Every finding on record at Adept Nursing & Rehab of Midtown

Licensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure all food stored in the facility's kitchen was labeled, dated, and/or sealed, ensure refrigerators (fridge) and freezers did not contain expired products to prevent foodborne illness, and ensure the interior bottom, bottom vents of refrigerators and freezer, top of the double door oven, and all dishes, plates, and serving containers were stored and maintained in a clean and sanitary manner to prevent cross contamination. This had the potential to affect all residents that consumed food prepared in the facility kitchen. The total facility census was 49. Findings are:A record review of the facility's Food Safety Requirements with a date reviewed/revised of 10/2025 revealed facility staff shall inspect all food product, and beverages for proper storage to include labeling, dating, and monitoring food so it is used by its use by date. All equipment used shall be cleaned and sanitized. A record review of the facility's Sanitation Inspection policy with date reviewed/revised date of 10/2025 revealed all food service areas would be kept clean and sanitary. A.An observation on 04/27/2026 at 5:55 AM to 6:28 AM revealed:The Atosa 2 door reach-in fridge contained: - 1 pack of a white substance not labeled. - 1 large Zip Lock style bag that contained a white substance not sealed or labeled. - 1 pack of yellow slices wrapped in plastic wrap not labeled or dated. - 1 large Zip Lock style bag that contained a package labeled turkey breast that was opened, not dated. - 1 steam pan that contained a plastic and aluminum foil wrapped substance not labeled or dated. - 1 bag of a brown slices of a substance, not labeled. - 2 half pint containers of 1% chocolate milk with a use by date of 04/20/2026. - 1 gallon jug of 2% chocolate milk with an expiration date of 04/26/2026. - 3 bags of green items not labeled or dated.The Advantco 2 door reach-in freezer contained: - 1 open Zip Lock style bag that contained a brown substance that was not labeled. An observation on 04/27/2026 at 6:28 AM with the facility's Cook-D revealed:The Atosa 2 door reach-in fridge contained: - 1 pack of a white substance not labeled. - 1 large Zip Lock style bag that contained a white substance not sealed or labeled. - 1 pack of yellow slices wrapped in plastic wrap not labeled or dated. - 1 large Zip Lock style bag that contained a package labeled turkey breast that was opened, not dated. - 1 steam pan that contained a plastic and aluminum foil wrapped substance not labeled or dated. - 1 bag of a brown slices of a substance, not labeled. - 2 half pint containers of 1% chocolate milk with a use by date of 04/20/2026. - 1 gallon jug of 2% chocolate milk with an expiration date of 04/26/2026. - 3 bags of green items not labeled or dated.The Advantco 2 door reach-in freezer contained: - 1 open Zip Lock style bag that contained a brown substance that was not labeled. In an interview on 04/27/2026 at 6:28 AM, the facility's Cook-D confirmed that all the above items were not labeled, dated, and/or sealed and should have been. In an interview on 04/28/2026 at 6:46 AM, the facility's Certified Dietary Manager (CDM) confirmed the CDM observed all the listed items above on 04/27/2026 and the items were not labeled, dated, or sealed and should have been. B.An observation on 04/27/2026 at 5:55 AM to 6:28 AM revealed: - The Atosa 2 door reach-in fridge bottom vents contained lint, food debris, and food splatters. - The Advantco 2 door reach-in freezer bottom vents contained lint, food debris, and food splatters. - The True single door reach-in fridge interior bottom contained food debris and food splatters, and the bottom vent contained lint, food debris, and food splatters. - The top of the Sunfire double-door oven contained food debris. - The shelves on the North side of the kitchen by the dish machine contained small plates, bowls, and thermal plate containers all with the potential food contact surfaces facing up and uncovered. An observation on 04/27/2026 at 6:28 AM with Cook-D revealed: - The Atosa 2 door reach-in fridge bottom vents contained lint, food debris, and food splatters. - The Advantco 2 door reach-in freezer bottom vents contained lint, food debris, and food splatters. - The True single door reach-in fridge interior bottom contained food debris and food splatters, and the bottom vent contained lint, food debris, and food splatters. - The top of the Sunfire double-door oven contained food debris. - The shelves on the North side of the kitchen by the dish machine contained small plates, bowls, and thermal plate containers all with the potential food contact surfaces facing up and uncovered. In an interview on 04/27/2026 at 6:28 AM, the facility's Cook-D confirmed that all the above equipment contained lint, food debris, or food splatters and the food serving items on the shelves by the dish machine were stored upright and uncovered and should have been food-serving side down. In an interview on 04/28/2026 at 6:46 AM, the facility's Certified Dietary Manager (CDM) confirmed the CDM observed all the above equipment contained lint, food debris, or food splatters and the food serving items on the shelves by the dish machine were stored upright and uncovered and should have been food-serving side down.

Licensure Reference Number 175 NAC 12-006.05(G) Based on interview and record review, the facility failed to ensure a gradual dose reduction (GDR),tapering of a dose of medication) was completed in the required timeframe for 1 (Resident 1) of 4 sampled residents' duloxetine (a medication used to treat depression), monitor for behaviors and adverse consequences (negative outcomes), and document non-pharmalogical interventions related to 1 (Resident 1) of 4 sampled residents' duloxetine and trazodone (a medication used to treat depression that can be used to treat insomnia) medications. The facility census was 49. Findings are:A.A record review of the facility's Gradual Dose Reduction of Psychotropic Drugs policy with a date reviewed/revised of 10/2026 revealed that a resident's psychotropic (medication that alters one's mind) medications would receive a GDR and behavioral interventions unless clinically contraindicated (cause a return of behavioral symptoms). A GDR should be completed after the first year of use unless it was clinically contraindicated or the physician provided a rational (reason) why it should not be attempted. A record review of Resident 1's Clinical Census dated 04/28/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medical Diagnosis dated 02/12/2026 reveled the resident had diagnoses of Adjustment Disorder With Mixed Anxiety And Depression and Insomnia (a sleep disorder). A record review of Resident 1's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 03/23/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to understand). The resident was independent with person and oral hygiene (cleaning) and upper body dressing, required setup or clean-up assistance with eating, partial/moderate assistance with bathing. Substantial/maximal assistance with lower body dressing, and dependent on staff for toileting hygiene and footwear. The resident required substantial/maximal assistance with bed mobility and was dependent on staff for transfers. The resident did not have behavior symptoms. A record review of Resident 1's Care Plan Report with an admission date of 04/22/2025 revealed the resident demonstrated behavioral concerns with a revision date of 03/31/2026, and staff was to monitor and document behavior episodes and interventions. The resident used Black Box (warnings issued highlighting serious risks of the drug) medications and staff was to monitor for adverse reactions and report. The resident used psychotropic medications related to the mood disorder with anxiety and depression and had interventions to review the GDR as needed, the pharmacist would review the medications and forward suggestions to the physician, and the facility would monitor and document target behaviors, mood, or nursing staff problems. A record review of Resident 1's Clinical Physician Orders dated 04/28/2026 revealed the resident had orders for duloxetine, one 60 milligram (mg) delayed release capsule, with a start date of 05/28/2024. The original start date for the duloxetine was 03/20/2026 at one 20 mg capsule, on 05/20/2024 the dose was increased to one 30 mg capsule, then the dose was increased to 60 mg on 05/28/2024. A record review of the facility pharmacy's Study of Psychoactive by Resident dated 11/05/2025 revealed Resident 1 was on 20 mg duloxetine(an antidepressant medication), on 05/28/2024 it was increased to 60 mg for pain, and the last GDR was 05/01/2025. A record review of the facility pharmacy's Consultant Recommendation to Physician printed 05/06/2025 revealed Resident 1 had been using duloxetine 60 mg once a day for pain since 05/28/2024 and a trial dose reduction may be reasonable at that time. The physician/prescriber was crossed out and a different physician was written in. Neither physician provided a response or signed the Consultant Recommendation to Physician printed 05/06/2025. A record review of the facility pharmacy's Consultant Pharmacist MRR (medication regimen review) Recommendation to Prescriber with a MRR dated of 04/08/2026 revealed Resident 1 was receiving psychotropic medications duloxetine 60 mg once a day, trazadone 25 mg at hours of sleep, and Buspar (a medication used to treat anxiety) 10 mg two times per day. GDR was required twice in the first year of therapy and annually thereafter unless clinically contraindicated. Clinical contraindication is defined as previous failure of reduction AND documentation by the MD (medical doctor) detailing medical rationale for continued use of the current dose. The Consultant Pharmacist MRR Recommendation to Prescriber had not been responded to or signed. In an interview on 04/29/2026 at 2:33 PM, the facility's Regional Nurse Consultant (RNC) firmed it was the RNC's expectation that the physician would respond to a GDR within a few days to a week, but it may sit on a physician's desk a little longer. In an interview on 04/29/2026 at 11:23 AM, the facility's Administrator confirmed the facility did not have a GDR for Resident 1's duloxetine. B.A record review of the of the facility's undated Psychotropic Medication(s) policy revealed psychotropic medications are to be used only when the physician determines the medication is appropriate to treat the resident's specific, diagnosed condition and is beneficial as demonstrated by monitoring and documenting the response to the medication. Non-pharmalogical approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropics medications. A record review of Resident 1's Order Summary Report dated 04/28/2026 revealed the resident had orders for duloxetine - one 60 milligram (mg) delayed release capsule once per day and trazadone - 50 mg, 0.5 tablet at bedtime related to insomnia. The Order Summary Report revealed the only psychotropic monitoring for behaviors, side effects, and interventions was for the buspirone (a antianxiety medication, same as Buspar). A record review of Resident 1's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February - April 2026 revealed the psychotropic monitoring for behaviors, side effects, and interventions was for use of the buspirone. A record review of Resident 1's Electronic Medical Records (EMR) did not reveal that behaviors were being monitored in the Tasks, or that behaviors, side effects, or non-pharmalogical interventions were completed on paper and scanned into the EMR. In an interview on 04/29/2026 at 9:15 AM, the Director of Nursing (DON) confirmed the only medication monitoring for behaviors, side effects, and interventions was for the buspirone on the MAR & TAR.

