Every finding on record at Colonial Haven

Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview; the facility failed to have informed consent and/or comprehensive informed consent for the use of psychotropic medications (any medications that affect behavior, mood, thoughts, or perception) in advance of administration that included the current dose and/or alternate treatment plan options for Residents 4, 5, 9, 18, and 27. The sample size was 6 and the facility census was 32. Findings are: A. Review of the facility policy Use of Psychotropic Medication(s) dated 1/14/26 revealed it was the policy of the facility to ensure residents only received psychotropic medications when other nonpharmacological interventions were clinically contraindicated. These medications were to be used only to treat the residents' medical symptoms and not used for discipline or staff convenience. The following compliance guidelines were identified: -psychotropic drugs include antipsychotics, antidepressants, hypnotics and antianxiety medications. -psychotropic medications are to be used only when a practitioner determined the medication(s) was appropriate to treat specific, diagnosed and documented conditions and the medication was beneficial to the resident as evidenced by monitoring and documentation of the resident's response to the medication(s). -the indications for initiating, maintaining, or discontinuation of medication(s), as well as the use of non-pharmacological approaches, was to be determined by evaluating the residents' physical, behavioral, mental and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks and the preferences and goals for treatment. -prior to initiation or increasing a psychotropic medication. The resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. -the facility was to document that the resident or the resident representative was informed in advance of the risks and benefits of the proposed care, and the treatment alternatives. -the facility was to document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deemed to use (written consent, narrative not etc.) B. Review of Resident 9's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 6/17/26 revealed the resident was admitted [DATE] with diagnoses of Non-Alzheimer's dementia, other fractures, malnutrition, depression, and anxiety. The following was assessed regarding the resident: -severe cognitive impairment. -no behaviors exhibited. -received antipsychotic, antidepressant, and opioid medications. Review of a facsimile (fax) dated 3/31/26 at 7:23 PM revealed a new order for Alprazolam (medication used to treat anxiety or panic attacks) 0.25 milligram (mg) 1 tablet every 8 hours as needed for anxiety for 14 days. Review of a fax dated 5/20/26 at 12:15 PM revealed a new order for Alprazolam 0.25 mg daily for 7 days. Review of a fax dated 5/23/26 at 12:42 PM revealed a new order to give Resident 9 an additional 0.25 mg of Alprazolam at 4:00 PM for a total of 0.5 mg for the next 3 days. Further review of Resident 9's medical record revealed no documentation the resident and/or the resident's representative were informed of the risks, benefits, or alternative treatments for the use of the antianxiety medication Alprazolam on 3/31/26, 5/20/26 and on 5/23/26. Review of Resident 9's Psychotropic Medication Therapy Informed Consent Form dated 2/17/26 at 2:18 PM revealed the resident's representative gave a verbal consent to increase the dosage of the medication Zoloft (medication used to treat depression) from 50 mg to 75 mg to treat the resident's anxiety. However, there were no identified symptoms, evidence of potential effects or adverse effects, and/or alternate non-pharmacological treatment options identified. Review of Resident 9's Psychotropic Medication Therapy Informed Consent Form dated 2/17/26 at 2:25 PM revealed the resident's representative gave a verbal consent for use of Alprazolam 0.25 mg as needed for anxiety. Further review of the resident's medical record revealed the facility failed to identify the resident's symptoms for use of the medication, evidence of potential effects or adverse effects, and/or alternate non-pharmacological treatment options. Review of Resident 9's Psychotropic Medication Therapy Informed Consent Form dated 4/1/26 at 3:30 PM revealed the resident's representative gave verbal consent for use of Alprazolam .25 mg twice a day for 30 days to treat the resident's anxiety. Further review of the resident's medical record revealed there were no indicated symptoms, evidence of potential effects or adverse effects, and/or alternate non-pharmacological treatment options. Review of Resident 9's Psychotropic Medication Therapy Informed Consent Form dated 4/22/26 at 2:11 PM revealed the resident's representative gave verbal consent for the facility to increase Zoloft from 75 mg to 100 mg daily to address the resident's anxiety. However, there was no evidence the facility had educated the representative regarding potential effects or adverse effects, and/or nonpharmacological interventions. Review of Resident 9's Psychotropic Medication Therapy Informed Consent Form dated 5/20/26 at 1:24 PM revealed the resident's representative gave verbal consent for the administration of Trazadone (medication used to treat depression) for a diagnosis of dementia with behaviors. However, there was no documentation to indicate the dosage of medication the resident was to receive or how often the resident was to receive. In addition, there was no evidence the facility had educated the representative regarding potential effects or adverse effects, and/or