Every finding on record at Callaway Good Life Center, Inc

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1)Licensure Reference Number 175 NAC 12-006.04(B)(ii)(2)The facility failed to ensure that 12 hours of required ongoing education was documented for nurse aides and medication aides who had been working in the facility for longer than one year and who required 12 hours of yearly training for 3 of 3 sampled staff. This had the potential to affect all residents. The census was 29.Findings were:Record review of the facility policy Abuse, Neglect, and Exploitation dated 12/01/2025 and signed by the Former Facility Director (FFA) revealed that existing staff will receive annual education through planned in-services and as needed.Record review of the facility policy Resident Rights with a copy right date of 2016 revealed that the nursing facility must provide a safe, clean, comfortable environment ensuring that the residents can receive care and services safely.In an interview with the Facility Administrator (FA) on 4/21/2026 at 10:15 AM it was revealed that the Director of Nursing (DON) had all of the information pertaining to the continuing education for employees including the 12 hours of mandatory education required by both nurse aides and medications aides. In a confirmation interview with the Director of Nursing (DON) on 4/21/2026 at 3:10 PM, the DON confirmed that all medication aides and nurse's aides must have 12 hours of continuing education every year based on the hire date to hire date anniversary of each employee. The DON confirmed that Medication Aide (MA)-E, MA-F and MA-G did not have 12 hours of continuing education documented in the employee files. The DON also stated that the education hours from the year 2024 were missing and unaccounted for therefore the facility could not show that the employees had received any education during that time frame. A.Record review of the Facility Employee List with the dates of hire revealed that Medication Aide (MA) E was hired as a medication aide on 6/24/2022.Record review of the continuing education hours for MA-E whose revealed a total of 6.74 hours of continuing education logged and documented in the previous year. MA-E had 3.87 hours of confirmed in-house training and 2.87 hours of online Relias computer training encompassing a time period of 6/24/2024 to 6/24/2025. B. Record review of the Facility Employee List with the dates of hire revealed that Medication Aide (MA) F was hired as a medication aide on 8/22/2019.Record review of the continuing education hours for MA-F revealed a total of 9.55 total hours of continuing education logged and documented in the previous year. MA-F had 3.8 hours of confirmed in-house training and 5.75 hours of online Relias computer training encompassing a time period of 8/22/2024 to 8/22/2025. C.Record review of the Facility Employee List with the dates of hire revealed that Medication Aide (MA) G was hired as a medication aide on 8/10/2022.Record review of the continuing education hours for MA- G revealed a total of 6.17 hours of continuing education logged and documented in the previous year. MA-G had 3.8 hours of confirmed in-house training and 2.37 hours of online Relias computer training encompassing a time period of 8/10/2024 to 8/10/2025.

Licensure Reference Number 12-006.12(D)(i)Based on observation and record review the facility failed to ensure items the medication room refrigerator was stored separately by route of administration and food stuff items were not stored with medication items. This had the potential to affect all the residents in the facility. The facility census was 28.Findings are:Record review of a facility policy titled Medication Storage and dated 01/21/2026 revealed Medications are stored separately ensuring proper sanitation and segregation.In an observation completed on 04/21/2026 at 11:30 PM of the facilities medication room a square dorm sized refrigerator was in the medication room. Inside the refrigerator on the bottom shelf were multiple boxes of insulin pens (an injectable medication) and medication bottles with suppositories (a medication placed inside the rectum) kept in them. On the same bottom shelf were 8-ounce plastic containers of liquid nutritional supplement drinks (a food stuff item).In an interview completed on 04/21/2026 at 2:45 PM with the Director of Nursing, the DON confirmed that items stored in the medication room refrigerator should be stored separately by route of administration and food stuff items should not be stored with medication items in the refrigerator and were.

Based on record review and interview, the facility failed to ensure that the Payroll Based Journal was submitted for the first quarter of 2026 by the due date of February 14, 2026. This had the potential to affect all residents. The facility census was 29. Record review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (PBJ) (a CMS-mandated system for nursing facilities to electronically report auditable staffing data, including hours worked, job roles, and pay types, to ensure transparency and quality of care, revealed that the PBJ data which must be submitted and received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely) was not submitted to or received by CMS by the date that the PBJ was required. The PBJ Staffing Data Report for the first quarter of 2026 dated October 1 to December 31, 2025, was due on February 14, 2026. In an interview with the Facility Administrator (FA) on 4/20/2026 at 9:05 AM revealed that the FFA would look into this as the information should have been submitted and received by CMS prior to the date that the information was due. In a confirmation interview on 4/21/2026 at 2:30 PM with the Business Office Manager (BOM) confirmed that the PBJ report for the time period of 10/01/2025 to 12/31/2025 had not been submitted to CMS by the date required.

Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review, and interview the facility failed to ensure that staff delivered resident meals in a sanitary manner to prevent the potential for foodborne illness and cross-contamination. This affected 15 of 22 residents in the facility dining room (Residents 22, 28, 19, 10, 35, 27,15, 20, 17, 16, 23, 21, 18, 25, and 9). The facility census was 29.Findings are:Record review of the facility policy titled Hand Hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among residents and health care personnel) dated 1/21/26 revealed that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations of the facility. Hand hygiene is indicated and will be performed between resident contacts, after handling contaminated objects, before and after handling clean or soiled items. Record review of the FDA (Food and Drug Administration) Food Code 2022 revealed that clean tableware (forks, knives, spoons, bowls, cups, serving dishes, tumblers, and plates) is to be handled to prevent contamination. Clean tableware will be handled so that contamination of food and lip contact surfaces is prevented. Observation on 4/20/26 at 12:14 PM in the facility dining room revealed that Dietary Aide-A (DA-A) carried a plated meal to Resident 11 and sat the plate on the table in front of the resident. DA-A's hands contacted the table top in front of the resident. DA-A returned to the service counter (DA-A did not perform hand sanitization). DA-A picked up a plated meal and carried the plated meal to Resident 22. DA-A sat the meal on the table in front of the resident. DA-A returned to the service counter and picked up two plated meals from the service counter. (DA-A had not performed hand sanitization). DA-A carried a plate in the left hand with the thumb on the top surface of the plate (food surface) and carried a plate with the right hand with the thumb on the top surface of the plate. DA-A sat a plate on the table in front of Resident 28 and the other plate on the table in front of Resident 19. DA-A went to the beverage counter and picked up 2 drink glasses. (DA-A had not performed hand sanitization). DA-A went to the beverage cart and used the scoop to put ice in a glass. DA-A opened a container of juice and poured the juice into the glass and delivered it to Resident 10. DA-A sat the glass on the table in front of Resident 10 and then returned to the beverage cart. DA-A used the scoop to put ice into a glass. DA-A carried the glass with ice and a can of diet coke to Resident 10. DA-A opened the can of diet coke and poured it into the glass and sat the glass in front of Resident 10. DA-A returned to the service counter. (DA-A did not perform hand sanitization). DA-A picked up a plated meal with the thumb of the right hand on the food surface of the plate. DA-A carried the plate to Resident 35 and sat the plate on the table in front of the resident. DA-A returned to the service counter. (DA-A did not perform hand sanitization). DA-A picked up a plated meal and carried it to Resident 27 with the thumb of the right hand on the top of the plate. DA-A sat the plate on the table in front of Resident 27. DA-A went to the beverage cart and picked up the pitcher of iced tea. (DA-A did not perform hand sanitization). DA-A went to the table of Resident 15 and picked up the used tea glass from the resident with the left hand. DA-A poured tea into the glass (a refill) and sat the glass back on the table in front of the resident. DA-A sat the iced tea pitcher back on the beverage cart. (DA-A did not perform hand sanitization). DA-A walked to the table where Resident 20 was seated in a wheelchair. DA-A put their right hand on the handle on the back of the wheelchair and rested the left hand on the table in front of the resident. DA-A offered a choice of dessert to Resident 20. DA-A went to a dessert cart and picked up a plate with a piece of chocolate cake and delivered it to Resident 20. (DA-A did not perform hand sanitization). DA-A walked over to Resident 17 seated at a table. DA-A placed the right hand on the wheelchair handle on the back of the resident's wheelchair and rested the right hand on the table in front of the resident. DA-A offered Resident 17 a choice of pie or cake. DA-A went to the dessert cart and picked up a plate with a serving of chocolate cake and sat it on the table in front of Resident 17. The time was now 12:19 PM. (DA-A did not perform hand sanitization). DA-A went to the plastic drawers next to the beverage counter. The four wheel walker of Resident 16 sat in front of the drawers. DA-A grabbed the handles of the walker with both of the hands and repositioned the walker. DA-A reached into a drawer and grabbed two containers of tartar sauce. (DA-A did not perform hand sanitization). DA-A carried the tartar sauce to Resident 27. DA-A pulled the seal off of the two tartar sauce containers and sat them on the table for Resident 27. DA-A went to the beverage counter and grabbed a drink glass. (DA-A did not perform hand sanitization). DA-A carried the glass to the beverage cart and used the scoop to put ice into the glass. DA-A filled the glass with water and took it to Resident 23. DA-A sat the glass on the table in front of the resident. (DA-A did not perform hand sanitization). DA-A went to the table of Resident 21. DA-A picked up the used knife and fork from Resident 21. DA-A used the knife and fork to cut up the chicken into bite sized pieces for the resident. Nursing Assistant-B (NA-B) went to the kitchen service counter and picked up a plate of food. NA-B held the plate with the thumb on the top of the plate and carried it to Resident 18. NA-B sat the plate on the table in front of the resident. NA-B went to the kitchen service counter and performed hand sanitization with alcohol based sanitizer. DA-A walked to the drawers next to the beverage counter. (DA-A did not perform hand sanitization). DA-A removed two containers of barbecue sauce from a drawer and took them to Resident 18. DA-A peeled the seal off of the barbecue sauce and picked up Resident 18's knife. DA-A used the knife to remove barbecue sauce from the containers and put it on the resident's meat on the plate. DA-A walked over to Resident 25 at a different table. (DA-A did not perform hand sanitization). DA-A placed their left hand on one of the wheelchair handles of Resident 25's wheelchair and rested their right hand on the table in front of the resident. DA-A went to the kitchen service counter and picked up two plated meals. (DA-A did not perform hand sanitization). DA-A carried one plate with the thumb of the left hand on the top of the plate and the other plate with the thumb of the right hand on the top of the plate. DA-A sat one of the plated meals on the table in front of Resident 23 and the other plated meal in front of Resident 9. DA-A returned to the kitchen service counter. (DA-A did not perform hand sanitization). DA-A picked up a plated meal and carried the plate to Resident 10. DA-A sat the plate on the table in front of the resident. DA-A returned to the kitchen service counter. (DA-A did not perform hand sanitization). DA-A picked up a plated meal and carried the plate to Resident 25. DA-A sat the plate in front of Resident 25. (DA-A did not perform hand sanitization). Interview on 4/21/26 at 4:17 PM with the facility Dietary Manager (DM) confirmed that staff are required to perform hand sanitization between resident contacts while delivering resident meals during meal service. The DM confirmed that hand sanitization is required after touching objects that may be contaminated. The DM confirmed that plates are to be carried without the thumb or fingers on the top food surface of the plate next to the food.

Licensure Reference Number 175 NAC 12-006.12(A)Based on record review and interview the facility failed to ensure a prescribed psychotropic medication had an approved diagnosis or indication for use for 1 resident (Resident 5) of 5 sampled residents. The facility census was 28.Findings are:Record review of a facility policy titled Use of Psychotropic Medication and dated 01/21/2026 revealed an adequate indication for use means that the medication administered is consistent with manufacturer's recommendations.Record review of a document titled Highlights of Prescribing Information (www.fda.gov/drugsatfda) and dated 2013 revealed Seroquel or Quetiapine Fumarate (an antipsychotic psychotropic medication) had indications and usages listed as Schizophrenia, Bipolar 1 disorder, and bipolar disorder.Record review of an admission Record revealed the facility admitted Resident 5 on 08/30/2023 with diagnosis of Dementia(a progressive decline in cognitive function that effects memory, language, and behavior), Psychotic disturbance of mood and Anxiety (a severe anxiety or mood disorder), and Depression (a common serious mood disorder characterized by persistent sadness, loss of interest in activities, fatigue, and cognitive difficulties, lasting at least two weeks). Record review of Resident 5's Medication Administration Record (MAR) for the month of April 2026 revealed Resident 5 had a physician order to receive Seroquel oral tabled 25 milligrams once daily for an indication or diagnosis of mind dementia with agitation. This medication was documented as to have been administered every day of the month at a listed time of 1:00 PM. A physician order to receive Quetiapine oral tablet 25 milligrams once daily at bedtime for an indication or diagnosis of depression. This medication was documented as to have been administered every day of the month at a listed time of 7:00 PM.In an interview completed on 04/22/2026 at 1:45 PM with the facility Director of Nursing, (DON), the DON confirmed that the diagnosis or indication for use of Resident 5's Seroquel and Quetiapine medication did not meet the facility policy stated adequate indication for use as the listed indication or use of mild dementia with agitation and depression were not manufacturer recommended uses for these/this medication.

Licensure Reference Number 175 NAC 12-006.09(G)(ii)Based on record review and interview, the facility failed to complete a summary or recapitulation of stay as required for 1 resident (Resident 32) of 2 sampled residents. The facility census was 28.Findings are:Record review of Resident 32's Electronic Medical Health Record (EMHR) revealed the facility admitted Resident 32 on 02/05/2026 and discharged Resident 32 on 02/14/2026.Record review of Resident 32's Progress Notes revealed that on 02/14/2026 at 9:55 AM the facility discharged Resident 32 from the facility to their private home accompanied by their spouse and that personal belongings, discharge instructions, and a medication list was provided to the resident's spouse. There was no documentation of a summary or recapitulation of the residents stay at the facility in the progress notes.In an interview conducted on 04/22/2026 at 2:45 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 32 discharged from the facility on 02/14/2026. The DON confirmed that a summary or recapitulation of the residents stay at the facility was not completed upon the residents' discharge from the facility and should have been.

Licensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 2 residents (Resident 5 and Resident 6) of 5 sampled residents and failed to comprehensively complete the Care Area Assessment (CAA) a critical component of MDS that functions as a decision making frame work to determine if a specific person centered care plan intervention is required) for 1 residents (Resident 5) of 5 sampled residents, and failed to complete an Prospective Payment System (PPS) a standardized, Medicare-required evaluation used to classify patients into payment groups based on clinical needs) Discharge assessment as required for 1 resident (Resident 1) of 5 sampled residents. The facility census was 28.Findings are:A.Record review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 dated October 2025 revealed Section O Special treatments, procedures, and programs coding instructions check all treatments, procedures, and programs that the resident received or performed with in the last 14 days of the Assessment Reference Date (ARD).Record review of Resident 5's Treatment Administration Record for the month of January 2026 revealed the resident had a physician's orders for a CPAP to be applied every night at its current settings at bedtime for sleep apnea. This order was documented to have been performed as ordered every night for the month of January 2026.The comprehensive MDS assessment for Resident 5 dated 01/14/2026 revealed in Section O Special Treatments, Procedures, and Programs, item G1 non-invasive mechanical ventilator (a machine that provides respiratory support without and artificial airway using a mask to deliver positive pressure to assist breathing) was not checked as being used at any time in the 14 days prior to the ARD of 01/14/2026.In an interview completed on 04/22/2026 at 11:30 AM with the facility Director of Nursing (DON), the DON confirmed that Resident 5 utilized a CPAP machine every night. The DON confirmed that this should have been coded on the MDS dated [DATE] and was not. The DON confirmed that the MDS was not coded correctly.B.Record review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 dated October 2025 revealed Section K 0520 Nutritional Approaches coding instructions to check all nutritional approaches that were performed with in the last 7 days of the ARD of 02/10/2026.Record review of Resident 6's Physician Orders on 04/21/2026 revealed the resident was prescribed a regular diet with regular texture and liquid consistency. The comprehensive MDS assessment for Resident 6 dated 02/10/2026 revealed in Section K 0520 the resident was coded to have received an mechanically altered diet.In an interview completed on 04/22/2026 at 10:05 AM with the Dietary Manager (DM), the DM stated that Resident 6 received a regular diet and had no dietary restrictions.In an interview completed on 04/22/2026 at 11:30 AM with the facility DON, the DON confirmed that Resident 6 was prescribed and received a regular diet. The DON confirmed that the comprehensive MDS dated [DATE] was not coded correctly due to the resident not receiving a mechanically altered diet.C.Review of a facility policy titled MDS 3.0 Completion and dated 12/18/2025 revealed Key findings regarding a resident's status are documented in the CAA's including the nature of the condition, complications and risk factors that affect the care planning decision factors that must be considered.Record review of Resident 5's CAA Worksheet for the comprehensive MDS dated [DATE] revealed the following:-The Cognitive Loss or Dementia CAA in the analysis of findings area no narrative or description of the problem or the condition affecting the resident, no description of the impact of the problem or need on the resident and the rational for the care plan decision.-The Visual Function CAA in the analysis of finding area no identification if the problem or need was actual or potential, no narrative or description of the problem or the condition affecting the resident, no description of the impact of the problem or need on the resident and the rational for the care plan decision.-The Communication CAA in the analysis of findings area no narrative or description of the problem or the condition affecting the resident, no description of the impact of the problem or need on the resident and the rational for the care plan decision.-The Urinary Incontinence CAA in the analysis of findings area no narrative or description of the problem or the condition affecting the resident, no description of the impact of the problem or need on the resident and the rational for the care plan decision.-The Psychosocial Well-Being CAA in the analysis of findings area no narrative or description of the problem or the condition affecting the resident, no description of the impact of the problem or need on the resident and the rational for the care plan decision.-The Falls CAA in the analysis of findings area no narrative or description of the problem or the condition affecting the resident, no description of the impact of the problem or need on the resident and the rational for the care plan decision.-The Nutritional Status CAA in the analysis of findings area no narrative or description of the problem or the condition affecting the resident, no description of the impact of the problem or need on the resident and the rational for the care plan decision.-The Pressure Ulcer or Injury CAA in the analysis of findings area no narrative or description of the problem or the condition affecting the resident, no description of the impact of the problem or need on the resident and the rational for the care plan decision.-The Psychotropic Drug Use CAA in the analysis of findings area no narrative or description of the problem or the condition affecting the resident, no description of the impact of the problem or need on the resident and the rational for the care plan decision.In an interview completed on 04/22/2026 at 11:30 AM with the facility DON, the DON confirmed that Resident 5's CAA's were not completed comprehensively and should have been.D. Review of a facility policy titled MDS 3.0 Completion and dated 12/18/2025 revealed Part A PPS Discharge Assessment is required when a resident's Medicare Part A (Medicare) stay ends but the resident remains in the facility.Record review of Resident 1's Clinical Census on 04/21/2026 revealed the resident admitted to the facility on [DATE] with Medicare Replacement listed as a primary payor. On 11/11/2025 Resident 1's primary payor source changed to Medicaid. Record review of Resident 1's Clinical MDS list on 04/21/2026 revealed an Entry MDS was completed on 10/29/2025, an Admission/Medicare 5 day MDS was completed on 11/05/2026, and a Quarterly-None PPS MDS was completed on 02/05/2026. There was no PPS Discharge MDS Assessment completed on the date of 11/11/2025 when Resident 1's payor source changed.In an interview completed on 04/22/2026 at 11:30 AM with the facility DON, the DON confirmed that Resident 1's primary payor source changed from Medicare to Medicaid on 11/11/2025 and no PPS Discharge MDS Assessment was completed as required.

Licensure Reference Number 175 NAC 12-006.09FBased on record review and interview the facility failed to complete a baseline care plan (a written plan required to be developed within 24 hours of admission detailing the instructions needed for staff to provide initial effective and person-centered quality care for a resident) within 24 hours as required for 1 of 3 residents (Resident 15) and failed to provide a written summary of the baseline care plan to the resident/resident representative for 1 of 3 residents (Resident 16). The facility census was 29.Findings are:A.Record review of the facility policy titled Baseline Care Plan dated 2/18/26 revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission (the baseline care plan is required to be developed within 24 hours in Nebraska). The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including initial goals, physician orders, dietary orders, therapy services, and social services. The admitting nurse shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative. Initial goals shall be established that reflect the resident's stated goals and objectives. Interventions will be initiated that address the resident's current needs. Record review of the admission Record for Resident 15 dated 4/22/26 revealed that Resident 15 admitted into the facility on [DATE]. Record review of the progress note dated 12/5/25 at 10:45 AM revealed that Resident 15 admission was on 12/5/25 at 10:45 AM. Resident's siblings were present during admission.Record review of the baseline care plan for Resident 15 dated 12/7/25 revealed that the baseline care plan was completed and signed by the nurse on 12/7/25. (Two days after admission).Interview on 4/21/26 at 4:20 PM with the facility Director of Nursing (DON) confirmed that a baseline care plan is required to be developed within 24 hours of the resident admission to identify care needs of the resident for facility staff caring for the resident. The DON confirmed that the baseline care plan for Resident 15 was not completed within 24 hours as required. B.Record review of the facility policy titled Baseline Care Plan dated 2/18/26 revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission (the baseline care plan is required to be developed within 24 hours in Nebraska). The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including initial goals, physician orders, dietary orders, therapy services, and social services. The admitting nurse shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative. Initial goals shall be established that reflect the resident's stated goals and objectives. Interventions will be initiated that address the resident's current needs. A written summary of the baseline care plan will be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the initial goals of the resident, a summary of the resident's medications and dietary instructions, and any services and treatments to be administered by the facility and personnel acting on behalf of the facility. The written summary of the baseline care plan will be provided to the resident and representative by completion of the comprehensive care plan. The person providing the written summary of the baseline care plan shall obtain a signature from the resident/representative to verify that the summary was provided and make a copy of the summary for the medical record. Record review of the admission Record for Resident 16 dated 4/22/26 revealed that Resident 16 admitted into the facility on 9/5/25. Record review of the baseline care plan for Resident 16 dated 9/5/25 revealed that the baseline care plan was completed and signed by the nurse on 9/5/25.Record review of the medical record for Resident 16 revealed no documentation that a baseline care plan was reviewed with the resident/resident representative. The medical record revealed no documentation that a written summary of the baseline care plan was provided to the resident/resident representative as required. Interview on 4/21/26 at 4:20 PM with the facility Director of Nursing (DON) confirmed that a baseline care plan is required to be developed within 24 hours of the resident admission to identify care needs of the resident for facility staff caring for the resident. The DON confirmed that a written summary must be reviewed with and provided to the resident and/or resident representative prior to the completion of the resident comprehensive care plan. The DON confirmed that there had been gaps in the facility process to ensure that this occurred.

Licensure Reference Number 175 NAC 12-006.09(E)(i)Based on record review and interview the facility failed to develop a comprehensive care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident based on the resident comprehensive assessment) for resident care needs identified in the resident assessment for 2 of 2 residents reviewed (Residents 16 and 12). The facility census was 29.Findings are:A.Record review of the facility policy titled Comprehensive Care Plans dated 2/18/26 revealed that it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The care planning process will include an assessment of the resident's strengths and needs. The comprehensive care plan will be developed within 7 days after completion of the comprehensive Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) assessment. The comprehensive care plan will describe at a minimum the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The comprehensive care plan will include measurable objectives to meet the resident's needs as identified in the resident's comprehensive assessment. Record review of the admission Record dated 4/22/26 for Resident 16 revealed that Resident 16 admitted into the facility on 9/5/25. Diagnoses included dehydration, overactive bladder, and urinary tract infection.Record review of the MDS assessment for Resident 16 dated 9/11/25 revealed that it was the admission assessment for Resident 16. The MDS assessment documented that Resident 16 had an active diagnosis of a urinary tract infection and was currently taking an antibiotic. Record review of the progress note for Resident 16 dated 9/6/25 at 3:29 AM revealed that Resident 16 is currently on an antibiotic to treat a urinary tract infection.Record review of the progress note for Resident 16 dated 1/2/26 at 3:00 PM revealed that the facility received a call from the clinic that Resident 16 was positive for a urinary tract infection and an antibiotic medication was ordered by the provider.Record review of the progress note for Resident 16 dated 4/7/26 at 7:23 PM revealed that Resident 16 has been more confused today. Resident 16 has a history of having a urinary tract infection. Foul odor was noted in the resident's brief. The resident's brief was saturated and appeared to have been on for some time. Record review of the progress note for Resident 16 dated 4/8/26 at 4:33 PM revealed that the provider gave orders to start an antibiotic related to probable urinary tract infection.Record review of the current comprehensive care plan for Resident 16 dated 4/20/26 revealed that it did not include resident ability or need of assistance for toileting. The care plan did not include a care focus for resident urinary tract infections and risk for urinary tract infections. The care plan did not include any interventions to monitor Resident 16 for urinary tract infections or interventions to prevent urinary tract infections.Interview on 4/21/26 at 4:20 PM with the facility Director of Nursing (DON) confirmed that care needs identified in the resident MDS assessment are to be included in the resident's comprehensive care plan. The DON confirmed that resident risk of urinary tract infection should be identified and included in the resident care plan to direct staff on cares to monitor and prevent urinary tract infection.B.Record review of the admission Record dated 4/22/26 for Resident 12 revealed that Resident 12 admitted into the facility on 3/9/26. Diagnoses included diabetes and edema (swelling caused by excess fluid trapped in the body's tissues).Record review of the MDS assessment for Resident 12 dated 3/17/26 revealed that it was the admission assessment for Resident 12. The MDS assessment documented that Resident 12 had an active diagnosis of high blood pressure, edema, and diabetes. Record review of the order summary (a list of all physician orders for a resident) for Resident 12 dated 4/21/26 revealed that Resident 12 had physician orders for insulin (a medication injected into the skin to treat high blood sugar due to diabetes) 4 times daily. Record review of the progress note for Resident 12 dated 3/9/26 at 10:50 AM revealed that Resident 12 was admitted into the facility from the hospital after treatment for hyperglycemia (high blood sugar in the bloodstream) and weakness.Record review of the progress note for Resident 12 dated 3/31/26 at 3:39 PM revealed that Resident 12's feet and legs remain edematous (swollen or puffy due to an abnormal accumulation of excess watery fluid).Record review of the current comprehensive care plan for Resident 12 dated 4/20/26 revealed that it did not include a focus area of resident medical care needs for diabetes or edema. Interview on 4/21/26 at 4:20 PM with the facility Director of Nursing (DON) confirmed that care needs identified in the resident MDS assessment are to be included in the resident's comprehensive care plan. The DON confirmed that resident diabetes and edema should be identified and included in the resident care plan.

Licensure Reference Number 175 NAC 12-006.09(F)Based on observation, record review, and interview, the facility failed to ensure a residents Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) was revised reflecting a resident current fall prevention intervention was listed for 1 resident (Resident 5) of 5 sampled residents. The facility census was 28.Findings are:Record review of a facility policy titled Comprehensive Care Plans dated 02/18/2026 revealed it is the policy of the facility to develop and implement a comprehensive care plan for each resident.In an observation completed on 04/21/2026 at 2:45 PM Resident 5 was observed to be lying in their bed with both of their legs over the edge of the bed on the floor and a alarm was sounding in the resident's room. Staff entered the room and assisted the residents with care needs.In an interview completed on 04/22/2026 at 8:15 AM with Medication Aide F (MA-F), MA-F stated that Resident 5 had a history of falls. The MA stated that one of the interventions to prevent the resident from falling was to have a personal alarm on to alert staff to when the resident was attempting to self-transfer.Record review of Resident 5's Electronic Medical Health Record (EMHR) the EMHR revealed that on 04/07/2026 the resident's provider approved an order for the resident to have a bed and chair alarm.Record review of Resident 5's Medication Administration Record (MAR) for the month of April 2026 revealed an order to maintain bed fall alarm and chair fall alarm twice daily with a start date of 04/07/2026. This was signed as completed twice daily from 04/07/2026 to 04/21/2026.Record review of Resident 5's CCP revealed the focus of Resident 5 being at risk for falls. There was no intervention on the residents CCP for a chair and bed alarm.In an interview completed on 04/23/2026 at 11:50 AM with the Director of Nursing (DON), the DON confirmed that a bed and chair alarm were being utilized as a fall prevention intervention for Resident 5. The DON confirmed that this was not listed on the residents CCP and should have been.

