Every finding on record at Cloverlodge Care Center

Licensure Reference Number 175 NAC 12-006.10 (D)Based on observation, record review and interview; the facility failed to ensure a medication error rate of less than 5%. Insulin pen was not primed for 3 (Resident 28, Resident 24, and Resident 12) of 3 sampled residents that received insulin. The facility census was 29.A.Review of the facility policy Medication Administration Procedures Subcutaneous Injection with Insulin Pens dated 7/22 revealed the following:-An insulin pen was used to administer insulin in subcutaneous tissue in order to promote slow medication absorption and prolong medication action and were administered in a safe and accurate manner.-The procedure for safe administration included checking the expiration date, explaining the procedure to the recipient, site selection, preparation of the injection, and preventing air that may have collected in the needle by priming the pen with 2 units of the medication until a drop of the medication is visible on the tip of the needle before proceeding with the injection. B.Review of Resident 28's Medication Administration Record (MAR) dated July 2026 revealed the following medication order:-Tresiba Subcutaneous Insulin inject 10 units subcutaneously in the morning related to Diabetes Mellitus with Diabetic Neuropathy. An observation on 7/14/25 at 7:40 AM revealed Licensed Practical Nurse (LPN)-C dialed 10 units Tresiba Insulin on the insulin pen and then administered the insulin to Resident 28 in the right lower abdomen. LPN-C did not prime the insulin pen prior to dialing and administering the 10 units of Tresiba Insulin. C.Review of Resident 24's MAR dated July 2026 revealed the following medication order:- Humalog Subcutaneous Solution Pen-injector. Inject as per sliding scale (amount of insulin to administer is determined by the residents blood sugar level) subcutaneously before meals:-70-150=30 units.-151-200=33 units.-201-250=36units.-251-300=39 units.-301-350=42 units.-351-400=45 units. An observation on 7/14/26 at 11:15 AM revealed that LPN-C completed a blood sugar check on Resident 24 that was 236. Per the sliding scale insulin directions LPN-C dialed 36 Units Humalog Insulin on the insulin pen and then administered the insulin to Resident 24 in the left upper arm. LPN-C did not prime the insulin pen prior to dialing and administering the 36 units of Humalog Insulin. D.Review of Resident 12's MAR dated July 2026 revealed the following medication order:- Novolog Subcutaneous Solution pen injector, inject 12 units subcutaneously three times per day related to Type 2 Diabetes.Novolog Insulin inject subcutaneously as per sliding scale insulin before meals for the following blood sugars:-150-200=2 units.-201-250=4 units.-251-300=6 units.-301-350=8 units.-351-400=10 units.401plus=12 units. An observation on 7/14/26 at 11:25 AM revealed LPN-C completed a blood sugar check on Resident 12 that was 380. Per the insulin orders LPN-C dialed 22 units Novolog Insulin (12 units routine and 10 units sliding scale) on the insulin pen and then administered the insulin to Resident 12. LPN-C did not prime the insulin pen prior to dialing and administering the 22 units of Novolog Insulin. E.An interview was completed on 7/14/26 at 11:45 AM with LPN-C. LPN-C confirmed that the insulin pen was not primed prior to dialing and administering the ordered insulin to Resident's 28, 24 and 12.An interview was completed on 7/14/26 at 2:10 PM with the Director of Nursing (DON). The DON confirmed that insulin pens were to be primed with 2 units of insulin prior to dialing and administering the ordered insulin.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18(B), and 175 NAC 12.006.18(D) Based on observations, record review and interviews: the facility failed to utilize appropriate infection control practices when completing a dressing change and for the storage of respiratory equipment for Resident 7; and failed to complete glove changes and hand hygiene at appropriate intervals during cares for Residents 4 and 28. The total sample size was 21 and the facility census was 29. Findings are: A. Review of the facility policy Hand Hygiene (undated) revealed the staff were to exercise proper hand hygiene technique to prevent the transmission of infectious agents. Hand hygiene was to be completed when: -before and after resident contact. -after removing and disposing of gloves and other protective equipment. -after contact with blood, body fluids, mucous membranes, non-intact skin and wound dressings. -when moving from a contaminated resident body site to clean site during patient care. -after contact with inanimate objects or medical equipment close to the resident. The policy further indicated gloves were not a substitute for hand hygiene and gloves were to be used before contact with blood or body fluids, mucous membranes and non-intact skin. Staff were to change or remove gloves if moving from a contaminated to a clean site or environment. B. Review of the undated facility policy Skin and Wound Care-Wound Care: Dressing Application revealed the follow procedure to be followed for wound care: -perform hand hygiene. -establish a clean field with the supplies and equipment necessary. -don (put on) gloves. -remove soiled dressing. -discard dressing and gloves in appropriate containers. -perform hand hygiene and place on clean gloves. -cleanse wound with normal saline or wound cleanser per physician orders. -dress the wound with appropriate dressing. -discard soiled supplies and perform hand hygiene. C. Review of the facility policy Enhanced Barrier Precautions (EBP-involves gown and glove use during high-contact resident care activities known to be colonized or infected with a multidrug-resistant organism (MDRO-bacteria that have become resistant to certain antibiotics) reviewed/revised 4/12/24 revealed it was the policy of the facility to implement EBP for the prevention of transmission of MDRO's. The policy indicated an order would be obtained for EBP for residents based on the following criteria: -Chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers, and -Indwelling medical devices such as central lines, urinary catheters and feeding tubes, even if the resident was not known to be infected or colonized with an MDRO. The policy further identified Personal Protective Equipment (PPE-items such as gowns, gloves, face shield that are worn to protect care givers) for EBP were only necessary when performing high-contact care activities: -dressing. -bathing. -transferring. -providing hygiene. -changing linens -changing brief or assisting with toileting cares. -device care or use: central lines, urinary catheters, feeding tubes. -wound care: any skin opening requiring a dressing. D. Review of the facility form titled Oxygen Administration and Safety dated 12/2019 revealed oxygen tubing was to be placed in an Infection Prevention (IP) pouch when not in use. E. Review of Resident 7's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/8/26 revealed diagnoses of anemia, renal insufficiency, depression, and respiratory failure. The assessment identified the resident had a surgical wound and moisture associated skin damage (MASD-incontinence-associated dermatitis, perspiration and drainage) and received surgical wound care with application of a nonsurgical dressing. In addition, the assessment identified use of continuous oxygen therapy. Observations of Resident 7's room throughout the survey revealed the following: -7/13/26 at 12:11 PM the resident was seated in the dining room for the noon meal. The resident's oxygen cannula/tubing was coiled on the floor underneath of the resident's bed. The oxygen tubing was dated 7/2/26. A blue IP pouch was attached to the top of the oxygen concentrator -7/14/26 at 8:43 AM the resident was assisted to the dining room for the breakfast meal. Observation of the resident's room revealed the oxygen tubing was uncovered and draped across the arm of the resident's recliner with the nasal cannula hanging down the side of the recliner. The blue IP pouch remained intact to the oxygen concentrator. -7/14/26 at 12:28 PM observation of the resident's room revealed the oxygen tubing/cannula was coiled on the floor next to the oxygen concentrator and not in the blue IP pouch attached to the concentrator. The tubing/cannula had not been exchanged and remained dated 7/2/26. Observation of wound care for Resident 7 on 7/15/26 at 1:35 PM with Licensed Practical Nurse (LPN)-L revealed the following: -entered the resident's room wearing a disposable gown and carried several washcloths and a hand towel. LPN-L removed items from the top of the resident's bedside table which included the television remote, a Kleenex box, and a water container. -without cleansing the surface of the table, placed a hand towel on the table as a barrier. LPN-L placed the washcloths and wound care supplies on the barrier. -without performing hand hygiene, staff placed on clean gloves, adjusted the resident's clothing and proceeded to remove the dressing from the resident's abdomen. -while still wearing the same gloves, LPN-L placed the washcloths directly into the sink basin and covered them with warm water. -staff applied Hibiclens (powerful antiseptic soap that is effective for skin cleansing and infection prevention) to one of the washcloths and used to cleanse the resident's surgical incision. -removed gloves, failed to perform hand hygiene and placed on clean gloves. LPN-L removed the remaining washcloths from the sink basin and used them to rinse the wound. The wound was then patted dry. -while still wearing the same gloves, used a measuring device directly to the wound bed to measure the wound. -while still wearing the same gloves, reached into the pocket of LPN's uniform and removed a pen and placed it on the barrier. -opened a package which contained a small square of Aquacel Ag (wound dressing that absorbs fluid, protects wounds and kills bacteria). Without cleansing, staff used a pair of scissors to cut a strip from the Aquacel large enough to cover the wound. -used the pen to date a Mepilex (highly conformable dressing that absorbs drainage, maintains a moist wound environment and minimizes the risk for maceration) dressing and applied over the wound. -LPN-L adjusted the resident's clothing, removed gown and gloves and placed in the trash receptable inside of the resident's room. LPN-L used hand sanitizer and exited the room. -LPN-L re-entered the room holding several pieces of paper and wearing a disposable gown. Papers were placed on the bedside table. Without performing hand hygiene or wearing gloves, LPN-L proceeded to measure bruising to the resident's right hand/wrist and left hand and a blister to the left hand. LPN-L then documented measurements on the papers, proceeded to clean up supplies, removed the disposable gown and performed hand hygiene before exiting the room. During the dressing change performed by LPN-C on 7/15/26 at 1:35 PM, Medication Aide (MA)-J entered the resident's room and exchanged the oxygen tubing and cannula to the resident's oxygen concentrator and portable oxygen tank. MA-J confirmed the current tubing was dated 7/2/26 and indicated the oxygen tubing/cannulas were to be changed every week and were to be dated accordingly. MA-J further confirmed if the resident was not utilizing the oxygen tubing/cannula, they should have been placed in the IP pouch and should not have been left on the floor or on the resident's recliner. During an interview on 7/15/26 at 1:44 PM, LPN-L confirmed the following: -staff were to perform hand hygiene before putting on/taking off gloves. -should have changed gloves during the dressing change, when going from a clean site to a dirty site. -should not have placed clean washcloths in the handwashing sink basin as this was not a clean filed. -should not have used soiled gloves to remove the pen from the pocket of staff's uniform. -failed to cleanse the scissors before using to cut a dressing which was then placed directly on the resident's wound bed. -the resident was currently on EBP due to the chronic wound to the resident's abdomen. -staff should have been wearing gloves when measuring the resident's bruises/blister F. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted on [DATE]; had moderate cognitive impairment; had diagnoses of Hypertension, Diabetes, Dementia, and Parkinson's Disease; required assistance with dressing, putting on footwear, bed mobility, and transfers; and was dependent with toileting. Review of Resident 4's Care Plan, last revised 6/5/26 revealed the resident required staff assistance with transfers, toileting, dressing, and mobility; had cognitive impairment; and had diagnoses of Dementia, Diabetes, Parkinson's Disease, and Muscle Weakness. Observation on 7/14/26 at 11:15 AM Nursing Assistant (NA)-F followed Resident 4, who was self-propelling their wheelchair, to the resident room. NA-F assisted the resident so the resident was placed in front of the bathroom, obtained the resident's walker, applied a gait belt to the resident, and assisted the resident to stand and ambulate into the bathroom. NA-F, without wearing gloves, pulled the resident's pants and then brief down and the resident sat down on the toilet. When the resident was finished, NA-F applied gloves without performing hand hygiene. NA-F performed peri cares on the resident using pre-moistened wet wipes. NA-F, continued to wear the same pair of soiled gloves, and assisted to pull the resident's brief and then pants up. NA-F, continued to wear the same pair of gloves, obtained the resident's walker and assisted the resident to standing position. NA-F removed their gloves and did not perform hand hygiene. NA-F ambulated with the resident to the wheelchair and the resident sat down. NA-F obtained a washcloth, used warm water to wet it and handed the washcloth to Resident 4. NA-F then washed their hands with soap and water, then dried their hands and turned the faucet off with the same paper towel they used to dry their hands. NA-F removed the trash and the used wet washcloth from the resident room. G. Review of Resident 28's MDS dated [DATE] revealed the resident was admitted on [DATE]; had moderate cognitive impairment; had diagnoses of Stroke, Hypertension, Dementia, Depression, weakness on one side, and Psychotic Disorder; and was dependent with transfers, dressing, bed mobility, and toileting. Review of Resident 28's Care Plan, last revised on 12/9/25 revealed the resident required staff assistance with toileting, dressing, transfers and mobility and had diagnoses of weakness and paralysis affecting the left side, Hypertension, Diabetes, Mood Disorder, Psychosis, Dementia, and muscle weakness. Observation on 7/14/26 at 1:20 PM NA-F and NA-G entered the resident room and applied gloves. No hand hygiene was observed to be performed. The NA's hooked the resident up to a full body lift and transferred the resident to the resident's bed. Both NA's rolled the resident to remove the resident's pants and unhooked the resident's brief. Resident 28 was incontinent. NA-G pushed the front of the brief down between Resident 28's legs and using pre-moist wet wipes, performed peri cares. NA-F rolled the residents onto their left side and NA-G performed peri cares on the back side of the resident and removed the soiled brief from under the resident. NA-G, continued to wear the same pair of soiled gloves, obtained a clean brief and applied it to the resident. NA-F assisted to roll the residents onto the brief. NA-G, continued to wear the same pair of gloves, pulled the clean brief up between the resident's legs and secured it at the waist. NA-G, continued to wear the same pair of soiled gloves and assisted NA-F with pulling the resident's pants up. NA-G continued to wear the same pair of soiled gloves, obtained a blanket from the foot of the bed and covered the resident. NA-G continued to wear the same pair of soiled gloves and handed the resident their call light. NA-G and NA-F removed their gloves. NA-G removed the trash from the resident room and NA-F cleaned the lift with wipes. NA-G and NA-F then exited the room. NA-F was observed to perform hand hygiene using alcohol-based hand rub. NA-G was not observed to perform hand hygiene. H. Interview on 7/16/26 at 12:00 PM with the DON confirmed gloves should be changed when going from a soiled area to a clean area, and hand hygiene should be completed when gloves were removed.

Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview; the facility failed to have comprehensive informed consent for the use of psychotropic medication (any medications that affect behavior, mood, thoughts, or perception) in advance of administration for Resident 23. The sample size was 5 and the facility census was 29. A.Review of the facility Psychoactive Medication and Medication Regimen Review Standard dated 6/2026 revealed the following;-Consent for the Use of Psychoactive Medication forms were completed prior to initiating and with the increase of any psychoactive medication. It was to be reviewed and updated quarterly in conjunction with the care planning process and as needed. B.Review of Resident 23's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 5/20/26 revealed the resident was admitted [DATE] with a diagnosis of Non-Alzheimer Dementia, Depression and Diabetes. The following was assessed regarding the resident:-severe cognitive impairment.-received antipsychotic and antianxiety medications. Review of the Resident 23's Medication Administration Record (MAR) dated July 2026 revealed the resident continued to receive the following medications:-Celexa (antidepressant medication) 40 milligrams (mg) to be given one time daily for anxiety related to major depressive disorder with a start date of 6/26/25.-Seroquel (antipsychotic medication) 12.5 mg to be given one time a day for dementia with agitation. Review of Resident 23's physician orders revealed the following order:-Seroquel (antipsychotic medication) 12.5 mg to be given one time a day for psychotic symptoms signed by the physician on 3/26/26. Review of a Psychotropic Medication Therapy Informed Consent Form for Celexa revealed no Psychotropic Medication Therapy Informed Consent Form had been completed for the start date of 3/26/26.Review of a Psychotropic Medication Therapy Informed Consent Form dated 7/13/26 (89 days after medication start date) revealed the resident had an order for Seroquel for targeted behaviors of agitation and anger. Further review revealed no evidence of nonpharmacological interventions attempted. During an interview with the Director of Nursing (DON) on 7/14/26 at 2:10 PM the DON confirmed that the facility did not obtain consent for Celexa for the start date of 3/26/26 and the consent for Seroquel was completed after the medication was initiated for Resident23.

Licensure Reference Number 175 NAC 12-006.09(G)(i)(ii)Based on record review and interview; the facility failed to notify the State Ombudsman when Resident 33 was discharged to home. The sample size was 1 and the facility census was 29.Findings are:Review of Resident 33's Minimum Data Set (MDS- a federally mandated assessment tool used in Care Planning) dated 6/12/26 revealed the resident was admitted on [DATE]; was cognitively intact; had diagnoses of Heart Failure, Hypertension, Renal Disease, and Asthma; and was discharged home on 6/12/26.Review of the emails sent to the Ombudsman related to discharges and transfers for June and July revealed no evidence the Ombudsman was notified of Resident 33's discharge to home.Interview on 7/15/26 at 2:45 PM with the Social Services Director confirmed the Ombudsman was not notified of Resident 33's discharge as required.Interview on 7/16/26 at 11:15 AM with the Administrator revealed the facility did not have a policy on discharge and notifying the State Ombudsman. Further interview confirmed the State Ombudsman should be notified of resident's transferred or discharges as required.

