Every finding on record at Cascades at Skyview

Licensure Reference Number 175 NAC 12-006.04(D)(i)Based on record review and interview, the facility failed to submit a director of nursing continuous coverage notification to the state agency as required. This had the potential to affect all residents.Findings are: Record review of the Change of Director of Nursing Notification Form submitted to the Department of Health and Human Services by the facility revealed no Director of Nursing (DON) coverage between the dates of 4/29/2026 and 5/4/2026. Interview with Regional Nurse Consultant (RNC) at 6/16/2026 at 11:35 AM revealed that RNC was the DON during the gap stated above, but it was not recorded on paper to confirm. Interview with Administrator (ADM) at 6/16/2026 at 11:35 AM confirmed that the Change of Director of Nursing Notification Form does show a gap of DON coverage between 4/29/2026 and 5/4/2026. ADM confirmed the facility does not have written proof of DON coverage in that time frame.

175 NAC 12-006.11(E)Based on observations and record reviews, the facility failed to perform hand hygiene with soap and water for a minimum of 20 seconds. The facility failed to ensure cleanliness of the kitchen to prevent the potential for cross contamination. The facility also failed to label and seal stored foods. This had the potential to affect all residents. The facility showed a census of 25.Findings are: Observations made beginning at 8:20 AM on 6/11/2026 revealed in the dry storage area, there were 4 boxes of baking soda on the shelf, each with an expiration date of July 2024. Also, in the dry storage there was 1 large bag of macaroni noodles that were open and unsealed with no open date on the packaging. Inside the storage area there were 3 separate freezers. Inside one of the freezers there was 1 bag of hashbrowns that were not sealed and did not have an open date listed on the packaging. That same freezer also had a package of frozen corn tortillas that did not have an expiration or best by date. Inside another freezer there was one more bag of hashbrowns that were unsealed and undated. Inside 2 of the 3 freezers there were multiple bags of frozen peas that did not have expiration date or best by date. Inside one freezer was a bag of cinnamon rolls in a plastic bag tied, with no open date. There was also a large blue bag filled with chopped carrots that was not sealed and did not have an open date on it. Inside a freezer there was a plastic Ziploc bag with fish fillets inside them that did not have an open date marked. There was one bag of ground sausage in a Ziploc bag with a date of 5/21 and was not sealed. There was one bag of frozen waffles that did not have an expiration or best by date as well as a large plastic bag of frozen bread that was not sealed and did not have an open date. Additional observations inside the kitchen revealed there was a grey fuzzy substance on the chains holding up the hood vent above the stove/oven. The ice machine lid was covered in a dry white substance and appeared to have a slow water drip coming from the top portion of the machine that ran down the lid of where the ice was held.An interview with the Dietary Manager (DM) at 8:30 AM on 6/11/26 confirmed the expiration dates on the 4 boxes of baking soda.Observations that began at 10:40 AM on 6/11/26 of meal preparation revealed DM performed hand hygiene via soap and water for 10 seconds and donned (put on) new gloves and then began to prepare fruit cups for residents. At 10:55 AM the DM removed their gloves and then performed hand hygiene with soap and water for 7 seconds. The DM then donned new gloves, touched a paper on the prep counter then put on oven mitts and removed the chicken from the oven. The DM then removed the left oven mitt from their hand, then closed and locked the oven door. The DM removed the tin foil from the chicken and then grabbed a thermometer and cleaned it with appropriate wipe. The DM put the thermometer into a piece of chicken to check the temperature and then put thermometer down on top of stove and stepped away to help the Cook-D. When the DM returned, they used the thermometer-without recleaning it- to temp the chicken again at 10:57 AM and the chicken was temping at 96F (Fahrenheit). The DM removed their gloves and put the thermometer on counter, put on oven mitts and placed chicken back in oven. At this time the DM demonstrated that if the lock on the oven door is not latched, the door does fall open and stated, The oven stops working randomly. food always takes longer to cook than it should. Cook-D was attempting to seal and store a bag of salad and discovered there was a hole in the back of the bag causing food to fall out so the cook placed a piece of clear tape over the hole and placed bag of salad back in the fridge. The DM was then preparing salad dressing cups for the residents and touched a piece of paper that was on the prep counter with their gloved hands and then continued to prepare the salad dressing cups. At 11:49 AM Cook-D came back into the kitchen from an unknown location, did not perform hand hygiene and donned new gloves. At this time the DM took a cleaning rag from a red bucket and used it to wipe down the preparation counter. Cook-D then removed his gloves, performed hand hygiene with soap and water for 10 seconds, donned new gloves and then grabbed a loaf of bread and removed several pieces of bread from the bag. Cook-D was then called out of the kitchen by another staff member and kept their gloves on. At this time the DM removed a container of cottage cheese from the fridge with their gloves hands and then put cottage cheese into individual cups. The DM then put the trays with the cottage cheese cups into the refrigerator and then removed a silver bin full of broccoli. The DM then removed the plastic wrap from the broccoli, then removed gloves and walked out of kitchen. The DM came back into the kitchen with a box of aluminum foil, tore off a section and then placed it over the broccoli. The DM then put water into the broccoli and placed the silver bin of broccoli and water in oven. The DM then removed their gloves and used a rag from red bucket to wipe down counter. The DM then performed hand hygiene with soap and water for 6 seconds. At this time Cook-D was making sandwiches with gloved hands by putting peanut butter on 4 pieces of bread, but then stopped, removed their gloves, left the kitchen at 11:41 AM, and then came back at 11:42 AM with a box full of individual jelly packets, did not perform hand hygiene, and donned new gloves. Cook-D then proceeds to put jelly on 4 different pieces of bread. At 11:45 AM the DM donned gloves and then put on oven mitts and took the chicken out of the oven, then removed the aluminum foil from the silver pan. The DM then grabbed the thermometer and placed the thermometer into chicken which temped at 205F. The DM then transferred all the chicken to another silver pan from the steam holding tray. The DM then manually shredded the chicken and stated there were no pureed diets for residents, only mechanical soft. At this time Cook-D removed their old gloves and used hand sanitizer to perform hand hygiene, then donned new gloves and put away a box of plastic wrap. Cook-D then used the same gloved hands to touch the paper that had been sitting on the prep counter and then wrote down the temperature of the chicken on a white board on the side of the steam holding tray. The DM then removed the broccoli from the oven using the oven mitts and added more water to it. The DM then removed their gloves and walked out of the kitchen in search of a pen. The DM walked back into the kitchen at 11:59 AM, did not perform hand hygiene and donned a new pair of gloves. The DM then opened the fridge door with their gloved hands and removed the sauce for the chicken and placed the sauce in a pot on the stove and heated it while stirring it with a whisk. At this time the DM began preparing mechanical soft broccoli for residents and preparing the steam holding tray for foods. The ND advised staff to rewash their hands with soap and water- which they did for over 2 seconds each and then continued training Cook-D on serving residents.Record review of an undated facility policy labeled 'Food Storage' revealed the following statements:-It is recommended that food items are to be dated upon receipt with the month, day and year (00/00/00).-All opened and partially used foods shall be dated, labeled and sealed before being returned to the storage area.This policy has a separate section on page 23, labeled 'Frozen' with the following statements:-Cover all food containers-Wrap all food well to prevent freezer burn, label if product is not identifiable, and date of entry to freezer.-Opened boxes of food must be securely closed to preserve quality.

Licensure number 175 NAC 12-006.05Based on record review and interviews, the facility failed to ensure residents and/or resident representatives were informed of and consented to treatment prior to the administration of psychotropic medications for 2 (Resident 4 and Resident 21) of 5 sampled residents. The facility identified a census of 25 residents.Findings include: A. Record review of Resident 4's admission Record dated June 10, 2026 revealed Resident 4 admitted to the facility on [DATE] with a diagnosis of major depressive disorder. Record review conducted on June 10, 2026, of Resident 4's Doctor's Progress Note dated December 5, 2025, revealed Resident 4 was prescribed Seroquel (an antipsychotic medication used to treat major depressive disorder). Record review of Resident 4's medical record revealed no evidence of informed consent being obtained prior to the first dose of their Seroquel being administered. B. Record review of Resident 21's admission Record dated June 10, 2026 revealed Resident 21 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder, post-traumatic stress disorder and irritability and anger. Record review conducted on June 10, 2026, of faxed order from provider dated March 12, 2026 revealed Resident 21 was prescribed Risperdal (an antipsychotic medication used to treat several mental health disorders) for inappropriate sexual behavior. Record review of Resident 21's medical records revealed no evidence of informed consent being obtained prior to the first dose of their Risperdal being administered. Record review of Nursing Note with verbal order from provider dated March 11, 2026 revealed Resident 21 was prescribed Olanzapine (an atypical antipsychotic medication used to treat mental health issues) was prescribed for mood disorder unspecified with hypersexuality. Record review of Resident 21's medical records revealed no evidence of informed consent being obtained prior to the first dose of their Olanzapine being administered. Interview with the Director of Nursing (DON) on June 10, 2026 at 10:23 AM, revealed residents admitted to the facility on psychotropic medications should have informed consent completed upon admission. The DON stated informed consent should also be obtained when new psychotropic medications are initiated. The DON confirmed informed consent may be obtained in person or through documented telephone consent with the resident representative. The DON confirmed there was no informed consent obtained for Resident 4 and Resident 21 prior to starting these antipsychotic medications.

Licensure Reference Number 175 NAC 12-006.09(D)Based on record review, observation, and interview, the facility failed to ensure the MDS was coded accurately to reflect wandering behavior for one (Resident 16) of twelve sampled residents. The facility identified a census of 25.Findings are: Record review of Resident 16's admission Record dated 6/15/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 16's Diagnosis Information dated 6/15/2026 revealed a diagnosis of 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]) was added on 2/10/2025. A diagnosis of Metabolic Encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body which can cause confusion and memory loss) was added on 2/10/2025. A diagnosis of Restlessness and Agitation (involve feelings of inner tension, mental distress, and an inability to sit still; that can manifest as pacing, wandering, repetitive actions, or verbal outbursts) was added on 2/10/2025. Record review of Resident 16's Order Recap Report dated 6/15/2026 revealed the resident had an order for a Wanderguard (patient-safety technology used to keep residents with cognitive impairments [such as dementia] safe while promoting freedom of movement within a facility) with a start date of 6/9/2025. The order was revised on 7/19/2025, 3/24/2026, and 4/9/2026. Record review of Resident 16's undated Care Plan revealed the resident is an elopement risk/wanderer which was initiated on 6/9/2025 and revised on 2/6/2026. An observation on 6/10/2026 at 8:14 AM revealed Resident 16 walking to the door at the end of the 100 hallway. An alarm was set off, and a staff member went out to get the resident who had gone approximately 15 steps out the door. Observation revealed Resident 16 holding hands with a staff member walking through the halls on:6/11/2026 at 10:44 AM6/15/2026 at 8:19 AM6/16/2026 at 8:40 AM Observation on 6/15/2026 at 1:52 PM revealed Resident 16 walking down the 100 hallway telling a surveyor they need to use the bathroom while walking towards the exit door at the end of the hall. A dietary aide stopped the resident from exiting and helped the resident walk to the 400 hallway to get a nurse aide to help the resident. Resident 16 had a wanderguard on their left ankle. Observation on 6/15/2026 at 2:34 PM revealed Resident 16 wandering the 400 hallway alone. Observation on 6/16/2026 at 8:54 AM revealed Resident 16 walking the halls following a surveyor. Observation on 6/16/2026 at 11:26 AM revealed Resident 16 wandering the 200 hallway alone then Administrator (ADM) came over and guided the resident to the dining room. Observation on 6/16/2026 at 4:00 PM revealed Resident wandering 100 hall towards the exit door. MDS Coordinator (MDS-C) caught up to the resident to stop Resident 16 from opening the exit door. An interview on 6/15/2026 at 2:52 PM with Registered Nurse (RN)-A confirmed that Resident 16 had been wandering since the day Resident 16 was admitted to the facility. Wandering was nothing new for the resident. RN-A confirmed that because the resident wandered everyday, the nurses did not chart the behavior. The nurses would only chart when Resident 16 was exit seeking. RN-A confirmed that Resident 16 was care-planned for wandering. An interview with the Regional Nurse Consultant (RNC) on 6/16/2026 at 9:00 AM revealed the facility does not have an 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) policy as they follow 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) to complete the MDS's. A record review of the RAI Manual dated October 2025 revealed that on page E-18 to E-19 in Chapter 3, Section E that the line E0900: Wandering - Presence & Frequency requires assessing the medical record and interviewing staff to determine whether wandering occurred during the 7-day look-back period. Wandering is defined as the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. E0900 should be coded as 0 if the behavior was not exhibited. E0900 should be coded as 1 if wandering occurred 1-3 days during the 7-day look-back period, 2 if it occurred 4-6 days, or 3 if it occurred daily. Coding 1-3 would trigger E1000: Wandering - Impact, which assesses if the wandering places the resident at significant risk of getting to a potentially dangerous place or if the wandering significantly intrudes the privacy or activities of others. A. Record review of Resident 16's Progress Notes revealed a nursing note from 8/8/2025 at 3:06 PM that Resident 16 had been wandering more that day than their normal. Record review of Resident 16's Quarterly MDS dated [DATE] revealed that section E0900 was coded as 1 indicating that wandering behavior occurred 1-3 days. Record review of Resident 16's Modified Quarterly MDS dated [DATE] revealed that section E0900 was coded as 0 indicating that wandering behavior was not exhibited. Interview with MDS-C on 6/15/2026 at 3:58 PM confirmed that the Progress Note dated 8/8/2025 reflected Resident 16 wandering and that the MDS should have been coded as 1. B. Record review of a Resident 16's Progress Notes revealed a Provider Visit Note dated 11/8/2025; the resident was being seen for a follow up on Resident 16's depression, anxiety, and wandering. Record review of Resident 16's Quarterly MDS dated [DATE] revealed that section E0900 was coded as 0 indicating that wandering behavior was not exhibited. C. Record review of Resident 16's Progress Notes revealed a nursing note from 2/1/2026 at 5:41 PM that Resident 16 was ambulating around the facility independently per 'gender' norm, exit seeking. Record review of Resident 16's Progress Notes revealed a nursing note from 2/2/2026 at 5:51 AM that Resident 16 was ambulating independently before going to bed and was given Tylenol for restlessness. Record review of Resident 16's Significant Change MDS dated [DATE] revealed that section E0900 was coded as 0 indicating that wandering behavior was not exhibited. Interview with MDS-C on 6/15/2026 at 3:58 PM confirmed that the note on 2/1/2026 and 2/2/2026 reflected Resident 16 wandering and that the MDS should have been coded as 1. D. Record review of Resident 16's Quarterly MDS dated [DATE] revealed that section E0900 was coded as 0 indicating that wandering behavior was not exhibited. Record review of the Elopement Risk Scale dated 4/18/2026 revealed Resident 16 was at risk for elopement/wandering. Interview with MDS-C on 6/15/2026 at 3:58 PM confirmed that because Resident 16's Care Plan said the resident was a wanderer that the MDS should match that focus and code the resident for wandering.

Based on record review and interview, the facility failed to provide behavioral health care and services to one sampled resident (Resident 5). The facility identified a census of 25 residents. Findings are:Record review of a facility document titled, admission record, revealed Resident 5 was admitted on [DATE] with diagnoses of arthropathy (arthritis) in their left shoulder, chronic bronchitis, protein-calorie malnutrition, obstructive bladder dysfunction, history of falling, and depression. Record review of Resident 5's comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities) dated 3/4/26 revealed the following:Section C revealed Resident 5 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score 15 of a possible 15 points, indicating they were cognitively intact.Section I (Active diagnoses) revealed Resident 5 had an active diagnosis of depression within the last 7 days.Section N (Medications) revealed Resident 5 was taking an antidepressant in the last 7 days.Record review of Resident 5's undated care plan revealed:Resident 5 was determined not to be able to make informed decision by the provider on 1/7/26. Date initiated was 2/6/26.Resident 5 had a diagnosis of depression, and documented goal was to remain free of symptoms of distress, depression, anxiety, and sad mood. The date the goal was initiated was 12/10/25.An intervention in Mood/Behavior, dated 12/10/25 stated the facility would arrange for a psych consult for Resident 5.Other interventions for Resident 5's in the mood and behavior section were to monitor, document, and report any emotional distress, offer reassurance of a safe environment, and assess for unmet needs, all dated 12/10/25. A record review of Resident 5's progress notes in the electronic medical record (EMR) revealed the following:-On 9/18/25, the Social Services Director (SSD) completed measured Resident 5's BIMS score at 11/15 which indicated moderate impaired cognition, with no concerns found regarding the resident's mood or behavior.-On 9/19/25, at 8:10 PM, a nursing note revealed that Resident 5 left a note at their table in the dining room that stated the government wanted them dead. A staff member then found Resident 5 in the courtyard with a fork held to their abdomen and told the staff member the government was trying to take all their belongings. Resident 5 had learned earlier in the day they would need to make a list of their assets as part of the Medicaid application before it could be approved. Resident 5 was taken to the hospital for evaluation after the fork incident and comments.-On 9/20/25, at 3:00 AM, a nursing note revealed the facility had received information from the hospital that the resident was no longer suicidal and would be returning to the facility.-On 9/20/25, at 3:30 AM, a nursing note revealed the Resident 5 returned to the facility and stated, I did a foolish thing, and was apologetic and emotional. The note stated Resident 5 would be monitored every 15 minutes.-On 9/22/25, a nursing note revealed the 15-minute checks were discontinued following a visit by a provider, and Resident 5's requested that all their mail be screened so any financial or insurance matters could be handled by SSD. Record review of an untitled facility document dated 2/27/26 revealed a letter on facility letterhead that notified Resident 5 and their representative that the resident would be discharged 30 days after receipt of the letter, as well as pursue legal recourse to recover a past due balance. A record review of Resident 5's progress notes in the electronic medical record (EMR) revealed the following:-On 3/3/26, the SSD scheduled a care conference with Resident 5's representative for 3/12/26.-On 3/13/26, SSD informed Resident 5 that their Medicaid application was denied, the facility would look for placement in a different facility for the resident and asked for Resident 5's input on a location.-On 3/16/26, Resident 5 reported to nursing staff that they were suicidal, discussed feelings of helplessness with staff, and denied having a specific plan or time frame. Resident 5 reported that the facility was going to put them out on the street.-On 3/25/26, Resident 5 stated they wished to appeal their Medicaid application denial, and SSD communicated with State resources and the ombudsman on the resident's behalf.-On 3/26/26, Resident 5's family member called the facility to check on Resident 5's emotional well-being since their house had been sold, then the family member spoke to the resident on the phone.-On 4/4/26, a nurse received new orders to discontinue several medications including escitalopram, an antidepressant. Another note on 4/7/26 revealed the same information.No additional information about Resident 5's psychological care was included in the progress notes after that date. A review of the Medication Administration Record for April 2026 revealed the order for Resident 5's escitalopram 20 mg daily at bedtime started on 7/29/25.A record review of Resident 5's physician orders on 6/16/26 revealed no orders for any psychotropic medications, and no orders to monitor or document any behaviors related to depression or other mental illness.An interview on 6/16/26 at 1:27 PM with the Social Service Director (SSD) revealed Resident 5's suicidal ideation was due to finances, so the resident is no longer managing their own finances. SSD assisted Resident 5 with the Medicaid application process, and it was more complex and lengthier than usual in this case. SSD was not aware of any additional interventions for mental health, behavioral assistance, or related services that were completed with Resident 5 following their expressions of depressive and suicidal thoughts.An interview on 6/16/26 at 2:00 PM with the MDS Coordinator confirmed there was no documentation that the psychiatric or psychological evaluation recorded on the care plan had been completed.An interview on 6/16/26 at 2:20 PM with the Regional Nurse Consultant (RNC) revealed the psych consult was not completed for Resident 5 as stated on the care plan and it should have been. The interview also confirmed that there should have been more monitoring by staff with Resident 5 after they verbalized/exhibited suicidal behavior in September 2025 and March 2026.