Licensure Reference Number 175 NAC, 12-006.09Based on observation, interview, and record review the facility failed to ensure a topical medication gel was applied in the amount as ordered by the provider for 1 resident (Resident 20) of 1 sampled resident. The facility census was 28.Findings are:Record review of a facility policy titled Administering Medications and dated 2019 revealed medications are administered in accordance with prescriber orders.Record review of Resident 20's Order Summary on 04/21/2026 revealed a provider order stating Diclofenac Sodium External Gel (a medication that is applied topically to relieve pain) 1% with directions to apply 2grams topically to joints every 6 hours as needed.In an observation completed on 04/21/2026 at 9:57 AM of medication administration to Resident 20 by Medication Aide F (MA-F), MA-F squeezed an unmeasured amount of a opaque white gel onto their gloved hand. The MA rubbed the unmeasured amount of the gel onto the residents' left hip. The MA then squeezed another unmeasured amount of the gel onto their gloved hand and rubbed the unmeasured amount of the gel onto the residents left shoulder. The MA then squeezed another unmeasured amount of the gel onto their gloved hand and rubbed the unmeasured amount of the gel onto the residents left elbow.In an interview completed on 04/21/2026 at 10:05 am with MA-F, MA-F confirmed that the cream that they applied to Resident 20's left hip, shoulder, and elbow was Diclofenac Sodium Gel. The MA confirmed that the prescribed amount of the gel to be applied to the joints was 2 grams and each dose should be measured prior to applying using the clear marked measuring device. The MA confirmed that they did not measure the amount of the gel that they applied to Resident 20's left hip, shoulder, and elbow ensuring that the prescribed 2 grams was applied to each joint as ordered.In an interview completed on 04/22/2026 at 2:45 PM with the facility Director of Nursing (DON), the DON confirmed that MA-F should have used the clear measuring device to measure out each dose of gel that they applied to Resident 20's joints and did not. The DON confirmed that the providers' orders were not followed.

Licensure Reference Number 175NAC 12-006.11(E) Based on record review, observation and interviews, the facility failed to ensure that food was stored and prepared in a manner to prevent food borne illnesses. This had the potential to affect all residents eating food prepared in the kitchen. The facility census was 28. Findings are: Record review of the Policy and Procedure Manual for Long Term Care operation manual revised December 2014 sub-section refrigerators and freezer on page 24 revealed; 2.) monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 4.) food service managers and designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 7.) all food shall be appropriately dated to ensure proper rotation by expiration dates. 8.) supervisors will be responsible for ensuring food items in the pantry, refrigerators, and freezers are not expired or past the perish dates. Record review of the menu for the noon meal revealed the kitchen staff were to prepare and serve bacon, lettuce and tomato sandwiches, French fries, and Jello. There were no recipes being followed nor were there any instructions denoting serving sizes Record review of the temperature logs from the refrigerators and freezer revealed that there were many open spaces on the temperature logs for the month of May. The following dates did not have temperatures recorded during the time period of 05/01/2025 to 05/19/2025; The walk-in refrigerator, walk-in freezer and kitchen refrigerator log revealed the following dates had no temperatures recorded on the temperature log. -May 2; AM and PM temperatures are blank -May 3; AM temperature is blank -May 4; AM and PM temperatures are blank -May 5; AM temperature is blank -May 6; AM and PM temperatures are blank -May 7; PM temperature is blank -May 8; PM temperature is blank -May 9; PM temperature is blank -May 10; PM temperature is blank -May 13; AM and PM temperatures are blank -May 14; AM and PM temperatures are blank -May 15; AM and PM temperatures are blank -May 16; AM and PM temperatures are blank - May 17; AM temperature is blank -May 19; AM temperature is blank Record review of the food temperature record for the month of May 2025 revealed that temperatures were taken sporadically. The temperatures are as follows: May 1; Breakfast; cereal 163.7 and meat entree 168.3. - Noon meal; Meat dish 159.9 and starch (FF) 162.0 - Evening meal: no temperatures recorded May 2; No temperatures recorded May 3; Breakfast; no temperatures recorded - Noon meal; Meat dish was 165 and starch was 145. - Evening meal; no temperatures recorded May 4; no temperatures recorded May 5; no temperatures recorded May 6; Breakfast no temperatures recorded - Noon meal; starch was recorded as 280. - Evening meal; Milk was recorded as 165. May 7; no temperatures recorded May 8: no temperatures recorded May 9; no temperatures recorded May 10; no temperatures recorded May 11; no temperatures recorded May 12; no temperatures recorded May 13; Breakfast; eggs 165 - Noon meal; Meat regular - 145 Meat ground 145 - Evening meal; Meat dish 189, puree vegetables 208 May 14: Breakfast - eggs 165 and cereal 155 - Noon meal- ground main dish 198 - Evening meal - no temperatures recorded May 15; no temperatures recorded May 16; no temperatures recorded May 17; no temperatures recorded May 18; no temperatures recorded May 19; Breakfast milk 178 and eggs 148 - Noon meal; 250 milk, 160 ground Meat/main dish and 165 Vegetables. Observation on 05/19/2025 at 9:30 AM in the small refrigerator revealed one clear, plastic, quart sized container of nacho cheese that did not have a label and was not dated, 6 small plastic containers of nacho cheese that were not labeled or dated, and turkey that was not labeled or dated in a plastic zip lock baggie. Observation on 05/19/2025 at 9:35 in the walk-in refrigerator revealed a tray of filled dessert cups was covered with plastic wrap but not labeled or dated. Interview on 05/19/2025 at 9:43 AM with Cook-A who stated not knowing when the nacho cheese was used and why it wasn't labeled. Cook-A revealed that the dessert cups were for the noon meal and had just been prepared for the noon meal but had not been dated or labeled. Observation on 05/20/2025 at 9:43 AM as Cook-A removed the nacho cheeses and turkey during the interview. Interview on 05/19/2025 at 9:45 AM with [NAME] A confirmed [NAME] A had not recorded the temperatures of the refrigerators or freezers for the morning. [NAME] A also revealed that there was a menu for the day, but there was no recipe being followed in creating the noon meal. [NAME] A stated I just have a menu that I go by today and we are serving BLTs and Fries. Observation on 05/19/2025 at 9:55 AM of Dietary Aide (DA) B cleaning in the dining room area following breakfast service. DA B brought a broom and a dustpan to the dining room area and began sweeping the floor. DA B stopped at one point, leaned the broom and the long handled dustpan against the counter, took the old coffee filter and grounds from the coffee pot, then replaced with a new coffee filter and grounds, and started the coffee maker then started sweeping again. Interview on 05/19/2025 at 10:00 AM with DA B who confirmed to not washing hands with soap and water after handling the broom and dustpan before making the new pot of coffee. Observation on 05/20/2025 at 10:10 AM of [NAME] A cutting up tomatoes for the noon meal. [NAME] A retrieved a box of tomatoes from the walk-in refrigerator. [NAME] A donned gloves, took a tomato from the box, sliced the tomato, then placed it in a clean metal serving pan. This action was repeated 3 times. At that time, [NAME] A removed and discarded gloves, reached for a different knife, and donned a new pair of gloves, reached for another tomato, sliced this tomato and added the slices to the metal serving container. Two more tomatoes were sliced and then [NAME] A removed and discarded the gloves, reached for plastic wrap, covered the metal container with plastic wrap, and covered the sliced tomatoes. [NAME] A dated and labeled the sliced tomatoes and took them to the refrigerator. [NAME] A then returned the box of tomatoes to the walk-in refrigerator. Interview on 05/19/2025 at 10:15 with [NAME] A who confirmed that the tomatoes had not been washed prior to slicing the tomatoes. Confirmed not washing hands between glove changes. Observation on 05/19/2025 at 10:20 AM as [NAME] A recorded temperatures of the walk-in freezer and refrigerators. Interview with [NAME] A on 05/19/2025 at 10:23 AM who confirmed [NAME] A did not wash hands with soap and water between gloves changes. [NAME] A confirmed that the tomatoes had been removed from the box and not washed prior to slicing the tomatoes. Observation on 05/19/2025 at 10:45 AM. [NAME] A and DA B looked though the kitchen drawers trying to find a food thermometer. Staff finally found a thermometer in the dining room area drawers near the coffee maker. Once found, [NAME] A cleaned the thermometer prior to testing the bacon that was being removed from the oven for the Bacon/Lettuce/Tomato sandwiches that were on the noon meal menu. Observation on 5/19/2025 at 12:15 AM of the temperature check of the oven baked French fries prior to serving; French fries temperature were 135 degrees Fahrenheit and seated in a pan in the steam table. COOK-A did not recheck the temperature of the bacon in the steam table prior to serving. Record review of the Food Temperature record for the month of May 2025 revealed that the noon meal had the following temperatures recorded; Noon meal; 160 degrees for ground Meat/main dish and 165 degrees for Vegetables. Observation on 05/19/2025 at 12:22 PM revealed the only foods served from the steam table were Bacon, Lettuce, Tomato sandwiches and oven baked French fries. Coffee, juices, water, and milk were served cold at the resident tables in the dining room in drinking glasses. There was no hot milk served. Interview 05/19/2025 at 12:47 PM with Resident 1 who stated that the meals are ok, but the hot foods are not always very hot, especially if the foods are delivered to my room. If my food comes on a tray, it is usually not very warm at all. Interview on 05/19/2025 at 1:15 PM with the facility Dietary Manager (DM) confirmed the temperatures on the food temperature record log for the month of May 2025 were not complete. DM Confirmed the refrigerator and freezer temperatures were not recorded twice daily. DM did not know why the temperatures had not been recorded. Observation on 05/19/2025 of meal tray served at 1:20 PM revealed the oven-baked French fries was 128 degrees. Oven baked French fries were not warm and no longer crunchy. Interview on 05/19/2025 at 2:55 PM of Resident 2 who stated the food served is usually pretty good. Sometimes the hot food could be a little warmer though. But overall, the food is pretty good. Interview on 05/19/2025 at 2:55 PM of Resident 3 who stated the food served is usually pretty good. Sometimes the hot food could be a little warmer and it isn't like I used to make it. But I really don't have any complaints. Interview on 05/19/2025 at 3:05 PM with the facility DM revealed DM had only been in the position as Dietary Manager since March. DM is also the Environmental Services Supervisor and had taken on the role when the former Dietary Manager left the facility. DM had not taken the Serve Safe class nor had anyone else in the dietary department. One person was starting that class on 05/20/2025. DM revealed (gender) was a school cook prior to coming to work at the facility. DM felt overwhelmed with all of the responsibilities for which DM was responsible because DM also worked in environmental services and housekeeping. DM was not sure how everything was supposed to work in the dietary department. DM was excited to have one of the cooks starting the Serve Safe class the following day.