Licensure Reference Number 175 NAC 12-006.051Based on record review and interview; the facility failed to provide Residents 3 and 26 with the required Advanced Beneficiary Notice of Noncoverage information prior to discharge from Medicare services and the facility failed to ensure Resident 3 made an informed decision related to ongoing care services. The sample size was 3 and the facility census was 29.Findings are:A.Review of Resident 3's Skilled Nursing Facility Beneficiary Notification Review revealed the residents Skilled Services Episode began on 4/15/26 and the Last Covered Medicare Day was 5/30/26. The Notice of Medicare Non-Coverage was provided to the resident/resident representative on 5/26/26, however the facility did not provide the resident/resident representative with the required information related to the costs of the non-covered Medicare benefits for the resident/resident representative to make an informed decision on receiving ongoing care services or not. Further review revealed the resident/resident representative did not select an option related to receiving ongoing care services or not, which was required.B.Review of Resident 26's Skilled Nursing Facility Beneficiary Notification Review revealed the residents Skilled Services Episode began on 4/27/26 and the Last Covered Medicare Day was 5/28/26. The Notice of Medicare Non-Coverage was provided to the resident/resident representative on 5/22/26, however the facility did not provide the resident/resident representative with the required information related to the cost of the non-covered Medicare benefits in order for the resident/resident representative to make an informed decision on receiving ongoing care services or not.C.Interview on 7/15/26 with the Social Services Director confirmed there was no documentation that the cost of ongoing care services was provided to the resident/resident representative for Residents 3 and 26. Further interview confirmed Resident 3 did not choose an option related to receiving ongoing care services or not.Interview on 7/15/26 at 2:10 PM with the Administrator confirmed the required information was not included on the Beneficiary Notices for Residents 3 and 26 and further interview confirmed Resident 3 did not choose an option to receive ongoing care services or decline to receive them.

Licensure Reference Number 175 NAC 12-006.19(B) Based on observations, interviews, and record reviews, the facility failed to maintain the facility walls and woodwork in a manner to promote a clean and homelike environment. This affected 16 of 30 resident rooms and the facility census was 29. Findings are: A record review of the Facility Assessment with a revision date of 4/15/25 revealed the facility's physical environment promoted the health and safety of the resident population, and each department manager followed procedures for maintaining inventory and equipment, and used the TELS (Technology for Enhanced Long-Term Care) system to track equipment and preventative maintenance. During a tour of the facility on 4/22/25 between 8:37 AM and 9:15 AM the following concerns were identified: -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. -In room [ROOM NUMBER] the wall beside the bed had gouged drywall with chipping paint. -In room [ROOM NUMBER] the wall beside the bed had gouged drywall with chipping paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. The wall behind the resident's recliner had gouged drywall and chipped paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. The wall behind the resident's recliner had gouged drywall and chipped paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. The wall behind the resident's recliner had gouged drywall and chipped paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. The wall beside the bed had gouged drywall with chipping paint. -In room [ROOM NUMBER] the wall behind the resident's recliner had gouged drywall and chipped paint. -In room [ROOM NUMBER] the wall beside the bed had gouged drywall with chipping paint. -In room [ROOM NUMBER] the wall beside the bed had gouged drywall with chipping paint. -In room [ROOM NUMBER] the wood trim on the bottom of the closet door was deeply marred and had chipping paint. During an interview on 4/22/25 at 8:28 AM the facility Housekeeper/Laundry Supervisor revealed the facility used the TELS system to let the maintenance department know of items in need of repair. In addition, they confirmed the facility was aware of the multiple areas of drywall gauges and missing paint on the walls behind recliners and beds and that the areas had been there for quite a while and was unsure why they had not been repaired. During an interview on 4/23/25 at 1:33 PM the Maintenance Director revealed being aware of multiple rooms that needed drywall repair, and repaired woodwork, but confirmed those repairs had not been completed. The Maintenance Director reported knowing the repairs were needed for quite a while. During an interview on 4/23/25 at 1:48 PM the Administrator confirmed the facility has multiple areas of drywall and woodwork that needed repair.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review; the facility failed to follow infection control guidelines related to medication administration which had the potential to affect all residents. The facility also failed to complete hand hygiene during the provision of cares for Residents 11, 13, and 18. The facility census was 29. Findings are: A. A record review of the facility policy Safe Medication Administration Practices, last revised 5/20/24 revealed staff were to do the following: -avoid distractions and interruptions when preparing and administering medications, -check the residents medical record to make sure that all required documents were present and current, -monitor and document the effectiveness of all medications administered, -dispose of all containers to avoid cross-contamination after removal of a medication from its original container, and -perform hand hygiene. An observation on 4/22/25 at 8:03 AM with Medication Aide (MA)-C revealed that while obtaining Tramadol (an oral medication used to treat pain) for a resident out of a locked drawer in the medication cart, MA-C pushed the medication out of the medication card directly into their hand and then placed the medication into the medication cup. An observation on 4/22/25 at 8:20 AM with MA-C revealed while obtaining Glipizide (an oral medication used for the management of blood sugars) for a resident, MA-C pushed the medication from the medication card directly into their hand then placed the medication into the medication cup. Interviews on 4/22/25 at 8:03 AM and 8:20 AM with MA-C confirmed MA-C pushed the medications into their hand but should have pushed the medication out of the card into a medication cup. Interview on 4/23/25 at 2:50 PM with the Director of Nursing (DON) confirmed that medications were to be pushed out of the medication card into the medication cups, not into staff hands. B. A record review of the facility policy Hand Hygiene, last revised on 9/12/17 revealed the following: -staff would exercise proper hand hygiene techniques to prevent the transmission of infectious agents, -the facility adopted the Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, -hand hygiene was to occur before and after resident contact, after removing gloves, after contact with bodily fluids, when there was potential exposure to organisms, before handling medications or food, after blowing their nose, sneezing, coughing, and touching hair or face, -hands would be washed with soap and water when visibly soiled or contaminated with dirt, blood, or bodily fluids, -alcohol-based hand rub was preferred of hands were not visibly soiled or contaminated, and -gloves were not a substitute for hand hygiene. A record review of Resident 11's Minimum Data Set (MDS, a federally mandated assessment tool used in Care Planning) dated 2/26/25 revealed the resident had severe cognitive impairment, was dependent with dressing, toileting, and personal hygiene, was frequently incontinent of bladder and bowel and had diagnoses of Alzheimer's Disease and dementia. A record review of Resident 11's Care Plan, last revised 4/10/25 revealed the resident was dependent with dressing, personal hygiene, and toileting; required assistance with bed mobility and transfers; and the resident had cognitive impairment. Observation on 4/22/25 at 9:55 AM Nursing Assistant (NA)-G had Resident 11 sitting on the edge of the bed with a gait belt on. NA-G assisted the resident to ambulate to the bathroom. NA-G, while not wearing any gloves, pulled Resident 11's pants and soiled brief down. The resident sat on the toilet. NA-G put on a clean pair of gloves without performing hand hygiene and removed the soiled brief. Still wearing the same pair of gloves, NA-G obtained a new brief from the resident's dresser, applied it to the resident and applied the resident's pants. NA-G removed their gloves and without performing hand hygiene applied a new pair of gloves. NA-G performed peri cares and doffed the gloves. No hand hygiene was observed. NA-G applied new gloves, assisted the resident to pull their pants up, then doffed the gloves without performing hand hygiene. NA-G ambulated with the resident back to the resident's bed and assisted the resident to change their clothes. NA-G ambulated the resident back to the bathroom and assisted the resident with brushing their teeth and hair and washing their face and hands. NA-G ambulated the resident back to the resident recliner, covered with a blanket and turned the tv on. NA-G left the resident room, and no hand hygiene was observed. C. A record review of Resident 13's MDS dated [DATE] revealed the resident had severe cognitive impairment, was dependent with toileting, and dressing, was frequently incontinent with bladder and bowel habits and had a diagnosis of dementia. A record review of Resident 13's Care Plan, last revised 1/30/25 revealed the resident was dependent with toilet use and dressing the lower half of the body, and required assistance with upper body dressing, bed mobility, personal hygiene and transfers. Further review revealed the resident had cognitive impairment. Observation on 4/22/25 at 9:15 AM revealed NA-F assisted the resident into the bathroom. NA-F pulled the resident's pants and brief down without wearing gloves. Resident 13 was incontinent of a bowel movement. NA-F instructed Resident 13 to sit down on the toilet and NA-F put on gloves without performing hand hygiene. NA-F removed the residents soiled brief and applied a clean brief. NA-F performed peri-cares and removed their gloves. NA-F did not perform hand hygiene and pulled the resident's brief and pants up. NA-F ambulated with Resident 13 to their recliner and the resident sat down. NA-F removed the trash from the bathroom and disposed of properly. No hand hygiene was observed. Interview on 4/23/25 at 2:50 PM with the DON confirmed hand hygiene should be performed after removing gloves. 51391 D. A record review of Resident 18's MDS dated [DATE] revealed the resident had severe cognitive impairment, was dependent on staff for toileting, dressing, personal hygiene, rolling left to right in bed and chair to bed/bed to chair transfer. Resident 18 was always incontinent of bowel and bladder and had diagnoses of progressive neurological condition, dementia, Parkinson's Disease and Psychotic Disorder. An observation on 4/22/25 at 9:40 AM revealed that NA-G had gloves on, transferred resident 18 with the mechanical lift onto their bed, checked the resident for being incontinent of bowel and bladder, resident did not need to be changed. NA-G removed their gloves and no hand hygiene was observed. NA-G reapplied gloves, repositioned the resident in bed, covered the resident with a blanket, removed gloves, picked up the trash from the room and exited the room. No hand hygiene was observed. An interview with the DON on 4/23/25 at 2:50 PM confirmed hand hygiene should be performed after removing gloves.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review the facility failed to assess Resident 21 for safe mechanical lift use to prevent the potential for accidents. The sample size was 3 and the facility census was 29. Findings are: A record review of the facility's Sit to Stand Lift Competency dated 10/2024 revealed the following: -the resident must be able to bear weight on at least 1 leg, -staff would report to the supervisor when a change in resident transfer was noted, and -staff would use the correct lift sling based on the assessment of the residents. If the sling fit was inappropriate notify the supervisor. A record review of Resident 21's current Care Plan with a revision date 2/22/24 revealed that Resident 21 had an Activity of Daily Living self-performance deficit related to left arm functional limitation, history of stroke, and weakness. Activity of Daily Living interventions were: -toilet use: the resident was dependent on staff for toileting care with 1-person assist, and -resident transferred with 1-2 person assist with mechanical lift. The resident also had the potential for impairment to skin integrity related to functional limitation in left arm and leg. An intervention listed for this concern was that the facility educated staff to watch elbows when using the mechanical for transfer into bathroom. A record review of Resident 21's Nursing Progress Notes revealed the following: -3/25/25 at 4:24 PM a skin tear was noted to the resident's right elbow measuring 2 centimeters (cm) by 2 cm. Staff was educated to watch the resident's elbows when in the mechanical lift being transferred. Resident does chicken wing (arms poorly support the resident weight forcing the elbows upward) when in the mechanical lift. An observation on 4/22/25 at 10:30 AM with Nursing Assistant (NA)-G revealed when Resident 21 was transferred with the mechanical lift the resident's elbows were pointed out to the side of the lift on both arms. The resident was assisted with toileting cares and when standing resident up from the toilet with use of mechanical lift, the resident was bearing weight to legs poorly and the resident's arms and shoulders were being pulled on by the mechanical lift. NA-G cued the resident to stand up, yet the resident was unable to stand up and bear full weight to legs. An interview on 4/22/25 at 10:45 AM with NA-G confirmed that when Resident 21 was transferred with use of the mechanical lift, the resident's elbows extended out to both sides and resident chicken wings. Resident 21's shoulders were pulled on when the resident chicken wings. When the resident was being transferred with the mechanical lift staff had to make sure that the resident's elbows do not hit the doorway of the bathroom. NA-G confirmed that if a resident had a difficult time when being transferred with a mechanical lift the Director of Nursing (DON) was to be notified. NA-G confirmed that the DON had not been notified of Resident 21's elbow's sticking out to the side, chicken winging, and shoulders being pulled on with all transfers when using the mechanical lift. An interview on 4/22/25 at 12:00 PM with the DON confirmed that when a resident's transfer status has changed the supervisor was to be notified, a transfer evaluation or therapy screen should be done if the mechanical lift caused them to chicken wing. The DON confirmed that there was not a transfer evaluation or therapy screen completed after reviewing the documentation from 3/15/25. Further interview confirmed that NA-G had not notified the supervisor of how the resident's transfer went on the morning of 4/22/25. An interview on 4/22/25 at 2:25 PM with the DON confirmed that NA-G voiced concerns with resident's transfer with the use of the mechanical lift going from the bathroom to the wheelchair the morning of 4/22/25. Resident was not bearing weight to her legs and was chicken winging causing the resident's shoulders to be pulled on. MA-C confirmed that the resident's sling used when transferring with the mechanical lift does slide up at times and then the resident chicken wings and resident's shoulders are pulled on.

Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview; the facility failed to implement and maintain a cleaning schedule for kitchen items and equipment to prevent the potential for food borne illness. This had the potential to affect all facility residents. The facility census was 33. Findings are: The following concerns were identified during the follow up kitchen tour on 5/13/24 from 11:40 AM through 12:05 PM: -a thick layer of black burnt on grease was noted on the inside surface and back surface of the grill attached to the oven and the inside surfaces of the oven especially around the doors were also covered with burnt on food residue; The outside surface of the oven also had areas of food residue, and the floor beneath the oven had grease and food debris visible. -The walk-in refrigerator had food residue running down the outside surface of the refrigerator below the access doors and next to the walk-in door where the garbage cans were located. -The reach-in refrigerator in the dry storage area had a very soiled handle and the surrounding surface area around the handle was also soiled. -The facility toaster was also coated with burnt on grease and covered in breadcrumbs inside and below the toaster on the stainless-steel cabinet it was sitting on. -The wall behind the steam table (used to keep prepared food warm during meal service) was soiled with food debris. -The microwave oven had spattered food present inside that had not been cleaned after use. -The food serving cart used to take food items to residents had wheels that were covered in dirt and debris and had food residue and crumbs in all the corners of all 3 shelves. - The floor just underneath and below the cupboards in the snack and serving area adjacent to the kitchen also had dirt and debris on the floors and one cupboard door was chipped and pealing and was not a cleanable surface. During an interview on 5/14/24 at 10:02 AM The Food Services Supervisor (FSS) confirmed the facility had not implemented and maintained a cleaning schedule for kitchen items and equipment such as the ovens, the stove top grill, the floor under the oven, a gray storage cabinet beneath a food preparation area, the outsides of the sugar and flour bins beneath the food preparation area, the outside walls of both the walk in and the reach in refrigerators, the toaster and the area beneath the toaster, the microwave, and the wall directly behind the steam table in which the prepared food was served from were not on a routine cleaning schedule. In addition, the FSS confirmed the facility had no evidence they were cleaning kitchen items/equipment on a routine schedule and did not have a policy for kitchen sanitation.

