Every finding on record at Brookestone of David City

License reference number 175 NAC 12-006.12(D)(i)Based on observations, record reviews and interviews, the facility failed to ensure medications were securely stored to prevent potential unauthorized access on the 200 and 300 hallways. This had the potential to affect 14 residents that were independent with ambulation and wheelchair mobility. The facility census was 53.Findings are: Record review of the facility's Medication Storage and Utilization policy last reviewed on 03/19 revealed all medication storage areas, rooms and carts must be locked. An observation on 06/01/2026 at 10:05 AM revealed the 300-hall medication cart was unlocked with no staff near the medication cart. During this time, staff members are observed to walk past the unlocked medication cart. In an interview on 06/01/2026 at 10:06 AM with Registered Nurse (RN-B) confirmed that the medication cart on the 300 hall should have been locked and was not. During an observation on 06/02/2026 from 9:05 AM to 9:08 AM, revealed the 200-hall medication cart was unlocked with no staff near the medication cart. At 9:08 AM, Medication Aide (MA-D) was observed to lock the cart. In an interview on 06/02/2026 at 9:09 AM, MA-D confirmed that the medication cart should have been locked and was not. During an observation on 06/02/2026 from 11:05 AM to 11:07 AM the 200-hall medication cart was unlocked with no staff near the medication cart. At 11:08 AM Licensed Practical Nurse (LPN-C) confirmed that the medication cart on hall 200 should have been locked and was not. During an interview on 06/02/2026 at 2:30 PM with the Assistant Director of Nursing (ADON), the ADON confirmed it was the expectation that all medication carts remained locked when staff were not utilizing the medication cart.

.Licensure Reference Number 175 NAC 12-006.05(S) Based on observations, record reviews and interviews, the facility staff failed to provide privacy during the provision of personal care for 1(Resident 1) of 4 sampled residents. The facility staff identified a census of 53.Findings are: Record review of Resident 1's admission Record dated 6/1/2026 revealed an admission date to facility of 07/08/2025. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 04/09/2026 revealed the facility staff assess the following about the resident:-Brief Interview for Mental Status (BIMS- a screening tool used to assess cognition relating to the mental process involved in knowing, learning, and understanding things). The BIMS assessment uses a point system that ranges from 0 to 15 points:0 to 7 points indicates severe cognitive impairment; 8 to 12 points indicate moderate cognitive impairment; and 13 to 15 points indicate that cognition is intact. Resident 1's BIMS score was 15/15.-Resident 1 was dependent on staff assistance for toileting hygiene transfers. A record review of Resident 1's undated Care Plan revealed the resident required the assistance of two staff and a mechanical lift for transfers. In an interview on 06/01/2026 at 9:29 AM with Resident 1 revealed that staff do not provide privacy when performing cares with Resident 1. Resident 1 further revealed that there were often other residents and families walking or sitting in the gazebo. An observation on 06/03/2026 at 10:40 AM revealed Resident 1's window shade was up and that Resident 1 observed other residents walking around the gazebo. During an observation on 06/03/2026 at 11:15 AM, Nurses Aides (NA)- E and -F assisted Resident 1 to the bathroom by utilizing the sit to stand lift, without first providing privacy by pulling Resident 1's shade down. Registered Nurse (RN)-A was present and also observed NAs -E and -F assisting Resident 1 to the bathroom. During an observation on 06/03/2026 at 11:20 AM, NAs -E and -G assisted Resident 1 out of the bathroom by utilizing the sit to stand lift, without first pulling Resident 1's shade down. In an interview on 06/03/2026 at 12:08 PM, NA-E confirmed that Resident 1's shade should have been pulled down when the resident was assisted to the bathroom. In an interview on 06/03/2026 at 12:10 PM with RN-A, the RN confirmed that staff should have provided privacy while assisting Resident 1 to the bathroom. In an interview on 06/03/2026 at 12:13 PM with the Assistant Director of Nursing (ADON), the ADON revealed it was the facility expectation to provide privacy when providing cares to the residents. In an interview on 06/03/2026 at 12:34 PM, ADON confirmed that the facility did not have a privacy policy but each care policy, such as peri care, stated to provide privacy to the resident.

Licensure Reference Number 175 NAC 12-006.09(C)(ii) Based on interviews and record reviews, the facility failed to complete a Significant Change Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems), within 14 days following the determination that a significant change had occurred for two (Residents 5 and 25) of 15 residents sampled. The facility census was 53 at the time of the survey. The findings are: A. Review of Resident 5's Physician Order Sheet dated 6/1/2026 revealed that they were admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one entire side of the body) and hemiparesis (muscle weakness affecting only one side of the body due to damage to the brain) following a cerebral infarction (stroke) affecting right dominant side, Type 2 Diabetes Mellitus (a chronic condition where the body either resists the effects of insulin or doesn't produce enough to maintain normal blood sugar levels), chronic kidney disease, urinary retention, and depression. Review of Resident 5's admission MDS dated [DATE], revealed that Resident 5 was at risk for pressure ulcers and no wounds were present at time of this assessment. Review of Resident 5's electronic medical record (EMR) revealed: 5/01/2026: a reddened area to Resident 5's coccyx with a 1centimeter (CM) by 2 cm blister on top of the red area. 5/01/2026: treatment of Calmoseptine ointment to intact blister on coccyx every shift was added to the Medication Administration Record. 5/04/2026: the reddened area to coccyx measured 2.7 cm by 2.2 cm. 5/07/2026: skin covering the wound had peeled back, exposing 75% of the wound bed with no measurements of the coccyx wound 5/08/2026: wound, identified as Stage 2 (a shallow, open wound that affects the top two layers of skin, often appearing as a blister or crater), measured 3.1 cm by 3 cm. The wound bed was yellow/white and no drainage was present. 5/10/2026: wound identified as Stage 3 (involving full-thickness skin loss extending into the subcutaneous tissue) and measured 1.6 cm by 2.2 cm. There was serosanguinous (wound drainage that is thin in consistency and pink or red in color due to the presence of blood) drainage but no odor from the wound was present. The note indicated that Resident 5 was experiencing pain related to the wound and that a new treatment was needed for the wound. 5/12/2026: order for wound treatment every 8 hours as needed with Therahoney and Optifoam dressing with pink oxide tape to border for wound. 5/13/2026: nurse progress note review revealed that treatment not provided due to Therahoney not being available. Review of the Medication Administration Record revealed that this treatment was initiated on 5/14/2026. 