Every finding on record at Carl T Curtis Health Education Center Nursing Home

Based on record review and interview, the facility failed to conduct ongoing reviews for antibiotic stewardship and ensure that medical criteria was used for infection surveillance. This had the potential to affect all residents that resided in the facility. The facility census was 23.Findings are:Review of a facility policy Infection Prevention and Control Program with a revised date of October 2018, Section 8 revealed: Antibiotic Stewardship a. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. b. Medical Criteria and standardized definitions of infections are used to help recognize and manage infections. c. Antibiotic usage is evaluated and practitioners are provided feedback on reviews. Review of a policy Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes with a revised date of December 2016 revealed: Policy Statement Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee. 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. resident name and medical record number; b. unit and room number; c. date symptoms appeared; d. name of antibiotic (see approved surveillance list); e. start date of antibiotic; f. pathogen identified (see approved surveillance list); g. site of infection; h. date of culture: i. stop date; j. total days of therapy; k. outcome; and l. adverse events. Record review of an untitled and undated document/spreadsheet, reported by the Director of Nursing and Infection Preventionist to be the antibiotic stewardship spreadsheet, did not include total days of antibiotic therapy, outcome or adverse events. An interview with the Infection Preventionist RN, on 1/29/26 at 8:56 AM confirmed the facility did not have medical criteria and standardized definitions of infections that were used to help recognize and manage infections and while the electronic medical record generated a spreadsheet for antibiotics, there was not a formal system for the infection preventionist or designee to review.

Licensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview, the facility failed to identify and monitor specific target behaviors for the use of antipsychotic medications [a group of medications used to treat symptoms of psychosis, such as hallucinations and delusions] for 2 (Residents 4 and 20) of 5 residents reviewed for unnecessary medications. The facility census was 23. Findings are:A.Record review of a facility policy entitled Behavioral assessment, Intervention and Monitoring dated 2001 revealed the following information: Policy statement: Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. General Guidelines:1.Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric or environmental causes. a. Behavior is regulated by the brain and is influenced by experiences, personality traits, environment, and interactions with other people.b. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. Assessment:2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations:a. the residents' usual patterns of cognition, mood and behavior;b. the residents' usual method of communicating things like pain, hunger, thirst, and other physical discomforts;c. the residents' typical or past responses to stress, fatigue, fear, anxiety, and depression.Management:1.The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. 7. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychological needs, and strives to understand, prevent and relieve the residents distress or loss of abilities. 8. Interventions and approaches will be based on a detailed assessment of physical , psychological and behavioral symptoms and their underlying causes. The care plan will include, as a minimum: a. a description of the behavior symptoms including frequency, intensity, duration, outcomes, location, environment and precipitating factors or situations; b. targeted and individualized interventions for behavioral and psychological symptoms; c. the rationale for the interventions and approaches; d. specific and measurable goals for targeted behaviors e. how the staff will monitor for the effectiveness of the interventions. 10: When medications are prescribed for behavioral symptoms, documentation will include: e. Specific target behaviors and expected outcomes; h. Monitoring for efficacy and adverse consequences; B.Record review of Resident 4's current Face Sheet dated 1/27/26 revealed that Resident 4 was admitted to the facility on [DATE] and included a diagnosis of generalized anxiety disorder, major depressive disorder, recurrent, in partial remission, personal history of traumatic brain injury and vascular dementia, mild, with anxiety. Record review of Resident 4's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's plan of care) dated 12/23/25 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 4. The MDS rating for scores 0-7 indicate severe cognitive impairment. The MDS identified that Resident 4 exhibited no behaviors, was dependent with activities of daily living and used antipsychotic medications daily with indications for use. Record review of Resident 4's current Physician Orders dated 1/27/26 revealed a physician order for Quetiapine [an antipsychotic medication used to treat symptoms of psychosis, such as hallucinations and delusions] 50 mg 2 times per day for major depressive disorder, recurrent, in partial remission with indications for use: anxiety. The medication had been started on 4/29/25 and changed to the current dose on 1/15/26. The orders included an order for Rexulti [an antipsychotic medication used to treat agitation associated with dementia] 2 mg tab every day by mouth with indications for use: agitation. The medication had been started on 4/29/25. Record review of Resident 4's current Physician Orders dated 1/27/26 revealed an order written on 2/21/25 to monitor antipsychotic medications for dry mouth, constipation, blurred vision, disorientation / confusion, difficulty urinating, hypotension [ low blood pressure], dark urine, yellow skin, nausea / vomiting, lethargy, drooling, extrapyramidal symptoms such as tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue. The orders did not identify specific target behaviors to monitor for the use of the antipsychotic.Record review of Resident 4's Medication Administration Record [MAR], which included December 2025 and [DATE], revealed that Resident 4 received Quetiapine 50 mg 2 times per day and Rexulti 2 mg once per day.Record review of Resident 4's Comprehensive Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) did not identify resident specific target behaviors to be monitored for the use of antipsychotic medicationsRecord review of Resident 4's Electronic Medical Record revealed that no specific target behaviors had been identified and no monitoring for specific target behaviors had been completed. Interview on 01/28/2026 at 1:50 PM with the Director of Nursing [DON] confirmed there were no specific target behaviors identified to monitor for the use of the Rexalti and the Quetiapine for Resident 4. The DON confirmed there were no specific target behaviors identified in the care plan. The DON confirmed that the orders to monitor were for side effects, not specific target behaviors for Resident 4. C.Record review of Resident 20's admission Face Sheet dated 1/26/26 revealed that Resident 20 was admitted to the facility on [DATE] and included a diagnosis of generalized anxiety disorder, other recurrent depressive disorders, agoraphobia [ a specific anxiety about being in a place or situation where escape is difficult, embarrassing or where help may not be available] and Schizophrenia [a psychotic disorder characterized by hallucinations, delusions [fixed beliefs], disorganized thinking or behavior and flat, inappropriate affect]. Record review of Resident 20's quarterly MDS dated [DATE] revealed a BIMS score of 14, which indicated intact cognition. The MDS identified that Resident 4 exhibited verbal behaviors directed toward others 1 - 3 days per week and rejected cares 1 - 3 days per week. The MDS identified that Resident 20 was independent with activities of daily living and used antipsychotic medications daily with indications for use. Record review of Resident 20's active Physician Orders dated 1/26/26 revealed a physician order for Rexulti 2 mg tab -1 tablet by mouth at bedtime for Schizophrenia with indications for use: agitation. The medication had been started on 5/07/25. Record review of Resident 20's active Physician Orders dated 1/26/26 revealed orders written on 5/23/25 to monitor antipsychotic medications for dry mouth, constipation, blurred vision, disorientation / confusion, difficulty urinating, hypotension [ low blood pressure], dark urine, yellow skin, nausea / vomiting, lethargy, drooling, extrapyramidal symptoms such as tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue. The orders did not identify specific target behaviors to monitor for the use of the antipsychotic. Record review of Resident 20's Medication Administration Record [MAR], which included December 2025 and [DATE], revealed that Resident 20 received Rexulti 2 mg 1 tablet by mouth at bedtime. The order started on 5/7/25. Record review of Resident 20's Comprehensive Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) did not identify resident specific target behaviors to be monitored for the use of antipsychotic medications. Record review of Resident 20's Electronic Medical Record revealed that no specific target behaviors had been identified and no monitoring for specific target behaviors had been completed. Interview on 01/28/2026 at 1:50 PM with the Director of Nursing [DON] confirmed there were no specific target behaviors identified to monitor for the use of the Rexalti for Resident 20. The DON confirmed there were no specific target behaviors identified in the care plan. The DON confirmed that the orders to monitor were for side effects, not specific target behaviors for Resident 20.

