Every finding on record at Brookestone Acres

Based on observation, record review, and interviews, the facility failed to ensure that the posted Daily Nurse Staffing Form had an accurate census. This had the potential to affect all the residents in the facility. The facility census was 74 at the time of survey. Findings are:During an observation on 9/8/25 at 9:42 AM revealed the posted Daily Nurse Staffing Form near the front door stated the average census was 78.During an interview on 9/8/25 at 10:10 AM the Administrator (Adm) confirmed the current facility census was 74.During an observation on 9/9/25 at 8:32 AM revealed the posted Daily Nurse Staffing Form near the front door stated the average census was 78.During an interview on 9/9/25 at 10:10 AM the Assistant Director of Nursing (ADON) confirmed the current facility census was 74.During an observation on 9/10/25 at 8:32 AM revealed the posted Daily Nurse Staffing Form near the front door stated the average census was 78.During an interview on 9/10/25 at 10:10 AM the Adm confirmed the current facility census was 75.During an interview on 09/10/2025 at 10:19 AM the Staffing Coordinator (SC) confirmed that the posted Daily Nurse Staffing Form should have the actual facility census listed. It was also confirmed that the daily nurse staffing form is printed on Mondays for the past weekend.During an interview on 09/10/2025 at 10:52 AM the Regional Nurse Consultant (RNC) stated that it was a brand new computer program and there is no facility policy or procedure for filling out the Daily Nurse Staffing Form. During an interview on 09/10/2025 at 11:33 AM the Adm confirmed that the posted Daily Nurse Staffing Form was not accurate with the average daily census and it should have the actual facility daily census. During an interview on 09/11/2025 at 8:40 AM the Administrator confirmed that the posted Daily Nurse Staffing Form should be printed and hung before the day and updated as needed.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interviews, the facility failed to complete the care plan (a comprehensive, written document that outlines the personalized healthcare needs, goals, and interventions for a resident, based on a thorough assessment of the medical, functional, and psychosocial status) and to conduct the interdisciplinary care conference on three residents (Resident 1, 21, and 46) out of three residents sampled. The facility census was 74. Findings are: During an interview on 9/09/2025 at 2:15 PM the administrator confirmed the facility is behind on care plan conferences but the facility had an active Performance Improvement Plan (PIP) in place due to past non-compliance with the resident care conferences. During an interview on 09/09/2025 at 3:54 PM the Social Services (SS) confirmed that the care conferences have been behind. The facility started a plan on 8/1/2025 to get the care conferences caught up. A. During an interview on 9/8/25 at 1:24 pm Resident 1 revealed that (gender) hasn’t had a care plan conference for “quite a while”. Record review of Resident 1’s facility's nursing assessments and progress notes for the last 6 months did not reveal any care plan meeting notes. Record review of Resident 1’s Quarterly Minimum Data Set (MDS –a comprehensive assessment of each resident’s functional capabilities used to develop a resident’s plan of care) dated 8/20/2025 revealed that the resident admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident’s cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 10, with a primary diagnosis of Multiple Sclerosis. During an interview on 09/9/2025 at 4:32 PM the SS confirmed that there were no care plan meeting notes, care conference summary or care plan acknowledgment forms for Resident 1. B. During an interview on 9/8/2025 at 10:34 am Resident 21 revealed (gender) hasn’t had a care plan conference for “a long time”. Record review of Resident 21’s facility's nursing assessments and progress notes for the last 6 months did not reveal any care plan meeting notes. Record review of Resident 21’s Quarterly MDS dated [DATE] revealed that the resident admitted to the facility on [DATE], had a BIMS score of 15, with a primary diagnosis of Multiple Sclerosis. During an interview on 09/9/2025 at 4:32 PM the SS confirmed that there were no care plan meeting notes, conference summary or care plan acknowledgment forms for Resident 21. During an interview on 9/09/2025 at 4:30 PM the SS confirmed the care plans and conferences were still an issue and behind on completion. SS confirmed the PIP was not effective, and the facility will continue to work on the issue. SS confirmed the facility completed a Past Non-compliance plan on 8/1/2025 and there was no improvement with the process. Facility provided their current facility PIP's that included: skin integrity, and pressure injury prevention and falls. Record review of current facility PIP's revealed no process improvement plan for care plan conferences. An interview on 09/10/2025 at 3:25 PM with Administrator confirmed that the performance improvement projects have measurable goals and that they review the long term quality measures to find areas that need improvement, but confirmed the facility had no active plan to address the past due care plan conference. C. A record review of Resident 46’s “Clinical Census” revealed an admission date of 8/12/2024. A record review of Resident 46’s “Minimum Data Set” (MDS)(this comprehensive assessment evaluates each resident's functional capabilities) dated 07/31/2025 revealed a brief interview for mental status (BIMS) score of 15 which indicated the resident was cognitively intact. A record review of the Facility’s “Care Plan Acknowledgement Forms” dated 9/5/2024, 3/6/2025, and 5/5/2025 revealed care plan meetings were held. No “Care Plan Acknowledgement Form” was located for the November 2024 quarterly and the August 2025 annual care conference meeting. In an interview on 9/09/2025 at 2:15 PM with the administrator (Adm), confirmed the facility is behind on care plan conferences but the facility had an active process improvement plan (PIP) in place due to past non-compliance with the care conferences. In an interview on 9/09/2025 at 3:53 PM with Social Services (SS) confirmed the care plan conferences continue to be behind, a PIP was initiated on 8/1/2025 but the facility was still behind on the care conferences. In an interview on 9/09/2025 at 4:30 PM with SS confirmed the care plans and conferences were still an issue and behind on completion. SS confirmed the PIP was not effective, and the facility will continue to work on the issue. SS confirmed the facility completed a Past Non-compliance plan on 6/1/2025 and there was no improvement with the process. In an interview on 9/10/2025 at 8:35 AM with SS, confirmed there is no current system for scheduling the care plan conferences, when the MDS is due, an invite is sent to the family. SS confirmed that this does not always happen timely. In an interview on 9/10/2025 at 8:45 AM with MDS nurse, confirmed the facility use utilizes the MDS schedule in point click care (electronic documentation system) to trigger the care plan process. MDS nurse confirmed the care plan notice does not always get sent to the families timely and confirmed this was an issue. MDS nurse confirmed no awareness of the process that SS follows for the care plan process. In an interview on 9/10/2025 at 11:26 AM Resident 46 confirmed no involvement with care plan meetings or being invited and unaware if their children were invited. A record review of the SS's PIP initiated 8/1/2025 revealed an area of concern including timely completion of care plan conferences for residents in accordance with regulatory guidelines and facility policy. Components of the plan included: 1. Performance expectations: Scheduled and conducted within required timeframes (quarterly, annually, upon significant change. Documented accurately and completely in the resident's medical record. Coordinated with interdisciplinary team members and family/responsible parties. Compliance with Centers for Medicare and Medicaid services (CMS) regulations and state specific Long-Term Care (LTC)-requirements. 2. Observed performance issues included: Multiple care conferences have been delayed or missed. Lake of timely documentation following scheduled care conferences. Inconsistent communication with families and team members regarding scheduling. 3. Impact of performance issues included: Non-compliance with state and federal regulations. Potential negative impact on resident care planning and outcomes. Increased risk of citations during surveys. Decreased trust and satisfaction with residents and families. 4. Improvement goals included: Complete 100% of care conferences on time for the next 90 days. Ensure documentation is entered within 24 hours of the conference. Maintain a tracking system for upcoming conferences. Communicate proactively with families and team members to ensure participation. 5. Action plan included: Utilize the facility's electronic health record (EMR) tools for alerts and reminders. Meet weekly with the supervisor to review upcoming conferences and progress. Collaborate with the MDS coordinator and social services to streamline scheduling. Utilize cliniconex (communication software program used for scheduling and messaging) program to streamline invites vs mailing invitations by mail. The action plan included consequences of non-compliance and was signed and dated by SS on 8/1/2025. In an interview on 9/10/2025 at 9:00 AM with the administrator, confirmed there is no policy on care planning and the SS does not have a current process for tracking. Adm. confirmed this is an area that needs immediate improvement.

