Every finding on record at Adept Nursing & Rehab of Blue Hill

Licensure Reference Number 175 NAC 12.006.04(H)(ii)Based on record review and interviews, the facility failed to have a qualified individual to act as the director of food and nutrition services. This had the potential to affect all the residents receiving food items from the kitchen. The facility census was 25.Findings are:Record review of a facility supplied document titled admission Agreement and not dated revealed the facility would provide nourishing palatable well-balanced diet that meets the residents daily nutritional and special dietary needs.Record review of a facility supplied document titled Facility Assessment and dated 04/07/2026 revealed in the section listed as information about our staff under food and nutrition services a type listing of Dietary Manager with the Regional Dietary Manager (RDM) listed as the responsible individual.Record review of a document titled Professional Staff completed by the Facility Administrator on 08/12/2026 listed the RDM as the Dietary Manager.In an interview completed on 08/13/2026 at 8:47 AM with the Dietary Aide (DA), the DA stated that the facility did not have a Dietary Manager at this time due to the position being open.In an interview completed on 08/13/2026 at 8:50 AM with the Cook, the [NAME] stated that the facility did not have a Dietary Manager at this time.In an interview completed on 08/13/2026 at 1:35 PM with the Facility Administrator (FA), the FA stated that the director of food and nutrition services for the facility would be the Dietary Manager. The FA confirmed that the facility had been with out a Dietary manager for approximately a month and was actively working to employee a individual for this position. The FA stated that the Registered Dietitian and a Dietary Manager from another facility visited the facility weekly during this time.In an interview completed on 08/18/2026 at 3:30 PM with the Regional Director of Operations (RDO), the RDO stated that the individual listed as the Dietary Manger on both the facility assessment and the professional staff documents was the Regional Dietary Manager and not the Dietary Manager for the facility. The RDO stated that the facility did not have a Dietary Manager at this time so the Registered Dietitian and a Dietary Manager from another facility visited the facility weekly on different days at this time.

Licensure Reference Number 175 NAC 12-006.11(E)Licensure Reference number 175 NAC 12-007.01(A)Based on record review, observation and interview, the facility failed to store food items in a sanitary manner and at temperatures to prevent the potential for food born illness and failed to maintain kitchen equipment in a sanitary manner. This had the potential to affect all of the residents receiving food stuff items from the kitchen. The facility census was 25.Findings are:Record review of a facility policy titled Sanitation Inspection and dated 04/08/2026 revealed it was the policy of the facility that all food service areas shall be kept clean and sanitary. The dietary manager should develop and provide food service personnel with standard operating procedures for sanitation and daily inspections. A.In an observation completed on 08/12/2026 at 9:05 AM of the kitchen facilities the following was observed:-The cupboard door handles used to open the cupboards located beside the food prep area and above the food prep sink to have sticky debris that adheres to one's fingers when grasping the handles to open the cupboard doors.-The double door refrigerator located beside the hand-washing sink to have dried white and yellow fluid spills visible to the bottom of the device and food debris crumbs in the bottom of the device.-In the dry goods storage area, a box of bananas is present. Visible in the top of the box of bananas is a banana that is brown and mushy in appearance split open with white fuzz protruding from the split in the skin of the banana.-The double door refrigerator located in the dry goods storage area has a box of tomatoes present. Visible in the box are 3 tomatoes with round black spots. One of the tomatoes with the round black spots also has white visible fuzz on top of the black spot.-In the dry goods storage area is a 4 wheeled cream colored 3 shelf cart with empty egg crates and cardboard boxes that are empty being stored on it in front of the facilities canned goods storage area.-The heating and or cooling device in the dry goods storage area has 2 cardboard boxes of juice sitting on top of it. These are located right beneath a bug light. On top of the cardboard boxes is debris consistent with dead flying pests.-The white chest freezer located in the basement of the facility where food items are stored to have brown, black buildup to the top of the freezer and the handle of the freezer used when opening it has sticky debris that comes off on one's hands when using the handle to open the freezer to obtain food items from it.-The double door freezer also located in the basement to have food items stored in clear plastic bag visible is frozen pieces of chicken. The clear plastic bag is open exposing the meat to the elements of the freezer.In an interview completed on 08/17/2026 at 11:36 AM with the Cook, the cook confirmed that the door handles to the cupboards was sticky and not clean, confirmed that there was food debris and spills dried on the inside of the double door refrigerator, confirmed that the egg crates and boxes should have been taken to the trash and not stored on the cart in the dry storage area, and confirmed that the white chest freezer had buildup and soiling present on it and on the handle. The cook confirmed that the bananas were not good for consumption and should have been disposed of and the tomatoes were not good for consumption and should have been disposed of. B.Record review of a facility policy titled Monitoring of Cooler/Freezer Temperature and dated 04/08/2026 revealed it was the policy of the facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. All refrigerated storage must be maintained at or below 41 degrees. If temperatures are above 41 degrees the supervisor will be notified immediately for corrective action.In an observation completed on 08/17/2026 at 9:05 AM of the facilities kitchen the double door refrigerator located beside the hand washing sink to have a document titled Refrigerator/Freezer Temperature Log and dated August 2026 to be taped to it. Review of the log revealed:-On August 3nd a morning temperature of 44 and evening temperature of 42 degrees was recorded. In the box titled Action taken there is an X. There is no notation present of an action taken of the temperature re checked to correct the temperature of the refrigerator.-On August 5th a morning temperature of 44 and no evening temperature was recorded. In the box titled Action taken there is an X. There is no notation present of an action taken of the temperature re checked to correct the temperature of the refrigerator.-On August 8th a morning temperature of 44 and evening temperature of 42 degrees was recorded. In the box titled Action taken was no notation present of an action taken of the temperature re checked to correct the temperature of the refrigerator.-On August 9th a morning temperature of 44 and evening temperature of 40 degrees was recorded. In the box titled Action taken there was no notation present of an action taken of the temperature re checked to correct the temperature of the refrigerator.-On August 12th a morning temperature of 42 and evening temperature of 42 degrees was recorded. In the box titled Action taken there was no notation present of an action taken of the temperature re checked to correct the temperature of the refrigerator.-On August 13th a morning temperature of 44 and evening temperature of 32 degrees was recorded. In the box titled Action taken there is an X. There is no notation present of an action taken of the temperature re checked to correct the temperature of the refrigerator.-On August 14th a morning temperature of 44 and evening temperature of 42 degrees was recorded. In the box titled Action taken there is an X. There is no notation present of an action taken of the temperature re checked to correct the temperature of the refrigerator.In an interview completed on 08/17/2026 at 11:35 AM with the Dietary Aide (DA), the DA stated that the refrigerator temperatures are checked by the cooks twice daily and recorded on the log. The DA stated that the temperature is to be below 40 degrees they think.In an interview completed on 08/17/2026 at 11:36 AM with the [NAME] the [NAME] stated that they check the temperatures of the refrigerators and freezers at the beginning of their shift- which is twice a day. The cook stated that at this time there is no dietary manager to report the temperatures to when above 41 degrees for further direction or corrective action.C.In an observation completed on 08/12/2026 at 9:05 AM of the kitchen facilities the following was observed:-The stainless-steel steam table that food is served to the resident from is observed to have yellow white granular build up and debris present to the sides and at the bottom of the steam wells.-The white stand up freezer located in the dry goods storage area had visible build up of condensation and frost to the interior of the freezer approximately 1/4th of an inch thick.-The white stand-up freezer located in the basement had visible build up of condensation and frost to the interior of the freezer approximately 2 inches thick.-The white chest freezer located in the basement had visible buildup of condensation and frost to the interior of the freezer approximately 1/2 an inch thick.In an interview completed on 08/12/2026 at 9:15 AM with the Cook, the [NAME] stated that they try to descale and lime the steam table routinely. The cook confirmed that there is buildup of scale and lime present to the steam table and there should not be. The cook stated that they try to defrost the freezers monthly. The cook confirmed that the freezers had a build up of frost and condensation and should not.

Licensure Reference Number 175 NAC 12-006.02 Based on record review, observation and interview, the facility management and administration failed to utilize resources to ensure the provision of care and services were provided to the facility residents to attain or maintain the highest practicable physical well-being, psychosocial well-being, and safety of all residents as identified in the deficient practices cited. The facility census was 25. Based on record review and interview the facility failed to ensure that the resident/resident representative was provided the required Centers for Medicare and Medicaid Services (CMS) notifications of the ending of their Medicare Part A skilled services (a program that covers the cost of short-term skilled nursing facility (SNF) care for up to 100 days in a SNF). This prevented the resident/resident representative from making an informed decision regarding their choice for further care and financial options, and of the right to appeal the decisionInterview on 8/13/26 at 10:13 AM the facility Social Services Director (SSD) confirmed that Resident 17's discharge from Medicare Part A services was initiated by therapy. The SSD confirmed that an SNF-ABN (Advance Beneficiary Notice of Noncoverage) was required to be provided to Resident 17 but that the SSD forgot to do it.This is a repeat deficiency.F684; The facility failed to provide continued assessment and monitoring of a resident to prevent hospitalization.In an interview completed on 08/13/2026 at 11:05 AM with the facility Assistant Director of Nursing (ADON), the ADON confirmed that the residents record should have documented that the resident was being assessed and monitored from 07/09/2026 for a minimum of 3 days every shift. The ADON confirmed that the resident's provider should have been notified of the emesis and elevated temperature that was documented on 07/08/2026 and was not. The ADON agreed that the timely notification of the provider and continued assessment and monitoring may have prevented the resident's hospitalization.This is a repeat deficiencyF697: The facility failed to ensure that pain medications were available to administer as ordered.Interview on 8/18/26 at 2:14 PM with the facility Assistant Director of Nursing (ADON) confirmed that the Tramadol for Resident 2 had been unavailable at times. The ADON confirmed that the facility is required to have the Tramadol available for Resident 2 as ordered by the physician.F726; The facility failed to ensure that all nursing staff were given yearly and as needed competency reviews to determine competency related to medication administration and nursing cares.In an interview on 8/17/26 at 3:05 PM with the Assistant Director of Nursing (ADON) revealed that no competency or skill review days had been completed in the past year. In a confirmation interview with the Regional Director of Nursing (RDN) on 8/18/26 at 3:15 PM it was confirmed that there is no documentation that the Medication Aides and the Nursing Assistants were competency tested and given a skills test in the past year. There were no records found that indicated that nurses - RNs, LPNs, and DON were given a competency test or skills test in the past year or any time recently. The RDN agreed that due to the Peripherally Inserted Central Venous Catheter (PICC) line, the medication error related to the incorrect administration of insulin using the insulin pen, and the wound care that did not meet the standards of care and the ineffective infection control measures during the wound care process, that a competency and skills day needed to be implemented for all nursing staff. In a confirmation interview with the Regional Director of Operations (RDO) on 8/18/26 at 3:16 PM it was revealed that because the competency testing had not been completed for any of the nursing staff in the past year, that it needed to be completed quickly to ensure that resident cares were being done correctly.F759; The facility failed to ensure a medication error rate of 5% or less with an observed medication error rate of 6.06% (2 medication errors during 33 medication administrations). Interview on 8/18/26 at 2:18 PM with the facility Assistant Director of Nursing (ADON) confirmed that the insulin pen has to be primed before use to ensure the correct amount of insulin. The ADON confirmed that the needle is required to be kept in place for 6-10 seconds during administration of insulin using an insulin pen to ensure the correct amount of insulin is administered. The ADON confirmed not priming the insulin pen or keeping the needle in the skin for 6-10 seconds is a medication error. Interview on 8/18/26 at 2:18 PM with the facility ADON confirmed that medications not administered within an hour before or an hour after the scheduled time is a medication error. The ADON confirmed that the late administration of the IV antibiotic for Resident 14 was a medication error.This is a repeat deficiency.F812; The facility failed to store food in a sanitary manner to prevent the risk of food borne illness, failed to maintain the kitchen equipment in a sanitary manner to prevent the risk of food borne illness, failed to maintain dishware in a sanitary manner to prevent the risk of food borne illness, and failed to store food items in a manner to prevent the risk of food born illness. This had the potential to effect all of the residents receiving food stuff items from the kitchen.This is a repeat deficiencyF880: The facility failed to have an effective infection control program in place to ensure handwashing and hand sanitization occurred when required. The facility failed to ensure that staff changed gloves when required and failed to perform hand sanitization (hand hygiene-hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) before and after putting on gloves as required.Interview on 8/18/26 at 2:20 PM with the ADON confirmed that hand sanitization is to be performed before putting on gloves and after taking gloves off. The ADON confirmed that the DON's gloves should have been changed if potentially contaminated prior to continuing medication administration of insulin. In an interview with the Regional Director of Operations and the Regional Nurse Consultant on 8/18/26 at 3:30 PM it was confirmed that the facility staff worked with a Regional Infection Control Consultant (RICC) and that the ADON who was in charge of the Infection Control needed to call the RICC to assist with the Infection Control processes in the facility.This is a repeat deficiencyF921; The facility failed to provide a safe, sanitary, and comfortable environment for residents, staff, and public as noted by pooled condensation and dripping water on the floor from overhead pipes in the basement, one dehumidifier that was partially plugged into the wall but was not working and was standing in the pooled water condensation of the basement, two large automotive 12 volt batteries sitting in pooled water condensation in the basement in the room adjacent the laundry room with the washing machines, and two double hampers approximately 30 long x 30 wide x 15 deep filled with overflowing trash and dirty linens which smelled of urine and fecal matter in the commons area which led to the resident dining room and the only public entrances to all 4 resident hallways. Interview with the Regional Director of Operations (RDO) on 8/12/26 at 13:10 revealed that the condensation was a problem and would go to the city to purchase dehumidifiers and have them placed in the basement area. The RDO would work with maintenance staff to remove the pooled water condensation, contact outside assistance to ask about having pipes wrapped to assist with condensation issues in the humid environment, purchase fans, and have the 12-volt batteries removed from the basement.In a confirmation interview with the Facility Administrator (FA) on 8/17/26 at 9:20 AM it was revealed that the batteries had been removed from the basement area. Dehumidifiers were purchased for the basement as were fans to assist in the circulation of the air in the basement to dry all areas.In a confirmation interview with the RDO on 8/18/26 at 9:40 AM it was revealed that the staff had worked hard to get the condensation diverted from dripping on the floor of the basement and that a trough was built to allow the water to drain into a drain in the basement.In a confirmation interview with the RDO on 8/18/26 at 3:30 PM it was revealed that the hampers in the commons area are actually supposed to be behind closed doors and that they would be removed to the dirty utility room and not allowed to be in the commons are in order to keep the odiferous trash and soiled linens away from residents, staff, and visitors.F923; The facility failed to ensure that the ventilation system was working throughout the facility in all resident rooms.Interview on 8/12/26 at 4:18 PM with the Maintenance Supervisor (MS) revealed that none of the ventilation fans on the 100 hall, 300 hall, and 400 hall are working. MS was not aware that the ventilation system in room [ROOM NUMBER] was also not working.Interview with the Regional Director of Operations (RDO) on 8/13/26 at 1:15 PM who confirmed that there are repairs needed to the ventilation system and that staff are trying to get someone to come to the facility to fix this. Hoping to have someone there either tomorrow or next week. In an interview with the RDO on 8/18/26 at 11:20 AM it was confirmed that the ventilation system is still not working and that no parts have arrived to fix the issue.This is a repeat deficiency.