nonpharmacological interventions. Review of Resident 9's Psychotropic Medication Therapy Informed Consent Form dated 5/27/26 at 3:56 PM revealed an order for Seroquel (antipsychotic medication) 25 mg 1/2 tablet for dementia with behavioral disturbances. Further review revealed no evidence to indicate how often the resident was to receive the medication, or that the facility had provided the representative with education as to the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of Resident 9's Psychotropic Medication Therapy Informed Consent Form dated 6/22/26 at 8:50 PM revealed a new order for Alprazolam .25 mg to be given as a one-time dose for agitation/anxiety. However, there was no evidence the facility had educated the representative regarding potential effects or adverse effects, and/or nonpharmacological interventions. During an interview with the Director of Nursing (DON) on 6/24/26 at 8:45 AM the DON confirmed there were no consents completed by the resident and/or the resident's responsible party prior to administration of the following medications: -3/31/26 order for Alprazolam .25 mg BID prn x14 days for increased anxiety/agitation.-5/20/26 order for Alprazolam .25 mg x7 days for increased anxiety. -5/23/26 order for Alprazolam .25 mg added to .25 mg x 3 days (total of .5 mg) for increased behaviors. In addition, the consents did not include documentation of non-pharmacological interventions attempted prior to initiation of medications and/or treatment alternatives, a list of symptoms the resident was displaying, and the potential effects or adverse effects of the medications. C. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of Parkinson's disease, Non-Alzheimer's dementia and depression. The assessment indicated the resident's cognition was severely impaired, and the resident was taking an antipsychotic, antidepressant and anticonvulsant medications. Review of a Psychotropic Medication Therapy Informed Consent Form dated 10/14/25 at 2:00 PM revealed the resident had an order for Cymbalta (medication used to treat depression) 60 mg for diagnosis of depression. Further review revealed no evidence to indicate how often the resident was to receive the medication, or that the facility had provided the representative with education as to the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of a Psychotropic Medication Therapy Informed Consent Form dated 10/14/25 at 2:00 PM revealed the resident had an order for Rexulti (medication used for agitation) 34 mg for diagnosis of Parkinsons. Further review revealed no evidence to indicate how often the resident was to receive the medication, or that the facility had provided the representative with education as to the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted before use of the medication. Review of a Psychotropic Medication Therapy Informed Consent Form dated 10/15/25 at 1:00 PM revealed an order for Ativan 1 mg to be given every 6 hours as needed for increased anxiety with use of the medication to be evaluated in 6 months. Additional review revealed no evidence to indicate how often the resident was to receive the medication, or that the facility had provided the representative with education as to the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of a Psychotropic Medication Therapy Informed Consent Form dated 11/3/25 at 3:00 PM revealed the facility had obtained verbal consent from the resident's representative for administration of Wellbutrin (medication used to treat depression) for diagnosis of depression. Further review revealed no evidence as to how often the resident was to receive the medication and at what dosage, the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of the Resident's Medication Administration Record (MAR) dated 6/2026 revealed the resident continued to receive the following medications: -Wellbutrin 150 mg daily for major depressive disorder dated 11/3/25. -Rezulti 34 mg for diagnosis of Parkinson's dated 10/15/25. -Cymbalta 60 mg daily for diagnosis of major depressive disorder. -Ativan 1 mg every 6 hours as needed for anxiety re-ordered for 180 days on 2/12/26. During an interview on 6/24/26 at 2:09 PM, the DON confirmed the consent forms for the resident's psychoactive medications (Wellbutrin, Ativan, Rezulti and Cymbalta)) did not contain the required information as none of the consents identified the resident's symptoms, potential effects and/or side effects as well as the non-pharmacological interventions attempted prior to initiation of the medications. In addition, the consent forms for Wellbutrin did not identify how often the resident was to take the medications and at what dose and the Cymbalta, and Nuplazid did not indicate how often the medications were to be administered. D. Review of Resident 18's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnosis of Alzheimer's disease, Non-Alzheimer's dementia, anxiety disorder, and bipolar disorder. The resident was cognitively intact with no identified behaviors. The resident was receiving an antipsychotic, antidepressant, antianxiety, hypnotic and opioid medication. Review of a Psychotropic Medication Therapy Informed Consent Form dated 1/8/25 revealed the facility had received a verbal consent from the resident's representative for use of Trazadone for insomnia. Further review revealed no evidence as to how often the resident was to receive the medication or at what dosage, the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of a Psychotropic Medication Therapy Informed Consent Form dated 1/8/25 at 8:00 AM revealed the facility had obtained verbal