Every finding on record at Alpine Village Retirement Center

Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview; the facility failed to present the resident/resident representative with a nonpharmacological treatment option along with the consent for the use of psychotropic medications (medications that alter consciousness, mood and thoughts) for 4 (Resident's 1, 4, 21 and 25) of 5 sampled residents. The facility census was 24.Findings are: A. Review of the facility policy Psychotropic Medication Use Policy last revised 2/15/24 revealed the facility would utilize the least amount of psychotropic medications while still maintaining a safe environment and showed the following: -each resident would have a proper diagnosis; -the pharmacy would routinely monitor and request dose reductions; -the facility would utilize the lowest effective dose; -residents would have interventions in their care plans to assist in re-directing undesired mood and behaviors; -resident/resident representative would be educated on the medications, diagnosis, dose changes and side effects; and -consent forms would be completed with new orders for psychotropic medications and any increase in psychoactive medications. B. Review of the facility policy Antipsychotic Medication Use with a revision date of 7/28/26 revealed the facility only used antipsychotic medications when it was necessary to treat a specific condition. The facility completed consent forms for all new antipsychotic medication orders and with any dose increases. C. Review of the facility policy Residents Rights undated revealed the resident and/or resident representative had the right to be fully informed of their medical condition, to participate in person-centered care and the right to refuse and/or discontinue medications and treatments, and to formulate advanced directives. D. Review of Resident 4's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 6/10/26 revealed the resident was admitted [DATE]; was cognitively intact; was independent with dressing, eating, transfers and hygiene; the resident did not exhibit any behaviors; had diagnoses of diabetes, stroke, anxiety, depression, and post-traumatic stress disorder (PTSD); and the resident received antipsychotic, antianxiety and antidepressant medications. Review of Resident 4's Medication Review Report with active medications as of 7/30/26 revealed the resident received the following medications: -aripiprazole (an antipsychotic) 20 milligrams (mg) at bedtime for PTSD; -buspirone (an antianxiety) 30 mg twice daily for anxiety; -fluoxetine (an antidepressant) 40 mg daily for depression; and -trazodone (an antidepressant) 75 mg at bedtime for depression. Review of Resident 4's facility forms Psychoactive Medication Therapy Informed Consent Form revealed the following consents: -on 6/9/25 consent for aripiprazole was obtained; -on 6/9/25 consent for trazodone was obtained; -on 9/30/25 consent for buspirone was obtained; and -on 5/11/26 consent for fluoxetine was obtained. There was no evidence that the facility documented and offered alternative nonpharmacological treatment intervention options. E. Review of Resident 25's MDS dated [DATE] revealed the resident was admitted [DATE]; had severe cognitive impairment; required staff assistance with dressing, toileting, transfers, and hygiene; had severe cognitive impairment; the resident did not exhibit behaviors; had diagnoses of dementia, anxiety, and depression; and received antidepressant medications. Review of Resident 25's Medication Review Report with active medications as of 7/30/26 revealed the resident received the following medications: -bupropion (an antidepressant) 75 mg twice daily for anxiety and depression; and -venlafaxine (an antidepressant) 150 mg daily for depression. Review of Resident 25's facility forms Psychoactive Medication Therapy Informed Consent Form revealed the following consents: -on 2/18/25 consent for bupropion was obtained; and -on 2/18/25 consent for venlafaxine was obtained. There was no evidence that the facility documented and offered alternative nonpharmacological treatment intervention options. Interview on 7/30/26 with the Director of Nursing (DON) at 2:00 PM confirmed Resident 4 was receiving antipsychotic, antianxiety and antidepressant medications; and Resident 25 was receiving antidepressant medications. Further interview confirmed the facility did not have evidence that alternative nonpharmacological treatment interventions were offered to the resident/resident representative. F. Review of Resident 21's MDS dated [DATE] revealed the resident had severe cognitive impairment, delusions, and other behaviors 1-3 days weekly. The resident had diagnoses of dementia, anxiety and depression. The resident used devices including a bed alarm (notifies staff of attempts to get out of bed unassisted) and wander alarm (lets staff know if the resident attempts to exit the facility). Medications taken were antipsychotic, antianxiety, and antidepressant medications. Review of Resident 21's Medication Administration Record dated July 2026 revealed the following psychotropic medications. -mirtazapine (Remeron) 7.5 mg daily at bedtime dated 1/24/25.-citalopram (Celexa) 20 mg 1 tab daily at bedtime dated 11/12/25. -quetiapine (Seroquel) 25 mg 1/2 tab daily at 12:00 PM dated 3/4/26.-lorazepam (Ativan) 0.5 mg daily at noon dated 3/24/26.-lorazepam (Ativan) 0.5 mg every 4 hours as needed for anxiety and restlessness dated 4/24/26. Review of Resident 21's facility forms Psychoactive Medication Therapy Informed Consent Form revealed the following consents:-on 5/5/25 consent for citalopram 20mg daily was obtained;-on 5/5/25 consent for mirtazapine 7.5mg daily was obtained;-on 3/2/26 consent for quetiapine 12.5mg was obtained;-on 3/17/26 consent for lorazepam 0.5mg daily at 12:00 was obtained;There was no evidence that the facility documented and offered alternative nonpharmacological treatment intervention options. During an interview on 7/29/26 at 3:00 PM the DON confirmed the facility was obtaining consent for the use of psychotropic medications for Resident 21, however the consent contained information about potential therapeutic effects and adverse effects, but no evidence of alternate non-pharmacological treatment options. G. Review of Resident 1's MDS dated [DATE] revealed the resident had severe cognitive impairment, rejected care and wandered 1-3 days in the prior 7 days, required assistance for hygiene needs, dressing, and bathing. Further review of the MDS showed the resident had a diagnosis of dementia and took antipsychotic and antianxiety medication. Review of Resident 1's Medication Administration Record dated July 2026 revealed active orders for the current psychotropic medications;-lorazepam (Ativan) 0.5mg taken twice daily and every 4 hour as needed for anxiety.-quetiapine (Seroquel) 50mg taken 3 times daily for behavior disturbance associated with dementia. Review of Resident 1's facility forms Psychoactive Medication Therapy Informed Consent Form revealed the following consents:-on 6/9/26 consent for quetiapine (Seroquel) was obtained.-on 7/13/26 consent for lorazepam (Ativan) was obtained.There was no evidence that the facility documented and offered alternative nonpharmacological treatment intervention options. During an interview on 7/30/26 at 2:45 PM the DON confirmed the facility had not provided Resident 1 and/or their responsible party of alternative treatment options when obtaining consent for the use of psychotropic medications.

Licensure Reference Number 175 NAC 12-006.18Based on record review and interview; the facility failed to test Residents for COVID-19 when they presented with signs and symptoms of a respiratory illness, to prevent the potential spread of infection for 3 (Residents 1, 19, and 26) of 12 sampled residents. The facility census was 24.Findings are: A. Review of the facility policy COVID management with a revision date of 8/14/25 revealed the following:-The facility routinely monitored and provided surveillance of the workplace/facility to determine compliance with infection prevention and control policies and monitored for signs and symptoms of COVID-19. -The facility was alert to signs and symptoms of COVID-19 and tested residents and staff if the following were present: fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea. B. Review of Resident 1's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/17/26 revealed the resident had severe cognitive impairment, rejected care 1-3 days and wandered daily in the prior 7 days, required assistance for hygiene needs, dressing, and bathing. Further review of the MDS revealed the resident had a diagnoses of hypertension (high blood pressure), diabetes and dementia. Review of Resident 1's Progress Notes revealed the following;-On 7/28/26 at 9:18 PM the resident was monitored for respiratory symptoms, was fatigued, and had a nonproductive cough and ongoing assessment (of the residents' condition) would continue. -On 7/29/26 at 2:14 PM the resident had a weak dry cough, increased lethargy, and a body temperature of 99.1. The provider was updated and gave no new orders other than to monitor. -On 7/29/26 at 3:23 PM the resident was given a COVID-19 antigen rapid test with negative results. During an interview on 8/3/26 at 9:12 AM the Director of Nursing (DON) confirmed Resident 1 was not tested for COVID-19 when presenting with a respiratory infection and the facility only tested after the survey team asked for evidence of a COVID test. C. Review of Resident 19's MDS dated [DATE] revealed the resident had diagnoses including coronary artery disease, hypertension, kidney disease, and vascular (affecting circulation) disease affecting the extremities. The resident was not up to date on the COVID-19 vaccine. Review of Resident 19's Progress Notes revealed the following;-On 7/17/26 at 8:30 AM the resident was noted to have a harsh cough, reported a runny nose and chest congestion. -On 7/17/26 at 7:21 PM the resident presented with a consistent cough, coarse lung sounds and was assessed for respiratory complications. -On 7/18/26 at 9:54 PM the resident presented with an occasional cough and nasal sounding voice. -On 7/19/26 at 10:06 AM the resident reported increased cough, reported being tired and was given cough syrup. -On 7/20/26 at 7:30 AM the resident reported coughing caused chest discomfort which radiated down to the groin. The resident requested cough syrup. -On 7/20/26 at 10:21 PM the resident continued to cough, was weak and shaky during transfers (moving from one sitting surface to another). -On 7/21/26 at 10:21 PM the resident continued to cough, was given cough syrup and was assessed as having clear lungs. -On 7/22/26 at 8:00 PM an occasional cough continued. -On 7/23/26 at 7:35 PM an occasional cough persisted. -On 7/24/26 at 10:00 PM the resident was observed to have a cough and assessed as having clear lungs. -On 7/25/26 at 2:08 PM the resident had a weak dry cough and reported feeling a little better but continued to have nasal congestion. -On 7/26/26 at 10:43 AM the resident had a cough but no other symptoms. -On 7/28/26 at 9:39 PM the resident had a weak cough and indicated that ongoing assessment of the resident's respiratory status would continue. There was no evidence the facility completed a COVID-19 test throughout the course of the resident's illness (7/17/26- 7/28/26). During an interview on 8/3/26 at 9:12 AM the DON confirmed Resident 19 was not COVID-19 tested when symptoms of a respiratory illness were observed. D. Review of Resident 26's MDS dated [DATE] revealed the resident had severe cognitive impairment, complex medical conditions including hypertension, heart failure, kidney disease, diabetes, and dementia. Review of Resident 26's Progress Notes revealed the following;-On 7/17/26 at 8:30 AM the resident was noted to have a congested cough, sore throat, and head/chest congestion. The resident's body temperature was 99.1 and oxygen saturation was 88% (normal being 90-100%). -On 7/17/26 at 10:37 AM the physician was notified via a fax (facsimile) of the residents symptoms. -On 7/17/26 at 3:00 PM a Physician's Assistant (PA) responded and reported a plan to see the resident on 7/22/26. The facility was to call if symptoms worsened. -On 7/17/26 at 11:46 PM the resident had a cough and elevated body temperature of 100.4. -On 7/18/26 at 3:06 PM the resident reportedly dozed in a chair reported feeling terrible and freezing. The resident was given Tylenol for a body temperature of 100.5 and the temperature dropped to 99.3. -On 7/18/26 at 7:00 PM the resident had a cough, eye drainage, coarse lung sounds, and was weak and tired. -On 7/19/26 at 7:15 PM the resident continued to have a frequent congested cough and sounded nasal. The resident was also wheezing. -On 7/20/26 at 8:00 AM the resident continued to cough and cough up gunk and had wheezing lung sounds. -On 7/21/26 at 4:46 AM the resident had coarse lung sounds. -On 7/21/26 at 8:00 AM the resident continued to have a cough and was weak and tired. -On 7/22/26 at 2:52 PM the resident had clear lung sounds, was pale, weak and congested with loose cough. -On 7/23/26 at 2:03 PM the resident remained in the resident room due to coughing, remained lethargic and the medical clinic was updated. -On 7/24/26 at 8:45 AM the provider (doctor) ordered a decongestant (mucinex) and an antibiotic (azithromycin).-further review revealed Resident 26 continued to be monitored, however no COVID-19 test was performed until 7/29/26 at 3:27 PM. During an interview on 8/3/26 at 9:12 AM the DON confirmed Resident 26 was not tested for COVID-19 when presenting with a respiratory illness. The facility only tested after the survey team asked for evidence of a COVID test on 7/29/26. E. During an interview on 7/29/26 at 2:21 PM the Director of Nursing (DON) confirmed the facility was not testing all residents who presented with symptoms of a respiratory infection for COVID 19. Some random tests had been performed and the resident's physician ordered testing if they felt it was needed.

