Every finding on record at Arbor Care Center-Valhaven, LLC

Licensure Reference Number 175 NAC 12-006.9(I) Based on observation, interview and record review, the facility failed to ensure hot water was kept away from vulnerable residents in the dining room which had the potential to effect 1 (Resident 40) of 23 sampled residents; and the facility failed to implement interventions to prevent falls for 1 (Resident 40) of 1 sampled resident. Findings are:A. An observation of the dining room on 8/6/25at 12:45PM revealed the kitchen staff had prepared a cart for the dirty dishes with 3 plastic tubs of water that had visible steam rising from the surface. The cart was in the dining room beside the doorway leading to the dishwashing room. A dining table was on either side of the cart. Resident 44 was seated at the table to the left of the cart. Resident 44 was observed to be independently mobile with a walker. An observation on 8/6/25 at 12:50PM of Dietary Aide (DA) N temperature testing the water in the tubs the dishes. The temperatures were 150.9 degrees, 158.7 degrees and 161.1 degrees. The DA moved the cart to inside the dishwashing station. An interview on 8/6/25 at 12:50PM with DA N, confirmed they had prepared the tubs with the soapy hot water. DA N confirmed they use very hot water to help dissolve the leftover food on the plates. The DA N confirmed the residents in the dining room could reach the hot water as it was located outside of the kitchen door leading to the dishwashing station. The DA N confirmed that the hot water could cause a lot of damage to an elderly persons' skin. An interview on 8/6/25at 12:55PM with the Dietary Manager confirmed they aware that the kitchen staff used a cart with soapy hot water in tubs to place the dirty dishes after meals. DM confirmed (gender) was aware the cart was in the dining area outside the kitchen door and confirmed that the reported hot water temperatures sounded about right. The DM confirmed that the hot water was accessible to the residents who were in the dining room and could pose a risk of burns to the residents. An interview on 8/6/25 at 1:20PM with Nurse Aide L (NA) revealed (gender) sat with residents who needed help during meals. NA L confirmed Resident 44 could have reached the hot water as it was close to their table. NA L stated Resident 44 would be most at risk because Resident 44 is mobile, has dementia and was sitting closest to the water. NA L confirmed it is not the nurse aides' task to monitor the hot water. An interview on 8/6/25 at 1:30PM with NA M confirmed (gender) had been seated at the assisted dining table in the dining room for the lunch service. NA M confirmed they were not aware the tubs held hot water. NA M confirmed they did not know if any of the residents seated near the tubs on the cart were mobile and/or confused. An interview on 8/6/25 at 1:45PM with Registered Nurse (RN) J confirmed (gender) were seated at the assisted dining table helping residents during lunch. RN J confirmed the nursing staff were not responsible for monitoring the hot water dishes. RN J confirmed Resident 44 was the most mobile and confused person sitting near the hot water. RN J confirmed (gender) were not aware that it was very hot water. A record review of the Dietary Aide duties provided by the DM revealed there are two dietary aides on for AM and two for PM shift. Clearing the dish cart is the responsibility of the dietary aides. There are no specific instructions relating to the collection and/or presoaking of dirty dishes. B. Record review of Resident 40's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-22-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status was scored as a 2. According to the MDS Manual a score of 0-7 indicates a person has severe cognitive impairment. -had a recent surgery for a hip fracture. -required total assistance with hygiene, toileting, dressing, bathing, dressing, and transfers. Record review of Resident 40's Comprehensive Care Plan (CCP) dated 11-02-2023 revealed Resident 40 was at risk for further falls related to severe cognitive impairment, psychoactive drug use, and poor safety awareness. The CCP also listed dates of previous falls: -11-13-24 on floor in front of wheelchair in the common area -04-17-2025 on the floor in room -06-01-2025 fall out of wheelchair -06-11-2025 on floor sitting between bed and roommates bed resulting in a fractured left femur. The goal was falls will be minimized and managed through the next review date. Interventions listed were bed in low position, reapproach to assist with transfers if the resident becomes agitated, dycem (a non-slip material that keeps objects from sliding or rolling) to the top and bottom of the wheelchair cushion, red tape to wheelchair brakes, therapy to evaluate and treat as indicated for left hip fracture, medication review, ensure resident is wearing appropriate footwear when transferring and a tilt wheelchair. An observation conducted on 08-07-2025 at 12:52 PM revealed Resident 40 was sitting in a tilt wheelchair in the dining room, wearing gripper socks and there is no red tape present on the wheelchair brakes. An observation on 08-11-25 at 6:00 AM revealed Resident was in bed, wheelchair was next to bed with no dycem on the top or the bottom of the wheelchair cushion and there was no red tape on the wheelchair brakes. An observation conducted with Nursing Assistant (NA) P and Medication Aide (MA) G on 08-12-2025 at 6:50 AM in Resident 40's room confirmed dycem was not present on the top and the bottom of the wheelchair cushion and red tape was not present on the brakes of the tilt wheelchair. An interview was conducted with MA G during the observation at 08-12-2025 at 8:00 AM revealed MA G had no knowledge of Resident 40 needing dycem or tape to the wheelchair brakes. An interview with Registered Nurse (RN) I on 08-12-2025 at 9:20 AM confirmed Resident 40 was to have dycem to the top and the bottom of the wheelchair cushion and confirmed the brakes on the tilt wheelchair should have red tape on the brakes. A follow-up interview was conducted on 08-12-2025 at 11:00 AM with RN I that confirmed the dycem to the wheelchair cushion and red tape to the wheelchair brakes were not in place and have been replaced. Record review of the facility policy titled Fall Prevention and Fall Leaf Program dated 02-2023 revealed the purpose of the policy was to ensure fall risks are identified and interventions are implemented in an effort to prevent falls, as possible, and to maintain a safe environment for each resident of the facility.