5/22/2026: wound identified as Stage 3 (full-thickness skin loss extending into the subcutaneous tissue) and measured 4 cm by 3.3 cm. The drainage was purulent (a thick, cloudy, or milky fluid, also referred to as pus) and had an odor to it. The wound bed was yellow and black and noted to have deteriorated. The entry of 5/22/2026 further indicated that the physician was notified and questioned whether consultation with a wound specialist would be appropriate. 5/29/2026: Wound was classified unstageable and measured 4.2 cm by 3.5 cm. Large amounts of purulent and foul odorous drainage were noted with eschar (dead tissue) to the wound bed. 5/30/2026: Wound bed was yellow in color with soft slough (a byproduct of the inflammatory phase of healing; slough blocks healthy tissue growth and harbors bacteria) and a large amount of odorous drainage present. The issue surrounding the wound was red and swollen; no wound measurements were provided. 6/1/2026: Wound bed was yellow and black with slough present. Two tunneling (narrow passageways or tracts extending beneath the skin from a primary wound surface into surrounding tissues) areas were noted within the wound. The tissue surrounding the coccyx wound had a lip of dark pink, swollen tissue; no wound measurements were provided. 6/2/2026: Wound measured as 4.4 cm by 4.0 cm with a depth of 2.1 cm. Serosanguinous, odorous drainage was noted. The wound documentation revealed the wound to be covered with white colored slough tissue and had a black wound bed. Tunneling in 2 areas were identified within the wound and the lip remained. Review of Resident 5's Weight Summary dated 6/3/2026 revealed the following measurements of weight: 4/24/2026: 181.4 pounds (lbs) 4/25/2026: 176.0 lbs – a loss of 2.98% from admission weight 5/01/2026: 171.5 lbs – a loss of 5.46% from admission weight 5/12/2026: 169.0 lbs – a loss of 6.84% from admission weight 5/22/2026: 167.5 lbs – a loss of 7.66% from admission weight 5/26/2026: 165.5 lbs – a loss of 8.77% from admission weight Record review of Resident 5's EMR revealed a Progress Note on 4/30/2026 by Registered Dietician (RD) documenting that Resident 5's skin was intact. No new recommendations for Resident 5 were identified by RD on that date. Continued review of Resident 5's Progress Notes revealed an entry by RD dated 5/19/2026, that identified a weight loss of 11.9 pounds or 6.6% from 4/24/2026 to 5/19/2026 and the presence of a pressure ulcer to Resident 5's coccyx. Review of a nutritional review for Resident 5, completed by the RD on 6/2/2026, revealed that the pressure ulcer to Resident 5's coccyx had deteriorated and continued weight loss was noted for Resident 5. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2025 revealed in Chapter 2, pages 2-27 through 2-28 that an unplanned weight loss of 5% or greater within 30 days and emergence of a new pressure ulcer at Stage 2 or higher would constitute a significant change in resident status and necessitate completion of an MDS significant change in status assessment. Interview of the Assistant Director of Nursing (ADON), who is also MDS coordinator for this facility, on 6/3/26 at 12:05PM regarding Resident 5's condition. ADON confirmed that Resident 5 had sustained a significant weight loss and had developed a Stage 3 pressure ulcer. Further confirmed that a significant change MDS should have been completed for Resident 5. B. A record review of the facility's Action Summary with a print date of 6/3/2026 revealed that Resident 25 was admitted to the facility on [DATE] on hospice services (a specialized type of healthcare focused on the comfort, dignity, and quality of life for a terminally ill person nearing the end of life), and was still residing in the facility. A record review of Resident 25's MDS dated [DATE] revealed Resident 25 was receiving hospice services. A record review of Resident 25's hospice Plan of Care Update Report dated 2/25/2026 revealed Resident 25 was discharged from hospice services on 2/11/2026. A record review of Resident 25's quarterly MDS's dated 5/7/2026 revealed Resident 25 was not receiving hospice services. Further record review of Resident 25's medical records revealed no evidence of a significant change MDS being completed between admission and the quarterly MDS on 5/7/2026. A record review of the facility's Resident Matrix with a print date of 6/1/2026 revealed Resident 25 was not on hospice services. A record review of the facility's MDS Completion policy with a review date of 2/13/2027, under types of assessment, revealed that a significant change assessment is required when a resident receiving hospice services discontinues those services and remains in the facility. During an interview on 6/2/2026 at 9:16 AM with the Life Enrichment Supervisor (LES) it was confirmed Resident 25 was admitted on hospice services but graduated from hospice to start therapy. During an interview on 6/2/2026 at 10:20 AM with the Assistant Director of Nursing (ADON) it was confirmed a significant change of condition MDS should have been completed when Resident 25 discharged from hospice services, and that was not done.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) reflected hypoglycemic (medication used to help reduce the amount of sugar present in the blood) medication use for two (Resident 23 and Resident 28) of 15 sampled residents. The facility census was 57. Findings are: A review of the CMS's (Centers for Medicare and Medicaid [NAME]) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2024, revealed the following regarding hypoglycemic (including insulin) medication use: Check if a hypoglycemic medication was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days.) In an interview on 2/13/25 at 8:38 AM, the Assistant Director of Nursing/MDS Coordinator (ADON/MDS) confirmed that the facility follows the RAI Manual when completing an MDS. A. A review of Resident 23's January 2025 Medication Administration Record (MAR) revealed that [gender] received Metformin (a hypoglycemic medication) 1000 milligrams (mg) two times a day (BID) between 1/7/25 and 1/13/25. A review of Resident 23's MDS, dated [DATE], revealed that hypoglycemic medication use was not checked as taken by [gender] at any time during the 7-day observation period. In an interview on 2/13/25 at 8:38 AM the ADON/MDS Coordinator confirmed that Resident 23 had received a hypoglycemic medication during the 7-day observation period, that it was not check on the MDS and that it should have been. B. A review of Resident 28's November 2024 MAR revealed that [gender] received the following hypoglycemic medications between 11/20/24-11/26/24: Humalog (insulin) 100unit/milliliters (ml) 12 units BID, Insulin Detemir 100unit/ml 15 units BID and Humalog 100unit/ml per sliding scale before meals. A review of Resident 28's MDS, dated [DATE], revealed that hypoglycemic medication use was not checked as taken by [gender] at any time during the 7-day observation period. In an interview on 2/13/25 at 8:49 AM the ADON/MDS Coordinator confirmed that Resident 28 had received hypoglycemic medication via insulin during the 7-day observation period, that it was not check on the MDS and that it should have been.

