Every finding on record at Arbor Care Centers-Countryside LLC

Licensure Reference Number 175 NAC 12-006.05Based on record review and interview; the facility failed to follow 1 (Resident 1) of 4 sampled residents' consent to not publish photographs of the resident. The facility census was 32.Findings are:A. Review of the facility policy Resident Rights reviewed 3/20 revealed the following:- The facility would inform the resident both orally and in writing in a language that the resident understands his or her rights and regulations governing resident conduct and responsibilities during the stay in the facility.-The facility would provide the residents with prompt notice (if any) of changes in any State or Federal laws related to resident rights or facility rules during the resident's stay in the facility. Receipt of any information must be acknowledged in writing.-The resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident. B. Review of Resident 1's admission Agreement signed by the resident's legal representative on 12/9/25 revealed the following:-Attachment J, Consent to Photograph/Publish, had a written note on the form Please do NOT publish photo.No initials were next to the following areas on the Consent to Photograph:-Use my name in connection with any publication (including but not limited to newspaper, displays, television, radio, books, report, websites and brochures) for marketing and/or other facility purposes.-Use photographs and video of me in any publication (including but not limited to newspaper, displays, television, radio, books, reports, websites and brochures) for marketing and/or other facility purposes.-Use any quotations and comments made verbally by me and/or concerning me (including but not limited to newspaper, displays, television, radio, books, report, websites and brochures) for marketing and/or other facility purposes. An interview conducted with the Administrator on 6/15/26 at 2:30 PM confirmed that the facility was notified on 6/8/26 of pictures of Resident 1 being seen on social media. Resident 1 did have photographs published on social media by the facility. Resident 1's Consent for Photography on admission, 12/9/25, was marked no and signed by the resident's legal representative. The facility's computer system revealed the photo release consent was marked yes. Corrective Actions taken by the facility were as followed:-Resident 1's photos were removed from the facility's face book page on 6/8/26.-The facility stopped taking pictures and publishing social media on 6/8/26. -The facility audited all residents' photo release forms.-All residents or legal representatives were issued new photo release forms.-The facility's computer system photo release consent entries would be corrected to accurately reflect the signed preferences. The facility would be conducting an all staff in service meeting on 6/18/26 going over the following items:-Resident rights regarding photography,-social media postings and-privacy requirements. admission staff were re-educated on proper documentation and facility computer entry. Quarterly audit process was implemented to ensure the ongoing accuracy of photograph release documentation. An interview with the Director of Corporate Services on 6/15/26 at 3:15 PM revealed that on 6/9/26 a letter was sent out to all residents or legal representatives that an error had occurred in posting pictures to face book when a resident did not want photographs posted. Staff were being retrained on the correct social media/privacy practice to protect all the residents. A Consent to Photograph was sent to residents or legal representatives on 6/9/26 to ensure the facility had the current decisions of the resident or family.

Licensure Reference Number 175 NAC 12-006.10(D)Based on record review and interview; the facility failed to ensure 1 resident (Resident 4) of 4 sampled was free of significant medication errors. The facility had a census of 36. Findings are:A. Review of the facility policy Medication Error dated September 2024 revealed a medication error was the preparation, provision, or administration of medications that was not in accordance with the following:-Physician Orders;-Manufacturer's specifications regarding the preparation or administration of the drug;-Accepted professional standards that apply to professionals providing services; and-The five rights which included the right resident, the right drug, the right dosage, the right route and the right time. B.Review of the facility policy Medication Administration dated September 2024 revealed medications were administered by licensed nurses, or other staff who were legally authorized as ordered by the physician and in accordance with standards of practice. Compliance Guidelines included:-Ensure the six rights of medication administration were followed which included the right resident, the right drug, the right dosage, the right route, the right time, and the right documentation;-Review the Medication Administration Record (MAR) to identify the medication to be administered;-Compare the medication with the MAR to verify the resident name, medication form, dose, route and time;-Administer the medication as ordered;-Observe the resident consumption of medication;-Sign the MAR after administration;-If the medication is a controlled substance, sign the narcotic book;-Report and document any adverse side effects or refusals; and-Correct any discrepancies and report to nurse manager. C.Review of Resident 4's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 2/12/26 revealed the resident was admitted on [DATE] with diagnoses of Urinary Tract Infection, Seizure Disorder, Anxiety and Depression; the resident had moderate cognitive impairment; required assistance with toileting, dressing, transfers and hygiene; and received antibiotic and anticonvulsant (medications to prevent seizures) medications. Review of Resident 4's Care Plan last revised 2/6/26 revealed the resident had a seizure disorder with a history of seizures and interventions included to give medications as ordered; the resident required staff assistance with bed mobility, dressing, toileting, transfers and personal hygiene; and had diagnoses of Urinary Tract Infection, Genetic Intellectual Disability, Anxiety Disorder, Autistic Disorder, Major Depressive Disorder, and Seizures. Review of the facility form Order Summary Report with Active Medication Orders for Resident 4 revealed the resident had orders for the following anticonvulsant medications:-Brivaracetam (a controlled substance/anti-seizure medication) give 50 milligrams (mg) two times a day (8:00 AM {morning} and 8:00 PM {afternoon or evening});-Clobazam (a controlled substance/benzodiazepine class used to treat seizures) give 20mg two times per day (7:00 AM and 7:00 PM);-Lamictal (anti-seizure/mood stabilizer medication) 200mg give 3 tablets every day (8:00 AM);-Perampanel (a controlled substance/ anti-seizure medication) 8mg every night at bedtime (8:00 PM); and-Zonisamide (anti-seizure medication)100mg give 3 capsules two times per day (9:00 AM and 8:00 PM). Review of Resident 4's MAR for February 2026 revealed the following documentation regarding anticonvulsant medications 2/12/26 through 2/16/26:-Brivaracetam- received 11 out of 12 doses (did not receive the 8:00 AM on 2/14/26 and was charted as medication not available);-Clobazam- received 12 out of 12 doses;-Lamictal- received 5 out of 6 doses (did not receive the 8:00AM dose on 2/17/26);-Perampanel- received 6 out of 6 doses; and-Zonisamide- received 12 out of 12 doses. Review of the facility forms Resident Narcotic Record for Resident 4 revealed the following doses were not signed out as given:-on 2/12/26 the 8:00 AM dose of Brivaracetam was not given/signed out;-on 2/13/26 the 7:00 AM dose of Clobazam was not given/signed out;-on 2/14/26 the 8:00 PM doses of Brivaracetam and Perampanel were not given/signed out;-on 2/15/26 the 8:00 PM doses of Brivaracetam and Perampanel were not given/signed out; and-on 2/16/26 the 8:00 AM dose of Brivaracetam was not given/signed out. Review of Resident 4's Progress Notes revealed the following entries:-On 2/17/26 at 11:00 PM the residents call light was on. The resident was found on the floor and post-seizure activity was present which included deep, loud snoring respirations were present and lasted 5 minutes. The resident was drowsy but was responding verbally to questions. The Physician and the residents Guardian were updated of the fall and seizure activity.-On 2/18/26 at 8:05 AM, the resident had a seizure at 6:00 AM that lasted 55 seconds and was witnessed. Between 6:00 AM and 7:50 AM two additional smaller seizures were observed. The residents Physician was called and ordered to send the resident to the hospital for increased seizure activity. The resident's Guardian was also called.-On 2/18/26 at 10:53 AM the Director of Nursing Services (DNS) received a call from the emergency room Physician stating they were admitting the resident to the hospital; and-On 2/18/26 at 1:35 PM the residents Guardian stated the resident would not be returning to the facility. Review of the facility Incident Report dated 2/18/26 revealed the facility updated the Physician, who is the facility Medical Director, of the medication errors resulting in seizure activity for Resident 4 on 2/18/26. The Physician/Medical Director's response was that the facility needed to treat the incident as a medication error. Review of the facility forms Verbal Counseling for Medication Aide (MA) -D dated 2/18/26 revealed MA-D received verbal counseling for signing off Brivaracetam on 2/12/26 at 8:00 AM and Clobazam on 2/13/26 at 7:00 AM as given but did not take the medication from the narcotic locked box and sign the medications out on the narcotic count sheets. MA-D was verbally reminded to complete the 6 rights of medication administration and not to sign off the medications as given until after the resident takes the medications. MA-D was given a copy of the Medication Administration Policy. Review of the facility forms Verbal Counseling for MA- I dated 2/18/26 revealed MA-I received verbal counseling for signing off Brivaracetam in the computer as given on 2/16/26 at 8:00 AM but did not take the medication out of the narcotic locked box and sign it out on the narcotic sheet. The corrective action was verbal counseling to complete the 6 rights of medication pass and to only sign the medications as given after the medication was administered. The facility gave MA-I a copy of the Medication Administration Policy. Review of the facility form Meeting dated 3/18/26 revealed the facility Pharmacist lead a meeting titled Medication Information. The staff were updated on a new process the facility put into place for pill cassettes. The staff were to pop out the pill from the numbered window that would correspond to the date. Interview on 3/24/26 at 7:30 AM with the DNS revealed the facility had identified the medication errors the day the resident went to the hospital. Further interview confirmed the facility put a process in place to account for the medications which included new cassettes for the medications so that the medications would be popped out of the numbered window that corresponded to the current date so the staff could track which medications were given/not given. The DNS confirmed 7 medication errors occurred between 2/12/26 and 2/16/26. MA-D and MA-I were verbally counseled and given a copy of the Medication Administration Policy. An agency Registered Nurse (RN) made the omission errors on 2/14/26 and 2/15/26. The Administrator called the agency, spoke to the supervisor and told them the facility would not allow that RN back to the facility. Interview on 3/24/26 at 12:30 PM with the DNS and the Administrator confirmed the anticonvulsant medications were omitted 7 times between 2/12/26 and 2/16/26 which resulted in Resident 4 being transferred to the hospital for seizure activity. Further interview confirmed the errors were a significant medication error.

Licensure Reference Number 175 12-006.10(A)(ii) Licensure Reference Number 175 NAC 12-006.10(A)(iii) Licensure Reference Number 175 12-006.10(C) Based on record review and interview; the facility failed to ensure 1 (Resident 4) of 4 sampled residents records had accurate documentation of medication administration. The facility census was 36. Findings are:A.Review of the facility policy Medication Administration dated September 2024 revealed medications were administered by licensed nurses, or other staff who were legally authorized as ordered by the physician and in accordance with standards of practice. Compliance Guidelines included:-Ensure the six rights of medication administration were followed which included the right resident, the right drug, the right dosage, the right route, the right time, and the right documentation;-Review the Medication Administration Record (MAR) to identify the medication to be administered;-Compare the medication with the MAR to verify the resident name, medication form, dose, route and time;-Administer the medication as ordered;-Observe the resident consumption of medication;-Sign the MAR after administration;-If the medication is a controlled substance, sign the narcotic book;-Report and document any adverse side effects or refusals; and-Correct any discrepancies and report to nurse manager. B.Review of Resident 4's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 2/12/26 revealed the resident was admitted on [DATE] with diagnoses of Urinary Tract Infection, Seizure Disorder, Anxiety and Depression; the resident had moderate cognitive impairment; required assistance with toileting, dressing, transfers and hygiene; and received antibiotic and anticonvulsant (medications to prevent seizures) medications.Review of Resident 4's Care Plan last revised 2/6/26 revealed the resident had a seizure disorder with a history of seizures and interventions included to give medications as ordered; the resident required staff assistance with bed mobility, dressing, toileting, transfers and personal hygiene; and had diagnoses of Urinary Tract Infection, Genetic Intellectual Disability, Anxiety Disorder, Autistic Disorder, Major Depressive Disorder, and Seizures.Review of the facility form Order Summary Report with Active Medication Orders for Resident 4 revealed the resident had orders for the following anticonvulsant medications:-Brivaracetam (a controlled substance used to treat seizures) give 50 milligrams (mg) two times a day (8:00 AM and 8:00 PM);-Clobazam (a controlled substance/benzodiazepine class used to treat seizures) give 20mg two times per day (7:00 AM and 7:00 PM);-Lamictal (anti-seizure/mood stabilizer medication) 200mg give 3 tablets every day (8:00 AM);-Perampanel (a controlled substance/ anti-seizure medication) 8mg every night at bedtime (8:00 PM); and-Zonisamide (anti-seizure medication)100mg give 3 capsules two times per day (9:00 AM and 8:00 PM). Review of Resident 4's MAR for February 2026 revealed the following documentation regarding anticonvulsant medications 2/12/26 through 2/16/26:-Brivaracetam- received 11 out of 12 doses (did not receive the 8:00 AM on 2/14/26 and was charted as medication not available);-Clobazam- received 12 out of 12 doses;-Lamictal- received 5 out of 6 doses (did not receive the 8:00AM dose on 2/17/26);-Perampanel- received 6 out of 6 doses; and-Zonisamide- received 12 out of 12 doses. Review of the facility forms Resident Narcotic Record for Resident 4 revealed the following doses were not signed out as given:-on 2/12/26 the 8:00 AM dose of Brivaracetam was not given/signed out;-on 2/13/26 the 7:00 AM dose of Clobazam was not given/signed out;-on 2/14/26 the 8:00 PM doses of Brivaracetam and Perampanel were not given/signed out;-on 2/15/26 the 8:00 PM doses of Brivaracetam and Perampanel were not given/signed out; and-on 2/16/26 the 8:00 AM dose of Brivaracetam was not given/signed out. Interview on 3/24/26 at 12:30 PM with the Director of Nursing Services (DNS) and the Administrator confirmed the medications were signed as given in the MAR, but the medications were not administered. Further interviews confirmed Resident 4's Medical Record documentation was not accurate to reflect that the resident did not receive the medications.