Based on record review and interviews, the facility failed to provide a written reason for the transfer to the hospital for Resident 24. The facility census was 23. Findings are:Record review of Resident 24's Discharge Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 12/19/25 identified the facility re-admitted Resident 24 on 12/9/25 with diagnoses of Peripheral Vascular Disease (PVD), Diabetes Mellitus (DM), acquired absence of right leg above knee, pressure-induced deep tissue damage of sacral region, infection following a procedure, unspecified, initial; acquired absence of left leg below knee. The MDS identified that Resident 24 had moderately impaired cognition. Functional abilities were noted as independent with eating, dependent with toileting hygiene, bathing, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. Record review of the Clinical Census for Resident 24 revealed the resident was sent to the hospital on [DATE] and 12/29/25. Record review of the facility Bed-Hold Notice dated 12/16/25 revealed no reason for transfer was identified on the form. The facility was unable to locate or provide a form for the 12/19/25 transfer to the hospital. Interview on 1/28/2026 at 3:00 PM with the facility Administrator confirmed that the reason for transfer was not filled out for Resident 24 when (gender) left to go to the hospital on [DATE] and the facility was unable to locate a Bed-Hold / Transfer Notice for discharge on [DATE]. The Administrator confirmed that the reason for transfer should have been documented on the bed hold / transfer form.

License Reference Number 175 NAC 12-006.18(D)Based on record review, observation and interview, the facility failed to ensure a staff member performed hand hygiene before donning gloves (putting on) and failed to clean the rubber stopper on an insulin flex pen (a pre-filled disposable device used to inject insulin) prior to administering insulin for Resident 5. The facility had a census of 23.Findings are:A record review of the facility Handwashing/Hand Hygiene policy from the Nursing Services Policy and Procedure Manual for Long-Term Care, 2001 MED-PASS, Inc. revealed the following:Administrative Practices to Promote Hand HygieneAll personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for hand hygiene.Hand washing is indicated: Immediately before touching a resident.Before performing an aseptic (free from contamination caused by harmful bacteria, viruses or other microorganisms) task, for example, placing an indwelling device (a medical instrument inserted into the body to remain for a time, such as a catheter) or handling an invasive medical device (an instrument that fully or partially penetrate the body, either through the skin or a bodily orifice, for diagnostic or therapeutic purposes).After contact with blood, body fluids, or contaminated surfaces.After touching a resident.After touching the resident's environment.The use of gloves does not replace hand washing/hand hygiene.Applying and removing glovesPerform hand hygiene before applying non-sterile gloves.A record review of the manufacturers' instructions provided by the facility for the use of a prefilled insulin pen contained the following:Wash your hands with soap and water before you start to prepare your injection. Pull off the pen cap. Wipe the rubber stopper with an alcohol swab. Remove the protective tab from a disposable needle. Screw the needle tightly to your Flex pen (a pre-filled disposable device used to inject insulin).An observation of insulin administration on 1/27/2026 at 9.45 AM by Registered Nurse (RN) A to Resident 5 revealed RN A removed the cap from Resident 5's insulin Lantus (Glargine) flex pen and attached a disposable needle to it. RN A turned the dial on the pen to prepare 2 units of insulin, depressed the pen to flush the 2 units through the needle, and then prepared 10 units of insulin for administration. RN A used hand sanitizer and took the insulin pen and an alcohol wipe to the residents room. RN A knocked on the door with and opened it using their bare hand on the handle. RN A donned gloves without washing their hands or using hand sanitizer, used an alcohol swab to wipe Resident 5's left arm and then pressed the insulin pen to the sanitized area and administered the insulin.An interview on 1/27/2026 at 9:45 AM with RN A confirmed RN A did not use hand sanitizer before donning gloves and should have done so. RN A confirmed they (gender) did not use an alcohol swab to clean the rubber stopper of the insulin flex pen before administering insulin and should have done so. RN A confirmed these 2 actions were an infection control breach.An interview on 1/28/2026 at 1:10 PM with the Director of Nursing (DON) confirmed RN A should have performed hand hygiene before donning gloves and should have cleaned the rubber stopper of the insulin flex pen with an alcohol swab before attaching a needle and administering insulin.

Licensure Reference Number 175 12-007.04 D Based on observation and interview, the facility failed to ensure that ventilation systems were operational in resident bathrooms in 21 (Rooms 1, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25) of 21 occupied resident bathrooms. The facility census was 21. Findings are: An observation on 10/30/24 between 8:30 AM to 9:00 AM with the facility Maintenance Director revealed that the ventilation system was not functional and would not draw a 1 ply square of toilet paper to the surface of the ventilation cover in resident bathrooms in resident rooms 1, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, and 25. Interview on 10/30/24 at 9:05 AM with the Maintenance Director confirmed that the ventilation system did not draw a 1 square ply of toilet paper in resident bathrooms in resident rooms 1, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, and 25. The Maintenance Director confirmed that the ventilation systems had not been checked for draw and that there was no documentation of when the last time the system had been checked to ensure it was operational.

