumovax, and Covid revealed that the resident's guardian signed a consent on 12/4/25 for Resident 14 to receive the Influenza vaccine, the Pneumococcal vaccine and the Covid vaccine.Review of Resident 14's admission Order Clarification Order revealed that the physician signed an order on 12/5//25 stating to administer the Pneumovax, Influenza and Covid vaccine.Review of Resident 14's Immunization Record revealed that the resident had not received the Influenza, Pneumovax and Covid vaccine.An interview on 6/4/26 at 10:15 AM with the Director of Nursing confirmed that Resident 14 had not received the Pneumovax, Influenza and Covid vaccine ordered on 12/5/25.

Licensure Reference Number 175 NAC 12-006.05Based on record review and interview; the facility failed to complete Gradual Dose reductions or have documented contraindications for Resident 3's antidepressant. The sample size was 5 and the facility census was 45. Findings are:A. Review of the facility policy Use of Psychotropic Medication(s) with a revision date of 4/21/25 revealed the following:-the facility ensured residents only receive psychotropic medications when other nonpharmacological interventions were clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint; -psychotropic medications were used only when a practitioner determined that the medication was appropriate to treat specific, diagnosed, and documented conditions and the medication was beneficial to the resident, as demonstrated by monitoring and documentation or the resident's response;-prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative were informed in advance of the risks and benefits or the proposed care, including any 'black box (warning indicating a particular medication may have severe reactions, the potential for preventable harm, and/or strict usage restrictions) warnings in advance, and treatment alternatives;-residents had the opportunity to accept or decline the initiation or increase of a psychotropic medication;-the facility documented the resident or resident representative was informed of the risks and benefits, other treatment options; and-residents who use psychotropic medications would receive gradual dose reductions, unless clinically contraindicated. B. Review of Resident 3's Minimum Data Set (MDS- a federally mandated assessment tool used in Care Planning) dated 4/30/26 revealed the resident was admitted [DATE]; was cognitively intact; did not exhibit any behaviors; was independent with dressing, toileting and hygiene; had diagnoses of Dementia, Anxiety, Psychotic Disorder, Schizophrenia, and Post-Traumatic Stress Disorder; and received antipsychotic, antianxiety and antidepressant medications. Review of Resident 3's Care Plan last revised 6/1/26 revealed the resident had a mood disorder and received psychotropic medications related to anxiety, delusional disorder and schizophrenia. Staff were to observe and report any adverse side effects. Review of the facility form Order Summary Report with active orders as of 6/3/26 revealed Resident 3 received Celexa (an antidepressant medication) and Lorazepam (an antianxiety medication).Review of the following facsimiles (fax) related to Resident 3 revealed:-on 12/3/25 a Gradual Dose Reduction (GDR) was sent to the provider for Celexa. The provider denied a request for a GDR. The provider documented Keep Same. There was no evidence that a resident specific clinical rationale was documented; and-on 12/3/25 a GDR was sent to the provider for Lorazepam. The provider denied the request for the GDR. The provider documented Keep Same. There was no evidence that a resident specific clinical rationale was documented. Interview on 6/4/26 at 12:30 PM with the Registered Nurse (RN) Consultant confirmed the resident was receiving psychotropic medications of antidepressant and antianxiety. Further interview confirmed there was no evidence a clinical rationale for the contraindicated GDR was documented.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(iv)(1)Based on observations, record review, and interview; the facility failed to provide appropriate care and services for the management of Resident 4's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) to prevent the potential for infections. The sample size was 3 and the facility census was 45.Findings are:A. Review of the facility policy titled Catheter Care with a revision date of 11/13/24 indicated a goal to prevent urinary tract infections and to maintain proper functioning of the urinary drainage system. B. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/13/26 revealed the resident was admitted [DATE] with diagnoses of heart failure, Multi-Drug Resistant Organism (MDRO-microorganism which is resistant to multiple antibiotics), anxiety, heart failure, high blood pressure, and depression.Review of Resident 4's current Care Plan with a revision date of 4/24/26 revealed the resident had an indwelling urinary catheter and identified the following interventions:-change the catheter as directed by the resident's physician.-monitor for signs of a urinary tract infection (UTI) such as decreased urine output, odorous urine smell, leakage around the catheter, dark urine, and any complaints of discomfort related to the catheter.-provide catheter cares twice a day. Review of an Order Summary Report with active orders as of 6/3/26 revealed the following orders related to the resident's indwelling catheter:-ensure catheter cares are completed each shift.-change catheter every 30 days for infection control or with dislodgement.-monitor catheter output each shift. Observations of Resident 4 included the following:-6/1/26 at 9:59 AM, the resident was observed seated in a wheelchair in the resident's room. A privacy bag which contained a urinary catheter drainage bag was hanging from a brace underneath the seat of the wheelchair.-6/1/26 at 11:59 AM, the resident was independent with wheelchair mobility from the residents' room to the dining room. The resident's urinary catheter drainage bag was covered with a privacy bag which remained underneath of the resident's wheelchair seat. The urine to the catheter drainage tube was cloudy with a milky like discharge and was in direct contact with the floor in the corridors and then the dining room. -6/2/26 at 10:07 AM, the resident was seated in a wheelchair in the resident's room. Bath Aide (BA)-F positioned a walker in front of the resident, removed the privacy bag with the urinary catheter drainage bag from the wheelchair and tied the bag to a lower brace of the walker. Resident 4 stood and then ambulated from the resident's room to the bath house. BA-F lowered the resident's slacks and removed a lightly soiled incontinence brief from the resident and assisted the resident onto a shower chair. BA-F removed the drainage bag from the privacy bag and indicated there was no hanging hook at the top of the bag to use with positioning the catheter bag. Resident 4 commented it probably came off when someone wheeled over top of it. BA-F then placed the catheter drainage bag directly on the floor of the shower room. As BA-F picked up the soiled brief and slacks, BA-F stepped directly on top of the drainage bag. BA-F left the catheter drainage bag on the floor throughout the resident's shower. -6/3/26 at 11:52 AM, the resident was independent with wheelchair mobility from the resident's room to the dining room. The catheter drainage tube was in direct contact with the floor from the resident's room, in the corridors and the dining room.-6/4/26 at 7:57 AM, the resident was independent with wheelchair mobility from the resident's room to the dining room. The urinary catheter drainage tube was in direct contact with the floor in the corridor and in the dining room. During an interview on 6/2/26 at 11:02 AM, BA-F confirmed the resident had an indwelling urinary catheter and confirmed the urinary catheter drainage bag and the drainage tube should not have come in direct contact with the floor of the resident's room, the shower room, the corridors, or the dining room.

Licensure Reference Number 175 NAC 12-006.09(E)Based on record review and interview; the facility failed to develop and implement and/or review and revise a Comprehensive Care Plan for resident 7's Enhanced Barrier Precautions. The sample size was 3 and the facility census was 45.Findings are:Review of the facility policy Comprehensive Care Plan last updated 12/3/25 revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident and included the following:-the comprehensive care plan would be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) assessment:-any services that would otherwise be furnished, but were not provided due to the resident exercising their rights;-resident specific interventions that reflected the resident's needs and preferences;-the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment; and-the care plan would be updated in a timely manner to ensure that services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident 7's MDS dated [DATE] revealed the resident was admitted on [DATE]; was cognitively intact; was independent with dressing, transfers, and hygiene and was dependent with toileting; had an indwelling catheter; and had diagnoses of renal disease, anxiety, depression, psychotic disorder and respiratory failure. Review of the facility form Order Summary Report with active orders as of 6/3/26 revealed Resident 7 had the following orders:-change the foley catheter monthly with a start date of 2/23/26;-Enhanced Barrier Precautions (EBP) due to the indwelling foley catheter dated 12/23/26;-ensure catheter cares were completed every shift dated 12/17/26; and-monitor foley catheter output every shift. Review of Resident 7's Care Plan last revised 4/2/26 revealed the resident had an indwelling catheter; was independent with dressing, eating, grooming, oral cares, and transfers and was dependent with toileting; and had diagnoses of anxiety, depression, urinary incontinence, weakness and pain. There was no evidence of documentation that the resident had EBP implemented. Interview on 6/4/26 at 10:00 AM with Registered Nurse- K revealed the resident did have an indwelling catheter. Further interview confirmed the resident was on EBP and that EBP was not included in Resident 7's Care Plan.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview; the facility failed to report the potential neglect of Resident 12 (not receiving laboratory work as ordered and IV (Intravenous-administered through an intravenous (placed in a vein) catheter (fluids or medications)) to the State Agency as required. The sample size was 12 and the facility census was 45. Findings are: Review of the facility policy Vulnerable Adult dated 10/19/22 revealed the facility supported zero tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of resident property. The facility reported maltreatment of vulnerable adults in compliance of requirements included suspected abuse. The process included identification, recognition, and reporting. The facility description of neglect was the facility failure to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Reports were made to Department of Health and Human Services (DHHS)/Adult Protective Services (APS) by the facility Administrator or Director or Nursing (DON). Review of Resident 12's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated 4/23/25 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Clinically Complex medical conditions, and Renal (kidney) Insufficiency. Review of Resident 12's Care Plan initiated on 12/26/25 revealed the resident had severe chronic kidney disease (stage 4-severe), and chronic lung disease. A revision on 12/31/25 indicated the resident did not want to be resuscitated. The resident had cognitive impairment and the resident's family chose long term placement in the nursing facility. Review of Resident 12's Progress Notes revealed the following:-On 1/14/26 at 6:03 PM the facility received an order to stop Lasix (diuretic) and Potassium Chloride (supplement used to replace potassium often depleted by the use of diuretics) and the check a BMP (Basic Metabolic Profile- standard laboratory (lab) test to check things including kidney function, fluid balance, and blood glucose levels) in 2 days.-On 1/16/26 at 12:49 PM the resident returned from a urology (medical specialty that treats disorders of the genitourinary (involving the reproduction and urinary systems) appointment. There was no evidence ordered lab for the BMP was completed at the facility or the urology clinic. -On 1/21/26 at 9:04 AM the facility noted that after a follow up appointment the facility identified the BMP had not been obtained on 1/16/26 as ordered by urology. In addition, the resident had not received 1 liter of LR (lactated ringers- IV solution used to replace lost fluids and essential electrolytes) also ordered on 1/14/26 and scheduled to be given on 1/15/26 at a 10:00 AM appointment.-On 1/21/26 at 11:03 PM the BMP laboratory findings were reviewed by the physician with a critical high Creatinine of 6.1 thus the resident was transferred to the emergency room (ER). Review of the facility reports to the State Agency from 6/1/25 through 6/1/26 revealed no evidence of a report containing information about Resident 12's not having received ordered labs or IV fluids in January 2026. During a phone interview on 6/3/26 at 2:24 PM the facility Administrator confirmed that after the missed orders and labs for resident 12 were identified, the facility investigated and determined an agency staff member had not processed physician's orders according to facility protocol thus the facility implemented forms for Agency Staff orientation that included multiple areas to ensure facility processes were being followed. This included a check list and multiple forms for review with the most notable being the facility process to triple note new orders with the nurse receiving the order and then with the oncoming nurse for the next shift. A review was then conducted by the facility Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop careplans)/Care plan Registered Nurse (RN), and then a final review by the Director of Nursing (DON) before the order was sent to medical records for scanning to the electronic medical records. Further interview confirmed the facility had received a notification from the hospital when the resident was discharged back to the facility following treatment for the critically high lab findings. The hospital after identifying the error reported the concern to Adult Protective Services (APS). The Administrator also confirmed that a representative from APS was at the facility and conducted an investigation, however, the facility did not report the potential abuse/neglect (significant error of a laboratory omission and IV fluids not given), investigation and findings to the State Agency as required.

Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview, the facility failed to ensure background checks through the State Nurse Aide registry were completed on 2 of 5 sampled employees. The facility census was 45 with a total sample size of 25. Findings are:A. Review of the facility policy titled Vulnerable Adult updated 10/19/22 revealed the facility supported zero tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of resident property. All potential employees were to receive a background check and verification of certification status for nursing assistants. The facility would not employee or otherwise engage individuals who:-had been found guilty of abuse, neglect, exploitation. Misappropriation of property or mistreatment by a court of law.-had a finding entered into the State Nurse Aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property.-had a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. B. Review of 5 employee files on 6/2/26 revealed no evidence Van Driver-U (hired 4/15/26) and Universal Worker-V (hired 4/29/26) had background checks completed through the State Nurse Aide registry at the time they were hired. During an interview on 6/3/26 at 9:28 AM the Business Office Manager confirmed the facility was not checking the Nurse Aide/Medication Aide Registry for negative finding for all newly employed staff.

Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview; the facility failed to complete gradual dose reductions or have documented contraindications for antipsychotic medications for Residents 3 and 4. The sample size was 5 and the facility census was 45. Findings are:A. Review of the facility policy Use of Psychotropic Medication(s) with a revision date of 4/21/25 revealed the following: -the facility ensured residents only receive psychotropic medications when other nonpharmacological interventions were clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint; -psychotropic medications were used only when a practitioner determined that the medication was appropriate to treat specific, diagnosed, and documented conditions and the medication was beneficial to the resident, as demonstrated by monitoring and documentation or the resident's response; -prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative were informed in advance of the risks and benefits or the proposed care, including any 'black box (warning indicating a particular medication may have severe reactions, the potential for preventable harm, and/or strict usage restrictions) warnings in advance, and treatment alternatives; -residents had the opportunity to accept or decline the initiation or increase of a psychotropic medication; -the facility documented the resident or resident representative was informed of the risks and benefits, other treatment options; and -residents who use psychotropic medications would receive gradual dose reductions, unless clinically contraindicated. B. Review of Resident 3's Minimum Data Set (MDS- a federally mandated assessment tool used in Care Planning) dated 4/30/26 revealed the resident was admitted [DATE]; was cognitively intact; did not exhibit any behaviors; was independent with dressing, toileting and hygiene; had diagnoses of Dementia, Anxiety, Psychotic Disorder, Schizophrenia, and Post-Traumatic Stress Disorder; and received antipsychotic, antianxiety and antidepressant medications. Review of Resident 3's Care Plan last revised 6/1/26 revealed the resident had a mood disorder and received psychotropic medications related to anxiety, delusional disorder and schizophrenia. Staff were to observe and report any adverse side effects. Review of the facility form Order Summary Report with active orders as of 6/3/26 revealed Resident 3 received Loxapine (an antipsychotic medication) with a start date of 3/31/25. Review of the facsimile (fax) related to Resident 3 revealed on 8/6/25 a Gradual Dose Reduction (GDR) was sent to the provider for Loxapine. The provider denied a request for a GDR. There was no evidence that a resident specific clinical rationale was documented. Interview on 6/4/26 at 12:30 PM with the Registered Nurse (RN) Consultant confirmed the resident was receiving an antipsychotic medication and further interview confirmed there was no evidence a clinical rationale for the contraindicated GDR was documented. C. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of heart failure, Multi-Drug Resistant Organism (MDRO-microorganism which is resistant to multiple antibiotics), anxiety, and depression. The following was assessed regarding the resident: -cognitively intact. -no behaviors exhibited. -received antipsychotic, antidepressant, anti-anxiety, and opioid medications. Review of Resident 4's current Care Plan last revised 3/6/26 revealed the resident had a recurrent depressive disorder, mixed anxiety disorder, and mood disorder. Staff were to monitor and document target behaviors; educate the resident of the possible outcomes of not complying with cares and treatments; provide opportunities for choices; and allow time to talk and express feelings. Review of the facility form Order Summary Report with active orders as of 6/3/26 revealed the resident received Abilify (an antipsychotic medication) 1 milligram (mg) daily with a start date of 5/31/25. Review of the Recommendation History Report from the Consultant Pharmacist with Monthly Medication Reviews (MMR) revealed a recommendation on 1/2/26 for a GDR of the residents' Abilify 1 mg daily to reach the minimum effective dose. If the GRD was denied a request was made for documentation by the Primary Care Provider (PCP) that the risk versus the benefits were considered with individualized rationale for why the medications was medically necessary at the current dose. Review of the Consultant Pharmacist MMR dated 2/2/26 revealed no response was found in the resident's medical record regarding the recommendation of a GDR for the Abilify 1 mg daily made on 1/2/26. Review of the Consultant Pharmacist MMR dated 3/2/26 revealed Resident 4's PCP had still not addressed a GDR of the resident's Abilify 1 mg daily. Interview on 6/3/26 at 3:00 PM with the RN Consultant confirmed the resident continued to receive Abilify 1 mg daily. The Consultant Pharmacist had made recommendations for a dose reduction of the medication on 1/2/26, 2/2/26 and again on 3/2/26 but there was no evidence the resident's PCP had addressed the pharmacists' recommendations.

Licensure Reference Number 175 NAC 12-006.02(H). Based on observation, interview and record review the facility staff failed to report an elopement to the State Agency within the required timeframes for 1(Resident 1) of 3 residents sampled. The facility census was 46. The findings are:The findings are:Record review of the facility's undated policy titled Reporting requirements revealed whomever identifies or is notified first at the community that there is a potential self-report of any type should notify the Director of Nursing (DON) and Administrator immediately after ensuring safety of residents and staff. The administrator and/or DON will notify police for any physical or potential physical abuse. The Administrator or DON will notify the Clinical Specialist who will communicate the decision to report or not report. The Administrator/DON will work with the Clinical Nurse Specialist on the initial and 5-day investigation. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff had assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 5. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment.-required total assistance with toileting-required extensive assistance with dressing and hygiene-could walk 150 feet independently. Record review of Resident 1's Progress Notes (PN) dated 2-21-2026 revealed Resident 1 had opened the back door of the facility and went out into the parking lot. The alarm on the door did sound and Resident 1 was redirected back into the facility.An interview conducted with Nursing Assistant (NA) on 02-26-2026 at 10 AM revealed NA A heard a door alarm, checked the front door and saw no one going out the door and then went to the backdoor and it was closed, when NA A opened the back door Resident 1 was observed walking in the back parking lot.Record review of the facility's reports to the state agency revealed the elopement was not reported in the required timeframes.Interview with the Director of Nursing (DON) conducted on 02-26-2026 at 2:00 PM confirmed the facility had not reported the elopement to the state agency and should have.

Licensure Reference Number 175 NAC 12-006.18 Based on record review and interview; the facility failed to implement an Antibiotic Stewardship (coordinated plan aimed at optimizing antibiotic use to prevent resistance, unnecessary exposure, and adverse outcomes) Plan to identify if the facility use of antibiotic was within the criteria defined to prevent the overuse or unnecessary use, of antibiotics and/or to prevent potential adverse outcomes. This had the potential to affect all residents residing within the facility. The facility census was 45. Findings are: A record review of the facility Antibiotic Prescribing Practices dated 10/2019 revealed that antibiotic use protocols, including prescribing practices, were implemented as part of the facilities Antibiotic Stewardship Program for the purpose of optimizing treatment of infections and reducing adverse effects associated with antibiotic use. A record review of the facility Antibiotic Stewardship Policy dated 3/2023 revealed the facility implemented an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The program's purpose was to optimize the treatment of infections while reducing adverse events associated with antibiotic use. The facility Infection Preventionist led the Antibiotic Stewardship Program with administrative support, coordinated antibiotic stewardship activities, maintained documentation and served as a staff resource. The program utilized protocols and a system to monitor antibiotic use, including completing infection screening evaluations, laboratory testing in accordance with standard of practice, and monitoring antibiotic use including data collection forms, process, and outcome measures. A record review of the facility's Infection Surveillance dated May 2024 through May 2025 revealed no culture (identifying present bacteria for analysis) results, no pathogen (an organism causing disease) data, and no review to determine if antibiotic use/prescribing criteria had been met. During an interview on 5/1/25 at 2:43 PM the Infection Preventionist (IP) confirmed the facility had not identified, tracked, or trended the organisms identified through laboratory testing to determine if antibiotic use was appropriate or meeting the identified treatment criteria for antibiotic use.