The facility failed to ensure physician orders for CPAP ( Continuous Positive Airway Pressure) devices included the required pressure setting for Residents 53 and 60.F695 - Respiratory CareLicensure Reference Number: 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review the facility failed to ensure that physician orders for Continuous Positive Airway Pressure (CPAP) therapy (a type of non-invasive ventilator that delivers pressurized air through a mask to keep the airway open during sleep) included complete and specific settings (pressure, ramp time, humidity, or other specifications) for 2 of 2 sampled residents (Resident 53 and Resident 60) in a facility census of 74. This failure had the potential to result in inadequate or unsafe respiratory care delivery.A.A record review of resident 53's Care Plan (a detailed document that outlines the specific healthcare needs, goals and interventions for the resident) dated September 9, 2025 revealed an intervention listed as CPAP as ordered under the altered respiratory function focus.A record review of resident 53's Clinical Physician Orders dated September 10, 2025 revealed an active order for CPAP when sleeping - every night shift. No pressure, ramp time, or humidity settings were identified.A record review of resident 53's Minimum Data Set (MDS, a federally mandated clinical assessment of all residents in Medicare or Medicaid certified nursing homes) Quarterly assessment dated [DATE] revealed the resident was receiving a non-invasive mechanical ventilator (CPAP) as part of the treatment plan.A record review of resident 53's Medical Diagnosis report dated September 9, 2025 revealed active diagnoses of Chronic Respiratory Failure with Hypoxia (a condition in which the lungs cannot supply enough oxygen to the blood) and Obstructive Sleep Apnea (a sleep disorder where breathing repeatedly stops and starts due to airway blockage), conditions requiring CPAP therapy.A record review of the facility's policy dated November 18, 2024 revealed that implementation required verifying the practitioner's order including settings before initiating CPAP therapy.In an interview conducted with the DON (Director of Nursing, the licensed nurse responsible for oversight of nursing services) at 11:40 a.m. on September 10, 2025, confirmed that physician orders for the CPAP machines for Resident 53 and Resident 60 did not include specific settings or specifications. The DON confirmed that the physician orders were incomplete and should have included the CPAP settings. The DON confirmed that per home settings could not be identified by staff and that she did not know what per home settings meant.B.A record review of resident 60's Care Plan dated August 27, 2025 revealed interventions related to sleep apnea (a disorder in which breathing repeatedly stops and starts during sleep) with CPAP (Continuous Positive Airway Pressure, a type of non-invasive ventilator that delivers pressurized air through a mask to keep the airway open during sleep) use and Amyotrophic Lateral Sclerosis (ALS, a progressive neurodegenerative disease affecting nerve cells in the brain and spinal cord), including CPAP while sleeping at night.A record review resident 60's Clinical Physician Orders dated September 10, 2025 revealed an active order for new CPAP with current settings. No settings were documented.A record review of resident 60's Order Summary dated September 10, 2025 revealed an active order for CPAP at HS (hour of sleep) per home settings every evening and night shift. No settings were documented.A record review of resident 60's Minimum Data Set (MDS, a federally mandated clinical assessment of all residents in Medicare or Medicaid certified nursing homes) Comprehensive assessment dated [DATE] revealed CPAP documented under Section O as a non-invasive ventilator in use.A record review of the facility's policy dated November 18, 2024 revealed that implementation required verifying the practitioner's order including settings before initiating CPAP therapy.In an interview conducted with the DON (Director of Nursing, the licensed nurse responsible for oversight of nursing services) at 11:40 a.m. on September 10, 2025, confirmed that physician orders for the CPAP machines for Resident 53 and Resident 60 did not include specific settings or specifications. The DON confirmed that the physician orders were incomplete and should have included the CPAP settings. The DON confirmed that per home settings could not be identified by staff and that (gender) did not know what per home settings meant.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D(l)(i)(3) Based on observations, record review, and interviews; the facility failed to implement, to revise and/or develop new interventions to prevent further falls for 2 (Residents 14 and 41) of 4 sampled residents. The facility census was 75. Findings are: A. Review of the facility Fall Prevention/Management Standard with a revised date of 1/2024 revealed the following guidelines: -residents were to be reviewed during the pre-admission/admission process to identify and determine risk for falls. -when a resident was identified at risk for falls, the care plan was to reflect the potential for injury/safety risk. Approaches/interventions were to be implemented and maintained related to identified areas of risk. All team members were to be knowledgeable of the resident's fall interventions. -falls were to be investigate as they occurred, and the staff were to collect factual evidence related to the fall event using the Root Cause Analysis process. The Root Cause Analysis is a process to find out what happened, why it happened and to determine what can be done to prevent it from happening again. -when the evaluation was completed, and the Charge Nurse had gathered enough information for a detailed report, they were to complete a Fall Scene Investigation Report. Appropriate interventions were to be implemented to prevent future falls based on information from the Fall Scene Investigation. The care plan was to be reviewed and revised with the dated interventions added. B. Review of Resident 41's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/9/24 revealed the following was assessed regarding the resident: -admitted [DATE] with diagnoses of dementia, hemiplegia (muscle weakness or paralysis on one side of the body) and depression. -was totally dependent on staff for assistance with bed mobility, transfers, dressing and toileting. -occasionally incontinent of urine. -had a history of falls with 2 falls without injury and 2 falls with injury (except major) since the previous assessment. Review of the resident's current Care Plan dated 5/17/24 revealed the resident had a history of falls and remained at risk related to confusion, dementia, and awareness of safety needs. The following interventions were identified: -5/17/24 anticipate and meet resident needs. -5/26/24 gripper socks when in bed. -6/3/24 assist the resident to the bathroom after all meals, stay with the resident and then transfer to bed, the recliner, or the recliner in the wife's room. -6/5/24 toilet the resident after the morning shift change. -6/6/24 get the resident up first for the day. -6/6/24 give the resident verbal reminders not to transfer or to ambulate without assistance. -6/8/24 encourage the resident to sit in the commons area before meals for visual assurance of safety. -6/9/24 keep the resident's walker and wheelchair next to the resident for safety. -6/10/24 frequent checks of the resident around mealtimes and staff to attend the resident when the resident leaves the dining table. -6/15/24 toilet the resident first on midnight rounds. -6/30/24 call light pendant to be worn on the outside of the resident's shirt. -6/30/24 check on the resident frequently. -7/4/24 resident to be brought to the commons area for visual safety assessment in the afternoon. -7/5/24 Dycem non-skid pad underneath cushions in chairs. -7/10/24 physically assist the resident the resident from the dining room to the resident's room, toilet and offer to transfer to the bed or the recliner. -7/13/24 both shoes to be worn during transfers. -7/17/24 non-skid floor strips on floor of bathroom. -8/15/24 toilet after the 2:00 PM shift change. Review of Fall Scene Investigation Reports for Resident 41 revealed the following: -6/3/24 at 2:10 PM the resident had a fall in the resident's room when attempting to self-transfer into the bathroom. New interventions identified were use of a pendant call light and to toilet the resident after meals. -6/4/24 at 11:30 PM the resident was found on the floor between the bed and the nightstand, and the resident indicated a need to use the bathroom. The resident was barefoot, and a new intervention was developed to make sure the resident wore gripper socks in bed and to provide more frequent toileting. -6/5/24 at 6:10 AM the resident fell when attempting to self-transfer to the bathroom. The resident was last toileted at 5:00 AM. A new intervention was developed to have the resident be the first gotten ready for the day. -6/8/24 at 11:00 AM the resident had attempted to self-transfer from the recliner to the wheelchair and fell . New intervention indicated for the staff to take the resident to the commons area prior to meals for visual assurance of safety. -6/10/24 at 6:05 PM the resident had a fall in their room when attempting to self-transfer into the bathroom. The resident had independently left the dining room after the evening meal. The report indicated the resident was last toileted at 10:35 AM (8 1/2 hours earlier). New interventions were listed for frequent checks, 1:1 with the resident if doing report or a shift change, to toilet immediately after leaving the dining room and staff to stay with the resident if wanting to leave the table in the dining room after meals. -6/13/24 at 8:45 AM the resident was found sitting on the floor of the bathroom in front of the toilet. Staff failed to document the last time the resident was toileted. The night shift had gotten the resident up and dressed, then laid the resident back in bed. The day shift got the resident up at about 6:45 AM and the resident was taken to breakfast at 7:45 AM. The resident then left the table at around 8:30 AM. The staff implemented a new intervention to position the resident by the window in the main dining room to make it easier for the staff to identify when exiting the dining room independently. -6/13/24 at 2:30 PM the resident had attempted to self-transfer to the wheelchair to get to the bathroom. The resident had been given a laxative that morning and had no results. New interventions included; walk-to-dine for all meals, to place in a regular dining room chair, increase the resident's laxative to twice a day and encourage increased fluid intake. -6/15/24 at 12:20 AM the resident attempted to self-transfer out of bed and into the wheelchair to use the bathroom. A new intervention was identified to toilet the resident first on midnight rounds. -6/19/24 at 6:30 PM the resident was in the wheelchair and had just finished eating in the dining room. The resident left the dining room independently and fell when attempting to self-transfer into bed. The staff were to ensure the resident was assisted to the bathroom immediately after meals and to offer to reposition the resident in bed or the recliner after toileting. -6/30/24 at 4:00 PM the resident fell when attempting to self-transfer into the bathroom for toileting. The resident's call light pendant was in place but was underneath of the resident's shirt. A new intervention was indicated to place the pendant on the outside of the resident's shirt. -7/4/24 at 4:30 PM the resident had a fall when attempting to self-transfer into the wheelchair to get to the bathroom. New interventions were developed for a medication review and a 3-day Bowel and Bladder assessment. -7/5/24 at 