Licensure Reference Number NAC 12-006.04 (F)(i)(5) Based on observation, record review, and interviews, the facility failed to notify the medical provider when a prescribed medication was not given for 6 days for 1 (Resident 7) of 2 sampled residents. The facility had a total census of 21 residents. Findings are: A record review of policy entitled Nursing Standards of Practice Policy for Documentation dated 2020 revealed: If a medication/treatment is not available, document the attempts made to obtain the item. If unsuccessful, contact the Director of Nursing, physician, or pharmacist for assistance. A record review of Resident 7's Census Report revealed Resident 7 was admitted on [DATE]. A record review of Resident 7's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 10/7/24 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. A BIMS score of 15 revealed that Resident 7 was cognitively intact. Resident 7's functional abilities revealed Resident 7 could eat independently and required supervision/touching assistance for toileting, bed mobility and transfers. The diagnosis included in the MDS were heart failure, hypertension, cirrhosis, gastro-esophageal reflux, end stage renal disease, diabetes, hyperlipidemia, thyroid disorder, anxiety, respiratory failure, and obstructive sleep apnea. An observation of medication pass at 10/29/24 at 7:55 AM by Medication Aide-E (MA-E) for Resident 7 revealed MA-E was unable to find the Lactulose in the medication cart. All medications except the Lactulose were administered as prescribed. A record review of the Medication Administration Record (MAR) for Resident 7 dated 10/29/24 revealed an order for Lactulose 10 grams per 15 milliliters (ml); take 30 ml twice a day by mouth for cirrhosis of the liver to reduce blood ammonia levels. The MAR further revealed the last documented administration of Lactulose was on 10/24/24 AM dose. The MAR also revealed Lactulose was documented as not available from 10/24/24 through 10/29/24. In an interview with MA-E 10/29/24 at 8:30 AM revealed MA-E ordered the Lactulose on 10/24/24 for Resident 7. MA-E confirmed the Lactulose had not been available since last given 10/24/24 in the morning. MA-E had notified the charge nurse on 10/28/24 and 10/29/24 of the Lactulose not being available. In an interview on 10/29/24 at 12:00 PM with the Registered Nurse (RN-D) regarding Resident 7's Lactulose, revealed RN-D planned to call the pharmacy to find out why the Lactulose had not arrived. RN-D was not aware of any other attempts that have been made to contact the pharmacy. RN-D was not aware if the medical provider had been notified of the medication Lactulose not being given to Resident 7 since the morning of 10/24/2024. A record review on 10/29/24 of Resident 7's Progress notes since 10/24/24 did not reveal any attempts of the pharmacy or medical provider being notified of the Lactulose not being available. In an interview on 10/30/24 at 8:37 AM with RN-D revealed the Lactulose for Resident 7 had arrived last night from the pharmacy. RN-D denied notification of the medical provider of the Lactulose being unavailable since 10/24/24. RN-D confirmed the Lactulose was started again on 10/30/24 in the morning. In an interview on 10/30/24 at 12:03 PM with Nurse Consultant confirmed that the medical provider had not been notified that Resident 7 had not received the prescribed Lactulose since the morning of 10/24/24. NC-A confirmed Resident 7 missed 6 days of the prescribed Lactulose.

Licensure Reference Number NAC 12-006.10(D) Based on observation, record review, and interviews, the facility failed to ensure medication was available for 6 days resulting in a significant medication error for 1 (Resident 7) of 2 sampled residents. The facility had a total census of 21 residents. Findings are: A record review of policy entitled Nursing Standards of Practice Policy for Documentation dated 2020 revealed: If a medication/treatment is not available, document the attempts made to obtain the item. If unsuccessful, contact the Director of Nursing, physician, or pharmacist for assistance. A record review of Resident 7's Census Report revealed Resident 7 was admitted on [DATE]. A record review of Resident 7's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 10/7/24 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. A BIMS score of 15 revealed that Resident 7 was cognitively intact. Resident 7's functional abilities revealed Resident 7 could eat independently and required supervision/touching assistance for toileting, bed mobility and transfers. The diagnosis included in the MDS were heart failure, hypertension, cirrhosis, gastro-esophageal reflux, end stage renal disease, diabetes, hyperlipidemia, thyroid disorder, anxiety, respiratory failure, and obstructive sleep apnea. An observation of medication pass at 10/29/24 at 7:55 AM by Medication Aide-E (MA-E) for Resident 7 revealed MA-E was unable to find the Lactulose in the medication cart. All medications except the Lactulose were administered as prescribed. A record review of the Medication Administration Record (MAR) for Resident 7 dated 10/29/24 revealed an order for Lactulose 10 grams per 15 milliliters (ml); take 30 ml twice a day by mouth for cirrhosis of the liver to reduce blood ammonia levels. The MAR further revealed the last documented administration of Lactulose was on 10/24/24 AM dose. The MAR also revealed Lactulose was documented as not available from 10/24/24 through 10/29/24. In an interview with MA-E 10/29/24 at 8:30 AM revealed MA-E ordered the Lactulose on 10/24/24 for Resident 7. MA-E confirmed the Lactulose had not been available since last given 10/24/24 in the morning. MA-E had notified the charge nurse on 10/28/24 and 10/29/24 of the Lactulose not being available. In an interview on 10/29/24 at 12:00 PM with the Registered Nurse (RN-D) regarding Resident 7's Lactulose, revealed RN-D planned to call the pharmacy to find out why the Lactulose had not arrived. RN-D was not aware of any other attempts that have been made to contact the pharmacy. RN-D was not aware if the medical provider had been notified of the medication Lactulose not being given to Resident 7 since the morning of 10/24/2024. A record review on 10/29/24 of Resident 7's Progress notes since 10/24/24 did not reveal any attempts of the pharmacy or medical provider being notified of the Lactulose not being available. In an interview on 10/30/24 at 12:03 PM with Nurse Consultant confirmed that a significant medication error occurred for Resident 7 due to the medication Lactulose being unavailable for 6 days.