Licensure Reference Number 175 NAC 12-006.09 Based on observations, record review, and interviews; the facility failed to ensure laboratory work was obtained in a timely manner for Resident 10; to monitor Resident 33's fluid restriction; to follow Resident 33's physician orders related to eye drops and the resident's edema wear; to assess Resident 40's wound; and to follow Residents 23 and 196's physician orders regarding medications. The sample size was 5 and the facility census was 45. Findings are: A. A record review of the facility policy Provision of Physician Ordered Services dated September 2024 revealed the following: -the facility would maintain a schedule of diagnostic tests (such as laboratory) in accordance with the physician's orders, -qualified nursing personnel would submit timely requests for physician ordered services to the appropriate entity, -qualified nursing personnel would receive and review the diagnostic test reports and communicate the result with the ordering practitioner within 24 hours of receipt, and -documentation of diagnostic tests, results, and date/time of physician notification would be maintained in the resident's medical record. A record review of Resident 10's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 4/24/25 revealed the resident had a serious mental illness, was cognitively intact, had moderate depression, exhibited verbal behaviors, was independent with activities of daily living, and diagnoses included anemia, schizophrenia, dementia, anxiety, and depression. A record review of Resident 10's Care Plan last revised 4/24/25 revealed the resident was independent with activities of daily living; had diagnoses of schizophrenia, anxiety, and depression; and staff were to obtain lab work per orders and notify the physician of the results. A record review of the facility form Order Summary dated 2/27/25 for Resident 10 revealed orders were received for blood tests: a Hemoglobin A1C (measures the average blood sugar level over a 3 month time period), Complete Blood Count (CBC- analyzes the size and quality of blood cells), Basic Metabolic Panel (BMP-measures fluid balance, electrolytes and kidney function), Thyroid-Stimulating Hormone (TSH-measures the thyroid hormone function), Lipid Panel (measures cholesterol in the blood), a Vitamin B12 level, and a urinalysis. A record review of Resident 10's lab results dated 3/5/25 revealed the urinalysis was obtained (9 days after it was ordered). A record review of Resident 10's lab results dated 3/18/25 revealed the blood work (Hemoglobin A1C, CBC, BMP, TSH, Lipid Panel, and Vitamin B12 were obtained (22 days after they were ordered). An iron panel was added onto the labs by the provider and the provider noted they would like to talk to the resident in the clinic about the blood test results with an appointment made for 3/25/25. A record review of Resident 10's Progress Notes an entry dated 3/25/25 revealed the resident returned from the appointment with new medication orders and needed an ifob stool sample (a type of stool test that checks for hidden or occult blood in the stool). A record review of the facility form Order Summary dated 4/15/25 for Resident 10 revealed an order was put in for the occult stool sample (21 days after the progress note entry). A record review of Resident 10's lab results dated 4/24/25 revealed the stool sample was collected (30 days after the progress note entry and 9 days after the order was put in). A record review of Resident 10's Progress Notes revealed no documentation that orders were received for lab work on 2/27/25, there were no entries that blood work was obtained on 3/18/25, there were no entries that blood work was refused, no documentation that the facility received the order for the stool test on 4/15/25 and no documentation that the facility obtained the stool sample on 4/24/25. Interview on 5/5/25 at 2:10 PM with the Director of Nursing (DON) confirmed staff should have documented in the resident's medical record any refusals to obtain the lab work, when the lab work was obtained, and when the results were received and sent to the provider. Further interview confirmed the labs were not obtained in a timely manner. 29638 B. A record review of the Unavailable Medications Policy dated September 2024 revealed the facility was to utilize uniform guidelines for unavailable medications. The following guidelines were identified; -the facility was to maintain a contract with a pharmacy provider to supply the facility with routine, as needed and emergency medications. -a supply of commonly used medications was to be maintained in-house for the timely initiation of medications. -staff were to take immediate action when it was known a medication was not available: 1) determine the reason for unavailability, length of time the medication was unavailable and what efforts had been attempted by the facility or the pharmacy provider to obtain the medication; 2) notify the physician of inability to obtain medication upon notification or awareness that medications were not available. Obtain alternate treatment order and/or specific orders for monitoring the resident while medication was on hold; and 3) if the facility allows, determine if the resident has a home supply and obtain an order to use the home medication supply. -if a resident missed a scheduled dose of the medication, the staff were to follow the procedures for a medication error, including notifying the physician/family, completion of a medication error report and monitoring the resident for adverse reactions to omission of the medication. A record review of Resident 23's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of cancer, atrial fibrillation, dementia, and malnutrition. The following was assessed for Resident 23: -cognition was severely impaired. -verbal behaviors directed at others and rejection of care. -required staff assistance with toileting, dressing, transfers, personal hygiene, and bed mobility. -received an anticoagulant (medication used to help prevent blood clots) daily. A record review of Resident 23's Medication Administration Record (MAR) dated 3/2025 revealed an order dated 3/6/25 for Xarelto (anticoagulant) 15 milligrams (mg) 1 tablet daily. Further review of the MAR revealed from 3/18/25 to 3/24/25 (7 days) the medication was not administered. A record review of Resident 23's Nursing Progress Notes revealed the following regarding administration of the Xarelto 15 mg daily: -3/18/25 at 9:40 AM the staff were unable to find the medication. -3/19/25 at 8:54 AM the staff were unable to find the medication. -3/21/25 at 10:27 AM the staff were unable to find the medication. -3/22/25 at 7:40 AM the staff were awaiting pharmacy. -3/23/25 at 7:52 AM staff were awaiting drug from the pharmacy. -3/24/25 at 10:31 AM staff were waiting for the pharmacy to deliver the medication. C. A record review of Resident 196's Face Sheet revealed the resident was admitted [DATE] with diagnoses of low back pain, diverticulosis, irritable bowel syndrome, adult failure to thrive, pressure ulcer to the sacral region and malnutrition. A record review of Resident 196's admission orders dated 3/20/25 revealed the following: -Potassium and Sodium Phosphate (electrolyte replacement) powder one packet daily. -Aspirin 81 mg twice a day. -Amlodipine (medication used to treat high blood pressure) 10 mg daily. A record review of Resident 196's MAR dated 3/2025 revealed the following: -from 3/21-3/24 the Amlodipine 10 mg daily was not available/administered. -from 3/21 to 3/23 the Potassium and Sodium Phosphate packets were not available/administered. -from 3/21 to 3/24 the Aspirin 81 mg was not available/administered. During an interview on 5/6/25 at 9:29 AM the DON confirmed the following regarding Residents 23 and 196: -Resident 23 did not receive the Xarelto 15 mg daily from 3/18/25 to 3/24/25. -Resident 196 did not receive Amlodipine 10 mg daily and Aspirin 81 mg twice a day from 3/21/25 to 3/24/25 and did not receive the Potassium and Phosphate packets daily from 3/21/25 to 3/23/25. -no evidence the facility had determined why the resident's medications were not available from the pharmacy. -no evidence of any actions taken to obtain alternate orders for the resident's missing medications. -no monitoring of the residents while these medications were on hold. 51391 D. A record review of the facility's Fluid Restriction Policy with a date of March 2025 revealed the following: -facility was to ensure that fluid restrictions will be followed in accordance with physician's orders, -the nurse will obtain and verify the physician's order for the fluid restriction and an order written to include the breakdown of the amount of fluid per 24 hours between the nutrition and nursing department. The fluid intake will be recorded in the medication record, and -the resident had the right to refuse the fluid restriction, if refused, documentation should support the reason for the refusal, the education of the risks and benefits, and any supporting documentation of the resident's continued refusal, assessment for any changes in condition related to the refusal, and the notification of the physician about the resident's refusal. A record review of the facility's Skin Assessment Policy dated December 2024 revealed the following: -a full body, or head to toe, skin assessment would be conducted by a licensed or registered nurse weekly, -Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions, -Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title, b. Document observations, c. Document type of wound, and d. Describe wounds (measurements, color, type of of tissue in wound bed, drainage, odor, pain). A record review of Resident 33's April 25 MAR revealed a physician order for: -1800 milliliter (ml) fluid restriction for 24 hours start date 6/27/24, -no fluid intake documented 3 out of 90 shifts, and -the resident's intake exceeded 1800 ml 20 days out of 30. A record review of Resident 33's nurse documentation revealed that the physician had not been notified when the resident exceeded the 1800 ml per day and no documentation was found showing why the resident was on a fluid restriction. Interview on 5/5/25 at 10:55 AM with the DON confirmed that resident was on an 1800ml fluid restriction, staff were not monitoring the fluid intake amount and notifying the physician if resident exceeded the 1800 ml intake. DON unable to provide documentation that stated why the resident was on a fluid restriction. A record review of Resident 33's December 2024 MAR revealed the resident had an order for: -prednisoLONE Acetate eye drops (decrease inflammation) 1 drop to right eye four times a day for post cataract surgery for 1 month. The order had a start date of 12/10/24 at 5:00 PM and a discontinue date of 1/7/25 at 10:00 AM. A record review of Resident 33's MAR for December 2024 revealed that the resident did not receive the eye drops on 12/30/24 at 9:00 PM and missed 3 doses on 12/31/24. A record review of Resident 33's MAR for January 25 revealed the resident received 6 of the 25 doses of the eye drops. A record review of Resident 33's nurse documentation from 12/30/24 to 1/7/25 revealed the eye drop medication was waiting to be received from the pharmacy. No documentation was found to reveal that the pharmacy was notified of needing the medication or the physician being notified of the eye drops not being administered. Interview on 5/5/25 at 10:55 AM with the DON confirmed that the pharmacy was notified on 1/4/25 of needing the eye drops, eye drops were not received, and the pharmacy was not notified of the eye drops not being received. DON also confirmed that the physician was not notified of eye drops not administered from 12/30/24 at 9 PM to 1/7/25. A record review of Resident 33's December 2024 MAR revealed the resident had an order for: -Thigh high compression garments on during the day off at night with a start date 6/27/24. A record review of Resident 33's MAR for December 2024 and January 2025 revealed the resident did not have the compression garments from 12/21/24 to 1/26/25. A record review of Resident 33's nursing documentation from 12/21/24 to 1/26/25 revealed that the compression garments were not being put on because the facility was waiting for a larger size of compression garments. The physician was notified on 1/13/25 of the resident's increased non-pitting edema to all extremities