10:15 AM the resident attempted to self-transfer from the recliner to the wheelchair to use the bathroom. A gel cushion was in the seat of the recliner and had gotten tucked into the back of the chair making the front of the recliner seat [NAME]. Staff placed a Dycem non-slip pad between the gel cushion and the recliner seat to prevent the cushion from sliding. -7/10/24 at 8:30 AM the resident was found on the floor of the resident's room after self-transferring out of the recliner. The facility implemented a new intervention for staff to keep the resident in the dining room/living room until staff was able to take to the bathroom and then safely transfer into the bed/recliner. No further interventions were developed. -7/13/24 at 6:40 PM the resident fell when attempting to self-transfer from the wheelchair and into the resident's bed. Staff were to toilet the resident after meals and then place the resident into bed. No further interventions were identified. -7/17/24 at 7:45 AM the resident fell when attempting to self-transfer into the bathroom. Staff failed to document when the resident was last toileted. The resident was eating the breakfast meal in the resident's room. A new intervention for non-slip strips to be placed on the bathroom floor was identified. -7/26/24 at 7:25 PM the resident fell when attempting to self-transfer from the recliner to the wheelchair. Resident was more confused and seemed more worried than usual. The staff initiated 15-minute checks on the resident. -8/15/24 at 3:30 PM the resident had a fall in the resident's room when attempting to self-transfer and indicated a need to use the bathroom. A new intervention was indicated for staff to toilet the resident at shift change. Observations of Resident 41 revealed the following: -8/27/24 at 12:09 PM the resident was in the wheelchair with bilateral foot pedals in place and staff provided total assist with mobility from the resident's room to the dining room. The resident had not been seated in the common's area to increase visual supervision prior to the meal and staff failed to walk the resident to the dining room and to transfer the resident into a regular chair once in the dining room. -8/27/24 at 1:41 PM the resident was provided total assist with mobility out of the dining room and to the resident's room. Staff made no attempt to ambulate with the resident back to the resident's room. -8/28/24 at 7:17 AM staff assisted the resident out of the recliner and into the wheelchair. Staff failed to toilet the resident prior to going to the dining room, made no attempt to walk the resident or to position the resident into a regular chair once in the dining room. -8/28/24 at 12:47 PM the staff provided the resident total assist with wheelchair mobility out of the dining room to the resident's room. The resident was not seated in a regular chair and the staff did not provide an opportunity for the resident to participate in the walk-n-dine program. An interview with the Director of Nursing on 8/27/24 at 2:42 PM confirmed the following: -the Charge Nurses were responsible for identifying causal factors and then developing a new intervention or revising current interventions with each resident fall. -Resident 41 was at high risk for ongoing falls and was very difficult to keep from falling. -the resident was to be toileted before and after meals or every 2 hours especially at night. -with the resident's fall on 6/8/24 at 11:00 AM the resident was attempting to self-transfer out of the recliner and into the wheelchair. A new intervention was indicated to take the resident out to the commons area prior to meals for visual assurance of safety. -with the resident's fall on 6/10/24 at 6:05 PM the resident left the dining room unattended and attempted to self-transfer into the bathroom. The Fall Scene Investigation Report indicated the last time staff toileted the resident was at 10:30 AM despite an intervention dated 6/4/24 for frequent toileting. -with the resident's fall on 6/13/24 at 2:30 PM the resident attempted to self-transfer into the bathroom. New interventions were identified for walking the resident to/from the dining room for all meals and to transfer into a regular chair in the dining room. -with the fall on 6/19/24 at 6:30 PM the resident left the dining room in the wheelchair and self-propelled to the resident's room then attempted to self-transfer into bed. Staff had failed to walk the resident to the dining room, to place the resident in a regular chair, to walk the resident back to their room and to toilet the resident immediately after the meal. -with the resident's fall on 7/4/24 at 4:30 PM the resident had attempted to self-transfer into the wheelchair. New interventions were identified for a medication review and a 3-day Bowel and Bladder assessment. The medication review was completed 7/11/24 with no changes and no patterns or changes with identified with the Bowel and Bladder assessment to prevent further falls. -with the fall on 7/13/24 at 6:40 PM the resident had left the dining room in the wheelchair independently and self-transferred out of the wheelchair trying to put self in the bed. The resident was not walked to/from the dining room and had not been placed in a regular chair in the dining room. In addition, the resident was not immediately toileted after the evening meal. -with the fall on 7/10/24 at 8:30 AM the resident independently left the dining room in the wheelchair and fell when attempting to self-transfer in the resident's room. The resident was not walked to/from the dining room and had not been placed in a regular chair in the dining room. In addition, the resident was not immediately toileted after the breakfast meal. During an interview on 8/28/24 at 7:34 AM, Nurse Aide (NA)-A confirmed the resident was to be toileted every 2 hours, and/or before and after all meals. NA-A indicated the staff did not place the resident in the commons area before or after meals but would normally take the resident back to their room. NA-A was unaware the resident was on a walk-to-dine program or that the resident was to be transferred out of the wheelchair and into a regular chair when in the dining room for meals. 45739 C. Review of Resident 14's MDS dated [DATE] revealed the resident was cognitively impaired, had diagnoses of heart disease, arthritis, and dementia, was dependent with toileting, dressing, transfers and personal hygiene, and had two or more falls without injury. Review of Resident 14's Care Plan last revised 7/24/24 revealed the following: -the resident had dementia, -required assistance with bed mobility, dressing, transfers, and personal hygiene, and -fall interventions included: place items frequently used within reach, keep the wheelchair next to the bed, traction strips on the floor in the bathroom, toilet before and after meals, take the resident back to the resident room to assist to bathroom as needed and help transfer into bed after meals, initiate routine bowel movement, take from the dining room to the bathroom immediately after lunch; and offer to lay down after lunch after being toileted. Review of the facility forms Fall Scene Investigation Reports regarding Resident 14 revealed the following: -6/25/24 at 3:50 AM the resident was observed on the floor. The resident stated they were trying to go to the restroom and had gone 2 days without a bowel movement. The intervention implemented was to toilet the resident after breakfast daily and to stay with the resident to promote a daily bowel movement. No new intervention had been implemented, and -7/26/24 at 1:00 PM the resident was observed on the floor. The resident stated they were trying to get into bed. The intervention implemented was to assist to bed after breakfast and lunch. No new intervention was implemented. Interview on 8/29/24 at 1:35 PM with the DON and the Administrator confirmed new interventions were not implemented for Resident 14 for falls on 6/25/24 and 7/26/24.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to have a diagnosis for the use of an antipsychotic (a drug or substance that affects how the brain works) medication and to attempt a gradual dose reduction (GDR) and/or have a documented contraindication for use of the antipsychotic medication for 1 (Resident 50) of 5 sampled residents. The facility census was 75. Findings are: A. Review of the Psychoactive Medication and Medication Regimen Review Management Standard dated 6/2024 revealed the following: -residents were not given psychotropic 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. -psychotropic medications included antipsychotics, antidepressants, anti-anxiety, and hypnotics. -attending physicians assumed leadership in medication management by developing, monitoring, and modifying regimens in collaboration with residents, families/responsible parties, other professionals, and the interdisciplinary team. -the indication for use of psychotropic medications were documented in the medical record. -residents and their families were educated on the benefits and risks of psychotropic medications as well as alternate treatments available. -residents who used psychotropic medications received gradual dose reductions, unless clinically contraindicated, to discontinue those medications. -the Physician in collaboration with the Consultant Pharmacist re-evaluated the use of medication and considered whether the medication could be reduced or discontinued. B. Review of Resident 50's Minimum Data Set (MDS- federally mandated comprehensive assessment used to develop resident Care Plans) dated 8/15/24 revealed the resident had diagnoses of Alzheimer's disease, dementia, anxiety, and depression. The resident had no behaviors, and the resident took an antipsychotic and an antianxiety medication. Review of Resident 50's Physician's Orders revealed an order for the antianxiety medication Lorazepam cream 1 milligram (mg)/milliliter (ml) 0.5 ml to be applied topically twice a day for anxiety and restlessness dated 8/4/23. Review of Resident 50's Monthly Medication Review (MMR) dated 1/18/24 revealed the Consultant Pharmacist had made a recommendation to attempt a GDR for the resident's Lorazepam or to provide a clinical rationale as to why the GDR should not be attempted. The resident's Physician returned the recommendation on 2/28/24 with a response to continue the medication as needed. Further review revealed no clinical rational was provided regarding why a GDR could not be attempted for the resident's Lorazepam. Review of Resident 50's Physician Orders revealed an order dated 9/21/23 for the antipsychotic medication Seroquel 25 mg to be administered twice a day for a diagnosis of dementia. Review of an MMR dated 11/22/23 revealed the Consultant Pharmacist had sent a note to the resident's physician asking for a diagnosis for the resident's Seroquel and requesting a trial GDR for the medication or a documented rationale versus benefit as to why a GDR should not be attempted. Review of the physician's response dated 12/6/23 revealed a new diagnosis of agitation/dementia and to continue use of the medication with no GDR due to a potential risk of injury to self or others. Further review revealed no documentation regarding a clinical rationale for continued use of the Seroquel. Review of an MMR dated 5/16/24 revealed the Consultant Pharmacist again asked the resident's physician for an appropriate diagnosis for use of the Seroquel and requested a trial GDR for the medication or a documented clinical rationale as to why no GDR was to be attempted. The physician responded on 5/20/24 to continue use of the medication for the resident's safety. During an interview on 8/28/24 at 3:02 PM, the Director of Nursing confirmed the facility had no evidence the facility had attempted a GDR of Resident 50's Lorazepam and Seroquel and had no evidence of a documented contraindication by the provider.

