Every finding on record at Adept Nursing & Rehab of Gretna

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g). The facility failed to obtain settings and ensure tubing and mask was changed for the use of a noninvasive ventilator for 1 (Resident 3) of 1 residents sampled, failed to monitor oxygen saturations to ensure oxygen blood levels were maintained for 1 (Resident 1) of 4 residents sampled and failed to ensure oxygen tubing was dated for 2 (Residents 2 and 42) of 4 residents sampled. The facility census was 40. The findings are: A.Record review of the facility's undated policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) revealed it is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standards of practice. The facility will obtain an order for the use of CPAP, BiPap, AVAPS, or Trilogy device and settings from the practitioner. The facility will replace equipment routinely in accordance with manufacturer recommendations. General guidelines for face mask and tubing changes was once every 3 months. Record review of the facility's undated policy titled Oxygen Administration revealed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: -type of oxygen delivery system -when to administer, such as continuous or intermittent and/or when to discontinue. -equipment settings for the prescribed flow rates. -monitoring of oxygen saturation levels and/or vital signs as ordered. -monitoring for complications associated with the use of oxygen. The staff shall perform hand hygiene and wear gloves when administering oxygen. Other infection control measures include: -follow manufacturer recommendations for the frequency of cleaning equipment filters. -change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. B. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as 15. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact. -required partial assistance with upper body dressing. -required extensive assistance with hygiene and bed mobility. -required total assistance with toileting, bathing, lower body dressing and transfers. -was receiving oxygen therapy. -was using a noninvasive ventilator. Record review of Resident 3's Order Summary (OS) printed on 03-02-2026 revealed an order to apply Trilogy Noninvasive Ventilator mask at bedtime, with heated humidity and 4 liters of oxygen bled in (oxygen attached to the ventilator). Further review of the OS revealed the absence of settings for the Trilogy noninvasive ventilator or orders for replacement of the Trilogy face mask and tubing. An interview conducted with the Director of Nursing (DON) on 03-05-2026 confirmed the settings for the Trilogy noninvasive ventilator was not obtained from the practitioner and the facility has no record of the last time the face mask and tubing had been changed. C.Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as13. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required partial assistance with upper body dressing and personal hygiene. -required substantial assistance with bed mobility. -required total assistance with toileting, bathing, lower body dressing, and transfers. -was receiving oxygen therapy. Record review of Resident 1's OS printed on 03-02-2026 revealed an order for oxygen titrate (adjusting the flow rate of supplemental oxygen up or down to maintain a blood oxygen saturation) 2 to 4 liters to maintain oxygen saturations greater than 90% continuous via nasal cannula. Record review of Resident 1's Electronic Health Record including progress notes, vital sign documentation, Medication and Treatment Administration Records (MAR and TAR) revealed only daily oxygen saturation monitoring. An interview conducted with the DON on 03-05-2026 at 1:15 PM confirmed in order to ensure Resident 1 was receiving the correct flow of oxygen to keep blood oxygen saturations greater than 90% the staff would need to check Resident 1's oxygen saturations more than once a day and at least shiftly. D. A record review of a Medicare 5 day MDS dated [DATE] revealed Resident 2 had a BIMs of 14/15 indicating cognitively intact, required set up for eating, partial/moderate assist for oral hygiene, upper body dressing, substantial/max assist for toileting hygiene, shower bathing, and lower body dressing, dependent for putting on and taking off footwear, and required oxygen for intermittent use. A record review of order summary report revealed the following orders; 12/29/25 for Oxygen therapy 2 liters per minute via nasal canula to keep oxygen saturation level greater than 88%. 12/31/25 Oxygen at 1 liter via nasal canula at night. A record review of the Medication Administration Record for January and February 2026 revealed Oxygen was signed out daily. An observation of Resident 2 on 3/3/26 at 8:06 A.M. revealed Oxygen on per nasal canula at 2 liters per minute. An oxygen concentrator next to the bed had a plastic baggie dated 2/26/26, no markings on the tubing to indicate the date. An observation of Resident 2 on 3/4/26 at 5:53 A.M. revealed oxygen on per nasal canula at 2 liters per minute. An oxygen concentrator next to the bed had a plastic baggie dated 2/26/26, no markings on the tubing to indicate the date. An observation of Resident 2 on 3/5/26 at 7:22 A.M. revealed oxygen on per nasal canula at 2 liters per minute. An oxygen concentrator next to the bed had a plastic baggie dated 2/26/26, no markings on the tubing to indicate the date. Interview with DON on 03/05/2026 at 7:26 AM confirmed the oxygen tubing should be marked with the date the tubing was changed. E. Record review of Resident 42's admission Face Sheet revealed an admission date of 4/16/25 and diagnoses that included Chronic Pulmonary Obstructive Disease, obstructive sleep apnea, respiratory failure with hypoxia and dependance on supplemental oxygen. Record review of Resident 42's MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment, total dependance on staff for all activities of daily living and oxygen use while a resident. Record review of Resident 42's Physician Orders revealed the following order: 07/19/2025 O2 [Oxygen] 4 LPM [liters per minute] via NC [nasal cannula]. May titrate as able with goal of O2 saturations greater than 94% every shift. Observations on 03/02/2026 at 8:58 AM and 10:23 AM revealed Resident 42 in bed with Oxygen in place and running on a concentrator at 4 liters per minute via nasal cannula. The tubing had no date that identified when it had last been changed. Observations on 03/03/2026 at 7:55 AM and 03/04/2026 at 6:02 AM revealed Resident 42 in bed with Oxygen in place and running on a concentrator at 4 liters per minute via nasal cannula. The tubing had no date that identified when it had last been changed. Record review of Resident 42's February and March 2026 Treatment Administration Records revealed no information documented as to when the tubing had last been changed for the use of the oxygen. Interview on 03/04/2026 at 11:15 AM with the DON: confirmed that the Oxygen tubing was not dated and should be dated when changed, changed weekly and documented on the TAR.

Licensure Reference Number 175 NAC 12-006.10(D). Based on observation, interview and record review the facility failed to ensure a medication error rate of 5% or less as evidenced by 3 errors out of 25 opportunities for error resulting in a medication error rate of 12%. The facility census was 40. The findings are:Record review of the facility's undated policy titled Medication Errors revealed it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors.Medication error means the observed or identified preparation or administration of medications or biologicals which were not in accordance with the prescriber's order; manufacturer's specifications regarding preparation and administration of medication or biological; or accepted professional standards and principles which apply to professionals providing services. The facility shall ensure medications will be administered as follows:-according to physician's orders-per manufacturer's specifications regarding preparation and administration of the drug or biological-in accordance with the accepted standards and principles which apply to professionals providing services. The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. A.Record review of Resident 35's Physician's Orders (PO) revealed an order for torsemide 80 milligrams (mg), give by mouth in the morning for edema (swelling). An observation conducted on 03-04-2026 at 7:10 AM of Medication Aide (MA) D administering medications to Resident 35 revealed a medication torsemide 80 mg was unavailable for administration. An interview conducted on 03-04-2026 at 7:15 AM with MA D revealed MA D would inform the charge nurse of the need to obtain the torsemide from the facility's medication bank. An interview conducted on 03-04-2026 at 8:30 AM with Licensed Practical Nurse (LPN) E revealed Torsemide 80 mg was not available in the facility's medication bank and the pharmacy had been notified. An interview conducted on 03-04-2026 at 2:00 PM with LPN E confirmed the Torsemide for Resident 35 had not arrived from the pharmacy and Resident 35 had missed a dose and a missed dose is a medication error. B.Record review of Resident 24's PO revealed an order for sucralfate (a medication used to treat stomach ulcers) 1 gram (GM) by mouth before meals and at bedtime. An observation conducted on 03-04-2026 at 12:45 AM of MA C administering medications to Resident 24 revealed the sulcrafate 1 GM was administered after Resident 24 had already eaten lunch. An interview conducted on 03-04-2026 at 12:50 PM with MA C confirmed the medication was given after the meal and should have been administered before. C.Record review of Resident 33's PO revealed an order for finasteride 5 mg by mouth one time a day for urinary retention. The finasteride was scheduled to be given at 8:00 PM. An observation conducted on 03-04-2026 at 1:00 PM of MA C administering medications to Resident 33 revealed MA C administered finasteride 5mg. An interview conducted with the Director of Nursing (DON) on 03-05-2026 at 8:30 AM confirmed the finasteride 5mg should have been administered at 8:00 PM for Resident 33 and confirmed missed doses and medications given at the wrong time were medication errors.

Based on record review and interview the facility failed to update advanced directives in the medical record for 1 (Resident 1) of 17 residents sampled. The facility census was 40. The findings are:Record review of the facility policy dated 10-01-2022 titled Communication of Code Status revealed it is the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. The facility will follow facility policy regarding resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive. When an order is written pertaining to a resident's presence or absence of an Advance Directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include: Full Code, Do Not Resuscitate, Do Not Intubate and Do Not Hospitalize. The nurse who notates the order is responsible for documenting the directions in all relevant sections of the medical record.Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as13. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required partial assistance with upper body dressing and personal hygiene.-required substantial assistance with bed mobility.-required total assistance with toileting, bathing, lower body dressing, and transfers.-was receiving oxygen therapy. Record review of Resident 1's Advance Directive Information ([NAME]) dated 01-07-2026 revealed Resident 1 had changed the advance directive from I wish Cardio-Pulmonary Resuscitation (CPR) to I do not want CPR. Record review of Resident 1's Comprehensive Care Plan (CCP) printed on 03-02-2026 revealed Resident 1 had orders that include a status of Full Code. An interview conducted on 03-02-2026 at 11:43 AM with Licensed Practical Nurse (LPN) A confirmed there was a discrepancy between the [NAME] and the CCP and there should not have been.

Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview, the facility failed to identify and monitor specific target behaviors and side effects for the use of psychotropic medications for Residents 42 and 43 and failed to ensure AIMS testing had been completed for Resident 6 and failed to monitor and evaluate sleep patterns for the continued use of hypnotic medications for 3. A total of 5 residents were reviewed for unnecessary medication use. The census was 40. Findings are:A. Record review of a facility policy (undated) entitled Use of Psychotropic medication revealed the following information: It is the intent of this policy to ensure that residents receive psychotropic medications when nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the residents' medical symptoms. Definitions: Adverse Consequences is a broad term referring to unwanted, unintended, or dangerous effects that a drug may have, such a impairment / decline in an individual's mental or physical condition or functional or psychosocial status. Policy Explanation and Compliance Guidelines: 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. Psychotropic medications that are to be used only when a practitioner determines that the medication(s) is appropriate to treat a residents specific, diagnosed and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The indications for initiating, maintaining or discontinuing medications, as well as the use of non-pharmacological approaches, will be determined by evaluating the residents physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of the relative risks and benefits, and the preferences and goals for treatment. 13. Residents that receive an antipsychotic medication will have an abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change, change in antipsychotic medication PRN [as needed] or as per facility policy 15. The resident's response to the medication(s), including progress towards goals and presence / absence of adverse consequences, shall be documented in the resident's medical record. B. Record review of Resident 42's admission Face Sheet revealed that Resident 42 was admitted to the facility on [DATE] and included a diagnosis of bipolar disorder [a mood disorder], major depressive disorder, recurrent severe with psychotic symptoms and generalized anxiety disorder. Record review of Resident 42's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's plan of care) most recent quarterly MDS dated [DATE] revealed that Resident 42 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 03 which indicated that Resident 42 was severely cognitively impaired. (a score of 0 - 7 indicated severe cognitive impairment, required total dependance on staff for activities of daily living [dressing, bathing, grooming, transfers, toileting and Hygiene], and used antipsychotic and antidepressant medications daily with indications for use present. Record review of Resident 42's Physician Orders revealed the following psychotropic medication orders: 11/15/25 Seroquel [an antipsychotic medication used to treat psychosis which includes symptoms like hallucinations and delusions [fixed beliefs]. Oral Tablet 50 mg [milligrams] (Quetiapine Fumarate) Give 100 mg by mouth at bedtime for anxiety, delusion. 11/15/25 Seroquel Oral Tablet 50 mg (Quetiapine Fumarate) Give 50 mg by mouth in the afternoon for anxiety, delusion. 11/15/25 Seroquel Oral Tablet 50 mg (Quetiapine Fumarate) Give 50 mg by mouth in the morning for anxiety, delusions related to bipolar disorder. 11/18/25 Sertraline [an antidepressant medication] HCl Oral Capsule 150 mg, Give 150 mg by mouth one time a day related to major depressive disorder, recurrent. Record review of Resident 42's Comprehensive Care Plan [CCP, a document that includes measurable objectives and timetables to meet a residents medical, nursing, and mental and psychosocial needs thata re identified in the comprehensive assessment] dated 2/27/26 identified that Resident 42 used psychotropic medications with the following interventions identified: Psychotropic Drug Use: [Resident 42] receives psychotropic medications related to depression, anxiety, bipolar disorder and delusional disorder Date Initiated: 04/25/2025 Revision on: 05/08/2025 [NAME] will be free from discomfort related to psychotropic medication therapy through the next 90 days. Date Initiated: 05/08/2025 Revision on: 12/02/2025 Target Date: 05/06/2026 Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 05/08/2025 Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness. Antidepressant side effects include Dry mouth, dry eyes, blurred vision, constipation, urinary retention, sedation/drowsiness, excessive weight gain, and suicidal ideations. Date Initiated: 05/08/2025 Administer anti-anxiety medications as ordered by physician. Side effects antianxiety medications: Drowsiness, lack of energy, slow reflexes, slurred speech, confusion, depression, dizziness, Impaired thinking and judgment, forgetfulness, gastric distress, changes in vision. Paradoxical side effects: Mania, Hostility and rage, impulsive behavior, and Hallucinations. Date Initiated: 05/08/2025 Evaluate effectiveness and side effects of medications routinely for possible decrease/elimination of psychotropic medications. Date Initiated: 05/08/2025 SW Monitor/record/report to MD [Medical Doctor] prn [as needed] side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Date Initiated: 05/08/2025 Monitor interaction of resident with other people for appropriateness. Date Initiated: 05/08/2025 Record review of Resident 42's CCP dated 2/27/26 identified that Resident 42 exhibited ongoing behavioral concerns with the following interventions: Behavioral Problem: [Resident 42] has a behavior problem as evidenced by: refusing to accept caregivers suggestions, arguing, making false accusations, making racially in appropriate statements. Date Initiated: 04/25/2025 Revision on: 12/30/2025 [Resident 42]'s behavior will not interfere with the delivery of care or services, or result in harm to self or others through the next review date. Date Initiated: 05/10/2025 Revision on: 12/02/2025 Target Date: 05/06/2026 Administer medications as ordered. Monitor and document for effectiveness and potential adverse side effects. Date Initiated: 05/10/2025 Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. Date Initiated: 05/10/2025 Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others. Date Initiated: 05/10/2025 Assist to develop more appropriate methods of coping and interacting. Encourage to express feelings appropriately. Date Initiated: 05/10/2025 Psychiatric consult per indication or physician's order. Date Initiated: 05/10/2025 Record review of Resident 42's Medication Administration Record [MAR] for [DATE] and [DATE] revealed that Resident 42 received Seroquel and Sertraline per the physicians orders. Record review of Resident 42's Electronic Medical Record, MAR and TAR [treatment administration record] revealed that no specific side effects had been identified and no behavior monitoring had been completed related to the antipsychotic and antidepressant medication use. Interview on 03/04/2026 at 11:48 AM with the Director of Nursing [DON] confirmed no specific target behaviors had been identified on the TAR for the use of the Seroquel and the Sertraline and should have been. The DON confirmed that behavior monitoring had not been documented on the TAR and should have been. The DON confirmed target behaviors and side effect monitoring should be monitored daily and documented on the TAR. The DON confirmed that side effects and some target behaviors had been identified in the care plan, but they did not make it on the TAR for documented monitoring. C. Record review of Resident 6's admission face sheet revealed an admission date of 6/17/24 and diagnoses that included Schizoaffective Disorder Bipolar Type [a mental condition that combines symptoms of Schizophrenia such as hallucination and delusions with mood disorder symptoms]. Record review of Resident 6's annual MDS dated [DATE] revealed that Resident 6 had a BIMS score score of 07 which indicated that Resident 6 was severely cognitively impaired. (a score of 0 - 7 indicated severe cognitive impairment), was independent with activities of daily living [dressing, bathing, grooming, transfers, toileting and Hygiene], rejected cares 1-3 days per week and used antipsychotic and antidepressant medications daily with indications for use present. Record review of Resident 6's Physician Orders revealed the following psychotropic medication orders: 05/01/2025 Quetiapine Fumarate Oral Tablet 150 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for behaviors related to schizoaffective disorder, bipolar type 05/01/2025 Quetiapine Fumarate Oral Tablet 200 MG (Quetiapine Fumarate) Give 1 tablet by mouth in the morning for behaviors related to schizoaffective disorder, bipolar type Record review of Resident 6's Medication Administration Record [MAR] for [DATE] and [DATE] revealed that Resident 6 received Seroquel per the physicians orders. Record review of Resident 6's AIMS testing revealed that Resident 6 had not had an AIMS test performed since 08/25/2025. Interview on 03/04/2026 at 1:59 PM with the DON confirmed that Resident 6 had not had an AIMS test since August of 2025. The DON confirmed that AIMS testing should be done quarterly and this was not done for Resident 6. D. A record review of the Quarterly MDS, dated [DATE] revealed Resident 43 had a BIMS of 15/15 indicating intact cognition, with no behaviors noted. Resident 43 was noted to be Independent with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, transferring self in and out of bed, and required partial/moderate assistance to shower/bathe self. Medications listed on MDS were antipsychotic, antianxiety, and antidepressant Record review of Medical Diagnosis sheet in the electronic medical record revealed diagnosis of Bipolar Disorder dated 10/14/25, General Anxiety Disorder dated 5/9/23, Major Depressive Disorder, single episode, unspecified, dated 5/9/23 A record review of the Order Summary Report revealed the following orders 2/24/26 Buspirone HCL oral Tablet 7.5mg. Give 1 tablet by mouth two times a day. 12/1/25 Clonazepam Oral tablet Denigrating 0.5mg. Give 1 tablet by mouth in the morning. 10/14/25 Duloxetine HCL Oral Capsule Delayed Release Particles 60 mg. Give 1 capsule by mouth one time a day. 10/14/25 Escitalopram Oxalate oral tablet 5mg. give 1 tablet by mouth one time a day. 10/14/25 Quetiapine Fumarate Oral Tablet 25 mg. Give one tablet by mouth at bedtime. Give with 50mg tablet for a total of 75mg. 10/14/25 Quetiapine Fumarate Oral Tablet 50 mg. Give one tablet by mouth at bedtime. Give with 25mg tablet for a total of 75mg. A record review of the Care Plan Report dated 10/14/25 with a focus on psychotropic drug use did not list any target behaviors. An interview with the DON on 3/6/26 at 7:26 AM confirmed there were no target behaviors documented for Resident 43.

Licensure Reference Number 175 NAC 12-006.09(F0(iii) Based on record review and interview, the facility failed to review and revise the Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) to ensure the correct advanced directive information was identified for 1(Resident 8) of 1 resident reviewed for Hospice. The facility census was 40. Findings are: Record review of Resident 8's admission Face Sheet revealed an original admission date of 06/08/2023 and the Clinical Census identified a re-admission to Medicaid Hospice Services on 2/19/26. Record review of Resident 8's significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 2/27/26 revealed that Resident 8 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14 (a score of 13 - 15 indicated the resident is cognitively intact), required extensive to total assistance from staff with activities of daily living and received Hospice services while a resident. Record review of the Hospice admission for the Coordination of Care documents dated 2/19/26 identified a Hospice admission diagnosis of Cerebral Infarction. Record review of a Do Not Resuscitate Order document dated 2/19/26 revealed a signed document that identified that Resident 8 understood that a Do-Not-Resuscitate (DNR) order means that if the heart stops beating or breathing stops, no medical treatment will be started or continued. The document was signed by Resident 8's legally authorized representative. The legally authorized representative checked the box that indicated that Resident 8 did want a DNR order. Record review of Resident 8's Physician Orders revealed an order for Do Not Resuscitate dated 2/19/26. Record review of Resident 8'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 January 2026 revealed the following information for Resident 8: My Advanced Directives are full code.Date Initiated: 06/20/2023Revision on: 08/20/2025 I do not want to change myadvance directive at this time.Date Initiated: 06/20/2023Revision on: 07/11/2025Target Date: 03/06/2026 Request change in doctor's order if appropriate.Date Initiated: 06/20/2023 Resident will be given assistance to set up an appointment with their doctor asneeded to discuss changes in their advanced directive.Date Initiated: 06/20/2023 Resident will be informed/educated about advanced directives and be giveninformation per resident request.Date Initiated: 06/20/2023 Interview on 03/04/2026 at 9:50 AM with the facility Social Worker confirmed that Resident 8's CCP had not been updated to include a no code status and should have been. The SW confirmed that it should have been changed after the resident went on Hospice and the facility got the DNR order and the signed documents from Hospice. The SW confirmed that Resident 8's CCP still identified a full code status.