and neck, shortness of breath and not having the compression garments due to larger size being ordered. No follow up documentation was received from the physician. An interview on 5/5/25 at 10:55 AM with the DON confirmed that Resident 33 should not have gone from 12/21/24 to 1/26/25 without some type of compression garment, the physician should have been notified before 1/13/25 and there was no follow up with the physician after 1/13/25. An interview on 5/5/25 at 2:30 PM with the Business Office Manager (BOM-M) confirmed that the compression garments were ordered on 12/19/24, and on 1/13/25 a larger size of compression stockings were ordered and received on 1/27/25. E. A record review of Resident 40's MDS dated [DATE] revealed that resident was admitted on [DATE] with: -diagnoses of non-traumatic brain dysfunction and dementia, -cognition was severely impaired, -dependent on staff for toileting hygiene, bathing, dressing, bed-mobility, transfers, -always incontinent of bowel and bladder, and -3 unstageable non-removable dressing: Known but not stageable due to non-removable dressing/device. a record review of Resident 40's care plan revealed that resident was admitted with an unstageable pressure injury to the left shoulder, left outer trochanter and left outer thigh. Left shoulder and left outer thigh were healed. Observation of cares on 5/1/25 at 10:50 AM revealed that Resident 40 had a wound dressing intact to left hip with a date of 5/1/25. Observation of Resident 40 on 5/5/25 at 10:30 AM revealed a wound dressing to left hip with a date of 5/5/25. Observation on 5/6/25 at 8:10 AM of skin treatment to Resident 40's left hip by the DON revealed that there was an open area to the left hip. A record review of Resident 40's nursing documentation revealed that no weekly documentation for left hip was being completed. Interview with the DON on 5/6/25 at 11:15 AM confirmed that the facility has not completed weekly documentation or measurements to monitor the wound on the left hip.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observations, record review and interviews; the facility failed to assure a safe environment as the staff failed to 1) utilize safe transfer techniques with use of the mechanical lift to prevent potential accidents for Resident 31; 2) revise current interventions or develop new interventions to prevent ongoing falls for Resident 5; and 3) implement assessed fall interventions for Residents 29, 34 and 40. The sample size was 8 and the facility census was 45. Findings are: A record review of the facility policy Safe Resident Handling/Transfers dated 7/24/23 revealed it was the policy of this facility to ensure the residents were handled and transferred safely to prevent or minimize risks of injury and provide and promote a safe, secure and comfortable experience for the residents while keeping the employee safe in accordance with current standards and guidelines. All residents required safe handling when transferred to prevent or minimize the risk of injury to themselves and the employee that assisted them. The Interdisciplinary Team or designee was to evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. Mechanical lifting equipment or other approved transfer aids were to be used based on the resident's needs to prevent manual lifting except in medical emergencies. Mechanical lifts included equipment such as full body lifts (mechanical device that allows residents to be transferred between a bed and a chair using hydraulic power and requires no weight bearing assistance), sit-to-stand lifts (a mobile lift that allows patient transfers from a seated position to a standing position. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) or ceiling track mounted lifts. The following procedure was to be followed: -2 staff members were to be utilized when transferring residents with a mechanical lift. -staff were to be educated on the use of safe handling/transfer practices to include use of the mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. -staff members were expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. -resident's lifting and handling was to be performed according to the resident's individual plan of care. -staff were to perform mechanical lift/transfers according to the manufacturer's instructions for use of the device. A record review of the facility'sFall Prevention Program Policy dated 9/2024 revealed each resident was to be assessed for fall risk and was to receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive care plan. Fall interventions were to be monitored for effectiveness and the care plan was to be revised as needed. If any resident has a fall the facility will: -assess the resident. -complete a post-fall assessment. -complete an Incident Report. -notify the physician and the family. -review the resident's care plan and update as indicated. -document all assessments and actions. A. A record review of Resident 31's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 3/13/25 revealed the resident was admitted [DATE] with diagnoses of previous stroke, high blood pressure, hemiplegia (paralysis on 1 side of the body), seizure disorder, and depression. The following was assessed for Resident 31: -cognitively intact. -dependent on staff for assistance with toileting hygiene, showering/bathing, dressing, transfers, and bed mobility. -occasionally incontinent of urine. A record review of Resident 31's Care Plan dated 3/21/24 revealed the resident was at risk for falls related to left side hemiplegia, neuropathy, and convulsions. An intervention dated 4/3/24 was identified by the therapy department for two nursing staff to be used for all transfers for the resident utilizing the sit-to-stand mechanical lift. One staff member was to control the lift, and the other staff was to manage the resident's left hand/shoulder. The staff were to use both of their hands (one on the resident's left hand and one on the resident's arm) to ensure proper positioning and to prevent injury risk. During an interview on 4/30/25 at 10:13 AM, Resident 31 identified a history of a previous stroke with left side paralysis/contractures. The resident reported that when the resident was transferred with the mechanical lift, there were always supposed to be 2 staff to assist with the transfer. However, now the staff frequently only used 1 staff person to transfer the resident with the lift and this made the resident feel uncomfortable. During an observation on 5/1/25 at 11:01 AM, Resident 31 was transferred from the commode to the recliner with the mechanical lift. Nurse Aide (NA)-D used the controls to lift the resident from the commode to a standing position and NA-F stood directly behind the resident. The resident used the right hand to hang onto the lift handle, but the resident's left hand/arm hung at the resident's side. When the resident was transferred from the commode, staff failed to place the resident's left hand on the handle of the lift and to hold the left hand in place and to support the resident's left arm/shoulder. The resident was unable to maintain weight bearing status once stood and started to bend at the knees with the resident's left side hanging flaccid. NA-F performed hygiene cares for the resident and then staff quickly moved the resident over to the recliner and lowered the resident to the seat. During an interview on 5/1/25 at 11:45 AM, NA-E and NA-F confirmed 2 staff were not always available to assist Resident 31 with transfers in the mechanical lift. NA-E and NA-F verified education was provided by the therapist for 2 staff to be used for all transfers when using the lift for Resident 31. B. A record review of Resident 29's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of dementia, psychotic disturbance, Alzheimer's disease, history of traumatic brain injury, osteoarthritis, and anxiety. The following was assessed for Resident 29: -severe cognitive impairment. -dependent on staff for assist with eating/drinking, personal hygiene, toileting hygiene, showering/bathing, dressing, transfers, and bed mobility. -functional limitation of range of motion with impairment to both sides of both upper and lower extremities. A record review of Resident 29's Care Plan dated 2/4/25 revealed Resident 29 was at risk for falls related to poor balance and need to use the full mechanical lift for all transfers. The care plan indicated the resident had a fall on 2/7/25 with a new intervention for a mesh Stop Sign across the entrance door of the resident's room and had a fall out of bed on 4/2/25 at 4:15 AM with an intervention for a body pillow to be used to assist with positioning in the resident's bed. Observations of Resident 29 in the resident's room revealed the following: -On 4/20/25 at 10:00 AM the resident was in the wheelchair. The mesh Stop Sign was not across the door of the resident's room. -On 5/1/25 at 7:40 AM the resident was in the room in the wheelchair and the mesh Stop Sign was not across the door of the room. -On 5/1/25 at 10:35 AM and at 2:02 PM the resident was lying in the bed. The body pillow was in a chair next to the resident's bed and was not utilized as a fall intervention. In addition, the mesh Stop Sign had not been placed across the resident's room door. -On 5/5/25 from 8:02 AM to 9:30 AM the resident was lying in bed. The body pillow was in a chair next to the resident's bed and was not utilized in the bed. In addition, the mesh Stop Sign had not been placed across the resident's room door. -On 5/5/25 at 10:35 AM the resident was transferred from the wheelchair and into the resident's bed. The body pillow remained in the chair next to the resident's bed. -On 5/6/25 at 7:39 AM the resident was positioned in the bed. The body pillow had not been placed in the resident's bed and the mesh Stop Sign was not in place across the resident's room door. During an interview on 5/5/25 at 8:57 AM the Director of Nursing (DON) confirmed the following regarding Resident 29's falls: -On 2/7/25 at 3:10 AM, the resident was found lying on the floor next to the resident's bed. Due to the resident's contractures and total dependence on staff for mobility, the staff felt another resident, who had also been found in the room, had removed the resident from bed and laid the resident on the floor. A new intervention was put into place to place a mesh Stop Sign across the doorway of the resident's room to keep any wandering residents out of Resident 29's room. -On 4/2/25 at 4:00 PM the resident was found on the floor beside the resident's bed. A new intervention was put into place for a body pillow to be placed in the bed to assist the resident with positioning and prevent further falls from the bed. -Both interventions remained in place and should have been implemented throughout the survey. 