Every finding on record at Adept Nursing & Rehab of Grand Island

Licensure Reference Number 175 NAC 12-006.12(D)(i)Licensure Reference Number 175 NAC 12-006.12(D)(v)Based on record review, observations, and interview, the facility failed to ensure that medication refrigerator temperatures were monitored daily and that medications stored in the medication refrigerators were stored at the correct temperatures. This had the potential to affect all residents of the facility. The facility census was 54.Findings were:Record review of the policy Medication Storage reviewed and dated 3/31/26 revealed that it is the facility policy to ensure all medications housed on the premises will be stored in the pharmacy and or medication rooms according to the manufacturers' recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 1a.) All drugs were to be stored in locked compartments under proper temperature controls. 6a.) All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. b.) Temperatures are maintained within 36-46 degrees Fahrenheit (F). Charts are kept on each refrigerator, and temperature levels are recorded daily by the charge nurse or other designee. c.) In the event that a refrigerator is malfunctioning, the person discovering the malfunction must promptly report such findings to Maintenance Department for emergency repair.A.Record review of the novolog (an insulin used to lower blood sugar levels in adults and children with diabetes) insulin container in the refrigerator revealed that this medication needs to be stored unopened in the refrigerator at a temperature of 36-46 Degrees F.Record review of the Ozempic (a prescription brand-name medication that contains semaglutide and is FDA-approved to improve blood sugar levels in adults with type 2 diabetes) container in the refrigerator revealed that this medication needs to be stored unopened in the refrigerator at a temperature of 36-46 Degrees F.Record review of the Trulicity (a prescription injection given once a week to help manage blood sugar in adults with diabetes) container in the refrigerator revealed that this medication needs to be stored unopened in the refrigerator at a temperature of 36-46 Degrees F. until ready for use.Record review of the Mounjaro (a prescription injection containing the active drug tirzepatide, which is FDA-approved to improve blood sugar control) container in the refrigerator revealed that this medication should be stored in a refrigerator at a temperature between 36 F and 46 F (2 C to 8 CRecord review of the Humalog revealed that this medication needs to be stored unopened in the refrigerator at a temperature of 36-46 Degrees F. ) in the medication refrigerator revealed this medication must be refrigerated at 36 F to 46 F (2 C to 8 C).Record review of the container of Lantus (an insulin used to lower blood sugar levels in adults and children with diabetes) in the medication refrigerator that it should be stored unopened in the refrigerator at 36 F to 46 F.Record review of the Toujeo (an insulin used to control high blood sugar in adults) pens and 3 Novolog insulin (an insulin used to lower blood sugar levels in adults and children with diabetes) container in the medication refrigerator revealed that the medication must be stored in the refrigerator at a temperature of at 36 F to 46 F.Record review of the container of the Daptomycin (a medication - an injectable antibiotic used to treat serious bacterial infections caused by Gram-positive bacteria, including tough strains like Staphylococcus aureus (MRSA)) in the medication refrigerator revealed that the medication is to be stored in a refrigerator at 36 F to 46 F.Record review of the latanoprost (to lower high pressure inside the eye) eye drop container in the medication refrigerator revealed that the medication is to be stored between 36 F to 46 F.Record review of the oral solution of lorazepam solution (a prescription medication in the benzodiazepine class that slows down the central nervous system to induce calmness, relaxation, and relief from severe anxiety) stored in the mediation refrigerator revealed the medication must be stored in a refrigerator at 36 F to 46 F.Record review of the injectable lorazepam stored in the mediation refrigerator revealed the medication must be stored in a refrigerator at 36 F to 46 F.Observation on 8/26/26 at 12:50 PM in the medication storage room near the nurses' station and the laundry area revealed a medication refrigerator was a small, apartment sized refrigerator, black in color and stood approximately 32-33 inches tall. Inside the refrigerator were many smaller containers (approximately 3 x 4 x 8 in size) which contained refrigerated medications for several residents. -The containers were stacked on top of each other on each shelf.-There was one bisacodyl suppository (medication for constipation) for the following residents: Residents 20, 51, 47, 5, 12, 28, 18, 29, 50, 19, 48, 53, and 38.-There were 2 bisacodyl suppositories for Resident 44 and Resident 43.-The following residents had the following in the refrigerator:a. Resident 13 - 10 Humalog insulin pensb. Resident 28 - 2 Toujeo pensc. Resident 48 1 box of Lispro insulin (an insulin used to lower blood sugar levels in adults and children with diabetes)d. Resident 59 - 3 Lantus insulin pens, 1 box of lispro insuline. Resident 51 - 3 box of Novolog insulin and 3 Mounjaro pensf. Resident 58 - 1 Lantus pen and 1 Trulicity [NAME]. Resident 15 - 1 box Novolog insulinh. Resident 30 - 1 Trulicity peni. Resident 10 - 1 Trulicity penj. Resident 23 - 2 Trulicity pens, 2 boxes of Lantus insulin, and 1 Humalog insulin pen.k. Resident 3 - 1 box Novolog insulin and 3 Trulicity pens,l. Resident 5 - 4 boxes of Daptomycinm. Resident 11 - 1 Lantus insulin pen, 1 Ozempic pen, and one box Novolog insulinn. Resident 20 - 2 boxes of Lantanoprost eye drop solutiono. Resident 22 - 1 box Lantanoprost eye drop solutionp. Resident 9 - 1 box lorazepam oral concentrate 2 mg/mlq. Resident 44 - 1 lorazepam injection-One emergency box of medications to serve the facility residents which contained -1 lantus pen of insulin -4 vials of ready to inject lorazepam (a prescription medication in the benzodiazepine class that slows down the central nervous system to induce calmness, relaxation, and relief from severe anxiety) 2 milligram/milliliter -There was no medication temperature log on the medication refrigerator. -The temperature reading in the refrigerator was 24 Degrees F.- The thermometer in the medication refrigerator was attached to the top division bar in the refrigerator door on the top shelf. Interview on 8/26/26 at 12:50 PM with Registered Nurse (RN)-A revealed RN-A had worked at the facility for the past month as a travel nurse. The night shift nursing staff are the ones who take the refrigerator temperatures. RN-A did not know where the refrigerator temperature log was kept but confirmed it was not on the refrigerator. RN-A was unable to find the temperature log in the medication room. RN-A took the reading of the refrigerator temperature and stated that the temperature was 24 degrees F at that time. RN-A did not know what temperature the medication refrigerator was to be kept at when medications were stored in the refrigerator. At that point, RN-A then returned to the nurses' station and started working on the computer charting system. Observation on 8/26/26 at 3:15 PM in the medication room refrigerator that the temperature was 31 degrees F.Interview on 8/26/26 at 3:15 PM with Medication Aide (MA)-H who confirmed that the temperature log in the medication room was 31 degrees F. Interview on 8/26/26 at 3:40 PM with the Assistant Director of Nursing (ADON) who revealed that the medication refrigerator temperature is supposed to be checked every day. I believe the night staff do the temperature checks and that the sheet is on the outside of each medication refrigerator on the door. The ADON was not certain what the temperature of the refrigerator was supposed to be but would look at that policy and find out the answer to that question.Interview on 8/26/26 at 3:50 PM with the Regional Director of Nursing (RDN) who revealed the temperature logs should be on the outside of the medication refrigerator and those temperatures are monitored daily and recorded. Observation and inspection of the Medication Storage Room near the nurses' station and laundry with the RDN 8/26/26 at 3:55 PM revealed that there was no temperature log on the outside of the refrigerator. The temperature was then 36 degrees. Interview with the RDN on 8/26/26 at 3:55 PM revealed that the thermometer was on the door separation bar which when the door was closed was in the freezer or close to the freezer. I would check that the refrigerator temperature is ok and that it is not in the right temperature zone because of the placement of the thermometer. When asked to review the temperature log for the refrigerator, the RDN stated that it should have been on the refrigerator.Observation on 8/26/26 at 4:00 PM revealed nursing staff looked in the medication room, the nurses' station, and the Charge Nurse room through drawers, books, folders, and binders looking for the refrigerator logbook. In a confirmation interview with the RDN on 8/26/26 at 4:48 PM confirmed that staff were unable to find the medication refrigerator logbook and it is unknown what the temperatures in the refrigerator were in the past. However, in that there are so many medications in that refrigerator and the medications are stacked atop each other, the RDO is going to ask management about getting a second refrigerator or coming up with a plan for a different area where a larger medication refrigerator can be put in to protect medications and keep them at the correct temperature. The medications on the top shelf are so close to the freezer portion this could cause an issue.B.Observation on 8/26/26 at 4:38 PM of the medication refrigerator in the behavioral health unit nurses' station revealed there was a refrigerator log on the refrigerator dated August 2026 titled Daily Temperature log. The handwritten dates and temperatures recorded were as follows:-8.1.26 No information-8.2.26 No information-8.3.26 No information-8.4.26 No information-8.5.26 No information-8.6.26 No information-8.8.26 - 50 degrees Fahrenheit (F) - written time was illegible-8.9.26 - 50 degrees F-8.13.26 - 50 degrees F-8.18.26 - 38 degrees FIn an observation on 8/26/26 at 4:38 PM there was one insulin pen in the refrigerator of the behavioral health area's nurses' station refrigerator.In a confirmation interview with the RDN on 8/26/26 at 4:48 PM confirmed that staff did not take the temperatures in the behavioral health area either.

Licensure Reference Number 175 NAC 12-006.19Licensure Reference Number 175 NAC 12-006.19(A)Based on observation, record review, and interview the facility failed to ensure that common areas were maintained, resident rooms were cleaned and maintained, repairs were identified and completed, lighting was maintained, and noise levels were homelike. This affected all facility residents. The facility census was 54.Findings are:Record review of the undated facility Admissions Agreement revealed that the facility agrees to provide lodging and a clean, healthful, sheltered environment that is properly outfitted. The section titled Statement of Resident's Rights revealed that the facility shall insure that all residents are afforded their right to self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care for personal needs. The facility shall encourage and assist each resident in the fullest possible exercise of these rights. Each resident shall have the right to use personal possessions unless to do so would infringe upon the rights or health and safety of the resident or of other residents. Record review of the facility document titled Manage Tasks for This Facility dated 8/27/26 revealed that environmental rounds for facility safety are to be completed weekly. Routine environmental rounds to check for safe and clean environment are due monthly. Record review of the undated facility Housekeeping Weekday Daily Duties checklist revealed that housekeeping staff will clean, mop, and straighten up the bathhouse. Housekeeping staff will clean, wash, and sanitize the bathrooms of resident rooms and mop the bathroom floor/tile and room floor. Further review revealed staff would make sure curtains and privacy divider curtains are hung correctly.Observation on 8/25/26 at 12:05 PM in the facility C wing bathhouse revealed that the ceiling above the facility whirlpool tub had an approximately 2 foot by 4 foot area of missing drywall exposing the material beneath that had yellow brown staining present surrounding a white plastic air vent that is in the ceiling. The blue foam seat placed inside the tub that is used for each resident using the whirlpool tub to sit on had visible scuffed and worn areas that were no longer blue, but were a light yellow brown in color exposing the underlying soft porous material that was not a cleanable surface.An interview with the Regional Maintenance Supervisor (RMS) on 8/25/26 at 1:30 PM confirmed that the ceiling above the whirlpool was damaged and needed to be repaired. The RMS revealed that all staff are responsible for reporting any facility maintenance concerns to the maintenance department.Observation of facility resident common areas on 8/26/26 from 7:03 AM to 7:15 AM revealed that the patterned hallway carpet from the C nurse's station to the main dining room was worn and soiled with the pattern in the center of the carpet worn off and lightly visible. The carpet was missing at the entrance to the main dining room where the hallway carpet and dining room floor tile meet with an approximately 2 inch wide section worn off per visual measurement. The red carpet squares at the C nurse's station were soiled with black stains and impacted debris. The hallway starting with room [ROOM NUMBER] through room [ROOM NUMBER] revealed that the patterned carpet was soiled and worn with the pattern worn off down the center of the hallway. A hole in the wall above the vinyl baseboard measuring approximately 6 centimeters (cm) by 12 cm per visual measurement was present outside of room [ROOM NUMBER]. The brown metal door frames of resident rooms 24-36 were chipped and paint scrapes were present. The handrail end outside of room [ROOM NUMBER] had a hole with sharp plastic edges exposed. The wall above the handrail from the left of room [ROOM NUMBER] to room [ROOM NUMBER] had continuous scraped paint on the wall. A hole was present measuring approximately 4 cm by 10 cm per visual measurement just below the handrail on the wall outside of room [ROOM NUMBER]. The carpet was stained with large gray/black stains outside of room [ROOM NUMBER] near the corner sink. The handrail was loose on the end outside of room [ROOM NUMBER]. The bolt holding the handrail was pulled out of the wall. The section of red carpet squares in the hallway outside of room [ROOM NUMBER] was soiled with black colored stains, debris, and wear. The hallway outside of rooms 39-44 had patterned carpet worn in the center through the hallway. The blue door entering the hallway with rooms 45 through 49 had paint chipped off throughout the lower part of the door. The brown handrails between rooms 46 through 49 was scraped exposing tan underneath. The metal handrail across from room [ROOM NUMBER] at the turn in the hallway towards the exit from the hallway had the end broken off exposing sharp metal. The metal drywall corner at the top of the baseboard below the sharp metal handrail was exposed due to missing drywall. A triangle piece of vinyl flooring was missing at the edge of the flooring where the carpet of the hallway between rooms 39-44 and the vinyl flooring of the hallway containing rooms 45-49 meet. The center of the patterned carpet outside the tiled dining room by the therapy room was worn with the pattern worn off. The carpet was soiled with brown/tan/black and various colored stains and impacted brownish gray debris. Inside the doors of the locked care unit entry adjacent to the therapy room had patterned carpet that was soiled with a large brown-black-tan stain outside of room [ROOM NUMBER]. The patterned carpet is worn and soiled. The red carpet squares outside of the B nurse's station were soiled, stained, and worn. The patterned carpet outside rooms 4 through 13 was worn with the pattern worn and soiled. The carpet outside of room [ROOM NUMBER] was stained with orange spilled and impacted debris. The wall above the handrail had scrapes throughout across from rooms [ROOM NUMBERS]. The patterned carpet was worn and soiled running from rooms 14 through 17 to the doorway past the locked unit dining room. A large brown colored stain approximately 12 inches in diameter per visual measurement was in the carpet outside of room [ROOM NUMBER]. A black stain on the carpet at the wall outside of room [ROOM NUMBER] was present. The red square carpet outside the southwest doors of the locked care unit between rooms [ROOM NUMBERS] was stained with imbedded gray debris and other soiling. The patterned carpet in the hallway outside of rooms 21-23 was worn and soiled with the pattern worn in the center through the hallway. The carpet across from room [ROOM NUMBER] had a large rectangular area with black tape and gray tape. A strip of black tape runs down the middle of the hall for approximately 5 feet and a strip of black tape approximately 1 foot long from the middle strip towards the wall holding the rectangle piece of carpet down. Gray tape approximately 2 feet long connected from the 1 foot black tape to the wall. The wall was missing the baseboard. A gap at the end of the patterned carpet of approximately 1 inch per visual measurement is between the patterned carpet and the red carpet square flooring. Observations on 8/26/26 from 12:47 PM to 1:01 PM during a walk through of the facility with the Regional Director of Operations (RDO), the Facility Administrator, and the Regional Maintenance Supervisor confirmed the presence of the environmental issues in the resident common areas of the facility that this surveyor noted during the surveyor observations on 8/26/26 from 7:03 AM to 7:15 AM listed above. The RDO confirmed that the issues were required to be addressed and maintained by the facility. The RDO revealed that the taped carpet across from room [ROOM NUMBER] was due to a plumbing issue and vinyl plank tile was to be placed once it arrived. An invoice for the tile was requested by this surveyor. The RDO did not supply an invoice for vinyl plan flooring. Observation on 8/24/26 at 11:53 AM in the room of Resident 10 revealed that the floor vinyl baseboard was loose and pulled away from the wall just entering the bathroom. Drywall plaster was caved in above the loose baseboard. The vinyl floor baseboard was peeled away from the wall on the right side of the toilet. The toilet base and along the edges of the bathroom walls the floor was soiled with buildup of brown-gray-black soiling. The wall on the right side of the soap dispenser that had been moved had exposed unfinished wall. One of the 3 light bulbs above the sink was not working. Interview on 8/27/26 at 12:31 PM with the Regional Maintenance Supervisor (RMS) during a walk through environmental review in the room of Resident 10 confirmed that the floor vinyl baseboard was loose and pulled away from the wall just entering the bathroom. Drywall plaster was caved in above the loose baseboard. The vinyl floor baseboard was peeled away from the wall on the right side of the toilet. The toilet base and along the edges of the bathroom walls the floor was soiled with buildup of brown-gray-black soiling. The wall on the right side of the soap dispenser that had been moved had exposed unfinished wall. One of the 3 light bulbs above the sink was not working. Observation on 8/24/26 at 11:37 AM in the room of Resident 58 revealed that the wall on the right side of the soap dispenser that had been moved had exposed unfinished wall. Interview on 8/27/26 at 12:34 PM with the RMS during a walk through environmental review in the room of Resident 58 confirmed that the right side of the soap dispenser that had been moved had exposed unfinished wall. Observation on 8/24/26 at 11:40 AM in the room of Resident 34 revealed that the bathroom floor was soiled with buildup of brown-gray-black soiling. The white resident assistance call cord was soiled with a tan/brown soiling/debris. The vinyl baseboard under the sink was loose and pulled from the wall. Interview on 8/27/26 at 12:35 PM with the RMS during a walk through environmental review in the room of Resident 34 confirmed that the bathroom floor was soiled with buildup of brown-gray-black soiling. The resident assistance call cord was soiled with tan/brown soiling. The vinyl baseboard under the sink was loose and pulled from the wall. Observation on 8/24/26 at 11:43 AM in the room of Resident 1 revealed that the bathroom exhaust vent cover was soiled with cobwebs and gray fluffy debris. The toilet base and along the edges of the bathroom walls at the floor was soiled with buildup of brown-gray-black soiling. The wall on the right side of the soap dispenser that had been moved had exposed unfinished wall. The right side of the wall entering the bathroom contained multiple white unfinished drywall patches. The bathroom was dark with only 1 of 2 bulbs above the sink working. Interview on 8/27/26 at 12:37 PM with the RMS during a walk through environmental review in the room of Resident 1 confirmed that the toilet base and along the edges of the bathroom walls at the floor was soiled with buildup of brown-gray-black soiling. The wall on the right side of the soap dispenser that had been moved had exposed unfinished wall. The right side of the wall entering the bathroom contained multiple white, unfinished drywall patches. The bathroom was dark with only 1 of 2 bulbs above the sink working. Observation on 8/24/26 at 11:47 AM in the room of Resident 13 revealed that the bathroom vent cover was soiled with cobwebs and gray fluffy debris. The seams between the tiles in the bathroom floor had areas of soiling with black debris. The towel rack to the left of the sink had screw holes on each side from repositioning the bar needing to be filled and finished. The wall on the right side entering the bathroom had torn drywall and plaster. The vinyl baseboard was loose and had strips of tape holding it to the wall. Paint was scraped off the wall behind the head of Resident 13's bed. The floor was soiled with gray-black soiling in the resident room along with unidentified debris. A white water stain was under the unoccupied bed in the room.Interview on 8/27/26 at 12:38 PM with the RMS during a walk through environmental review in the room of Resident 13 confirmed that the seams between the tiles in the bathroom floor had areas of soiling with blackish debris. The towel rack to the left of the sink had screw holes on each side from repositioning the bar needing to be filled and finished. The wall on the right side entering the bathroom had torn drywall and plaster. The vinyl baseboard was loose and had strips of tape holding it the to the wall. Paint was scraped off the wall behind the head of Resident 13's bed. The floor was soiled with gray-black soiling in the resident room along with unidentified debris. A white water stain was under the unoccupied bed in the room.Observation on 8/24/26 at 11:50 AM in the room of Resident 8 revealed that the bathroom exhaust vent cover was soiled with gray-white fluffy debris. The bathroom was dark with only the middle bulb of the 3 light bulbs above the sink working. The floor seam between the bathroom floor and resident room floor was soiled with brown debris buildup.Interview on 8/27/26 at 12:40 PM with the RMS during a walk through environmental review in the room of Resident 8 confirmed that the bathroom was dark with only the middle bulb of the 3 light bulbs above the sink working. The floor seam between the bathroom floor and resident room floor was soiled with brown debris buildup.Observation on 8/24/26 at 2:02 PM in the room of Resident 36 revealed that repaired drywall was exposed on the long wall by the bathroom needing painted. The window curtain was falling off. Vinyl baseboard trim was missing at entry into the bathroom and trim was loose and stuck out from the bathroom doorway and entrance to the residents room.Interview on 8/27/26 at 12:42 PM with the RMS during a walk through environmental review in the room of Resident 36 confirmed that repaired drywall was exposed on the long wall by the bathroom needing painted. The window curtain was falling off. Vinyl baseboard trim was missing at entry into the bathroom and trim was loose and stuck out from the bathroom doorway and entrance to the residents room.Observation on 8/24/26 at 11:02 AM in the room of Resident 18 revealed that the caulking around the toilet base was cracked and had missing pieces. The toilet base was soiled with a buildup of black-brown debris resembling sludge.Interview on 8/27/26 at 12:44 PM with the RMS during a walk through environmental review in the room of Resident 18 confirmed that the caulking around the toilet base was cracked and had missing pieces. The toilet base was soiled with a buildup of black-brown debris resembling sludge.Observation on 8/24/26 at 12:57 PM in the room of Resident 30 revealed that the privacy divider curtain was unhooked and hanging on the floor. Interview on 8/27/26 at 12:45 PM with the RMS during a walk through environmental review in the room of Resident 30 confirmed that the privacy divider curtain was unhooked and hanging on the floor. Observation on 8/24/26 at 10:07 AM in the room of Resident 47 revealed that the toilet base had no caulking around the base of the toilet. Yellow orange to dark brown staining and debris soiled the base of the toilet and the flooring. Interview on 8/27/26 at 12:46 PM with the RMS during a walk through environmental review in the room of Resident 47 confirmed that the toilet base had no caulking around the base of the toilet. Yellow orange to dark brown staining and debris soiled the base of the toilet and the flooring. Observation on 8/24/26 at 10:41 AM in the room of Resident 11 revealed that patched areas on the bathroom walls needed painted. The corner of the bathroom wall was chipped away and needed repair. Interview on 8/27/26 at 12:48 PM with the RMS during a walk through environmental review in the room of Resident 11 confirmed that patched areas on the bathroom walls needed painted. The corner of the bathroom wall was chipped away and needed repair. Observation on 8/24/26 at 1:46 PM at the room of Residents 3 and 32 (roommates) revealed that each resident had a tv in the room. Both televisions were very loud and could be heard down the hallways to the C nurse's station.Interview on 8/27/26 at 12:49 PM with the RMS during a walk through environmental review outside the room of Residents 3 and 32 confirmed that both televisions inside the room were very loud and could be heard down the hallways to the C nurse's station.Observation on 8/24/26 at 11:12 AM in the room of Resident 4 revealed that dark brown soiling buildup was around the toilet base. The white resident assistance call cord was soiled with brown debris. Interview on 8/27/26 at 12:50 PM with the RMS during a walk through environmental review in the room of Resident 4 confirmed that dark brown soiling buildup was around the toilet base. The white resident assistance call cord was soiled with brown debris. Observation on 8/24/26 at 1:02 PM in the room of Resident 52 revealed that two toilet paper rolls sat in the sink and were soaked with water. [NAME] soiling buildup was around the base of the toilet. The light bulbs above the sink flickered and one of the 3 bulbs was missing. A package of briefs sat on the floor.Interview on 8/27/26 at 12:53 PM with the RMS during a walk through environmental review in the room of Resident 52 confirmed that there was brown soiling buildup around the base of the toilet, that the light bulbs above the sink flickered, and one of the 3 bulbs was missing.Observation on 8/24/26 at 12:46 PM in the room of Resident 36 revealed that the bathroom had brown soiling around the base of the toilet. Packages of briefs sat on the floor.Interview on 8/27/26 at 12:55 PM with the RMS during a walk through environmental review in the room of Resident 36 confirmed that the bathroom had brown soiling around the base of the toilet.