Licensure Reference Number 175 NAC 12-006.17 Based on observations, record review and interview; the facility failed to implement hand hygiene measures to prevent the potential spread of infection for Resident 5 and failed to wear the required Personal Protective Equipment (PPE) when providing management/care of Resident 34's catheter. The sample size was 14 and the facility census was 33. Findings are: A. Review of the undated facility policy Infection Prevention and Control Program revealed the facility developed and maintained an infection prevention and control program that provided a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. B. Review of the undated facility policy Standard Precautions revealed the following: -team members followed accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions (precautions used during the provision of all care, established to prevent infection and or the spread of infection), and -hand hygiene would be done, for a minimum of 20 seconds, before and after all patient care and after removing and disposing of gloves and other protective equipment. C. Review of Resident 5's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident Care Plans) dated 4/3/24 revealed the following; -the resident had severe cognitive impairment and dementia, -was incontinent of bladder, and -received substantial assistance with transfers, toileting, and toileting hygiene. During an Observation of care for Resident 5 on 5/13/24 at 9:51 AM, Nurse Aide (NA)-H entered Resident 5's room. NA-H did not perform hand hygiene (wash hands or sanitize). NA-H put on gloves and assisted the resident from a wheelchair to the bathroom using a stand-up mechanical lift. NA-H pulled down the resident pants and incontinence brief and then using the mechanical lift sat the resident on the toilet. After going to the bathroom NA-H assisted the resident to stand, assisted the resident with toileting hygiene and pulled up the brief and pants. NA-H then removed the gloves but did not perform hand hygiene. The resident was then assisted back into the wheelchair and positioned for comfort. NA-H exited the room and did not perform hand hygiene. D. During an interview on 5/13/24 at 1:55 PM, Licensed Practical Nurse/Infection Preventionist (LPN/IP) revealed staff are to perform hand hygiene prior to administering care, each time gloves are changed and after completing care to prevent the potential spread of infection. 29638 E. Review of the facility policy for Enhanced Barrier Precautions (EBP-use of PPE to reduce the transmission of multi drug-resistant organisms (MDRO- organisms resistant to at least one or more classes of antimicrobial agents) between residents) dated 4/12/24 revealed EBP was to be initiated on residents with any of the following: -chronic wounds such as pressure injuries, diabetic foot ulcers, or venous stasis ulcers (non-healing wound around the ankle and lower legs caused by blood flow problems), -indwelling medical devices such as central lines, urinary catheters, feeding tubes and tracheostomy tubes, and -surgical wounds that have drains (device to remove fluid as it collects), a recent dehiscence (closed incision which re-opens either internally or externally), have been left open to heal or shows signs of infection. The policy further revealed use of PPE would be required with high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use and wound care. F. Review of Resident 34's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of dementia, Alzheimer's disease, anemia, end stage renal disease, and urinary tract infection in the last 30 days. The resident was assessed with severe cognitive impairment; required substantial to maximal staff assistance with dressing, personal hygiene, and transfers; required total assistance with toileting; and had an indwelling urinary catheter. Observations of cares completed on 5/13/24 at 10:46 AM by NA-H revealed the following: -entered the resident's room, washed hands, and placed on a clean disposable gown, a pair of disposable gloves and goggles, -emptied the resident's urinary catheter drainage bag and removed disposable gloves, -without washing hands or performing hand hygiene, transferred the resident onto the bed and laid the resident on their back, -without use of gloves, NA-H lowered the resident's slacks and grabbed the uncovered catheter drainage bag, pulled the bag through the left leg and out the top of the slacks, -still without use of gloves, continued to hold the catheter drainage bag and ran the bag down the top of the resident's slacks and out the bottom of the right pant leg, -secured the catheter tubing to a catheter secure band on the upper right thigh, - adjusted the resident's slacks, covered with a blanket, and attached the call light to the blanket, and -finally washed hands before exiting the resident's room. During interviews on 5/13/24 from 11:06 AM to 12:26 PM, NA-H and the Director of Nursing (DON) confirmed NA-H should have been wearing gloves when handling Resident 34's urinary catheter drainage bag as the resident was on EBP because of the resident's catheter.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18E1 Based on observations, record review and interviews; staff failed to utilize a full body lift (device that allows residents to be transferred between 2 surfaces using hydraulic power and requires no weight bearing assistance from the resident) and a sit-to-stand mechanical lift (mobile lift that allows for resident transfer from a seated to a standing position) in a manner to prevent potential accidents for 2 (Residents 9 and 34) of 4 sampled residents. The facility census was 33. Findings are: A. Review of a Lift and Transfer Program Policy dated 2/19 revealed that 2 team members were required to be involved with the entire process of assisting a resident and operating a full body lift. B. Review of Resident 9's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/3/24 revealed diagnoses of non-traumatic brain dysfunction, heart failure, arthritis, and dementia. The assessment indicated the resident's cognition was severely impaired, the resident was dependent for transfers, dressing, bed mobility, and toileting hygiene, and the resident was always incontinent of bowel and bladder. Review of Resident 9's current Care Plan with a revision date of 1/4/24 revealed the resident was to have total assist of 2 staff for transfers with the full body lift. During an observation on 5/9/24 at 1:23 PM, Nurse Aide (NA)-H used the full body lift to transfer the resident from the wheelchair to the bed. NA-H attached the lift sling which was positioned underneath of the resident to the lift and used the hand control to raise the resident out of the wheelchair. NA-H physically maneuvered the lift close to the resident's bed and while continuing to use the hand control manipulated the resident's body over the bed and lowered the resident onto the bed. NA-H did not have assistance from another staff member with this transfer but completed the transfer independently. During an interview on 5/9/24 at 2:45 PM, the Director of Nursing and the Administrator verified NA-H should not have transferred Resident 9 independently and 2 staff should be utilized with all full body lift transfers to prevent potential injuries or falls. C. Review of a Sit-to Stand Competency form completed by NA-H on 3/10/24 revealed the following procedure for use of the sit-to-stand lift: -identify the correct lift and harness by checking source that designates the resident's mechanical lift needs, -inspect the lift and harness for safe use, -explain lift procedure to the resident and lock wheels of bed or chair, -begin with the resident seated. If in bed, raise the back of the bed and then assist resident to dangling position, -position the harness around the resident's upper body at least 2-3 inches below the under arm, -position the resident's arms outside the harness, -fasten the safety belt around the resident's waist/pelvis, -position the lift in front of the resident opening the legs of the lift with the leg spreader bar if necessary to fit around furniture. Assist the resident to place feet squarely on the footrest, -carefully advance the lift toward the resident, until shins rest against the shin pad if possible. Fasten shins with the shin strap to keep shins and feet in place. Shin rest should be below the resident's knees for comfort. Adjust as needed, -fasten the loops of the harness to the lift arm hooks using the shortest loops possible. Use the same loop on both sides. Instruct the resident to hold the padded handles with both hands if able, -while raising the resident up, be sure to grasp the loose end of the waist strap and tighten as the resident is raised. Gently keep the slack removed from the belt throughout the process, -using the up button on the hand control, slowly raise the resident to a standing. The resident should be encouraged to bear weight as they are lifted and lean back if possible, and -transfer the resident to the desired location. D. Review of Resident 34's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of dementia, Alzheimer's disease, anemia, end stage renal disease, and urinary tract infection in the last 30 days. The resident was assessed with severe cognitive impairment; required substantial to maximal staff assistance with dressing, personal hygiene, and transfers; required total assistance with toileting; and had an indwelling urinary catheter. Review of Resident 34's current Care Plan with a revision date of 12/11/23 revealed the resident was to be trtansferred with 1 staff assist using the sit-to-stand mechanical lift. During an observation on 5/13/24 at 10:46 AM, NA-H transferred Resident 34 out of the wheelchair and onto the bed with the sit-to-stand lift. NA-H placed and secured the harness around the resident's upper body. NA-H assisted to place the resident's feet on the footrest of the lift and placed the resident's shins against the shin pad. However, NA-H failed to secure the resident's lower legs with the shin strap before standing the resident up from the wheelchair and transferring the resident onto the bed. During an interview on 5/13/24 at 11:06 AM, NA-H confirmed staff had been trained to secure the resident's lower legs with the shin strap of the sit-to-stand lift but indicated the resident's room was too crowded to secure the resident's legs. An interview with the DON on 5/13/24 at 12:26 PM verified NA-H should have assured Resident 34's lower legs were secured to the shin pad of the mechanical lift before transferring the resident to promote the resident's safety.

Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide Resident 34 or the resident's representative, bed hold information when the resident was transferred to the hospital. The sample size was 1 and the facility census was 33. Findings are: Review of the undated facility Notice of Bed Hold Policy revealed the facility advised the resident and or family of the bed hold policy, in writing and when possible, within 24 hours of an emergency transfer to inform them of the bed hold rate (daily cost/rate for the type of room being held for the resident). Review of Resident 34's Nursing Progress Notes revealed the resident was transferred to the hospital on 2/1/24. Review of Resident 34's medical record from 2/1/24 through 3/1/24 revealed no evidence the resident or the resident's representative were notified of the facility bed hold policy when Resident 34 was transferred to the hospital on 2/1/24. During an interview on 5/9/24 at 11:08 AM, the Social Service Director (SSD) and the Administrator confirmed the facility had no documented evidence Resident 34 or their representative were provided with the required bed hold information when discharged to the hospital on 2/1/24.

Licensure Reference Number 175 NAC 12-006.02(1) Based on record review and interview, the facility failed to submit transfer and discharge notifications to the State Ombudsman (an official appointed to investigate individuals' complaints and serves as a consumer advocate) as required for 1 (Resident 34) of 1 sampled resident. The facility census was 33. Findings are: Review of the Resident 34's Nursing Progress Notes revealed the resident was transferred and admitted to the hospital on 12/8/23, 2/1/24 and again on 4/16/24. During an interview on 5/9/24 at 11:08 AM, the Social Service Director (SSD) and the Administrator confirmed the facility had no documented evidence the State Ombudsman was notified of Resident 34's hospital discharges.