51391 C. A record review of Resident 34's MDS dated [DATE] revealed the resident had diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, dementia, anxiety and depression. The following was assessed regarding the resident: -cognitive skills for decision making were severely impaired, -inattention and disorganized thinking fluctuate, -dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing and personal hygiene, transfers, bed mobility and wheelchair mobility, -always incontinent of bowel and bladder, -receiving hospice care, -had bed alarm daily and other alarm daily, and -functional limitation of range of motion with impairment to 1 lower extremity. A record review of Resident 34's care plan dated 9/22/23 revealed the resident was at risk for falls related to diagnosis of Alzheimer's disease, used the full mechanical lift for all transfers, and had a history of falls. The care plan indicated the resident had: -A tabs alarm initiated 10/22/24, -secure tabs alarm to the waistband of the pants initiated 11/11/24, -chair alarm initiated 11/21/24, and -do not leave the resident unattended alone in their room when they are in their wheelchair, and assist to the recliner or bed before leaving the room initiated 11/21/2024. On 5/5/25 at 11:00 AM, documentation for the fall from 12/18/24 was reviewed with the DON. Documentation revealed that the resident was sitting on the floor in front of their wheelchair on their bottom. The resident was trying to put a blanket on the bed and slid out. The resident had no alarms in place. Observations of Resident 34 in their room revealed the following: -on 4/30/25 at 10:00 AM Resident 34 was sitting in their room in wheelchair with their eyes closed, no staff were in the room. -On 5/1/25 at 2:25 PM Resident 34 was sitting in their room in wheelchair, eyes opened, reaching for items, sitting forward in the wheelchair. No staff were in the room. During an interview on 5/5/25 at 11:00 AM, DON confirmed the following: -Resident 34 did get left alone in their room in the wheelchair at times, -The resident did not have alarms in place as care planned when their fall occurred on 12/18/24. D. A record review of Resident 40's MDS dated [DATE] revealed the resident had diagnoses of non-traumatic brain dysfunction and dementia. The following was assessed regarding the resident: -cognitive skills for decision making were severely impaired, -had poor attention continuously and disorganized thinking fluctuate, -dependent on staff for oral hygiene, toileting hygiene, bathing, dressing and personal hygiene, transfers, bed mobility and wheelchair mobility, -always incontinent of bowel and bladder, and -had 1 fall with no injury. A record review of Resident 40's care plan dated 3/10/25 revealed the resident was at risk for falls related to diagnosis of dementia, need to use full mechanical lift for all transfers and was dependent on staff for mobility in wheelchair. The care plan indicated the resident had a fall on 3/6/25 with an intervention to lay down after meals. Observations of Resident 40 revealed the following: -On 4/30/25 at 9:45 AM the resident was sitting in the wheelchair in the lobby area watching TV. -On 4/30/25 at 11:00 AM the resident was sitting in the wheelchair in the lobby area watching TV, closed eyes off and on. -On 4/30/25 at 12:10 PM staff pushed the resident into the dining room for noon meal. -On 4/30/25 at 2:00 PM the resident was sitting in the wheelchair in the lobby area, eyes were closed. -On 5/1/25 at 10:20 AM the resident was sitting in wheelchair in the resident's room with eyes closed. -On 5/1/25 at 10:50 AM the resident had been laid down in bed. -On 5/1/25 at 1:45 PM the resident was sitting in wheelchair in the lobby area, eyes were open and the resident was rocking back and forth in wheelchair. -On 5/1/25 at 2:25 PM the resident was being laid down in bed. An interview with the DON on 5/6/25 at 11:15 AM confirmed that the resident was to be laid down after meals and the expectation was for this to be within 30 minutes of completing meal. DON confirmed that the resident did not always get laid down after meals. 45739 E. A record review of Resident 5's MDS dated [DATE] revealed the resident had a serious mental illness, was cognitively intact, was independent with activities of daily living, had an indwelling catheter, had diagnoses of renal disease, neurogenic bladder (a condition where a problem in the brain, spinal cord, or peripheral nerves disrupts the signals that control bladder function and can lead to difficulty emptying the bladder or holding urine), diabetes, anxiety, bipolar disorder, and schizophrenia, had 2 or more falls without injuries and 1 with a major injury, and had a feeding tube. A record review of Resident 5's Care Plan, last revised 4/29/25 revealed the resident was at risk for falls, required a standby assist with walker but often self-transferred and had the following fall interventions in place: -bed and chair alarms implemented 4/30/24, -encourage non-skid footwear implemented 4/30/24, -transfers and ambulates with a standby assist with walker implemented on 4/30/24, and -new gripper socks implemented 1/1/25. A record review of Resident 5's Fall Risk Evaluation dated 4/3/25 revealed the resident was a high risk for falls. A record review of the facility Incident Reports for Falls for Resident 5 revealed the following: -A fall on 2/23/25 at 4:00 PM where the resident was found on the floor in the resident room next to the bed with an intervention of bed and chair alarms applied, -A fall on 3/11/25 at 4:15 AM where the resident was found sitting on the floor at the end of the bed with no socks on with an intervention to be a standby assist with a walker for transfers and ambulation, and -A fall on 4/24/25 at 12:52 AM where the resident was found lying on their back beside the bed with an intervention to ensure gripper socks were worn. Interview with the DON on 5/6/25 at 8:45 AM confirmed the falls on 2/23/25, 3/11/25, and 4/24/25 did not have new interventions implemented to prevent further falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and interview; the facility failed to implement, evaluate and/or revise nutritional interventions to address a significant weight loss for 2 (Residents 13 and 38) of 3 sampled residents. The facility census was 45. Findings are: A. Review of a Weight Monitoring policy dated 5/17 revealed the facility was to assure that all residents maintained acceptable parameters of nutritional status. The policy further revealed significant unintended weight loss may indicate a nutritional problem. The following process was identified: -the physician was to be informed of a significant change in weight in order to develop nutritional interventions; -the Registered Dietician (RD) or the Dietary Manager (DM) were to be consulted to assist with nutritional interventions and then interventions were to be documented in the Progress Notes; and -the Interdisciplinary Team was to communicate changes to the staff. B. Review of Resident 38's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/5/19 revealed [DIAGNOSES REDACTED]. was 162 pounds (lbs.). In addition, the assessment indicated the resident had an order for [REDACTED]. Review of Resident 38's current Care Plan dated 1/29/19 revealed the resident had a potential for nutritional problems and/or weight loss as evidenced by a consistent carbohydrate diet. The care plan identified the resident had a significant weight loss since admission to the facility. The following interventions were identified: -encourage fluids with meals, snacks, medication administration, mid-afternoon, at bedtime and as needed; -independent with eating after set-up assist. (MONTH) require supervision at times; -offer alternatives when food is refused; -offer snacks in the mid-morning and in the mid-afternoon; and -RD to evaluate and make diet change recommendations. Review of Resident 38's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) revealed the resident's weight on 1/30/19 was 166 lbs. Review of the resident's Admission Nutritional Assessment signed as completed by the RD on 2/3/19 at 8:26 AM, revealed the resident had a poor appetite and a low [MEDICATION NAME] level (indication of protein deficiency). The RD made a recommendation for the DM to interview the resident to determine dietary supplements (food/fluid with additional calories) or fortified foods (additional calories or protein added to foods) the resident would accept. Review of Resident 38's medical record revealed no evidence the DM interviewed the resident to identify food preferences regarding dietary supplements or fortified foods. Review of the resident's Weights and Vitals Summary Sheet revealed the following regarding Resident 38's weights: -weight on 2/13/19 was 161 lbs. (down 4 lbs. in 2 weeks); -weight on 2/18/19 was 152 lbs. (down 9 lbs. in 5 days and down 14 lbs. or a 8 percent (%) loss since admission); and -weight on 3/27/19 was 148 lbs. (down 4 lbs. or a 3% loss in 1 month). Review of a Nutritional Assessment completed on 3/28/19 at 12:41 PM by the RD revealed the resident had a significant change of status since admission. The resident had a severe weight loss which resulted from an infection. A recommendation was again made for the DM to interview the resident to determine fortified food options or supplement preference. Review of Resident 38's medical record revealed no evidence the DM interviewed the resident to identify food preferences regarding dietary supplements or fortified foods. Review of Weights and Vitals Summary Sheet revealed the resident's weight on 4/10/19 was 146 lbs. (down 20 lbs. or a 12% loss in 3 months). During an observation on 4/18/19 of the breakfast meal from 8:13 AM to 8:39 AM the resident was served an 8 ounce glass of water, orange juice and milk with a bowl of cold cereal. Interview on 4/18/19 at 8:40 AM with Nurse Aide-F revealed the resident was not on a fortified diet and did not receive a nutritional supplement. During an interview on 4/18/19 at 1:04 PM, the DM confirmed Resident 38 was not on a fortified diet and was not receiving any nutritional supplements. In addition, the DM confirmed Resident 38 had not been interviewed to determine preferences regarding fortified foods and/or nutritional supplements. C. Review of Resident 13's MDS dated [DATE] revealed the resident's cognition was moderately impaired with [DIAGNOSES REDACTED]. The same assessment indicated the resident required supervision with food and fluid intakes, had a weight of 177 lbs. and the resident had a weight loss of 5% in the last month or a loss of 10% or more in the last 6 months. The resident was not on a physician prescribed weight-loss regimen. Review of Weights and Vitals Summary Sheet revealed the following regarding Resident 13's weights: -1/21/19 weight was 188 lbs. -2/24/19 weight was 177 lbs. (down 11 lbs. or a 6% loss in 1 month). Review of Resident 13's current Care Plan with a revision date of 2/27/19 revealed the resident was at risk for impaired nutritional status due to need for a therapeutic diet, [DIAGNOSES REDACTED]. The following nutritional interventions were identified: -monitor intake at meals, offer alternate choices as needed. Alert the RD and the DM to any decline in intakes; and -provide a high protein snack twice daily. Review of a Nutritional Progress Note by the RD dated 3/5/19 at 12:19 PM, revealed the resident continued with significant weight loss and indicated the resident was consuming 50-100% of meals. No additional recommendations were identified by the RD despite the resident's continued weight loss. Review of Weights and Vitals Summary Sheet revealed the resident's weight on 4/15/19 was 179 lbs. Review of Resident 13's Medication Administration Record [REDACTED]. During an interview on 4/17/19 at 1:01 PM, the DM confirmed the following regarding Resident 13's weight loss: -the resident's weights had a history of [REDACTED]. -the resident continued to have weight loss; -the resident had an order which was initiated on 8/24/18 for a high protein snack to be given twice a day. The snack was provided by the nursing staff and intake was documented on the resident's MAR; -the resident's high protein snack had been discontinued on 11/2/18; and -no further nutritional interventions had been developed to address the resident's significant ongoing weight loss.