Licensure Reference Number 175 NAC 12-006.04(H)(ii)(1) Based on record review and interview; the facility failed to employ a qualified Dietary Manager (DM). This had the potential to affect the food service provided to all residents who were served food from the kitchen. The facility census was 33. Findings are: Review of the facility Job Description Dietary Services Supervisor with a revised date of 7/11 revealed the necessary qualification of a DM was to meet State requirements. An interview on 5/12/25 at 8:45 AM, the DM verified that the required education was not completed to meet the qualification for the DM position. An interview on 5/12/25 at 1:45 PM, the facility Administrator verified that the current DM did not have the required training to meet the qualification for DM position. The administrator also confirmed that the Registered Dietician was not full-time at the facility.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) & 12-006.09 Based on record reviews and interviews; the facility failed to ensure a change of condition for Resident 12 was identified, and the resident's Primary Care Provider (PCP) was notified in a timely manner. The sample size was 2 and the facility census was 33. Findings are: A. Record review of the facility policy Notifying Physician with a Change of Condition revealed the facility was to promptly notify the PCP of changes in the resident's medical/mental condition and/or status. The Charge Nurse was to notify the resident's PCP when there were any of the following: -an accident or incident. -an injury of unknown source. -a significant change in the resident's physical/emotional/mental condition. -need to alter the resident's medical treatment significantly. -need to transfer the resident to a hospital or outside of the facility. -discharge without proper medical authority. A significant change in condition was defined as a major decline or improvement in the residents' status which would not: -resolve itself without intervention. -impacted more than one area of the resident's health status. -required interdisciplinary review and/or revision to the care plan. B. Record review of Resident 12's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/12/25 revealed the resident was admitted [DATE] with diagnoses of anemia, end stage renal disease, dementia, malnutrition, anxiety, depression and chronic obstructive pulmonary disease. The resident's cognition was severely impaired and the resident had behaviors which included delusions, rejection of cares, and wandering. The resident had 2 falls with injuries (except major) since the previous assessment and was occasionally incontinent of bowel and bladder. Record review of Resident 12's Nursing Progress Notes revealed the following: -8/11/24 at 3:11 PM the resident was found sitting on the floor of the resident's room. The resident reported sitting in the wheelchair and attempting to straighten the cushion in the seat of the recliner. When the resident stood, the resident's shoes got stuck to the floor and the resident unable to move, slid down to the floor. No acute injuries were noticed. The resident's PCP was notified of the fall. -8/11/24 at 5:04 PM the resident refused to go to the dining room for the evening meal. -8/11/24 at 6:46 PM the resident reported pain/discomfort in the right hip and groin area. Ice was applied to the area and the resident identified only some relief. -8/11/25 at 6:50 PM the resident continued to report pain/discomfort to the right hip and groin area due to the unwitnessed fall. -8/12/24 at 3:32 PM the resident refused ambulation with continued complaints of right hip pain. -8/13/24 at 2:37 AM the resident continued to complain of right hip pain. -8/14/24 at 10:56 AM the resident requested to remain in bed and refused breakfast. The resident was complaining of right sided pain The resident told staff the resident just could not take the pain anymore and the family made the resident a physician appointment. -8/14/24 at 12:33 PM the resident returned from the physician appointment and an x-ray report revealed the resident had a fracture to the right 11th rib. Record review of Resident 12's electronic medical record revealed no evidence from 8/11/24 at 3:11 PM when the PCP was notified of the resident's fall until 8/14/24 when the resident was diagnosed with a rib fracture, the PCP was updated regarding the resident's ongoing complaints of pain to the resident's right thigh, pelvis and right sided rib pain. Interview with the Director of Nursing on 5/14/25 at 9:20 AM confirmed the PCP was notified of the residents fall on 8/11/24 at 3:11 PM however, the staff failed to update the PCP regarding the resident's continued complaints of pain to the right hip, right thigh/pelvis and then the resident's right torso until the resident was seen by the PCP on 8/14/24 and diagnosed with a rib fracture.

Licensure Reference Number 175 NAC 12-00618 Based on observations, record review and interview; the facility failed to ensure the appropriate use of Personal Protective Equipment (PPE) gown and gloves, during the provision of care for Residents 15 and 27. The sample size was 13 with a census of 33. Findings are: A. Review of the facility policy Alpine Village Enhanced Barrier Precautions with a revision date of 5/25 revealed the following: -Enhanced Barrier Precautions (EBP) refers to an infection control intervention indicated for residents with wounds that require a dressing regardless if wound had an infection, -PPE, gown and gloves, was only necessary when performing high-contact care activities, -High-contact resident care activities included: dressing, transferring, providing hygiene, changing linens, toileting assistance, and wound care, and -EBP should be used for the duration of the affected residents stay in the facility or until the wound was resolved. B. Review of Resident 15's weekly skin assessment dated [DATE] revealed that Resident 15 had a pressure ulcer (a localized injury to the underlying tissue typically caused by prolonged pressure to the area) to the right buttock that measured 1 centimeter (cm) by 0. 8 cm. The front of the lower right leg had a chronic non pressure area that measured 3 cm by 1.3 cm. Review of Resident 15's Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 4/1/25 revealed that the resident required substantial assistance with bed mobility and transfers. Review of Resident 15's care plan revealed that on 3/20/25 EBP was initiated due to open wounds that required a dressing. The following observation was made related to Resident 15: -5/12/25 at 9:20 AM EBP sign on the resident's room door. -5/12/25 at 9:25 AM Nursing assistant (NA-I) and NA-L, completed toileting cares. After completing toileting cares NA-I did not put gloves back on, NA-I and NA-L transferred the resident to bed, NA-I touched the residents' clothing and blankets and assisted with positioning the resident in bed without gloves on. C. Review of Resident 27's weekly skin assessment dated [DATE] revealed that the resident had a pressure ulcer to the left buttock. Review of Resident 27's MDS dated [DATE] revealed that the resident was dependent on staff for bed mobility and required substantial assistance with transfers. The resident had a pressure ulcer with pressure ulcer care. Review of Resident 27's care plan revealed that on 3/21/25 EBP were initiated for a skin opening that required a dressing. The following observation was made related to Resident 27: -5/12/25 at 9:45 AM There was an EBP sign on the door of resident's room, and PPE was outside of resident's room in the hall, -5/14/25 at 8:55 AM NA-L and NA-P completed toileting cares. After toileting cares were completed NA-P did not put gloves on, NA-L and NA-P transferred resident to bed, NA-P then touched linens, pillows and the resident without gloves on. On 5/15/25 at 11:00 AM an interview with the Director of Nursing, (DON) confirmed that when a resident is in EBP staff should be wearing gloves with all high contact care activities including transfers and touching bed linens.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i)(1) Based on observations, record reviews and interviews, the facility failed to implement assessed interventions to prevent weight loss for 2 (Residents 12 and 31) of 3 sampled residents. The facility had a census of 33. Findings are: A. Review of the facility policy Weight Assessment and Interventions with a revision date of 12/08 revealed the facility would strive to prevent, monitor, and intervene when undesirable weight loss was identified for a resident. The physician and the facility staff were to identify conditions that could contribute to weight loss which could include; cognitive or functional decline, chewing or swallowing abnormalities, pain, medication adverse consequences, environmental factors, increased need for calories/protein, fluid and nutrient loss and inadequate availability of food and fluids. Weight loss interventions were to be developed/implemented with consideration of each resident's preferences, need for diet modifications, use of supplementation and/or feeding tubes, functional factors which could impede independence with eating and end of life decisions. B. Review of Resident 12's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/12/25 revealed the resident was admitted [DATE] with diagnoses of anemia, end stage renal disease (ESRD), dementia, malnutrition, anxiety, depression, and chronic obstructive pulmonary disease (COPD). The assessment indicated the resident had severe cognitive impairment, was independent with eating and/or drinking required extensive assistance with eating and/or drinking and was identified as having a therapeutic diet. The resident's weight was 127 pounds (lbs.). Review of a Weights and Vitals Summary Sheet (a form used to document a resident's weights, blood pressure, respirations, temperature, and pulse) revealed on 12/17/24 the resident's weight was 132 lbs. Review of a Dietary Progress Note by the Registered Dietician (RD) dated 12/23/24 at 11:09 AM revealed the resident had a weight loss after a hospitalization for a femur (thigh bone located in the upper leg spanning from the hip joint to the knee joint) fracture. The following nutritional interventions were identified; fortified (added nutrients) foods at meals, a Clear Nutritional Supplement (added nutrients and protein) at the evening meal, protein powder twice a day and a planned afternoon snack. Review of documentation of the residents' intakes of the Clear Nutritional Supplement provided at the evening meal from 12/24/24 to 12/31/24 revealed the