Based on observation, intervention and record review, the facility failed to maintain a Medication Error rate of less than 5%. Observation of 26 medications revealed 2 errors with a resulting rate of 7.69%. The medication errors are related to 1 (Resident 8) of 4 sampled residents. The facility staff identified a census of 49. Findings are:A record review of the facilities Medication Administration policy with a revision date of 10/25 revealed the following:'Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentation Record review of a facility policy titled 'Insulin Pen Policy' with an implemented date of 8/2025 and a date reviewed/revised as 10/2025 revealed the following: Policy: It is the policy of this facility to use insulin pens (an injection device that allows you to deliver preloaded insulin into your subcutaneous tissue) in order to improve the accuracy of insulin dosing, provide increased resident comfort and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge.Policy Explanation guide and Compliance Guidelines:6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir.11. Procedure:h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise.ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Record review of Resident 8's treatment administration record (TAR) dated 4/2026 revealed the following:-Fiasp FlexTouch 100 unit/milliliter [ml] solution pen-injector, inject 8 units subcutaneously before meals related to type 2 diabetes mellitus with hyperglycemia.-Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 unit/ml (Insulin Glargine) Inject 75 units subcutaneously two times a day related to type two diabetes mellitus with chronic kidney disease. Hold if blood sugar is less than 100. Call Dr for blood sugars less than 100 or greater than 450.Observation of a medication administration on 4/28/26 at 8:15 A.M. to 8:30 A.M. revealed Licensed Practical Nurse (LPN) A gathered supplies to give insulin to Resident 8, entered the room, and obtained blood sugar with a reading of 143. LPN A obtained an Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) pen, cleansed the hub with an alcohol wipe, applied the needle, turned the dose selector to 75 units, and without priming the pen injected the insulin into Resident 8's lower abdomen. LPN A obtained a Fiasp FlexTouch 100 unit/ml Solution pen-injector pen, cleansed the hub with an alcohol wipe, turned the does selector to 8 units, and without priming the pen injected the insulin into the lower abdomen. In an interview with LPN A on 4/28/26 at 8:30 A.M. confirmed the insulin pen was not primed prior to administering the insulin. In an interview with the Director of Nursing on 4/28/26 at 1:15 P.M. it was confirmed the insulin pen should have been primed prior to selecting the dose and it would be considered a medication error.

Based on observation, interview and record review the facility staff failed to prime an insulin pen prior to administering insulin on 2 of 2 observations for 1 (Resident 8) of 1 sampled resident who received insulin, resulting in a significant medication error. The facility identified a census of 49. Findings are:Record review of a facility policy titled 'Insulin Pen Policy' with an implemented date of 8/2025 and a date reviewed/revised as 10/2025 revealed the following:'Policy: It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort and serve as a teaching aid to prepare residents for self-administration of insulin therapy upon discharge.Policy Explanation guide and Compliance Guidelines:6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir.11. Procedure:h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise.ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Record review of Resident 8's treatment administration record (TAR) dated 4/2026 revealed the following:-Fiasp FlexTouch 100 unit/milliliter[ml] solution pen-injector, inject 8 units subcutaneously before meals related to type 2 diabetes mellitus with hyperglycemia.-Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 unit/ml (Insulin Glargine) Inject 75 units subcutaneously two times a day related to type two diabetes mellitus with chronic kidney disease. Hold if blood sugar is less than 100. Call Dr for blood sugars less than 100 or greater than 450.Observation of a medication administration on 4/28/26 at 8:15 A.M. to 8:30 A.M. revealed Licensed Practical Nurse (LPN) A gathered supplies to give insulin to Resident 8, entered the room, and obtained blood sugar with a reading of 143. LPN A obtained an Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine) pen, cleansed the hub with an alcohol wipe, applied the needle, turned the dose selector to 75 units, and without priming the pen injected the insulin into Resident 8's lower abdomen. LPN A obtained a Fiasp FlexTouch 100 unit/ml Solution pen-injector pen, cleansed the hub with an alcohol wipe, turned the does selector to 8 units, and without priming the pen injected the insulin into the lower abdomen. In an interview with LPN A on 4/28/26 at 8:30 A.M. confirmed the insulin pen was not primed prior to administering the insulin. In an interview with the Director of Nursing on 4/28/26 at 1:15 P.M. it was confirmed the insulin pen should have been primed prior to selecting the dose and it would be considered a medication error.

Licensure Reference Number 175 NAC 12.006.18(B) Based on observation, interview, and record review, the facility failed to ensure hospice staff donned (put on) personal protective equipment (PPE) during wound care in a manner to prevent cross contamination for 1 (Resident 45) of 2 sampled residents. The facility census was 49. Findings are:A record review of the facility's Enhanced Barrier Precautions (EBP) policy with a date reviewed/revised of 04/01/2026 revealed EBP was an infection control intervention designed to reduce transmission of multidrug-resistance organisms (MDRO) that employ targeted gown and glove use during high contact cares such as wound care. A record review of the undated Enhanced Barrier Precautions sign revealed providers and staff must wear gloves and a gown for high-contact resident care activities such as wound care. A record review of Resident 45's Order Summary Report dated 04/27/2026 revealed the resident had wound care orders for wounds on the left inner heel and open area above the left heel, skin tear to the left shin, and scabs on the left shin. A record review of Resident 45's Clinical Physician Orders dated 04/27/2026 revealed the resident was in EBP due to wounds and ensure appropriate PPE was used during resident care activities. An observation on 04/28/2026 at 8:57 AM revealed there was an EBP sign to the left of the door to Resident 45's room. The Hospice Registered Nurse (HRN)-B was in the room and had removed the dressing on the ankle. The HRN-B did not have a gown on. Licensed Practical Nurse (LPN)-C entered the room to complete wound care on Resident 45's left lower extremity (LLE)(left lower leg and foot). HRN-B touched the resident's LLE wounds twice and lifted the LLE five times, without a gown on, while LPN-C applied dressings to the resident's wounds. In an interview on 04/28/2026 at 9:30 AM, HRN-B confirmed HRN-B did not have a gown on during wound care on Resident 45 and should have had a gown on.