Licensure Reference Number 175 NAC 12-006.02(H) Based on observation, interview, and record review, the facility failed to notify the State Agency of an alleged elopement within the required time frame for 1 (Resident 17) of 1 sampled resident; and the facility failed to submit the written report for a resident-resident altercation within 5 days for 1 (Resident 5) of 1 sampled resident. Findings are:A. An observation on 8/6/2025 at 12:12PM revealed Resident 17 had attempted to push open an exit door. Resident 17 had a wander guard (a wander management system designed to protect residents at risk of wandering in senior living communities) around their right ankle. A record review of Resident 17's Minimum Data Set (MDS – a federally mandated standardized data assessment tool that measures health status in nursing home residents) revealed Resident 17 had a BIMS (Brief Interview for Mental Status – a federally mandated tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) of 7 indicating Resident 17 had severely impaired cognition (the mental process of acquiring knowledge and understanding). The MDS revealed Resident 17 uses a wheelchair. A record review of Resident 17's Care Plan revealed Resident 17 eloped (left the facility without authorization) out of the 200 Hall exit on 7/9/2025. A record review of a Progress Note dated 7/9/2025 at 11:45PM written by Registered Nurse RN J revealed Resident 17 had exited the facility through the back door. A record review of the Elopement report revealed it was called to APS (Adult Protective Services) PM 7/10/2025 at 2:25PM. An interview on 8/12/2025 at 2:52PM with the Director of Nursing (DON) confirmed the report was not called in at the time of the elopement because the DON was asleep when the floor nurse informed them via text of the elopement. B. Record review of Resident 5's admission Record printed 8/7/2025 revealed the facility admitted the resident on 8/27/2008 and identified the resident had diagnoses that included cerebral palsy (a disability resulting from damage to the brain before, during, or shortly after birth and outwardly manifested by muscular incoordination and speech disturbances), dysarthria (difficulty articulating words due to disease of the central nervous system), paranoid schizophrenia (a mental illness characterized especially by delusions of persecution, grandiosity, or jealousy and by hallucinations [such as hearing voices] chiefly of an auditory nature), generalized anxiety disorder (a condition characterized by excessive anxiety and worry about a variety of events or activities (e.g., work or school performance) that occurs more days than not, for at least 6 months), and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies). Record review of Resident 5's annual MDS assessment dated [DATE] identified the resident had a BIMS of 10 of 15. According to the MDS manual, a score of 10 indicated the resident had moderately impaired cognitive function. Record review of a 5-day investigation involving Resident 5 identified a resident-to-resident interaction occurred on 3/10/2025 where Resident 5 struck the right upper arm of another resident. Record review of e-mail submission of the 5-day investigation showed the investigation was not transmitted to the State Agency (SA) until 3/17/2025, six days after the date of the incident. An interview on 8/11/2025 at 11:42 AM with the Administrator confirmed the 5-day report was not sent to the SA until 3/17/2025 and should have been submitted no later than 3/14/2025. Review of facility policy entitled Abuse, Neglect and Exploitation dated September 2022 revealed: Policy Explanation and Compliance Guidelines: -2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations of suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. -VII. Reporting/Response -A. The facility will have written procedures that include: -1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: -a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or -b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. -B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Licensure Reference Number 175 NAC 12-006.09(G)(ii) Based on interview and record review, the facility failed to provide a report to the receiving facility for an emergency transfer for 2 (Residents 4 & 40) of 2 sampled residents and the facility failed to notify the Ombudsman of transfer for 4 (Residents 1, 40, 54 & 58) of 4 sampled resdients. Findings are:A. An interview on 8/7/2025 at 10:03am with Resident 3 revealed they were admitted to hospital on [DATE] for significant hypoxia (shortness of breath) and chest pain. A record review of Resident 3's medical chart did not reveal a progress note confirming the Ombudsman had been notified of the resident discharge. B. An interview on 8/6/2025 at 11:41AM with Resident 54 revealed they were admitted to hospital in June 2025 for kidney issues. A record review of a provider progress note dated 6/6/2025 revealed Resident 54 had been hospitalized for pneumonia. A record review of Resident 54's medical chart did not reveal a progress note confirming the Ombudsman had been notified of the resident discharge. C. An interview on 8/7/2025 at 9:15AM with Resident 1 revealed they were in hospital. A record review of Resident 1's progress notes revealed a note by Registered Nurse (RN) K dated 6/5/2025 revealed Resident 1 was sent to the emergency room due to right sided weakness and altered mental status. A record review of Resident 1's medical chart did not reveal a progress note confirming the Ombudsman had been notified of the resident discharge. D. A closed record review of Resident 58's Electronic health record revealed the resident had discharged home on 7/18/2025. A record review of Resident 58's medical chart did not reveal a progress note confirming the Ombudsman had been notified of the resident discharge. An interview on 8/12/25 at 11:15pm with Social Services Director confirmed they were not aware the ombudsman needed to be notified of any resident discharges from the facility, and they did not send notifications of discharge for Resident 1, Resident 3, Resident 54, and Resident 58. A record review of the facility's Transfer and Discharge Policy, dated September 2022 revealed the following: Section 12. Emergency Transfers/Discharges - h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. E. Record review of Resident 40's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-22-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status was scored as a 2. According to the MDS Manual a score of 0-7 indicates a person has severe cognitive impairment. -had a recent surgery for a hip fracture. -required total assistance with hygiene, toileting, dressing, bathing, dressing, and transfers. Record review of Resident 40's Progress Note dated 06-11-2025 revealed Resident 40 was transferred to the hospital. Record review of Resident 40's Progress Notes dated 06-11-2025 and 06-12-2025 did not indicate the Ombudsman had been notified of the transfer. An interview with the Director of Nursing (DON) on 08-12-2025 at 1:33PM confirmed the Ombudsman had not been notified of the transfer on 06-11-2025 and should have. A record review of the facility's Transfer and Discharge Policy, dated September 2022 revealed the following: Section 12. Emergency Transfers/Discharges - h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices.

Licensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview, the facility failed to accurately enter pressure ulcer information on the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 1 (Resident 6) of 20 residents sampled. The facility staff identified a census of 54.The findings are:Record review of an undated facility policy entitled MDS 3.0 Completion revealed: -4. Care Plan Team Responsibility for Assessment Completion: -a. Interdisciplinary Responsibility for Completion of MDS Sections: -ii. Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections. -b. Coding of Assessment: -i. All disciplines shall follow the guidelines in Chapter 3 of the current RAI manual for coding each assessment.Record review of Centers for Medicare and (&) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual) dated October 2023 revealed: -Step 3: Determine Present on admission -For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement.Record review of Resident 6's admission Record printed 8/11/2025 revealed the facility admitted the resident on 1/29/2021 and identified diagnoses that included pressure ulcer of the right buttock, stage 3.Record review of Resident 6's Weekly Wound Evaluation (WWE) dated 3/26/2023 identified the resident had a new pressure ulcer to the right buttock that was first identified on 3/26/2023. Further review of the WWE identified the pressure ulcer was identified by the facility as in-house acquired.Record review of Resident 6's Wound Treatment Plan (WTP) dated 4/8/2025 identified the skin breakdown to the right buttock is recurrent in nature. Further review of the WTP showed that the wound was resurfaced (healed).Record review of Resident 6's WTP dated 4/22/2025 identified the right buttock wound had reopened on 4/22/2025.Record review of Resident 6's annual MDS dated [DATE] revealed a Stage 3 pressure ulcer that was present on admission.An interview on 8/12/25 at 11:32 AM with the Nurse Consultant (NC) confirmed the pressure ulcer on the MDS was incorrectly coded as present upon admission or reentry.

Licensure Reference Number 175 NAC 12-006.04 Based on record review and interview the facility failed to ensure staff were tested for competency of clinical skills for 5 (Medication Aides (MA) E, F, and G, Licensed Practical Nurse (LPN) H, and Registered Nurse (RN) I)of 5 sampled nursing staff files. The facility census was 54. The findings are:Record review of MA E 's employee file revealed a hire date of 09-24-2019, and no record of competency testing for clinical skills. Record review of MA F's employee file revealed a hire date of 07-24-2019, and no record of competency testing for clinical skills. Record review of MA G's employee file revealed a hire date of 04-20-2016, and no record of competency testing for clinical skills. Record review of LPN H employee file revealed a hire date of 03-17-2025 and no record of competency testing for clinical skills. Record review of RN I's employee file revealed a hire date of 04-10-2024 and no record of competency testing for clinical skills. An interview with the Nurse Consultant (NC) on 08-12-2025 at 11:30 AM confirmed competency testing of clinical skills had not been conducted in the last year. Record review of the facility policy dated 09-2022 titled Training Requirements revealed it is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff. Competencies and skill sets for all new and existing staff must be consistent with their expected roles. Documentation of required training will be placed into the individual's personnel file.