resident did not receive, refused, or consumed 0 percent (%) of the supplement on 12/25, 12/26, and 12/31 (3 out of 8 days). Review of documentation of the residents' intakes of the Clear Nutritional Supplement provided at the evening meal for January 2025 revealed Resident 12 did not receive, refused or consumed 0 % of the supplement on 1/1, 1/2, 1/3, 1/4 1/6, 1/8, 1/9, 1/10, 1/13, 1/17, 1/18, 1/19, 1/23, 1/24, 1/26, 1/30 and 1/31 ( 17 out of 31 days). Review of documentation of the residents' intakes of the Clear Nutritional Supplement provided at the evening meal for February 2025 revealed Resident 12 did not receive, refused or consumed 0 % of the supplement on 2/1, 2/6, 2/7, 2/8, 2/9, 2/13, 2/14, 2/15, 2/16, 2/21, 2/22, 2/27 and 2/28 (13 out of 28 days). Review of Resident 12's Weights and Vitals Summary Sheet revealed on 3/17/25 the resident's weight was 127 lbs. (down 5 lbs or a 4% weight loss in 3 months). Review of a Nutritional Progress Note by the RD dated 3/20/25 at 6:35 PM revealed in addition to fortified foods at all meals, a planned afternoon snack, protein powder twice a day, and 6 ounces of Clear Nutritional Supplement at the evening meal, a new recommendation was identified for the staff to add 8 ounces of Clear Nutritional Supplement at the noon meal on Tuesdays, Thursdays, and Saturday. The resident was to receive a cola drink at the noon meal on Monday, Wednesday, Friday, and Sunday. Review of documentation of the residents' intakes of the Clear Nutritional Supplement provided at the evening meal for March 2025 revealed Resident 12 did not receive, refused or consumed 0 % of the supplement on 3/3, 3/6, 3/7, 3/9, 3/11, 3/18, 3/19, 3/20, 3/22, 3/25, 3/26, 3/27, 3/28, 3/29 and 3/31 (15 out of 31 days). Review of the documentation of the residents' intakes of the Clear Nutritional Supplement provided at the noon meal on Tuesdays, Thursdays and Saturdays from 3/12/25 to 3/31/25 revealed Resident 12 did not receive, refused or consumed 0 % of the supplement on 3/13, 3/15, 3/18, 3/20, 3/22, 3/25 and 3/29 (7 out of 11 days offered). Review of documentation of the residents' intakes of the Clear Nutritional Supplement provided at the evening meal for April 2025 revealed Resident 12 did not receive, refused or consumed 0 % of the supplement on 4/4, 4/5, 4/6, 4/7, 4/10, 4/11, 4/15, 4/18, 4/20, 4/21, 4/24, 4/25, and 4/27 (13 out of 30 days). Review of documentation of the residents' intakes of the Clear Nutritional Supplement provided at the noon meal on Tuesdays, Thursdays and Saturdays for April 2025 revealed Resident 12 did not receive, refused or consumed 0 % of the supplement on 4/1, 4/5, 4/8, 4/10, 4/12, 4/15, 4/17, 4/19, 4/24, 4/26, and 4/29 (11 out of 13 days the supplement was offered). Review of documentation of the residents' intakes of the Clear Nutritional Supplement provided at the evening meal from 5/1/25 to 5/13/25 revealed Resident 12 did not receive, refused or consumed 0 % of the supplement on 5/2, 5/3, 5/4, 5/5, 5/7, and 5/11 (6 out of the 13 days the supplement was offered). Review of documentation of the residents' intakes of the Clear Nutritional Supplement provided at the noon meal on Tuesdays, Thursdays and Saturdays from 5/1/25 to 5/14/25 revealed Resident 12 did not receive, refused or consumed 0 % of the supplement on 5/1, 5/3, 5/8, 5/10, and 5/13 (5 out of the 6 days the supplement was offered). Review of Resident 12's Weights and Vitals Summary Sheet revealed on 5/13/25 the resident's weight was 127 lbs. During an observation on 5/13/25 at the noon meal, Resident 12 was served potatoes with extra butter for fortification, meatloaf, pea salad and tapioca pudding. Resident 12 did not receive the 8 ounces of Clear Nutritional Supplement as recommended by the RD. During an interview on 5/14/25 at 9:59 AM, the Dietary Manager (DM), confirmed the resident was to receive 8 ounces of the Clear Nutritional Supplement at the noon meal on Tuesdays, Thursdays, and Saturdays. In addition, the resident was to receive 6 ounces of the Clear Nutritional Supplement at the evening meal each day. The DM was aware the supplement was not always offered and/or intake of the supplement documented and had provided ongoing education to the dietary staff regarding the supplements. C. Review of Resident 31's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of non-traumatic brain dysfunction, anemia, ESRD, dementia, malnutrition, anxiety, depression, post-traumatic stress disorder (PTSD) and COPD. The resident's cognition was severely impaired; the resident was independent with eating and/or drinking; weight was 108 lbs.; and the resident had a mechanically altered diet. Review of the resident's Weights and Vitals Summary Sheet dated 12/20/24 revealed the resident's weight was 119 lbs. Review of a Dietary Progress Note by the RD dated 12/23/24 at 3:24 PM confirmed the resident's weight was 119 lbs. The Progress Note indicated Resident 31 was consuming 51-64% of meals. No nutritional recommendations were identified. Review of Resident 31's Weight and Vitals Summary Sheet revealed the following: -1/24/25 weight was 114 lbs. (down 5 lbs. or a 4% loss in 1 month). -2/21/25 weight was 110 lbs. (down 4 lbs. or a 4% loss in 1 month). Review of a Dietary Progress Note by the RD on 3/6/25 at 6:59 PM revealed the resident had just returned from a Mental Health facility and the resident's weight was 109 lbs. The following weight loss interventions were identified: -8 ounces of Clear Nutritional Supplement at noon and the evening meal. -snacks offered/provided 3 times a day. -all meals to be fortified. -glass of half and half instead of milk at the breakfast meal. Review of the documentation of the residents' intakes of the Clear Nutritional Supplement provided at noon from 3/7/25 to 3/31/25 revealed Resident 31 did not receive, refused or consumed 0 % of the supplement on 3/7, 3/8, 3/9, 3/11, 3/12, 3 /13, 3/14, 3/15, 3/16, 3/18, 3/19, 3/21, 3/22, 3/23, 3/26, 3/27, 3/28, 3/28 and 3/31 (19 out of the 25 times the supplement was offered). Review of the documentation of the residents' intakes of the Clear Nutritional Supplement provided at the evening meal from 3/7/25 to 3/31/25 revealed Resident 31 did not receive, refused or consumed 0 % of the supplement on 3/7, 3/8, 3/11, 3/13, 3/19, 3/20, 3/22, 3/25 and 3/26 (9 out of the 25 times the supplement was offered). Review of Resident 31's Weight and Vitals Summary Sheet revealed the resident's weight on 3/14/25 was 107 lbs. (down 3 lbs. in 1 month). Review of the documentation of the residents' intakes of the Clear Nutritional Supplement provided at noon for 4/2025 revealed Resident 31 did not receive, refused or consumed 0 % of the supplement on 4/4, 4/5, 4/6, 4/7, 4/12, 4/13, 4/20 and 4/29 (8 out of 30 days the supplement was offered). Review of the documentation of the residents' intakes of the Clear Nutritional Supplement provided at the evening meal for 4/2025 revealed Resident 31 did not receive, refused or consumed 0 % of the supplement on 4/1, 4/2, 4/4, 4/5, 4/7, 4/10, 4/14, 4/15, 4/17, 4/20, 4/21, 4/24, 4/25, 4/27 and 4/28 (15 out of 30 days the supplement was offered). Review of a Dietary Progress Note dated 5/8/25 at 5:19 PM revealed the resident's weight had not improved. The resident's weight remained 107 lbs. No additional recommendations were identified. Review of the documentation of the residents' intakes of the Clear Nutritional Supplement provided at noon from 5/1/25 to 5/14/25 revealed Resident 31 did not receive, refused, or consumed 0 % of the supplement on 5/1, 5/2, 5/4, 5/6, 5/10, and 5/13 (6 out of 14 days). Review of the documentation of the residents' intakes of the Clear Nutritional Supplement provided at the evening meal from 5/1/25 to 5/13/25 revealed Resident 31 did not receive, refused, or consumed 0 % of the supplement on 5/2, 5/3, 5/4, 5/7, and 5/11 (5 out of 13 days). Observations of Resident 31 in the dining room revealed the following: -5/12/25 at 11:42 AM the resident was served green beans, French fries, 2 chicken strips and blue berry cobbler with whipped cream. No fortification was observed with the meal. -5/13/25 at 7:46 AM the resident was served the breakfast meal which consisted of 2 slices of bacon, 3 orange slices, and a pancake. The resident did not receive a glass with half and half and no food items appeared to be fortified. An interview with the DM on 5/14/25 at 9:59 AM confirmed there was no extra butter added to the green beans at the noon meal on 5/12/25 which was the food item to be fortified. In addition, the resident was to receive a glass of half and half at the breakfast meal in place of a glass of milk and the resident should have received the fortified hot cereal at the breakfast meal on 5/13/25.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure 1 resident (Resident 14) was free of unnecessary medications related to long term use of an antibiotic medication. The antibiotic did not specify a duration and had no supporting documentation for clinical use based on laboratory results. The sample size was 1 and the facility census was 31. Findings are: A review of the facility policy Antibiotic Stewardship - Orders for Antibiotics updated 4/2024 revealed when an antibiotic is indicated the orders will include; drug name, dose, frequency of administration, duration of treatment (start and stop date or number of days of therapy), route of administration and indications for use. Appropriate indications for use of antibiotics include; 1) clinical definition of active infection or suspected sepsis (a very serious condition that occurs as a result of a complication with an infection] and 2) supporting laboratory data. A Review of Resident 14's Medication Administration Record dated 4/1/24 to 4/30/24 revealed the resident was prescribed an antibiotic medication [Nitrofurantoin 100 milligrams daily for prophylactic (preventive) Urinary Tract Infection (UTI)] with a start date of 2/14/23. There was no stop date or duration specified. During an interview with Licensed Practical Nurse (LPN)-E on 4/8/24 at 11:35 AM, LPN-E confirmed the following: -Resident 14 was prescribed an antibiotic since 2/14/23 for prevention of UTI's; -the ordered antibiotic did not have a specified duration or stop date; -there was no evidence of diagnostic laboratory work to support the continued use of the antibiotic; -the resident developed UTI's while taking the prophylactic antibiotic medication; and -antibiotics should have a specified duration, clinical rationale/diagnosis and evidence of laboratory data to determine the type of bacteria and appropriate antibiotic to treat the infection.