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to provide diet modifications to prevent potential aspiration for Resident 57 and to provide assessment and monitoring for Residents 31 and 39 who were receiving [MEDICAL TREATMENT] (A method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood). The sample size was 43 and the facility census was 68. Findings are: A. Review of the facility policy and procedure titled Thickened Liquids with a revision date of 3/9/15 revealed the following: - Thickened liquids will be served to residents as ordered by the physician. - The Food Services Director will record the ordered consistency on the resident's tray card. - Pre-thickened liquids will be used whenever possible. - For beverages which must be thickened, the beverage will be thickened by the dietary staff prior to leaving the kitchen. Review of an undated facility policy titled, Thickened Liquids revealed there were 3 types of thickened liquids: -Nectar Consistency- a consistency of nectar, or milkshakes; -Honey Consistency- a consistency of honey and thicker than nectar consistency; and -Pudding Consistency- the thickest of the three consistencies and the consistency of pudding. B. Review of a Hospital Progress Note dated 9/14/16 revealed Resident 57 was admitted to the hospital on [DATE]. Further review revealed Resident 57 aspirated after being admitted to the hospital with [REDACTED]. Review of Resident 57's Progress Note dated 9/21/16 at 4:51 PM revealed the resident returned to the facility from the hospital on [DATE] at 2:15 PM. Review of Resident 57's Order Summary Report revealed an order for [REDACTED]. Review of a Telephone Order dated 9/23/16 revealed Resident 57's diet was changed to a full-liquid diet with liquids thickened to honey consistency due to difficulty swallowing. Review of Resident 57's Progress Note dated 9/23/16 at 1:51 PM confirmed Resident 57's diet was changed to a full liquid diet with honey consistency. Review of the Resident 57's Progress Note dated 9/24/16 at 2:57 PM revealed after lunch the resident became more gurgly and wet sounding and was unable to cough or clear throat. Oxygen saturations (the concentration of oxygen in the blood, normal levels are 95-100 percent (%)) were checked and in the low 80 %. The resident was moaning and appeared to be in respiratory distress. Upon assessment the resident's lung sounds were very wet with audible wheezes heard. The facility was unable to get the resident's oxygen saturations above 81-82% on 3 Liters of oxygen and the resident's extremities were cool to the touch. The resident was transferred to the hospital. Review of a Hospital Progress Note dated 9/25/16 revealed the resident came into the hospital hypoxic (a condition in which the body or a region of the body is deprived of oxygen) on 9/24/15. The resident was found to have a mouthful of food and once this was suctioned the oxygen saturations improved. Review of the Hospital Diagnostic Imaging report dated 9/25/16 showed infiltration (presence of a substance more dense than air) at the left lung base. Review of Resident 57's current Care Plan with a revision date of 9/26/16 revealed the resident was on puree liquefied diet which was honey thickened in consistency. Review of Resident 57's Progress Note dated 9/27/16 at 3:35 PM revealed the resident returned to the facility from the hospital on [DATE] at 12:50 PM. Review of Resident 57's Progress Note dated 9/28/16 at 2:09 PM confirmed the resident's diet upon return from the hospital was to continue the full-liquid diet with honey thick consistency. Review of Resident 57's Progress Note dated 10/13/16 at 1:54 PM revealed the resident had a choking episode at lunch and vomited. Review of Resident 57's diet cards dated 11/15/16 and 11/16/16 indicated the resident was on a liquefied puree diet with nectar thick liquids, although the actual diet order was for honey thick consistency full-liquid diet. Review of the communication board posted in the kitchen on 11/15/16 at 12:30 PM revealed a note regarding Resident 57 which indicted the dietary staff were not to thicken the resident's liquids for meals. Observations of meal preparation revealed the following: -On 11/15/16 from 11:18 AM to 11:45 AM, Cook-X pureed the turkey. An unmeasured amount of broth and milk was added to the turkey to further liquefy the food. Cook-X then pureed the stuffing and added an unmeasured amount of broth and milk to the stuffing to further liquefy the food. No recipe was used. -On 11/15/16 at 11:51 AM Dietary Aide (DA)-Y prepared pureed cake using a recipe. Then DA-Y prepared the liquid cake by adding an unmeasured amount of milk. During an interview on 11/15/16 at 12:30 PM, Cook-X- stated Resident 57 was on an all liquid diet with thickened liquids. Cook-X stated the dietary department had the resident's dietary consistency listed as nectar thick, but nursing would tell them the resident should receive honey thick consistency so Cook-X did somewhere in between. Cook-X stated this was so the liquids did not set up too much, which was difficult for the resident to swallow. Further interview revealed the nursing staff could add thickener at the table if the nursing staff felt the drinks needed more. Cook-X confirmed recipes were not used when preparing the puree and liquids diets. Nursing Assistant (NA)-Q was observed assisting Resident 57 with the noon meal on 11/15/16 at 12:50 PM. The resident was observed to have a small cough after taking drinks of the liquefied turkey, stuffing, and cake. During an interview on 11/15/16 at 3:00 PM, Cook-Z revealed dietary staff had been notified by nursing that they (dietary) were not to thicken Resident 57's liquids anymore because the liquids were getting too thick and instead nursing would thicken them at the table before giving them to the resident. Cook-Z stated the resident was supposed to receive honey thick liquids but confirmed the diet card listed nectar thick consistency. During an interview with the Dietary Manager (DM) on 11/15/16 at 3:30 PM, the DM confirmed there were discrepancies in Resident 57's diet consistency regarding whether it should be nectar or honey thick, but confirmed it was to be honey thick. The DM confirmed the dietary staff would not thicken the drinks all the way (to honey thick) because the drinks were getting too thick so dietary would leave them thinner and then nursing could adjust them as needed. During an interview on 11/15/16 at 4:05 PM, NA-Q was unsure what consistency Resident 57's liquids should have been at the noon meal on 11/15/16. NA-Q thought the liquids were to be nectar thick but was not sure. During further interview NA-Q revealed the kitchen thickened the liquids, but nursing would adjust the liquids at the table if they felt it was too thick or too thin. During an interview with NA-AA on 11/15/16 at 4:32 PM, NA-AA did not know what consistency Resident 57's liquids were supposed to be and stated the kitchen thickened them. NA-AA was not aware of nursing being responsible for thickening the resident's liquids instead of the dietary staff. NA-AA was not sure if Resident 57's diet was actually a liquid diet or more a puree consistency that could be drank. NA-AA indicated the diet served to Resident 57 sometimes had chunks in it', like pieces of broccoli. Observation on 11/15/16 at 6:03 PM revealed Resident 57 was served a glass of non-thickened orange juice. The Administrator was notified and the Administrator indicated the orange juice would be thickened before offering it to the resident. During an interview with the Administrator on 11/15/16 at 6:29 PM, the Administrator confirmed the NA's had not had any training on thickening liquids and the different diet consistencies. Observation on 11/16/16 at 8:00 AM revealed Resident 57 was served a glass of non-thickened orange juice. Further observation revealed a container of powdered thickener setting on the table in front of the resident. Licensed Practical Nurse-H observed the non-thickened orange juice and requested a thickened glass of orange juice from dietary. During an interview on 11/16/15 at 8:45 AM, DA-W confirmed Resident 57 was provided non-thickened orange juice at breakfast. DA-W confirmed nursing had been thickening the resident's liquids and DA-W had not been notified of any changes. During an interview on 11/16/16 at 10:00 AM, NA-D was aware Resident 57 was on an all liquid diet, but thought the consistency was to be pudding thick. Observation on 11/16/16 at 12:10 PM revealed Resident 57 was served orange juice that appeared pudding thick as it was so thick that it did not spill out of the cup when the cup was tipped over. NA-P was notified and NA-P stated the liquid would be returned to dietary and a new orange juice would be requested. During interviews on 11/16/16 at 12:10 PM, NA-M and NA-P confirmed they had not had any training on thickening liquids and the different diet consistencies. The immediate jeopardy was abated to a D level on 11/16/16 at 5:30 PM when: 1) Residents receiving thickened liquids and liquefied diets were identified and diets were confirmed. 2) Dietary staff were instructed to thicken all liquids according to diet orders. 3) A plan was created to train all dietary staff members prior to them adjusting diet and/or liquid consistencies. This training consisted of education and demonstrations. Training of the dietary staff will be completed by the DM, who was trained by the Registered Dietician (RD) on 11/16/16. 4) Liquids to be thickened just prior to being sent out of the kitchen to prevent the consistency from changing. 5) Nursing staff will be in-serviced regarding policy of dietary responsibility for thickening liquids, and educated so the nursing staff can help identify incorrect diet orders. 6) A dietary communicating slip will be used for any new dietary or supplement order to improve communication between dietary and nursing. 7) Speech therapy recommendations will be given to nursing and dietary and signed by both departments. 8) Any new dietary orders will be monitored in Clinical Start-Up (a daily meeting Monday through Friday). 9) The DM, RD, Administrator, and the DON will take turns completing audits of each meal to check dietary tickets against correct diet and liquids for 2 weeks to ensure each resident on thickened liquids are receiving the accurate diet. 10) The plan of correction will be reviewed by the Quality Assurance Committee for the next 3 months. 11) Recipes are to be used whenever possible and dietary staff trained to adjust consistencies as needed as the recipes may not always produce the correct results. 12) The facility placed an order from their supplier for pre-thickened liquids. 13) The facility placed an order from their supplier for liquid thickener, which does not change consistencies over time (instead of the powdered thickener). C. Review of the facility policy titled [MEDICAL TREATMENT] Management ([MEDICAL TREATMENT]) dated 9/2013 revealed the following related to [MEDICAL TREATMENT] provided at an off-site [MEDICAL TREATMENT] Center: - Assure facility completed [MEDICAL TREATMENT] Communication form accompanies the resident to [MEDICAL TREATMENT] on treatment days, to communicate resident information and to coordinate care between [MEDICAL TREATMENT] Center and the facility. - Post [MEDICAL TREATMENT], staff to assess the [MEDICAL TREATMENT] every hour for 4 hours, documenting any bleeding, pain, redness and swelling. - Maintain and record fluid restrictions, as ordered. - Evaluate and document arteriovenous (AV- joining of an artery and a vein under the skin in the patients arm and used to access the patient's blood for [MEDICAL TREATMENT]) fistula daily for thrill (A thrill is checked by lightly placing fingertips over the fistula site and feeling for vibration of blood circulating through the fistula.) and bruit (A bruit is checked by placing a stethoscope over the fistula area and listening for blood flow.) and monitor for any signs and symptoms of infection. Evaluate central venous (CV-tubes placed in a vein in the neck, groin or back. Each central venous catheter has two openings; one takes blood from your body to be cleaned by the [MEDICAL TREATMENT] machine and the clean blood returns to your body through the other) catheter daily for signs and symptoms of infection and document. - Manage dietary restrictions as ordered. D. Review of Resident 31's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/25/16 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was receiving [MEDICAL TREATMENT]. Review of Resident 31's current Care Plan with revision date 8/15/16 revealed the resident was receiving [MEDICAL TREATMENT] 3 times weekly on Mondays, Wednesdays and Fridays. Nursing interventions included the following: - check access site (catheter) daily for signs of infection (redness, hardness, swelling, pain, drainage, elevated body temperature and body chills); - observe for post [MEDICAL TREATMENT] hang over-vital signs, mental status, excessive weight gain between treatments, nausea, vomiting, weakness, headache or severe leg cramps; and - 1800 milliliter (ml) fluid restriction, 480 ml at meals, 150 ml during the day and evening shifts and 60 ml on the night shift. Review of [MEDICAL TREATMENT] Communication Forms (a form completed with each [MEDICAL TREATMENT] treatment and used to communicate information and recommendations between the facility and the [MEDICAL TREATMENT] center) for Resident 31 from 10/1/16 through 11/16/16 revealed the section to be completed by the Nursing facility prior to the resident's [MEDICAL TREATMENT] treatment was missing documentation related to assessment of the [MEDICAL TREATMENT] and the resident's vital signs for the following dates: 10/3/16, 10/5/16, 10/7/16, 10/10/16, 10/12/16, 10/14/16, 10/19/16, 10/21/16, 10/26/16, 10/28/16, 10/31/16, 11/2/16 and 11/4/16. Review of Resident 31's medical record revealed no documentation to indicate assessments of vital signs and condition of the [MEDICAL TREATMENT] were completed by the facility upon Resident 31's return