Licensure Reference Number 12-006.18(B) Based on observation, record review, and interview, the facility failed to don (put on) and doff (take off) gowns during cares and treatments of a resident with a supra-pubic indwelling catheter (a tube placed in the abdomen to drain urine from the bladder to a bag) per Enhanced Barrier Precaution Protocol for 1 of 1 Residents (Resident 1) observed for the care of the catheter. The facility identified a census of 21 residents. Findings are: Record review of Enhanced Barrier Precautions (EBP) Policy dated 2022 revealed the following: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions, will be implemented during high-contact resident care activities when caring for resident that have an increased risk for acquiring a Multi-Drug Resistant Organisms (MDRO, bacteria that resist treatment with more than one antibiotic) such as a residents with wounds, indwelling medical devices (supra-pubic indwelling catheter) or residents with infection or colonization with an MDRO. The purpose of EBP is to prevent opportunities for transfer of MDROs to employees' hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or body fluids. High contact resident care activities include: -Providing hygiene, -Changing briefs or assisting with toileting, -Device care or use for urinary catheter. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 10/1/2024 revealed an admitted [DATE]. Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) with a score of 2 which indicated Resident 1 was severely cognitively impaired. Resident 1 was dependent on staff for toileting, bed mobility, and transfers. Resident 1 had an indwelling suprapubic catheter. An observation on 10/29/24 at 9:30 AM revealed outside of Resident 1's doorway hanging beside the door was an EBP Precautions sign which instructed staff to wear gown and gloves with Resident 1 when providing high contact resident care activities. The personal protective equipment (PPE) was located directly below the EBP sign outside of the room, which included disposable gowns to use. An observation on 10/29/24 at 9:42 AM of staff emptying indwelling suprapubic catheter bag revealed upon entering the room Nursing Assistant B (NA-B) and Nursing Assistant C (NA-C) did not don a personal protective gown before entering Resident 1's room. Nursing Assistant-C (NA-C) completed hand hygiene in the bathroom. Nursing Assistant-B completed hand hygiene in the bathroom. Both NA-B and NA-C applied clean gloves. NA-B emptied the urine from the catheter bag into the graduate to measure and then disposed of the urine in the toilet. An observation on 10/29/24 at 10:38 AM, NA-B and NA-C provided supra-pubic catheter care, peri-care, and brief change for Resident 1. Upon entering the room neither NA-B nor NA-C donned a personal protective gown. Both NA-B and NA-C did HH in the bathroom with soap and water for 23 seconds prior to cares. NA-B and NA-C applied gloves after HH was completed. After the completion of cares, both NA-B and NA-C did HH in the BR for 25 seconds. In an interview at 10/29/24 at 10:38 AM with NA-B confirmed a gown should have been worn when providing catheter care, peri-care, and when emptying the supra-pubic indwelling catheter for Resident 1. In an interview at 10/29/24 at 10:38 AM with NA-C confirmed a gown should have been worn when providing catheter, peri-care, and emptying the supra-pubic indwelling catheter for Resident 1. In an interview at 10/29/24 at 10:38 AM with Nurse Consultant-F (NC-F) confirmed a gown should have been worn when providing catheter, peri-care and emptying the supra-pubic indwelling catheter for Resident 1.

Licensure Reference Number 175 NAC 12-006.12B Based on record review and interview; the facility Pharmacist failed to identify and report medication irregularities related to medication that did not have a diagnoses for 2 (Residents 4 and 9) of 5 sampled residents. The facility identified a census of 19. Findings are: A. Record review of the facility's Drug Regimen Review Policy/Procedure revised September 25, 2015 revealed the following: -1. b) DRR (Drug Regimen Review) activities include but are not limited to the following: -a) A written diagnosis or indication supports each medication order. -c) Indications for use and therapeutic goals are consistent with current medical literature and clinical practice guidelines. B. Record review of Resident 4's Order Summary sheet dated December 2023 revealed the following medications did not have a written indication for use: -Midodrine (medication used to treat low blood pressure) 10 mg (milligrams) Tab (tablet) 1 tablet by mouth 3 times a day as need if systolic blood pressure is less than (Indications for Use: Prophylaxis)(action taken to prevent disease, especially by specified means or against a specified disease. -Levocetirizine (a antihistamine) 5 mg tab 1/2 tablet (2.5 mg) by mouth twice weekly on Wednesday and indications for use was identified as prophylaxis. - Pantoprazole (medication used for acid reflux ) 40 mg tab 1 tablet by mouth every day with the related diagnoses of a cardiac murmur. On 12-20-2023 at 2:25 PM a interview was conducted with the Director of Nursing. During the interview the DON reported not being able to provide information's the facility pharmacist had identified Resident 4's medications did not have the diagnoses C. Record review of Resident 9's Order Summary sheet dated December 2023 revealed the following medications did not have a written indication for use: -Lamotrigine (antiepileptic medication) 150 mg tablet 1 tablet by mouth 2 times with a indications for use identified as prophylaxis. -Pentoxifylline (a hemorrheologic medication ER 400 mg 1 tablet by mouth every with a indications for use identified as prophylaxis -Rexulti (antipsychotic medication) 2 mg tab 1 tablet by mouth at with a indications for use identified as prophylaxis -Artificial Tear Drops, 1 drop into both eyes every 4 hours as needed with a indications for use identified as prophylaxis -Chlorhexidine (a antimicrobial medication) Gluconate 0.12% 15 ml (milliliters) by mouth 2 times a day with a indications for use identified as prophylaxis On 12-20-2023 at 2:25 PM an interview was conducted with the DON. During the interview the DON reported not being able to provide information's the facility pharmacist had identified Resident 9 medications did not have a diagnoses.