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record, review the facility failed to develop and implement a behavioral management plan for 1 (Resident 12) of 1 sampled resident. The facility census was 54. The findings are:Record review of Resident 12's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-10-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 7. According to the MDS Manual a score of 0-7 indicates a person has severe cognitive impairment.-had physical behavior symptoms directed toward others 1-3 days a week.-had verbal behavior symptoms directed toward others 4-6 days a week.-resident's behavior puts the resident at significant risk for physical illness or injury.-resident's behavior significantly interferes with the resident's care.-residents behavior significantly interferes with the resident's participation in activities or social interactions.-resident's behavior significantly disrupts care or living environment.-resident's behavior symptoms have worsened.-required partial assistance with toileting, bathing, and dressing.-required set-up and supervision with eating and hygiene.-was independent with bed mobility, transfers and ambulation. Record review of Resident 12's Comprehensive Care Plan (CCP) dated 04-18-2025 revealed a focus area of Resident-to-resident altercation:-4-18-25 Resident-to-resident altercation, Resident 12 was hit in the left leg by another resident resulting in Resident 12 hitting the other resident back.-07-01-25 Resident-to-resident altercation, Resident 12 hit another resident in the stomach and the other resident hit Resident 12 on the left side of the face.-7-04-2025 Resident-to-resident altercation, Resident 12 hit another resident on the left upper arm-unprovoked. Guardian indicated Resident 12 can act out when (gender) doesn't get (gender) wants.-8-03-2025 Resident-to-resident altercation, Resident 12 hit another resident on the hand during the noon meal because the other resident was repeatedly tapping his fingers on the table.The goal identified on the CCP was Resident 12 will not hit another resident through the review date. Interventions on the CCP revealed the following:-04-18-2025 residents were immediately separated from each other, assessments completed, no injury observed. Offer 1-to-1, activities if agitated.-04-18-2025 encourage Resident 12 to go to nursing staff when there is a concern with other residents.-07-01-2025 discussed with Resident 12 to talk with staff if (gender) needs to express something and if needed go to (gender) room to be clear of busy areas at times of increased frustration.-07-06-2025 residents were immediately separated. Resident 12 went to their room to play with toys and Resident 12 was educated on voicing concerns or frustration with staff, and it was not appropriate to touch other residents.-07-06-2025- social services contacted Resident 12's guardian to get a psychiatric evaluation.-08-03-2025 do not sit by the other resident during meals and activities. Record review of Resident 12's Progress Notes (PN) dated 10-28-2024 revealed Resident 12's guardian had returned a call to the facility and was updated that Resident 12 hit another resident. Record review of the facility's investigation into the resident-to-resident altercation on 10-18-2024 revealed the preventative measure put into place by the facility was Resident 12 had a 1-to-1 conversation with the Director of Nursing (DON) on the importance of not striking out at others, Resident 12 was able to acknowledge what (gender) was wrong and apologized. The other resident involved was talked to about the importance of talking to the charge nurse with concerns about other residents and to try not to correct other residents on their own. Record review of Resident 12's An observation on 08-07-2025 at 12:00PM revealed Resident 12 was sitting at (gender)assigned table which places (gender) back to the aisle between 2 sets of tables. An observation on 08-11-2025 at 12:00 PM revealed Resident 12 sitting at (gender) assigned table in the dining room and (gender) was sitting away from the table enough to cross legs which encroaches on aisle between the tables. An observation with the DON and the Nurse Consultant (NC) on 08-12-2025 at 11:30 AM of Resident 12's assigned seat in the dining room revealed Resident 12's seat placed (gender) back to the aisle between 2 tables and Resident 12 was sitting away from the table to cross legs which places Resident 12 in the aisle. A follow-up interview was conducted with the DON and NC on 08-12-2025 at 11:40 AM revealed the facility did not identify the triggers of Resident 12's aggressive behavior and had not considered moving Resident 12's assigned seat in the dining room to reduce the occurrence of those triggers. An interview with the DON on 08-12-2025 at 12:00 PM confirmed the same intervention of educating Resident 12 about going to the staff when frustrated was used after repeated aggressive behavior and confirmed that a behavior management plan had not been developed to include non-pharmacological interventions and environmental adjustments. Record review of the facility policy titled Behavior Management Plan dated 02-2020 revealed residents who exhibit behavioral concerns may require a behavior management plan to ensure they are receiving appropriate services and interventions to meet their needs. The interdisciplinary team, including the family member, should develop a behavioral plan for each resident with identified behaviors on the MDS. A behavior management plan can include a schedule of daily life events, which addresses the individuality of the resident. The plan should include the recreation schedule, non-pharmacological interventions, and environmental adjustments needed to help the resident meet his or her highest practicable well-being.

Licensure Reference Number 175 NAC 12-006.04(B) and 175 NAC 12-006.04(B)(ii). Based on interview and record review, the facility failed to ensure that 2 (Nurse Aides (NA) D, and Medication Aide (MA) F) of 8 sampled staff files had ongoing abuse training; and failed to ensure ongoing dementia training for 5 (NA D, MA E, F, G, Licensed Practical Nurse (LPN) H) of 8 sampled staff files. The facility census was 54. The findings are: Record review of Nursing Assistant (NA) D's employee file revealed a hire date of 07-02-2024, and no record of abuse or dementia training. Record review of Medication Aide (MA) E 's employee file revealed a hire date of 09-24-2019, and a Course Completed History (CCH) dated 06-04-2025 revealed 5.75 hours of ongoing training was completed from 01-13-2024 to 08-06-2025 and only 1 hour of dementia training was completed. Record review of MA F's employee file revealed a hire date of 07-24-2019, and a Course Completed History (CCH) dated 06-04-2025 revealed 1.25 hours of ongoing training was completed from 03-14-2024 to 08-06-2025 with 1 hour of dementia training completed and no abuse training was recorded. Record review of MA G's employee file revealed a hire date of 04-20-2016, and a Course Completed History (CCH) dated 06-04-2025 revealed 1.0 hours of ongoing training was completed from 02-29-2024 to 08-06-2025 and no dementia training was completed. Record Review of Licensed Practical Nurse (LPN) H's employee file revealed a hire date of 03-17-2022 and no record of dementia training in the last year. An interview with the Nurse Consultant (NC) on 08-11-2025 at 2:30 PM confirmed NA D and MA F did not have annual abuse training, and NA D, MA E, MA F, MA G, and LPN H did not have 4 hours of ongoing dementia training. Record review of the facility policy dated 09-2022 titled Training Requirements revealed it is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff consistent with their expected roles. Training requirements should be met prior to staff providing services to the residents, annually and as necessary based on the facility assessment. The training includes dementia management and care of the cognitively impaired and abuse, neglect and exploitation prevention. Record review of the facility policy dated 09-2024 titled Training revealed each employee must receive ongoing training to ensure competency and continued compliance with regulations and facility policy. This training must include 4 hours of dementia care if the licensee cares for residents with Alzheimer's Disease or Dementia.

Licensure Reference Number 175 NAC 12-006.04(B)(i)(ii)1 Based on interview and record review the facility failed to ensure nursing assistants had 12 hours of on-going training per year for 2 (Nurse Aide (NA) C, and D) of 2 sampled nursing assistant files. The facility census was 54. The findings are: Record review of NA C's employee file revealed a hire date of 07-22-2022, and a Course Completed History (CCH) dated 06-04-2025 revealed 10 hours of ongoing training was completed from 01-03-2024 to 08-06-2025. Record review of NA D's employee file revealed a hire date of 07-02-2024, and no documentation of on-going training. An interview with the Nurse Consultant (NC) conducted on 08-11-2025 at 2:30 PM confirmed NA C and NA D did not complete 12 hours of ongoing training annually. Record review of the facility policy dated 09-2024 titled Training revealed the facility must provide initial and ongoing training designed to meet the needs of the resident population. Ongoing training of nurse aides must consist of 12 hours per year on topics appropriate to the employee's job duties, including meeting the physical, psychosocial, and mental needs of the residents.

Licensure Reference Number 175 NAC 12-006.04 Based on interview and record review, the facility failed to check the nurse aid registry for 2 of 5 sampled employee files. The facility census was 54. The findings are: Record review of the facility policy titled Staffing Requirements dated 09-2024 revealed for employment eligibility the facility must maintain evidence of registry checks. A check for adverse findings must include the following registries: Nurse Aide Registry, Adult Protective Services Central registry, Central Registry of Child Protective Services and the Sex Offender Registry. Record review of the facility policy titled Background Investigations dated 10-10-2025 revealed the facility will not employ individuals who have a finding entered in the state nurse aide registry concerning abuse, neglect, exploitation, misappropriation of property, or mistreatment by court of law. Record review of Housekeeper (HK) A's employee file revealed a hire date of 07-15-2025 and the absence of a nurse aid registry check. Record review of Nursing Assistant (NA) B's employee file revealed a hire date of 05-05-2025 and the absence of a nurse aid registry check. An interview conducted with the Nurse Consultant (NC) on 08-11-2025 at 2:00PM confirmed the nurse aide registry was not checked for HK A and NA B and should have prior to working directly with the residents in the facility.

