Every finding on record at Clarkson Community Care Center Inc

Licensure Reference Number 175 NAC 12-006.02(8)Based on record review and interview; the facility failed to investigate and submit a completed investigation report related to abuse and neglect to the State Agency within the required time frame for Residents 1 and 2. The sample size was 3 and the facility census was 29.Findings are: A. Review of the facility policy Abuse, Neglect and Exploitation with an implementation date of 9/2017 revealed each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. In response to allegations of abuse, neglect exploitation or mistreatment, the facility was to: -ensure all alleged allegations were reported immediately, but not later than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury. But not later than 24 hours if the advents that caused the allegation did not involve abuse and did not result in serious bodily injury. To be reported to the Administrator of the facility and to other officials (including the State Survey Agency and Adult Protective Services (APS) where state law provides for jurisdiction in long-term care facilities) in accordance with State law. -have evidence all alleged violations were thoroughly investigated. -prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in process. -report the results of all investigations to the Administrator or their designee and to the other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified the appropriate corrective action taken. B. Review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) revealed the resident was admitted on [DATE]; had severe cognitive impairment; required staff assistance with toileting, dressing, transfers, mobility and hygiene; had diagnoses of Alzheimer's Disease, Dementia, Anxiety and Pain; had a fall in the month prior to admission, and one fall with no injury since admission to the facility; and was admitted to the facility on Hospice Services. Review of Resident 1's Care Plan last revised 5/7/26 revealed the resident had impaired cognitive function related to Dementia; required staff assistance with bed mobility, dressing, eating, hygiene, and toileting; and the resident was at risk for falls related to their confusion, balance problems and unaware of safety needs. Review of Resident 1's Progress Notes from 5/22/26 through 5/26/26 revealed the following entries: -On 5/22/26 at 4:17 AM the resident was standing in front of a recliner. The writer and a Certified Nursing Assistant (NA) witnessed the resident fall and land on their right hip. -On 5/23/26 at 7:49 AM during a bath a large purple bruise was observed to the right hip. The resident did not cry out when the area was assessed and palpated but would not able to follow commands to perform range of motion exercises. The resident had been ambulating on the leg since the fall on 5/22/26. -On 5/23/26 at 11:59 AM the resident was observed to be favoring their left leg leading to an unsteady gait. The resident seems to be experiencing discomfort related to the fall on 5/22/26. -On 5/23/26 at 3:08 PM the resident was making comments like Oh this leg hurts and nursing staff attempted to give pain medication but the resident refused and would spit out initially but did finally accept the medication. The resident continued to favor the left extremity. -On 5/24/26 at 4:29 PM the resident was observed walking in the hallway, stopped to pull their pants and brief down and started to squat to relieve themselves. The NA observed the resident fall forward, hit their head on the medication cart and fall onto their right hip. The resident refused vital signs and a neurological assessment. The resident was noted to hobble and favor their left side while ambulating. The resident continued to self-ambulate although the resident was unsteady. -On 5/24/26 at 4:58 PM an attempt to notify the resident's responsible party was unsuccessful and unable to leave them a message. -On 5/24/26 at 6:01 PM the Hospice nurse was in the facility and assessed the resident. The Hospice nurse notified the family of the fall and assessment and planned to keep the resident comfortable. -On 5/25/26 at 12:56 PM the Hospice nurse spoke with the residents responsible party and stated the family would like to focus on pain management and comfort medications for the resident. -On 5/26/26 at 2:45 PM The Director of Nursing (DON) was reviewing documentation that resident had been experiencing discomfort with ambulation after a fall. The DON confirmed the family was aware and were choosing no follow up. A report was made to APS. Review of the investigation report dated 5/26/26 revealed the facility investigated the fall on 5/22/26 and 5/24/26. An attached facsimile (fax) dated 5/29/26 revealed the facility attempted to fax the report, but the fax contained a printout that had no response and The following data could not be sent report attached. Interview with the DON on 6/15/26 at 1:30 PM revealed the DON was not aware that the report did not go through. Further interview confirmed the investigation report was not submitted to the State Agency within 5 working days. C. Review of Resident 2's MDS dated [DATE] revealed diagnoses of fractures and other multiple traumas, atrial fibrillation, high blood pressure, deep vein thrombosis, urinary tract infection in the last 30 days, arthritis, and Alzheimer's disease. The following was assessed regarding the resident: -moderate cognitive impairment. -required staff assistance with toileting, transfers, dressing and personal hygiene. -bowel and bladder incontinence. -one fall with a major injury since the previous assessment. Review of the resident's current Care Plan with a revision dated of 3/17/26 revealed the resident was at risk for falls due to diagnosis of high blood pressure and osteoarthritis. Fall prevention interventions included: anticipating and meeting the resident's needs; ensuring the call light was in reach, with prompt assistance for all requests; and ensuring the resident was wearing appropriate footwear when ambulating. Review of an Incident Audit Report dated 4/18/26 at 2:15 AM revealed the resident was found seated on the floor of the bathroom of the resident's room. The resident's head was bleeding and the resident voiced complaints of a headache and of neck pain. The on-call physician was notified and an order was received to transfer the resident to the hospital for evaluation. Review of a Progress Note dated 4/18/26 at 4:00 AM revealed the facility was notified by the hospital the resident had a spinal neck fracture. Review of a Progress Note dated 4/18/26 at 6:18 AM revealed APS was notified of the resident's fall with injury. Review of the facility investigations of potential abuse/neglect from 9/3/25 to 4/20/26 revealed no investigation was completed regarding Resident 2's fall with a significant injury. During an interview on 6/15/26 at 11:00 AM, the DON the resident had a fall on 4/18/26 at 2:15 AM and sustained a significant injury. APS was notified but the facility failed to submit an investigation related to the resident fall to the State Agency within the required time frame.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i) Based on record review and interview; the facility failed to identify causal factors of falls and to revise and/or develop interventions based on those factors to prevent ongoing falls for Residents 1 and 3. The sample size was 3 and the facility census was 29. Findings are:A. Review of the facility policy Fall Risk Assessment with an implementation date of 10/21/25 revealed it was the policy for the facility to provide an environment that was free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. An explanation and compliance guidelines included the following: -a risk assessment was to be completed upon admission, quarterly or when a significant change was identified. -the risk assessment was to identify environmental hazards and individual risks, including the need for supervision and to evaluate and analyze hazards and risks. -an at risk care plan was to be completed for each resident to address items identified on the risk assessment and was to be updated accordingly. -the at risk care plan was to include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice, to reduce the risk of an accident. -monitor the effectiveness of interventions and modify the interventions, as necessary. B. Review of Resident 3's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/14/26 revealed diagnoses of anemia, heart failure, coronary artery disease, high blood pressure, aphasia (communication disorder affecting speech, understanding, reading, and writing due to brain injury), Non-Alzheimer's dementia, hemiplegia (loss of movement or control to one side of the body), anxiety, and depression. The following was assessed for the resident: -cognition was moderately impairment. -behaviors which included wandering and verbal/physical behaviors directed toward others. -required substantial to maximal assistance with toileting, dressing and bathing/showering. -bowel and bladder incontinence. -history of falls with 2 falls since the previous assessment. Review of a Fall Risk Assessment completed 12/11/25 revealed a score of 15 which indicated the resident was at high risk for falls. Review of a Fall Data Collection form revealed the resident had a fall on 3/6/26 at 6:12 AM. The resident was found seated on the floor next to the bed with the resident's back to a dresser. The resident reported trying to turn on a light and lost balance. The fall alarm sounded and alerted the staff. The resident was alert but confused. An intervention was identified for 15 minute checks. Further review revealed no documentation regarding the 15 minute checks to identify how long they were completed and what staff was responsible for completing. Review of a Fall Data Collection form revealed the resident had a fall on 4/20/26 at 2:20 AM. The fall occurred in the bathroom of the resident's room. The resident indicated loss of balance when self-transferring to the toilet. The resident was identified as confused with increased weakness. The reason for the fall was identified as an unwillingness to accept staff assistance. A new intervention was listed for the resident to make sure the resident felt the back of legs touch the bed. Review of a Fall Data Collection Form dated 6/10/26 revealed the resident was found on the floor in front of the resident's wheelchair at 6:45 PM. The resident was confused and had been self-propelling in the corridor. No causal factors were identified. An intervention to remind the resident not to get up alone was listed. During an interview on 6/15/26 at 1:20 PM, Nurse Aide (NA)-D reported the resident was always confused with short and long term memory loss and the resident would not remember to use the call light or to wait for staff assistance before self-transferring. Interview with the Director of Nursing (DON) on 6/15/26 at 1:45 PM confirmed the following: -the resident was at high risk for falls. -on 3/6/26 at 6:12 AM, the resident had a fall when trying to turn on a light at bedside. An intervention was indicated for 15 minute checks. There was no evidence that the 15 minute checks were completed, how long they were done and who was responsible for completion. The DON verified the intervention did not address the resident's inability to safely turn on a light at bedside which was the casual factor of the fall. -on 4/20/26 the resident had a fall in the bathroom of the resident's room at 2:20 AM. The resident reported a loss of balance when self-transferring to the toilet. An intervention was listed to make sure the resident felt the back of the resident's legs touch the bed before sitting down to prevent further falls. A causal factor on the form indicated the resident was unwilling to accept staff help. The DON verified the intervention for the resident to make sure the back of the resident's leg touched the bed did not address the resident's failure to wait for staff assistance with transfers. -on 6/10/26 at 6:45 PM, the resident was found on the floor in front of the resident's wheelchair in the corridor. The assessment indicated the resident was confused and had been self-propelling in the corridor. Further review revealed no casual factors were identified. An intervention was listed to remind the resident not to get up alone. The DON acknowledged no causal factors were identified. In addition, the resident had ongoing confusion and an intervention to remind the resident not to self-transfer was not a measurable or an effective intervention. C. Review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) revealed the resident was admitted on [DATE]; had severe cognitive impairment; required staff assistance with toileting, dressing, transfers, mobility and hygiene; had diagnoses of Alzheimer's Disease, Dementia, Anxiety and Pain; had a fall in the month prior to admission, and one fall with no injury since admission to the facility; and was admitted to the facility on Hospice Services. Review of Resident 1's Care Plan last revised 5/7/26 revealed the resident had impaired cognitive function related to Dementia; required staff assistance with bed mobility, dressing, eating, hygiene, and toileting; the resident was at risk for falls related to their confusion, balance problems and unaware of safety needs; and the resident had falls on 5/22/26 and 5/24/26 with interventions of a bed alarm applied to alert the staff to self-transferring out of bed per hospice nurse, anticipate the residents needs, educate the resident/family/caregivers about safety and what to do if a fall occurred, and to follow the facility fall protocol. Review of the Fall Risk Assessment completed 4/29/26 revealed a score of 12 which indicated the Resident 1 was at high risk for falls. Review of the Fall Data Collection Form dated 4/21/26 at 4:00 AM revealed the resident was observed lying on the floor in the resident room on their left side. The resident had been trying to get out of bed. The incident was unwitnessed. The root cause of the fall was identified as confusion and the intervention implemented was 1:1 supervision. Review of the Fall Data Collection Form dated 5/24/26 at 4:00 PM revealed Resident 1 was witnessed to fall at the nurses station. The resident was attempting to toilet themself next to the medication cart and fell, hitting their head on the medication cart and falling onto their right side. The resident was unable to state what happened. The root cause of the fall was identified as weakness, confusion, pain, toileting needs, and wandering. The intervention implemented was close observation. Interview with Medication Aide (MA)-B revealed the resident had a decline, was now using a full body lift for transfers and the fall intervention was a bed alarm when the resident was in bed. Interview with the DON on 6/15/26 at 1:30 PM confirmed the resident was identified to be high risk for falls, the intervention implemented for the fall on 4/21/26 was 1:1 supervision, and the intervention implemented for the fall on 5/24/26 was close observation. The DON confirmed the interventions implemented for the falls on 4/21/26 and 5/24/26 were not measurable and were not based on the identified causal factors of the falls.