Licensure Reference Number 175 NAC 12-006.12(D)(i)(2)Based on record review and interview; the facility failed to accurately account for narcotic medications. This had the potential to affect all residents receiving narcotic medications in the facility. The facility sample size was 4 and the census was 36.Findings are:A.Review of the facility policy Controlled Substance Administration and Accountability Policy dated April 2025 revealed the following:-It was the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility would have safeguards in place to prevent loss, diversion or accidental exposure of controlled substances.-Inventory verification for areas without automated dispensing systems would be completed by two licensed nurses accounting for all controlled substances and the nurses would exchange keys at the end of each shift.B.Review of the Controlled Drug-Count Record form (signatures verified that staff had counted the narcotics and the count had been verified by both nurses coming on and going off shift to be correct) for Hall 200 dated February 2026 revealed the following:- The Nurse coming on from 6A-6P did not sign the Narcotic Count form 12 out of 28 days. -The Nurse coming on from 6P-6A did not sign the Narcotic Count form 2 out of 28 days.-The Nurse going off from 6A-6P did not sign the Narcotic Count form 12 out of 28 days.-The Nurse going off from 6P-6A did not sign the Narcotic Count form 2 out of 28 days. Review of the Controlled Drug-Count Record form for Hall 100 dated March 2026 revealed the following:- The Nurse coming on from 6A-6P did not sign the Narcotic Count form 3 out of 24 days. -The Nurse coming on from 6P-6A did not sign the Narcotic Count form 1 out of 23 days.-The Nurse going off from 6A-6P did not sign the Narcotic Count form 5 out of 23 days.-The Nurse going off from 6P-6A did not sign the Narcotic Count form 2 out of 24 days. Review of the Controlled Drug-Count Record form for Hall 200 dated March 2026 revealed the following:- The Nurse coming on from 6A-6P did not sign the Narcotic Count form 1 out of 24 days. -The Nurse coming on from 6P-6A did not sign the Narcotic Count form 5 out of 23 days.-The Nurse going off from 6A-6P did not sign the Narcotic Count form 1 out of 23 days.-The Nurse going off from 6P-6A did not sign the Narcotic Count form 1 out of 24 days. Review of Controlled Drug-Count Record form for Hall 300 March 2026 revealed the following:- The Nurse coming on from 6A-6P did not sign the Narcotic Count form 2 out of 24 days. -The Nurse coming on from 6P-6A did not sign the Narcotic Count form 2 out of 23 days.-The Nurse going off from 6A-6P did not sign the Narcotic Count form 2 out of 23 days.-The Nurse going off from 6P-6A did not sign the Narcotic Count form 1 out of 24 days. An interview with the Director of Nursing (DON) on 3/24/26 at 12:30 PM confirmed that the nurse coming on and the nurse going off would count all the narcotic medications. When the nurses confirmed that the count was correct the nurses would sign the Controlled Drug-Count Record confirming that all narcotic medication were accounted for. Further interview confirmed that the Controlled Drug-Count Record forms were not completed/signed off as required to confirm the narcotic count was correct.

Licensure Reference Number 175 NAC 12-006.04(B)(i)Based on record review and interview; the facility failed to ensure 4 out of 5 staff had the required initial training within 2 weeks of employment which included resident rights, emergency preparedness, abuse and neglect and dementia care. This had the potential to affect all residents of the facility. The facility census was 38.Findings are:Review of the Abuse, Neglect, and Exploitation Policy dated September 2024 revealed new employees would be educated on abuse, exploitation (treating someone unfairly) and misappropriation (unauthorized use of someone's property) of resident property during initial orientation. Training topics would include: prohibiting all forms of abuse, neglect, misappropriation of resident property and exploitation; identifying what constituted as abuse; recognizing signs of abuse; the reporting process; and understanding behavioral symptoms that may increase the risk of abuse. Review of the Nursing Assistant (NA)-Q's file revealed a hire date of 11/3/25. There was no evidence the initial training had been completed. Review of NA-R's file revealed a hire date of 10/28/25. There was no evidence the initial training had been completed. Review of Licensed Practical Nurse (LPN)-T's file revealed a hire date of 10/21/25. There was no evidence the initial training had been completed. Review of the Administrative Assistant's file revealed a hire date of 10/20/25. There was no evidence the initial training had been completed. Interview with the Administrator on 12/18/25 at 10:00 AM confirmed the facility did not have evidence that NA-Q, NA-R, LPN-T, and the Administrative Assistance had received the required initial training.

Licensure Reference Number 175 NAC 12-006.18(B)(D) Based on observation, record review and interview; the facility failed to implement Enhanced Barrier Precaution (EBP-involved gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug resistant organism (MDRO-bacteria that have become resistant to certain antibiotics) as well as those at increased risk for MDRO, residents with wounds or indwelling medical devices) during toileting assistance for Resident 2, catheter cares for Resident 10 and wound care for Resident 7; failed to provide cleaning of resident care equipment to prevent cross-contamination and or potential infections for Resident 10 and failed to complete gloving and hand hygiene at appropriate intervals during the provision of care for Residents 1,7,10 and 41. The sample size was 13 and the facility census was 38.Findings are: A. Review of the facility policy Enhanced Barrier Precautions revised May 20, 2024, revealed the following: - EBP would be used for residents with any of the following: wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers or unhealed surgical wounds) and/or indwelling medical devices (urinary catheters, feeding tubes, tracheostomy tubes) even if the resident is not known to be infected or colonized with an MDRO. - Personal Protective Equipment (PPE-gown and gloves) for EBP is only necessary when performing high-contact activities and may not need to be put on prior to entering the resident's room. High Contact activities include the following: -Dressing, -Bathing, -Transferring, -Providing hygiene, -Changing linens, -Changing briefs or assisting with toileting, -Device care or use: urinary catheters, feeding tubes, tracheostomy tubes and -Wound care: any skin opening requiring a dressing. B. Review of the facility policy CPAP (Continuous positive airway pressure-a respiratory intervention used to provide an airway during periods of sleep apnea. It used air pressure generated by a machine, delivered through a tube into a mask that fits over the nose) Cleaning Policy dated 2024 revealed the following: -It was the policy of this facility to clean CPAP equipment in accordance with current CDC (Centers for Disease Control) guidelines and manufacturer's recommendations to prevent the occurrence or spread of infection. Guidelines to clean the CPAP are as follows: -Equipment could become colonized with infectious organisms and serve as a source of respiratory infections. -Staff were to wash hands and wear gloves whenever touching the equipment. -Dust the machine as needed and wipe clean with damp cloth and mild detergent. -If humidification was required, distilled or sterile water would be used to fill the humidifier chamber. Empty after each use and wipe dry. -Clean the mask frame daily after use with CPAP cleaning wipe or soap and water, dry well, cover with a plastic bag or completely enclose in machine storage when not in use. Weekly cleaning activities include: -Wash headgear/straps in warm, soapy water and air dry. -Wash tubing with warm soap water and air dry. Follow the manufacturers' recommendations for the frequency of cleaning/replacing filters and servicing the machine. Replace the equipment immediately if it is broken, malfunctions or if visible soiling remains after cleaning. Replace equipment routinely in accordance with manufacturers' recommendations. General guidelines: Face mask and tubing-once every 3 months. Headgear, non-disposable filters and humidifier chamber-once every 6 months and the disposable filters twice a month. C. Review of the Hand Hygiene Policy dated June 2025 revealed the following: -Hand hygiene is a general term for washing hands with soap and water or the use of an alcohol-based hand rub (ABHR). -Hand hygiene should be completed before contact with residents, putting on gloves and inserting or manipulating a device. -Hand hygiene should be completed after contact with resident's skin, bodily fluids or excretions, personal items, non-intact resident's skin, wound dressings or contaminated items and after removing gloves. D. Review of Resident 10's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 12/13/25 revealed the resident had an indwelling catheter and a surgical wound with surgical wound care. Review of Resident 10's Care Plan dated 11/29/25 revealed the following: -The resident was in EBP, staff were to wear a gown and gloves when urinary bag was emptied/catheter cares completed and when wound treatment was completed. -The resident had an indwelling catheter related to surgery. -The resident had altered respiratory status related to Sleep Apnea. CPAP settings per preprogrammed settings via full face mask. Review of Medication Administration Record (MAR) dated 12/25 revealed an order to ensure CPAP mask is on at bedtime (no cleaning instructions identified). Review of Treatment Administration Record (TAR) dated 12/25 revealed an order for dressing change to left superior scrotum. Clean with normal saline, lightly pack wound with calcium alginate, secure with paper tape. Change daily. The following observations revealed the CPAP machine not being cleaned: -12/15/25 at 7:45 AM revealed residents CPAP laid on the bedside table, mask connected to the tubing and the water chamber was dry. -12/15/25 at 12:45 PM CPAP remained on the bedside table connected to the tubing. -12/16/25 at 7:45 AM CPAP mask/tubing laid on the floor with the machine on the dresser by the bed. -12/16/25 at 10:30 AM CPAP mask/tubing remained on the floor. -12/16/25 at 11:15 AM CPAP mask/tubing continued to lay on the floor beside the bed. -12/17/25 at 10:40 AM CPAP mask/tubing laid in the top drawer of the dresser beside the bed. During an observation of provision of care for Resident 10 on 12/17/25 at 7:20 AM Registered Nurse (RN-L) put on gown and gloves, removed old dressing from surgical area to scrotum, changed gloves, completed treatment to surgical area, removed gloves and exited the room. (No hand washing or hand hygiene was observed with cares.) During an observation of provision of care for Resident 10 on 12/17/25 at 7:30 AM, Nursing Assistant (NA-M), entered resident room, put on gloves, emptied resident's catheter bag, emptied the graduate cylinder (a container used to collect and measure urine or other bodily fluids), removed gloves and washed hands. (No gown was worn when cares were completed with catheter bag and urine.) E. Review of Resident 7's MDS dated [DATE] revealed the resident had a stage 4 unstageable pressure ulcer with eschar. Review of Resident 7's Care Plan dated 9/12/25 revealed the resident was on EBP related to open wounds. Always wear a gown and gloves for cares when in resident's room. Review of resident's TAR dated 12/25 revealed an order to cleanse left heel with 1/2 Dakin's (antimicrobial wound cleanser) soaked gauze, apply Triad (absorbs moisture and softens skin) paste to skin surrounding the open area, apply 1/2 Dakin's-soaked gauze to wound bed, cover with pad, secure with gauze wrap and tape 2 times daily. During an observation of provision of care for Resident 7 on 12/16/25 at 11:00 AM Licensed Practical Nurse (LPN-D) entered resident room, put on gloves, (no hand hygiene was completed or gown put on), removed dressing from left heel, poured Dakins solution on wound, changed gloves, (did not wash hands), completed treatment to left heel, put sock and boot on left foot and removed gloves. (Did not wash hands prior to exiting the room). F. Review of Resident 41's record revealed an admission date of 12/12/25. Care Plan revealed that the resident was incontinent of bladder related to cancer and weakness, was on EBP related to have a tracheostomy (opening in the neck to provide an airway) and a g-tube (feeding tube inserted into the abdomen used to deliver nutrition). During an observation of provision of care for Resident 41 on 12/16/25 at 3:00 PM, NA-V and NA-W, entered the room, put on gown and gloves, completed incontinent cares and repositioned resident to comfort, removed gloves and gown and left the room. (No handwashing was completed). G. An interview with RN-L on 12/17/25 confirmed that staff have not cleaned Resident 10's CPAP per the facility policy. An interview with RN-O, Infection Control Nurse, on 12/17/25 at 10:30 AM confirmed that Resident 7 and Resident 10 were on EBP and staff should have worn gown and gloves with Resident 7 when wound treatment was completed and with Resident 10 when catheter bag was emptied. Further interview confirmed that staff should have completed hand hygiene when entering the room, before and after removing gloves, and when exiting the room. H. Review of Resident 1's Care Plan with a revision date of 10/15/25 revealed the resident had a Multidrug Resistant Organism (MDRO- infection/organism resistant to many antibiotics) to open skin areas and staff were to exercise Enhanced Barrier Precautions (EBP-use of Personal Protective Equipment during high contact care to prevent the potential spread of MRDO infections). The EBP's were to remain in effect during the duration of the resident's stay or resolution by the physician. Staff were to use a gown and gloves for all cares including bathing, transferring, providing hygiene care, changing linens, changing briefs or assisting with toileting in the resident's room. The resident was dependent on staff with Activities of Daily Living (ADLs). The resident utilized a mechanical lift and an electric wheelchair. In addition, the resident was involuntary of bowel and incontinent of bladder. During an observation of care for Resident 1 on 12/16/25 at 9:45 AM Nurse Aides (NA)-F and Medication Aide (MA)-E entered the room, performed hand hygiene and put on gowns, gloves and masks. They transferred the resident to bed using a full-body mechanical lift. The resident was wearing a disposable brief and was noted to be involuntary of bowel and incontinent of bladder. The resident's soiled brief was changed, and the resident was cleaned with disposable wipes, then without changing gloves or performing hand hygiene NA-F applied a clean brief. I. Review of Resident 2's Care Plan with a revision date of 4/22/25 revealed the resident received EBP due to an inactive MRDO. The precautions were to remain in effect during the duration of the resident's stay or resolution by the physician. Staff were to use a gown and gloves for all cares including bathing, transferring, providing hygiene care, changing linens, changing briefs or assisting with toileting in the resident's room. During an observation of care for Resident 2 on 12/17/25 at 12:40 PM NA-F responded to the resident's call light hand sanitized, entered the resident's room put on disposable gloves, but no gown. The resident was sitting on the toilet and NA-F assisted the resident to stand and provide perineal care and pull up the resident's pants all while not wearing a gown. The resident was assisted into a wheelchair and then into an easy chair. NA-F then removed the disposable gloves, hand sanitized and exited the room. During an interview on 12/17 at 12:46 PM, NA-F revealed being unaware Resident 2 was on EBP and confirmed being aware that residents on EBP should have care while staff were wearing both gowns and gloves. J. During an interview on 12/18/25 at 11:40 the Infection Preventionist Register Nurse (RN-0) confirmed staff should always change gloves, complete hand hygiene and put on clean gloves after completing a task involving soiling, and prior to proceeding with a clean task. In addition, staff were to wear a gown and gloves during high contact care such as toileting and perineal care for residents on EBP's.