Licensure Reference Number 175 NAC 12-006.11E Based on observations, interviews and record review; the facility failed to perform hand hygiene, wear hair and beard nets in the kitchen to prevent food-borne illness for all the residents. This had the potential to affect all resident that ate out of the kitchen. The facility census was 43. Findings are: An observation on 7/17/24 at 8:35 AM revealed the Dietary Manager (DM)-H in the kitchen without a beard net on while food was out during breakfast meal service. An observation on 7/17/24 at 11:37 AM revealed DM-H did not have a beard net on during meal preparation for lunch services. An observation on 7/18/24 at 8:36 AM with Cook-I revealed Cook-I washed [gender] hands with soap and water for 10 seconds then donned (put on) clean gloves and touched toast with [gender] gloved hands. An observation on 7/18/24 at 8:56 AM revealed Cook-I removed [gender] gloves, and washed [gender] hands with soap and water for 6 seconds then donned gloves and continued to cook French toast. An interview on 7/18/24 at 2:17 PM with DM-H revaled the facilities expectation is to wash hands for 30 seconds. DM-H stated they can sing happy birthday during this to ensure enough time. An interview on 7/18/24 at 2:20 PM with DM-H revealed that the facility does have an expectation for staff to wear a beard net if they have a beard. An observation on 7/22/24 at 10:18 AM revealed Cook-K returned to kitchen after a break and picked up clean plates. The obersvation did not reveal that Cook-K washed [gender] upon return from break. An interview on 7/22/24 at 10:21 AM with Cook-K confirmed [gender] should have washed [gender] hands when [gender] returned to kitchen. An observation on 7/22/24 at 12:28 PM of the Dietary Aide (DA)-N and Cook-L revealed both staff came into kitchen without a hair nets on during lunch service in which food was being served. The observation did not reveal that hand hyigene was completed by DA-N and Cook-L with return to the kitchen. An interview on 7/22/24 at 12:32 PM with DA-N and Cook-L revealed they should have washed their hands when entering the kitchen, donned a hair net prior to entering the kitchen. Hand hygiene Policy updated 2021 revealed: 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 5. Hand hygiene technique when using soap and water: c. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Dietary Employee Personal Hygiene Policy copyright date 2019 from The Compliance Store revealed: It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. Hair Restraints - a. All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food.

Licensure Reference Number 175 NAC 12-007.04 (F) Based on observation, record review, and interview, the facility failed to ensure that the emergency electrical power system activated within 10 seconds to supply emergency power during a power outage for all residents. Facility census was 43. Finding are: The National Fire Protection Association's (NFPA) Life Safety Code 99, 2012 edition located at 6.5.3 and 6.5.3.1 reveal that the life safety and equipment branches shall be installed and connected to the alternate source of power specified in 6.4.1.1.4 and 6.4.1.1.5 so that all functions specified [NAME] for the life safety and equipment branches are automatically restored to operation within 10 seconds after interruption of the normal source. The above requirement is mandated for an emergency generator as part of the Essential Electrical System that is defined as a system of alternate sources of power and all commercial distribution systems and ancillary equipment, designed to ensure continuity of electrical power to designated areas and functions of a health care facility during disruption of normal power sources, and also to minimize disruption with the internal wiring system. An observation on 07/22/24 at 10:00 AM revealed a complete power outage to the entire facility. Nursing staff observed going into resident rooms for residents who had oxygen to switch the resident's oxygen concentrator (a medical device that uses the air in the atmosphere, filters it, and converts the air to 90% to 95% Oxygen) into the Red Outlets (outlets that are supplied power from the emergency generator during a power outage), or to switch the resident to a portable tank of oxygen. The emergency generator for the facility became operational at 10:02 AM. During this two-minute time span (between 10:00 AM to 10:02 AM) there was no electrical power to supply emergency exit signs, lighted means of egress (path to exit the building), or any electric powered medical equipment such as an oxygen concentrator. An interview with the facility's Administrator on 07/22/2024 at 12:01 PM confirmed that the entire facility lost electrical power for approximately 2 minutes around 10:00 AM that morning. Facility's Administrator stated that their expectation is that the emergency generator should activate within 10 second after a power outage. A record review of an undated facility policy labeled Emergency Generator Malfunction/Failure revealed: Policy: If the facility loses emergency back-up power (i.e. facility generator) or malfunctions, the facility will 1) Contact Administrator and 2) following discussion with the Maintenance Director/designee contact an outside generator contractor to obtain a portable generator of equivalent size or bigger to provide emergency back-up power to the facility. Procedure: If the electrical power is interrupted at the facility and the facility loses power and the emergency generator does not restore power within 10 seconds of the power outage, the Charge Nurse will immediately contact the Facility Administrator and Maintenance Director about the facility power outage and the emergency generator malfunction. Record review of facility's Emergency Generator -Monthly Test Log from January 4, 2023 through July 2, 2024 revealed the seconds to transfer range (how long does it take for the emergency generator to start after disruption of electrical power) ranged from 3-5 seconds.

Licensure Reference Number 175 NAC 12-006.09D Based on observation, record review and interview; the facility failed to identify the use of personal alarms on the residents Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) for 1 (Resident 18) of 4 sampled residents. The facility census was 43 Findings are: A record review of the Admission Record with the printed date of 7/22/24 revealed Resident 18 was admitted to the facility on [DATE] with the diagnoses of: Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Schizoaffective disorder( mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression), Obsessive-compulsive disorder(Excessive thoughts (obsessions) that lead to repetitive behaviors (compulsions), Vascular dementia(Brain damage caused by multiple strokes), Major Depressive Disorder with severe psychotic symptoms (distinct type of depressive illness in which mood disturbance is accompanied by either delusions, hallucinations). A record review of Resident 18's MDS dated [DATE] revealed in Section C- Brief Interview for Mental Status ( BIMS, a test used to get a quick snapshot of a residents cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed that in section P- Restraint and alarms, the wander guard is marked 0 (not used). An observation on 7/17/24 at 2:30 PM revealed that Resident 18 had a wanderguard (alert system) on (genders) left wrist. A record review of the Physicians orders dated 7/7/21 revealed an order to check that the wanderguard device is working every day and evening shift. A record review of the Care Plan (written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 11/02/23 revealed focus of elopement risk/wanderer, with the intervention of a Wanderguard alarm bracelet. An interview on 7/22/24 at 1:30 PM with Registered Nurse-B verified that the MDS section P should of been marked as yes to the use of the wanderguard and section P was marked as no to the use of the wanderguard.

Based on record review and interview, the facility failed to ensure a Preadmission Screening Resident Review (PASARR, a federally mandated screening process to ensure Nursing Home residents with mental illness and/or developmental disabilities) receive the care and services they need in the most appropriate setting was accurately completed for 1 (Resident 17) out of 4 record reviews of PASARR screens. The facility census was 43. Findings are: A record review of facility's undated policy labeled Resident Assessment-Coordination with PASARR Program revealed the following information: Policy: The facility coordinated assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder (MD), intellectual disability (ID), or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level 1 Screen-initial pre-screening that is completed prior to admission. i. Negative Level I Screen- permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level 1 Screen- necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (Cannot be completed by the facility) that determines where the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. A record review of admission data revealed Resident 17 was admitted to the facility on [DATE]. Resident 17's admission diagnoses included: Anxiety Disorder, Unspecified, Metabolic Encephalopathy, Panic Disorder (Episodic Paroxysmal Anxiety), Delusional Disorders, Post-Traumatic Stress Disorder, Unspecified. A PASARR screen completed by facility staff on 06/29/2023 revealed that a PASARR Level II Evaluation and Determination was not required at that time because there was no diagnosis or suspicion of Serious mental Illness (SMI) or intellectual Disability or related condition (ID/RC) indicated. An interview on 07/18/2024 at 2:30 PM with Registered Nurse-B confirmed that the initial PASARR completed on 06/29/2023 should have included admission diagnosis of: anxiety disorder, panic disorder, delusional disorder, and post-traumatic stress disorder and that a PASARR Level II screen would have triggered and should have been completed prior to the Resident 17 admitting to the facility. Record review of Resident 17's medical record on 07/18/2024 revealed no other completed PASARR screens since 06/29/2023.