Licensure Reference Number: 175 NAC 12-006.04D(i) Based on record reviews and interviews; the facility failed to provide full time hours for the designated Director of Nursing (DON) who was working as a Charge Nurse. This failure had the potential for affecting nursing care to all the residents. The total sample size was 15 and the facility census was 30.Findings are: Review of an undated Job Description for the Director of Nursing (DON) revealed the DON was responsible for effective overall management of the Nursing Department and coordination with other disciplines to provide quality care to all residents. The following duties and responsibilities were identified:-ensure nursing interventions meet the physical, personal, and cognitive needs of each resident as well as maximize their self-care capacities, identify, independence, choice, and opportunity for social interaction. -monitors the outcomes of nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agencies standards, coordinating the facility committees, and monitoring the effective use of resources.-assumes full responsibilities for the operation and management of the facility in the temporary absence of the Administrator as directed by the Administrator.-develops short and long range plans for the nursing department that are compatible with those of the facility.-assists in recruiting and selects nursing service employees appropriate to facility need and guidelines of the budget.-works in establishing and facilitating effective employee relations. -maintains adequate staffing ratios and levels of preparation to meet the needs of residents. -participates in the selection of residents admitted by evaluating the level and amount of care required by prospective residents in relation to existing nursing capabilities.-coordinates requirements and cooperates with all other departments in providing favorable physical, social, and emotional environment for residents.-shall work during the day, 4-5 days a week, totaling 40 hours per week, except when it was necessary to vary working hours to provide supervision. Review of the Facility Assessment Resource Tool for staffing revealed the following recommendations regarding Nursing Services. Full time DON, 3 Registered Nurses (RN), 2 Licensed Practical Nurses (LPN), 7 Medication Aides (MA), and 24 Certified Nursing Assistants (CNA). Review of Nursing Schedules for August 2025 revealed from 8/1/25 to 8/29/25 the DON worked as the Charge Nurse on 8/1/25 from 6PM to 9PM, 8/2/24 from 6AM to 10PM, 8/4/25 from 6AM to 6PM and from 6PM to10PM, 8/5/25 from 6AM to 6PM, 8/6/25 from 6AM to 2:30PM, 8/7/25 from 6AM to 6PM, 8/8/25 from 6AM to 6PM, 8/9/25 from 4PM to 10PM, 8/10/25 from 2PM to 10PM, 8/11/25 from 6AM to 6PM, 8/12/25 from 6AM to 6PM, 8/13/25 from 2PM to 6PM, 8/14/25 from 6AM to 6PM, 8/15/25 from 6AM to 1PM, 8/16/25 from 12PM to 6PM, 8/17/25 from 6AM to 6PM, 8/18/25 from 1PM to 6PM, 8/19/25 from 6AM to 6PM, 8/20/25 from 2PM to 6PM, 8/21/25 from 6AM to 10AM, 8/22/25 from 1PM to 6PM, 8/23/25 from 6AM to 6PM and from 6PM to 10PM, 8/24/25 from 6AM to 6PM and from 6PM to 10PM, 8/25/25 from 6AM to 6PM, 8/26/25 from 6AM to 8AM, 8/27/24 from 6AM to 6PM, 8/28/25 from 6AM to 6PM, and on 8/29/25 from 6AM to 9PM. During an interview on 9/2/25 at 3:11 PM, the DON verified working as the only full time RN in the building. The DON worked several hours each week in the Charge Nurse position and was only designating approximately 4 hours a week for the DON role. In addition, the DON reported due to the current schedule the DON had failed to report a fall with injury for Resident 24 on 8/1/25 and an injury of unknown origin on 8/8/25 for Resident 7 as potential abuse allegations and had failed to complete a Discharge Summary for Resident 35 after the resident was discharged home.

Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview; the facility fails to obtain informed consent for the use of psychotropic (medications that effect the brain and alter mental processes, emotions, and behavior) medications for Residents 12,16, 17, and 29. The sample size was 5 and the facility census was 30. Findings are: A. Review of the facility undated policy Use of Psychotropic Medication revealed the following;-Residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). -The indications for use of psychotropic drugs were documented in the medical record. -Targeted symptoms for monitoring were documented in the resident record.-Residents and/or their representative/s were educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. B. Review of Resident 12's MDS (Minimum Data Set-federally mandated comprehensive assessment used to develop resident care plans) dated 7/8/25 revealed the resident cognitive impairment and a TBI (traumatic brain injury). The resident received assistance with bed mobility, transfers, toileting, bathing, and dressing. In addition, the resident had received antipsychotic, antidepressant, and hypnotic medication. Review of Resident 12's Care Plan with a revision date of 7/8/25 revealed the resident took psychotropic medication for behavior management and the facility was to educate the resident/family/caregivers about the risks and benefits, side effects and/or toxic symptoms of the medication/s given. Review of Resident 12's Order Summary dated 9/3/25 revealed the following psychotropic medications:-Ativan (Lorazepam)-an antianxiety medication-1milligram/s (mg) daily -Buspirone HCL an antianxiety medication 5mg two times daily-Lorazepam Oral Concentrate an antianxiety medication 20mg per milliliter (ml), give 1/2 ml by mouth every 2 hours as needed-Seroquel (Quetiapine) an antipsychotic medication 50mg 1 tablet daily-Sertraline HCL an antidepressant medication 50mg 1 tablet daily-Trazadone HCL an antidepressant medication 50mg 1 tablet daily Review of the Psychotropic Informed Consent dated 2/2/25 revealed the facility listed the medication Seroquel (Quetiapine) 25mg 1/2 tab daily on the form. There was no evidence the facility obtained informed consent for the resident's current dose of 50mg of Quetiapine, or any consent for the use of Ativan (Lorazepam), Buspirone, Sertraline, or Trazadone. During an interview on 9/2/25 at 11:44 AM the Director of Nursing (DON) confirmed the facility had no evidence they obtained informed consent for the current dose of Seroquel/Quetiapine or any evidence of consent for the psychotropic medications Sertraline, Trazadone, Buspirone, and Ativan/Lorazepam for Resident 12. C. Review of Resident 16's MDS dated [DATE] revealed Resident 16 had cognitive impairment, used a walker and a wheelchair, received assistance with transfers, toileting, bathing, and dressing, and was occasionally incontinent of urine. The resident had a diagnosis of dementia. Additional information on Resident 16's MDS revealed Resident 16 used a Bed, chair and wander alarms used. Further review revealed the resident had taken antipsychotic and antianxiety medications. Review of Resident 16's Care Plan with a revision date of 6/16/25 revealed the use of a antipsychotic and antianxiety medications for behavior management and the facility was to educate the resident/family/caretaker/s about the risks, benefits, and the side effects of and/or toxic symptoms of psychoactive medications being given. Review of Resident 16's Order Summary revealed the following psychotropic medications:-Lorazepam 0.5 mg daily-Quetiapine 50mg two times daily During an interview on 9/3/25 at 11:19 AM the DON confirmed the facility had no evidence the facility obtained informed consent for Resident 16's psychotropic medications Lorazepam and/or Quetiapine. D. Review of Resident 29's MDS dated [DATE] revealed the resident received assistance with bathing, dressing, hygiene, toileting, bed mobility, and transfers. The resident had Dementia, Anxiety, and Depression. Further review revealed the resident had taken antipsychotic and antidepressant medications. Review of Resident 29's Psychotropic Informed Consent dated 1/27/25 revealed signed consent for Seroquel/Quetipine 25mg daily. There was no further consent for Duloxetine (antidepressant) or for the current dose of Seroquel/Quetiapine 50mg daily. Review of Resident 29's Care Plan with a revision date of 6/12/25 revealed the resident had mood and behavior concern as well as hallucination. The resident had Parkinson's disease and took psychotropic medications. Staff were to educate the resident/family/caregiver about the benefits, risks, and side effects of his psychotropic medication. Review of Resident 29's Order Summary dated 9/3/25 revealed the resident took the following psychotropic medication:-Duloxetine (antidepressant) 60mg daily-Quetiapine 50mg daily During an interview on 9/3/25 at 11:19 AM the DON confirmed the facility had no evidence the facility obtained informed consent for Resident 29's current dose of the antipsychotic medication Seroquel/Quetiapine and no consent for the antidepressant medication Duloxetine. E. Review of Resident 17's MDS dated [DATE] revealed the resident had severe cognitive impairment; required assistance with toileting, dressing, and hygiene; had diagnoses of Alzheimer's Dementia, Anxiety, and Depression; and received antianxiety and antidepressant medications. Review of Resident 17's Care Plan last revised 8/21/25 revealed the resident had cognitive impairment related to Dementia and received antianxiety and antidepressant medications. Review of the facility form Psychotropic Informed Consent for Resident 17 revealed consent for Sertraline 25mg was obtained on 2/14/25. Review of Resident 17's Order Summary Report with active medication orders as of 9/3/25 revealed the resident had an order for Sertraline 50 mg daily with a start date of 3/11/25. Interview on 9/2/25 at 2:00 PM with the DON confirmed Resident 17 had an increase of the Sertraline on 3/11/25 and there was no evidence the facility obtained signed informed consent.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review, and interview; the facility failed to review and revise Care Plans to accurately reflect Residents 5 and 6's Enhanced Barrier Precautions (EBP-an infection control strategy that involves the use of gown and gloves during high contact resident care activities to reduce the spread of drug resistant organisms in settings such as nursing homes) and Residents 7, 12, 16, and 24's fall interventions. The sample size was 12 and the facility census was 30. Findings are: A. Review of the facility policy Baseline Care Plan undated revealed the following:-The facility developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the residents that met professional standards of quality. Review of the undated facility policy Comprehensive Care Plans revealed the following;-The facility developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental health and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.-Resident specific interventions that reflected the resident's needs and preferences and aligned with the resident's cultural identity, as indicated. Review of the facility undated Care Plan Revision Upon Status Change policy revealed the following;-the purpose was to review and revise the care plan as needed to provide a consistent process including updated or modified interventions and to ensure the care plan reflected the resident's current status. B. Review of Resident 12's Minimum Data Set (MDS-federally mandated assessment used to develop resident care plans) dated 7/8/28 revealed the resident was cognitively impaired, used both a w/c and walker, and received assistance with transfers, toileting hygiene, dressing and bathing. The resident had 2 or more falls with minor injuries and used bed, chair, and wander alarms daily. The resident was diagnosed with dementia. Review of Resident 12's Fall Events revealed the following:-On 5/25/25 at 10:10 AM the resident was found in lobby on hands and knees. The fall was alarm ringing. There was no evidence the facility identified a cause for the fall or updated the care plan.-On 6/8/25 at 2:50 PM the resident was found sitting on the floor in another resident's room. There was no evidence the facility identified a cause for the fall or updated the care plan. -On 6/8/25 at 1:30 PM the resident was seen kneeling out of the wheelchair to pick up food off the floor in the dining room. The facility had no evidence they updated the care plan. -On 6/22/25 at 4:40 PM the resident was seen falling near the nurses' station after standing up from a wheelchair, attempted to walk and then fell. The resident obtained a small abrasion on the left side of back. There was no evidence the facility identified a cause for the fall or updated the care plan. Review of Resident 12's Care Plan with a revision date of 7/8/25 revealed the resident was at risk for falling and had falls on 5/1/25, 5/13/25, 5/25/25, 6/8/25 x 2, and 6/22/25. Interventions included encouraging activity such as folding laundry, prompt response to assistance requests, educating the resident/family/caregivers about safety, ensuring the functioning of bed and chair alarms, anticipating the resident's needs, ensuring a safe environment, and re-evaluation to ensure continued appropriateness of interventions. On 5/1/25 the care plan was updated, indicating staff were to ensure anti-rollbacks on the wheelchair were functioning properly, and to ensure the bed and chair alarms were functioning properly. On 5/13/25 the staff were to check the residents' blood pressure for 3 days and notify the doctor with the results. There was no evidence the facility implemented any new interventions after 5/13/25. During an interview on 9/3/25 at 8:41 AM the Director of Nursing (DON) confirmed that Charge Nurses were to review falls and implement new measures to prevent ongoing falls for Resident 12. Further review revealed the facility had no evidence the facility was identifying causal factors and implementing new measures to prevent falls for Resident 12 and revising the care plan of new interventions. C. Review of Resident 16's MDS dated [DATE] had cognitive impairment, used a walker and a wheelchair, received assistance with transfers, toileting, bathing, and dressing, and was occasionally incontinent of urine. The resident had a diagnosis of dementia. Bed, chair and wander alarms were in use. Further review revealed the resident had fallen and sustained minor injury. Review of Resident 16's Fall Events revealed the following;-On 5/21/25 at 7:15 AM the resident was sitting on the floor beside the bed and reported sliding off the bed while try to put on shoes. The pressure pad alarm (fall alarm) was not working. There was no indication what the facility did to correct or ensure a function pressure pad alarm or updated the care plan. -On 5/25/25 at 3:10 AM the resident was lying on the floor with forehead against the nightstand. There was no evidence the facility identified a cause for the fall or updated the care plan.-On 5/30/25 at 6:00 AM the resident was found sitting on the floor in front of the bed. There was no evidence the facility identified a cause for the fall or updated the care plan.-On 6/15/25 at 4:00 PM the resident was on a floor mat next to the bed with head next to the night stand. A bruised and area was noted on right side of the head with some bleeding from the bruised area. There was no evidence the facility identified a cause for the fall or updated the care plan. -On 6/22/25 at 12:15 AM The resident was lying on the floor beside the bed with forehead touching the nightstand. There was no evidence the facility identified a cause for the fall or updated the care plan. Review of Resident 16's Care Plan with a revision date of 6/13/25 revealed the resident was determined to be at high risk for falling due to confusion, gait/balance problems, poor communication/comprehension, psychoactive (mind altering) drug use, and a lack of safety awareness. The facility staff were to keep the residents' call-light in reach and encourage it's use. The resident required prompt responses to all requests for assistance. The resident was to be encouraged to participate in physical activity to promote strength and improved mobility. In addition, staff were to review past falls to determine possible causes, and alter causes if possible. There was no evidence the care plan approaches were updated following the residents falls on 5/21/25, 5/25/25, 5/30/25, 6/15/25, and 6/22/25. During an interview on 9/3/25 at 8:41 AM the DON confirmed that Charge Nurses were to review falls and implement new measures to prevent ongoing falls for Resident 16. In addition, the facility failed to update Resident 16's Care Plan with new fall prevention interventions following falls. D. Review of Resident 5's MDS dated [DATE] revealed the resident was cognitively intact; required assistance with dressing, hygiene, and mobility; had heart disease; and had a Stage 2 (a partial thickness skin loss that presents as an abrasion, blister or a shallow crater) pressure ulcer with application of a dressing. Review of Resident 5's Care Plan last revised 7/29/25 revealed the resident required extensive assist with mobility, transfers, dressing, toileting, and hygiene; was at risk for skin breakdown, and there was no documentation that the resident had EBP in place. Interview with Resident 5 on 8/27/25 at 1:21 PM revealed the resident had an open wound with a dressing to their buttocks and staff had to wear Personal Protective Equipment (PPE-gowns and gloves) while providing cares. The following observations were made for Resident 5: -on 8/27/25 at 10:00 AM there was a sign on the residents door indicating the resident had EBP in place with PPE noted behind the resident door, and -on 8/28/25 at 12:50 PM the resident had refused an observation of cares, but the EBP sign was located on the resident's door and NA-C was observed performing hand hygiene and putting on a gown and gloves upon entering the resident room. Review of Resident 5's Order Summary Report with active orders as of 9/3/25 revealed they had an order for a duoderm (a type of wound dressing with a water proof backing used to protect wounds to buttocks wound every 7 days and as needed with an order date of 6/27/25. Interview on 8/28/25 at 12:50 PM with the DON confirmed the resident was on EBP. Further interview on 9/3/25 at 9:30 AM confirmed EBP was not implemented onto Resident 5's care plan. E. Review of Resident 6's MDS dated [DATE] revealed the resident was cognitively intact; dependent with toileting and dressing and was independent with hygiene; had diagnoses of Diabetes, Anxiety, and Schizophrenia (a mental health condition that affects the way a person thinks, feels, and behaves); and was frequently incontinent of bladder. Review of Resident 6's Care Plan last revised 8/21/25 revealed the resident required assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. There was no documentation that the resident had EBP in place. The following observations were made for Resident 6: -on 8/27/25 at 1:30 PM, there was a sign on the resident's door indicating the resident had EBP in place with PPE noted behind the resident door, and -on 9/2/25 at 12:10 PM, the resident was in the resident room working with NA-C and NA-H. Both NA's had on PPE. The resident refused to allow observation of cares and there was a sign on the resident's door indicating EBP was in place. Interview on 9/3/25 at 9:30 AM with the DON revealed Resident 6 had EBP in place due to the resident having a urinary tract infection. Further interview confirmed that EBP was not implemented onto the resident's care plan. F. Review of Resident 7's MDS dated [DATE] revealed the resident was cognitively intact; was independent with toileting, dressing, and hygiene; had diagnoses of Stroke, Heart Disease, Arthritis, and Fractures; and had 2 or more falls with no injury, 1 fall with a minor injury, and 1 fall with a major injury. Review of Resident 7's Care Plan last revised 8/21/25 revealed the resident required assistance with mobility, was at a high risk for falls, and there was 1 documented fall intervention implemented in 2025. Review of the facility incident forms for falls regarding Resident 7 revealed the following: -a fall on 3/27/25 at 9:45 PM the resident was found on the floor on their hands and knees with no immediate intervention, -a fall on 6/16/25 at 9:45 PM the resident was found on the floor by the bed laying on their left side with no immediate intervention, -a fall on 6/26/25 at 7:05 AM the resident was found sitting on the floor on their buttocks with no immediate intervention. Interview with the DON on 9/3/25 at 11:45 AM confirmed interventions were not changed/revised for Resident 7's falls on 3/27/25, 6/16/25, and 6/26/25. G. Review of Resident 24's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of anemia, heart failure, stroke, and depression. The following was assessed for the resident: -cognition was moderately impairment. -incontinent of bowel and bladder. -required moderate staff assistance with personal hygiene, dressing, transfers, toileting hygiene and bed mobility. -two or more falls without injury since the previous assessment. Review of an Incident Report dated 4/25/25 at 6:10 PM revealed the resident was found on the floor of the resident's room next to the bed. Resident 24 indicated attempting to get into bed and then sliding onto the floor. Review of an Incident Report dated 5/3/25 at 10:11 PM revealed the staff found the resident on the floor outside of the resident's bathroom. The resident's walker was lying sideways on the floor next to the resident. Review of an Incident Report dated 6/25/25 at 1:00 PM revealed the resident was found seated on the floor and reported trying to transfer out of bed without locking wheelchair brakes and then falling to the floor. Review of an Incident Report dated 7/1/25 at 2:30 AM revealed the resident was found on the floor of the resident's room. The resident identified attempting to get out of the bed to use the bathroom and then falling. A new intervention was identified to ensure the resident wore gripper socks at night. Review of the current Care Plan for Resident 24 with a revision date of 7/1/25 revealed the resident was at risk for falls due to deconditioning, problems with gait and balance and history of falls. The residents' falls on 6/25/25 and on 7/1/25 were identified on the assessment. The following interventions were identified with the dates of their implementation: -12/10/24 hourly rounds for safety. -12/10/24 encourage the resident to use the call light and wait for assistance with walking/toileting. -12/10/24 signs placed in the resident's room and bathroom to remind the resident to use the call light and wait for assistance. -12/10/24 chair/bed electronic fall alarm. -12/10/24 video monitor placed to allow staff to see when the resident was attempting to get out of bed without assistance. -7/1/25 gripper socks on at night. Review of a Nursing Progress Note dated 8/21/25 revealed at 2:15 AM, the staff heard a loud noise and found the resident on the floor of the resident's room. A laceration was observed to the back of the resident's head and the resident complained of pain to the right elbow. The resident was transferred to the emergency room for evaluation. Observations of Resident 24 on 9/2/25 revealed the following: -8:30 AM the resident was seated in the wheelchair in the facility dining room at the breakfast meal. No fall alarm was observed to the resident's chair. -9:45 AM the resident was lying in bed in the resident's room. No fall alarm was in place to the resident's bed. -10:03 AM and 12:57 PM the resident was in the wheelchair and no fall alarm was in place. During an observation on 9/3/24 at 7:15 AM revealed Resident 24 was seated in a wheelchair in the commons area next to the Nurses Station. No fall alarm was observed on the resident's wheelchair. During an interview on 9/2/25 at 11:13 AM, the DON confirmed the residents' falls on 4/25/25 at 6:10 PM, 5/3/25 at 10:11 PM and on 8/21/25 at 2:15 AM were not identified on the resident's care plan. In addition, the fall alarm to the resident's bed and wheelchair were no longer in use as the resident was noncompliant. This intervention should have been removed from the residents' care plan.