Licensure Reference Number 175 NAC 12-006.09G and 175 NAC 12-006.02(A) Based on record review and interview, the facility failed to complete the required discharge notifications to the State Ombudsman when residents were transferred or discharged from the facility and complete discharge summaries for Residents 37 and 39. The sample size was 2 and the facility census was 38. Findings are: A. Review of Resident 37's Care Plan dated 10/10/25 revealed the resident was admitted to the facility with pneumonia and pancreatic cancer. Review of Resident 37's Progress Notes revealed the following: -On 10/10/25 at 7:14 PM the resident was admitted to the facility from a hospital on with increased weakness, a cancer diagnosis and the resident's family was in hopes the resident could have Physical Therapy and return home. -On 10/12/25 at 8:22 AM revealed, the resident was sent to the Emergency Room. -On 10/12/25 at 1:00 PM the resident's family reported the resident would most likely not return to the facility and return home receiving Hospice services. Review of the Interdisciplinary Discharge summary dated [DATE] at 2:56 PM revealed the resident was admitted on [DATE], there was no discharge date , reason for discharge, or final summary of the resident's status. There was no indication of medication disposition. B. Review of Resident 39's Care Plan dated 11/10/25 revealed the resident was admitted to the facility on [DATE], the resident had recent rib and spine fractures, infected surgical wounds with Intravenous Antibiotic treatment, and respiratory failure. In addition, the resident had self-care deficits. Review of Resident 39's Progress Notes revealed the following: -On 11/19/25 at 9:50 AM the resident reported no concerns related to the Care Plan and hoped to eventually discharge from therapy and return home. -On 11/24/25 at 10:55 AM stated the resident discharged from the facility at 10:15 prior to receiving discharge orders from the Primary Care Physician. Review of Resident 39's Interdisciplinary Discharge Summary revealed the Resident was admitted to the facility on [DATE], there was no discharge date recorded, no reason for the discharge, or a final summary of the Resident's status from Nursing Services. There was no indication of medication disposition. C.During an interview on 12/18/25 at 11:13 AM the Director of Nursing confirmed the facility had not completed discharge summaries for Residents 37 and 39.D.Review of the facility records revealed the facility had no evidence of Ombudsman notifications of the facility transfers and/or discharges for the calendar year 2025. E.During an interview on 12/18/25 at 12:04 PM the Regional Director of Corporate Services confirmed the facility had no evidence they were notifying the State Ombudsman of facility transfers and/or discharges.

Licensure Reference Number 175 NAC 12-006.09Based on observation, record review and interview; the facility failed to provide evidence of follow up evaluations and condition assessments to identify potential complications following a fall for Resident 10 and failed to follow physician's orders for treatment of a foot ulcer for Resident 7. The sample size was 13 and the facility census was 38. Findings are:A. Review of the facility policy Fall Prevention Program dated September 2024 revealed the following:-Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -When any resident experiences a fall, the facility would complete the following:A. Assess the resident.B. Complete a post-fall assessment.C. Complete an incident report.D. Notify physicians and family.E. Review the resident's care plan and update as indicated.F. Document all assessments and actions.G. Obtain witness statements in the case of an injury. B. Record review of nursing documentation for Resident 10 on 12/16/25 at 6:09 PM revealed that Resident 10 slipped and fell in room, resident was alert and oriented times 3, denied hitting head, no neuro assessments were needed, and no injuries were present. Vital signs were completed, Director of Nursing notified, and fax was sent to the physician. An observation of Resident 10 on 12/17/25 at 7:20 AM revealed that the resident had dry red drainage to the right facial cheek and shirt, Resident 10 confirmed that the injury occurred with the fall the prior evening. An interview with the Administrative Assistant (AA-N) on 12/17/25 at 7:50 AM confirmed that Resident 10 did have a fall on 12/16/25 around 6:00 PM, red drainage was noted on the side of right cheek, Licensed Practical Nurse (LPN-D) was notified. An interview with the Director of Nursing (DON) on 12/17/25 at 7:50 AM confirmed that neuro assessments and vital signs should have been completed related to resident fall being unwitnessed with an injury. An interview with the DON on 12/17/15 at 3:50 PM confirmed that the physician was notified of the resident injury and vital signs were being completed every shift for 72 hours. Record review of nursing documentation on 12/18/25 at 9:00 AM revealed that there were not any follow up documentation, assessments or vital signs completed related to the fall on 12/16/25 for Resident 10. An interview with the DON on 12/18/25 at 9:45 AM confirmed that there were not any follow up charting or vital signs completed related to Resident 10's fall from 12/16/25 and there should have been vital signs with an assessment completed. An interview with the Administrator on 12/18/25 at 10:30 AM confirmed that a post fall evaluation was not completed after the resident had a fall on 12/16/25. C. Record review of Resident 7's Treatment Administration Record (TAR) for 10/25 revealed the following order: Cleanse left heel with dial soap and water. Apply xeroform (non-adherent, sterile, petrolatum gauze dressing) and waterproof foam dressing. Wrap heel with gauze. Change dressing daily. The treatment was not signed off in the TAR on 10/3/25, 10/7/25, 10/8/25, 10/11/25, 10/16/25, 10/17/25, 10/22/25, 10/23/25 and 10/27/25. Record review of Resident 7's TAR for 11/25 revealed the following order: Cleanse left heel with 1/2 Dakins (antimicrobial wound cleanser) soaked gauze. Apply Gentelle Blue (antimicrobial dressing) to wound bed, cover with pad, secure with Coban. Change Monday, Wednesday and Friday. The treatment was not signed off as completed on 11/7/25, 11/10/25 and 11/12/25. On 11/21/25 the treatment order to the left heel was changed to: Cleanse with 1/2 Dakins soaked gauze, apply Triad (absorbs moisture and softens skin) paste to skin surrounding the open area, apply 1/2 Dakins soaked gauze to wound bed, cover with pad, secure with gauze wrap and tape 2 times daily. The treatment was not signed off as completed on 11/23/25 and 11/24/25. The treatment was not completed at 8:00 PM on 11/22/25 and 11/29/25 due to the resident sleeping. Record review of Resident 7's TAR for 12/25 revealed the following order: Cleanse left heel with 1/2 Dakins soaked gauze, apply Triad paste to skin surrounding the open area, apply 1/2 Dakins soaked gauze to wound bed, cover with pad, secure with gauze wrap and tape 2 times daily. The treatment to the left heel was not signed off as being completed on 12/1/25, 12/4/25, 12/8/25 and 12/11/25. The treatment was not completed at 8:00 PM on 12/1/25, 12/2/25, 12/9/25, 12/13/25, 12/15/25 and 12/16/25 due to the resident sleeping. An interview on 12/18/25 at 11:45 AM with the DON confirmed that if the treatment to the left heel was not signed off it was not completed and signing off that the treatment was not completed due to the resident sleeping was not appropriate and confirmed the staff are not following the physician orders.

Licensure Reference Number 175 NAC 12-006.05(21)Based on observation, record review and interview; the facility failed to ensure Resident 10's dignity by not covering the urinary drainage bag. The sample size was 3 and the facility census was 38.Findings are:A. Review of the facility policy titled Catheter Care dated September 2024 revealed the following:- It was the policy of this facility to ensure that residents with indwelling catheters received appropriate care and maintained dignity and privacy when indwelling catheters were in use. - Privacy bags would be available and catheter drainage bags would always be covered while in use. B. Review of Resident 10's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 12/13/25 revealed the resident had an indwelling catheter. Review of Resident 10's Care Plan dated 11/29/25 revealed Resident 10 had an indwelling catheter and the urinary catheter bag and tubing was to be placed away from the entrance of the door to the room. The following observations revealed Resident 10's urinary drainage bag was not covered:-12/15/25 at 7:45 AM Resident 10's urinary drainage bag was hanging on the lower side of the walker, uncovered. The resident voiced rarely going to the dining room for meals because everyone can see the bag.-12/15/25 at 12:45 PM the urinary drainage bag was hanging on the lower bar of the walker, uncovered. -12/17/25 at 7:20 AM the urinary drainage bag was hanging on the lower bar of the walker, uncovered. -12/17/15 at 2:05 PM the urinary drainage bag was hanging on the lower bar of the walker, uncovered. -12/18/25 at 8:10 AM the urinary drainage bag was hanging on the lower bar of the walker, uncovered and voiced that everyone can see the bag and know that there is a problem. An interview on 12/17/25 at 10:30 AM with Registered Nurse (RN)-O, Infection Control Nurse, confirmed that urinary drainage bags should be always covered.