Licensure Reference Number 175 NAC 12-006.09D3(5) Based on record review and interview; the facility failed to follow the bowel protocol to prevent constipation for two (Resident 23 and 35) of two sampled residents. The facility census was 57. Findings are: A. Review of Resident 23's Bowel Movement Task, dated 1/13/25 to 2/11/25, revealed that [gender] did not have a bowel movement (BM) between the following dates: 1/15-1/18/25, 1/26-2/1/25 and 2/3-2/8/25. Review of Resident 23's Order Summary Report, dated 2/11/25, revealed the following medications used to promote bowel movements: -Milk of Magnesia Oral Suspension 400 milligram (mg)/5 milliliters (ml), give 30ml by mouth every 24 hours as needed, -Dulcolax Rectal Suppository 10mg insert 1 suppository rectally every 24 hours as needed. A review of Resident 23's January 2025 Medication Administration Record (MAR) revealed that [gender] received a Dulcolax suppository on 1/19/25, Milk of Magnesia on 1/23/25 and 1/31/25 and all were recorded that they were effective in promoting a BM. A review of Resident 23's electronic health record (EHR) revealed no documentation that a bowel assessment had been completed during the above listed dates or that [gender] medical provider had been notified due to not having a BM. In an interview on 2/13/25 at 10:57 AM, the Assistant Director of Nursing/Minimum Data Set (ADON/MDS) Coordinator revealed that the facility's bowel protocol is that a resident on day 1 of no BM is to receive fruit laxative or prune juice, on day 2 the Milk of Magnesia should be given, on day 3 the Dulcolax suppository should be given, and if the resident still has not had a BM by day 4 the resident's medical provider should be notified. The ADON/MDS Coordinator confirmed that the bowel protocol had not been followed for Resident 23 when [gender] had not had a BM 4 days (1/15-1/18/25), and 6 days (1/26-2/1/25 and 2/3-2/8/25) and that it should have been. 45613 B. During an interview on 2/10/25 at 2:02 PM Resident 35 stated I get constipated sometimes and my stomach hurts. Review of Resident 35's bowel records for last 30 days revealed that from 1/22/25 - 1/26/25 the resident did not have a bowel movement (BM) and was 5 days with no BM. Review of Resident's 35'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 11/28/24 revealed -resident was admitted to facility on 4/11/22 -BIMS score of 15 -primary diagnosis of post polio syndrome -resident is dependent for toileting transfer and for chair/bed to chair transfers Review of Resident 35's Comprehensive Care Plan - (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) dated 7/21/22 the resident is dependent with wheel chair mobility, and dependent with full body lift for all transfers. Review of Resident 35's MAR revealed the resident did not receive any medications to prevent constipation in Dec, 2024, January, or Feb of 2025 Review of Residents 35's Progress Notes dated from 1/01/25 through 2/1/25 revealed no bowel assessments or documentation of bowel medications given or MD notification regarding bowels. Review of facility's undated bowel protocol revealed: -Day 1 = prune juice, prunes or fruit lax, -Day 2 = give MOM, -Day 3 = dulcolax suppository, -Day 4 = enema. In an interview on 02/11/25 at 02:21 PM the ADON confirmed no progress note regarding bowel assessments and no bowel PRN's given in January and the MD should have been notified. In an interview on 02/13/25 at 11:16 AM the ADON confirmed that BM/constipation is not on the resident's careplan and that the fruit lax given on the 1st day of no BM is provided by the kitchen and is not charted in the residents MAR.

Licensure Reference Number 175 NAC 12-006.18(B) Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, record review and interviews; the facility failed to ensure hand hygiene (HH-using an alcohol-based hand rub (ABHR) or washing hands with soap and water) was completed in a manner to prevent the potential for cross-contamination during peri-care (washing the genitals and anal area) for one (Resident 19) of one sampled residents for incontinence cares and failed to complete peri-care in a manner to prevent cross-contamination during wound care for one (Resident 15) of one sampled residents for wound care. The facility census was 57. Findings are: A review of the facility's Hand Hygiene competency, dated 12/2019, revealed the following: -Hand hygiene using antimicrobial soap and water: 4. Lather and rub hands together for full 20 seconds, -When to wash hands: before each resident contact, after touching a resident or handling their belongings, after any contact with body fluids, after handling contaminated items (linens/garbage/briefs, etc), before and after gloving, -When can hand sanitizer be used: before/after direct contact with resident, after contact with resident's intact skin, after removing gloves or between changing gloves. A review of the facilities Incontinent brief competency, dated 7/09, revealed the following: -4. Obtain the appropriate perineal cleansing supplies and items needed, -5. Wash hands and put on gloves, -9. Perform proper peri-care, -10. Remove gloves, wash hands or sanitizer gel, replace gloves, -11. If resident is standing, position brief on their buttocks, -12. Gently extend the front of the brief between the resident's legs, -13. Position the front of the brief and fasten, -14. Remove gloves and wash hands. A. A review of Resident 19's Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 1/9/25, revealed that Resident 19 was dependent upon staff with toilet hygiene and was frequently incontinent of bladder. A review of Resident 19's electronic health record (EHR) revealed that Resident 19 had a Urinary Tract Infection (UTI-infection of any part of the urinary system) and was treated with an antibiotic from 1/9-1/13/25. In an observation on 2/13/25 from 12:39 PM to 12:45 PM of Resident 19 being assisted to the toilet, with the Assistant Director of Nursing/MDS Coordinator (ADON/MDS) present, by Nursing Assistant (NA)-A and NA-B revealed the following: upon entering Resident 19's room NA-B touched [gender] facial hair, did not complete HH and put gloves on. NA-A placed the gait belt around Resident 19's waist and assisted [gender] to a standing position and then pivoted to the toilet. NA-B pulled Resident 19's pants down and NA-A sat [gender] down on the toilet. NA-A removed the saturated brief and placed in the trash can with no gloves on. No HH was completed by NA-A. NA-A retrieved clean pants for [gender] while NA-B wiped the cushion in the wheelchair with a wet wipe, placed it in the trash can, grabbed a clean washcloth, dried the cushion off and placed the washcloth on the counter. When NA-A returned to the bathroom with clean pants, NA-B took the trash bag out of the trash can, grabbed a new trash bag from within the can, gave that to NA-A, placed the trash bag with the brief in it back in the trash can and then changed [gender] gloves. No HH was completed prior to putting new gloves on. NA-A placed the pants that Resident 19 had been wearing into the trash bag, assisted with putting [gender] clean pants on and did not complete HH. NA-A assisted Resident 19 to a standing position, while NA-B provided peri-cares to [gender]. NA-B obtained a new brief and applied the brief and pulled [gender] pants up, without changing gloves after providing peri-care. NA-A pivoted [gender] towards the wheelchair and sat [gender] down. NA-B removed [gender] gloves and washed hands with soap and water for seven seconds. In an interview on 2/13/25 at 12:47 PM, the ADON/MDS Coordinator confirmed that NA-A did not complete hand hygiene or wear gloves at any point while assisting Resident 19 and should have worn gloves and completed hand hygiene when gloves wore changed. It also confirmed that NA-B did not complete hand hygiene after touching [gender] facial hair, change gloves or complete HH after wiping down and drying the wheelchair cushion, placed a dirty washcloth on the counter, change gloves and complete HH after providing peri-care and applying the new brief and washed hands with soap and water for only seven seconds. B. A review of Resident 15's admission record, dated 2/11/25, revealed a diagnosis of Pressure Ulcer of sacral region, stage 2 (PU-a pressure sore located on sacrum (the bony area at the base of the spine) where the skin has broken open, forming a shallow, open wound that extends into the deeper layers of the skin) with 12/18/24 listed as the date of onset. A review of Resident 15's MDS, dated [DATE], revealed that Resident 15 is always incontinent of bladder, dependent upon staff for toilet hygiene, had a Stage 2 pressure ulcer, and received PU care. An observation on 2/13/25 from 1:06 PM to 1:19 PM of peri-care and wound care for Resident 15, with the Infection Preventionist (IP) present, provided by NA-A and the Licensed Practical Nurse (LPN) revealed the following: NA-A assisted Resident 15 to [gender] left side while the LPN supported [gender] on [gender] left side. NA-A removed Resident 15's brief and tossed into the trash can on the other side of the bed next to the LPN. NA-A wiped Resident 15's buttocks using a different wet wipe, that had been placed on the bed, with each wipe. NA-A did not change [gender] gloves or complete HH. NA-A removed the dressing to [gender] sacral region, grabbed a new wet wipe and wiped from Resident 15's rectum across the open wound. This was done three times with a new wipe each time. NA-A then removed [gender] right glove and put on a new one without completing HH. NA-A placed the new brief against Resident 15's buttocks, removed [gender] gloves and did not complete HH. Resident 15 was then positioned onto [gender] right side. The LPN did change [gender] gloves after Resident 15 was repositioned to [gender] right side but did not complete HH. The LPN cleansed the wound with wound cleanser, changed [gender] gloves, completed HH, applied new gloves, applied the new treatment and dressing. Resident 15 was then assisted back onto [gender] back, the brief attached, covered up and [gender] call light was placed within [gender] reach. The LPN and NA-A then completed handwashing for the correct amount of time. In an interview on 2/13/25 at 1:23 PM, the IP, confirmed that NA-A and the LPN did not complete HH when their gloves were changed at the times mentioned above, NA-A tossed the dirty brief across the bed to the trash can and that NA-A wiped across Resident 15's wound after [gender] had wiped Resident 15's rectal area.