Licensure Reference Number 175 NAC 12-006.09(I)(i)Based on interview and record review; the facility failed to review for causal factors and implement measures to prevent ongoing falls for Resident's 12, 16, 7, and 24. The sample size was 4 and the facility census was 30. Findings are: A. Review of the undated facility policy Accidents and Supervision revealed the following;-The resident environment remained as free from accident hazards as possible.-Each resident received adequate supervision and assistive devices to prevent accidents. -The facility established and utilized a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents through Identification, Evaluation and Analysis, Implementation of Interventions, and Monitoring and Modification. Review of the undated facility Fall Checklist revealed the following;-The fall and an intervention were to be added to the resident care plan.-The investigation included a root cause analysis of the fall and an intervention to prevent future falls. B. Review of Resident 12's Minimum Data Set (MDS-federally mandated assessment used to develop resident care plans) dated 7/8/28 revealed the resident was cognitively impaired, used both a w/c and walker, and received assistance with transfers, toileting hygiene, dressing and bathing. The resident had 2 or more falls with minor injuries and used bed, chair, and wander alarms daily. The resident was diagnosed with dementia. Review of Resident 12's Fall Events revealed the following:-On 5/1/25 at 5:30 PM the resident was found sitting on the floor in the hallway, holding onto the handrail. The resident reported getting something out of a pocket and sliding to knees. It was noted the antiroll backs on the w/c were loose and the residents' alarm was turned off. Further note indicated the resident had turned the alarm off 2 previous times during the shift. The resident's plan of care was ongoing. There was no evidence the facility identified a cause for the fall. -On 5/1/25 at 8:50 PM the resident was found lying on the floor in the facility lobby. The wheelchair brakes were not locked. There was no evidence the facility identified a cause for the fall. -On 5/13/25 at 9:20 PM the resident was found kneeling on the floor in front of the wheelchair in a linen closet. The resident got back into the wheelchair unassisted after the fall and reported slipping out of the wheelchair while try to get a nightgown. -On 5/25/25 at 10:10 AM the resident was found in lobby on hands and knees. The fall was alarm ringing. There was no evidence the facility identified a cause for the fall.-On 6/8/25 at 2:50 PM the resident was found sitting on the floor in another resident's room. There was no evidence the facility identified a cause for the fall.-On 6/8/25 at 1:30 PM the resident was seen kneeling out of the wheelchair to pick up food off the floor in the dining room. The facility had no evidence they were reviewing each fall for causal factors and/or implementing new measures to prevent on-going falls. -On 6/22/25 at 4:40 PM the resident was seen falling near the nurses' station after standing up from a wheelchair, attempted to walk and then fell. The resident obtained a small abrasion on the left side of back. There was no evidence the facility identified a cause for the fall. Review of Resident 12's Care Plan with a revision date of 7/8/25 revealed the resident was at risk for falling and had falls on 5/1/25, 5/13/25, 5/25/25, 6/8/25 x 2, and 6/22/25. Interventions included encouraging activity such as folding laundry, prompt response to assistance requests, educating the resident/family/caregivers about safety, ensuring the functioning of bed and chair alarms, anticipating the resident's needs, ensuring a safe environment, and re-evaluation to ensure continued appropriateness of interventions. On 5/1/25 the care plan was updated, indicating staff were to ensure anti-rollbacks on the wheelchair were functioning properly, and to ensure the bed and chair alarms were functioning properly. On 5/13/25 the staff were to check the residents' blood pressure for 3 days and notify the doctor with the results. There was no evidence the facility implemented any new interventions after 5/13/25. During an interview on 9/3/25 at 8:41 AM the Director of Nursing (DON) confirmed that Charge Nurses were to review falls and implement new measures to prevent ongoing falls for Resident 12. Further review revealed the facility had no evidence the facility was identifying causal factors and implementing new measures to prevent falls for Resident 12. C. Review of Resident 16's MDS dated [DATE] had cognitive impairment, used a walker and a wheelchair, received assistance with transfers, toileting, bathing, and dressing, and was occasionally incontinent of urine. The resident had a diagnosis of dementia. Bed, chair and wander alarms were in use. Further review revealed the resident had fallen and sustained minor injury. Review of Resident 16's Fall Events revealed the following;-On 5/21/25 at 7:15 AM the resident was sitting on the floor beside the bed and reported sliding off the bed while try to put on shoes. The pressure pad alarm (fall alarm) was not working. There was no indication what the facility did to correct or ensure a function pressure pad alarm. -On 5/25/25 at 3:10 AM the resident was lying on the floor with forehead against the nightstand. There was no evidence the facility identified a cause for the fall.-On 5/30/25 at 6:00 AM the resident was found sitting on the floor in front of the bed. There was no evidence the facility identified a cause for the fall.-On 6/15/25 at 4:00 PM the resident was on a floor mat next to the bed with head next to the night stand. A bruised and area was noted on right side of the head with some bleeding from the bruised area. There was no evidence the facility identified a cause for the fall. The bed was replaced with a low bed. -On 6/22/25 at 12:15 AM The resident was lying on the floor beside the bed with forehead touching the nightstand. There was no evidence the facility identified a cause for the fall. Review of Resident 16's Care Plan with a revision date of 6/13/25 revealed the resident was determined to be at high risk for falling due to confusion, gait/balance problems, poor communication/comprehension, psychoactive (mind altering) drug use, and a lack of safety awareness. The facility staff were to keep the residents' call-light in reach and encourage it's use. The resident required prompt responses to all requests for assistance. The resident was to be encouraged to participate in physical activity to promote strength and improved mobility. In addition, staff were to review past falls to determine possible causes, and alter causes if possible. There was no evidence the care plan approaches were updated following the residents falls on 5/21/25, 5/25/25, 5/30/25, 6/15/25, and 6/22/25. During an interview on 9/3/25 8:41 AM the DON confirmed that Charge Nurses were to review falls and implement new measures to prevent ongoing falls for Resident 16. In addition, the facility failed to update Resident 16's Care Plan with new fall prevention interventions following falls. D. Review of Resident 7's MDS dated [DATE] revealed the resident was cognitively intact; was independent with toileting, dressing, and hygiene; had diagnoses of Stroke, Heart Disease, Arthritis, and Fractures; and had 2 or more falls with no injury, 1 fall with a minor injury, and 1 fall with a major injury. Review of Resident 7's Care Plan last revised 8/21/25 revealed the resident required assistance with mobility, was at a high risk for falls, and there was 1 documented fall intervention implemented in 2025. Review of the facility incident forms for falls regarding Resident 7 revealed the following: -a fall on 3/27/25 at 9:45 PM the resident was found on the floor on their hands and knees with no immediate intervention, -a fall on 6/16/25 at 9:45 PM the resident was found on the floor by the bed laying on their left side with no immediate intervention, -a fall on 6/26/25 at 7:05 AM the resident was found sitting on the floor on their buttocks with no immediate intervention. Interview with the DON on 9/3/25 at 11:45 AM confirmed there were no interventions for the falls on 3/27/25, 6/16/25, and 6/26/25 documented. E. Review of Resident 24's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of anemia, heart failure, stroke, and depression. The following was assessed for the resident: -cognition was moderately impairment. -incontinent of bowel and bladder. -required moderate staff assistance with personal hygiene, dressing, transfers, toileting hygiene and bed mobility. -two or more falls without injury since the previous assessment. Review of an Incident Report dated 4/25/25 at 6:10 PM revealed the resident was heard calling for assistance. The staff found the resident on the floor of the resident's room next to the bed. Resident 24 indicated attempting to get into bed and then slid onto the floor. Further review of the report revealed no causal factors were identified regarding the fall. Review of the resident's electronic medical record revealed no evidence a new intervention was developed or that current interventions were reviewed and/or revised. Review of an Incident Report dated 5/3/25 at 10:11 PM revealed the staff found the resident on the floor outside of the resident's bathroom. The resident's walker was lying sideways on the floor next to the resident. Review of the resident's electronic medical record revealed no documentation to indicate causal factors were assessed, a new fall intervention was developed/implemented or that current interventions were reviewed and/or revised. Review of an Incident Report dated 6/25/25 at 1:00 PM revealed the resident was heard calling for help. The resident was found seated on the floor and reported to staff attempting to transfer out of bed, not locking wheelchair brakes, and then falling to the floor. The resident had been sleeping on top of the comforter and was incontinent of urine. Further review of the report revealed no evidence current fall interventions were assessed for revision or that a new intervention was developed to prevent further falls. Review of an Incident Report dated 7/1/25 at 2:30 AM revealed the resident was found on the floor of the resident's room. The resident identified attempting to get out of the bed to use the bathroom and then falling. A new intervention was identified to ensure the resident wore gripper socks at night. Review of a current Care Plan with a revision date of 7/1/25 revealed the resident was at risk for falls due to deconditioning, problems with gait and balance and history of falls. The following interventions were identified with the dates of their implementation: -12/10/24 hourly rounds for safety. -12/10/24 encourage the resident to use the call light and wait for assistance with walking/toileting. -12/10/24 signs placed in the resident's room and bathroom to remind the resident to use the call light and wait for assistance. -12/10/24 chair/bed electronic fall alarm. -12/10/24 video monitor placed to allow staff to see when the resident was attempting to get out of bed without assistance. -7/1/25 gripper socks on at night. Review of a Nursing Progress Note dated 8/21/25 revealed at 2:15 AM, the staff heard a loud noise and found the resident on the floor of the resident's room. A laceration was observed to the back of the resident's head and the resident complained of pain to the right elbow. The resident was transferred to the emergency room for evaluation. Review of the resident's electronic medical record revealed no evidence an Incident Report had been completed to determine causal factors and no new fall interventions were identified or current interventions revised to prevent further falls. During an interview on 9/2/25 at 11:13 AM, the DON confirmed the staff were to assess each fall to determine causal factors and then to develop new interventions or revise current interventions to prevent further falls. The DON verified with Resident 24's falls on 4/25/25 at 6:10 PM, 5/3/25 at 10:11 PM, and on 8/21/25 at 0215 the facility staff failed to identify causal factors and to revise and/or develop new interventions to prevent ongoing falls. Regarding the resident's fall on 6/25/25 at 1:00 PM, causal factors were identified however, no new interventions were developed.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report a fall with injury for Resident 24 and an injury of unknown origin for Resident 7 as potential allegations of abuse and/or neglect. The sample size was 2 and the facility census was 30. Findings are: A. Review of the undated facility policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed it was the policy of the facility to report all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation of resident property. Allegations were to be reported immediately to the Administrator and to other appropriate agencies in accordance with current state and federal regulations within the prescribed timeframes. The Administrator or designee was to notify the appropriate agencies immediately; as soon as possible, but no later than 24 hours after the discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming suspicion. B. Review of Resident 24's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/6/25 revealed the resident was admitted [DATE] with diagnoses of anemia, heart failure, stroke, and depression. The following was assessed for the resident: -cognition was moderately impairment. -incontinent of bowel and bladder. -required moderate staff assistance with personal hygiene, dressing, transfers, toileting hygiene and bed mobility. -two or more falls without injury since the previous assessment. Review of a Nursing Progress Note dated 8/21/25 revealed at 2:15 AM, the staff heard a loud noise and found the resident on the floor of the resident's room. A laceration was observed to the back of the resident's head and the resident complained of right elbow pain. The resident was transferred to the emergency room for evaluation. Review of Discharge Instructions dated 8/21/25 at 6:10 AM revealed the resident was to wear a sling for 1-2 days to the right arm and to use ice and Tylenol to address the resident's pain. In addition, an order was received to have the 9 staples to the back of the resident's head removed in 10 days. Review of the facility's reports of alleged and/or suspected abuse from 8/22/24 through 8/21/25 revealed no documentation a report had been filed for the allegation of potential abuse/neglect related to Resident 24's fall with injury. During an interview on 9/2/25 at 11:13 AM, the Director of Nursing (DON) confirmed the following regarding Resident 24: -the resident had an unwitnessed fall on 8/21/25 at 2:15 AM in the resident's room and sustained a laceration to the back of the head which required sutures. -the facility did not report the resident's fall with injury to the State Agency as a potential abuse/neglect allegation. C. Review of Resident 7's MDS dated [DATE] revealed the resident was cognitively intact; was independent with toileting, dressing, and hygiene; had diagnoses of Stroke, Heart Disease, Arthritis, and Fractures; and had 2 or more falls with no injury, 1 fall with a minor injury, and 1 fall with a major injury. Review of Resident 7's Care Plan last revised 8/21/25 revealed the resident required assistance with mobility, was at a high risk for falls, and on 7/29/25 the resident had a fall. The resident and family declined for the resident to be sent to the emergency room. On 8/12/25 the resident complained of arm/chest pain when lifting their arm. The resident was sent to their Primary Care Practitioner (PCP) and had an Xray done which showed a new 8th rib fracture, although they were unable to determine the age of the fracture. Review of the facility form Consultation Visit Report dated 8/8/25 for Resident 7 revealed the resident was complaining of sharp pain to the left upper chest which increased with pressure, deep breathing, cough and movement. The resident rated pain 10 out of 10. The resident first alerted staff of the pain on 8/7/25 in the afternoon during therapy. The PCP documented the resident was sent for a chest Xray and rib Xray and the PCP would inform the facility of results once they had them. Review of the facility form Imaging Information dated 8/12/25 with Xray results revealed Resident 7 had an old left 10th rib fracture and the age was not able to be determined of a rib fracture to the left 8th rib that was not identified on a prior scan which suggested the fracture to the 8th rib was acute (sudden onset, opposite of chronic). The PCP documented that the resident had a fracture of the 8th rib, unable to tell how old it is but it could possibly be new and the fracture to the 10th rib was old. Review of Resident 7's Progress Notes revealed the following entries: -an entry on 8/9/25 at 2:00 AM The resident was seen in clinic on 8/8/25. The resident taken for X-rays of the chest and left ribs and the PCP will report results next week., -an entry on 8/12/25 at 4:52 PM A fax was received with results of X-rays. It states: Chest X-ray is clear; X-ray of left ribs shows a fracture of the 8th rib. They can't tell how old it is. It possibly could be new. Resident 7 has a fracture of the 10th rib, this is an old fracture, but it did not heal correctly., and -an entry on 8/12/25 at 9:04 PM Fax returned stating the resident has a fracture of 8th posterior left rib. The residents Power of Attorney was notified. Interview on 9/2/25 at 11:45 with the DON confirmed the rib fracture was not reported to the State Agency within the required time frame.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on interview and record review; the facility failed to investigate and to submit the results of the investigation to the State Agency within the required time frame a fall with significant injury for Resident 24 and an injury of unknown origin for Resident 7. The sample size was 2 and the facility census was 30. Findings are: A. Review of the undated facility policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed it was the policy of the facility to report all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation of resident property. Allegations were to be reported immediately to the Administrator. The Administrator or designee were to ensure all alleged or suspected violations were thoroughly investigated and were to prevent further potential abuse while the investigation was in progress. The results of all investigations were to be reported to other officials in accordance with state law, including the State Survey and Certification Agency within 5 working days of the event. If the alleged or suspected violation was verified, appropriate corrective action was to be taken. B. Review of Resident 24's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/6/25 revealed the resident was admitted [DATE] with diagnoses of anemia, heart failure, stroke, and depression. The following was assessed for the resident: -cognition was moderately impairment. -incontinent of bowel and bladder. -required moderate staff assistance with personal hygiene, dressing, transfers, toileting hygiene and bed mobility. -two or more falls without injury since the previous assessment. Review of a Nursing Progress Note dated 8/21/25 revealed at 2:15 AM, the staff heard a loud noise and found the resident on the floor of the resident's room. A laceration was observed to the back of the resident's head and the resident complained of pain to the right elbow. The resident was transferred to the emergency room for evaluation. Review of Discharge Instructions dated 8/21/25 at 6:10 AM revealed the resident was to wear a sling for 1-2 days to the right arm and to use ice and Tylenol to address the resident's pain. In addition, an order was received to have the 9 staples to the back of the resident's head removed in 10 days. Review of the facility's reports of alleged and/or suspected abuse from 8/22/24 through 8/21/25 revealed no documentation an investigation was completed regarding Resident 24's fall with significant injury. During an interview on 9/2/25 at 11:13 AM, the Director of Nursing (DON) confirmed the following regarding Resident 24: -the resident had an unwitnessed fall on 8/21/25 at 2:15 AM in the resident's room and sustained a laceration to the back of the head which required sutures. -the facility failed to complete an investigation of potential abuse/neglect for the resident's fall and to submit the results of the investigation to the State Agency. C. Review of Resident 7's MDS dated [DATE] revealed the resident was cognitively intact; was independent with toileting, dressing, and hygiene; had diagnoses of Stroke, Heart Disease, Arthritis, and Fractures; and had 2 or more falls with no injury, 1 fall with a minor injury, and 1 fall with a major injury. Review of Resident 7's Care Plan last revised 8/21/25 revealed the resident required assistance with mobility, was at a high risk for falls, and on 7/29/25 the resident had a fall. The resident and family declined for the resident to be sent to the emergency room. On 8/12/25 the resident complained of arm/chest pain when lifting their arm. The resident was sent to their Primary Care Practitioner (PCP) and had an Xray done which showed a new 8th rib fracture, although they were unable to determine the age of the fracture. Review of the facility form Consultation Visit Report dated 8/8/25 for Resident 7 revealed the resident was complaining of sharp pain to the left upper chest which increased with pressure, deep breathing, cough and movement. The resident rated pain 10 out of 10. The resident first alerted staff of the pain on 8/7/25 in the afternoon during therapy. The PCP documented the resident was sent for a chest Xray and rib Xray and the PCP would inform the facility of results once they had them. Review of the facility form Imaging Information dated 8/12/25 with Xray results revealed Resident 7 had an old left 10th rib fracture and the age was not able to be determined of a rib fracture to the left 8th rib that was not identified on a prior scan which suggested the fracture to the 8th rib was acute (sudden onset, opposite of chronic). The PCP documented that the resident had a fracture of the 8th rib, unable to tell how old it is but it could possibly be new and the fracture to the 10th rib was old. Review of Resident 7's Progress Notes revealed the following entries: -an entry on 8/9/25 at 2:00 AM The resident was seen in clinic on 8/8/25. The resident taken for X-rays of the chest and left ribs and the PCP will report results next week., -an entry on 8/12/25 at 4:52 PM A fax was received with results of X-rays. It states: Chest X-ray is clear; X-ray of left ribs shows a fracture of the 8th rib. They can't tell how old it is. It possibly could be new. Resident 7 has a fracture of the 10th rib, this is an old fracture, but it did not heal correctly., and -an entry on 8/12/25 at 9:04 PM Fax returned stating the resident has a fracture of 8th posterior left rib. The residents Power of Attorney was notified. Interview on 9/2/25 at 11:45 with the DON confirmed the rib fracture was not investigated and a report was not submitted to the State Agency within the required time frame.