Licensure Reference Number 175 NAC 1-005.06(D)Licensure Reference Number 175 NAC 1-005.06(E)Licensure Reference Number 175 NAC 12-006.18(B)Based on observation, record review, and interview the facility failed to implement cleaning procedures to prevent the potential for the spread of pathogens during the bathing process. This had the potential to affect all of the residents residing in the facility; failed to utilize 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) during glove changes during wound care for 2 residents (Residents 18 and 8) and during catheter care for 1 resident (Resident 8) to prevent the potential for cross-contamination; and failed to ensure that Enhanced Barrier Precautions (gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organism and residents at increased risk) were followed for 2 of 2 residents observed (Residents 8 and 13) to prevent the potential for cross-contamination to other residents or staff. The facility census was 54.Findings are: A. Record review of a document titled [NAME] Spas and dated 12/18/2018 revealed under system cleaning instructions after every bath to clean and disinfect the tub with [NAME] cleaner/disinfectant by using the following steps 1. Close and lock the door. 2. Press the Tub Fill Button and turn the Temperature Control Knob all the way to the left to its warmest level to heat the disinfectant solution and maximize its effectiveness. 3. Remove any visible tissue, residue, or fluids from the tub by pressing the Shower Button and rinsing the inside tub surfaces with the shower sprayer. 4. Press the Fill Button again to turn off the water. Allow the tub to drain, and place the drain plug over the drain. 5. On the Aqua-Aire Tubs, press and hold the Disinfect Button located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all of the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot well of the tub. 6. Using the long-handled brush, available from your [NAME] distributor, thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. Let disinfectant stay on surface for 10 minutes or, as recommended by the instructions on the disinfectant concentrate container. 7. Remove the plug from the drain. 8. Rinse the tub's interior surfaces thoroughly with the shower sprayer. 9. Press and hold the Rinse button located on the left side of the control panel until clear water runs from all the air jets. Then release the Rinse button. 10. Finish rinsing the interior surfaces of the tub with the shower sprayer. 11. Start the air blower by pushing the Aqua-Aire Button. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. If this was the last bath of the day, allow the blower to run for 2 minutes to dry out the system. 12. Stop the Aqua-Aire blower by again pushing the Aqua-Aire button. 13. Visibly check that the tub and the reservoir (if applicable) was effectively cleaned during the disinfecting procedure. If not, repeat the procedure. 14. If there is a delay of one or more hours before the next bath, we recommend using a towel to wipe off all excess water. In an observation completed on 08/25/2026 at 12:05 PM of the facility bath house the following was observed: -The celling above the facility whirlpool tub has an approximately 2 foot by 4 foot area of missing dry wall exposing the material beneath that has yellow brown staining present surrounding a white plastic air vent in appearance device that is inset into the celling. -The blue foam seat placed inside the tub that is used for each resident using the whirlpool tub to sit on has visible scuffed and worn areas that are no longer blue in color that are a light yellow brown in color exposing the underlying soft pours material that is not a clean able surface. -The drain of the tub to have visible black and brown hair wrapped around the drain bottom on the metal rungs. -The bottom of the door jam of the whirlpool tub has visible standing water that is brown in color with large white particles of debris present. -The door to the whirlpool tub to the area where it comes in contact with the door jam is visible black dried debris. -The side of the tub is visible white flakey build up/debris consistent with calcium and lime deposit. This deposit is also present to the metal fixture that holds the chair that the residents sit on while in the whirlpool tub. Also present is yellow brown flakey material to the back lower corner of the tub. -The black jet discharge areas to the inside of the tub has visible white flakey buildup to the bottom inner portion of the jets where water can possibly pool and sit and on the top where the jet comes out of the whirlpool tub material. -The resident shower area is a white plastic stand/bench with a visible black, brown hair wad dried and stuck in place to the lower rung. -The resident shower chair is made of white pvc and blue plastic mesh. The shower chair is covered in a dried white calcium lime build up. The build up increases in presence and visibility to all joints of the device including movable and non-movable. In an interview completed on 08/25/2026 at 12:18 PM with Nurse Aide F (NA-F), NA-F stated that they routinely are the individual that is assigned the task of resident bathing. The NA stated that all of the residents residing off of the secured unit use this room/area for bathing either using the shower with the shower chair or the whirlpool tub. The NA stated that at this time they use the Super Sani-Cloth Sanitizing Wipes to clean the facility shower chair between bathing each resident. The NA stated that there used to be a spray that they left on for 10 minutes but ran out of that and have not gotten more so was told to use the Super Sani Cloth wipes to clean the shower between residents. The NA stated that the maintenance person was responsible for changing the chemical that is used for cleaning the tub behind the locked door of the tub. The NA stated that they were unaware if there was or was not any chemical present that is to be used to clean the tub. In an interview completed on 08/25/2026 at 1:30 PM with the Regional Maintenance Supervisor (RMS), the RMS stated that they did not know where the key to the whirlpool tub that was needed to unlock the door on the tub where the chemical to clean the tub is stored. At 1:45 the RS stated that they had contacted the prior Maintenance individual, and they did not know where the key was and was not aware of a locked door on the whirlpool tub and had not ever been notified of the need to change the chemical stored there that was to be used to clean the whirlpool tub. The RMS confirmed that they had located the key for the door and opened the door and confirmed that there was no bottle present containing the chemical that was to be used to clean the whirlpool tub. In an interview completed on 08/25/2026 at 1:55 PM with the facility Infection Preventionist (IP) the IP confirmed that the resident whirlpool, shower, and bathing area were not being cleansed per manufacturer recommendations and in a manner to prevent the spread of pathogens during bathing. In an interview completed on 08/25/2026 at 1:55 PM with the facility Director of Nursing (DON), the DON confirmed that the resident whirlpool, shower, and bathing area were not being cleansed per manufacturer recommendations and in a manner to prevent the spread of pathogens during bathing. The DON confirmed that there was no method to telling how long the facilities bathing area had gone since being cleansed in a manner to prevent the potential of the spread of pathogens. B. Record review of a facility policy titled Hand Hygiene and dated 07/07/2026 revealed it was the policy of the facility for staff to perform hand hygiene when indicated, using the proper technique consistent with accepted standards of practice. Hand hygiene technique when using soap and water included to rub hands together vigorously for at least 20 seconds and to use clean towel to turn off the faucet. When using gloves hand hygiene should be performed prior to donning gloves, and immediately after removing gloves. In an observation completed on 08/26/2026 at 12:05 PM of wound care being provided to Resident 18 by Registered Nurse A (RN-A) the following was observed: -With gloved hands the RN used a 4X4 piece of gauze to cleanse the residents wound located to their inner left heel. The RN then removed their gloves and applied new gloves. The RN did not complete hand hygiene after removing the soiled gloves and before applying the new gloves. -With gloved hands the RN applied a dressing over the wound located to the residents inner left heel. The RN then removed their gloves and entered the resident bathroom and completed hand hygiene using soap and water for 8 seconds. The RN obtained paper towels and used the paper towels to dry their hands and then shut off the water using the paper towels used to dry their hands. The RN did not complete hand hygiene for at least 20 seconds and use clean paper towels to shut off the water. -The RN applied gloves to both of their hands. With gloved hands the RN used a piece of 4X4 gauze moistened with normal saline to clean the wound located to the residents right abdominal fold. The RN then removed their gloves and applied new gloves. The RN did not complete hand hygiene after removing the soiled gloves and before applying the new gloves. -With gloved hands the RN applied a small amount of ointment to their gloved finger and used their gloved finger to spread the ointment onto the residents wound located to their right abdominal fold. The RN then removed their gloves and applied new gloves. The RN did not complete hand hygiene after removing the soiled gloves and before applying the new gloves. The RN then removed a dressing from its package and placed it over the ointment covered wound to the residents right abdominal fold. The RN then removed their gloves and entered the resident bathroom and completed hand hygiene using soap and water for 10 seconds. The RN obtained paper towels and used the paper towels to dry their hands and then shut off the water using the paper towels used to dry their hands. The RN did not complete hand hygiene for at least 20 seconds and use clean paper towels to shut off the water. In an interview completed on 08/26/2026 at 12:20 PM with RN-A, RN-A confirmed that hand hygiene should be performed between each glove change and that they did not complete hand hygiene between each of their glove changes. The RN confirmed that hand hygiene with soap and water should be for at least 20 seconds and a clean paper towel should be used to shut off the water. The RN confirmed that they did not complete hand hygiene with soap and water for the required time and used the paper towels they dried their hands with to shut off the water and should not have. C. Record review of the facility policy titled Hand Hygiene (HH)(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. Record review of the admission Record for Resident 8 dated 8/25/26 revealed that Resident 8 admitted into the facility on 5/29/26. Diagnoses included sepsis with unspecified organism (a life-threatening reaction to an infection; but the germ or bacteria causing the infection has not been identified, that causes the immune system to harm healthy tissues and organs). Record review of the current care plan dated 8/24/26 for Resident 8 revealed that Resident 8 had a pressure ulcer (a localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.). Interventions included using barrier precautions while providing resident cares and providing wound care per the physician's order. Record review of the Order Summary dated 8/25/26 for Resident 8 revealed that Resident 8 had a physician's order to cleanse the left buttock every day with wound cleanser and pat dry. Apply Triad paste (a sterile, zinc oxide-based paste used to manage light-to-moderate weeping wounds, skin tears, and pressure ulcers, especially in hard-to-dress body folds or creases). Cover with a small silicone dressing. Observation on 8/25/26 at 9:44 AM at the treatment cart outside of the room of Resident 8 revealed that Registered Nurse-A (RN-A) gathered supplies and reviewed the physician's order for the wound care for Resident 8. RN-A opened the silicone foam dressing package and documented the date and the initial of RN-A on the foam dressing. RN-A performed hand hygiene (HH) with Alcohol Based Hand Sanitizer (ABHR) and put on disposable gloves. RN-A picked up the supplies from the top of the treatment cart and entered the room of Resident 8. Resident 8 was seated in the recliner in the room. RN-A asked Resident 8 if they would like their shoes on since they would have to stand up. Resident 8 agreed. RN-A used the gloved hands to hold the slippers by the bottom surface as RN-A assisted Resident 8 to put on the right and then left slipper. RN-A removed and disposed of the gloves. RN-A put on a new pair of gloves (RN-A did not perform HH prior to putting on the gloves). Resident 8 stood up at the bedside and pulled the pants and underwear down to their knees. A tan foam dressing was in place over the inner left and right buttocks. RN-A removed the dressing with the soiled gloved hands. A red and slightly purple area was present on the inner left buttock that measured approximately 7 centimeters (cm) in length and 3.5 cm wide per visual measurement. A discolored area was located on the left buttock within the discolored area. The open wound measured approximately 1.5 cm in length and 0.7 cm in width and a depth of 0.1 cm per visual measurement. The wound bed was light pink. A discolored area on the inner right buttock measured approximately 8 cm long and 5 cm wide per visual measurement. The area was a dark purple/red. RN-A revealed that wound clinic measures the wound on Wednesdays so the facility just does the dressing changes. RN-A cleansed the wound with gauze saturated in water using the soiled gloved hands. RN-A used gauze to pat the wound area dry. RN-A removed and discarded the soiled gloves. RN-A put on a new pair of gloves (RN-A did not perform HH). RN-A opened the tube of Triad paste and squeezed an unmeasured amount onto the gloved fingers of the right hand and applied the paste to the wound on the left buttock and the discolored areas of the left and right inner buttocks. RN-A removed the backing from the dated and initialed foam dressing and applied the dressing over the wound and discolored areas of the inner left and right buttocks. RN-A assisted Resident 8 to sit down in the recliner. RN-A discarded the used supplies and removed the trash bag from the trash can. RN-A removed the soiled gloves and discarded them in the trash bag. RN-A tied the trash bag shut and placed it into a garbage can in the resident's bathroom. RN-A positioned items on the over bed table in reach of Resident 8. RN-A exited the resident's room. Interview on 8/26/26 at 1:51 PM with the facility Infection Preventionist (IP) confirmed that staff are required to perform hand hygiene before putting gloves on and after removing gloves. The IP confirmed that soiled gloves should be changed between tasks. D. Record review of the facility policy titled Indwelling Catheter Use (a flexible plastic hollow tube inserted into the bladder to continuously drain urine) and Removal dated 11/26/25 revealed that the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures. Record review of the current care plan dated 8/24/26 for Resident 8 revealed that Resident 8 had a urinary catheter and is at risk for urinary tract infections and injury. Interventions included performing catheter care as per order. Observation on 8/26/26 at 1:41 PM at the room of Resident 8 revealed that Nurse Aide-C (NA-C) entered the resident room. NA-C put on gloves (NA-C did not perform HH prior to putting on the gloves). NA-C went into the resident's bathroom and obtained a graduate cylinder (a container with markings to measure liquid amount). NA-C placed a paper towel on the floor with the gloved hands and sat the graduate cylinder on the paper towels. NA-C removed the urinary catheter bag from the cloth privacy cover with the soiled gloved hands. NA-C removed the drain tube from the holder on the urinary catheter bag with the gloved hands. NA-C opened the drain tube clamp and emptied a small amount of urine from the urinary catheter bag into the graduate cylinder. NA-C closed the clamp on the drain tube clamp and used an alcohol prep pad to wipe the end of the drain tube. NA-C returned the drain tube into the holder on the urinary catheter bag. NA-C placed the urinary catheter bag back into the cloth privacy cover and hung the bag from the trash can. NA-C carried the graduate cylinder into the resident's bathroom and emptied the urine into the toilet. NA-C removed and discarded the soiled gloves and exited the room of Resident 8. NA-C went down the hall and applied hand sanitizer to the hands. Interview on 8/26/26 at 1:51 PM with the facility Infection Preventionist (IP) confirmed that staff are required to perform hand hygiene before putting gloves on and after removing gloves. The IP confirmed that soiled gloves should be changed between tasks. E. Record review of the facility policy titled Enhanced Barrier Precautions (EBP) (An infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Precautions involve gown and glove use during high-contact resident care activities high-contact resident care activities (Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting) for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition such as residents with wounds or indwelling medical devices) dated 4/1/24 revealed that the facility will implement enhanced barrier precautions for the prevention of transmission of multi-drug resistant organisms. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. An order for EBP precautions will be obtained for residents with wounds and/or indwelling medical devices. High contact care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care, and wound care (any skin opening requiring a dressing). Record review of the facility Enhanced Barrier Protection (EBP) Roster dated 8/24/26 revealed that Resident 8 was listed as requiring EBP due to wound and catheter. Record review of the current care plan dated 8/24/26 for Resident 8 revealed that Resident 8 had a pressure ulcer (a localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.). Interventions included using barrier precautions while providing resident cares and providing wound care per the physician's order. Record review of the Order Summary dated 8/25/26 for Resident 8 revealed that Resident 8 had a physician's order to cleanse the left buttock every day with wound cleanser and pat dry. Apply Triad paste (a sterile, zinc oxide-based paste used to manage light-to-moderate weeping wounds, skin tears, and pressure ulcers, especially in hard-to-dress body folds or creases). Cover with a small silicone dressing. Observation on 8/25/26 at 9:44 AM at the treatment cart outside of the room of Resident 8 revealed that Registered Nurse-A (RN-A) gathered supplies and reviewed the physician's order for the wound care for Resident 8. RN-A opened the silicone foam dressing package and documented the date and the initial of RN-A on the foam dressing. A sign outside of the room door of Resident 8 titled Enhanced Barrier Precautions revealed that everyone must clean their hands before entering and leaving the room. Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing/showering, Transferring, Changing linens, Providing hygiene, Changing briefs or assisting with toileting, Device care or use (urinary catheter), and Wound Care (any skin opening requiring a dressing). RN-A performed hand hygiene (HH) with Alcohol Based Hand Sanitizer (ABHR) and put on disposable gloves. RN-A picked up the supplies from the top of the treatment cart and entered the room of Resident 8. Resident 8 was seated in the recliner in the room. RN-A asked Resident 8 if they would like their shoes on since they would have to stand up. Resident 8 agreed. RN-A did not put on a gown. RN-A used the gloved hands to hold the slippers by the bottom surface as RN-A assisted Resident 8 to put on the right and then left slipper. RN-A removed and disposed of the gloves. RN-A put on a new pair of gloves (RN-A did not perform HH prior to putting on the gloves). Resident 8 stood up at the bedside and pulled the pants and underwear down to their knees. A tan foam dressing was in place over the inner left and right buttocks. RN-A removed the dressing with the gloved hands. A red and slightly purple area was present on the inner left buttock that measured approximately 7 centimeters (cm) in length and 3.5 cm wide per visual measurement. A discolored area was located on the left buttock within the discolored area. The open wound measured approximately 1.5 cm in length and 0.7 cm in width and a depth of 0.1 cm per visual measurement. The wound bed was light pink. A discolored area on the inner right buttock measured approximately 8 cm long and 5 cm wide per visual measurement. The area was a dark purple/red. RN-A revealed that wound clinic measures the wound on Wednesdays so the facility just does the dressing changes. RN-A cleansed the wound with gauze saturated in water. RN-A used gauze to pat the wound area dry. RN-A removed and discarded the gloves. RN-A put on a new pair of gloves (RN-A did not perform HH). RN-A opened the tube of Triad paste and squeezed an unmeasured amount onto the gloved fingers of the right hand and applied the paste to the wound on the left buttock and the discolored areas of the left and right inner buttocks. RN-A removed the backing from the dated and initialed foam dressing and applied the dressing over the wound and discolored areas of the inner left and right buttocks. RN-A assisted Resident 8 to sit down in the recliner. RN-A discarded the used supplies and removed the trash bag from the trash can. RN-A removed of the gloves and discarded them in the trash bag. RN-A tied the trash bag shut and placed it into a garbage can in the resident's bathroom. RN-A positioned items on the over bed table in reach of Resident 8. RN-A exited the resident's room. (RN-A provided wound care without wearing a gown for EBP as required). Record review of the Treatment Administration Record (TAR) (a legal 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 Resident 8 dated 8/25/26 at 3:13 PM revealed that RN-A documented that RN-A performed the wound care consisting of cleansing the left buttock with wound cleanser and pat dry, apply Triad paste, and cover with a small silicone dressing on 8/25/26. Interview on 8/26/26 at 1:51 PM with the facility Infection Preventionist (IP) confirmed that Resident 8 is on EBP due to catheter and wound. The IP confirmed that staff are required to wear gown and gloves for EBP for wound care and emptying the catheter. Interview on 8/26/26 at 4:28 PM with RN-A confirmed that Resident 8 is on Enhanced Barrier Precautions. RN-A confirmed that gown and gloves are to be worn for wound care but that RN-A did not wear a gown during wound care for Resident 8 on 8/25/26. F. Record review of the facility Enhanced Barrier Protection (EBP) Roster dated 8/24/26 revealed that Resident 13 was listed as requiring EBP due to a wound. Observation on 8/25/26 at 11:20 PM in the room of Resident 13 revealed a door hanger on the back of the resident room door that contained blue disposable gowns in the bottom pockets. Record review of the current care plan for Resident 13 dated 8/24/26 revealed that Resident 13 is incontinent of urine and bowel movements. Interventions included isolation contact precautions (wearing a gown and gloves before room entry and discard gown and gloves before room exit) due to extended-spectrum beta-lactamases (ESBL) (bacteria found in a urine sample that produce enzymes that make the bacteria resistant to many common antibiotics- a Multi-Drug Resistant Organism) in the urine. Record review of the most recent Wound Assessment Report for Resident 13 dated 8/11/26 revealed that a left abdominal skin fold wound measured 30 cm in length, 41 cm in width and 0.1 cm deep. Resident 13 had a left rear upper thigh wound that measured 0.1cm in length, 0.1 cm in width and 0.1 cm deep. Resident 13 had a right breast wound that measured 6 cm in length, 26 cm in width, and 0.1 cm deep. The report was signed by Nurse Practitioner-J (NP-J). Observation on 8/25/26 at 11:23 AM revealed that Medication Aide-B (MA-B) brought a mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own) into the room of Resident 13. MA-B put on disposable gloves (MA-B did not put on a gown). Nurse Aide-C entered the room of Resident 13 and put on disposable gloves (NA-C did not put on a gown). Resident 13 was lying in the bed. NA-C removed the covers from Resident 13 exposing the resident's bare legs and feet. MA-B undid the fasteners on Resident 13's brief. NA-C handed a package of wipes to MA-B. MA-B opened the wipe package and removed a wipe. MA-B wiped the front private area of Resident 13. NA-C assisted Resident 13 to roll onto the resident's right side. The posterior upper thighs both had light fiery red skin that was flaky. The area on the posterior left upper thigh onto the left buttock measured approximately 30 centimeters (cm) in length and 16 cm in width per visual measurement. The area on the right upper thigh onto the right buttock measured approximately 24 cm in length and 15 cm in width per visual measurement. MA-B dispensed an unmeasured amount of Triad Hydrophilic Wound Dressing (a sterile, zinc oxide-based paste used to manage light-to-moderate weeping wounds, skin tears, and pressure ulcers, especially in hard-to-dress body folds or creases) paste onto the gloved fingers and rubbed it over the wound areas of Resident 13's posterior thighs and buttocks. MA-B and NA-C both removed their disposable gloves. MA-B and NA-C both put on new disposable gloves (neither MA-B nor NA-C performed hand hygiene (HH)). Resident 13 was incontinent of urine. MA-B used wipes to cleanse the front private area of Resident 13. The uniform of MA-B rubbed on the bedding while cleansing the front private area of Resident 13. MA-B and NA-C positioned a clean brief underneath Resident 13. MA-B and NA-C both removed their disposable gloves. MA-B and NA-C both put on new disposable gloves (neither MA-B nor NA-C performed HH). MA-B obtained a pair of pants from the resident's closet and began to put the pants on Resident 13. NA-C put socks on the feet of Resident 13. MA-B positioned a total body lift sling (a fabric device with straps that is placed underneath a resident when a mechanical assistive device is used to transfer a resident with difficulty or the inability to stand up on their own from a seated or lying position) underneath the left side of Resident 13. NA-C assisted Resident 13 to roll onto the resident's right side towards NA-C. NA-C's uniform rubbed the bedding and the resident. MA-B pulled the pants up to the resident's waist. NA-C and MA-B assisted Resident 13 to roll onto the resident's left side. NA-C positioned the lift sling and pulled the pants up to the resident's waist on the left side. MA-B removed and discarded their gloves. MA-B and NA-C connected the lift sling straps to the total body lift. MA-B used the bare hands to operate the lift and lifted Resident 13 from the bed. NA-C removed and discarded their gloves. MA-B transported Resident 13 from the bed to a position over the wheelchair. NA-C leaned over the back of the wheelchair to position Resident 13 in the wheelchair as MA-B lowered Resident 13 into the wheelchair. MA-B and NA-C unhooked the lift sling from the total body lift. MA-B moved the lift out of the resident's room. NA-C removed the shirt from Resident 13 and assisted Resident 13 to put on a tank top. MA-B sprayed Resident 13's underarms with deodorant. Resident 13 sprayed body spray on their own arms. MA-B put a sweater on Resident 13. NA-C put on gloves and stripped the bedding from Resident 13's bed (NA-C was not wearing a gown). Resident 13 requested a hair brush. MA-B brushed Resident 13's hair with the brush. NA-C removed the gloves (NA-C did not perform HH). Neither MA-B nor NA-C wore a gown for required EBP/contact precautions while performing the high-contact resident cares for Resident 13. Interview on 8/26/26 at 1:38 PM with NA-C confirmed that NA-C was not aware that Resident 13 has been on EBP. NA-C confirmed that NA-C only wore gloves during cares for Resident 13 and did not wear a gown. Interview on 8/26/26 at 1:51 PM with the facility IP confirmed that staff are required to wear gown and gloves for r