License Reference Number 175 NAC 12.006.09(H)(iii)(2)Based on observation, interview and record review, the facility failed to ensure staff members performed hand hygiene when providing wound care to 2 residents (Residents 2 and 3) of 3 residents surveyed. The facility had a census of 46.A record review of the facilities Infection Prevention and Control Program, reviewed on 1/1/2025 revealed the following:Policy:This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Policy Explanation and Compliance Guidelines:All staff are responsible for following all policies and procedures related to the Program.Standard Precautions:All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.A record review of the facilities Hand Hygiene policy reviewed 11/2/2025 revealed the following:Policy:All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Policy Explanation and Compliance Guidelines:Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.This includes: After handling contaminated objects,Before applying and after removing personal protective equipment (PPE), including gloves.Before and after handling clean or soiled dressings, linens, etc.After handling items potentially contaminated with blood, body fluids, secretions, or excretions.When, during resident care, moving from a contaminated body site to a clean body site.Additional Considerations: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.A. A record review of Resident 2's Clinical Resident profile sheet revealed Resident 2 was admitted to the facility on [DATE] with the following diagnoses: surgical aftercare for surgery on the genitourinary system, Acute kidney failure (a sudden, often reversible loss of kidney function occurring within hours or days), sepsis (a life-threatening reaction to an infection that causes the immune system to harm healthy tissues and organs) due to enterococcus (bacteria normally found in the human gut which can cause infection, and severe protein-calorie malnutrition (undernutrition cause by inadequate intake of protein and calories).A record review of Residents 2's Minimum Data Set (MDS - a federally mandated standardized tool used in nursing homes to evaluate resident health status and care needs) dated 1/17/2026, revealed Resident 2 had a Brief Interview for Mental Status (BIMS - a standardized screening tool use in long-term care settings to assess cognitive function) of 11, indicating Resident 2 is moderately cognitively intact.(experiences noticeable memory or thinking problems greater than normal ageing but still maintains independence in daily functioning).A record review of Resident 2's progress note dated 4/5/2026 revealed Resident 2 was sent to the Emergency department on 4/5/2026 via 911 for a decrease in level of consciousness.A record review of Resident 2's progress note dated 4/9/2026 revealed Resident 2 returned from the hospital with an admitting diagnosis of Sepsis with Acute Organ dysfunction (the sudden, rapid decline of one or more vital organs) without Septic Shock (a life-threatening medical emergency where severe infection causes dangerous drops in blood pressure and cellular abnormalities, causing organ failure). A record review of a clinical note from Tissue Analytics (wound care service) dated 1/16/2026, by Advanced Practice Nurse Practitioner, revealed the following: Recently admitted to facility, wound present on admission. Pressure Ulcer Stage 3, Measurements are Length 4.58cm, width 3.14cm, depth 0.20cm.A record review of a clinical note from Tissue Analytics dated 4/3/2026, by APRN revealed the following: Pressure Ulcer Stage 4. Continue current treatment. Wash wound with wound cleanser, pat dry. Apply facility brand skin barrier (an ointment that provides a protective seal on the skin) (Prevent Essentials ointment type) 2cm around the wound opening. Apply Adaptic (a non-adhering wound dressing) into the wound first, then the wound vac (a medical device used to speed healing of chronic, large, or infected wounds) dressing. Apply wound vac at previous settings (-125mmHg - a unit of measurement) Using white foam on the wound base. Change Monday, Wednesday, Friday and as needed. Remove old foam gently, moisten with gauze if necessary.A record review of a clinical note from Tissue Analytics dated 4/10/2026, by APRN, revealed the following: Pressure Ulcer Stage 4, measurements are length 2.30cm, width 2.24cm and depth 2.00cm. A new wound order reads as follows: DC (discontinue) wound orders. Wash wound area, pat dry. Paint the peri wound (area around the wound) with skin prep (a protective wipe that forms a barrier on intact skin to improve dressing adhesion and reduce friction) and let dry. Fill wound with rolled gauze, slightly moistened with Vashe (a safe non-toxic wound cleaner). Make sure to squeeze out the excess. Cover with dry gauze bed, then cover with ABD's (large absorbent dressing) or Mepilex (a soft, absorbent, silicone dressing) (generic equivalent) Change daily and as needed for soiling, saturation, or accidental removal. An observation on 4/14/2026 at 10:10 AM of wound care provided to the resident by Licensed Practical Nurse (LPN) A and assisted by Nurse Assistant (NA) B revealed the following: LPN A and NA B entered Resident 2's room after knocking and announced themselves. LPN A placed the wound supplies on a towel over a table. The supplies consisted of scissors, sharpie pen, skin prep wipes, wound cleanser, gauze 4 x 4s, Vashe, a roll of kerlix (a highly absorbent, 100% cotton, crinkle-weave gauze dressing) a bordered dressing and gloves. Both LPN A and NA B washed their hands and donned gowns and gloves. LPN A and NA B assisted Resident 2 to roll onto their left side exposing the wound area. NA B stabilized Resident 1 on their side by holding them on their right hip and right shoulder. LPN A removed the dressing from the wound and discarded it in the trash along with their gloves. LPN A donned clean gloves without using hand sanitizer and sprayed wound cleanser on 4 x 4 gauze pads. LPN A used a gauze pad to remove a thin layer of ointment at the edges of the wound. LPN A discarded the gauze pad and donned clean gloves without using hand sanitizer and wiped the peri wound area with a dampened gauze pad, in a circular motion around the open wound. LPN A then used the same gauze pad to clean the open wound bed. LPN A discarded the pad, changed gloves without using hand sanitizer and repeated the process, pulling a damp gauze pad from the outer edge of the wound to the center of the wound bed. LPN A discarded the gauze pads and changed gloves without performing hand hygiene. LPN A opened a packet of skin prep, wiped the enclosed pad around the wound and allowed it to dry. LPN A changed gloves without performing hand hygiene and cut a piece of kerlix from the kerlix roll and rolled it up. LPN A soaked the kerlix in the Vashe and squeezed out the excess. LPN A inserted the rolled up kerlix into the wound and used their gloved fingers to push the gauze into place. LPN A changed gloves without performing hand hygiene and placed a layer of dry 4 x 4 gauze pieces over the wet kerlix to form a pad. NA B removed their gloved left hand from Resident 2's right hip and held the gauze pieces in place while LPN A opened the bordered dressing, dated it with a sharpie pen and placed it over the gauze pieces to secure them in place. LPN A assisted NA A to reposition Resident 2 and discarded the remaining dressing supplies in the trash. LPN A and NA A both removed their gowns and gloves, washed their hands, and exited the room. An interview on 4/14/2026 at 10:50 AM with LPN A confirmed they had not used hand hygiene in between glove changes and should have done so. LPN A recognized this was an opportunity for cross contamination. LPN A confirmed they had cleaned the wound from the outside edge of the wound to the wound center, and this was an opportunity for cross contamination. LPN A confirmed NA B should not have touched the gauze pad to stabilize it. NA B's gloved hand had been touching Resident 2 and had moved from a dirty area to directly touch the wound dressing, providing a path for cross contamination.An interview on 4/14/2026 at 11:00AM with NA B confirmed they had touched Resident 2's wound dressing with a gloved hand that had been on the residents skin. NA B confirmed they was not aware that they should not have stabilized the gauze pad and did not know it was an opportunity for cross contamination of the wound. B. A record review of Resident 3's Clinical Resident Profile sheet revealed Resident 3 was admitted to the facility on [DATE] with the following diagnoses: Type 2 diabetes mellitus with diabetic nephropathy (chronic high blood sugar damages the kidneys filtering system leading to decreased kidney function), Idiopathic Gout (inflammatory arthritis caused by the build up of uric acid crystals in joints), PTSD (a mental health condition triggered by witnessing or experiencing life-threatening, terrifying events), major depressive disorder (severe mental health condition characterized by at least 2 weeks of pervasive low mood, loss of interest and low energy), anxiety disorder (persistent, excessive fear or worry that interferes with daily life) schizophrenia (a chronic severe mental health disorder, characterized by hallucinations, delusions, and disorganized thinking), chronic pain (pain that lasts for more than 3 months), cognitive communication deficit (a communication impairment resulting from underlying cognitive issues - such as memory, attention, executive function, and information processing) erythema interigo (an inflammatory rash occurring in skin folds), chronic pain, localized edema (swelling) Heart disease, Myocardial infarction (heart attack), Neuralgia (burning nerve pain) and Neuritis (inflammation of one or more nerves) 9)A record review of Resident 3's Annual MDS, dated [DATE], revealed Resident 3 had a BIMS of 15 indicating they were cognitively intact. A record review of Resident 3's Tissue Analytics wound note, dated 4/10/2026, by APRN B, revealed the following wound description. Left Great Toe. Length 0.84cm, Width 1.08cm, depth 0.10cm. Wound note revealed this area is macerated. Will change treatment to Medi honey (medical grade, sterilized wound dressing) and alginate (a highly absorbent, natural fiber dressing derived from seaweed).A record review of Resident 3's progress notes revealed the following wound care order, dated 4/11/26, by APRN B. Discontinue previous order to left great toe and start: Wash with facility cleanser, pat dry. Apply skin prep to the peri wound and allow it to dry. Apply a small amount of Medi honey to the wound bed. Apply a small amount of alginate AG to the wound bed, cut to fit size/shape. Avoid placing over healthy tissue as it can cause maceration. Cover with Mepilex (generic) Change EOD and PRN for soiling, saturation, or accidental removal as needed. An observation of wound care on 4/14/2026 at 10:35 AM to Resident 3 by LPN A revealed LPN A gathered the wound supplies which consisted of Medi honey paste, skin prep, wound wash, gauze pads, a dated, bordered dressing, gloves and placed them on a clean table covered by a towel. LPN A washed their hands and donned gloves and a gown. Resident 3 was able to assist by lifting their left leg and suspending their foot over the side of the bed. LPN A removed residents sock and the old dressing. LPN A changed gloves without hand hygiene, sprayed wound wash onto a gauze pad and cleaned the wound. LPN A moved from the edges of the wound to the center and back again, wet more gauze without changing gloves or performing hand hygiene and repeated the cleaning action of moving from the intact skin to the wound bed and back to the intact skin. LPN A changed gloves without hand hygiene and wiped the peri wound area with skin prep. LPN A changed gloves without performing hand hygiene and applied a thin layer of Medi honey to the wound bed with their gloved hand. LPN A changed gloves without hand hygiene and cut a piece of silver alginate to fit the wound bed, placed it over the Medi honey, and covered it with the dated, bordered dressing. LPN A replaced Resident 3's sock and discarded the trash. LPN A then washed their hands and exited the room. An interview on 4/14/2026 at 10:50 AM with LPN A confirmed they had not used hand hygiene in between glove changes and should have done so. LPN A recognized this was an opportunity for cross contamination. LPN A confirmed they had cleaned the wound back and forth from the outside edge of the wound to the wound center, and this was an opportunity for cross contamination.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review the facility failed to implement interventions to prevent falls for 2 (Resident 1 and 2) of 3 residents sampled. The facility census was 40. Findings are: Record review of the facility policy titled Fall Prevention Program dated 08-2024 revealed the following: -each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -the facility uses a standardized risk assessment for determining a resident's fall risk. -the risk assessment categorizes residents according to low, moderate, or high risk. -upon admission the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. -the nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. -each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. -interventions will be monitored for effectiveness. -the plan of care will be revised as needed. A. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 02-16-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 3/15. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -The resident required set up and supervision for eating and upper body dressing. -The resident required substantial assistance with toileting, bathing, lower body dressing and transfers. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 03-17-2025 revealed Resident 1 had the potential for falls related to having had a stroke and a history of seizures. The CCP also indicated that Resident 1 was to have an alarm to bed and wheelchair. An observation on 3-18-2025 at 2:40 PM of Resident 1 sitting in a wheelchair next to the nurse's station revealed no alarm in use on the wheelchair. An observation on 3-20-2025 at 8:05 AM of Resident 1 sitting in the wheelchair in the library revealed no alarm in use on the wheelchair. An interview on 3-20-2025 at 10:35 AM with the Director of Nursing (DON) which confirmed Resident 1 did not have a fall alarm on the wheelchair and should have had one. B. Record review of Resident 2's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 9/15. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment. -The resident required substantial assistance with bathing and lower body dressing. -The resident required partial assistance with toileting, personal hygiene, upper body dressing, transfers and bed mobility. Record Review of Resident 2's CCP dated 02-13-2025 revealed Resident 2 had a history of falls and was to have a clip alarm when in chair and bed, and a fall mat when in bed. An observation on 3-18-2025 at 1:50 PM revealed Resident 2 sitting in a wheelchair, in room without a clip alarm in use. An observation on 3-20-2025 at 6:50 AM revealed Resident 2 lying in bed without a clip alarm in place, or a fall mat next to bed. An interview on 3-20-2025 at 7:55 AM with Nurse Aid (NA)-C which revealed Resident 2 does not use a clip alarm or a fall mat. An interview with the DON on 3-20-2025 at 10:35 AM confirmed Resident 2 should have had a clip alarm and a fall mat when in bed.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on interview and record review the facility failed to provide baths according to the plan of care for 2 (Resident 17 and 34) of 3 residents sampled. The facility census was 40. The findings are: A. Record review of Resident 17's Minimum data Set ( MDS: a federally mandated assessment tool used for care planning) dated 11-26-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 0. According to the MDS Manual a score of 0 to 7 indicates a person has a severe cognitive impairment. -Required extensive assistance with toileting, bathing, transfers and lower body dressing. -Required limited assistance with eating, hygiene, and bed mobility. Record review of Resident 17's Care Plan dated 07-03-2023 revealed Resident 17 wanted a bath once a week on Wednesday with Resident 17 required substantial assistance with bathing. Record review of Resident 17's Electronic Health Record (EHR) revealed a bath was provided on: 12-04-2024 and 12-14-2024, a 10 day span of time between baths. An interview was conducted on 01-06-2024 at 12:00 PM with the Director of Nursing (DON). During the interview the DON reported 10 days is too long in between baths for Resident 17. B. Record review of Resident 34's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 14. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact. -Required substantial assistance with bathing and lower body dressing -Required total assistance with transfers and toileting. Record Review of Resident 34's Bathing Preferences Document dated 07-12-2024 revealed Resident 34 wanted 2 baths a week. Record review of Resident 34's EHR revealed Resident 34 received a bath on: 12-05-2024, and 12-15-2024, a 10 spam between baths. An interview conducted on 01-06-2024 at 12:00 PM with the Director of Nursing (DON) revealed 10 days is too long in between baths for Resident 34. Record review of the facility policy titled Resident Showers dated 08-2024 revealed the following policy statement: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. The policy explanation and compliance guidelines revealed residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.