Licensure Reference Number 175 NAC 12-006.12B Based on record review and interview; the facility staff failed to ensure 1 resident (Resident 9) of 5 sampled resident had a rational for the use of multiple antidepressant medications. The facility staff identified a census of 19. Findings are: A record review of the Drug Regimen Review Policy/Procedure, Redlers Long Term Care Pharmacy revised on September 25, 2015 revealed the following information: -DRR(Drug Regimen Review) activities include but are not limited to the following: -f) Duplication of medication orders include a written rationale for the duplication. -Nursing facility regulations require that duplicate drug therapy be avoided. This is any drug that duplicates a particular drug effect on the resident. Record review of Resident 9's Order Summary Report printed on 12-19-2023 revealed Resident 9 had orders for the following antidepressant medications: -Duloxetine 60 mg (milligrams), 1 capsule by mouth every day with a related diagnosis of Major Depressive Disorder, recurrent with severe with psychotic (related to or affected with a mental disorder) symptoms.- -Paroxetine CR 25 mg 2 tablets by mouth every day with a related diagnosis of Major Depressive Disorder, recurrent with severe with psychotic symptoms. -Trazodone 100 mg. 1 tablet by mouth at bedtime with a related diagnosis of Major Depressive Disorder,recurrent and severe with psychotic symptoms. On 12-20-2023 at 2:25 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 9 was on 3 antidepressant medications and did not have the clinical rational for the use of the 3 antidepressant medication.

Reference Number 175 NAC 12-006.12B Based on record review and interview the facility failed to ensure that 1 resident (Resident 9) had rational for the use of 2 antipsychotic medications and failed to have the clinical indications of medication use for 2 residents (Resident 8 and 17) of 5 residents sampled. The facility identified a census of 19. Findings are: A. Record review of the Drug Regimen Review Policy/Procedure revised September 25, 2015 revealed the following information: -f) Duplication of medication orders include a written rationale for the duplication. -Nursing facility regulations require that duplicate drug therapy be avoided. This is any drug that duplicates a particular drug effect on the resident. B. Record review of Resident 9's Order Summary Sheet with active order as of 12-19-2023 revealed Resident 9 ordered medication included the following -Quetiapine (a antipsychotic medication) 100 milligrams (mg) tablet. 1 tablet by mouth 3 times a day for a related diagnoses of mental disorder, not otherwise specified, major depressive disorder, recurrent, severe with psychotic symptoms; anxiety disorder. -Quetiapine ER 400 mg tablet. 1 tablet by mouth at bedtime with a related Diagnoses: major depressive disorder, recurrent, severe with psychotic symptoms; anxiety disorder, unspecified. -Rexulti ( a antipsychotic medication) 2 mg tablet 1 tablet by mouth at bedtime. On 12-20-2023 at 2:25 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed there was not a diagnoses for the use of the Rexulti and further confirmed there was not a clinical indication for the use of 2 antipsychotic medications. 47733 C.) Review of a Drug Regimen Review (DDR), (Monthly Report) dated 9-25-2015 revealed the following -Procedures: -b. DDR activities include but are not limited to the following: -1 a. A written diagnosis or indication supports each medication order. D. Record review of Resident 8's OSR with active order as of 12-19-2023 revealed Resident 8 admitted to the facility with the diagnoses of Mild Neurocognitive Disorder, secondary to traumatic brain injury.,Generalized Anxiety Disorder,Major Depressive Disorder; recurrent without psychosis. and Adrenal Insufficiency. Further review of Resident 8's OSR dated 12-19-2023 revealed the following medications: -Atorvastatin ( medication that helps reduce cholesterol) 80 mg at bed time for Diabetes Mellitus with underlying Chronic Kidney Disease. -Fluoxetine (antidepressant ) 20 mg cap one capsule, by mouth every day with a related diagnose of anxiety disorder. -Hydrocortisone (steroid medication) 10 mg tab, 2 tablets (20 mg) by mouth 2 times a day for the use of pain). -Quetiapine (antipsychotic medication) ER 150 mg 1 tablet by mouth daily at 5 PM with the related diagnoses of anxiety disorder. -Rexulti (antipsychotic medication) 2 mg tab,1 tablet by mouth at bedtime for the related diagnoses of anxiety disorder. Record review of the Note To Attending Physician/Prescriber dated 8/28/23 revealed the facility pharmacy had requested a diagnosis for use of the quetiapine. Further review of the Note To Attending Physician/Prescriber dated 8-28-2023 revealed Resident 8's practitioner did not provide a diagnoses for the quetiapine On 12-2023 at 2:23 PM an interview was conducted with the DON. During the interview the DON confirmed the above medications did not have the diagnoses related to the indications of the medications. E. Record review of Resient 17's OSR with current orders as of 12-20-2023 revealed Resident 17 admitted to the facility on [DATE] with the diagnoses of Dementia without behavioral disturbance, Psychotic disturbance, Mood disturbance,and anxiety. Further review of Resident 17's OSR dated 12-20-2023 revealed the following medications: -Donepezil ( medication used to improve memory) 10 mg tab 1 tablet by mouth at bedtime with a related diagnoses of major depressive disorder. -Levetiracetam ( a anticonvulsant medication) 100 mg/ml solution 7.5 ml (750 mg) by mouth every 12 hours for the indications of prophylaxis. -Sertraline (antidepressant medication) 50 mg tab 1 tablet by mouth every day for the related diagnoses of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance or mood disturbance,and anxiety. On 12-20-2023 at 2:23 PM an interview was conducted with the DON. During the interview the DON confirmed the above medication did not have the required clinical indications. The DON reported the practitioner does not always give the diagnoses for the ordered medications.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview, the facility failed to identify the root cause of a fall and initiate interventions to prevent further falls for 1 (Resident 13) of 1 sampled resident. The facility staff identified a census of 19. The findings are: The facility's policey of Review of the Falls - Clinical Protocol revised March 2018 revealed the following: -For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. -Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. A progress note dated 10/20/2022 at 9:50 PM revealed the staff observed Resident 13 through the monitor, sitting on the edge of the bed, bending over to pick something up on the floor and falling out of the bed. No injuries noted upon assessment. Resident had just come from the bathroom. Review of the current care plan for Resident 13 with a date initiated of 09/29/22 and a revision date of 10/27/22 revealed Resident 13 is High risk for falls related to an unsteady gait and mobility. The care plan revealed a witnessed fall on 10/21/22. Further review revealed an intervention to review information on past falls and attempt to determine cause of falls. Record possible root causes and alter or remove any potential causes if possible. There were no new interventions for the fall occurring 10/20/22. Record review of Resident 13's medical record revealed no documentation of possible root cause of the fall occurring 10/20/22. Record review of Resident 13's medical record revealed no fall assessment had been completed since 09/29/22 admission. Review of Incident report dated 10/20/22 revealed staff observed resident through the monitor, sitting on the edge of his bed, bending over to pick something up on the floor and falling out of bed. An interview with RN-A (Registered Nurse) on 11/29/22 at 12:19 PM while reviewing the care plan confirmed there was no new intervention for the fall occurring 10/20/22, no fall risk assessment had been completed and there was no documentation in the medical record of identifying a root cause to determine a cause of the fall or an intervention for the fall.