Licensure Reference Number 175 NAC 12-006.12(D)(vii) Based on observation and record review, the facility failed to ensure a secure disposal of medication for 1 (Resident 4) of 3 sampled residents. The facility identified a census of 23. Findings are: Record Review of Resident 4's care plan, revised on 11/11/2024 revealed an admission date of 5/27/2022.Record review of Resident 4's order summary dated 2/18/2026 revealed an order for Potassium Chloride with an indication of nutritional supplement and a start date of 4/16/2025.Record Review of the facility's Discarding and Destroying Medication policy revised November 2022 revealed Non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications.Observation made on 2/18/2026 at 9:42 AM revealed that MA-A prepared Resident 4's AM (morning) medications, which included their Potassium Chloride, and carried the medications into Resident 4's room in a medication cup. MA-A then mixed the medications into the resident's pudding. Resident 4 stated they did not want to take the Potassium Chloride tablet. MA-A was then observed scooping the Potassium Chloride tablet out of the pudding and placed it into the trash can in Resident 4's room, showing this surveyor that the medication cup was then empty. MA-A then left Resident 4's room without taking the trash bag containing the Potassium Chloride tablet with them.Interview at 1:15 Pm on 2/18/2026 with Regional Nurse Consultant confirmed this was not the correct way to dispose of medications.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview, the facility failed to ensure their medication error rate was less than 5%. Out of 31 medication administration opportunities, there were 6 medication errors affecting 2 (Residents 6 and Resident 4) of 3 sampled residents, resulting in a 19.35% medication error rate. The facility identified a census of 23.Findings are:A.Record review of Resident 6's order summary dated 2/1/2026 revealed an order for Calmoseptine External Ointment 0.44-20.6% with an indication of Apply to bilateral buttocks topically four times a day for barrier protection with a start date of 1/7/2025. Record review of Resident 6's order summary also revealed and order for Multivitamin Oral tablet with an indication of Give 1 tablet by mouth one time a day related to pressure ulcer of sacral region with a start date of 5/22/2025. Record Review of Resident 6's care plan, revised 5/23/2025, revealed an admission date of 6/11/2025. Observation at 8:30 AM on 2/18/2026 of medication administration revealed Medication Aide-A (MA-A) charted 'given' on Resident 6's scheduled Calmoseptine ointment, and multivitamin oral tablet. During observation the Calmoseptine cream and the multivitamin were not removed from the medication cart to give to the resident. Interview with MA-A during medication administration (2/18/2026 at 8:30 AM) confirmed charting Calmoseptine cream as given, but not giving medication until resident was out of dining room. B. Record review of Resident 4's order summary dated 2/18/2026 revealed an order for Flonase Allergy Relieve Nasal Suspension for an indication of Nasal Congestion and drainage with a start date of 7/29/2025; Ipratropium Bromide Nasal Solution 0.06% with an indication for Sinusitis with a start date of 1/28/2026 ; Nystatin Powder for an indication for apply under breasts topically every 8 hours as needed for itching with a start date of 9/9/2024; Nystatin Powder for an indication for apply under breast topically 3 times a day for itching with a start date of 9/9/2024; Potassium Chloride Oral Tablet for an indication of Nutritional Supplement with a start date of 4/16/2025. Record review of facility policy Guidelines for Charting and Documentation revised April 2012 revealed Chart all changes in the residents medication Document treatments .If an error is made while recording data in the medical record, line through the error with a single line and then record the correct data Documentation pertaining to a resident's refusal of treatment should include Residents response and reason(s) for refusal, Documentation that the resident was informed of the purpose of the treatment and the consequences of not receiving the care, Date and time the physician was notified of the residents refusal of treatment in addition to the physicians response . Record review of Resident 4's electronic medication administration record revealed MA-A charted 'given' on Resident 4's Nystatin Powder, Flonase Nasal Spray, Ipratropium Bromide Nasal Solution, and Potassium Chloride oral tablet at 9:42 AM on 2/18/2026. Observation on 2/18/2026 at 9:42 AM revealed MA-A removed only oral tablet medications and placed them into a medication cup. MA-A then brought medication into Resident 4's room. MA-A mixed all oral tablet medications into Resident 4's pudding cup. Resident 4 confirmed she did not want the Potassium Chloride Pill. MA-A scooped the Potassium Chloride pill out of pudding container and placed in trash bin inside resident room, showing this surveyor the empty pudding container to confirm disposition of Potassium Chloride tablet. MA-A then left the residents room, leaving the trash bag open with the Potassium Chloride in the residents room. Observed MA-A make no attempts to discuss the need for the Potassium Chloride with Resident 4. No observations made of MA-A notifying nursing or providers of Resident 4 medication refusal. Interview at 11:00 AM on 2/18/2024 Resident 4 confirmed the Nystatin Powder, Flonase Nasal Spray, and Ipratropium Bromide Nasal Solution were not offered. Interview with Resident 4 confirmed they do not use the nasal spray until they have blown their nose, and they use the nystatin powder after showering or when excessively sweating.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1)Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on observations, record reviews, and interviews; the facility failed to develop and implement interventions to prevent the development of a pressure ulcer for 1 (Resident 6) of 1 sample resident and the failed to implement interventions and complete wound care treatments as ordered for 4 (Resident 2, 3, 6, and 18) of 4 sampled residents. The facility identified a census of 25.Findings are: A record review of a facility policy, Prevention of Pressure Ulcers, (dated March 2005) revealed the following: - Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. - The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. - Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. - Under General Preventative Measures: - Identify risk factors for pressure ulcer development. Factors that indicate residents at risk include decreased or impaired mobility; co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus; drugs that may affect wound healing such as steroids; impaired blood flow; resident refusal or treatments; cognitive impairment; exposure of skin to urinary and fecal incontinence; undernutrition, malnutrition, and hydration deficits; and past history of pressure ulcers. - Change position at least every two hours or more frequently if needed. - Routinely assess and document the condition of the resident's skin for any signs and symptoms of irritation or breakdown. A record review of facility policy, Pressure Ulcer Treatment, (dated December 2007) revealed the following: - Pressure ulcer treatment requires a comprehensive approach, including: 1. Debridement. 2. Managing infections. 3. Managing systemic issues (edema, venous insufficiency, etc.). 4. Maximizing the potential for healing. 5. Pain control. - Stage 1 Pressure Ulcer was defined as intact skin with non-blanchable (an area of skin that remains red when pressure is applied). - Stage 1 Pressure Ulcer interventions and care strategies included to determine cause of pressure and relieve; redistribute pressure; implement pressure-relieving devices; evaluate until redness is no longer persistent; notify physician, family, and appropriate facility personnel; and initiate a skin grid and care plan. For incontinence, cleanse, consider a toileting program or schedule and use protective barrier cream. For immobility, implement a turn schedule. - Stage 2 Pressure Ulcer was defined as partial thickness loss of the middle layer of skin presenting as a shallow open ulcer. - Stage 3 Pressure Ulcer was defined as a full thickness loss of the middle layer of skin with the potential for fat to be visible. - Stage 4 Pressure Ulcer was defined as a full thickness loss of the middle layer of skin where the bone, tendon, or muscle is exposed. - An unstageable pressure ulcer was defined as a full thickness loss of the skin where the base of the ulcer is covered by slough (a type of dead, devitalized tissue that appears in a wound as a soft, yellow, stringy, or thick, adherent material. It impedes wound healing by preventing new tissue growth, harboring bacteria, and blocking oxygen and nutrients. Removing slough is necessary for the wound to heal properly and is often done through a process called debridement.) or eschar (a layer of dead, leathery tissue, often black, brown, or tan, that forms over a wound or burn. It can be a sign of tissue death). - The first steps in the procedure of wound care were to first check the Treatment Administration Record (TAR) and obtain necessary supplies. A. A record review of an admission Record revealed the facility admitted Resident 2 on 1/20/2017. Resident 2 had diagnoses of 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), Chronic Inflammatory Demyelinating Polyneuritis (CIPD, a rare autoimmune disorder where the body's immune system attacks the myelin sheath, the protective covering of the nerves, primarily in the peripheral nervous system which can lead to progressive weakness and sensory changes in the arms and legs) and a Stage 4 Pressure Ulcer (a severe, open wound with full-thickness tissue loss that extends through the skin and into underlying muscle, tendon, or bone.) A record review of Resident 2's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) with a date of 8/25/2025 revealed Resident 2 had one-sided extremity impairment of their upper and lower extremities. Additionally, Resident 2 was dependent on staff for bathing and required substantial assistance for transferring in and out of the tub/shower. A record review of Resident 2's Care Plan Report revealed a focus area for skin integrity and pressure ulcer/injury with a last revised date of 9/3/2025. The area revealed Resident 2 was at risk for skin integrity impairment and pressure ulcer development due to impaired mobility, suprapubic catheter, bowel incontinence, and occasional moist skin folds due to obesity. Resident 2 had a stage Pressure Ulcer to her coccyx/sacrum. Interventions were as follows: - Assist me in staying clean, dry, and comfortable with a start date of 4/21/2024. - Cleanse wound with Anasept cleanser, apply skin preparation, moisten a 2x2 gauze with Anasept, gently pack into the wound wound and cover with border dressing twice a day and as needed with a last revised date of 10/16/2025. A record review of Resident 2's TAR for October 2025 revealed an order with a start date of 10/15/2025 to cleanse the resident's sacral would with Anasept spray, apply skin preparation, moisten a 2x2 gauze with Anasept, gently pack into the wound, fold another 2x2 gauze into quarter placing over the top of the wound, and cover with a border dressing twice a day and as needed. Additional review of the TAR order found the following: - On 10/17/2025, there was no evidence the order had been completed for the morning shift and was documented as held with reason of Other/See Progress Note on the night shift. - On 10/23/2025, the order was documented as held with reason of Other/See Progress Note. - On 10/31/2025, the order was documented as held with reason of Other/See Progress Note. A record review of Resident 2's TAR for November 2025 revealed an order with a start date of 10/15/2025 to cleanse the resident's sacral would with Anasept spray, apply skin preparation, moisten a 2x2 gauze with Anasept, gently pack into the wound, fold another 2x2 gauze into quarter placing over the top of the wound, and cover with a border dressing twice a day and as needed. The order had been documented as held with reason of Other/See Progress Note on 11/1/2025 night shift. A record review of Resident 2's Progress Notes revealed the following: - On 10/18/2025, Resident 2's wound treatment was documented as not completed with a free text entry reason of Day nurse did treatment before [gender] left. - On 10/20/2025, Resident 2's wound treatment was documented as not completed with a free text entry reason of Resident is sleeping most of the night. - On 10/24/2025, Resident 2's wound treatment was documented as not completed with a free text entry reason of Dressing intact. - On 10/28/2025, Resident 2 was started on fluconazole (an antifungal medication) for a skin yeast infection. - On 10/31/2025, Resident 2's wound treatment was documented as not completed with a free text entry reason of Treatment not done, unable to find the Anasept cleanser. - On 11/2/2025, Resident 2's wound treatment was documented as not completed with a free text entry reason of Reposition resident, dressing intact day shift did treatment late. - On 11/4/2025 at 8:37 AM, the nurse received orders for the Nurse Practitioner (NP) to send Resident 2 via ambulance to the hospital for wound evaluation and treatment. - On 11/4/2025 at 10:15 AM, the nurse placed a call to set transportation for Resident 2 to be transferred to the hospital, noting the wound dressing was intact. A record review of Resident 2's visit notes with the NP revealed the following: - Resident 2 was seen on 10/21/2025 to follow up on their wound progression. In this note, the NP noted the wound to have shown improvement, with drainage decreasing and less areas of slough and eschar. - Resident 2 was seen again on 10/28/2025 to follow up on wound progress. The note revealed the wound appeared to be consistent with a possible yeast infection. Resident 2 started on an antifungal medication. The note also revealed concerns with the wound healing have slowed, questioning the potential benefit of restarting wound vacuum therapy. - Resident 2 was seen again on 11/3/2025 per the staff request for wound concerns. The note revealed the wound was significantly worse with an increase in length, width, and depth since the last evaluation on 10/30/2025. The note also revealed the current order to cleanse the wound with Anasept spray, but at the time of the assessment was unavailable. An interview on 11/13/2025 at 12:12 with the NP revealed the following: - On 10/28/2025, the NP had notified the Director of Nursing (DON) of wound worsening and brought forth the idea of ordering a wound vacuum. - Verified the night shift nurse had not brought forth the concern of Resident 2's further worsening and stated the night shift nurse had admitted to not have changed the dressing, citing the lack of Anasept being available. - Revealed Resident 2 had passed away on 11/6/2025 from osteomyelitis (bone infection) and sepsis (infection in the blood stream), citing the failure of providing the dressing changes as ordered and a lack of bathing as the main contributors to the osteomyelitis/sepsis. A record review of Resident 2's Documentation Survey Report v2 (a report that includes all bathing documentation for the month) from October 2025 revealed Resident 2 had received a bath on the following dates: 10/2/2025, 10/7/2025, 10/9/2025, 10/14/2025, 10/23/2025, 10/28/2025, and 10/30/2025. It was documented Resident 2 refused on 10/19/2025. A record review of Skin Assessment & Bathing Documentation forms for Resident 2 revealed the following: - Documentation Resident 2 had received a bath on 10/18/2025. - Documentation Resident 2 had refused a bath on 10/23/2025. - Documentation Resident 2 had received a bath on 10/28/2025, 10 days since their previous bath. A record review of a Resident Refusal of Shower/Bed Bath revealed a date of 10/23/2025. An interview on 11/13/2025 at 2:25 with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) revealed the following: - The DON confirmed the facility was out of Anasept as of 10/31/2025 but had been unaware and acknowledge the order was not new and should have been in supply. - The RNC urgently order additional Anasept spray on 11/3/2025 due to the worsening of Resident 2's wound. - Confirmed Resident 2 had gone from 10/18/2025 to 10/28/2025 (10 days) without a bath. B. A record review of Resident 6's admission Record revealed the facility admitted Resident 6 on 12/11/2018. Resident 6 had diagnoses of dementia and generalized muscle weakness. A record review of Resident 6's quarterly MDS with a date of 8/12/2025 revealed Resident 6 required moderate assistance with rolling left and right, substantial assistance with sitting to lying, and was fully dependent on staff for all other transfers and movements. Additionally, the MDS identified Resident 6 at risk for the development of pressure ulcers. Under skin and ulcer/injury treatments, a pressure reducing device for the chair and application of ointments/medication other than to the feet was identified. A record review of Resident 6's Care Plan Report revealed no evidence Resident 6 had been identified as at-risk for pressure ulcers prior to 11/5/2025. An interview on 11/17/2025 at 9:00 AM with the Director of Nursing (DON) confirmed Resident 6 was at risk for the development of a pressure ulcer due to their incontinence and immobility. An additional risk factor of impaired nutrition occurred within the last two weeks. The DON confirmed Resident 6 did not have a care plan developed for their risk of pressure ulcers prior to 11/5/2025 and should have, including interventions of repositioning and incontinence care to prevent the breakdown. A record review of Resident 6's Treatment Administration Record (TAR) from October 2025 revealed an order to complete a skin assessment and document finding in a weekly skin assessment under the assessment tab every Thursday for skin integrity with a start date of 8/14/2025. The order had been documented as completed on 10/2/2025, 10/9/2025, and 10/16/2025. There was no evidence that this had been completed on 10/23/2025 or 10/30/2025 as ordered. A record review of Resident 6's assessments under the assessment tab for Weekly Skin Assessment revealed assessments had been completed on 10/2/2025, 10/9/2025, 11/6/2025, and 11/13/2025. There was no evidence that a skin assessment had been completed on 10/16/2025. A record review of Resident 6's Weekly Skin Assessment with a date of 10/9/2025 revealed the resident's skin was intact. A record review of Resident 6's Weekly Skin Assessment with a date of 11/6/2025 revealed resident skin was intact, except for their sacral area where a dressing was intact. A record review of Skin Assessment and Bathing Documentation forms for Resident 6 revealed the following: - On 10/6/2025, Nurse Aide (NA)-G had written pick marks on chest. - On 10/12/2025, Medication Aide (MA) – F had circled wound on the form, circling areas of the resident's left chest and sacral area. Registered Nurse (RN) – A had additionally signed the form. A record review of Resident 6's note from their visit with the NP on 10/21/2025 revealed Resident 6 presented with an unstageable sacral pressure injury. The wound was non-blanchable with a black/dark purple center. An order for wound care was provided to the facility. An interview on 11/17/2025 at 9:50 AM with MA-F confirmed they had found an open wound on Resident 6's sacral area on 10/12/2025. MA-F was unable to recall if she had notified the charge nurse but had provided the Skin Assessment and Bathing Documentation form for RN-A to sign. An interview on 11/17/2025 at 9:52 AM with RN-A confirmed they had signed the Skin Assessment and Bathing Documentation form on 10/12/2025 but was unable to recall if they had completed a skin assessment. RN-A confirmed documentation of the skin assessment should have been documented in the resident's medical record if it had been completed. An interview on 11/17/2025 at 9:55 AM with the DON confirmed there had been no documented skin assessment completed between 10/9/2025 and 10/21/2025, when the wound had been documented as being found in the resident's medical record. Additionally, the wound had gone without treatment from 10/12/2025 to 10/21/2025. Additional record review of Resident 6's Care Plan Report revealed on 11/5/2025 a focus area for pressure ulcers had been added. This area revealed Resident 6 had an unstageable pressure ulcer to their sacrum due to impaired mobility, incontinence and decrease food and fluid intake. An intervention to follow facility policies for the prevention/treatment have also been added. An observation on 11/12/2025 at 8:10 AM revealed Resident 6 laying on their back in bed. Resident 6's air mattress was set to 180 pounds (lbs.) An observation on 11/12/2025 at 9:45 AM revealed Resident 6 laying on their right side in bed. Resident 6's air mattress continued to be set at 180 lbs. An observation on 11/12/2025 at 11:10 AM revealed Resident 6 laying on their right side in bed. Resident 6's air mattress continued to be set at 180 lbs. An interview on 11/12/2025 at 11:11 AM with RN-A revealed Resident 6's current weight was 88 lbs. as of Sunday (2 days prior.) An interview on 11/12/2025 at 11:15 AM with the DON confirmed Resident 6's bed was set for 180 lbs., which exceeded the correct setting of near 88 lbs. The DON was unsure why it was set so high as there should be an order on the TAR for the nurses to check that the air mattress was set to the correct level. An observation on 11/12/2025 from 1:00 PM to 3:50 PM revealed Resident 6 to be positioned on their right side facing the wall. An interview on 11/12/2025 at 3:55 PM with NA-E confirmed Resident 6 had not been repositioned on evening shift (since 2:00 PM) and had been laying on their right side since prior to shift change when dayshift repositioned the resident that way after lunch. C. A record review of Resident 18's admission Record revealed Resident 18 was re-admitted to the facility on [DATE]. Resident 18 had diagnoses of a Stage 2 Pressure Ulcer (an open wound involving the loss of the outermost layer of skin) and generalized muscle weakness. A record review of Resident 18's significant change MDS with a date of 9/13/2025 revealed Resident 18 had one-side impairment of their upper extremities. Resident 18 required substantial assistance for rolling left and right and was fully dependent on staff for position changes and transfers. A record review of Resident 18's Care Plan Report (last revised 10/1/2025) revealed Resident 18 had 3 stage 2 pressure injures to their sacrum and buttocks. Interventions of the following had been added: - Follow facility policies for the prevention/treatment of skin breakdown. - Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. - The resident requires supplemental protein, amino acids, vitamins and minerals as ordered to promote wound healing. A record review of Resident 18's visit notes with the NP from 10/28/2025 revealed Resident 18 had ongoing challenges with their pressure ulcers, including a stage 2 ulcer on their right buttock, 2 unstageable areas, and two resolving stage 1 pressure ulcers on both buttocks. The NP expressed concerns that the wound was not progressing as expected despite the now controlled urinary incontinence. Additionally, the note revealed Resident 18 was dependent on staff for turning and reposition, which was essential for [gender] wound management. Resident 18's weight was documented as 133.8 pounds (lbs.) An observation on 11/12/2025 at 8:10 AM revealed Resident 18 had been lying in bed. Their air mattress had been set for a weight of 170-230 lbs. An observation on 11/12/2025 at 1:15 PM revealed Resident 18 to be lying on their left side. The air mattress continued to be set for a weight of 170-230 lbs. An observation on 11/12/2025 at 3:45 PM revealed Resident 18 continued to be laying on their left side. Resident 18 was stating their rear hurt. The air mattress continued to be set for a weight of 170-230 lbs. An interview on 11/12/2025 at 3:50 PM with Registered Nurse (RN) – A revealed they were unsure of what setting Resident 18's air mattress should be set on and referred the question to the nearby DON. An interview on 1/12/2025 at 3:51 PM with the DON revealed the resident's air mattress should be set according to their weight. A follow up interview on 11/12/2025 at 3:52 PM with RN-A confirmed Resident 18's bed was set to 170-230 pounds, which exceeded Resident 18's current weight status of 136 lbs. Additionally, RN-A confirmed Resident 18 had been in this position since after returning from lunch, sometime around 1:00 PM, and should be repositioned every two hours. Further observation on 11/12/2025 at 3:52 PM revealed Resident 18 continue to complain of pain. RN-A asked Resident 18 if they would like Tylenol for their pain. RN-A did not offer to reposition Resident 18 until after being prompted by this surveyor, which Resident 18 accepted assistance with repositioning. RN-A was assisted by the DON to reposition. A follow up interview on 11/12/2025 at 4:01 PM with Resident 18 revealed repositioning helped some with their rear pain. D. A record review of Resident 3's Order Summary Report dated 11/12/2025 revealed the resident was admitted to the facility on [DATE]. The report also revealed the resident had an order to cleanse the right superior aspect of ear, both areas with wound cleanser, and apply bacitracin-zinc with a cotton tipped applicator twice a day. The order had a start date of 11/6/2025. An observation on 11/12/25 at 1:02 PM revealed the Director of Nursing (DON) was at the nurse's station preparing to perform wound care for Resident 3. The DON checked their orders in a binder, then placed the supplies needed into a plastic container and carried them to the resident's room. After the DON performed wound cares to the resident's Moisture Associated Skin Damage (MASD) on their thigh and buttocks, two aides assisted the resident out of their bed and into their wheelchair. While this took place, the DON performed HH via ABHR, opened a package of sterile gauze, put on new gloves, and squirted Skintegrity wound cleanser onto the gauze. The DON used the gauze to cleanse Resident 3's right upper ear, then threw the gauze and their gloves into the trash and performed HH via ABHR. After putting on new gloves, the DON put Hydrogel onto a Q-Tip and rubbed it onto the area in the crease of the resident's upper right ear. The DON then removed their gown and gloves, put their supplies back into the plastic container, and carried their supplies back to the nurse's station. An interview on 11/12/25 at 1:58 PM with the DON confirmed they used Hydrogel for the treatment to Resident 3's right ear. The DON stated they did not realize Resident 3's order had been changed from Hydrogel to bacitracin-zinc six days prior. An interview on 11/12/25 at 1:59 PM with the Registered Nurse Consultant confirmed Resident 3's right ear treatment order had been changed from Hydrogel to bacitracin-zinc in the electronic medical records six day prior.