Licensure Reference Number 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure it was free of a medication error rate of 5% or greater. Observations of 30 medications administered revealed 2 errors resulting in a medication error rate of 6.67 %. The medication errors affected 2 (Resident 148 and 31) of 9 residents sampled. The facility identified a census of 43. Findings are: A. A record review of Resident 148's Medication Administration Record dated 7/1/2024 - 7/31/24 revealed an order for Hydrocortisone (perianal) External Cream 2.5%. Apply to hemorrhoids topically every 8 hours as needed for pain, itching with a start date of 4/30/2024. An observation on 07/18/2024 at 12:10 PM revealed Medication Aide (MA)-C prepared medications for Resident 148 that included Procto- Medication Cream, apply three times a day for hemorrhoids. With assistance from facility staff members, Resident 148 was assisted into bed and staff wiped the rectal area of the resident with personal care wet wipes. MA-C opened the brand-new tube of Procto- Medication Cream, which is equivalent to Hydrocortisone (Perianal) External Cream 2.5%. MA-C then squeezed the tube of the Procto- Medication Cream onto Resident 148's rectum which left small tubular strands of the medication around the rectum. MA-C then raised Resident 148's brief back in place and then with staff member assistance, staff repositioned Resident 148 in bed. MA-C did not apply a thin layer of the medication with gloved fingers to hemorrhoids. Interview with the Director of Nursing (DON) on 07/18/2024 at 02:30 PM conducted. DON reports that the expectation on administering a topical medication is to apply a small amount of the cream or ointment onto a gloved hand/fingers and then apply medication using gloved fingers to the affected area as prescribed. DON reports that squirting a tube of medication directly onto the affected area and not lightly rubbing the medication to the area is incorrect. DON confirmed that the improper administration of this medication would be considered a medication error. B. A record review of Resident 31's Medication Administration Record dated 7/1/2024 -07/31/2024 revealed an order with a start date of 6/20/2020 for Aspirin EC (Enteric Coated) tablet delayed release 81 MG (milligram), give 1 tablet by mouth one time a day related to Venous Insufficient (Chronic) (Peripheral). The order further revealed instructions as follows: do not crush. An observation on 7/22/2024 at 8:39 AM revealed that Meducatuib Aide (MA)-D was preparing medications for Resident 31 that included Aspirin EC 81 mg. MA-D then took a small medication cup that contained Resident 31's morning medications to the dining room where Resident 31 was sitting at a dining room table. MA-D began to spoon one of the resident's pills into [gender] mouth. Resident 31 accepted the Tylenol tablet, but the resident started to chew the medication and spit out half of the pill (Tylenol). MA-D then took the one half of the un-swallowed Tylenol and the other medications and reported that [gender] is going to crush these medications. MA-D went back to the medication cart and crushed Resident 31's pills, which contianed Aspirin EC, and placed them in a small amount of applesauce. MA-D returned to Resident 31 and offered [gender] a small bite of applesauce that included all of morning medications which consisted of the Aspiring EC. Resident 31 opened [gender] mouth and accepted the spoon with the crushed medications in applesauce and swallowed them. An interview with the Director of Nursing on 7/22/2024 at 10:45 AM confirmed that enteric coated medications should not be crushed and that crushing and then administering an Enteric Coated Aspirin would be considered a medication error. A record review of facility policy labeled Medication Errors, date implemented: 10/23, date reviewed/revised: 2/23 revealed a definition: Medication Error means the observed or identified preparation or administration of medications or biologics which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services.

Licensure Reference Number 175 NAC 1-005.06D Based on observation, interview and record review, the facility staff failed to ensure hand hygiene and glove changes were performed during personal cares for 1 (Resident 3) of 4 residents. The facility census was 43. Findings are: Record review of facility Hand Hygiene Policy updated 2021 revealed: Policy: Hand Hygiene Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident and visitors. Policy Explanation and Compliance Guidelines included: Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standard of practice. An observation on 7/18/2024 at 9:00 AM of Infection Preventionist (IP)-E revealed IP-E entered Resident 3's room. IP-E put on a pair of gloves without washing hands and gathered paper towels from the bathroom and placed paper towels and a graduate cylinder (a plastic container that typically measures excreted or generated body fluids) on the resident's bedside tray table. IP-E removed gloves and then washed hands with soap and water for greater than 20 seconds, dried hands, applied gloves, and put on (donned) an isolation gown, and face shield. IP-E emptied the contents from Resident 3's urostomy (an opening in the belly (abdominal wall) that's made during surgery) bag into the graduate cylinder. EP-E then took the graduate cylinder into the bathroom and emptied the contents into the toilet, rinsed out the graduate cylinder with water from the adjacent sink and emptied the graduate cylinder into the toilet then left the graduate cylindar in the bathroom. IP-E then asked Resident 3 if [gender] would like a drink of water. IP-E grabbed the water pitcher without changing gloves and held the straw with IP-E's fingers and brought the straw to the resident's lips. IP-E attempted to give water to the resident two more times. Resident 17 refused the water by closing [gender] lips shut and turning [gender] head away from IP-E. IP-E placed water pitcher back on the bedside table. An interview on 7/18/2024 at 9:15 AM with IP-E confirmed [gender] should have changed gloves and performed and hygiene after emptying the urostomy bag. An interview on 7/18/2024 at 2:30 PM with Director of Nursing revealed that after emptying urostomy contents, IP-E should have removed gloves, performed hand hygiene with soap and water for at least 20 seconds before offering Resident 3 some water.

Licensure Reference 175 NAC 12- 006.17 Based on interviews, observations and record reviews; the facility failed to implement infection control measures to prevent the spread of COVID-19 for 23 out of 44 residents. The facility census was 44. Findings are: A. Observation upon entrance to the facility at 8:13 AM on 7/19/2023 revealed posted signage requesting that all visitors to the facility were to wear masks. Further observations during the entrance to the facility revealed the facility staff were wearing surgical masks while residents were not wearing masks. Interview with the Infection Preventionist (IP) on 7/20/23 at 12:27 PM revealed that several residents and staff had signs and symptoms of a respiratory infection. Interview with Nurse Consultant (NC) on 7-24-2023 revealed that facility follows ICAP (Infection Control Assessment Promotion Program) recommendations concerning COVID- 19. Record review of ICAP recommendations include that symptomatic individuals should use isolation precautions until a negative (antigen or rapid test) Covid- 19 test is repeated 48 hours after the first test is negative. On 7/24/23 at 12:51 PM the Director of Nursing (DON)and the Facility Administrator reported two dietary staff members had tested positive for COVID. Observation on 7-24-2023 at 1:00 PM revealed the DON began testing all residents for COVID-19. During the observation the DON donned a gown and went from room to room without changing the gown, testing residents for COVID-19. On 7-24-2023 at 2:30 PM an interview was conducted with the DON. During the interview the DON reported a total of 23 residents tested positive for COVID-19. Record review of ICAP recommendations on 7/25/23 revealed that gowns are to be removed prior to exiting the room of a resident with suspected COVID-19 infection. 45613 B. Observation on 7/25/23 at 10:12 AM revealed red lettering on the door that indicated Resident 44 was positive for COVID. Observation on 7/25/23 at 10:12 AM of Housekeeper (Hskp)-B revealed exited room with a gown, N95 mask and gloves on while hands moved quickly up and down in front of face. Interview on 7/25/23 at 10:13 AM with Hskp-B confirmed that that PPE (Personal Protective Equipment - used to protect healthcare workers, patients, and others from potentially contacting and /or spreading potential infections) should have been removed before exiting the room. Record review of the Facility's Infection Prevention and Control Program Policy, date implemented 5/16/23, revealed that all staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Interview on 07/25/23 at 10:16 AM with Infection Preventionist (IP)-A confirmed Hskp-B should have removed PPE before leaving Resident 44's room.