Number of residents sampled: 1Number of residents cited: 1Based on record review and interview; the facility failed to ensure a comprehensive discharge summary for completed for Resident 35. Licensure Reference Number NAC 175-12 006.09(G)(i)7Based on record review and interview; the facility failed to document a recapitulation (a complete summary of the residents stay in nursing facility from admittance to discharge) for a resident-initiated discharge for 1 (Resident 35) of 1 sampled resident. The facility identified a census of 30. Findings are: A. Review of the facility Discharge Summary and Plan with a revision date of 12/2016 revealed when a resident's discharge was anticipated, a discharge summary and post-discharge plan were to be developed to assist the resident to adjust to their new living environment. The discharge summary was to include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge. The summary was to include the following:-current diagnoses.-medical history.-course of illness, treatment, and/or therapy since entering the building.-current laboratory, radiology, consultation, and diagnostic tests results. -physical and mental functioning.-ability to perform activities of daily living.-sensory and physical impairments.-nutritional status.-special treatments and procedures.-mental and psychosocial status.-discharge potential.-dental condition.-activities potential.-rehabilitation potential. -cognitive status.-medication therapy. B. Review of Resident 35's undated Care Plan revealed the resident was admitted [DATE]. The resident had been living independently at home, fell and dislocated the resident's right shoulder. The resident had a goal to return to home when safe and when care and rehabilitation goals were met. Review of a Nursing Progress Note dated 6/13/25 at 11:55 AM revealed the resident was discharged home with all belongings and own medications. Review of a Discharge Summary-Interdisciplinary form dated 6/13/25 at 1:04 PM for Resident 35 revealed no documentation of a recapitulation summary of the residents stay at the facility. During an interview with the Director of Nursing (DON) on 9/3/25 at 9:52 AM the DON confirmed a discharge summary with a recapitulation of the resident's stay at the facility had not been completed when the resident was discharged on 6/13/25.