Licensure Reference Number 175 NAC 12-006.09(H)(iii) Based on observation, interview and record review the facility failed to follow practitioner's orders for wound care and skin integrity for 2 (Resident 5 and 34) of 4 sampled residents. The facility census was 40. The findings are: A. Record review of Resident 5's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 11-02-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact. -required substantial assistance with toileting, lower body dressing, and bathing. -required total assistance with putting on and taking off footwear. Record review of Resident 5's Order Summary sheet printed on 12-31-2024 revealed an order for a double layer of compression to both lower extremities of small edema wear (blue) followed by tubigrip size F apply from below the knee to tips of toes. An observation on 12-31-2024 at 12:30 PM revealed Resident 5 had tubigrip (a compression bandage for swelling) and edema wear (a compression bandage) over the tubigrip to both lower legs. An observation on 01-02-2025 at 10:10 AM revealed Resident 5 had returned from taking a bath and both legs had a tubigrip dressing with an edema wear dressing over the top. An interview with Registered Nurse (RN) B on 01-02-2025 at 10:15 AM revealed confirmed the compression dressings were applied in the wrong order. RN B reported the correct order was to apply the edema wear first followed by the tubigrip dressing. B. Record review of Resident 34's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 14. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact. -Required substantial assistance with bathing and lower body dressing -Required total assistance with transfers and toileting. Record review of Resident 34's order summary printed 12-31-2024 revealed an order for wound care to a sacral wound as follows: -Wound treatment: Sacral wound: Vashe compress to wound for 10 minutes then apply triad paste directly into the wound bed, change daily on every day shift. An observation on 01-02-2025 at 12:04 PM of RN E providing wound care for Resident 34 revealed a border dressing dated 12-31-2024 was on Resident 34's sacral area. An interview conducted with RN E on 01-02-2025 at 12:15 PM revealed the dressing to Resident 34's sacrum was a daily dressing change. RN E confirmed the date on the dressing was 12-31-2024 and should have been changed on 01-01-2025. Record review of the facility policy titled Wound Treatment Program dated 08-2023 revealed the following: Policy: 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. Policy Explanation and Compliance Guidelines: Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(B) Based on observation, interview and record review the facility failed to implement interventions to prevent potential falls for 1 (Resident 17) of 4 residents sampled. The facility census was 40. The findings are: Record review of Resident 17's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 11-26-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 0. According to the MDS Manual a score of 0 to 7 indicates a person has severe cognitive impairment. -required substantial assistance with toileting, showering, lower body dressing, and transfers. -required limited assistance with eating, hygiene, and bed mobility. Record review of Resident 17's care plan dated 06-15-2020 with a revision date of 09-26-2024 revealed Resident 17 was a fall risk and had fallen on 12-18-2024 while attempting to self-transfer. An intervention with a initiation date of 12-18-2024 revealed staff were to be in attendance with eyes on resident when Resident 17 was up in chair in their room. An observation on 01-02-2025 at 1:37 PM revealed Resident 17 was up in chair in room. During this observation, there were no staff present in Resident 17's room, at the nurse's station across the hall from the room, or in the hallway. An interview with Nursing Assistant (NA) F on 01-02-2025 at 1:45 PM revealed that Resident 17 was to be supervised while eating, otherwise the resident did not require supervision. An interview with Medication Aid (MA) D on 01-02-2025 at 1:50 PM revealed Resident 17 required supervision was while eating and no other time. An observation on 01-06-2025 at 12:30 PM revealed Resident 17 was sitting in a chair in their room, without the presence of staff in the room, at the nurse's station or in the hallway. An interview with Licensed Practical Nurse (LPN) A on 01-06-2024 at 12:35 PM confirmed Resident 17 was alone in their room without staff superviison. LPN A further reported Resident 17 did not need to be supervised while sitting in chair in room. An interview was conducted on 01-06-2025 at 12:46 PM with the Director of Nursing (DON) confirmed the intervention for Resident 17's fall on 12-18-2024 was to have staff supervise the resident while up in chair in room. Record review of the facility policy titled Fall Risk assessment dated ,d+[DATE] revealed the following: -Policy: it is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. -The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified. -The risk assessment will contain the following components: -a. Identify environmental hazards and individual risks, including the need for supervision. -b. Evaluate and analyze hazards and risks. -An at risk for falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. -The at risk for falls care plan will include interventions, including supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident.