Licensure Reference Number 175 NAC-12-006.09C3 Based on record reviews and interviews the facility failed to complete a discharge summary as required for 3 sampled discharged residents (48, 100 and 101)of 3 residents. The facility census was 44. Findings are: A. Record review of Resident 48's progress notes and assessments revealed that Resident 48 was discharged to the hospital on 5/3/23 and no discharge summary was found in the records. An interview with the Director of Nursing (DON) on 7/20/23 at 2:06 PM confirmed that a discharge summary for Resident 48 was not found in the residents' record, and there should have been one. B. Record review of Resident 100's progress notes and assessments revealed that Resident 100 was discharged to the hospital on 1/16/23 and no discharge summary was found in the records. An interview with the DON on 7/20/23 at 3:15 PM confirmed that a discharge summary for Resident 100 was not found in the residents' record, and there should have been one. 45613 C. Record review of Resident 101's progress notes dated 1/19/23 revealed the resident's admission to the facility was on 1/19/23. Record review of Resident 101's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed the resident's discharge to home was on 1/26/23. Record review of Resident 101's electronic health record dated 1/26/23 revealed no discharge summary. Interview on 7/20/23 at 09:07 AM with the Social Services Director (SSD) confirmed that Resident 101 was discharged to home on 1/26/23. Interview on 07/24/23 at 08:21 AM with the Director of Nursing (DON) confirmed there was no discharge summary completed for resident 101 and there should have been. Record review of the facility's Transfer and Discharge policy, dated September 2022 revealed the following: -A discharge summary should be prepared for the resident and documented in the medical records when discharged to the community.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility staff failed to evaluate the use of an electric recliner for safety for 2 (Resident 17 and 40) of 3 sampled residents. The facility staff identified a census of 47. Findings are: A. Record review of the facility policy for Power Recliner/Riser Chair dated 5-2021 revealed the following information: -Power Recliner/Riser Chair Criteria: -Purpose: To ensure safe use of power recliner/riser chair by residents to decrease risk for injury. The following criteria needs to be met for residents using a power recliner/riser chair. -The resident must: 1. Have the risk assessment form for the power recliner/riser chair completed by therapy team member or nursing team member as designated by the facility Executive Director (ED). 2. Be able to elevate and lower the feet of the recliner as asked by staff member. 4. Be able to follow at least 3 steps direction and have an adequate BIMS (Brief Interview of Mental Status). 5. Be able to reposition as needed in the power recliner/riser chair as needed for safe seating to avoid sliding out of the chair. B. Record review of Resident 40's Admission Care Plan (ACP) dated 6-4-2023 revealed Resident 40 admitted to the facility on [DATE]. Further review of Resident 40's ACP dated 6-02-2023 revealed Resident 40 sleeps in a recliner and Resident 40 was at risk for falls. Record review of Resident 40's Minimum Data Set (A federally mandated assessment tool used for care planning) signed as completed on 6-14-2023 revealed the facility staff assessed the following about the resident: -BIMS was a 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. -Required limited assistance of 1 staff person to physically assist for bed mobility, transfers, personal hygiene. -Required extensive assistance with toilet use with 1 staff person physically assisting with the task. -Required total assistance with dressing with 1 staff person physically assisting with the task. Record of Resident 40's medical record that included Resident 40's Progress Notes (PN), practitioner orders, Care Plan and therapy notes revealed there was no evidence the facility staff had completed a safety assessment for the use of Resident 40's electric recliner. Record review of Resident 40's PN dated 6-2-2023 revealed the facility staff documented Resident 40 had poor balance and unsteady gait. Record review of Resident 40's PN dated 6-15-2023 revealed Resident 40 had fallen in the room at approximately 2:00 PM. According to Resident 40's PN dated 6-15-2023, Resident 40 fell from the recliner and the reason for the fall was Resident 40's recliner was ( . up to high) resulting in skin tears to the right knee, left elbow and a hematoma ( localized bleeding, similar to a fluid filled blister ) to the right side of the forehead. Record review of Resident 40's PN dated 6-15-2023 with a time of 4:45 AM revealed Resident 40 was sent to the hospital as Resident 40 had a change in condition. Record review of a facility investigation report dated 6-16-2023 of Resident 40's fall on 6-15-2023 revealed Resident 40 had fallen from the recliner while attempting to place socks on and Resident 40 was sent to the hospital at 4:45 AM related to a condition charge. The Director of Nursing (DON) had called the hospital on 6-15-2023 for an updated of Resident 40's condition. According to the investigation dated 6-16-2023 for Resident 40's fall from the recliner revealed the DON was informed Resident 40 was place in Intensive Care Unit (ICU) and that Resident 40 had a Subgaleal Hematoma ( blood collection between skin, scalp and skull). Further review of the investigation report dated 6-16-2023 into Resident 40's fall from the recliner revealed the facility staff identified the casual factors for the fall included the recliner was not in the lowest position and Resident 40 was not wearing oxygen as ordered. Record review of Resident 40's current orders revealed Resident 40 readmitted to the facility on [DATE]. Observation on 7-05-2023 at 10:20 AM revealed Resident 40 was seated in a electric recliner in an upright position. Resident 40's feet were approximately a foot from the floor. Further observation revealed Resident 40 had a hematoma to the right forehead dark purple to almost black in color and the size of a small egg. In addition, Resident 40 had multiple areas of facial bruising. On 7-05-2023 at 10:27 AM an interview was completed with Resident 40. According to Resident 40, Resident 40 was attempting to place socks onto the feet when falling on 6-15-2023. According to Resident 40, Resident 40 tilted the electric recliner forward to reach the feet when the fall occurred. During the interview Resident 40 confirmed not being able to touch the floor with (gender) feet. Resident 40 reported it would be helpful to be able to touch the floor. Observation on 7-05-2023 at 10:55 AM with the DON was completed revealing Resident 40 demonstrated not being able to touch the floor in an upright position. On 7-05-2023 at 10:55 AM during the observation, the DON confirmed Resident 40 was not able to touch the floor. The DON stated that's unacceptable. On 7-05-2023 at 1:37 PM a interview was conducted with Nurse Consultant (NC) A. During the interview NC A reported Resident 40 did not have a safety assessment for the use of the electric recliner before or after the fall on 6-15-2023. NC A reported the expectation is electric recliners for residents be assessed prior to use. C. Record review of Resident 17's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was 13. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and had falls. Record review of Resident 17's Comprehensive Care Plan (CCP) last reviewed on 4-21-2023 revealed Resident 17 admitted to the facility 10-14-2023. Further review of Resident 17's CCP last reviewed on 4-21-2023 revealed Resident 17 was at risk and had multiple falls. Observation on 7-05-2023 at 7:15 AM revealed Resident 17 was seated in an electric recliner in Resident 17's room. Observation on 7-05-2023 at 10:40 AM revealed Resident 17 was seated in a electric recliner in Resident 17's room. Review of Resident 17's medical record that included PN, practitioner orders and therapy notes revealed there was no evidence the facility staff had assessed Resident 17's ability to safely use the electric recliner. On 7-05-2023 at 1:37 PM a interview was conducted with Nurse Consultant (NC) A. During the interview NC A reported resident 17 did not have a safety assessment for the use of the electric recliner. NC A reported the expectation is electric recliners for residents be assessed prior to use.