Licensure Reference Number 175 NAC 12-006.04(B)(ii)Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1)Based on record review and interview the facility failed to ensure that nurse aides and medication aides completed a minimum of 12 hours of ongoing training annually as required for 3 of 5 sampled staff. The facility census was 54.Findings are:Record review of the Facility assessment dated [DATE] revealed that the facility's training program includes an orientation process and ongoing training for all new and existing staff including nursing and other direct care staff. The facility conducts a formal evaluation of the training program. Record review of the facility policy titled Continuing Education dated 8/18/26 revealed that all levels of employees are expected to complete required trainings within designated time frames. Interview on 8/26/26 at 5:32 PM with the Regional Director of Operations (RDO) confirmed that the expectation is for all nurse aides and medication aides to complete at least 12 hours of ongoing education each year.Record review of the facility Employee List dated 8/25/26 revealed that Nurse Aide-F (NA-F) had a hire date of 6/19/24.Record review of the documented continuing education training hours for NA-F for the most recent year 6/19/25 through 6/19/26 (based on the hire date of 6/19/24) revealed that NA-F completed a total of 7 hours of ongoing training. NA-F did not complete the required minimum training of at least 12 hours. Record review of the facility Employee List dated 8/25/26 revealed that Medication Aide-B (MA-B) had a hire date of 6/28/24.Record review of the documented continuing education training hours for MA-B for the most recent year 6/28/25 through 6/28/26 (based on the hire date of 6/28/24) revealed that MA-B completed a total of 9.3 hours of ongoing training. MA-B did not complete the required minimum training of at least 12 hours. Record review of the facility Employee List dated 8/25/26 revealed that Medication Aide-G (MA-G) had a hire date of 4/9/25.Record review of the documented continuing education training hours for MA-G for the most recent year 4/9/25 through 4/9/26 (based on the hire date of 4/9/25) revealed that MA-G completed a total of 4.25 hours of ongoing training. MA-G did not complete the required minimum training of at least 12 hours. Interview on 8/26/26 at 5:32 PM with the Regional Director of Operations (RDO) confirmed that the expectation is for all nurse aides and medication aides to complete at least 12 hours of ongoing education each year. The RDO confirmed that the ongoing training of at least 12 hours was not completed by staff NA-F, MA-B, or MA-G as required.

Licensure Reference Number 175 NAC 1-005.06(C)Licensure Reference Number 175 NAC 12-006.18Based on record review and interview the facility failed to as part of their infection control program to maintain policies and procedures for antibiotic stewardship. This had the potential to affect all of the residents residing in the facility. The facility census was 54.Findings are:Record review of a facility policy titled Antibiotic Stewardship Program and dated 06/01/2026 revealed it was the policy of the facility to implement an Antibiotic Stewardship Program as part of the facilities overall infection prevention and control program. The facility would use antibiotic use protocols including use of the Centers for Disease Control's (CDC's) National Healthcare Safety Network (NHSN) Surveillance definitions, updated McGreer criteria or other surveillance tool to define infections, the Loeb Minimum Criteria could be used to determine whether to treat and infection with antibiotics. In monitoring of antibiotic use nursing would monitor the initiation of antibiotics on residents and complete daily Hot Charting to monitor signs and symptoms for the duration of antibiotic therapy plus 3 days. New or changed orders for antibiotics based on the antibiotic time out recommendations would be obtained from the provider. Record review of a document titled Core Elements of Antibiotic Stewardship for Nursing Homes and dated 09/10/2026 from https://www.cdc.gov/antibiotic-use revealed under broad interventions to improve antibiotic use that the facility had the responsibility to develop and implement algorithms for the assessment of residents suspected of having and infection and implementation of a structured communication tool to guide nursing-physician interactions when an infection is suspected and any tools or forms utilized to improve communication should become part of the resident's medical record. Antibiotic time outs should be performed as a formal process designed to prompt a reassessment of ongoing need for and choice of an antibiotic. Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are started.Record review of NHSN Long term Care Facility Component Manual dated January 2026 revealed Surveillance is defined as the congoing systematic collection, analysis, interpretation and dissemination of data. When conducting surveillance facilities should use clearly defined surveillance definitions that are collected in a consistent way. This method ensures accurate and comparable data is collected. Data collection requires active, resident based, prospective surveillance of events.A.Record review of resident 18's Progress Notes revealed on 08/10/2026 the resident voiced c/o and increase in pain and warmth to their lower legs. The resident was seen by the in-house provider that day and an antibiotic medication was prescribed for 10 days. There was no documentation present that an SBAR was completed for this resident. There was no documentation present that a laboratory specimen was requested prior to the start of the antibiotic therapy to verify the presence of or absence of an infection that the antibiotic therapy was prescribed for.Record review of Resident 18's Medication Administration Record for the Month of August 2026 revealed on 07/10/2026 the resident was administered the first dose of the antibiotic as prescribed. The last dose of the antibiotic therapy was documented to have been administered on 08/24/2026.Record review of Resident 18's Progress Notes revealed no documentation the first dose of the antibiotic was received on 08/10/2026. There was no documentation present two to three days after the start of the antibiotic therapy indicating that the antibiotic therapy use was re evaluated and reviewed by the facility and or the provider. Documentation was present on 08/14/2026 and 08/15/2026 that the resident was receiving antibiotic therapy and was not exhibiting adverse signs or symptoms from the antibiotic therapy. There was no other daily or routine documentation present during the course of the antibiotic therapy for monitoring. Record review of resident 18's Progress Notes revealed on 08/10/2026 the resident voiced c/o and increase in pain and warmth to their lower legs. The resident was seen by the in-house provider that day and an antibiotic medication was prescribed for 10 days. There was no documentation present that an SBAR was completed for this resident. There was no documentation present that a laboratory specimen was requested prior to the start of the antibiotic therapy to verify the presence of or absence of an infection that the antibiotic therapy was prescribed for. Record review of resident 18's Progress Notes revealed on 07/10/2026 the resident was seen by the in house provider that day and an antibiotic medication was prescribed for 10 days. There was no documentation present that an SBAR (SBAR is a structured communication framework that stands for Situation, Background, Assessment, and Recommendation) was completed for this resident. Record review of Resident 18's Medication Administration Record (MAR) for the month of July 2026 revealed that the resident was administered the first dose of the antibiotic on 07/10/2026 in the evening. On 07/15/2026 through 07/20/2026 the antibiotic was documented as not administered.Record review of Resident 18's Progress Notes from 07/10/2026 revealed documentation on 07/13/2026 the resident was seen by another in house provider for shoulder pain. On 07/14/2026 the resident was seen again by the inhouse provider and was complaining of loss of appetite and vomiting with the inability to keep oral medication down. The provider ordered labs to be completed. The provider did not give orders to hold or discontinue the antibiotic that started on 07/10/2026. On 07/15/2026 the resident started declining oral medications due to nausea and staff started administering an as needed medication for the nausea and a Urinary specimen was obtained and sent for resulting at the laboratory. Documentation revealed that the resident denied urgency, hesitancy, and pain with urination. On 07/17/2026 the resident continued to refuse the antibiotic medication and stated to staff that they were allergic to the medication. On 07/18/2026 documentation was present that the resident was receiving therapy for a urinary tract infection, and the resident was complaining of generalized weakness and an inability to walk to the bathroom and nausea with the inability to keep down food. The resident stated that they believed that the antibiotic therapy was causing these symptoms and had started feeling much better since declining to take the medication. There was no documentation present that a time out was performed for the antibiotic therapy 48-72 hours after starting the antibiotic therapy. There was no daily documentation present for the duration of the antibiotic therapy and three days after completion of the antibiotic therapy. There was no documentation present that the provider stopped the antibiotic therapy after seeing the resident on 07/14/2026. There was no documentation present that the provider listed the possibility of adverse reaction to this medication in the residents EMHR. In an interview completed on 08/26/2027 at 3:30 PM with the Regional Infection Preventionist (RIP), the RIP confirmed as part of the facility's antibiotic stewardship program residents on antibiotic therapy should have daily Hot Charting in progress notes for the duration of the antibiotic therapy and for three days after therapy has been completed. The RIP confirmed that Resident 18 was seen in house by the provider on 07/14/2026 and the provider did not give orders to discontinue or hold the antibiotic therapy due to possible adverse reaction. The RIP stated that it is an expectation for staff to utilize the SBAR (a structured communication tool) when communicating a probable or possible infection to providers and should be present in the resident's electronic medical health record. The RIP stated that the McGreer's is completed for each resident after completion of the antibiotic therapy and kept in the infection control binder. The infection control binder was not part of the resident's medical health record.B.Record review of a facility policy titled Antibiotic Stewardship Program and dated 06/01/2026 revealed at least annually the facility would provide feed back to providers on their antibiotic use data in the form of a written report to improve prescribing practices and resident outcomes.On 08/27/2026 at 10:00 AM a request was made to the Regional Director of Nursing (RDO) for a copy of the most recent report provided to 3 of the facilities providers on their antibiotic use data.On 08/27/2026 at 4:30 PM surveyor exit from the facility, the facility was unable to provide the requested report that was to be provided to providers on their antibiotic use and data.C.Record review of a facility policy titled Antibiotic Stewardship Program and dated 06/01/2026 revealed that education regarding antibiotic stewardship would be provided at least annually to facility staff, prescribing practitioners, residents, and families.On 08/27/2026 at 10:00 AM a request was made to the Regional Director of Nursing (RDO) for a copy of the most recent education regarding antibiotic stewardship that was provided to facility staff, prescribing practitioners, residents and families. On 08/27/2026 at 4:30 PM surveyor exit from the facility, the facility was unable to provide the requested most recent education regarding antibiotic stewardship that was provided to facility staff, prescribing practitioners, residents and families.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation and interview, the facility failed to ensure the snack and nutrition refrigerators on the unit were maintained. This had the potential to affect all residents residing on the unit. The facility census was 54. Findings are: An observation on 8/26/26 at 4:30 PM in the secure unit of the facility revealed a form posted on the refrigerator, titled, Daily Temperature Log dated August 2026.The temperature logs revealed:8/1/26 through 8/6/26 temperature was found to be blank.8/7/26 - date and temperature were found to be blank.8/8/26 - temperature was recorded at 50.8/9/26 - temperature was recorded at 50.8/10/26 through 8/12/26 - date and temperature were found to be blank.8/13/26 - temperature was recorded at 50.8/14/26 through 8/17/26 - date and temperature were found to be blank.8/18/26 - temperature was recorded at 38.8/19/26 through 8/26/26 - date and temperature were found to be blank. An observation on 8/26/26 at 4:30 PM in the secure unit of the facility with Nurse Aide (NA)-K revealed several cups of drinks and food items in the refrigerator:-2 8-ounce (oz) cups of white fluid in a solid state, unknown substance to this surveyor and NA-K, no label or date.-2 8 oz cups of red fluid, no name, or date.-1 8 oz cup of yellowish fluid, no name or date.-two sandwiches with a name of a resident who was deceased , per NA-K with a date listed of 8/3/26.-a cup of pudding like consistency, yellow/brown color, no label or date.-a plate of salad, green and brown lettuce, cheese, and chopped egg with a pinkish/brown meat on top covered in plastic wrap, no name or date. An interview on 8/26/26 at 4:30 PM with NA-K revealed being uncertain who cleans the refrigerator and records the temperature. An interview on 8/27/26 at 8:30 AM with NA-L revealed being uncertain who cleans the refrigerator and records the temperature. An observation on 8/27/26 at 8:30 AM in the secure unit of the facility revealed the refrigerator temperature log posted a new temperature recording of 8/26/26 revealing a temperature of 40. An observation on 8/27/26 at 8:30 AM in the secure unit of the facility with NA-L revealed a plate of salad, green and brown lettuce, cheese, and chopped egg with pinkish/brown meat on top covered in plastic wrap, no name or date. A record review of the 2022 United States Food and Drug Administration Food Code reveals, that it continues to recommend that food establishments limit the cold storage of time/temperature control for safety foods, ready-to-eat foods to a maximum temperature of 45-41 Fahrenheit (F; a temperature scale). An interview on 8/27/26 at 8:45 AM with the Dietary Manager (DM) revealed being uncertain who cleans the refrigerator and records the temperature in the secure unit. The DM further revealed the facility follows the 2022 United States Food and Drug Administration Food Code, and all food items need to be dated and clearly labeled otherwise discarded.

Licensure Reference Number 175 NAC 12-006.09(C)(i) Based on record review and interview the facility failed to complete a Comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) within the required time frames for 3 (Residents 16, 64, and 18) of 5 sampled residents. The facility census was 54. Findings are: Record review of a facility policy titled MDS 3.0 Completion and dated 09/29/2026 revealed an admission (Comprehensive) Assessment must be completed within 14 days of admission counting the day of admission as day 1. A.Record review of an admission Record dated 08/25/2026 revealed that the facility admitted Resident 16 on 06/23/2026. Record review of Resident 16's MDS Summary on 08/25/2026 revealed an admission Medicare 5-day assessment with the Assessment Reference Dated (ARD) of 06/30/2026. Record review of the admission MDS Assessment for Resident 16 with the ARD of 06/30/2026 revealed in section Z0500 signature of Registered Nurse Assessment Coordinator verifying assessment completion was dated 07/07/2026 and signed by the MDS Coordinator (MDSC). Resident 16's MDS assessment with the ARD of 06/30/2026 was signed as complete 15 days after the resident's admission to the facility and should have been signed as complete 14 days after the resident's admission to the facility. In an interview completed on 08/27/2026 at 1:00 PM with the facility Regional Director of Nursing (RDO), the RDO confirmed that Resident 16's admission Comprehensive assessment was completed outside of the required 14-day time frame. B.Record review of an admission Record on 08/25/2026 revealed that the facility admitted Resident 64 on 06/03/2026. Record review of Resident 64's MDS Summary dated 08/25/2026 revealed an admission Medicare 5-day assessment with the Assessment Reference Dated (ARD) of 06/10/2026. Record review of the admission MDS Assessment for Resident 64 with the ARD of 06/10/2026 revealed in section Z0500 signature of Registered Nurse Assessment Coordinator verifying assessment completion dated 06/25/2026 and signed by the MDS Coordinator (MDSC). The assessment with the ARD of 06/10/2026 was signed as complete 23 days after Resident 64's admission to the facility and should have been signed as complete 14 days after the resident's admission to the facility. In an interview completed on 08/27/2026 at 1:00 PM with the facility Regional Director of Nursing (RDO), the RDO confirmed that Resident 64's admission Comprehensive assessment was completed outside of the required 14-day time frame. C.Record review of a facility policy titled MDS 3.0 Completion and dated 09/29/2025 revealed a Annual Assessment is a comprehensive assessment completed using an Assessment Reference Date (ARD) no greater then 366 days from the most recent prior comprehensive assessment counting ARD to ARD. Record review of Resident 18's MDS Summary dated 08/25/2026 revealed:-An Admission/Comprehensive assessment with the ARD of 11/29/2024.-An Annual/Comprehensive assessment with the ARD of 12/28/2025. There were 384 days from the ARD of 11/29/2024 to 12/28/2025 for Resident 18. There was not a comprehensive assessment completed between 11/29/2024 to 12/28/2025. There was not a comprehensive assessment completed within 366 days of the comprehensive assessment with the ARD of 11/29/2024. In an interview completed on 08/27/2026 at 1:00 PM with the facility RDO, the RDO confirmed that a comprehensive assessment was not completed within the required time frame of 366 days from the 11/29/2024 comprehensive assessment and should have been.