Based on record review and interview, the facility staff failed to collaborate with hospice to develop a coordinated plan of care and failed to communicate with hospice regarding changes in the resident's condition for 1 (Resident 13) of 1 sampled resident. The facility staff identified a census of 19. The findings are: Record review of Resident 13's medical record revealed an admitted [DATE]. Resident 13 was receiving Hospice Care upon admission to the facility Review of the MDS (A federally mandated assessment tool used for care planning) dated 10/9/22 for Resident 13 revealed Resident 13 was receiving hospice. Review of the undated plan of care for Resident 13 revealed no focus of hospice was identified or addressed. Review of the progress notes for Resident 13 from admission to 11/27/22 revealed no documentation of hospice being notified of any change in condition regarding resident care. ie. fall, ER visit. Review of the binder provided by Hospice for Resident 13 revealed no care plan available and no schedule for Hospice visits. Review of the Hospice agreement with the facility dated 8/2012 revealed a comprehensive set of services identified and coordinated by an interdisciplinary team to provide for the physical, psychosocial, spiritual and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care. Further review of the agreement revealed a Hospice plan of care means a written plan of care established in collaboration with Hospice Interdisciplinary team, facility staff, attending physician, Hospice Medical Director and patient and family. The plan of care is established based on assessment of each patient family needs. The plan of care identifies the care and service needs in order to manage the terminal illness and related conditions. The Hospice plan of care specifically identifies which care and services are provided by Hospice, as well as which care and services is provided by facility staff. An interview with RN-A (Registered Nurse) on 11/29/22 at 12:19 PM confirmed that Hospice was not addressed on Resident 13's facility care plan and was not aware of where the Hospice Care plan would be. An interview with LPN-C (Licensed Practical Nurse) on 11/29/22 at 12:47 PM revealed the facility staff does not call Hospice until after notification of regular MD if there are changes. LPN-C is not aware of when Hospice comes into the facility for visits. LPN-C revealed that if the facility staff did call hospice it would documented in the progress notes. An interview with the Administrator on 11/29/22 at 2:09 PM confirmed the Hospice plan of care should have been present on admission to the facility, the facility staff should be aware of when hospice comes to see the resident and Hospice staff should communication with facility staff about resident. The Administrator further confirmed that the facility care plan should address hospice care. On11/30/22 at 12:37 PM an interview was conducted with Hospice RN-D which confirmed the Hospice plan of care for Resident 13 was brought into the facility on [DATE]. Hospice RN-D further confirmed there had been no collaboration between the Hospice and the facility to develop a plan of care. Hospice RN-D reported the hospice care plan is updated every 2 weeks but has not been communicated with the facility. Interview with the DON (Director of Nursing) on 11/30/22 at 12:40 PM confirmed the facility care plan did not address Hospice and hospice and the facility staff had not collaborated on an individualized plan of care for resident.

Licensure Reference Number 175 NAC 12 - 006.09D2a Based on observation, interview and record review, the facility failed to identify a pressure ulcer (localized damage to the skin and or underlying soft tissue usually over a bony prominence), obtain treatment and identify casual factors for Resident #1. Facility census was 19 residents. Findings are: Record review of Resident #1's Braden Scale assessment (a standardized assessment to predict risk of pressure ulcer development) dated 10/12/22 revealed a score of 12 (12 is considered a high risk to develop pressure ulcers/wounds). Record review of Resident #1's diagnoses list for November 2022 revealed Peripheral Vascular Disease and Type 2 Diabetes Mellitus Record review of the MDS (Minimum Data Set: a federally mandated assessment tool used for care planning) for Resident #1 dated 10/26/22 revealed bed mobility, toilet use, bathing and transfer was total dependence and dressing was one-person physical assist. Observation on 11/30/22 at 7:10 AM revealed that Registered Nurse (RN) - E performed the wound dressing of Resident 1's right foot after the shower was completed in the bath house. The pressure ulcer to the left metatarsophalangeal joint (MTP), (inner aspect of foot) had no treatment provided at this time. Interview on 11/30/22 at 7:10 AM with RN-E confirmed that there was no treatment ordered for the left MTP joint pressure ulcer. Observation on11/30/22 at 12:08 PM revealed Resident #1 sitting in the resident's wheelchair in the hallway with a Prevalon boot (pressure ulcer relieving device) on the right foot and a sock on the left foot. Record review of Resident #1's Medication Administration Record (MARs) and Treatment Administration Record (TARs) for the month of November 2022 revealed there was no treatment for the left MTP joint pressure ulcer. Record review of Resident #1's Physician orders for November 2022 revealed there was no documentation of a treatment for the resident's left MTP joint pressure ulcer. Record review of Resident #1's progress notes for November 2022 revealed that the left MTP joint pressure ulcer had not been identified, and there was no documentation that the physician was notified of the pressure ulcer. Record review of Resident #1's skin assessments of November 2, 10, 17 and 24, 2022, revealed no documentation of a left MTP joint pressure ulcer. Record review of the resident's care plan dated 10/12/22 revealed on 10/14/22 Resident #1 had an unstageable pressure ulcer to right metatarsal and had potential for pressure ulcer development related to diagnoses of Diabetes and Peripheral Vascular Disease. There was no mention of left MTP joint pressure ulcer.