Licensure Reference Number 175 NAC 12-006.11E Based on interview and record review, the facility failed to ensure dishwasher temperatures were maintained at acceptable levels to prevent the potential for food born illness. This had the potential to affect all residents. The facility census was 37. Findings are: Review of the facility's Dishwasher Temperature Log revealed the following related to dishwasher temperature ranges: -wash cycle temperatures should be 150 degrees or higher for a minimum of 40 seconds; -rinse cycle temperatures should be 180 degrees or higher for 18 seconds but not to exceed 194 degrees; and -if temperatures are not within the acceptable temperature range, the machine is to be shut down and notify maintenance. Review of the dishwasher temperature logs dated 3/1/23 through 3/31/23 revealed the following: -3/1/23 a rinse temperature at breakfast of 170 degrees. -3/2/23 a rinse temperature at breakfast of 174 degrees. -3/3/23 through 3/5/23 no dishwasher temperatures were checked at breakfast and lunch meals. -3/6/23 a rinse temperature at breakfast of 178 degrees. -3/7/23 a rinse temperature at breakfast of 167 degrees and at lunch 175 degrees. -3/8/23 a rinse temperature at breakfast of 170 degrees. -3/10/23 a rinse temperature at breakfast of 176 degrees. -3/11/23 a rinse temperature at breakfast of 176 degrees. -3/12/23 a rinse temperature at breakfast of 170 degrees. -3/13/23 a rinse temperature at breakfast of 178 degrees. -3/14/23 a rinse temperature at breakfast of 170 degrees. -3/15/23 a rinse temperature at breakfast and lunch of 170 degrees. -3/16/23 a rinse temperature at breakfast of 170 degrees and at lunch 171 degrees. -3/18/23 a rinse temperature at breakfast of 176 degrees and at lunch 178 degrees. -3/22/23 a rinse temperature at supper of 170 degrees. -3/23/23 a rinse temperature at breakfast of 176 degrees and at lunch 170 degrees. -3/26/23 a rinse temperature at supper of 174 degrees. -3/27/23 a rinse temperature at breakfast of 170 degrees. -3/29/23 a rinse temperature at breakfast of 176 degrees. Review of the dishwasher temperature logs dated 4/1/23 through 4/25/23 revealed the following: -4/1/23 a rinse temperature at breakfast of 170 degrees. -4/2/23 a rinse temperature at breakfast of 172 degrees. -4/3/23 a rinse temperature at breakfast of 172 degrees and at lunch 165 degrees. -4/10/23 a rinse temperature at breakfast of 174 degrees. -4/11/23 a rinse temperature at breakfast of 170 degrees. -4/13/23 a rinse temperature at breakfast of 178 degrees. -4/14/23 a rinse temperature at breakfast of 178 degrees. -4/15/23 a rinse temperature at breakfast of 176 degrees. -4/16/23 a rinse temperature at breakfast of 170 degrees. -4/17/23 a rinse temperature at breakfast of 175 degrees. -4/18/23 a rinse temperature at breakfast of 168 degrees. -4/19/23 a rinse temperature at breakfast of 174 degrees. -4/20/23 a rinse temperature at breakfast of 175 degrees. -4/21/23 a rinse temperature at breakfast of 174 degrees. -4/22/23 a rinse temperature at breakfast of 170 degrees and at lunch 175 degrees. -4/23/23 a rinse temperature at breakfast of 175 degrees. -4/24/23 a rinse temperature at breakfast of 178 degrees. -4/25/23 a rinse temperature at breakfast of 178 degrees. An interview with the dietary manager on 5/1/23 at 2:30 PM confirmed the following: -the facility had a high temperature dishwasher and the acceptable ranges should be a minimum of 150 degrees for the wash cycle and 180 degrees for the rinse cycle; -if temperatures fall below the acceptable ranges staff should re-run the cycle 2 to 3 more times to ensure temperatures did not meet the minimum ranges; -if temperatures remained below the minimum acceptable ranges, the machine is to be shut down and dishes are to be washed manually following sanitation guidelines, and notify the dietary manager and/or the maintenance staff member for repair; -dishwasher rinse temperatures were below the acceptable ranges 21 out of 31 days in March, 2023 and 18 of 25 days in April 2023; and -staff had not notified the dietary manager or the maintenance staff member about the low dishwasher temperatures and continued to use the machine in March and April 2023.

Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview the facility failed to ensure the kitchen steam table and ceiling air vents were clean to prevent potential food borne illness. This had the potential to affect all residents. The facility census was 31. Findings are: Observations during the follow up kitchen tour on 2/23/22 at 9:50 AM revealed the following: -a dried white substance was on the underside of the top of the steam table that had dripped down the legs of the steam table, -a dried white substance had dripped onto the bottom shelf of the steam table where the serving pans are located, -brown spots were coated on the bottom of the liner pans that were in the steam table, and -an air vent in the ceiling located directly above a cart with a dishware and dry goods, was dirty and covered with dust. An interview on 2/23/22 at 10:04 AM with Dietary Cook-J stated that they rinse out the steam table liner trays daily. An interview with the Dietary Manager (DM) on 2/23/22 at 10:12 AM confirmed the dried substance on the steam table was not acceptable and should have been cleaned up. In addition, staff were expected to clean kitchen equipment daily, but the DM was not able to provide evidence of documentation this had been done for the past 3 months.

Licensure Reference Number 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to ensure food was served at palatable temperatures. This had the potential to affect all residents. The facility census was 31. Findings are: A. Review of the quantified recipes provided by Sysco dated 9/17/18 for each item served (baked chicken, beef stew, bacon cheddar red skin potatoes, soft mashable potatoes, green beans, and carrots) on 2/17/22 at the noon meal revealed to hold food at a minimum temperature of 135 or 140 degrees or higher for service. An interview with Resident 26 on 2/16/22 at 11:04 AM revealed that food was served warm and food delivered to resident rooms were warmer than the food received in the dining room. Observation on 2/17/22 at 11:45 AM revealed food was on the steam table and uncovered. Dietary Cook (DC-I), checked the temperature of each food item and revealed the following temperatures: -mashed potatoes- 120 degrees, -cheddar potatoes- 115 degrees, -ground chicken- 105 degrees, -gravy- 130 degrees, - baked chicken- 120 degrees. An observation on 2/17/22 at 11:50 AM revealed DC-I returned the cheddar potatoes to the oven. The ground chicken was placed in the microwave to be reheated. The temperature of the ground chicken was 120 degrees and returned to the microwave and heated a second time. The final temperature of the ground chicken was 140 degrees before returning the item to the steam table. DC-I then placed the baked chicken in the microwave with a re-heated temperature of 140 degrees for the first batch, and 170 degrees for the second batch before being returned to the steam table. The cheddar potatoes were removed from the oven and placed back into the steam table with a temperature of 140 degrees. The mashed potatoes and gravy were not reheated. Observation on 2/17/22 at 12:10 PM revealed food was served to one hallway at a time and each plate was covered with tin foil. After all of the room trays were served, the test tray food temperatures were checked at 12:20 PM by staff-L, who delivered the room trays. The temperatures of food items were: -mashed potatoes- 90 degrees, -green beans- 100 degrees, - baked chicken- 110 degrees, - carrots- 100 degrees, and -cheddar potatoes- 110 degrees. On 2/17/22 at 12:00 PM an interview with DC-I revealed that food needed to be kept at 140 degrees on the steam table. An interview on 2/17/22 at 12:05 PM with DC-J confirmed that food should be served at 140 degrees. An interview on 12/17/22 at 12:25 PM with the Dietary Manager confirmed that food should be served at a minimum temperature of 135 to 140 degrees. B. Review of Resident 10's Minimum Data Set (MDS-a federally mandated comprehensive assessment used in the development of the resident's care plan) dated 11/24/21 revealed the following; diagnoses of cancer, [CONDITION(S)], and [CONDITION(S)], and had a BIMS (Brief Interview for Mental Status) assessment of 15 out of 15 indicating normal cognitive function. An interview with Resident 10 on 2/16/22 at 11:44 AM revealed that hot food was not served hot, and was sometimes warm but not always. Observation of Resident's 10's meal service through the course of the survey revealed the following; -on 2/16/22 at 12:01 PM the resident was served a food tray with a plate covered with tin foil in the resident room and the resident reported the food was warm but not hot. -on 2/17/22 at 9:02 AM the resident was served a food tray in the resident room with tin foil covering the hot food items and the resident reported the food was warm but not hot. -on 2/17/22 at 2:02 PM the resident reported receiving stew for lunch that was warm and tasted good but was not hot. C. Review of Resident 17's MDS dated [DATE] revealed the following; the resident had dementia, a BIMS score of 12 out of 15 indicating moderate cognitive impairment, and received supervision with eating. Review of Resident 17's Progress Note revealed the following; -on 10/8/21 at 10:00 the resident was sitting in the dining room and stated my food is cold and the staff suggested that it had been sitting too long, then the resident reported that it came out cold., and -no evidence the staff offered to warm up the food or offer an alternative. An interview with Resident 17 on 2/16/22 at 11:30 AM revealed the resident felt the food was served cold whether it was served in the resident room or the dining room. Observation of Resident 17's random meal service through the course of the survey revealed the following; -on 2/16/22 at 12:05 PM the resident was served a food tray on a plate covered in foil in the resident room consisting of mashed potatoes, gravy, ground meat, beans, and dessert. The resident reported the food was barely warm. -on 2/17/21 at 12:32 PM the resident was served a food tray on a plate covered in foil and the resident reported the food was barely warm. D. During an observation on 2/17/22 at 12:20 PM of staff member L checking the temperatures of a test meal tray immediately following delivery of the last meal tray revealed the following food temperatures for the hot food items; -mash potatoes -90 degrees -chicken- 110 degrees -green beans-100 degrees -carrots-100 degrees -cheddar potatoes - 110 degrees E. Review of the facility menu for 12/17/22 revealed that hot food was to be served at a temperature of 135 to 140 degrees. F. During an interview on 2/17/22 at 12:25 PM the Dietary Manager confirmed that hot food should be served at a temperature of at least 135 to 140 degrees. During an interview on 2/23/22 at 11:17 AM the facility administrator confirmed that hot food should be served at a temperature of at least 135 degrees or as stated on the individual food recipes.