Licensure Reference Number 175 NAC 12-006.17 Based on observations, record review and interview, the facility failed to wear personal protective equipment (PPE) and clean reusable equipment in accordance with facility policy to prevent the potential spread of Covid-19. The sample size was 22 and the facility census was 57. Findings are: A. Review of the facility policy Cleaning, Storage, and Maintenance dated 2/2019 revealed the following related to cleaning and disinfecting of mechanical lifts/sling pads (an assistive device used to transfer a person safely from one location to another): -When handling contaminated slings, disposable protective gloves shall be used. Additional PPE should be used when appropriate. -Slings must be laundered when used for residents on isolation precautions. -Disinfect all surfaces that come in direct contact with the resident's skin with a [NAME] Health Services (VHS) approved disinfectant between each resident use. B. Review of the facility policy Covid-19 Guidelines dated 5/11/23 revealed the following: -Residents who test positive for Covid-19 will be placed on isolation precautions identified as Red Zone Isolation. Residents should be isolated to their room and wear a face mask when staff provide direct cares. Staff should wear an N95 or higher respirator/mask, eye protection, isolation gown and gloves. -Residents identified at risk for Covid-19 will be placed in Yellow Zone Isolation. Staff should wear an N95 mask or higher and eye protection. Additional PPE should be used as indicated. C. Observation of staff providing cares to Resident 23 on 8/3/23 from 07:15 AM - 07:35 AM revealed the following: -A yellow colored sign was posted on the outside of the room that indicated the resident was on Yellow Zone Isolation and staff should wear an N95 mask and eye protection before entering the room. -Nursing Assistant (NA)-N was wearing an N95 mask, the bottom strap was missing and secured with one strap at the top. The mask was not secured properly with both straps. -NA-N assisted the resident to transfer to the bathroom using a mechanical sit/stand lift (a device used to safely transfer a resident from one location to another) and secured the resident to the lift with a sling pad. While the resident was seated on the toilet, the excess strap from the waste belt of the sling pad, fell between the resident's bare legs and made contact with the resident's skin. -After the resident cares were completed, NA-N exited the room with the mechanical sit/stand lift and moved it to the hallway. NA-N disinfected the mechanical lift, but did not clean, disinfect or launder the sling pad that was used directly on the resident on isolation precautions. Interview with NA-N confirmed the sling pad should have been disinfected with an approved product and the N95 mask should have 2 straps attached to secure the mask properly and it did not. 45739 D. Interview on 8/1/23 at 7:30 AM with the Infection Preventionist (IP-L) revealed there were 2 Covid-19 positive residents on the 300 hallway. IP-L instructions were to wear N95's (a respiratory device mask designed to achieve a very close fit to protect and filter airborne particles) and eyewear in the 300 hallway. Observation on 8/1/23 at 7:35 AM the doorway leading into the 300 hallway was closed with signage on the door stating the hallway was a yellow zone. An N95 mask and a face shield or eye protection were required to go into the hallway. Observation on 8/3/23 at 8:44 AM revealed Nursing NA-Q was in the 300 hallway wearing an N95 mask with only the top strap on, the bottom strap had been cut and the N95 mask was not fitted to NA-Q's face. The N95 mask hung below NA-Q's chin. NA-Q was not wearing any protective eyewear or a face shield. Interview with NA-Q on 8/3/23 at 8:44 AM NA-Q revealed that NA-Q was not wearing the N95 mask correctly, NA-Q was supposed to be utilizing both straps on the N95 mask and was not wearing any protective eye wear because it was too big for NA-Q's face and kept falling off. Observation on 8/3/23 at 8:45 AM Licensed Practical Nurse-R (LPN-R), was wearing an N95 mask using only the top strap. Interview with LPN-R revealed that LPN-R was supposed to wear both straps on the N95 mask. Interview 8/3/23 at 8:54 AM with the Director of Nursing (DON) and the Administrator confirmed staff in the 300 hallway should be wearing the N95 masks appropriately with 2 straps, the mask should be covering their faces, and staff should be wearing protective eye wear.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to notify the provider for a condition change for 1 resident (Resident 39). The sample size was 1 and the facility census was 57. Findings are: A. Review of Resident 39's Nursing Progress Notes dated 5/25/23 at 1:37 PM revealed the resident was being monitored for a potential Urinary Tract Infection (UTI) related to symptoms of aggression, very odorous urine and the resident was more lethargic (a state of fatigue involving a lack of energy and motivation for physical and mental tasks). Review of Resident 39's record Monitoring for Suspected Urinary Tract Infections dated 5/25/23 through 5/28/23 revealed the following regarding the resident's urinary status: -on 5/25/23, the urine was cloudy with a foul odor, had symptoms of lethargy, malaise (a general feeling of discomfort, illness or uneasiness) and a change in mental status; -on 5/26/23, the urine had a foul odor and symptoms of malaise and lethargy were noted; -on 5/27/23, the urine was cloudy with a foul odor and symptoms of lethargy and a change in the resident's mental status was noted; and -on 5/28/23, the physician was to be updated for recommendations or orders and was not notified until 5/31/23 (6 days after symptoms were first identified). In addition, the monitoring form indicated if a resident had a significant change of condition (ie. lethargy and/or a change in mental status) the nurse should notify the physician immediately. Review of Resident 39's medical record revealed the following: -a Clinical Assessment and Communication Tool Template for Suspected UTI dated 5/31/23 was sent to the physician by facsimile at 5:02 PM; -the resident's symptoms were foul urine odor, cloudy urine, lethargy, malaise and there was a change in mental status; and -the physician ordered a Urine Analysis (UA) sample be obtained. Review of Resident 39's Nursing Progress Notes dated 5/31/23 through 6/11/23 revealed the following: -6/1/23 at 5:55 PM, the nurse was unable to obtain the urine sample and there was no evidence the physician was notified; -6/2/23 at 3:35 PM, the nurse was unable to obtain the urine sample and there was no evidence the physician was notified; -6/3/23 there was no evidence of documentation a UA sample was obtained or attempted; -6/4/23 at 2:53 PM, the nurse was unable to obtain the urine sample and updated the physician by facsimile, requesting to use a urinary catheter (a soft, thin tube inserted into the bladder used to pass urine from the body) to obtain the urine sample; -6/7/23 at 2:27 PM (3 days later), an order was received for staff to use a catheter to obtain the urine sample with two unsuccessful attempts noted; -6/7/23 at 6:56 PM, the resident had 5 nickel sized clots of dark red blood noted and there was no evidence the physician was notified; -6/8/23 at 2:16 AM, the resident had a fever of 102.2 and was given 1000 milligrams of Tylenol; -6/8/23 at 3:00 AM, the physician was notified via phone, at 3:45 AM the resident was transferred to the ER and returned to the facility at 9:00 AM with a diagnosis of a UTI; -6/8/23 at 10:40 AM, the resident was observed shaking, breathing heavy and sporadically .very tense and clenching hands/arms/torso. The resident was transferred to the ER at 11:40 AM and was admitted to the hospital. During an interview on 8/3/23 at 11:30 AM with the Infection Preventionist (IP- a professional who ensures healthcare workers and patients are doing things appropriately to prevent infections), the IP confirmed the following regarding Resident 39: -the resident had a significant change of condition identified on 5/25/23 related to symptoms of lethargy and a change in mental status; -the physician should have been notified of the resident's condition change immediately on 5/25/23 and was not notified until 6 days later on 5/31/23; and -the resident was diagnosed with a UTI and was hospitalized on [DATE].

Licensure Reference Number 175 NAC 12-006.02(1) Based on record review and interview, the facility failed to submit transfer and discharge notifications to the State Ombudsman (an official appointed to investigate individuals' complaints and serves as a consumer advocate) as required for Resident 9. The facility census was 57. Findings are: Review of Resident 9's Census List revealed the resident was discharged to the hospital on 4/19/23, 5/22/23, and 6/24/23. Review of Resident 9's Medical Records revealed no evidence the State Ombudsman was notified of any discharges from 4/19/23 through 6/24/23. During an interview on 8/2/23 the Social Services Director confirmed the facility did not notify the State Ombudsman of Resident 9's hospital discharges.

Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide Resident 9 or the resident's representative, bed hold information when the resident was transferred to the hospital. The sample size was 22 and the facility census was 57. Findings are: Review of the undated facility Notice of Bed Hold Policy revealed the facility advised the resident and or family of the bed hold policy, in writing within 24 hours of an emergency transfer to inform them of the bed hold rate (daily cost/rate for the type of room being held for the resident). Review of Resident 9's Census List revealed the resident was transferred to the hospital on 4/19/23, 5/22/23, and again on 6/24/23. Review of Resident 9's medical record from 4/19/23 through 6/25/23 revealed no evidence the resident or the resident's representative were notified of the facility bed hold policy. During an interview on 8/1/23 at 3:15 PM the Director of Nursing confirmed the facility had no documented evidence that Resident 9 or their representative were provided with the required bed hold information when discharged to the hospital on 4/19/23, 5/22/23, and 6/24/23.