Licensure Reference 175 NAC 12-006.09C3a Based on record review and interview, the facility failed to ensure a Discharge Summary including a recapitulation (a short summary) of stay was completed for 1 (Resident 46) of 1 sampled residents upon discharge from the facility. The facility census was 47. Findings are: A record review of Resident 46's Electronic Health Record (EHR) revealed the resident was admitted on [DATE] with diagnoses of: aftercare following surgery on the circulatory system, a history of a coronary artery bypass graft (a medical procedure to improve blood flow to the heart), high blood pressure, atrial fibrillation (an irregular heartbeat), and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). A record review of Resident 46's EHR revealed that the resident was discharged to their home on 12/11/2023. A record review of Resident 46's EHR, including the Assessments tab, revealed no Discharge Summary form or recapitulation of stay. In an interview conducted on 03/11/2024 at 9:34 AM, the Director of Nursing confirmed there was no recapitulation of stay for Resident 46.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, interview, and record review, the facility failed to implement gait belt usage during transfers for 1 (Resident 14) of 3 sampled residents. The facility identified a census of 42. Findings are: Record review of Compressive Care Plan saved electronically on 4/12/23 revealed that resident returned from the hospital on 3/13/23 with a fracture to the Right Fibula. Record review of Physical Therapy (PT) O notes reveals Resident goal is to transfer from bed to chair, with moderate assist with one assist and a FWW (front wheeled walker). An observation 4/11/23 at 12:50 PM revealed the PT transferred Resident 14 to the chair without a gait belt (a belt that allows for a more controlled transfer) on the resident. The resident and PT did use Resident 14's walker during the transfer. 4/11/23 1:04 PM An Interview was conducted with the Director of Nursing (DON). During the interview the DON reported a gait belt should have been used during the transfer.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on record review and interview the facility failed to implement an individualized toileting plan for 1 (Resident 14) of 1 sampled resident. The facility identified census of 42. Findings are: Record review of the care plan confirmed no individualized toileting plan documented. Record review of Kardex (a way to communicate the residents care to the NA) reveals no individualized toileting plan. Record review of Minimum Data Set (MDS), a federally mandated assessment tool used for care planning) dated 3/30/23 revealed the facility assessed the following; -Brief Interview on Mental Status (BIMS) was a 10. According to the MDS Manual a score 8-12 indicates moderately impaired cognition. -Required extensive assist with toileting. -Frequently incontinent of bladder. -Occasionally incontinent of bowel. -No toileting program has been attempted. Record review of Resident 14's bladder assessment dated [DATE] revealed that Resident 14 was incontinent and should be toileted upon waking/going to bed, before meals, and as needed. An interview on 4/11/23 at 10:08 AM Resident 14 reported staff do not take Resident 14 to the toilet frequently. An interview with Director of Nursing (DON) on 4/11/23 at 1:12 PM reported Resident 14 is toileted at 1:00 PM and 3:00 AM. An interview on 4/11/23 at 1:12 PM with the DON, reported that Resident 14 was on a toileting program. An interview on 4/11/23 at 1:35 PM was conducted with Nursing Assistant (NA) M. During the interview NA M reported that Resident 14 is assisted with toileting every 2 hours. An interview on 4/12/23 at 10:43 AM with DON confirmed the bladder assessment dated [DATE] does not correlate with the toileting schedule.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to protect residents from abuse, failed to investigate allegations of abuse and submit the investigation to the state agency within the required time frames for 2 (Resident 1 and 3) of 3 sampled residents. The facility staff identified a census of 44. The findings are: A. On 10/11/2022 at 11:00 AM an interview was conducted with Resident 3. During the interview Resident 3 stated that a couple of weeks ago a NA (Nursing Assistant) jerked (gender) arm to pull (gender) out of bed and caused a bruise to the right wrist. Resident 3 stated that multiple staff was told about the incident and (gender) was told that the person doesn't work on the hall anymore. Record review of Resident 3's Minimal Data Set (MDS:a federally mandated comprehensive assessment tool used for care planning) dated 08/18/22 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) revealed Resident 3 was assessed at a 15. According to the MDS Manuel, a score of 13-15 indicates a person is cognitively intact. Review of the current Comprehensive Care Plan revealed that Resident 3 required extensive assistance of 1 staff with a gait belt and a walker for transfers. Record review of the weekly skin assessment dated [DATE] revealed that Resident 3 was noted to have a blue/dark purple bruise to R) inner wrist area measures 5.9cm x 5cm. No pain or discomfort noted. Area noted to be from lab draw. Review of an email sent on 09/30/2022 from the SSD (Social Service Supervisor) to the DON (Director of Nursing) and the ADM (Administrator) regarding a complaint from Resident 3. The email stated that Resident 3 has a bruise on (gender) hand that Resident 3 says is from an aide pulling (gender) up this morning. Resident 3 does not believe that (gender) was hurt on purpose but did yell ouch when it happened and the aide kept pulling. An interview was conducted with SSD on 10/11/22 at 11:26 AM which revealed that SSD had knowledge of the bruise to the resident's wrist and stated that (gender) spoke with Resident 3 regarding the staff pulling (gender) arm to get (gender) out of bed. An interview with LPN (Licensed Practical Nurse) A at 11:35 AM revealed that on 09/30/22 NA C reported a bruise on Resident 3's right wrist. LPN A stated an assessment of the bruise was completed at that time. LPN A stated that Resident 3 told (gender) that an aid had jerked (gender) arm trying to pull (gender) out of bed. LPN A stated the DON was made aware of the bruise and the allegation from Resident 3. Interview with NA B at 11:35 AM revealed that (gender) was the aide that Resident 3 was talking about. NA B stated that (gender) did touch the bruise on Resident 3's wrist on 09/30/22. An interview with DON