consent from the resident's representative for use of Zyprexa for the resident's bipolar disorder. Further review revealed no evidence as to how often or at what dosage the resident was to receive the medication, the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of a Psychotropic Medication Therapy Informed Consent Form dated 5/5/25 at 1:00 PM revealed a verbal consent by the resident's representative for use of Ativan .5 mg for anxiety. Further review revealed no evidence as to how often the resident was to receive the medication, the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of a Psychotropic Medication Therapy Informed Consent Form dated 5/5/25 at 1:00 PM revealed the facility had obtained verbal consent for use of Zoloft 50 mg to be given for anxiety. Further review revealed no evidence as to how often the resident was to receive the medication, the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of the residents' MAR dated 6/2026 revealed Resident 18 continued to receive the following medications: -Zyprexa 7.5 mg 1 tablet daily for bipolar disorder dated 8/18/23. -Zoloft 50 mg 1 tablet daily for anxiety dated 5/6/25. -Trazadone 50 mg 1 tablet daily for insomnia. During an interview on 6/25/2026 at 8:51 AM, the DON confirmed the consent forms for the resident's psychoactive medications ( Trazadone, Zyprexa, Ativan and Zoloft) did not contain the required information as none of the consents identified the resident's symptoms, potential effects and/or side effects as well as the non-pharmacological interventions attempted prior to initiation of the medications. In addition, the consent forms for Zyprexa and Trazadone did not identify how often the resident was to take the medications and at what dose and the Zoloft did not indicate how often it was to be administered. E. Review of Resident 5's MDS dated [DATE] revealed the resident had a diagnosis of Non-traumatic Brain Dysfunction, Non-Alzheimer's Dementia, and Depression with severe cognitive impairment and received hospice services. The resident had little interest or pleasure 12-14 days, trouble falling asleep 7-11 days and trouble concentrating 12-14 days. The resident took an antidepressant medication daily. Review of Resident 5's care plan with a revision date of 4/8/26 revealed the resident had impaired cognitive function related to dementia and received hospice care with a diagnosis of senile degeneration of brain. In addition, the resident used an antidepressant medication and the facility monitored for effectiveness and side effects every shift. Review of the resident's physician's orders revealed the following: -On 9/4/25 the provider ordered Paroxetine (antidepressant) 30mg one at bedtime for dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. -On 3/12/26 the hospice provider ordered Lorazepam (antianxiety) 0.5ml every 2 hours as needed for anxiety and restlessness. Review of Resident 5's Psychoactive Medication Therapy Informed Consent Form dated 9/4/25 revealed consent to treat with the ordered medication Paroxetine 30mg, however there was no evidence an alternative treatment plan was devised or offered as an alternative to the use of the psychoactive medication. Review of Resident 5's medical record revealed that Resident 5 did not have a Psychoactive Medication Therapy Informed Consent Form completed for the medication Lorazepam. Review of Resident 5's MAR dated June 2026 revealed the resident received Paroxetine 30mg 1 tablet daily at bedtime. An interview with the DON on 6/24/26 at 10:35 AM confirmed the facility did not complete an informed consent for the use of Lorazepam and the informed consent for Paroxetine did not include an alternative treatment plan. F. Review of Resident 27's MDS dated [DATE] revealed the resident had Alzheimer's Dementia with severe cognitive impairment and rejected care 1-3 days in the prior week. The resident took antipsychotic, antianxiety, and antidepressant medication daily. Review of Resident 27's Care Plan with a revision date of 6/23/26 revealed the resident had impaired cognitive function related to dementia. In addition, the resident used antidepressant, anti-anxiety, and antipsychotic medications and the facility monitored for effectiveness and side effects every shift. The residents' targeted behaviors included rude comments, sexual behaviors toward staff, hitting/striking out, anxiety, refusal of care, and insomnia. Reviewed the facility Physician Records revealed the following: -On 2/21/25 the provider ordered Ativan (antidepressant) 0.5mg every 4 hours as needed and Ativan 0.5mg routinely at noon. In addition, Trazadone (antidepressant) 50mg at bedtime for insomnia.-on 2/27/26 the provider discontinued Quetiapine (antipsychotic) 25mg twice daily and order Quetiapine 50mg daily; in addition, the provider discontinued Sertraline (antidepressant) 50mg daily and ordered Sertraline 75mg daily. Review of Resident 27's Psychoactive Medication Therapy Informed Consent Form dated 2/21/25 revealed consent to treat with the ordered Medication Trazadone, however there was no dose of the medication stated and no evidence an alternative treatment plan was devised or offered as an alternative to the use of the psychoactive medication. Review of Resident 27's Psychoactive Medication Therapy Informed Consent Form dated 2/20/25 revealed a consent to treat with the anti-anxiety medication Lorazepam (Ativan), however there was no dose of the medication stated and no evidence an alternative treatment plan was devised or offered as an alternative to the use of the psychoactive medication. Review of Resident 