Licensure Reference Number 175 NAC 12-006.04(i)Licensure Reference Number 175 NAC 12-006.04(ii)Based on record review and interview, the facility failed to ensure that all nursing staff were given yearly and as needed competency reviews to determine competency related to medication administration and nursing cares. Based on record reviews and interviews, the facility failed to ensure that unlicensed staff had completed yearly competencies and skills testing ensuring knowledge of medication administration resident cares, and failed to ensure that licensed nursing staff had the knowledge to complete resident care tasks as they pertained to insulin administration and wound care. This affected all residents in the facility. The facility census was 25.Findings were:Record review of the job description of the Director of Nursing (DON) with a copyright date of 2023 revealed that the DON's purpose is to plan, organize, develop, and direct the overall operations of the Nursing Service Department in accordance with local, state, and federal standards and regulations, established policies and procedures, and as may be directed by the administrator and the medial director to provide appropriate care and services. The major responsibilities were to plan, develop, organize, implement, evaluate, and direct the overall operations of the nursing services department, as well as its programs and activities, in accordance with current state and federal laws and regulations; to interpret and communicate policies and procedures to nursing staff and monitor staff practices and implementation; evaluate work performance of all nursing personnel; to conduct observations of nursing var and supervise development of in-service education to ensure nursing staff is competent in current knowledge and skills; follow established infection control policies and procedures; and provide direct nursing are as necessary.Record review of the job description for the Registered Nurse (RN) with a copyright date of 2023 revealed this individual may provide direct nursing care to the resident an supervises the day to any nursing activities performed by the licensed practical nurse (LPN) and Nursing Assistants in accordance with local, state, and federal standards and regulations, guidelines and established policies and procedures. Those reporting to the RN were LPNs, medication aides, and nursing aides. Some of the major responsibilities of the RN were following the nursing model to promote holistic care for the residents, ensuring policies and procedures were complied with by nursing personnel assigned, preparing and administering medications a per physicians' orders and observing for adverse effects, providing nursing leadership to nursing personnel assigned to the unit, providing direct care skills such as wound care and intravenous medication (IV) (medications that are given directly into the vein) administration, etc. in accordance with current policies and procedures, may assist in evaluating work performance of nursing personnel, and other duties assigned. Additionally, the RNs were to complete all assigned training and skills competency tasks.Record review of the Charge Nurse job description with a copyright date of 2023 revealed that licensed practical nurses (LPNs) provided direct nursing care to the residents and supervised the day-to-day nursing activities performed by the nurses' aides and medication aides in accordance with local, state, and federal standards and regulations, guidelines and established policies and procedures. Some of the major job responsibilities were to prepare and administer medications as per physicians' orders and observe for adverse effects, provide direct care skills such as wound care, IV medication administration and other duties in accordance with policies and procedures. Additionally, the charge nurses and LPNs were to complete all assigned training and skills competency tasks. Record review of the Medication Aide job description with a copyright date of 2023 revealed that all medication aides assist licensed nursing staff by administering daily medications as ordered by the physician in accordance with established nursing standards, facility policies and procedures and state requirements. Medication Aides (MAs) reported to the DON, RN, LPN or charge nurse. MA responsibility included delivering routine daily oral, inhalation, and topical medications to residents under direct supervision or a licensed nurse, serve for drug interactions and report problems to nurses, record medication administration according to the company policies and procedures, perform tasks including vital signs, medications dose calculations, stocking and removal of discontinued medications, complied wi.th standards of business conduct, and state and federal regulations and guidelines, and completed all assigned training and skills competencies.Record review of the Certified Nursing Assistant (NA) job description with a copyright date of 2023 revealed that the purpose of the position is to provide services to residents in accordance with care plans, facility policies and procedures and at the direction of a supervisor. NA's assisted with activities of daily living, lifting, turning and moving residents, baths, dining, obtaining resident weights, tracking and reporting skin conditions and skin breakdowns, and completed all assigned training and skills competencies.In an interview on 8/17/26 at 3:05 PM with the Assistant Director of Nursing (ADON) revealed that no competency or skill review days had been completed in the past year. In a confirmation interview with the Regional Director of Nursing (RDN) on 8/18/26 at 3:15 PM it was confirmed that there is no documentation that the Medication Aides and the Nursing Assistants were competency tested and given a skills test in the past year. There were no records found that indicated that nurses - RNs, LPNs, and DON were given a competency test or skills test in the past year or any time recently. The RDN agreed that due to the PICC line, the medication error related to the incorrect administration of insulin using the insulin pen, and the wound care that did not meet the standards of care and the ineffective infection control measures during the wound care process, that a competency and skills day needed to be implemented for all nursing staff. In a confirmation interview with the Regional Director of Operations (RDO) on 8/18/26 at 3:16 PM it was revealed that because the competency testing had not been completed for any of the nursing staff in the past year, that it needed to be completed quickly to ensure that resident cares were being done correctly. A.Record review of the files for the 5 facility staff members ongoing training for the past year revealed that the ongoing training did include the regulatory in-service hours to renew licensure. However, there was no evidence of any competency tests or skills reviews that had been completed for any of the individuals that were reviewed.-MA-J had the required 12 hours of yearly in-service training but no competency or skills test had been completed for the review period of 2/13/25 to 2/13/26.-MA-O had the required 12 hours of yearly in-service training but no competency or skills test had been completed for the review period of 3/31/25 to 3/31/26.-MA-K had the required 12 hours of yearly in-service training but no competency or skills test had been completed for the review period of 8/18/25 to 8/17/26.-MA-L had the required 12 hours of yearly in-service training but no competency or skills test had been completed for the review period of 10/22/24 to 10/22/25-MA-M had the required 12 hours of yearly in-service training but no competency or skills test had been completed for the review period of 2/21/25 to 2/21 26.B.Record review of the facility policy titled Medication Errors dated 5/6/26 revealed that the facility will provide, for the protections and of the health, welfare, and rights of each resident by ensuring that residents receive care and services safely in an environment free of significant medication errors. The facility will ensure that medications will be administered according to physician's orders and in accordance with accepted standards and principles which apply to professionals providing services. The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. Medication administered not in accordance with the prescriber's order includes incorrect dose, incorrect route, incorrect person, incorrect medication, and incorrect time of administration. If a medication error occurs, the nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. Monitor and document the resident's condition and document actions taken in the medical record.Record review of the facility policy titled Insulin Pen dated 1/8/26 revealed that the facility will use insulin pens to improve the accuracy of insulin dosing. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. The procedure revealed the steps to gather needed supplies (insulin pen, alcohol prep pads, sterile insulin pen needle); perform hand hygiene; put on gloves. Removed the pen cap from the insulin pen and wipe the rubber seal with an alcohol pad. Screw the needle onto the insulin pen. Prime the insulin pen by turning the dose selector to 2 units (priming removes any air trapped in the insulin reservoir and needle). With the needle pointing up, push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Turn the dose selector to the ordered dose. Cleanse the skin with an alcohol pad. Gently pinch up the skin at the injection site and hold. Inject the needle straight at a 90-degree angle to the skin. Fully depress the plunger until the dosing numbers count back to zero. Keep the needle in the skin for up to 6 to 10 seconds and then remove the needle from the skin (holding the needle in the skin ensures that all of the insulin dose is administered).Observation on 8/17/26 at 11:57 AM at the facility dining room revealed facility Director of Nursing (DON) did not administer insulin according the physician orders or according to the manufacturer's instructions for the use of the insulin pen as DON did not swab the insulin pen with alcohol prior to attaching the insulin needle, the insulin was administered late, the insulin pen was not primed, and the insulin needle and pen were not left in place for the required length of time to ensure that the resident received all of the injected insulin.Interview on 8/18/26 at 9:08 AM with the facility DON confirmed that the DON did not prime the insulin pen prior to the insulin administration for Resident 3 on 8/17/26 and did not hold the needle in place during the administration as required.Interview on 8/18/26 at 2:18 PM with the facility Assistant Director of Nursing (ADON) confirmed that the insulin pen has to be primed before use to ensure the correct amount of insulin. The ADON confirmed that the needle is required to be kept in place for 6-10 seconds during administration of insulin using an insulin pen to ensure the correct amount of insulin is administered. The ADON confirmed not priming the insulin pen or keeping the needle in the skin for 6-10 seconds is a significant medication error.Observation during the survey period of 8/12/26 to 8/18/26 of medication administration of 33 meds by nursing staff revealed a medication error rate of 6.06 % due to 2 medication errors with one error being a significant medication error. Record review of the policy Wound Treatment Management dated 11/11/25 revealed that the policy was to promote wound healing of various types of wounds by evidence-based practice treatments in accordance with current standards of practice and physician orders. Wound treatments were to be provided in accordance with physician orders, including cleansing methods, types of dressings, and frequency of dressing changes. Dressing changes were to be done as ordered by the physician, in accordance to the manufacturer's recommendations, and treatments were to be based on the type of wound and the characteristic of the wound. Finally, the treatments were to be documented in the resident's electronic medical record when completed and monitored for lack of progress in healing, changes in the characteristic of the wound, and documented changes in accordance with the wishes and the rights of the resident.Record review of the Order Summary (a listing of all physician's orders for a resident) for Resident 14 dated 8/17/26 revealed that Resident 14 had an order for Cefepime 2 Grams (a strong antibiotic given to treat severe bacterial infections) intravenously (administered into the vein- an IV) three times a day for Sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues) for 39 Days. The order date was 8/9/26.Observation on 8/17/26 at 4:45 PM at the room of Resident 14 revealed that the ADON and DON entered the room of Resident 14. The ADON carried a vial of Cefepime antibiotic, a small IV bag, and alcohol prep pads. The DON removed the used administration set from the IV pump with direction from the ADON. The DON exposed the right arm of Resident 14 and asked, is it painful or anything?. Resident 14 responded no. The DON told Resident 14 it looks good. The ADON hung the IV bag and routed the administration set tubing through the IV pump. The ADON removed the cap from the port on the Peripherally Inserted Central Catheter (PICC line- a long, thin, flexible tube put into a vein in the upper arm used to provide intravenous medications and fluids) on the right arm of Resident 14. The ADON wiped the top of the port with an alcohol prep pad and attached a syringe with normal saline. The ADON pushed the plunger on the syringe and flushed the PICC line with 10 milliliters (ml) of the normal saline. The ADON removed the syringe from the PICC line port and wiped the top of the port with an alcohol prep pad. The ADON attached the IV administration set tubing to the PICC line port and set the IV pump to run at 200 ml per hour and a volume of 100 ml. The ADON started the IV pump and unclamped the administration set tubing clamp. The ADON removed the gown and gloves. The DON removed their gown and gloves. Observations of wound care during the survey period of 8/12/26 to 8/18/26 revealed that nursing staff did not follow infection control procedures per the usual standards of care and evidence-based practice for wound care and dressing changes and infection prevention protocols when doing dressing changes.In an interview on 8/17/26 at 3:05 PM with the Assistant Director of Nursing (ADON) revealed that no competency or skill review days had been completed in the past year. The ADON confirmed that Medication Aides and Nursing Assistants were not given routine competency tests or skills training at the time of hire. They merely go through orientation with another staff member and then when that is finished, they are on their own. There have been no competency-based skills testing to ensure that staff are following medication administration as ordered or as regulations require.When asked about competency training for nurses when orders are for rarely performed in-house procedures such as PICC LINES, the ADON stated that there were no completed competencies for PICC LINES either. At the time of the survey, there was a resident with a wound vac (A (vacuum-assisted closure), also known as negative pressure wound therapy (NPWT) is a medical device that uses gentle suction to help complex, slow-healing, or severe wounds heal faster. It draws out extra fluid, reduces swelling, brings the edges of the wound together, and helps new healthy tissue grow.) and another resident with a PICC LINE. We probably should review these as well with the nursing staff since these are not something we do very often. We used to have a wound care company that worked with the wound vacs and would talk to the nurses about what needed to be done to care for the devices. But they aren't coming to the facility this time.When asked for competency records for the following people, the ADON stated that there were no recent competency records if any:-LPN-P had no competency testing related to wound care, PICC lines or other nursing skills.-LPN-C had no competency testing related to wound care, PICC lines or other nursing skills.-LPN-A had no competency testing related to wound care, PICC lines or other nursing skills.-RN-N had no competency testing related to wound care, PICC lines or other nursing skills.-DON - had no competency testing related to wound care, PICC lines or other nursing skills.-ADON - a licensed practical nurse - had no competency testing related to wound care, PICC lines or other nursing skills.In a confirmation interview with the Regional Director of Nursing (RDN) on 8/18/26 at 3:15 PM it was confirmed that there is no documentation that the Medication Aides and the Nursing Assistants were competency tested and given a skills test in the past year. There were no records found that indicated that nurses - RNs, LPNs, and DON were given a competency test or skills test in the past year or any time recently. The RDN agreed that due to the PICC line, the medication error related to the incorrect administration of insulin using the insulin pen, and the wound care that did not meet the standards of care and the ineffective infection control measures during the wound care process, that a competency and skills day needed to be implemented for all nursing staff. In a confirmation interview with the Regional Director of Operations (RDO) on 8/18/26 at 3:16 PM it was revealed that because the competency testing had not been completed for any of the nursing staff in the past year, that it needed to be completed quickly to ensure that resident cares were being done correctly.

Licensure Reference Number 175 NAC 1-005.06(D)Licensure Reference Number 175 NAC 1-005.06(E)Licensure Reference Number 175 NAC 12.006.18Based on observation, record review, and interview the facility failed to ensure that staff kept linens in the hallways covered and stored to reduce the risk of transmission of infection and use safe handling work practices; failed to ensure soiled laundry and trash was kept in the soiled utility areas to maintain a sanitary environment for residents, staff, and visitors; failed to ensure staff changed gloves when required and failed to perform hand sanitization (hand hygiene-hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) before and after putting on gloves as required. The facility census was 25.Findings are:Based on record review, interview, and observation, the facility failed to implement the policies cited in the infection control program by ensuring that the staff were using hand washing procedures to prevent the spread of infections from one person to another. This had the potential to affect 2 of 2 sampled residents while observing the meal service at the table where residents needed assistance. The facility census was 25. Findings were: Record review of the policy dated 4/1/24 and review on 6/1/26 Infection Prevention and Control Program revealed that the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The definition of the word staff included all facility staff) with direct or indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. The policy had an explanation to the compliance guidelines that all staff are responsible for following all policies and procedures related to the program. Surveillance within the program revealed that a.) a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. b.) the Infection Preventionist serves as the leader in the surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to Quality Assessment and Assurance Committee. c.) the Registered Nurses and Licensed Practical Nurses participate in surveillance through assessment of residents and reporting changes of condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections. Standards of precautions revealed that A.) all staff shall assume that all residents are potentially infected of colonized with an organism that could be transmitted during the course of providing resident cares. B.) Hand Hygiene shall be performed in accordance with our facility's established hand hygiene procedures. A description of linens revealed that b.) clean linen shall be separated from soiled linens at all times, c.) clean linen shall be delivered to resident care units on covered linen carts with covers down, d.) linen shall be stored on a all resident care units on covered carts, shelves, in binds, drawers, or linen closets, e.) soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. A. Observation on 8/18/2026 at 7:45 AM of an uncovered linen cart located down in the 200 hallway across from the door of the facility tub room. Towels, wash clothes, and briefs among other items were on the uncovered linen cart. Observation on 8/18/2026 at 10:00 AM of an uncovered linen cart located down in the 200 hallway across from the door of the facility tub room. Towels, wash clothes, and briefs among other items were on the uncovered linen cart. Observation on 8/18/2026 at 12:35 PM of an uncovered linen cart located down in the 200 hallway across from the door of the facility tub room. Towels, wash clothes, and briefs among other items were on the uncovered linen cart. Observation on 8/18/2026 at 3:25 PM of an uncovered linen cart located down in the 200 hallway across from the door of the facility tub room. Towels, wash clothes, and briefs among other items were on the uncovered linen cart. Interview with the Regional Director of Operations on 8/18/2026 at 3:30 PM who confirmed that the linen cart is supposed to be covered when in the hallway and should have actually been stored in the clean linen room instead of being in the hallway. B. Observation on 8/13/26 at 9:15 AM there were two double hampers approximately 30 long x 30 wide x 15 deep filled with overflowing trash and dirty linens which smelled of urine and fecal matter in the commons area. This commons area was where nurses stored two medications carts, contained the two public restrooms, had chairs available for residents sit in and watch staff and others, led directly to the resident dining room, and where the only public entrances to all 4 resident hallways that residents, staff, and members of the public had to pass near when visiting with residents in their rooms. Observation on 8/13/26 at 2:35 PM in the commons area there was one overflowing hamper of soiled linens and odiferous (smelly) trash was seated against the wall nearest the entrance to the 200 hall. Observation on 8/18/26 at 7:50 AM in the commons area there were two hampers of soiled linens and odiferous trash next to the walls in the commons area. The area smelled of urine. Observation on 8/18/26 at 11:50 AM in the commons area there were two filled hampers of soiled linens and odiferous trash next to the walls in the commons area. The area smelled of urine. Observation on 8/18/26 at 3:00 PM in the commons area there were two overflowing hampers of soiled linens and odiferous trash next to the walls in the commons area. The area smelled of urine. In a confirmation interview with the Regional Director of Operations (RDO) on 8/18/26 at 3:30 PM it was revealed that the hampers in the commons area are actually supposed to be behind closed doors and that they would be removed to the dirty utility room and not allowed to be in the commons area in order to keep the odiferous trash and soiled linens away from residents, staff, and visitors. C. Record review of the facility policy titled Hand Hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) dated 7/7/26 revealed that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. Perform hand hygiene prior to putting on gloves and immediately after removing gloves. The Hand Hygiene Table revealed that hand hygiene is required when hands are visibly dirty, between resident contacts, after handling contaminated objects, before applying and after removing personal protective equipment including gloves and gowns, before preparing or handling medications, before and after handling clean or soiled dressings or linens, before performing resident care procedures, when moving from a contaminated to a clean body site and after handling items potentially contaminated with blood body fluids secretions or excretions. Observation on 8/17/26 at 11:53 AM at the facility dining room revealed that Resident 3 was seated at a table. Two other residents were in the dining room. The facility Director of Nursing (DON) entered the dining room and went to Resident 3. The DON put on disposable gloves (the DON did not perform hand sanitization prior to putting the gloves on). The DON went to the treatment cart and the computer mouse fell to the floor. The DON used the gloved hands to pick up the computer mouse from the floor. The DON did not change gloves (the gloves were contaminated from picking up the computer mouse from the floor). The tablemate of Resident 3, Resident 19, arrived at the dining room and sat at a chair at the table of Resident 3. The DON sat the glucometer (a medical device used to measure and display the amount of sugar in the blood for residents with diabetes) on the table in front of Resident 3. There were now 6 other residents present in the dining room. The DON opened an alcohol prep pad and wiped the pad of a fingertip on the left hand of Resident 3. The DON used the lancet (a small sterile blade used to obtain a small amount of blood for testing) and poked the pad of the fingertip on the left hand. The DON applied a drop of blood from the finger to the test strip in the glucometer The glucometer displayed a blood sugar result of 364. The DON announced the blood sugar result aloud and then showed the glucometer to Resident 3. The DON removed the gloves and disposed of them. The DON performed hand sanitization. The DON pushed the treatment cart out of the dining room and parked it near the entry to the nurse's station at 11:57 AM. The DON looked at the resident record on the laptop computer sitting on the top of the treatment cart. The DON carried an insulin pen, insulin pen needle, and the glucometer into the nurse's station and sat them on the desk. The DON picked up the insulin pen and needle from the desk in the nurse's station at 12:16 PM. The DON removed the cap from the insulin pen. The DON placed the needle on the end of the insulin pen (the DON did not wipe the top of the insulin pen with an alcohol prep pad prior to putting the needle on the pen). The DON dialed a dose of 10 units of insulin. The DON opened an alcohol prep pad package. The DON put on gloves (the DON did not perform hand sanitization prior to putting the gloves on). The DON carried the alcohol prep pad and the insulin pen into the dining room. The DON used the alcohol prep pad and wiped an area on the left upper arm of Resident 3. The DON removed the cap from the insulin pen and injected the insulin into the upper right arm of Resident 3. The DON immediately removed the insulin pen needle from the skin of Resident 3 without holding the needle in place. The time was now 12:18 PM. The DON carried the insulin pen back into the nurse's station with the gloved hands. Interview on 8/17/26 at 1:00 PM with the DON confirmed that the DON did not disinfect the top of the insulin pen before putting the needle on the pen. Interview on 8/18/26 at 2:20 PM with the ADON confirmed that hand sanitization is to be performed before putting on gloves and after taking gloves off. The ADON confirmed that the DON's gloves should have been changed if potentially contaminated prior to continuing medication administration of insulin. D. Observation on 8/17/26 at 1:13 PM in the room of Resident 14 revealed that Resident 14 sat in a wheelchair. Nurse Aide-G (NA-G) brought the mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own) into the resident's room. Medication Aide-F (MA-F) NA-G each put on a yellow personal protective gown and then gloves (MA-F and NA-G did not perform hand sanitization prior to putting on the gown and gloves as required). MA-F connected the lift sling positioned underneath Resident 14 to the hooks on the mechanical total body lift. MA-F and NA-G transferred Resident 14 from the wheelchair and into the bed with the mechanical total body lift. MA-F and NA-G repositioned the resident in the bed and removed the pants from the resident for Licensed Practical Nurse-A (LPN-A) to change the dressing on the outside of the resident's right knee. Interview on 8/18/26 at 2:20 PM with the ADON confirmed that hand sanitization is to be performed before putting on gloves and after taking gloves off. The ADON confirmed that hand sanitization is to be performed prior to putting on personal protective equipment including gowns.