Licensure Reference Number 175 NAC 12-006.04D2a Based on record review and interview the facility failed to ensure the Dietary Manager (DM) had the required qualifications. This had the potential to affect food service provided to all residents who were served food from the kitchen. The facility census was 34. Findings are: A. Review of the facility Job Description: Dietary Services Supervisor revised 7/2011 revealed the DM would carry out the assigned duties in accordance with current federal and state regulations. The DM would meet current requirements established by the regulatory agencies or be enrolled in a class to meet such requirements. Record review of the DM's personnel file revealed a job description signed and dated by the DM on 7/13/20 but no evidence that the DM had enrolled in or completed the required training. An Interview with the facility Administrator on 9/16/20 at 2:00 PM confirmed the DM had not been enrolled in or completed the required training.

Licensure reference number 175 NAC 12-006.17 Based on observation, interview, and record review; the facility failed to implement infection control practices and Centers for Medicare and Medicaid Services (CMS) guidelines to prevent potential cross contamination including the spread of COVID-19 related to: 1) residents not wearing masks in common areas in which they were within 6 feet of others; 2) failure to implement transmission based precautions for Resident 6 after a leave of absence and to provide increased monitoring of resident 6 after appointments outside of the facility; 3) washing hands and changing gloves at appropriate intervals during the provision of wound care for Resident 2; and 4) failure to implement standard precautions during the administration of medications in resident rooms. These practices had the potential to affect all residents in the facility. The total sample size was 18 and the facility census was 34. Findings are: A. Review of Infection Control Assessment and Promotion Program (ICAP) with revision date 4/17/20 revealed the following regarding the need for a cohorting plan when a positive case of COVID-19 is confirmed or suspected: -identification of zones for placement of residents based on their symptoms and exposure risks; -red zone for all residents that have tested positive for COVID-19, who are symptomatic or are suspected positive. Healthcare workers to wear full Personal Protective Equipment (PPE- gloves, gowns, masks and eye protection); -yellow zone for all residents who are asymptomatic (showing no symptoms) but who may have been exposed to COVID-19. All residents in the Yellow Zone should be on COVID level precautions and should wear COVID level PPE; -if a resident has suspected positive or has tested positive for COVID-19 and has a roommate, the roommate should be transferred to a private room in the yellow zone; and -ideally, all zones should have dedicated staff but if staff have to work in multiple zones, it is preferred that they plan ahead and batch all the care-giving activities together in a way to finish the work in one zone, before moving to the next zone. B. Review of the CMS Center for Clinical Standards and Quality, Safety and Oversight Group dated 4/24/20 revealed the following guidance for infection control and prevention of Coronavirus Disease 2019 (COVID-19): -the facility should consider the necessity of appointments outside of the facility to the resident's health, whether it is critical for the resident to attend; -if attending the appointment is necessary, the facility should help arrange for the resident to attend the appointment by taking precautions to minimize the risk of transmission of COVID-19; and -the facility should monitor the resident upon return for fever and signs and symptoms of respiratory infection for 14 days after the outside appointment (preferably in a space dedicated for the observation of asymptomatic residents). C. Review of the Long-Term Care COVID-19 Phasing Guidance dated 6/15/20 revealed facilities could move to Phase 3 if they met certain criteria. Further review revealed certain mitigation steps were to be implemented in Phase 3. The guidance revealed universal source control pertained to everyone in the facility. Residents and visitors were to wear cloth face coverings or facemasks, if able to tolerate and wear safely. D. Review of the facility COVID-19 Cohorting Plan (revised 6/14/20) revealed resident monitoring was to be completed daily and was to include temperature and oxygen saturation checks as well as monitoring of potential symptoms. Symptoms were to include cough, fever, shortness of breath, fatigue, headache, and loss of taste or smell. If a confirmed or suspected case of COVID-19 was present in the facility, each resident was to be monitored and/or assessed twice a day or three times a day pending guidance from ICAP. E. Review of Resident 6's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/24/20 revealed active [DIAGNOSES REDACTED]. The following was assessed regarding the resident: -cognition was intact; -required extensive staff assistance with dressing, transfers, toilet use and personal hygiene; and -occasionally incontinent of bowel and bladder. Review of Nursing Progress Notes for Resident 6 revealed the following: -8/4/20 at 10:16 AM the resident was seen outside of the facility for a chiropractor appointment; -8/6/20 at 9:25 AM the resident left the facility for a chiropractor appointment; -8/6/20 at 9:15 PM the resident had an apathetic appearance. The resident reported a headache which the resident reported as an 8 out of 10 on the pain scale. In addition, the resident voiced a complaint of nasal drainage; -8/11/20 at 9:00 AM the resident left the facility for a chiropractor appointment; -8/13/20 at 9:25 AM the resident was out of the facility for a chiropractor appointment; and -8/18/20 at 9:25 AM the resident was out of the facility for a chiropractor appointment. Review of Resident screening logs dated 8/4/20 through 8/18/20 revealed the resident was screened for potential COVID-19 signs/symptoms only once a day. Review of Nursing Progress Notes revealed the following: -8/20/20 at 10:08 AM the resident was seen at the chiropractor office; and -8/25/20 at 9:19 AM the resident left the facility for a chiropractor appointment. Review of Resident screening log dated 8/26/20 revealed the resident was screened for potential COVID-19 signs/symptoms only once a day. Review of a Nursing Progress Note on 8/27/20 at 9:25 AM revealed the resident was seen at the chiropractor office. Review of a Social Service Progress Note dated 8/27/20 at 3:00 PM revealed the resident's family was notified that a facility staff member had tested positive for COVID-19. Review of Nursing Progress Notes revealed the following: -8/29/20 at 8:00 AM the resident want out on a leave of absence with spouse; and -8/30/20 at 8:11 PM the resident returned to the facility. Review of Resident 6's medical record revealed no evidence the resident was screened for potential COVID-19 signs/symptoms upon return to the facility on [DATE] after the resident's leave of absence. Review of a Nursing Progress Note dated 9/1/20 at 9:25 AM revealed the resident left the facility for a chiropractor appointment. Review of a Nursing Progress Note dated 9/3/20 at 9:25 AM revealed the resident was out of the facility for a chiropractor appointment. Review of a Nursing Progress Note revealed the following: -9/5/20 at 9:36 AM revealed the resident left the facility with spouse at 7:55 AM to go home for the day; and -9/5/20 at 8:10 PM the resident returned to the facility from outing with spouse. Review of a Nursing Progress Note dated 9/6/20 at 8:21 AM revealed the resident left the facility to go home with spouse for the day. Review of a Nursing Progress Note dated 9/8/20 at 10:07 AM revealed the resident was out of the facility for a chiropractor appointment. Review of a Nursing Progress Note dated 9/14/20 at 1:33 PM revealed the resident reported a severe headache, a slight increase in nasal drainage and fatigue. A COVID Rapid Test with a Point of Care device was done as the resident had been out on a recent leave of absence. The test result was negative. Review of a Nursing Progress Note dated 9/15/20 at 9:25 AM revealed the resident had left the facility for a chiropractor appointment. Review of a Nursing Progress Note dated 9/17/20 at 9:25 AM revealed the resident was out of the facility for a chiropractor appointment. Interview with the Director of Nursing (DON) on 9/17/20 at 10:24 PM confirmed the following: -residents who left the facility for frequent medically necessary appointments, should receive increased monitoring and were to be screened twice a day for signs and symptoms of COVID-19; -staff failed to screen Resident 6 twice a day from 8/4/20 to 8/18/20 and on 8/26/20 even though the resident had frequent appointments outside of the facility; -residents gone from the facility for a leave of absence should be placed in isolation for 14 days upon their return to the facility; -Resident 6 went home with spouse from 8/29/20 to 8/30/20 and again on 9/5/20 and 9/6/20; -Resident 6 was removed from isolation on 9/13/20; and -Resident 6 should have remained in isolation until 9/20/20. F. Observation on 9/15/20 at 11:35 AM revealed Resident 29 was seated in a wheelchair at the Nurse's Station. The resident was coughing and made no attempt to cover mouth. Resident 29 self-propelled wheelchair down the 200 corridor, to the front living room and back to the Nurse's Station. Resident 29 was not wearing a mask. Observations of Resident 29 on 9/16/20 from 9:00 AM to 11:49 AM revealed the following: -9:00 AM the resident was seated in a wheelchair and was self-propelling the chair in the 100 corridor. Resident 29 was not wearing a mask; -9:47 AM remained in wheelchair without benefit of a face covering. The resident was positioned at the Nurse's Station and Licensed Practical Nurse (LPN)-C and LPN-D were seated at the Nurse's Station. Neither of the staff provided the resident with cues to return to the resident's room or assisted the resident with putting on a mask; -10:14 AM the resident kicked open the door to the Social Service Director's office and propelled into the office. The resident then backed up the wheelchair and proceeded out to the front living room. Resident 29 remained without a face mask; and -11:21 AM to 11:49 AM the resident remained without a face covering, seated in the wheelchair and positioned in front of the Nurse's Station. Interview with LPN-C on 9/16/20 at 1:30 PM revealed the residents were to wear a mask whenever they were out of their rooms and in the corridors. G. Observations of Resident 2 revealed; On 9/15/20 at 7:59 AM the resident was sitting in the commons area near the Nurse's Station not wearing a face mask. Facility staff were present and did not encourage or remind the resident to wear a face mask. On 9/15/20 at 9:00 AM the resident was sitting in the commons area by the Nurse's Station not wearing a face mask. On 9/15/20 at 11:00 AM the resident was sitting in the commons area by the Nurse's Station with a face mask visible below the chin. Facility staff were present at the Nurse's Station and did not encouraged or remind the resident to put the face mask on. On 9/15/20 at 12:00 PM the resident was sitting in the commons area by the Nurse's Station with a face mask visible below the chin. Facility staff present at the Nurse's Station did not remind or encourage the resident to put the face mask on. On 9/15/20 at 12:10 PM the resident was sitting in the commons area by Nurse's Station with a face mask below the chin. Facility staff walked by and greeted the resident but did not remind or encourage the resident to put the face mask on. H. Review of the facility policy Handwashing/Hand Hygiene dated 8/2015 revealed that the facility considered hand hygiene the primary means to prevent the spread of infection and all personnel would follow handwashing/hand hygiene procedures to help prevent the spread of infection. Further review of the policy directives revealed that 1.) Handwashing with soap and water was indicated when hands were visibly soiled or following contact with a resident with infectious diarrhea, and 2.) the use of alcohol based hand rub (ABHR) was indicated before handling clean or soiled wound dressings, after handling used dressings, and after removing gloves. I. Review of the facility policy Personal Protective Equipment/Using Gloves dated 9/2010 revealed objectives to prevent the spread of infection, protect wounds from contamination, protect hands from potentially infectious material, prevent the spread of infection, prevent contamination of the patient, and to decrease the risk of infection when changing dressings. Further review revealed that gloves were to be used when touching excretions, secretions, body fluids, mucous membranes or non-intact skin. J. Review of the facility policy Dressings- Dry/Clean dated 9/2013 revealed directives for handwashing prior to procedures, prior to putting on clean gloves, following removal of soiled gloves, and prior to applying clean dressings. K. Observation of Resident 2's pressure ulcer (skin breakdown caused by prolonged pressure and lack of circulation to a skin area) dressing change on 9/16/20 at 1:10 PM revealed: -LPN-C entered the bathing area with a treatment cart and supplies needed for the dressing change located on top of the treatment cart. -LPN-C put on gloves and measured the open area then removed gloves (did not sanitize or wash hands), put on clean gloves and applied skin prep (adhesive liquid to aid in keeping the dressing intact) to the skin surrounding the pressure ulcer. -LPN-C opened the package to the dressing and removed the protective adhesive tabs from the dressing. -LPN-C noticed that the right glove was soiled with BM (bowel movement) and proceeded to remove the right glove while holding the clean dressing in the left gloved hand. The left glove was not removed and hands were not washed or sanitized. -LPN-C applied a clean glove to the right hand (without washing or sanitizing) and then applied the dressing to the pressure ulcer. -LPN-C removed gloves, sanitized the top of the treatment cart, and then sanitized hands with ABHR. L. Interview with the DON on 9/17/20 at 2:00 PM confirmed that staff should; 1.) encourage and/or assist residents who are out of their rooms to wear a face mask, and 2.) wash or sanitize their hands between all glove changes, and wash their hands with soap and water any time their hands are visibly soiled. M. On 9/15/20 at 11:58 AM, Nursing Assistant (NA)-I was observed to place their hand directly on the outside of their face mask and cough. NA-I then took an isolation gown and gloves and put them on without doing hand hygiene first. NA-I then entered Resident 186's room. N. On 9/15/20 at 12:02 PM Dining Assistant (DA)-J was observed in a room with Resident 3 and Resident 20. DA-J was setting up Resident 3's lunch and arranging the items on the bedside table wearing a gown, gloves, mask, and eye protection. The resident's roommate (Resident 20) was using a cordless phone. Resident 20 stated they were done with the phone. DA-J then took the cordless phone and exited the room. DA-J walked with the cordless phone while still wearing the same gown and gloves and placed the phone at the nurse's station. The phone was not cleaned after use. DA-J then changed gloves but did not complete hand hygiene prior to putting new gloves on and re-entered Resident 3's room to assist the resident with lunch. O. Observations with Registered Nurse (RN)-K on 9/17/20 revealed: - At 8:15 AM, RN-K exited Resident 15's room with a thermometer and a pulse oximeter. Prior to cleaning the items they were placed directly on a stool in the hallway outside of Resident 15's room. The stool was not cleaned afterwards. -At 8:25 AM, RN-K prepared Resident 8's medications. RN-K went to put on an isolation gown and placed RN-K's face shield face down on the same stool in the hallway (outside of Resident 15's room). After getting the gown on RN-K picked up the face shield and put it on without completing hand hygiene. RN-K then put gloves on, picked up Resident 8's medication cup and entered Resident 8's room without completing hand hygiene. - At 8:35 AM, RN-K prepared Resident 32's medications. Prior to entering Resident 32's room RN-K took the clean medication cup with medication in it and placed it directly on one side of the night stand in the hallway (that had isolation equipment on it) then removed the staff's face shield and placed it face down on the other side of the night stand. RN-K put on an isolation gown, picked up the face shield and put it back on and donned gloves. At no time was hand hygiene completed and the face shield and the night stand were not cleaned. RN-K then picked up the medication cup and entered Resident 32's room. -At 8:45 AM, RN-K (while still in Resident 32's room) removed the face shield and placed it on a table/dresser in the resident's room face down while doffing the RN's gown and gloves. RN-K then picked up the face shield and put it back on. Neither the resident's dresser/table nor the staff's face shield were cleaned afterwards.