Licensure Reference Number 175 NAC 12-006.09B1 Based on record review and interview, the facility failed to ensure Resident 4's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) was coded to reflect the resident's health status. The sample size was 22 and the facility census was 57. Findings are: Review of Resident 4's Preadmission Screening and Resident Review (PASRR-federally required screening required for all individuals being considered for nursing facility admission, to determine if the person has or was suspected of having a mental illness, intellectual disability, or related disorder, and used to ensure that individuals were not inappropriately placed in nursing homes for long term care) dated 2/25/20 revealed the resident had a level 2 (extended) assessment completed and the facility needed to document this by marking yes to question 1500A on the MDS indicating the resident had a serious mental illness, developmental disability, or related disorder. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted on [DATE], had a diagnosis of a psychotic disorder, and question 1500A indicated no to the question if a level 2 screen had been completed. Review of Resident 4's Care Plan with a revision date of 3/22/23 revealed the resident used psychoactive (affecting the mind) medication due to mental issues. During an interview on 8/1/23 at 3:40 PM the Director of Nursing confirmed that Resident 4 had a level 2 PASRR screen completed, did have a mental illness diagnosis, however the MDS assessment completed on 1/26/23 was inaccurately coded and did not reflect that a level 2 screen had been completed.

License Reference Number 175 NAC 12-006.09C3 Based on record review and interview, the facility failed to complete a discharge summary for Resident 56. The sample size was 3 and the facility census was 57 residents at the time of the survey. Findings are: Record review of Resident 56's Progress Note dated 6/26/2023 at 9:15 PM, revealed the resident had been transferred to the hospital. Review of Resident 56's records revealed there was no discharge summary. An interview with the Administrator on 8/2/2023 at 8:00 AM, revealed Resident 56 had discharged to the hospital on 6/26/2023 and did not return to the facility. An interview with the Administrator on 8/2/2023 at 8:27 AM confirmed the facility did not do a discharge summary for Resident 56. An interview with the Director of Nursing on 8/2/2023 at 10:31 AM revealed the facility had a process they followed for discharges and a discharge summary needed to be completed within 30 days. The DON confirmed a discharge summary had not been completed for Resident 56.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review: the facility failed to implement interventions to protect from a potential burn from a hot liquid spill for Resident 10. The sample size was 5 and the facility census was 57. Findings are: Review of the Hot Liquid Management Guidelines policy dated 3/2016 revealed if residents were assessed at high risk upon admission, readmission, quarterly and with a significant change the following elements were to be implemented: - reduce the temperature of the hot liquid, - use adaptive equipment/clothing as necessary, - update the care plan, - place hot items towards the center of the table but within a comfortable reaching distance for the resident, - remind residents that you have served them a hot beverage, and - residents with hot liquids should not be left unsupervised. Review of Resident 10's Hot Liquid Screening form on admitted d 2/20/23 revealed therapist recommendations for cool hot liquids and all drinks would have lids. A Hot Liquids Risk Assessment completed 3/23/23 revealed the resident had a risk factor of confusion, and the resident had a history of accidents/injury with use of hot beverages. Review of the Resident's Progress Notes revealed an entry on 3/3/23 at 8:00AM revealed the resident accidently spilled coffee on their thigh and was assisted to remove their pants. The nurse assessed the resident's skin and noted redness to the inner thighs. A cold/wet washcloth was applied. Review of the Investigation Report sent into the state agency on 3/10/23 revealed interventions were to have [NAME] cups (a lightweight cup with a handle and a lid with a straw) for all liquids, cups with hot liquids were to be served half full, a clothing protector with a fluid resistance backing would be placed in the resident's lap for all hot liquids, and supervision would be provided with all meals. Review of the Resident's Care Plan last revised 3/22/23 revealed the following: - the resident had a history of cognitive impairment related to dementia, - hot liquid burn preventions interventions included: all cups need lids, cool hot liquids, clothing protector on lap with hot liquids, place hot items towards the center of the table but within a comfortable reaching distance, provide room with adequate lighting, and remind the resident that the beverage served wass hot. Interview with the Resident on 7/31/23 at 11:20 AM revealed that the resident had an incident a few months back when the resident spilled their hot coffee in their own lap at breakfast. The resident was unsure of interventions put into place. Observation on 8/3/23 at 8:21 AM Resident 10 was sitting in the resident room in the dark with the television on. There was a regular coffee cup full of coffee with no lid on the cup. The cup was sitting on the tray table. The resident wasn't wearing a clothing protector. The resident stated that the coffee was hot, but the resident would just use the blanket on the resident lap to catch any spills. Interview with Licensed Practical Nurse (LPN-R) on 8/3/23 at 8:27 AM revealed the resident was high risk for hot spills with interventions to prevent hot spills including: the resident should have a cup with a lid on it, a clothing protector on the resident lap with hot liquids, hot liquids should be placed towards the center of the table, the light should be on in the resident room and to remind the resident that beverages are hot. At 8:27 AM LPN-R enters the resident room and confirmed the light was not on in the resident room, coffee was not served in a covered mug and there was no clothing protector in place. Interview with Director of Nursing and the Administrator on 8/3/23 at 8:54 AM confirmed the resident was at high risk for hot liquid spills and should have a clothing protector and a covered mug in place.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure Resident 9's antipsychotic (medication that works by altering brain chemistry to help reduce psychotic symptoms like hallucinations (seeing things not present), delusions (fixed and firm belief not supported by evidence), and disordered thinking) medication had an appropriate indication for use. The sample size was 5 and the facility census was 57. Findings are: Review of Resident 9's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 7/4/23 revealed 1.) diagnoses of hypertension, urinary tract infection, diabetes, anxiety, and depression. 2.) the resident received extensive assistance with bed mobility, transfers, toileting, and dressing, 3) the resident was frequently incontinent of bladder, received anti-anxiety and antidepressant medication 5 of the previous 7 days, and had no indication of hallucination, delusion, disordered thinking, or insomnia (inability to sleep). Review of Resident 9's Progress revealed the following; -on 7/1/23 at 4:30 AM the resident rested all night in bed and there was no evidence the resident had insomnia, -on 7/3/23 at 3:52 AM Quetiapine Fumarate 25mg was ordered as needed for restlessness and insomnia, -on 7/10/23 at 7:35 AM the resident's daughter called to speak to a nurse and was upset about the resident reporting not sleeping well, -on 7/11/23 at 11:52 AM the resident was given Quetiapine Fumarate due to being restless in bed, and unable to sleep, and further review revealed no evidence that any measures were taken to address the resident's insomnia prior to the use of the antipsychotic medication Quetiapine Fumurate. Review of Resident 9's Physician Order dated 7/12/23 revealed an order for Quetiapine Fumarate (antipsychotic medication) daily for insomnia. Review of Resident 9's Care Plan with a revision date of 8/1/23 revealed no evidence the resident had insomnia, hallucinations or delusions, or was taking the antipsychotic medication Quetiapine Fumarate. During an interview on 8/1/23 at 3:40 PM the Director of Nursing (DON) confirmed the facility had no evidence that Resident 9 was provided with alternative measures to address insomnia prior to the use of the antipsychotic medication Quetiapine Fumarate. Further interview revealed the DON was unaware of any hallucinations, delusions, or psychosis.