Licensure Reference Number 175 NAC 12-001-005.06(C)Based on record review and interview the facility failed to implement their policy and procedures for having an effective antibiotic stewardship program. This had the potential to affect all of the residents residing in the facility. The facility census was 25.Findings are:Record review of a document titled Core Elements of Antibiotic Stewardship for Nursing Homes and dated 09/10/2025 from https://www.cdc.gov/ revealed an antibiotic time out is a formal process designated to prompt a reassessment of the ongoing need for the choice of an antibiotic once more data is available. Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated.Record review of a facility policy titled Antibiotic Stewardship Program and dated 06/01/2026 revealed it was the facility of the policy to implement and Antibiotic Stewardship Program as part of overall infection prevention and control. The program would include antibiotic use protocols and a system to monitor antibiotic use. The facility would use the CDC's NHSN Surveillance Definitions, updated McGreer criteria, and or other surveillance tool to define infections. The Loeb Criteria could be used to determine whether to treat an infection with antibiotics. New or changed orders for antibiotics based on the antibiotic time out recommendations will be obtained from the provider.A.Record review of Resident 6's Electronic Medical Health Record (EMHR) revealed: -On 06/24/2026 the resident was prescribed doxycycline (an antibiotic medication) 100 milligrams twice daily for 7 days. The documented stated the resident had signs and symptoms of an upper respiratory infection. No signs, symptoms, or assessments of the residents respiratory system were documented. -A follow up note dated 06/24/2026 by the facility Nurse Practitioner. The note documented no assessment of Resident 6's respiratory status indicating an acute respiratory infection.-No documentation was present of the resident complaining of cough, shortness of breath, adventitious lung sounds, sputum production, elevated temperature, or decreased blood oxygen levels.-No documentation was present in the resident's EMHR 48 to 72 hours after the antibiotic was initiated indicating that the antibiotic use was reviewed by the facility and or the provider reassessing the appropriateness of the use of the antibiotic.In an interview completed on 08/18/2026 at 11:35 AM with the facility Infection Preventionist (IP) who also acts as the facilities Assistant Director of Nursing (ADON), the ADON stated that the facility utilizes McGreers criteria and this document is to be completed in the assessment tab of the residents EMHR. The ADON confirmed that this documentation was not completed and the findings communicated to the resident's provider for the prescribing of the antibiotic to Resident 6. The ADON confirmed that this should have been completed as part of the facility's antibiotic stewardship program and was not. The ADON confirmed that antibiotic time out's were not being completed as required as part of the facilities antibiotic stewardship program. B.In an interview completed with Resident 1 on 08/12/2026 at 11:32 AM, Resident 1 stated that they have a chronic rash and or irritation that is red and itchy and is present under their abdominal fold and both breasts. The resident states they have suffered with it for more than a year now and nothing seems to get rid of it. The resident stated that they have been on creams, ointments, and even had taken an oral medication recently for it that did not work to get rid of it.Record review of Resident 1's EMHR revealed:-An order for Azithromycin (an antibiotic medication) 250 milligrams three times a week on Monday, Wednesday, and Friday with an indication for use of prophylaxis and dated 06/20/2025.-An order for Nystatin Powder (an antifungal topical medication) to be applied topically twice a day with an indication or skin alteration.-Documentation that on 05/07/2026 the resident was prescribed Diflucan (an oral antifungal medication) for 3 days.In an interview completed on 08/18/2026 at 11:35 AM with the facility ADON, the ADON confirmed that skin fungal and or yeast infections is a side effect of use of antibiotic medications. The ADON confirmed that this had not been addressed or reviewed with the provider related to the resident receiving the long term antibiotic use. The ADON confirmed that as part of the antibiotic stewardship program this should have been reviewed and addressed with the provider and was not.

Licensure Reference Number 175 NAC 12-006.19Based on record review, observation and interview, the facility failed to ensure that essential resident care equipment - washing machines and dryers - were kept in working order. This affected all residents in the facility. The facility census was 25. Findings are:Record review of the Facility Assessment, last reviewed and updated on 4/14/26, revealed that the building is a 62-bed single level skilled nursing facility made of brick and mortar with a tarred roof and a basement. The maintenance director or an administrator do regular walk-throughs of the facility (inside and outside) to look for any areas of concern or damage that may need repair. The Maintenance Director troubleshoots or completes the repair. If the job is unable to be completed by the maintenance director, an outside professional is hired to come and complete the work/repair. The Facility Assessment also stated that when equipment is needed, whether new or replacements, each department head follows procedures for obtaining purchase orders or capital expenditure authorizations for obtaining the needed equipment.Observations on 8/12/26 at 11:50 AM revealed three washing machines in the basement laundry area. Two machines were commercial industrial-sized front-loading machines. The commercial machine on the right side was rusted on the bottom approximately 5 inches up from the bottom of the machine. The third washing machine was a top load household size machine. This was the only machine that had any laundry in it and at the time was spinning on the rinse cycle. In the room adjacent to the washing machines, were three commercial industrial-sized dryers. The first dryer, on the left, did not have the inside metal drum and was not hooked up to ventilation. The second dryer had just finished drying a load of clothes and had white linens inside. The third dryer was empty. Outside the door to the laundry room where the washers were located were two plastic bags of laundry from the kitchen with moisture condensation inside the bags. In a room near the laundry area were 3 large laundry carts, approximately 2 1/2 feet wide x 4 feet long x 3 feet deep, all contained soiled linens in separate plastic bags. Interview with the Laundry and Housekeeping Supervisor (HSKS) on 8/12/26 at 11:50 AM revealed that the only washing machine and dryers that currently worked in the facility were the household washing machine and the middle dryer. The two commercial sized washing machines broke down and were not working. The first dryer did not have all the working parts and pieces to work. HSKS was not sure why the third dryer was not working. The HSKS revealed that the soiled linens which had an odor of urine were donated clothing and blankets. The two plastic bags of soiled linens from the kitchen were from the day before and that morning. Interview on 8/12/26 at 4:18 PM with the Maintenance Supervisor (MS) revealed that the washing machines and the dryers in the basement do have problems. MS had just come from a staff meeting in which the Administrator and the Regional Director of Operations and others were discussing the washing machines. A call had been placed to a local appliance store to ask about quotes for new washing machines and dryers. MS stated that both commercial washing machines were so rusted out that they simply could not be repaired by the appliance repairman. So, the staff were trying to decide what they were going to do about the washers and the dryers. A tour of the the facility basement and laundry area was conducted on 8/12/26 from 1:05 PM to 1:20 PM with the Facility Administrator (FA) and the Regional Director of Operations (RDO).In an interview on 8/12/26 at 1:14 PM, the FA stated that 2 of the washing machines were in working order as the second washer had been fixed. The FA confirmed that the first dryer was torn apart and that the third dryer didn't work.In an interview on 8/12/26 at 1:16 PM, the RDO reported that the second washer had been fixed. The RDO also stated that only one of the dryers worked and that the first dryer had parts removed. The RDO revealed that the facility had not had any issues with the dryer keeping up with the loads of wash and getting everything dried and returned to the residents. The RDO also revealed that if there were any issues in not being able to keep up with the laundry, the RDO or another staff member would take clothing to the laundromat and get clothes washed, folded, and returned to the facility quickly.Neither the FA or the RDO voiced knowledge that the middle washing machine was no longer working. In an interview with the RDO on 8/17/26 at 9:15 AM revealed that the basement had been cleaned, laundry had been washed, and two washing machines were now in the basement because maintenance was able to fix one of the commercial machines.In an interview with an anonymous Resident Representative on 8/18/26 at 10:00 AM it was revealed that the laundry service in the facility has been a huge issue. They don't have enough soaker pads for my spouse who is incontinent at times. Secondly, my spouse has about 6 to 8 pairs of shorts. It has been very hot outdoors. My spouse likes to wear shorts, but we had to wait about 3 days for any of those shorts to be returned from laundry. The turn-around time on the laundry here can be 2 weeks. It is terrible. I don't know what takes them so long. I used to do my spouse's laundry at home but started letting the facility do it as it is a lot of work lugging laundry back and forth all the time. I just want to know; Where is the Laundry?Observations of the washing machines on 8/18/26 at 11:55 AM revealed the first commercial sized washing machine was not working. The second commercial sized washing machine was filled with linens and the door was open. The 3rd household sized machine was in the midst of a wash cycle. The room which had the 3 large laundry carts had been emptied of soiled linens. One cart had 2 small plastic bags of soiled linens. The second cart contained 3 plastic bags of soiled linens. The cart that was heaped with blankets and other clothing was empty.Interview on 8/18/26 at 10:20 AM with housekeeping and laundry staff member (HKS-D) revealed that the middle washing machine was not working, and staff were told to turn off the breaker for an hour or two and then to turn it back on to see if it would work. Interview on 8/18/26 at 1:15 PM with the RDO revealed that the second commercial washing machine was fixed by maintenance and was now working again.

Licensure Reference Number 175 NAC 006.19Based on record review, observation and interview, the facility failed to provide a safe, sanitary, and comfortable environment for residents, staff, and public as evidenced by pooled condensation and dripping water on the floor from overhead pipes in the basement; one dehumidifier that was partially plugged into the wall but was not working and was standing in the pooled water condensation of the basement; two large automotive 12-volt batteries sitting in pooled water condensation in the basement in the room adjacent to the laundry room; and two double hampers overflowing with trash and dirty linens which smelled of urine and fecal matter in the commons area. This had the potential to affect all residents in the facility, as well as staff and public visitors of the facility. The facility census was 25. Findings were:Record review of the undated blank Resident admission Agreement given to all residents at the time of admission revealed on page 47 that the facility would provide a safe environment per the Resident Rights. The resident has a right to a safe, clean, comfortable environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide a safe, clean, comfortable and homelike environment allowing the resident to use his or her personal belongings to the extent possible. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. On page 50, Attachment 4 revealed that residents have the right to receive visitors.Record review of the job description of the Administrator dated 2023 revealed that the Administrator leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. The Administrator was required to be knowledgeable of the skilled nursing home regulations, procedures, laws, regulations, and guidelines pertaining to long-term care. The duties and responsibilities of the Administrator had many aspects including ensuring delivery of compassionate quality of care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff, employee turnover, general cleanliness, physical plant condition, and optimal resident functioning-physically and psychosocially. The Administrator read and stayed informed regarding regulatory, business practices and other changes influencing facility outcomes; thereby facilitating continued success for all, promoted safe work practices, safety rules, and accident prevention procedures to prevent employ injury and illnesses. Additionally, the Administrator treats all residents with dignity and respect, and promotes and protects all residents' rights. The Administrator also needed to establish a culture of compliance by adhering to all facility policies and procedures, complying with standards of business conduct and state and federal regulations and guidelines.Observations on 8/12/26 at 11:50 AM in the facility basement revealed at the bottom of the stairs and around the corner to the right dripping water and pooled water condensation on the floor from overhead pipes in the basement and one dehumidifier partially plugged into the wall but not working which stood in the pooled water condensation of the basement. Down the hall in the room adjacent to the laundry room with 3 washing machines, there were 2 12-volt automotive batteries seated on the floor in another pool of water condensation. Interview with the Regional Director of Operations (RDO) on 8/12/26 at 1:10 PM revealed that the condensation was a problem and would go to the city to purchase dehumidifiers and have them placed in the basement area. The RDO would work with maintenance staff to remove the pooled water condensation, contact outside assistance to ask about having pipes wrapped to assist with condensation issues in the humid environment, purchase fans, and have the 12-volt batteries removed from the basement.Observation on 8/13/26 at 9:15 AM there were two double hampers approximately 30 long x 30 wide x 15 deep filled with overflowing trash and dirty linens which smelled of urine and fecal matter in the commons area. This commons area was where nurses stored two medications carts, contained the two public restrooms, had chairs available for residents to sit in and watch staff and others, led directly to the resident dining room, and was where the only public entrances to all 4 resident hallways that residents, staff, and members of the public had to pass near when visiting with residents in their rooms.Observation on 8/13/26 at 2:35 PM in the commons area revealed there was one overflowing hamper of soiled linens and odiferous trash was seated against the wall nearest the entrance to the 200 hall.In a confirmation interview with the Facility Administrator (FA) on 8/17/26 at 9:20 AM it was revealed that the batteries had been removed from the basement area. Dehumidifiers were purchased for the basement as were fans to assist in the circulation of the air in the basement to dry all areas.Observation on 8/18/26 at 7:50 AM in the commons area there were two hampers of soiled linens and odiferous trash next to the walls in the commons area. The area smelled of urine.In a confirmation interview with the RDO on 8/18/26 at 9:40 AM it was revealed that the staff had worked hard to get the condensation diverted from dripping on the floor of the basement and that a trough was built to allow the water to drain into a drain in the basement.Observation on 8/18/26 at 11:50 AM in the commons area there were two filled hampers of soiled linens and odiferous trash next to the walls in the commons area. The area smelled of urine.Observation on 8/18/26 at 11:55 AM in the basement where one dehumidifier and one fan were plugged into the wall at the bottom of the stairway, the cement no longer had any pooled water, and the air felt less humid. The batteries were no longer in the basement and the water was no longer pooled in that area.Observation on 8/18/26 at 3:00 PM in the commons area there were two overflowing hampers of soiled linens and odiferous trash next to the walls in the commons area. The area smelled of urine.In a confirmation interview with the RDO on 8/18/26 at 3:30 PM it was revealed that the hampers in the commons area are actually supposed to be behind closed doors and that they would be removed to the dirty utility room and not allowed to be in the commons area in order to keep the odiferous trash and soiled linens away from residents, staff, and visitors.

Licensure Reference Number 175 NAC 12-007.03(K)Based on record review, observation and interview, the facility failed to ensure that the ventilation system was working throughout the facility in all resident rooms. This affected 23 of 25 residents (Residents 9, 11, 2, 12, 13, 8, 14, 15, 16, 17, 18, 4, 19, 5, 20, 6, 1, 3, 22, 7, 23, 24, and 26). The facility census was 25. Findings are:Record review of the Facility Assessment, last reviewed and updated on 4/14/26, revealed the maintenance director an administrator do regular walk throughs of the facility (inside and outside) to look for any areas of concern or damage that may need repair. Maintenance Director troubleshoots or completes the repair. If the job is unable to be competed by the maintenance director, an outside professional is hired to come and complete the work/repair. The Facility Assessment also stated that when equipment is needed, whether new or replacements, each department head follows procedures for obtaining purchase orders or capital expenditure authorizations for obtaining the needed equipment.Observation 08/12/2026 at 1:04 PM in room [ROOM NUMBER] of Resident 11 revealed that the bathroom vent did not pull a 1-ply square of toilet paper. Observation 08/12/2026 at 1:30 PM in room [ROOM NUMBER] of Resident 23 revealed that the bathroom vent did not pull a 1-ply square of toilet paper.Observation 08/12/2026 at 1:35 PM in room [ROOM NUMBER] of Resident 15 revealed that the bathroom vent did not pull a 1-ply square of toilet paper.Observation 08/12/2026 at 1:38 PM in room [ROOM NUMBER] of Resident 5 revealed that the bathroom vent did not pull a 1-ply square of toilet paper.Observation 08/12/2026 at 1:42 PM in room [ROOM NUMBER] of Resident 9 revealed that the bathroom vent did not pull a 1-ply square of toilet paper.Observation 08/12/2026 at 1:47 PM in room [ROOM NUMBER] of Resident 26 revealed that the bathroom vent did not pull a 1-ply square of toilet paper.Interview on 8/12/26 at 4:18 PM with the Maintenance Supervisor (MS) revealed that none of the ventilation fans on the 100 hall, 300 hall, and 400 hall were working. MS was not aware that the ventilation system in room [ROOM NUMBER] was also not working. I am not certain what it is that they need but there is something that has to be replaced. I have been calling a maintenance worker to come to the facility almost daily to have someone come repair it and nobody has shown up yet.Interview with the Regional Director of Operations (RDO) on 8/13/26 at 1:15 PM who confirmed that there are repairs needed to the ventilation system and that staff are trying to get someone to come to the facility to fix this. The RDO hoped to have someone there either tomorrow or next week. In an interview with the RDO on 8/18/26 at 11:20 AM it was confirmed that the ventilation system is still not working and that no parts have arrived to fix the issue.