Licensure Reference Number: 175 NAC 12-006.02 (8) Based on record reviews and interview, the facility failed to notify law enforcement of an allegation of resident to resident sexual abuse for 2 (Residents 5 and 29) of 2 sampled residents. The facility census was 34. Findings are: A. Review of a facility policy titled Reporting Suspicion of a Crime (revision date July 2017) revealed the Administrator, the Director of Nursing (DON) or any other designated individual was to report (within the required time frames) any reasonable suspicion of a crime against a resident to the State Agency and local law enforcement agency. Examples of crimes that would be reportable include but are not limited to: -rape; -assault and battery; and -sexual abuse. B. Review of a facility investigation report completed on 9/17/20, revealed the facility investigated an incident which occurred on 9/13/20. The report indicated at 10:45 PM, the staff were unable to find resident 29 in the resident's room. A search was conducted and the staff located Resident 29 in Resident 5's room. Staff witnessed Resident 29 in Resident 5's bed. Resident 29's buttocks were exposed and the resident was facing Resident 5. Resident 29 was asked by the staff to place on clothing and to leave Resident 5's room. Resident 5 was wide awake and without expression. Resident 5 was examined and found to have one side of pajama bottoms lowered and the resident's pajama top had been raised. The staff asked Resident 5 what had happened and the resident did not respond. The report further indicated the Administrator was notified of the incident on 9/13/20 at 11:05 PM. However, the report identified law enforcement was not notified and the report further identified law enforcement would be notified in the future. Review of Resident 29's Nursing Progress Notes dated 9/16/20 at 8:51 AM revealed the facility had contacted the Ombudsman regarding the incident between Residents 5 and 29 which had occurred on 9/13/20. The Ombudsman indicated Resident 29 had committed sexual abuse to another resident and Resident 29 was a danger to others. Interview with the Administrator and the DON on 9/16/20 at 10:44 AM confirmed the following: -Resident 5 and Resident 29 had developed a recent relationship. The residents would sit together in the front solarium and visit and staff had seen Resident 29 going into Resident 5's room as well; -staff had discouraged room visits due to the need for social distancing but also because Resident 5's family preferred staff were able to monitor the situation; -on 9/13/20 at 10:45 PM, staff found Resident 29 in Resident 5's room and in bed with Resident 5; -Resident 5 was not wearing any clothing to the lower torso; -Resident 29's clothing had been partially adjusted. Resident 5 was unable to tell staff what had occurred; and -the facility reported the incident to Adult Protective Services but failed to report the incident to local law enforcement.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7(a) (b) Based on interview and record review; the facility failed to develop and/or revise fall prevention interventions for the prevention of ongoing falls for Resident 11. The sample size was 2 and the facility census was 34. Findings are: Review of Resident 11's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/8/20 revealed the following: -severe cognitive impairment; -extensive assistance with bed mobility, transfers, dressing and toilet use; -unsteady and only able to stabilize with human assistance when moving from a seated to standing position, while walking, when turning around and facing the opposite direction while walking, when moving on and off the toilet, and during surface-to-surface transfers (between bed and chair or wheelchair); and -frequently incontinent of bowel and bladder. Review of the undated current Care Plan indicated Resident 11 was at risk for falls and had poor safety awareness. Nursing interventions included the following: -11/20/17 nonskid rug placed at bedside; and -4/29/18 automatic brakes applied to wheelchair. Review of a Post Fall assessment dated [DATE] at 4:30 AM revealed the resident had a fall out of bed. The fall was not witnessed and the resident indicated sliding out of bed. Currently identified fall prevention interventions included a nonskid rug at the bedside, automatic brakes to the resident's wheelchair, a defined edge mattress to the bed and the bedside table to be positioned by the closet. The report further revealed the resident had not been toileted since 10:00 PM. The resident indicated a need to use the bathroom and the report revealed the resident had not been toileted since 10:00 PM on 4/4/20. The resident was wearing one shoe and one sock. A new intervention was developed for the resident to wear gripper socks at all times. Further review revealed no evidence the staff had addressed the resident's toileting schedule as a potential causal factor for the fall. Review of a Post Fall assessment dated [DATE] at 8:20 PM revealed the resident was found on the floor next to the resident's bed. The resident was unable to identify a reason for the fall and stated I just rolled out of bed. Review of the report revealed no new interventions were identified and/or current fall interventions were not revised. Review of a Post Fall assessment dated [DATE] at 9:30 PM revealed the resident had a fall in the resident's room when self-transferring out of bed. A new intervention was put into place for a work order to fix the automatic brakes on the resident's wheelchair and for the staff to make sure the wheelchair was next to the bed when the resident was lying down. Review of a Post Fall assessment dated [DATE] at 2:25 PM revealed the resident had been self-propelling wheelchair in the corridor. The resident became stuck on the wall continued to try and move forward and then fell out of the chair face first. review of the resident's medical record revealed [REDACTED]. Review of a Post Fall assessment dated [DATE] at 7:45 AM revealed the resident was found on the floor of the resident's room and next to the bed. The assessment indicated the nonskid rug next to the bed had been removed so that housekeeping could mop the floor of the resident's room. However, staff failed to assure the floor was dry before returning the rug next to the resident's bed. Staff were educated to ensure the floor was completely dry before placing rug by the bed. Review of a Post Fall assessment dated [DATE] at 1:20 PM revealed the resident was found on the floor next to the resident's bed. review of the resident's medical record revealed [REDACTED]. Interview with the Director of Nursing on 9/17/20 at 11:30 AM revealed staff were to complete a Post Fall Assessment after each fall, identify causal factors and then either develop new interventions or revise current interventions to try and prevent further falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review and interview; the facility failed to evaluate and implement interventions for the prevention of hot liquid spills for 3 of 3 residents (Residents 4, 19 and 29) who were reviewed related to a history of hot liquid spills. The total facility census was 32. Findings are: A. Review of the facility policy titled Hot Liquids Assessment, Revised 2/25/19, included that following: -to identify and protect residents who are at risk for burning themselves while drinking hot liquids; -residents will be identified by utilizing a Hot Liquids Risk Assessment tool; -assess all residents on admission, annually and with a significant change; -residents considered At Risk (score of 6-9 on the assessment) will wear a long vinyl insulated clothing protector and/or have a lidded cup; -residents considered High Risk (score of 10 or greater) will wear a long vinyl insulated clothing protector, use a cup with a lid and have added either 1/4 cup cold water/broth to hot liquids or have their hot liquid food (soup/hot cereal) dished up and set aside in the kitchen until it reaches 145 degrees or less before it is served to the resident; -staff will notify the DON (Director of Nursing)/Administrator immediately of any hot liquid spills so a State report can be filed; -monitor skin for 4 days following hot liquid spills, whether injury occurs or not; and -if injury occurs a weekly skin occurrence will be created and initiated, and monitoring will continue until the area is resolved. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/25/18 included the following: -[DIAGNOSES REDACTED]. -severely impaired cognition; and -required extensive assistance with eating. Review of Resident 19's Care Plan dated 6/18/18 revealed the resident was at risk for hot liquid spills/burns, and lids for coffee cups and vinyl insulated clothing protectors are utilized. Review of a Hot Liquids Risk assessment dated [DATE] indicated a score of 6 which indicated Resident 19 was At Risk for hot liquid spills. Review of Progress Notes dated 8/3/18 at 2:40 PM revealed Resident 19 spilled coffee at the lunch meal. Staff were present at the time. The area was assessed and the skin observed to be pink. Ice was applied. The area was reassessed at 2:00 PM and the skin remained red and cold from ice, and tender to touch. The ice was removed in order to assess whether the redness was related to the ice or a potential burn. Review of a Skin Occurrence assessment dated [DATE] at 6:15 PM revealed the following related to Resident 19: -had a burn on the right inner thigh measuring 0.7cm (centimeters) x (by) 1.7cm; -spilled coffee on lap at lunch time and the area was assessed throughout the day; -at 4:45 PM observed a small dime size or less intact blister; -the area was tender and the surrounding skin red; and -a physician's order was obtained for [MEDICATION NAME] (a cream used to prevent and treat wound infections in residents with burns) daily. Review of a Skin Occurrence assessment dated [DATE] at 10:35 AM revealed the following related to Resident 19: -had a fluid filled blister on the left upper/inner thigh measuring 1.1cm x 1.0cm; -an open area that most likely started as a fluid filled blister that is now drained measuring 1.0cm x 0.5cm; and -spilled coffee on lap 8/3/18 and an area presented to the right inner thigh initially with this area presenting last evening. Review of the Care Plan entry dated 8/3/18 revealed the resident spilled hot coffee at lunch, the hot liquid risk assessment was updated, and lids to be placed on cups utilized by Resident 19 (an intervention identified on the Care Plan dated 6/18/18). There was no evidence a Hot Liquids Risk Assessment was completed for Resident 19 following the hot liquid spill, or since 7/30/18. Furthermore, there was no evidence the facility assessed the circumstances surrounding the incident and/or the probable causal factors, or that interventions were reviewed and revised to prevent further incidents. During interview on 2/26/19 at 8:40 AM, the Director of Nursing (DON) verified Resident 19 should have been reassessed for risk of hot liquid spills following the incident on 8/3/18. C. Review of Resident 4's MDS dated [DATE] included the following: -[DIAGNOSES REDACTED]. -severely impaired cognition; and -required extensive assistance with eating. Review of Resident 4's current Care Plan revealed the following: -8/30/18 - spilled lukewarm chocolate drink with no injuries. Coffee cups are lidded and vinyl clothing protector is worn; -11/29/18 - Hot Liquids Risk Assessment completed, score 06, indicating at risk for hot liquid spills/burns. Spouse/POA signed a Waiver of Interventions to refuse the lid on the coffee. Vinyl clothing protector is offered; and -12/29/18- spilled lukewarm chocolate drink with no injuries. Coffee cups are lidded and vinyl clothing protector is worn. Review of Hot Liquid Spill Forms (completed when an episode occurs and submitted to the DON and Dietary Manager for follow-up) revealed the following related to Resident 4: -8/30/18 at 10:15 AM - drinking hot chocolate on couch by nurses' station. Cup did have lid on. Noted hot chocolate spilled on floor and 2 nickel size spill spots on the right inner pant leg. The hot chocolate was lukewarm to touch and no injuries were noted; and -12/29/18 at 10:00 AM - in recliner near nurse's desk holding cocoa and spilled in lap. Staff immediately assisted to room and changed pants. Skin in the mid to upper bilateral inner thighs pink. No redness, swelling, blisters or indication of discomfort. Cool packs applied for 20 minutes. No pinkness or indication of discomfort when skin assessed when cool packs removed. Dietary staff notified and they stated cocoa is cooled before leaving the kitchen. There was no evidence a Hot Liquids Risk Assessment was completed for Resident 4 following the hot liquid spill episode, or since 11/29/18. Furthermore, there was no evidence the facility assessed the circumstances surrounding the incidents and/or the probable causal factors, or that interventions were reviewed and revised to prevent further incidents. During meal observations on 2/21/19 at 8:29 AM and 12:00 PM, on 8/25/19 at 8:03 AM and 12:01 PM, and on 2/26/19 at 8:15 AM, Resident 4 was observed seated at the dining room table drinking hot chocolate from a coffee cup with no lid. During interview on 2/26/19 from 8:40 AM until 10:36 AM, the DON indicated Resident 4's spouse signed a Waiver of Intentions to refuse the lid on Resident 4's coffee cup as they noted the resident would not drink from a lidded cup and would take the lid off. The DON further verified the Waiver of Intentions related to the spouse's refusal to allow lidded coffee cups had not been reviewed with the spouse since 10/25/17. D. Review of Resident 29's Care Plan revealed on 11/27/18 a Hot Liquid Risk Assessment was completed and the resident was at risk for hot liquid spills and used a lidded cup and a vinyl clothing protector. Review of Resident 29's Hot Liquids Risk assessment dated [DATE] indicated a score of 8 which indicated the resident was At Risk for hot liquids spills. Review of Resident 29's Progress Notes revealed: - On 12/31/18 at 7:08 PM, it was reported the resident had a minor coffee spill. Upon inspection a fifty-cent piece sized red area was noted to the resident's right upper thigh. - On 1/6/19 at 9:25 AM, the reddened area to the resident's thigh from the coffee spill was resolved. Review of Resident 29's Medical Record revealed no evidence to indicate an investigation was completed using the Hot Liquid Spill Form to determine causal factors and to implement interventions to prevent further incidents. Interviews with the DON on 2/25/19 at 1:26 PM and 2:54 PM confirmed an investigation should be completed after a hot liquid spill using the Hot Liquid Spill Form. Further interview confirmed the Hot Liquid Spill Form was not completed after Resident 29's hot coffee spill. During an interview with Dietary Aide-G on 2/26/19 at 11:35 AM, Dietary Aide-G revealed the facility used 2 different sets of water/coffee carafes. The set used for the resident's that needed assistance (which included Resident 29) was temped down by adding cold water and should be below 150 degrees. Further interview confirmed the temperatures were not recorded to ensure the hot liquids were cooled consistently below 150 degrees.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review and interview; the facility failed to ensure hand hygiene and/or gloving was provided when indicated during the completion of blood glucose testing for Resident 10 and with administration of an eye drop for Resident 25. This had the potential to put 8 residents (Residents 25, 15, 19, 23, 1, 8, 29 and 12) who received routine eye drops and 5 residents (Residents 10, 32, 29, 12 and 18) who received routine blood glucose testing at increased risk for potential cross contamination. The total sample size was 21 and the facility census was 32. Findings are: A. Review of the facility policy titled Standard Precautions (undated) revealed standard precautions included the following practices: -hand hygiene refers to hand-washing with soap or using an alcohol based hand rub; -hands were to be washed with soap and water whenever visibly soiled with dirt, blood or body fluids, or after direct or indirect contact with such; -wear gloves when anticipated direct contact with blood, body fluids, mucous membranes, non-intact skin and potentially infected material; -change gloves as necessary during the care of a resident to prevent cross contamination from one body site to another; and -remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident and wash hands immediately to avoid transfer of microorganisms. B. During an observation of blood glucose testing on 2/21/19 at 11:30 AM, the following was observed: -Registered Nurse (RN)-D gathered supplies at the medication cart in the corridor, then entered Resident 10's room and set up supplies on a table. Without washing hands, RN-D donned gloves and proceeded to perform blood glucose testing; -RN-D removed disposable gloves and without performing hand hygiene, gathered supplies and returned to the medication cart; -still without completing hand hygiene, RN-D donned a clean pair of gloves and proceeded to cleanse the glucometer (a machine used to determine a resident's blood glucose level); and -RN-D removed gloves and without washing hands or using hand sanitizer proceeded to push the medication cart to the dining room. C. During an observation on 2/25/19 at 9:11 AM, RN-I positioned the medication cart outside of Resident 25's room. Without performing hand hygiene or donning a pair of gloves, RN-I administered an eye drop into both of Resident 25's eyes. D. During an interview with the Director of Nursing on 2/26/19 at 11:45 AM the DON confirmed the following: -staff were to follow the facility policy regarding hand hygiene and the use of disposable gloves; -8 residents (Residents 25, 15, 19, 23, 1, 8, 29 and 12) received routine eye drops; and -5 residents (Residents 10, 32, 29, 12 and 18) had routine blood glucose testing.