on 10/11/22 at 11:45 AM revealed there was no documentation of an investigation of the allegation from Resident 3 that an aid jerked (gender) arm to pull (gender) out of bed causing a bruise. The DON confirmed that (gender) did not remove the NA from the floor or initiate an investigation on the allegation from Resident 3. The DON further confirmed that the allegation was potential abuse and should have been called into the state agency and investigated thouroughly. B. Record review of a significant change Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 8/31/22 revealed that Resident 1 was admitted to the facility on [DATE]. Resident 1 had a Brief Interview for Mental Status [BIMS, A test used to acccess cognitive function. ] score of 15. A score of 13-15 points indicates that the person is intact cognitively. The MDS identified that Resident 1 needed extensive assistance of 2 staff with bed mobility and transfers and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/11/12 at 10:55 AM revealed the following staff working on the 100 hall of the facility: LPN A, NA B (training to be a med aide with LPN A), NA E, NA F and NA G (in training). Observation on 10/11/22 at 11:00 AM revealed Resident 1 seated in a wheelchair in the resident's room on the 100 hall of the facility. Interview on 10/11/22 at 11:05 AM with Resident 1 revealed a concern with NA B when NA B assisted the resident with bed mobility. Resident 1 stated that NA B and another staff member [unable to remember the name] assisted the resident to turn in bed and that Resident 1 asked NA B to not touch the knees as they were painful. NA B did touch the resident's knees during the assist with turning and Resident 1 stated ouch and pushed NA B's hands away. NA B then touched the resident knees again even after Resident 1 had asked NA B not to touch them again. Resident 1 stated that this caused pain to the knees as they were bone on bone. I talked with the SSD after this happened. Resident 1 stated that NA B continued to work in the facility after the incident and had been seen around the facility. Interview on 10/11/22 at 11:25 AM with the SSD revealed that the SSD recalled talking with Resident 1 about the incident with NA B which involved NA B touched Resident 1's knees which caused Resident 1 pain. The SSD revealed that an email had been sent to the DON and the ADM in regards to the allegation of NA B being rough with Resident 1. Record review of an email from the SSD to the DON and the ADM dated 9/30/22 at 2:59 PM revealed the following: 1. [Resident 1] is upset with [NA B] because [gender] is too rough. [Resident 1] does not believe that [NA B] is this way purposefully but doesn't seem to know better or care. [Resident 1] said that [NA B] didn't get [gender] up until 10:00 AM and that [Resident 1] told [NA B] not to touch [gender] knees but [NA B] did anyway and it hurt. [Resident 1] said [NA B] is rough and doesn't talk to [Resident 1]. [Resident 1] doesn't want [NA B] to take care of [gender] anymore. Record review of a response dated 9/30/22 at 4:29 PM from the DON to the SSD and the ADM revealed the following response: When the incident was discussed with [Resident 1], [gender] did not get up until 10:00 AM, the aides asked [Resident 1] if [gender] wanted to get up and stated at that time that no [gender] did not. Nothing was said about [Resident 1] asking [NA B] not to touch [gender] knees, [Resident 1] just said that [NA B] touched her knees and [Resident 1] doesn't like having [gender] knees touched. After the conversation, the nurse verified that it was NA D that got [Resident 1] up this am, not [NA B]. Interview on 10/11/22 at 11:33 AM with the DON revealed that the DON and the SSD had talked about that incident with NA B and Resident 1. The DON stated that Resident 1 did not say anytihng about NA B being rough, just that the NA had touched the knees and didn't like the knees being touched. The DON confirmed that no formal investigation had been completed into the incident and it had not been reported to the state agencies as an allegation of potential abuse. The DON confirmed that NA B and NA D had both assisted to get Resident 1 up that day, not just NA D. The DON confirmed that the incident was not looked at as an allegation of potential abuse. The DON confirmed that NA B had not been suspended after the allegation and continued to work in the facility. Interview on 10/11/22 at 12:21 PM with the ADM revealed that the ADM was on vacation at the time of the email and had no recollection of the email stream or the incidents. The ADM stated that the incidents should have been reported and investigated as an allegation of potential abuse and NA B should have been immediately suspended from duty during the investigation of the incidents. Record review of Policy and Procedure entitled Abuse and Neglect Prevention Standard dated March 2017 revealed the following: V. Investigation: A. All allegations of abuse / neglect will be investigated and reported in accordance with state and Federal laws. B. In the situation of an allegation of abuse, the following people shall be notified immediately: Administrator, Director of Nursing and Social Services. C. The suspected team member will be suspended immediately while an in depth, documented investigation is conducted. VI. Protection: A. Residents will be protected from harm during an investigation. B. Residents will be separated or moved to a place of safety away from a harmful or abusive situation to prevent reoccurrence and for their own protection. C. Team members suspected of abuse will immediately be suspended until the results of the investigation are complete. VII. Reporting / Response: Any alleged physical, mental, verbal or sexual abuse; mistreatment, neglect, misappropriation of resident property, exploitation or involuntary seclusion of a resident by a team member is to be reported to the proper authorities. A. Report all alleged violations involving abuse (physical, mental, verbal, or sexual) immediately, but no later than 2 hours after the allegation has been made. B. Report all alleged violations involving neglect, exploitation, mistreatment including injuries of unknown source and misappropriation of resident property, if the allegation does not involve serious bodily injury immediately but no later then 24 hours. G. After conducting an internal investigation, you must submit a report of all investigation results to the state within 5 working days. The facility will take necessary corrective action depending on investigation results.