Licensure Reference 175 NAC 12-006.09(H) Based on interviews and record reviews, the facility failed to ensure residents were free from neglect by ensuring adequate supplies to meet residents' needs for 2 (Resident 2 and Resident 14) of 2 sampled residents. The facility identified a census of 25.Findings are:A record review of the SCARAB (Skyview Care and Rehab at Bridgeport) Facility Assessment - 2025 (dated 11/10/2025) revealed the following:- Services offered include pressure injury prevention and wound care.- The nurse management team assesses medical supplies weekly to ensure availability.A.A record review of the facility's policy, Wound Care (dated December 2011) in preparation for wound care, assembled all equipment and supplies needed. A record review of an admission Record revealed the facility admitted Resident 2 on 1/20/2017. Resident 2 had diagnoses of 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), Chronic Inflammatory Demyelinating Polyneuritis (CIPD, a rare autoimmune disorder where the body's immune system attacks the myelin sheath, the protective covering of the nerves, primarily in the peripheral nervous system which can lead to progressive weakness and sensory changes in the arms and legs) and a Stage 4 Pressure Ulcer (a severe, open wound with full-thickness tissue loss that extends through the skin and into underlying muscle, tendon, or bone.) A record review of Resident 2's Care Plan Report revealed a focus area for skin integrity and pressure ulcer/injury with a last revised date of 9/3/2025. The area revealed Resident 2 was at risk for skin integrity impairment and pressure ulcer development due to impaired mobility, suprapubic catheter, bowel incontinence, and occasional moist skin folds due to obesity. Resident 2 had a stage Pressure Ulcer to her coccyx/sacrum. An intervention of Cleanse wound with Anasept cleanser, apply skin preparation, moisten a 2x2 gauze with Anasept, gently pack into the wound and cover with border dressing twice a day and as needed with a last revised date of 10/16/2025 had been added. A record review of Resident 2's TAR for October 2025 revealed an order with a start date of 10/15/2025 to cleanse the resident's sacral would with Anasept spray, apply skin preparation, moisten a 2x2 gauze with Anasept, gently pack into the wound, fold another 2x2 gauze into quarter placing over the top of the wound, and cover with a border dressing twice a day and as needed. Additional review of the TAR order revealed on 10/31/2025, the order was documented as held with reason of Other/See Progress Note. A record review of Resident 2's TAR for November 2025 revealed an order with a start date of 10/15/2025 to cleanse the resident's sacral would with Anasept spray, apply skin preparation, moisten a 2x2 gauze with Anasept, gently pack into the wound, fold another 2x2 gauze into quarter placing over the top of the wound, and cover with a border dressing twice a day and as needed. The order had been documented as held with reason of Other/See Progress Note on 11/1/2025 night shift. A record review of Resident 2's Progress Notes revealed on 10/31/2025, Resident 2's wound treatment was documented as not completed with a free text entry reason of Treatment not done, unable to find the anasept cleanser. A record review of Resident 2's visit notes with the NP revealed the following:- Resident 2 was seen on 10/28/2025 to follow up on wound progress. The note revealed the wound appeared to be consistent with a possible yeast infection. Resident 2 started on an antifungal medication. The note also revealed concerns with the wound healing have slowed, questioning the potential benefit of restarting wound vacuum therapy.- Resident 2 was seen again on 11/3/2025 per the staff request for wound concerns. The note revealed the wound was significantly worse with an increase in length, width, and depth since the last evaluation on 10/30/2025. The note also revealed the current order to cleanse the wound with Anasept spray, but at the time of the assessment was unavailable. An interview on 11/13/2025 at 12:12 with the NP revealed the night shift nurse had admitted to the NP to not have changed the dressing after 10/31/2025, citing the lack of Anasept being available and confirmed that Anasept was still not available on 11/3/2025. Additionally, the NP revealed Resident 2 had passed away on 11/6/2025 from osteomyelitis (bone infection) and sepsis (infection in the blood stream), citing the failure of providing the dressing changes as ordered and a lack of bathing as the main contributors to the osteomyelitis/sepsis. An interview on 11/13/2025 at 2:25 with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) revealed the following:- The DON confirmed the facility was out of Anasept as of 10/31/2025 and had been aware of being out. On 11/3/2025, they urgently placed an order for additional Anasept spray due to the worsening of Resident 2''s wound. - The last time Anasept had been ordered was on 9/27/2025. The DON additionally confirmed Resident 2's wound treatment order had been in place since 10/14/2025 and Anasept spray should have been ordered and available. B.A record review of Resident 14's admission Record revealed the resident was admitted to the facility on [DATE] with a principal diagnosis of Type I Diabetes Mellitus with Diabetic Polyneuropathy (diabetes of a form that usually develops during childhood or adolescence and is characterized by a severe deficiency of insulin secretion resulting from atrophy of the islets of Langerhans and causing hyperglycemia and a marked tendency toward ketoacidosis). A record review of Resident 14's October 2025 MAR revealed the following orders:-Insulin (medication used to treat diabetes) Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML (milliliter), inject as per sliding scale: if blood glucose is 201 - 225 = 2; 226 - 250 = 3; 251 - 299 = 4; 300 - 350 = 5; 351 - 375 = 6; 376 - 400 = 7; 401 - 402 = 8 and call provider. Give one time a day before supper. This order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the dose on 10/21/2025.-Tresiba (medication used to treat diabetes) FlexTouch Subcutaneous Solution Pen injector 100 UNIT/ML, inject 25 unit subcutaneously one time a day. The order had a start date of 9/20/2025. The blood glucose and insulin were documented as NA on 10/22/2025.-Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML, inject as per sliding scale: if blood glucose is 176 - 200 = 3; 201 - 225 = 4; 226 - 250 = 5; 251 - 299 = 7; 300 - 350 = 8; 351 - 375 = 9; 376 - 400 = 10; 401 - 402 = 12 call provider. Give two times a day. The order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the midday dose on 10/21/2025 and for the AM dose on 10/22/2025.-Monitor blood glucose levels four times a day and PRN. Notify provider if blood sugar is less than 80 or greater than 400 or if the resident is symptomatic. This order had a start date of 9/02/2025. The blood glucose was documented with an X on the 10/21/2025 midday, PM, and HS (hour of sleep) administration times and for the AM administration time on 10/22/2025. The midday time on 10/22/2025 revealed a blood glucose of 528. A record review of Resident 14's Progress Notes for October 2025 revealed no progress notes documented by the facility staff related to notifying the provider about the resident not receiving blood glucose checks or insulin the evening of 10/21/2025 and morning of 10/22/2025. An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, the NP was made aware that the facility had not obtained any of the strips, therefore Resident 14's blood glucose level had not been obtained since the previous morning, and the resident had not received any of their scheduled insulin doses. NP stated the strips arrived prior to lunchtime on 10/22/2025 and at that time Resident 14's blood glucose was 528 and the NP had to order an extra dose of insulin to help lower the level. NP stated Resident 14 was a very fragile diabetic and that missing blood glucose checks, and insulin doses could have easily caused Resident 14 significant harm. An interview on 11/13/25 at 12:20 PM with the DON confirmed the code NA on the MAR indicated not applicable. The DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available and that the facility did not attempt any other method of obtaining strips, which resulted in Resident 14 not having their blood glucose level checked for four consecutive scheduled times. The DON also confirmed that Resident 14 did not receive their scheduled insulin doses during that timeframe.

Licensure Reference 175 NAC 12-006.09(H)Based on observations, interviews, and record review, the facility failed to identify and address uncontrolled pain and withdrawal symptoms when the resident could no longer reliably swallow their oral medications for 1 (Resident 6) of 1 sampled resident. The facility identified a census of 25.Findings are: A record review of the facility's policy, Pain - Clinical Protocol (dated October 2022) revealed the following:- Nursing staff will identify any situation or interventions where an increase in the residents' pain may be anticipated.- Nursing staff will reassess the resident's pain at regular intervals, at least every shift for acute pain or significant changes in levels of chronic pain.- Nursing staff will evaluate and report on the residents' use of standing and as needed pain medications.- There was no evidence of how pain should be evaluated for residents who are non-verbal. A record review of Resident 6's admission Record revealed the facility admitted Resident 6 on 12/11/2018. Resident 6 had diagnoses of dementia and generalized muscle weakness. A record review of Resident 6's quarterly MDS with a date of 8/12/2025 revealed Resident 6 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 0/15, which indicated severe cognitive impairment. Additionally, it revealed Resident 6 is sometimes understood and sometimes understands others. A record review of Resident 6's Care Plan Report revealed a focus area of pain was initiated on 1/15/2024. The area revealed Resident 6 had chronic pain due to osteopenia (low bone density) and had generalized aches and pain. Interventions were as follows:- Administer analgesia (pain medication) per the orders.- Anticipate the resident's need for pain relief and respond immediately to any complaints of pain.- Evaluate the effectiveness of pain interventions. A record review of Resident 6's Order Summary as of 11/12/2025 revealed the following orders:- buspirone 5 milligrams (mg) to be given three times a day for anxiety/depression.- celecoxib 100 mg to be given once a day for arthritis in the hip.- fluvoxamine 100 mg to be given once a day for depression.- hydrocodone 5-325 mg with a half a table to be given three times a day for pain.- hydrocodone 5-325 mg once a day for pain.- methocarbamol 500 to be given three time a day for muscle weakness. A record review of Resident 6's Progress Notes revealed the following:- On 10/28/2025 at 12:31PM, Resident 6's order for Hydrocodone was documented as not given with note that resident had refused the medication.- On 10/28/2025 at16:33, it was documented that the resident's hydrocodone was held. There was no reason provided.- On 10/30/2025 at 10:07 AM, Resident's buspirone was documented as not given with note that resident kept pushing hand away and would not open mouth.- On 10/30/2025 at 10:08 AM, Resident's fluvoxamine, hydrocodone, methocarbamol, and celecoxib were documented as not given with note that resident kept pushing hand away and would not open mouth.- On 10/302025 at 11:49 AM, Resident's buspirone, hydrocodone, and methocarbamol was documented as not given with note stating resident would not open mouth and kept pushing their hand away.- On 11/1/2025 at 2:20 PM, Residents buspirone and methocarbamol were documented as not given with note stating resident refused.- On 11/2/2025 at 12:27-12:29 AM, Resident's hydrocodone and buspirone were documented as not given and note stating resident sleeping soundly.- On 11/3/2025 at 4:28 PM, Resident's hydrocodone was documented as not given without a reason provided.- On 11/3/2025 at 8:04 PM, Resident's buspirone and methocarbamol were documented as not given with a reason of resident refused.- On 11/7/2025 at 10:14 AM, a note was charted that Resident 6's medication were crushed and put into yogurt. Resident took four small bites then refused.- On 11/7/2025 at 8:45 PM, a note was charted that resident only took one small bite of medication and was unable to complete the rest.- On 11/8/2025 at 11:41 PM, resident's buspirone, methocarbamol, and hydrocodone were documented as not given with a reason of resident refused.- On 11/9/2025 at 9:37 AM, resident's methocarbamol was documented as not given with a reason of resident only taking a few bites than refusing.- On 11/11/2025 at 1:45 AM, it was noted the writer had asked the Director of Nursing (DON) if it would be possible to obtain comfort medication for day as the resident is not taking any medication, so the resident could remain comfortable.- On 11/11/2025 at 9:15 PM, resident's buspirone was documented as not given with a reason of resident refused.- On 11/12/2025 at 12:37 AM, resident's hydrocodone was documented as not given with a reason of resident refused. An observation on 11/12/2025 at 9:45 AM revealed Resident 6 had been laying in bed. Resident 6 had been displaying non-verbal indications of pain, including facial grimacing and groaning. Posturing appeared to be rigid. An observation on 11/12/25025 at 11:10 AM revealed Resident 6 could be heard groaning from down the hallway. Resident 6 continued to be displaying non-verbal indication of pain including facial grimacing, furrowed brows, tense/rigid body posturing, restless legs, and loud/constant groaning. An interview on 11/12/2025 at 11:20 AM with the DON and Registered Nurse (RN) - A confirmed resident's assessment of non-verbal pain indications would rate at 6/10. RN-A stated they had difficulty administering Resident 6's medications, including their pain medications as the resident would only accept a few bites of the crushed medication. The DON revealed unaware if the resident not swallowing their medications had been reported to the Nurse Practitioner (NP) but stated comfort cares had been discussed, but no changes to the resident's regimen had been made due to an issue with the Power of Attorney (POA). Further record review of Resident 6's Progress Notes revealed the following:- On 11/12/2025 at 10:03 AM, RN-A had documented the resident would only take a few bites of their medication that had been crushed and put in pudding.- On 11/12/2025 at 11:34 AM, the DON documented they had spoken to the POA about change in medication, the DON followed up with the NP about comfort care medication being approved by the family. An interview on 11/13/2025 at 12:22 with the NP revealed the NP had been unaware until informed by this surveyor now that Resident 6 had not been taking their oral medications. The NP revealed Resident 6 did have a baseline behavior of mumbling, but being able to hear the resident from down the hallway would be outside their normal and would identify this as a non-verbal indication of pain. The NP also identified Resident 6's restless legs as being uncomfortable from withdrawals from the fluvoxamine and methocarbamol, as the resident needs these medications due to their tight spasticity in their legs.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interviews, the facility failed to notify the provider of a change in condition for 3 (Residents 2, 6, and 14) of 6 sampled residents and failed to notify the provider of the inability to follow provider orders for diabetic care for 3 (Residents 14, 7, and 17) of 3 sampled residents. The facility census was 25.A record review of the facility's policy Change in a Resident's Condition or Status (dated February 2021) revealed the nurse would notify the resident's attending physician or physician on call when there has been a significant in the resident's physical/emotion/mental condition or the need to alter the resident's medical treatment significantly within 24 hours. A. A record review of Resident 6's admission Record revealed the facility admitted Resident 6 on 12/11/2018. Resident 6 had diagnoses of dementia and generalized muscle weakness. A record review of Resident 6's quarterly MDS with a date of 8/12/2025 revealed Resident 6 required moderate assistance with rolling left and right, substantial assistance with sitting to lying, and was fully dependent on staff for all other transfers and movements. Additionally, the MDS identified Resident 6 at risk for the development of pressure ulcers. Under skin and ulcer/injury treatments, a pressure reducing device for the chair and application of ointments/medication other than to the feet was identified. A record review of Resident 6's Treatment Administration Record (TAR) from October 2025 revealed an order to complete a skin assessment and document finding in a weekly skin assessment under the assessment tab every Thursday for skin integrity with a start date of 8/14/2025. The order had been documented as completed on 10/2/2025, 10/9/2025, and 10/16/2025. There was no evidence that this had been completed on 10/23/2025 or 10/30/2025 as ordered. A record review of Resident 6's assessments under the assessment tab for Weekly Skin Assessment revealed assessments had been completed on 10/2/2025, 10/9/2025, 11/6/2025, and 11/13/2025. There was no evidence that a skin assessment had been completed on 10/16/2025. A record review of Resident 6's Weekly Skin Assessment with a date of 10/9/2025 revealed the resident's skin was intact. A record review of Resident 6's Weekly Skin Assessment with a date of 11/6/2025 revealed resident skin was intact, except for their sacral area where a dressing was intact. A record review of Skin Assessment and Bathing Documentation forms for Resident 6 revealed the following: - On 10/6/2025, Nurse Aide (NA)-G had written pick marks on chest. - On 10/12/2025, Medication Aide (MA) – F had circled wound on the form, circling areas of the resident's left chest and sacral area. Registered Nurse (RN) – A had additionally signed the form. A record review of Resident 6's note from their visit with the Nurse Practitioner (NP) on 10/13/2025 revealed no evidence the NP had been made aware of the resident's new skin wound. A record review of Resident 6's note from their visit with the NP on 10/21/2025 revealed Resident 6 presented with an unstageable sacral pressure injury. The wound was non-blanchable with a black/dark purple center. An order for wound care was provided to the facility. An interview on 11/17/2025 at 9:50 AM with MA-F confirmed they had found an open wound on Resident 6's sacral area on 10/12/2025. MA-F was unable to recall if [gender] had notified the charge nurse but had provided the Skin Assessment and Bathing Documentation form for RN-A to sign. An interview on 11/17/2025 at 9:52 AM with RN-A confirmed they had signed the Skin Assessment and Bathing Documentation form on 10/12/2025 but was unable to recall if they had completed a skin assessment or notified the provider and family. RN-A confirmed documentation of the skin assessment and notification to the family and provider should have been documented in the resident's medical record if it had been completed. An interview on 11/17/2025 at 9:55 AM with the DON confirmed there had been no documented skin assessment completed between 10/9/2025 and 10/21/2025, when the wound had been documented as being found in the resident's medical record. Additionally, the DON confirmed there was no evidence the facility had notified the physician prior to 10/21/2025 or had notified the family. B. A record review of the facility's policy, Wound Care (dated December 2011) in preparation for wound care, assembled all equipment and supplies needed. A record review of an admission Record revealed the facility admitted Resident 2 on 1/20/2017. Resident 2 had diagnoses of 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), Chronic Inflammatory Demyelinating Polyneuritis (CIPD, a rare autoimmune disorder where the body's immune system attacks the myelin sheath, the protective covering of the nerves, primarily in the peripheral nervous system which can lead to progressive weakness and sensory changes in the arms and legs) and a Stage 4 Pressure Ulcer (a severe, open wound with full-thickness tissue loss that extends through the skin and into underlying muscle, tendon, or bone.) A record review of Resident 2's Care Plan Report revealed a focus area for skin integrity and pressure ulcer/injury with a last revised date of 9/3/2025. The area revealed Resident 2 was at risk for skin integrity impairment and pressure ulcer development due to impaired mobility, suprapubic catheter, bowel incontinence, and occasional moist skin folds due to obesity. Resident 2 had a stage Pressure Ulcer to [gender] coccyx/sacrum. An intervention of Cleanse wound with Anasept cleanser, apply skin preparation, moisten a 2x2 gauze with Anasept, gently pack into the wound and cover with border dressing twice a day and as needed with a last revised date of 10/16/2025 had been added. A record review of Resident 2's TAR for October 2025 revealed an order with a start date of 10/15/2025 to cleanse the resident's sacral would with Anasept spray, apply skin preparation, moisten a 2x2 gauze with Anasept, gently pack into the wound, fold another 2x2 gauze into quarter placing over the top of the wound, and cover with a border dressing twice a day and as needed. Additional review of the TAR order revealed on 10/31/2025, the order was documented as held with reason of Other/See Progress Note. A record review of Resident 2's Progress Notes revealed on 10/31/2025, Resident 2's wound treatment was documented as not completed with a free text entry reason of Treatment not done, unable to find the anasept cleanser. A record review of Resident 2's TAR for November 2025 revealed an order with a start date of 10/15/2025 to cleanse the resident's sacral would with Anasept spray, apply skin preparation, moisten a 2x2 gauze with Anasept, gently pack into the wound, fold another 2x2 gauze into quarter placing over the top of the wound, and cover with a border dressing twice a day and as needed. The order had been documented as held with reason of Other/See Progress Note on 11/1/2025 night shift. A record review of Resident 2's visit notes with the NP from 11/3/2025 revealed Resident 2 was seen again on 11/3/2025 per the staff request for wound concerns. The note revealed the wound was significantly worse with an increase in length, width, and depth since the last evaluation on 10/30/2025. The note also revealed the current order to cleanse the wound with Anasept spray, but at the time of the assessment was unavailable. An interview on 11/13/2025 at 2:25 with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) revealed the facility had been out of the Anasept spray as of 10/31/2025 and confirmed there was no documentation that the physician had been notified of the facility being out of Anasept spray and the inability to complete Resident 2's wound treatment as ordered. C. A record review of the facility policy Diabetes- Clinical Protocol with revision date of December 2020 revealed in the Monitoring and Follow Up section that the staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia. A record review of Resident 14's admission Record revealed the resident was admitted to the facility on [DATE] with a principal diagnosis of Type I Diabetes Mellitus with Diabetic Polyneuropathy (diabetes of a form that usually develops during childhood or adolescence and is characterized by a severe deficiency of insulin secretion resulting from atrophy of the islets of Langerhans and causing hyperglycemia and a marked tendency toward ketoacidosis). A record review of Resident 14's September 2025 Medication Administration Record (MAR) revealed the resident had an order to monitor blood glucose levels four times a day and PRN (as needed) with a start date of 9/2/2025. The order also stated to notify the provider if the resident's blood sugar was less than 80 or greater than 400, or if resident was symptomatic. Further review of the documentation for this order revealed the resident had the following blood glucoses done in the morning that were below 80: -On 9/3/25 their blood glucose was 61, -On 9/5/25 their blood glucose was 70, -On 9/7/25 their blood glucose was 64, -On 9/14/25 their blood glucose was 50, -On 9/15/25 their blood glucose was 44, -On 9/19/25 their blood glucose was 48, and -On 9/20/25 their blood glucose was 50. A record review of Resident 14's September 2025 Medication Administration Record (MAR) revealed the resident had an order for Glucagon Emergency Kit 1 milligram (MG), inject 1 dose intramuscularly every 4 hours as needed for BS (Blood Sugar) below 60 and unable to consume oral. This order had a start date of 4/29/2024. Further review of this order revealed it had been documented as given on 9/8/2025 at 6:16 AM for a BS of 54, on 9/15/2025 at 7:08 AM for a BS of 44, and on 9/16/2025 at 5:56 AM for a BS of 46. A record review of Resident 14's September 2025 Medication Administration Record (MAR) revealed the resident had an order for Glutose 15 Gel 40 %, give 1 dose orally every 8 hours as needed for signs and symptoms of hypoglycemia. This order had a start date of 4/29/2024 and there was no evidence of this being administered or attempted during the month of September. A record review of Resident 14's Progress Notes for the month of September 2025 revealed a note on 9/8/2025 at 6:26 AM stating the resident had a blood glucose of 54, glucagon injection had been administered, and the practitioner had been notified. There was no documentation stating the resident had been unable to consume oral medication that morning. Further review of the Progress Notes revealed no evidence of the provider being notified by the facility of any other blood glucose readings that were below 80 or of the resident requiring a glucagon injection on 9/15/2025 and 9/16/2025. An interview on 11/13/25 at 11:10 AM with the Nurse Practitioner (NP) revealed the NP was not aware of the resident requiring the use of the glucagon injections for their low blood glucose levels on 9/15/2025 and 9/16/2025 until the pharmacist reached out to them about it on 9/19/2025. The NP also stated that Resident 14 was a very fragile diabetic, and they would have expected the facility to notify them of the need to utilize glucagon injections. An interview on 11/13/25 at 12:20 PM with the DON confirmed the injectable glucagon was given to Resident 14 three times in September. The DON confirmed there was no evidence of the provider being notified of this on 9/15/2025 or on 9/16/2025. An interview on 11/17/2025 at 2:15 PM with the administrator confirmed that when a nurse notifies the provider of a concern related to the residents, the nurse should then enter a progress note in the resident's medical record regarding what they notified the provider about. D. A record review of Resident 14's October 2025 MAR revealed the following orders: -Insulin (medication used to treat diabetes) Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML (milliliter), inject as per sliding scale: if blood glucose is 201 - 225 = 2; 226 - 250 = 3; 251 - 299 = 4; 300 - 350 = 5; 351 - 375 = 6; 376 - 400 = 7; 401 - 402 = 8 and call provider. Give one time a day before supper. This order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the dose on 10/21/2025. -Tresiba (medication used to treat diabetes) FlexTouch Subcutaneous Solution Pen injector 100 UNIT/ML, inject 25 unit subcutaneously one time a day. The order had a start date of 9/20/2025. The blood glucose and insulin were documented as NA on 10/22/2025. -Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML, inject as per sliding scale: if blood glucose is 176 - 200 = 3; 201 - 225 = 4; 226 - 250 = 5; 251 - 299 = 7; 300 - 350 = 8; 351 - 375 = 9; 376 - 400 = 10; 401 - 402 = 12 call provider. Give two times a day. The order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the midday dose on 10/21/2025 and for the AM dose on 10/22/2025. -Monitor blood glucose levels four times a day and PRN. Notify provider if blood sugar is less than 80 or greater than 400 or if the resident is symptomatic. This order had a start date of 9/02/2025. The blood glucose was documented with an X on the 10/21/2025 midday, PM, and HS (hour of sleep) administration times and for the AM administration time on 10/22/2025. The midday time on 10/22/2025 revealed a blood glucose of 528. A record review of Resident 14's Progress Notes for October 2025 revealed no progress notes documented by the facility staff related to notifying the provider about the resident not receiving blood glucose checks or insulin the evening of 10/21/2025 and morning of 10/22/2025. An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, the NP was made aware that the facility had not obtained any of the strips, therefore Resident 14's blood glucose level had not been obtained since the previous morning, and the resident had not received any of their scheduled insulin doses. NP revealed the facility could not provide justification for why no one had notified the NP about the blood glucose monitoring strips not arriving the evening prior. NP stated the strips arrived prior to lunchtime on 10/22/2025 and at that time Resident 14's blood glucose was 528 and the NP had to order an extra dose of insulin to help lower the level. NP stated Resident 14 was a very fragile diabetic and needs their blood glucose checked frequently due to unpredictable and erratic levels. NP also stated that missing blood glucose checks, and insulin doses could have easily caused Resident 14 significant harm. An interview on 11/13/25 at 12:20 PM with the DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available and that the facility did not attempt any other method of obtaining strips, which resulted in Resident 14 not having their blood glucose level checked for four consecutive scheduled times. The DON also confirmed that Resident 14 did not receive their scheduled insulin doses during that timeframe. The DON confirmed the facility did not reach back out to the NP after being unable to obtain the strips the evening of 10/21/2025. E. A record review of Resident 7's admission Record revealed the resident was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus without complications (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). A record review of Resident 7's October 2025 MAR revealed the following orders: - Insulin Glargine Subcutaneous Solution Pen injector 100 UNIT/ML, inject 20 unit subcutaneously one time a day, to be given at HS. The order had a start date of 10/21/2025. There was documentation of the medication being administered on 10/21/2025 but the associated blood glucose was documented as NA. - Insulin Glargine Subcutaneous Solution Pen injector 100 UNIT/ML, inject 50 unit subcutaneously one time a day, in the AM. The order had a start date of 10/22/2025. There was documentation of the medication being administered on 10/22/2025 but the associated blood glucose was documented as NA. An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, Resident 7 wanted to speak with them. NP stated that Resident 7 reported their blood glucose had not been checked the evening prior or that morning, but their insulin had still been administered. NP revealed the facility could not provide justification for why no one had notified the NP about the blood glucose monitoring strips not arriving the evening prior. An interview on 11/13/25 at 12:20 PM with the DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available, that the facility did not attempt any other method of obtaining strips, and the facility did not reach back out to the NP after being unable to obtain the strips the evening of 10/21/2025. F. A record review of Resident 17's 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 17's October 2025 MAR revealed an order to obtain blood glucose checks before meals and at bedtime and to notify the provider if the resident's blood sugar was less than 60 or greater than 400 or if resident is symptomatic. The order had a start date of 9/10/2025. The order revealed documentation that a blood glucose check had not been completed for any of the scheduled times on 10/21/2025 or for the 7:00 AM and 11:00 AM times on 10/22/2025. A record review of Resident 17's Progress Notes for the month of October 2025 revealed no evidence of the facility notifying the provider of the inability to obtain blood glucose checks per the provider's orders on 10/21/2025 and 10/22/2025. An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, the NP was made aware that the facility had not obtained any of the strips, and the facility could not provide justification for why no one had notified the NP about the blood glucose monitoring strips not arriving the evening prior. An interview on 11/13/25 at 12:20 PM with the DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available, that the facility did not attempt any other method of obtaining strips, and the facility did not reach back out to the NP after being unable to obtain the strips the evening of 10/21/2025.