Licensure Reference Number 175 NAC 12-006.12Based on record review and interview; Residents 8 and 9 did not have the required consent for the use of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety and hypnotics). The sample size was 13 and the facility census was 38.Findings are:A. Review of the facility policy Use of Psychoactive Drugs with a review date of 2/2020 revealed the following:-Residents and their representatives should be educated on the risk and benefits of drug use as well as alternative treatments and non-pharmacological interventions. B. Review of Resident 8's Medication Administration Record (MAR) for the month of December 2025 revealed the resident received Sertraline (antidepressant) 100 milligrams (mg) daily for Depressive Disorder.Review of Resident 8's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 10/30/25 revealed the resident received an antidepressant and had a diagnosis of depression. Review of Resident 8's Informed Consent for Psychopharmacological Medications revealed resident received Sertraline 100mg daily. There was no reason for the medication or side effects to the medication listed. C. Review of Resident 9's MAR for the month of December 2025 revealed that the resident received the following medications:-Seroquel (an antipsychotic that regulates mood, behaviors and thoughts)100 mg at bedtime with a start date of 4/9/25.-Seroquel 50 mg in the morning restarted 7/3/25.-Sertraline (antidepressant) 100 mg daily started 3/4/25.-Lamictal (mood stabilizer) 100 mg 2 times daily decreased 6/24/25.-Lorazepam (antianxiety) 0.5 mg 2 times daily with a start date of 3/19/25. Review of Resident 9's MDS dated [DATE] revealed the resident received an antipsychotic, antianxiety and antidepressant medication. The resident had a diagnosis of Non-Alzheimer's Dementia and Depression. Review of Resident 9's Informed Consent for Psychopharmacological Medication revealed resident received the following:-Seroquel 50 mg 2 times daily for depression. -Sertraline 50 mg every bedtime for mood disorder and depression.-Lamictal 100 mg 2 times daily for mood disorder.-Lorazepam 0.5 mg 2 times daily for anxiety.-Lorazepam 1 mg every 8 hours as needed. - No side effects for medications were documented.-The responsible party signed the same consent form on 3/11/25 and 4/10/25. An interview with the Director of Nursing on 12/16/25 at 2:00 PM confirmed that the Informed Consent for Psychopharmacological Medication did not have the side effects for the medications listed for Resident's 8 and 9 and resident 9's Informed Consent did not have the correct medications with correct dosages. Further interview confirmed each time a new order for a psychotropic medication is received or a psychotropic medication was increased a new informed consent should be completed and this was not completed for Resident 9.

Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview, the facility failed to ensure Resident 25 received the required face to face physician evaluations to continue the use of PRN (as needed) antipsychotic (used to treat psychotic disorders/symptoms) medications. The sample size was 5 and the facility census was 38. Findings are: Review of the facility policy Use of Psychoactive Drugs dated 2/2020 revealed the following: -Residents were not given psychotropic (mind altering) drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. -A psychotropic drug was any drug that affected brain activities associated with mental processes and behavior. Psychotropic drugs included but were not limited to the following categories: antipsychotics, antidepressants, anti-anxiety and hypnotics. -The indications for use of any psychotropic drug were documented in the medical record. Documentation included specific condition/s as diagnosed by the physician.-PRN (as needed) orders for psychotropic drugs shall be used only when the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record and for a limited duration of 14 days.-If the attending prescriber believed the medication was appropriate to be extended beyond the 14 days, they documented their rationale in the resident's medical record and indicate the duration for the PRN order. -PRN orders for antipsychotic medications were limited to 14 days with no exceptions and the attending physician or prescribing practitioner when writing a new order first evaluated the resident to determine if the new order was appropriate. Review of Resident 25's Medication Administration Records dated 5/2025 through 12/2025 revealed the resident had orders for the topical medication Ativan (anti- anxiety) 1milligram, Benadryl (antihistamine) 25milligrams, and Haldol (antipsychotic) 5milligrams/milliliter (ABH cream) apply 1mg every 4 hours as needed (PRN) for anxiety and/or agitation. There was no indication the medication which included an antipsychotic medication was being limited to 14 days as required. The medication was administered 16 times in May 2025, 13 times in June 2025, 4 times in August 2025, 4 times in August 2025, 5 times in September 2025, 9 times in October 2025, 11 times in November 2025, and 4 times in December of 2025.Review of the Resident 25's Hospice Physician's Orders on 9/22/25, 10/6/25, 10/22/25, 12/3/25, and 12/18/25 revealed no evidence the resident was seen or re-evaluated by the physician when the orders for the ABH cream were renewed. During an interview on 12/18/25 at 11:15AM the Director of Nursing (DON) acknowledged being unaware that use of antipsychotic PRN medications were limited to 14 days and required the resident to be re-evaluated face to face by the ordering provider. In addition, the DON confirmed the Resident 25's physician had not completed in person evaluations of the resident each time the PRN antipsychotic medication was given beyond 14 days.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on record review and interview, the facility failed to provide bathing assistance to Resident 45 at intervals to meet the resident's needs. The sample size was 13 and the facility census was 38. Findings are: Review of the undated facility Bathing Policy Statement revealed the facility provided each resident with bathing services at a frequency that met the residents' individual needs and preferences. Additional baths were provided as needed for incontinent episodes, skin care needs, or physician's orders Review of Resident 45's Care Plan dated 9/28/25 revealed the resident was admitted on [DATE], had dementia, bladder incontinence and self-care deficits related to a recent hip fracture, infections, and dementia. The resident was unable to bear weight on the left leg and staff were to provide the resident with assistance with Activities of Daily Living (ADL's) including bathing. Review of Resident 45's Bathing Records revealed bathing occurred on 10/10 (13 days after admission), 10/16, 10/23, 11/5 (13 days after the previous bath, and 11/18 (13 days after the previous bath). During an interview on 12/17/25 at 11:32 AM the Director of Nursing confirmed Resident 45 was incontinent, and dependent on the staff for ADL's including bathing, and the facility had no evidence the resident was being bathed at least weekly.

License Reference Number 175 NAC 12-006.18(A)Based on record review and interview; the facility failed to have evidence Resident 4 and 7 were up to date and/or offered/given pneumococcal vaccinations. The sample size was 5 and the facility census was 38. Findings are:A. Review of the facility policy Vaccination dated September 2024 revealed each nursing facility would annually, no later than October 1, offer onsite vaccinations for pneumococcal to all residents. B. Review of Resident 4's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 10/1/25 revealed the resident was admitted [DATE] with diagnoses of Heart Failure, High Blood Pressure, and Kidney Disease; had moderate cognitive impairment; and their pneumococcal vaccination was not up to date and it was not offered. Review of Resident 4's Medical Record revealed no evidence the resident had been offered or received/declined the pneumococcal vaccination. C. Review of Resident 7's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of Anemia, High Blood Pressure, Diabetes, Alzheimer's Disease, Dementia, Depression, and Chronic Lung Disease; had severe cognitive impairment; and their pneumococcal vaccination was not up to date and it was not offered. Review of Resident 7's Medical Record revealed no evidence the resident had been offered or received/declined the pneumococcal vaccination. D. Interview with Registered Nurse-O and the Director of Corporate Services on 12/18/25 at 1130 AM confirmed Residents 4 and 7 were not offered (and should have been) and did not receive the pneumococcal vaccination.

Licensure Reference Number 175 NAC 12-006.04(F) Based on record review and interview the facility failed to provide the required 8 hours of Registered Nurse (RN) coverage daily. The sample size was 14 and the facility census was 34. Findings are: A. Based on record review of the nurse's schedule for November 2024 there was not any RN coverage on 11/1/24, 11/2/24 and 11/3/24. During an interview on 12/5/24 at 10:00 AM with the Director of Nursing (DON) the DON confirmed that there was not any RN coverage on 11/1/24, 11/2/24 and 11/3/24.

Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview; the facility failed to follow the pharmacist's recommendations to address irregularities in medication regimens for Resident's 1 and 27. The sample size was 5 and the facility census was 34. Findings are: Review of the undated facility policy Medication Regimen Review (MMR) revealed the following: -The MMR was a thorough process of review and assessment conducted by a Consultant Pharmacist of the medications ordered for each resident, with a goal of promoting positive outcomes and minimizing adverse consequences associated with medications. -The MMR occurred monthly for each resident and recommendations were reported to the Administrator, Director of Nursing, attending physicians, and the Medical Director as it applied. -The Consultant Pharmacist utilized federally mandated standards of care, in addition to other applicable standards. -The Consultant Pharmacist provided reporting each month including documented concerns, irregularities, clinically significant risks, adverse consequences that resulted from of could be associated with medications. -The reports included nursing issues as well as communication to attending physicians. -Letters were provided to attending physicians regarding any significant potential or actual medication concerns. -Facility staff notified the attending physicians and obtained responses within a timely manner. Review of Resident 1's Minimum Data Set (MDS-federally mandated comprehensive assessment use in the development of resident care plans) dated 9/18/24 revealed the resident received antipsychotic, antianxiety, antidepressant and antibiotic medications. Review of Resident 1's Pharmacist Review and Recommendations revealed the following: 5/28/24- The Pharmacist recommended a sleep assessment, Risperdal (antipsychotic medication) 0.25 milligrams (mg) at bedtime required review for a dose reduction, a stop date needed added to the Medication Administration Record (MAR) for PRN (as needed) Ativan (Anti-anxiety medication), and there was no evidence of a response, and the recommendation was to send to the provider again. 5/31/24- The Pharmacist recommended reducing Risperdal from 0.25 mg daily to 0.25 mg every other day. The provider signed the recommendation. but did not indicate whether they agreed. 9/23/24- The Pharmacist requested a review for a dose reduction of Risperdal and Zoloft (anti-anxiety medication), there was no evidence a response was received. In addition, a review for clarification of the resident's use of Nitrofurantoin (antibiotic) daily was generated with no evidence of documented continued need or rationale. 10/21/24 the provider documented that the dose reductions of the Risperdal and Zoloft were clinically contraindicated, however there was no evidence clarification of the of the Nitrofurantoin was received. During an interview on 12/5/24 at 11:36 AM Registered Nurse (RN)-L confirmed the facility had no evidence they had been forwarding pharmacy recommendations to providers for review in a timely manner, and confirmed the facility had no evidence that recommended identified irregularities for Resident's 1 were addressed in a timely manner or in accordance with facility policy. 51391 C. Review of Resident 27's MDS dated [DATE] revealed the resident received antipsychotic, antianxiety and antidepressant medications. Review of Resident 27's Pharmacist review and recommendations revealed on 5/31/24 the Pharmacist noted that Resident 27 was on 2 antianxiety and insomnia medications and a stop date needed added to the MAR for Ativan (Antianxiety medication) 0.5 mg every 6 hours PRN. The provider documented why resident was on antianxiety medications but did not indicate whether they agreed. There was no response from the provider for the 2 insomnia medications and a stop date for the Ativan. The Pharmacist recommendations were sent to the provider again -On 9/23/24 the Pharmacist requested a stop date be added to the MAR for Xanax (antianxiety medication) PRN, the provider did not respond, and the recommendation was not sent again. -On 10/21/24 the Pharmacist requested a stop date added to the MAR for Xanax PRN and a response from the provider was received on 11/19/24 to continue Xanax PRN for 6 months. During an interview on 12/5/24 at 11:36 AM RN-L confirmed the facility had no evidence they had been forwarding pharmacy recommendations to providers for review in a timely manner, and confirmed the facility had no evidence that recommended identified irregularities For Resident's 27 were addressed in a timely manner or in accordance with facility policy.

Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review, and interview the facility failed to implement Enhanced Barrier Precautions (EBP-an infection control interventions designed to reduce transmission of Multi-Drug-Resistant Organisms (MRDO's) that employed targeted gown and glove use during high contact resident care activities) during the provision of care for Residents 20 and 25 and failed to maintain ongoing evidence of antibiotic surveillance in the facility. Findings are: A. Review of the facility policy Enhanced Barrier Precautions dated [DATE] revealed the following: -It was the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of MRDO's. -EBP referred to controlled interventions designed to reduce the transmission of MRDO's that employed gown and glove use during high contact resident care activities. -When EBP were implemented, the facility made gowns and gloves available immediately near or outside the resident's room. -PPE (Personal Protective Equipment- such as gown and gloves) were necessary when performing high-contact resident care activities including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care, or wound care. B. Review of Resident 20's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 11/7/24 revealed the resident received substantial assistance with dressing, partial assistance with transfers, and substantial assistance with hygiene. In addition, the resident was frequently incontinent of bladder, and always involuntary of bowel. Review of Resident 20's Diagnosis Report dated 12/5/24 revealed skin ulcers of the right and left lower extremities, and a pressure ulcer on the right heel. Review of the undated facility list of residents in isolation included Resident 20 and indicated the resident was on EBP for wounds. During an observation of the provision of care for Resident 20 on 12/5/24 at 1:24 PM Nurse Aid (NA)-I entered the resident's room, performed hand hygiene, put on gloves but did not put on a gown. NA-I proceeded to assist the resident to stand up from a wheelchair, walk to the bathroom, pull down clothing, remove a wet brief, perform toileting hygiene, change the resident's brief and pants and walk back to the wheelchair all while not wearing a gown. C. Review of Resident 25's MDS dated [DATE] revealed the resident received moderate assistance with transfers, and substantial assistance with dressing and hygiene. Review of Resident 25's Care Plan with a revision date of 9/23/24 revealed the resident was on EBP, had an active MRDO to a wound on the left leg and staff were to wear gown and gloves for care in the resident's room. Those cares included, dressing, bathing, transferring, providing hygiene, changing bed linens, changing briefs and/or when assisting with toileting. During an observation on 12/3/24 at 11:40 AM NA-I entered resident 25's room to assist the resident to the bathroom. NA-I performed hand hygiene and then put on gloves but did not put on a gown, then assisted the resident by pushing the wheelchair to the bathroom and then, locked the wheelchair brakes and provide touching assistance for the resident to stand up and then assisted the resident to pull down pants and sit on the toilet. After the resident finished NA-I assisted the resident in performing perineal care and apply a skin cream to the buttocks and then removed the gloves and provided guidance back to the wheelchair. This was also completed while not wearing a gown. C. During an interview on 12/5/24, NA-I confirmed not using a gown during the provision of care for Resident's 20 and 25. NA-I reported being aware that both residents were on EBP but reported not being unaware of the need to wear gloves and a gown during high contact resident care. D. During an interview on 12/5/24 on 2:23 PM the Infection Preventionist (IP) confirmed staff were to be wearing gloves and a gown during cares with resident's on EBP which included but was not limited to transfers, dressing, and toileting. E. Review of the facility Infection Surveillance requested over that past 13 months revealed the facility was only able to provide one month (November 2024) of the requested surveillance. There was no evidence the required surveillance had been completed for the time frame requested. F. During an interview on 12/4/24 at 2:47 PM the IP confirmed the facility had no evidence they are conducting ongoing and real time surveillance of infections or evidence they were reviewing their antibiotic use in accordance with their Antibiotic Surveillance plan.