Based on record review and interview, the facility failed to report allegations of abuse and misappropriation of resident property within the regulated time period. This affected one resident (Resident 1). The facility census was 28. Findings are: Record review of the Abuse and Neglect Reporting policy 05/15/2025 revealed that the facility will not condone resident abuse or neglect, misappropriation of property or exploitation by anyone. If alleged abuse, neglect, misappropriation of property or exploitation does occur, the facility will take appropriate action to intervene, document incidents, investigate, take measures to prevent further occurrences and report it to the proper authorities. Under the subheading Policy interpretation and Implementation revealed 1.) All staff, residents, visitors, etc. are required to immediately report any incidents or suspected incidents of resident mistreatment, abuse, or neglect, exploitation, including injuries of unknown source and misappropriation of property. Such reports may be made without fear of retaliation from the facility or its staff. The definitions of abuse included d.) mental abuse; verbal or non verbal which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Examples include, but are not limited to; mocking, isolation, humiliation, harassment, and threats of punishment or deprivation. g.) misappropriation of resident property; to take a resident's personal belongings or financial resources either with or without the resident's knowledge for one's own use or a use not in the best interest of the resident. Also defined deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without he resident's informed consent. Procedure revealed 1.) any alleged violations involving mistreatment, exploitation, abuse or neglect - including injuries or an unknown source and misappropriation of resident property - must be reported. 6.) when an alleged or suspected case of mistreatment, exploitation, misappropriation of resident's property, abuse or neglect is reported, the Director of Nursing or Administrator or designee will notify the following persons or agencies of such incident: 1. Within 24 hours: a. APS 24 hour hotline. Report allegations of abuse, neglect or exploitation immediately. Within 2 hours of allegation, if a suspicion of abuse, neglect or exploitation results in bodily injury or harm. b. Law Enforcement Agency; when there us serious physical injury, incidents of theft .law enforcement should be notified within 2 hours. 9. An internal investigation will be completed by the facility within 5 working days of the notification of allegations. 10. The facility manager or administrator will send via fax a copy of the completed internal investigation including facility conclusions/follow through within five working days. Record review of the grievance form dated 5/15/2025 revealed Resident 1 had filed a grievance with the Director of Nursing and reported mail being opened by staff, missing clothing, staff taking personal items that Resident 1 had been told were not allowed in the facility, staff not cleaning this resident's side of the room in a double occupancy room, a missing welcome sign, and feeling picked on by the Administrator and feeling like (gender) was unable to speak to the Administrator honestly. Record review of the grievance form dated 5/16/2025 and signed by the Social Services Director (SSD) stated that the facility had called the state ombudsman. The social services director had then communicated the situation with the Administrator who stated he did not want to report the situation, and that the Administrator knew where the wax melt was but would not say who took it. Furthermore, on 5/16/2025 during the morning management meeting, the Environmental Services Supervisor admitted to taking Resident 1's wax melt. The wax melt (candle warmer) was given to the SSD who went to Resident 1 and explained that due to the fire hazard the item cannot be kept in the facility and that it could be put into storage instead. Interview on 5/19/2025 at 12:47 PM with Resident 1 who stated (facility staff) have opened my mail and they have gone through the things in my room. They always think I am smoking. The facility staff stole my wax melting burner twice. I found it the first time. Then they took it again. I had a welcome sign that was on my door that someone took it. After I complained someone put it back on my door. They stopped cleaning my side of the room too. The Administrator (ADM) and the head of housekeeping (DM) don't like me. I have talked to the ADM about this and the ADM doesn't believe me when I say people are stealing my things. I also talked to the Director of Nursing (DON)about it and filed a grievance. Interview on 5/19/2025 at 1:15 PM with the Director of Nursing (DON) who revealed that Resident 1 had reported to the DON on 05/15/2025 that Resident 1 had a candle warmer, and it had been taken from the resident's room. Resident 1 found it on a staff member's desk. Resident 1 took it back to (gender) room. Later a staff member went back to the room of Resident 1 and took the Candle warmer again without telling Resident 1. This time I believe it was hidden under the desk of another staff member. Staff members found the candle warmer in the room of Resident 1 and didn't tell the resident they were taking it from the room the first time. The second time they took it out of the room when the resident was gone too. Nobody told this resident they were taking it. Resident 1 got very angry when found out the candle warmer was missing again. Other staff members stated she was yelling at staff because (gender) things had been taken from Resident 1's room. Resident 1 felt that her things had been stolen. When Resident 1 came to me about what was occurring, I started my own investigation into the matter on 5/15/2025, but I did not report this to the state. The Environmental Services staff are not cleaning Resident 1's side of the room daily as they do all the other Resident rooms because they are afraid of being accused of stealing items. The staff don't want Resident 1 in the room when they are cleaning. I think if they cleaned the room while Resident 1 was in the room, Resident 1 would see that nobody is stealing anything. The Business Office Manager (BOM) did open Resident 1's mail, but stated that was an accident. Resident 1 is still angry about that too. the DON Confirmed this had not been reported to the state and was going to send in a report. Interview on 5/19/2025 at 1:40 PM with Registered Nurse (RN) C who stated that nobody from Environmental Services wants to clean the side of the room that belongs to Resident 1 (This is a double occupancy room.). Last Thursday, 5/15/2025, Resident 1 was yelling at the ADM about items being stolen from (gender) room. Resident 1 stated that her candle wax burner had been taken from her room twice and nobody told her. It seems like some of the staff pick on Resident 1. She has a lot of stuff in her room. I believe someone stole the Welcome sign she had on her door because it was brought to the attention of staff during a meeting and the sign just magically reappeared on the door of Resident 1. I feel that if administration or environmental services are going to take things from the room of a resident, that residents [NAME] to be told and not just have things taken from the room. Interview on 05/19/2025 at 3:05 PM with the head of environmental services (DM) who revealed that we clean all the rooms the same way each day. We use a check off sheet as we go from room to room. Families will bring in items that are all supposed to have the name written on it and added to inventory lists. Sometimes families bring stuff in and we aren't here and things don't get labeled. But we do try to keep everything labeled with Resident names. We don't purposefully snoop or look for things in resident rooms, but when we find things that are not supposed to be there or can be or are a hazard, we will remove those things from the room. We removed a candle warmer from the room of Resident 1. We didn't tell the resident at the time. We removed it because it is not allowed. Resident 1 is kind of a hoarder and hasn't let us inventory much of (gender) stuff that has been brought in because (gender) didn't want us looking though the belongings. We haven't cleaned Resident 1's side of the room since Friday (4 days ago). Resident 1 called me a lot of names. Then Resident 1 got upset because we hadn't cleaned Resident 1's side of the room as we had only cleaned the roommate's side. We aren't supposed to move anything in the room that belongs to Resident 1, who is a hoarder, so cleaning is difficult. At first I was the only one accused of taking the candle warmer from the room and now Resident 1 is blaming everyone from Environmental Services. We probably need to take a mediator to the room when we clean the room because we are all afraid of being accused of stealing. Interview on 5/19/2025 at 3;15 with the facility ADM who stated that if contraband is found in a resident's room, we will take it immediately especially if it is a potential hazard to all residents. The candle warmer is a fire hazard and so that was removed from the room of Resident 1. We did not tell Resident 1 we took either the first or the second time it was removed from the room. ADM confirmed this incident was not reported to the state as the ADM did not feel there was a reason to turn this in.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record reviews, the facility failed to prepare and serve food in a safe manner to prevent the potential for foodborne illness. This had the potential to affect all facility residents eating out of the kitchen. The facility census was 28. Findings are: On 02/04/2025 at 8:28 AM upon initial observation, Dietary Aide-I (DA-I) was observed wearing gloves at the time of meal service. DA-I prepared plates of food to be served to residents sitting in the dining room. DA-I was observed picking up biscuits with gloved hands breaking them open, then picking up the ladle which scooped a white gravy, then poured the product on the biscuit. DA-I picked up a plastic card that contained writing on it and handed the card to Dietary Aide-H (DA-H) and the plate of food, where DA-H then retrieved the plate and brought it out to the resident to eat. DA-H hand sanitized after providing that plate and obtaining another plate for another resident. DA-I did not change gloves until service was completed. An observation on 02/05/2025 at 8:24 AM Dietary Aide-G (DA-G) was observed wearing gloves and preparing plates of food to be served to residents sitting in the dining room. DA-G was observed to be scooping a piece of breakfast cake with a spatula and pushing the food onto the plate with the gloved hand. DA-G was observed to be opening the refrigerator, managing the plastic dietary cards with gloved hands, delivering plates of food with the same gloved hands, not changing gloves throughout breakfast service. An observation on 02/06/2025 at 8:21 AM DA-G was observed to be wearing gloves while plating up food. DA-G had a stack of toast on the counter. DA-G was observed to the picking up the toast with the gloved hands and placing them on the plates for service. DA-G was also observed to be opening the refrigerator, managing the plastic dietary cards, delivering plates of food with the same gloved hands. An observation on 02/06/2025 at 9:30 AM meal preparation for lunch service revealed DA-G was to be cooking meatballs without a recipe. When asked about the recipe, the Dietary Manager (DM) printed off a recipe from the Internet and provided me with a recipe that DA-G did not use. DA-G obtained the following products for making the meatballs, 2 6-pound tubes of raw ground beef and 2 large onions. DA-G started the preparation by washing hands and donning gloves. DA-G obtained a knife and stuck it in the center of the tubes of ground meat and sliced in straight though cutting into the meat and pulling the meat out and placing into a container. DA-G then stuck the second tube of meat with the knife and sliced it through and dumped the meat in the container with the other meat. DA-G realized that part of the meat was frozen, so put the partially frozen meat in a separate container and moved aside. DA-G then changed gloves, not washing hands, grabbed the onions and began slicing them and dicing them, then sat the onions aside. DA-G took seasoning bottles and began to sprinkle on top of the meat, celery salt without measuring, black pepper without measuring, and garlic salt without measuring. DA-G began to mix the meat up to incorporate all the seasoning. DA-G then cracks 3 eggs into the meat, the recipe calls for 1 egg per pound of meat. The leftover frozen meat is cut into smaller portions and placed into the microwave oven for 5 minutes, and again for 6 minutes. On 02/06/2025 at 9:52 AM DA-G then cleans up the counter, the onion skins and puts the seasonings away. DA-G took a measuring cup, measures up breadcrumbs and parsley in the same cup, places the breadcrumbs and parsley in the meat mixture, cracked two more eggs, and pulled out the meat in the microwave. The meat in the microwave is partially brown and other parts red and pink. With gloved hands, DA-G mixes the meat together for 9 minutes. The gloves are then changed, and DA-G took a cookie scooper, additional gloves and scoops meat mixture creating a ball and placed in a small lined pan. The onions are then added to the remaining mixture of meat, mixed again. Gloves are changed and meatballs are formed and placed in a larger pan, then placed into the oven on 375-400 degrees at 10:19 AM. DA-G washes hands and gets out frozen potatoes, a can of peas and the butter in a container sitting next to the microwave. The butter is doused on the frying griddle and a scoop of butter is placed in a pot on the stove. DA-G opened the frozen potatoes, put them on the griddle and spreads them out. DA-G then opens the can of peas, drains the can. DA-G then got a large pitcher of water and begins to fill the steam table full of water and turns the table on at 10:30 AM. DA-G began cleaning up the preparation table. DA-G washed hands then dumps the can of peas into the pan of butter, then the pan of peas and butter are placed into the steam table. The potatoes stirred up on the griddle and seasoning is added to the potatoes. DA-G gets out a pan, adds the potatoes to the pan and the pan is placed into the steam table. The griddle was scrubbed down and cleaned using a foam brick and scrapper. Grilled cheese is then being made and prepared for the alternate meal option on the griddle. Once the sandwiches are made, they are added to the steam table at 11:15 AM and covered with a lid. DA-G takes the meatballs out of the oven then without measuring, doused with a bottled barbeque sauce stirred up and placed back into the oven. The temperature of the meatballs are taken reading 133 Fahrenheit. The meatballs go back into the oven then taken out at 11:48 AM and read 165 degrees Fahrenheit and moved to the steam table. At 11:59 AM DA-G put gloves on and lifted the lids to the steam table and grabbed a plastic card that states the resident information about their diet on the card. DA-G read the card and prepared a plate for a resident and handed the plate to a server. An interview with DA-G on 02/06/2025 at 12:17 PM revealed that the peas and the potatoes being served were never temped for a set or holding temperature. DA-G states they forgot to temp the potatoes and that they did not think temping the peas was necessary. The interview further revealed that thawing the meat in the microwave typically does not happen, however did not take the meat out earlier than expected. An interview with the DM on 02/06/2025 at 1:04 PM revealed that thawing meat in the microwave is not appropriate, and that DA-G was not aware that this shouldn't be done. The interview continued to reveal that temping all foods including ready made foods is necessary and states that staff may not be aware of the process. The interview further revealed that wearing gloves throughout the serving process is not a replacement of washing hands. A record review of the facility policy titled, Policy and Procedure [NAME] for Long Term Care-Food Service dated April 2018 revealed the policy under Food Handling statement: Food will be stored, prepared and served so that the risk of foodborne illness is minimized. Policy interpretation and implementation reveals: 1. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees; b. Inadequate cooking and improper holding temperatures; c. Contaminated equipment; and d. Unsafe food sources. 5. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state specific requirements. Federal standards require that refrigerated food be stored below 41 degrees Fahrenheit, and that freezers keep frozen foods solid. 6. Potentially hazardous foods will be cooked to the appropriate internal temperature and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms.

Licensure Reference Number 175NAC 12-0006.04(B) Based on record review and interview the facility failed to ensure that Nurse Aides completed the required continuing education hours for 3 of 5 sampled Nurse Aides. The facility census was 28. A record review of a facility supplied document titled Course Completion History dated 02/10/2025 revealed that Nurse Aide M (NA-M) had completed 2.37 hours of continuing education hours from 01/01/2024 to 02/10/2025. A record review of a facility supplied document titled Course Completion History dated 02/10/2025 revealed that Nurse Aide N (NA-N) had completed 1.63 hours of continuing education hours from 01/01/2024 to 02/10/2025. A record review of a facility supplied document titled Course Completion History dated 02/10/2025 revealed that Nurse Aide O (NA-O) had completed 4 hours of continuing education hours from 01/01/2024 to 02/10/2025. In and interview completed on 02/10/2025 at 3:00 PM with the facility Director of Nursing (DON), the DON confirmed that NA-M, NA-N, and NA-O had not completed the minimum of 12 hours of continuing education as of 02/10/2025. The DON confirmed that all Nurse Aides should have a minimum of 12 hours of continuing education completed every year.

Licensure Reference Number 175 NAC 12-007.04(D) Based on observation and interview, the facility failed to ensure that the ventilation system was operational in in rooms 7, 8, 9, 10, 11, 14, 15, and 19. This affected 8 bathrooms used by 13 residents. facility census was 28. An observation on 02/04/2025 at 11:45 AM revealed that bathrooms in rooms [ROOM NUMBER] did not have functional ventilation as tested when a 1-ply square of toilet paper was held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw, and the ventilation system did not work. An observation on 02/04/2025 at 1:30 PM revealed that bathrooms in rooms 7, 8, 9, 10, and 11 did not have functional ventilation as tested when a 1-ply square of toilet paper was held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw, and the ventilation system did not work. An observation on 02/10/2025 at 4:00 PM with the Administrator (Admin) revealed that bathrooms in rooms 7, 8, 9, 10, 11, 14, 15, and 19 did not have functional ventilation as tested with 1-ply square of toilet tissue held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw, and the ventilation system did not work. An interview with the Admin on 02/10/2025 at 4:10 PM confirmed that the ventilation system was not functioning in the bathrooms of rooms 7, 8, 9, 10, 11, 14, 15, and 19 and that the ventilation system should be working.

Licensure Reference Number 175NAC 12-006.09 C Based on record review and interview the facility failed to ensure a comprehensive resident assessment was completed once every 12 months for 1 resident (Resident #8) of 3 sampled residents, and a Quarterly Assessment (which a non-comprehensive assessment of a resident) was completed at least every 92 days for 1 resident (Resident #4) of 3 sampled residents. The facility census was 28. A. 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 2024 revealed an comprehensive annual assessment must be completed on an annual basis at least every 366 days. Review of a facility policy titled Comprehensive Assessments dated 03/2022 revealed the annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis or at least every 366 days. A review of Resident #8's electronic medical record completed on 02/06/2025 at 10:30 AM revealed Resident #4 comprehensive annual assessment had an assessment reference date of 01/17/2023 with a completion date of 01/27/2023. Resident #8 did not have another comprehensive assessment scheduled as of 02/06/2025 10:30 AM. In an interview conducted on 02/06/2025 at 1:00 PM with the facility 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) coordinator (IP/MDS) confirmed that a comprehensive annual assessment had not been completed for Resident #8 since 01/07/2023 which is greater than 366 days. In an interview conducted on 02/06/2025 at 1:00 PM with the facility Administrator (ADM), the ADM confirmed that Resident #8 did not have a comprehensive assessment completed annually or every 366 days per regulatory guidelines. B. 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 2024 revealed the Quarterly assessment for a resident must be completed at least every 92 days. Review of a facility policy titled Resident Assessments dated 05/2022 revealed that the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. A review of Resident #4's electronic medical record completed on 02/06/2025 at 10:30 AM revealed Resident #4 had a Quarterly assessment completed on 10/10/2023 and an Annual or comprehensive assessment completed on 07/01/2024. Tracking only assessments were completed between the dates of 10/10/2023 and 07/01/2024 which is 265 days. In an interview conducted on 02/06/2025 at 1:00 PM with the facility 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) coordinator (IP/MDS) the IP/MDS confirmed that a Quarterly assessment was not completed every 92 days from 10/10/2023 to 07/01/2024 for Resident #4. In an interview conducted on 02/06/2025 at 1:00 PM with the facility Administrator (ADM), the ADM confirmed that Resident #4 did not have a quarterly assessment completed every 92 days per regulatory guidelines.