Licensure Reference Number 175 NAC 12-006.09(J)(ii) Based on observation, interview and record review the facility failed to provide assistive equipment for eating for 1 (Resident 17) of 2 residents sampled. The facility census of 40. The findings are: Record review of Resident 17's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 11-26-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 0. According to the MDS Manual a score of 0 to 7 indicates a person has severe cognitive impairment. -required substantial assistance with toileting, showering, lower body dressing, and transfers. -required limited assistance with eating, hygiene, and bed mobility. Record review of Resident 17's care plan dated 06-15-2020 revised on 09-26-2024 revealed Resident 17 was a risk for a potential nutritional problem related to having had a stroke with subsequent swallowing problems. Interventions included on the care plan were to provide and serve the diet as ordered. A Scoop plate, weighted utensils, and 2 handled cups were to be provided at meals. Record review of a green colored dietary slip dated 12-31-2024 for Resident 17 revealed the following: -Diet: was a regular diet -Texture consistency was pureed -Other instruction were: no straws, supervision the at meals, provide a scoop plate, 2 handled cup, and a specialty plate. -Adaptive equipment was identified as a weighted utensils, 2 handled cup with lid for all liquids. An observation on 12-31-2024 at 12:30 PM revealed Resident 17 sitting on the side of the bed eating lunch. Resident 17 was served puree chicken pot pie, puree asparagus, puree cranberry bar served on a regular plate and weighted utensils were provided. Resident 17 was also served a cup of coffee in a maroon one handled cup and a glass of juice. An observation on 01-02-2025 at 8:17 AM revealed Resident 17 was sitting on the side of the bed with bedside table in front of resident. Resident 17 was drinking coffee from a maroon one handled cup without a lid and a glass of juice without handles. An interview with Nursing Assistant (NA) E on 01-02-2024 at 10:00 AM confirmed that Resident 17 was drinking coffee from a maroon cup with one handle and no lid and was served juice in a glass without handles. An observation on 01-06-2025 at 8:53 AM revealed Resident 17 was sitting in a chair eating breakfast. Resident 17 was served a bowl of hot cereal, and pureed sausage and a pureed pancake on a regular plate with weighted utensils. Resident 17 had a cup of coffee in a maroon one handled cup without a lid, and a regular glass of juice without handles. An interview on 01-06-2025 at 8:55 AM with NA E confirmed Resident 17 was not provided with a scoop plate or 2 handled cups for liquids with the breakfast meal. An interview on 01-06-2025 at 9:06 AM with the Dietary Manager (DM) C confirmed that Resident 17 is to be served meals on a scoop plate with 2 handled cups for all liquids.

Licensure Reference Number 175 NAC 12.006.17D Based on observations, interviews, and record review; the facility failed to ensure that staff performed hand hygiene (sanitizing) using hand sanitizer or wash hands with soap and water for at least 20 seconds to prevent cross contamination for 1 (Resident #9) of 1 sampled resident. The facility census was 50. Findings are: Observation on 5/22/24 at 8:02 AM for incontinent cares for Resident #9 with NA-A and NA-B and assisting the resident with repositioning. Director of Nursing (DON) was in room observing also. Received permission from Resident #9 for surveyor to observe cares. NA-A had gloves on when surveyor entered room. The NA then had placed the equipment on bedside table. NA-A pulled cleansing wipes out of the container and sprayed No Rinse foam cleanser onto the wipes, then assisted with removing old brief and placed soiled brief in the trash can.The NA-A did not perform hand hygiene or change gloves. NA-A then cleansed penis and groins with wipes. NA-A did not dry the area. NA-A and NA-B repositioned resident onto left side and NA-A then cleansed buttocks and anus with wipes but did not dry area. The resident was then repositioned onto [gender]'s back. NA-A changed gloves at this time with no hand hygiene and assisted changing the draw sheet on the bed and applied clean brief. NA-A removed [gender] gloves and threw them in the trash, and then removed the trash can liner to take to hopper room. In an interview on 5/22/24 at 8:12 AM with NA-A revealed, I don't think I forgot anything, maybe I should have changed my gloves when I washed (gender's) bottom. In an interview on 5/22/24 at 8:15 AM with the DON revealed the expectation was for NA-A to do frequent hand washing and changing of gloves during cares. DON confirmed the NA should have performed hand hygiene and changed gloves after removing the brief and perform hand hygiene when the gloves were changed. The DON confirmed the NA did not meet the facilities expectation of hand hygiene. DON revealed the facility has talked about getting small bottles of sanitizer for staff to carry. DON revealed that NA-A needed to dry areas after cleansing. Record review of Perineal Care Policy undated revealed: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Policy Explanation and Compliance Guidelines: 6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate. 12. Males: i. Pat dry 16. Remove gloves and discard. Perform hand hygiene. Record review of Hand Hygiene policy dated 4/1/24 revealed: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 4. hand hygiene technique when using an alcohol-based hand rub: a. Apply to palm of one hand the amount of product recommended by the manufacturer. b. Rub hands together, covering all surfaces of hands and fingers until hands feel dry. c. This should take about 20 seconds. 5. Hand hygiene technique when using soap and water. a. Wet hand with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off the faucet. 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.