Licensure Reference Number 175 NAC 12-006.09(C)(ii)Based on record review and interview; the facility failed to ensure a Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) was completed for Resident 12 for a hospice admission. The sample size was 12 and the facility census was 30.Findings are: Review of the undated facility policy MDS 3.0 Completion revealed the following;-The residents were assessed, using a comprehensive assessment which used core elements for use in assessing nursing home residents.-According to Federal regulation, the facility conducted initial and periodic comprehensive, accurate and standardized assessment of each resident's functional capacity, using the resident assessment instrument specified by the State. -Assessments completed included initial/admission assessment, annual assessment, and significant change assessment.-All disciplines followed the guidelines used in the current Resident Assessment Instrument (RAI-a standardized, comprehensive process used in nursing facilities to evaluate resident's needs, strengths, and preferences to create individualized care plans and ensure high quality care and life) manual for coding each assessment.Review of the undated facility policy Hospice Services Facility Agreement revealed the following;-The facility policy was to provide and/or arrange for hospice services to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. -If hospice is furnished in the facility through an agreement, the facility ensured the hospice services met professional standards.-The facility had a designee responsible for working with hospice representatives for coordination of care planning, communication with hospice representatives, and coordination of care provision. Review of Resident 12's Physician Orders revealed the resident was admitted to hospice on 4/28/25. Review of Resident 12's MDS quarterly assessment dated [DATE] revealed the resident had cognitive impairment, received assistance with bed mobility, transfers, toileting, bathing, and dressing. The resident had neurological conditions including a traumatic brain injury and was also receiving hospice services. Further review of Resident 12's MDS assessments revealed no assessments were completed following Resident 12's admission to hospice until 7/8/25 (more than 2 months later) and revealed no significant change assessment was completed as required when a resident is admitted to hospice care. During an interview on 9/3/25 at 11:00 AM the Director of Nursing confirmed the facility had not completed a significant change MDS as required when the Resident 12 was admitted to hospice.

Licensure Reference Number 175 NAC 12-006.09(B)(iv)Based on record review and interview; the facility failed to ensure Resident 2's MDS (Minimum Data Set-federally mandated comprehensive assessment used to develop resident care plans) was coded accurately to reflect which type of medications were being administered. The sample size was 12 and the facility census was 30.Findings are: Review of the undated facility policy MDS 3.0 Completion revealed the following;-The residents were assessed, using a comprehensive assessment which used core elements for use in assessing nursing home residents.-According to Federal regulation, the facility conducted initial and periodic comprehensive, accurate and standardized assessment of each resident's functional capacity, using the resident assessment instrument specified by the State. -Assessments completed included initial/admission assessment, annual assessment, and significant change assessment.-All disciplines followed the guidelines used in the current Resident Assessment Instrument (RAI-a standardized, comprehensive process used in nursing facilities to evaluate resident's needs, strengths, and preferences to create individualized care plans and ensure high quality care and life) manual for coding each assessment.Review of Resident 2's MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] and had diagnoses of heart disease, hypertension, and fractures and had received antidepressant, hypnotic, anticoagulant, antibiotic, opioid, and anticonvulsant medication. Review of Resident 2's Medication Administration record dated August 2025 revealed no evidence the resident had taken hypnotic medication. Review of Resident 2's Care Plan dated 8/6/25 revealed the resident was admitted to the facility following a hospitalization following a fall for a rehabilitative stay with a plan to return home. There was no evidence the resident had insomnia and no evidence the resident was taking hypnotic medication. During an interview on 9/3/25 at 11:25 AM the Director of Nursing (DON) confirmed Resident 2 was not taking a hypnotic medication and the MDS with a reference date of 8/8/25 Section N (Medications) was not accurately coded.During an interview on 9/3/25 at 1:00 PM Licensed Practical Nurse (LPN)-G confirmed having coded Resident 2's MDS as having taken a hypnotic medication not knowing the medication was actually an antidepressant and not a hypnotic.

Licensure Reference Number 175 NAC 12-006.09ABased on record review and interview: the facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) screen was completed accurately for 1 (Resident 6) of 1 sampled residents. Findings are: Review of the facility policy Resident Assessment Coordination with PASARR Program, undated revealed the following:-the facility would coordinate assessments with the preadmission screening and resident review to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate for their needs,-all applicants would be screened for serious mental disorders, intellectual disabilities and related conditions,-a negative Level I screen permitted admission and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later,-a positive Level I screen necessitated a PASARR Level II evaluation prior to admission,-PASARR Level II was a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that would determine whether the individual had a mental disorder, intellectual disability or a related condition, determined the appropriate setting for the individual, and recommended any specialized services and/or rehabilitative services the individual needed,-the Social Services Director would be responsible for keeping track of each resident's PASARR screening status and would refer to the appropriate authority, and-any resident who exhibited a newly evident or possible serious mental disorder, intellectual disability, or a related condition would be referred promptly to the state mental health or intellectual disability authority for Level II review. Review of Resident 6's Minimum Data Set (MDS- a federally mandated assessment tool used in Care Planning, dated 8/13/25 revealed the resident was admitted on [DATE], received antipsychotic and antianxiety medications, and diagnoses included Anxiety and Schizophrenia (a mental health condition that affects the way a person thinks, feels, and behaves). Review of Resident 6's Care Plan last revised 8/21/25 revealed the resident was taking antidepressant and antipsychotic medications. Review of Resident 6's Order Summary Report with active medications as of 9/3/25 revealed an order for Latuda (an antipsychotic medication) with a start date of 8/1/25 with a diagnosis of Schizoaffective Disorder (a mental health condition including Schizophrenia and a mood disorder), Bipolar (a mental health disorder that causes changes in a person's mood, energy, and ability to function). Review of Resident 6's PASARR dated 8/1/25 revealed no documentation that the resident was taking an antipsychotic with a mental health diagnosis. An interview on 9/2/25 at 2:00 PM with the Director of Nursing confirmed Resident 6 was taking an antipsychotic, had a diagnosis of Schizoaffective disorder with Bipolar that was not indicated on the PASARR and it should have been included.

Licensure Reference Number 175 NAC 12-006.09(E)Based on record review and interview; the facility failed to ensure Resident 2's Care Plan was comprehensive and accurately reflected the residents diagnoses and high-risk medication use. The sample size was 12 and the facility census was 30. Findings are: Review of the facility policy Baseline Care Plan undated revealed the following:-The facility developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality. Review of the undated facility policy Comprehensive Care Plans revealed the following;-The facility developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental health and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.-Resident specific interventions that reflected the resident's needs and preferences and align with the resident's cultural identity, as indicated. Review of Resident 2's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop care plans) dated 8/8/25 revealed the resident was admitted to the facility on [DATE] with diagnoses including heart disease and fractures. In addition, the resident was taking medications including antidepressant, hypnotic, anticoagulant, diuretic, opioid, and anticonvulsant medication. Review of Resident 2's Care Plan with a revision date of 8/26/24 revealed the resident was admitted following a fall and plan to return home following rehabilitation. The care plan revealed no evidence the resident was taking antidepressant, anticoagulant, diuretic, or anticonvulsant medication or the need to monitor for potential adverse effects or risks of those medications. Further review revealed no evidence the resident had multiple heart-related diagnosis or the required monitoring of those conditions. During an interview on 9/3/25 at 11:25 AM Interview with the Director of Nursing confirmed all residents were to have a comprehensive care plan completed following the initial MDS completion and confirmed Resident 2's Care plan was not comprehensive and did not include black box medication warnings for use of high-risk medications such as antidepressant, anticoagulants, diuretic, and anticonvulsant medications. In addition, the care plan did not address the resident's heart disease related diagnoses.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to complete an assessment for Resident 6 for potential adverse effects from antipsychotic ( a type of medication that alters the chemicals in the brain to effect change in behavior, mood and emotion). The sample size was 5 and the facility census was 30. Findings are: Review of the facility undated policy Use of Psychotropic Medication revealed the following;-Residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s),-the indications for use of psychotropic drugs were documented in the medical record,-targeted symptoms for monitoring were documented in the resident record,-Residents and/or their representative/s were educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions, and -Residents who used psychotropic drugs would have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, as needed or as per facility policy. Review of Resident 6's Minimum Data Set (MDS- a federally mandated assessment tool used in Care Planning) dated 8/13/25 revealed the resident was admitted on [DATE], received antipsychotic and antianxiety medications, and diagnoses included Anxiety and Schizophrenia (a mental health condition that affects the way a person thinks, feels, and behaves). Review of Resident 6's Care Plan last revised 8/21/25 revealed the resident was taking antidepressant and antipsychotic medications. Review of Resident 6's Order Summary Report of active medication orders as of 9/3/25 revealed an order for Latuda (an antipsychotic medication) with a start date of 8/1/25 with a diagnosis of Schizoaffective Disorder (a mental health condition including Schizophrenia and a mood disorder), Bipolar (a mental health disorder that causes changes in a person's mood, energy, and ability to function). Review of the facility form AIMS- Abnormal Involuntary Movement Scale for Resident 6 dated 8/19/25 revealed the assessment was open and there was no documentation that the assessment had been completed. An interview on 9/2/25 at 2:00 PM with the Director of Nursing confirmed Resident 6 was receiving an antipsychotic medication. Further interview confirmed that an AIMS assessment had not been completed and should have been completed upon admission to the facility.