Licensure Reference Number 175 NAC 12-006.18 Based on record review and interview; the facility failed to follow the facility Antibiotic Stewardship Policy for Resident 1 to ensure all antibiotics ordered had stop dates and or documented clinical rationale for ongoing use. Findings are: Review of the facility policy Antibiotic Stewardship Program (ASP) with a revision date of 3/2023 revealed the following: -The facility implemented an ASP as part of the overall infection prevention and control program and the purpose was to optimize the treatment of infections while reducing adverse events associated with antibiotic use. -The Infection Preventionist (IP), with oversight from the Director of Nursing (DON) served as the leader of the ASP. -The Medical Director, Consultant Pharmacist, and attending Physicians supported the program through active participation in the development, promotion, and implementation of a facility wide system for monitoring the use of antibiotics. -All prescriptions for antibiotic included a specific dose, duration, and indication for use. Review of Resident 1's Minimum Data Set (MDS-federally mandated comprehensive assessment use in the development of resident care plans) dated 9/18/24 revealed the following: -the resident received substantial assistance with dressing and transfers and was dependent for toileting hygiene, -was frequently incontinent of bladder and occasionally involuntary of bowel, -and had received antibiotics. Review of Resident 1's Care Plan with a revision date of 9/24/24 revealed the resident was frequently to always incontinent of urine, had Chronic Cystitis (chronic pain bladder inflammation without evidence of active infection) and was on a scheduled antibiotic for prevention. Review of Resident 1's Medication Administration record dated Dec. 2024 revealed the resident was taking the antibiotic medication Nitrofurantoin Macrocrystal (antibiotic) 100 milligrams one time daily with a start date of 12/16/20. During an interview on 12/4/24 at 2:47 PM the facility Infection Preventionist Registered Nurse (IP-RN) confirmed the facility had no evidence they are conducting ongoing and real time surveillance of infections or evidence they were reviewing their antibiotic use in accordance with their Antibiotic Stewardship plan. In addition, the IP confirmed the resident's Antibiotic order had no defined duration.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, record review and interview; the facility failed to implement interventions to prevent potential falls for Resident 27. The total sample size was 3 and the facility census was 34. Findings are: A. Review of the facility Fall Prevention and Fall Leaf Program with a revised date of 2/2020 revealed the following fall prevention procedure: Fall Prevention Procedure: - A fall risk care plan (a written document that outlines the care and support a person needs based on their health needs) would be developed for all residents as deemed appropriate by the Care Plan Coordinator. - If a resident had a fall a Fall Incident & Investigation report would be completed. The report would be reviewed at the next Clinical Team Meeting to determine what interventions would be added to prevent further falls. B. Review of Resident 27's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/21/24 revealed diagnoses of Non-Traumatic Brain Dysfunction, Dementia, Anxiety and Depression and indicated the resident had physical and verbal behaviors. Resident 27 was dependent on staff for assist with transfers and for wheelchair mobility. The resident had 2 falls with no injury and 2 falls with only minor injury since the last MDS was completed. Review of Resident 27's care plan revealed that the resident was transferred with a mechanical lift and sat in a reclining wheelchair when not laying in the bed. A fall was documented on the care plan with a date of 11/30/24 identifying Resident 27 was on the floor with the resident's pelvis positioned over the wheelchair. On 12/1/24 an intervention was initiated to not leave the resident alone in their room when in the wheelchair. Observations of Resident 27 in the resident's room on 12/2/24 revealed the following: -7:00 AM The resident was seated in a reclining wheelchair with eyes open and was watching television, no staff were in the room. -9:15 AM The resident was again seated in the reclining wheelchair and was watching television; no staff were observed in the resident's room. -10:30 AM The resident was laying in the reclining wheelchair with eyes closed, no staff were in the room. Observations of Resident 27 in the resident's room on 12/3/24 revealed the following: -7:25 AM The resident was seated in the reclining wheelchair. The resident was awake and had thrown the blanket covering the resident and the call light onto the floor while trying to get up from the wheelchair, no staff were available in the room. -7:35 AM The resident remained in the reclining wheelchair. No staff were observed in the resident's room. -2:30 PM The resident was seated in the reclining wheelchair and was trying to get up independently. No staff were in the resident's room at the time until the resident began to call out and then staff entered the room and provided assistance with repositioning. During an observation of Resident 27 on 12/4/24 at 7:10 AM, the resident was alone in the resident's room and was seated in the reclining wheelchair. The resident was attempting to get up out of the chair and was calling out looking for the resident's car. No staff responded to the resident. Observations of Resident 27 in the resident's room on 12/5/24 revealed the following: -7:15 AM The resident was seated in the reclining wheelchair. The resident was awake and alert and was calling out for staff assistance. No staff were observed in the resident's room. -9:35 AM The resident was seated in the reclining wheelchair in the resident's room with no staff available. -1:00 PM The resident was seated in the reclining wheelchair in the room. The resident was awake, and the resident's legs were to the side of the wheelchair with the resident attempting to sit forward in chair. No staff were in the room. During an interview with Nursing Assistant (NA)-Q on 12/5/24 at 10:00 AM, NA-Q verified the resident transferred with a mechanical lift and staff provided assistance with wheelchair mobility to meals and activities. The resident did try to get out of the bed and wheelchair at times with increased restlessness. During an interview with NA-F on 12/5/24 at 10:05AM, NA-F verified the resident transferred with a mechanical lift and was dependent on staff for wheelchair mobility to meals and activities and has had falls related to trying to self-transfer attempts. During an interview with the Director of Nursing (DON) on 12/5/24 at 11:30 AM, the DON verified that Resident 27 had been left alone in the room and was seated in the wheelchair at times. In addition, the DON verified the staff failed to follow the fall intervention which indicated the resident was not to be left alone in the wheelchair in the resident's room and that further falls may occur.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview; the facility failed to ensure Resident 1's long term use of an antibiotic had a clinical rationale for continued use or an ordered duration of use. The sample size was 5 and the facility census was 34. Findings are: Review of the facility policy Antibiotic Stewardship Program (ASP) with a revision date of 3/2023 revealed the following: -The facility implemented an ASP as part of the overall infection prevention and control program and the purpose was to optimize the treatment of infections while reducing adverse events associated with antibiotic use. -The Infection Preventionist (IP), with oversight from the Director of Nursing (DON) served as the leader of the ASP. -The Medical Director, Consultant Pharmacist, and attending Physicians supported the program through active participation in the development, promotion, and implementation of a facility wide system for monitoring the use of antibiotics. -All prescriptions for antibiotic included a specific dose, duration, and indication for use. Review of Resident 1's Minimum Data Set (MDS-federally mandated comprehensive assessment use in the development of resident care plans) dated 9/18/24 revealed the following: -the resident received substantial assistance with dressing and transfers and was dependent for toileting hygiene, -was frequently incontinent of bladder and occasionally involuntary of bowel, -and had received antibiotics. Review of Resident 1's Care Plan with a revision date of 9/24/24 revealed the resident was frequently to always incontinent of urine, had Chronic Cystitis (chronic pain bladder inflammation without evidence of active infection) and was on a scheduled antibiotic for prevention. Review of Resident 1's Medication Administration record dated Dec. 2024 revealed the resident was taking the antibiotic medication Nitrofurantoin Macrocrystal (antibiotic) 100 milligrams one time daily with a start date of 12/16/20. During an interview on 12/4/24 at 2:47 PM the facility Infection Preventionist Registered Nurse (IP-RN) confirmed the facility had no evidence they are conducting ongoing and real time surveillance of infections or evidence they were reviewing their antibiotic use in accordance with their Antibiotic Surveillance plan. In addition, the IP confirmed the Resident 1's antibiotic order had no defined duration.

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(3)(c) Based on record review and interview the facility failed to evaluate adverse finding regarding criminal background checks for 3 of 5 sampled staff to protect residents from potential abuse. The facility census was 34. Findings are: Review of the facility policy Abuse Neglect and Exploitation dated [DATE] revealed the following: -The facility provided protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibited and prevented abuse, neglect, exploitation and misappropriation of resident property. -Developed policies and procedures to investigate any allegations. -Provided ongoing oversight and supervision of staff to assure policies were implemented. -Screened all potential employees for a history of abuse, neglect, exploitation or misappropriation including background, reference, and credential checks, and documented proof of the screening that occurred. -New employees were educated on abuse, neglect, exploitation and misappropriation during initial orientation, and all employees received annual training. -The facility implemented policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation to achieve a safe environment, abuse identification, assessment and intervention to ensure resident health and safety. -The facility reported all alleged violation to the Administrator, state agency, adult protective services and all other required agencies within the specified time frames. Review of the facility policy Human Resources Background Investigations dated 10/10/20 revealed the facility conducted background investigations on each individual making application for employment. -If the background investigations disclosed any material misrepresentation or omission by the applicant indicating the applicant may not have been appropriate for hiring, the company conducted further investigation to determine the applicant's suitability for the position. -If the company determined the applicant or team member to be unsuitable, they were not employed and/or terminated. Review of the following staff files revealed the following criminal background findings: -Nurse Aid (NA)-M, criminal background check revealed criminal findings of careless driving, possession of marijuana, and driving under suspension, -NA-N criminal background check revealed criminal findings or pending cases including possession of controlled substances, transporting a child while intoxicated, driving under suspension, shoplifting, and attempt of a felony. -Medication Aid (MA)-O, criminal background check revealed findings of Driving Under the influence of alcohol. -There was no evidence the facility investigated the background finding to determine if the individuals were appropriate for hiring or suitable for the positions in which they were hired in compliance with the facility Abuse and Background Investigation policies. During an interview on 12/4/24 at 10:07 AM the facility Administrator revealed hiring decisions were finalized through Human Resources (HR) after review of the resident's background checks. Hiring decisions were based on the nature of the conviction and how long ago a crime was committed. She was unsure how the facility recorded review of the background checks or conclusion of the hiring decisions. During an interview on 12/4/24 at 3:00 PM the facility Administrator confirmed the facility had not followed it's hiring, and HR policy related to criminal background check and had no documented evidence the findings on the criminal history checks were further investigated to determine if the employees were appropriate or suitable for positions on the nursing staff of the facility.