Licensure Reference Number 175NAC 12-006.09 (B) Based on record review and interview the facility failed to ensure that 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) assessments were completed accurately for 2 (Resident #8 and Resident #25) of 5 sampled Residents. The facility census was 28. A. Review of a facility policy titled Resident Assessments dated 05/2022 revealed that the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and all persons who have completed any portion of the MDS for must sign the document attesting to the accuracy of the information. Review of Resident #8 Quarterly MDS dated [DATE] revealed in section N 0350 documentation that Resident #8 received insulin injections 7 days a week during the look back period. This section was signed by Licensed Practical Nurse J (LPN-J) on 12/10/2024. Review of Resident #8 Medication Administration Record dated 10/01/2024 to 10/31/2024 on 02/06/2025 revealed no documentation of Resident #8 receiving insulin injections. Resident #8 received Victoza, which is an injectable non-insulin diabetic medication that is used to help control blood sugar levels, injection every day. In an interview conducted on 02/06/2025 at 1:00 PM with the facility Minimum Data Set coordinator (IP/MDS) confirmed that Resident #8 Quarterly MDS dated [DATE] was coded incorrectly in section N 0350. The IP/MDS confirmed that the resident receiving Victoza injection did not qualify as receiving a insulin injection daily as was coded and signed on the MDS. B. Review of Resident #25 Quarterly MDS dated [DATE] revealed in section N 0415 letter E Anticoagulant was coded as yes indicating Resident #25 was taking an anticoagulant medication. Review of Resident #25 Medication Administration Record dated 11/04/2024 to 12/04/2024 on 02/06/2025 revealed no documentation of Resident #25 receiving an anticoagulant medication. Resident #25 received Aspirin, which is a nonsteroidal anti-inflammatory medication daily. This section was signed by Licensed Practical Nurse J (LPN-J) on 12/16/2024. In an interview conducted on 02/06/2025 at 1:00 PM with the facility 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) coordinator (IP/MDS) the IP/MDS confirmed that Resident #25 Quarterly MDS dated [DATE] was coded incorrectly in section N 0415. The IP/MDS confirmed that the resident receiving Aspirin did not qualify as the resident receiving an anticoagulant medication. In an interview conducted on 02/06/2025 at 1:00 PM with the facility Administrator (ADM), the ADM stated that LPN-J who coded and signed the MDS for Resident #8 was no longer completing MDS's for the facility. The current IP/MDS would be completing the MDS's for the facility going forward.

Licensure Reference Number 175NAC 12-0006.12 Based on interview and record review the facility failed to ensure residents medication regimen were free from unnecessary medications for 1 resident (Resident #25) of 3 sampled residents. The facility census was 28. Record review of Drugs.com on 02/06/2025 revealed Ketoconazole is an antifungal medication that is only recommended when other effective antifungal therapy is not available or tolerated. Record review of Drugs.com on 02/06/2025 revealed Nystatin Powder is a topical antifungal medication. Record review of Resident #25 Physician Orders on 02/06/2025 revealed Resident #25 had orders to receive Ketoconazole External Cream 2% to affected areas topically at bedtime dated 05/20/2024 and Nystatin External Powder topically every morning and at bed time under the right breast dated 07/02/2024. In an interview completed on 02/04/2025 at 5:10 PM with Resident #25, Resident #25 stated that they self-apply Nystatin Powder under their right breast when it is red and itchy. The resident stated that the nurses apply a cream to the same area at night before they go to bed. In an interview completed on 02/10/2025 at 8:50 AM with Registered Nurse A (RN-A), RN-A stated that Resident #25 has an order for Ketoconazole External Cream 2% to applied topically at bedtime. The RN stated that the nurse on duty applies the cream to the resident's skin folds including under the resident's right breast. In an interview completed on 02/10/2025 at 3:10 PM with the facility Director of Nursing (DON), the DON stated Resident #25 had a physician order to self-administer the Nystatin powder. The DON confirmed that the nurse on duty was also applying the Ketoconazole cream to the same area that the resident was reporting to be applying the Nystatin Powder. The DON confirmed that both medications should not be used to the same area.

Licensure Reference Number 175NAC 12-00006.12 Based on record review and interview the facility failed to ensure that an antipsychotic medication had the correct diagnosis for use. This affected 1 resident (Resident # 3) of 5 sampled residents. The facility census was 28. Record review of a facility policy titled Behavioral Assessment Intervention and Monitoring revealed the facility will comply with regulatory requirements related to the use of medication. Indications and usage for Seroquel (an antipsychotic medication) listed as Schizophrenia (a mental illness that is characterized by disturbances in thought, perception, and behavior, by a loss of emotional responsiveness and extreme apathy, and by noticeable deterioration in the level of functioning in everyday life), and Bipolar Disorder (a condition characterized by dramatic shifts in mood, energy, and activity levels that affect a person's ability to carry out day-to-day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs that are experienced by everyone). Review of an Admission Record revealed the facility admitted Resident #3 on 08/30/2023 with diagnoses that included Alzheimer's Disease (a degenerative brain disease of unknown cause that usually starts in late middle age or in old age, that results in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood), Dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior) , and Altered Mental Status (a change in a person's mental function, including their awareness, cognition, or consciousness). Resident #3 did not have a diagnosis of depression. Review of Resident #3 Quarterly 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) dated 11/12/2024 revealed Resident #3 received an Anti-Psychotic medication daily. Review of Resident #3 Physician Orders on 02/06/2025 revealed Resident #3 had a prescribed order to receive Seroquel (an antipsychotic medication) 25 milligrams at bedtime for a diagnosis of depression dated 05/01/2024. In an interview completed on 02/10/2024 at 3:10 PM with the facility Director of Nursing (DON), the DON confirmed that Resident #3 was receiving an antipsychotic medication with the diagnosis of depression. The DON confirmed that Resident #3 did not have a diagnosis of Schizophrenia or bipolar disorder indications for use of the Seroquel medication.

Licensure Reference Number 175NAC 12-006.10D Based on record review and interview, the facility failed to protect residents from significant medication errors for 1 resident (Resident 1) of 5 residents reviewed. This caused the resident to require hospitalization for treatment. The facility census was 33. Findings are: Record review of the facility policy titled Pain Management dated 2022 revealed that opioids (pain relief medications- a narcotic) will be prescribed and dosed in accordance with current professional standards of practice and manufacturers guidelines to optimize their effectiveness and minimize adverse consequences. Facility staff will reassess resident's pain management for effectiveness and/or adverse consequences such as Sleepiness-dizziness-and/or confusion; Depression; Itching and Sweating. Record review of the facility policy titled Administering Topical Medications (medications absorbed through the skin) dated 2010 revealed the purpose of the procedure is to provide guidelines for the safe administration of topical medications. The section titled Trans-dermal patches (a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through the skin and into the bloodstream) revealed the instructions to clean and dry a selected area that is approved for application of the patch. Rotate sites with each new application. Remove old patch. Report other information in accordance with facility policy and professional standards of practice. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/23/24 for Resident 1 revealed Resident 1 admitted to the facility on [DATE]. The MDS revealed that Resident 1 received an opioid. Record review of the Physician Orders for Resident 1 dated 3/5/24 revealed that Resident 1 had an order to apply two Fentanyl 25 micrograms (mcg)/hour (hr) patches (a topical opioid patch that releases 25 mcg of opioid per hour through the skin) to the skin every three days. Record review of the Medication Administration Record (e-MAR) for Resident 1 dated 3/5/24 for February 2024 revealed that Registered Nurse-A (RN-A) applied two 25 mcg/hr patches to the skin of Resident 1 on 2/27/24. Record review of the Medication Administration Record (e-MAR) for Resident 1 dated 3/5/24 for March 2024 revealed that Registered Nurse-B (RN-B) applied two 25 mcg/hr patches to the skin of Resident 1 on 3/1/24. Interview on 3/5/24 at 2:18 PM per phone with RN-B revealed that RN-B had not received any training on topical patches from the facility. RN-B confirmed that RN-B applied two fentanyl 25 mcg/hr patches on Resident 1 on 3/1/24. RN-B revealed that prior to administering the two fentanyl patches on 3/1/24, RN-B looked on Resident 1's body for the fentanyl patches that had been placed on Resident 1 on 2/27/24. RN-B confirmed that RN-B did not locate the 2/27/24 patches on Resident 1 to remove them before applying the two new patches. RN-B revealed that if the old patches cannot be found, RN-B suspects that they came off in the bath or fell off and are no longer on the resident's skin. Record review of Resident 1's Progress Note dated 3/3/24 at 10:42 AM revealed it was a late entry for 6:15 AM. The previous night nurse reported Resident 1 was sleeping soundly and would not wake up to take their 6:00 AM Tylenol dose. Resident 1 was noted to have a total of four 25 mcg/hr fentanyl patches on their skin. Two patches were dated 2/27/24 and two patches were dated 3/1/24. The night shift removed the two patches that were dated 2/27/24. Record review of Resident 1's Progress Note dated 3/3/24 at 10:46 AM revealed it was a late entry for 7:45 AM. The nurse went into the room of Resident 1 to give the morning medications. Resident 1 was noted to have snoring like respirations (breathing). Resident 1 did not respond to verbal stimuli or touch. Resident 1 did moan when painful stimuli was applied. Resident 1 provided no resistance when the resident's arms were moved and only moaned softly when legs were moved. Respirations 16 (breaths per minute). Oxygen saturation (the percentage of oxygen saturation in the bloodstream) went from 0 to 67% and would jump up to 88% when Resident 1 took a deep snoring breath. (For adults, the normal range of oxygen saturation is 95 - 100%. A value lower than 90% is considered low oxygen saturation, which requires external oxygen supplementation.) Record review of Resident 1's Progress Note dated 3/3/24 at 12:10 PM revealed it was a late entry for 8:10 AM. The resident's physician examined Resident 1 and ordered that Resident 1 be given a dose of Narcan (a medication used to treat narcotic overdose in an emergency situation) for possible opioid overdose. Resident 1 continued to be unresponsive. Resident 1's oxygen saturations were 67-70%. Record review of Resident 1's Progress Note dated 3/3/24 at 12:20 PM revealed it was a late entry for 8:15 AM. The Narcan was given and the Physician was at the resident's bedside. The resident did not respond verbally or open their eyes and continued to have snoring like respirations. Resident 1's respirations increased to 26 breaths per minute. The physician then ordered Resident 1 to be sent to the hospital for further evaluation. Record review of Resident 1's Progress Note dated 3/3/24 at 12:33 PM revealed it was a late entry for 9:15 AM. Resident 1 was transported to the hospital by ambulance. Resident 1 continued to moan loudly but did not respond to verbal stimuli. Resident 1's pupils were dilated and fixed (considered a grave sign in a patient with deteriorating consciousness). Record review of Resident 1's Progress Note dated 3/3/24 at 12:35 PM revealed it was a late entry for 10:47 AM. A call was placed to the hospital for an update. The hospital informed the facility Resident 1 was being admitted to the hospital. The physician revealed that the physician is unsure if the cause of the resident condition is from the fentanyl or if Resident 1 had some other Central Nervous Event (a health condition affecting the brain or spinal nerves) during the night. Record review of of Resident 1's Hospital History and Physical dated 3/4/24 revealed the provider had concerned of excessive pain medication and was provided narcan but did not return to [gender] baseline. Interview on 3/5/24 at 3:55 PM with the Director of Nursing (DON) revealed steps staff are expected to follow for administration of topical medications starts with verification of the physician's order. The staff should review the administration history for the resident to verify it has been the required number of days since the last administration for the new administration to be performed. Staff are expected to visibly inspect the resident's skin to find the old patch/patches. Staff then remove the old patch and place it in the sharp's container for disposal. Staff write the date and their initial on the patch and put the new patch on the resident's skin. Staff apply pressure to the patch for 10 seconds and then cover the patch with a tegaderm (a transparent medical dressing). Staff are then expected to sign off the administration (application of the patches) and document the time of administration on the individual resident narcotic tracking sheet. The DON confirmed that the facility did not have a process for staff to follow if the old patches could not be found. The DON revealed that the expectation would be for another staff member to assist in locating the old patches. The DON confirmed that RN-B did not locate and remove the old fentanyl patches on Resident 1 prior to applying the new fentanyl patches on 3/1/24. The DON confirmed that this resulted in Resident 1 having four fentanyl patches in place at the same time instead of the ordered two patches.

Licensure Reference Number 175 NAC 12.006.10D Based on observation, interview, and record review, the facility failed to ensure 1 resident (Resident 6) out of 5 sampled residents in the facility receiving insulin, received the correct amount of insulin. This caused the resident to be transported to the hospital for treatment. The total facility census was 32. Findings are: A record review of the facility's policy titled Insulin Administration dated September 2014 revealed, dosage requirements must be verified before administration. Review of the facility's document titled Insulin Pen updated 1/11/2024 revealed, to always review physician orders prior to administering medication and all med aides will co-sign with a nurse before administration. A record review of Resident 6's undated Admission Record revealed, the resident was admitted to the facility on [DATE] and had a diagnosis of Type 2 diabetes mellitus. A record review of Resident 6's Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 1/9/2024 revealed 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) of 15 which indicated the resident was cognitively intact. A record review of Resident 6's facility Medication Error Report dated 12/30/2023 revealed, the resident received the wrong dose of insulin by Medication Aide (MA)-J and was taken to the hospital for treatment. A record review of Resident 6's Physician Orders with a printed date of 2/28/2024 revealed, an order with a start date of 6/20/2022 for NovoLog (short acting insulin) 10 units three times a day to be given with meals in addition to sliding scale insulin. A record review of Resident 6's Progress Note dated 12/30/2023 at 6:37 PM revealed, the resident was to receive 10 units plus 4 units for a total of 14 units of NovoLog. The Progrses Note revealed the resident actually recieved 100 units plus 4 units for a total of 104 units of NovoLog insulin. Then, Resident 6's provider was notified and orders were followed, and the resident was transported to the hospital at 1 PM and returned to the facility at 6:35 PM. A record review Resident 6's Emergency Department Discharge Information from the hospital revealed, a diagnosis for the visit on 12/30/23 was hypoglycemia. A record review of Competency Assessment Insulin Administration for MA-J dated 1/11/24 revealed, MA-J demonstrated and stressed the importance of comparing blood glucose to resident's sliding scale to dose appropriately. Nurse to co sign before any insulin administration. A record review of competencies from all medication aides reviewed with return demonstrations with no concerns. All completed before 1/8/24. In an interview on 2/26/2024 at 11:45 AM with Resident 6 revealed, they were taken to the hospital when [gender] recieved too much insulin at the facility. In an interview on 2/28/2024 at 3:23 PM with the Director of Nursing (DON) revealed the medication error to Resident 6 on 12/30/2023happened on 12/30/23 and the meeting with the Medical Director was on 1/8/24. DON further revealed, that glucagon is in the emergency drug box for emergencies. Interview on 2/29/2024 at 10:34 AM with the DON confirmed that MA-J had given Resident 6 an extra 90 units of NovoLog insulin and that it was a significant medication error.