Licensure Reference Number 175 NAC 12-006.18(B)Based on observation, record review, and interview; the facility failed to ensure hand hygiene was completed at appropriate intervals during wound care for Resident 16 to prevent potential cross-contamination. The sample size was 12 and the facility census was 30. Findings are: Review of the facility policy Hand Hygiene with a revision date of 7/1/25 revealed the following: -All staff to perform hand hygiene procedures to prevent the spread of infection to other personnel and residents. -Staff were to perform hand hygiene as indicated using proper technique consistent with accepted standards of practice. -The use of gloves did not replace hand hygiene. If the task required gloves, staff were to perform hand hygiene prior to putting on gloves and immediately after removing gloves. -Hand Hygiene is to be performed using soap and water when hands were visibly soiled, and/or soiled with blood or other body fluids, and following exposure to curtain pathogens/bacteria,after caring for a resident with known or suspected diarrhea, and /or after handling items potentially contaminated with blood, body fluids, secretions or excretions -Hand Hygiene should also be performed during resident care when moving from a contaminated body site to a clean body site.During an observation of wound care on for Resident 16 on 9/2/25 at 10:26 AM the Licensed Practical Nurse (LPN-G) Infection Preventionist (IP) for the facility entered the resident's room, put on disposable gloves, set up treatment supplies, and then removed a foam dressing from the residents right knee and left great toe (medial aspect) without changing gloves between the wounds. LPN-G then disposed of the dressings, changed gloves and without hand sanitizing put on clean gloves, cleaned the left great toe wound with wound cleaner/normal saline applied to gauze, and then while wearing the same gloves cleaned the right knee wound with normal saline using a clean gauze. LPN-G then removed the gloves and put on clean gloves without sanitizing and proceeded to place clean dressing on both the left great toe and right knee while again using the same gloves. LPN-G then removed the gloves and performed hand hygiene. Review of Resident 12's Care Plan with a revision date of 7/30/25 revealed the resident had pressure injuries (skin breakdown secondary to lack of circulation from prolonged pressure to an area of skin, to the right knee and the left great toe. Staff were to treat the areas as ordered and monitor for effectiveness as well as documenting the status of wound healing. Review of Resident 12's Order Summary Report dated 9/3/25 revealed the current orders: -Cleanse area to the right knee with normal saline and pat dry, apply petroleum gauze and then a foam dressing every other day. -Cleanse area to the left great toe with normal saline and pat dry, apply petroleum gauze and then a foam dressing every other day. During an interview on 9/3/25 at 9:40 AM the Director of Nursing confirmed that hand hygiene should be performed after removing gloves and care provided for wounds requires separate treatment for each wound to prevent potential cross-contamination between the wounds and LPN-G should not have cares for both wounds on Resident 16 wearing the same gloves. During an interview on 9/3/25 at 1:45 PM LPN-G confirmed using the same gloves while caring for Resident 16's left great toes and right knee and confirmed not performing hand hygiene between glove changes.

Licensure Reference Number 175 NAC 12-006.9 Based on observations, interviews, and record reviews; the facility failed to follow Resident 1's physician orders regarding fluid consistency. The sample size was 3. The facility census was 27. Findings are: Record review of the facility's policy titled Thickened Liquids dated 2022, revealed that thickened liquids are needed for individuals with difficulty swallowing. Definitions included Nectar like liquids are mildly thick and Honey like liquids are moderately thick. Record review of the facility's Accident/Unusual Occurrence report completed on 10/27/24 at 8:30 PM revealed that Resident 1 was sent to the emergency room after noted to be coughing after drinking thin liquids. The resident's diet was nectar thick liquids. Record review of Resident 1's undated facility admission record revealed an original entry to facility on 1/16/2019 and that the resident was readmitted to the facility on [DATE] with a diagnosis of pneumonitis (swelling and irritation, or inflammation of the lung tissue) due to inhalation. Record review of Resident 1's Progress Notes dated 10/26/24 revealed that the resident was given thin liquids during snack time and then began to cough. Record review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 9/18/24 revealed: -moderate cognitive impairment, -no behaviors or no rejection of cares, -resident needs supervision with food and fluids. Record review of Resident 1's Comprehensive Care Plan revealed a focus with a revision date of 10/30/24 revealed a potential for altered hydration status related to dementia and dysphagia. Honey thick liquids ordered. Record review of Resident 1's Physician Orders revealed a diet order dated 10/28/24 for Honey consistency liquids. Interview on 10/31/24 at 9:29 AM with Certified Dietary Manager (CDM) confirmed that Resident 1 had an order of nectar thickened liquids before hospitalization and came back to the facility with honey thickened liquid order. Interview on 10/31/24 at 3:16 PM with Nursing Assistant (NA) - A confirmed that (gender) had given thin liquids to Resident 1 and it resulted in the resident admission to the hospital. An interview with the Director of Nursing (DON) on 10/31/24 at 3:59 PM confirmed the resident had a physician order for thickened liquids and was given thin liquids and should not have been.

Licensure Reference Number 175 NAC 12-006.18B Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interviews; the facility failed to utilize handwashing and gloving techniques to prevent the potential for cross contamination during the provision of care for 3 (Residents 2,11, and 14) of 12 residents sampled. The facility also failed to develop and implement policies and procedures to prevent and protect residents from an onset of the communicable disease Legionella (a bacteria that thrives in water, that has the potential to cause Legionnaires Disease, a type of pneumonia). This had the potential to affect all the residents. The facility failed to prevent the potential for cross contamination for staff testing for Covid. The facility census was 33. Findings Are. A. A review of the facilities Infection Prevention and Control Program policy dated 7/9/2024 revealed the following for Standard Precautions practice: -All staff should assume that all residents are potentially infected or colonized with an organism. -Hand hygiene is to be performed per facility policy -PPE should be used per facility policy. A review of the facilities Handwashing/Hand Hygiene policy dated 2001 revealed that hand hygiene must be performed: -Before and after performing any nonsurgical invasive procedures or an invasive device. -Before handling clean or soiled dressings, gauze pads etc. -Before moving from a contaminated body site to a clean body site during res care. -After contact with res intact skin, blood, or bodily fluids, -After contact with objects in the immediate vicinity of the resident. -Before and after isolation precaution settings. -After handling used or contaminated dressings or equipment. -After removing gloves. A review of the facility competency Matrix-Finger Stick -Glucose Level Competency dated 2006, revealed the following steps for the procedure: -Perform Hand Hygiene and gather supplies. -Place glucose meter on a clean barrier. -Put on gloves prior to procedure and obtaining the blood. -Remove gloves and wash hands when procedure completed. A review of the policy Glucometer Disinfection dated 2020 revealed the following: -Glucometers should be cleaned and disinfectant wipe after each use leaving the disinfectant on the machine so that it dries. An observation on 8/20/24 at 11:30 AM the Liscensed Practical Nurse (LPN)-A placed a glucometer on Resident 11's table without a barrier. LPN-A performed a finger stick (a minimally invasive procedure that involves pricking the fingertip to collect a small amount of blood for testing) for Resident 11 glucose reading without gloves on. LPN-A then placed the blood drop onto the glucometer testing strip, and then removed the testing strip with blood and held it in [gender] bare hand while walking to the medication cart located in the hallway. LPN-A then opened the sharps container lid and placed the testing strip in the container. LPN then placed the glucometer in the medication cart draw. Observation did not reveal LPN-A cleaning the glucometer prior to storage. Next LPN-A touched the following without performing hand hygiene: -sides of the med cart, -top of the med cart, -computer keyboard, -computer screen, -keys to the med cart, -med cart lock, -drawer for the glucometer storage. An Interview conducted on 8/20/24 at 12:21 PM with LPN-A confirmed the following: -The glucometer was not placed onto a barrier. -No gloves were worn with Resident 11 while perfoming a fingerstick and appliying blood onto the test strip. -No gloves were worn to carry the used testing supplies back to the medication cart for disposal. -That the glucometer machine was not cleaned after use nor prior to storage in medication cart drawer. LPN-A also confirmed the following items were then touched prior to performing any hand hygiene was completed: -The sharps container, -The top and sides of the med cart, -The computer keyboard and screen, -The keys and lock to the med cart, -The drawer for the glucometer storage. An interview on 08/21/24 at 1:00 PM with LPN-E revealed LPN-A should have completed hand hygiene and wore gloves prior, during and after residnet cares per facility policy and CDC recommendations. LPN-E further revealed that the facility follows CDC guidelines and standards of care. An interview on 8/21/24 at 1:15 PM with the DON confirmed that it is the expectation that items used for glucose testing should be disposed of while wearing gloves, and the glucometer is to be disinfected prior to storage. DON also confirmed it is the expectation of all the staff to complete hand hygiene and use gloves prior to, during, and after any procedure involving resident cares, or any process in which Standard Precautions would be applied. B. An observation on 8/20/24 at 12:30 PM of LPN-A administering medications through a Gastrostomy tube (GT a tube placed into the stomach that can be accessed on the outside of the body, used for nutrition and medication administration) for Resident 2 was completed. The LPN-A did not perform hand hygiene nor complete a glove change between the following steps of the procedure: -After auscultation (listen to) for the GT placement and before checking a wound dressing site surrounding the GT. -When LPN-A touched a wound dressing (that was saturated with a thick greenish red drainage, and the GT port entry was a strawberry red color), replacing it, then gathered wound care supplies. -When LPN-A gathered wound care supplies to change the wound dressing. -When LPN-A changed a wound dressing, and then completed medication administration per GT. The following items in the resident's room were touched while LPN-A was gathering supplies and in the process of a procedure wore the same gloves. -The bedside table. -The residents gown. -The residents' linens. -The resident pillow -The closet door. -The cartons that the dressings were in. -The clean dressing supplies. -Drawer to the bedside stand. -The GT port access. -The abdominal binder. An interview on 08/21/24 at 1253 AM with LPN -A confirmed that the following noted steps/procedures were completed without hand hygiene and that the same gloves at been worn for the following: -From GT auscultation to GT wound care, - When obtaining supplies - When changing the GT wound dressing - When administering the medications through a GT. LPN-A then confirmed that the following items in the resident's room were touched with the contaminated gloves. -The bedside table. -The residents gown. -The residents' linens. -The resident pillow -The closet door. -The cartons that the dressings were in. -The clean dressing supplies. -Drawer to the bedside stand. -The GT port access. -The abdominal binder. -The bedside table. An interview on 08/21/24 at 1:00 PM with LPN-E confirmed that per facility policy and CDC recommendations, that LPN-A was to use hand hygiene and wear gloves before any procedure that involves blood or body fluids. LPN-E states that the facility follows CDC guidelines and standards of care. An interview on 8/21/24 at 1:15 PM with the DON confirmed that it is the expectation that items used for glucose testing should be disposed of while wearing gloves, and the glucometer is to be disinfected prior to storage. DON also confirmed it is the expectation of all the staff to complete hand hygiene and use gloves prior to, during, and after any procedure involving resident cares, or any process in which Standard Precautions would be applied. C. A review of the undated Catheter Care Policy revealed the following: -perform hand hygeine and don clean gloves prior to procedure, -pull back the foreskin and use a clean wipe to wipe around the meatus with an outward motion, then continue on down the penis shaft, -Remove gloves and perform hand hygiene. An observation on 8/21/24 at 10:15 AM of Nurse Aide-B providing perineal and catheter cares on Resident 14. NA-B completed the upper body bathing and dressing. The supplies were gathered for the resident cares. NA-B did not remove gloves after bathing Resident 14. During the observation NA-B touched the bed frame, headboard, call light, bed remote, and the packages containing the supplies for cares using the same gloves. NA-B then removed Resident 14's brief for disposal touching the inside of the brief while removing it from underneath the resident The brief was soiled with urine. NA-B put the brief in the trash and then performed peri care (the practice of washing the genital and anal areas of the body). NA -B completed the peri care, dried the areas with a towel and then stated to provide foley catheter cares. There was not a doffing (taking off) of gloves and hand hygiene in between procedures. NA-B then completed peri cares. When these procedures were completed, the NA gathered the supplies and placed the on the bedside table and the sink located in the resident's room. NA-B then doffed gloves and washed hands. An interview on 8/21/24 at 10:30, with NA-B confirmed that there was not a glove change prior to providing peri care, and that again gloves were not changed prior to catheter cares. NA-B confirmed that gloves worn throughout both provisions were used initially for the bathing and dressing of Resident 14's upper body. The NA also confirmed [gender] touched or handled of the following with dirty gloves: -The residents headboard and bedframe. -The residents call light. 'The remote to the bed. -The packages that contained the cleansing supplies. NA-B also confirmed that there was contact with her gloved hands to the inner portion of the soiled brief and hand hygiene was not completed. An interview on 08/21/24 at 1:00 PM with LPN-E confirmed that per facility policy and CDC recommendations, staff are to use hand hygiene and wear gloves before any procedure that involves blood or body fluids, or the possibility of a communicable disease. LPN-E states that the facility follows CDC guidelines and standards of care. An interview on 8/21/24 at 1:15 PM with the DON confirmed that it is the expectation for all the staff to complete hand hygiene and use gloves prior to, during, and after any procedure that they are performing resident cares and may be exposed to blood, body fluids, and/or a communicable disease. That the facility follows the CDC recommendations for Standard Precautions and infection control. D. A review of the Infection Prevention and Control Program policy dated 2024 revealed under #17-Water Management: - A water management program has been established as part of the overall infection prevention and control program -Control measures and testing protocols are to be in place to address potential hazards An interview on 08/20/24 at 8:47 AM with the Maintenance Director (MD) confirmed that there is not a Water Management Program for Legionella at the facility. An interview on 8/21/24 at 1330 with the DON confirmed that there is not a water management program for Legionella at this time. A review of the policy Coronavirus testing dated 2020 and under the section Conducting Testing #5 states the following: -The facility will maintain proper infection control and use recommended personal protective equipment (PPE). E. A further review of the policy under Documentation of Testing letter H revealed the following: -The facility will document staff test results in a secure manner. An observation on 8/22/24 at 08:15 AM of the facilities nurse's station (located just inside the entrance of the facility) revealed the following: -Covid testing kits located behind the counter and accessible to anyone. -2 used tests on the desk top complete with name of staff member, results showing in plain sight, and no barrier underneath the used tests. -A list of employee's names that had tested , as well the test results. In plain sight. -No hand sanitizer, no gloves, no other forms of PPE (Personal Protective Equipment) (supplies used to protect one from communicable disease.). were located near where the employees were completing these tests. -No disinfecting wipes of any kind located near the covid station. -No staff were within eyesight. An interview on 8/22/24 at 8:30 AM with LPN-E confirmed that the testing station was not in an appropriate location, and that there was a list of documented staff information with the results of testing laying on top of the desk in view of Covid testing supplies, used covid tests long the nurse's station, and no barrier underneath. Also confirmed that there was not appropriate testing equipment out as missing was the antibacterial wipes or cleansing solution, no Personal Protective Equipment (PPE) (Protects a person from communicable disease). 48271 F. Observation on 08/22/24 07:15 AM Upon entering the facility the Dietary Manager was at the nurse's desk with 2 other staff members testing for COVID. The Test kits were sitting behind the nurse's desk. Staff then opened the COVID test kit and without gloves tested themselves. No gloves were used when they tested themselves and no barrier was placed down on the nurse's desk where they laid their test after swabbing their noses. There was no sanitizer anywhere by the nurse's desk. The sign in sheet on the desk with names of staff and results of the COVID test had 10 staff members on the list. An interview on 8/22/24 at 8:30 AM with the Infection control nurse confirmed that the testing for COVID was not to be done at the nurse's desk and that barriers and gloves should have been used and the barriers and gloves was not used.