Licensure Reference Number 175 NAC 12-006.09(G)(ii)Based on record review and interview the facility failed to ensure that the Ombudsman was notified of all transfers and discharges from the facility, failed to ensure that the resident bed hold was obtained for 2 of 2 residents reviewed (Residents 9 and 13), and failed to ensure that transfer information was communicated to the hospital for 1 of 1 residents reviewed (Resident 13). The facility census was 54.Findings are: Record review of the facility policy titled Transfer and Discharge (including AMA) (against medical advice) dated 7/15/26 revealed that the policy applies to all residents. Orientation for discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility. The section titled Emergency Transfers to Acute Care revealed that the facility will obtain a physician's order for emergency transfer or discharge. Ensure that necessary information is provided with, or as part of the facility's transfer form. Necessary information includes: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information; c. Advance directive information; d. All other information necessary to meet the resident's needs, which includes: i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; ii. Diagnosis and allergies; iii. Medications (including when last received); and iv. Most recent relevant labs, other diagnostic tests, and recent immunizations. e. All special instructions and/or precautions for ongoing care, as appropriate, such as: i. Treatments and devices such as oxygen or catheters; ii. Transmission based precautions; iii. Special risks such as risk for falls, elopement, bleeding, or pressure injury. f. The resident's comprehensive care plan goals; g. All other information necessary to meet the resident's needs. For those residents being transferred due to an emergency to acute care (hospital). The facility will provide a notice of transfer and the facility's bed hold notice policy to the resident and representative an indicated. The social Services Director or a designee will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable as in a list of residents on a monthly basis as long as the list meets all requirements for content of such notices. The original copies of the transfer form and Advance Directives will accompany the resident. Copies will be retained in the medical record. Provide orientation for transfer or discharge to minimize anxiety and ensure safe and orderly transfer or discharge. Document assessment findings and other relevant information regarding the transfer in the medical record. Provide a notice of transfer and the facility's bed hold notice policy to the residents and representatives. The Social Services Director will provide copies of notices for emergency transfers to the Ombudsman. Record review of the undated Resident Admissions Agreement revealed Attachment 9. This was a temporary Bed Hold agreement that stated for Medicaid residents only, the following criteria must be met in order for the facility to hold the bed under Medicaid. If the resident is being transferred to a hospital, the Resident's bed can be held for up to 14 days in any 12-month period. After hospitalization or other absence, it is anticipated the Resident will require nursing facility services. The Resident desires that his/her bed be reserved. The Resident continues to meet the necessary resident requirements and is able to be cared for by the facility. The resident has resided at the facility for a minimum of 30 days. A. Record review of the Census Report on 8/26/26 revealed that Resident 9 was transferred to the emergency room on [DATE] and on 4/21/26. Resident 9 was on Medicaid. Record review of the Progress Notes revealed that the following events occurred: -On 12/25/25 at 12:45 PM Resident had a loss of appetite, had vomited the day before, had an onset of difficulty swallowing, had an excessive cough, and had dark colored urine. Orders were obtained to send the resident to the emergency room for further examination. - On 12/25/25 at 1:05 PM Paramedics arrived to transport Resident 9. - On 12/25/25 at 1:06 PM Paramedics departed the facility with Resident 9. - On 12/25/25 at 1:08 PM Report about the incident and Resident 9's health was called to the receiving facility. -On 4/21/26 at 9:11 AM Resident had been having multiple emesis after the surgery, difficulty swallowing and coughing. Resident was sent to the emergency room, 911 was called, primary physician was notified, and emergency contact was notified. - On 4/21/26 at 2:09 PM Resident was admitted to the local hospital for a possible abscess to the vocal cords. - On 4/23/26 at 6:14 PM Resident admitted to the facility from hospital where Resident 9 was hospitalized due to an abscess of the vocal cords. A complete resident assessment followed. Review of the electronic medical records for Resident 9 revealed that there were no copies of bed holds in the medical record. Interview on 8/26/26 at 9:30 with Social Services Director (SSD) revealed the SSD completes bed holds with the hospitalizations. The SSD further revealed they completed a bed hold for Resident 9's 4/21/26 admission to the hospital but would have to find it. The SSD reported they also completed the Ombudsman notification. The SSD further reported as for the 12/25/25 emergency room (ER) visit, the SSD does not complete bed holds if the resident goes to the ER and return within 24 hours and they don't send Ombudsman notifications if they return right away either. The SSD reported they wouldn't have notified the Ombudsman of the ER visit and did not do a bed hold for 12/25/25. Record review of the readmission Agreement given to Resident 9 on 4/23/26 revealed this to not be a bed hold form but was instead an agreement for readmission following a hospital stay. This agreement was signed by the SSD and Resident 9. Interview on 8/26/26 at 12:10 PM with the Regional Director of Operations (RDO) who presented the information pertaining to bed holds for the 12/25/25 and the 4/21/26 hospital visits and Ombudsman notification. The RDO confirmed that the information presented was not the information that was sent to the Ombudsman but was instead a computer-generated list of transfers, discharges, and deaths of Residents from the facility. In a confirmation interview with the SSD on 8/26/26 at 4:10 PM the SSD confirmed that there was no Ombudsman notification for Resident 9 on the 12/25/25 transfer to the ER and confirmed that there was no bed hold filled out for 12/25/25. The info presented for the bed hold on 4/21/26 was a readmission agreement and not a bed hold and was completed on 4/23/26. The SSD further confirmed that there was no bed hold presented to Resident 9 or to the resident representative for the hospital transfer and stay on 4/21/26. There was an email that was sent to the Ombudsman about the hospitalization. B. Record review of the facility policy titled Transfer and Discharge (including AMA) (against medical advice) dated 7/15/26 revealed that the policy applies to all residents. Orientation for discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility. The section titled Emergency Transfers to Acute Care revealed that the facility will obtain a physician's order for emergency transfer or discharge. Ensure that necessary information is provided with, or as part of the facility's transfer form. The original copies of the transfer form and Advance Directives will accompany the resident. Copies will be retained in the medical record. Provide orientation for transfer or discharge to minimize anxiety and ensure safe and orderly transfer or discharge. Document assessment findings and other relevant information regarding the transfer in the medical record. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative. Record review of the admission Record dated 8/25/26 for Resident 13 revealed that Resident 13 admitted into the facility on 7/18/25. Diagnoses included Anxiety; Atherosclerotic Heart Disease (a buildup of fatty plaque deposits in the arteries that supply blood to the heart); and Diabetes. Record review of the progress note dated 6/30/26 at 4:00 PM for Resident 13 revealed that Resident 13 complained of shortness of breath and pain all over. At approximately 6:30 PM the medication aide reported that Resident 13 complained of not feeling well and the resident had a low pulse. The nurse went to Resident 13 for further assessment. Resident 13's heartbeat was difficult to feel. Emergency Medical Services were called and Resident 13 was transferred to the hospital emergency room. Record review of the hospital discharge packet dated 7/2/26 revealed that Resident 13 was admitted to hospital with bradycardia. Record review of the progress note dated 7/13/26 at 4:22 PM (13 days after Resident 13 was transferred to the hospital) for Resident 13 revealed that at 9:16 PM Resident 13's child was contacted and informed of the previous situation and informed that Resident 13 had been transferred to the hospital. Review of the medical record for Resident 13 revealed that it contained no bed hold notification for Resident 13's transfer and hospitalization on 6/30/26. Record review of the Clinical Census dated 8/25/26 for Resident 13 revealed that Resident 13 was hospitalized from [DATE] through 7/2/26. Interview on 8/27/26 at 11:15 AM with the Regional Director of Nursing (RDON) confirmed that a bed hold was not obtained as required for Resident 13's hospital stay 6/30/26 through 7/2/26. C. Record review of the facility policy titled Transfer and Discharge (including AMA) (against medical advice) dated 7/15/26 revealed that the policy applies to all residents. Orientation for discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility. The section titled Emergency Transfers to Acute Care revealed that the facility will obtain a physician's order for emergency transfer or discharge. Ensure that necessary information is provided with, or as part of the facility's transfer form. Necessary information includes: a. Contact information of the practitioner who was responsible for the care of the resident; b. Resident representative information; c. Advance directive information; d. All other information necessary to meet the resident's needs, which includes: i. Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; ii. Diagnosis and allergies; iii. Medications (including when last received); and iv. Most recent relevant labs, other diagnostic tests, and recent immunizations. e. All special instructions and/or precautions for ongoing care, as appropriate, such as: i. Treatments and devices such as oxygen or catheters; ii. Transmission based precautions; iii. Special risks such as risk for falls, elopement, bleeding, or pressure injury. f. The resident's comprehensive care plan goals; g. All other information necessary to meet the resident's needs. The original copies of the transfer form and Advance Directives will accompany the resident. Copies will be retained in the medical record. Provide orientation for transfer or discharge to minimize anxiety and ensure safe and orderly transfer or discharge. Document assessment findings and other relevant information regarding the transfer in the medical record. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative. The Social Services Director will provide copies of notices for emergency transfers to the Ombudsman. Record review of the admission Record dated 8/25/26 for Resident 13 revealed that Resident 13 admitted into the facility on 7/18/25. Diagnoses included Anxiety; Atherosclerotic Heart Disease (a buildup of fatty plaque deposits in the arteries that supply blood to the heart); and Diabetes. Record review of the progress note dated 6/30/26 at 4:00 PM for Resident 13 revealed that Resident 13 complained of shortness of breath and pain all over. At approximately 6:30 PM the medication aide reported that Resident 13 complained of not feeling well and the resident had a low pulse. The nurse went to Resident 13 for further assessment. Resident 13's heartbeat was difficult to feel. Emergency Medical Services were called and Resident 13 was transferred to the hospital emergency room. Record review of the hospital discharge packet dated 7/2/26 revealed that Resident 13 was admitted to hospital with bradycardia. Record review of the Clinical Census dated 8/25/26 for Resident 13 revealed that Resident 13 was hospitalized from [DATE] through 7/2/26. Review of the medical record for Resident 13 revealed that it contained no transfer form or documentation of information that was provided to the hospital for Resident 13's transfer and hospitalization on 6/30/26. Record review of the progress note dated 7/13/26 at 4:22 PM (13 days after Resident 13 was transferred to the hospital) for Resident 13 revealed that at 9:16 PM Resident 13's child was contacted and informed of the previous situation and informed that Resident 13 had been transferred to the hospital. Interview on 8/27/26 at 11:15 AM with the Regional Director of Nursing (RDON) confirmed that a transfer form was not completed for Resident 13's hospital transfer on 6/30/26 as required.