Based on record review and interview, the facility failed to report to the State agency an allegation of potential abuse and/or neglect related to a hot liquid spill that resulted in injury for Resident 19. 3 residents were reviewed for abuse, and the total facility census was 32. Findings are: A. Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property (not dated) included the following related to reporting of potential abuse and/or neglect: -allegations are reported in accordance with Federal and State law; and -all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law. B. Review of Resident 19's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/25/18 included the following: -[DIAGNOSES REDACTED]. -severely impaired cognition; and -required extensive assistance with eating. Review of Progress Notes dated 8/3/18 at 2:40 PM revealed Resident 19 spilled coffee at the lunch meal. Staff were present at the time. The area was assessed and the skin observed to be pink. Ice was applied. The area was reassessed at 2:00 PM and the skin remained red and cold from ice, and tender to touch. The ice was removed in order to assess whether the redness was related to the ice or a potential burn. Review of a Skin Occurrence assessment dated [DATE] at 6:15 PM revealed the following related to Resident 19: -had a burn on the right inner thigh measuring 0.7cm (centimeters) x (by) 1.7cm; -spilled coffee on lap at lunch time and the area was assessed throughout the day; -at 4:45 PM observed a small dime size or less intact blister; -the area was tender and the surrounding skin red; and -a physician's order was obtained for [MEDICATION NAME] (a cream used to prevent and treat wound infections in residents with burns) daily. Review of a Skin Occurrence assessment dated [DATE] at 10:35 AM revealed the following related to Resident 19: -had a fluid filled blister on the left upper/inner thigh measuring 1.1cm x 1.0cm; -an open area that most likely started as a fluid filled blister that is now drained measuring 1.0cm x 0.5cm; and -spilled coffee on lap 8/3/18 and area presented to right inner thigh initially with this area presenting last evening. There was no evidence this incident of alleged abuse and/or neglect was reported to the State agency in accordance with the facility policy and State law. During interview on 2/26/19 at 8:40 AM, the Director of Nursing (DON) confirmed Resident 19's hot liquid spill incident was not reported to the State agency, and verified a report should have been made.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to assess causal factors and develop interventions to 1) prevent ongoing bruising/skin tears for Resident 37, and 2) prevent ongoing skin tears for Resident 17. The sample size was 15 and the facility census was 42. A. Review of Resident 17's current Care Plan with a review date of 10/23/17 revealed the resident was at risk for impaired skin integrity related to impaired mobility. Observation of Resident 17 on 12/12/17 at 9:49 AM revealed a skin tear to the right hand with steri-strips (surgical tape strips used to close small wounds) in place and a skin tear to the left forearm with steri-strips in place. Review of Resident 17's Skin Occurrence Assessments from 8/31/17 through 12/9/17 revealed the following: - On 8/31/17, the resident had a skin tear to the middle finger of the left hand caused by the resident's dresser. No new interventions were identified. - On 10/27/17, the resident had a deep slit between the 4th and 5th toes on the left foot. No causal factors or new interventions were identified. - On 11/9/17, the resident had a skin tear to the left lateral forearm. No causal factors or new interventions were identified. - On 12/4/17, the resident had a skin tear to the back of the right hand from the grab bar in the bathroom. No new interventions were identified. - On 12/9/17, the resident had a skin tear to the left forearm from bumping into a railing. No new interventions were identified. During an interview on 12/14/17 at 11:40 AM the Director of Nursing (DON) confirmed causal factors were not assessed for skin tears and/or bruising, and interventions were not put in place to prevent potential recurrence. B. Review of Resident 37's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/22/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment and displayed adverse physical and verbal behaviors. Review of Resident 37's Skin Occurrence assessment dated [DATE] at 2:02 PM revealed a Skin tear noted to the medial back of right hand measuring 2 cm (centimeters) by 0.3 cm after resident was seen hitting wall with back of hand. Resident was hitting wall with a knocking motion using back of hand. Review of a Skin/Wound QI (Quality Improvement) Log dated 8/17/17 (no time indicated) revealed Resident 37 sustained a 1.4 cm x 0.9 cm skin tear on the top of the left hand after hitting hand on the lift (mechanical lift used to transfer the resident in and out of bed/chair). Review of a Skin Occurrence assessment dated [DATE] at 5:26 PM revealed a skin tear was observed on Resident 37's right hand at 4:00 PM which measured 1 cm x 0.1 cm. There was no documentation as to the potential cause of the injury. Review of the Skin/Wound QI Log dated 9/29/17 revealed the intervention for prevention of further skin tears was mindful hand placement. Review of a Progress Note dated 10/9/17 at 7:20 PM revealed Resident 37 was hitting at staff while being transferred into bed with a mechanical standup lift. The resident sustained [REDACTED]. Review of a Skin Occurrence assessment dated [DATE] at 10:01 AM revealed Resident 37 struck out during transfer with the mechanical standup lift. The resident bumped the top of the left hand on the mechanical standup lift and sustained 2 skin tears which measured 0.6 cm x 0.5 cm x 0.1 cm and 2.3 cm x 0.1 cm. Review of Resident 37's Care Plan (revision date 12/5/17) revealed the resident was at risk for skin breakdown related to impaired mobility, diabetes, obesity and incontinence. There were no interventions for the prevention of bruises and skin tears caused by the resident striking out at the mechanical standup lift or from hitting the wall. On 12/13/17 at 8:00 AM, Resident 37 was observed to have a large bruised area on the left forearm and the top of the left hand. Interview with Nursing Assistant (NA)-B on 12/14/17 at 9:40 AM revealed Resident 37 received skin tears and bruises due to the resident striking out during transfers with the mechanical standup lift. NA-B further indicated Resident 37 frequently hit the bathroom wall with a fist while seated on the toilet which caused bruises on the resident's hands and knuckles. Interview with the DON on 12/14/17 at 11:50 AM confirmed there was no evidence to indicate interventions were developed in an attempt to prevent further skin tears and bruises as a result of Resident 37's combative behaviors.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to ensure Resident 16 was safe to be outside without staff supervision. The facility census was 42 and the sample size was 15. Findings are: Review of Resident 16's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/11/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had modified independence with cognitive skills for daily decision making and displayed episodes of disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Review of Resident 16's Care Plan dated 4/20/17 revealed the use of a Wanderguard (a bracelet worn by the resident and sounds an alarm if the resident comes within a certain distance of the exit door). Review of a Wandering Risk assessment dated [DATE] revealed Resident 16 was at moderate risk for wandering. Review of Resident 16's Progress Notes dated 11/16/17 at 11:53 AM revealed the resident was at moderate risk for wandering per the assessment completed 11/16/17 following a recent room change. Documentation indicated the following: -no increased confusion or attempts to exit the facility had been noticed; -the Wanderguard was discontinued; and -staff would continue to monitor for exit seeking behaviors. Review of Progress Notes dated 12/6/17 at 10:21 AM revealed Resident 16 was .attempting to enter the Assisted portion (assisted living) of the facility today-to this time has attempted 3 times and each time was either redirected or pushed to (resident's) room by staff. There was no evidence to indicate Resident 16's attempt to exit the facility was assessed. On 12/11/17 at 10:30 AM, Resident 16 was observed seated in a wheelchair and was attempting to re-enter the facility from outside through the front door. The resident was unable to completely open the front door and the wheelchair became wedged against the door which prevented the resident from independently re-entering the building. The Business Office Manager (BOM) was present in the office next to the front door and immediately assisted the resident back into the building. Interview with the BOM on 12/14/17 at 7:55 AM revealed Resident 16 was allowed to sit outside without supervision. The BOM confirmed Resident 16 required assistance to re-enter the building on 12/11/17 as the resident did not consistently remember how to use the handicapped automatic door opener. Interview with the Director of Nurses (DON) on 12/14/17 at 8:03 AM confirmed an assessment had not been completed to ensure Resident 16 was safe to sit outside without staff supervision.