Licensure Reference Number NAC ,d+[DATE].09D Based on observations, record review and interviews; the facility failed to assess and manage pain for 1 (Resident 18) of 1 sampled resident. The facility census was 24. Findings are: Record review of Resident 18's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated [DATE] revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was an 8. According to the MDS Manual, a score of ,d+[DATE] indicates moderately impaired cognition. -Section J of the MDS indicates that the resident was on a scheduled pain medication and the resident utilized PRN (as needed) pain medication, and that the resident verbalized having pain frequently. Record review of Resident 18's current diagnosis list revealed the resident has a diagnosis of Unspecified Osteoarthritis (a degenerative joint disease that causes pain) and a diagnosis of Unspecified Pain. Record review of Resident 18's Comprehensive Care Plan (CCP) revised on [DATE] revealed Resident 18 experiences pain in both legs and hips and utilized scheduled and PRN pain medication. The CCP also revealed non-pharmacological interventions of, change positions slowly or offer heat or cold therapy, and to monitor for worsening pain symptoms and report to the physician. Observation on [DATE] at 10:20 AM revealed Resident 18 sitting in a recliner in the commons area, grimacing. The resident had an emesis bag on lap and was reaching for staff asking if the doctor was going to see the resident today for pain. Observation on [DATE] at 10:40 AM revealed Resident 18 sitting in a recliner in the commons area with vomit on the resident's blanket, shirt, and some vomit in the emesis bag. The Director of Nursing (DON) was assisting the resident. Observation on [DATE] at 12:30 PM revealed Resident 18 sitting in a wheelchair in the commons area with an overbed table in front of the resident with soda crackers and a glass of water on it, an emesis bag in the resident's lap, and the resident was grimacing and groaning. A staff member encouraged the resident to eat and drink and resident complained of back pain. The staff member asked the resident if the pain was due to vomiting and then left the resident. Observation on [DATE] at 1:49 PM revealed Resident 18 sitting in a wheelchair in the commons area asking for help. Several staff members walked by the resident without responding to the resident. Observation on [DATE] at 3:00 PM revealed Resident 18 sitting in a wheelchair and vomiting yellow bile on the carpet in the commons area/central hallway. Observation on [DATE] 03:20 PM revealed Resident 18 in bed in the resident's room at the end of the hallway away from staff. The resident was trying to sit up and grimacing and moaning. No staff were near the resident room. Record review of Resident 18's physicians orders revealed the resident had the following orders for pain and nausea: -Acetaminophen (a medication used for mild pain) 325 milligrams (mg) two tablets orally every four hours as needed for pain: none administered. -Zofran (a medication used for nausea) 4 mg tablet, dissolve one tablet on the tongue ever four hours as needed for nausea. -Tramadol HCL (a medication used for moderate pain) 50 mg tablet, one tablet orally one time a day as needed for osteoarthritis: none administered. -Acetaminophen 325 mg take two tablets orally at bedtime for leg cramps: last administered at 10:00pm on [DATE]. -Tramadol HCL 50 mg tablet, take one tablet orally twice a day at 10 AM and 10 PM. last administered at 10am on [DATE], resident vomited at 10:20am. -An order for a pain assessment every shift. assessed at 10am and patient rated pain at a 2 but was grimacing and moaning and asking to see the doctor at 10:20am. Record review of the Electronic Medication Administration Record revealed the following: -Zofran 4 mg had been administered on [DATE] at 11:20 PM and on [DATE] at 10:24 AM. No other doses administered on [DATE]. -The scheduled Tramadol HCL 50 mg tablet had been administered on [DATE] at 10:00 AM. No other doses administered on [DATE]. -No other pain or nausea medications administered on [DATE]. Record review of the Physician Visit note from [DATE] revealed the resident had been up with vomiting and diarrhea all night and that the physician discussed hospice with the son and the family will consider a hospice evaluation. Record review of the Physicians Orders from the [DATE] visit revealed the following medications were discontinued: Atorvastin (a medication used to treat high cholesterol), Donepezil (a medication used to treat dementia), Preservision (an eye drop vitamin) and Magnesium Oxide (a supplement). No orders for pain management by another route were noted. Interview on [DATE] at 3:21 PM with the DON revealed the resident was seen by the physician earlier in the day and the physician called the son about hospice care and discontinued some medications. Record review of the nurses' notes dated [DATE] at 7:00 PM revealed Resident 18 had a distended abdomen; no bowel sounds and complaints of pain. Call placed to physician for comfort orders, awaiting physician call back. Record review of the nurse's notes dated [DATE] at 7:30 PM revealed the staff notified charge nurse that Resident 18 had expired. Interview on [DATE] at 8:48 AM with the DON (Direcotr of Nursing) confirmed that Resident 18 had expired at 7:30 PM the previous evening. Interview on [DATE] at 12:49 PM with the DON confirmed that the facility did not address the resident's pain yesterday and that the 10:00 AM dose of Tramadol was probably vomited up at 10:20AM and no other pain medications were administered.

Licensure Reference Number 175 NAC ,[DATE].09D7 Based on record reviews and interview, the facility failed to provide interventions to prevent falls with injuries for one closed record resident reviewed (Resident 1) and for one current sampled resident (Resident 2). The facility census was 30 with five current sampled residents and one closed record. Findings are: A. Review of Resident 1's Departmental Notes, dated [DATE], revealed the resident was admitted to the facility from the hospital post surgical revision of a shunt (device to divert flow from one main route to another, from the brain to the abdomen) secondary to a brain bleed and Acute [MEDICAL CONDITION] (brain disorder). Review of the Care Plan, goal date [DATE], revealed the resident had a history of [REDACTED]. Review of the Departmental Notes revealed the following including: - [DATE] at 2:35 PM gait unsteady and periods of of confusion; - [DATE] at 4:45 PM poor safety awareness; - [DATE] at 3:27 PM periods of confusion, poor safety awareness, gets up unassisted and doesn't remember to ask for help; - [DATE] at 3:33 PM frequent episodes of confusion, gait unsteady; - [DATE] at 3:16 PM ambulated on own; - [DATE] at 3:46 PM periods of confusion, required verbal cues to use the call light and wait for assistance; - [DATE] at 8:30 AM Nursing assistant reported the resident had increased difficulty ambulating to the bathroom, leaned backwards and to the right and while standing in the bathroom leaned forward in front of the toilet; 11:00 AM remained confused to place; 12:15 PM assisted to ambulate to the dining room with use of wheeled walker, gait unsteady with shuffling gait; 3:30 PM found on the floor by the doorway to room, did not respond to verbally and had bright red drainage from right back of head; 3:40 PM call placed to 911 for transport to the hospital; 3:45 PM resident remained unresponsive, continued to have bright red drainage from the right back of head, pulse 68, respirations labored and blood pressure ,[DATE]; 4:00 PM the resident was transported to the hospital per rescue unit; 6:45 PM call from spouse to report that the resident had bleeding at the brain and they chose no surgical interventions at this time. Review of the facility Investigation Report, dated [DATE], revealed the resident expired at the hospital on [DATE]. Interview with the DON (Director of Nursing) on [DATE] at 10:45 AM confirmed the resident was a high risk for falls and interventions in place were not effective to prevent the fall and injuries. B. Review of Resident 2's Care Plan, goal date [DATE], revealed the resident had a recent fall with a brain bleed and had a [DIAGNOSES REDACTED]. The resident had periods of forgetfulness and confusion, history of hallucinations and delusions (visual images and ideas not based on reality), had some impaired hearing, [DATE] was treated for [REDACTED]. The resident required staff assistance for bed mobility, transfers, toileting,ambulation with a walker and used a wheelchair for mobility due to weakness, unsteady gait and poor balance. Review of the Departmental Notes revealed the following including: - [DATE] at 12:25 PM resident was admitted to the facility; - [DATE] at 11:00 AM resident tried to arise without utilizing the call light, rose from the wheelchair with brakes unlocked and the walker across the room, educated to use the call light for assistance; 12:13 PM the resident was up with walker to the bathroom, call light was not activated, continued to have poor safety awareness; - [DATE] at 4:00 PM resident had been getting up on own and staff reminded the resident to call for help to prevent a fall; - [DATE] at 4:30 PM food intake remained poor; - [DATE] at 9:25 PM found the resident on the floor beside the bed, resident stated hit head on the floor and possibly the bottom of the bedside table, noted a hematoma (swelling of blood) on top of the head and a spot of blood on the eye brow, educated to use the call light for assistance; - [DATE] at 10:48 PM periods of confusion, ambulated from room to another resident room, abrasion on forehead from incident last evening; - [DATE] at 3:00 PM periods of confusion, intake remained poor, abrasion to right forehead and fading bruising to right cheek; - [DATE] at 11:09 AM very impulsive, attempted several times to self transfer; - [DATE] at 10:17 PM attempted to get out of bed; - [DATE] at 4:00 PM periods of confusion, gait slow and unsteady, intake remained poor, fading area of bruising to the left cheek and abrasion to the right forehead; - [DATE] at 5:26 PM required two staff assistance with ambulation with walker, gait slow and unsteady; - [DATE] at 3:02 PM not feeling well, slow to respond, left eye darker than the right, gait very unsteady, Tylenol given for complaints of a headache, did not eat any breakfast or dinner; - [DATE] at 11:42 PM resident had trouble swallowing supper and medications; - [DATE] at 11:48 AM on an antibiotic for a urinary tract infection, appetite poor; - [DATE] at 8:30 PM found resident sitting on the floor in front of the lift chair was in a high lift position, stated slid out of the chair, no injuries noted, instructed to use the call light for assistance to get up; - [DATE] at 12:05 PM found resident on the floor in front of the lift recliner with the recliner in high standing position, confused to place, stated slipped out of the chair, denied hitting head; - [DATE] at 6:00 PM found the resident on the floor in front of the recliner with head on the bottom bar of the tray table, call light not activated; - [DATE] at 1:43 PM the sit to stand mechanical lift was used for transfers as resident was shaking and not able to help with the transfer; - [DATE] at 1:08 PM the resident required one to two assistance with transfers and at time, the lift had to be used as the resident was unable to stand, had a tendency to lean back, appetite poor; - [DATE] at 12:20 AM the resident had a fair appetite at supper; - [DATE] at 12:00 PM refused lunch and refused to go to room, confused, had problems following commands and leaned backwards with ambulation; - [DATE] at 4:30 PM the resident was confused to place, doesn't remember to use the call light, gait very unsteady, required two assist with activities of daily living, transfers and ambulation; [DATE] at 11:30 AM physical therapy and occupational therapy reported that the resident had a severe posterior lean and change in exterior tone and had to use the mechanical sit to stand lift for transfers at the end of the session, the resident's cognition continued to be poor and if not getting worse, unable to be reoriented, call placed to family member who approved the resident to be seen at the local hospital to evaluate the resident's change in condition; - [DATE] at 1:00 PM the clinic called to report that the resident would be transported to the hospital for a brain bleed. Interview with the DON on [DATE] at 11:00 AM confirmed that effective fall interventions were not in place to prevent recurrent falls and injuries.