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview and record review the facility failed to implement a fluid restriction for 1(Resident 28) of 2 residents sampled. The facility census was 40. The findings are:Record review of the facility's undated policy titled Fluid Restriction revealed fluid restrictions may be ordered by a qualified professional (Physician, Nurse Practitioner, or when delegated to the Registered Dietician) as a part of a fluid management program for residents with edema, heart failure or dialysis. The amount of fluid allowed per 24 hours is written as a Physician's order using the approved community process. The fluid restriction order is sent to dining services in writing via the designated diet order form. Responsibility for dividing and communicating the allowed milliliters (ml) of fluids between Dining Services and Nursing Services per 24 hours is facilitated by the Dining Manager. Record review of Resident 28's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as 12. According to the MDS Manual a score of 7-12 indicates moderate cognitive impairment.-required extensive assistance with toileting, bathing and lower body dressing.-required limited assistance with upper body dressing, bed mobility and transfers. Record review of Resident 28's Medication Administration Record for February 2026 revealed Resident 28 was on a 1500 ml fluid restriction without division of fluids between Dietary and Nursing Services.Record review of Resident 28's Comprehensive Care Plan (CCP) printed on 03-02-2026 revealed the absence of a fluid restriction. Record review of Resident 28's Dietary Meal Ticket (DMT) printed on 03-04-2026 revealed no information regarding a fluid restriction or how much fluid Resident 28 should have with each meal. An observation on 03-03-2026 at 12:00 PM revealed Resident 28 was in the dining room for lunch and had a Styrofoam cup of water. An observation on 03-03-2026 at 12:15 PM revealed Resident 28 was in (gender) with family eating Arby's. Resident 28 had a medium size soda, and a water pitcher in the room that was half gone. An interview conducted on 03-04-2026 at 9:00 AM with Resident 28 revealed (gender) had an order for a fluid restriction but isn't being enforced right now. An interview with Nursing Assistant (NA) B on 03-04-2026 at 11:00 AM revealed NA B was not aware of a fluid restriction for Resident 28.An interview with the Director of Nursing (DON) on 03-05-2026 confirmed the fluid restriction was not implemented and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2). Based on interview and record review the facility failed to obtain orders for treatment of a pressure ulcer for 1(Resident 51) of 2 residents sampled. The facility census was 40. The findings are:Record review of the facility policy dated 08-2025 titled Wound Treatment Management revealed the policy was to promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with the current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. Record review of Resident 51's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-could not make themselves understood.-required partial assistance with bed mobility, eating and hygiene.-required substantial assistance with upper body dressing and transfers.-required total assistance with toileting and lower body dressing. Record review of Resident 51's Admission/readmission Assessment ([NAME]) dated 01-09-2026 revealed a pressure ulcer had been identified to the sacral area (the area just above the tailbone) measuring 2.0 by 1.0 centimeters (cm). Record review of Resident 51's Order Summary (OS) printed on 03-02-2026 revealed no order for the treatment of the pressure ulcer to the sacrum. An interview conducted with Registered Nurse (RN) F on 03-05-2026 at 10:35 AM revealed Resident 51 had a pressure ulcer to the sacral area and confirmed the physician was not notified and an order was not obtained and should have been.

Licensure Reference Number 175 NAC 12-006.12(vi)Based on record review and interview the facility failed to ensure a rationale was provided for the continued use of ibuprofen for Resident 43. The facility identified a census of 40.Findings are:A.A Record review of a Policy entitled Medication Regimen Review dated 8/3/25 and revised 8/3/25 revealedPolicy:The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and included a review of the resident's medical chart.4. The pharmacist shall document, either manually or electronically, that each medication review has been completed. a. The pharmacist shall document either that no irregularity was identified or the nature of any identified irregularities. b. The pharmacist does not need to document continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendations. B.A record review of the Quarterly Minimum Data Set (MDS , a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 1/16/26 revealed Resident 43 had a Brief Interview for Mental Status (BIMS) of 15/15 indicating intact cognition, with no behaviors noted. Resident 43 was noted to be Independent with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, transferring self in and out of bed, and required Partial/moderate assistance to shower/bathe self.A record review of a Physicians Order dated 2/12/26 revealed an order for Ibuprofen Oral Capuls 200mg, Give 2 capsules by mouth two times a day for PainA record review of a Physician Order dated 2/9/26 revealed an order for Ibuprofen Oral Capsule 200mg, Give 2 capsuled by mouth every 12 hours as needed for Pain Record review of a document entitled Pharmacist's Recommendation to Prescriber date 1-27-2026 for Resident 43 revealedPrescriber: [Physicians name]Resident is on the anticoagulant Xaretlo and is taking the following nonsteroidal anti-inflammatory drug (NSAID):Ibuprofen cap 200mg: Take two capsules (400 mg) by mouth twice dailyAnticoagulants in combination with NSAID's can increase the risk of bleeding. Recommendation:Discontinue the above NSAID order for IbuprofenPhysicians ResponseDisagree - (Clinical record must include clear rationale)Prescriber's Comments:Take 400mg Ibuprofen every 12 hours as needed for pain-dated 2/6/26 In an interview with the DON on 3/6/26 at 10:36 a.m. confirmed the prescriber had not documented the rationale for ibuprofen.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(iii)(1 & 2)Based on observations, interviews, and record review, the facility failed to evaluate causal factors and failed to implement interventions to prevent pressure wounds for 1 (Resident 3) of 4 sampled residents. The facility staff identified a census of 44.The findings are:Record review of Resident 3's 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) dated 7/1/2025 revealed the facility staff identified the following about the resident: -Resident 3 was rarely or never understood and had short and long-term memory problems. -Resident 3 did not exhibit behaviors. -Resident 3 was dependent upon staff for all cares including bed mobility, transfers, hygiene, and toileting. -Resident 3 had a gastrostomy tube (g-tube, a flexible tube passed into the stomach for introducing fluids and liquid food into the stomach) and that Resident 3 received 51% or more of calories through and 501 milliliters (mL) per day or more of fluids through the g-tube. -Resident 3 was identified as at-risk for pressure ulcer development. -Resident 3 had one stage 4 pressure ulcer present on admission.Record review of Resident 3's Braden Risk Evaluation-V2 dated 6/30/2025 identified the resident was at high risk for pressure ulcer development.Record review of Resident 3'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) identified Resident 3 had an actual impairment of skin integrity dated 3/28/2025, and had the potential for the development of a pressure ulcer dated 5/5/2025. The CCP identified interventions that included: -4/17/2025: Bed mobility dependent, transfers dependent. -5/5/2025 Air mattress to bed -5/5/2025 Off load heels as ordered and as needed -5/5/2025: Reposition frequently or more often as needed or requested. -5/5/2025: Pressure relieving/reducing devices on bed/chair. -7/8/2025 Blisters/wounds to bilateral feet -7/16/2026 Foot board removed from bedRecord review of Resident 3's Skilled Nursing Visit Note dated 7/4/2025 identified Resident 3 had impaired skin integrity with a goal to be free from additional wounds.Record review of Resident 3's Order Summary Report printed 8/19/2025 revealed the following provider orders: -Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after feeding is stopped dated 3/24/2025. -Keep Negative Pressure Wound Therapy (wound vac) @ 120 millimeters of mercury (mmHg), assess pump per shift, ensure pump is charged/plugged in (check middle of cord), change canister when full, document output dated 5/8/2025. -If wound vac comes off, okay to pack wound with gauze lightly soaked with saline until next wound vac change day, cover with Mepilex (an absorbent, soft foam dressing) dated 6/30/2025. -Wound vac to coccyx at 120mmHg with continuous suction. Assess pump Q shift for function and change canister prn if full and document output dated 7/10/2025. -Cleanse with Vashe wound cleanser (a hypochlorous acid-based wound cleanser designed to cleanse, irrigate, moisten, and debride acute and chronic wounds, including ulcers and burns, as well as minor cuts and abrasions), cut and apply double layer of collagen alginate (a composite wound dressing made from a combination of natural collagen fibers and acts as a scaffold for new tissue growth, providing a moist wound environment that supports wound healing) to wound bed, specifically over exposed bone, apply DuoDerm (a hydrocolloid dressing that creates an airtight seal and is used to help manage wound under a vacuum assisted closure device) to peri-wound, apply protective layer of film, apply black sponge from wound bed to hip then apply top layer of film, apply suction appliance. Do not allow resident to lay on her back. Change dressing every Tuesday, Thursday, and Saturday dated 7/13/2025. -Pedal Wounds - cleanse area with soap and water, pat dry, apply betadine paint to wound, allow to completely dry daily by facility or hospice nurse dated 8/18/2025.A. Record review of Resident 3's Progress Notes (PN) dated 7/6/2025 identified a fluid filled blister on the bottom Resident 3's right foot measuring 5.5 centimeters (cm) by (x) 4.5 cm and an open area remained to the right heel.Record review of Resident 3's PN dated 7/8/2025 revealed facility staff contacted Resident 3's hospice provider regarding blisters/pressure wounds on bilateral feet. The hospice provider reported they would be at the facility on 7/9/2025. New orders were received for all pedal wounds: Betadine wet to dry dressing: A betadine-soaked gauze followed by dry gauze and abdominal pad (ABD, a large, multi-layered, and highly absorbent dressing) over them as well for padding and so betadine doesn't leak through to socks/bedding. Secure with kerlix (a sterile gauze bandage made of pre-washed, fluff-dried, 100% woven cotton gauze that provides bulk and cushioning) and a light layer of Coban (self-adherent elastic wrap that functions like a tape but sticks only to itself) (no compression) change three times a week and as needed (PRN). Hospice will bring supplies on 7/9 to assess skin, prevalon boot, and bed length.Record review of an Incident Audit Report dated 7/8/2025 regarding Resident 3's new skin alteration revealed a left heel pressure wound 4 cm x 4.5 cm area is black and blister like. Bottom of right foot 6cm x 4.2cm black blister, fluid filled, area is intact. Right heel 3cm x 3cm area is black and non-fluid filled. Further review of the Incident Audit Report revealed other predisposing physiological factors was marked yes and other information was marked bedbound.Record review of Resident 3's Skilled Nursing Visit Note dated 7/9/2025 by the hospice Registered Nurse showed Notified by LPN yesterday of new pedal wounds. RT (right) plantar black fluid filled sack. Blister like wound not to be popped-6 cm x 4cm x 2cm; RT heel 3x3cm appears to be eschar with pink to epithelializing area with frank blood visualized under the skin around wound. LT heel 4cm x 4.5cm appears to be eschar with pink to epithelializing area. Wound care supplies left. Will plan on calling DME (durable medical equipment) to check what's needed to place a ‘bed extender.' PT is 6 feet 0 inches and with HOB elevated feet are continuously pushing against prafo boots and footboard.Record review of Resident 3's Tissue Analytics (TA) dated 8/14/2025 identified a left heel unstageable pressure ulcer that measured 2.99 cm x 3.88 cm. Further review of the TA identified a right plantar foot unstageable pressure ulcer that measured 3.63 cm x 4.59 cm.Observation on 8/20/2025 at 10:35 AM of Resident 3's right foot revealed an eschar (a thick, dry, dark, and leather layer of dead tissue that forms over a wound or burn) covered fluid-filled blister with an intact covering at the middle of the right foot extending to the edge of the right foot. The skin surrounding the top edge of the blister had a light purple colored appearance, while the remaining three edges of the wound were free from discoloration. There was no swelling or drainage identified. Observation of the left heel revealed an eschar covered dry blister covering the back of the heel of the left foot. The skin surrounding the blister was free from discoloration and there was no swelling or drainage identified.Observation on 8/20/2025 at 10:35 AM of Registered Nurse (RN)-F performing bilateral foot wound treatment revealed RN-F performed the wound treatment as prescribed. After the treatment, RN-F called for staff to help reposition Resident 3 to the head of the bed. Prior to repositioning, Resident 3's bilateral feet were at the edge of the foot of the bed, and no footboard was present.An interview on 8/20/2025 at 10:40 AM with RN-F revealed the left heel and right plantar foot wounds were facility acquired. RN-F stated the footboard was a factor as Resident 3's feet pushed against it, so the footboard was later removed. RN-F confirmed that Resident 3 was very tall and needed a longer bed.An interview on 8/20/2025 at 3:08 PM with the Director of Nursing (DON) revealed when a new wound is developed, causal factors would be discussed in the morning clinical meeting. The DON revealed [gender] was unsure of the causal factors for the right plantar and left heel wounds. The DON confirmed the footboard was removed from Resident 3's bed on 7/16/2025, 11 days after identification of the wounds to bilateral feet. The DON reported the hospice company did send a longer bed for Resident 3 and since facility staff were unaware of the longer bed's delivery, it was sent back.B. Record review of undated Operating Instructions for Drive 14026, a low air loss mattress replacement system (a specialized type of medical mattress designed to prevent and treat pressure ulcers) revealed staff should determine the patient's weight and set the control knob to that weight setting on the control unit.Record review of Resident 3's Weight Summary printed 8/20/2025 identified Resident 3's weight as 176.8 pounds on 6/20/2025. There were no additional recent weights for review.Observation on 8/19/2025 at 3:04 PM revealed a low air loss mattress control unit set at 200.Observation on 8/20/2025 at 10:35 AM revealed a low air loss mattress control unit set at 200.Observation on 8/20/2025 at 3:27 PM revealed a low air loss mattress control unit set at 250.An interview on 8/20/2025 at 10:40 AM with RN-F confirmed the air mattress was set at 200 pounds. RN-F revealed that she was unaware of what setting the air mattress should be at or how the setting is determined.An interview on 8/20/2025 at 1:37 PM with the DON revealed the air mattress control unit was not set by the resident's weight and the setting was determined by touch.An interview on 8/20/2025 at 3:27 PM with the Assistant Director of Nursing (ADON) confirmed the control unit was set at 250 pounds. The ADON revealed that it is difficult to tell where the air mattress should be set because hospice discontinued the weight order.C. Observation on 8/19/2025 at 2:32 PM of Resident 3's coccyx wound identified a circular wound with a tear-drop shaped extension at the bottom of the wound. The wound bed was beefy red, and the surrounding skin was clean, dry, and free from discoloration. There was no drainage. The wound vac canister was absent from drainage.Observation on 8/19/2025 from 2:32 PM through 3:04 PM of Registered Nurse (RN)-F performing wound treatment to Resident 3's coccyx wound with the ADON present revealed after performing hand hygiene and donning (applying) a gown and gloves, RN-F removed the prior wound vac dressing and one piece of black foam and discarded. RN-F doffed (removed) gloves, performed hand hygiene, and donned new gloves. RN-F cleansed the wound using a can of normal saline and 4 x 4 gauze squares using a new piece of gauze with each wipe and cleaning the outside of the wound followed by the inside of the wound. RN-F doffed gloves, performed hand hygiene, and donned new gloves. RN-F cut DuoDerm in half and applied one piece to either side of the coccyx wound. RN-F doffed gloves, performed hand hygiene, and applied a double layer of calcium alginate to the wound bed. RN-F doffed gloves, performed hand hygiene, cut a rectangular shaped piece of black foam in half and placed the black foam on top of the circular wound, and applied draping. RN-F attached the suction device directly to the wound vac site. RN-F changed the suction canister and turned the device on. The foam compressed and the device display showed 120mmHg. Resident 3 was repositioned in bed and heel boots were applied.An interview on 8/19/2025 at 3:42 PM with RN-F confirmed normal saline was used to wash the wound instead of the provider-ordered Vashe wound wash. RN-F revealed the facility was out of Vashe. RN-F further confirmed the suction device was not bridged from the wound to the hip as ordered.During an interview on 8/19/2025 at 3:47 PM, the Director of Nursing (DON) confirmed black foam should be trimmed to the size of the wound and placed in the wound.A telephone interview on 8/20/2025 at 12:45 PM with Advanced Practice Registered Nurse (APRN)-G, confirmed black foam should be trimmed to the size and shape of the wound and placed gently in the wound. APRN-G revealed the wound had the potential to deteriorate if the black foam was not trimmed to the size and shape of the wound.Record review of a facility policy entitled Negative Pressure Wound Therapy dated revised 8/2024 revealed: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. This policy addresses the use of negative pressure wound therapy (NPWT) for the treatment and management of wounds. - Negative pressure wound therapy is an active wound care treatment that uses controlled sub-atmospheric (negative) pressure to assist and accelerate wound healing. The therapy may be gauze based, foam based, or peel and stick, and includes an evacuation tube and a computerized pump that applies the negative pressure. -1. Negative pressure wound therapy will be provided in accordance with physician orders, including the desired pressure setting, continuous or intermittent therapy, and frequency of dressing change. Clean technique shall be utilized unless otherwise specified by the physician. -8. General application process: -a. Carefully remove the existing wound dressing and discard. -b. Cleanse the wound according to physician order. -e. Select foam type or gauze appropriate to the size and characteristics of the wound, and place gently into the wound. -i. Fill the entire wound base and sides, tunnels, and undermined areas. -g. Apply the tubing to the dressing. -ii. Using the attached tubing adhesive drape, or additional dressing drape, seal the tubing assembly on top of the dressing and ensure that it will not lie on bony prominences. -12. The physician shall be notified of any complications associated with the use of NPWT.There was no further information available for review at the time of the survey exit.

Licensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure the chemical low-temperature (temp) dish machine reached a minimum temp of 120 degrees Fahrenheit (F)(a temperature scale) during all wash and rinse cycles. This had the potential to affect 43 residents that consumed food from the kitchen. The total facility census was 44. Findings are:A record review of the facility's Dishwasher Temperature policy dated 8/2023 revealed all items cleaned in the dishwasher would be washed in water that is sufficient to sanitize any and all items. Manufacturer's instructions shall be followed for washing and sanitizing. The wash temp shall be 120 degrees F. Water temperatures shall be measured and recorded prior to each meal.A record review of the facility's undated Dishwashing: Machine Operation Guideline and (&) Procedure Manual revealed all dishwashing machines should be operated according to the manufacturer's recommendation. The staff should check the dishwashing machine first and if the unit has not been used for several hours, allow the dishwashing machine to cycle for one or two cycles to allow the dishwashing machine to come up to proper function. If the machine is found out of the acceptable range for either final rinse temp or chemical sanitizing concentration, do not proceed to wash dishes. A record review of the National Sanitation Foundation (NSF) Machine Operational Requirements sticker on the facility's dish machine revealed wash temperature was a minimum of 120 degrees F, and the minimum rinse temperature was 120 degrees F.A record review of the facility's Dish Machine Temperature Log - Low Temperature dated July 2025 revealed the minimum temperature is 120 degrees F or to manufacturer rating. On 07/26/2025 breakfast log revealed a wash temp of 115 degrees F. 07/24/2025 and 07/26/2025 did not reveal any readings were recorded.A record review of the facility's Dish Machine Temperature Log - Low Temperature dated August 2025 revealed the minimum temperature is 120 degrees F or to manufacturer rating. Only 3 of 19 days were breakfast readings recorded. 08/02/2025, 08/05/2025, 08/12/2025, and 08/19/2025 did not reveal any readings were recorded.A record review of the undated American Dish Service AF-3D Dishwasher - Specification Sheet revealed Supply Water Temp: 120 degrees F minimum (low-temp chemical sanitize).A record review of American Dish Service Installation Instructions dated 08/20/2025 revealed water heaters or boilers must provide the minimum temperature of 120 degrees F required by the machine listed above. An observation on 08/19/2025 at 2:19 PM revealed Dietary Aide (DA)-B rinsed off dishes and put them on a rack. DA-B then opened the dishwasher and removed a large cookie sheet and put it away, DA-B pushed the rack of sprayed off dishes in the dishwasher, started the dishwasher, and returned to spraying off other dishes. The thermometer on the dish was read 116 degrees F during the wash cycle and 124 degrees F during the rinse cycle. At 2:24 PM, DA-B removed the dishes from the dish machine and started another load. DA-B put the cleaned dishes from the dishwasher away in their designated areas in the kitchen. The 2nd observed load in the dishwasher reached 119 degrees F on the wash cycle and 128 degrees F on the rinse cycle. When that cycle was completed, DA-B put the dishes away in their designated area in the kitchen.An observation on 08/20/2025 at 7:37 AM revealed that DA-A loaded the dishwasher with a rack of 4 plates and 4 plastic trays and started the machine. DA-A continued to spray off dishes in the sink as the dish machine ran. The wash temp reached 80 degrees F and the rinse temperature reached 100 degrees F on the thermometer. At 7:39 AM DA-A unloaded the dishwasher, pushed another load of 2 plates, a large plastic pitcher and lid, and 1 bowl in, and started the dishwasher. DA-A put one of the plates back on the dirty side and put the rest away in the kitchen. The load that was started at 7:39 AM wash temp reached 90 degrees F and the rinse temp reached 94 degrees F. At 7:47 AM DA-A unloaded the dishwash and put the dishes away. In an observation on 08/20/2025 at 7:41 AM with the facility's Cook-A, that had been identified as the assistant dietary manager revealed DA-A ran a load of 2 large bowls and 1 plate through the dishwasher. The was temp reached 98 degrees F and a rinse temp of 101 degrees F. At 7:45 AM DA-A ran a load of 11 plates and 2 bowls through the dishwasher and the wash temp reached 102 degrees F and a rinse temp of 119 degrees F. At 7:55 AM, DA-B put the dishes away in the kitchen.In an interview on 08/20/2025 at 7:47 AM, DA-A confirmed the thermometer on the dishwasher was not working right and the machine used twice as much detergent as it should. DA-A confirmed DA-A forgets to look at temp gauge on the dishwasher. In an interview on 08/20/2025 at 10:05 AM, DA-A confirmed the dishes that were put away that morning were used for the lunch food preparation and service. In an interview on 08/20/2025 at 11:16 AM, the facility's Registered Dietician (RD) confirmed the facility's dishwasher should have reached a minimum temperature of 120 degrees F during the wash and rinse cycles.In an interview on 08/20/2025 at 3:05 PM, The facility's Regional Director of Operations (RDO) confirmed the facility's dishwasher machine was an American Dish Service Model AF-3D. The RDO confirmed the dishwasher should have reached a minimum 120 degrees F during the wash and rinse cycles.In an interview on 08/20/2025 at 7:50 AM, Cook-A confirmed Cook-A observed the above temperatures on the dishwasher as DA-A ran the machine on 08/20/2025 at 7:41 AM and 7:45 AM. Cook-A confirmed the minimum wash and rinse temps should have been 120 degrees F and the machine did not reach that. In an interview on 08/21/2025 at 7:15 AM, the facility's Administrator confirmed all but 1 of the 44 residents that reside at the facility consume food from the kitchen.