Licensure Reference Number 175 NAC 12-006.10B1 Based on observation, record review and interview the facility failed to ensure 1 resident (Resident 13's) medications were properly secured. The sample size was 1 and the facility census was 57. Findings are: A. An observation of Resident 13 on 07/31/23 revealed the following: -At 10:30 AM the resident was seated in [gender] room alone and had a small, clear plastic cup with multiple medications inside on a table. -At 10:35 AM there were 8 loose medications sitting on top of the resident's table. The resident asked this surveyor what the brown and white capsules (3 of them) were and was unsure if [gender] should take them due to an upcoming medical procedure. -At 10:55 AM Licensed Practical Nurse (LPN)-A, was asked to assist the resident with the medication concern and LPN-A informed the resident the 3 brown and white capsules were Budesonide capsules and were prescribed for [gender] lungs to help with breathing. The resident stated [gender] thought the medication was to stop diarrhea and did not want to take it, if that was what the medication was for. LPN-A informed the resident [gender] would remove the Budesonide capsules and [gender] did not have to take them. LPN-A, then removed the 3 Budesonide capsules and wrapped them inside a disposable glove and disposed of the medication in the resident's trashcan. B. Review of the facility policy Self-Administration of Medications dated 2/2018 revealed the following: -The purpose of the policy was to allow residents the independence to safely self-administer medications with an appropriate physician's order and assessment by the Interdisciplinary Team (IDT) to assure safety and resident competency. -A Medication Self-Administration Screen Assessment must be completed and each medication must be observed to ensure that the resident can safely administer each route of medication to be administered. -No resident will be allowed to self-administer any medication until the IDT has obtained the information necessary to make an assessment of the resident's ability to safely self-administer his/her own medications. -If the IDT determines the resident to be safe to self-administer medications, a physician's order must be obtained for self-administration of specific medications under consideration. -The Medication Self-Administration Screen will be completed quarterly and with a significant change of condition. The IDT will evaluate the results of the assessment and make the determination of the resident's ability to continue to self-administer medications. -The resident will verbally let the nurse know when they have taken the medications so the nurse can document the resident has self-administered the medications. -The resident's comprehensive care plan should reflect the resident's process for self-administration of their medications. C. Review of Resident 13's medical record revealed no evidence the resident was assessed and determined by the IDT as safe to self-administer medications. In addition, there was no evidence of a physician's order for self-administration of medications and no evidence the resident's comprehensive care plan identified the resident was safe to self-administer medications. During an interview with LPN-A on 7/31/23 at 1:25 PM, LPN-A confirmed the following related to Resident 13 and medication administration: -the resident had not been assessed and determined to be safe by the IDT to self-administer medications; -the resident did not have a physician's order to self-administer medications; -the resident's Budesonide medication was not properly disposed of according to facility protocol; and -the resident's morning medications were left unsecured with the resident and should not have been.

Licensure Reference Number 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to serve hot foods at a palatable temperature. This had the potential to affect all residents. The facility census was 54. Findings are: Review of the quantified recipes provided by DiningRD.com by Health Technologies dated 2022 revealed that hot foods are to be served and maintained temperatures of 135 degrees Fahrenheit or higher. Interviews on 5/2/22 at 1:27 PM with Resident 14 revealed The hot foods are not always hot. Also on 5/4/22 at 12:40 pm The lunch meal was hot today, but that is the hottest it has been in awhile. Observation on 5/4/22 at 12:27 PM after all trays had been served, temperatures on a test tray were checked by the Dietary Manager (DM) and revealed the following temperatures: -mashed potatoes and gravy: 131 degrees, -sauteed zucchini: 134 degrees, -puree ham: 129 degrees, and -puree zucchini: 120 degrees. Interview on 5/4/22 at 12:31 PM with the DM revealed that foods are to be cooked to at least 165 degrees and served at 135 degress or higher.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview; the facility failed to ensure interventions were in place to protect Resident 105 after an allegation of potential staff to resident abuse and Resident 9 after an allegation of potential resident to resident abuse involving Resident 105. The sample size was 2 and the facility census was 54. Findings are: A. Review of the facility policy titled Abuse and Neglect Prevention Standard with revision date 3/2017 revealed all residents had the right to be free from abuse, neglect and misappropriation of property. The policy indicated all observations and/or allegations of potential abuse were to be immediately reported to a supervisor, the facility Administrator or designee and in accordance with the state and federal laws. If a team member was suspected of abuse, the team member was to be suspended immediately while an in-depth documented investigation was conducted. Residents were to be protected from harm during an investigation and moved to a safe area, if indicated, to prevent a reoccurrence. After completion of the in-depth investigation, the facility was to submit a report of all investigation results to the State Agency within 5 working days. B. Review of Resident 105's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/5/22 revealed the resident's cognition was severely impaired and the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had behaviors which included verbal behaviors directed at others and other behavioral symptoms not directed at others (hitting, scratching self, pacing, rummaging, and verbal/vocal symptoms like screaming). Resident 105 required extensive staff assistance with bed mobility, transfers, toilet use, dressing and personal hygiene. Review of Resident 105's undated current Care Plan revealed the resident had the potential for out-of-character responses due to dementia related diagnoses. The following interventions were identified: -no male care givers due to history of [CONDITION(S)]; -utilize video chat device for visits with family; -when resident is concerned about something happening to others, reassure the resident the police have been notified and are handling the situation; and -intervene as soon as anxious behavior is noted to prevent an escalation in behaviors. Review of a Progress Note dated 1/3/22 at 12:44 AM revealed the resident had reported statements a man had come into the resident's room and asked the resident to touch his wee-wee. The resident then indicated the man had tried to grab the resident. The resident reported this had occurred somewhere between 8:30 PM and 10:30 PM. Review of facility investigations of potential allegations of abuse and/or neglect from 3/9/21 through 5/2/22 revealed no investigation had been completed regarding the resident's allegation of potential staff to resident sexual abuse and no interventions were put into place to protect the resident from further potential abuse. C. Review of Resident 9's MDS dated [DATE] revealed the resident was cognitively intact and the resident had no behaviors. The assessment further indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 105's Nursing Progress Notes dated 3/13/22 at 12:15 PM revealed Resident 9 had reported last night at the evening meal, Resident 105 was very upset. Resident 9 had attempted to calm Resident 105 down and Resident 105 slammed a set of silverware down on the dining room table and stated someone here is going to die tonight. Resident 105 further stated the resident was going to get a gun and shoot everyone dead. The Progress Note indicated Resident 9 was afraid to leave the resident's room and the resident reported feeling unsafe. Review of Resident 9's Nursing Progress Notes dated 3/17/22 at 8:10 PM revealed the resident was in bed crying and shaking. Resident 9 expressed ongoing concerns related to Resident 105's behaviors and reported barricading self in room due to Resident 105's threats. The resident stated repeatedly the resident did not feel safe. Review of facility investigations of potential allegations of abuse and/or neglect revealed the Director of Nursing (DON) and the Administrator had been notified of the resident to resident altercation between Resident 9 and Resident 105 on 3/13/22 at 11:00 AM, however, the facility failed to report/investigate the incident and to put interventions in place to protect Resident 9 until 3/18/22 (5 days after the incident had occurred). D. Interview with the DON on 5/5/22 at 9:47 AM, confirmed the following: -was unaware of Resident 105's allegation of potential staff to resident abuse which the resident indicated occurred on 1/3/22 at 12:44 AM and no interventions had been put into place to protect Resident 105; and -the resident to resident altercation between Resident 105 and Resident 9 should have been reported and investigated immediately with interventions put into place to protect Resident 9 and assure the resident's safety.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to report to the state agency and submit their investigation within 5 working days for an allegation of potential staff to resident abuse involving Resident 105 and to report to the state agency and submit an investigation within the required time frame for an allegation of resident to resident abuse involving Resident 9 and Resident 105. The sample size was 2 and the facility census was 54. Findings are: A. Review of the facility policy titled Abuse and Neglect Prevention Standard with revision date 3/2017 revealed all residents had the right to be free from abuse, neglect and misappropriation of property. The policy indicated all observations and/or allegations of potential abuse were to be immediately reported to a supervisor, the facility Administrator or designee and in accordance with the state and federal laws. If a team member was suspected of abuse, the team member was to be suspended immediately while an in-depth documented investigation was conducted. Residents were to be protected from harm during an investigation and moved to a safe area, if indicated, to prevent a reoccurrence. After completion of the in-depth investigation, the facility was to submit a report of all investigation results to the State Agency within 5 working days. B. Review of Resident 105's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/5/22 revealed the resident's cognition was severely impaired and the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had behaviors which included verbal behaviors directed at others and other behavioral symptoms not directed at others (hitting, scratching self, pacing, rummaging, and verbal/vocal symptoms like screaming). Resident 105 required extensive staff assistance with