Based on record review, observation, and interview, the facility failed to ensure that all areas were clean and free of dirt and debris, that malodorous areas were kept to a minimum, that resident areas were maintained and repaired when needed, and that the facility had a comfortable and homelike environment for all residents in the facility. This affected all residents in the facility. The facility census was 25. Record review of the blank, undated Resident admission Agreement given to all residents at the time of admission to the facility revealed the following:-the facility provides nursing and related services to help assure resident safety and that our residents attain or maintain the highest practicable physical, mental and psychosocial well-being as determined by resident assessments and individual care plans.-Social services- the facility provides a comprehensive social series program in accordance with the resident plan of care to help promote the preservation of the resident's physical and mental health.-Attachment 3 revealed the federal resident rights which included a) the residents have a right to dignified existence, self-determination, and communications with and access to persons and services inside and outside the facility including those specified in the section. 1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance of enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. 2) The facility must provide equal access to quality regardless of diagnosis, severity of condition, or payment source.-Planning and implementing care - the resident has the right to be informed of and participate in his or her treatment including; -The right to receive the services and/or items included in the plan of care-Respect and dignity- the resident has the right to be treated with respect and dignity including the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.-The resident has the right to a safe clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely. The facility must provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.Observation in room [ROOM NUMBER] on 8/12/26 at 11:10 AM of the bathroom sink. There was a note on the faucet that stated, the hot water will be dripping at all times.Observation in room [ROOM NUMBER] on 8/12/26 at 11:15 AM of a patched area on the wall on the left side of the room that was not completely repaired and was not painted and carpet that had several stains.Observation in room [ROOM NUMBER] of a clean bedpan sitting on the toilet ready for use. It was not bagged. The bathroom door/curtain was not closed. The bedpan had what appeared to be brown fecal matter on the edge of the bedpan.In a confirmation interview with Medication Aide (MA) E confirmed that the bedpan was ready for use but definitely not clean nor bagged or covered.Observation in room [ROOM NUMBER] on 8/12/26 at 1:38 PM of two lights above the bathroom sink that are not working.Observation on 8/12/26 from 1:30 pm to 1:47 PM revealed the ventilation system not working in rooms throughout the 300 and 400 hallways.In a confirmation interview with the Maintenance Supervisor (MS) on 8/12/26 at 2:15 PM two lights were not working in the bathroom of room [ROOM NUMBER] and new light bulbs would be inserted. MS also confirmed that the bathroom sink in room [ROOM NUMBER] drips all the time and needs fixed or replaced.In a confirmation interview on 8/12/26 at 4:18 PM with the MS who revealed that none of the ventilation fans on the 100 hall, 300 hall, and 400 hall are working. MS as not aware that the ventilation system in room [ROOM NUMBER] was also not working and stated I am not certain what it is that they need but there is something that needed to be replaced. I have been calling a maintenance worker to come to the facility almost daily to have someone come repair it and nobody has shown up yet.Observation on 8/13/26 at 9:15 AM revealed two double hampers approximately 30 long x 30 wide x 15 deep filled with overflowing trash and dirty linens which smelled of urine and fecal matter in the commons area. This commons area was where two medications carts were left in view of all residents, staff, and facility visitors going to resident rooms, was where two public restrooms were located, had chairs in which residents sat to watch and observe staff and others, led directly to the resident dining room, and were the only public entrances to all 4 resident hallways that residents, staff, and members of the public had to pass near when visiting with residents in their rooms.Observation on 8/13/26 at 11:53 AM of air conditioning unit at the far end of the 100 hall revealed a brown/grey dirt and debris with an oily residue that was felt after touching. Observation on 8/13/26 at 12:00 PM of the baseboard in the 100 hallway where two areas were broken and needed fixed.Interview with the Housekeeping Supervisor (HSKS) on 8/13/26 at 12:05 PM who stated that the hallway of the 100 hall was cleaned and complete. HSKS stated that they are a contracted company that cleans that facility and is in charge of cleaning almost everything; resident rooms, dining room, living room, offices, chapel, family dining room, hallways, etc. This includes the hallway walls, doors, handrails, and air conditioning units.Interview with HSKS on 8/13/26 at 12:08 PM who then revealed that the air conditioning vent had not been cleaned. HSKS stated that this air conditioning unit would be cleaned later.Observation on 8/13/26 at 12:12 PM of bugs in the overhead lights in the hallways. Many of the lights in the 200 hall had bugs that needed to be removed. The carpet in the 200 hallway had darkened areas that looked to be stains. There were also ceiling tiles that were discolored and broken on the edges.Observation on 8/13/26 at 12:15 of the tub in the resident tub room. The tub had a white or grey colored build up on the knobs that could be scraped with the end of a pen cap. It looked to be soap build up or mineral buildup by the coloration.Observation on 8/18/26 at 7:50 AM in the commons area there were two hampers of soiled linens and malodorous trash next to the walls in the commons area. The area smelled of urine.In a confirmation interview with the Regional Director of Operations (RDO) on 8/18/26 at 9:20 AM while touring the facility, the RDO confirmed that there were two areas of the 100 hallway base board that needed fixed, confirmed the contracted housekeeping staff are in charge of cleaning all aspects of the facility including the halls and air conditioning units, that there were ceiling tiles that were discolored and stained and some with broken edges that needed to be replaced, confirmed that there were bugs in several of the light fixtures, confirmed that one sink in the 200 activities area needed to be caulked, confirmed that the wall repair in room [ROOM NUMBER] was not completed and that the repair needed to be finished, confirmed that the carpet in room [ROOM NUMBER] and other areas in the facility was either worn or discolored with stains, confirmed that the tub needed to be delimed and cleaned thoroughly, and confirmed that there were rooms that needed a deep cleaning, among other repairs and conditions throughout the facility that needed attention. In an interview on 8/18/26 at 10:00 AM with an anonymous Resident Representative, it was revealed that in their spouse's room, the wall had an area that needed repaired and looked awful. The Anonymous Resident Representative voiced concerns and was upset about many parts of their spouse's care and living conditions. Nobody has ever come back to fix it. And the carpet is my spouse's room is absolutely disgusting. We pay for our loved ones to have care, and part of that is to live in a room that feels like home. In a confirmation interview with the RDO on 8/18/26 at 3:20 PM it was revealed that the hampers in the commons area are actually supposed to be behind closed doors and that they would be removed to the dirty utility room and not allowed to be in the commons are in order to keep the odiferous trash and soiled linens away from residents, staff, and visitors.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(4)Based on observation, record review, and interview the facility failed to ensure that the individualized resident care plan (a detailed written interdisciplinary comprehensive plan with approaches and interventions for staff to meet the resident's needs that are identified in the resident's comprehensive assessment) contained the information for staff to care for resident contracture (a permanent tightening of muscles, tendons, skin, and other soft tissues that stops a joint or body part from moving) for 1 of 1 residents (Resident 17). The facility census was 25.Findings are:Record review of the facility policy titled Comprehensive Care Plans (CCP) dated 2/5/25 revealed that it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe at a minimum the services that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The CCP will describe any specialized services or specialized rehabilitation services the nursing facility will provide. The CCP will describe resident specific interventions that reflect the resident's needs and preferences. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) assessment . The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) assessment dated [DATE] for Resident 17 revealed that Resident 17 admitted into the facility on 2/10/25. The assessment revealed that Resident 17 had an impairment of the upper extremity (wrist or hand) on one side. Record review of the Order Recap (a record of all current and discontinued physician's orders for a resident) dated 8/17/26 revealed that Resident 17 had a physician's order to monitor the palm of the left hand due to contracted fingers (a permanent bending of the fingers towards the palm of the hand) putting pressure on the palm. Ensure that the resident is wearing a palm pad to prevent skin breakdown. Observation on 8/12/26 at 9:06 AM in the room of Resident 17 revealed that Licensed Practical Nurse-A (LPN-A) stood to the left of Resident 17. Resident 17 was seated in a wheelchair. LPN-A used a swab stick to try and clean Resident 17's left palm underneath the contracted fingers. The fingers of Resident 17's left hand were stiff and bent towards the palm. The fingertips were against the palm of Resident 17's left hand. Resident 17 stated ouch while LPN-A used the swab stick to swab the left palm underneath Resident 17's bent fingers . LPN-A then attempted to place a soft splint on Resident 17's left hand. LPN-A tried to position part of the splint underneath the bent fingers. LPN-A turned the splint several different directions and stated that LPN-A was unfamiliar with the splint and how it was to be put on. LPN-A continued to reposition the splint and struggled to determine which way it went on the left hand. LPN-A left the splint on the left hand and stated that they would have therapy check on it. Record review of the current care plan for Resident 17 dated 8/12/26 revealed that Resident 17 had a self-care performance deficit related to congestive heart failure (a chronic condition where the heart muscle is too weak or stiff to pump blood well) and chronic obstructive pulmonary disease (a chronic disease that blocks air flow and makes breathing hard). The care plan contained no indication that Resident 17 had a contracture. The care plan contained no interventions to guide staff on how to care for the contracted fingers on Resident 17's left hand.Interview on 8/18/26 at 2:12 PM with the facility Assistant Director of Nursing (ADON) confirmed that Resident 17 had a contracture of the left hand requiring care. The ADON confirmed that the contracture is identified in the resident's MDS assessment. The ADON confirmed that the care plan for Resident 17 does not have information for staff to provide the care for the contracture or for the splint to be used. The ADON confirmed that the care plan is required to have information for care of Resident 17's hand contracture. The ADON revealed that they would correct the care plan.

Licensure Reference Number 175 NAC 12-006.09(D)Based on record review, observation, and interview the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 3 residents (Resident 1, Resident 7, and Resident 12) of 5 sampled residents and failed to complete the Care Area Assessment Work Sheet as required for 1 resident (Resident 7) of 1 sampled residents. The facility census was 25.Findings are:Record review of a facility policy titled MDS 3.0 Completion and dated 09/25/2025 revealed that residents are assessed using a comprehensive assessment process in order to identify care needs and to develop and interdisciplinary care plan. All disciplines shall follow the guidelines in Chapter 3 of the current Resident Assessment Instrument (RAI) Manual for coding each assessment.In an interview completed on 08/13/2026 at 1:10 PM with the facility Director of Nursing (DON) the DON stated that the MDS Coordinator (MDSC) works remotely. The DON stated that information for MDS completion is gathered by reviewing records in the residents Electronic Medical Health Record (EMHR) and via information that is shared over phone calls with the facility staff and the MDSC. The DON confirmed that the MDSC is the responsible party for the completion of the MDS process in the facility.A.Record review of a document titled Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 and dated October 2025 revealed O0110C1 oxygen therapy directions to code continous or intermittent oxygen administered during the look back period (7 days prior to the Assessment Reference Date (ARD).Record review of Resident 1's quarterly MDS with the ARD of 06/04/2026 in the section O0110C3 was coded to reflect that the resident did not receive intermittent oxygen therapy during the 7 day look back period.In an interview completed with Resident 1 on 08/12/2026 at 11:32 AM, Resident 1 stated that they use supplemental oxygen delivered via nasal cannula at night every night.In an observation completed on 08/13/2026 at 11:35 AM there was a blue rectangle oxygen concentrator present with a clear plastic tube reaching to the residents' bed attached to it that held the residents nasal canula for the delivery of the oxygen to the resident.Record review of Resident 1's Electronic Medical Health Record (EMHR), the EMHR showed that Resident 1 had provider orders for supplemental oxygen to be administered to keep oxygen saturation rate between 89-94% every day and night shift for comfort with a start date of 11/15/2025. Documentation was present that this was done/completed every day and night every day during the look back period for the MDS with the ARD of 06/04/2026.In an interview completed on 08/13/2026 at 1:10 PM with the facility ADON, the ADON confirmed that Resident 1 used supplemental oxygen every night. The ADON confirmed that the MDS should have been coded to reflect this and was not.B.Record review of a document titled Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 and dated October 2025 revealed K0200 height and weight with instructions to record the last resident weight that was taken within 30 days of the ARD. If the last recorded weight was taken more than 30 days prior to the ARD or the previous weight is not available weigh the resident again. If the residents cannot be weighed use the standard no information code (-) and document the rationale in the residents' medical record.Record review of Resident 7's Significant Change MDS with the ARD of 07/21/2026 revealed in section K0200 Weight a (-) mark was entered documenting that no information was available to complete the assessment.Record review of Resident 7's EMHR revealed the resident had a weight documented on 06/09/2026 of 204.0. There was no other weight recorded for the resident in the 30 days of the ARD of 07/21/2026. There was no documentation present in the residents EMHR of the resident being re weighed or the rational for why no information was available for the residents' weight being obtained in the 30 days prior to the ARD.In an interview completed on 08/13/2026 at 1:10 PM with the facility ADON, the ADON confirmed that Resident 7 should have had a weight documented in their record in the 30 days prior to the ARD or documentation present for the rational as to why the weight was not present. The ADON confirmed that the MDS should not have been coded with the (-) without the documentation of the rational as to why the weight was not obtained.C.Record review of a document titled Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 and dated October 2025 revealed H0300: Urinary Continence code 9 should be entered if the resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days (look back period).Record review of Resident 12's Quarterly MDS with an ARD of 07/25/2026 revealed in section H0100 Appliances was coded A. indwelling catheter (including suprapubic catheter and nephrostomy tube) documenting that the resident had an indwelling catheter. Section H0300 was coded 3, reflecting the resident was always incontinent (having no episodes of continent voiding). In an observation completed on 08/12/2026 at 11:48 AM Resident 12 was observed to be lying in their bed with their eyes closed. A clear plastic tube was visible to the outer edge of the residents' bed going from under the residents' blanket into a white bath towel wrapped receptacle sitting on the floor under the residents bed. There was yellow liquid visible in the tubbing.In an interview completed on 08/12/2026 at 11:50 AM with Nurse Aide B (NA-B), NA-B stated that Resident 12 had an indwelling urinary catheter since they returned from the hospital last month. In an interview completed on 08/13/2026 at 1:45 PM with Licensed Practical Nurse C (LPN-C), LPN-C stated Resident 12 returned from a hospitalization with an indwelling urinary catheter in the month of July.Record review of Resident 12's Progress Notes on 08/13/2026 revealed documentation of an Admit/Readmit note stating the resident was readmitted to the facility on [DATE] from the hospital due to having sepsis and a urinary tract infection. The documentation stated that the resident had an indwelling urinary catheter present. In an interview completed on 08/13/2026 at 1:10 PM with the facility ADON, the ADON confirmed that Resident 12 had an indwelling catheter since readmission to the facility on [DATE]. The ADON confirmed that the residents' Quarterly assessment dated [DATE] was not coded correctly in section H0300.D.Record review of a document titled Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 and dated October 2025 revealed M0210 Unhealed Pressure Ulcers/Injuries to code 0 if the resident does not have one or more unhealed pressure ulcers/injuries and to code 1 yes if the resident has one or more unhealed pressure ulcers/injuries.Record review of Resident 12's Quarterly MDS with an ARD of 07/25/2026 revealed in section M0210 was coded 0 documenting that the resident did not have an unhealed pressure ulcer/injury.Record review of Resident 12's Progress Notes on 08/13/2026 revealed:-Documentation of an Admit/Readmit note stating the resident was readmitted to the facility on [DATE] from the hospital due to having sepsis and a urinary tract infection. The documentation stated that the residents' right heel was red boggy and tender to touch. -Documentation on 07/23/2026 that a treatment was performed to the residents left great toe and right heel and the residents responsible party was contacted to request permission of an in-house wound care nurse to see the resident weekly. The resident was evaluated by the in-house wound nurse and was documented to have pressure related skin ulcer/injury to the left heel.In an interview completed on 08/13/2026 at 1:10 PM with the facility ADON, the ADON confirmed that Resident 12 had a pressure-related skin ulcer or injury to the during the 7 day look back period for the quarterly MDS with the ARD of 07/25/2026. The ADON confirmed that the residents' Quarterly assessment dated [DATE] was not coded correctly in section M0210.E.Record review of a facility policy titled MDS 3.0 Completion and dated 09/25/2025 revealed that based on the Care Areas Assessments (CAA) review key findings regarding a resident's status are documented, including the nature of the condition, complications and risk factors that affect the care planning decision, factors that must be considered in developing care plan interventions and the need for referrals or evaluation by appropriate health professionals. Written documentation of the CAA findings and decision-making process may appear anywhere in the resident's record. To use the relevant columns on the CAA summary section of the MDS to document location and date of the information and the decision to proceed or not to proceed to care planning. Record review of a document titled Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 and dated October 2025 revealed the process for completion of the Care Areas Assessments (CAA's) focuses on evaluating the triggered care areas.Record Review of Resident 7's CAA work sheet for the significant change MDS with an ARD of 07/21/2026 revealed the following:-The Cognitive Loss/Dementia CAA was triggered by data entered into the residents MDS. In the section labeled Analysis of findings under the heading is this problem/need there is no information documented. Documentation should be present stating if the problem is actual or potential and is not. Under the heading nature of the problem/condition there is no information documented. Documentation should be present stating the nature of the resident's problem or condition. There is no documentation present of where to find this information in the residents' record. In the section labeled Care Plan Considerations under the heading if the care planning for this problem, what is the overall objective there is no overall objective documented or where to find this information in the residents' record. The work sheet was signed as the person completing by Social Service Director (SSD) and dated 07/21/2026.-The Functional Abilities CAA was triggered by data entered into the residents MDS. Under the heading nature of the problem/condition there is no information documented. Documentation should be present stating the nature of the resident's problem or condition. There is no documentation present of where to find this information in the residents' record. The work sheet was signed as the person completing by the MDSC and dated 07/27/2026.-The urinary incontinence and indwelling catheter CAA was triggered by information entered into the residents MDS. Under the heading nature of the problem/condition there is no information documented. Documentation should be present stating the nature of the resident's problem or condition. There is no documentation present of where to find this information in the residents' record. The work sheet was signed as the person completing by the MDSC and dated 07/27/2026.-The falls CAA was triggered by information entered into the residents MDS. Under the heading nature of the problem/condition there is no information documented. Documentation should be present stating the nature of the resident's problem or condition. There is no documentation present of where to find this information in the residents' record. The work sheet was signed as the person completing by the MDSC and dated 07/27/2026.-The nutritional status CAA was triggered by information entered into the residents MDS. In the section labeled Analysis of findings under the heading is this problem/need there is no information documented. Documentation should be present stating if the problem is actual or potential and is not. Under the heading nature of the problem/condition there is no information documented. Documentation should be present stating the nature of the resident's problem or condition. There is no documentation present of where to find this information in the residents' record. In the section labeled care plan considerations under the heading describe the impact of their problem/need on the resident and the rationale for care plan decision there is no information documented. Documentation should be present providing this information or documentation of where to find the information in the residents' record. The work sheet was signed as the person completing by the MDSC and dated 07/27/2026.-The dental care CAA was triggered by information entered into the residents MDS. In the section labeled Analysis of findings under the heading is this problem/need there is no information documented. Documentation should be present stating if the problem is actual or potential and is not. The work sheet was signed as the person completing by the MDSC and dated 07/27/2026.-The pressure ulcer or injury care CAA was triggered by information entered into the residents MDS. In the section labeled Analysis of findings under the heading is this problem/need there is no information documented. Documentation should be present stating if the problem is actual or potential and is not. The work sheet was signed as the person completing by the MDSC and dated 07/27/2026.In an interview completed on 08/13/2026 at 1:10 PM with the facility Assistant Director of Nursing (ADON), the ADON confirmed that Resident 7's CAA work sheet was not completed as required and should have been.