Licensure Reference Number: 175 NAC 12-006.09D7b Based on record and interview, the facility failed to prevent an accident as the staff walked away leaving the resident sitting on the edge of the wheelchair for one sampled resident (Resident 15). The failure resulted in a resident fall requiring medical attention for suture repair to the forehead. Facility census was 34. Findings are: Review of the facility accident and investigation report revealed Resident 15's fall was 4/16/16 at 7:45 PM. LPN-A (Licensed Practical Nurse) noted the resident sitting at the edge of the wheelchair (w/c). The nurse left the resident's room to get assistance to reposition the resident and when the nurse returned to the room the resident had fallen face down on the floor. A laceration was noted to the forehead measuring 6 cm. (centimeters). The resident was sent to the emergency room where the forehead was sutured. Review of the facility form entitled Resident Incident Report revealed Resident 15 was admitted to the facility on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of Resident 15's MDS (Minimun Data Set; a federally mandated comprehensive assessment tool used care planning) dated 4/20/16, revealed the resident's cognition was scored 3 out of 15. The bed mobility was extensive assist of two person. Transfer was extensive assist of two persons. The resident fell in the last month prior to admission and had fallen in the last 2-6 months prior to admission. No fractures were related to a fall in the last 6 months. Interview with the Administrator on 5/4/2016 at 2:19 PM revealed LPN-A had gone into the room and the resident was on the edge of the wheelchair so the LPN left the room to get help and when the LPN came back to the room the resident was face down on the floor. The Administrator revealed the topic of resident safety was discussed in the nurses meeting. Interview with LPN-A on 5/4/2016 at 2:55 PM revealed on 4/16/2016 the nurse entered Resident 15's room to find the resident was sitting on the edge of the wheelchair. The nurse told the resident to not move or fall. The nurse left the room to get help to assist in moving the resident and was gone about 5 minutes. Upon return to the resident's room, LPN A found the resident on the floor with a lot of blood. LPN-A did not turn on the call light and did not call out for help from the room. Also LPN-A did not attempt to move the resident back in the wheelchair. Review of Resident 15's care plan, dated 2/17/16, revealed a history of falls and multiple falls since admission and prior to admit. The resident slid down in the recliner, rolled out of bed, and had falls in trying to toilet independently. Interventions were as follow: -Monitor for changed in condition may warrant increased supervision/assistance and notify the physician, -Uses a wheelchair for long distance mobility, ensure slipper socks when not wearing shoes, recliner was changed for a better fit, -Encourage resident to use call light for assist, reeducate resident to ask for assist for all ambulation and transfers, if awake at night encourage to stay in bed or offer to bring her to TV room, -Continue hourly rounds, keep BR door closed while the resident was awake, -If awake while in bed offer toileting or to get up in w/c. Assist with 2 staff member for all transfers and weight bearing tasks, -Refer to restorative nursing program, offer to transfer resident to recliner or bed ASAP (as soon as possible) after meals to prevent the resident from trying to transfer self or slipping out of wheelchair, utilize horse shoe pillow when in bed, -Requires 2 assist for dressing, grooming, bathing and weight bearing tasks, 1 person assist with bathing, transfer with mechanical lift. Review of the facility documentation for education on resident safety revealed no documentation on staff education on resident safety.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D Based on record review and interviews; the facility failed to implement the Pain Management Program for 1 resident (Resident 17). The resident voiced complaints that pain and range of motion (ROM) exercises, to promote optimum relief of pain, were not implemented. The facility census was 22 and the survey sample size was 24. Findings are: Review of a FACE SHEET dated 8/3/09 revealed Resident 17 was admitted to the facility on [DATE]. Review of a Cumulative [DIAGNOSES REDACTED]. During an interview on 6/14/12 at 1:49 PM, Resident 17 stated the resident had nerve pain that hurt all the time. Resident 17 revealed medication only helped slightly. Resident 17 expressed the belief (the resident) would always have a certain amount of pain, because there was not any pill that could totally take care of nerve pain. Review of a Pain Assessment completed for Resident 17 dated 11/29/11 revealed: = "type of pain: [MEDICAL CONDITION], phantom pain R) (right) lower ext" (extremity); = "characteristics of pain: "sharp pain where it is touched"; = duration/frequency: "most of the time it's when they move my leg. Pressure on my legs"; = what relieves: "exercising my legs when I am laying down". Review of Resident 17's COMPREHENSIVE CARE PLAN dated 5/14/12 revealed: - PROBLEMS/NEEDS/CONCERNS: Alteration in comfort related to [MEDICAL CONDITION] manifested by complaints of pain/discomfort, resident request to have left leg flexion and extension when (the resident) gets up; -- PLANS AND APPROACHES included "PROVIDE 20 REPS (repetitions) OF L) (left) LEG EXTENSION/FLEXION WHEN GOTTEN UP FROM REST OR PER RESIDENT REQUEST" and "ASSIST WITH PASSIVE ROM TO BILATERAL LOWER EXTREMITIES WHEN GOTTEN UP AND AT HS (hour of sleep)". Review of a History and Physical revealed Resident 17 was hosptalized on [DATE] through 4/8/12 for the amputation of the left great toe. During an interview on 6/19/12 at 12:15 PM, Resident 17 revealed (gender) wasn't having a good day because (the resident's) leg hurt. Resident 17 explained staff used to do exercises with (gender) legs before (the resident) got up, before (Resident 17) was in the hospital, but had quit doing it. Resident 17 stated no one exercised or stretched (the resident's) legs before (gender) got up today. Resident 17 said it helped relieve the pain when staff did the exercises first. During an interview on 6/19/12 at 1:47 PM, NA- L (Nurses Aide) revealed exercises had been done with Resident 17's leg in the past, but haven't always done them while (the resident) was working with physical therapy, because Resident 17 said it hurt. During an interview on 6/19/12 at 1:51 PM, NA-M revealed the leg exercises had not been done with Resident 17 because the staff hadn't been told to continue them after Resident 17 returned from the hospital. During an interview on 6/19/12 at 2:01 PM, the Director of Nursing (DON) revealed Resident 17's leg exercises were supposed to be done, per the resident's request. The DON explained Resident 17 had not been able to tolerate [MEDICATION NAME] or other medications for [MEDICAL CONDITION]. Review of the facility's "Care Plan Approaches Report" for 5/1/12 through 6/19/12 revealed "ASSIST WITH PASSIVE ROM TO BILATERAL LOWER EXTREMITIES WHEN GOTTEN UP AND AT HS DOCUMENT" was documented as having been completed twice. The times documented were day shift on 5/31/12 and day shift on 5/18/12. Review of the facility's policy "PAIN DATA COLLECTION AND MANAGEMENT" dated 11/09 revealed: - "A pain management plan can include, but not be limited to, a medical regime. The analysis should help determine what other methods or alternatives of pain control/relief may be implemented prior to contacting a physician. The Care Team and nurses must continually monitor and evaluate the pain management plan"; - Procedure # 7 "Residents identified at high risk for pain will be reviewed weekly"; - Procedure #8 "Document the effectiveness of the pain management plan at least monthly. All pain medications, routinely scheduled and PRN are reviewed in the Nursing Documentation".

LICENSURE REFERENCE: 175 NAC 12-006.09D7,12-006.09D7a and 12-006.09D7b Based on observation, record review and interview, the facility failed to assess skin tears for causal factors and make changes to the care and environment to protect two residents from further injuries. The facility had a census of 22 and a survey sample of 24. This affected Resident 26 and Resident 19. Findings are: A. According to the 6/8/12 FACE SHEET Resident 26 was admitted to the facility on [DATE]. The following are [DIAGNOSES REDACTED]. Observation on 6/14/2012 at 11:31 AM revealed that Resident 26 had ecchymotic looking knuckles of the right hand and index finger. The right hand knuckles appeared bruised and a small skin tear was noted on the knuckle of the right thumb. The resident was observed wearing long sleeves and having arm protectors that covered the back of the hands to the upper forearms bilaterally. Review of the INCIDENT REPORT dated 4/6/12 for Resident 26 revealed; Resident received a 2 cm (centimeter) V-shaped skin tear to the right inner arm. The skin tear was caused from the wedding ring of an employee as the employee was preparing the resident for a mechanical lift transfer. Immediate intervention - Steri-strips were applied to the skin tear. The staff member was re-educated on the policy of " no wearing rings with stones during patient cares " . The incident INVESTIGATION revealed that Resident 26 had a history of [REDACTED]. Review of the INCIDENT REPORT dated 4/25/12 for Resident 26 revealed; Resident was self-propelling in the hall and found to have a 2 cm by 2 cm skin tear on the right 5th finger. The 2nd knuckle had an older appearing skin tear and a skin tear to the back of left hand. Immediate intervention - The resident was to " wear geri-gloves daily " . The incident INVESTIGATION revealed that Resident 26 was confused, had poor safety awareness and very fragile skin. The INVESTIGATION failed to document if the facility had implemented the arm protectors as outlined on the 4/6/12 INCIDENT REPORT. The INVESTIGATION documented that Resident 26 required supervision during wheelchair mobility to assure that the resident was not getting too close to the walls. Review of the INCIDENT REPORT dated 5/23/12 for Resident 26 revealed; Resident was observed to have blood on the sleeve of the long sleeve shirt. The cause of the blood was a 0.6 cm by 0.6 cm skin tear on the left upper arm. The skin tear " could have occurred if the sit-to-stand sling brushed arm " . Immediate intervention - Staff should move resident's wheelchair to the center of the hall if self-propelling. Staff should not brush arms on sit-to-stand lift sling. The incident INVESTIGATION revealed that Resident 26 had Dementia, poor safety awareness and very thin fragile skin. The INVESTIGATION documented that the resident " pulls arm protectors off. " The facility failed to document if the facility had implemented the arm protectors as outlined on the 4/6/12 INCIDENT REPORT and why the resident was pulling off the protectors. The INVESTIGATION documented that Resident 26 required supervision during wheelchair mobility to assure that the resident was not getting too close to the walls. (Supervision during wheelchair mobility was already an intervention after the 4/25/12 INCIDENT.) Review of the INCIDENT REPORT dated 5/30/12 for Resident 26 revealed; Resident was being transferred using the sit-to-stand lift. The resident had increased confusion and was unable to understand the need to hold the handles. When lifted, the resident bumped the right hand causing a 1 cm by 1 cm V-shaped skin tear on the right thumb. Immediate intervention - Staff will use the Hoyer lift for transfers. The incident INVESTIGATION revealed that Resident 26 had Dementia, no safety awareness and very thin fragile skin. The INVESTIGATION documented that the resident could not understand how to hold the handles of the sit-to-stand lift. The INVESTIGATION failed to identify why the staff continued to lift the resident with the sit-to-stand lift when the resident was unable to understand the need to hold the handles. Review of the INCIDENT REPORT dated 6/8/12 for Resident 26 revealed; Resident was observed to have a quarter size skin tear to the left upper arm. Immediate intervention - Resident wears long sleeves and has thin skin. The incident INVESTIGATION revealed that Resident 26 had Dementia, no safety awareness and very thin fragile skin. The INVESTIGATION documented that the skin tears to the resident ' s upper left arm match where the resident would hit the rail when self-propelling in the wheelchair. The resident was noted to already be using arm protectors and long sleeves. The INVESTIGATION documented that the resident pulled off the arm protectors. The facility would plan to have the resident " wear long sleeved sweaters if not too warm. " The INVESTIGATION failed to identify why the resident was not being supervised when self-propelling as per the plan after the 4/25/12 INCIDENT. The INVESTIGATION failed to identify why the resident was pulling off the arm protectors. Review of the INCIDENT REPORT dated 6/19/12 for Resident 26 revealed; Resident was moaning " ow-ow " . When staff were turning the resident, a 1.5 cm U-shaped skin tear opened over a previous ecchymotic area of the left inner elbow. Immediate intervention - Guide the resident ' s arms/hands to the front of the abdomen while repositioning. There was no INVESTIGATION available to review for the 6/19/12 INCIDENT. Interview on 6/20/12 at 10:47 AM with the DON (Director of Nursing) confirmed that the intervention of the arm protectors/geri gloves did not work for the resident as the resident got too hot and pulled them off. The DON admitted that adding more layers of clothing (as planned after the 6/8/12 INCIDENT) during the summer months was not a solution for Resident 26. The DON reported knowing that 4 of the 6 accident injuries between 4/6/12 - 6/19/12 were caused when staff were providing care for Resident 26. The DON confirmed that staff had not been observed actually using the mechanical lifts with Resident 26 to assure correct and safe use of the equipment. The DON confirmed that staff were not observed providing care to Resident 26, such as transfers and repositioning, to assure that all interventions were implemented to protect the resident. The DON reported a failure of the facility to evaluate environmental surfaces such as wheelchair arm rests that could pose a safety risk to a resident with fragile skin. Interview on 6/20/12 at 11:04 AM with the Administrator confirmed that the Administrator was aware that the facility had a large number of skin tears per the total number of residents. The Administrator was also aware of specific residents that had repeated injuries such as skin tears. B. Review of a FACE SHEET dated 3/21/12 revealed Resident 19 was admitted to the facility on [DATE]. Review of a Cumulative [DIAGNOSES REDACTED]. Observation on 6/14/12 at 10:13 AM; revealed a skin tear on the top of Resident 19's left hand. Steri-strips had been applied to the skin tear Resident 19 stated (the resident) didn't remember what happened, but must have hit it on something, then added "my skin is so fragile it doesn't take much" During an interview on 6/19/12 at 2:09 PM, the DON revealed the expectation that any open areas on resident's skin were to be looked at daily and documented on the Medication Administration Record (MAR). The DON revealed there was no documentation on Resident 19's MAR for checks completed of the skin tear on Resident 19's left hand, and stated (Resident 19) bumps the hands "so many times". The DON revealed no incident report was found related to the skin tear; and the DON was unable to find any documentation in the medical record about the skin tear. During an interview on 6/20/12 at 11:14 AM, RN-B (Registered Nurse) revealed (the RN) knew about the skin tear on the top of Resident 19's left hand, then stated, "I don't know when it happened, but there should be an incident report".