Licensure Reference Number 175 NAC 12-006.11D Based on observation, interview and record review, the facility failed to serve food that was palatable and at safe temperatures to prevent the potential for food borne illness. This had the potential to affect all residents receiving food from the kitchen. Findings are: Interview on 11/27/23 at 2:40 PM with Resident 5 revealed the facility food is cold and bland. Observation on 11/29/23 at 12:10 PM of food temperatures on a test tray with Cook-B revealed: -the chilli was 177.4 degrees Fahrenheit, -the apple crisp was 152.0 degrees Fahrenheit -the lettuce salad with ranch dressing was 50 degrees Fahrenheit -the lettuce salad with ranch dressing temperature was rechecked at 59 degrees Fahrenheit and 60 degrees Fahrenheit (F) utilizing another thermometer from the kitchen. Interview on 11/29/23 at 2:27 PM with the Dietary Manager (DM)-C revealed the chilli that was served today on 11/29 tasted terrible, it tasted like tomato soup with beans. The DM-C also confirmed 20 residents would have recieved the salad. A record review of the dietary food temperature logs titled Production Sheet-Copy of weeks 1-4, Dining RD.com and covering the last 14 days revealed the following food and temperatures which were out of recommended range; -10/28/23, Egg Salad Cold Plate with a documented temperature of 45 F, -10/28/23, Creamy fruit salad (mech soft) with a documented temperature of 45 F, -10/29/23, Boston Creme Pie with a documented temperature of 45 F, -10/29/23, Crispy Chicken Strip Salad with a documented temperature of 42 F, -10/29/23, Chopped Cranberry Apples (dental soft) with a documented temperature of 45 F, -10/30/23, there were no temperatures documented on this date, -10/31/23, Pico Salad with a documented temperature of 45 F, -11/1-11/5/23, there were no temperatures docuemnted through this date range, -11/6/23, Seasonal Fresh Fruit and sliced bannanas with a documented temperature of 45 F, -11/7/23, Apple Salad [NAME] with a documented temperature of 54 F, -11/8/23, Cheese & Egg Casserole with a documented temperature of room temp, -11/8/23, Pear Spice Upside Down Cake and Biscuit with a documented temperature of room temp for both, -11/9/23, Biscuit with a documented temperature of room temp, -11/9/23, Pumpkin Pie with a documented temperature of warm and Herbed Dinner Roll with a documented temperature of room temp, -11/10/23, Tartar Sauce and Coleslaw with a documented temperature of 45 F, -11/11/23, Cranberry Crumble with a documented temperature of 45 F, -11/14/23, Chocolate Chip Cake with a documented temperature of room temp. An interview on 11/29/23 at 1:58 PM with the facility Administrator, after review of the above listed kitchen food temperature logs, confirmed that food was being served outside of recommended safe food temperatures and should not have been. A record review of the undated facility policy titled Record of Food Temperatures read as follows; 1. Food temperatures will be check on all items prepared in the dietary department. 4. Potential hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. 11. No food will be served that does not meet the food code standard temperatures. 14. Food temperatures will be verified using a thermometer which is both clean, sanitized, and calibrated to ensure accuracy. A record review of the undated facility policy titled Food Preparation Guidelines read as follows; 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfactions include: a. Providing meals that are varied in color and texture. b. Using spices or herbs to season food in accordance with recipes. c. Serving hot foods/drinks hot and cold food/drinks cold. d. Addressing resident complaints about food/drinks. e. Honoring resident preferences, as possible, regarding foods and drinks.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to clean and store respiratory equipment in a manner to prevent the potential for cross contamination for four (Residents 8, 9, 36, and 41) of four residents sampled. The facility identified a census of 38. Findings are: A. A record review of the demographic information revealed Resident 8 had been accepted into the facility on [DATE] with a primary diagnosis of malignant neoplasm of the larynx, unspecified. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 8/30/23, Section C, revealed Resident 8 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function)score of 13. An observation on 11/27/23 at 02:50 PM revealed the CPAP (Continuous Positive Airway Pressure - a treatment that uses mild air pressure to keep your breathing airways open) mask for Resident 8 to be hanging off the loop rail on the bed and still intact. An observation on11/28/23 at 02:50 PM revealed a CPAP mask for Resident 8 to be hanging off the loop rail on the bed and still intact. An interview on 11/28/23 at 01:43 PM with Licensed Practical Nurse (LPN)-D confirmed that the CPAP mask should be rinsed and allowed to air dry and then should be stored in the bag. LPN-D confirmed that the CPAP mask for Resident 8 was not being cleaned and stored properly. A record review of the undated facility policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) revealed it did not contain guidance related to cleaning and storage of the mask or tubing B. An observation on 11/27/23 at 3:30 PM revealed Resident 9's oxgyen tubing to be resting on top of the oxygen machine with the nasal cannula touching the machine. A bag was noted to be attached to the machine for tubing storage. During an interview on 911/27/23 at 3:30 PM Resident 9 voiced only wearing the oxygen at nighttime. An observation on 11/28/23 at 1:35 PM revealed the oxygen tubing for Resident 9 was draped over the top of the oxygen concentrator with the nasal cannula touching the front of the machine and not stored in a bag. An interview on 11/28/23 at 01:43 PM with LPN-D confirmed that oxygen tubing should be stored in a bag when not in use. LPN-D confirmed that the oxygen tubing for Resident 9 was not being cleaned and stored properly C. An observation on 11/29/23 at 7:54 AM, when accompanied by the facility DON (Director of Nursing) revealed Resident 36's CPAP (Continuous Positive Airway Pressure - a treatment that uses mild air pressure to keep your breathing airways open) mask to be attached to the tubing and machine and hanging off the nightstand. The facility DON was present during the observation and confirmed that the CPAP mask and tubing were not being stored in a bag as per facility policy. During an interview on 11/29/23 at 11:30 AM, Resident 36 confirmed that the CPAP mask and tubing were not being stored in the bag when not in use. A record review of the undated facility policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy) revealed it did not contain guidance related to cleaning and storage of the mask or tubing. D. An observation on 11/27/23 at 11:24 AM revealed that Resident 41 was noted to have a nebulizer machine resting on the heater with the nebulizer kit and mask intact and hanging from the machine. An observation on 11/28/23 at 1:35 PM revealed the nebulizer mask and kit for Resident 41 was intact and hanging from the machine and not stored in a bag. An interview on 11/28/23 at 01:43 PM with LPN-D confirmed that the nebulizer kit and mask should be rinsed and allowed to air dry and then should be stored in the bag. LPN-D confirmed that the nebulizer mask and kit for Resident 41 were not being cleaned and stored properly. During an interview on 11/29/23 at 11:25 AM, Resident 41 confirmed that the nebulizer kit and tubing were not rinsed after use or stored in a bag. Resident 41 voiced they only change it weekly. A record review of the undated facility policy titled Nebulizer Therapy read as follows; Care of Equipment 1. Clean after each use. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag.

Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case) within the required timeframe for 1 (Resident 2) of 3 sampled residents. The facility identified a census of 38. Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Findings are: A record review of Resident 2's demographic information revealed the resident readmitted from the hospital to the facility on [DATE]. A record review of Resident 2's census information revealed Resident 2 had returned to the facility on [DATE] under Medicare A (insurance coverage by Medication covering skilled nursing facility care) services A record review of Resident 2's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 7/15/23, Section C, revealed the resident was rarely understood. A record review of Resident 2's Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) revealed that Resident 2's Medicare Part A Skilled Services began on 7/11/2023 and the last covered day of Medicare Part A services was 8/12/23. The signature line indiciated Resident 2 had signed the SNF ABN form on 9/18/23. An interview on 11/29/23 at 10:40 AM with the facility Social Worker (SW), after review of the SNF ABN signed on 9/18/23 by Resident 2, confirmed the notice of skilled nursing coverage ending had not been provided or signed within the required timeframe of at least two days before the end of a Medicare covered Part A stay and should have been. A record review of the undated facility policy titled Advance Beneficiary Notices read as follows: 6a. If a reduction in care occurs and the beneficiary wants to continue to receive the care that is no longer considered medically reasonable and necessary, the facility shall issue an ABN prior to furnishing non-covered care. b. If services are being terminated and the beneficiary wants to continue receiving care that is no longer considered medical reasonable and necessary, the facility shall issue an ABN prior to furnishing non-covered care. 7. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The notices must not be provided while the resident/representative is under duress or in an emergency situation. 8. The Business Office Manager, or designee, is responsible for issuing notices.