LICENSURE REFERENCE NUMBER 175 NAC 12.009 Based on observation, record review and interview; the facility staff failed to monitor the condition of a Dialysis [the process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally] Arterio-Venous Fistula [an access site, catheter, into the vein in the arm used for the introduction of dialysis solution) site for 1 (Resident 7) of 1 resident reviewed that received Dialysis services. This had the potential for the resident to experience serious complications related to not monitoring the access site after Dialysis treatments. The facility census was 19. Findings are: Record review of a facility policy dated September 2010 entitled Hemodialysis Access care included the following: - Care of Arterio-Venous Fistula: 3. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). 4. To prevent infection and / or clotting: D. check for signs of infection (warmth, redness, tenderness or edema [swelling] at the access site when performing routine care and at regular intervals. H. Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to her the whoosh or bruit' of blood flow through the access. Record review of Resident 7's most recent quarterly Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 9/30/22 revealed that Resident 7 was cognitively intact with special treatments that included Dialysis while a resident. Interview on 11/29/22 at 9:56 AM with Licensed Practical Nurse [LPN] C revealed that Resident 7's Dialysis access site was located in the upper left arm. LPN C stated that staff look at the site before and after dialysis treatments and document the thrill and bruit in the progress Notes. Observation on 11/29/22 at 10:32 AM with LPN C revealed Resident 7 seated in a wheelchair. Resident 7 pulled up the sleeve of the shirt and showed LPN C the access site in the left upper arm. The site did not appear to have any signs of infection. Record review of Resident 7's Electronic Medical Record, including Progress Notes and Treatment Administration Records revealed no documentation of the monitoring of the Dialysis Fistula site for Resident 7. Interview on 11/29/22 at 12:24 PM with the facility Administrator confirmed there was no documentation of the monitoring of the fistula site for Resident 7.

Based on record review and interview, the facility failed to ensure a new PASRR (Pre-Admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) review had been completed after a diagnosis of a mental disorder was identified for 2 (Residents 3 and 5) of 2 reviewed for PASRR. The facility census was 19. Findings are: A. Record review of an undated facility policy entitled PASSR revealed the following: - 1. Facility will complete PASSR for pre-admission criteria and with any change in condition that may indicate the potential for mental disorder or intellectual disability. Record Review of Resident 3's Admission PASRR dated 9/9/08 was completed as as a level 1 review. The rationale documented on the level 1 screen determined that Resident 3 exhibited no evidence to suggest presence or known conditions of mental illness, mental retardation, or a condition related to mental retardation. As such, no further level 1 screening was required unless the individual was later suspected or found to have a mental illness or intellectual disability condition. Record review of Resident 3's annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 6/9/22 revealed that Resident 3 was admitted on [DATE] and section A1500 for PASRR revealed that Resident 3 was not considered by the State level 2 PASRR process to have a serious mental illness or intellectual disability or a related condition. The MDS further identified Resident 3 to have a current psychiatric diagnosis of Psychotic Disorder [ a mental health problem that causes people to perceive things differently and involves delusions]. Record review of Resident 3's Diagnoses list printed on 11/30/22 revealed that Resident 3 had a diagnosis of Delusional Disorder [a serious mental illness characterized by fixed false beliefs] that was received on 1/27/22. Record review of Resident 3's Medication Administration Record [MAR] dated February 2022 revealed that Resident 3 was started on Aripiprazole [an antipsychotic medication used to manage delusions and psychotic behaviors] 5 milligrams every day. The medication was started on 2/1/22. Record review of Resident 3's Electronic Medical Record revealed that a new PASRR had not been completed since 9/9/08 while Resident 3 had a new mental illness diagnosis of Psychotic Disorder identified on 1/27/22. Interview on 11/29/22 at 01:40 PM with the facility Administrator [ADM] ADM confirmed that Resident 3 received a new diagnoses of delusional Disorder on 1/27/22 and that a new referral for PASRR review had not been made to determine if a Level 2 PASRR was indicated. 40338 B. Record review of Resident 5's Admission PASSAR on 09/21/2015 was completed as a level 1 review. The rationale documented on the level 1 screen for this individual determined that there was not evidence to suggest presence or known conditions of mental illness, intellectual disability or a condition related to intellectual disability. As such no further Level 1 screening is required unless the individual is later suspected or found to have a mental illness or intellectual disability condition. Review of the MDS dated [DATE] revealed a diagnosis of Depression and Psychotic disorder and section A1500 of the MDS revealed resident had not been evaluated by Level II PASSAR. A review of Resident 5's diagnosis list revealed a diagnosis of Delusional Disorder dated 07/30/21 and Major depressive disorder dated 06/30/21. Record review of Resident 5's electronic medical record revealed that a new PASSAR had not been completed since 09/21/2015. Interview on 11/29/22 at 01:40 PM with the facility ADM confirmed that Resident 5 received a new diagnosis of Delusional Disorder on 07/30/21 and Major Depressive Disorder on 06/30/21 and that a new referral for PASSAR had not been make to determine if a Level II PASSAR was indicated.

Licensure Reference Number 12-007.04D Based on observation and interview, the facility failed to ensure that the ventilation exhaust systems were working in Resident bathrooms in 10 ( Rooms 8, 9, 10, 11, 12, 13, 14, 22, 23 and 24) of 14 occupied resident rooms. This had the potential to affect 10 residents that resided in those rooms. The facility census was 14. Findings are: Observation on 07/14/21 between 10:30 AM and 10:45 AM with the Maintenance Director revealed no working ventilation systems in the bathrooms of resident rooms rooms 8, 9, 10, 11, 12, 13, 14, 16, 17, 22, 23 and 24. A one ply square of toilet paper was held flat against the ventilation system cover in the bathrooms of those rooms. The ventilation system in those rooms did not hold the paper to the outside of the ventilation system which indicated that there was no air draw and the ventilation system did not work. Interview on 07/14/21 at 10:35 AM with the Maintenance Director confirmed there was no draw in the bathrooms and that the systems had not been routinely checked to ensure the exhaust systems were working. Interview 07/14/21 11:52 AM with the Maintenance Director confirmed that 3 main exhaust systems on the roof were not working, the breakers were on but they were not working. he will pull it apart and see what has happened.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) was coded to relfect the resident received [CONDITION(S)] services for 1 (Resident 12) of 14 sampled residents. The facility census was 14. Findings are: Record review of Resident 12's Admission MDS with an Assessment Reference Date of 12/20/20 revealed that Resident 12 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 07/13/21 at 08:13 AM with Licensed Practical Nurse [LPN] A confirmed that Resident 12 went to [CONDITION(S)] 3 times per week. Record review of Resident 12's most recent quarterly MDS dated [DATE] revealed that [CONDITION(S)] services were not identified in Section O Special Treatments on the MDS and the boxes were left blank. Interview on 07/14/21 at 12:29 PM with the facility MDS Coordinator confirmed that Resident 12's MDS did not identify that [CONDITION(S)] services were provided while a resident at the facility.