from [MEDICAL TREATMENT] treatments in accordance with the Care Plan and facility policy. Review of Resident 31's Treatment Administration Record (TAR) dated 11/2016 revealed the resident was to be on an 1800 ml fluid restriction per 24 hours. The resident was to receive 480 ml of fluid with each meal, 150 ml of fluid during the day and evening shifts and 60 ml of fluid on the night shift. Review of a Resident 31's TAR for 11/2016 revealed no documentation to indicate the amount of fluids the resident consumed each meal and during each shift were monitored and recorded to maintain the resident's fluid restriction. Interviews on 11/15/16 from 11:39 AM until 5:00 PM revealed the following: - NA-P was aware the resident was on a fluid restriction, however, NA-P indicated the nursing staff was no longer recording fluid intake after meals or throughout the shifts. - The Director of Nursing (DON) confirmed the Charge Nurse assigned to Resident 31 on the days the resident went to [MEDICAL TREATMENT] was responsible for completing the [MEDICAL TREATMENT] Communication Form and for assessing and documenting the resident's condition after [MEDICAL TREATMENT]. In addition, the nursing staff should be documenting the resident's fluid intake after each meal and with each shift to assure compliance with the resident's fluid restriction. E. Review of Resident 39's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Resident 39's current Care Plan with revision date 9/24/16 revealed the resident was receiving [MEDICAL TREATMENT] 3 times weekly. Nursing interventions included the following: -Check access site-catheter-AV Fistula-for signs of infection; -Diet and fluid restrictions as ordered. Review of Resident 39's medical record revealed no evidence that assessments of the [MEDICAL TREATMENT] were completed. Review of Resident 39's TAR dated 11/2016 revealed the resident was on a 2000 ml fluid restriction; however, there was no evidence to indicate the amount of fluids the resident consumed each shift was monitored and recorded. Interview with the DON and Licensed Practical Nurse (LPN)-H on 11/14/16 at 3:50 PM confirmed there was no documentation regarding Resident 39's fluid intake. In addition, the DON and LPN-H confirmed Resident 39's [MEDICAL TREATMENT] was supposed to be assessed every shift and results of the assessment were to be recorded on the TAR. Interview with DA-W on 11/15/16 at 1:07 PM revealed DA-W poured and served Resident 39's fluids for the noon meal that day. DA-W was not aware Resident 39 was on a fluid restriction. Interview with the Dietary Manager on 11/15/16 at 3:58 PM confirmed the dietary department was not aware Resident 39 was on a fluid restriction.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record reviews and interviews; the facility failed to revise and implement interventions for the prevention of falls for Resident 14 who sustained falls with injury. The facility census was 75. Findings are: Review of Resident 14's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/3/15 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had no cognitive impairment, required extensive assistance of 2 persons for transfers and had no falls in the past 3 months. Review of Resident 14's Care Plan (dated 8/13/15) revealed the resident was at risk for fall related injuries as evidenced by a history of falls. The Care Plan indicated Resident 14 was self-mobile in the wheelchair (w/c) in the halls and .will only put right leg on w/c pedal. The Care Plan further indicated Resident 14 liked to have Resident 36 push Resident 14's w/c when going outside to smoke cigarettes and .up and down the halls. Interventions included the following: -Encourage/remind to be patient and wait for staff assistance. Remind not to lean forward in w/c. -Observe and educate other residents of safety when they push (Resident 14's) w/c. -Remind resident to be sure to lift feet when being wheeled by others. Review of a Post Fall Analysis/Plan dated 9/15/15 revealed Resident 14 fell out of the w/c on 9/14/15 at 7:50 PM. Documentation indicated the resident had been outside the building in the smoking gazebo. The charge nurse was wheeling the resident down the sidewalk to reenter the building when the front right wheel of the w/c went off the sidewalk. The resident fell forward out of the w/c onto the left knee. Documentation indicated recommendations/interventions to prevent reoccurrence were to use caution-always keep all 4 wheels on sidewalk and OT (Occupational Therapy) for w/c positioning. Review of a Verification of Investigation form dated 9/15/15 revealed an investigation regarding Resident 14's fall was completed. Documentation indicated Resident 14 voiced (resident) was not sitting correctly in the w/c and the staff member was going too fast. The resident was subsequently admitted to the hospital with [REDACTED]. Documentation further indicated 2 residents (Residents 36 and 20) present at the time of the accident were interviewed and both denied the staff member was wheeling Resident 14 too fast. There was no evidence the residents were questioned regarding Resident 14's positioning while seated in the w/c. The charge nurse involved with the accident was interviewed and reported the wheel of Resident 14's w/c went off the right side of the sidewalk and when attempting to correct this, the resident tumbled out of the w/c onto (resident's) knee. There was no evidence the charge nurse was questioned regarding how fast the resident was being wheeled, use of w/c foot pedals and the resident's positioning in the w/c. Review of Progress Notes dated 9/17/15 at 4:05 PM revealed Resident 14 was readmitted from the hospital at 2:45 PM with the left leg wrapped with an ace wrap (elastic type of bandage designed to provide support and compression after an injury) and a knee immobilizer (leg brace) on the left leg. Documentation indicated the resident was informed staff would not be able to take the resident outside to smoke until approved by therapy. Review of the current Care Plan dated 8/13/15 revealed the following revisions: -9/14/15-Occupational Therapy (OT) consult for w/c positioning -9/17/15-Resident to remain in knee immobilizer/non weight bearing on the left leg. There was no evidence in the medical record to indicate Resident 14 was reassessed upon readmission to the facility on [DATE] to assure safe w/c positioning and use of w/c foot pedals. Review of the OT Plan of Care dated 9/25/15 revealed Resident 14 was evaluated that day (8 days following the resident's readmission to the facility). Documentation indicated OT was to be provided 3 times per week as nursing staff was unable to maintain adequate and safe position in the w/c. A goal was identified for nursing staff to follow positioning protocol with moderate assistance in order to prevent deformity and/or skin breakdown. Observation on 9/30/15 at 9:00 AM revealed Resident 14 was served the breakfast meal in the resident's room. The resident was positioned in a w/c with a knee immobilizer on the left leg and the left leg positioned on an elevated footrest. The resident's right foot was on the floor and the right w/c foot pedal was not in place. Resident 14 used the right foot and leg to move about in the room. Resident 14 commented about remaining in the room due to having a bad cold and was no longer going outside to smoke cigarettes. Interview with the Administrator on 10/1/15 at 10:46 AM revealed there was no evidence the outside area where Resident 14's fall occurred had been assessed to assure there were no safety hazards. The Administrator verified there was no evidence to indicate the investigation included information regarding Resident 14's positioning in the w/c at the time of the fall and whether the w/c footrests were in use. There was no evidence in the medical record to indicate an assessment was completed to assure it was safe for Resident 36 to continue to push Resident 14's w/c. Review of Progress Notes dated 10/2/15 at 6:42 PM revealed Resident 14 fell out of the w/c as Resident 36 wheeled Resident 14 out of the dining room. Documentation indicated the left foot pedal was in place on Resident 14's w/c but the right foot pedal was not in place as the resident was able to self-propel the w/c. Documentation indicated Resident 36 was educated to not wheel other residents. Resident 14 was subsequently transferred to the hospital. Interview with the Administrator and Director of Nurses on 10/5/15 verified Resident 14 fell out of the w/c while being wheeled by Resident 36 on 10/2/15 and Resident 14 remained hospitalized . The Administrator indicated facility policy was revised to not allow residents to wheel other residents. The DON provided evidence of education provided to all staff members regarding this policy.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record reviews and interviews; the facility failed to identify the presence of pressure ulcers and/or to provide interventions for the prevention and treatment of [REDACTED]. The facility census was 75. Findings are: A. Review of the facility policy titled Skin Integrity Guideline (revised 1/2011) revealed the following: -The purpose of the policy was to provide a systemic approach and monitoring process for skin and to decrease pressure ulcer formation by identifying those residents who were at risk and developing interventions. -Residents were to be observed by the nursing assistant daily for reddened/open areas and changes were to be reported to the licensed nurse and documented. -Positioning schedules were to be initiated to meet individual resident needs and minimize concentrated pressure to the skin. B. Review of Resident 46's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/17/15 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS further indicated the resident was at risk for development of pressure ulcers, no pressure ulcers were present upon admission and the resident required extensive assistance of 2 persons for bed mobility. Review of the Immediate Plan of Care dated 8/12/15 indicated Resident 46 was at risk for pressure ulcers due to a bed mobility problem, was bedfast and had bowel incontinence. Interventions for prevention of pressure ulcers included a plan to turn/reposition the resident every 2 hours and use of heel protectors (devices such as padded boots which are designed to reduce pressure to the heels). Review of the medical record revealed no evidence to indicate Resident 46's heels were assessed for development of pressure ulcers. Review of Progress Notes dated 9/15/15 at 2:38 PM revealed a hard raised area was observed on Resident 46's right buttocks area next to the coccyx. Documentation indicated a plan to .keep pressure off that area to see if it resolves. Review of Progress Notes dated 9/17/15 revealed Resident 46 was seen by the Healthcare Practitioner due to .a red bump noted to (resident's) coccyx and the .area was red and a hard bump noted. Review of Resident 46's Treatment Administration Record (TAR) dated 9/2015 revealed orders dated 9/17/15 for a daily skin assessment for 7 days and application of a [MEDICATION NAME] (a foam dressing used to minimize trauma to a wound and surrounding skin) dressing applied to the coccyx area and changed every 72 hours. Review of the 9/2015 TAR revealed daily skin assessments of the reddened area to Resident 46's buttocks were completed for 7 days ending on 9/24/15 although there was no documentation which included a description of the reddened coccyx area. There was no evidence in the medical record to indicate Resident 46's reddened coccyx area was assessed from 9/24/15 through 9/30/15 although review of the TAR for 9/2015 indicated the [MEDICATION NAME] dressing to the coccyx was replaced on 9/29/15. Resident 46 was observed lying on back in bed on 9/30/15 at 6:49 AM, 7:55 AM, 8:30 AM, 9:25 AM, 10:20 AM, 11:40 AM and 12:30 PM. Review of Progress Notes dated 9/30/15 at 2:28 PM revealed no evidence to indicate the resident refused to be repositioned off of back and onto a side lying position. Documentation indicated the resident had a bath that day and also had .a large loose stool and was .incontinent of bowel and bladder. Review of a Weekly Skin Review form dated 9/30/15 revealed Resident 46's skin was intact and the resident had No new skin issues at this time. Observations and staff interviews completed on 10/1/15 from 8:35 AM until 9:00 AM revealed