Licensure Reference Number 175 NAC 12-006.09(J)Based on record reviews and interviews, the facility failed to implement interventions to maintain a resident's weight and prevent weight loss for 1 resident (Resident 12) of 1 sampled residents. The facility census was 25.Findings are:Record review of a facility policy titled Weight Monitoring dated 12/02/2025 (reviewed/revised) revealed the facility would ensure that all residents maintain acceptable parameters of nutritional status. Obtaining a residents weight can be a useful indicator of nutritional status significant unintended changes in weight may indicate a nutritional problem. Interventions would be identified, implemented, monitored, and modified as appropriate consistent with the residents' assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. A weight monitoring schedule would be developed. admitted residents would have their weight monitored weekly for 4 weeks and if a resident had weight loss the weight would be monitored weekly.Record review of Resident 12's admission Record revealed Resident 12 had an initial admission dated of 10/05/2022 with diagnosis of dementia (which is a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior) and type two diabetes (which is a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).Record review of Resident 12's Electronic Medical Health Record (EMHR) revealed the following documentation:-On 06/09/2026 documentation of an annual nutrition assessment completed by the facility Registered Dietitian (RD). In the documentation it is recorded that the resident had a weight of 147.5 and had no significant weight changes as of that date.-On 07/20/2026 documentation of an Admit/Readmit note stating the resident was readmitted to the facility on [DATE] from the hospital due to having sepsis and a urinary tract infection. The documentation stated that the resident had a weight of 135.0.-On 07/21/2026 documentation that the resident was weak and refusing to eat and only taking liquids with much encouragement.-On 07/22/2026 documentation that the resident was refusing to eat food and take liquids with out much encouragement.-On 07/23/2026 documentation that the resident was sleepy most of the time appetite was poor when taken to the dinning room for meals would put head on the table or refuse to go to meals.-On 07/25/2026 documentation by the RD that an updated weight on the resident was being requested and a readmission nutrition assessment stating that the resident was triggering for a significant weight loss of 8.5% in 30 days, 9.8% in 90 days, and 12.3% in 180 days. Since re-admission the resident has refused 7 meals, consumed one meal at 75%, and 7 meals at bites to 25% and the resident had a pressure related skin injury. The resident was currently receiving a nutritional drink with the morning meal, and the RD was recommending 120 milliliters of 2Cal (nutritional supplement drink) or Med Pass (nutritional supplement drink) four times a day and that the RD had notified the residents provider of such via fax.-Documentation that the resident had provider orders to receive Ensure Clear (a nutritional supplement drink) 8 ounces daily for weight management dated 09/23/2025 and Med Pass or equivalent product 2.0 120 milliliters four times a day dated 07/25/2026.-Documentation of the Ensure Clear 8 ounces not administered on 07/23/2026 and 07/24/2026. There was no documentation present of alternatives being offered or other interventions attempted for the resident to replace this caloric intake. - Documentation of the Med Pass 2.0 or equivalent was refused for 3 of the 4 administrations on 07/27/2026, 2 of the 4 administrations on 07/30/2026, and 1 of the 4 administrations on 07/31/2026. There was no documentation present of alternatives being offered or other interventions attempted for the resident to replace this caloric intake.Record review of Resident 12's Medication Administration Record (MAR) for the month of August 2026 revealed:-Documentation of the Med Pass 2.0 or equivalent was refused by the resident 1 of the 4 administrations on 08/01/2026, 1 of the 4 administrations on 08/02/2026, 1 of the 4 administrations due to sleeping on 08/03/2026. On 08/05/2026 the Med Pass 2.0 or equivalent was documented as not being administered due to being unavailable and the nurse was notified. Starting on 08/06/2026 through 08/09/2026 and was only administered 1 of the 4 prescribed times on 08/11/2026. There was no documentation present of alternatives being offered or other interventions attempted for the resident to replace this caloric intake. There was no documentation present of the provider or RD being notified of Resident 12 not receiving prescribed Med Pass 2.0. -Documentation on 06/03/2026 a weight of 147.5 -Documentation on 07/02/2026 a weight of 135-Documentation on 08/03/2026 by the RD of a request for an updated weight due to the resident not being weighed in at least 30 days.-on 08/05/2026 a weight of 131.5There was no documentation present in Resident 12's Electronic Medical Health Record (EMHR) that the resident's weight had been re-evaluated after the RD requested on 07/25/2026. There was no documentation present that the resident was weighed weekly for 4 weeks after admission. There was no documentation present that the resident was weighed weekly after the significant weight loss was documented by the RD on 07/25/2026. There was no documentation present that resident's provider had been notified of the resident not receiving the supplement as prescribed. There was no documentation that the facility offered an alternate substance of caloric value to the resident at the times the resident declined the supplement and or the supplement was not available in the facility.In an interview completed on 08/13/2026 at 10:50 AM with Medication Aide Q (MA-Q), MA-Q stated that the medication aide administers the supplements that are listed on the residents Medication Administration Record (MAR), the MA stated that if a resident declines the supplement or the supplement is not available they are unaware if a alternate is to be offered and that the nurse is notified and this is documented in the MAR.In an interview completed on 08/13/2026 at 11:05 AM with the facility Assistant Director of Nursing (ADON), the ADON stated that they were not aware that the resident (Resident 12) was not consuming their supplement as prescribed. The ADON confirmed that the resident's weight was not being obtained and or evaluated as directed in the facility policy after re admission to the facility and recognition of the resident having a weight loss.In an interview completed on 08/13/2026 at 11:05 AM with the facility Director of Nursing (DON), the DON stated that they were not aware that Resident 12 was not consuming their supplement as prescribed. The DON confirmed that the resident's weight was not being obtained and or evaluated as directed in the facility policy after re admission to the facility and recognition of the resident having a weight loss and should have been. The DON confirmed that the RD and or the resident's provider was not notified that the resident supplement was not being administered as prescribed. The DON confirmed that there was no documentation present that the resident was offered an alternative caloric substance when the supplement prescribed was being declined by the resident or not available in the facility.

Licensure Reference Number 175 NAC 12-006.09(F)Based on record review, observation, and interviews, the facility failed to revise a resident's comprehensive plan of care reflecting the changes in interventions as residents' care needs changed for 2 (Resident 1 and Resident 12) of 5 sampled residents. The facility census was 25.Findings are:Record review of a document titled admission Agreement and not dated revealed the facility would update the residents' plan of care to describe the services that are to be furnished to maintain or improve the resident's physical, mental, and psychosocial status.Record review of a facility policy titled Comprehensive Care Plans and dated 02/05/2025 revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident consistent with the residents medical, nursing, and mental and psychosocial needs.A.Record review of a facility policy titled Fall prevention program and dated 10/06/2025 revealed it was the facility policy after a resident experienced a fall for the facility to review the resident's care plan and update it as needed.Record review of Resident 1's Electronic Medical Health Record (EMHR) revealed:-Documentation present that on 07/27/2026 Resident 1 had a witnessed fall to the floor while ambulating in the hallway after returning indoors from the outside.-Documentation that on 07/28/2026 the facility's intradisciplinary team met and discussed Resident 1's fall on 07/27/2026. The documentation stated that the temperature outdoors the day of the fall was excessively warm and that the resident was educated on the need to sit and rest when overly tired and to utilize the seat on their walker or the chairs in the offices along the hall as needed.Record review of Resident 1's Care Plan on 08/13/2026 revealed a Focus of the resident was at risk for falls and on 03/21/2025 the resident eased themselves down on to their knees and had had an unwitnessed fall on 05/29/2026. There was an initiation date of 02/15/2024 and a last revision date of 05/30/2026. The residents Care Plan did not reflect that the resident was no longer at risk for falls but had current falls and did not reflect that the resident had suffered a fall on 07/27/2026. Review of the intervention/tasks portion of the residents Care Plan on 08/13/2026 revealed no changes to interventions to prevent the possibility of reoccurrence of the fall that occurred on 07/27/2026.In an interview completed on 08/13/2026 at 1:10 PM with the facility Assistant Director of Nursing (ADON), the ADON stated that the intradisciplinary team meets weekly and reviews falls. The ADON stated it is during this meeting that the intervention to prevent reoccurrence of the fall is reviewed and the care plan is updated with the change or new intervention. The ADON confirmed that Resident 1's care plan did not reflect the residents fall on 07/27/2026 and did not indicate the intervention that was placed to prevent the fall from reoccurring and should have been.B.Record review of a facility policy titled Pressure injury Prevention and Management and dated 03/31/2026 revealed it was the policy of the facility that after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for the prevention and management of pressure injuries with appropriate interventions. Interventions on a resident's plan of care will be modified as needed. Considerations for the need included new onset and resident noncompliance.Record review of Resident 12's Care Plan on 08/13/2026 revealed a focus of the resident having bowel and bladder incontinence with an initiation date of 08/14/2023 and a revision date of 02/28/2026. Interventions were listed as to check the resident every 2 hours and assist with toileting as needed, to encourage the resident to use the call light when needing to be changed, monitor and document for signs and symptoms of urinary tract infection, and to provide pericare after each episode. All had an initiation date of 08/14/2023 and a revision date of 03/04/2026.In an observation completed on 08/12/2026 at 11:48 AM Resident 12 was observed to be lying in their bed with their eyes closed. A clear plastic tube was visible to the outer edge of the residents' bed going from under the residents' blanket into a white bath towel wrapped receptacle sitting on the floor under the residents bed. There was yellow liquid visible in the tubbing.In an interview completed on 08/12/2026 at 11:50 AM with Nurse Aide B (NA-B), NA-B stated that Resident 12 had an indwelling urinary catheter since they returned from the hospital last month.In an interview completed on 08/13/2026 at 1:45 PM with Licensed Practical Nurse C (LPN-C), LPN-C stated Resident 12 returned from a hospitalization with an indwelling urinary catheter in the month of July.Record review of Resident 12's Progress Notes on 08/13/2026 revealed documentation of an Admit/Readmit note stating the resident was readmitted to the facility on [DATE] from the hospital due to having sepsis and a urinary tract infection. The documentation stated that the resident had an indwelling urinary catheter present.Resident 12's care plan did not reflect that the resident had an indwelling urinary catheter and was no longer deemed incontinent of bladder and having the urinary catheter present. The residents' care needs were not changed on their care plan reflecting the change in the residents' care needs do to having an indwelling urinary catheter.In an interview completed on 08/13/2026 at 1:10 PM with the facility ADON the ADON confirmed that resident 12 had an indwelling urinary catheter and this changed the residents care needs and urinary continence. The ADON confirmed that this was not reflected on the resident's care plan and should have been.Record review of Resident 12's Care Plan on 08/13/2026 revealed a focus of the resident being at risk for an alteration in nutritional status with an initiation date of 08/14/2023 and a revision date of 03/27/2026. Record review of Resident 12's Progress Notes on 08/13/2026 revealed:-On 06/09/2026 documentation of an annual nutrition assessment completed by the facility Registered Dietitian (RD). In the documentation it is recorded that the resident had a weight of 147.5 and had no significant weight changes as of that date.-On 07/20/2026 documentation of an Admit/Readmit note stating the resident was readmitted to the facility on [DATE] from the hospital due to having sepsis and a urinary tract infection. The documentation stated that the resident had a weight of 135.0.-On 07/21/2026 documentation that the resident was weak and refusing to eat and only taking liquids with much encouragement.-On 07/22/2026 documentation that the resident was refusing to eat food and take liquids without much encouragement.-On 07/23/2026 documentation that the resident was sleepy most of the time appetite was poor when taken to the dining room for meals would put head on the table or refuse to go to meals.-On 07/25/2026 documentation by the RD that an updated weight on the resident was being requested and a readmission nutrition assessment stating that the resident was triggering for a significant weight loss of 8.5% in 30 days, 9.8% in 90 days, and 12.3% in 180 days. Since re-admission the resident has refused 7 meals, consumed one meal at 75%, and 7 meals at bites to 25% and the resident had a pressure related skin injury. The resident was currently receiving a nutritional drink with the morning meal, and the RD was recommending 120 milliliters of 2Cal (nutritional supplement drink) or Med Pass (nutritional supplement drink) four times a day and that the RD had notified the resident's provider of such via fax.There were no changes to the resident's care plan indicating that the resident as of 07/25/2026 had a significant weight loss. The residents' care needs were not changed on their care plan reflecting the change in the residents' care needs do to having an indwelling urinary catheter.In an interview completed on 08/13/2026 at 1:10 PM with the facility ADON the ADON confirmed that the residents current care plan did not reflect that the resident had a significant weight loss and changes to the residents' care needs and or interventions due to this and should have.Record review of Resident 12's Care Plan on 08/13/2026 revealed a focus of the resident had the potential for impairment to skin integrity. And the resident had a scab on their left great toe and redness to their abdomen groin and buttock with an initiation date of 08/14/2023 and a revision date of 02/08/2026. Interventions were listed of Heel boots to both heels when in bed dated 11/14/2024, Air mattress to the residents' bed dated 08/14/2023 and a revision date of 08/23/2023, and to apply barrier cream and keep the residents' skin clean and dry dated 01/14/2025.-Documentation of an Admit/Readmit note stating the resident was readmitted to the facility on [DATE] from the hospital due to having sepsis and a urinary tract infection. The documentation stated that the residents' right heel was red boggy and tender to touch.-Documentation on 07/23/2026 that a treatment was performed to the residents left great toe and right heel and the residents responsible party was contacted to request permission of an in-house wound care nurse to see the resident weekly. The resident was evaluated by the in-house wound nurse and was documented to have pressure related skin ulcer/injury to the right heel.There were no changes to the resident's care plan indicating that the resident as of 07/23/2026 had a pressure related skin injury. The residents' care needs were not changed on their care plan reflecting the change in the residents' care needs do to having a pressure-related skin injury.In an interview completed on 08/13/2026 at 1:10 PM with the facility ADON the ADON confirmed that the residents current care plan did not reflect that the resident had a pressure related skin injury and changes to the residents' care needs and or interventions due to this and should have.

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(1)Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2) Based on record review and interview, the facility failed to ensure that all background checks and registry checks were performed for unlicensed staff. This affected 2 of 6 sampled staff members hired in the past year, Dietary Aide-(DA) H and Medication Aide (MA) I. The facility resident census was 25. Findings were:A. Record review of the employee file for Dietary Aide (DA)-H (whose date of hire was 3/13/26 and first day of work was 4/3/26) revealed that the file did not contain a background check or documentation of registry checks on the Nebraska Nurse Aide registry, the Adult Protective Services Central Registry, the Central Register of Child Protection Cases, and the Sex Offender Registry. In a confirmation interview with the Regional Director of Operations (RDO) on 8/17/26 at 11:10 AM it was confirmed that the Facility Administrator had looked through all the staff files with the RDO and the background check and the registry checks were not found. Because of this oversight by the facility staff, the background check and registry checks were being completed at that time. B. Record review of the employee file for Medication Aide (MA) -I (whose date of hire was 4/8/26 and first day of work was 4/16/26) revealed that the file did not contain the nurse aide registry check. There was a note in the file that stated that the registry check for the Adult Protective Services Central Registry check and the Central Register of Child Protection Cases had been requested three times and the information still had not been received. IN a confirmation interview with the Facility Administrator (FA) on 8/17/26 at 2:50 PM it was confirmed that the file for MA-I was missing the Nurse Aide registry check and the information from the Adult Protective Services Central Registry and the Central Register of Child Protection Cases was requested 3 times and was still not back as of that date.