bed mobility, transfers, toilet use, dressing and personal hygiene. Review of Resident 105's undated current Care Plan revealed the resident had the potential for out-of-character responses due to dementia related diagnoses. The following interventions were identified: -no male care givers due to history of [CONDITION(S)]; -utilize video chat device for visits with family; -when resident is concerned about something happening to others, reassure the resident the police have been notified and are handling the situation; and -intervene as soon as anxious behavior is noted to prevent an escalation in behaviors. Review of a Progress Note dated 1/3/22 at 12:44 AM revealed the resident had reported statements a man had come into the resident's room and asked the resident to touch his wee-wee. The resident then indicated the man had tried to grab the resident. The resident reported this had occurred somewhere between 8:30 PM to 10:30 PM. Review of facility investigations of potential allegations of abuse and/or neglect from 3/9/21 through 5/2/22 revealed Resident 105's allegation was not reported, no investigation was completed and the results of the investigation were not sent to the state agency regarding the potential staff to resident allegation of sexual abuse. C. Review of Resident 9's MDS dated [DATE] revealed the resident was cognitively intact and the resident had no behaviors. The assessment further indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 105's Nursing Progress Notes dated 3/13/22 at 12:15 PM revealed Resident 9 had reported last night at the evening meal, Resident 105 was very upset. Resident 9 had attempted to calm Resident 105 down and Resident 105 slammed a set of silverware down on the dining room table and stated someone here is going to die tonight. Resident 105 further stated the resident was going to get a gun and shoot everyone dead. The Progress Note indicated Resident 9 was afraid to leave the resident's room and the resident reported feeling unsafe. Review of Resident 9's Nursing Progress Notes dated 3/17/22 at 8:10 PM revealed the resident was in bed crying and shaking. Resident 9 expressed ongoing concerns related to Resident 105's behaviors and reported barricading self in room due to Resident 105's threats. The resident stated repeated the resident did not feel safe. Review of facility investigations of potential allegations of abuse and/or neglect revealed the Director of Nursing (DON) and the Administrator had been notified of the resident to resident altercation between Resident 9 and Resident 105 on 3/13/22 at 11:00 AM, however, the facility failed to report/investigate the incident and to put interventions in place to protect Resident 9 until 3/18/22 (5 days after the incident had occurred). D. Interview with the DON on 5/5/22 at 9:47 AM, confirmed the following: -was unaware of Resident 105's allegation of potential staff to resident abuse which the resident indicated occurred on 1/3/22. No report was made, investigation completed or sent to the state agency; and -the resident to resident altercation between Resident 105 and Resident 9 should have been reported and investigated immediately with the investigation submitted to the state agency within 5 working days in accordance with state regulations.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS-assessment to assess for potential adverse effects of antipsychotic medication) assessment for Resident 28. The sample size was 5 and the facility census was 54. Findings are: Review of the facility policy, Out of Character Response Prevention and Medication Management dated 1/2017 revealed the following; -Neurological side effects of medication can occur at any time from the first few days of treatment up to years later. -Tardive Dyskinesia is abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movement of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected. -Abnormal Involuntary Movement Scale (AIMS) were to be completed initially when medication orders were received, if the resident was admitted on antipsychotic medication, quarterly, and as needed. This was a method to identify adverse effects or possible neurological effects of [CONDITION(S)] (medication that affect a person's mental state) medication. Review of Resident 28's Medication Order Summary revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 28's Minimum Date Set (MDS-a federally mandated assessment used for the development of the resident's care plan) dated 3/23/22 revealed the following; -the resident had depression, anxiety, and [CONDITION(S)], and -had taken an antipsychotic medication daily during the week prior to the assessment. Review of Resident 28's Care Plan dated 3/30/22 revealed the resident took medication for depression and anxiety and an AIMS assessments would be completed initially, quarterly, and as needed. An interview on 5/5/22 at 10:58 AM with the Director of Nursing (DON) confirmed that Resident 28 was taking an antipsychotic medication daily and the facility had not completed an AIMS assessment to assess for potential adverse effect of the medication.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on record review and interview; the facility failed to provide the necessary care and monitoring of a pressure ulcer for (Resident 1 and 3) of 5 sampled residents to promote healing. The facility census was 65. Findings are: A. Review of Skin and Wound Management Standard policy and procedure with revision date 4/2019 revealed all residents would be assessed for pressure ulcer risk with interventions identified for pressure ulcer prevention. If a new pressure ulcer was identified, staff were to provide ongoing monitoring of the area until healed. Pressure ulcers were to be assessed, staged and measured every 7 days or more frequently if indicated. Assessment was to include measurement of the length, width and depth, identification of any odor, drainage or pain and a description of the wound bed and the skin surrounding the wound bed. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/26/21 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further revealed the resident required extensive to total staff assistance with bed mobility, transfers, toilet use and personal hygiene; and the resident had two, Stage 1 (intact skin with non-blanchable redness) pressure ulcers, two, Stage 2 (partial thickness skin loss that presents as an abrasion, blister or shallow crater) pressure ulcers and one Stage 3 (full thickness tissue loss) pressure ulcer. Review of the resident's undated current Care Plan revealed Resident 1 was at risk for the development of pressure ulcers related to immobility, malnutrition and diabetes. The resident was identified as having a Stage 3 pressure ulcer to the right lateral foot, a Stage 1 pressure ulcer to the left lateral foot and the left heel and two Stage 2 pressure ulcers to the coccyx. All areas were present on admission to the facility. Nursing interventions included the following: -float heels with pillows; -air mattress to bed; -frequent repositioning and turning; -pressure relieving device to chair at all times; -PROFO boots (device worn on the calf and foot which is similar to a boot and used for prevention of pressure sores and contractures) to bilateral feet at all times; -treatments to skin as ordered; -wound clinic consult as needed; and -weekly monitoring and assessment by a professional nurse. Review of Pressure Ulcer Records for the resident's left lateral foot revealed the following: -7/20/21 the Stage 2 pressure ulcer measured 2 centimeters (cm) by 1.3 cm There was no drainage and the ulcer was superficial; -7/24/21 the Stage 2 pressure ulcer was now classified as a Stage 3 and measured 1.5 cm x 2 cm with a depth of 0.2 cm. The wound had a small amount of drainage and appeared to be deteriorating; -8/11/21 (18 days later) the Stage 3 pressure ulcer measured 1.5 cm by 1 cm with black tissue. Staff documented the wound was declining; -8/17/21 the Stage 3 pressure ulcer measured 0.6 cm by 0.6 cm with a depth of 2 cm. The wound bed remained black. The resident was to be seen on this date, at the Wound Clinic; -8/25/21 the Stage 3 pressure ulcer measured .5 cm by .8 cm. The wound was classified as Unstageable (full thickness loss in which the base of the ulcer is covered by slough and/or eschar. The wound bed was covered by a brown scab; and -8/31/21 the Stage 3 pressure ulcer measured .3 cm by .3 cm and the wound bed had a yellow scabbed appearance. Review of Pressure Ulcer Records for the resident's left heel revealed the following: -7/20/21 Stage 1 pressure ulcer which measured 1.8 cm by 2.2 cm; -7/24/21 Stage 1 pressure ulcer measured 2.4 cm by 2.4 cm the wound had opened and had a scant amount of drainage; -8/11/21 (18 days later) the pressure ulcer was now Unstageable and measured 2 cm by 2 cm with a red/black wound bed; -8/17/21 the Unstageable pressure ulcer measured 2.6 cm by 2.5 cm with a depth of 0.3 cm. The resident was to be seen on this date at the Wound Clinic; -8/21/21 the Unstageable pressure ulcer measured 2.2 cm by 2 cm and the wound bed was now covered with a black scab; and -8/25/21 the Unstageable pressure ulcer measured 3.1 cm by 3 cm and continued to have a black scab to the wound bed and the skin surrounding the wound bed was yellow. Pressure Ulcer Records for the resident's right lateral foot revealed the following: -7/20/21 Stage 3 pressure ulcer which measured 2.1 cm by 2.5 cm with a depth of 0.1 cm. The wound bed was red/yellow and the wound had a scant amount of drainage; -7/24/21 the Stage 3 pressure ulcer measured 1.2 cm by 1 cm with a depth of 0.1 cm. The area remained opened with a scant amount of drainage; -8/11/21 (18 days later) the pressure ulcer was now Unstageable and measured 1.3 cm by 1.3 cm. The edges of the wound were black in color and the wound had declined; -8/17/21 the pressure ulcer remained Unstageable and measured 1 cm x 1 cm with a depth of 0.4 cm; and -8/25/21 the pressure ulcer was classified as a Stage 3 and measured 2 cm by 1.5 cm with a depth of .2 cm The wound had a dark black center with yellow pink edges around the wound. C. Review of Resident 3's MDS dated [DATE] revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further revealed the resident required total staff assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; and the resident had one Stage 2 pressure ulcers. Review of Resident 3's undated current Care Plan revealed the resident had a potential for skin skin breakdown related to fragile skin, urinary incontinence and a history of pressure ulcers. 6/5/21 the resident was identified as having a Stage 2 pressure ulcer. Nursing interventions were identified as following: -reposition frequently; -2 assist with bed mobility; -air mattress to bed; -assess and measure skin breakdown weekly by a professional nurse; -pressure reliveing cushion to wheelchair; and -treatments and preventative skin treatments as ordered. Review of Pressure Ulcer Records related to the resident's coccyx revealed the following assessments: -7/2/21 the resident's Stage 2 pressure ulcer measured 2 cm by 1 cm with no drainage; -7/13/21 the Stage 2 pressure ulcer measured 1.4 cm by 1.5 cm; and -8/8/21 (26 days later) the resident's coccyx was now open. The wound bed was a pale pink with the skin surrounding the wound bed red/pink in color and there was no drainage. Review of Resident 3's medical record revealed no evidence additional assessments were completed/documented of Resident 2's Stage 2 coccyx pressure ulcer after 8/8/21. D. During interview on 9/1/21 at 2:40 PM, the Director of Nursing confirmed the staff failed to complete an assessment and then document the assessment of Resident 1 and 3's pressure ulcers on a weekly basis to assure healing.