Licensure Reference Number 175 NAC 12-006.09(I)Licensure Reference Number 175 NAC 1-009.04(D)(i)(1)Based on observation, interview, and record review, the facility failed to ensure bathing and showering water temperatures (temps) did not exceed 110 degrees Fahrenheit (F)(a temperature unite of measure) to prevent potential accidents. The facility census was 44.Findings are:A record review of the facility's Resident Showers policy with a date reviewed/revised of 7/2025 revealed the staff should help the resident sit on the shower chair, turn the shower on, the water temperature should be 98.6 degrees F to 120 degrees F. They could use a thermometer if one was available or test the water on the inside of the staff's wrist. A record review of the facility's Safe Water Temperatures policy with a date reviewed/revised of 7/2025 revealed water temperature should be set at no 98.6 degrees F to 120 degrees F or the state's allowable maximum water temperature. The Maintenance staff would check water heater temperature controls and the temps of tap water in all hot water circuits weekly and as needed.A record review of the facility's Testing and Logging Water Temperatures steps dated 08/23/2025 revealed For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this can still cause burns if exposure reaches five minutes. Although 100 degrees Fahrenheit is considered a safe water temperature for bathing. On 08/19/2025 the bathhouse 100-hall shower was 116.2 degrees F, the 200-hall shower was 115.7 degrees F, and the 100-hall tub was 115.9 degrees F.A record review of the facility's Task Name: Test and log the hot water temperatures log dated 08/13/2025 revealed bathhouse 200's temp was 115.7 degrees F and the bathhouse 100 was 115.6 degrees F.A record review of the facility's Task Name: Test and log the hot water temperatures log dated 07/21/2025 - 07/30/2025 revealed on 7/22/2025 bath house 200's temp was 109.6 degrees F and the bath house 100 was 115.3 degrees F. On 07/23/2025 bath house 200's temp was 113.4 degrees F, bath house 100's tub was 111.4 degrees F, and the bath house 100 was 116.4 degrees F. On 07/24/2025 bath house 200's temp was 111.6 degrees F, Bath house 100 tub was 113.4 degrees F, and the bath house 100 was 111.9 degrees F. On 07/30/2025 bath house 200's temp was 112.6 degrees F, Bath house 100's tub was 112.8 degrees F, and the bath house 100 was 115.2 degrees F.A record review of the facility's Resident Listing Report dated 08/20/2025 revealed out of the 45 residents listed, 1 was in the hospital and 22 were marked as being cognitively impaired (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The report revealed 3 residents often refuse and self bathe.An observation on 08/19/2025 at 12:42 PM with the facility's Regional Lead Maintenance (RLM) revealed the RLM tested the 200-hall bath house sink, and the temperature was 115.5 degrees F. The RLN tested the 200-hall shower, and the temp was 113.7 degrees F. An observation on 08/19/2025 at 12:52 PM with the facility's RLM revealed the RLM tested the 100-hall bath house tub, and the temperature was 115.7 degrees F. The RLN tested the 100-hall bath house shower, and the temp was 116.4 degrees F. In an interview on 08/19/2025 at 3:34 PM, the RLM confirmed that the maximum bathing temperature should be 110 degrees F and the bath house's tubs and showers were not below that.In an interview on 08/20/2025 at 3:35 PM, the facility's Regional Director of Operations (RDO) confirmed the safe bathing temperatures was less 110 degrees F and the facility did not have a policy specific to bathing in a tub.In an interview on 08/21/2025 at 7:15 AM, facility's Administrator confirmed the Resident Listing Report dated 08/20/2025 that the Administrator provided revealed out of the 45 residents listed, 1 was in the hospital and 22 were marked as being cognitively impaired and confirmed those 22 residents bathed in the bath houses, however 3 residents often refuse and self bathe.

LICENSURE REFERENCE NUMBER175 NAC 1-005.06 (D & E)LICENSURE REFERENCE NUMBER175 NAC 12-006.18 (B & D)Based on observation, interview, and record review, the facility failed to utilize a gown during personal cares for a resident who was identified as being in Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition [e.g., residents with wounds or indwelling medical devices]) for 1 (Resident 4) of 3 sampled residents; and the facility failed to ensure staff performed hand hygiene between glove changes to prevent cross contamination for 1 (Resident 4) of 5 sampled residents. The facility staff identified a census of 44.The findings are: A. Record review of a facility policy entitled Enhanced Barrier Precautions dated revised 5/31/2025 revealed: -EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. -2b. An order for enhanced barrier precautions will be obtained for residents with any of the following: -i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. -3b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. -4. High-contact resident care activities include: -a. dressing -b. bathing -c. transferring -d. providing hygiene -e. changing linens -f. changing briefs or assisting with toileting -g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters -h. Wound care: any skin opening requiring a dressing.Record review of Resident 4's admission Record printed 8/20/20025 revealed the facility admitted the resident on 11/20/2024 and identified diagnoses which included multiple sclerosis (MS, a demyelinating disease marked by patches of hardened tissue in the brain or the spinal cord and associated especially with partial or complete paralysis and jerking muscle tremor), paraplegia, non-pressure chronic ulcer of the left foot, and unspecified open wound of left buttock.Record review of Resident 4's quarterly 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) dated 5/10/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a score of 14 indicated the resident was cognitively intact. Further review of the MDS identified the resident was dependent upon staff for bed mobility and transfers, had an indwelling urinary catheter, and was always incontinent of bowel. The MDS identified Resident 4 had two Stage 2 pressure ulcers that were present on admission.Record review of Resident 4's Order Summary Report printed 8/20/2025 lacked an order for EBP.Record review of Resident 4'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) revealed the facility required EBP due to pressure injury and urinary catheter. The CCP further directed staff to wear gowns and gloves during high-contact resident care activities.Observation on 8/20/2025 at 9:55 AM revealed an EBP sign that has the letter B written at the bottom.Observation on 8/20/2025 from 9:55 AM through 10:20 AM revealed Nurse Aide (NA)-D and NA-E assisted Resident 4 with morning care. NA-D and NA-E each performed hand hygiene and donned (applied) gloves. Without donning a gown, NA-D assisted Resident 4 with perineal care in bed after a bowel movement and applied a new brief. Without donning a gown, NA-D changed Resident 4's urinary catheter drainage bag to a leg bag and assisted Resident 4 to roll side-to-side in bed to pull up a pair of slacks. Without donning a gown, NA-D and NA-E placed the lift sling under Resident 4, crossed the straps and secured the lift sling to the Hoyer lift, and transferred the resident to the wheelchair.An interview on 8/20/2025 at 10:23 AM with NA-E revealed NA-E was not aware of the need to utilize EBP when providing high contact cares with Resident 4.An interview on 8/20/2025 at 10:25 AM with the Director of Nursing (DON) confirmed Resident 4 was in EBP for wound and urinary catheter. The DON was unsure of the reason for the letter B being marked at the bottom of the sign.An interview on 8/20/2025 at 12:29 PM with NA-D revealed NA-D was not aware of the need to utilize EBP when providing high contact cares with Resident 4. B. Record review of a facility policy entitled Hand Hygiene dated revised 5/31/2024 revealed: -6. Additional considerations: -a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Observation on 8/20/2025 from 9:55 AM through 10:20 AM of Resident 4's morning routine revealed NA-D washed hands with soap and water for 35 seconds and donned gloves. NA-E washed hands with soap and water for 28 seconds and donned gloves. NA-D provided perineal to Resident 4 after a bowel movement. Without changing gloves and without the benefit of hand hygiene, NA-D applied a new brief to Resident 4. Without changing gloves and without the benefit of hand hygiene, NA-D applied Resident 4's socks. NA-D doffed (removed) gloves, and without the benefit of hand hygiene donned new gloves and changed Resident 4's urinary drainage bag to a leg bag.NA-E removed a bed pad, retrieved a trash bag from the bottom of the trash receptacle, and placed the bed pad in the bag. NA-E doffed gloves, and without the benefit of hand hygiene, donned new gloves and obtained the lift transfer sling. With the assistance of NA-D, the lift sling was placed under Resident 4.NA-E doffed gloves and without the benefit of hand hygiene left the room to obtain the lift from its storage space.An interview on 8/20/2025 at 10:25 AM with NA-E confirmed hand hygiene was not performed between glove changes and should have been.An interview on 8/20/2025 at 12:29 PM with NA-D confirmed hand hygiene was not performed between glove changes and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2) Based on observation, interview and record review the facility failed to evaluate, monitor and implement interventions for pressure ulcer prevention and to promote wound healing for 2 (Resident 2 and 3) of 3 residents sampled. The facility census was 43. The findings are: A.Record review of Resident 2' Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-27-2025 revealed the facility staff assessed the following about the resident: -an admitted [DATE] -had a right hip fracture. -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -Required extensive assistance with toileting, lower body dressing and bathing. -Required partial assistance with bed mobility, transfers, upper body dressing and personal hygiene. -Resident was at risk of developing pressure ulcers. -Required pressure relieving surfaces to the bed and wheelchair. Record review of Resident 2's admission assessment dated [DATE] revealed Resident 2 admitted to the facility with a surgical incision to the right hip that was 8 centimeters (cm), maceration associated skin damage (MASD: skin erosion due to prolonged exposure to moisture) to the sacrum (the bone between the 2 hip bones) without measurements, and an unmeasured area to the left heel that had a small amount of redness. Review of Resident 2's Care Plan, Progress Notes, Practitioner Orders and Skin Evluation Sheets revealed there was no indications the facility staff implemented interventions to prevent futher skin breakdown to Resident 2's left heel. Record review of a skin evaluation dated 03-31-2025 identified a stage 1 pressure area to the right and left buttock and did not identify any skin irregularities to the left heel. Record review of Resident 2's progress notes dated 04-02-2025 revealed an unmeasured skin issue was identified to the left heel. Record review of Resident 2's wound assessment conducted by a Nurse Practitioner (NP) on 04-03-2025 revealed a pressure ulcer stage 3 measuring 1.64 centimeters (cm) in length and 2.99 cm in width to the left heel. The wound bed was red without dead skin tissue present. No treatment orders were identified on the wound assessment. Record review of Resident 2's Comprehensive Care Plan (CCP) revealed the following under Pressure Ulcer Risk -Resident 2 had the potential for the development of a pressure ulcer and on 04-02-2025 had an open area to the left heel. Date initiated 04-08-2025. -The goal was resident's current skin concerns will show signs of healing with a decrease in size through the next review date. Date initiated 04-08-2025 Interventions identified on the CCP that were initiated on 04-08-2025: -prevalon boot (pressure relieving boot) per physician's orders. -reposition frequently or more often as needed or requested. -apply moisture barrier with each incontinent change. -provide nutritional supplements as ordered to maintain skin integrity. -weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Two other goals were added to the CCP on 04-25-2025 of Stage 3 pressure ulcer to left medial heel will improve/resolve by the review date and a Stage 2 pressure ulcer to the sacral area will improve/resolve by the review date. Additional interventions were initiated on 04-25-2025 of a low air loss mattress. Record review of Resident 2's progress notes dated 04-05-2025 revealed a big blister was noted to the left heel measuring 2 cm by 3 cm that was covered with a band-aid. Record review of Resident 2's wound assessment conducted by a NP on 04-10-2025 revealed the stage 3 pressure ulcer to the left heel measured 2.70 cm length by 2.86 cm in width. The wound bed had a moderate amount of dead skin tissue revealing a decline in the wound condition since 04-03-2025. New orders identified on the assessment were to cleanse the wound with mild soap and water, apply Santyl (a wound debridement) ointment to the wound bed, cover with mepilex (a type of wound dressing) daily and as needed and for a prevalon boot to be worn while in bed. Record review of Resident 2's Treatment Administration Record (TAR) for April 2025 revealed an order for a pressure relieving boot dated 04-11-2025 and a treatment for the stage 3 pressure ulcer to the left medial heel dated 04-12-2025. An observation on 05-05-2025 at 12:00 PM of Registered Nurse (RN) A providing wound care to Resident 2's stage 3 pressure ulcer to the left heel which revealed a dry brown round shaped area. During the observation, RN A measured the wound at a length of 3.5 cm by 1.5 cm in width. An interview was conducted with the Director of Nursing (DON) on 05-05-2025 at 3:30 PM revealed orders for treatment were not obtained on 04-03-2025 and the facility should have followed up with the practitioner for orders. The DON also confirmed that treatment for the stage 3 pressure ulcer to the left heel was not initiated until 04-12-2025 and the wound had worsened. B. Record review of Resident 3's face sheet printed on 05-01-2025 revealed an admitted [DATE]. Record review of Resident 3's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 9. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment. -required extensive assistance with eating and bed mobility. -required total assistance with toileting, bathing, dressing and transfers. -was identified at risk of pressure ulcer development and currently did not have one. Record review of Resident 3's CCP dated 08-17-2025 and revised on 12-05-2023 revealed Resident 3 had a potential for pressure ulcer development related to decreased mobility. The goal was Resident 3 would be free from pressure ulcers through the review date. Interventions included the following: -turn and reposition at least every 2 hours and as requested. Date initiated 09-02-2022. -administer treatments as ordered and monitor for effectiveness. Date initiated 08-17-2022. -assess/monitor/record wound healing as needed: Measure length, width, and depth. Assess and document the status of the wound perimeter, wound bed and healing progress. Report improvements and declines to the practitioner. Date initiated 08-17-2022 -follow facility policies/protocols for the prevention/treatment of skin breakdown.Date initiated 08-17-2022. -monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs of infection, wound size and stage. Date initiated 08-17-2022. -pressure reducing mattress and wheelchair cushion. Date initiated 08-17-2025 -monitor nutrition status.Serve diet as ordered, monitor intake and record. Date initiated 08-17-2022. Record review of Resident 3's progress note dated 04-17-2025 revealed an open area was noted to the left side of the back below the shoulder blade measuring 3 cm in length by 2.5 cm in width. Record review of Resident 3's Weekly Skin Evaluation (WSE) dated 04-17-2025 revealed Resident 3 was evaluated as having an open area to the left shoulder that measureed 3 cm by 2.5 cm. Record review of Resident 3's entire health record including the care plan, progress notes, practitioner's orders, and weekly skin evaluations revealed no indication of the resolution of the left shoulder open area. An observation on 05-05-2025 at 2:35 PM of RN A and the Assistant Director of Nursing (ADON) providing wound care for Resident 3 right foot and ankle revealed an undated foam dressing to the left side of Resident 3's back and an undated foam dressing to the sacrum. Furthermore, the ADON removed both dressings which revealed an open wound to the left side of the back approximately the size of a quarter with yellow slough (dead tissue) in the center, and an open wound to the sacrum that was round approximately 2.5 cm in length by 2.5 cm in width with yellow slough in the center. An interview with ADON on 05-05-2025 at 2:55 PM confirmed the wound to the sacrum was a pressure ulcer and the area on the left side of back could have been caused by friction. An interview with RN A was conducted on 05-05-2025 at 3:00 PM confirmed there were no treatment orders for the wounds to the left back or sacrum. An interview conducted with the DON on 05-05-2025 at 3:30 PM confirmed the wounds had not been measured and a treatment had not been requested. Record review of the facility policy titled Pressure Injury Prevention and Management revealed the following: -Policy- the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. -the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions and modifying the interventions as appropriate.