Licensure Reference 175 NAC 12-006.09(H)(i)(3) Based on record review and interview, the facility failed to assist residents with bathing for 3 (Resident 2, 6, and 18) of 3 sample residents. The facility identified a census of 24.Findings are: A. A record review of Resident 6's admission Record revealed the facility admitted Resident 6 on 12/11/2018. Resident 6 had diagnoses of 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 generalized muscle weakness.A record review of Resident 6's quarterly MDS with a date of 8/12/2025 revealed Resident 6 was fully dependent on staff for bathing and required total assistance for transferring in and out of the tub/shower. A record review of Resident 6's Documentation Survey Report v2 for September 2025 revealed Resident 6 received a bath on 9/26/2025. A record review of Resident 6's Documentation Survey Report v2 for October 2025 revealed Resident 6 received a bath on 10/6/2025, 10/17/2025, and 10/22/2025, 10/24/2025 and 10/31/2025. A record review of Resident 6's Documentation Survey Report v2 for November 2025 revealed Resident 6 received a bath on 11/10/2025 and 11/14/2025. A record review of Skin Assessment & Bathing Documentation forms for Resident 6 revealed the following:- Documentation Resident 6 received a bath on 10/12/2025.- Documentation Resident 6 received a bath on 10/14/2025.- Documentation Resident 6 received a bath on 10/23/2025. An interview on 11/17/2025 at 9:00 AM with the DON confirmed the following:- Resident 6 had not received a bath between 9/26/2025 and 10/6/2025 (10 days).- Resident 6 had not received a bath between 10/31/2025 and 11/10/2025 (10 days). B.A record review of Resident 18's admission Record revealed Resident 18 was re-admitted to the facility on [DATE]. Resident 18 had diagnoses of a Stage 2 Pressure Ulcer (an open wound involving the loss of the outermost layer of skin) and generalized muscle weakness. A record review of Resident 18's significant change MDS with a date of 9/13/2025 revealed Resident 18 had one-side impairment of their upper extremities. Resident 18 was also fully dependent on staff for bathing and required total assistance with transfer in and out of the tub/shower. A record review of Resident 18's Documentation Survey Report v2 from October 2025 revealed Resident 18 had a bath on 10/8/2025, 10/18/2025, and 10/29/2025. Not applicable had been documented on 10/25/2025. An interview on 11/17/2025 at 9:30 AM with the DON confirmed Resident 18 had not received a bath between 10/8/2025 and 10/18/2025 (10 days) nor 10/18/2025 and 10/29/2025 (11 days). C.A record review of an admission Record revealed the facility admitted Resident 2 on 1/20/2017. Resident 2 had diagnoses of dementia , Chronic Inflammatory Demyelinating Polyneuritis (CIPD, a rare autoimmune disorder where the body's immune system attacks the myelin sheath, the protective covering of the nerves, primarily in the peripheral nervous system which can lead to progressive weakness and sensory changes in the arms and legs) and a Stage 4 Pressure Ulcer (a severe, open wound with full-thickness tissue loss that extends through the skin and into underlying muscle, tendon, or bone.) A record review of Resident 2's 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) with a date of 8/25/2025 revealed Resident 2 had one-sided extremity impairment of their upper and lower extremities. Additionally, Resident 2 was dependent on staff for bathing and required substantial assistance for transferring in and out of the tub/shower. A record review of Resident 2's Documentation Survey Report v2 (a report that includes all bathing documentation for the month) from October 2025 revealed Resident 2 had received a bath on the following dates: 10/2/2025, 10/7/2025, 10/9/2025, 10/14/2025, 10/23/2025, 10/28/2025, and 10/30/2025. It was documented Resident 2 refused on 10/19/2025. A record review of Skin Assessment & Bathing Documentation forms for Resident 2 revealed the following:- Documentation Resident 2 had received a bath on 10/18/2025.- Documentation Resident 2 had refused a bath on 10/23/2025.- Documentation Resident 2 had received a bath on 10/28/2025, 10 days since their previous bath. A record review of a Resident Refusal of Shower/Bed Bath revealed a date of 10/23/2025. An interview on 11/13/2025 at 2:25 with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) confirmed Resident 2 had gone from 10/18/2025 to 10/28/2025 without a bath.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)&(iv)Licensure Reference Number 175 NAC 12-006.10 Based on observations, interviews, and record reviews; the facility failed to follow their bowel protocol to prevent constipation for 1 (Resident 6) of 4 sampled residents, and failed to implement orders as written by the provider for 4 (Residents 1, 3, 11, and 17) of 5 sampled residents. The facility census was 25. A. A record review of a facility policy titled Bowel and Bladder program and Toileting Program dated October 2010 stated every night shift, the charge nurse is responsible for reviewing the Clinical Dashboard Alerts and completing the Bowel Movement (BM) Monitoring Form: -Interventions for no BM x 3 days: Milk of Magnesia 30 ml (Milliliter), by mouth (po) -monitor for effectiveness. -Interventions for no BM x 4 days: Bisacodyl suppository 10 mg (Milligrams) per rectum PRN (as needed) -monitor for effectiveness. -Interventions for no BM x 5 days: Fleets Enema 1 unit per rectum PRN-Monitor for effectiveness. -Evaluating Effectiveness-SMALL BMs do not count as effective A record review of the Nurse Practitioners (NP) report dated 10/23/2025 on Resident 6, revealed the chief complaint documented had been abdominal pain. Further review revealed NP documented Resident 7 had not had a bowel movement for 11 days. The NP ordered Polyethylene 17 GM (Grams) per scoop, orally daily for 30 days on 10/23/2025. A Medication Record (MAR) for October 2025 revealed Polyethylene 17 GM was not administered until 10/28/2025 in the AM. A record review of Resident 6s Task: Bowel Elimination document revealed from 10/28/2025 through 11/3/2025 (total of 7 days), revealed no documentation that the resident had a bowel movement for the dates shown. A record review of the (MAR) dated 10/1/2025 through 10/31/2025 revealed Resident 6 had a PRN (as needed) order for a bowel protocol with a start date of 08/12/2019. An interview on 11/17/2025 at 11.50 AM with Registered Nurse (RN)-A who gave a confirming statement no bowel movements were charted in the medication administration record for 10/28/2025 through 11/3/2025. An interview on 11/17/2025 at 11.50 AM with RN-A confirmed no PRN Milk of Magnesia (MOM) was administered as per the Bowel and Bladder program and Toileting Program policy for no BM after 3 days. Further confirming a Bisacodyl suppository was not administered after day 4 with no BM, and a Fleets enema was not administered after day 5 with no BM. B. A record review of Resident 1's admission Record revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Progress Notes revealed an admission Summary note dated 10/30/25 at 4:11 PM stating the resident had arrived at the facility via the facility van. A record review of Resident 1's October 2025 Medication Administration Record revealed: -levofloxacin (an antibiotic) oral tablet 750 milligrams (mg), give 1 tablet by mouth one time a day for UTI (urinary tract infection) for 6 days. The order had a start date of 10/31/25 at 4:00 PM. -Ipratropium Bromide nasal solution 0.06 %, 2 spray in both nostrils two times a day for rhinorrhea (runny nose). The order had a start date of 10/31/2025 at 4:00 PM. -Saccharomyces boulardii (a probiotic) Oral Capsule 250 MG, give 1 capsule by mouth two times a day for Prophylaxis (prevention). The order had a start date of 10/31/2025 at 4:00 PM. -Acetaminophen (an over-the-counter pain medication) oral tablet 500 MG, give 1 tablet by mouth every 6 hours as needed for pain. The order had a start date of 10/31/2025 at 1:15 PM. -Bisacodyl (a laxative) oral tablet delayed release 5 MG, give 1 tablet by mouth as needed for constipation, may have daily. The order had a start date of 10/31/2025 at 1:15 PM. -Triamcinolone Acetonide external cream 0.1 %, apply to affected area topically every 12 hours as needed for pruritus (itching) of skin. The order had a start date of 10/31/2025 at 2:15 PM. A record review of Resident 1's Discharge Orders from the hospital dated 10/30/25 revealed no evidence the facility was to wait to start any medications, besides the levofloxacin, until 10/31/25. A record review of Resident 1's admission Medication Regimen Review from the pharmacy dated 10/30/25 revealed no evidence of a directive to wait to start the resident's medications until 10/31/25. An interview on 11/13/25 at 12:20 PM with the DON confirmed Resident 1 was admitted to the facility at 4:00 PM on 10/30/2025. The DON confirmed there was no evidence of a reason for the resident's medication orders not being put in on the date of admission. C. A record review of Resident 11's admission Record revealed the resident was admitted to the facility on [DATE] and had a diagnosis of Major Depressive Disorder. A record review of Resident 11's Provider Visit note dated 10/23/2025 revealed the resident the resident was seen to follow up on their mood and behavioral changes. The resident described feeling persistently down, depressed, and hopeless. In the treatment section of the note, it stated the provider was going to start the resident on escitalopram oxalate (an antidepressant medication) 5 mg daily. A record review of Resident 11's Provider Order Form dated 10/23/2025 revealed an order to start escitalopram 5 milligrams (MG) by mouth daily. The order was noted by RN-B, there was no date indicating when the RN noted the order. A record review of Resident 11's Order Summary revealed an order for escitalopram oxalate 5 mg daily with a start date of 10/27/2025. A record review of Resident 11's Provider Visit note dated 10/30/2025 revealed the resident was seen for a follow up on depression, anxiety, and wandering. The note stated the provider had ordered escitalopram oxalate 5 mg daily on 10/23/2025 and that the resident had not received this medication on 10/24, 10/25, 10/26, or 10/27; and that the medication was reordered. An interview on 11/13/2025 beginning at 11:10 AM with the NP confirmed that the NP had given the facility an order to change Resident 10's tizanidine order from routine to as needed on 10/23/2025 and the facility did not change the order until 10/27/2025. D. A record review of Resident 17's admission Record revealed the resident was admitted to the facility on [DATE] and had a new diagnosis added on 10/20/2025 of otitis media (ear infection) to the right ear. A record review of Resident 17's Provider Visit note dated 10/20/2025 revealed the resident had persistent ear discomfort and wax buildup in their right ear. The note stated that attempted right ear irrigation was unsuccessful, and the wax would need to be softened prior to removal. In the treatment section of the note, it stated the resident was to start carbamide peroxide solution, 6.5%, 5 drops into the affected ear twice a day for four days, then on day 5 irrigate the right ear. A record review of Resident 17's Physician's Order Form dated 10/20/2025 revealed an order for carbamide peroxide solution, 6.5%, 5 drops into the affected ear twice a day for four days. There was also an order stating the day following the completion of the carbamide ear solution, irrigate right ear. This order was noted by the DON on 10/20/2025. A record review of Resident 17's October 2025 MAR revealed the following orders: -Carbamide Peroxide-Saline otic kit 6.5 %, instill 5 drop in right ear two times a day every 4 days related to otitis media to the right ear until 10/25/2025. The order had a start date of 10/21/2025 and was documented as administered on 10/21/2025 and 10/25/2025. -day following the completion of the carbamide ear solution, irrigate right ear one time only related to otitis media to the right ear for 1 day. This order had a start date of 10/26/2025 and there was no documentation of it being completed. A record review of Resident 17's Provider Visit note dated 10/27/25 revealed the resident reported decreased hearing in their right ear. The provider identified this as likely due to impacted cerumen and noted that ear drops and irrigation had been ordered but not completed. In the treatment section of the note, it stated the Carbamide peroxide 6.5% otic solution, 5 drops in the right ear twice daily for 4 days and on day 5 irrigating the right ear was not completed so the provider reordered it. A record review of Resident 17's Physician's Order Form dated 10/27/25 revealed an order for carbamide peroxide solution, 6.5%, 5 drops into the affected ear twice a day for four days. There was also an order stating the day following the completion of the carbamide ear solution, irrigate right ear. Further record review of Resident 17's October 2025 MAR revealed an order for carbamide peroxide otic solution 6.5 %, instill 5 drops in the right ear two times a day for wax build up for 8 administrations. This order had a start date of 10/27/2025. An interview on 11/13/25 at 12:20 PM with the DON confirmed that the order entered on 10/21/2025 was entered incorrectly. The DON stated that once the facility realized this, they discussed it with the NP, and they received a new order to start the carbamide peroxide treatment again. E. A record review of Resident 3's Order Summary Report dated 11/12/2025 revealed the resident was admitted to the facility on [DATE] and had a diagnosis of Major Depressive Disorder. A record review of Resident 3's Provider Order Form dated 10/7/2025 revealed an order to start fluoxetine 10 mg by mouth daily for Major Depressive Disorder. A record review of Resident 3's October 2025 MAR revealed the following: - fluoxetine HCl oral tablet 10 mg, give 1 tablet by mouth one time a day related to Major Depressive Disorder. This order had a start date of 10/09/2025 and a discontinued date of 10/14/2025. - fluoxetine HCl oral tablet 10 mg, give 1 tablet by mouth one time only for depression for 1 Day. This order had a start date of 10/16/2025 at 1:45 PM and was documented as administered the same day. - fluoxetine HCl oral tablet 10 mg, give 1 tablet by mouth one time a day for depression. This order had a start date of 10/17/2025. A record review of Resident 3's Progress Notes for the month of October 2025 revealed no evidence of a reason for their fluoxetine to have been discontinued on 10/14/2025. An interview on 11/13/25 at 12:20 PM with the Regional Nurse Consultant (RNC) confirmed the fluoxetine was discontinued on 10/14/2025, a one-time dose was given on 10/16/2025, and the medication was re-entered on 10/17/2025. The RNC also confirmed the order should not have been discontinued on 10/14/2025.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interviews, the facility failed to provide and report timely laboratory services for 4 (Residents 7, 8, 14, and 17) of 7 sampled residents and failed to perform blood glucose monitoring per the provider's orders for 3 (Residents 7, 14, and 17) of 3 sampled residents. The facility census was 25.A. A record review of Resident 7's face sheet revealed Resident 7 was admitted on [DATE] with diagnoses of congestive heart failure, Type 2 diabetes mellitus (a disease in which the body cannot regulate blood sugar effectively), obesity, hypertension, and atrial fibrillation (an abnormal heart rhythm that is irregular in the chambers of the heart are out of sync). A record review of a facility document scanned into Resident 7's electronic medical record dated 10/3/25 revealed a new provider order from the Nurse Practitioner (NP) to obtain a BMP (Basic Metabolic Panel, a blood test that measures 8 substances in the blood that relate to chemical balance and metabolism) on 10/17/25. A record review of Resident 7's nurses notes in PCC revealed an entry on 10/3/25 which stated that the provider visited Resident 7 in the facility and ordered a BMP to be drawn on 10/17/25. A record review of Resident 7's provider orders in the electronic medical record (Point Click Care, PCC) revealed an order entered 10/3/25 to obtain a BMP with a start date of 10/17/25 and an end date of 10/19/25. A record review of resident 7's progress notes in PCC for the month of October 2025 did not reveal any mention of lab work to be collected (or an attempt to collect any). A record review of a facility document titled Clinical Laboratory Report, dated 10/23/25 revealed a blood sample from Resident 7 was collected on 10/23/25 at 2:56 PM and received at the laboratory on the same day at 3:35 PM. The document also revealed results of a comprehensive blood panel (CMP, a blood test that measures 14 substances in the blood that relate to chemical balance, kidney, and liver function) for Resident 7. A record review of Resident 7's electronic medical record did not reveal any other lab results for the month of October 2025. An interview with the Director of nursing (DON) on 11/13/25 at 9:43 AM confirmed that Resident 7's BMP order was supposed to be drawn on 10/17/25 but was not drawn until 10/23/25 and should have been collected on 10/17/25. The interview also confirmed there was no documentation of efforts to collect or obtain a sample or report results to the provider. B. A record review of Resident 8's face sheet revealed Resident 8 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, a history of urinary tract infections (UTIs), coronary heart disease (a type heart disease that affects the main vessels that supply blood to the heart), and blindness category 5 in both eyes (profound vision loss). A record review of a facility document scanned into Resident 8's electronic medical record, dated 10/15/25 revealed a new provider order from the NP to obtain several blood tests, and urine microalbumin and creatinine. A record review of the nursing progress notes in PCC between10/15/25 and 10/24/25 revealed no documentation of efforts to collect or submit a urine sample for lab testing for Resident 8. An interview on 11/14/25 at 9:43 AM with the Regional Nurse Consultant (RNC) revealed that Resident 8 was usually continent of urine, needed assistance to get to the bathroom, and was blind. The interview revealed the resident preferred to catch the urine in a hat, a container that is placed in the toilet to collect urine before it reaches the water. An interview on 11/17/25 at 12:30 PM with the NP revealed that the NP asked nursing staff several times between 10/15/25 and 10/24/25 to obtain a urine sample from Resident 8. The interview also revealed that the NP reported taking the resident to the bathroom during that period, the resident had been continent in the toilet, but no hat had been present in order to collect a urine sample. A record review of a facility document titled Clinical Laboratory Report, dated 10/24/25 revealed results of a lab testing including urine microalbumin and urine creatinine from a sample that had been collected from Resident 8 on 10/24/25. An interview on 11/14/25 at 9:43 AM with the DON confirmed that the urine tests were ordered on 10/15/25 to be collected promptly but were not collected until 10/24/25, 9 days later. The interview also confirmed that the blood tests ordered on 10/15/25 were collected on 10/18/25. The interview confirmed that there was no documentation in Resident 8's medical record that the provider was notified of a delay in sample collection or that the facility received a change in the provider's order. C. A record review of Resident 14's face sheet revealed Resident 14 was admitted on [DATE] with diagnoses of type 1 diabetes mellitus (a chronic condition in which the body does not produce insulin, which is essential in regulating blood sugar), dementia (a decline in cognitive function affecting memory, thinking, and behavior), and epilepsy (a complex neurological disorder which leads to seizures). A record review of a note written by Resident 14's provider NP on 10/22/25 revealed that Resident 14 had a Vitamin D level on 9/17/25 that was considered low, and that the next level would be obtained on 10/28/25. A record review of Resident 14's electronic medical record revealed a provider order entered on 9/19/25 for a Vitamin D level to be drawn on 10/28/25. An interview with RNC 11/14/25 at 9:43 AM revealed the order for collecting Resident 14's blood for a Vitamin D level was electronically signed off on 10/29/25 at 12:38 PM. A record review of Resident 14's electronic medical record revealed a nurses note for 11/6/25 at 7:00 AM which stated blood was drawn for a Vitamin D level at that time. A record review of Resident 14's medical record revealed no Vitamin D level results for the resident between 10/1/25 and 11/14/25. The interview with RNC 11/14/25 at 9:43 AM confirmed there was no documentation in Resident 14's medical record of Vitamin D level results, or notifying the provider of a delay in collecting a sample. D. A record review of Resident 17's face sheet revealed Resident 17 was admitted on [DATE] with diagnoses of rheumatoid arthritis, Type 2 diabetes mellitus, obesity, recurrent UTIs, and chronic kidney disease. A record review of Resident 17's census records in the electronic medical record revealed that the resident was in the hospital from [DATE] to 10/11/25. A record review of Resident 17's electronic medical record revealed a scanned provider note dated 10/13/25 stating Resident 17 was seen by the NP for readmission to the facility following hospitalization due to rheumatoid arthritis flare and a urinary tract infection. A record review of Resident 17's electronic medical record revealed a progress note dated 10/17/25 which stated Resident 17 was seen by the facility NP at 7:11 AM for a follow-up which included a complaint of urinary retention. A record review of Resident 17's electronic medical record revealed a scanned copy of a provider order from an office visit on 10/17/25 outside the facility to obtain a urine sample on 10/20/25 for urinalysis (UA) and to call the provider with results. A record review of Resident 17's electronic medical record revealed a scanned copy of a provider order from the NP dated 10/27/25 for urinalysis (UA), culture and sensitivity (C/S) if needed, and signed by a nurse. A record review of Resident 17's electronic medical record revealed results from a urinalysis from the hospital lab for a specimen collected on 10/28/25. The results revealed the presence of bacteria, and a urine culture was set up. A record review of Resident 17's electronic medical record revealed a provider order starting on 10/31/25 for Ciprofloxacin (an antibiotic) to treat a urinary tract infection. A record review of Resident 17's electronic medical record revealed no documentation of efforts to collect or submit a urine sample, or mention of UA results prior to the urinalysis being reordered on 10/27/25. An interview with the DON 11/14/25 at 9:43 AM confirmed Resident 17's urine was not collected for the 10/20/25 urinalysis. A record review of an undated facility policy titled, Lab management system, revealed the steps and responsibilities in the process of laboratory orders and results for the facility beginning with receiving the order and including how to communicate results to the provider. The policy revealed that new lab orders were recorded on a Lab Tracking Log, lab requisitions were completed accurately, and that all labs were drawn on the day ordered. An interview with NP 11/13/25 at 12:30 PM revealed their expectation was that orders for lab testing would be collected within 48–72-hours if the test was routine (such as chronic disease monitoring), and on the same day or within 24 hours if it was ordered on a more urgent basis. An interview with DON on 11/13/25 at 4:10 PM confirmed the facility was not following the process outlined in the facility policy titled, Lab management system. E. A record review of the facility policy Diabetes- Clinical Protocol with revision date of December 2020 revealed in the Monitoring and Follow Up section that the staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia. A record review of Resident 14's admission Record revealed the resident was admitted to the facility on [DATE] with a principal diagnosis of Type I Diabetes Mellitus with Diabetic Polyneuropathy (diabetes of a form that usually develops during childhood or adolescence and is characterized by a severe deficiency of insulin secretion resulting from atrophy of the islets of Langerhans and causing hyperglycemia and a marked tendency toward ketoacidosis). A record review of Resident 14's October 2025 MAR revealed the following orders: -Insulin (medication used to treat diabetes) Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML (milliliter), inject as per sliding scale: if blood glucose is 201 - 225 = 2; 226 - 250 = 3; 251 - 299 = 4; 300 - 350 = 5; 351 - 375 = 6; 376 - 400 = 7; 401 - 402 = 8 and call provider. Give one time a day before supper. This order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the dose on 10/21/2025. -Tresiba (medication used to treat diabetes) FlexTouch Subcutaneous Solution Pen injector 100 UNIT/ML, inject 25 unit subcutaneously one time a day. The order had a start date of 9/20/2025. The blood glucose and insulin were documented as NA on 10/22/2025. -Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML, inject as per sliding scale: if blood glucose is 176 - 200 = 3; 201 - 225 = 4; 226 - 250 = 5; 251 - 299 = 7; 300 - 350 = 8; 351 - 375 = 9; 376 - 400 = 10; 401 - 402 = 12 call provider. Give two times a day. The order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the midday dose on 10/21/2025 and for the AM dose on 10/22/2025. -Monitor blood glucose levels four times a day and PRN. Notify provider if blood sugar is less than 80 or greater than 400 or if the resident is symptomatic. This order had a start date of 9/02/2025. The blood glucose was documented with an X on the 10/21/2025 midday, PM, and HS (hour of sleep) administration times and for the AM administration time on 10/22/2025. The midday time on 10/22/2025 revealed a blood glucose of 528. A record review of Resident 14's Progress Notes for October 2025 revealed no progress notes documented by the facility staff related to notifying the provider about the resident not receiving blood glucose checks or insulin the evening of 10/21/2025 and morning of 10/22/2025. An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, the NP was made aware that the facility had not obtained any of the strips, therefore Resident 14's blood glucose level had not been obtained since the previous morning, and the resident had not received any of their scheduled insulin doses. NP revealed the facility could not provide justification for why no one had notified the NP about the blood glucose monitoring strips not arriving the evening prior. NP stated the strips arrived prior to lunchtime on 10/22/2025 and at that time Resident 14's blood glucose was 528 and the NP had to order an extra dose of insulin to help lower the level. NP stated Resident 14 was a very fragile diabetic and needs their blood glucose checked frequently due to unpredictable and erratic levels. NP also stated that missing blood glucose checks, and insulin doses could have easily caused Resident 14 significant harm. An interview on 11/13/25 at 12:20 PM with the DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available and that the facility did not attempt any other method of obtaining strips, which resulted in Resident 14 not having their blood glucose level checked for four consecutive scheduled times. The DON also confirmed that Resident 14 did not receive their scheduled insulin doses during that timeframe. The DON confirmed the facility did not reach back out to the NP after being unable to obtain the strips the evening of 10/21/2025. F. A record review of Resident 7's admission Record revealed the resident was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus without complications (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). A record review of Resident 7's October 2025 MAR revealed the following orders: - Insulin Glargine Subcutaneous Solution Pen injector 100 UNIT/ML, inject 20 unit subcutaneously one time a day, to be given at HS. The order had a start date of 10/21/2025. There was documentation of the medication being administered on 10/21/2025 but the associated blood glucose was documented as NA. - Insulin Glargine Subcutaneous Solution Pen injector 100 UNIT/ML, inject 50 unit subcutaneously one time a day, in the AM. The order had a start date of 10/22/2025. There was documentation of the medication being administered on 10/22/2025 but the associated blood glucose was documented as NA. An interview on 11/13/25 at 12:20 PM with the DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, did not obtain additional strips until mid-morning on 10/22/2025, and Resident 7's blood glucose was not obtained per the provider orders on 10/21/2025 and 10/22/2025. G. A record review of Resident 17's 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 17's October 2025 MAR revealed an order to obtain blood glucose checks before meals and at bedtime and to notify the provider if the resident's blood sugar was less than 60 or greater than 400 or if resident is symptomatic. The order had a start date of 9/10/2025. The order revealed documentation that a blood glucose check had not been completed for any of the scheduled times on 10/21/2025 or for the 7:00 AM and 11:00 AM times on 10/22/2025. An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, the NP was made aware that the facility had not obtained any of the strips, and the facility could not provide justification for why no one had notified the NP about the blood glucose monitoring strips not arriving the evening prior. An interview on 11/13/25 at 12:20 PM with the DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available, that the facility did not attempt any other method of obtaining strips, and the facility did not reach back out to the NP after being unable to obtain the strips the evening of 10/21/2025.