Licensure Reference Number 175 NAC 12-006.09C3 Based on interview and record review the facility failed to complete a recapitulation of stay for 1 (Residents 33) of 3 sampled residents. The facility identified a census of 38. Findings are: A. A record review of Resident 33's demographic information revealed that Resident 33 admitted to the facility on [DATE] with a primary diagnosis of Heart Failure, Unspecified. A record review of Resident 33's Progress Notes dated 10/13/23 through 10/14/23 revealed Resident 33 had discharged with family. An interview on 11/28/23 at 2:20 PM with the facility DON confirmed that no recapitulation of stay had been completed for Resident 33. A record review of the undated facility policy titled Transfer and Discharge (including AMA) read as follows; 14. b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but is not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. ii. A final summary if the resident's status. iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). iv. A post discharge plan of care that is developed with the participation of the resident and the resident's representative(s) which will assist the resident to adjust to his or her new living environment.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8 Based on observation, interview and record review; the facility failed to meet the nutritional needs for 1 (Resident 12) of 3 sampled residents. The facility staff identified a census of 39. The findings are: Record review of Resident 12's weight documented on 4/8/22 was 168.3 lbs. (pounds) and current documented weight on 10/23/22 was 141 lbs. which is a decrease of 16.22 % in 6 months or 27.3 lbs. Review of the Registered Dietician Evaluation dated 04/13/22 revealed Resident 12 is a nutrition risk. Weight is down. Tube feeding meets calorie needs and is adequate. Meal intake is poor. Resident 12 is offered meals but refuses. Review of the Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 8/3/22 revealed a weight of 155 lbs. and identified weight loss. Additionally the MDS revealed Resident 12 requires extensive assistance of 1 staff with eating. Review of care plan revealed the following: - NUTRITION - Resident 12 is at risk for alteration in nutritional status related to: Cerebralvascular Accident ([CONDITION(S)]: damage to the brain from interruption of the blood supply), dysphagia (dificulty swallowing foods or fluids) and refusing meals. -Goal of Resident 12 will tolerate tube feed and will consume foods and fluids as desired and tolerated. -Interventions include: *Provide assistance for meals if indicated *Staff is to offer any food items Resident 12 might eat ie: breakfast sandwiches, supplements.- FEEDING TUBE (a surgically placed device used to give direct access to the stomach for supplemental feedings)- Initially placed on 3/22/22 Resident 12 is receiving gastric tube feeding due to declining meals/meds(guardian requested gastric tube feeding). -Goal of Resident 12 will tolerate g-tube feeding without complication. -Interventions include: *Monitor for signs of early stage aspiration pneumonia such as coughing, fever, shortness of breath, wheezing and excessive sweating. *Monitor signs of gastric tube intolerance such as nausea, vomiting, diarrhea, abdominal pain and abdominal distention and notify my physician and Registered Dietician. Record review of Resident 12's medical record revealed Resident 12 was admitted to Hospice Services on 05/02/22 for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Client Coordination Note dated 5/2/22 revealed: Resident 12 had a g- tube placed 7/29/21 and the tube feedings were stopped on 11/16/21 with the g-tube being removed on 12/22/21. Resident 12 discharged to skilled services on 12/24/21. Resident 12 had a functional decline at the Skilled Nursing Facility and is no longer able to feed self. Resident 12 had a g- tube reinserted 4 weeks ago and continues with weight loss. Resident 12 and family in agreement with hospice services for end of life cares and support. Record review of the Treatment Administration Record (TAR) for May 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A new order for g-tube feeding dated 5/19/22 of 25ml per hour continuous and documented as given. Review of Resident 12's Hospice order dated 5/31/22 revealed to discontinue the tube feeding. Further review of Resident 12's medical record revealed no indication of reason to discontinue the tube feeding. Review of the Hospice order dated 08/02/22 revealed to assist the resident with meals. An observation on 10/24/22 at 12:25 PM revealed Resident 12 was served a lunch meal tray. Staff set the lunch plate on the over bed table next to the resident and left the room. An observation on 10/24/22 at 12:29 PM revealed Resident 12 grabbed the plate of food from the over bed table and moved it to (gender) lap. An observation on 10/24/22 from 12:32 PM to 01:05PM revealed Resident 12 set the lunch plate back on the over bed table and took 2 bites of food with (gender) fingers. No staff assistance was provided during the observation. An observation on 10/25/22 at 08:55 AM revealed Resident 12 was served breakfast. The dietary staff sat 2 bowls of food on the overbed table. An observation on 10/25/22 from 09:00 AM to 09:27 AM revealed no staff assisted Resident 12 with eating. The meal tray continued to be in front of the resident on the overbed table. Resident 12 did not eat anything. Interview conducted on 10/25/22 at 02:47 PM with NA F (Nurse Aide) confirmed that Resident 12 needs help with eating and probably would do better if they got (gender) up and took (gender) to the dining room. Interview conducted with NA E on 10/25/22 at 02:52 PM confirmed that Resident 12 needs help with eating and most of the time (gender) does not get assistance. Interview with the Interim Director of Nursing (DON) on 10/25/22 at 02:00 PM confirmed that the resident has had a significant weight loss and the DON was unable to locate information on why Resident 12's tube feeding was discontinued on 5/31/22. The DON further confirmed that Resident 12 does require assitance with eating and should be getting assistance from staff for meals.

Licensure reference: 175 NAC 12-006.04D2a Based on record review and interviews, the facility failed to ensure the Dietary Department Manager met qualifications. This has the potential to affect all 39 residents of the facility. Findings are: A review of an undated staff list revealed Dietary Staff Member G was the Dietary Manager In an interview on 10/26/22 at 1:02 PM Dietary Staff Member G reported taking the dietary manager classes with an expectation the classes would be completed in November of 2022. In an interview on 10/27/22 at 11:29 AM, the Consultant Registered Dietitian reported being in the facility 6 hours every other week.

Licensure reference: 175 NAC 12-006.11D Based on observations and interview, the facility failed to ensure food was palatable and served at preferred temperatures. This has the potential to affect all residents of the facility. Findings are: In confidential interviews conducted on 10/24/22 between 10:30-11:34 AM, 3 of 3 sampled residents reported the following food concerns: -all processed food -food is terrible, no alternatives -food is terrible -no variety -no alternatives except hamburger or hotdog Observations of a test tray sampled on 10/24/22 at 12:37 PM revealed the flowing -Broccoli chicken [NAME] entree temperature of 132.6 F [Fahrenheit] -Peas and carrots 116.6 F warm to taste -Noodles 106.3 F cool and chewy In an interview on 10/24/22 at 12:37 PM, the Dietary Department Manager reported a goal that food temperatures should be at least 135 F on the plate. In an interview on 10//27/22 at 1:25 PM, the Dietary Department Manger reported all residents of the facility eat food prepared at the facility.