Licensure Reference Number: 175 NAC 12-006.09C1a Based on record review and interview, the facility failed to ensure a baseline care plan was initiated within 48 hours of admission for 1 resident (Resident 116). The facility Census was 14. Findings are: Review of Resident 116's Electronic Medical Record (EMR) revealed Resident 116 was admitted on [DATE] and no baseline care plan was documented in Resident 116's EMR. Review of the Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 116's EMR revealed no care plan was developed within 48 hours of admission to ensure care needs were met. Interview on 07/13/21 at 2:59 PM with the MDS (Minimum Data Set) Coordinator revealed a baseline care plan had not been developed for Resident 116.

Licensure Reference Number 12-006.09C Based on record review and interview, the facility failed to develop a Comprehensive Care Plan [CCP, a person centered written plan developed to address the residents' medical, physical, mental and psychosocial needs] related to Antipsychotic [ a medication used to treat delusions] use for Resident 8. The sample size was 14 and the facility census was 14. Findings are: Record review of Resident 8's Psychiatric Progress Note dated 6/18/21 revealed that Resident 8 was started on [MEDICATION(S)] [ an antipsychotic drug used to treat psychotic disorders (conditions that cause difficulty telling the difference between things or ideas that are real or not real] 0.25 milligrams to be given by mouth three times per day for [CONDITION(S)] delusional thinking [fixed false beliefs]. Record review of the Nursing Drug Handbook 2018 revealed that the continued use of [MEDICATION(S)] could have several severe adverse reactions such as seizures, lethargy, [CONDITION(S)], sedation, drug to drug interactions and contraindications and cautions with the advisory to monitor the patient closely when those drugs were in use. Record review of Resident 8's CCP revealed that a CCP had not been developed in relation to the Antipsychotic use. There was no specific identification of warnings or possible side effects to be monitored related to the use of the Antipsychotic medication [MEDICATION(S)]. Interview on 07/14/21 at 10:03 AM with the facility MDS Coordinator confirmed that Resident 8's CCP had not been developed for the use of the antipsychotic medication [MEDICATION(S)].

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to identify the development of a pressure ulcer for 1 (Resident 9) of 3 sampled residents. The facility staff identified a census of 17. Findings are: Record review of a Progress Note (PN) dated 9-28-2017 revealed Resident 9 had been evaluated with multiple wounds to the right foot. According to the PN dated 9-28-2017, the wounds were to Resident 9's second and third right toes and 5th metatarsal head. On 10-11-2017 at 11:50 AM an interview was conducted with Wound Specialist (WS) D. During the interview WS D reported the wounds to Resident 9's right food were not caused from pressure, but from vascular issues. Observation on 10-12-2017 at 9:30 AM of Resident 9's wound treatment revealed Licensed Practical Nurse (LPN) E and LPN F obtained the required supplies for Resident 9's right foot treatment. LPN F removed the soiled dressing from the right foot and completed the treatment as ordered. Further observation of Resident 9's right foot revealed a blackened area on the right foot heel that measured approximately 0.3 centimeters and had a defined edge to the wound area. On 10-12-2017 at 9:30 AM, an interview was conducted with LPN E and LPN F. During the interview, both LPN E and LPN F reported the area to Resident 9's right heel was new. LPN E and LPN F reported they were not aware Resident 9 had developed an additional wound. On 10-12-2017 at 10:45 AM, an interview was conducted with Resident 9's Physician. During the interview Resident 9's Physician reported the area to Resident 9's heel was a pressure ulcer. On 10-16-2017 at 1:09 PM, a follow up interview was conducted with Resident 9's Physician. During the interview, Resident 9's Physician reported the pressure ulcer to Resident 9's right heel was un-stageable (Un-stageable:Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed), per the National Pressure Ulcer Advisory Panel.

Licensure reference: 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility failed to implement interventions for weight loss for one (Resident 9) of 15 sampled residents. The facility had a total census of 17 residents. Findings are: Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident weights under the vital section of the electronic medical record revealed Resident 9's weight on 7/19/17 was 160 lbs. (pounds) and 146.2 lbs. on 10/9/17 which is a loss of 13.8 lbs. or 8.6%. Observations on 10/12/17 at 7:26 AM revealed Resident 9 ate all of meal. Resident 9 was edentulous. Observations on 10/12/17 at 11:37 AM revealed Resident 9 ate 50% of meal. Resident 9 was observed to be edentulous. A review of a Nutrition Note dated 9/27/17 revealed Resident 9 had a current body weight 151.2 lbs. with a mechanical soft diet. Resident 9 was identified as eating 100% of meals. Resident 9's physician requested extra calories per day. The dietitian recommended Prostat 30 ml (nutritional supplement) twice a day with 200 kcal and 30 gram protein and half sandwiches three times per day between meals to provide extra calories. A review of the facility Supplement and Special Snack list for October 2017 revealed Resident 9 was to receive a 1/2 meat sandwich three times per day. Observations on 10/12/17 at 1:55 PM revealed the afternoon snack cart had no sandwich on the cart for Resident 9. In an interview on 10/12/17 at 1:55 PM, Dietary Aide A reported Dietary Aide A would provide Resident 9 with jello. In an interview on 10/16/17 at 11:25 AM, Dietary Manager B reported Resident 9 was scheduled to receive a half sandwich at evening snack only. The Dietary Manager reported sandwiches may be available at other times or if a staff member or resident requested one. In an interview on 10/16/17 at 10:25 AM, Registered Dietitian C reported Resident 9 should be getting a half sandwich 3 times per day. Registered Dietitian C was not aware that Resident 9 was edentulous and confirmed Resident 9 needed to be reassessed related to extra calorie needs.