F755 Licensure Reference: 175 NAC 12-006.12 Based on record review and interview, the facility failed to have documented physician orders for the administration of medications to 2 [Residents 3 and 4] of 6 sampled residents. The facility had a total census of 55 residents. Findings are: A. A review of Resident 3's Physician Visit/Communication Form dated 11/8/21 revealed Resident 3's physician was asked if Resident 3's physician wanted Resident 3 to have monoclonal therapy. Resident 3's physician responded with Did [Resident 3 gender] test pos [positive] for and with PCR [polymerase chain reaction]? If so-yes The Physician Visit/Communication Form did not include a name of the medication, dose, frequency or route. A review of Resident 3's Casirivimab-Imdevimab [a monoclonal antibody medication] Treatment Order Form with positive [CONDITION(S)]-CoV-2 test date of 11/8/21 revealed the following options for orders: -Casirivimab 600 mg and imdevimab 600 mg administered as a single IV infusion given once peripherally over 21 minutes with a 0.2/0.22 micron in-line filter. -Casirivimab 600 mg and imdevimab 600 mg administered together as 4 subcutaneous injections administered consecutively, each at a different body site, into the thigh, back of the upper arm, or abdomen, except 2 inches (5 cm) around the navel. The waistline should be avoided. An option for administration of the medication was not selected on Resident 3's order form and the order form was not signed by Resident 3's physician. In an interview on 2/9/22 at 10:47 AM, Social Worker B reported that Social Worker B filled out the Treatment Order form with the information available and emailed the form to the designated pharmacist. Social Worker B reported the form was sent with the physician's order for monoclonal therapy. A review of Resident 3's Progress Note dated 11/10/21 revealed monoclonal therapy was given subcutaneously in right upper quadrant, right lower quadrant, left upper quadrant, and left lower quadrant. The Progress Note dated 11/10/21 did not identify the name of the medication or dose given to Resident 3. A review of Resident 3's 11/2021 MAR [Medication Administration Record]/TAR [Treatment Administration Record] did not reveal a physician's order for Casirivimab-Imdevimab or any documentation of Casirivimab-Imdevimab being administered to Resident 3. In an interview on 2/9/22 at 11:04 AM, Registered Nurse A reported the medication came to the facility with a pharmacy label identifying the resident's name. Registered Nurse reported the administration was only charted in the nurses' notes and was not documented on the Medication Administration Record. B. A review of Resident 4's Physician Visit/Communication Form dated 11/8/21 revealed Resident 4's physician was asked if Resident 4's physician wanted Resident 3 to have monoclonal therapy. Resident 4's physician responded yes. The Physician Visit/Communication Form did not include a name of the medication, dose, frequency or route. A review of Resident 4's Casirivimab-Imdevimab [a monoclonal antibody medication] Treatment Order Form with positive [CONDITION(S)]-CoV-2 test date of 11/8/21 revealed the following options for orders: -Casirivimab 600 mg and imdevimab 600 mg administered as a single IV infusion given once peripherally over 21 minutes with a 0.2/0.22 micron in-line filter. -Casirivimab 600 mg and imdevimab 600 mg administered together as 4 subcutaneous injections administered consecutively, each at a different body site, into the thigh, back of the upper arm, or abdomen, except 2 inches (5 cm) around the navel. The waistline should be avoided. An option for administration of the medication was not selected on Resident 4's order form and the order form was not signed by Resident 4's physician. In an interview on 2/9/22 at 10:47 AM, Social Worker B reported that Social Worker B filled out the Treatment order form with the information available and emailed the form to the designated pharmacist. Social Worker B reported the form was sent with the physician's order for monoclonal therapy. A review of Resident 4's Progress Note dated 11/8/21 revealed monoclonal therapy was given subcutaneously in right upper quadrant, right lower quadrant, left upper quadrant, and left lower quadrant. The Progress Note dated 11/8/21 did not identify the name of the medication or dose given to Resident 4. A review of Resident 4's 11/2021 MAR [Medication Administration Record]/TAR [Treatment Administration Record] did not reveal a physician's order for Casirivimab-Imdevimab or any documentation of Casirivimab-Imdevimab being administered to Resident 4. In an interview on 2/9/22 at 11:04 AM, Registered Nurse A reported the medication came to the facility with a pharmacy label identifying the resident's name. Registered Nurse reported the administration was only charted in the nurses' notes and was not documented on the Medication Administration Record. C. In interviews on 2/9/22 at 12:47 PM and 1:17 PM, the Acting Director of Nursing reported the facility does not have a policy and procedure regarding physician's orders. The Acting Director of Nursing reported physician's orders for medications should include the name of the medication, the dose, the frequency, the route, the physician's name and the name of the patient.

F842 Licensure Reference: 175 NAC 12-0016 Based on record review and interview, the facility failed to ensure complete medical records for 2 [Residents 3 and 4] of 6 sampled residents. The facility had a total census of 44 residents. Findings are: A. A review of Resident 3's electronic medical record did not reveal any documentation of results of PCR [polymerase chain reaction] COVID testing, representative notification of positive COVID-19 test, or representative consent for monoclonal antibiotic treatment [a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of lab report dated 11/8/21 printed from Nulirt computer system revealed Resident 3 had tested positive for COVID-19 by PCR test. A review of Resident 3's Progress Note dated 11/10/21 revealed monoclonal therapy was given subcutaneously in right upper quadrant, right lower quadrant, left upper quadrant, and left lower quadrant. In an interview on 2/8/22 at 11:35 AM, Registered Nurse A reported that PCR testing is done at a laboratory outside of the facility and the results are not scanned into the resident's medical record. A review of handwritten notes dated 11/8/21 provided by the Administrator revealed Resident 3's family had consented to monoclonal antibodies treatment. In an interview on 2/8/22 at 2:03 PM, the Administrator reported contacting resident's family regarding positive COVID-19 tests and asking family member about the resident receiving monoclonal antibodies. The Administrator reported obtaining verbal consent for the treatment but did not document the consent in the resident's medical record. B. A review of Resident 4's electronic medical record did not reveal any documentation of results of PCR polymerase chain reaction] COVID testing or representative consent for monoclonal antibiotic treatment. A review of lab report dated 11/5/21 print from Nulirt computer system revealed Resident 4 had tested positive for COVID-19 by PCR test. A review of Progress Note dated 11/4/21 revealed Resident 4's family member was notified of positive COVID-19 test. Progress Note dated 11/4/21 did not identify if Resident 4's family member had consented to monoclonal antibodies treatment. A review of Resident 4's Progress Note dated 11/10/21 revealed monoclonal therapy was given subcutaneously in right upper quadrant, right lower quadrant, left upper quadrant, and left lower quadrant. In an interview on 2/8/22 at 11:35 AM, Registered Nurse A reported that PCR testing is done at a laboratory outside of the facility and the results are not scanned into the resident's medical record. In an interview on 2/9/22 at 12:47 PM and 1:12 PM, the Administrator reported talking with all families regarding the monoclonal antibody treatment but not documenting the consent for the treatment

Based on record review and interview, the facility failed to document in the resident medical record the COVID-19 point of care testing offered, completed and the results of each test for 2 [Residents 1 and 5] of 6 sampled residents. The facility had a total census of 44 residents. Findings are: A review of Resident 1 and 5's electronic medical record did not reveal any documentation of COVID-19 testing offered, completed and the results of the testing. In an interview on 2/8/22 at 1:10 PM, Registered Nurse A reported that testing done at the facility is not documented in resident's medical record. In an interview on 2/9/22 at 12:47 PM, the Administrator reported the facility has been testing residents for COVID-19 twice a week starting 12/23/21 to date.