the following: -Resident 46 was lying in bed on back when Nursing Assistant (NA)-E and Registered Nurse (RN)-N entered the room to provide morning cares. The resident was wearing bilateral heel protectors. -Interview with NA-E revealed NA-E came on duty at 6:00 AM and no incontinence care or repositioning had been provided for Resident 46 until 8:35 AM (2 hours and 35 minutes). NA-E further indicated the night shift staff were the last to provide repositioning and incontinence care for Resident 46. NA-E was uncertain what time the night shift staff completed Resident 46's care before their shift ended at 6:00 AM. -NA-E and RN-N provided perineal care as Resident 46 was incontinent of urine and feces. -NA-E and RN-N repositioned the resident to the side and there was no [MEDICATION NAME] dressing on the resident's coccyx area. -Resident 46 had an open skin area on the right buttocks area and RN-N commented it looked like a pressure ulcer as the skin area was open. -NA-E stated the open skin area on the resident's buttocks was present yesterday when NA-E provided care and NA-E reported this to the charge nurse on 9/30/15. -NA-E stated Resident 46 did not have pressure ulcers on the heels yesterday. -Upon request, NA-E removed the resident's bilateral heel protectors. -Resident 46 had a reddened area on the right outer heel. RN-N measured the area and commented it measured 1 centimeter (cm) by .3 cm. -Resident 46 had a black colored area on the left heel. RN-N measured the area and indicated it measured 2 cm by 1.5 cm. RN-N verified it was an unstageable pressure ulcer (The staging system is a method of summarizing characteristics of pressure ulcers, including the extent of tissue damage. An unstageable pressure ulcer is full thickness tissue loss in which the base of the ulcer is covered by slough which may be tan, brown or black in color). -NA-E stated Resident 46's heels were not visualized by NA-E during provision of care on 9/30/15 but it had been reported to NA-E that the resident had no problems with pressure ulcers on the heels. Interview with Licensed Practical Nurse (LPN)-M on 10/1/15 at 9:05 AM confirmed the night shift staff reported Resident 46's buttocks area was pretty raw back there due to diarrhea during the night. LPN-M was not aware of pressure ulcers on the resident's heels. RN-N stated during interview on 10/1/15 at 9:37 AM that the open skin area on Resident 46's buttocks was approximately .5 cm in size and the area on Resident 46's left heel was a deep tissue injury. RN-N verified there was no evidence to indicate Resident 46's heels had been assessed for pressure sores. RN-N verified there was no evidence the pressure ulcer on the resident's buttocks had been assessed or reported to the physician. C. Review of Resident 50's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was at risk for development of pressure ulcers, no pressure ulcers were present and the resident had moisture associated skin damage. Review of the Wound Evaluation Flow Sheet dated 3/1/15 revealed weekly documentation was started regarding Resident 50's excoriated skin on the right and left buttocks area. Review of Resident 50's TAR revealed an order dated 3/3/15 for the resident to be repositioned by 2 persons every 2 hours around the clock. Review of the Wound Evaluation Flow Sheet dated 8/23/15 revealed Resident 50 continued to have excoriated skin on the right and left buttocks and the skin remained intact. Review of a Physician Verbal Order form dated 8/26/15 revealed a progress note that stated Resident 50 had .New coccyx ulcers (pressure ulcers). Review of the Care Plan (revision date 9/7/15) indicated Resident 50 was at risk for pressure ulcers and skin integrity problems. Interventions included the following: -Conduct weekly skin inspections. -Observe skin daily and during baths. Provide thorough skin care after incontinent episodes and apply barrier cream. -Reposition frequently. Review of the Wound Evaluation Flow Sheets dated 9/21/15 indicated Resident 50 had excoriated areas to the buttocks. Documentation indicated the excoriated area on the left buttock measured 6 cm by 13 cm and the right buttock measured 13 cm by 10 cm. Documentation further indicated the skin was intact and surrounding tissue was pink in color. Review of Resident 50's medical record revealed no further assessments were completed regarding the resident's excoriated skin areas. Observations and staff interviews completed on 9/30/15 from 8:09 AM until 8:36 AM revealed the following: -Resident 50 was lying in bed on back when NA-C and NA-D entered the room to provide morning cares. -Resident 50's disposable incontinent brief was saturated with urine and a cloth soaker/incontinent pad positioned under the resident's buttocks was saturated with dark yellowish-brown colored urine. -NA-C and NA-D verified the cloth soaker/incontinent pad was wet with drying urine. -Interview with NA-C and NA-D revealed they started duty at 6:00 AM and no incontinence care or repositioning had been provided for Resident 50 until they entered the room at 8:09 AM. NA-C and NA-D indicated the night shift staff were the last to provide repositioning and incontinence care and they were uncertain what time the night shift had completed Resident 50's care before their shift ended at 6:00 AM. -The skin on Resident 50's right and left buttocks areas was red, excoriated and open. -NA-C and NA-D provided perineal care for Resident 50 and applied a barrier cream (a moisturizing cream used to protect the skin from irritants such as urine or feces). -NA-C verified Resident 50 had problems with skin breakdown of the buttocks and indicated staff .just can't get it healed up. NA-C verified the skin area on the resident's buttocks was not intact. On 9/30/15, Resident 50 was observed lying in bed and positioned on the right side from 2:15 PM until 5:15 PM without benefit of repositioning (3 hours). Interview with the Director of Nurses (DON) on 10/1/15 at 12:02 PM revealed the DON was aware of Resident 50's excoriated skin areas of the buttocks. The DON was not aware the skin areas were open and verified the resident was to be repositioned every two hours. D. Review of Resident 53's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assist for transfers and toileting, was frequently incontinent of urine and occasionally involuntary of bowel. The MDS further indicated Resident 53 was at risk for pressure ulcer development and identified the resident had an area of MASD (moisture associated skin damage). The assessment identified use of pressure reducing devices to chair and bed and application of ointment/medications. Review of Resident 53's Progress Notes revealed the following: -8/23/15 at 6:41 PM, open areas were found on the resident's right and left gluteal folds (prominent fold on the back of the upper thigh that marks the upper limits of the thigh from the lower limit of the buttock). The open area to the left gluteal fold measured 1.5 x 1.0 cm and the right gluteal fold measured 3.0 x 1.5 cm. The Progress Note indicated the skin breakdown was related to the resident's refusal to allow staff to assist to the bathroom when incontinent with urine. -8/28/15 at 11:48 AM, the resident refused to allow staff to complete a skin assessment. -8/31/15 at 1:30 PM, staff attempted to apply a barrier cream (ointment used to protect skin from moisture and to assist in healing skin breakdown) to the resident's gluteal folds but the resident would not wake up and the treatment was not completed. Review of Braden Scale for Predicting Pressure Sore Risk dated 9/2/15 revealed the resident was at risk for pressure ulcer development. Review of Resident 53's Nursing Progress Notes revealed the following: -9/3/15 at 8:08 PM, staff attempted to apply barrier cream to gluteal folds but resident refused and threw a walker at the staff. -9/6/15 at 1:54 PM, the resident refused to allow staff to apply barrier cream to gluteal folds. -9/8/15 at 1:31 PM, the resident refused to allow staff to apply barrier cream to gluteal folds. -9/11/15 at 10:00 AM a skin assessment was completed. Further review of documentation revealed no evidence the resident's gluteal folds were assessed. Review of Resident 53's current Care Plan dated 9/11/15 revealed the resident was at risk for altered skin integrity and pressure ulcers due to need for assist with mobility, frequent incontinence of bowel and bladder, resistance with cares and refusal of treatments at times. The resident was identified as having a history of redness to coccyx area. Interventions included the following: -Weekly skin assessments. -Observe skin with daily cares and weekly baths. -Provide pressure reduction/relieving mattress. -Provide thorough skin care after incontinent episodes and apply barrier cream as ordered. -Float heels (use of a pillow or assistive device to elevate heels and relieve pressure). Review of Resident 53's Nursing Progress Notes revealed the following: -9/18/15 2:24 PM, a skin assessment was completed. Further review of documentation revealed no evidence the resident's gluteal folds were assessed and the assessment indicated the resident's skin was intact. -9/19/15 at 2:11 PM, the resident refused to allow staff to apply barrier cream to gluteal folds. Resident 53 was observed seated in a recliner in the resident's room with lower legs hanging in a dependent position, the resident's heels rested directly on the floor with no pressure reduction device in place to float heels and no pressure relieving cushion to the seat of the recliner on the following dates and times: -9/28/15 from 9:00 AM to 2:00 PM (5 hours). -9/29/15 from 8:00 AM to 1:20 PM (5 hours and 20 minutes) During an observation of toileting cares on 9/29/15 from 1: 38 PM to 1:42 PM, NA-A and NA-B assisted the resident out of the recliner and into the resident's bathroom. The seat of the resident's recliner, the resident's slacks and the resident's disposable incontinent brief were saturated with urine and feces. NA-A applied the barrier cream to the resident's gluteal folds upon completion of cares. Resident 53 was cooperative and no resistance with toileting cares were observed. During an interview on 9/29/15 from 1:45 PM to 1:55 PM, NA-A indicated the resident had not been toileted since 5:00 AM that morning. Resident 53 had denied the need to use the bathroom and staff did not further encourage the resident due to history of resistance with cares. NA-A voiced awareness of skin breakdown to the resident's gluteal folds. During observations on 9/30/15 from 7:06 AM to 12:25 PM (5 hours and 19 minutes), Resident 53 was observed seated in a recliner in the resident's room with lower legs hanging in a dependent position with no pressure reduction devise to float heels and no pressure relieving cushion observed to the seat of the recliner. During observation of toileting cares on 10/1/15 from 10: 40 AM to 10:57 AM, NA- A assisted Resident 53 out of the recliner and into the resident's bathroom. The resident's slacks and the resident's disposable incontinent brief were soiled with urine. NA-A indicated the resident was last toileted between 4:00 AM and 5:00 AM by the night shift. Observations of the resident's gluteal folds revealed the resident's right gluteal fold had a stage 1 pressure ulcer and the left gluteal fold had a stage 2 pressure ulcer. Resident 53 displayed no resistance with cares when toileted by staff. During an interview on 10/1/15 from 11:00 AM to 11:15 AM, the DON confirmed the following: -Staff were to complete weekly skin assessments on all residents and if an area of breakdown was observed, staff were to measure and assess the area weekly. -Resident 53's right gluteal fold had a Stage 1 (reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device) pressure ulcer and the area to the left gluteal fold was a Stage 2 (partial thickness loss of dermis) pressure ulcer. -Resident 53 slept in the recliner at night, ate meals and usually spent the entire day seated in the recliner. No pressure reduction device had been placed in the seat of the recliner and the resident's heels were not floated when seated in the recliner. -Resident 53 should have been repositioned and offered an opportunity to use the bathroom at least every 2 hours. -A toileting plan should have been developed for Resident 53 and the resident should have been toileted according to the plan to prevent skin breakdown.