Licensure Reference Number 175 NAC 12-006.05(E)Licensure Reference Number 175 NAC 12-006.05(G)Based on record reviews, observations, and interviews, the facility failed to inform in advance of the risks and benefits of all psychotropic medications for 4 residents (Resident 3, 9, 6, and 41) of 6 residents sampled, and failed to obtain consent for wound care for 2 residents (Resident 8 and 13) of 2 residents sampled. The facility census was 54.Findings are: A record review of a policy titled, Use of Psychotropic Medications dated 8/1/23 and reviewed and revised on 5/6/26 revealed that it is the intent of this policy to ensure that residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these modifications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience which would deem it a chemical restraint. Policy explanation and compliance guidelines revealed: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: Antipsychotics, antidepressants, anti-anxiety , and hypnotics. 4. When a medication(s) is used that can affect brain activity and the documented use appears to be a substitution for another psychotropic medication rather than for the original or approved indication, then the medication(s) is subject to the requirements pertaining to psychotropic medications. 5. The indications for initiating, maintaining or discontinuing medication(s), as well as the use of non-pharmacological approaches, will be determined by evaluation of the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. 6. Non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. 9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or the increase of psychotropic medication. 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options, and the preferred option to accept or decline in a format the facility deems to use. 16. Psychotropic medication used on an as needed (PRN) basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believed it is appropriate to extend the order beyond 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time-period and indicate a specific duration. A. Record review of the working Comprehensive Care Plan (a detailed, personalized roadmap created by a healthcare team to guide the medical, physical, emotional, and social support of a resident in a facility) printed and reviewed on 8/27/26 revealed Resident 3 had diagnoses of major depressive disorder (a serious mental health condition that causes a lasting feeling of sadness, emptiness, and a loss of interest in normal activities), sleep apnea (a common sleep disorder that causes breathing to stop or become very shallow repeatedly during sleep), nicotine dependence, pain, diabetes, fibromyalgia (a chronic, long-term medical condition that causes widespread body pain, severe fatigue, and sleep or memory problems), and anxiety disorder. The care plan revealed that Resident 3 had major depressive disorder but did not specify any target behaviors or behaviors that needed to be followed to monitor depression and anxiety. Record review of the Medication Orders for Resident 3 revealed orders for: -fluoxetine oral capsule 40 milligrams (mg), give 40 mg by mouth one time a day for anxiousness associated with depression with a start date of 10/28/25 and had no end date. -trazodone oral tablet, give 25 mg by mouth at bedtime for insomnia with a start date of 7/30/26 and no stop date. Record review of the electronic Medication Administration Record (MAR; a legal record of the medications administered to a patient at a facility by a health care professional) for the month of August 2026 revealed that Resident 3 received fluoxetine 40 mg every morning for depression and anxiety and Resident 3 received trazodone 25 mg every night for insomnia. Record review of the Consent for the Use and Treatment of Psychoactive Medications form revealed that Resident 3 did not have a consent for treatment form in the medical record. In a confirmation interview with the Director of Nursing (DON) on 8/26/26 at 11:40 AM, it was revealed that the DON had been working at the facility for a little over one week. In that time, it was discovered that several residents either did not have the consents for the use of the psychoactive medications in their files or that the consents were not completed correctly. The DON confirmed that Resident 3 did have an order for fluoxetine and tramadol, neither medication had an end date, and that there was no evidence consent was obtained for the use of these medications. In a confirmation interview with the Regional Director of Nursing (RDN) on 8/26/26 at 11:42 AM it was revealed that the nursing staff are trying to get all of the resident forms prepared and to complete consents for psychotropic medications accurately with the name of the medication, the dose of the medication, the times the medication can be given, and a date of expiration for the orders. B. Record review of the hospice admission records for Resident 9 revealed this resident was admitted to hospice for care on 5/8/26. Record review of the Medical Diagnoses for Resident 9 revealed the resident had diagnoses of transient ischemic attacks (TIA, a temporary blockage of blood flow to a part of the brain that causes stroke-like symptoms for a short time), nicotine (an addictive chemical found in tobacco products like cigarettes, cigars, chewing tobacco, and e-cigarettes) dependence, arthritis, a history of falling, wheezing, and others. There was no noted diagnosis of anxiety or diagnoses for other mood behaviors. Record review of the Medications Orders for Resident 9 revealed an order for lorazepam (a prescription medication in the benzodiazepine class that slows down the central nervous system to induce calmness, relaxation, and relief from severe anxiety) to be used as needed for anxiety and restlessness. Record review of the MAR for Resident 9 revealed that no lorazepam had been given to this resident at the time of the review on 8/26/26. Record review of the Consent for the Use and Treatment of Psychoactive Medications form had a date of 8/24/26 and was blank with no information about Resident 9. In a confirmation interview with the Director of Nursing (DON) on 8/26/26 at 11:40 AM, it was revealed that the DON had been working at the facility for a little over one week. In that time period, it was discovered that several residents either did not have the consents for the use of the psychoactive medications in their files or that the consents were not completed correctly. The DON confirmed that Resident 9 did have an order for lorazepam and that there was no evidence consent was obtained for the use of this medication. In a confirmation interview with the Regional Director of Nursing (RDN) on 8/26/26 at 11:42 AM it was revealed that the nursing staff are trying to get all of the resident forms prepared and to complete consents for psychotropic medications accurately with the name of the medication, the dose of the medication, the times the medication can be given, and a date of expiration for the orders. C. Record review of the working comprehensive care plan for Resident 6 reviewed on 8/27/26 revealed diagnoses of alcohol abuse, nicotine dependence, pain, an ileostomy (artificial opening in the skin to allow stool to be expelled when the large intestine cannot be used), surgical aftercare related to the ileostomy, abnormalities of gait and mobility, muscle weakness, and unsteadiness on feet. The care plan stated the resident had adjustment issues related to the admission, had a potential for falls, and was taking a high risk, black box medication. The goal was Resident 3 would have no adverse reactions from the medication use. Staff were to review for adverse reactions and report abnormals as detected, and the facility would rely on the pharmacist reviewing medications to make recommendations to the physician. Record review of the August 2026 MAR for Resident 6 revealed that the order for the quetiapine 25 milligram tablet to be given by mouth every 8 hours as needed (PRN) for delirium had a start date of 6/30/26, was scheduled to be given PRN only, did not have an end date, and was not given to the resident during the month of August. The order for the quetiapine 50 mg tablet was scheduled to be given nightly at bedtime for agitation, was started on 8/21/26 given every night at bedtime for agitation, and had no end date. There was no monitoring of the behaviors for Resident 6. Record review of the Consent for the Use and Treatment of Psychoactive Medications form revealed that Resident 6 did not have a consent for treatment form in the electronic medication record at the time of admission, at the time the PRN quetiapine was started on 6/30/26, or at the time the quetiapine 50 mg nightly at bedtime was ordered for agitation. In a confirmation interview with the Director of Nursing (DON) on 8/26/26 at 11:40 AM it was revealed that the DON had been working at the facility for a little over one week. In that time period, it was discovered that several residents either did not have the consents for the use of the psychoactive medications in their files or that the consents were not completed correctly. The DON confirmed that Resident 6 did have an order for quetiapine, did not have a diagnosis of agitation and the two orders for quetiapine did not have an end dates. Further interview confirmed one order for the quetiapine was for an as needed medication, and that there was no evidence of informed consent for the use of this medication. In a confirmation interview with the Regional Director of Nursing (RDN) on 8/26/26 at 11:42 AM it was revealed that the nursing staff are trying to get all of the resident forms prepared and to complete that consents for psychotropic medications accurately with the name of the medication, the dose of the medication, the times the medication can be given, and a date of expiration for the orders. D. A record review of a MAR for Resident 41 dated 8/25/26 revealed current psychotropic medications taken were: -clozapine 50 milligrams (MG) give 3 tablets by mouth at bedtime for treatment-resistant schizophrenia bipolar type (persistent psychotic and manic or depressive symptoms despite trying at least two adequate antipsychotic trials). The start date was 7/10/25. -lorazepam (medication used to treat anxiety disorders, short-term anxiety symptoms, insomnia, and severe seizures) 0.5 MG give 1 tablet by mouth every 12 hours as needed for anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The start date was 7/22/26. -lorazepam 2 MG give 1 tablet by mouth at bedtime for anxiousness related to bipolar disorder (mental health condition that causes extreme shifts in mood, energy, activity levels, and the ability to clear thoughts). The start date was 7/10/25. -sertraline 25 MG give 1 tablet by mouth one time a day for major depressive disorder related to depressive episodes (a common and serious mood disorder that causes a persistent feeling of sadness and loss of interest in daily life). The start date was 7/11/25. -trazodone oral tablet 300 MG give 1 tablet by mouth at bedtime for insomnia (sleep disorder that makes it hard to fall asleep, stay asleep, or wake up too early and fail to fall back asleep) associated with depression related to other specified depressive episodes. The start date was 7/10/25. A record review of a form titled, Psychotropic Medication Informed Consent dated 7/10/25 for Resident 41 revealed the following medications listed for consent: -clozapine no listed dosage, lorazepam no listed dosage, sertraline no listed dosage, and trazodone no listed dosage. Also listed are its drug class and benefits of the medication which lists a decrease in anxiety, depression and psychosis. Reasons listed for use of medication are anxiety, bipolar, depression and schizophrenia. The potential adverse reactions and/or side effects listed were found to be blank. Non-pharmacological (treatments and lifestyle habits that do not use medications or chemical drug) interventions listed were found to be blank. An area where informed consent is listed revealed, the risks and benefits of the above named medication(s) have been explained to me in a manner that is easy for me to understand, either verbally and/or in writing. I understand I have the right to refuse these medications and/or withdrawal my consent at any time by informing facility staff, this area were found to be blank, no signature follows for resident or medical decision maker and no signature follows for staff member who provided education. Also listed on the form was a box found to be blank that reveals the resident does not have capacity to give informed consent, and the medical decision maker lives out of state. During an interview with the Regional Director of Nursing (RDN) on 8/25/26 at 3:00 PM revealed informed consents were not completed correctly as required and have identified this as an ongoing concern. The RDN confirmed the informed consent for Resident 41 failed to list the dosage and non-pharmacological intervention information necessary to provide an adequate informed decision. E. Record review of the undated facility Statement of Resident's Rights revealed that the facility shall insure that all residents are afforded their right to self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care for personal needs. The facility shall encourage and assist each resident in the fullest possible exercise of these rights. The section titled Right to Clinical Care and Treatment revealed that each resident shall have the right to adequate and appropriate medical care, and to be fully informed by a physician on his or her total health status, including but not limited to his/her medical condition, diagnosis, prognosis, and treatment plan. The resident shall have the right to ask questions and have them answered. Each resident shall have the right to refuse medication and treatment after being fully informed and understanding the probable consequences of such actions. Each resident shall have the right to be fully informed in advance about his or her care and treatment and about any changes and treatment that may affect the resident's well-being. Record review of the Service Agreement with wound care consultation services dated 4/14/26 revealed that the wound care consultation services include examination and diagnosis of wounds, providing recommended wound care plans, and performing medically necessary procedures such as bedside debridement (the medical process of removing dead, damaged, or infected tissue and foreign debris from a wound) and the application of cellular tissue products (often called skin substitutes—is the clinical procedure of placing covers onto open wounds to promote healing). The facility shall obtain resident's or their personal representative's consent for Provider Practitioners to treat each resident using the General Consent to Treat form attached as Exhibit A or a similar form and place in each resident's chart a standing order for that resident to receive the services. Record review of exhibit A attachment titled General Consent and Authorization form revealed that the patient voluntarily consents to wound care consultation services by (blank line to be filled in with the name of the wound care consultation service) and its clinicians who provide wound care consulting services at the patient's facility of residence. The patient has the right to give or refuse consent to any proposed service or treatment. The General Consent and Authorization revealed that the patient acknowledges that they have been informed that treatment for wound care can include physical exams and treatment, debridement, dressing changes, biopsies, the application of cellular tissue products, diagnostics, laboratory work (such as wound cultures), off-loading devices, imaging studies, consults with other providers, and wound care plans. The patient acknowledges that they were given the opportunity to ask any questions related to the services or treatments being provided and that any questions were answered. The Authorization revealed descriptions of the benefits of wound care consultation services, risks and side effects of wound care consultation services, likelihood of achieving goals, refusal of and alternative to wound care consultation services, general description of wound debridement, risks/side effects of wound debridement, patient identification and wound images, use and disclosure of Protected Health Information, financial responsibility, and telemedicine consultations. The consent form revealed that the patient hereby acknowledges that they read or have had the contents of this document read to them and agree to the contents of this document. The patient has had the opportunity to ask questions of the provider's clinician and has received answers to all of their questions. By signing, the patient consents to the care, treatment, and services described in the document and orally by the provider, and consents to the creation of images to record their wounds, and consent to the transfer of protected health information between the provider and the facility. Record review of the admission Record for Resident 8 dated 8/25/26 revealed that Resident 8 admitted into the facility on 5/29/26. Record review of the Wound Assessment Report dated 6/25/26 for Resident 8 revealed that Resident 8 had a pressure injury (a localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) on the left buttock that had reopened. The wound measured 1.4 centimeters (cm) in length, 1.4 cm in width and 0.1 cm deep. The report was signed by Nurse Practitioner-I (NP-I). Record review of the Wound Assessment Report dated 7/2/26 for Resident 8 revealed that the pressure injury on the left buttock measured 1.2 cm in length, 0.9 cm in width and 0.1 cm deep. The report was signed by NP-I. Record review of the Wound Assessment Report dated 7/9/26 for Resident 8 revealed that the pressure injury on the left buttock measured 0.3 cm in length, 0.3 cm in width and 0.1 cm deep. The report was signed by NP-I. Record review of the Wound Assessment Report dated 7/16/26 for Resident 8 revealed that the pressure injury on the left buttock measured 0.3cm in length, 0.3 cm in width and 0.1 cm deep. The report was signed by NP-I. Record review of the Wound Assessment Report dated 7/21/26 for Resident 8 revealed that the pressure injury on the left buttock measured 0 cm in length, 0 cm in width and 0.1 cm deep. The report revealed the wound status as resolved. The report was signed by NP-I. Record review of the Wound Assessment Report dated 7/28/26 for Resident 8 revealed that the pressure injury on the left buttock measured 0.4cm in length, 0.1 cm in width and 0.1 cm deep. The report was signed by NP-I. Record review of the Wound Assessment Report dated 8/4/26 for Resident 8 revealed that the pressure injury on the left buttock measured 1.6 cm in length, 1.5 cm in width and 0.1 cm deep. The report was signed by NP-I. Record review of the Wound Assessment Report dated 8/11/26 for Resident 8 revealed that the pressure injury on the left buttock measured 11.0 cm in length, 7.0 cm in width and 0.0 cm deep. The report was signed by Nurse Practitioner-J (NP-J). Record review of the Wound Assessment Report dated 8/20/26 for Resident 8 revealed that the pressure injury on the left buttock measured 0.2 cm in length, 0.2 cm in width and 0.0 cm deep. The report was signed by NP-I. Record review of the medical record for Resident 8 revealed that it contained no resident consent/authorization for wound care by the wound care consultation services. Observation on 8/25/26 at 9:44 PM at the treatment cart outside of the room of Resident 8 revealed that Registered Nurse-A (RN-A) gathered supplies and reviewed the physician's order for the wound care for Resident 8. RN-A picked up the supplies from the top of the treatment cart and entered the room of Resident 8. Resident 8 was seated in the recliner in the room. Resident 8 stood up at the bedside and pulled the pants and underwear down to their knees. A tan foam dressing was in place over the inner left and right buttocks. RN-A removed the dressing with gloved hands. A red and slightly purple area was present on the inner left buttock that measured approximately 7 centimeters (cm) in length and 3.5 cm wide per visual measurement. A discolored area was located on the left buttock within the discolored area. The open wound measured approximately 1.5 cm in length and 0.7 cm in width and a depth of 0.1 cm per visual measurement. The wound bed was light pink. A discolored area on the inner right buttock measured approximately 8 cm long and 5 cm wide per visual measurement. The area was dark purple/red. RN-A revealed that wound clinic staff measures the wound on Wednesdays so the facility just does the dressing changes. Observation on 8/27/26 at 10:16 AM at the room of Resident 8 revealed that Nurse Practitioner-I (NP-I) was at the recliner with Resident 8. NP-I came to the room doorway and removed and discarded their gloves. NP-I confirmed that NP-I just completed the wound treatment for Resident 8. Interview on 8/26/26 at 1:51 PM with the facility Infection Preventionist (IP) confirmed that the nurse practitioners from the wound clinic perform wound care consultation services in the facility and treat the pressure injury wound for Resident 8. Interview on 8/27/26 at 1:46 PM with Regional Director of Nursing (RDON) confirmed that the facility did not have a consent for wound care consultation to treat Resident 8. F. Record review of the admission Record dated 8/25/26 for Resident 13 revealed that Resident 13 admitted into the facility on 7/18/25. Record review of the Wound Assessment Report dated 7/28/26 for Resident 13 revealed that a left abdominal skin fold wound measured 0.1cm in length, 0.1 cm in width and 0.1 cm deep. Resident 13 had a left rear upper thigh wound that measured 0.1cm in length, 0.1 cm in width and 0.1 cm deep. Resident 13 had a right breast wound that measured 0.2 cm in length, 1.5 cm in width, and 0.1 cm deep. The report was signed by Nurse Practitioner-I (NP-I). Record review of the Wound Assessment Report dated 8/4/26 for Resident 13 revealed that a left abdominal skin fold wound measured 0.1cm in length, 0.1 cm in width and 0.1 cm deep. Resident 13 had a left rear upper thigh wound that measured 0.1cm in length, 0.1 cm in width and 0.1 cm deep. Resident 13 had a right breast wound that measured 0.2 cm in length, 1.5 cm in width, and 0.1 cm deep. The report was signed by NP-I. Record review of the Wound Assessment Report dated 8/11/26 for Resident 13 revealed that a left abdominal skin fold wound measured 30 cm in length, 41 cm in width and 0.1 cm deep. Resident 13 had a left rear upper thigh wound that measured 0.1cm in length, 0.1 cm in width and 0.1 cm deep. Resident 13 had a right breast wound that measured 6 cm in length, 26 cm in width, and 0.1 cm deep. The report was signed by Nurse Practitioner-J (NP-J). Record review of the medical record for Resident 13 revealed that it contained no resident consent/authorization for wound care by the wound care consultation services. Observation on 8/25/26 at 11:23 AM revealed that Medication Aide-B (MA-B) went into the room of Resident 13. Nurse Aide-C entered the room of Resident 13. Resident 13 was lying in the bed. NA-C removed the covers from Resident 13 exposing the resident's bare legs and feet. MA-B undid the fasteners on Resident 13's brief. NA-C handed a package of wipes to MA-B. MA-B opened the wipe package and removed a wipe. MA-B wiped the front private area of Resident 13. NA-C assisted Resident 13 to roll onto the resident's right side. The rear upper thighs both had light fiery red skin that was flaky. The area on the rear left upper thigh onto the left buttock measured approximately 30 centimeters (cm) in length and 16 cm in width per visual measurement. The area on the rear right upper thigh onto the right buttock measured approximately 24 cm in length and 15 cm in width per visual measurement. MA-B dispensed an unmeasured amount of Triad Hydrophilic Wound Dressing (a sterile, zinc oxide-based paste used to manage light-to-moderate weeping wounds, skin tears, and pressure ulcers, especially in hard-to-dress body folds or creases) paste onto the gloved fingers and rubbed it over the wound areas of Resident 13's posterior thighs and buttocks. Observation on 8/27/26 at 10:16 AM at the room of Resident 8 revealed that Nurse Practitioner-I (NP-I) was at the recliner with Resident 8. NP-I came to the room doorway and removed and discarded their gloves. Interview on 8/27/26 at 10:16 AM with NP-I revealed that NP-I had already seen Resident 13 prior to seeing Resident 8. Interview on 8/27/26 at 1:46 PM with Regional Director of Nursing (RDON) confirmed that the facility did not have a consent for wound care consultation to treat Resident 13.

Licensure Reference Number 175 NAC 12-006.02(H)Adult Protective Services Act, Nebraska Revised Statute 28-372Based on record review and interview the facility failed to report suspicion/allegation of misappropriation and abuse to the state agency within the required time frames. This affected 2 of 2 residents (Residents 41 and 66). The facility census was 54.Findings are:A record review of a facility policy titled, Abuse, Neglect and Exploitation dated and revised on 7/22/25 revealed; it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of resident property. V. Investigation of alleged abuse, neglect and exploitation. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: 1. Identify staff responsible for the investigation; 3. Investigating different types of alleged violations; 6. Providing complete and thorough documentation of the investigation. VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse of result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. A. An interview with Resident 41 on 8/24/26 at 11:25 AM revealed they were missing money, paintings and poetry and believed the facility was not doing anything about it. Record review of Resident 41's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) dated 10/13/25 revealed Resident 41 was paranoid believing staff take items out of room and fixate on staff. A record review was completed of grievance logs from May 2025 through August 2026 and the following information was revealed from these grievance logs: -There were no logs available for the months of October 2025 through March 2026. -In September 2025 Resident 41 submitted 3 grievances. There was no information as to the details of the grievances or the disposition of the grievances. -In July 2026, Resident 41 submitted a grievance for an event that occurred on 7/19/26. The log revealed the grievance was unfounded and a written decision was provided to the resident on 7/23/26. Record review of facility provided documents revealed there were no details available to review for the grievance Resident 41 submitted on 9/10/25. Record review of the grievance for Resident 41 dated 7/19/26 revealed the resident stated a nurse was asked to provide an as-needed (PRN) medication; however, the nurse had to wait until the next shift came to work to provide the medication. Investigation into the allegation revealed that the resident was interviewed but later could not recall the incident, the grievance was subsequently closed without further review or investigation. An interview with Social Services Director (SSD) on 8/25/26 at 10:14 AM revealed the facility had received a lot of concerns related to missing items. If someone stated there was a missing item, the facility would search immediately for the item before labeling it as a missing item because it could be easily found if it was just misplaced. During the interview, the SSD stated money was different, if it was cash, the residents would sign the money out and were reminded not to leave money lying around. The residents were offered a lock box upon move-in and periodically thereafter. When asked if money was ever investigated or replaced, SSD revealed that if money was listed as stolen, missing or misplaced, the facility did not do much for it as they have some residents who would make up stories so they could get the facility to purchase items, like cigarettes, for them. SSD was further interviewed about missing items and/or missing money for Resident 41, which revealed some of the items the resident was referring to were being stored in the activity closet, and SSD did not ever remember the resident stating they were missing money. SSD stated Resident 41 had not had any cash for several months due to an issue with Social Security. A record review of an incident reported to Adult Protective Services on 1/2/26 revealed Resident 41 had been missing money, however the facility had no additional details regarding the incident. Further review of the incident revealed no investigation followed the incident. B. Record review of the facility Grievance Logs dated from May 2025-August 2026 revealed a grievance dated 5/31/25 for Resident 66 regarding cares. Record review of the Grievance Form dated 5/31/25 for Resident 66 revealed that an unidentified nurse aide isn't careful with the resident's right leg and always bumps into the doorways or things and the resident's leg gets hurt. Today they also took the resident's small flashlight and perfume went missing. Resident 66 was finished eating breakfast and requested to be returned to the resident's room. The unidentified nurse aide said no. The grievance form had a handwritten intake number for the report to Adult Protective Services (APS) and Reported 6/11/25 at 2:50 PM. Record review of the facility Abuse, Neglect or Misappropriation investigation dated 6/11/25 for Resident 66 revealed that the Administrator/Director of Nursing was notified of the potential abuse on 6/9/25 at 2:00 PM. The date of the incident was documented as 5/31/25. The investigation form revealed that APS was called on 6/9/25 at 2:50 PM. This was 9 days after the potential abuse, neglect, and misappropriation occurred and was identified on the Grievance Form dated 5/31/25. Interview on 8/26/26 at 4:17 PM with the Regional Director of Operations (RDO) confirmed that the potential abuse of Resident 66 was not reported to the state agency in the required timeframe.

Licensure Reference Number 175 NAC 12-006.9(H)(iii)(3) Based on observation, record review, and interview the facility failed to provide wound care in a manner consistent with professional standards of practice, in a manner to prevent the potential for cross contamination, and as prescribed by the provider for Resident 18, and failed to ensure provider recommendations were completed or followed up on for 2 (Residents 18 and 11) of 5 sampled residents. The facility census was 54. Findings are:Record review of a facility policy titled Wound Treatment Management and dated 11/11/2025 revealed it was the policy of the facility to promote wound healing in various types of wound to provide evidence-based treatments in accordance with current standards of practice and physician orders. A.Record review of a document from the 2026 Wound Care Education Institute titled Top Tips for Best Wound Cleansing Practices and dated 06/30/2017 revealed to gently clean the wound in full or half circles beginning in the center and working toward the outside cleansing at least one inch beyond the end of the new dressing or two inches beyond the wound margins. If needed, dry the wound using the same procedure as for cleaning. Record review of a facility policy titled Cleaning and Disinfection of Resident-Care Equipment and dated 06/01/2026 revealed each user is responsible for routine cleaning and disinfection of multi-use items after each use and particularly before use for another resident. In an observation completed on 08/26/2026 at 12:05 PM of wound care being provided to Resident 18 by Registered Nurse A (RN-A) the following was observed:-RN-A opened a plastic container with a white cap labeled Normal Saline and poured the clear liquid into 3 separate clear plastic medication cups setting each of the cups on the residents 3 drawer bedside stand. A clean barrier was not placed between the medication cups and the bedside stand. The RN did not cleanse or sanitize the bedside stand prior to placing the medication cups onto it.-RN-A obtained 4X4 gauze from an opened white package that contained multiple pieces of 4X4 gauze at least 1/2 inch in depth that was not labeled with an opened date or the residents name with a gloved hand. The RN placed the piece of gauze into a clear plastic medication cup that contained Normal Saline. The RN used a dabbing motion to cleanse the wound located at the resident's inner left heel. The RN did not cleanse the wound in circular or half circle motion working from the inside to the outside of the wound. The RN did not cleanse the skin surrounding the wound at least one inch beyond the end of the new dressing or two inches beyond the wound margins.-RN-A obtained a pair of scissors from the top of the resident's 3 drawer bedside stand and used the scissors to cut the package of a dressing labeled calcium alginate with silver. The RN did not cleanse the scissors after picking them up off a potentially contaminated surface and using them to cut the dressing package. In an interview completed on 08/26/2026 at 12:15 PM with RN-A, RN-A confirmed that they did not cleanse the wound using the proper technique. The RN confirmed that they did not cleanse the bedside stand or the scissors prior to use. The RN confirmed that they did not place a clean barrier down between the resident's bedside stand and placing the clear plastic medication cups on it. B.Record review of Resident 18's Order Summary dated 08/26/2026 at 12:00 PM revealed the resident had an order for Gentamicin Sulfate Topical Ointment 0.1% with directions to apply to the resident's right lower abdomen topically three times a day. The order also stated to cleanse the area with wound cleanser or normal saline, pat dry, and apply a thin layer of the ointment then place a calcium alginate with sliver dressing. In an observation completed on 08/26/2026 at 11:39 AM of wound care being provided to Resident 18 by RN-A the following was observed:-RN-A used a 4X4 piece of gauze wet with normal saline to cleanse the wound located to the resident's right abdominal/groin fold. The RN cleansed the wound in a linear fashion going from the area closest to the resident's back and wiping towards the resident's peri area using the same piece of gauze to complete multiple wipes over the resident's wound. The RN did not use a clean/new gauze or a different section of the gauze for each wipe. The RN did not cleanse the wound in circular or half circle motion working from the inside to the outside of the wound.-RN-A, with gloved hands removed another piece of gauze from the white paper package containing multiple pieces of gauze and used the piece of gauze to dry the wound using a dabbing motion. The RN did not dry the wound in circular or half circle motion working from the inside to the outside of the wound.-RN-A removed a tube of ointment from a box labeled with the resident's name and Gentamicin (an antibiotic medication) Sulfate Topical Ointment 0.1%. The RN with gloved hands squeezed the tube and expressed an approximately 1-centimeter sized amount of the ointment onto their gloved finger. The RN then applied the ointment to the residents wound located on their right abdominal/groin fold. The RN used the same finger to spread the ointment over the entire wound in a linear fashion going from the center of the wound to the outer aspects of the wound. The RN did not use a different finger or new expression of ointment for each wipe potentially contaminating one area of the wound from another area of the wound.-RN-A cut a dressing in half labeled calcium alginate wound dressing 4 inches by 8 inches. The RN did not cleanse the scissors prior to cutting the dressing in half. The RN with gloved hands removed the cut in half piece of calcium alginate dressing and placed it into/over the resident's lower half of wound located to their left abdominal/groin fold. Then the RN removed the other piece of the calcium alginate dressing and placed it over the upper half of the wound. In an interview completed with RN-A on 08/26/2026 at 12:15 PM RN-A confirmed that they did not cleanse or dry the residents wound using the correct technique. The RN confirmed that they should have used a different finger or new expression of the ointment for each wipe spreading the ointment over the resident's wound. The RN confirmed that they did not cleanse their scissors prior to cutting the calcium alginate dressing and should have. The RN confirmed that they did not follow the providers order for applying a calcium alginate with sliver dressing to the resident's wound. In an interview completed on 08/26/2026 at 2:35 PM with the facility Regional Director of Nursing (RDO), the RDO confirmed that RN-A did not perform wound care for Resident 18 using current standards of practice and following provider orders. C.Record review of a document addressed to Resident 18 from a local health care provider and dated 06/09/2026 revealed in regard to a phone call from the facility about Resident 18's reoccurring cellulitis to their lower extremities that arrangements for the resident to see infectious disease could be made and to notify the provider if the resident was willing to see infectious disease for a consultation for this matter. Record Review of Resident 18's Electronic Medical Health Record revealed no evidence from 06/09/2026 to 08/26/2026 stating that the provider's recommendations for the resident to consult with infectious disease was reviewed with the resident and what the resident's wishes were in regard to this recommendation. In an interview completed on 08/27/2026 at 11:00 AM with the facility RDO, the RDO confirmed that there was no evidence that the provider's recommendations from 06/09/2026 had been reviewed with the resident or followed up on to know what the resident's wishes were in regard to the recommendations to consult with infectious disease related to the recurrent cellulitis. D.Record review of Resident 11's Progress Notes revealed documentation that on 08/07/2026 the resident was assessed to have abnormalities to their left arm and was sent to the local emergency room for evaluation. Documentation was also present on 08/08/2026 that the resident returned to the facility and that their sodium level was 129 (normal range for sodium is 135-145) and this was to be re-checked on 08/11/2026. Record review of a document titled Discharge Instructions and dated 08/07/2026 revealed documentation that the resident's sodium level was 129 and the provider recommended that the resident had their sodium level re-checked in the next several days. A diagnosis for the visit was listed as ground level fall and a low sodium level. Record review of Resident 11's Electronic Medical Health Record revealed no evidence of Resident 11's laboratory specimen being obtained or the resident's or responsible party's declination to follow the recommendation obtained on 08/07/2026 to have the resident's sodium level re-checked. In an interview completed on 08/27/2026 at 11:00 AM with the facility RDO, the RDO confirmed that the recommendations to have the resident's sodium level re-checked was not completed as recommended by the emergency room provider and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(6) Based on record review, observation, and interview the facility failed to ensure a resident that entered the facility with an indwelling urinary catheter (tubing placed in the bladder via the urethra to drain urine from the bladder) an attempt was made to remove the indwelling urinary catheter and/or the resident had justification for the use of the indwelling urinary catheter for 1 (Resident 16) of 5 sampled residents. The facility census was 54. Findings are:Record review of a facility policy titled Indwelling Catheter Use and Removal dated 11/26/2025 revealed it was the policy of the facility to ensure that indwelling urinary catheters are justified or removed according to regulations and current standards of practice. Residents that admit with an indwelling catheter or subsequently receive one will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that the catheter is necessary. Appropriate indications for indwelling catheter use include acute urinary retention or bladder outlet obstruction, need for accurate measurements of urinary output, assistance in healing of open sacral or perineal wounds in incontinent residents (typically stage 3 or 4), requirement of prolonged immobilization, improve comfort for end of life care if needed. Record review of Resident 16's admission Record revealed the facility admitted Resident 16 on 06/23/2026 with diagnoses of fracture of the right femur with the presence of a right artificial hip joint and cerebral infarction (stroke). In an observation completed on 08/24/2026 at 10:35 AM Resident 16 was observed to be lying on their back in their bed in their room. Visible was a clear plastic tubing going from under the resident's blanket at hip level and into a dark blue plastic cover attached to the frame of the resident's bed. A thin liquid red brow in color was visible in the entirety of the tubing. Record review of Resident 16's Electronic Medical Health Record revealed:-documentation that the resident was admitted to the facility from an acute hospital on [DATE] with an indwelling urinary catheter.-no diagnosis of urinary retention or obstruction.-no diagnosis of alterations in skin integrity to the resident's coccyx.-no documentation of the need for accurate measurements of urinary output.-no provider orders for an indwelling urinary catheter with the indication for continuation of use of the indwelling urinary catheter. Record review of Resident 16's Care Plan Report on 08/26/2026 revealed a focus of the resident was admitted with an indwelling catheter due to urinary retention dated 07/07/2026. Record review of Resident 16's Diagnosis Report on 08/26/2026 revealed no evidence of a diagnosis of urinary retention for Resident 16. In an interview completed on 08/26/2026 with Registered Nurse A (RN-A), RN-A confirmed that Resident 16 had an indwelling urinary catheter. The RN confirmed that residents with indwelling urinary catheters should have provider orders that include the indication for the continuation of the catheter and Resident 16 did not have provider orders for the indwelling urinary catheter or an indication for the use of the indwelling urinary catheter. In an interview completed on 08/26/2026 at 2:35 PM with the facility Regional Director of Nursing (RDO), the RDO confirmed that Resident 16 did not have a provider order including the indication for the continuation of the indwelling urinary catheter and should. The RDO confirmed that the resident was admitted to the facility with the indwelling urinary catheter and the facility should have gotten provider orders for the continuation of the use of the indwelling urinary catheter on admission to the facility or removed the indwelling urinary catheter and did not.