Based on interview and record review, the facility failed to ensure 3 facility employees [NA-C (Nurse Aide), NA-D, and RN-F (Registered Nurse)] of 16 sampled unvaccinated staff members were tested for COVID-19 in accordance with CMS (Centers for Medicare and Medicaid Services) guidelines and per the County Community Transmission Rate recommendation. This had the potential to affect all residents that resided in the facility. Facility census was 54. Findings are: Review of a Centers for Medicare and Medicaid Services (CMS) memo QSO-20-38-ND revised 09/10/2021 revealed that routine testing of unvaccinated staff should be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing frequency. The facility should test all unvaccinated staff at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the last week. On 12/01/2021 at 02:40 PM the facility's Administrator delivered an undated, un-named document that lisedt all staff members and their vaccination status. Review of that document revealed that the following staff were not vaccinated for COVID-19: -NA-C -NA-D -RN-F Record review of the facility's [NAME] County Positivity Rate Tracking Log for 06/22/21 - 09/14/21 and a COVID-19 Level of Community Transmission Tracking Log for 10/04/21 - 11/15/21 revealed the facility was using a combination of both for staff testing frequency. These documents revealed: -9/7/21, testing color was yellow and the testing frequency was weekly. -9/14/21, testing color was red and the testing frequency was twice weekly. -10/4/21, testing color was red and the testing frequency. Unvaccinated staff needed to be tested 2x/week. -10/18/21, testing color was red and the testing frequency. Unvaccinated staff needed to be tested 2x/week. -11/1/21, testing color was red and the testing frequency. Unvaccinated staff needed to be tested 2x/week. -11/15/21, testing color was red and the testing frequency. Unvaccinated staff needed to be tested 2x/week. Interview on 12/01/21 at 02:40 PM with the Administrator revealed the facility went into outbreak status on 10/30/21 and ended the outbreak status on 11/28/21. A record review of the National Healthcare Safety Network, Line listing - Long Term Care (LTC) Staff COVID-19 Testing logs dated [DATE], the staff schedules, and the Time Detail Record dated 12/2/21 revealed the following about the 3 unvaccinated staff members: -NA C was tested on e time a week for the following weeks: -9/7/21 -9/10/21 -9/17/21 -9/20/21 -9/24/21 -9/27/21, worked 9/29, 10/1, 10/2, 10/3 -10/4/21 , worked 10/8, 10/9, 10/11, 10/13, 10/16, 10/17 -10/18/21, worked 10/20 -10/30/21 -11/1/21, workded 11/3, 11/5 -11/17/21, worked 11/15, 11/19 -11/22/21 RN F tested on e time a week for the following weeks: -9/8/21, worked 9/8, 9/10, 9/14, 9/17, 9/21, 9/24, 9/28 -9/30/21, worked 9/30, 10/5, 10/7, 10/11, 10/15, 10/18, 10/20 -No testing between 9/30/21 and 10/31/21 -11/1/21, worked 11/1, 11/5 -11/8/21, worked 11/8, 11/10, 11/16, 11/19, 11/29, 11/30 NA D tested on e time a week for the following weeks: -10/11/21, worked 10/14, 10/15, 10/16, 10/20, 10/21, 10/25, 10/26, 10/28, 10/29, 10/30, 10/31, 11/3 An interview on 12/02/2021 at 11:02 AM with RN-A, one of the facility's Infection Preventionists, confirmed that staff COVID-19 testing was not completed according to the [NAME] County Transmission rates between 09/01/2021 and 11/30/2021. In an interview on 12/02/21 at 11:34 AM, RN-A confirmed there was no additional staff COVID-19 testing for RN F, NA C or NA D and that they had not been tested according to the recommended testing frequency of 2 times per week.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to identify an allegation of verbal abuse, complete an investigation and submit the results of the investigation to the required State Agencies (Adult Protective Services and Department of Health and Human Services) within the required timeframe's for 1 (Resident 7) of 26 sampled residents. The facility census was 54. Findings are: A. Record review of facility Abuse and Neglect Prevention Standards revised 3/17 under the investigation section revealed the following information: - A. All investigations of abuse/and or neglect will be investigated and reported in accordance in accordance with state and federal laws. - B. In the situation of an allegation of abuse, the following people will be notified immediately: Administrator, Director of Nursing, and Social Services. - C. The team member will be suspended immediately while an in depth documented investigation is conducted. Under the section entitled Protection the following was revealed: - Team members suspected of abuse will be immediately suspended until the results of the investigation are complete. Under the section entitled Reporting/Response the following was revealed: - Any alleged physical, mental, verbal or sexual abuse etc is to be reported to the proper authorities. - A. Report all alleged violation involving abuse (physical, mental, verbal or sexual abuse) immediately, but no later then 2 hours after the allegation has been made. - G. After conducting an internal investigation, you must submit a report of all investigation results to the state within 5 working days. The facility will take necessary corrective actions depending on the investigation results. B. Record review of a facility Complaint / Grievance Report dated 7/30/21 and signed on 8/1/21 revealed Resident 7 stated they [the resident and the roommate] were mistreated by Nurse Aide [NA] C and that NA C came into the room and yelled at Resident 7 on the morning of 7/30/21. The findings of the grievance revealed that the residents expressed that the NA C came into the room earlier then usual to assist them to get up. Resident 7's roommate told the NA C that Resident 7 liked to sleep in later on some days. NA C picked up the corner of Resident 7's bed covers and asked what she wanted for breakfast. NA C's actions were quick moving. Review of the section entitled Reportable to state agency identified that this was not considered to be a reportable incident on the grievance form. The complaint was started on 7/30/21 and was reported to the LPN. The Administrator was notified on 7/31/21 and began documentation of the of the grievance. C. Interview on 11/30/21 at 12:33 PM with the facility Administrator confirmed that the Complaint /Grievance had not been identified as an allegation of verbal abuse and had not been investigated or reported to the required State Agency's within the required timeframe's.

LICENSURE REFERENCE NUMBER 12-006.02(8) Based on record review and interview, the facility failed to ensure 1 (Resident 7) of 26 sampled residents were protected from potential abuse and/or neglect. The facility census was 54. Findings are: A. Record review of facility Abuse and Neglect Prevention Standards revised 3/17 under the investigation section revealed the following information: - A. All investigations of abuse/and or neglect will be investigated and reported in accordance in accordance with state and federal laws. - B. In the situation of an allegation of abuse, the following people will be notified immediately: Administrator, Director of Nursing, and Social Services. - C. The team member will be suspended immediately while an in depth documented investigation is conducted. Under the section entitled Protection the following was revealed: - Team members suspected of abuse will be immediately suspended until the results of the investigation are complete. Under the section entitled Reporting/Response the following was revealed: - Any alleged physical, mental, verbal or sexual abuse etc is to be reported to the proper authorities. - A. Report all alleged violation involving abuse (physical, mental, verbal or sexual abuse) immediately, but no later then 2 hours after the allegation has been made. - G. After conducting an internal investigation, you must submit a report of all investigation results to the state within 5 working days. The facility will take necessary corrective actions depending on the investigation results. B. Record review of a facility Complaint / Grievance Report dated 7/30/21 and signed on 8/1/21 revealed Resident 7 stated they [the resident and the roommate] were mistreated by Nurse Aide [NA] C and that NA C came into the room and yelled at Resident 7 on the morning of 7/30/21. The findings of the grievance revealed that the residents expressed that the NA C came into the room earlier then usual to assist them to get up. Resident 7's roommate told the NA C that Resident 7 liked to sleep in later on some days. NA C picked up the corner of Resident 7's bed covers and asked what she wanted for breakfast. NA C's actions were quick moving. Review of the section entitled Reportable to state agency identified that this was not considered to be a reportable incident on the grievance form. The grievance was started on 7/30/21 and was reported to the Licensed Practical Nurse and the Administrator. The Administrator was notified of the grievance on 7/31/21 and completed documentation of the grievance on 8/1/21. C. Record review of the facility Staffing Schedules for July 2021 revealed that NA C continued to work during the day shift of 7/30/21 after the incident and during the evening shift on 7/31/21 and then was scheduled off until 8/3/21. D. Interview on 11/30/21 at 12:33 PM with the facility Administrator confirmed that the Complaint /Grievance dated 7/30/21 had not been identified as an allegation of verbal abuse, had not been investigated and that NA C had not been suspended immediately after the allegation had been reported to the administrator. The Administrator confirmed that NA C continued to provide residents with direct care assistance on 7/30/21 and 7/31/21.