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D8b Based on observations, record review, and interview; the facility failed to provide nutritional interventions and evaluate their effectiveness to prevent significant weight loss for one resident (Resident 21). The facility census was 22 and the survey sample size was 24. Findings are: Review of a FACE SHEET dated 4/25/12 revealed Resident 21 was admitted to the facility on [DATE]. Review of a Cumulative [DIAGNOSES REDACTED]. Review on 6/14/12 of the WEIGHT document for Resident 21 revealed: The height (in inches) of the resident was: 58 The Admission Weight Data for this resident was: Date: 04/17/2012; Weight: 126; BMI: 26 Date: 05/01/2012; Weight: 118; BMI: 25 Date: 05/17/2012; Weight: 114; BMI: 24 Date: 06/11/2012; Weight: 113 The resident lost 6.35% from 4/17/12 to 5/1/12 (14 days). The resident lost 9.52% from 4/17/12 to 5/17/12 30 days). Review of Resident 21's Comprehensive Care Plan dated 6/1/12 revealed: - HIGH RISK FOR SKIN INTEGRITY IMPAIRMENT R/T NUTRITIONAL RISK, MOBILITY IMPAIRMENT, RISK FOR FRICTION AND SHEAR -=- "ENCOURAGE NUTRITIONAL APPROACHES, PROVIDE SUPPLEMENT/MAGIC CUPS AND ASSIST TO EAT". -=- "ENCOURAGE NUTRITION, GIVE SUPPLEMENT AND OFFER MAGIC CUP AS ORDERED AND DESIRES". - POTENTIAL ALTERATION IN NUTRITION R/T PROBLEM EATING M/B SYMPTOMS [MEDICAL CONDITION] CHANGE IN ENVIRONMENT -=- WILL EAT 50% OF ALL MEALS; WILL EAT SO WT STABILIZES -==- OFFER ALTERNATES WHEN RESIDENT REFUSES OR DOES NOT EAT FOOD PROVIDED -==- OFFER RESIDENT ASSISTANCE AT MEALS -==- OFFER A SMALL SHAKE OF MAGIC CUP AND CARNATION INSTANT BREAKFAST MIX ON AFTERNOON SNACK CART FOR ADDED NUTRITION DUE TO POOR MEAL INTAKE. ASSIST RESIDENT WHEN TAKING TO HER ROOM TO DRINK IT -==- NURSING PROVIDE HOUSE SUPPLEMENT OF CHOICE Observation on 6/18/12 at 3:23 PM revealed a cup of strawberry "shake" on Resident 21's bed side table which was 1/2 full. Resident 21 was not in the room. Observation on 6/18/12 at 3:30 PM revealed Resident 21 sitting in a wheelchair. The strawberry shake was not within Resident 21's reach, and staff were not present to give the resident assistance drinking the shake. During an interview on 6/19/12 at 11:20 AM, Resident 21 revealed the resident did not get a shake this AM. Resident 21 stated "I really like shakes", especially strawberry, and would like to have more of them, but the resident hadn't thought to ask for them. During an interview on 6/19/12 at 11:32 AM, Cook-J (Dietary cook) revealed Resident 21's supplement didn't get made this AM, because we were running late, so Resident 21 didn't get it. . During an interview on 6/19/12 at 1:32 PM, the Dietary Manger (DM) revealed the dietary staff sent supplements with the snack cart. The DM stated (gender) wished someone would help Resident 21, because the resident drank better when someone gave Resident 21 assistance. During an interview on 6/19/12 at 1:52 PM, NA-M (Nurses Aide), revealed the dietary staff made Resident 21's supplement and it was sent out on the snack cart. NA-M revealed Resident 21 didn't always have a shake on the snack cart "so then we give (Resident 21) some juice". NA-M stated Resident 21 always drank it. During an interview on 6/19/12 at 2:31 PM, the Director of Nursing (DON), revealed Resident 21 just ate bites at meals then was done. The DON revealed Resident 21 was to receive a supplement 3 times a day and it was sent out on the snack cart. The DON explained the supplement was a "shake" that was made with carnation instant breakfast (CIB) and a magic cup. Observation on 6/19/12 at 3:10 PM revealed Resident 21 lying in bed with eyes open and a shake supplement was on the bedside table. There was no staff present to give the resident assistance drinking the shake. Observation on 6/19/12 at 3:27 PM revealed Resident 21 in bed with eyes open. The supplement was on the bedside table, with the same amount of shake in the glass. There was no staff present to give the resident assistance drinking the shake. Review of signed Physician order [REDACTED]. - 6/4/12: "increased house supplement 60 ml (milliliters) po (by mouth) to 90 ml po TID (3 times a day)". - 4/17/12: "(Resident 21) is only taking bites of meals" "House supplement of choice 60 ml TID and magic cup supplement as desires". The facility failed to evaluate the effectiveness of the supplement and requested an increase the amount of the supplement only after Resident 21 had experienced a 9.5% weight loss. No new interventions had been implemented. Review of documentation given by the Dietary Manager which recorded the supplements prepared and placed on the snack cart revealed a CIB/magic cup shake had not been sent for Resident 21 on 9 days out of 15 in June 2012. Review of Resident 21's "Medication Administration Record" for June 2012 revealed: - Nothing documented regarding house supplement for 4 scheduled times from 6/1/12 - 6/19/12; - Documentation of 60 ml intake (of the 90 ml ordered) house supplement for 16 times from 6/5/12 - 6/19/12. Review of Resident 21's "Dining Report" of daily totals revealed: - Documentation of no intake of supplements/nourishments for 7 of 32 days from 5/18/12 - 6/18/12 - Documentation of 200 cc (centimeters/milliliters) or less of supplement/nourishment intake for 16 of 32 days from 5/18/12 - 6/18/12 (daily total ordered was for 270 cc); - Documentation of 25% or less of meal intake for 25 of 32 days from 5/18/12 - 6/18/12. During an interview on 6/19/12 at 3:30 PM, the Dietary Manager revealed there was confusion between the nursing and dietary departments related to what supplements Resident 21 was supposed to be getting and when. The DM revealed the result of this confusion was the inability to know how much supplement had been offered to Resident 21, which also made it difficult to evaluate the effectiveness of the supplements.

LICENSURE REFERENCE NUMBER: 175 NAC ,[DATE].07C Based on observations, record review, and interviews conducted during the annual standard survey, the facility failed to ensure the Quality Assessment and Assurance Committee (QA&A) developed and implemented plans of action to correct multiple issues of deficient practice relevant to resident care and services. The facility failed to implement plans of action to maintain correction for 5 previously cited areas of deficient practice (F253, F309, F363, F371, and F441) identified during the survey on [DATE] and on [DATE]. The facility census was 22. Findings are: A. Interview on [DATE] at 1:25 PM with the QA&A Committee (Quality Assessment & Assurance Committee) Coordinator and the facility Administrator revealed the following issues cited during the [DATE] survey had not been identified or studied by the QA&A committee and resulted in harm to residents: Failure to implement resident pain management programs resulting in pain experienced by residents (F309). Failure to identify causal factors of resident accidents and failure to implement interventions resulting in resident injuries (F323). The Coordinator reported that the facility had a " safety committee " that reported to the QA&A Committee, however, the safety committee did not study resident safety. The QA&A Committee Coordinator also reported that the facility failed to routinely do skills competency evaluations of staff using resident care equipment to assure safe use. Failure to implement interventions for residents with unplanned weight loss resulting in significant unplanned weight loss (F325). B. The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the annual standard survey were completed. The facility failed to maintain corrections for the regulations identified as repeat deficiencies and failed to identify and develop plans of action to prevent deficient practice in the areas identified below. Please refer to the Tag citations for specific detailed findings: - F253 Failed to maintain the maintenance and cleanliness of the environment. Previously cited on [DATE]. - F309 Failed to identify and implement interventions to promote resident well-being by implementing pain management programs. Previously cited on [DATE]. - F363 Failed to follow the preplanned menu during meal service. Previously cited on [DATE]. - F371 Failed to ensure dietary sanitation practices were consistently implemented. Previously cited on [DATE]. - F441 Failed to ensure hand hygiene and gloving techniques were completed for the prevention of infections. Previously cited on [DATE].

Licensure Reference: 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility failed to implement and monitor nursing and dietary interventions to promote healing of pressure sores and prevent new sores from developing. The facility had a census of 23 and a survey sample of 10. This affected Resident 22 and Resident 23 . Findings are: A. According to the 4/22/11 FACE SHEET Resident 23 was admitted to the facility on [DATE]. A 4/17/11 Hospital HISTORY AND PHYSICAL revealed the following [DIAGNOSES REDACTED]. A 4/20/11 DISMISS INSTRUCTION ADDENDUM from the hospital confirmed that Resident 23 had been treated by the wound care specialist for " pressure ulcers to bilateral ischials that were purple, Deep Tissue Injury " . The INSTRUCTIONS included that Resident 23 should have [MEDICATION NAME] to bilateral ischials every 8 hours, an Iris cushion where ever the resident is sitting and lay on sides or at least a 30 degree tilt when in bed. Review of the 4/21/11 INITIAL INTERDISCIPLINARY DATA COLLECTION TOOL revealed that Resident 23 had a 1.2 cm (centimeter) by 0.6 cm pressure sore on the right buttock and a 0.5 cm by 0.5 cm pressure sore on the left buttock. Review of the 4/21/11 ITCP (INITIAL TEMPORARY CARE PLAN) revealed that Resident 23 had pressure ulcers. The goal was for the resident to have the open wounds healed by discharge. The ITCP approaches included that Resident 23 would have a pressure relief mattress, ambulate, rest on the side of bed and the treatment would be provided as ordered. The 4/20/11 interventions from the wound specialist were not included on the ITCP. On 5/3/11 an intervention was added for the resident to eat all the protein provided but failed to address possibly adding extra protein to aid in wound healing. Observation on 5/3/11, 5/4/11 and 5/5/11 revealed that Resident 23 had no Iris cushion available to use when sitting in the dining chair, activity room chair or recliner in room. Resident 23 reported on 5/5/11 that there was no Iris cushion, or any type of cushion, available to use in the chairs that the resident sat in. Interview with the DON (Director of Nursing) on 5/5/11 at 10:15 AM confirmed that the facility failed to provide a pressure relief seating cushion for Resident 23. According to Potter/Perry Fundamentals of Nursing 6th edition, the standard for pressure ulcer prevention states to provide a pressure reduction or relief surface to lay on, reposition client every 90 minutes with clients sitting in a chair no longer than 2 hours, consult dietitian for nutritional evaluation and provide adequate nutritional and fluid intake. Observation on 5/3/11 at the noon meal revealed that Resident 23 was not served milk (milk was on the preplanned menu). The dietary staff failed to serve milk and failed to offer a substitute to replace the protein in the milk not served. The resident was shorted 4 grams of protein by not being served the milk or an equal protein substitute. Resident 23 reported liking milk and not refusing any food/beverage items served. Observation of the noon meal revealed that Resident 23 was not served any extra protein items. Review of the DINING RECORD for 4/21/11 - 5/4/11 revealed the facility was not keeping track of Resident 23's daily protein intake. Interview with the DM (Dietary Manager) on 5/5/11 at 10:15 AM confirmed that the DM was on leave when Resident 23 was admitted and the protein interventions did not get planned or implemented until the return of the DM. According to Mary D. [MEDICAL CONDITION] "The Advanced Practitioners Guide To Nutrition and Wounds" copyright 2004, dietary protein is needed to build new tissue. The elderly and injured have increased needs for dietary protein. Higher intakes of daily protein were associated with greater wound healing rates. Review of the 5/3/11 DAILY SKILLED NOTE revealed that Resident 23 was assessed as continuing to have a 3 cm red area with a dry flaky center on the right buttock. B. Resident 22 was admitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. Review of Resident 22's INITIAL INTERDISCIPLINARY DATA COLLECTION TOOL dated 4/18/2011 revealed that the resident was admitted to the facility with a 4.5 cm (centimeter) by 3.9 cm necrotic area/decubitus with [MEDICAL CONDITION] on the left buttocks. There was no documentation of any tunneling of the decubitus at the time of admission to the facility on [DATE]. Review of Resident 22's WOUND FLOW SHEET dated 4/21/2011 revealed that the area had increased in size and measured 4.5 cm in length by 4 cm in width with 2 cm depth and 1.5 cm tunneling from 5 o'clock to 8 o'clock. Further review of Resident 22's WOUND FLOW SHEET dated 4/28/2011 revealed that the area had again increased in size from 4.5 cm by 3.9 cm on admission to 5 cm in length by 4 cm in width with 2 cm depth. In addition, there was 4 cm of tunneling at 5 o'clock to 8 o'clock. There had been no further measurements documented since 4/28/2011 to date of review on 5/5/2011. Interview with DON on 5/9/2011 at 12:05 PM revealed that RN (Registered Nurse) B who did the skin assessments and measurements, had worked on 5/5/2011; however, RN B had not gotten the measurements done when in the building to assess the pressure sore and ensure that healing was occurring. Observation of the noon meal on 5/3/2011 at 12:05 PM revealed that Resident 22 was not served 8 oz (ounces) of milk or a slice of bread as per the menu. Not serving the milk shorted Resident 22 of 8 grams of protein for that meal. During observation of the breakfast meal on 5/4/2011, Resident 22 was not served any cereal or 8 oz of milk, which again shorted the resident of 8 grams of protein for that meal. According to the Taber's Cyclopedic Medical Dictionary 20th edition, copyright 2005: proteins in the diet provide the amino acids necessary for the growth and repair of animal tissue. Interview on 5/5/2011 at 1:50 PM with the DM (Dietary Manager) revealed that the last time the consulting Dietitian had been in the facility was April 4th, 2011 prior to the admission of Resident 22 and was not scheduled to be in the facility until May 19th, 2011. There was no documentation that the Dietitian had assessed or evaluated Resident 22's status to ensure that the resident was receiving adequate protein to promote healing of the decubitus on the buttocks. The SSD (Social Service Designee) had completed the INITIAL NUTRITIONAL DATA COLLECTION TOOL on 4/25/2011 and noted that Resident 22 had experienced weight loss. However, there was no documentation to indicate how much weight loss had occurred or if it was a significant amount of weight loss that needed to be addressed with extra supplements to stabilize the resident's weight. In addition, there was no documentation on the INITIAL NUTRITIONAL DATA COLLECTION TOOL dated 4/25/2011 that Resident 22 had a pressure ulcer on the left buttocks and that dietary interventions needed to be assessed and provided to assist and promote healing. Further interview on 5/5/2011 at 1:50 PM with the DM revealed that Resident 22 was on the HS (bedtime) snack cart list to receive egg salad on crackers. This intervention had been initiated on 4/19/2011 according to the HS snack list; however, there was no documentation of the intake on Resident 22's DINING RECORD to evaluate the effectiveness of this intervention. Review of the April and May 2011 MAR (Medication Administration Record) revealed that Resident 22 had been receiving House Supplement 120 cc (cubic centimeters) TID (three times a day) since 4/18/2011; however, there was no amount consumed documented to evaluate the effectiveness of the intervention. Observation on 5/5/2011 at 9:40 AM of the pressure sore on Resident 22's left buttocks revealed that the area was uncovered when facility staff started to provide incontinent cares. During the incontinent cares, the pressure sore was contaminated with feces by NA (Nursing Assistant) M wiping over the pressure sore with a feces soiled perineal wipe. NA M then wiped around the edges of the pressure sore several times with the feces soiled perineal wipe, contaminating the whole area around the pressure sore. Observation on 5/5/2011 at 11:30 AM and at 1:20 PM of the pressure sore on Resident 22's left buttocks revealed that it was still not covered with a dressing. Interview on 5/5/2011 at 1:20 PM with NA M revealed that when (gender) came on duty at 6:00 AM, the pressure sore on Resident 22's left buttocks did not have a dressing over it to protect it from rubbing on the incontinent brief and to prevent feces from contaminating the area. NA M stated that the pressure sore had been uncovered all day. Review of Resident 22's TAR (Treatment Administration Record) revealed documentation that the pressure sore on the left buttocks had a wet-to-dry dressing ordered to be changed daily. Documentation on the TAR for 5/5/2011 contained documentation that the dressing treatment had been provided and signed off by LPN (Licensed Practical Nurse) C. Observation on 5/5/2011 from 9:40 AM to 1:20 PM revealed that the pressure sore was uncovered the whole day.