LICENSE REFERENCE NUMBER 175 NAC 12-006.097b Based on record review and interview; the facility failed to implement interventions for suicidal statements for one (Resident 1) of 1 sampled resident. The facility staff identified a census of 46. The findings are: Record review of Resident 1's medical record revealed an admitted [DATE] with diagnoses of Other symptoms and signs involving cognitive functions and awareness, [CONDITION(S)] and Hypertension. Review of a Social Service Note dated 06/24/22 revealed the Social Service Director (SSD) updated Hospice of Resident 1 stating (gender) has thoughts of hurting self at times. Resident 1 stated the thought comes and goes every 3-4 days. Resident 1 stated the resident had no plan. The resident's family member was in the room during this discussion. Plastic bags, scissors, nail clipper and tweezers taken home by family. Review of a Social Service Note dated 07/06/22 revealed a Mood assessment was completed with Resident 1. Resident 1 stated the resident was down, tired and feels bad about (gender) daily. Resident 1 stated (gender) thinks about hurting (gender) about every 3 days. Resident 1 stated (gender) would not tell staff if (gender) had a plan to hurt (gender). Review of the Note to staff dated 07/06/22 that was taped on the wall in the nurses charting room revealed Resident 1 had stated (gender) has thoughts of causing harm to (gender). Please be aware no sharps, etc. in room. Notify your charge nurse with any concerns. Hospice is aware. Review of the Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 07/01/22 revealed the following -Brief Interview for Mental Status score of 6. According to the MDS Manuel a score of 6 indicates a resident is moderately cognitively impaired. -The Mood section documentation/coding revealed thoughts that would be better off dead or hurting yourself was coded yes 2-6 days. Feeling bad about yourself or that you are a failure was coded yes 12-14 days. Record review revealed no documentation of immediate interventions put into place for suicidal statements. Further review of the record revealed no follow up documentation for the suicidal statements. Review of a Suicide Risk Policy dated 08/10/2021 revealed Residents believed to be at significant risk for committing suicide will be provided specific steps staff will take to reduce risk and provide treatment for residents' condition. Additional intervention steps may be taken to address a particular patients individual circumstances when authorized by a physician order. Suicide precautions will be discontinued when clinically contraindicated. -Documentation in the Progress notes will include the reason for implementing, continuing, and discontinuing suicide precautions. - Family of the resident will notified of significant risk. - Staff will document 15-minute visual checks on the Observation Flow Sheet. Documentation will include staff observations and interventions, resident activities, and behaviors. - Effort will be made to discharge the resident from the facility to an appropriate mental health facility. Return to the facility may occur when the residents' mental health status has stabilized. An interview conducted on 07/18/22 at 9:30 AM with the Director of Nursing (DON) confirmed that 15 minute checks were not completed and there was no follow up documentation for the suicidal statements.

Licensure Reference Number 175 NAC 12.006.09D8a Based on observation and interview, the facility failed to ensure that the meal trays delivered to the residents' rooms were maintained at an appetizing temperature. This had the potential to affect all residents in the facility receiving in-room meal trays. Total census was 44. Findings are: Record review of the facility's Food Preparation Guidelines and Serving Policy dated 07/2020 revealed room trays would be served at a temperature that is palatable, and all room trays must be served on covered heat-preserving serving items. In an Interview with Resident 46 on 03/02/2022 at 03:14 PM the resident confirmed the food was always cold when Resident 46 received it because the trays sit in the hall a long time before the staff bring the tray into the room. Observation on 03/03/2022 at 12:26 PM revealed a test tray was delivered to the conference room as the last tray delivered down the 100 hall. The test tray was delivered on a plastic tray with a covered hard plate. The Dietary Service Manager (DSM) tested the temperature of the food on the tray with the following results: Bacon wrapped beef tested at 135 degrees, Potatoes tested at 110 degrees, Fried cabbage tested at 114.5 degrees Observation on 03/07/2022 at 12:05 PM revealed the cart with the residents' room trays on it was delivered to the South end of the 100 hallway and was not moved until 12:27 PM when the nursing assistants started room tray delivery. Interview on 03/03/2022 at 12:26 PM with the DSM confirmed the food temperatures on the test tray should have been higher and the DSM confirmed the Potatoes the DSM ate were a little undercooked. The DSM confirmed the plate warmer the kitchen used had a defective cord and needed repaired. Interview with the DSM on 03/08/2022 at 12:05 PM confirmed that 44 of 44 residents consume food from the kitchen.

Licensure Reference Number: 175 NAC 12-006.09 Based on observation, record review, and interview; the facility failed to implement interventions to prevent the development and aide in healing of a pressure sore for 1 of 3 residents reviewed (Resident 3). The facility census was 46. Findings are: Review of Resident 3's medical record revealed Resident 3 had a [DIAGNOSES REDACTED]. Review of Resident 3's care plan dated 11/01/2016 revealed Resident 3 was at risk for pressure ulcer/skin breakdown related to Resident 3 required assistance with bed mobility. The intervention was to offload feet with Prevalon Boots (a padded boot to relieve pressure) both feet when in bed. Review of Resident 3's Weekly Wound Assessment sheet dated 3/13/2017 revealed Resident 3 developed a pressure ulcer on the right foot on the bunion area of the great toe. The wound was described as a Stage 3 ( full thickness tissue loss) blister and the interventions will be heel boots at all times. Review of Resident 3's care plan dated 3/14/2017 revealed a revision that Resident 3 was to have Prevalon boots on at all times. Observation on 3/16/2017 at 12:45 PM revealed Resident 3 sitting in a tilt n space wheelchair. Resident 3's feet were exposed with no covering on Resident 3's feet, a pillow on the foot rests of the wheelchair and the area of the wound resting on the pillow. No Prevalon boots were observed on resident feet or in the room. Observation on 3/16/2017 at 1:10 PM revealed Resident 3 in bed. There were no Prevalon boots on Resident 3's feet and the open area was resting directly on the mattress of the bed. Observation on 3/20/2017 at 3:00 PM revealed Resident 3 lying in bed. There were no Prevalon boots on Resident 3. There was a cushioned ring on Resident 3's ankle but the ring did not hold the foot from touching the mattress . Interview on 3/20/2017 at 3:05 PM with NA-A (Nurse Aide ) revealed NA-A thought the Prevalon boots had been discontinued and were not being used. Review of Resident 3's Weekly Wound assessment dated [DATE] revealed the Pressure Ulcer on Resident 3's right toe measured 1.3 centimeters (cm) in length. Review of Resident 3's Weekly Wound assessment dated [DATE] revealed the Pressure Ulcer on Resident 3's right toe measured 3.9 cm in length. Interview on 3/20/2017 at 4:15 PM with the Assistant Director of Nursing revealed the Prevalon boots had not been discontinued and that the Prevalon boots should be on at all times. The cushioned ring was not sufficient to provide pressure relief. Not having the Prevalon boot on put Resident 3 at increased risk for additional skin breakdown and a size increase in the current pressure ulcer.