Licensure Reference Number 175 NAC 12-006.09(H)Based on record review and interview the facility failed to ensure residents receiving antibiotic therapy received routine monitoring during the course of the therapy for 1 resident (Resident 18) of 5 sampled residents. The facility census was 54.Findings are: Record review of a facility policy titled Antibiotic Stewardship Program and dated 06/01/2026 revealed it was the policy of the facility to implement an Antibiotic Stewardship Program as part of the facilities overall infection prevention and control program. The facility would use antibiotic use protocols in monitoring antibiotic use, nursing would monitor the initiation of antibiotics on residents and complete daily Hot Charting to monitor signs and symptoms for the duration of antibiotic therapy plus 3 days. Record review of resident 18's Progress Notes revealed on 08/10/2026 the resident voiced c/o and increase in pain and warmth to their lower legs. The resident was seen by the in-house provider that day and an antibiotic medication was prescribed for 10 days. There was no documentation present that an SBAR was completed for this resident. There was no documentation present that a laboratory specimen was requested prior to the start of the antibiotic therapy to verify the presence of or absence of an infection that the antibiotic therapy was prescribed for.Record review of Resident 18's Medication Administration Record for the Month of August 2026 revealed on 07/10/2026 the resident was administered the first dose of the antibiotic as prescribed. The last dose of the antibiotic therapy was documented to have been administered on 08/24/2026.Record review of Resident 18's Progress Notes revealed no documentation the first dose of the antibiotic was received on 08/10/2026. There was no documentation present two to three days after the start of the antibiotic therapy indicating that the antibiotic therapy use was reevaluated and reviewed by the facility and or the provider. Documentation was present on 08/14/2026 and 08/15/2026 that the resident was receiving antibiotic therapy and was not exhibiting adverse signs or symptoms from the antibiotic therapy. There was no other daily or routine documentation present during the course of the antibiotic therapy for monitoring. Record review of resident 18's Progress Notes revealed on 07/10/2026 the resident was seen by the in-house provider that day and an antibiotic medication was prescribed for 10 days. There was no documentation present that an SBAR was completed for this resident. Record review of resident 18's Progress Notes revealed on 08/10/2026 the resident voiced c/o and increase in pain and warmth to their lower legs. The resident was seen by the in-house provider that day and an antibiotic medication was prescribed for 10 days. There was no documentation present that an SBAR was completed for this resident. There was no documentation present that a laboratory specimen was requested prior to the start of the antibiotic therapy to verify the presence of or absence of an infection that the antibiotic therapy was prescribed for. Record review of Resident 18's Medication Administration Record (MAR) for the month of July 2026 revealed that the resident was administered the first dose of the antibiotic on 07/10/2026 in the evening. On 07/15/2026 through 07/20/2026 the antibiotic was documented as not administered.Record review of Resident 18's Progress Notes on 07/10/2026 revealed no documentation that antibiotic therapy was started. Documentation was present on 07/13/2026 the resident was seen by another in house provider for shoulder pain. On 07/14/2026 the resident was seen again by the inhouse provider and was complaining of loss of appetite and vomiting with the inability to keep oral medication down. The provider ordered labs to be completed. The provider did not give orders to hold or discontinue the antibiotic that started on 07/10/2026. On 07/15/2026 the resident started declining oral medications due to nausea and staff started administering an as needed medication for the nausea and a Urinary specimen was obtained and sent for resulting at the laboratory. Documentation revealed that the resident denied urgency, hesitancy, and pain with urination. On 07/17/2026 the resident continued to refuse the antibiotic medication and stated to staff that they were allergic to the medication. On 07/18/2026 documentation was present that the resident was receiving therapy for a urinary tract infection, and the resident was complaining of generalized weakness and an inability to walk to the bathroom and nausea with the inability to keep down food. The resident stated that they believed that the antibiotic therapy was causing these symptoms and had started feeling much better since declining to take the medication. There was no documentation present that a time out was performed for the antibiotic therapy 48-72 hours after starting the antibiotic therapy. There was no daily documentation present for the duration of the antibiotic therapy and three days after completion of the antibiotic therapy. There was no documentation present that the provider stopped the antibiotic therapy after seeing the resident on 07/14/2026. There was no documentation present that the provider listed the possibility of adverse reaction to this medication in the residents EMHR. In an interview completed on 08/26/2027 at 3:30 PM with the Regional Infection Preventionist (RIP), the RIP confirmed as part of the facility's antibiotic stewardship program residents on antibiotic therapy should have daily Hot Charting in progress notes for the duration of the antibiotic therapy and for three days after therapy has been completed. The RIP confirmed that Resident 18 was seen in house by the provider on 07/14/2026 and the provider did not give orders to discontinue or hold the antibiotic therapy due to possible adverse reaction.

Licensure Reference Number 175 NAC 12-006.09(G)(i)Based on record review and interview the facility failed to ensure that discharge information, including a discharge summary (a concise summary of the resident's stay and course of treatment in the facility and how the resident discharged from the facility), was documented in the medical record as required for 1 of 1 residents reviewed (Resident 65). The facility census was 54.Findings are:Record review of the facility policy titled Transfer and Discharge (including AMA) (against medical advice) dated 7/15/26 revealed that the policy applies to all residents. Orientation for discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility. The section titled Discharge Against Medical Advice (AMA) revealed that AMA only applies when a resident expresses their wishes to be discharged earlier than outlined in the care plan. The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. Documentation of this notification should be entered in the nurses notes by the nursing department. Social services should document any discussion held with the resident/family in the social service progress notes. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 65 dated 6/1/26 revealed that Resident 65 admitted into the facility on 7/10/25. The type of MDS assessment was documented as a discharge assessment for unplanned resident discharge. Record review of the care plan dated 8/26/26 for Resident 65 revealed that discharge plans for Resident 65 were for Resident 65 to remain in the facility as a result of continued need for the services of skilled nursing staff as evidenced by an inability to provide self-care.Record review of the Against Medical Advice (AMA) Form for Resident 65 dated 6/1/26 revealed that Resident 65 was leaving on their own insistence and against the advice of their attending physician and the facility. A handwritten note on the form revealed that the Social Services Director (SSD) and the Director of Nursing (DON) explained the meaning and definition of AMA. Resident 65's Power of Attorney (POA) refused to sign the form and stated that it was not legal and wrong. The POA noted that they have all of the resident's medications and don't need a doctor's order. The POA revealed that they can take the resident home anytime they want. Record review of the progress notes for Resident 65 revealed no documentation by nursing or social services about the discharge of Resident 65. Record review of the second to last progress note in the medical record for Resident 65 dated 5/25/26 at 1:42 PM revealed that Resident 65 refused their bath and told the bath aide to get out of their room.Record review of the last progress note in the medical record for Resident 65 was dated 5/26/26 at 11:32 AM and labeled as a follow-up note revealed that Resident 65 was recently noted to refuse shower with no known aggravating or alleviating factors. The note listed current medications for Resident 65. Review of the medical record for Resident 65 revealed that it contained no discharge summary for Resident 65.Interview on 8/27/26 at 1:44 PM with the Regional Director of Operations (RDO) confirmed that the facility did not have a discharge summary for Resident 65 as required.

Licensure Reference Number 175 NAC 12-006.09(F) Based on record review and interview the facility failed to revise a resident's plan of care reflecting the resident was receiving hospice (end of life care) services for 1 (Resident 16) of 5 sampled residents. The facility census was 54. Findings are:Record review of an undated facility Admissions Agreement revealed following acceptance for admission a plan of care and treatment for the resident shall be developed and routine care and treatment would be provided by the facility in accordance with the residents plan of care. 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 resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. In an interview completed on 08/24/2026 at 4:20 PM with Resident 16's representative, the resident's representative stated that they had elected for the resident to receive care services from Hospice. Record review of Resident 16's Census revealed the resident was admitted to the facility on [DATE] and was admitted to hospice services on 08/05/2026. Record review of Resident 16's Care Plan Report on 08/25/2026 revealed no focus, goal, or intervention reflecting the resident was receiving hospice care services as of 08/05/2026. In an interview completed on 08/27/2026 at 1:00 PM with the facility Regional Director of Nursing (RDO), the RDO confirmed that Resident 16 was receiving care services from hospice and this should have been reflected on the residents Care Plan and was not.

Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview, the facility failed to ensure that behavior monitoring for residents on psychoactive medications was completed for 3 of 6 residents sampled (Residents 3, 9 and 6); failed to ensure that PRN psychotropic medications had an end date of 14 days, and if continued, had the required clinical rationale and/or physician review which specified the need for 3 of 6 sampled residents (Residents 6, 9, and 41). The facility census was 54. Findings are: A. A record review of a policy titled, Use of Psychotropic Medications dated 8/1/23 revealed, it is the intent of this policy to ensure that residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience which would deem it a chemical restraint. Policy explanation and compliance guidelines revealed: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: Antipsychotics, antidepressants, anti-anxiety , and hypnotics. 4. When a medication(s) is used that can affect brain activity and the documented use appears to be a substitution for another psychotropic medication rather than for the original or approved indication, then the medication(s) is subject to the requirements pertaining to psychotropic medications. 5. The indications for initiating, maintain or discontinuing medication(s), as well as the use of non-pharmacological approaches, will be determined by evaluation the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. 6. Non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. 9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or the increase of psychotropic medication. 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options, an the preferred option to accept of decline in a format the facility deems to use. 16. Psychotropic medication used on an as needed (PRN) basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believed it is appropriate to extend the order beyond 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time-period and indicate a specific duration. A record review of a Medication Administration Record (MAR; a legal record of the medications administered to a patient at a facility by a healthcare professional) for Resident 41 dated 8/25/26 revealed current PRN psychotropic medications taken were: -lorazepam (medication used to treat anxiety disorders, short-term anxiety symptoms, insomnia, and severe seizures) 0.5 MG give 1 tablet by mouth every 12 hours as needed for anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The start date was 7/22/26 and no end date was listed for the medication. The MAR revealed in August of 2026 the medication was dispensed 3 times from 8/1/26 through 8/25/26. During an interview with the Regional Director of Nursing (RDN) on 8/25/26 at 3:00 PM it was confirmed Resident 41's PRN psychotropic medications were not listed with an end date. B. Record review of the working Comprehensive Care Plan (CCP, a detailed, personalized roadmap created by a healthcare team to guide the medical, physical, emotional, and social support of a resident in a facility) printed and reviewed on 8/27/26 revealed Resident 3 had diagnoses of major depressive disorder (a serious mental health condition that causes a lasting feeling of sadness, emptiness, and a loss of interest in normal activities), sleep apnea (a common sleep disorder that causes breathing to stop or become very shallow repeatedly during sleep), nicotine dependence, pain, diabetes, fibromyalgia (a chronic, long-term medical condition that causes widespread body pain, severe fatigue, and sleep or memory problems), and anxiety disorder. The care plan revealed that Resident 3 had diagnosis of major depressive disorder but did not specify any target behaviors or behaviors that needed to be followed to monitor depression and anxiety. Record review of the Medication Orders for Resident 3 printed 8/27/26 revealed orders for: -fluoxetine oral capsule 40 mg, give 40 mg by mouth one time a day for anxiousness associated with depression was started on 10/28/25. -trazodone oral tablet, give 25 mg by mouth at bedtime for insomnia with a start date of 7/30/26. Record review of the MAR for the month of August 2026 revealed that Resident 3 received fluoxetine 40 mg every morning for depression and anxiety and trazodone 25 mg every night for insomnia. There was no evidence of monitoring the resident's symptoms or responses to the psychotropic medications. In a confirmation interview on 8/26/26 at 4:20 PM the DON confirmed that there were no target behaviors or behavior monitoring for Resident 3. C. Record review of the Hospice admission records for Resident 9 revealed this resident was admitted to hospice care on 5/8/26. Record review of the Medical Diagnoses on 8/26/26 for Resident 9 included transient ischemic attacks (TIA, a temporary blockage of blood flow to a part of the brain that causes stroke-like symptoms for a short time), nicotine dependence, arthritis, a history of falling, and wheezing. Record review of the Medications Orders on 8/24/26 for Resident 9 revealed an order for lorazepam (a prescription medication in the benzodiazepine class that slows down the central nervous system to induce calmness, relaxation, and relief from severe anxiety) to be used as needed for anxiety and restlessness dated 6/16/26. The order for the lorazepam did not identify an end date. Record review of the August 2026 MAR for Resident 9 revealed that no lorazepam had been given to this resident in August at the time of the review on 8/26/26. Further review of the MAR revealed there was no target behaviors or behaviors to observed for associated with the use of lorazepam. Record review of the Electronic Health Record for Resident 9 revealed a lack of clinical rationale from the prescriber to support the continued order for as-needed lorazepam. In a confirmation interview with the Director of Nursing (DON) on 8/26/26 at 11:40 AM it was revealed that the DON had been working at the facility for a little over one week. The DON confirmed that Resident 9 did have an order for lorazepam, the ordered as-needed lorazepam did not have an end date, and there was no behavior monitoring or identified target behaviors. D. Record review of the working CCP for Resident 6 reviewed on 8/27/26 revealed diagnoses of alcohol abuse, nicotine dependence, pain, an ileostomy, surgical aftercare related to the ileostomy, abnormalities of gait and mobility, muscle weakness, and unsteadiness on feet. The care plan stated the resident had adjustment issues related to the admission, had a potential for falls, and was taking a high risk, black box medication. Further review of the CCP identified the resident would have no adverse reactions from the medication use and staff were to review for adverse reactions and report abnormals as detected, and the facility would rely on the pharmacist reviewing medications to make recommendations to the physician. The CCP lacked any detail regarding target behaviors. Record review of the August 2026 MAR for Resident 6 revealed that the order for the quetiapine 25 mg tablet to be given by mouth every 8 hours as-needed (PRN) for delirium had a start date of 6/30/26, was scheduled to be given PRN Only, did not have an end date, and had not been given to the resident during the month of August. The order for the quetiapine 50 mg tablet was scheduled to be given nightly at bedtime for agitation, was started on 8/21/26 given every night at bedtime for agitation. There was no monitoring of the behaviors for Resident 6. Record review of the August 2026 electronic Treatment Administration Record for Resident 6 revealed that there was no monitoring for behaviors portrayed daily by Resident 6. Record review of the Electronic Health Record for Resident 6 revealed no evidence the physician completed an in-person review to support the continued order for as-needed quetiapine. In a confirmation interview with the Director of Nursing (DON) on 8/26/26 at 11:40 AM it was confirmed that Resident 6 did have an order for quetiapine, did not have a diagnosis for agitation, and the as-need order for quetiapine did not have an end date. In a confirmation interview on 8/26/26 at 4:20 PM the DON confirmed that there were no target behaviors or behavior monitoring for Resident 6.

Licensure Reference Number 175 NAC 12-006.09(C)(ii) Based on record review and interview the facility failed to complete a Significant Change in Status Assessment (SCSA) 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) within 14 days of the change in status identification for 1 (Resident 64) of 5 sampled residents. The facility census was 54. Findings are:Record review of a facility policy titled MDS 3.0 Completion and dated 09/29/2025 revealed a Significant Change in Status Assessment (SCSA) is required when a resident enrolls in a hospice program or changes hospice provider and remains in the facility. A SCSA assessment is to be completed within 14 days of the identification of the change in status. Record review of Resident 64's Census dated 08/25/2026 revealed the resident admitted to the facility on [DATE] and was admitted to hospice care services on 06/12/2026. Record review of Resident 64's MDS Summary revealed:-An Entry MDS with the Assessment Reference Date (ARD) of 06/03/2026.-An admission Medicare 5-day MDS with the ARD of 06/10/2026.-An End of Perspective Payment System (PPS) MDS with the ARD of 06/11/2026-An Death in Facility MDS with the ARD of 07/04/2026. There was no record of a SCSA assessment being completed within the 14 days (06/26/2026) of Resident 64 change of status when enrolled in a hospice program nor was hospice indicated in the assessments that were completed. In an interview completed on 08/27/2026 at 1:00 PM with the facility Regional Director of Nursing (RDO), the RDO confirmed that Resident 64 began hospice care services on 06/12/2026 and this qualified the resident to have a SCSA assessment completed. The RDO confirmed that a SCSA assessment was not completed for Resident 64 and should have been.

Licensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to ensure that comprehensive care plans were comprehensive and person-centered. This affected 2 of 5 sampled residents (Residents 6 and 3). The facility census was 54. Findings were:Record review of the policy Comprehensive Care Plans dated 8/1/23 and reviewed and revised on 2/5/25 revealed the policy was to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Person-centered care was defined as to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.The care planning process included an assessment of the resident's strength and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma-informed care as indicated.The comprehensive care plan would be developed within 7 days of the comprehensive resident assessment and consider all of the care assessment areas that were triggered.The comprehensive care plan will develop at a minimum the following:The services that are to be furnishedAny services that would be furnished but are not provided due to the resident's exercise of his/her right to refuse treatmentAny specialized services or rehabilitation services as a result of a mental health screeningThe resident's goals for admission, desired outcomes, and preferences for future discharged ischarge plans as appropriate6. The comprehensive care pan will include measurable objective and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed. A.Record review of Minimum Data Set (MDS, a standardized, federally mandated clinical assessment tool used by nursing homes to evaluate the health status, functional capabilities, and needs of every resident) dated 7/7/26 revealed that Resident 6 needed some supervision and assistance with dressing, oral hygiene, personal hygiene, and toileting hygiene. The resident assessment also revealed Resident 6 had an ostomy (an opening (called a stoma) on the abdomen to allow waste or urine to exit the body when normal elimination is not possible), and occasional incontinence. Resident 6 had diagnoses for a history of alcohol abuse, hepatitis, and received an antipsychotic medication (medications used mainly to manage psychosis, hallucinations, delusions, and severe mood or behavior disorders) and an antiplatelet medication (medications that stop blood cells called platelets from sticking together and forming dangerous blood clots). The Assessment and care area assessments (CAAs, a problem-solving framework used in nursing homes and long-term care facilities to build personalized care plans) also identified areas of concern that included activities of daily living, urinary tract infections, dehydration, pressure ulcers, and the use of antipsychotics. Record review of the Comprehensive Care Plan, reviewed on 8/27/26 for Resident 6 revealed that the person-centered care plan contained the following:-The resident had a surgical wound on 7/9/26 but did not describe where the wound was located or when the wound had healed. -The care plan contained no evidence that Resident 9 had an ostomy - in this instance an ileostomy ( a surgical created opening in the belly to route waste out of the small intestine, bypassing the large intestine and collected in a pouch on the abdomen.) There were no goals or interventions to help Resident 6 work with the ostomy site.-The care plan did reveal that Resident 6 was on a black box medication (medications that carry the strictest safety alert required by the U.S. Food and Drug Administration (FDA) to highlight severe, life-threatening, or permanently disabling side effects) but failed to mention what the medication was and to include any interventions or target behaviors or behavior monitoring.-The care plan identified areas for the activities of daily living that needed to be addressed but were left blank with no description, goals, or interventions. In an interview with Registered Nurse (RN)-A on 8.26.26 at 9:50 AM, RN-A revealed nurses were supposed to be able to go to the care plan to learn about cares for a resident quickly. RN-A revealed that the care plan was not very informative because it did not discuss the fact that the Resident 6 had an ileostomy or that the resident was preparing to go back to surgery soon to have the intestines put back together after a time of healing. RN-A also confirmed that the care plan did not discuss Resident 6's need for an antipsychotic medication. In a confirmation interview with the Regional Director of Nursing (RDN) on 8/26/26 at 2:40 PM revealed that the RDN knew the information of the wound was a part of the care plan, but that the information about the ileostomy was not on the care plan. The RDN confirmed that once the ileostomy site was healed, the care pan was not updated and confirmed that there was information about a medication that had a black box warning but did not address the specific medication class or the medication. The RDN confirmed that there were no target behaviors or behavior monitoring interventions to accompany the antipsychotic medication. B.Record review of the MDS dated [DATE] revealed Resident 3 takes medications categorized as antianxiety medication, antidepressant medication, opioid medication, anticoagulant medication, antiplatelet medication, and hypoglycemic medication. The MDS also revealed that Resident 3 had diagnoses for cardiac heart failure, anxiety, depression, diabetes, chronic pain, morbid obesity, and history of a trans ischemic attack and had a complex medical history. Record review of the Physician Orders for Resident 3 dated 8/27/26 revealed the following high risk medication orders:Trulicity (a medication to help control blood sugars) 1.5 mg (milligrams) subcutaneously (in the fat tissue) weekly for diabetes (A black box medication)Xarelto 20 mg, give 1 tablet by mouth in the evening for atrial fibrillation (A black box medication)Trazodone (a medication for depression) 25 mg by mouth at bedtime for insomnia (A black box medication)Clopidogrel Bisulfate (medication to prevent blood clots) oral tablet 75 MG, give 1 tablet by mouth one time a day for treatment to prevent peripheral artery thromboembolism (blood clots) (A black box medication)Fluoxetine (a medication for depression) HCl oral capsule 40 MG, give 40 mg by mouth one time a day for anxiousness associated with depression (A black box medication)Insulin Aspart (an insulin to treat high blood sugars in those affected with diabetes) inject as per sliding scale: if 0 - 199 = 0 0 units ; 200 - 250 = 2 units; 251 - 299 = 3 units ; 300 - 350 = 4 units; 351 - 400 = 5 units; 401 - 450 = 8 units; 451 - 999 = 10 units Call MD, subcutaneously three times a day for DM (diabetes mellitus) with mealsOxycodone oral tablet 5 MG, give 1 tablet by mouth every 8 hours as needed for pain (A black box medication)Trazodone (a medication for depression) give 25 mg by mouth at bedtime for Insomnia (A black box medication) Record review of Resident 3's Comprehensive Care plan on 8/27/26 revealed that the resident was taking medications with a black box warning. The medications listed were Xarelto (a medication to assist in the prevention of blood clots) an anticoagulant, and Trulicity (a once-weekly injectable medication used to improve blood sugar control in adults with type 2 diabetes.) There were no person-centered interventions related to these medications and no evidence of the other high risk medications they were taking. In a confirmation interview with the Regional Director of Nursing (RDN) on 8/27/26 at 9:50 AM, the RDN confirmed that the person-centered Comprehensive Care Plan did not have all the information that should have been included in the care plan.

Licensure Reference Number 175 NAC 12-006.09(D) Based on record review and interview, the facility failed to accurately code the MDS Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) for 2 (Residents 4 and 41) of 5 sampled residents. The facility census was 54. Findings are:Record review of a facility policy titled MDS 3.0 Completion and dated 09/29/2026 revealed according to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's function capacity, using the Resident Assessment Instrument specified by the State. A.Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2025 revealed in K0300 Weight Loss with coding instructions to code 0 if the resident did not or it is unknown if the resident had weight loss of 5% or more in the last month or 10% or more in the last six months, and to code 1 if yes the resident had weight loss of 5% or more in the last month or 10% or more in the last six months and it was a physician prescribed weight loss regimen, and to code 2 yes if the resident had weight loss of 5% or more in the last month or 10% or more in the last six months and it was not a physician prescribed weight loss regimen. Definition of calculating the weight loss instructions were listed to start with the resident's weight closest to 180 days ago and multiply it by 0.9 or 90%. The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal or less than the resulting figure, the resident has lost 10% or more body weight. Record review of Resident 4's quarterly MDS with the Assessment Reference Date (ARD) of 07/13/2026 revealed K0300 was coded '0' indicating the resident did not have a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Record review of Resident 4's Weight Summary record revealed:-On 07/08/2026 Resident 4's documented weight was 127.2 pounds. On 12/29/2026 (weight obtained closest to the 6-month (180 days) time period for the assessment) Resident 4's documented weight was 161.4 pounds. This reflects a 34.2-pound weight loss. Resident 4's weight of 161.4 pounds multiplied by 0.9 equals 145.26. Per the coding instructions for this section the resident's weight of 172.2 pounds is less than the calculated 145.26 indicating per the coding instructions the resident had a 10% or greater weight loss with an actual calculated weight loss of 21%. Resident 4's MDS with the ARD of 07/13/2026 section K0300 should have been coded 1 or 2 reflecting the 10% or greater weight loss and was not. In an interview completed on 08/27/2026 at 1:00 PM with the facility Regional Director of Nursing (RDO), the RDO confirmed that Resident 4's weight loss of 10% or more should have been coded on their MDS with the ARD of 07/13/2026 and was not. B.Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2025 revealed in Section J1400 Prognosis with coding instructions to code 1 yes if the resident is receiving hospice services. The manual also revealed in Section O0110K1 Hospice care to code this section if the resident has been identified as being on a hospice program. Record review of Resident 41's Electronic Medical Health Records revealed documentation that Resident 41s had provider orders for Hospice care services dated 10/24/2025. Record review of Resident 41's MDS with the ARD of 07/26/2026 revealed in Section J1400 Prognosis, does the resident have a condition or chronic disease that may result in life expectancy less than 6 months to code 0 for No and 1 for Yes. The MDS was coded 0-No to this question and should have been coded 1 yes to this question. In Section O1110 item K1 Hospice care was not coded as received while a resident. This section should have been coded to reflect the resident was receiving hospice care. In an interview completed on 08/27/2026 at 1:00 PM with the facility Regional Director of Nursing (RDO), the RDO confirmed that Resident 41 receiving hospice care should have been coded on the MDS with the ARD of 07/26/2026 and was not.

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2)(a)Based on record review and interview the facility failed to ensure that a nurse aide registry check (a compilation of all nursing aides who meet the requirements to practice under that title within their state. It serves to verify their credentials for employment, any disciplinary action against the nurse aide, and provides a level of safety to the public) was completed prior to hire as required for 4 of 5 sampled staff. The facility census was 54.Findings are:Record review of the facility policy titled Background Investigations dated 8/18/26 revealed that job reference checks, licensure verifications and criminal conviction record checks are conducted on all persons making an application for employment. The human resources department will contact the nurse aide registry to verify that the applicant's certification is in good standing. The facility will not employ individuals who have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. Record review of the facility policy titled Abuse, Neglect and Exploitation dated 7/22/25 revealed that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. The facility will maintain documentation of proof that the screening occurred. Record review of the facility Employee List dated 8/25/26 revealed that Nurse Aide-D (NA-D) had a hire date of 3/26/26.Record review of the employee file (a file containing documentation of all pre-employment background checks and other employee information) for NA-D revealed that it did not contain a Nurse Aide Registry Check for NA-D.Record review of the facility Employee List dated 8/25/26 revealed that Nurse Aide-C (NA-C) had a hire date of 4/3/26.Record review of the employee file for NA-C revealed that it did not contain a Nurse Aide Registry Check for NA-C.Record review of the facility Employee List dated 8/25/26 revealed that Licensed Practical Nurse-E (LPN-E) had a hire date of 4/27/26.Record review of the employee file for LPN-E revealed that it did not contain a Nurse Aide Registry Check for LPN-E.Record review of the facility Employee List dated 8/25/26 revealed that Housekeeping Supervisor (HSKS) had a hire date of 7/15/26.Record review of the employee file for HSKS revealed that it did not contain a Nurse Aide Registry Check for HSKS.Interview on 8/26/26 at 3:45 PM with the Regional Director of Operations confirmed that the facility did not have documentation of a Nurse Aide Registry check as required for NA-C, NA-D, LPN-E, or HSKS.

Licensure Reference Number 175 NAC ,d+[DATE].09 Based on record review and interview, the facility failed to request emergency medical services promptly to provide emergency care services for 1 (Resident 1) of 1 sampled resident. This caused the resident to not receive timely emergency care services resulting in the death of the resident. The facility census was 45. Findings are: Record review of the undated facility policy titled Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) revealed that it is the policy of the facility to adhere to resident rights to formulate advanced directives. The facility will implement guidelines regarding cardiopulmonary resuscitation. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experiences a cardiac arrest the facility staff will provide basic life support including CPR prior to the arrival of emergency medical services. Record review of the American Heart Association (AHA) CPR and ECC (Emergency Cardiovascular Care) Guidelines dated ,d+[DATE] revealed that the chain of survival (the chain of events that must occur in rapid succession to maximize the chances of survival from sudden cardiac arrest) for out of hospital cardiac arrest, the first step is the activation of emergency response (emergency medical services). The second step is high quality CPR. Record review of Resident 1's Progress Note dated [DATE] at 11:00 PM revealed Resident 1 arrived at the facility per a van and was taken to their room. Resident 1 was oriented to the room, call light, and staff. Record review of the Admission Record for Resident 1 dated [DATE], revealed Resident 1 had diagnoses of: heart disease with heart failure, severe obesity, and chronic respiratory failure. The Admission Record revealed that Resident 1 had an advanced directive to have CPR in the event of cardiac arrest. Record review of the Advance Directive Information form dated [DATE] for Resident 1 revealed that Resident 1's wish was to receive CPR. The form revealed that CPR stands for cardiopulmonary resuscitation, which instructs the nursing staff to provide artificial breathing and circulation in the event breathing or heartbeat, or both have ceased. 911 will be called and every effort will be made to keep the resident/patient alive. Record review of Resident 1's Progress Note dated [DATE] at 4:19 AM revealed at 12:40 AM the nurse aide found Resident 1 not responding. The nurse checked the resident's chart and found the resident wish was for CPR. The nurse started CPR. The nurse asked the nurse aide to continue CPR while the nurse went to call the Director of Nursing. The nurse called the doctor of Resident 1 at 1:26 AM (this was 46 minutes after CPR was started). The doctor advised to call 911 immediately. The nurse called 911 for emergency services at 1:29 AM (this was 49 minutes after CPR was started). Interview on [DATE] at 2:10 PM with Registered Nurse-A (RN-A) confirmed that RN-A was the nurse working at the time that Resident 1 was not responding on [DATE]. RN-A revealed that a nurse aide told RN-A that Resident 1 was not responding, and RN-A ran to the resident immediately. RN-A revealed that RN-A found Resident 1 had no pulse. RN-A went to the chart to see if Resident 1's wish was for CPR or no CPR. RN-A found that Resident 1 wished for CPR to be performed and ran to the room to begin CPR. RN-A revealed that after 6 minutes of CPR, RN-A told a nurse aide to continue CPR so that RN-A could call the Director of Nursing. RN-A revealed that the time was 10:51 PM. RN-A confirmed that 911 was not called until 1:29 AM. Record review of the Action Summary (a report of residents that died in the facility) revealed that Resident 1 died in the facility on [DATE] at 1:42 AM. Interview on [DATE] at 10:52 AM with the facility Director of Nursing (DON) confirmed that when a resident's wish is for CPR, the nurse should call 911 to request emergency medical services and start CPR when a resident is in cardiac arrest. The DON confirmed that the call to 911 should happen immediately. The DON confirmed that the nurse progress note for Resident 1 revealed there was a delay of at least 49 minutes between the start of CPR for Resident 1 and the call to 911. The DON confirmed that Resident 1 died in the facility. Record review of the Abatement Statement for F684 Quality of Care dated [DATE] submitted by the Facility Administrator on [DATE] at 4:56 PM revealed the following: - the Registered Nurse on duty ([DATE]) that did not follow facility policy was suspended pending the outcome of the facility investigation, - facility staff and agency staff working [DATE] were educated on the Medical Emergency Response policy to call 911 immediately, the CPR policy, and Abuse and Neglect Reporting. - staff education will continue until all staff are educated prior to their next scheduled shift on the Medical Emergency Response policy to call 911 immediately, the CPR policy, and Abuse and Neglect Reporting, - all staff will be re-educated on on the Medical Emergency Response policy to call 911 immediately, the CPR policy, and Abuse and Neglect Reporting during the all staff meeting on [DATE], - all new staff will be educated on the above policies during general orientation, - all agency staff will be educated on the above policies during orientation to the building, - all new staff and new agency staff will be provided with a log in to the electronic health record in person or in an envelope posted by the time clock. Included in the envelope will be directions to log into the electronic health record immediately. There will be a name and number to call for assistance if the login will not work.