Licensure Reference Number 175 NAC 12-009D7 Based on record review and interview; the facility failed to implement interventions for the prevention of an elopement (when a resident takes action to leave the facility unattended and without staff's knowledge) for 1 (Resident 9) of 2 residents reviewed. The facility census was 31. Findings are: A. Review of the facility policy Elopement Prevention and Management with revision date of 1/16, revealed each resident was to receive adequate supervision and assistance for their safety. The facility was to maintain a safe environment for all residents which included assessment of any cognitively impaired residents who displayed impaired decision making skills to determine concerns that may place them at risk for elopement. The policy defined attempted elopement as the resident taking actions to leave the facility structure, but the facility alarm systems and staff responded immediately and appropriately. Staff were to complete an Incident Report/Investigation with each elopement/attempted elopement. All residents were to be evaluated prior to admission and were to have ongoing reviews to determine proper placement and a safe environment. If a resident was determined to be at risk for potential elopement, appropriate interventions were to be implemented. An Elopement Risk Assessment used to assist with determining and documenting a resident's elopement risk was to be completed on admission, 72 hours after admission, 30 days after admission, quarterly, annually and with any change in condition. In addition, the Elopement Risk Manual (binder kept at the Nurse's station which contained Missing Resident Identification forms and a picture of residents at risk) was to be kept updated in regards to residents at risk for elopement. Discontinuation of a resident from the Elopement Risk Manual would occur when the resident no longer posed a risk for elopement and the resident's care plan would be updated to identify the resident was no longer at risk for elopement. B. Review of Resident 9's Minimum Data Set (MDS) (a comprehensive assessment tool used for care planning) dated 11/24/21 revealed the resident was admitted on [DATE] and had diagnoses of non-traumatic [CONDITION(S)], unspecified dementia, heart failure, Non-Alzheimer's dementia and [CONDITION(S)]. The resident's cognition was assessed as severely impaired. Review of an Elopement/Wandering Review dated 9/14/19 at 11:45 AM revealed the following regarding Resident 9: -cognitively impaired with poor decision making skills; -diagnosis of dementia; -able to ambulate independently with/without use of an assistive device (including a wheelchair); -communication problems; and -the resident was in a high risk category for elopement. Review of a Nursing Progress Note dated 9/23/21 at 6:15 AM revealed the exit door alarm was activated on the 100 corridor. Resident 9 was observed to be pushing on the door handle and the door opened a small amount. The resident was wearing only 1 shoe and the resident's gown and slacks were on backwards. The resident was re-directed to the resident's room. Review of an Elopement/Wandering Review dated 9/23/19 at 7:15 AM revealed in addition to items identified with assessment completed 9/14/19, the resident now had a history of trying to leave the facility without supervision and without informing the staff. The resident verbalized the desire to go home and had wandered aimlessly in the facility. The assessment identified Resident 9 had attempted to go out the facility exit door outside of the resident's room and this was the first incident since admission. The resident was assessed at high risk for elopement. Review of a Post Elopement and Attempted Elopement Checklist dated 9/23/19 at 6:40 AM revealed after the resident's attempted elopement, a Missing Resident Identification form was completed and was placed in the Elopement Risk Manual at the Nurse's station. In addition, staff were to provide the resident toileting assistance if the resident was anxious or to offer the resident an activity. Review of a Nursing Progress Note dated 9/23/19 at 12:00 PM revealed the door alarm was sounding on the 100 corridor and the resident was observed pushing on the door handle. The resident identified a need to go outside to look for a child and then bring them in before they were lost and the resident was unable to find. The resident was redirected to the resident's room. Review of the resident's medical record revealed no evidence a Post-Elopement and Attempted Elopement Checklist was completed to determine causal factors for the attempted elopement and to review/revise elopement prevention interventions. Review of a Nursing Progress Note dated 9/23/19 at 6:10 PM revealed at 4:30 PM the resident was self-propelling in the wheelchair. The resident attempted to push open the exit door on the 100 corridor and the exit door alarm began to sound. The resident was redirected to the dining room for the evening meal. Review of a Post-Elopement and Attempted Elopement checklist completed 9/23/19 at 4:35 PM revealed no additional interventions were developed or current interventions revised to prevent further elopement attempts. Review of Nursing Progress Notes dated 9/26/19 revealed the following: -3:46 AM the resident had not slept throughout the night and was wandering in the corridors; -4:34 PM the resident's family was notified of the resident's exit seeking and the family consented to moving the resident to a room closer to the Nurse's station: and -4:42 PM the resident was found on the floor by an exit door. Review of Resident 9's Nursing Progress Notes revealed the following: -6/1/20 at 12:45 AM the resident reported seeing snakes in the resident's room and indicated something was on the ceiling; and -6/16/20 at 4:29 PM the resident was removed from the Elopement Risk Manual due to no recent attempts at elopement. Review of an Elopement/Wandering Review dated 6/16/20 at 4:36 PM revealed Resident 9 continued to have impaired cognition and decision making skills with a history of leaving the facility unattended and without telling the staff. The assessment indicated the resident remained in the high risk category for potential elopement despite the resident being removed from the Elopement Risk Manual. Review of Resident 9's Nursing Progress Notes revealed the following: -7/18/20 at 3:49 AM the resident called staff to remove all the ants crawling on the resident's floor and then indicated there was a fire by the closet; -7/19/20 at 3:46 PM the resident continued to have hallucinations regarding ants on the floor; -9/8/20 at 1:31 PM the resident refused to eat the noon meal and reported a need to go and find the resident's car; -10/5/20 at 1:34 AM the resident identified seeing snakes throughout the night; -10/9/20 at 11:38 PM the resident had been hallucinating throughout the evening and was looking under the bed for children; -10/13/20 at 2:23 PM the resident was once again added to the Elopement Risk Manual due to out of character responses and -1/5/21 at 1:52 PM the resident was removed from the list in the Elopement Risk Manual which was stored at the Nurse's station. Review of an Elopement/Wandering Review dated 1/5/21 at 5:34 PM revealed the resident was assessed at high risk for wandering/elopement despite being removed from the Elopement Risk Manual. Review of Nursing Progress Notes revealed the following: -1/24/21 at 1:21 AM the resident was hallucinating. The resident was looking for a small child and for the people who had just dropped off the resident; -2/4/21 at 4:51 PM the resident was found ambulating independently in the corridor without the resident's wheelchair. The resident was again looking for children as well as a cat and reported hearing noises; -2/4/21 at 5:45 PM the resident was ambulating in the corridor without the wheelchair and indicated a need to go home; 2/4/21 at 9:13 PM the resident remained anxious, was concerned about family and wanted to go home; -2/14/21 at 1:35 AM the resident had hallucinations, seeing bugs on the floors and the walls. The resident was taken to the Nurse's station for increased supervision and the resident propelled the wheelchair to the front lobby exit door. The resident continued to roll around the front lobby by the door; -2/16/21 at 1:19 AM the resident exited the resident's room in the wheelchair and headed to the front door indicating a need to get home; and -2/19/21 at 5:37 PM the staff heard the 200 corridor exit door alarming. No residents were visible by the door. The Charge Nurse was alerted and staff looked through the Elopement Risk Manual but all of the residents identified in the manual were accounted for. A search of the facility revealed Resident 9 was not in the resident's room. Staff looked outside and found Resident 9 in the wheelchair on the sidewalk south of the exit door by the 300 corridor. The resident was assisted back into the facility and to the resident's room; -2/19/21 at 8:26 PM the resident was in the corridor self-propelling the wheelchair and looking for a child. The resident was moved to room 203. Review of a Post-Elopement Checklist dated 2/19/21 at 9:00 PM indicated staff would be placing the resident back on the list of residents at risk for elopement in the Elopement Risk Manual. Interview on 2/22/22 at 2:41 PM with the Director of Nursing and the Administrator confirmed the following regarding Resident 9: -was assessed on admission in the high risk category for potential wandering and elopement; -9/23/19 at 6:15 AM was found pushing the handle for the 100 corridor exit door and was able to open the door a small amount before the staff responded. The staff completed a Post-Elopement and Attempted Elopement Checklist and the resident was placed into the Elopement Risk Manual due to high risk for elopement; -the resident made 2 additional attempts to elope on 9/23/19 but staff failed to complete the Post-Elopement and Attempted Elopement Checklist with the additional elopement attempts. The resident was not placed into the Elopement Risk Manual until 9/24/19. No additional interventions were developed/implemented; -6/16/20 the resident was removed from the Elopement Risk Manual despite ongoing episodes of hallucinations and the Elopement/Wandering Review which indicated the resident remained at high risk for elopement/wandering; -10/13/20 the resident was placed back in the Elopement Risk Manual due to behaviors and hallucinations; -1/5/21 the resident was removed from the Elopement Risk Manual even though an Elopement/Wandering Review indicated the resident remained in the high risk category for wandering/elopement; -from 1/24/21 through 2/16/21 the resident was having increased behaviors which included hallucinations, wandering in the corridors, talking about going home and approaching the exit doors; -no additional interventions were developed and the resident was not placed back into the Elopement Risk Manual; and -2/19/21 at 5:37 PM the resident had an elopement out the 200 corridor exit door.