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B1(3) Based on interview and record review, the facility failed to complete a Significant Change MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) for Resident 2 related to an improvement in transfers, ambulation and bed mobility. The sample size was 14. The facility identified a census of 54. FINDINGS ARE: An interview on 11/29/21 at 03:10 PM with Resident 2 revealed (gender) had a fall resulting in a [CONDITION(S)] on August 7 2021. The interview on 11/29/21 at 03:10 PM with Resident 2 revealed (gender) had required 2 people to assist with bed mobility and transfers upon return from the hospital. The interview on 11/29/21 at 03:10 PM with Resident 2 revealed (gender) now required 1 person assist with bed mobility, transfers and ambulation. A record review of the MDS dated [DATE] section G, revealed Resident 2 had required an extensive 2 person assist with bed mobility, transfers and ambulation. A record review of the MDS dated [DATE] section G revealed Resident 2 had required supervision or touch assistance of 1 person. An interview with RN-A (Registered Nurse) on 11/30/21 at 03:01 PM, after review of the current level of assistance for Resident 2 indicated on the 10/1/21 MDS that no Significant Change MDS had been completed related to Resident 2's improvement in bed mobility, transfers and ambulation and confirmed a Significant Change should have been completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on interview and record review, the facility failed to ensure Resident 2's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) was coded to reflect the resident's current condition during the observaiton period related to a fall with major injury. The sample size was 14. The facility identified a census of 54. FINDINGS ARE: An interview on 11/29/21 at 03:10 PM with Resident 2 revealed (gender) had a fall resulting in a [CONDITION(S)] on August 7 2021. A record review on 11/29/21 at 03:15 PM of the facility Matrix (a document used to identify pertinent care categories for the last 30 days for all residents) indicated no falls with major injury had occurred for any resident residing in the facility. A record review conducted of the MDS dated [DATE], section J, indicated that Resident 2 had had 0 falls since the last assessment. An interview on 11/30/21 at 02:29 PM with RN-A (Registered Nurse), after review of the MDS dated [DATE], section J, for Resident 2, confirmed that it did not indicate a fall with major injury and should have.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record review and interview, the facility failed to review and revise the Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 2 related to the level of assistance needed to complete ADL's (Activities of Daily Living) and for Resident 19 related to the left lower extremity wound. The sample size was 14. The facility identified a census of 54. FINDINGS ARE: A. An interview with Resident 19 on 11/29/21 at 09:05 AM revealed (gender) had a wound on (gender) left leg which was currently being dressed twice daily by staff. A record review conducted of the Admission Record dated 11/30/2018 containing Admission Diagnosis's revealed Resident 19 to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the current running, undated, CCP revealed it did not contain any mention of the left lower extremity wound. An interview conducted on 11/30/21 at 04:10 PM with the facility interim DON (Director of Nursing), after review of the CCP for Resident 19, confirmed it did not contain information related to the left lower extremity wound. An interview conducted on 11/30/21 at 04:10 PM with the facility interim DON, after review of the CCP for Resident 19, confirmed it did not contain information related to the left lower extremity wound. B. An interview on 11/29/21 at 03:10 PM with Resident 2 revealed (gender) had a fall resulting in a [CONDITION(S)] on August 7 2021. The interview with Resident 2 on 11/29/21 at 03:10 PM revealed that Resident 2 had improved since the [CONDITION(S)] and currently required only 1 person to assist with ADL's including bed mobility, transfers and ambulations. A record review of the undated current running CCP for Resident 2, under the falls section, indicated Resident 2 required 2 people to assist with transfers and ambulation. An interview on 11/30/21 at 02:51 PM with LPN-B (License Practical Nurse) confirmed that Resident 2 currently required 1 person assist for transfers and mobility.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to implement and follow up on a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility had a total census of 54 residents. The sample size was 12. The findings are: A review of Resident 49's EMR (Electronic Medical Record) revealed an admitted [DATE] and a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a progress note dated 10/22/21 at 10:22 AM revealed Resident 49 had an open area between Resident 49's 4th and 5th toes on Resident 49's right foot. Resident 49's toe was red, warm, and swollen. Resident 49 was afebrile and denied pain. A fax and a call were placed to Resident 49's physician. A review of a Physician Visit/Communication Form for Resident 49 dated 10/22/21 revealed an update was sent to Resident 49's physician regarding the open area that was discovered between Resident 49's 4th and 5th right toes that date. Further review of the Physician Visit/Communication Form revealed Resident 49's physician wrote an order stating, (Resident 49) should be on [MEDICATION(S)] (an antibiotic) 1 PO (by mouth) BID (twice daily) x 10 days. The physician signed and dated the form on 10/23/21. A review of a progress note dated 10/25/21 at 1:23 PM revealed Resident 49 was seen in the local clinic due to the open area on Resident 49's right foot, 4th toe worsening. New orders were received after the visit to start [MEDICATION(S)] 500mg (an antibiotic) three times daily for 10 days. The probable diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a progress note dated 10/27/21 at 3:16 PM revealed the open area to Resident 49's right foot, 4th toes was worsening again. The toe itself was blackened and the initial wound was bigger, red, and had scant oozing. The toe and distal foot were also cooler to the touch. An appointment was made at the local clinic for 10/28/21. A review of a progress note dated 10/27/21 at 5:10 PM revealed an order was received for Resident 49 in regards to a fax sent on 10/22/21 stating (Resident 49) should be on [MEDICATION(S)] PO BID x 10 days. A review of a Physician Visit/Communication Form for Resident 49 dated 10/28/21 revealed a note from Resident 49's physician stating, Pt (patient) seen with a necrotic (dead tissue) fourth toe. Pt and (family member) reports of not having good blood flow to the (right) foot. (Resident 49) was given 1 gram of [MEDICATION(S)] (an injectable antibiotic) IM (intramuscular) and will contact (physician name) at (specialty hospital) for referral. Further review also revealed an order to give [MEDICATION(S)] 1 gram IM daily for 5 days starting tomorrow. A review of Resident 49's October and November 2021 MARs did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 49's medical record did not reveal any further documentation related to the order for [MEDICATION(S)] dated 10/23/21. In an interview on 11/29/21 at 3:49 PM, the Interim DON (Director of Nursing) reported the fax sent to Resident 49's physician on 10/22/21 was returned to the facility on [DATE] signed by the physician, but with no new orders. The Interim DON stated the nurse on duty on 10/23/21 refaxed the update after writing Do you have any new orders? and the order was faxed to the facility on [DATE]. The Interim DON confirmed the provider signature on the order was dated 10/23/21. The Interim DON also confirmed the order for [MEDICATION(S)] was never implemented and never clarified with the provider. The Interim DON reported the Interim DON called the clinic today and received an order to discontinue the [MEDICATION(S)] for Resident 49.