Licensure Reference 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to ensure that residents were monitored for adverse consequences while receiving anticoagulant therapy and antibiotic therapy for Resident 5 and 36. This practice resulted in hospitalization for Resident 5. The facility also failed to ensure [MEDICATION NAME] (pain reliever) dosages to Resident 9 didn't exceed the ordered dosage for Resident 9. Facility census 71. Findings are: A. Resident 5 was admitted to facility on 4/10/15 - with [DIAGNOSES REDACTED]. Observation of Resident 5 on 10/7/15 at 11:38 am revealed the resident was in the room seated in a wheelchair and the resident stated the resident was weak, tired, and not feeling well. The Resident did not want any lunch as the resident was going to a medical appointment at 1:00 pm. Review of Resident 5's Medical record on 10/8/15 for Medications revealed the resident was receiving Aspirin (blood thinning medication) 81 milligrams per day. The resident was also receiving [MEDICATION NAME] (blood thinning medication) alternating 2 and 3 milligrams daily. [MEDICATION NAME] (antibiotic) was ordered by the physician for 10 days on 10/2/15. Resident 5 had also received 10 days of [MEDICATION NAME] starting on 9/11/15. Review of Laboratory Data revealed that on 9/15/15 an INR (International Normalized Ratio; a blood clotting time which is a measure for safe and therapeutic administration of the [MEDICATION NAME]) was drawn. The value from the laboratory was 1.84. (normal range for therapeutic benefit is 2.0-3.0 to prevent blood over thinning causing bleeding). The next INR was not drawn until 10/8/15 and revealed 10.0 which was considered a critical lab value. During the time the first and second 10 day dosing's of [MEDICATION NAME] were prescribed, no lab values were recorded. Documentation in Nursing Notes from 10/4/15, 10/6/15 and 10/7/15 revealed the resident had bloody noses and was falling asleep often. Frequent nosebleeds times four days was recorded on 10/7/15 when the physician was notified of bleeding, lethargy (fatigue) and no appetite. The resident's lab results showed a corresponding Hemoglobin (red blood cells) value of 7.7 (Normal lab 14.0 - 18.0) on 10/8/15, indicating a blood loss. On 10/8/15, the Resident was sent to the emergency room and then admitted to the Intensive Care Unit and was in the hospital for 5 days with [MEDICAL CONDITION] ( low Hemoglobin) and Acute and [MEDICAL CONDITION]. The resident returned to the facility on [DATE] no longer receiving [MEDICATION NAME] Medication. Nursing Notes during October 2015 included: - 10/4/15; resident laying on left side in bed, bloody nose, resident is declining in ability - falls asleep often during any activity, requested dietary to move resident to assist table for cueing and assist as needed - resident understands and is agreeable at this time. - 10/5/15; out to meal - needs increase assist with cares. - 10/6/15; one small bloody nose today - resident was picking at inside of his nose and started a small bleed controlled quickly. - 10/7/15; complaining of lethargy and no appetite - lungs sounds moist with productive cough - currently taking [MEDICATION NAME] since 10/2/15 physician notified. - There was no evidence in the Nursing Notes during 10/4/15 and 10/6/15, when the resident was exhibiting bleeding that the nursing staff consulted or notified the attending physician nor were any labs ordered to verify the resident's clotting times. - 10/8/15 at 2:00 pm; INR= 10.0 - Doctor (name) ordered to send to emergency room . Notified that resident has had nose bleeds times three (3) in the last four (4)days Daughter (name) notified. - 10/8/15 at 5:15 pm; received word from (hospital name) resident admitted to ICU (Intensive Care Unit). Review of the Davis Drug Guide for Nurse's - Fourteenth Edition published in 2015 revealed during administration of [MEDICATION NAME] - careful monitoring required when starting new medications including antibiotics that can be high risk for significantly altering [MEDICATION NAME]'s effects, and report any symptoms of bleeding or bruising to health care professional immediately. Review of the facility Policy # CL-NUR-1608a for Clinical Management for Anticoagulation Therapy developed on 11/29/2010 - revealed anticoagulation medications are considered high-risk, which required clear, concise methods of ordering and administration. When resident's were receiving antibiotic therapy at the same time - INR levels will be done on the first day of antibiotic therapy. Levels will be drawn every three (3) days until five (5) days AFTER completion of antibiotic therapy. Side effects of anticoagulation therapy may include: SEVERE bleeding. All side effects were to be reported to the physician. B. Review of thee medical record for Resident 36 revealed admission to facility on 8/27/2015 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] Stage 3 (moderate kidney function failure), [MEDICAL CONDITION] (low red blood cells to carry oxygen to body), and Hypertension (high blood pressure). Resident 36 was admitted with orders for oxygen at night for Sleep apnea (breathing disorder) and had a Hemoglobin (measuring red blood cells in body) of 8.8 with the Normal range being 14.0-18.0. The medication administration records revealed resident was receiving [MEDICATION NAME] 2.5 milligrams daily (blood thinning medication to decrease blood clotting time). On 8/27/15 a Hemoglobin level of 8.0 was noted on laboratory records, indicating a further decrease in red blood cells available in the body. Nursing notes on 8/31/15 at 2:00 am revealed the resident had a large nose bleed from the right nostril. The nostril was packed with cotton and ice was applied. Clotting formed and bleeding stopped after 10 minutes. Physician was not notified of the nose bleed. Telephone order on 9/2/15 at 3:00 pm revealed an order from the doctor to hold the [MEDICATION NAME] until further notice and to get [MEDICATION NAME] (INR laboratory data measuring blood clotting time) before Noon. Nursing notes on 9/3/15 at 4:00 am revealed the resident had a large bloody nose in both nostrils. A PT/INR was drawn. Orders were received to send the resident to the emergency room . Resident 36 was treated at the hospital with Cautery (burning of tissue to seal off) and Silver [MEDICATION NAME] ( an inorganic compound applied to tissue to reduce/stop bleeding). The Physician ordered that the resident should return to the emergency room if prior nose bleeds resume as these types of nose bleeds require emergency room treatment. The emergency room admission was on a Wednesday and these records note a nosebleed since Monday. Resident 36 was noted to begin receiving the [MEDICATION NAME] medication on 9/6/15 of 2.5 milligrams per day. The [MEDICATION NAME] was increased on 9/18/15 to 2.5 milligrams two days/week and 3 milligrams 5 (five) days per week. Resident 36 had a physician order to have [MEDICATION NAME] (antibotic medication) ordered on [DATE] for 2 weeks for lower leg [MEDICAL CONDITION]. An INR was recorded on 10/7/15 as 1.31 clotting time - which is in the low normal range for clotting times. The Physician wrote an order for [REDACTED]. C. Review of Resident 9's Quarterly MDS (Minimum Data Set: a federally mandated comprehensive tool used for care planning) revealed that the resident's BIMs (Brief Interview for Mental Status) score was 3 (severely cognitively impaired). The resident required extensive to total assistance with all activities of daily living except eating. The resident had occasional pain rated at an eight. Review of Resident 9's Care Plan dated 8/13/15 revealed that the resident was at potential for pain related to [MEDICAL CONDITION] (weak, brittle bones), general discomfort. The resident used routine and as needed pain medications. The resident's goal was for pain not to affect the resident's activity of daily living status for the next 90 days. Interventions included: physician to review black box warning medications (last reviewed 6/6/15), administer routine medications or per non-verbal signs and symptoms, encourage the resident to rate pain on the pain scale, monitor effectiveness of medication, and notify the physician of increased pain. Review of Resident 9's Physician Orders dated 8/13/15 included: -Tylenol ([MEDICATION NAME] or APAP) 325 mg (milligrams) 1 tablet twice daily. -[MEDICATION NAME] (narcotic pain medication) 7.5 mg with/ APAP 325 mg 2 tablets at bedtime for intertrochanteric fracture ([MEDICAL CONDITION]). -Tylenol 325 mg 1 or 2 tablets every 4 hours as needed for pain or fever. -Tylenol 650 mg suppository rectally every 4 hours as needed for pain or fever. -[MEDICATION NAME] 7.5 mg/ APAP 325 mg 1-2 tablets every 4 hours as needed intertrochanteric fracture. -Do not exceed 3 grams (3000 mg) of Tylenol from all sources. Review of Resident 9's September 2015 MAR (Medication Administration Record) revealed: -Tylenol ([MEDICATION NAME] or APAP) 325 mg (milligrams) 1 tablet twice daily. -[MEDICATION NAME] (narcotic pain medication) 7.5 mg with/ APAP 325 mg 2 tablets at bedtime for intertrochanteric fracture ([MEDICAL CONDITION]). -Tylenol 325 mg 1 or 2 tablets every 4 hours as needed for pain or fever. -Tylenol 650 mg suppository rectally every 4 hours as needed for pain or fever. -[MEDICATION NAME] 7.5 mg/ APAP 325 mg 1-2 tablets every 4 hours as needed intertrochanteric fracture. -Do not exceed 3 grams (3000 mg) of Tylenol from all sources. -The resident routinely received 1300 mg of Tylenol from routine sources. -On 9/6/15 the resident received 2 tablets of [MEDICATION NAME] 7.5 mg/ APAP 325 mg at 4:15 AM, 3:10 PM, and 11 PM adding an extra 1950 mg of Tylenol. The resident exceeded the 3 grams in 24 hours of Tylenol by 250 mg in the 24 hour period. -On 9/18/15 the resident received the routine schedule amounts of Tylenol. The resident received [MEDICATION NAME] 7.5 and APAP 325 mg 2 tablets at 12 AM, 3:10 PM, and 11:55 PM for an additional total of 2275 mg of Tylenol. The resident's total Tylenol intake was 3575 in 24 hours. The resident exceeded the 3 grams by 575 mg in the 24 hour period. Review of Resident 9's August 2015 MAR indicated [REDACTED] -Tylenol ([MEDICATION NAME] or APAP) 325 mg (milligrams) 1 tablet twice daily. -[MEDICATION NAME] (narcotic pain medication) 7.5 mg with/ APAP 325 mg 2 tablets at bedtime for intertrochanteric fracture ([MEDICAL CONDITION]). -Tylenol 325 mg 1 or 2 tablets every 4 hours as needed for pain or fever. -Tylenol 650 mg suppository rectally every 4 hours as needed for pain or fever. -[MEDICATION NAME] 7.5 mg/ APAP 325 mg 1-2 tablets every 4 hours as needed intertrochanteric fracture. -Do not exceed 3 grams (3000 mg) of Tylenol from all sources. -The resident routinely received 1300 mg of Tylenol from routine sources. -On 8/4/15 a nurses' order was added for Tylenol 325 mg 2 tablets at 4 PM daily for seven days. The staff was to monitor the resident's pain level. This increased the residents Tylenol intake by 650 mg. -On 8/7/15 the resident received 2 additional [MEDICATION NAME] 7.5 mg/ APAP 325 mg tablets and Tylenol 325 mg 2 tablets. The resident received the routinely scheduled pain medication in addition to the as needed pain medication, and the nursing ordered, pain medication for a total of 3250 milligrams of Tylenol in a 24 hour period. Interview with the DON (Director of Nursing) on 10/14/15 revealed that Resident 9 did exceed 3 grams of Tylenol. The MARS stated not to exceed both 3 grams and 4 grams in different locations on the MAR.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.04C3a(6) Based on record review, staff interviews and family interviews, the facility failed to immediately notify physicians and legal representative when an accident with injury and significant change of condition occurred. Also the facility failed to ensure follow-up assessment for treatment and obtaining physicians orders which delayed treatment for 1 of 3 sampled residents (Resident 16). The facility had a census of 74 residents. The sample size was 3 residents. Findings are: Resident 16 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. A. Record review of the facility form entitled Medical Daily Skilled Nursing Notes for Resident 16, dated 12/4/2010 between 6 PM to 10 PM, found documentation that stated while @ (at) supper tonight the resident pulled the supper plate off on the lap and L (left) lower forearm (between the elbow and the back of the hand). Area on underside of forearm was red with 2-3 blisters. On top of the left forearm was an L-shaped 43 cm (centimeter) X 5.0 cm pinkish red area and on L upper thigh a light pink area that measured 0.8 X 3.0 cm. The area was cleansed with a skin prep and Vaseline gauze with non-adherent dressing was applied with conform bandage to the blisters and the thigh left open to air. Record review of Resident 16's medical file found no documentation that the facility staff had notified the legal representative or the physician of the burn the resident had experienced on 12/4/2010. Review of a facility form dated 12/5/2010 with a heading to the physician found a written description that read the resident pulled the supper plate off the table onto the lap. The resident had sustained 1 small light pink burn to the upper left thigh that measured 0.8 x 3.0 cm that was left open to the air. The inner aspect of the left lower forearm had an area that measured 3.0 x 10.0 cm and light to medium red with 2 small blisters and outer forearm an L shaped 4.3 x 5.0 cm pinkish-red area. Areas cleaned and with cold compresses for 10 min (minutes) covered with Vaseline gauze and wrapped with conform bandage. Will change drsng (dressing) daily until healed. The form was stamped with a faxed date of 12/5/2010 at 2240 (10:40 PM). By not notifying the physician timely, this delayed treatment for [REDACTED]. During an interview with LP-A (Licensed Practical Nurse) on 12/6/2010 at 6:35 PM confirmed Resident 16 had received a burn to the left forearm on 12/4/2010 between 6:00 PM and 6:30 PM. LP-A confirmed a fax was sent to the physician's office, even though the physician would not be in the office until Monday 12/6/2010, on 12/5/2010 at 2240 some 28 hours after the burn happened. When asked about the policy of the facility for treatment of [REDACTED]. I used Vaseline gauze to keep the wound moist. I had learned that at a different facility I worked". Then LPN-A was asked if the resident had been medicated for [MEDICAL CONDITION] the reply was "that was the resident's affected limb and he/she has an order for [REDACTED]. B. Record review of the facility form entitled Medicare Daily skilled Nursing Notes, dated 12/5/2010 between 10:00 PM and 6:00 AM showed a progress note that read when the resident was wiped a large amount of bright red blood and clots came from the rectum. During the interview on 12/6/2010 at 6:35 PM, LPN A was asked if the physician had been notified of the rectal bleeding and the response was " I didn't " . A phone interviews with legal representatives for Resident 16 on 12/6/2010 at 4:15 PM and 6:05 PM revealed the facility had not notified the legal representative of the burn the resident received to the left forearm on 12/4. Also there had been no notification of the bleeding from the rectum. Review of the facility form entitled Resident Condition Changes that Require Physician Notification, dated 10/1/01 indicated the following: -When in doubt, a call should be placed to the physician. -Emergent-a situation/condition that would warrant immediate physician notification and intervention. Review of the facility form entitled Communication with Family and Friends, dated 4/14/2003 indicated the facility must notify a resident's family of an accident of significant change of condition.

LICENSURE REFERENCE 175 NAC12-006.09D Based on record review and staff interview, the facility failed to assess an injury sustained from hot food being spilled on bare skin and then provide follow-up care for treatment of [REDACTED]. The facility had a census of 74 residents and a sample of 3. Findings are: Resident 16 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 16's MEDICARE DAILY SKILLED NURSING NOTES dated 12/4/2010 between 6 PM to 10 PM revealed the following entry by LPN (Licensed Practical Nurse) A: "While @ (at) supper tonight resident pulled supper plate off on lap and L) (left) lower forearm. Area on underside of forearm red c (with) 2-3 blisters. On top an L-shaped 43 cm (centimeter) x (by) 5.0 cm Pinkish-red and on L (arrow pointing up) thigh, a light pink area 0.8 x 3.0 cm. Area cleansed et (and) thigh left open to air and arm, skin prep applied to blisters and Vaseline gauze c non-adherent dressing and conform bandage. Denies pain when asked and no S/S (signs or symptoms) noted". Review of the facility policy and procedure titled treatment of [REDACTED]. Treatment: a. Immerse the burned skin in cool water until the pain subsides. Apply dry sterile gauze as a protective bandage. DO NOT use an antiseptic preparation ointment, sprays or home remedy on a severe burn. DO NOT break blisters or remove tissue. b. If the arms or legs are affected, keep them elevated. c. A physician must evaluate all second and third degree burns. d. Assess the need for a Tetanus immunization. e. Instruct the employee to report any signs or symptoms of infection. Redness, swelling, drainage, or fever is signs of infection. Seek medical attention immediately." Interview on 12/6/2010 at 6:35 PM with LPN A revealed that at the end of the 2 PM to 10 PM shift, LPN A had charted that the resident had received a burn from spilled food at the evening meal. LPN A stated that about 9 PM on 12/4/2010, LPN A had noted that Resident 16 had blisters forming on the arm. LPN A stated that (gender) used Vaseline gauze on the burn area due to wanting to keep the area moist. LPN A stated that (gender) did not realize how serious the injury was and did not directly call the physician to notify of the burn. The physician did not have input and direction in the care and treatment of [REDACTED]. Then the staff was to cover the area with [MEDICATION NAME] and wrap with Kling. Also the physician ordered a Tetanus shot to be administered. Further interview with LPN A on 12/6/2010 at 6:35 PM revealed that (gender) was not aware of the facility policy and procedure concerning treatment of [REDACTED]. LPN A stated that (gender) wanted to keep the area moist and so covered the area with the Vaseline gauze without physician's orders and did not follow the facility policy and procedure for treatment of [REDACTED]. LPN A stated that no blisters were noted on Resident 16's arm until around 9 PM on 12/4/2010; however, the physician still was not notified until 12/6/2010 to ensure that proper treatment and assessment of the area occurred. Interview on 12/7/2010 at 11:37 AM with NA (Nursing Assistant) K revealed that the incident of Resident 16 spilling the hot pureed food occurred about 6:30 PM on 12/4/2010. After Resident 16 spilled the food, NA C cleaned Resident 16 off and ordered another tray of food. NA K stated that it was probably 15 minutes before NA C took Resident 16 out of the dining room to the Nurse's Station for LPN A to make an assessment of the arm. Around 7:00 PM, NA K stated that (gender) took Resident 16 to the resident's room and wrapped the arm with a wet towel. NA K stated that no food was observed on the arm at that time but there was still food on Resident 16 clothing. NA K stated that Resident 16's arm was dark pinkish when wrapped with the wet towel. When NA K removed the towel around 7:15 PM, the arm was a lighter pink in color but NA K did not notice any blisters at that time. NA K stated that LPN A did not go to Resident 16's room until after the resident was put to bed but did not state a time.

LICENSURE REFERENCE: 175 NAC 12-006.09D7a Based on record review, observation and staff interview, the facility failed to ensure the safety of residents needing assistance with eating from receiving burns from hot spilled foods. This failure resulted in burns with resultant blisters forming on Resident 16's left lower forearm. The facility had a census of 74 residents and a sample of 3 residents was reviewed. Findings are: Resident 16 was admitted to the facility on [DATE] according to the ADMISSION RECORD on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 16's MEDICARE DAILY SKILLED NURSING NOTES dated 12/4/2010 between 6 PM to 10 PM revealed the following entry by LPN (Licensed Practical Nurse) A: "While @ (at) supper tonight resident pulled supper plate off on lap and L) (left) lower forearm. Area on underside of forearm red c (with) 2-3 blisters. On top an L-shaped 43 cm (centimeter) x (by) 5.0 cm Pinkish-red and on L (arrow pointing up) thigh, a light pink area 0.8 x 3.0 cm. Area cleansed et (and) thigh left open to air and arm, skin prep applied to blisters and Vaseline gauze c non-adherent dressing and conform bandage. Denies pain when asked and no S/S (signs or symptoms) noted". Review of the Taber's Cyclopedic Medical Dictionary (20th edition), burns are classified as: - First degree: damage is limited to the outer layer of the skin and is marked by redness, tenderness and mild pain - Second degree: burn that damages partial thickness of the epidermal and some dermal tissues. The burn is painful and red; blisters form and the wounds may heal with a scar. - Third degree: burn that extends through the full thickness of the skin and subcutaneous tissues beneath the dermis. The burn is painless because it destroys nerves in the skin. Scar formation and contractures are likely complications. Observation on 12/6/2010 at 4:46 PM revealed that Resident 16 had the following areas noted on the left inner forearm: a light pink area measuring 9.3 cm in length by 3.2 cm in width by the wrist and 1.8 cm at the top toward the elbow. A small broken blistered area measuring 1 cm x .8 cm was noted with a 5.8 cm x 3.2 cm reabsorbed area observed by the wrist area within the larger light pink area. In addition, there were blisters at the upper end of the light pink area which measured 1.9 cm x .8 cm, another measuring .5 cm x .4 cm and a third blister measuring 1.2 cm x .4 cm. When Resident 16's arm was turned over, another area was noted and measured 2.6 cm x 1.8 cm reddened/pink area with what appeared to be a reabsorbed blister in the middle of the area. When Resident 16 was questioned if the burns hurt, Resident 16 affirmed that they hurt. There was no reddened/pink area noted on the thigh of the left upper thigh. Review of Resident 16's admission orders [REDACTED]. Review of Resident 16's ADMISSION PLAN OF CARE dated 11/22/2010 revealed that the resident was unable to feed self. In addition, review of the facility ADMISSION SAFETY ASSESSMENT AND PLAN OF CARE dated 11/22/2010 revealed approaches to pour and keep hot liquids out of reach of the resident and monitor the temperature of coffee, tea and hot water. Facility staff should cool liquids to 140 degrees before serving to those residents at risk. The same precaution should have extended to hot pureed foods for residents needing assistance with eating. Review of the dietary temperatures for food served at the evening meal on 12/4/2010 at 6:00 PM revealed that the temperatures recorded prior to service of the pureed lasagna was 170 degrees F (Fahrenheit) and the pureed broccoli was 188 degrees F. At the end of service at 6:30 PM, the records revealed that the dietary department had run out of the 2 pureed items noted and there were no temperatures recorded. Review of the journal article from the Annals of Burns and Fire Disasters (June 2002) entitled Burn Injuries revealed that a burn is an injury consisting of the destruction of the skin and underlying tissues due to thermal, electrical or chemical causes. The extent and depth of the injury caused by heat depended on how long the heat affected the skin. Review of an Internet article entitled Thermal Burns (5/5/05) by Dr Jerome Naradzay (Director of Emergency Services at Mesa View Regional Hospital) revealed that soft tissue is burned if it is exposed to temperatures above 115 degrees F. The article also noted that the extent of damage depended on the surface temperatures and the contact duration. Interview on 12/6/2010 at 6:35 PM with LPN Licensed Practical Nurse) A revealed that (gender) had been working the evening shift on 12/4/2010 when Resident 16 spilled the hot food on the arm and thigh but was not in the dining room at the time of the incident. LPN A stated that (gender) did not realize the severity of the burn until later in the evening, around 9 PM, when blisters were observed on the arm of Resident 16. LPN A stated that Resident 16 usually didn't grab items off the table. LPN A also stated that the facility usually did not serve hot food to residents who needed assistance unless someone was there to assist the resident. LPN A stated that no one knew why hot food was served to Resident 16 without supervision. Interview on 12/7/2010 at 10:50 AM with NA (Nursing Assistant) C revealed that (gender) was working the evening of 12/4/2010 around 6:00 PM when Resident 16 received the burn from hot spilled food. NA C stated that Resident 16 must have been served the tray and then tried to feed self but pulled the tray off the table, spilling the hot food on the arm and thigh of the resident. NA C stated that (gender) wiped the food off the arm of Resident 16 and did not notice any redness on the arm. NA C stated that Resident 16 was not wearing long sleeves and the food was directly on the skin of the arm. NA C got the resident another plate of food and did not provide any type of first aid or seek the assistance of the charge nurse. NA C stated that Resident 16 was not immediately removed from the dining room for an assessment of the area nor was LPN A, charge nurse notified immediately to perform an assessment. NA C stated that it was probably 5-10 minutes before Resident 16 was taken to the charge nurse. NA C stated that on the way to the Nurse's Station, NA C observed that the arm was red. Interview on 12/7/2010 at 11:19 AM with NA L revealed that (gender) was at a different table assisting residents with eating on 12/4/2010 at the evening meal and noticed that Resident 16 had been served the evening meal. NA L stated that (gender) did not actually see Resident 16 dump the tray but did notice that the pureed food had been spilled. NA L stated that it was probably 10-15 minutes before Resident 16 was removed from the dining room. NA L stated that (gender) did not witness any assessment by LPN A, the charge nurse. Around 7:00 PM, NA L went to Resident 16's room and was shown Resident 16's arm by another NA. NA L stated that the arm was bright pink with no blisters observed. A cool wet washcloth was put on the area at that time, about 30 minutes after Resident 16 spilled the hot food on that arm and leg. Interview on 12/7/2010 at 11:37 AM with NA K revealed that the incident of Resident 16 spilling the hot pureed food occurred about 6:30 PM on 12/4/2010. NA K stated that (gender) did not see Resident 16 spill the food. NA K stated that there was no nursing staff at the table when the Dietary Aide served the tray to Resident 16. After Resident 16 spilled the food, NA C cleaned Resident 16 off and ordered another tray of food. NA K stated that it was probably 15 minutes before NA C took Resident 16 out of the dining room to the Nurse's Station for LPN A to make an assessment of the arm. Around 7:00 PM, NA K stated that (gender) took Resident 16 to the resident's room and wrapped the arm with a wet towel. NA K stated that no food was observed on the arm at that time but there was still food on Resident 16 clothing. NA K stated that Resident 16's arm was dark pinkish when wrapped with the wet towel. When NA K removed the towel around 7:15 PM, the arm was a lighter pink in color but NA K did not notice any blisters at that time. NA K stated that LPN A did not go to Resident 16's room until after the resident was put to bed. Interview on 12/7/2010 at 9:52 AM with DA (Dietary Aide) J revealed that nursing staff told dietary when they were ready for a meal to be served at the assisted residents' tables. DA J stated that they were not to leave a plate if nursing staff were not present. DA J thought it was policy to not leave the plate if no staff was present. DA J stated that (gender) did not know if someone told (gender) that or how long the policy had been in place. DA J stated that (gender) didn't think it was a good idea to leave food in front of a resident if nursing assistants were not there to help with eating. Interview on 12/7/2010 at 10:04 AM with the DM (Dietary Manager) revealed that the facility did not have a policy and procedure regarding meal service to residents that need assistance with eating. The DM stated that Dietary Aides were told in training not to leave plates of food if nursing staff were not present to assist residents with eating. Dietary Aides were instructed to take the plate back to the kitchen until nursing staff was present to assist residents with eating. The DM stated that both Dietary Aides working on 12/4/2010 had been interviewed and neither could remember if nursing staff were available to provide assistance to Resident 16 when the hot food was served. Interview on 12/6/2010 at 5:25 PM with the DON (Director of Nursing) revealed that the DON was not notified of Resident 16's burn until on the way to the facility on [DATE] at 4:15 PM. The DON stated that if (gender) had been notified, guidance could have been provided to the staff on the care and treatment of [REDACTED].