Licensure Reference Number 175 NAC 12-007.04D Based on observations and interviews; the facility failed to ensure bathroom ventilation systems were functioning, preventing lingering odors from permeating for 11 (rooms 201, 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214) of 12 rooms sampled. The facility census was 33. Findings are: Observations of the ventilation system in the residents bathroom's 201, 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214 on 8/19/24 at 8:00 AM using 1 square ply of toilet paper revealed the ventilation system in the bathrooms were not functioning. Observations of the ventilation system in the residents bathroom's 201, 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214 on 8/20/24 at 8:00 AM using 1 square ply of toilet paper revealed the ventilation system in the bathrooms were not functioning. Observations of the ventilation system in the residents bathroom's 201, 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214 on 8/21/24 at 8:00 AM using 1 square ply of toilet paper revealed the ventilation system in the bathrooms were not functioning. Interview on 8/22/24 at 1:30 PM with the Maintenance Director confirmed that the ventilation system did not draw a 1 square ply of toilet paper in the bathrooms in room [ROOM NUMBER], 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214. The maintenance director confirmed that the system is checked monthly as a safety check but that there is no documentation that the ventilation system in residents bathrooms were checked regularly to ensure they were operational.

Licensure Reference Number 175 NAC 12.006.09B Based on observation, interview, and record review; the facility failed to code the Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) assessment to reflect the behavior of 1 (Resident 21) of 5 sampled residents. The facility census was 33 at the time of survey. Findings are: Record review of the Resident Assessment Instrument (RAI) User's Manual dated October 2023 revealed the following: -Code 1, behavior of this type occurred 1-3 days. -Steps for Assessment: -Review the medical record for the 7-day look-back period. -Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident. -Observe the resident in a variety of situations during the 7-day look-back period. Record review of Resident 21's Admission Record revealed an admission to the facility on [DATE]. Review of Admission MDS dated [DATE] in Section C revealed a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 14, which indicated a mild cognitive impairment. Record review of Resident 21's MDS dated [DATE] in Section E behaviors not exhibited was marked for physical behaviors towards others and verbal behaviors: -No coded to the question: physical behavioral symptoms directed toward others. -No coded to the question: Verbal behavioral symptoms directed toward others. -No coded to the question: Other behavioral symptoms not directed toward others. Record review of Resident 21's nursing progress notes dated 8/7/24 revealed the resident had physical and verbal behaviors toward staff and other residents. Record review of Resident 21's Comprehensive Care Plan - (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) date initiated 4/18/22 revealed the resident has impaired thought processes. CCP date initiated 5/1/24 revealed behavior related to sexual phrases and inappropriate touching of other residents and staff. Record review of Resident 21's behavior monthly flow sheets for August 1-20th, 2024 revealed physical and verbal behaviors towards others documented on 8/7/24. Interview on 08/21/24 at 9:14 AM Licensed Practical Nurse (LPN) - E (who also completed the MDS) confirmed that Resident 21's behaviors documented on 8/7/24 were not marked on the MDS dated [DATE] and should have been. Interview on 08/21/24 at 9:19 AM the Director of Nursing (DON) confirmed that they use the RAI manual to ensure MDS accuracy. Interview on 08/21/24 at 09:21 AM the Social Services Director (SSD) confirmed the social work completed section E of the MDS and it was completed before the Assessment Reference Date (ARD) date and it did not include the behaviors that were documented on 8/7/24 and should have. It was further confirmed that the SSD does not look at the behavior monthly flow sheets or the target behaviors and there was no family or staff interviews done. Also confirmed there was no Social Service progress note during the assessment period of 8/1/24 through 8/8/24.

Licensure Reference Number NAC 12-006.090D Based on record reviews and interviews; the facility failed to obtain physician discharge orders, failed to prepare the resident and document plans for discharge, and failed to complete the discharge summary for 1 (Residnet 28) of 1 sampled resident prior to discharging the resident. The facility census was 33 at the time of survey. Findings are: Record review of the facility's policy titled Discharge Summary and Plan, dated December 2016 revealed that when a resident's discharge is anticipated a discharge plan will be completed. Record review of the facility's policy titled Discharge Documentation, dated December 2016 revealed that when a resident is discharged details of the discharge will be documented in the medical record. Record review of the facility's policy titled Discharge Summary and Plan, dated December 2016 revealed that a final summary of the resident's status will be completed at the time of discharge and will include a post discharge plan completed by the Interdisciplinary Team (IDT) and the resident/representative will be involved in the planning process. Record review of Resident 28's Discharge Summary dated 6/17/24 revealed the resident discharged from the long term care facility to assisted living on 6/17/24. Record review of Resident 28's Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 5/8/24 revealed a Brief Interview for Mental Status (BIMS-a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 14, which may indicate a mild cognitive impairment. Record review of Resident 28's Comprehensive Care Plan (CCP-written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) dated 2/2/18 revealed plans for long term care placement. Record review of Resident 28's physician orders dated 6/17/24 revealed no physician order for discharge for Resident 28. Record review of Resident 28's Care plan meeting note dated 3/14/24 revealed the careplan team met with the resident and the resident's representative and did not discuss plans to discharge. Interview on 08/21/24 at 11:42 AM the Director of Nursing (DON) confirmed there was no discharge orders or transfer sheet completed for Resident 28 prior to discharge and there should have been. Interview on 08/21/24 at 03:04 PM the Social Services Director (SSD) confirmed that there was no discharge planning for Resident 28 to move from the long term care to the assisted living. It was further confirmed that discharge was not discussed in the care plan meetings for Resident 28 and that the discharge summary was not completed upon discharge for Resident 28. Interview on 08/22/24 at 08:03 AM with the resident representative revealed that (gender) was not involved in any discharge planning assistance or teaching. It was further confirmed that discharge plans were not discussed in the careplan meetings for Resident 28.