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(1)Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2) Based on record review and interview, the facility failed to ensure that all background checks and registry checks were performed for unlicensed staff. This affected 2 of 6 sampled staff members hired in the past year, Dietary Aide-(DA) H and Medication Aide (MA) I. The facility resident census was 25. Findings were:A. Record review of the employee file for Dietary Aide (DA)-H (whose date of hire was 3/13/26 and first day of work was 4/3/26) revealed that the file did not contain a background check or documentation of registry checks on the Nebraska Nurse Aide registry, the Adult Protective Services Central Registry, the Central Register of Child Protection Cases, and the Sex Offender Registry. In a confirmation interview with the Regional Director of Operations (RDO) on 8/17/26 at 11:10 AM it was confirmed that the Facility Administrator had looked through all the staff files with the RDO and the background check and the registry checks were not found. Because of this oversight by the facility staff, the background check and registry checks were being completed at that time. B. Record review of the employee file for Medication Aide (MA) -I (whose date of hire was 4/8/26 and first day of work was 4/16/26) revealed that the file did not contain the nurse aide registry check. There was a note in the file that stated that the registry check for the Adult Protective Services Central Registry check and the Central Register of Child Protection Cases had been requested three times and the information still had not been received. In a confirmation interview with the Facility Administrator (FA) on 8/17/26 at 2:50 PM it was confirmed that the file for MA-I was missing the Nurse Aide registry check and the information from the Adult Protective Services Central Registry and the Central Register of Child Protection Cases was requested 3 times and was still not back as of that date.

Licensure Reference Number 175 NAC 12-006.05(B)Based on record review and interview the facility failed to ensure that the resident/resident representative was provided the required Centers for Medicare and Medicaid Services (CMS) notifications of the ending of their Medicare Part A skilled services (a program that covers the cost of short-term skilled nursing facility (SNF) care for up to 100 days in a SNF). This prevented the resident/resident representative from making an informed decision regarding their choice for further care and financial options, and of the right to appeal the decision. The facility census was 25.Findings are:Record review of the facility policy titled Advance Beneficiary Notices (CMS required notifications) dated 5/27/26 revealed that it is the facility policy to provide timely notices regarding Medicare eligibility and coverage. The facility shall inform Medicare beneficiaries of his or her potential liability for a payment. A liability notice shall be issued to Medicare beneficiaries before the facility provides an item or service that is usually paid for by Medicare. The facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and a Notice of Medicare Non-Coverage (NOMNOC) shall be issued when Medicare covered services are ending. To ensure that the resident or representative has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay. Record review of the admission Record dated 8/12/26 for Resident 17 revealed that Resident 17 admitted into the facility on 2/10/25. The admission Record revealed that Resident 17 did not discharge from the facility and remained a current resident in the facility. Record review of the medical record for Resident 17 revealed that Resident 17 began to receive Medicare Part A services on 3/18/26. A progress note dated 4/15/26 revealed concern that Resident 17 would not have any interaction with anyone once the resident came off of therapy services. A NOMNOC was mailed to the resident representative to sign. Record review of the NOMNOC dated 4/15/26 for Resident 17 revealed that the Medicare Coverage of the resident's skilled nursing facility services will end on 4/17/26. The date that the beneficiary's (Resident 17's) liability is expected to begin is 4/18/26.Record review of the medical record for Resident 17 revealed that it contained no SNFABN notice for the end of Medicare Part A services on 4/17/26.Interview on 8/13/26 at 10:13 AM with the facility Social Services Director (SSD) confirmed that Resident 17's discharge from Medicare Part A services was initiated by therapy. The SSD confirmed that an SNFABN was required to be provided to Resident 17 but that the SSD forgot to do it.

Licensure Reference Number 175 NAC 12-006.05(S)Based on observation, record review, and interview the facility failed to ensure that care and treatments were provided in a manner to protect resident privacy and dignity for 1 of 1 residents (Resident 3). The facility census was 25.Findings are:Record review of the undated facility admission Packet revealed that the facility will provide nursing services to help assure resident safety and for residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The information contained in the resident's medical record is confidential. Attachment 3 revealed that the resident has a right to a dignified existence. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The facility must protect and promote the rights of the resident. Record review of the admission Record dated 8/12/26 for Resident 3 revealed that Resident 3 admitted into the facility on [DATE]. Diagnoses included diabetes; anxiety; and mild intellectual disabilities (impaired ability for thinking and learning).Observation on 8/17/26 at 11:53 AM at the facility dining room revealed that Resident 3 was seated at a table. Two other residents were in the dining room. The facility Director of Nursing (DON) entered the dining room and went to Resident 3. Resident 19 entered the dining room and took a seat at the table with Resident 3. The DON sat the glucometer (a medical device used to measure and display the amount of sugar in the blood for residents with diabetes) on the table in front of Resident 3. There were now 6 other residents present in the dining room. The DON opened an alcohol prep pad and wiped the pad of a fingertip on the left hand of Resident 3. The DON used the lancet (a small sterile blade used to obtain a small amount of blood for testing) and poked the pad of the fingertip on the left hand. The DON applied a drop of blood from the finger to the test strip in the glucometer. The glucometer displayed a blood sugar result of 364. The DON announced the blood sugar result aloud and then showed the glucometer to Resident 3. The facility Assistant Director of Nursing (ADON) came to the table and visited with the DON. The DON was heard saying that Nobody is eating yet. The DON pushed the treatment cart out of the dining room and parked it near the entry to the nurse's station at 11:57 AM. The DON looked at the resident record on the laptop computer sitting on the top of the treatment cart. The DON carried an insulin pen, insulin pen needle, and the glucometer into the nurse's station and sat them on the desk. The laptop computer remained open displaying information for Resident 3. The computer screen was facing away from the wall and visible to residents and staff walking through the area. Licensed Practical Nurse-A (LPN-A) entered the nurse's station and visited with the DON. The DON exited the nurse's station and went to the treatment cart at 12:03 PM. The DON closed the laptop and then carried it to the desk in the nurse's station. The DON remained seated at the desk in the nurse's station with the insulin pen for Resident 3. The DON placed the needle on the end of the insulin pen. The DON carried an alcohol prep pad and the insulin pen into the dining room. The DON used the alcohol prep pad and wiped an area on the left upper arm of Resident 3. The DON removed the cap from the insulin pen and injected the insulin into the upper right arm of Resident 3. The time was now 12:18 PM. The DON carried the insulin pen back into the nurse's station. Interview on 8/17/26 at 1:00 PM with the DON confirmed that Resident 3 was administered a total of 10 units of insulin. The DON confirmed that the blood sugar check and insulin administration for Resident 3 should not be done in the dining room. The DON confirmed that the DON checked the blood sugar and administered insulin to Resident 3 in the dining room at the noon meal. Interview on 8/18/26 at 2:18 PM with the facility ADON confirmed that resident care including blood sugar checks and insulin administration are not to be performed in a public area such as the dining room as it is a dignity issue.

Licensure Reference Number 175 NAC 12-006.09Based on record review and interview, the facility failed to provide continued assessment and monitoring of a resident to potentially prevent hospitalization for 1 resident (Resident 12) of 5 sampled residents. The facility census was 25.Findings are:Record review of an undated document titled admission Agreement revealed that the facility would supply nursing and related services to help assure resident safety and that the residents attain or maintain the highest practicable physical, mental, and psychosocial wellbeing.Record review of Resident 12's Electronic Medical Health Record (EMHR) revealed:-Documentation on 07/08/2026 at 6:07 PM that the resident had 2 episodes of emesis (vomiting), complaints of a headache, and a temperature that was documented to be 102.3 to 104.3. All other vital signs were documented to be within normal limits for the residents. The residents had no cough, congestion or shortness of breath and the resident's lung sounds were documented to be clear. Blankets were removed from the resident, a cold washcloth was placed on their forehead, and Tylenol was administered to the resident.-Documentation on 07/09/2026 at 4:31 AM that the resident had complained of not feeling well after supper and had a fever after supper and received Tylenol. It was documented that the resident's temperature was 99.2 when it was re-checked and the resident had stated they were feeling better at that time. It was documented that nursing would continue to monitor the residents for signs and symptoms of illness.-Documentation on 07/13/2026 at 12:35 PM that the resident complained of severe right ankle and foot pain. The resident's provider was notified and the resident was taken to see their provider in the provider's office. The facility was notified by the provider's office that the resident needed to be transported to the local emergency room due to possibly being septic and a blood sugar of 457. The resident was then taken to the local emergency room and admitted to the local hospital with a diagnosis of sepsis and urinary tract infection.There was no documentation present in the Resident 12's EMHR of the resident being monitored or assessed from 07/09/2023 through 07/13/2026. There was no documentation of the resident's temperature being re-checked after 07/09/2026. There was no documentation of the resident's provider being contacted due to the episodes of emesis and elevated temperature.In an interview completed on 08/13/2026 at 11:05 AM with the facility Assistant Director of Nursing (ADON), the ADON confirmed that the resident's (Resident 12) record should have documentation indicating that the resident was being assessed and monitored from 07/09/2026 for a minimum of 3 days every shift. The ADON confirmed that the resident's provider should have been notified of the emesis and elevated temperature that was documented on 07/08/2026 and was not. The ADON agreed that the timely notification of the provider and continued assessment and monitoring possibly could have prevented the resident's hospitalization.

Licensure Reference Number 175 NAC 12-006.(H)(iv)(6)Based on record review, observation and interview the facility failed to ensure a resident entering the facility with an indwelling urinary catheter was assessed for the removal of the indwelling urinary catheter, attempted to remove the indwelling urinary catheter (a soft plastic tube inserted into a individuals bladder through the urethra), or had a diagnosis indicating the need for the continuation of an indwelling urinary catheter for 1 resident (Resident 12) of 1 sampled residents. The facility census was 25.Findings are:Record review of a facility policy titled Incontinence and dated 11/25/2025 revealed it was the policy of the facility to ensure that residents who enter the facility win an indwelling urinary catheter, will be assessed for the removal of the catheter as soon as possible unless the residents clinical condition demonstrates that catheterization is necessary.In an observation completed on 08/12/2026 at 11:48 AM Resident 12 was observed to be lying in their bed with their eyes closed. A clear plastic tube was visible to the outer edge of the residents' bed going from under the residents blanket into a white bath towel wrapped receptacle sitting on the floor under the residents bed. There was yellow liquid visible in the tubbing.In an interview completed on 08/12/2026 at 11:50 AM with Nurse Aide B (NA-B), NA-B stated that Resident 12 had an indwelling urinary catheter since they returned from the hospital last month. The NA stated that the receptacle wrapped in the towel was the resident's catheter drainage bag and was wrapped in the towel due to the drainage bag having to be set on the floor to ensure that it would drain.Record review of Resident 12's Census on 08/13/2026 revealed that the resident was transferred from the facility to the hospital on [DATE] and returned to the facility on [DATE].Record review of Resident 12's Progress Notes on 08/13/2026 revealed documentation of an Admit/Readmit note stating the resident was readmitted to the facility on [DATE] from the hospital due to having sepsis and a urinary tract infection. The documentation stated that the resident had an indwelling urinary catheter present. Further review revealed from 07/20/2026 through 08/13/2026 no documentation was present indicating the facility had requested to the provider for the continued use of the indwelling urinary catheter, requested removal of the indwelling urinary catheter, requested an indication for the continuation of the indwelling urinary catheter.Record review of Resident 12's Physician Orders on 08/13/2026 revealed the resident did not have physician orders for the indwelling urinary catheter or an indication for the indwelling urinary catheter.In an interview completed on 08/13/2026 at 1:45 PM with Licensed Practical Nurse C (LPN-C), LPN-C stated Resident 12 returned from a hospitalization with an indwelling urinary catheter in the month of July.In an interview completed on 08/13/2026 at 2:40 PM with the facility Assistant Director of Nursing (ADON), the ADON confirmed that Resident 12 returned to the facility on [DATE] with an indwelling urinary catheter. The ADON confirmed that the resident did not have provider orders including an indication for the indwelling urinary catheter.In an interview completed on 08/17/2026 at 5:00 PM with the Regional Director of Nursing (RDN), the RDN confirmed that the indwelling urinary catheter for Resident 12 was present on the residents re admission to the facility. The RDN confirmed that there had been no attempts to discontinue the use of the indwelling urinary catheter, there was no indication for the use of the indwelling urinary catheter, and there were no provider orders for the indwelling urinary catheter.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, record review, and interview, the facility failed to ensure that staff were trained to check the function of individual resident elopement prevention equipment to prevent elopement (unsupervised wandering that leads to the resident leaving the facility without facility staff knowledge). This affected 4 (Residents 1, 2, 3, and 4) of 4 residents identified as at risk for elopement. The facility census was 33. Findings are: Record review of the facility policy titled Wandering and Elopement dated 7/1/20 revealed that the facility will provide a system to identify residents at risk for unsafe wandering and elopement. The facility will provide a program of supervision and interventions to minimize risk of resident elopements. The facility will provide staff education for effective wandering/elopement management. Staff members receive appropriate training on wandering and elopement management. This will occur at a minimum, during orientation and annually. A wandering/elopement risk evaluation is completed for each resident to identify the level of risk that may lead to elopement. If it is determined that the resident is at risk for wandering/elopement, a plan is developed and implemented immediately and reviewed with staff. Alert devices like wander guard bracelets (a bracelet placed on a resident at risk to wander/elope that triggers alarms and can lock monitored doors to prevent the resident from leaving the facility unattended) will be checked for placement and function each shift and these checks will be documented in the medical record. Record review of Resident 1's Admission Record dated 2/8/24 revealed Resident 1 admitted into the facility on [DATE]. Resident 1 had a diagnosis of dementia. Record review of Resident 1's Elopement Evaluation dated 1/2/24 revealed Resident 1 wanders and does wander aimlessly. A score of 1 or higher indicates the resident is at risk for elopement. The Elopement Evaluation revealed Resident 1 had a score of 3. Record review of Resident 1's Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/7/24 revealed that Resident 1 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 8 (a score of 8 indicates moderate cognitive impairment). The MDS revealed Resident 1 was independent with transferring and walking. Record review of Resident 1's Baseline Care Plan (BCP) (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) dated 1/2/24 revealed Resident 1 was at risk for elopement. The BCP revealed that Resident 1 has a history of dementia and wanders throughout the facility. The BCP summary section revealed that Resident 1 was found wandering in the airport in Omaha and is forgetful. Record review of Resident 1's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 2/8/24 revealed Resident 1 was an elopement/wander risk due to dementia and impaired safety awareness. The Care Plan identified an intervention to apply a wander guard alert bracelet and check functioning as ordered. The Care Plan identified a wander guard was placed to Resident 1's left wrist which was dated 1/3/24. Record review of Resident 1's Order Summary (a listing of physician orders for a resident) dated 2/8/24 revealed an order to check the wander guard for function every shift dated 1/18/24. Observation on 2/8/24 at 9:13 AM revealed a wander guard sensor (a sensor connected to an entry/exit door to prevent a resident with a wander guard bracelet from leaving the facility unattended) on the front main entry door of the facility. Observation on 2/8/24 at 10:10 AM of Resident 1's room revealed Resident 1 had a gray wander guard bracelet in place on their left wrist. Record review of Resident 1's Progress Note dated 1/16/24 at 12:58 AM revealed that Resident 1 wanders at night. Record review of Resident 1's Progress Note dated 1/18/24 at 7:23 PM revealed that a staff member that was on break called the facility. The staff member reported that they thought they saw Resident 1 walking across the road to the Dollar General store. The staff member was instructed to go over to the store and check. Resident 1 returned to the facility with the staff member. Resident 1 was assisted to put dry warm clothes on. Resident 1 stated that they went to the store to get something but forgot that they didn't have any money. Interview on 2/8/24 at 2:06 PM with the facility Assistant Director of Nursing (ADON) revealed the ADON was present at the time Resident 1 eloped on 1/18/24. The ADON confirmed that the wander guard alarm on the front door of the facility did not sound an alarm. The ADON did not identify any reason or check as to why the door did not alarm. Record review of the Wander Guard User Instructions dated 2023 revealed the section titled Testing the Signaling Device. The section revealed that each signaling device (wander guard bracelet) is tested daily using a Universal Tester (a hand-held, battery powered device used to test wander guard bracelets and door monitors/sensors) and results documented in the resident's record. Record review of Resident 1's Treatment Administration Record (TAR) (a record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) for February 2024 revealed the medical task to check the wander guard every shift for functioning was documented by Licensed Practical Nurse-A (LPN-A) for the day and evening shift on 2/5/24, the day and evening shift for 2/6/24, and the day shift on 2/8/24. Further, the record review revealed there were not wander guard functioning checks in place prior to Resident 1's elopement on 1/18/2024. Interview on 2/8/24 at 10:52 AM with Licensed Practical Nurse-A (LPN-A) revealed that resident wander guards are checked daily and documented on the Treatment Administration Record (TAR). LPN-A revealed that LPN-A visually checks that the wander guard is in place on the resident. LPN-A confirmed that they were unaware of any other checks required other than visually verifying placement of the wander guard. LPN-A was unaware of any tester. Interview on 2/8/24 at 11:00 AM with the facility Director of Nursing (DON) revealed that the facility currently has 4 residents with a wander guard (Residents 1, 2, 3, and 4). The DON revealed that the wander guard is to be checked every shift for placement and function. The DON confirmed the wander guard bracelet is required to be tested with the wander guard tester. The DON revealed that a green light on the wander guard tester is required to show the wander guard is functioning. The DON revealed that checks of the wander guard placement and function are documented in the electronic health record on the Treatment Administration Record (TAR) by the nurse. The DON revealed that the facility maintenance person checks the wander guard sensors at the doors with a testing device. Observation on 2/8/24 at 12:58 PM at the treatment cart outside the nurse's station with the facility Director of Nursing (DON) revealed that the DON brought the Wander Guard user instructions to this surveyor. The DON picked up the Universal Tester and confirmed that it is the tester used to verify that the wander guards are functioning. This surveyor asked the DON what training on the tester had been provided to LPN-A. The DON confirmed that the facility had not performed any training with LPN-A on the use of the tester. LPN-A approached the cart and asked, that is what you use?. LPN-A confirmed that LPN-A had not received training to use the tester for the wander guard checks. Record review of Resident 2's TAR revealed LPN-A verified placement on 2/5/24 day and evening shift, 2/6/24 day and evening shift, and 2/8/24 day shift. Record review of Resident 3's TAR revealed LPN-A verified placement on 2/5/24 day and evening shift, 2/6/24 day and evening shift, and 2/8/24 day shift. Interview on 2/8/24 at 2:38 PM with the Facility Administrator (FA) confirmed that the expectation is for wander guards to be checked for placement and proper function every day. The FA confirmed that the facility investigation for the 1/18/24 elopement of Resident 1 revealed that Resident 1 left the facility through the front door. Record review of the Facility Abatement Statement received on 2/8/24 at 4:54 PM from the Regional Nurse Consultant (RNC) revealed the following: -All wander guard amulets (bracelets) in use immediately checked for placement, functioning, and expiration date. -Education provided immediately to all licensed nursed in the facility on monitoring the wander guard amulet for placement, functioning, and expiration date every shift every day. -Education will be provided to all licensed nurses, including agency licensed nurses, prior to working their next shift. -All newly hired licensed nurses will be educated on monitoring of wander guard amulets during general orientation. -All new agency licensed nurses will be educated on monitoring of wander guard amulets during orientation to the building.

Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, interview, and record review, the facility failed to implement interventions and treatment to promote healing of a newly identified pressure sore for 1 (Resident 2) of 3 sampled residents. The facility had a total census of 42 residents. The findings are: An observation on 10/4/22 at 10:18 AM revealed RN A (Registered Nurse) and LPN E Licensed Practical Nurse) provided wound care to Resident 2. Observations at this time revealed Resident 2 had a large ulcer to their left heel with a tan and white wound bed. Observations also revealed a moderate amount of red and brown drainage on the old dressing when it was removed by LPN E. The skin surrounding Resident 2's ulcer was reddened. A review of the facility's Pressure Injury Weekly Tracking Form, dated 9/8/22, revealed Resident 2 had an unstageable pressure ulcer to their left heel. Further review revealed the pressure ulcer was facility-acquired with an onset date of 8/25/22. A review of a Skin Alteration Evaluation for Resident 2 dated 9/8/22 revealed Resident 2 had a wound to their left heel with an onset date of 8/29/22. The wound was described as a boggy blister intact. The wound was identified as new. No measurements or staging was documented. A review of a second Skin Alteration Evaluation for Resident 2 dated 9/8/22 revealed Resident 2 had a wound to their left heel with an onset date of 8/29/22. The wound was documented as an open area measuring 3.0cm (centimeters) x 2.5cm. A note was included stating, reported Sunday, blister opened. No staging was documented, and the wound was identified as new. A review of a Skin Alteration Evaluation for Resident 2 dated 9/13/22 revealed resident 2 had a blister to their left heel with an onset date of 9/8/22 measuring 3.0cm x 4.6cm. The blister was described as intact boggy. No staging was documented, and the wound was identified as stable. A review of a Skin Alteration Evaluation for Resident 2 dated 9/20/22 revealed Resident 2 had a pressure ulcer to their left heel with an onset date of 8/25/22. The pressure ulcer was described as an intact fluid filled blister measuring 3.5cm x 5.6cm. No staging was documented, and the pressure ulcer was identified as deteriorated. A review of a Skin Alteration Evaluation for Resident 2 dated 9/24/22 revealed Resident 2 had a pressure ulcer to their left heel with an onset date of 9/24/22. The pressure ulcer was described as blister opened and measured 6cm x 4.5cm with a depth of 0.1cm. No staging was documented. A note was included stating the physician was notified this date. A review of a Skin Alteration Evaluation for Resident 2 dated 9/28/22 revealed Resident 2 had a wound to their left heel with an onset date of 8/25/22. The wound was documented as an open blister measuring 5.0cm x 4.0cm. The assessment indicated [CONDITION(S)] (redness) to the wound edges, a scant amount of bloody drainage, and that Resident 2 was experiencing pain. There was no staging documented and the wound was identified as deteriorated. Further review of the Skin Alteration Evaluations for Resident 2 revealed the following information regarding staging of pressure ulcers: -Suspected Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler compared to adjacent tissue. -Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. -Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. -Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. A review of Resident 2's September 2022 TAR (Treatment Administration Record revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -Left heel - cleanse open area with NS (normal saline) and cover with foam dressing and change daily. Further review revealed the order was dated 9/26/22 and was first documented as completed on 9/30/22. A review of Resident 2's medical record did not reveal any documentation of treatment or interventions related to a wound on Resident 2's left heel prior to 9/26/22. A review of Resident 2's undated CCP (Comprehensive Care Plan - a document outlining how to care for a resident) did not reveal any listed treatment or interventions related to a wound or pressure ulcer on Resident 2's left heel. In an interview on 10/4/22 at 3:50 PM, the RNC (Regional Nurse Consultant) confirmed no intervention or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .

LICENSURE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and interviews, the facility failed to ensure one resident (Resident 1) out of 3 sampled residents did not receive [MEDICAL CONDITION] hot liquids. The facility census was 32. Findings are: Record review of Resident 1's Admission Record dated 6-12-19 revealed date of admission of 3-5-18 and [DIAGNOSES REDACTED]. Review of Resident 1's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 4-21-19 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 9 which indicated Resident 1's cognition was moderately impaired. The resident had impairment in range in motion to one side of the body. Resident 1 required extensive assistance of 2 staff with bed mobility, dressing, and toileting. The resident was dependent on 2 staff for transfers and locomotion. Resident 1 required supervision of 1 staff with eating. The resident was on insulin, antipsychotic and antidepressant medications. Review of the admission/transfer/discharge/ form provided by the facility revealed the resident had been transferred to the hospital on 5-28-19 and was not in the facility during the time of the investigation. Review of PN (Progress Notes) dated 4-28-19 for Resident 1 revealed the resident had been very anxious during the evening shift which carried on into the night shift. At 2:45 AM on 4-29-19 the resident banged on the trashcan wanting to get up for the day and have a cup of coffee. The staff dressed the resident and sat the resident in the resident's wheelchair in the living room with a table to Resident 1's right side and placed the Styrofoam coffee cup with a lid on the table. The staff were not in the same room with the resident but heard the resident holler out ouch. The staff found the resident with the coffee cup tipped over and spilled coffee on the resident's pants. The resident was assessed and first aide administered. The skin assessment revealed a light pink area that blanched to the left thigh measured at 4 x 4 cm (centimeters), 2 red areas to right thigh that blanched and measured at 4 x 4.2 cm and below this area measured a 2nd site at 5 x 2.5 cm red area. Review of Skin and Wound Evaluation form for the right thigh burn wound on 4-30-19 at 7:12 AM revealed a 4.6 x 3.8 cm in size wound which appears as a reddened band of tissue with ruptured blisters within peeling edges - no signs or symptoms of infection. Doctor notified of open wounds, requested treatment orders on 4/30/19 - will follow-up. Currently cleansing and covering with [MEDICATION NAME] dressing to protect from clothing and resident scratching as witnessed with bathing. On Skin and Wound Evaluation form dated 5-16-19 revealed the right thigh burn wound measured 2.6 x 3.7 cm and the burn had darkened area of slough (dead tissue) cover. Treatment consisted of a Vaseline gauze covered with foam dressing. The facility had a contracted Wound Nurse come to the facility and assess the wound on 5-13-19. Review of the Wound Care Nurse documentation dated 5-14-19 revealed Resident 1 had a full thickness burn to the right thigh measured 3 x 6 cm with undetermined depth and serosanguinous drainage. The wound bed was 50% red/pink in color and 50% black tissue firmly adherent, hard eschar (dead tissue). Resident assessed for wound pain to have moderate pain as indicated with a furrowed brow, pursed lips, and holding breath. Recommendations were given for daily dressing changes. Review of the SOM (State Operational Manual) revealed the definition of a Third-degree burn was damage that penetrated the entire thickness of the skin and permanently destroyed tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first-and second-[MEDICAL CONDITION] third-degree burns, and dry leathery skin. The skin may appear charred or have patches that were white, brown, or black in color. Review of the facility investigation report of the burn for Resident 1 revealed on 4-29-19 at approximately 2:45 AM Resident 1 was assisted out of bed and into the wheelchair and taken to the living room at the resident's request. The resident had been agitated and had requested a cup of coffee. The NA (Nurse Aide) provided the resident with a cup of coffee in a paper cup with a lid. The staff left the resident to continue their work answering call lights and resident cares. When the staff returned to the nurse's station, they heard the resident calling out to them and observed the resident had spilled the coffee onto the front of the resident's pants. Record review of the SOM revealed Time and Temperature for a liquid to be at 155 degrees F it would only take 1 second to cause a 3rd degree burn; 148 degrees F would take 2 seconds and at 140 degrees F would take 5 seconds for a 3rd degree burn.[MEDICAL CONDITION] occur even at liquid temperatures below these listed, depending on an individual's condition and length of exposure. Review of Resident 1's medical record revealed absence of a hot liquid risk assessment. Inteview on 6-12-19 at 2:00 PM with the DON (Director of Nursing) confirmed the facility had not performed a hot liquid assessment on Resident 1 prior to the coffee burn incident or after the incident of the coffee burn. Review of Resident 1's undated Careplan revealed absence of having identified the resident at being at risk for hot liquids. The Careplan also was absent any interventions to prevent hot [MEDICAL CONDITION] lids on the resident's coffee cups prior to the incident of the coffee burn. The Careplan had an intervention dated 4-29-19 to use a bedside tray table when the resident wants to drink coffee outside of meal times and coffee/hot liquids must be served in a cup with a lid dated 4-29-19.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record reviews, and interviews; the facility failed to ensure staff followed the plan of care for fall interventions for one resident (Resident 104) of the 3 sampled residents. The facility census was 32. Findings are: Review of Resident 104's undated face sheet revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 11-10-16 revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aides in detecting cognitive impairment) score of 14 which indicated intact cognition. Resident 104 required limited assist of 2 staff with bed mobility, transfers, walking, locomotion, toileting, and personal hygiene. The resident required extensive assist of 2 staff with dressing. Resident 104 was always continent of the bowels and occasionally incontinent of the bladder. Review of the Nursing Notes dated 12-31-16 at 06:25 AM revealed the staff found Resident 104 on the floor in the resident's room. The resident was assessed and complained of pain in the left hip with any movement. Resident 104 was transferred to the hospital and required a surgical repair for a fractured left hip. Review of the Post Fall Investigation form for the fall dated 12-31-16 revealed the resident's bed alarm sensor pad was in place but the alarm box was not connected. Interview with the ADM (Administrator) confirmed the Facility Investigation report revealed Resident 104 had 2 different types of fall alarms used the night of 12-31-16, a bed alarm and a personal alarm or known as a TABS alarm. (A bed alarm utilized a pressure sensitive pad the resident lays on connected to an alarm box which rings with resident movement from the bed. The TABS alarm had a string attached to the resident's clothing with a clip. The other end of the string had a magnet attached to the alarm box. The alarm box had to be secured to a permanent fixture so when the resident stood and moved away from the alarm, the string pulled the magnet off the box and the alarm would ring. If the alarm box was not secure, the alarm magnet would not disconnect from the box and the alarm could not ring to alert the staff.) The ADM confirmed the staff interviewed revealed that , on 12-31-16, the night shift who worked with Resident 104 were unable to secure the TABS alarm box to a secured surface. Therefore, when Resident 104 attempted to get out of bed unassisted, the TABS alarm did not alert the staff of the resident's unwanted movement. The ADM also confirmed that, at the time of the fall, the investigation revealed the bed alarm sensor pad was on the bed but not connected to the bed alarm box so it did not ring and alert the staff when the resident independently got out of the bed. Interview on 01-30-17 at 1:00 PM with Nurse-C revealed the Facility was in a 3 week roll out phase of alarms which was a trial of eliminating fall alarms in the facility. Last week, the facility eliminated all fall alarms in the dining room during meals. Starting 01-31-17, the facility began only bed alarms to be used when in bed at night time. Nurse-C revealed there were only 2 residents that had alarms and Resident 104 was one of the two residents. Review of the Care Plan dated 09-14-16 revealed Resident 104 was a high risk for falls related to advanced age, weakness after having had pneumonia, and several actual falls with dates listed. Interventions listed included: educated resident to not get up fast and to sit before position changes, reminded the resident to use the walker when standing up, leave a night light on; educated the resident on the importance to use the call light when feeling weak, the staff to offer the toilet during rounds, keep the bed in a low position, keep a foot cradle on the bed (dated 10-19-16); keep the call light within reach, keep fall alarms on while in the bed and in the chair; Observation on 01-30-17 at 1:47 PM of Resident 104 revealed the resident was asleep in the resident's bed. The call light cord laid on the floor at the foot of the bed out of the reach of the resident. The foot cradle was not on the bed but on the floor on the opposite side of the room from the bed. The bed alarm cord extended from the bed and laid on the floor. There was no alarm box observed connected to the bed alarm. On 01-30-17 at 1:50 PM, NA-A (Nurse Aide) entered Resident 104's room. Interview with NA-A confirmed the call light was on the floor at the foot of the bed and not within the resident's reach. NA-A confirmed the foot cradle was supposed to be on the foot of the bed to help prevent a fall caused by the resident's feet from getting tangled in the covers. NA-A confirmed the resident was to have the bed alarm on when in the bed both during the day and at night. NA-A also confirmed the bed alarm sensor pad was not connected to an alarm box and an alarm box was not in the resident's room. NA-A obtained an alarm box and applied it to resident bed alarm. Interview on 1-30-17 at 1:55 PM with NA-B revealed today was the first day that the residents were to wear the bed alarms only when in bed for the roll out phase of alarms and currently there were only 2 residents with alarms. Resident 104 was one of the 2 residents. NA-B confirmed Resident 104 was to have a bed alarm on anytime the resident was in bed, this included during the day for a nap. Interview on 1-30-17 at 1:56 PM with NA-E revealed today was the first day that the residents were to wear the bed alarms only when in bed for roll out phase of alarms and currently there were only 2 residents with alarms. Resident 104 was one of the 2 residents. NA-E confirmed Resident 104 was to have a bed alarm on anytime the resident was in bed, this included during the day for a nap. Interview on 01-30-17 at 4:50 PM with Nurse D confirmed Resident 104 was one of the residents to have a bed alarm on only when in bed which started 01-30-17. Nurse D confirmed the bed alarm should be on whenever the resident was in bed anytime during the day or night. Interview with the DON (Director of Nursing ) on 01-30-17 at 4:45 PM confirmed the facility had started a roll out phase of alarms on January 23, 2017. The DON revealed the plan was the residents with alarms were only to use the bed alarms when in bed at night only effective 01-30-17 for 1 week, then next week no alarms at all. The DON revealed staff were educated but confirmed there must be some miscommunication based off of the observations and interviews from today. The DON confirmed the DON educated the staff at a meeting on 01-18-17 to be successful with no fall alarms, the staff were educated to ensure the other fall interventions must be used such a call lights within reach at all times and any other fall interventions care planned for a specific resident such as the foot cradle for Resident 104.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D7 Based on observation, record review, and interviews; the facility failed to assess for causal factors, and develop and implement care interventions to protect 2 residents (Residents 23 and 5) from falls with injury. The facility census was 31. Findings are: A. Review of an undated FACE SHEET revealed Resident 23 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident 23's MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) revealed on the admission assessment dated [DATE], Resident 23 had a BIMS (Brief Interview for Mental Status) score of 15. A score of 13-15 revealed the resident was cognitively intact; 08-12 was moderately impaired; and 00-07 the resident had severe impairment with cognition. Review of the quarterly assessment dated [DATE], revealed Resident 23 had a BIMS score of 11, which was a decline in the resident's cognitive ability. . Review of a FALL RISK REVIEW TOOL dated 1/7/13 revealed Resident 23 was a moderate risk for falls due to "impaired cognitive status - mild or severe", problems with balance, and "Needs assist of 1-2 people for transfers". Review of a fall investigation dated 1/31/13 revealed Resident 23 had fallen at 9:00 PM on 1/29/13. The investigation stated Resident 23 "had some period in recent history of confusion/disorientation", the resident had not used the call light, and had a [DIAGNOSES REDACTED]. The investigation revealed Resident 23 had sustained a 2 centimeter laceration to the scalp and required sutures. Review of Resident 23's CARE PLAN revealed: - Problem dated 1/4/13 "MODERATE RISK FOR FALLS R/T (related to) WEAKNESS AND RECENT FALL WITH R) (right) HIP FX (fracture)". -- Approaches dated 1/7/13 included: "Call light is useable and within reach", "Ensure proper foot wear"; "Encourage use of roller walker"; "Alarm while in bed and chair"; and "Fall documentation and analysis is completed if fall(s) occur to investigate root cause(s) and other prevention techniques". -Written notations revealed: 1/29/13 "fell in room - Laceration to posterior scalp (with) sutures". "1/29/13 :"I will utilize my call light for assist"; "Encourage resident to use call light when needs assistance, not to get up on own". 1/30/13: "if res (resident) is confused/anxious, offer to assist (the resident) to the LR (living room) or common area for increased observation". Review of a FAX COMMUNICATION TO PHYSICIAN dated 5/1/13 revealed Resident 23 was "more confused at times". Review of Resident 23's Speech Therapy notes dated 5/14/13 revealed "had more difficulty than usual with recalling information". Review of Resident 23's Occupational Therapy (OT) notes revealed: - 5/20/13: "Pt (patient) reports (Resident 23) had a fall over the weekend. Spoke with nursing and they had no information of the fall". "Pt appears to be more confused in the last week"; - 5/21/13: "Pt had unsteady gait today while ambulating"; and - 5/23/13: "Pt needed continual verbal cures to find the way to the Therapy room and back to room". "Pt had increased confusion today. Pt talking but not making sense". Review of Resident 23's Care Plan revealed no new fall prevention interventions had been established after 5/20/13. Review of Resident 23's medical record had no documentation that an investigation had been completed to identify causal factors of the reported fall on 5/2013. Review of an INCIDENT REPORT FORM dated 6/15/13 revealed at 6:30 PM on 6/15/13, Resident 23 was "found from a fall trying to get up by self to BR (bathroom) on edge of chair trying to get back into chair". "(Chair) Alarm ringing. Walker beside chair. Resident sitting on floor in front of chair. Call light attached to arm of chair". Resident 23's right elbow was bruised and swollen. Resident 23 was transferred to the hospital". Review of an undated POST FALL INVESTIGATION revealed Resident 23 had a fall at 6:30 PM on 6/15/13. The investigation revealed Resident 23 had been identified at risk for falls and had fallen once in the last 90 days. The investigation revealed Resident 23 had sustained a fractured right elbow and revision to care plan had been completed on 6/16/13. Review of Resident 23's CARE PLAN revealed no new interventions dated 6/16/13 had been established for fall prevention. Review of the results of X-rays done on Resident 23 on 6/15/13 confirmed that Resident 23 had a fracture of the right elbow and had fractured the right superior pubic ramus (pubic bone). During an interview on 6/18/13 at 12:13 PM, Certified Occupational Therapy Assistant (COTA) -B stated Resident 23's balance was not great, and the resident had difficulty with pulling up pants or bending over to get things out of a dresser drawer. COTA-B revealed Resident 23's steadiness had not gotten any better and needed hands on assistance to maintain balance, as well as with transfers and ambulation. COTA-B revealed the resident had a decrease in cognition, had trouble with sequencing, and did not believe Resident 23 would not have gotten up without assistance if the roommate hadn't shown the resident how to turn off the chair alarm. COTA-B revealed Resident 23 had been discharged from physical therapy, first because the resident had plateaued and wasn't progressing anymore, "but I (COTA-B) didn't want to stop therapy right away because I wanted to maintain Resident 23's physical and cognitive abilities" and "I was afraid if we stopped working with (gender), (Resident 23) would decline quickly". Review of Occupational Therapy notes revealed Resident 23 was discharged from OT on 5/22/13. During an interview on 6/18/13 at 2:17 PM, Medication Aide (MA) -R revealed supper was served to residents at 5:30 PM and residents were usually finished eating by 6:15 PM, but occasionally a resident may not be finished until 6:30 PM. MA-R revealed after the resident's supper "I go to supper and 1-2 other staff" also go to supper. MA-R explained most residents wanted to go to the bathroom after supper and the staff not taking break assisted them, which usually was a nurse and a nursing assistant (NA). MA-R revealed Resident 23 required the assistance of 1 staff member for transfers, toileting, and activities of daily living (ADLs). MA-R expressed the knowledge that Resident 23 had shut the chair alarm off during the last week and was not good using the call light, due to a mixture of not wanting to lose (gender) independence and forgetting to use it because the resident had increased confusion. During an interview on 6/18/13 at 2:25 PM, NA-T revealed supper was served at 5:30 PM, and took residents about 45 minutes to eat. NA-T explained most resident went to their rooms or went into the living room to watch TV. NA-T revealed it took 30-45 minutes to get all residents "settled", so was usually between 7:00 PM - 7:15 PM. NA-T stated 2 staff went on break, which left 1 NA on the floor with the charge nurse to assist resident with cares and answer call lights. NA-T explained when the NA had clocked in around 6:30 PM, after break, NA-B asked for assistance because Resident 23 had fallen. NA-T revealed (gender) had noticed Resident 23 had increased confusion in the past 3 months and knew Resident 23's roommate had taught the resident how to remove the bed/chair alarm. NA-T revealed Resident 23 did not use the call light and thought maybe it was due to the increased confusion. During an interview on 6/18/13 at 2:35 PM, Licensed Practical Nurse (LPN) -G revealed after supper residents that were dependent on staff assistance were supposed to be taken to the bathroom or toileting was to be offered. LPN-G revealed staff were not supposed to go on break until all residents were out of the dining room and settled into their rooms, watching TV, and toileting completed. LPN-G stated staff told the charge nurse they were going on break, but don't ask if it is a good time to go. LPN-G explained that on Saturday, 6/15/13. Resident 23 hadn't left the dining room until about 6:00 PM and should have been asked if the resident wanted to use the toilet after supper, but didn't know if NA-B was aware of that since the NA hadn't worked the afternoon shift before. LPN-G revealed after Resident 23 fell the resident stated (gender) was going to the bathroom. LPN-G stated Resident 23 forgot (gender) can't walk and needs assistance. LPN-G revealed Resident 23's chair/bed alarm had to be changed because the resident had learned to take it off, as the roommate had taught Resident 23. LPN-G stated in the past, Resident 23 used the call light, but didn't that night, and thought the chair was too low and may have been difficult for the resident to get up from it. LPN-G revealed Resident 23 had been more confused, and the fall could have been caused by a mixture of confusion that the resident didn't remember to use the call light and that Resident 23 just thought (gender) could go to the bathroom without assistance. LPN-G explained Resident 23 had not been placed into the living room for increased supervision, because the resident preferred to go to (gender) bedroom after supper. In living room Resident 23 would have have an alarm on, "we may have been able to get to (Resident 23) faster", but it would not provide increased supervision. LPN-G revealed the afternoon 2:00 PM - 10:00 PM) shift usually had 4 staff working; 2 nursing assistants, 1 medication aide, and the charge nurse. During an interview with the Director of Nursing (DON) and the Administrator on 6/19/13 at 12:41 PM, the DON revealed the expectation that staff were not to take breaks at same time and were to ask the charge nurse if it was ok to leave the floor to be sure nothing else needed to be done. The DON revealed residents were generally finished eating by 6:00 PM - 6:15 PM, then residents sat in the lobby, some residents got ready for bed which included personal hygiene, brushing teeth, toileting and changing clothes, and other residents went to bed. The DON stated after supper, some residents required the assistance of 2 staff and the mechanical lift for toileting or bathing. The DON expressed awareness that staff had not asked the charge nurse if the time they chose to take a break was ok. The DON stated Resident 23 used the call light, then revealed the DON hadn't heard that Resident 23 turned off the chair/bed alarm and was not aware of any increased confusion. The DON revealed placing Resident 23 in the living room for increased supervision was not an appropriate intervention during the evening (2:00 PM - 10:00 PM) shift or on weekends when the facility had less staff working. The Administrator explained if a resident was moved to the living room for increased supervision, "everyone would be responsible to supervise". The Administrator stated no one specific person was assigned to ensure increased supervision was provided and the facility did not use monitoring logs. B. Review of an undated FACE SHEET revealed Resident 5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. During an interview on 6/13/13 at 11:27 AM, LPN-R revealed Resident 5 had fallen on 6/7/13 at 8:30 PM. LPN-R explained the resident had tripped on the TV stand and lost (gender) balance. LPN-R revealed Resident 5 was x-rayed due to edema in the hip, but the resident did not have a fracture. Review of Resident 5's CARE PLAN revealed: - Problem dated 6/22/12 "HIGH RISK FOR FALLS ACCORDING TO THE FALLS RISK REVIEW TOOL R/T HISTORY OF FALLS WITH FX. L) (left) HIP. -- Approaches dated 7/24/12 included: "Call light is usable and within reach". "Keep room free of clutter, ensure proper food wear". "Equipment, needs wheeled walker". "Fall documentation and analysis is completed if fall occurs to investigate root cause and other prevention techniques". "Keep all my necessary items within reach". "Place my walker in an area or position that I need it for next time". - Written notations revealed: 3/12/13: "Dx (diagnoses): hepatic [DIAGNOSES REDACTED]", "makes res (resident) unsteady, confused"; 3/14/13: "Falling leaf attached to door frame to alert staff of my fall risk"; 3/18/13: "bed/chair alarms as I do not consistently call for assist (with) ambulation/transfers. I get shaky, unsteady quickly d/t (due to) my ^ (increased) ammonia levels", and 6/7/13: "Re educate Res (Resident 5) has to wait for staff to help (the resident with) ambulation". During an interview on 6/19/13 at 12:00 PM, Registered Nurse -D revealed no fall assessment had been completed for Resident 5, as the corporation considered every resident to be at risk for falls. During an interview with the DON and the Administrator on 6/19/13 at 12:13 PM, the DON revealed Resident 5 didn't always track, so re-education on call light usage was not appropriate due to Resident 5's confusion. The DON explained the day Resident 5 fell , the resident had been out of facility with family, so was overly tired and Resident 5 forgot to use the call light. The DON revealed staff should have been in Resident 5's room more frequently to check if (gender) needed any thing since they knew Resident 5 would be tired from being out. The DON revealed a new intervention was to put a personal TABS alarm on Resident 5, with the hope that staff would get to the resident before (gender) fell . The DON stated no intervention to address the risk identified Resident 5's [DIAGNOSES REDACTED]. The Administrator revealed family often visited or took Resident 5 out of the facility and tired the resident out, which increased Resident 5's risk for falls. The Administrator confirmed that risk was not addressed on the care plan and no interventions had been established. C. Review of the facility's SECOND DOWN GUIDELINES FOR FALL INTERVENTIONS dated 12/11/12 revealed "An immediate response should help to reduce fall risk until more comprehensive care planning occurs. Therefore, an immediate intervention should be put in place by the nurse during the same shift that the fall occurred. When investigation of the fall circumstances is thorough, it is usually clear what immediate action is necessary". "Some examples of immediate interventions are": - "Increased toileting with specified frequency of assistance from staff"; - "Increased assistance targeted for specific high-risk times"; - "Increased staff supervision targeted for specific high risk times". "The Second Down Fall Response": - "Review Second Down Guidelines", - "Complete investigation of a fall using 5 Star Post Fall Investigation", - "Record circumstances, outcomes & staff response", - "Implement immediate intervention(s)", - "Complete additional reviews/assessments as indicated by investigation", - "Develop an appropriate plan of care", - "Monitor implementation & resident response", and - "Modify as necessary".