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review and interviews, the facility failed to ensure significant medication errors did not occur for 2 (Residents 10 and 14) of 14 sampled residents. The facility census was 25.A.A record review of Resident 10's admission Record revealed the resident was admitted to the facility on [DATE] and had diagnoses of postlaminectomy syndrome (a complication after spinal surgery involving persistent pain), chronic pain syndrome and muscle spasms of the back. A record review of Resident 10's Provider Visit note dated 10/23/2025 revealed the resident was seen due to recent drowsiness and dizziness. The resident had described these symptoms as emerging after their Baclofen (a muscle relaxer) dose was increased from 10 milligrams (mg) to 15 mg, in addition to their ongoing use of tizanidine (a muscle relaxer). In the treatment section of this note, it stated the provider was going to change the resident's Tizanidine 2 mg to PRN (as needed) every 6 hours. A record review of Resident 10's Provider Order Form dated 10/23/25 revealed a new order to change the resident's routine tizanidine to PRN for muscle spasms. The order was noted by Registered Nurse (RN)-B on 10/27/25. A record review of Resident 10's Progress Note dated 10/24/2025 at 12:38 PM revealed that the Director of Nursing (DON) had contacted the Nurse Practitioner (NP) as the resident had been alert but not oriented after taking their medications for muscle spasms. The NP recommended the facility continue to monitor Resident 10 and hold their medication for muscle spasms. A record review of Resident 10's October 2025 Medication Administration Record (MAR) revealed the following orders:-Tizanidine HCl oral tablet 2 mg, give 1 tablet by mouth every 6 hours (midnight, 6 AM, noon, and 6 PM) for spondylolisthesis, thoracolumbar region (a forward slippage of a vertebra where the thoracic and lumbar spine join). This order had a start date of 10/21/2025 and a discontinue date of 10/27/2025.-Tizanidine HCl oral tablet 2 mg, give 1 tablet by mouth every 6 hours as needed for muscle spasms of the back. This order had a start date of 10/27/2025.- Baclofen oral tablet 10 mg, give 1.5 tablets by mouth three times a day for postlaminectomy syndrome. This order had a start date of 10/22/2025, was placed on hold on 10/26/2025 at 1:24 PM, then was discontinued on 10/27/2025. A record review of Resident 10's Provider Visit note dated 10/27/2025 revealed the resident was being seen to follow up on their pain and muscle spasms. The note stated the resident had begun taking new medications for muscle spasms and rigidity, however their interaction lead to increased sleepiness. An order was given to change the resident's routine tizanidine to PRN on 10/23/2025, the following day it was reported that the resident was experiencing excessive lethargy, and the resident's Baclofen was placed on hold. The resident continued to receive the tizanidine routinely on 10/23, 10/24, 10/25, 10/26, and 10/27, although the order was changed to PRN on 10/23. In the treatment section of the note, it stated to continue the tizanidine 2 mg by mouth every 6 hours as needed. An interview on 11/13/2025 at 11:10 AM with the NP confirmed that the NP had given the facility an order to change Resident 10's tizanidine order from routine to as needed on 10/23/2025 and the facility did not change the order until 10/27/2025. B.A record review of Resident 14's admission Record revealed the resident was admitted to the facility on [DATE] with a principal diagnosis of Type I Diabetes Mellitus with Diabetic Polyneuropathy (diabetes of a form that usually develops during childhood or adolescence and is characterized by a severe deficiency of insulin secretion resulting from atrophy of the islets of Langerhans and causing hyperglycemia and a marked tendency toward ketoacidosis). A record review of Resident 14's October 2025 MAR revealed the following orders:-Insulin (medication used to treat diabetes) Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML (milliliter), inject as per sliding scale: if blood glucose is 201 - 225 = 2; 226 - 250 = 3; 251 - 299 = 4; 300 - 350 = 5; 351 - 375 = 6; 376 - 400 = 7; 401 - 402 = 8 and call provider. Give one time a day before supper. This order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the dose on 10/21/2025.-Tresiba (medication used to treat diabetes) FlexTouch Subcutaneous Solution Pen injector 100 UNIT/ML, inject 25 unit subcutaneously one time a day. The order had a start date of 9/20/2025. The blood glucose and insulin were documented as NA on 10/22/2025.-Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 UNIT/ML, inject as per sliding scale: if blood glucose is 176 - 200 = 3; 201 - 225 = 4; 226 - 250 = 5; 251 - 299 = 7; 300 - 350 = 8; 351 - 375 = 9; 376 - 400 = 10; 401 - 402 = 12 call provider. Give two times a day. The order had a start date of 9/10/2025. The blood glucose and insulin were documented as NA for the midday dose on 10/21/2025 and for the AM dose on 10/22/2025. -Monitor blood glucose levels four times a day and PRN. Notify provider if blood sugar is less than 80 or greater than 400 or if the resident is symptomatic. This order had a start date of 9/02/2025. The blood glucose was documented with an X on the 10/21/2025 midday, PM, and HS (hour of sleep) administration times and for the AM administration time on 10/22/2025. The midday time on 10/22/2025 revealed a blood glucose of 528. A record review of Resident 14's Progress Notes for October 2025 revealed no progress notes documented by the facility staff related to notifying the provider about the resident not receiving blood glucose checks or insulin the evening of 10/21/2025 and morning of 10/22/2025. An interview on 11/13/25 at 11:10 AM with the NP revealed the NP was in the facility on 10/21/2025 at around 11:30 AM and overheard the staff discussing that they had run out of blood glucose monitoring strips. NP stated they were told by facility staff that they had ordered the strips, and the strips were to arrive in the facility later that day, and that if the strips did not arrive by suppertime, the facility was going to go to the pharmacy to purchase some. NP revealed that when they arrived back at the facility on 10/22/2025, the NP was made aware that the facility had not obtained any of the strips, therefore Resident 14's blood glucose level had not been obtained since the previous morning, and the resident had not received any of their scheduled insulin doses. NP stated the strips arrived prior to lunchtime on 10/22/2025 and at that time Resident 14's blood glucose was 528 and the NP had to order an extra dose of insulin to help lower the level. NP stated Resident 14 was a very fragile diabetic and that missing blood glucose checks, and insulin doses could have easily caused Resident 14 significant harm. An interview on 11/13/25 at 12:20 PM with the DON confirmed the code NA on the MAR indicated not applicable. The DON confirmed the facility ran out of blood glucose monitoring strips the morning of 10/21/2025, the order for new strips did not arrive that day as expected, and the facility did not have a backup supply in the facility. The DON also confirmed that the pharmacy did not have any strips available and that the facility did not attempt any other method of obtaining strips, which resulted in Resident 14 not having their blood glucose level checked for four consecutive scheduled times. The DON also confirmed that Resident 14 did not receive their scheduled insulin doses during that timeframe.

Licensure Reference Number 175 NAC 12-006.18 Based on observations, interviews, and record review; the facility failed to prevent the potential for cross contamination during wound care for 2 (Residents 3 and 6) of 3 sampled residents. The facility census was 25.Findings Are: A record review of the facility policy Wound Care with revision date of December 2011 revealed in the Steps in the Procedure section that Step 1 was to use a disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. A.A record review of Resident 3's Order Summary Report dated 11/12/2025 revealed the resident was admitted to the facility on [DATE]. The report also revealed the resident had the following wound care orders:-Cleanse right posterior thigh proximal and distal sites with wound cleanser, apply skin prep, apply hydrogel, cover with border dressing. This order had a start date of 10/28/2025. -Cleanse left buttock/sacral crease with wound cleanser, apply skin prep, apply calcium alginate, then apply the sacral dressing. This order had a start date of 10/29/2025. An observation on 11/12/25 at 1:02 PM revealed the Director of Nursing (DON) was at the nurse's station preparing to perform wound care for Resident 3. The DON checked their orders in a binder, then placed the supplies needed into a plastic container and carried them to the resident's room. Upon entering the resident's room, there were two nurse aides with gowns and gloves on who assisted the resident to lay in a flat position on their bed. The DON applied a gown and gloves, obtained a bottle of Skintegrity wound cleanser and sterile gauze from the plastic bin, and had the nurse aides roll Resident 3 to [gender] side. The DON then squeezed the Skintengrity wound cleanser from the bottle onto the resident's wound on their right thigh and wiped the area with the sterile gauze. The DON put the wound cleanser bottle on the table at the foot of the resident's bed, used their gloved hand to grab a measuring paper from the plastic bin, and measured the area to the resident's thigh with the paper and a permanent marker. The DON then capped the marker and laid it on the resident's bed, removed their gloves, and put on a new pair of gloves. DON obtained bordered gauze, hydrogel, and skin prep from the plastic container and placed these items, as well as the binder with the wound care orders on the resident's bed. The DON removed their gloves, performed hand hygiene (HH) via alcohol-based hand rub (ABHR), put on new gloves, and finished performing the wound care to the resident's thigh using the supplies that were laying on the resident's bed. The DON removed their gloves, performed HH via ABHR, and obtained a package of sterile gauze from the plastic container, placing it on the resident's bed. DON opened a new bottle of wound cleanser and placed the lid facing down on the bed, then applied new gloves, opened the gauze, squirted the wound cleanser onto the resident's buttocks, and wiped the area with the gauze. The DON then removed their gloves, performed HH via ABHR, put on new gloves, and obtained a measuring paper, a package of Sorbalgon, skin prep, and a package of bordered gauze, placing all items on the resident's bed. Next, the DON measured the wound, used a pair of scissors to cut a portion of the Sorbalgon out of the packaging, laid the scissors on the bed, then moved the scissors into the open package of Sorbalgon, applied the dressings that had been laid on the bed to the wound, removed their gloves and performed HH via ABHR. The DON then put the remaining Sorbalgon in the package, the scissors, and the bottle of wound cleanser back into the plastic bin with the remaining clean wound care supplies for Resident 3. An interview on 11/12/25 at 1:58 PM with the Director of Nursing (DON) confirmed they laid the clean wound care supplies on Resident 3's bed without first placing a clean barrier. An interview on 11/12/25 at 1:59 PM with the Regional Nurse Consultant (RNC) confirmed the DON should have placed a clean barrier prior to putting Resident 3's wound care supplies on the bed. B.A record review of Resident 6's Order Summary Report revealed the resident was admitted to the facility on [DATE]. The report also revealed the resident had an order for staff to cleanse sacrum with wound cleanser, apply skin prep, cut calcium alginate to fit, and cover with border dressing. The order had a start date of 10/28/2025. An observation on 11/13/25 at 3:23 PM revealed the DON performing HH via soap and water at the nurse's station. DON then took a plastic container from the wound treatment cart, gloves, ABHR, and an electronic tablet and carried the items to Resident 6's room. The DON placed the container on the resident's bedside table, obtained a gown and paper towel from the bathroom, and put on the gown. After the nurse aides that were in the room performed peri-cares on the resident and positioned the resident onto their right side, the DON placed Skintegrity wound cleanser bottle and a package of sterile gauze from the plastic container onto the paper towel, which had been laid on the resident's bed. The DON then put on gloves, removed the resident's soiled dressing from their sacrum using an alcohol wipe to release the adhesive, removed their gloves, and performed HH via ABHR. DON put on new gloves, cleansed the area with Skintegrity wound cleanser and sterile gauze, laid the wound cleanser bottle back on the paper towel, removed their gloves and performed HH via ABHR. After the DON checked Resident 6's order on the tablet, they opened new dressings from the plastic container, placed them on the paper towel, and put on new gloves. During this time, the Skintegrity wound cleanser bottle had rolled off the paper towel and was laying on the resident's bedding next to their pillow, the DON picked the bottle up and placed it directly onto the bedside table. Next, the DON performed the remainder of the wound care, which included opening a package of Sorbalgon and cutting a portion of the dressing off to use on the resident's wound and leaving the remainder of the dressing in the open packaging inside the plastic container, removed their PPE, and performed HH via ABHR. The DON then picked up the Skintegrity wound cleanser bottle, put it back in the plastic container with the rest of Resident 6's clean wound care supplies and carried the container out of the room. The plastic container had sealed wound care supplies, the open package of Sorbalgon, as well as wound measuring papers laying exposed inside of it. An interview on 11/13/25 at 3:38 PM with the DON confirmed the Skintegrity wound cleanser bottle was laying directly on Resident 6's bedding and then was placed back into the plastic container with the remainder of Resident 6's clean wound dressing supplies, contaminating the supplies.

Licensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility failed to: a) implement contact precautions as ordered by the physician, b) implement Enhanced Barrier Precautions (EBP) and adhere to infection control standards during wound care, c) and adhere to infection control standards during medication administration for 3 residents (Residents 3, 12 and 18.) These lapses created a risk of cross-contamination and potential transmission of infection to all residents residing within the facility. The facility identified a census of 28.Findings are: A. A record review of the Center for Disease Control's (CDC) article Carbapenem-resistant Pseudomonas Aeruginosa: A Serious Public Health Threat revealed pseudomonas aeruginosa bacteria are a common cause of infection in the healthcare setting. They can cause pneumonia, bloodstream infections, urinary tract infections (UTI), and surgical site infections, and they are particularly dangerous for patients with chronic lung disease. The bacteria is transmitted from person to person, via the hands of healthcare personnel or contaminated medical equipment and devices. Prevention strategies were as follows:- Perform hand hygiene. Staff should clean hands immediately before touching the resident.- Wear gown and gloves when caring for patient with pseudomonas aeruginosa. Pseudomonas aeruginosa can contaminate hands and clothes when caring for a resident, putting residents who are cared for afterward at risk for acquiring the infection. - Clean and Disinfect the patient environment and medical equipment. Staff should follow the facility's cleaning and disinfection protocol, ensure high-touch surfaces are cleaned frequently, dedicate non-critical medical equipment (stethoscopes, blood pressure cuffs) to the resident whenever possible and always clean and disinfect between residents. - Prevent transmission from sinks, toilets and other waster water plumbing. Pseudomonas aeruginosa can contaminate wastewater plumbing (sink drains, toilets). Water splashed from these sources have been associated with outbreaks of the organism. To prevent this, clean and disinfect countertops, handles, faucets, and sinks daily; keep patient care items at least three feet away from sinks and toilets; and do not discard patient waste in sinks. A record review of an admission Record revealed the facility re-admitted Resident 12 on 7/21/2025. Resident 12 was re-admitted with the primary diagnosis of pneumonia. A record review of Resident 12's visit with the Nurse Practitioner from 7/28/2025 revealed Resident 12 had symptoms of a suspected urinary tract infection (UTI) and reddened skin. Resident 12 was diagnosed with a UTI with pseudomonas aeruginosa and cellulitis (a bacterial skin infection.) The NP ordered Resident 12 to be placed in contact isolation precautions as the infection can spread through direct contact with contaminated surfaces or hands. An observation on 8/3/2025 at 8:02 revealed Nurse Aide (NA) - E answered Resident 12's call light. NA-E had entered the room partially with the sit-to-stand lift. NA-E had not donned any Personal Protective Equipment (PPE) of a gown or gloves prior to entering the room. Resident 12 stated they didn't need to go to the restroom at this time but needed a refill of water. NA-E received Resident 12's cup from them and exited the room. NA-E did not disinfect the sit-to-stand lift after entrance of the resident's room. NA-E shortly returned with more water for Resident 12 per their request. NA-E had not donned a gown or gloves prior to entering Resident 12's room. Hand hygiene of an Alcohol Based Hand Rub (ABHR) was used by NA-E only after exiting Resident 12's room for the final time. An interview on 8/6/2025 at 4:10 PM with the Chief Nursing Officer (CNO) revealed the facility does not don gown or gloves every time staff enter Resident 12's room, only when coming in contact with their urine, as the infection was found in Resident 12's urine. B) A record review of the facility's policy Enhanced Barrier Precautions (dated 8/6/2025) revealed the purpose of implementing EBP was to reduce the transmission of multidrug-resistant organisms (MDROs) n the facility. The policy defined EBP as a set of infection prevention practices requiring gown and glove use during high-contact resident care activities for resident known or suspect to be infect with a MDRO, or at increased risk. High-contact resident care activities with a high risk of transmitting pathogens include bathing/showering, dressing, changing linens, assisting with toileting, device care, wound care, and transferring/repositioning. Additionally, the policy revealed EBP would be implemented for residents with wounds and/or invasive medical devices. A record review of the facility's undated policy Pressure Ulcer Treatment revealed equipment and supplies necessary when performing pressure ulcer treatment include the fessing, tape, normal saline, and PPE of gown, gloves, mask etc. as needed. Steps of the pressure ulcer treatment procedure were as follows:1. Check the treatment administration record and obtain necessary supplies.2. Explain the procedure, provide privacy, and position the resident for the procedure.3. Assess the resident's level of pain before wound care.4. Wash hands before treatment. 5. Apply gloves.6. Remove the soiled dressing and place in an opened plastic bag. Remove soiled gloves and place in the bag. 7. Wash hands.8. Apply gloves.9. Clean area with normal saline and pat dry.10. Open package and remove dressing, maintaining sterility.11. Apply dressing/treatment according to the manufacturer's direction, the resident's care plan, and physician orders.12. Remove and discard gloves.13. Wash and dry hands thoroughly. A record review of the CDC's Wound Care Guide (dated 1/27/2023) revealed the following practices to prevent infection during wound care:- Prior to beginning wound care activities, clean supplies should be gathered then taken into the resident's room and placed on a clean surface away from potential sources of contamination. - Use an ABHR or wash with soap and water immediately before touching the resident, before moving from work on a soiled body site to a clean body site on the safe patient, after touch a resident or their immediate environment, immediately after glove removal, and after contact with blood, body fluids or contaminated surfaces. - During the procedure, separation should be maintained between clean and dirty supplies. For example, used bandages should be immediately discarded and not placed on a surface next to clean bandages.- Reusable equipment should be cleaned and disinfected after each use. - Any unused disposable supplies that entered the resident's care area should remain dedicated to that resident or be discarded. They should not be returned to the clean supply area. If supplies are dedicated to an individual resident, they should be properly labeled and stored in a manner to prevent cross-contamination or use on another resident, such as a designated cabinet in the resident's room. - Clean and disinfect any potentially contact mated surfaces after wound care activities are complete. These include any surfaces in close proximity to the resident and frequently touched surfaces in the resident's environment. A record review of Resident 18's admission Record revealed the facility re-admitted Resident 18 on 6/11/2025. Resident 18 had diagnoses of a stage 2 (characterized by the loss of the top two layers of skin, appearing as a shallow, open wound) pressure ulcer of their sacrum. A record review of Resident 18's Order Summary Report and Care Plan revealed no evidence EBP had been implemented. A continuous observation on 8/6/2025 beginning at 9:57 AM of Registered Nurse (RN) - A complete wound care treatment for Resident 18 revealed the following:- RN-A had gathered the supplies and placed on a bedside table next to the nurse's station. RN-A then pushed the bedside table down the hall without protection covering the supplies to Resident 18's room.- RN-A entered Resident 18's room and washed their hands, without donning any proper PPE. - After positioning and providing privacy, RN-A utilized ABHR. RN-A then placed a trash bag down on the resident's bed and donned gloves. RN-A then used both gloved hands to move the bedside table into a better position, contaminating their gloves.- RN-A then pushed Resident 18's incontinence brief further down with their gloved hands. RN-A then used their gloved hands to remove the old dressing. RN-A removed their gloves.- RN-A applied new gloves without the benefit of performing hand hygiene prior. Using the gauze with normal saline, RN-A cleansed the wound beginning at the area surrounding the wound working their way to the middle of the wound. The same gauze pad was utilized for the entire cleansing of the wound. - RN-A removed soiled gloves, applied ABHR, and applied new gloves. RN-A opened the Alginate with their gloved hands, cutting the packet open. RN-A opened the skin prep and dressing packages that had been exposed to potential contamination when brought down the hallway, contaminating their gloves. RN-A applied the skin prep around the edge of the wound, applied the Alginate, and then the dressing with the same gloved hands. An interview on 8/6/2025 at 10:10 AM with RN-A confirmed EBP had not been implemented for Resident 18. RN-A was unaware of the contamination during the wound care treatment procedure. C. A record review of the facility's undated policy Handwashing/Hand Hygiene revealed hand hygiene should be completed with an ABHR or soap and water in the following situations:- Before and after coming on duty- Before and after direct contact with residents- Before preparing or handling medications- Before donning gloves- After contact with objects in the immediate vicinity of the resident A continuous observation on 8/5/2025 beginning at 8:27AM of Mediation Aide (MA) - B revealed the following:- At 8:25 AM, MA-B had completed medication administration to a previous resident. At 8:27 AM, MA-B began preparing Resident 3's medication without the benefit of performing hand hygiene. MA-B did not sanitize the medication cart preparation surface prior to beginning. - MA-B used scissors to cut Resident 3's lidocaine patches in half. MA-B then utilized the scissors to cut open Resident 3's arginaid packet without sanitization of the scissors beforehand. - MA-B prepared Resident 3's medication, dispensing Resident 3's tums into a separate medication cup and the remainder into another. MA-B then sat the other medication cup on top of the medication cup with the Tums, touching the bottom of the medication cup to the Tums. - MA-B then applied gloves and proceeded to Resident 3's door, using their gloved hands to open the door. MA-B then assisted Resident 3 with applying their medicated cream to their hip as ordered with the same gloved hands.