Licensure Reference Number 175 NAC 12-006.09D2a Based on observations, interviews and record review, the facility failed to implement interventions to prevent Resident 1's pressure sore from developing and worsening and failed to implement interventions to prevent the potential development of a pressure sore for Resident 8. The sample size was 2. The facility census was 31. Findings are: A. Review of the facility policy Pressure Ulcer Prevention Plan dated 2/2020 revealed the following: -Identify high-risk residents by performing comprehensive skin assessments upon admission and re-admission. -Complete a Braden scale (an assessment tool used to determine a person's risk of developing a pressure ulcer) on admission, re-admission, and with a significant change of condition. -Complete daily skin checks by a licensed nurse for high-risk residents or a resident with a current pressure ulcer. -All residents will have a minimum of weekly skin checks by a licensed nurse with documentation on the Weekly Pressure Ulcer Record. -Ensure a prevention plan is in place for each individual resident based on the level of risk. -Interventions for high-risk residents include; increased frequency of repositioning, shift pressure on surfaces, use foam wedges/pillows for lateral positioning, maximal remobilization, protect heels, manage moisture, manage nutrition, reduce friction/sheering, elevate head of bed no more than 30 degrees, use a trapeze (a device used above the bed to assist a person with repositioning) when indicated, use lift sheets to move the resident and protect elbows and heels if exposed to friction. B. Review of the facility policy Turning and Repositioning dated 2/2020 revealed the purpose of the policy was to implement turning and repositioning to prevent and manage pressure injuries using the following guidelines: -All residents at risk of or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. In this case, small shifts in repositioning will be employed. -The facility has established routine turning and repositioning schedules consisting of every 2-4 hours. A maximum of 30 minutes before or after the scheduled time will be allotted for compliance with the schedule. -A routine turn schedule includes using both side-lying and back positions, alternating from the right, back and left side. It also includes assisting the resident to stand, or making small shifts of position, if in a chair. A resident's condition will determine whether or not a specialized turn schedule is warranted. -The frequency of turning and repositioning will be documented in the resident's plan of care and determined by the resident's; tissue tolerance, level of mobility/activity, skin condition, medical condition, treatment goals, type of pressure redistribution support surface in use and comfort levels. -Use the appropriate number of staff to perform the tasks safely. -To minimize friction and shear, use lift sheets or lift equipment to avoid pulling or dragging. -Avoid positioning the resident on surfaces with existing pressure injuries, including persistent redness. -Ensure heels are floated off the surface of the bed with pillows or devices designed to do so. If using a heel protector, the heel must still be floated. C. Review of Resident 1's undated care plan revealed the resident had the potential for skin breakdown related to a stroke and limited bed mobility. The resident required extensive assistance with repositioning, transfers and toileting with the following interventions: -prompt and assist with repositioning every 2-3 hours during the day and 1-2 times during the night if awake; -2 staff assistance and a bed pad to reduce friction & sheer, pressure relieving mattress for the bed, Roho cushion (a high quality seat cushion that provides pressure relief for persons at risk of pressure sores) to wheelchair; -encourage to float both heels off the mattress when in bed and off the recliner foot rest; and -while in the wheelchair assist with off-loading every 2-3 hours during the day, offer to assist with lying down between meals to get pressure off buttocks and get out of bed right before meals and back to bed right after meals if resident agrees to this. An observation of Resident 1 assisted with cares and wound treatment on 9/26/23 from 8:00 AM to 8:30 AM revealed the following: -8:00 AM to 8:10 AM, NA-N and NA-G performed incontinence cares for the resident and [gender] was incontinent of feces. There was a large adhesive foam dressing (sacral Mepilex) on the resident's sacral area. The lower section of the dressing closest to the anus, was loosened and not attached to the skin to prevent potential contamination of the wound. NA-N and NA-G had begun to secure the clean incontinence brief and were asked about the dressing's appearance before completing the task. NA-N then indicated [gender] would inform the nurse about the loose dressing before continuing with transferring the resident out of the bed. -8:20 AM, resident was positioned in bed on [gender] left side with a large re-usable pad underneath. Registered Nurse (RN)-C grabbed onto the edge of the pad with both hands behind the resident and pulled the pad, dragging the resident's body across the surface of the bed a few inches. This was not an appropriate technique for re-positioning the resident related to the potential for friction and shearing as indicated in the facility policy for Turning and Repositioning dated 2-2020. -8:25 AM, observation of the sacral wound revealed 2 opened areas positioned directly next to each other, one on the upper portion of the buttock crease and the 2nd one just above the anus. The upper wound was deep and had tan colored drainage inside the wound bed. The lower wound was deeper than the upper wound with a beefy red color and exposed a large amount of muscle tissue inside the wound. -8:30 AM, after the dressing change was completed, NA-N and NA-G, transferred the resident from the bed using a full body mechanical lift. The resident's wheelchair had 2 different cushions on the seat, the Roho cushion was on the bottom and a foam cushion was resting on top of the Roho cushion. NA-N and NA-G began lowering the resident into the wheelchair and just before [gender] was placed onto the seat cushion, they were asked about the 2 cushions in the wheelchair. NA-N, then stated the resident was supposed to have a Roho cushion in the chair, not the foam cushion and removed the foam cushion from the wheelchair. NA-N indicated [gender] had removed the foam cushion from the resident's chair once before and was aware the resident should not have a foam cushion because of the pressure ulcer to the resident's buttock. Review of Resident 1's medical record revealed the following: -Treatment Administration Record dated 7/1/23 to 7/31/23 indicated the resident had an order for a pressure relief cushion . -Weekly Skin Check dated 7/18/23 at 12:01 PM indicated the resident had no new skin issues. -Braden Scale assessment dated [DATE] indicated the resident was assessed as a high risk to develop pressure ulcers. -Weekly Skin Check dated 7/25/23 at 1:30 PM, indicated the resident had a Stage II Pressure Ulcer [an open area with a red or pink wound bed, without slough (shedding dead tissue) or bruising] to the coccyx (a person's tail bone) that measured 1.0 Centimeters (cm) X 0.8 cm. -Weekly Skin Check dated 8/1/23 at 7:21 PM indicated there were no new skin issues and the treatment to the coccyx wound was to be continued. There was no evidence of documentation related to the characteristics of the wound (i.e size and appearance of the wound) and no evidence a Skin and Wound Evaluation had been completed. -Treatment Administration Record (TAR) dated 8/1/23 - 8/31/23 indicated the resident had a treatment with a start date of 7/25/23 for the pressure ulcer on the coccyx that consisted of cleansing with saline, place Aquacel AG (a dressing with antimicrobial properties specialized for hard to heal wounds that are infected or at risk for infection) to wound bed and cover with a Sacral Mepilex (a type of adhesive foam dressing). The treatment was to be completed every 3 days and as needed until healed. -Weekly Skin Check dated 8/8/23 at 7:22 PM indicated there were no new skin issues and coccyx improving, continue with treatment. -Skin & Wound Evaluation dated 8/9/23 at 4:42 PM indicated the resident had a Stage II pressure ulcer to the coccyx that was acquired in the facility on 7/25/23, the surface of the wound was intact and the wound was assessed as healable. In addition, a new order was received for a Duoderm (a flexible, waterproof, opaque dressing used to cover a wound that can remain in place for several days) and nursing would continue to monitor the area and update the physician as needed. There was no evidence wound measurements and characteristics were documented to determine if the wound was improving. -Nursing progress note dated 8/15/23 at 2:09 PM indicated the facility attempted to update the resident's representative that the wound on the coccyx area was intact, darkened and looks a little irritated and the treatment was going back to the Mepilex dressing. -Weekly Skin Check dated 8/15/23 at 7:23 PM indicated there was a Duoderm in place to coccyx. No other skin issues noted at this time. There was no evidence the Skin and Wound Evaluation was completed regarding the wound measurements and characteristics to determine if it was improving. -Physician Fax Sheet dated 8/16/23 at 5:13 PM indicated the resident had a wound to the sacral area that had denuded (to strip something of its covering) skin with a request to change the treatment to Aqualcel AG to denuded area, cover with sacral Mepilex and change every 3 days and daily as needed. Cleanse the area with normal saline (a wound cleanser) prior to application. -Weekly Skin Check dated 8/22/23 at 10:26 AM indicated Continue with treatment to wound to coccyx. Wound base yellow slough. No new skin areas noted. There was no evidence of documentation related to the size of the wound to determine if it was improving with the current treatment. -Progress note dated 8/25/23 at 2:58 PM indicated the wound to the sacral area is pressure stage 2 with slough in wound bed. There was no evidence of documentation related to the size of the wound and if it was improving. -Weekly Skin Check dated 8/29/23 at 2:18 PM indicated there were no new skin issues and Continue with current treatment to coccyx wound. Resident scheduled to see wound clinic. There was no evidence of documentation regarding wound measurements and characteristics to determine if it was improving. -Weekly Skin Check dated 9/5/23 at 12:30 PM indicated there were no new skin issues and Continue with treatments to pressure area to coccyx. Resident has appointment with wound clinic on Thursday. There was no evidence of documentation related to the pressure ulcer size and wound characteristics and if signs of healing or worsening. -9/7/23, Physician Visit Record related to the coccyx wound indicated the physician ordered; a Roho cushion to the wheelchair, reposition onto hips while in bed, and Doxycycline (antibiotic) 100 milligrams (mg) by mouth twice a day for 2 week. -Skin & Wound Evaluation dated 9/12/23 at 11:33 AM indicated the resident had a Deep Tissue Pressure Injury that was new and acquired while a resident at the facility. There was no information included under the sections; Wound Measurements, Wound Bed characteristics, drainage, and the surrounding skin tissue characteristics. -9/14/23, a Physician Visit Record related to the coccyx wound indicated the wound was deep with significant slough with orders to; Remove the Fomi (foam) cushion from chair. Patient needs to sit directly on Roho cushion. Needs position change every 2 hours. -Skin & Wound Evaluation dated 9/20/23 at 12:02 PM indicated the resident had a sacral wound that was Unstageable: Obscured full-thickness skin and tissue loss acquired at the facility on 9/7/23. The wound measurements were 14.0 cm 2 (6.0cm long X 3.2 cm wide) with 30% of the wound bed filled with slough and 60% filled with Eschar (a type of necrotic tissue-typically dry, black and firm, that can develop on severe wounds). In addition, there were no issues related to the surrounding tissue/skin, however, the wound was noted to be deteriorating. -Physician Visit Report dated 9/21/23 indicated the resident was see for wound care which noted the pressure ulcer of the coccyx was a Stage 4 (considered more serious with sores extending below the subcutaneous fat into deep tissues including muscle, tendons and ligaments) with poor healing prognosis. In addition, the physician ordered frequent position changes (at least every 2 hours). An interview with the facility's nurse consultant on 9/27/23 at 2:30 PM, confirmed the following related to Resident 1: -the resident had a pressure ulcer to the sacral area that had worsened since it developed on 7/25/23; -nursing staff should be repositioning the resident every 2 hours; -nursing staff should have completed the Skin & Wound Evaluation for the resident's PU to the sacral/coccyx area weekly with information including measurements and wound characteristics to determine whether the wound was improving; -there was no evidence the ordered treatment for the PU was documented as completed on 8/3/23. D. Review of Resident 8's plan of care with a printed date of 9/27/23 revealed the resident had the potential for skin breakdown related to limited mobility and frequent bowel and bladder incontinence. In addition, the resident had been assessed as a high risk to develop pressure ulcers with the following interventions; use a pressure relieving mattress on the bed, a Roho cushion on the chair and to keep [gender] heels off the mattress and foot rest. An observation of Resident 8 on 9/27/23 at 10:55 AM, revealed the resident was seated in a wheelchair with a foam cushion under the resident and no Roho cushion was observed inside the resident's room. An interview with the nurse consultant on 9/27/23 at 11:35 AM confirmed the following regarding Resident 8: -the resident was assessed as high risk for the development of pressure ulcers; -the resident should have had a Roho cushion under [gender] while seated in the chair and did not; -staff were not able to locate a Roho cushion in the resident's room; and -the facility was not able to determine the amount of time the Roho cushion had not been used with the resident.