Licensure Reference Number: 175 NAC 12-006.09D7b Based on observation, interview and record review; the facility failed to assess for causal factors and put interventions in place to prevent repeated falls for Resident 1. The facility census was 55. Findings are: Review of Resident 1's electronic medical record revealed the following Diagnoses: [REDACTED]. Review of a facility report titled Total Events by Event Type dated 2/11/2015 through 6/11/2015 revealed Resident 1 had experienced 10 falls in the past 6 months. Review of a facility document titled Falls management Guideline Version #3 dated with a review date of 1/22/2015 revealed the following: Following a resident's fall: -appropriate interventions are implemented, - Care plan is updated. Review of Resident 1's progress notes dated 5/1/2015 at 4:45 PM revealed the resident had been observed lying face down on top of their walker in the resident's doorway. Nursing assessment stated the resident was independent with transfers and ambulation with walker. Injuries to Resident 1 included a skin tear above the right eye, nose bent to the left, upper lip split and missing a tooth. Review of Resident 1's progress note dated 5/1/2015 at 11:02 PM revealed that Resident 1 will remain at the hospital and will need surgery for [REDACTED]. Resident 1's care plan with a revised date of 3/17/2015, revealed Resident 1 was to be transferred and ambulated with contact Guard assist of 1-2 staff. No new intervention was initiated related to Resident fall on 5/1/2015. Review of Resident 1's progress notes dated 5/18/2015 revealed Resident 1 was found face down in front of their wheelchair complaining of arm pain and nose appears crooked. Resident 1 was transferred to the hospital and found to have a fracture of the ulna (small bone in the lower arm). Review of the facility form titled Verification of Investigation dated 5/22/2015 revealed that the intervention to attempt to prevent further falls was Seat belt in wheelchair to aide in resident's safety. Review of Resident 1's current care plan showed no new interventions related to the fall on 5/18/2015. An entry dated 5/22/15 stated PT (Physical Therapy) and OT (Occupational Therapy) to assess for wheelchair positioning. Review of Resident 1's Progress note titled Weekly Care Management Meeting dated 5/26/2015 at 9:35 PM did not mention therapy was working with the resident on wheelchair positioning. Observation on 6/11/2015 at 1:30 PM revealed Resident 1 was sitting in a wheelchair in their room. No wheelchair seatbelt was observed on Resident 1's wheelchair. Interview on 6/11/15 at 1:45 PM with the DON (Director of Nursing) revealed that Resident 1 was transferring from the wheelchair independently at the time of the fall and positioning was not a causal factor in the fall. Review of Resident 1's progress note dated 6/4/2015 at 2:10 PM revealed Resident 1 fell to the floor. Review of Resident 1's current care plan with a revised date on 5/22/2015 revealed no new interventions were initiated in response to Resident 1's fall on 6/4/2015. Review of Resident 1's Progress notes dated 6/5/2015 revealed an entry that the interventions in place for Resident 1's risk and history of falls was All interventions have been reviewed and found appropriate, continue with current plan of care. Interview on 6/11/15 at 2:00 PM with the DON revealed new interventions were not initiated after each fall. An assessment of causal factors was not completed after each fall to determine new interventions that may need to be implemented.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2B Based on observation, record review and interview; the facility staff failed to evaluate, monitor, and provide treatment for [REDACTED]. Findings are: A. Record review of the nurses notes of 07/03/13 identified Resident 50 as having many open superficial areas on the bottom. The resident's bottom was also extremely red. A fax was sent to the primary care physician requesting an order for [REDACTED]. Record review of the nurses notes on 07/07/13 revealed that the resident was complaining of the resident's backside hurting. Remedy cream ( a barrier cream) was applied to the superficial open areas on the buttocks. A physician visit on 07/09/13, the physician identified the open areas on the resident's bottom as being pressure ulcers. Interview with the Director of Nursing and LPN (Licensed Practical Nurse), Unit Manager held on 07/10/13 at 8:30 AM revealed no wound evaluation flow sheet was completed for monitoring the open areas on the resident's buttocks. The Director of Nursing stated that the expectation of the facility would be that a wound evaluation flow sheet would have been completed. The DON also stated that the areas were due to moisture and were not pressure areas. The DON stated that the open areas on the residents buttocks had not been viewed by the DON. Observation of toileting of the resident at 1:45 PM on 07/10/13 revealed that the resident was assisted with transfer by Nurse Aides E and F using a gait belt. The soiled brief that was removed from the resident was wet. Nurse Aide E stated the resident had last been toileted at 9:00 AM due to a resident appointment with a physician. Observation revealed two open areas on either side of the anus in the buttock's crease. The areas were bleeding and the resident stated "my ass hurts". The resident voided in the toilet and the NAs performed peri cares and applied Remedy Cream, a barrier cream. Review of the comprehensive care plan revealed the resident to be at risk for pressure ulcer/skin breakdown related to assistance required with bed mobility and the fact the resident was identified as having some urinary incontinence. Identified on 07/03/13 on the comprehensive care plan were many superficial open areas on the bottom, also reddened. The goal was for skin to remain intact. Interventions included: - complete a Braden scale, a tool for identifying resident's who were at risk for the development of skin issues; - conduct a weekly skin inspection; - elevate feet on pillow when in bed; - encourage resident to reposition at least q2hrs and assist as needed; - Nutritional and hydration support; - provide pressure reducing wheelchair cushion; - provide pressure reduction/relieving mattress; - provide thorough skin care after incontinent episodes and apply barrier cream; - added on 07/03/13 was urinalysis with culture and sensitivity. Review of the MAR (medication administration record) revealed the resident was receiving fortified milk at breakfast and dinner, fortified cereal at breakfast and fortified juice at lunch. Interview with the Director of Nursing was held on 07/11/13 at 1:45 PM and revealed that the expectations of the facility would be that when a physician was faxed there should be some type of response within 24 hrs. In this case, the facility did not receive a response to the original fax of 07/03/13 until 07/08/13. B. Record review of an Admission Record sheet dated 3-15-2013 revealed Resident 46 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Clinical Health Status (CHS) sheet dated 3-15-2013 revealed Resident 46 scored a 19 on the Braden's Scale (tool used for predicting pressure sore risk). According to the information on the form, a score of 15-18 placed the resident at risk for pressure ulcers. According to the form, the lower the score the higher the risk. Further review of the CHS sheet revealed Resident 46 was evaluated as having a stage 2 (Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater). No other pressure ulcer was identified on the form. Record review of a Wound Evaluation Flow Sheet (WEFS) for Resident 46 dated 4-03-2013 revealed Resident 46 was evaluated with a (... dry thin tan scab over the coccyx" area). The area was assessed as a stage 2 ulcer. Record review of Resident 46's medical chart did not have evidence that the casual factors for the development of the pressure ulcer had been completed. Record review of a physician order [REDACTED]. Record review of a nutritional assessment dated [DATE] revealed the facility Registered Dietician (RD) made recommendation with facility follow up completed. Record review of Resident 46's WEFS dated 4-16-2013 revealed a written entry that crossed out Shearing to coccyx and changed the area to a stage 4 (Full thickness skin loss with extensive destruction, tissue necrosis, or damage to bone or supporting structure) ulcer. Record review review of a Fax sheet sent to Resident 46's physician on 4-24-2013 revealed the fax contained documentation the ulcer to Resident 46's coccyx "is now a stage 3" (Stage 3, Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia) with 2 areas of tunneling". Record review of Resident 46's Nutrition Skin Note dated 4-26-2013 revealed the facility RD had made a recommendation for Arginad, 1 packet, 2 times a day to aid in wound healing. Record review of a Physician order [REDACTED]. An interview was conducted on 7-10-2013 at 10:05 AM with the facility Unit Manager. During the interview, Resident 46's RD recommendations dated 4-26-2013 was reviewed with the Unit Manager. When asked when the recommendation should have been followed up on, the Unite Manager stated "should have been completed by 4-28-2013" (48 hours).

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility Quality Assurance(QA) committee failed to correct ongoing issues relevant to F242, 280, 314, 315, and 329, and implement effective plans of action to identify and correct the deficient practices. The QA committee failed to ensure repeated deficiencies at F315, 329, and 280 were corrected and the correction maintained. The facility census was 60 at the time of the survey. Record review of an undated Meeting Date and Purpose sheet for the Quality Assurance commettee revealed the following: -Meeting Purpose; -Monitor core processes to identify trends and variations through appropriate analysis of data from multiple data sources. -Desired Results; Execution of process improvement plans that produce quality outcomes. On 7-10-2013 at 2:25 PM an interview was conducted with the facility Dietary Manager (DM). During the interview, the DM reported the facility QA committee had worked on room tray temperatures as an area to work on. The DM reported the problem area had been resolved. The DM was not aware of ongoing problem areas the committee was working on other than routine areas. On 7-11-2013 at 12:45 AM an interview was conducted with the Director of Nursing (DON). During the interview when asked if the QA committee had identified any problem areas the QA committee was working on related to pressure ulcers, personal cares, kitchen issues other than routine areas, the DON stated "no".