Licensure Reference Number 175 NAC 12-006.04 Based on observations, record review, and interview; the facility failed to have sufficient staff on duty to prevent the potential for serious harm or injury while performing transfers via Hoyer or sit-to-stand mechanical lifts, this had the potential to affect 11 (Residents 1, 4, 6, 9, 10, 11, 12, 13, 14, 15, and 16) of 11 residents sampled. The facility failed to have sufficient staff on duty to ensure residents receive assistance with their Activities of Daily Living per their plan of care for 6 (Resident 1,2,3,4,12,and 19). The total survey sample was 19. The facility identified a census of 36. The facility administrator was notified on 6/7/2025 at 9:20 PM of an Immediate Jeopardy (IJ) which began on 5/5/2025. The IJ was removed on 6/7/2025, as confirmed by surveyor onsite verification. Findings Are: A record review of a facility provided document SCARAB (Skyview Care and Rehab at Bridgeport) Facility Assessment- 2025 dated 6/4/2025 revealed under the staffing plan section, Our facility houses residents in four different halls (100, 200, 300, and 400 hall). Staffing is based on resident population and the residents' needs for care and support. Our census is reviewed daily with our staff schedule in our morning meeting with management and again in the nursing department morning meeting. We adjust the staffing plan as needed when we have a change in the census or for call-offs or new admissions. We monitor staff hours and census on a daily basis. A. A record review of the facility policy Lifting Machine, Using a Mechanical with revision date of July 2017 revealed in the General Guidelines that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The policy also revealed that the types of lifts that may be available in the facility are a floor-based full body sling lift, an overhead full body sling lift, and a sit to stand lift. A record review of the facility provided Resident List dated 6/7/25 revealed Residents 4, 9, 10, 14, and 16 were marked as utilizing a Hoyer lift. The list also revealed Residents 1, 6, 11, 12, 13, and 15 were marked as utilizing a Sit to Stand Lift. B. A record review of Resident 1's 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 4/9/2025 revealed the resident required substantial/maximal assistance from staff for transfers. A record review of Resident 1's undated Care Plan (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) revealed the resident required two-person assistance with the sit to stand for transfers. If Resident 1 was unable to stand, the care plan stated to use the total lift with two people. This was initiated on 3/10/2025. C. A record review of Resident 4's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 4's undated Care Plan revealed the resident required two-person assistance with the total lift for transfers. This was initiated on 5/1/2025. D. A record review of Resident 6's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 6's undated Care Plan revealed the resident required one-person assistance with the sit-to-stand lift when transferring in/out of bed and to/from the toilet. The care plan stated to use two-person assistance as needed for increased weakness or if the resident was unable to follow instructions. This was initiated on 8/7/2019 and revised on 4/21/2024. E. A record review of Resident 9's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 9's undated Care Plan revealed the resident required two-person assistance with the total lift for transfers. This was initiated on 4/30/2021. F. A record review of Resident 10's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 10's undated Care Plan revealed the resident required a 2-person pivot transfer with gait belt. The care plan also stated to use the total lift with 2 people if the resident was unable to stand, too tired or weak. This was initiated on 1/23/2025. G. A record review of Resident 11's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 11's undated Care Plan revealed the resident required two-person assistance with the sit-to-stand lift for transfers. This was initiated on 5/30/2025. H. A record review of Resident 12's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 12's undated Care Plan revealed the resident required substantial assistance by 2-person pivot transfer with a gait belt. The care plan also stated the resident would occasionally be agreeable to use a sit to stand lift. This was initiated on 10/26/2023 and revised on 1/31/2025. I. A record review of Resident 13's MDS dated [DATE] revealed the resident required substantial/maximal assistance with transfers. A record review of Resident 13's undated Care Plan revealed the resident required two-person assistance with stand/pivots with a gait belt to move between surfaces and as necessary. This was initiated on 7/15/2024. I. A record review of Resident 14's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 14's undated Care Plan revealed the resident required 2-person assistance with a Hoyer lift for transfers. This was initiated on 10/31/2020 and revised on 4/21/2024. J. A record review of Resident 15's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 15's undated Care Plan revealed the resident required 1-person assistance with transfers PRN (as needed). This was initiated on 7/2/2019 and revised on 5/5/2021. K. A record review of Resident 16's MDS dated [DATE] revealed the resident was dependent on staff for transfers. A record review of Resident 16's undated Care Plan revealed the resident required 2-person assistance for transfers with the use of the total lift. This was initiated on 1/21/2025. An interview on 6/7/25 at 6:30 PM with the Director of Nursing (DON) revealed one of the Nurse Aides (NA) working that evening was a minor and unable to utilize the mechanical lifts to transfer residents. The DON further reported the DON and this minor NA were the only staff scheduled to work the following evening from 2 pm until 10 pm. An interview on 6/7/25 at 6:50 PM with Medication Aide (MA)-H revealed MA-H had worked the past 7 days straight in an attempt to assist with the staffing shortage. MA-H stated that there were 30-some residents in the facility and normally 2-3 staff on duty would be sufficient but there were several residents that were high acuity (requiring significant staff assistance) so the current staffing levels were not enough to provide resident cares. MA-H stated that the evening prior, the staffing was the DON, the MA, and one NA. MA-H stated that there were 3 or 4 residents who required the Hoyer lift for transfers and there were several who utilized the sit-to-stand lift, but some of those residents really needed two staff present due to the residents chicken-winging (a situation where the resident's arms extend out to the side during the transfer, increasing the risk of the resident falling out of the lift sling). MA-H revealed that staff frequently transferred residents with the mechanical lifts alone because otherwise the residents would not get cares due to there not being enough staff on duty. MA-H also revealed that they had recently been told by facility management that it was now okay to use the sit-to-stand lifts alone, although this had not previously been an approved practice. An interview on 6/7/25 at 7:55 PM with Resident 4 revealed there were usually two staff to transfer the resident with the Hoyer lift, but not always. Resident 4 stated that occasionally there was only one staff present during the transfers. Resident 4 stated they felt kind of scared because everyone was leaving and that it was 24 hours a day that there had been less staff on duty than usual. An interview on 6/7/25 at 8:53 PM with MA-H confirmed that the staff had been utilizing the mechanical lifts without a second staff present while transferring the residents and that this had been occurring on a daily basis due to lack of staff on duty. MA-H stated they witnessed a staff completing a resident transfer via a mechanical lift without a second staff in the room the evening prior when MA-H entered the resident room to administer medications to the resident. An interview on 6/9/25 at 10:21 AM with Resident 12 revealed Resident 12 had resided in the facility for almost two years and utilized a sit-to-stand lift for transfers. Resident 12 stated that a lot of the time there was only one staff present in their room during the transfers because they are so short staffed here. An interview on 6/9/25 at 2:25 PM with NA-J revealed they had been working in the facility since about January of this year. NA-J confirmed that staff were supposed to have two staff present when transferring residents with the mechanical lifts. NA-J revealed that they had asked the therapy staff for assistance with transferring a resident with the sit-to-stand lift recently and the therapy staff stated that per state, you don't have to have two staff present, so NA-J did transfer the resident by themself. NA-J stated there have been many shifts with only one or two staff working on the floor and that staff rarely works just 8 hours because there is not enough staff and even after the staff gets off the floor, then they have to go back and do their charting. An interview on 6/11/25 at 9:26 AM with Resident 12 revealed that they had been getting transferred via the sit-to-stand lift with only one staff present for quite a while. Resident 12 stated, It's been so long I really couldn't tell you when it started. An interview on 6/11/25 at 10:57 AM with NA-I revealed the NA had been working in the facility for about 3 years. NA-I stated they were supposed to be on light duty but had been utilizing both the Hoyer and sit-to-stand lifts alone despite being on light duty because there was not ever enough staff on duty to use two people. NA-I stated it had been this way, due to lack of staff availability, since approximately January 2025. L. A record review of the facility policy Activities of Daily Living (ADL), Supporting with a revision date of March 2018 revealed that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. An interview on 6/7/25 at 10:14 PM with NA-L and NA-M revealed both NA's worked the night shift. NA-M stated that three nights earlier, it was after midnight before the staff finished getting the residents into bed for the night due to the lack of staff that had been available to provide cares for the residents on the evening shift. A record review of Resident 1's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 4/15, indicating severe cognitive impairment. The MDS also revealed the resident required partial/moderate to substantial/maximal assistance from staff for their oral, toileting, and personal hygiene. The resident also required substantial/maximal assistance for their shower/bathing needs. A record review of Resident 1's undated Care Plan revealed the resident required 1-person staff assistance with their bathing/showering, dressing, personal hygiene, and toilet use. M. A record review of facility provided document for Resident 1 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed that staff had documented on 5/14/25, 5/17/25, 5/21/25, 5/28/25, and 5/31/25 Not applicable, and on 5/24/25 Resident Refused. There was no other documentation. A record review of the facility document for Resident 1 titled The Spa at Skyview Bathing Schedule from 5/8/25 through 6/9/25 revealed the resident was scheduled to receive showers every Tuesday, Thursday, and Saturday. The documentation revealed the resident received a shower on 5/8/25, 5/27/25 and 6/3/25. An observation on 6/7/25 beginning after 6:00 PM revealed Resident 1 sitting in the dining room in their wheelchair asking for assistance as people walk past. Resident 1 remained sitting in their wheelchair and slowly wheeled self from inside the dining room out into the hallway outside the dining room. Resident 1 intermittently asked this surveyor to help them, and stated they wanted to go to bed, surveyor informed resident several times that someone would be along to help them soon. At 7:47 PM Resident 1 was observed telling the administrator that they wanted to go to bed. The administrator told the resident that the next NA they saw, the administrator would have them help the resident. At 8:11 PM, Resident 1 again asked this surveyor to help them to their bed. Administrator heard this and told the resident they would find someone to help. At 8:28 PM, Resident 1 had been taken to their room. Observations conducted on 6/9/25 of Resident 1 revealed the following: -At 9:20 AM Resident 1 was sitting in their wheelchair at a table in the dining room. -At 9:40 AM Resident 1 continued sitting at a table in the dining room but now had food in front of them. -At 10:05 AM Resident 1 remained at the dining room table. The resident had backed their wheelchair about a foot away from the table and they were not eating or drinking. -At 10:52 AM Resident 1 was sitting in the dining room, about 2 feet away from the table. The resident had their eyes closed and their chin was resting on their chest. -At 11:05 AM Resident 1 remained in the same position in the dining room. -At 11:27 AM Resident 1 remained in the same position in the dining room. -At 11:45 AM Resident 1 remained in the same position in the dining room. -At 11:53 AM staff approached Resident 1 and asked the resident if they wanted to scoot closer to the table. Resident 1 declined so then the staff handed the resident a cup of juice, which the resident began drinking. Resident 1 remained in the same position in their wheelchair. -At 11:55 AM the Chief Nursing Officer (CNO) moved Resident 1's wheelchair so the resident was facing their table. -At 12:45 PM Resident 1 remained in the dining room. -At 12:54 PM Resident 1 remained in the dining room. An interview on 6/9/25 at 12:54 PM with the DON confirmed Resident 1 had been in the dining room since the surveyor's arrival just after 9:00 AM. The DON also asked NA-I if anyone had assisted Resident 1 to the toilet during that timeframe and the NA stated, not that I know of. N. A record review of Resident 2's MDS dated [DATE] revealed the resident had a BIMS score of 14/15 indicating they were cognitively intact. The MDS also revealed the resident required partial/moderate assistance with shower/bathing and with toileting hygiene. A record review of Resident 2's undated Care Plan revealed the resident required the assistance of 1 person with bathing showering and with toileting use. An interview on 6/7/25 at 6:50 PM with MA-H revealed that Resident 2 had reported the evening prior that they were going to wash their hair in the sink because they had not been bathed in two weeks. An interview on 6/7/25 at 7:04 PM with Resident 2 revealed the resident had not been bathed in two weeks. Resident 2 stated there was one day they did not get bathed because there was no hot water, but otherwise it had been due to there not being staff available to complete bathing. Resident 2 also revealed they needed staff assistance with wiping their bottom after they used the toilet, and they sometimes had to wait 30 minutes or more for staff to come assist with this task. An interview on 6/11/25 at 9:52 AM with Resident 2 revealed the resident had been getting bathed routinely prior to the past two weeks when they did not receive any baths. Resident 2 stated they were scheduled to receive their baths every Wednesday and Friday, which they did not like because this meant they had one day between baths and then had to go several days until the next bath. A record review of facility provided document for Resident 2 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed that staff had documented on 5/21/25 Shower, and on 5/22/25 and 5/25/25 Not applicable. There was no other documentation. A record review of the facility document for Resident 2 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 2 was scheduled to receive a shower every Wednesday and Friday. The documentation revealed the resident received shower on 5/28/25 and 6/8/25. O. A record review of Resident 3's MDS dated [DATE] revealed the resident had a BIMS score of 14/15 indicating the resident was cognitively intact. The MDS also revealed the resident required partial/moderate assistance from staff for wheeling 150 feet and for shower/bathing. A record review of Resident 3's undated Care Plan revealed staff were to encourage physical activity and daily ambulation, and that resident was to use assistive device if necessary. The care plan also revealed the resident had the potential for ADL self-care performance deficit r/t fatigue, impaired balance, and pain to lower back, right hip, and right knee. The resident required assistance of 1 person for bathing/showering. An interview on 6/7/25 at 7:12 PM with Resident 3 revealed that the prior week had been their third week living in the facility and that there had been several staff who had resigned since they were admitted to the facility. Resident 3 stated they felt like it's a crisis due to the facility being low on help. The resident also stated it had been about two weeks since they had been assisted with bathing, so they had just been doing sponge baths on their own in their room. Resident 3 stated that they needed assistance wheeling back to their room in their wheelchair after meals due to their arthritis. Resident 3 also stated that the evening prior, they had to wheel back to their room independently because there was no staff available, and the resident had been having pain to their right hip and leg ever since. A record review of facility provided document for Resident 3 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed no showers had been documented for the resident since their admission. A record review of the facility document for Resident 3 titled The Spa at Skyview Bathing Schedule from 5/5 through 6/9 revealed the resident had not been added to the bathing schedule but that the resident had received a shower on 5/17/25 (date of admission), 5/28/25, 5/31/25, and on 6/8/25. P. A record review of Resident 4's MDS dated [DATE] revealed the resident had a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS also revealed the resident was dependent on staff for shower/bathing and toileting. A record review of Resident 4's undated Care Plan revealed the resident required 1-person assistance with bathing/showering and that for toileting, the resident did not have the core strength to sit up on the toilet or commode, so resident needed to be transferred to their bed for peri-cares to be performed. An interview on 6/7/25 at 7:55 PM with Resident 4 revealed that it was either last week or the week before that since their last bath but the facility staff had not shared a reason for this. A record review of facility provided document for Resident 4 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period, revealed that staff had documented on 5/30/25 that the resident had refused their shower that day. There was no other documentation. A record review of the facility document for Resident 4 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 4 was scheduled to receive a shower every Monday and Friday. The documentation revealed that the resident received a shower on 5/12/25 and 6/9/25. Q. A record review of Resident 12's MDS dated [DATE] revealed the resident had a BIMS score of 15/15 indicating the resident was cognitively intact. The MDS also revealed the resident required substantial/maximal assistance with shower/bathing and was dependent on staff for toileting hygiene. A record review of Resident 12's undated Care Plan revealed the resident required substantial assistance by one staff with bathing schedule and as necessary. The Care Plan also revealed the resident required substantial assistance of two staff with the sit-to-stand for toileting. An interview on 6/9/25 at 10:21 AM with Resident 12 revealed Resident 12 had resided in the facility for almost two years and utilized a sit-to-stand lift for transfers. Resident 12 stated that the prior week they had to wait for two hours before staff was able to take them to the bathroom. Resident 12 also revealed that they were supposed to get three showers a week but that they were lucky if they even got one. The resident stated that 9 days was the longest they have had to go without a shower and that this had happened within the last two months. An interview on 6/11/25 at 9:26 AM with Resident 12 revealed that it was about a month ago when they stopped getting bathed 3 times a week like they preferred. A record review of facility provided document for Resident 12 titled POC Response History Task: ADL- Bathing Schedule and dated 6/10/25 with a 30 day look back period revealed that staff had documented on 5/16/25 and 5/23/25 Not Applicable, and on 5/21/25, 5/26/25, and 5/30/25 Shower. There was no other documentation. A record review of the facility document for Resident 12 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 12 was scheduled to receive a shower every Monday, Wednesday, and Friday. The documentation revealed that the resident received a shower on 5/5/25, 5/9/25, 5/12/25, 5/26/25, 5/28/25, 6/3/25, and 6/9/25. R. A record review of Resident 19's MDS dated [DATE] revealed the resident had a BIMS score of 10/15 indicating the resident had moderate cognitive impairment. The MDS also revealed the resident was dependent on staff for their shower/bathing. A record review of Resident 19's undated Care Plan revealed the resident required 1-person assistance with bathing/showering. An interview on 6/11/25 at 10:18 AM with Resident 19 revealed the resident was supposed to get three baths a week but lately it had been pretty hit and miss. Resident 19 stated that it varied, sometimes they would get one or more baths a week and sometimes it would stretch into two weeks. Resident 19 stated that they couldn't say when this started, it was pretty much when the staff started quitting but the resident stated they could not really say how long ago that was either. A record review of facility provided document for Resident 19 titled POC Response History Task: ADL- Bathing Schedule and dated 6/11/25 with a 30 day look back period revealed that staff had documented on 5/16/25 and 5/19/25 not applicable. Staff had also documented Shower on 5/14/25, 5/23/25, 5/24/25, 5/28/25, 5/30/25, 6/4/25, 6/6/25, and 6/9/25. A record review of the facility document for Resident 19 titled The Spa at Skyview Bathing Schedule from 5/5/25 through 6/9/25 revealed Resident 19 was scheduled to receive a shower every Monday, Wednesday, and Friday. The documentation revealed that the resident received a shower on 5/9/25, 5/14/25, 5/16/25, 5/26/25, 5/30/25, 5/31/25, 6/4/25, and 6/9/25. An interview on 6/11/25 at 11:24 AM with the DON confirmed baths should be given to the residents at least once a week unless the resident wanted them more frequently. The DON revealed that the facility did not currently have a working bathtub and that there had not been a functional bathtub since prior to their date of hire which was 1/6/25, so all of the residents have had to take showers. An interview on 6/11/25 at 11:45 AM with the CNO revealed baths are given per resident preferences, which are established upon admission but were also reestablished as part of the facility's plan of correction following their recent survey. The CNO stated they went around to all residents and asked what they preferred, and the bathing schedule was developed based on this information. S. -Abatement Statement Correction to the resident(s) affected: All residents have been assisted to bed and adequate care provided. Specify how the immediacy of the deficient practice will be corrected for the residents identified and all residents at risk for the deficient practice. Integrated Staffing Solutions (ISS) Staffing will be utilized immediately; and within 24 hours. Staffing with all available personnel will be utilized. System Changes: The facility will have all available certified and licensed staff available, including members of the interdisciplinary team available to respond to residents to ensure needs are met. In-services will be completed by DON/NHA on staffing and resident care for staff present in facility and for remaining staff before their next shift. In-services will be completed by DON/NHA that all mechanical lifts must be operated by two (2) staff members and that staff under age [AGE] cannot operate a mechanical lift independently for staff present in facility and for remaining staff before their next shift. In-services will be completed by DON/NHA that staff should notify the director of nursing (DON) or the nursing home administrator (NHA) for staff present in facility and for remaining staff before their next shift. Monitoring: NHA will monitor pending staffing daily to ensure staffing is adequate for upcoming shifts. If staffing is not adequate, staff will be notified and asked to cover shifts. At the time of the survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on record review and interviews, the facility failed to ensure 1 (Resident 4) did not develop pressure ulcers (also known as bed sores, areas of damaged skin caused by staying in one position for too long, commonly formed under boney prominence's) that were unavoidable and failed to provide monitoring, treatment and care as ordered to promote healing for 3 (Residents 4, 6, and 18) of 3 sampled residents' pressure ulcers. The facility identified a census of 36. Findings are: A record review of an undated facility policy Pressure Ulcer Risk Assessment, revealed if pressure ulcers are not treated immediately upon discovery, they can quickly get larger and become very painful and infected for the resident. Pressure ulcers are a serious condition for the resident and once developed, can be extremely difficulty to heal. Resident's skin should be routinely assessed and the condition of the resident's skin documented per the following: -A pressure ulcer risk assessment will be completed upon admission, quarterly, annually, and with any significant changes. -Because a resident at-risk can develop a pressure ulcer within 2-6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. -Nurses will conduct skin assessments at least weekly to identify changes and for any presence of developing pressure ulcers. -Documentation of the skin assessment should be recorded in the resident's medical record and include date and time and size and location of any red or tender areas. A record review of an undated facility policy Pressure Ulcer Treatment revealed pressure ulcer treatment should focus on assessing the resident and the pressure ulcer(s), managing tissue loads, pressure ulcer care, managing infection, education and quality improvement. The policy also revealed documentation should include the following in the resident's medical record after pressure ulcer care: assessment of the wound (color, size, pain, drainage) and resident refusal of treatment. If a resident refuses care, an evaluation of the basis for refusal and the identification and evaluation of potential alternatives is indicated. A. A record review of an admission Record revealed the facility re-admitted Resident 4 to the facility on 4/23/2025. Resident 4 had diagnoses of Multiple Sclerosis (MS, a disease where the body's immune system mistakenly attacks the protective covering of nerve fibers in the brain and spinal cord that can cause muscles weakness, trouble walking, numbness, and difficulty with controlling bowel and bladder), chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung), nicotine dependence, generalized muscle weakness, and legal blindness. A record review of Resident 4's admission 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) with an Assessment Reference Date (ARD) 4/30/2025 revealed Resident 4 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15/15, which indicated Resident 4 was cognitively intact. In Section E regarding behavior, the MDS reflected that Resident 4 had not displayed any rejection of care. Additionally, the MDS revealed Resident 4 had no upper or lower extremity impairment and required maximal assistance for bed mobility and total dependence for toileting, bathing, and transfers. Resident 4 was frequently incontinent of urine and always incontinent of bowel. Furthermore, the MDS revealed Resident 4 was at-risk for developing pressure ulcer but had 0 pressure ulcers, wounds or other skin problems at the time of assessment. Resident 4 did have a pressure reducing device for their chair and orders for application or ointment/medications. A record review of Resident 4's Care Plan with a date of 5/1/2025 revealed Resident 4 required assistance with toileting. Resident 4 had no core strength to sit on the toilet or bedside commode so required to be transferred into their bed for incontinence care. Additional review of Resident 4's Care Plan revealed no focus care area regarding skin integrity or addressing Resident 4's risk for pressure ulcers with preventative interventions. A record review of Resident 4's Progress Notes from 4/23/2025 at 8:49 PM revealed Resident 4 had a 4-centimeter (cm) x 6 cm area of redness on the left groin and mild, generalized redness across their back. There was no evidence if the redness was blanchable (When a skin area blanches, it means the redness or color disappears when you press on it, leaving the skin appearing lighter. If an area of skin doesn't blanch when pressed, it could indicate a more serious condition like a pressure ulcer, non-blanching rash, or other skin damage.) A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 4/23/2025 revealed Resident 4 had redness on their left groin, diffuse redness across their back with skin intact and had no open areas. A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 4/30/2025 revealed Resident 4's skin was pink, dry, and intact without skin issues present. A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 5/6/2025 revealed Resident 4's skin was warm, dry, and intact, with no skin issues present. A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 5/13/2025 revealed Resident 4's was warm, dry, and intact with a 1 cm open area on their coccyx. There was no evidence the provider had been notified or interventions placed to prevent worsening of the area. A record review of Resident 4's Nursing Home Visit Note with Medical Provider (MP)-B from 5/15/2025 revealed Resident 4 had a sacral wound. Facility staff had reported to MP-B the sacral wound was present upon admission,however, MP-B noted the sacral wound was listed as resolved on the documentation from the discharging rehabilitation facility. MP-B placed orders to continue wound care, ensure Resident 4 had appropriate padding in their chair, frequently reposition as Resident 4 allowed, and update MP-B on wound progress every week. A record review of Resident 4's Progress Notes from 5/13/2025-5/27/2025 revealed no evidence of monitoring of Resident 4's pressure ulcer on their coccyx. The Progress Notes did reveal the following: -A note on 5/19/2025 at 3:16 AM revealed the dressing was clean, dry, and intact and staff were assisting Resident 4 with repositioning every 2 hours. -A note on 5/20/2025 at 5:36 AM revealed Resident 4 was being assisted with repositioning every 2-3 hours due to their pressure ulcer on their buttock. The dressing remained clean, dry, and intact. A record review of Resident 4's Weekly Skin Assessments V 2 revealed no evidence a weekly skin assessment had been completed for the week of 5/20/2025 or monitoring of Resident 4's pressure ulcer had been completed. A record review of Resident 4's Weekly Skin Assessment - V 2 with a date of 5/27/2025 revealed Resident 4's pressure ulcer on their sacrum was staged as a Stage 2 (partial-thickness skin loss involving the dermis, or middle layer of skin) with measurements of 1.0 cm x 1.0 cm. Another pressure ulcer was identified on Resident 4's left gluteal fold with measurements of 2.0 cm x 1.8 cm. And two areas of Moisture Associated Skin Damage (MASD) were also identified on both sides of Resident 4's buttocks. There was no evidence MP-B had been notified of the new pressure ulcer area or what interventions had been implemented to prevent worsening of the area. A record review of Resident 4's Progress Notes from 6/1/2025-6/4/2025 revealed the following: -On 6/1/2025 at 5:29 AM, Resident 4's dressing to their buttocks was changed with treatment and cleansing to the wound. There were no signs of infection. -On 6/1/2025 at 10:20 AM revealed Resident 4 had a pressure area that was blanchable that measured 3.5 cm x 4 cm on their right ischial tuberosity area of where the weight of the body rests when sitting, also known as the sit bone.) MP-B was notified via fax. -A late entry for 6/2/2025 at 11:04 AM was placed and revealed Resident 4 had two open wounds. The first wound on Resident 4's sacrum measured 2 cm x 0.5 cm x 1 cm and was staged as a Stage 3 (full-thickness skin loss where fat may be visible) Pressure Ulcer. The second wound on Resident 4's left gluteal area measured 6 cm x 4 cm x 1 cm and was also staged as a Stage 3 Pressure Ulcer. A call had been placed to MP-B's office to confirm the fax from 6/1/2025 had been received. -On 6/4/2025, a verbal reply confirming the fax sent was received by MP-B and approval for a wound clinic evaluation was obtained. A record review of Resident 4's TAR for June 2025 revealed the following: -An order to complete a skin assessment and document findings in a 'Weekly Skin Assessment - V 2 every Tuesday for skin integrity with a start date of 6/11/2024 had not been completed on 6/3/2025. -An order for Resident 4's wound dressing change once a day to cover with calmoseptine and ensure the area is not coming in contact with urine with a start date of 5/9/2025 had not completed on 6/2/2025 or 6/3/2025. A record review of an Evaluation of Clinically Unavoidable Pressure Injury with a faxed to the provider date of 6/5/2025, revealed interventions for Resident 4 prior to the development or worsening of a pressure injury included repositioning and pressure redistribution of chair cushion. Additionally, it revealed Resident 4 had clinical conditions or diagnoses that were primary risk factor for the development or worsening of pressure injuries of immobility, refusal of treatments, incontinence of bowel and/or bladder, COPD, Multiple Sclerosis, edema, history of pressure ulcers, and quadriplegia/hemiplegia/hemiparesis. The form was signed by MP-B on 6/5/2025. A follow-up interview on 6/9/2025 at 12:28 PM with the Chief Nursing Officer of the Hospital (CNOH) where Resident 4 received care revealed the CNOH had spoken with MP-B and MP-B had been informed by facility staff that Resident 4 had returned to the facility with the sacral wound, which would have made it unavoidable. MP-B was not aware Resident 4's sacral wound was not present upon re-admission to the facility and then developed within the facility. An interview on 6/4/2025 at 10:55 AM with Registered Nurse (RN) - C confirmed Resident 4 had no pressure ulcer present upon admission, but due to lack of staffing they are unable to keep up with the care and Resident 4 now has two Stage 3 Pressure Ulcers as a result. An interview on 6/4/2025 at 2:30 PM with the Director of Nursing (DON) confirmed Resident 4 had two pressure ulcer, both currently Stage 3, one on their sacrum/coccyx and one on their left gluteal fold/ischial tuberosity and that the facility's documentation confirmed Resident 4's pressure ulcers were not present upon re-admission to the facility, but had developed while in the facility and that the areas had not improved but were worsening. Additionally, the DON confirmed the facility had no evidence Resident 4's sacral wound condition/progress was monitored between 5/14/2025-5/26/2025 (13 days) or that Resident 4's wound dressing was completed on 5/28/2025, 6/2/2025, or 6/3/2025 as ordered at the time of the interview. An interview on 6/4/2025 at 2:33 PM with the facility's Chief Nursing Officer (CNO) revealed the following: -The CNO revealed the facility's process for monitoring wounds is to complete a weekly skin assessment and to notify the provider of any new wounds to obtain a new order. The provider can be notified through fax when initially discovered and staff should follow up by 8:00 AM the following day if no response. If there continues to be no response after 72 hours, management should be notified. At the time of the interview, the CNO confirmed the facility had no evidence MP-B had responded to the facility's fax from 6/1/2025 or follow up had been attempted between 6/2/2025 and 6/4/2025. At this time, the CNO asked the DON to contact the responsible nurse to log on to the electronic health record system remotely and chart a late entry. -At the time of the interview, the facility also had no evidence MP-B had been updated weekly of Resident 4's pressure ulcer progress as ordered on 5/15/2025. -The CNO confirmed Resident 4's Care Plan had no focus area regarding Resident 4 being at-risk for Pressure Ulcer or interventions to prevent pressure ulcers from developing had been developed or implemented and should have been at the time of the Care Plan development. - The CNO also confirmed Resident 4's Care Plan had not been revised or updated a focus area and interventions after Resident 4's development of Pressure Ulcers and should have been. -Initial interventions that had been put in place prior to the development of Resident 4's pressure ulcers were to place a different cushion in Resident 4's tilt and space wheelchair and heel protectors on their heels when in bed. -The facility's interventions for Resident 4's sacral pressure ulcer included to reposition Resident 4 when in bed and encourage position change when in their wheelchair, as well as a wheelchair cushion. B. A record review of an admission Record indicated the facility admitted Resident 18 on 5/21/2025 with diagnoses of generalized muscle weakness and a pressure ulcer on their sacrum, without a specified stage. A record review of Resident 18's admission MDS with an ARD of 5/28/2025 revealed Resident 18 had a BIMS score of 11/15, which indicated Resident 18 had moderate cognitive impairment. Additionally, it revealed Resident 18 utilized a walker and had no extremity impairment. Resident 18 required partial assistance with bathing and supervision for toileting, bed mobility, and transfers. Under Section H regarding bowel and bladder, the MDS revealed Resident 18 was frequently incontinent of urine and was always continent of bowel. Under Section M regarding skin conditions, the MDS revealed Resident 18 was at-risk for developing pressure ulcers and had one Stage 3 pressure ulcer present. Interventions were a pressure reducing device for chair, repositioning, nutrition and/or hydration intervention, pressure ulcer care, and applications of ointments/medications to affected area. A record review of Resident 18's Care Plan revealed a focus care area regarding pressure injuries with a last reviewed date of 5/23/2025. The area revealed Resident 18 was admitted with a Stage 3 pressure ulcer to their sacrum with the following interventions: -Administer treatments as ordered and monitor for effectiveness. -Assess, record, monitor wound healing with cares weekly. Measure length, width, depth where possible. Assess and document the status of the wound perimeter, wound bed, and healing progress. Report to the physician. -Monitor, document, and report as needed any changes in skin status of appearance, color, wound healing, signs of infection, wound size, and stage. -Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, and type of tissue and drainage. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. A record review of Resident 18's Order Summary Report with an active orders date of 6/10/2025 revealed the following orders: -Complete a skin assessment and document findings in a 'Weekly Skin Assessment - V 2 every Thursday on day shift with a start date of 5/22/2025. -Cleanse sacral pressure ulcer with wound cleaner, apply A&D ointment, and cover with a foam dressing daily for wound care of the sacral pressure ulcer with a start date of 5/22/2025. A record review of Resident 18's Medication Administration Record/Treatment Administration Record (MAR/TAR) from May 2025 revealed Resident 18's order for wound care of the sacral pressure ulcer was not documented as completed on 5/28/2025. A record review of Resident 18's MAR/TAR for June 2025 revealed Resident 18's order for wound care of the sacral pressure ulcer was not documented as completed on 6/2/2025 or 6/3/2025. A record review of Resident 18's Weekly Skin Assessment - V2 from 5/22/2025 - 6/5/2025 revealed the following: -On 5/22/2025, Resident 18's skin was documented as dry and intact except for buttocks. Buttocks have several wounds on gluteal folds and sacrum. There was no evidence measurements of Resident 18's sacral wound had been assessed or the root cause of the wound on Resident 18's gluteal folds had been identified, or interventions had been implemented for these. -There was no evidence an assessment had been completed for 5/29/2025 as ordered. -On 6/5/2025, Resident 18's skin was documented as continuing to have a sacral wound. There was no evidence of monitoring of qualities, measurements, or progress. Additionally, there was no evidence the gluteal fold had resolved or were present. An interview on 6/10/2025 at 2:30 PM with the DON confirmed Resident 18 had a stage 3 pressure ulcer on their sacrum upon admission. The DON also confirmed the facility had no evidence of monitoring the wound's progress, measurements had been obtained, or wound care had been completed on 5/28/2025, 6/2/2025, or 6/3/2025. C. A record review of an admission Record revealed the facility admitted Resident 6 on 1/20/2017. Resident 6 had diagnoses of COPD, generalized muscle weakness,, 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 Chronic Inflammatory Demyelinating Polyneuritis (CIPD, a rare autoimmune disorder where the body's immune system attacks the myelin sheath, the protective covering of the nerves, primarily in the peripheral nervous system which can lead to progressive weakness and sensory changes in the arms and legs). A record review of Resident 6's quarterly MDS with an ARD of 5/25/2025 revealed Resident 6 had a BIMS score of 10/15, which indicated Resident 6 had moderate cognitive impairment. Additionally, the MDS revealed Resident 6 had unilateral impairment in their upper and lower extremities and utilized a wheelchair. Resident 6 was dependent on staff for toileting, bathing, and dressing. Resident 6 required substantial assistance with bed mobility and transfers. Under Section H regarding Bowel and Bladder, the MDS revealed Resident 6 had an indwelling catheter and was always incontinent of bowel. Under Section M regarding Skin Conditions, the MDS revealed Resident 6 currently had one Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) Pressure Ulcer. Interventions included a pressure reducing device for their chair and bed, repositioning, nutrition and hydration intervention, pressure ulcer care, and application of ointments/medications. A record review of Resident 6's Care Plan revealed a focus area regarding skin integrity, with a last revised date of 4/14/2025, revealed Resident 6 was at-risk for skin integrity compromise due to impaired mobility, incontinence, and occasionally moist skin folds related to obesity. Additionally, it revealed Resident 6 had a Stage 4 Pressure Ulcer to their sacrum with a wound vac (a medical device used to promote wound healing by applying controlled negative pressure to the wound bed) in place. Interventions related to the pressure ulcer included the following: -Assist in staying clean and dry by providing incontinence care as needed. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. -Observe, document, and report as needed to the provider any changes in skin status of appearance, color, wound healing, signs of infection, wound size, and stage. -Weekly skin assessments, notify the provider and initiate intervention for areas of concerns. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, and type of tissue and drainage. -Low air pressure mattress on the bed. -Treatment per wound care orders from wound care provider at the hospital. -Reposition while in bed at lest every 2 hours as tolerated. -Heel protectors to both feet while resting in bed as tolerated. A record review of Resident 6's Order Summary Report with an active orders date of 6/9/2025 revealed the following orders: -Complete a skin assessment and document findings in a 'Weekly Skin Assessment - V 2' every Thursday on day shift for skin integrity with a start date of 6/13/2024. -Ensure wound vac is functioning at 125 millimeters of mercury (mmHG) every shift for wound care with a start date of 6/5/2025. -Give Arginaid (a supplement designed to support the unique nutritional needs of people with chronic wounds) twice a day for wound healing of the sacral wound with a start date of 2/1/2025. -Low flow air mattress to bed to assist with wound healing of the sacral wound with an order date of 1/31/2025. -Change wound vac dressing every 72 hours and as needed. Cleanse wound with normal saline, prep area around wound with skin prep and drape, pack wound depth with black foam and bridge to lateral trunk, not on a boney prominence, cushion tubing with foam, and anchor in place with drape for Stage 4 sacral pressure ulcer with a start date of 6/5/2025. -Zinc Sulfate 220 milligrams (mg) two times a day for wound healing with a start date of 6/6/2025. A record review of Resident 6's Medication Administration Record/Treatment Administration Record (MAR/TAR) for April 2025 revealed Resident 6's order for Arginiad twice a day for wound healing was documented as not given with a reason of Held/Other/See Progress Note on the following dates: -4/27/2025 PM, -4/28/2025 PM, -4/29/2025 AM, -4/29/2025 PM, - 4/30/2025 AM, -4/30/2025 PM. A record review of Resident 6's Progress Notes for 4/27/2025-4/30/2025 revealed Arginaid order was held or not given due to not being available. A record review of Resident 6's Medication Administration Record/Treatment Administration Record (MAR/TAR) for May 2025 revealed Resident 6's order for Arginiad twice a day for wound healing was documented as not given with a reason of Held/Other/See Progress Note on -5/27/2025 PM, - 5/29/2025 AM, -5/29/2025 PM, -5/30/2025 PM. A record review of Resident 6's Progress Notes for 5/27/2025-5/30/2025 revealed Arginaid order was held or not given due to not being available. A record review of Resident 6's Medication Administration Record/Treatment Administration Record (MAR/TAR) for June 2025 revealed Resident 6's order for Arginiad twice a day for wound healing was documented as not given with a reason of Drug Refused on 6/1/2025 AM, and Held/Other/See Progress Note on the following dates: -6/1/2025 PM, -6/2/2025 PM, -6/3/2025 AM, -6/3/2025 PM, -6/4/2025 AM, -6/4/2025 PM, -6/5/2025 AM, -6/5/2025 PM, -6/6/2025 AM, -6/6/2025 PM, -6/7/2025 AM, -6/7/2025 PM, -6/8/2025 AM, -6/8/2025 PM, -6/9/2025 AM. A record review of Resident 6's Progress Notes for 6/1/2025-6/9/2025 revealed Arginaid order was held or not given due to not being available. The physician was notified of the unavailability of the Arginaid and a new order was provided on 6/6/2025. A record review of Resident 6's Wound Care Visit Notes revealed the following: -On 5/16/2025, the note revealed Resident 6's wound vac was not running when the resident arrived at their appointment. Additionally, Resident 6 was noted to have a red area by the wound opening and was incontinent of bowel on the area around the wound. -On 5/22/2025, the note revealed Resident 6's sacral wound measured 1.6 cm x 1 cm x 2 cm with undermining (a situation where the tissue beneath the skin edges of a wound has broken down, creating a pocket or space) of 1.1 cm with orders to continue with current orders. -On 5/29/2025, the note revealed Resident 6's sacral wound measured 1.3 cm x 1 cm x 1 cm with undermining of 2.1 cm. A wound culture was obtained due to Resident 6 having feces in their wound and odor. Additionally, the note stated to continue with current plan and orders. An interview on 6/9/2025 at 10:50 AM with the DON confirmed the facility did not have Arginaid available on 4/27/2025-4/30/2025 but was ordered on 4/29/2025. Additionally, the DON confirmed the facility has not had Arginaid since 5/27/2025 due to being backordered until 6/16/2025. The provider had not been notified as of the time of the interview and should have been first contacted on 5/28/2025 when first backordered. A follow up interview on 6/9/2025 at 11:20 AM with the DON revealed the order for Arginaid had been placed on hold and would be having a pharmacy delivering the Arginaid this evening.