Licensure Reference Number 175 NAC 12-006.05(E). Based on observation, interview and record review the facility failed to notify the medical practitioner of new pressure ulcers for 2 (Resident 2 and 3) of 3 residents sampled. The facility census was 43. The findings are: A.Record review of Resident 2' Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-27-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -Required extensive assistance with toileting, lower body dressing and bathing. -Required partial assistance with bed mobility, transfers, upper body dressing and personal hygiene. Record review of Resident 2's progress notes dated 04-02-2025 revealed an unmeasured skin issue was identified to the left heel and the staff called the practitioner and obtained a one-time order to wash the left heel with soap and water and cover the wound with petroleum jelly. Record review of Resident 2's wound assessment conducted by a Nurse Practitioner on 04-03-2025 revealed a pressure ulcer stage 3 measuring 1.64 cm in length and 2.99 cm in width to the left heel. The wound bed was red without dead skin tissue present. No treatment orders were included in the assessment. An interview with the Director of Nursing (DON) on 05-05-2025 at 3:30 PM revealed the practitioner was made aware of the wound on 04-03-2025 and confirmed that orders were not received on 04-03-2025 and the practitioner should have been notified to request treatment orders. B. Record review of Resident 3's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 9. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment. -required extensive assistance with eating and bed mobility. -required total assistance with toileting, bathing, dressing and transfers. Record review of Resident 3's progress note dated 04-17-2025 revealed an open area was noted to the left side of the back below the shoulder blade measuring 3 cm in length by 2.5 cm in width. An observation on 05-05-2025 at 2:35 PM revealed a wound to the left side of the back and a wound to the sacrum. Record review of Resident 3's April 2025 TAR revealed no treatment orders for a wound on the left side of the back or the sacrum. Record review of the facility policy titled Notification of changes dated 2023 revealed the following: -policy-the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. -circumstances requiring notification include circumstances that require a need to alter treatment or obtain a new treatment. An interview with the DON on 05-05-2025 at 3:30 PM confirmed the practitioner was not notified of the wound to the left side of the back until today.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on interview and record review the facility failed to provide bathing services in accordance with the resident's preferences for 4 (Resident 1, 2, 3 and 5) of 4 residents sampled. The facility census was 43. The findings are: A.Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 01-30-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 6. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -Required moderate assistance with upper body dressing, bed mobility, and personal hygiene. -Required total assistance with lower body dressing, toileting, bathing, and transfers. Record review of a form titled Bath Preferences dated 01-28-2025 revealed Resident 1 wanted a bath twice a week. Record review of the facility documentation for baths in March and April of 2025 revealed Resident 1 received a bath on: -03-06-2025 -03-13-2025 -03-21-2025 -04-03-2025 -04-10-2025 Resident 1 should have received 2 baths the week of March 3, March 10, March 17, March 24, March 31, April 7, April 14, and April 21 for a total of 16 baths. B.Record review of Resident 2's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -admitted [DATE]. -BIMS was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -Required extensive assistance with toileting, lower body dressing and bathing. -Required partial assistance with bed mobility, transfers, upper body dressing and personal hygiene. Record review of a Bath Preference form dated 03-24-2025 revealed Resident 2 preferred 2 baths or showers per week. Record review of facility documentation for baths in March and April 2025 revealed Resident 2 received a bath on: -04-02-2025 -04-13-2025 -04-25-2025 Resident 2 should have received 2 baths/showers for the week of March 24, March 31, April 7, April 14, and April 2 for a total of 10 baths/showers. C. Record review of Resident 3's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 9. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment. -required extensive assistance with eating and bed mobility. -required total assistance with toileting, bathing, dressing and transfers. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 09-02-2022 revealed Resident 3 preferred 2 showers a week. Record review of the facility's bathing documentation for March and April 2025 revealed Resident 3 received a bath on: -03-01-2025 -03-21-2025 -04-02-2025 -04-09-2025 -04-12-2025 -04-16-2025 Resident 3 should have received 2 showers the week of March 3, March 10, March 17, March 24, March 31, April 7, April 14, April 21 and April 28 2025 for a total of 18 baths. D. Record review of Resident 5's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was not scored - required moderate assistance with bed mobility. -required total assistance with bathing, toileting, lower body dressing and transfers. Record review of Bathing Preferences for Resident 5 dated 02-27-2025 revealed a preference of 2 showers a week. Record review of the facility's bathing documentation for March and April of 2025 revealed Resident 5 received a bath on: -03-06-2025 -03-13-2025 -03-21-2025 -04-02-2025 resident refused -04-03-2025 -04-10-2025 Resident 5 should have received 2 showers the week of March 3, March 10, March 17, March 24, March 31, April 7, April 14, April 21 and April 28 2025 for a total of 18 showers. An interview conducted on 05-05-2025 at 3:30 PM with the Director of Nursing confirmed baths/showers were not provided according to preference for Resident 1, 2, 3 and 5. Record review of the facility policy titled Resident Rights dated 2023 revealed the following: -the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. -Self determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: -the resident has a right to choose activities, schedules, health care and providers of health care services consistent with his or her interests. -the resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on observation, record review and interview; the facility failed to ensure nurse staffing information was posted daily at the beginning of the shift and included the facility name, date, census, and the total number and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Nurses Aides who were responsible for resident care. This had the potential to affect all residents that resided in the facility. The facility census was 44. Findings are: Record review of a policy entitled Nurse Staffing Posting Information, dated 8-2023, revealed the following information: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time policy explanation and compliance guidelines: 1. The nurse staffing sheet will be posted on a daily basis and will contain the following information: a: Facility name b: The current date c: Facilities current resident census d: The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift i: Registered nurses ii: Licensed practical nurses / licensed vocational nurses iii: Certified nurse aides 2. The facility will post the nursing staffing sheet at the beginning of each shift 3. The information post did posted will be: a. presented in a clear and readable format b. in a prominent place readily accessible to residents and visitors 4. A copy of the schedule will be available to all supervisors to ensure the information posted is up to date and current. a. The information to reflect staff absences on that shift due to call outs and illness after the start of each shift actual hours will be updated to reflect such. b. Staffing shall include all nursing staff who are paid by the facility including contract staff any staff not paid for by the facility such as Hospice staff or individuals hired by families should not be included. 5. Nursing schedules and posted information will be maintained in the Human Resource Department for review for a minimum of 18 months or as required by state law. whichever is greater number. 6. The facility will upon oral or written request make the nurse staffing data available to the public for review the cost not to exceed the community standard. Observations throughout the facility on 10/9/24, 10/10/24, and 10/15/24 showed no information had been posted regarding the daily nurse staffing information. Interview on 10/15/24 at 10:59 AM with the Director of Nursing confirmed that the daily nurse staffing information had not been posted per the federal requirements and the facility policy.

Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to maintain the cleanliness and condition of walls, floors, fixtures, closet doors, lights, bathroom ceiling ventilation covers in 9 resident rooms (rooms 104, 106, 112, 116, 203, 204, 206, 210 and 212) of 33 occupied resident rooms in the facility. The facility census was 44. Findings are: Observation on 10/9/24 between 8:00 AM and 4:00 PM, during the initial pool observations of resident rooms, revealed the following environmental concerns: - Scrapes on walls behind the beds and on the walls in bathrooms in rooms 104, 106, 112, and 204. - [NAME] stained areas of the floor around the toilet base in rooms 106, 112, 203, and 206. - Scrapes on the closet doors in room [ROOM NUMBER]. - Cracked bathroom sink in rooms 104. - Closet door was pulled off of the track in room [ROOM NUMBER]. - Cracks in the linoleum in bathroom in room [ROOM NUMBER]. - Missing / loose transition strip between the bathroom and room [ROOM NUMBER] and 212. - Lights not functioning above the beds in room [ROOM NUMBER]. - Loose toilet roll holder in room [ROOM NUMBER]. - Ventilation cover was coated with a gray fuzzy substance in room [ROOM NUMBER] and 206. Observations on 10/16/24 between 08:30 and 09:10 AM with Regional Director of Operations and Maintenance Director [MD], during the environmental tour, revealed the following concerns: - Scrapes on walls behind the beds and on the walls in bathrooms in rooms 104, 106, 112, and 204. - [NAME] stained areas of the floor around the toilet base in rooms 106, 112, 203, and 206. - Scrapes on the closet doors in room [ROOM NUMBER]. - Cracked bathroom sink in rooms 104. - Closet door was pulled off of the track in room [ROOM NUMBER]. - Cracks in the linoleum in bathroom in room [ROOM NUMBER]. - Missing / loose transition strip between the bathroom and room [ROOM NUMBER] and 212. - Lights not functioning above the beds in room [ROOM NUMBER]. - Loose toilet roll holder in room [ROOM NUMBER]. - Ventilation cover was coated with a gray fuzzy substance in room [ROOM NUMBER] and 206 Interview on 10/16/24 at 09:15 AM with the MD confirmed the above observed areas of concerns and confirmed that they needed to be cleaned and fixed. The MD confirmed that there were no active work orders for the concerns identified during the environmental tour.

Licensure Reference Number 175 NAC 12-006.12E Based on observation, interview, and record review, the facility failed to secure residents medications and treatments in medication carts. The facility identified a census of 43. Findings are: Record review of the facility's undated policy titled Medication Storage revealed the following: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy explanation and compliance guidelines: General Guidelines: All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperatures. Observation on 5/1/24 at 6:52 AM revealed a medication cart next to an office that was unlocked and unattended. Continued observation revealed there were 2 carts down the 200 hall that were unlocked and unattended. Observation on 5/1/24 at 7:13 am Registered Nurse (RN) RN-A was entering room [ROOM NUMBER] with a treatment. RN-A then began having a conversation with the resident occupying that room. RN-A was completing the treatment in the resident's room, with the cart unlocked in the hall. Observation on 5/1/24 at 8:32 AM revealed RN-A was in room [ROOM NUMBER] performing a treatment with the door open. The treatment cart was outside room [ROOM NUMBER], and out of RN-A's view. The treatment cart was unlocked and unattended. An interview on 5/1/24 at 7:02 AM with Registered Nurse (RN) RN-A confirmed that the cart should not be left unlock and unattended. RN-A stated that when the RN left the cart to let the someone in the building, the RN didn't lock the cart before going to the door. An interview conducted with the Administrator (ADM) on 5/2/24 at 8:40 AM revealed, the facility has 15 self-ambulatory residents, and of those 15 residents 7 of them have cognitive impairment. The ADM confirmed the medication carts and treatment cart should be locked unless the nurse is preparing a treatment or medication.

Licensure Reference Number 175 NAC 12-006.09D2a Based on observation, interview, and record review, the facility staff failed to obtain treatment orders for pressure ulcers for 2 (Resident 1 and Resident 3) of 3 sampled residents. The facility identified a census of 43. Findings are: A. Record review of Resident 1's Clinical Census sheet dated 5/1/24 revealed Resident 1 was initially admitted to the facility 2/7/24, was hospitalized and readmitted to the facility 4/26/24. Record review of the Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated March 28th, 2024, revealed Resident 1's Brief Interview for Mental Status (BIMS) was 2 of 15. According to the MDS Manual a score of 0-7 indicates a person is severely cognitively impaired. Record review of Resident 1's After Visit Summary sheet dated 4/26/24 revealed Resident 1 had returned to the facility on [DATE] with a pressure ulcer on the left lateral foot. Record review on 5/1/24 of Resident 1's medical record that includes progress notes, care plan, admission orders, revealed there was no indication the facility staff had evaluated Resident 1's skin condition. Record review of Resident 1's skin assessment on 5/1/24 at 7:02 PM revealed the facility had not identified any skin breakdown to Resident 1's left heel wound. Record review of Resident 1's order summary for active orders as of 5/1/24 revealed no treatments for the wound on the left foot. Record review of Resident 1's Wound Dr's Dictation sheet dated 5/2/24 revealed there were no orders for the pressure wound on the left foot. Record review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2024 revealed there were no orders identified to treat Resident 1's left lateral foot. Observation on 5/1/24 at 10:30 AM of Registered Nurse (RN) RN-A completed a dressing change to the right foot. Further observation on 5/1/24 at 10:30 AM revealed RN-A identified skin issues to the left lateral foot. Continued observation on 5/1/24 at 10:30 AM revealed the left lateral foot has eschar (dead tissue) that measured approximately 4.0 centimeters (a metric measurement to measure a wound area (cm) in length by 3.0 cm wide, without drainage. An interview with Registered Nurse (RN)-A and Assistant Director of Nursing (ADON) on 5/1/24 at 10:30 AM confirmed there is no ordered treatment for Resident 1's left lateral foot. A follow up interview was conducted with the Assistant Director of Nursing (ADON) on 5/2/24 at 8:30 AM. During the interview the ADON confirmed there were no orders for wound care to the left lateral foot. B. Record review of Resident 3's Admission assessment dated [DATE] at 2:52 PM revealed no documentation of the left heel wound. Record review of Resident 3's Order Summary sheet for active orders as of 4/25/24 revealed no treatments for the wound on the left heel. Resident admitted to the facility for rehabilitation services on 4/25/24. Record review of of Resident 3's Wound Dr's dictation dated 5/2/24 revealed there were no orders for the pressure wound on the left heel. On 5/01/2024 at 8:30 AM an interview was conducted with Resident 3. During the interview Resident 3 reported having other open area to the left leg. Observation on 5/2/24 at 9:45 AM of the wound rounds with the Nurse Practitioner (NP) for Metro Geriatric Services revealed Resident 3's left heel had a pressure wound that is unstageable (a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) measuring 3.8 cm in length by 4.0 cm width by 0.1 cm depth with moderate serosanguineous (a descriptive word that describes a thin pink drainage) drainage. Interview with the ADON 5/2/24 at 8:30 AM confirmed there were no orders for wound care to Resident 3's left heel.

Licensure reference: 175 NAC 12-006.09D8a Based on observation, interview, and record review, the facility failed to ensure physician ordered therapeutic diet was provided for 1 [Resident 1] of 4 sampled residents. The facility had a total census of 44 residents. Findings are: A review of Resident 1's Admission Record revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus with diabetic polyneuropathy [a type of nerve damage that can occur with diabetes]. A review of Resident 1's Order Summary with active orders as of 1/29/24 revealed an order dated 1/8/24 for a Modified Renal CCHO [Consistent Carbohydrate] with regular texture and thin consistency liquids. Observations on 1/29/24 at 8:16 AM revealed a breakfast tray being delivered to Resident 1 with the following breakfast items, scrambled eggs, tater tots, toast, milk, coffee, and a bowl of frosted flakes. Further observation on 1/29/24 at 8:37 AM revealed Resident 1 ate eggs bites of toast and some of the tater tots. A review of facility Diet Spreadsheet for 1/29/24 revealed menu for a Liberal Renal CCHO diet was a follows: -Assorted juice-No citrus 1/2 cup -Choice of hot or cold cereal 4 oz [ounces] hot or 6 oz cold -Choice of Eggs 2 oz -Toast 1 slice -Margarine/Diet Jelly 2 tsp [teaspoons]/ 1 packet (pkt). -Milk, Whole 1/2 cup A review of Resident 1's tray card dated 1/30/24 revealed Resident 1's diet order was regular diet. In an interview on 1/29/24 at 3:05 PM, the Administrator confirmed that Resident 1 had a new diet order after return from hospital on 1/8/24. The Administrator reported the change in diet order had not been communicated to the dietary staff for input into the dietary computer system. A review of Dining RD Guideline & Procedure Manual policy titled Renal Precautions dated 2020 revealed the following information guidelines for Renal Precautions: -No citrus fruits/juices -No bananas -Milk to drink is limited to one cup per day -Potatoes and potato products are limited to one serving at lunch and/or supper -Salt is not used at the table and salt packets are not added to the tray

LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D Based on observations, record review and interview, the facility failed to provide CPR (Cardiopulmonary Resuscitation) in accordance with the resident's signed and documented advanced directives for Resident 77. In addition, the facility failed to identify code status on room name plates with as identified in the facility policy for Resident 51 and Resident 31. Resident census was 57. Findings are: Resident 77 was admitted to the facility on [DATE] according to the Face Sheet. Resident was admitted for rehab and nursing support related to L knee non-displaced lateral tibial plateau fracture according to the Discharge summary under the category nursing summary/discharge instructions. Resident 77 died on [DATE]. Resident 77 was assisted with ADL's (Activities of Daily Living) and participated with activities and therapy during resident stay at the facility. A document entitled Preferred Intensity of Medical Care and Treatment dated [DATE] and signed by the resident's daughter and POA (Power of Attorney) for Healthcare stated: I have fully discussed my future options for medical care and treatment, with both my physician and the facility. I have been informed of the benefits and risks of such options, and the potential consequences, and I am fully aware of my right to determine the course of my future treatment. Having considered all of these factors, I hereby direct my caregivers to honor my intentions with respect to the following treatments, should the need arise, all of which have been explained to me. An X marked the area of Resuscitate (Full Code) and Hospitalize. The document was signed by the resident's Healthcare Power of Attorney and witnessed by a facility representative. The physician signed the document and dated it on [DATE]. Record review of the Nurses Notes dated [DATE] at 2110 revealed the Med pass nurse went into the resident's room to give HS (hour of sleep) medications and found the resident with eyes open, unresponsive and no heart rate. No respirations, poor color. RN (Registered Nurse) C was called to the resident's room to examine the resident. Resident 77 was last checked at 8:55 pm. No unusual behaviors noted and no complaints at that time. At 9:15 pm, the PA (physician's assistant) was notified and stated: [DIAGNOSES REDACTED]. The Nurses Notes did not indicate that CPR was initiated. Resident 77's family and the Sheriff were notified of the resident's death. An additional note added to the Nurses Notes and dated [DATE] at 10:35 pm stated: Additional information regarding expiration: CPR was not initiated due to condition of body when found. MD aware. Family voiced no concerns. An interview with RN C was held on [DATE] at 3:07 PM. RN C was asked to indicate what she would do if she found a resident unresponsive. RN C responded that RN C would attempt to arouse the resident if the resident was unresponsive. RN C would then check the chart for a yellow sticker which is the facility indicator to initiate CPR. RN C would tell someone to call 911, initiate CPR, and grab someone to assist. RN C revealed that RN C had experienced a recent occurrance where the resident was a full code but when RN C found the resident, the resident had no heartbeat or respirations and pupils were fixed. RN C did not initiate CPR due to the resident's condition. When the physician was notified, the physician stated that nurses would not have been able to do anything anyway. An interview with the DON (Director of Nursing) on [DATE] at 3:20 PM revealed that the expectation of the DON would be that if a resident or responsible party has signed a document requesting full code, that a full code would be initiated. The DON stated CPR class recertification touches on when to initiate CPR. The residents who have requested full code status have a yellow round sticker on the resident chart and a yellow round sticker on the nameplate of the door of the resident's room. Review of the policy number CL-NUR-1804 entitled Emergency: Initiation of "Code Blue" and dated [DATE] indicated the following: 1.0 Purpose - To provide an organized, systematic process to notify appropriate staff emmgers of the need for assistance during a potential life-threatening situation. 2.0 Fundamental Information Equipment - Emergency Cart, Emergency oxygen supply, telephone 3.0 Procedure - 1. Follow clinical practice guidelines for CPR 2. Utilizing the overhead paging system, announce "Code Blue (location)"; Repeat 2 times. At minimum, the following individuals are to respond: Physician (if in facility), Director of Nurses, Charge Nurse, Respiratory Therapist (not applicable in all facilities. 3. A designated team leader will direct other staff members to assist with making phone calls, assure the emergency cart is brought to the scene and assure the safety of other residents in the area. 4. A licensed staff person must remain with the resident at all times. 5. Call 911 for emergency transfer to an acute care center. 6. Contact the resident's physician for further orders. 7. Contact the resident's responsible party to inform him/her of the change of condition. 8. Continue CPR efforts until the ambulance service arrives or until spontaneous respirations, pulse and blood pressure return. 9. Transport resident to the acute care center. 4.0 Documentation - In the progress notes, record: When and why the "Code Blue" was initiated If CPR was initiated, when and how long the resident received it Resident response and any complications Any interventions taken to correct complications Date, time of physician and responsible party notifications Resident disposition 5.0 Company related guidelines Perry/Potter reference manual: CPR; One-Person and/or Two-Person rescue Choking Manual ventilation (Ambu Bag) Interview with LPN (Licensed Practical Nurse) E on [DATE] at 3:45 PM indicated this LPN would initiate CPR and yell for help if (gender) were to find a resident unresponsive with the absence of respirations and a heart rate. LPN E indicated that if the resident was a full code, even if they were cold and blue LPN E would initiate CPR. LPN E received CPR training on [DATE] from the NE Safety Council. Interview with NA (Nurse Aide) F on [DATE] at 3:50 PM indicated that if NA F found a resident unresponsive, NA F would call for the charge nurse. NA F was unable to identify the significance of yellow dots found on the name plates of rooms. Observation of yellow dots indicating full code status held on [DATE] at 3:40 PM to 3:44 PM revealed yellow dots on the nameplates of the following rooms: room [ROOM NUMBER] 212, 217, 101, 108, and 117. Observation of yellow dots on charts indicating full code status held on [DATE] at 3:45 PM indicated yellow dots were present on charts 101A,107A, 108A,117A, 118A, 203B, 204B, 212B, 217A and 217B. The dots on the charts do no correspond with the dots on the door nameplates. Interview with RN H held on [DATE] at 3:45 PM indicated if RN H would enter a resident room and observed an unresponsive resident with the absence of heart rate and respirations, RN H would attempt to arouse the resident and check the chart to see if the resident is DNR( do not resuscitate) status. If the resident were a full code, RN H would attempt CPR. When questioned when CPR would not be initiated, RN H responded if a do not resuscitate order is present or unless the color has already changed and there are no signs of hope. Interview on [DATE] at 3:55 pm with NA I revealed NA I would get the charge nurse if she found a resident unresponsive and wait for them to tell her what to do. Interview with the DON held on [DATE] at 4:10 PM revealed the facility did not have a policy on how to identify DNR residents as opposed to full code written up on the yellow dot system but DON said "I can type something up." Interview held with the DON on [DATE] at 4:45 PM confirmed 2 nameplates by resident rooms did not have yellow dots, Residents 31 and 51. Residents 31 and 51 were determined to be full code status. The DON indicated (gender) had typed up dot guide today.Interview with the DON indicated nurses are informed of the yellow dot system during initial orientation. The following interventions were implemented by the facility on [DATE], [DATE] and [DATE] to abate the immediacy of the situation and protect residents who wanted to have CPR. An action plan was created listing CPR as the area of concern with a goal of residents receiving CPR according to current CPR guidelines. Approaches included: Audit placement of round yellow stickers daily times 1 month, then weekly times one month, then monthly times 3 months, then reassess and schedule audits on a prn random basis. Tentative schedule developed with a completion date of [DATE]; Assess monthly with QA(Quality Assurance). The outcome was all round yellow stickers were in place on the charts and beside name on door after replacing needed stickers. Move stickers under plastic on the resident name plate by their room door with a completion date of [DATE]. The outcome was all round yellow stickers are under plastic on the resident name plates by their door. Re-educate staff concerning CPR guidelines and protocols on all 3 shifts before they work with a completion date of [DATE] and [DATE] and current staff by [DATE]. The outcome was re-education completed on all three shifts and will continue until all staff reeducated before they work. Random questioning of staff concerning CPR policies and procedures weekly times one month, monthly times 1 month, then reassess and scheduel random questioning on a prn basis. Tentative schedule developed. The completion date was [DATE] and assess monthly with QA. The outcome indicated staff questioned gave correct answers to questions asked. Code Blue drills weekly times 1 month alternating shifts and assess then continue on a quarterly basis. Completion date was [DATE]. The first drill is scheduled for [DATE] quarterly schedule completed. Room changes or code status change with completion date of [DATE] Outcome will be social worker will give notice to DON with reminder to move round yellow stickers with move, and give copy of all code status changes to DON, audit weekly. On admission, admission nurse will put round yellow stickers on chart and by door under plastic on name plate and document on admission check list. Completion date of [DATE] with outcome to audit of all admissions upon admit. The final approach is to report findings to QA meeting monthly with the next QA meeting being [DATE]. The outcome will be to address all findings. All facility nursing staff who were scheduled to work were re-educated on the CPR policy on [DATE] and [DATE]. Based on the facilities actions, the IJ status was abated on [DATE].

Licensure Reference: 175 NAC 12-006.09D7 Based on observation, record review, and interview, the facility failed to provide supervision to prevent falls in accordance with plan of care for 2 residents (Residents 81 and 31). The facility had a total census of 57 residents, Findings are: A. Resident 81 was admitted to the facility on [DATE] according to Resident 81's care plan. A review of Resident 81's care plan revealed a problem dated 6/19/12 of having a potential for injury related to moderate fall risk, impaired vision and poor safety awareness from dementia. The care plan included the following interventions dated 6/22/12: do no leave resident unattended on toilet and do not leave resident alone in room while up in wheelchair. Resident 81's care plan interventions were updated on 10/26/12 to include lay down in bed after supper meal and mattress on floor by bed. The following interventions were added to Resident 81's care plan on 10/31/13 last up first down related to postural weakness in tilt chair, in high visible area when up, and mattress next to low bed in room. A review of Incident Report for Resident 81 dated 10/26/13 revealed Resident 81 was self-propelling in wheelchair by nurses' station, leaned over and feel forward onto head. Resident 81 sustained a skin tear and abrasion. The following was documented under final outcome lay down in bed after supper meal and mattress in floor by bed. A review of Incident Report for Resident 81 dated 10/31/13 at 12:50 PM revealed Resident 81 was found in room on floor on left side with left hip on foot pedal of wheelchair. Resident 81's legs were underneath wheelchair. Resident 81 sustained a 4 x 5 cm hematoma to left forehead and a 2 x 2 cm skin tear. Pressure and cold compress was applied to Resident 81's forehead. The following was documented under final outcome: hospice provided new wheelchair, keep in high visible area when up, limited time up in wheelchair, and mattress next to low bed when in room. In an interview on 12/3/13 at 1:53 PM, Nurse Aide D reporting pushing Resident 81 back from lunch and leaving resident in room. Nurse Aide D reported being unaware of intervention to not leave resident in room until after the fall happened. In an interview on 12/3/13 at 1:20 PM, the Director of Nursing reported the aide was careless in leaving the resident in the room. B. Resident 31 was admitted to the facility on [DATE] according to Resident 31's care plan. A review of Resident 31's care plan revealed a problem dated 5/16/13 of potential for injury related to fall risk, Alzheimers, and poor safety awareness. On 11/12/13, Resident 31's care plan was updated to include have resident by nurses' station when up in wheelchair. A review of Incident Report for Resident 31 dated 11/12/13 at 4:30 PM revealed Resident 31 was in 100 hallway in wheelchair with legs hanging over side, moving buttocks forward and tipping wheelchair forward. Resident slide off seat of wheelchair and sat on the legs of wheelchair. Resident 31 did not hit head and no apparent injury. The following was documented under final outcome screen to therapy and when up in wheelchair keep close to nurses' station. Observations on 11/26/13 at 2:02 PM and 12/3/13 at 9:41 AM revealed Resident 31 seated in wheelchair in Resident 31's room unattended. In an interview on 12/3/13 at 9:42 AM, Nurse Aide G reported that it was acceptable for Resident 31 to be up in wheelchair in room unattended. A review of nurse aide spread sheet being utilized by Nurse Aide G did not include intervention of keeping Resident 31 by nurses' station when up in wheelchair. In interviews on 12/3/12 at 1:14 PM and 1:30 PM, the Director of Nursing reported changes in interventions are passed on in report and put of care guide in notebooks at desk. The Director of Nursing reported the changes may not necessarily be added to spread sheets carried by nurse aides.

Licensure reference: 175 NAC 12-006.07 Based on record review and interview, the facility failed to identify deficient practices and develop a quality assurance plan as evidence by a repeat deficiency at F 464 and a new deficiency at F323. The facility had a total census of 57. Findings are A. A review of survey results revealed a deficiency was cited at F 464 related to adequate dining space during survey completed 10/4/12. A repeat deficiency was cited for survey completed F464 related to adequate dining space to prevent moving residents in the dining to allow other residents to enter and exit the dining room. In an interview on 12/3/13 at 10:49 AM, the Dietary Manager reported horseshoe shaped had been removed to provide more room in the dining room. The Dietary Manager reported monitoring the dining room on a daily basis to ensure all residents have adequate space to allow resident to enter and exit the dining room without having to move other residents. Interview with Administrator on 12/3/13 at 5 PM revealed dining room space had been reviewed by the quality assurance committee during the quarterly quality assurance meeting for 10/12, 11/12 and 12/12. B. A deficiency was cited at F323 for failure to provide adequate supervision to prevent falls for two residents. Care plan interventions for both Resident 81 and 31 included having residents by nurses ' station while up in wheelchair. Interviews with Nurse Aide D at 12/3/13 and 1:53 PM and Nurse Aide G on 12/3/13 at 9:42 AM revealed nurse aides were not aware of changes in interventions to prevent falls. Interview with the Director of Nursing on 12/3/13 at 1:22 PM revealed would be trigger for follow up by the quality assurance committee if a certain threshold is reached. C. In interviews on 12/3/11 at 11:15 AM and 11:17 AM, Nurse Aides K and L reported being unaware of concerns being addressed by the quality assurance committee.