Licensure Reference Numbers 175 NAC 12-006.09D7 Based on record review and interview; the facility failed to assure a safe environment was provided for residents identified at risk for falls as effective interventions were not provided to prevent falls with injuries for 1 (Resident 1) of 3 sampled residents. The facility census was 43. Findings are: Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/31/20 revealed [DIAGNOSES REDACTED]. The same assessment indicated the resident's cognition was severely impaired, the resident required extensive assist with transfers, bed mobility, dressing, toilet use and personal hygiene, was frequently involuntary of bowel and had a history of [REDACTED]. Review of Nursing Progress Notes revealed the following: -5/3/20 at 10:20 PM the resident was found on the floor in the resident's room. The resident indicated sliding out of the wheelchair while trying to undress for bed. The resident was wearing a regular sock on one foot and a gripper sock on the other. The resident was given a new pair of gripper socks; -5/4/20 at 1:41 PM an Occupational Therapy (OT) screen was initiated to assess the resident's wheelchair safety, undressing concerns, room and toileting safety; -5/11/20 at 8:15 AM the resident was found on the floor of the resident's room. The resident identified falling head first out of the wheelchair and having struck the right side of the resident's face on the floor. The resident had swelling and discoloration to the forehead and around the right eye. In addition, the resident sustained [REDACTED]. -5/12/20 at 12:15 PM an order was received from the resident's physician for an OT evaluation related to wheelchair safety, undressing concerns and room and toileting safety (8 days after the resident's fall out of the wheelchair on 5/3/20 and one day after the resident's fall from the wheelchair on 5/12/20); -5/12/20 at 12:51 PM a nursing order was written for a sit/stand fall alarm at all times. Staff were to monitor placement and function every shift; -5/18/20 at 5:45 PM an OT evaluation was completed and a plan of care was developed (15 days after the resident's fall on 5/3/20); -5/30/20 at 4:34 AM resident with increased confusion, the resident made attempts to self-transfer and then was able to quickly shut off the alarm when alarming; -6/1/20 4:12 AM up to the bathroom per self, alarm heard sounding and staff witnessed the resident trying to shut the alarm off; -6/1/20 at 11:40 AM a nursing order was initiated to discontinue the sit/stand alarm and to resume the motion alarm to the bathroom; and -7/2/20 at 11:00 PM staff were walking down the hall and heard the resident call out help. The resident was found on the floor of the resident's room between the bed and the wheelchair. The resident indicated attempting to pull back the covers on the bed and falling out of the wheelchair. Review of a Fall Report dated 7/2/20 revealed the facility identified a causal factor of the resident leaning forward to pull the covers back on the bed which caused the resident to slip out of the wheelchair. The resident was encouraged to call for staff assistance when pulling back bed linens. Review of Nursing Progress Notes revealed the following: -7/6/20 at 12:40 AM for the resident's safety, to continue to use motion alarm while the resident was so confused; and -7/7/20 at 10:30 PM the resident was found sitting on the floor of the resident's room. The resident stated I was making the bed. The resident sustained [REDACTED]. Review of a Fall Report dated 7/7/20 revealed root cause of the resident's fall was increased confusion as the resident was being treated for [REDACTED]. Review of a Nursing Progress Note dated 7/28/20 at 6:10 AM revealed the resident was found on the floor of the bathroom facing the hand washing sink. The resident voiced standing to wash hands, lost balance and fell . Review of a Fall Report dated 7/28/20 revealed the resident's call light was on at the time of the fall. The report identified a causal factor of self-transfer to the bathroom with a new intervention for a Tabs alarm. Review of Nursing Progress Notes revealed the following: -8/3/20 at 5:12 PM a nursing order was written for a Tab's alarm at all times (5 days after the resident's fall on 7/28/20); -8/6/20 at 2:49 AM when staff attempted to monitor placement and function of the Tabs alarm, they were unable to find the alarm; and -8/10/20 at 9:21 PM the resident was found on the floor of the resident's room next to the wheelchair. Review of a Fall Report dated 8/10/20 revealed the resident had a Tabs alarm ordered but there was no alarm on the resident and no alarm could be found in the resident's room. The report indicated a sit/stand alarm was placed. Review of a Fall Report dated 9/22/20 at 7:10 AM revealed the resident was found on the floor of the resident's room. The report identified causal factors of increased confusion and weakness. No fall alarm was in place. An intervention to prevent future falls was to make sure alarms were on and in working order. Review of Nursing Progress Note dated 9/23/20 at 4:22 PM revealed the following nursing orders: -discontinue motion sensor alarm; -bed alarm when in bed only; -Tabs alarm when up and out of bed; and -bolster mattress to bed. Review of a Fall Report dated 10/3/20 at 8:50 PM revealed the resident's alarm was sounding and the resident was found on the floor of the bathroom. Staff were to attempt to toilet the resident every 2 hours as a new intervention to prevent further falls. Review of a Fall Report dated 10/10/20 at 4:45 PM revealed the resident was found on the floor of the resident's room. The resident had attempted to self-transfer out of bed to the wheelchair which was positioned across the room. An intervention was put into place to keep the resident's wheelchair within reach when the resident was in bed. Review of Nursing Progress Notes revealed the following: -10/18/20 at 10:00 PM the resident was found on the floor in front of the wheelchair. The resident sustained [REDACTED]. The resident had taken off shoes and was wearing regular socks. No new interventions were identified to prevent further falls; and -10/21/20 at 6:30 PM the resident was found on the floor in front of the resident's wheelchair. The resident had a nose bleed, a 4 cm by 3 cm by 3 cm skin tear on the left elbow, a 1 cm skin tear to left forehead with a large black and blue lump between eyes. The resident had removed shoes and was only wearing socks, then slid to the floor when attempted to self-transfer. An intervention to remove shoes after the evening meal and to put gripper socks on the resident was identified. Review of a Fall Report dated 10/21/20 revealed the resident's fall alarm was not in place when the resident was found on the floor. An intervention to provide education to staff to assure fall alarms were in place was identified. Review of Nursing Progress Notes revealed the following: -10/29/20 at 4:30 PM the resident was positioned in a wheelchair in the doorway of the resident's room. Staff heard the resident's fall alarm and witnessed the resident lean forward and fall onto head. The resident sustained [REDACTED]. Previous laceration to right forehead reopened, the resident's right cheek was swollen and the resident had a laceration to the bridge of nose. The resident voiced complaint of pain to the neck and between shoulders. The resident was sent to the emergency room for evaluation and found to have a [MEDICAL CONDITION]; and -10/29/20 at 10/15 PM the resident returned from the emergency room with a neck collar in place. Review of a Fall Report dated 10/29/20 revealed the resident's fall occurred from leaning too far forward in the wheelchair. An intervention for OT to evaluate the resident's wheelchair was put into place to try and prevent further falls. Review of Nursing Progress Notes revealed the following: -10/30/20 at 1:09 PM family were notified the facility was going to try a tilt chair for the resident to try and prevent the resident from leaning forward in an attempt to eliminate further falls; -11/3/20 at 12:43 PM a new order was received for OT to evaluate and treat for potential changes in the resident's wheelchair (5 days after the resident's fall); -11/3/20 at 5:15 PM the resident was found lying face down on the floor of the resident's room. The resident was sent to the emergency room for evaluation; and -11/4/20 at 3:56 AM the resident returned from the emergency room . The resident had increased bruising to the resident's face with an abrasion to the forehead. Review of an OT Daily Treatment note indicated the resident's wheelchair positioning/safety was not evaluated until 11/5/20 (7 days after the residents fall on 10/30/20 and 2 days after the residents fall on 11/3/20). Interview with the Director of Nursing on 11/10/20 at 2:30 PM confirmed the following: -the resident is at high risk for falls; -each fall should have been assessed for causal factors and a new intervention was to be developed or current interventions were to be revised in an attempt to prevent ongoing falls; -the resident had a fall out of the wheelchair on 5/3/20. A new intervention was identified for an OT evaluation for wheelchair safety. The resident had a subsequent fall out of the wheelchair on 5/11/20. The resident sustained [REDACTED]. No order was obtained for an OT evaluation until 5/12/20 and the OT evaluation was not completed until 5/18/20; -the resident had a fall on 7/28/20 when self-transferring to the bathroom. An intervention was developed for a Tabs fall alarm. A nursing order for the alarm was not written until 8/3/20, 5 days after the fall; -the resident had falls on 8/6/20, 8/10/20 and on 9/22/20 in the resident's room. No fall alarm was found in the resident's room with any of these falls despite an order for [REDACTED].>-the resident had a fall out of the wheelchair on 10/29/20 and sustained a hematoma to the forehead, swelling and a laceration to the bridge of the resident's nose. The resident had complaints of neck pain and was seen in the emergency room . The resident had a C2 fracture. An intervention was identified for an OT evaluation regarding the resident's positioning in the wheelchair. The order for the OT evaluation was not obtained until 11/3/20. Resident 1 had another fall on 11/3/20 and was seen in the emergency room again. The resident was not evaluated by the OT regarding wheelchair positioning until 11/5/20.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7(a)(b) Based on observation, interview and record review; the facility failed 1) to ensure Residents 66 and 29, who were identified at risk for falls, were free from accident hazards related to the independent use of motorized recliners in their rooms, and 2) to identify causal factors of falls, to develop and/or revise fall prevention interventions, and to implement current interventions for the prevention of falls for Resident 42. 4 residents were reviewed for accidents related to falls, and the total facility census was 66. Findings are: A. Review of Resident 66's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/8/18 revealed the following: -severe cognitive impairment; -limited assistance with bed mobility, transfers, ambulation in the room and corridor; -extensive assistance with 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 -occasionally incontinent of bowels and bladder. Review of the Care Plan dated 5/28/18 indicated Resident 66 was at medium risk for falls due to impaired mobility related to low back pain, decreased cognition, impaired balance, and decreased safety awareness. Nursing interventions included the following: -limited to extensive assistance with transfers and ambulation; -sit/stand alarm (an alarm that sounds and alerts staff when the resident independently stands up from a seated position) was discontinued on 8/2/17; -encourage to stand straight with ambulation; has a hunched posture; -Occupational Therapy (OT) recommended SBA (stand by assistance) and/or set up assistance in the room due to impaired cognition and poor safety awareness; -provide education on needing to use call light and wait for staff assistance due to impaired safety, high fall risk, and impaired cognition; frequently shuts off alarms and self transfers in room; -educate to lock brakes on walker with all transfers; and -when noted up and walking around in room, provide assistance with finishing the care/task. Review of Progress Notes revealed the following related to Resident 66: -8/5/18 at 2:45 AM - self transferred and ambulated in the hall toward the nurses station. Intercepted by the nurse and provided a wheelchair due to bilateral hands shaking. Stated I want to go home. Returned to room and oriented to place and time of day. Blood sugar level was checked, found to be low, and treated with juice and a sandwich; and -8/13/18 at 5:45 PM - Restorative Therapy Aide (RTA) reported not able to ambulate as far as used to due to decreased activity tolerance. Review of a Rehabilitation Services Screen Request dated 8/16/18 revealed the following: -the resident's physician requests we get resident to sit back in recliner; -screen requested by Physical Therapy (PT) and OT to assess resident leaning forward; -screen completed by OT on 8/22/18 with a request for orders to evaluate and treat to address posture and positioning in the recliner and wheelchair; and -physician approval for OT to evaluate and treat the resident dated 8/28/18. Review of Progress Notes dated 9/1/18 revealed the following related to Resident 66: -2:45 AM - found lying on the left side in front of the motorized recliner in room. The recliner was observed to be in the highest position, and the resident was confused to time and day. There was a 5 cm (centimeter) laceration and surrounding hematoma (swelling) to the left forehead, and a 4 cm tear drop-sized abrasion to the left cheek; -4:45 AM - transported to the emergency room by ambulance; and -10:20 AM - admitted to the hospital with [REDACTED]. Review of the Fall Scene Investigation Report dated 9/1/18 revealed the following related to Resident 66's fall: -was attempting to self-transfer; -had raised the motorized recliner all the way up at other times in the past; -was found on the floor during rounds at 2:30 AM and had not used the call light to call for assistance; -refuses to sleep in bed and usually sleeps in recliner; and -the causal factor for the fall was determined to be motorized recliner in highest position and usually keeps hand control for recliner in lap. There was no evidence in Resident 66's medical record that use of the motorized recliner had been evaluated prior to the fall incident to determine if the resident could safely operate the recliner independently, and to assure the resident's safety. Review of Progress Notes dated 9/5/18 at 6:18 PM indicated Resident 66 was readmitted from the hospital and receiving Hospice