Licensure Reference Number: 175 NAC 12-006.09D7 Based on interview and record review, the facility failed to complete investigative documentation to prevent potential elopement/attempted elopements for Resident 2. The sample size was 1 and the facility census was 32. Findings are: Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/13/19 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 (which indicates severe cognitive impairment). Review of Resident 2's current undated Care Plan revealed the resident had a [DIAGNOSES REDACTED]. Interventions included encouraging activities, keeping a consistent routine, using simple statements, and providing orientation. Review of a Progress Note dated 4/6/19 at 3:31 PM revealed Resident 2 was brought back into the facility after eloping from the 300 wing hallway door. The nurse aide responded to the alarm promptly and was able to encourage the resident to return to the nursing home. Review of the facility policy Elopement Prevention and Management dated 1/2016 revealed with any elopement/attempted elopement the facility must complete the Incident Report Investigation form and a Post Elopement/Attempted Elopement Checklist. Review of Resident 2's Assessments revealed no evidence to indicate an Incident Report Investigation or Post Elopement/Attempted Elopement Checklist had been completed on 4/6/19. During an interview with the Administrator on 5/15/19 at 12:18 PM, the Administrator confirmed there was no evidence to indicate an Incident Report Investigation or a Post Elopement/Attempted Elopement Checklist had been completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview; the facility failed to develop interventions as needed for 1 (Resident 30) of 4 sampled residents for the prevention of weight loss. The facility census was 32. Findings are: Review of Resident 30's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/24/19 revealed [DIAGNOSES REDACTED]. The MDS identified the resident had severe cognitive impairment, required supervision with eating and had a weight of 141 pounds. No nutritional interventions were identified. Review of the Weights and Vitals Summary form (a document used to record the resident's weights) revealed the following regarding Resident 30's: -2/10/19 weight was 154 pounds; -2/17/19 weight was 153 pounds (down 1 pound in 1 week); -2/24/19 weight was 152 pounds (down 2 pounds in 2 weeks); -3/18/19 weight was 150 pounds (down 4 pounds or a 3% (percent) loss in 1 month); -3/24/19 weight was 150 pounds -4/7/19 weight was 144 pounds (down 10 pounds or a 6% loss in 2 months); and -4/21/19 weight was 141 pounds (down 9 pounds or a 6% loss in 1 month). Review of a Registered Dietician's (RD) Nutritional Progress Note dated 4/30/19 at 2:00 PM revealed an assessment was completed. The note identified the resident's skin was intact and the resident had no [MEDICAL CONDITION] (swelling). The resident did have a recent fracture but meal intakes and weights had been stable prior to the fracture. The note further identified the resident had a poor appetite following the fracture. No new recommendations were identified despite the resident's weight loss. Review of the resident's current Care Plan with revision dated of 5/1/19 revealed the resident was at potential risk for altered nutrition due to pain from recent (4/13/19) left fibular fracture. Nutritional interventions included the following: -chips and candy stored at bedside; -allow the resident adequate time to eat meals and offer assistance and cueing as needed (sitting on the assisted side of the dining room); -dietician to evaluate nutritional needs; -offer alternatives when menu identifies chicken or eggs (ate these items frequently as a child and so has grown tired of eating them); -monitor and document food intake at meals; and -weight to be obtained weekly. Review of the Weights and Vitals Summary form revealed the resident's weight on 5/12/19 was 144 pounds (up 3 pounds in a month). Interview with the Dietary Manager (DM) on 5/14/19 at 9:59 AM confirmed despite the resident's weight loss, the facility failed to develop and/or implement any nutritional interventions. The DM indicated the resident's intakes were beginning to improve and weight was starting to stabilize.

LICENSURE REFERENCE NUMBER 175 NAC 12.006.17D Based on observations, record review and interviews; the facility failed to provide appropriate care and services for the prevention of urinary tract infections for 1 (Resident 24) of 2 sampled residents who had an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). The facility census was 32. Findings are: Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/18/19 revealed [DIAGNOSES REDACTED]. The MDS further indicated Resident 24 had an indwelling urinary catheter. Review of the current Care Plan with revision date 1/14/19 indicated Resident 24 was at risk for potential infections related to use of the indwelling urinary catheter. Nursing interventions included the following: -anchor the catheter with a leg strap. Keep the catheter drainage bag (the receptacle that collects the urine) below the level of the bladder. -catheter care every shift with proper technique; -encourage increased fluid intakes; -observe for any blood in tubing or catheter related pain; -observe urine appearance and report abnormalities (cloudy urine, foul smell, blood tinged and decreased or absent urine output) to the charge nurse; and -use caution when providing assistance during transfers. Review of a Nursing Progress Note dated 3/11/19 at 4:50 PM revealed the resident had blood in the catheter today. Review of a Nursing Progress Note dated 3/12/19 at 4:29 AM revealed small amount of drainage noted from catheter and urine amber in color with some sediment. Review of a Nursing Progress Note dated 4/30/19 at 12:30 AM revealed the resident's catheter was draining cloudy urine and fluids were encouraged. Review of a Nursing Progress Note dated 5/1/19 at 4:26 AM revealed the resident had bloody urine. Review of Nursing Progress Notes dated 5/9/19 revealed the following: -1:15 PM staff identified the resident has been passing blood clots around the Foley catheter today. Minimal urine output was observed in the catheter drainage bag; -2:00 PM resident continued to have blood and small blood clots around the catheter insertion site with only a trickle of blood in the catheter tubing; and -4:20 PM per Physician order, Resident 24 was transferred to the emergency room for evaluation and then was admitted to the hospital. Review of a Nursing Progress Note dated 5/12/19 at 2:51 PM the resident returned from the hospital with an order for [REDACTED]. Observation of cares by Nursing Assistant (NA)-A and NA-B on 5/14/19 from 7:37 AM until 8:10 AM revealed the following: -the resident's urinary catheter drainage bag was hanging on the frame of the resident's bed. NA-B removed the drainage bag from the bed frame and proceeded to hang the drainage bag on the foot board of the resident's bed (above the level of the resident's bladder). NA-B used gloved hands and a washcloth to clean the skin surrounding the catheter with soap and water, and to clean the catheter at the insertion site; - NA-A and NA-B assisted the resident to sit on the side of the bed. NA-B removed the catheter drainage bag from the foot board of the resident's bed and placed the drainage bag on the base of the sit-to-stand mechanical lift (a mobile lift that allows for patient transfers from a seated position to a standing position. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability) where the resident's feet are to be placed; -the heel of Resident 24's shoe was resting directly on the top of the catheter drainage bag as the resident was lifted from the side of the bed and transferred into the wheelchair; -as the resident was lowered into the wheelchair; the tubing of the catheter became taunt and NA-A in an effort to relieve the tension, retrieved the drainage bag from the base of the sit-to-stand lift and placed the bag directly on the floor, underneath of the resident's wheelchair; and -when the resident was seated in the wheelchair, NA-A picked the drainage bag up from where it was lying on the floor and placed the drainage bag into a privacy cloth cover which was hanging on the frame under the seat of the resident's wheelchair. During an observation on 5/14/19 at 11:45 AM of a dressing change on Resident 24's left foot, the resident's urinary catheter drainage bag was observed lying uncovered and directly on the floor next to the resident's bed. Registered Nurse (RN)-C with a gloved hand, picked the drainage bag up from the floor and in an attempt to reposition the catheter tubing, raised the tubing up (well above the level of the resident's bladder) before placing the drainage bag back into the cloth privacy bag which hung from the frame of the resident's bed. During interview on 5/15/19 at 11:31 AM, the MDS Coordinator verified the following related to Resident 24's indwelling urinary catheter: -catheter drainage bag was to be positioned below the level of the resident's bladder at all times to prevent a back flow of urine from the bag or tubing into the resident's bladder; -the catheter drainage bag should not have been placed directly on the base of the sit-to-stand lift, underneath of the resident's shoe or directly on the floor of the resident's room; -these practices could all lead to increasing the resident's risk for potential urinary tract infections; and -the resident was hospitalized from [DATE] through 5/12/19 for treatment of [REDACTED].