LICENSURE REFERENCE 175 NAC 12-006.07C Based on record review and staff interview, the facility failed to ensure that the Quality Assessment and Assurance Committee identified quality issues that affected the residents. Facility census was 31 at the time of the survey and the survey sample size was 31. Findings are: Review of the facility Quality Improvement Plan dated 1/1/2007 revealed that the primary purposes of the Quality Improvement Program are: 2. To establish and provide a system whereby a specific process, and the documentation relative to it, is maintained to support evidence of an ongoing Quality Improvement Program, encompassing all aspects of resident care including safety/security and quality of life; 3. To develop monitoring tools that provide an effective mechanism to assure that each resident receives the necessary services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being. Authority: The Administrator has been delegated responsibility for assuring the Quality Improvement Program of the community is in compliance with regulatory requirements. The facility was found to be deficient in in multiple areas of regulatory compliance after the tasks of the annual standard survey were completed. The facility also failed to maintain correction for the regulations identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the areas identified below. Please refer to the Tag citations for specific detailed findings: F 159-Failed to ensure resident personal funds accounts were available on weekends; F 170-Right to have mail delivered on weekends; F 204-Failed to ensure that Discharge Planning for safe and orderly discharge occurred; F 225-Failed to investigate and report misappropriation of resident property; F 226-Failed to implement abuse policies and procedures concerning misappropriation of resident property. Previously cited on 4/5/2012. F 244-Failed to listen/act upon Group Grievances; F 318-Failed to prevent decrease in resident's range of motion; F 323-Failed to implement interventions to prevent resident falls; F 353-Failed to ensure sufficient Nursing staffing F 354-Failed to ensure there was RN (Registered Nurse) staffing 8 hours a day, 7 days a week; F 364-Failed to ensure that food was palatable in temperature; F 431-Failed to ensure that outdated drugs were not available for administration F 520-Failed to maintain an effective Quality Assurance Program. Interview on 6/19/2013 at 11:30 AM with the Quality Assurance Coordinator revealed that the Quality Assurance Committee had not identified or addressed the following issues: Monitoring for timely response to call lights; Sufficient Nursing staff to meet the needs of the residents; Sufficient RN coverage and staffing 8 hours a day, 7 days a week; Discharge Planning; Mail delivery on weekends; Reporting and investigation of misappropriation of resident's property and Provision of Range of Motion to prevent decline.

LICENSURE REFERENCE: 175 NAC 12-006.09D7, 12-006.09D7aBased on observation, record review and interview, the facility failed to assess residents with history of falls for causal factors and implement care interventions to protect residents from falls with injury. The facility had a census of 37 and a complaint survey sample of 3. This affected Resident 01.Findings are: According to the undated RESIDENT ADMISSION RECORD Resident 01 was admitted to the facility on [DATE], with a hospital return date of 7/2/12. The following [DIAGNOSES REDACTED]. Review of the Care Plan for Resident 01 revealed that the resident was identified as a high risk for falls related to a history of falls as far back as 12/31/11 and updated on 7/18/12. The goal for the fall risk was that Resident 01 would have no injury related to a fall. Observation on 10/9/12 at 10:05 AM confirmed the resident had the following interventions in the resident's room: a hi/lo bed, scoop mattress, pressure sensor pad on the bed and a fall mat. Review of a QIPFI (QUALITY IMPROVEMENT POST FALL INVESTIGATION) dated 7/1/12 revealed that Resident 01 was found on the floor at 8:05 AM. The resident was noted to have experienced increased confusion for the previous "few weeks" . The resident was hospitalized and returned back to the facility on [DATE]. Review of the Care Plan confirmed that the new intervention was to instruct the resident to call for help when feeling dizzy and weak. In an interview on 10/10/12 at 11:49 AM, the DON (Director of Nursing) reported that the new intervention of giving the resident instruction on using the call light was not a preventive solution due to the resident having increased confusion. Review of a QIPFI dated 7/3/12 at 3:15 PM revealed that Resident 01 was walking and bent over to pick something up and bumped head on a TV stand. The resident sustained [REDACTED]. Interview on 10/10/12 at 11:49 AM with the DON confirmed that the facility identified that Resident 01 was unsafe and unsteady when bending over. The new intervention was to move the resident to a room closer to the nursing station. The DON reported that moving the resident to a different room failed to address the root cause of the accident - the resident bending over. Review of a QIPFI dated 7/22/12 at 8:45 PM revealed that Resident 01 was found on the floor in the resident's room. Resident 01 sustained a bruise and hematoma. Resident 01 was later taken for X-rays and found to have a compression fracture. Interview on 10/10/12 at 11:49 AM with the DON confirmed that the facility identified that Resident 01 had medication changes that may have contributed to the resident being unsafe. The DON confirmed that the facility staff failed to implement new fall prevention interventions. Review of a QIPFI dated 7/25/12 at 4:30 PM revealed that Resident 01 was found on the floor in the resident's room next to the resident's bed. The resident was confused and crawling to the bathroom. Interview on 10/10/12 at 11:49 AM with the DON confirmed that the facility identified that Resident 01 had to use the bathroom as the causal factor. The DON confirmed that the facility staff failed to implement new fall prevention interventions to address the causal factors. Review of a QIPFI dated 8/12/12 at 4:15 PM revealed that Resident 01 was found on the floor in the resident's room. The resident sustained [REDACTED]. The DON confirmed that the facility staff failed to implement new fall prevention interventions. Review of a QIPFI dated 8/15/12 at 2:15 PM revealed that Resident 01 was found on the floor in the resident's room. An employee heard the resident's personal alarm sounding and when the employee responded the resident was in the process of falling to the floor. Resident 01 sustained bruises and skin tears. The QIPFI documented that Resident 01 was "more confused", "forgetful" and "more weak". Interview on 10/10/12 at 11:49 AM with the DON confirmed that the facility failed to identify the causal factor for the accident. The DON confirmed that the facility staff failed to examine the Care Plan to evaluate whether the previous fall prevention interventions had been implemented and the facility failed to implement new fall prevention interventions. Review of a QIPFI dated 8/19/12 at 10:30 AM revealed that Resident 01 was found on the floor in the living room. The resident's personal alarm was sounding. The resident sustained [REDACTED]. Interview on 10/10/12 at 11:49 AM with the DON confirmed that the facility failed to identify the causal factor for the accident. The DON confirmed that the facility staff failed to implement new fall prevention interventions. Review of a QIPFI dated 8/23/12 QIPFI at 7:45 PM revealed that Resident 01 was found on the floor in the resident's room. The resident sustained [REDACTED]. Interview on 10/10/12 at 11:49 AM with the DON confirmed that the facility failed to identify the causal factor for the accident. The DON confirmed that the facility staff failed to implement new fall prevention interventions. Review of a QIPFI dated 9/4/12 at 9:30 AM revealed that Resident 01 was found on the floor in the resident's room. When an employee heard a crash in the resident's room, the employee responded to find the resident on the floor and incontinent. The resident sustained [REDACTED]. Interview on 10/10/12 at 11:49 AM with the DON confirmed that the facility identified that Resident 01 had to use the bathroom as the causal factor. Interview on 10/10/12 at 11:49 AM with the DON confirmed that the facility failed to implement new fall prevention interventions. Review of a QIPFI dated 9/26/12 at 1:45 PM revealed that Resident 01 was found on the floor in the resident's room. The resident sustained [REDACTED]. The DON confirmed that the facility staff failed to implement new fall prevention interventions. Review of a QIPFI dated 9/26/12 at 9:00 PM revealed that Resident 01 was found on the floor on the fall mat by the resident's bed. The bed alarm was sounding. The resident sustained [REDACTED]. Interview on 10/10/12 at 11:49 AM with the DON confirmed that the facility failed to identify the causal factor for the accident. The DON confirmed that the facility staff failed to implement new fall prevention interventions.