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a. Based on record review and interview; the facility staff failed to implement assessed interventions to prevent a fall with injury for 1 (Resident 1) of 6 sampled residents. The facility staff identified a census of 67. Findings are: A. Review of the facility Lift and Transfer Program dated 2/19 revealed the following regarding the use of a full body lift (mechanical device that allows residents to be transferred between a bed and a chair using hydraulic power and requires no weight bearing assistance from the resident): -all team members were to be orientated to the Lift and Transfer Program policies and procedures. Team members to be competency tested on use of the full body lift when first hired, annually and as needed; -2 team members were required to be involved in the whole process of assisting the resident and operating a full body lift; -all residents were to be assessed on admission, quarterly and as needed to identify the degree of assistance needed to be lifted or transferred using the Lift and Transfer Review; and -use of a lift and the type of lift to be used was to be identified on the resident's care plan. B. Review of Resident 1's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 3/10/21 revealed diagnoses of pain, dementia, depressive disorder, [CONDITION(S)] and malnutrition. The MDS further revealed the following: -cognition was severely impaired; -required extensive staff assistance with eating, personal hygiene, bed mobility and dressing; -required total staff assistance of 2 with mobility, transfers and toileting; -chronic condition or disease which may result in a life expectancy of less than 6 months; -frequently incontinent of bowel and bladder; and -history of falls. Review of a Lift and Transfer Review dated 12/4/20 at 7:09 AM revealed the resident was unable to ambulate safely and to transfer independently. It was determined the resident required use of a full body lift, use of a small sling and two team members for completion of a safe transfer. Review of Resident 1's current Care Plan (undated) revealed Resident 1 was at risk for falls due to activity intolerance and disease process. Interventions identified on the care plan included: 1) 2 team members to assist with full body lift for all transfers; 2) assist to the bathroom at frequent intervals; 3) encourage use of call light and ensure within reach; 4) scoop mattress (mattress with a raised, defined edge which helps to reduce the risk of falls out of bed); 5) assist resident to the commons area when restless; 6) provide meaningful activity when restless; and 7) encourage increased visits from hospice. Review of a Functional Abilities assessment dated [DATE] at 7:00 AM revealed Resident 1 was dependent for all transfers and use of wheelchair. The resident was unable to ambulate due to medical condition and safety concerns. Review of Resident 1's Nursing Progress Notes revealed the following: -3/31/21 at 9:29 PM the resident was scooting out of wheelchair. Staff repositioned in bed for safety and the resident was found seated on the edge of the bed. The resident was repositioned in bed but was then found attempting to get out of bed and was pulling on the night stand. The resident was given [MEDICATION(S)] (medication used to treat anxiety) 0.5 milliliters (ml) to be given every 2 hours as needed for anxiety and restlessness; -4/7/21 at 1:06 PM the resident was observed seated on buttocks in front of the resident's recliner. No injuries were observed. The resident was administered [MEDICATION(S)] 0.5 ml for restlessness; -4/17/21 at 1:30 PM the resident received [MEDICATION(S)] 0.5 ml for anxiety and restlessness; -4/20/21 at 10:07 PM the resident received [MEDICATION(S)] 0.5 ml as the resident was attempting to self-transfer, to climb out of bed and was calling for spouse; -4/22/21 at 1:00 PM the resident was found on the floor of the resident's bathroom. The resident's left leg was externally rotated and shorter than the right. The resident's slacks were pulled down around knees. The resident complained of pain and indicated, I broke my hip; -4/22/21 at 2:09 PM the resident was sent to the emergency room for evaluation; and -4/22/21 at 4:31 PM the resident returned from the emergency room and was transferred into bed. The resident had been diagnosed with a fracture to the left femur with deformity with orders for comfort cares and pain management. During an interview on 4/28/21 at 10:05 AM, the Social Service Director (SSD) reported the following regarding Resident 1: -was on hospice; -SSD was walking by Resident 1's room on 4/22/21 at 1:00 PM and was alerted by the resident's roommate that Resident 1 needed assistance; -upon entering the Resident 1's room, the resident could be heard calling out for help and SSD found the resident on the floor of the resident's bathroom; -there was no full body lift in the resident's room or in the bathroom at the time the resident was found; and -the resident's tilt and space wheelchair (chair which provides alternatives in positioning with tilting or reclining of chair and allows resident to be self-mobile when in an upright position) had the foot pedals removed and was positioned in the entrance of the bathroom in front of the toilet. The brakes had not been engaged on the wheelchair. During an interview on 4/27/21 at 11:25 AM, Nurse Aide (NA)-B verified Resident 1 was at high risk for falls due to restlessness and anxiety. In addition, the resident had interventions identified on the current Care Plan for the resident to be positioned in the commons area if restless, for frequent toileting and for use of the full body lift for all transfers with use of 2 staff. NA-B confirmed the following regarding the resident's fall on 4/22/21: -NA-B had transferred Resident 1 without use of the lift and without assistance of another staff member throughout the day. NA-B assisted the resident to the bathroom around 9:30 AM before NA-B went to break; -NA-B was in Resident 1's room at approximately 12:30 PM and the resident was restless and anxious. The resident's tilt and space wheelchair was in the upright position but the foot pedals were not in place at the time. Despite the resident's restlessness, NA-B failed to place the foot pedals on the resident's chair or to position the resident in the Commons area for increased supervision; -the resident was found in the bathroom on the floor at 1:00 PM. The resident's slacks were lowered and the resident had been incontinent of urine; and -Resident 1 had not been assisted to the bathroom since that morning (over 3 hours previously). During an interview with the Director of Nursing (DON) on 4/28/20 at 12:00 PM, the DON confirmed NA-B failed to implement current fall prevention interventions for Resident 1 which included frequent toileting, use of the full body lift for all transfers and placing the resident in a supervised area when increased restlessness and anxiety observed. In addition, the DON confirmed Resident 1 required total staff assistance with wheelchair mobility and indicated NA-B should have assured Resident 1's proper positioning in the wheelchair with foot pedals in place and the chair tilted to prevent potential self-transfers and falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify physician's of a change in condition for 2 ( Resident 1 and 2) of 4 residents reviewed related to falls. Residents 1 and 2 sustained falls with immediately obvious injuries, and the Primary Care Practitioners (PCP) were not notified for treatment recommendations until 2 to 4 hours following the incidents. The facility census was 75. Findings are: A. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/27/19 revealed the resident had [DIAGNOSES REDACTED]. The resident had severely impaired cognition, and required extensive to total assistance with bed mobility, transfers, toileting and bathing. Review of Resident 1's current Care Plan with target dates of 5/15/19 indicated the resident had a history of [REDACTED]. Nursing interventions included the following: -anticipate and meet resident's needs; -verbal reminders not to ambulate or transfer without assistance; -keep bed beside wall due to right sided deficit; -place items frequently used within easy reach; -environment free of clutter and safety hazards, with adequate lighting, free of glare; and -scoop mattress to define the edges of the bed. Review of Nursing Progress Notes on 5/8/19 revealed the following related to Resident 1: -10:47 AM - Observed on the floor of the whirlpool room following a fall from the whirlpool chair during bathing. Initial Vital Signs (VS) were Temperature (T) 98.0 degrees, Pulse (P) 189, Respirations (R) 28, lying Blood Pressure (BP) 207/146, sitting BP 189/100. Had an abrasion on the front forehead measuring 5.3 cm (centimeters) x (by) 2.0 cm, a bruise on the left elbow 2 cm x 0.9 cm, and a skin tear on the left elbow 2 x 0.6 cm. Neuro checks (an assessment of neurological status including P, R and BP measurements, pupil size and reactivity, and equality of hand grip strength) were initiated; and -3:32 PM - Call placed to physician's office at 2:15 PM to call back to communicate on resident status. No call back at this time. This nurse called physician office again at 2:45 PM. At 3:00 PM the on-call physician gave this nurse verbal orders to send the resident to the emergency room . During interview on 5/8/19 from 12:36 PM until 1:40 PM, the Director of Nursing (DON) verified the first attempt to notify Resident 1's physician of the fall from the whirlpool chair was at 2:15 PM (3 hours and 28 minutes following the incident), and the PCP did not return the call until 3:00 PM. B. Review of Resident 2's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The resident was cognitively intact, required limited assistance with transfers and toileting, and extensive assistance with bed mobility. Review of Resident 2's current Care Plan dated 4/27/19 indicated the resident had a history and/or potential for falls related to impaired gait and balanced, poor safety awareness, and self transfers. Nursing interventions included the following: -anticipate and meet resident's needs; -call light reachable and use encouraged; -verbal reminders not to ambulate or transfer without assistance; -place items frequently used within easy reach; and -provide environment with adequate lighting; free of glare. Review of Nursing Progress Notes dated 5/7/19 revealed the following related to Resident 2: -6:15 PM - Sitting in a chair in the parlor of the 300/400 Wing awaiting the start of an activity. Observed by the activity facilitator to have stooped over and fell to the floor head first. Was reported to be unresponsive for 45 seconds to 1 minute following the fall; -7:30 PM - Event reported to the resident's child and will attempt to get an order to send to ED (Emergency Department); and -8:20 PM - Report of the event called in and given to (hospital) ED. During interview on 5/8/19 from 12:36 PM until 1:40 PM, the DON verified Resident 2's PCP was not notified until 8:20 PM (2 hours and 5 minutes after the incident). The DON indicated notification of the PCP should occur within an hour of the occurrence of an incident and/or change of condition.