services. During observation of nursing care on 10/3/18 from 9:21 AM until 9:50 AM, Nursing Assistant (NA)-H and NA-I provided repositioning and incontinent care for Resident 66. The resident was wearing a rigid cervical collar (neck brace used to immobilize and support the neck) and a wound was observed on the left side of the forehead, immediately above the hairline. During interviews on 10/04/18, the following was revealed: -7:00 AM - Licensed Practical Nurse (LPN)-J indicated at times Resident 66 activated the call light. And before staff could respond, elevated the recliner in order to be ready to go when staff arrived to provide assistance. LPN-J verified the resident required 1 person assist with ambulation to stabilize; and -8:46 AM - the Director of Nursing (DON) verified Resident 66's use of the motorized recliner had not been evaluated to determine if the resident could safely operate the recliner independently, and to assure the resident's safety. The resident would elevate the recliner in order to view birds outside the window, and tended to lean forward in the chair. The OT evaluation and treatment was never initiated due to the occurrence of the fall on 9/1/18 (4 days after the physician's orders [REDACTED]. B. Review of Resident 29's Morse Fall assessment dated [DATE] revealed the resident was at medium risk for falls. Review of Resident 29's current undated Care Plan revealed the resident had muscle weakness and was unable to ambulate. Further review revealed the resident had dementia and decreased cognition and required close supervision for safety. On 10/3/18 at 3:01 PM, Resident 29 was seated in a motorized recliner in the resident's room. The recliner was reclined back and the foot of the recliner was elevated. During an interview on 10/4/18 at 9:57 AM, NA-I revealed Resident 29 was usually placed in the motorized recliner after breakfast and the remote to the recliner was positioned in reach for the resident to use, if desired. During an interview on 10/4/18 at 2:00 PM, the DON confirmed a safety assessment had not been completed on Resident 29 to ensure the resident was safe to operate the motorized recliner. C. Review of an Incident/Accident Report dated 6/20/18 revealed Resident 42 had a fall at 11:10 PM. The resident's sit-to-stand alarm did not sound and the resident ambulated down the hallway and fell . The resident was last toileted at 7:00 PM with evening cares. At the time of the fall the resident was incontinent of a large amount of feces and needed to use the bathroom. The new intervention identified was to change the sit-to-stand alarm (The causal factors/new intervention did not address the resident's toileting needs). Review of an Incident/Accident Report dated 7/5/18 revealed Resident 42 attempted to self-transfer from the bed and the resident's sit-to-stand alarm did not sound. Resident 42 was incontinent of a large amount. The intervention identified was for a new alarm (The causal factors/new intervention did not address the resident's toileting needs). Review of Resident 42's Morse Fall assessment dated [DATE] revealed the resident was at high risk for falls. Review of Resident 42's current Care Plan dated 10/3/18 revealed the resident was at high risk for falls related to impaired mobility, balance issues, and impaired safety awareness. Fall prevention interventions included encouraging toileting every 2 hours and as needed, safety checks every hour and as needed when in bed, and a sit-to-stand alarm was to be on the resident at all times. Observations of Resident 42 from 10/3/18 revealed: - On 10/3/18 at 1:17 PM, the resident was seated in a wheelchair between the dining room and television sitting area. There was no sit-to-stand alarm to the wheelchair; - On 10/3/18 at 2:10 PM, the resident remained seated in a wheelchair between the dining room and television sitting area. There was no sit-to-stand alarm to the wheelchair; - On 10/3/18 at 2:25 PM, the resident was seated in the resident's recliner. There was no sit-to-stand alarm to the recliner; and - On 10/3/18 from 2:35 PM to 2:50 PM, the resident remained seated in the resident's recliner. There was no sit-to-stand alarm to the recliner. During an interview on 10/4/18 at 9:28 AM, NA-L confirmed Resident 42's fall prevention interventions included a sit-to-stand alarm to be used at all times. During an interview with the Special Care Unit (SCU) Coordinator on 10/4/18 at 10:34 AM the SCU Coordinator confirmed the resident was to have a sit-to-stand alarm in place at all times. If the resident had a fall then the Charge Nurse was responsible for assessing the resident, identifying causal factors, and identifying a new fall prevention intervention or revising current interventions.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on observations, record review, review of pressure ulcer policies and procedures and staff interview; the facility failed to provide treatment and services to prevent development of pressure ulcers and promote healing of existing ulcers for 3 of 15 sampled residents (Residents 40, 32 and 55). Sample size was 15. Facility census was 63. Findings are: A. Review of Resident 55's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/18/10 revealed [DIAGNOSES REDACTED]. The same MDS further identified the resident had short and long term memory problems with moderately impaired cognitive skills for decision making; required extensive assistance with bed mobility and/or transfer; was on a turning/repositioning program and had a Stage 3 pressure ulcer (full thickness of skin loss, exposing subcutaneous tissues and presents as a deep crater). Review of the facility policy and procedure dated 2001 for the Prevention of Pressure Ulcers revealed the resident's position should be changed every 2 hours when in bed and every hour when in a chair. The policy further stated that when a resident was in a chair, a gel or air cushion for pressure relief was indicated. Review of the 3/3/10 Braden scale (a measurement that identified risk of skin breakdown) revealed Resident 55 was at high risk to develop pressure ulcers. Review of Resident 55's Care Plan dated 3/24/10 revealed nursing staff were to provide assistance with bed mobility and encourage resident to reposition every 2 hours. The Care Plan further stated a pressure relieving mattress was applied to the resident's bed and a pressure relieving cushion was placed in the resident ' s wheelchair. Review of the E-Z Graph Wound Assessment Worksheet (a graph system that measures the size and depth of wounds) dated 7/7/10 revealed Resident 55 had a Stage 3 pressure ulcer to the left (L) hip which measured 3.7 cm (centimeter) by 1 cm with a wound depth of 1.2 cm. Review of the E-Z Graph Wound Assessment Sheets dated 9/8/10 revealed the L hip pressure ulcer was a Stage 3 which measured 1 cm by 0.6 cm with a depth of 1.5 cm. Further documentation indicated the resident developed a pressure ulcer to the right (R) inner ankle. Documentation indicated this pressure ulcer was non stageable (covered by a scab or dead tissue) and measured 0.5 cm by 0.4 cm. The wound was described as having a dark brown scab. Observations of Resident 55 on 9/21/10 and 9/22/10 revealed Resident 55 was up in the wheelchair from 6:30 AM until 4:00 PM. The wheelchair did not contain foot pedals and the resident ' s feet and legs were in a dependent position. No position changes were observed other than scheduled toileting. Interview with Nursing Assistant D on 9/22/10 from 10:25 AM until 10:22 AM revealed the resident usually did not lie down during the day. Observation of the treatment to the L hip on 9/22/10 from 10:00 AM until 10:20 AM revealed the resident had a Stage 3 pressure ulcer which measured 1 cm by 0.6 cm with a depth of 1.5 cm. Licensed Nurse C (LN-C) was observed to treat and measure Resident 55 ' s R ankle pressure ulcer on 9/23/10 from 10:10 AM until 10:25 AM. The pressure ulcer did not have a scab. LN-C indicated the pressure ulcer was a Stage 2 (partial thickness skin loss that presents as an abrasion, blister or shallow crater) and measured 0.4 cm by 0.4 cm. The resident was observed seated in the wheelchair with feet in dependent position on 9/23/10 from 6:30 AM until 4:00 PM. No position changes were observed other than scheduled toileting. Resident 55 was observed on 9/27/10 and 9/28/10 to be up in the wheelchair from 6:30 AM until 3:00 PM. On 9/29/10, the resident was observed up in the wheelchair from 6:30 AM until 1:15 PM. Documentation on the 9/29/10 E-Z Graph Wound Assessment Worksheet revealed the L hip Stage 3 pressure ulcer measured 1 cm by 0.6 cm with a wound depth of 2 cm (an increase of 0.5 cm depth). Interview with the Director of Nurses on 9/29/10 from 1:30 PM until 1:35 PM revealed the resident should not be up in the wheelchair the entire day until bedtime. B. Review of Resident 40's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further identified the resident had a history of [REDACTED]. in the bed/chair. Review of the Braden scale dated 1/27/10 revealed Resident 40 was at high risk to develop pressure ulcers. Review of the Care Plan dated 2/17/10, 5/12/10 and 8/4/10 revealed the resident had an air mattress (a mattress which provides alternating air pressure relief) on the bed. However, the Care Plan did not address if a pressure relieving cushion was provided for Resident 40's wheelchair. Review of Nurses Notes dated 8/10/10 at 9:45 PM and on 8/11/10 at 7:00 PM revealed a small amount of bloody drainage was noted to Resident 40's perineal area when perineal hygiene was provided. On 8/17/10 at 10:10 AM, Nurses Notes documented a "2 cm by 1 cm excoriated area to L buttock crack". A nursing intervention was initiated to apply [MEDICATION NAME] (a barrier protection cream) after each toileting and cover with dry cloth till healed. On 8/24/10 at 11:10 AM, Nurses Notes documented, " Excoriated area in crack of buttocks now black/red @ (at) edges, wound bed yellow". Review of the E-Z Graph Wound Assessment worksheet dated 8/24/10 revealed a 4 cm by 1.4 cm open area with a depth of 0.1 cm to the crack of the buttocks. The area was not staged. The graph worksheet further identified this information was sent to the MD (physician) and a request for an order for [REDACTED]. The OT indicated the resident would benefit from OT treatment in order to be set up with a pressure relieving wheelchair seating system. On 8/30/10 Resident 40 was seen at the wound clinic with orders to impregnate gauze with [MEDICATION NAME] and lightly pack the wound bed 2 times daily. On 8/31/10, the E-Z Graph worksheet documented wound location as, "L buttock, deep inside/crack of Buttocks". The wound was identified as a Stage 3 and measured 2.9 cm by 2 cm with a depth of 1.3 cm. Review of Care Plan documentation dated 9/1/10 revealed Resident 40 was to be up for meals only and reposition side to side when in bed. Review of Nurses Notes dated 9/2/10 at 10:00 PM revealed that while performing the pressure ulcer treatment to the L buttock, a foul odor was noted and the dressing was saturated with bloody greenish drainage. On 9/3/10 at 1:00 PM, the Nurses Notes documented that while performing the pressure ulcer treatment, the gauze packing that was removed from the pressure ulcer wound was saturated with red/green drainage. A foul odor was noted. The wound clinic MD was notified and ordered Keflex (an antibiotic used for infection). On 9/22/10, the pressure ulcer was documented as a Stage 3 and measured 2.2 cm by 2 cm with a depth of 0.8 cm. On 9/27/10, the resident returned to the wound clinic. The physician decreased the twice daily treatment to 1 time daily. On 9/29/10, the pressure ulcer was documented as a Stage 3 and measured 3 cm by 1.5 cm with a depth of 1 cm. C. Review of Resident 32's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 3/24/10, 6/6/10 and 9/1/10 MDS's further identified the resident had short and long term memory problems with severely impaired cognitive skills for daily decision making; was totally depended for bed mobility and transfers. The MDS's also identified the resident had functional limitation in range of motion for the arm and leg and full loss of range of motion of the hand. The 9/1/10 MDS further identified Resident 32 had a Stage 2 pressure ulcer, and the skin was desensitized to pain or pressure. Review of the Braden scale dated 3/31/10 and 9/7/10 revealed Resident 32 was at high risk to develop pressure ulcers. The Care Plan dated 4/14/10 revealed Resident 32 had contractures of the joints. Interventions were to wash bilateral hands and dry 2 times daily. The resident was to wear bilateral palm guards in the day time and a left hand palm guard at night. On 6/17/10, the OT changed the order to have the resident wear the R and L palm guards at all times. Review of Nurses Notes dated 8/2/10 at 6:35 AM revealed the left posterior 1st digit on the ring finger was excoriated and moist. At 5:30 PM on 8/2/10, the area was cleansed and a [MEDICATION NAME] (a dressing used for wound healing) dressing was applied along with the finger splint and hand splint. Review of the E-Z Graph Wound Assessment Worksheet dated 8/3/10 (no time documented) revealed the physician was notified of 2 Stage 2 pressure ulcers of the L palmar distal interphalangeal (DIP). The form stated, "Despite Nursing and OT interventions for DIP hyperextension (resident) developed x 2 (times 2) scabs, slough with cleansing". The physician gave orders for Resident 32 to be seen at a wound clinic. physician progress notes [REDACTED]. bilateral hand contractures". On 8/17/10, the E-Z Graph Wound Assessment Worksheet documented, "Palm guards to bilateral hands. Both areas scabbed with redness noted to entire pad of finger". On 9/1/10, this same graph documented a Stage 2, 0.2 cm by 0.2 cm with a 0.1 cm depth shallow wound at bed of finger. The treatment was to continue cleansing the finger with normal saline, apply dry gauze to wick moisture and apply palm guard continuous. On 9/6/10, the E-Z Graph documented that the Stage 2 pressure ulcer measured 0.5 cm by 0.4 cm with no depth documented. On 9/13/10 this same graph documented the pressure sore as a Stage 2 and measured 0.3 cm by 0.6 cm by 0.1 cm. The graph documented, "Treatment modified, palm guard with finger separators initiated. Memory foam to palm to offload fingertip". The graph also stated the OT had ordered a hand/wrist splint to improve off loading and positioning. On 9/17/10, the new hand splint was applied to Resident 32's left hand. On 9/23/10 the pressure ulcer measured 0.4 cm by 1.2 cm with a depth of 0.2 cm. This same graph documented, "interior wound skin white macerated, outer skin pulls away et (and) 'pocket' evident". D. Interview with the Director of Nurses on 9/29/10 from 1:30 PM until 1:33 PM revealed licensed nursing staff needed additional training regarding the prevention, identification and treatment of [REDACTED].