Licensure reference: 175 NAC 12-006.11E Based on observation, interview, and record review, the facility failed to ensure walls, floors, vents, non-food contact surfaces and equipment was maintained in a clean manner and in good repair, dishwasher sanitation concentration met manufacturer requirements, a service sink was available for use and mops/mop buckets were stored in a non-food preparation area, left over foods were labeled and dated with date of preparation, and food temperatures were maintained to prevent the potential for food-borne illness, This has the potential of affect all 39 residents of the facility. Findings are: A. Observations on 10/24/22 between 8:34 AM-9:06 AM and 10/26/22 between 9:17-9:25 AM revealed the following was not being maintained in a clean manner or good repair: -the handwashing sink was heavily soiled -the paint was wearing off the floor in the dry storage area -the floor under the shelves in the dry storage area was soiled with a build-up of dust -the shelves in the dry storage area were dusty -the floor thru out the kitchen including under equipment, the 4-compartment sink, and the dishwasher was heavily soiled -the sides and doors of the 2 reach-in refrigerators, the reach in freezer, the stove, and the convection oven were heavily soiled -the wall behind the dirty side of the dishwasher was soiled with a black substance on the tile -the guard on the bottom of the reach-in refrigerator was missing -the filter on the HVAC unit was heavily soiled with a build up on dust and tape/insulation was hanging down from the duct system -the vents on the HVAC duct system were soiled and rusty -the window behind the HVAC was cracked and had tape over the cracks -the dish [NAME] was soiled on the side and top -the shelf under the steam soiled was soiled with food debris In an interview on 10/27/22 10:08-10:30 AM, the Administrator and Dietary Department Manager confirmed the kitchen equipment and physical facilities were in need of cleaning and repair. B. Observations on 10/24/22 between 8:34 AM-9:06 AM revealed test of Chlorine based sanitizer in dishwasher revealed sanitizer concentration did not meet 50 ppm. Dishwasher sanitizer log had not been completed since 10/17/22. In an interview on 10/24/22 between 8:34 AM-9:06 AM, the Dietary Department Manager identified that the sanitizer concentration was testing between 10-25 ppm and need to be 50 ppm. The Dietary Department Manager confirmed the dishwasher log was not completed and should have been completed daily. In an interview on 10/25/22 at 2:09 PM Dishwasher Corporate Representatives, reported test strips for checking sanitizer concentration need to be replaced and also concentration of sanitizer going into the dishwasher needed to be adjusted. C. Observations on 10/24/22 between 8:34 AM-9:06 AM and 10/26/22 between 9:17-9:25 AM revealed the following: -mop bucket with dirty water in it stored under 4 compartment sink -soiled mops being stored next to reach in freezer with floor under mops soiled -soiled mop being stored next to shelf on dirty side of dishwasher -soiled mop head on floor under soiled side of dishwasher -soiled mops and broom stored next to dirty side of dishwasher In an interview on 10/24/22 between 8:34 AM-9:06 AM, the Dietary Department reported mop water was dumped into 4th compartment of 4 compartment sink. In an interview on 10/27/22 between 10:08 AM-10:30 AM, the Dietary Department Manager reported the kitchen has not had a utility sink during the time the Dietary Department Manager has worked at the facility. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: At least 1 service sink or 1 curbed cleaning facility equipped with a floor drain shall be provided and conveniently located for the cleaning of mops or similar wet floor cleaning tools and for the disposal of mop water and similar liquid waste. D. Observations on 10/24/22 between 8:34 AM-9:06 AM revealed the following unlabeled and undated food items in reach-in refrigerator that had been removed from original packaging: -tuna -2 sandwiches -pineapple Observations on 10/26/22 at 10:49Am revealed chicken salad stored in reach in that was not labeled or dated. In an interview on 10/24/22 between 10:08 AM-10:30 AM, the Dietary Department Manager confirmed foods should be labeled and dated with open date or preparation date. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: foods prepared and held in a food establishment for more than 24 hours hall be clearly marked with date of preparation and food prepared and packaged by a food processing plant and held refrigerated at a food establishment shall be clearly marked with the dated the original container was opened. E. Observations on 10/26/22 between 10:49 AM-11:30 AM revealed the following temperatures of food on the steam table in the kitchen taken by Cook C: -hotdogs 129.4 F [Fahrenheit] -hamburgers 121.8 F Observations on 10/26/22 at 12:29 PM revealed the following temperatures of food on the steam table in second floor dining room taken by Dietary Aide D: -hot dogs 129.5 F Observations on 10/26/22 at 12:54 PM revealed the following temperatures of food on the steam table in second floor dining room taken by Dietary Department Manager: -spinach 117 F -hamburgers 116.4 F -hotdogs 109.5 F In an interview on 10/27/22 between 10:08-10:30 AM, Dietary Department Manager reported hotdogs and hamburgers should be heated to a temperature of 165 F. Foods stored on the steam table should be at least 135 F. A review of facility policy titled Food Preparation and Service revised 4/2019 revealed the following: The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic micoorganisms that cause foodborne illness. F. In an interview on 10//27/22 at 1:25 PM, the Dietary Department Manger reported all residents of the facility eat food prepared at the facility.

Licensure Reference Number 175 NAC 12-006.09D2b Based on interview and record review, the facility failed to notify the provider and implement treatment after pressure ulcers were identified for 1 (Resident 1) of 3 residents reviewed. The facility had a total census of 46 residents. The findings are: A review of a Weekly Skin Check for Resident 1 dated 6/16/22 revealed Resident 1's skin was intact. A review of a Skin Alteration Evaluation for Resident 1 dated 6/22/22 revealed the following: -New skin alteration to the left side of Resident 1's sacrum (the bony structure at the base of the spine, connected to the pelvis) with an onset date of 6/22/22. The area was identified as a pressure ulcer, circular shaped, and measured 1.5cm (centimeters). No stage was identified. -New skin alteration to the right side of Resident 1's sacrum with an onset date of 6/21/22. The area was identified as a pressure ulcer, circular shaped, and measured 2cm. No stage was identified. A review of Resident 2's medical record did not reveal any update to Resident 1's provider or new treatment orders for Resident 2's two new pressure ulcers from 6/21/22 - 6/29/22. A review of Resident 1's June 2022 MAR (Medication Administration Record) and TAR (Treatment Administration Record) did not reveal any treatment orders for pressure ulcers. A review of a Skin Alteration Evaluation for Resident 1 dated 7/1/22 revealed the following: -Skin alteration to Resident 1's sacrum with an onset date of 6/21/22. The area was identified as a pressure ulcer measuring 11cm x 7cm. The pressure ulcer had irregular edges with surrounding redness and scant amounts of purulent (cloudy, containing pus) drainage. Resident 1 was experiencing pain. No stage was identified. The following note was written at the bottom of the evaluation, Resident was noted to have new superficial open areas at the (right) and (left) sides of sacral area with the entire sacral area reddened and was documented on 6/21/22. Today this area has become a stageable wound at the center of sacrum with some necrosis (dead tissue) noted. (Continued) superficial open areas to (right) and (left) sides - the superficial areas are now connecting to center open area - and reddened across the entire sacral area. Entire open area measures 11cm long x 7cm wide and scant (amount) of purulent drainage present. Temporary (dressing) - alginate wound (dressing) with antibacterial silver/covered with [MEDICATION(S)] (dressing) - applied until wound nurse (evaluates). A review of Resident 1's progress notes revealed the following: -6/30/22 at 3:51 PM - This nurse observed wound to sacrum area measuring 15cm width x 5cm length. Middle of the wound measuring 8cm width x 4.1cm length is dark and necrotic in appearance, small amount of drainage noted. Notified (Physician Name) and POA (Power of Attorney). Resident is resting in bed on side with pillow position under buttock. Reposition every 2 hours as needed. A review of Resident 1's July 2022 TAR revealed the following order dated 7/1/22: -Cleanse sacra wound with saline, apply skin prep, apply Santyl (a topical ointment that removes dead tissue from wounds), apply calcium alginate (a wound dressing derived from seaweed that is highly absorbent), and then cover with bordered gauze daily. A review of a wound assessment for Resident 1 dated 7/12/22 and completed by DNP E (Doctor of Nursing Practice) revealed Resident 1's sacral wound measured 9.53cm x 8.18cm with a depth of 0.2cm. Further review revealed the sacral wound had deteriorated since last seen and was 60% necrotic tissue with a foul odor. DNP E documented that the wound was significantly worse and was highly suspicious of a Kennedy Terminal Ulcer (a dark sore that develops rapidly during the final stages of life - skin breaks down as part of the dying process). DNP E noted that Resident 1 may require hospitalization for surgical debridement and was not currently on hospice. A review of a telephone order dated 7/12/22 from Resident 1's PCP (primary care provider) revealed an order to send Resident 1 to the ED (emergency department) for [CONDITION(S)]. In an interview on 8/3/22 at 3:46 PM, the DON (Director of Nursing) confirmed the facility was unable to locate any documentation to indicate that Resident 1's provider was notified about new pressure ulcers and treatment was implemented to heal new pressure ulcers prior to 7/1/22.