Licensure Reference Number 175 NAC 12-00604(D)Nebraska Revised Statute 71-6018.02(a) Based on record reviews and interviews, the facility failed to maintain acceptable documentation (timecards, time sheets, payroll information) that a Registered Nurse (RN) was on duty for a minimum of 8 consecutive hours a day, 7 days a week, as required. This had the potential to affect all 28 residents by limiting access to RN-level assessment, oversight, and decision-making related to resident care.Findings are: A record review of a facility provided document SCARAB (Skyview Care and Rehab at Bridgeport) Facility Assessment- 2025 dated 6/4/2025 revealed under the staffing type section, nursing services of the Director of Nursing (DON), RN, Licensed Practical Nurse (LPN), Nurse Aides (NA), and Medication Aides (MA) were needed to provide support and care for the facility's residents. Under the staffing plan section, it was revealed that a total of 5 licensed nurses providing direct care were needed. There was no evidence regarding the need for an RN to be on duty for a minimum of 8 consecutive hours a day, 7 days a week. 1.A record review of a facility provided document, Daily Assignment Sheet (dated 6/24/2025), revealed RN-U was listed as the nurse assigned to the 6PM-6AM shift. The same document listed no other RNs, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for RN-U, covering the date range 6/12/2025 to 8/14/2025, revealed no evidence RN-U had been on duty on either 6/24/2025 or 6/25/2025. A record review of the facility's documentation provided as evidence of RN coverage included the Chief Nursing Officer's (CNO) Vetus Time Study (dated June 2025). For 6/24/2025, the time study listed a task titled DON Coverage - RN Coverage with a total daily hour of 18.5 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 6/24/2025). 2. A record review of the facility provided document Nursing Coverage (dated 7/8/2025) revealed the CNO had been listed as the 6AM-6PM RN on duty. The same document listed no other RN, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated July 2025). For 7/8/2025, the time study listed a task titled Sky DON Coverage with a total of daily hours of 10 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/8/2025). 3. A record review of the facility provided document Nursing Coverage (dated 7/12/2025) revealed RN-P had been listed as the Registered Nurse for 2:00-10:00 PM and then the RN for 6PM-6AM. The same document listed no additional RNs, one LPN, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for RN-P, covering the date range 6/12/2025 to 8/14/2025, revealed RN-P had been on duty on 7/11/2025 at 10:03 PM to 7/12/2025 at 7:28 AM. There was no evidence RN-P had returned for an additional shift at 2:00 PM or later on 7/12/2025 or on 7/13/2025. A record review of the facility provided document Timecard Report, for the Nursing Home Administrator (NHA), covering dates 6/12/2025 to 8/14/2025, revealed the NHA had been on duty on 7/12/2025 from 4:10 PM to 6:00 PM and 7/13/2025 from 6:00 PM to 6:23 AM. A record review of a State of Nebraska - Department of Health and Human Services' License Details revealed the NHA had an active LPN license. Additional record review of the facility's documentation provided as evidence of all nursing staff, including agency/contract and management, who had worked from 6/12/2025-8/14/2025 including Timecard Reports, Timecard Detail Reports, and Vetus Time Studies revealed no evidence of a RN having been on duty of at least 8 consecutive hours for 7/12/2025. An interview on 8/18/2025 at 1:25 PM with the NHA revealed due to a time keeping error/glitch, the NHA's timecard had shown the NHA had worked the night shift on 7/13/2025, however, the NHA had covered the night shift for licensed nurse coverage on 7/12/2025. 4. A record review of the facility provided document Nursing Coverage (dated 7/13/2025) revealed there had been no RN listed on duty for the 24-hour period. The same document listed two LPNs and several NAs assigned to resident care throughout the 24-hour period. Additional record review of the facility's documentation provided as evidence of all nursing staff, including agency/contract and management, who had worked from 6/12/2025-8/14/2025 including Timecard Reports, Timecard Detail Reports, and Vetus Time Studies revealed no evidence of a RN having been on duty of at least 8 consecutive hours for 7/12/2025. 5. A record review of the facility provided document Nursing Coverage (dated 7/16/2025) revealed the CNO had been listed as the 6AM-6PM RN on duty. The same document listed no other RNs, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated July 2025). For 7/16/2025, the time study listed a task titled Sky DON Coverage with a total of daily hours of 8 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/16/2025). 6. A record review of the facility provided document Nursing Coverage (dated 7/17/2025) revealed the CNO had been listed as the 6AM-6PM RN on duty. The same document listed no other RNs, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated July 2025). For 7/17/2025, the time study listed a task titled Sky DON Coverage with a total of daily hours of 10 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/17/2025). 7. A record review of the facility provided document Nursing Coverage (dated 7/21/2025) revealed the CNO had been listed as the 6AM-6PM RN on duty. The same document listed no other RNs, two LPNs and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the Chief Nursing Officer's (CNO) Vetus Time Study (dated July 2025). For 7/21/2025, the time study listed a task titled Sky DON Coverage with a total of daily hours of 10.5 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not align with the facility's Daily Assignment Sheet (dated 7/21/2025). 8. A record review of the facility provided document Nursing Coverage (dated 7/25/2025) revealed RN-O had been listed as the Registered Nurse for 6PM-6AM. The same document listed no additional RNs, two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for RN-O, covering the date range 6/12/2025 to 8/14/2025, revealed no evidence RN-O had been on duty on 7/25/2025 or 7/26/2025. A record review of the facility provided document Timecard Report, for the Nursing Home Administrator (NHA), covering dates 6/12/2025 to 8/14/2025, revealed the NHA had been on duty on 7/25/2025 from 10:13 PM to 6:06 AM on 7/13/2025. Additional record review of the facility's documentation provided as evidence of all nursing staff, including agency/contract, who had worked from 6/12/2025-8/14/2025 including Timecard Reports, Timecard Detail Reports, and Vetus Time Studies revealed no evidence of a RN having been on duty of at least 8 consecutive hours for 7/25/2025. 9. A record review of the facility provided document Nursing Coverage (dated 7/26/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the Nurse Consultant (NC)'s Vetus Time Study (dated July 2025). For 7/26/2025, the time study listed a task titled RN Coverage with a total of daily hours of 8 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/26/2025). 10. A record review of the facility provided document Nursing Coverage (dated 7/27/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the Nurse Consultant (NC)'s Vetus Time Study (dated July 2025). For 7/27/2025, the time study listed a task titled RN Coverage with a total of daily hours of 8 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/27/2025). 11. A record review of the facility provided document Nursing Coverage (dated 7/31/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility's documentation provided as evidence of RN coverage included the NC's Vetus Time Study (dated July 2025). For 7/31/2025, the time study listed a task titled 24-hour report, dashboard review, stand up meeting, MDS (Minimum Data Sets) assessments, Medicare Meeting, MDS submission, RN Coverage (8 hours) with a total of daily hours of 8 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 7/31/2025). A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated July 2025). For 7/31/2025, the time study listed a task titled [NAME] IDR (Informal Dispute Resolution) Hearing - Travel to Sky - DON Orientation with a total of daily hours of 10.5 hours. However, the time study did not include documentation of specific hours spent on each task area, nor did it demonstrate that the hours were consecutive. A record review of Google Map's direction from [NAME], Nebraska to Bridgeport, Nebraska estimated the fastest route to be approximately 5 hours and 25 minutes long. 11. A record review of the facility provided document Nursing Coverage (dated 8/5/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed two LPNs, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for the DON covering the date range 6/12/2025 to 8/14/2025, revealed the DON had been on-duty on 8/5/2025 from 6:56 AM to 2:30 PM, a total of 7.57 hours. A record review of the facility's documentation provided as evidence of RN coverage included the CNO's Vetus Time Study (dated August 2025). For 8/5/2025, the time study listed a task titled Skyview-DON Coverage with a total of daily hours of 10 hours. However, the time study did not include documentation of specific hours worked, nor did it demonstrate that the hours were consecutive. Additionally, the information documented in the time study did not algin with the facility's Daily Assignment Sheet (dated 8/5/2025). 12. A record review of the facility provided document Nursing Coverage (dated 8/9/2025) revealed no RNs had been assigned to duty for the 24-hour period. The same document revealed one LPN, and several NAs assigned to resident care throughout the 24-hour period. A record review of the facility provided document Timecard Detail Report for the DON covering the date range 6/12/2025 to 8/14/2025, revealed 11 clock ins/clock outs between 7/28/2025 and 8/11/2025, however, there was no evidence the DON had been on duty on 8/9/2025. On 8/14/2025, the facility was requested to provide evidence of all nursing staffing coverage - including agency, contract staff, and management personnel who provided nursing coverage - form 6/12/2025 through 8/14/2025. An interview on 8/18/2025 at 11:25 AM with the NHA revealed the CNO does not clock in or out. The NHA stated that any shift without RN coverage would have been covered by the CNO. An interview on 8/18/2025 at 4:55 PM with the CNO revealed their time study is accurate and if it did not reflect their presence in the building on a particular day, they were not present. The CNO further revealed that in their absence, the NC would have provided RN coverage. An interview on 8/18/2025 at 5:50 PM was conducted with the NHA. When asked if besides the CNO, NC, DON, or other previously identified RNs may have provided RN coverage, the NHA responded, No not that I can think of. At that point, the DON entered the room. When the NHA was questioned about nurse coverage on the night shift and RN coverage for 8/9/2025, the DON interjected that they had worked the night shift on 8/9/2025 but acknowledged their timecard had not been clocking in or out correctly. The NHA confirmed the facility had no timecard correction form on file for the DON and instructed the DON to complete one at this time. Throughout the same interview, when asked about specific dates where RN coverage could not be confirmed by the already provided documentation, the NHA stated that further searching would be needed to identify any additional evidence of RN coverage and was unable to provide names of staff who may have fulfilled this requirement during the dates in question. At the time of exit, no additional evidence of RN staffing coverage had been received by the survey team. The facility was reminded during the exit conference of how to submit any further supporting documentation related to the investigation.

Licensure Reference Number: 175 NAC ,[DATE].05 (9) Based on record reviews and interviews, the facility failed to: 1) explore one sampled resident's (Resident 1) competency to make informed decisions regarding financial and health care decisions. This failure resulted in the resident with ongoing mental illness symptoms including delusions remaining responsible for financial decisions without further evaluation; and 2) implement abuse policies pertaining to suspected exploitation for one sampled resident (Resident 1), with limitations in daily living activities, mental illness diagnoses, and ongoing psychiatric symptoms including delusions, regarding the purchase of a vehicle. The failure resulted in the resident depleting the resident's checking account by $20,000 and the loss of another vehicle to complete the transaction. Facility census was 41. Sample size was 10 current residents. Findings are: A. Record review of Resident 1's Admission Record dated [DATE] revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of Resident 1's chart revealed there was no court action, Power of Attorney, or Guardianship appointed to manage the resident's affairs. Record review of a Physician's Determination of Capacity form signed by a Nurse Practitioner on [DATE] revealed a statement that read: This resident is mentally capable of making informed decisions. Record review of Resident 1's annual MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment completed on [DATE] revealed the following assessment results pertaining to the resident: - The facility failed to proceed with a BIMS (Brief Interview of Mental Status, a test for assessing memory) documenting the resident was rarely/never understood. - The resident exhibited symptoms of Delusions (Misconceptions or beliefs that are firmly held contrary to reality). - The resident exhibited verbal behavioral symptoms directed toward others (threatening, screaming at others, cursing) on ,[DATE] days of the 7 day look back period. - Current active [DIAGNOSES REDACTED]. Record review of a Psychiatric Nurse Practitioner's documentation revealed a Psychiatric History and Exam of Resident 1 dated [DATE]. The practitioner documented: (the resident) continues to be paranoid, accusatory, rude and irritable when interacting with others. Gets very confrontational with others . Pt (patient or resident) reports there is a conspiracy against (the resident) and mental health professionals just want to use information (the resident) gives against (the resident). under the Axis (mental health [DIAGNOSES REDACTED]. This greatly impacts ability to make appropriate medical decisions on (the resident's) behalf because (of) not able to realistically evaluate information given. (The resident) is not able to redirect and refuses to even listen to information or professional advice from others. It is my professional opinion that pt is not capable to making safe medical decisions on (the resident's) behalf and should have a guardian appointed to manage medical and financial affairs. Additional testing would be beneficial, but given (the resident') acute psychotic and agitated state, (the resident) is unwilling/unable to participate in any assessments. Record review of Resident 1's Primary physician's review of an Order Summary Report signed by the physician on [DATE] revealed the physician discussed long range goals with the resident. The physician noted the resident won't walk with physical therapy and apparently is own POA (Power of Attorney). The physician commented: Desire by patient to be wheelchair bound. Record review of Resident 1's Family Nurse Practitioner review of an Order Summary Report signed by the practitioner on [DATE] revealed the Nurse Practitioner recorded staff concerns with the resident's behavior over the past few weeks. The resident was refusing pain medication. The resident stated to the practitioner as to having just purchased vehicle within past month. The resident voiced having lost the resident's driver's license and stated having help from Person-A in purchasing the vehicle. The Nurse Practitioner's assessment and plan included the use of [MEDICATION NAME] (an antipsychotic medication used for behavior management, and treating delusional and hallucination behaviors) treatment for [REDACTED]. The Nurse Practitioner documented to consult with Behavioral Health to evaluate mental competency due to the residents [MEDICAL CONDITION] and Delusional State. The practitioner also ordered the facility to see if the resident's driver's license expired by contacting the Department of Motor Vehicles due to the resident's mental state. Interview with the Administrator and Director of Nursing on [DATE] at 4:50 p.m. confirmed the resident was admitted to the facility on [DATE]. The resident received psychiatric evaluations from a Psychiatric Nurse Practitioner. The resident had no court action appointing a POA or Guardian and was assessed as competent to make decisions on admission. The Administrator verified the resident had ongoing mental health behaviors, diagnoses, and was deemed suspect of making own decisions by the Psychiatric Nurse Practitioner on [DATE]. The Administrator verified the facility had not pursued any competency evaluations of the resident since admission and verified the resident experienced on-going delusions as evidenced by medical documentation and facility MDS records. B. Record review of Resident 1's Admission Record dated [DATE] revealed among the resident's contacts was Person-A, listed as the resident's Responsible Party. Record review of Resident 1's annual MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment completed on [DATE] revealed the following assessment results pertaining to the resident: - The facility failed to proceed with a BIMS (Brief Interview of Mental Status, a test for assessing memory) documenting the resident was rarely/never understood. - The resident exhibited symptoms of Delusions (Misconceptions or beliefs that are firmly held contrary to reality). - The resident exhibited verbal behavioral symptoms directed toward others (threatening, screaming at others, cursing) on ,[DATE] days of the 7 day look back period. - Current active [DIAGNOSES REDACTED]. Record review of a Psychiatric Nurse Practitioner's documentation pertaining to Resident 1's evaluations and treatment revealed the following: - [DATE]- The resident was diagnosed with [REDACTED]. - [DATE]- The resident was experiencing bizarre perceptions and paranoid that someone was going to harm (the resident) - [DATE]- The resident experienced off the wall comments not reality based. Threw soiled briefs on the floor and placed an overflowing urinal on the floor. - [DATE]- The resident was not calling for assistance, lying in a soiled brief. The resident experienced angry outbursts. A new [DIAGNOSES REDACTED]. - [DATE]- The resident exhibited outbursts of negativity, refused to work with Physical Therapy and staff. Significant mood swings. Times of confusion and agitation. The resident was making inappropriate comments toward the staff and racial comments toward other residents. The resident was making physical threats toward the staff. The Nurse Practitioner prescribed [MEDICATION NAME] (An antipsychotic tranquilizing medication used to control behaviors, delusions, and hallucinations). - [DATE]- The staff reported the resident's behaviors were getting out of control. The resident experienced extreme reactions to minor problems. The resident assaulted a visitor this past weekend. The resident was paranoid and believed the government had planted cameras in the facility to spy on people. The resident blocked another resident in the resident's room, yelled at the family of a resident, and ran over the foot of a family member using a wheelchair. The [MEDICATION NAME] was increased. [DATE]- The resident was delusional, grandiose. Accusatory of others lying to him, demanding on staff. The resident's thought processes were very discombobulated. The behaviors were consistent throughout the day. [DATE]- The resident continued to be paranoid, accusatory, rude, and irritable with others. The resident was confrontational with others. The resident believed there was a conspiracy against the resident. A [DIAGNOSES REDACTED]. This greatly impacted the resident's ability to make appropriate medical decisions due to not realistically evaluating information provided. The Nurse Practitioner documented It is my professional opinion that pt (patient or resident) is not capable of making safe medical decisions . and should have a guardian appointed to manage (the resident's) medical and financial affairs. Record review of Resident 1's Progress Notes revealed the following entries: - [DATE] at 8:45 a.m. a nurse was providing medication to the resident and documented: resident remains delusional in the belief that a therapist assistant was to bring the resident the deed to a farm the resident purchased for a feral cat farm. Attempts to redirect patient were unsuccessful. - [DATE] at 2:03 p.m. the charge nurse documented: Patient in to admin (administrative) offices asking for access to checkbook stating that (the resident) is buying a truck Administrator talking to resident in attempt to try and get (the resident) to change mind. Interventions unsuccessful at this time. - [DATE] at 4:15 p.m. the charge nurse documented: Patient stating that (the resident) purchased a truck today and is planning on leaving in it and heading south with no plans of returning to the facility. Management alerted to resident's comments in which reply was received with, '(The resident) is own person and can do as (the resident) wants. We can't do anything to stop (the resident). - [DATE] at 8:42 a.m. the RN (Registered Nurse, charge nurse) recorded a nurse aide reported the resident stating needing to have a bowel movement and refusing to go to the restroom. This nurse down to talk to resident and note that (the resident) has defacated in (the resident's) brief and then removed the brief smearing BM (Bowel Movement) all over self and the bed. When questioned why the resident refused to use the restroom, the resident responded you tell me and told the nurse it was their job to clean the resident. - [DATE] at 4:46 p.m. the charge nurse recorded the resident was planning to turning us (facility) in for allowing the birds to be cold. The resident was angry the facility allowed other residents to go out of the door in to the courtyard and it is to (sic) cold for the birds. Advised patient that the temperature outside is 68 degrees as of right now and the birds will not be harmed as a result of people opening the door. Patient remains upset and states Oh so your an RN does that stand for retarded nurse because the birds are freezing and I am reporting you . [DATE] at 11:01 the charge nurse documented that a Family Nurse Practitioner saw the resident in the facility. The charge nurse documented the patient delusional at time of appointment complaining of a driver's license being revoked. The nurse documented the resident's license was valid but received a renewal reminder in which the resident believed was a revocation. The nurse documented: Patient goes on to state that (the resident) is dying from agent orange and Round-Up poisoning. Unable to be redirected at this time. Noted to rapidly change topics and unable to follow conversation for more than ,[DATE] minutes. Requesting to be sent to a state that participates in the assisted suicides. The Nurse Practitioner wrote for [DIAGNOSES REDACTED]. Record review of a Family Nurse Practitioner's documentation on a Medication Review Report signed on [DATE] revealed the Nurse Practitioner documented: Staff states concerns c (with) Pt's behavior over past few weeks. The Nurse Practitioner documented refusal of medication and that the resident just purchased vehicle within past month. The Practitioner noted the resident lost a valid driver's license, unable to drive. States having help with Person-A in purchasing vehicle. The Nurse documented the Assessment/Plan included treating [MEDICAL CONDITION] on [MEDICATION NAME], and Delusional Disorder with instructions to: Consult BH (Behavioral Health) to evaluate mental capacity, [MEDICAL CONDITION], Delusional State with additional instructions to see if the resident's driver's license is expired- Contact DMV (Department of Motor Vehicles) due to mental state. Interview with Resident 1 on [DATE] at 11:15 a.m. revealed the resident's description of having purchased a 2020 Chevrolet Silverado. The resident described purchasing the vehicle over the phone from a dealership in another town. Record review of the facility's Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property policy (undated) revealed the following instructions and definitions: - Exploitation is defined as unfair treatment or use of a resident or taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. - Investigation instructions described: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. - Reporting- It is the policy of this facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations . exploitation . and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events . result in serious bodily injury . or not later than 24 hours if the events . do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services .) in accordance with State law through established procedures. Record review of the Nursing Facility Abuse/Neglect/Misappropriation Reporting Requirements (a guideline directing facilities related to reporting requirements) dated [DATE] revealed the following instructions and definitions: - Exploitation means the wrongful or unauthorized taking, withholding, appropriation, conversion, control, or use of money, funds, securities assets, or any other of property of a vulnerable adult or senior adult by any person by means of undue influence, breach of a fiduciary relationship, deception, or extortion, intimidation, force or threat of force, isolation, or by any unlawful means or by the breach of a fiduciary duty by the guardian, conservator, agent under a power of attorney, trustee, or any other fiduciary of a vulnerable adult or senior adult. - The instructions for reporting provide direction if there is reason to suspect or believe abuse has occurred . or conditions are present that could result in abuse/neglect the facility is instructed to take steps to protect the individual, notify administration, begin an internal investigation and Immediately report to Adult Abuse and Neglect Hotline within 2 hours if injury, within 24 hours if no injury. Interview with the Administrator and Director of Nursing on [DATE] at 4:50 p.m. confirmed Resident 1 was admitted to the facility on [DATE]. The Administrator confirmed the resident was seen by a Psychiatric Nurse Practitioner and diagnosed with [REDACTED]. The resident required the assistance of staff for daily living activities for transferring, toileting, and grooming. The resident was not walking much currently. The Administrator verified the resident was not likely to safely operate a motor vehicle. The Administrator verified the resident purchased a vehicle with the help of a car salesesmn, Person-A listed among the resident's personal contacts. The Administrator confirmed the resident wrote a check for the purchase in the amount of $20,000 and traded in another vehicle for the purchase. The Administrator expressed concern with the purchase to the resident and attempted to prevent the resident from writing the check, but deferred to the resident's choice. The Administrator was asked by the resident to see if the check cleared the bank and the Administrator verified having done so and verified the check had cleared. The Administrator confirmed the facility had not identified the incident as suspicious or possible exploitation of a vulnerable resident and confirmed Person-A assisted in the purchase and was listed among the resident's contact persons. The Administrator verified Person-A had no legal authority to make resident decisions. The Administrator confirmed the facility had not reported the incident to the Resident's medical practitioners (prior to [DATE]), psychiatric practitioners, Adult Protective Services, or the State Survey Agency for review. The facility had not conducted an internal investigation pertaining to the incident and failed to report the incident and forward an investigation to the State Agency as defined in facility abuse policies.