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview, the facility failed to assess causal factors and to develop and/or revise interventions for the prevention of falls for 1 resident (Resident 35). The sample size was 20 and the facility census was 44. Findings are: Review of Resident 35's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/13/16 indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident 35's current Care Plan with revision date 6/23/16 indicated the resident was at risk for falls related to impaired safety awareness and a history of frequent falls. Nursing interventions included: -Be sure the resident's call light was within reach at all times and to provide prompt response to all requests for assistance. -Ensure the resident has appropriate footwear when out of bed (black rubber soled lace up shoes). -Pin alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) to the resident's recliner, bed and wheelchair. -Low bed with a defined edge mattress. -Toilet the resident after meals. -Lift chair recliner. Review of Incident/Accident Report dated 6/26/16 at 3:45 PM revealed the resident was found lying on the floor of the resident's room. The resident's personal alarm was in place and was alarming at the time of the fall. Review of the Post Fall Assessment completed 6/26/16 at 3:45 PM revealed the resident had been seated in a lift recliner in the resident's room prior to the fall. The fall was unwitnessed and the resident was unable to identify the reason for the fall. A new intervention was identified to assess use of the recliner to determine if a different recliner should be implemented to prevent ongoing falls. Review of Resident 35's medical record revealed no evidence the facility assessed the use of the resident's lift recliner or that a different recliner was ever implemented for the resident. Review of Fall Risk assessment dated [DATE] revealed a score of 18 indicating the resident was at high risk for falls. Review of Incident/Accident Report dated 8/1/16 at 5:40 PM revealed staff responded to the resident's personal alarm and found the resident on the floor of the resident's room. The report indicated the resident had a laceration with dark bruising above the left eyebrow which measured 1.5 centimeters (cm) by 0.1 cm. Review of the Post Fall assessment dated [DATE] at 5:40 PM revealed the resident had attempted to self-transfer out of the wheelchair and fell into a night stand. Further review of the assessment revealed no causal factors were identified and no new interventions were developed to prevent ongoing falls. Interview with the Director of Nursing (DON) on 9/6/16 from 2:30 PM to 2:45 PM revealed there was no evidence the resident's lift recliner had been assessed after the resident's fall on 6/26/16 and confirmed a different recliner had never been provided for the resident. The DON further identified no causal factors were identified and no new interventions were developed after the resident fell on [DATE] to prevent ongoing falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on observations, record review and interview; the facility failed to revise Care Plans following a resident to resident altercation involving Residents 1 and 13. The sample size was 20 and the facility census was 44. Findings include: A. Review of Progress Notes dated 4/7/16 at 11:00 AM revealed a verbal confrontation was noted between Resident 1 and Resident 13 who were roommates. Documentation indicated Resident 13 reported being hit by Resident 1. Resident 13 was observed to have .a red mark to neck and shoulder area. Review of a facility investigation of potential abuse/neglect dated 4/11/16 revealed that on 4/7/16 at 11:00 AM, Resident 1 was seated in a wheelchair in the doorway of the room. Resident 1 was positioned directly behind Resident 13 who was also seated in a wheelchair. Staff responded after hearing yelling and Resident 13 reported being hit by Resident 1. Resident 1 voiced a need to use the bathroom and indicated Resident 13 was in the way. Resident 13 was noted to have a reddened area on the right side of the shoulder/neck. Documentation further indicated preventative measures put in place to prevent reoccurrence were to remind Resident 1 to use the call light for assistance and Resident 13 was removed from the room for lunch. B. Review of Resident 1's previous Care Plan (revision date 2/11/16) revealed the altercation with the roommate (Resident 13) on 4/7/16 was identified and the interventions were: -Staff to monitor and; -Roommate encouraged to spend time in the commons area (public sitting area of facility). Review of Resident 1's current Care Plan (revision dates 5/12/16 and 8/5/16) revealed the altercation with the roommate on 4/7/16 was not identified and there were no interventions to prevent a reoccurrence. C. Review of Resident 13's previous Care Plan (revision date 2/26/16) revealed the altercation with the roommate (Resident 1) on 4/7/16 was identified. The intervention to prevent a reoccurrence was to encourage Resident 13 to spend time in the commons areas. Review of Resident 13's current Care Plan (revision date 9/1/16) revealed no interventions were identified to prevent altercations with Resident 1. Observations on 8/31/16 revealed the following: -Resident 1 and Resident 13 were roommates; -1:35 PM-Resident 1 and Resident 13 were seated in wheelchairs on opposite sides of the room in their room; -2:19 PM-Resident 1 was lying in bed and Resident 13 was seated in a wheelchair on the opposite side of the room. Resident 1 and Resident 13 were observed seated in wheelchairs in their room on 9/6/16 from 10:00 AM until 12:01 PM. Interview with Nursing Assistant (NA)-C on 9/6/16 at 2:05 PM revealed Resident 1 was no longer self mobile in the wheelchair; however Resident 13 remained self mobile in the wheelchair.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observations, record review and interview; the facility failed to develop interventions to: 1) address Resident 1's adverse behaviors toward Resident 13 and; 2) address Resident 27's positioning. The sample size was 20 and the facility census was 44. Findings include: A. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/4/16 revealed [DIAGNOSES REDACTED]. Review of Progress Notes dated 4/7/16 at 11:00 AM revealed a verbal confrontation was noted between Resident 1 and Resident 13 who were roommates. Documentation indicated Resident 13 reported being hit by Resident 1. Resident 13 was observed to have .a red mark to neck and shoulder area. Review of a facility investigation of potential abuse/neglect dated 4/11/16 revealed on 4/7/16 at 11:00 AM, Resident 1 was seated in a wheelchair in the doorway of the room. Resident 1 was positioned directly behind Resident 13 who was also seated in a wheelchair. Staff responded after hearing yelling and Resident 13 reported being hit by Resident 1. Resident 1 voiced a need to use the bathroom and indicated Resident 13 was in the way. Resident 13 was noted to have a reddened area on the right side of the shoulder/neck. Documentation further indicated preventative measures put in place to prevent reoccurrence were to remind Resident 1 to use the call light for assistance and Resident 13 was removed from the room for lunch. Review of Resident 1's previous Care Plan (revision date 2/11/16) revealed the altercation with the roommate on 4/7/16 was identified and the interventions were: -Staff to monitor and; -Roommate encouraged to spend time in the commons area (public sitting area of facility). Observations on 8/31/16 revealed the following: -Resident 1 and Resident 13 were roommates; -1:35 PM-Resident 1 and Resident 13 were seated in wheelchairs on opposite sides of the room in their room; -2:19 PM-Resident 1 was lying in bed and Resident 13 was seated in a wheelchair on the opposite side of the room. Resident 1 and Resident 13 were observed seated in wheelchairs in their room on 9/6/16 from 10:00 AM until 12:01 PM. Interview with Nursing Assistant (NA)-C on 9/6/16 at 2:05 PM revealed Resident 1 was no longer self mobile in the wheelchair; however Resident 13 remained self mobile in the wheelchair. B. Review of Resident 27's current undated Care Plan revealed the resident had a [DIAGNOSES REDACTED]. Further review revealed no evidence the resident's positioning had been assessed. Observations of Resident 27 revealed: -On 9/1/16 at 7:38 AM, the resident was seated in an upright recliner bent over at the waist with the resident's chest and abdomen lying on the resident's lap. -On 9/6/16 at 9:26 AM, the resident was seated in an upright recliner with resident's lower back vertical and shoulders approximately 6 inches from the back of the recliner. -On 9/6/16 at 11:24 AM, the resident remained seated in the upright recliner but was now bent over at the waist with the resident's chest and abdomen lying on the resident's lap. -On 9/8/16 at 7:34 AM, the resident was seated in an upright recliner bent over at the waist with the resident's chest and abdomen lying on the resident's lap. Interviews on 9/8/16 with NA-C at 10:03 AM and Registered Nurse-F at 10:25 AM, revealed the facility had not tried any interventions to improve Resident 27's positioning when the resident was in the recliner. Interview with the Director of Nursing on 9/8/16 at 11:25 AM, confirmed Resident 27 had better positioning when initially placed in the recliner, but would tire over time and then become bent over in the recliner. Further interview confirmed Resident 27 had not been assessed for proper positioning in the resident's recliner. .

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on interview and record review, the facility failed to implement interventions to prevent further decline in bladder function and/or improve current bladder function for Resident 48. The sample size was 20 and the facility census was 44. Findings are: Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/18/16 revealed Resident 48 was admitted on [DATE], and was always continent of urine. Review of the MDS dated [DATE] revealed Resident 48 was occasionally incontinent of urine (meaning less than 7 episodes of incontinence during the 7 day assessment period). Review of Resident 48's Bowel and Bladder Program Screener (a tool used to review a residents bowel and bladder status and identify their ability for retraining) dated 7/13/16 revealed Resident 48 was incontinent of urine at least daily, and was a good candidate for retraining. Review or Resident 48's undated Care Plan revealed no interventions to prevent further decline in bladder function and/or improve current bladder function. Interview with Nursing Assistant-C on 9/8/16 at 10:01 AM revealed Resident 48 had an increase in bladder incontinence. Further interview revealed Resident 48 was toileted on a routine schedule that was consistent for all residents that required assistance with toileting. Interview with Licensed Practical Nurse-A on 9/8/16 at 10:08 AM, confirmed Resident 48 did not have a bladder retraining program. Interview with Registered Nurse -F on 9/8/16 at 10:28 AM confirmed Resident 48 had an increase in bladder incontinence.