27's Psychoactive Medication Therapy Informed Consent Forms dated 2/24/25, 3/13/25, and 3/18/25 revealed a consent to treat with the anti-psychotic medication Quetiapine (Seroquel), however there was no dose of the medication stated and no evidence an alternative treatment plan was devised or offered as an alternative to the use of the psychoactive medication. Review of Resident 27's Psychoactive Medication Therapy Informed Consent Form dated 2/17/26 revealed a consent to treat with the antidepressant medication Sertraline, however there was no dose of the medication stated and no evidence an alternative treatment plan was devised or offered as an alternative to the use of the psychoactive medication. Review of Resident 27's Medication Administration Record (MAR) date June 2026 revealed the resident received the following psychotropic medications:-Lorazepam/Ativan 0.5mg 1 tablet daily at 2:00 PM and 1 tablet every 12 hours as needed (PRN) for treatment of anxiety.-Quetiapine/Seroquel 75 mg daily at bedtime and 50mg daily at noon for treatment of behavioral disturbances related to dementia. -Trazadone 50mg daily at bedtime for treatment of insomnia. -Sertraline 75mg daily in the morning for treatment of anxiety and depressed mood. During an interview on 6/24/26 at 3:07 PM the DON confirmed the facility did not complete informed consents for the use of psychotropic medications (Lorazepam/Ativan, Quetiapine/Seroquel, Trazadone, and Sertraline) for Resident 27 that included the current dose ordered and/or alternative treatment plans.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i)(3) Based on record review and interviews; the facility failed to identify causal factors for falls and to develop fall prevention interventions based on causal factors to prevent ongoing falls for Resident 9. The sample size was 5 and the facility census was 32.Findings are: A. Review of the facility Fall Prevention Program with a revision date of 8/24 revealed it was the policy of the facility for each resident to be assessed for fall risk and for the residents to receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The following procedure was identified:-completion of a standardized risk assessment to determine a resident's fall risk. The risk assessment categorizes residents according to low, moderate or high risk.Upon admission the nurse was to complete a fall risk assessment along with the admission assessment to determine the resident's level of risk. The nurse would indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. -implementation of universal environmental interventions that decrease the risk of a resident falling which included, but not limited to: a clear pathway to the bathroom and bedroom doors; keep the bed locked and lowered to a level that allowed the resident's feet to be flat on the floor when the resident was sitting on the edge of the bed; the call light and frequently used items to be kept within reach; adequate lighting; and wheelchairs and assistive devices to be kept in good repair. -implement of routine rounding schedule.-monitor for changes in the resident's cognition, gait, ability to rise/sit, and balance.-encourage the resident to wear shoes or slippers with non-slip soles when ambulating.-ensure eyeglasses, if applicable are clean and the resident wears them when ambulating.-monitor vital signs in accordance with the facility policy.-complete a fall risk assessment every 90 days and as indicated if the resident's condition changes. If a resident would experience a fall, the facility would: -assess the resident.-complete a post-fall assessment. -complete an incident report.-notify the physician and the family.-review the resident's care plan and update as indicated.-document all assessments as actions. -obtain witness statements as indicated. B. Review of Resident 9's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 6/17/26 revealed the resident was admitted [DATE] with diagnoses of Non-Alzheimer's dementia, other fractures, malnutrition, depression, and anxiety. The following was assessed regarding the resident:-severe cognitive impairment.-no behaviors exhibited.-required staff assistance with all cares.-occasionally involuntary of bowel and frequently incontinent of urine.-received antipsychotic, antidepressant, and opioid medications. Review of an Incident Report dated 4/30/26 at 2:07 PM revealed the resident was found on the floor of the resident's room between the bed and the dresser. When questioned the resident stated, I just fell. Further review of the assessment revealed no causal factors were identified for the residents' fall. A sign was placed on the wall to remind the resident to call for staff assistance. Review of an Incident Report dated 5/4/26 at 6:50 PM revealed the resident was found lying on the floor in front of the bathroom door in the resident's room. The resident indicated moving the walker out of the way but the walker was at the resident's bedside and was not near where the resident had fallen. An intervention was listed for the Consultant Pharmacist to do a medication review. No further causal factors were identified. Review of the Consultant Pharmacist Monthly Medication Review (MMR) dated 5/7/26 at 4:04 PM revealed a request for the physician to complete a routine gradual dose reduction of psychoactive medications. Review of a facsimile from the residents' practitioner dated 5/8/26 at 9:39 AM revealed a new order to discontinue the resident's Alprazolam (medication used to treat anxiety) 0.25 milligram (mg) twice a day. Review of an Incident Report dated 5/25/26 at 1:20 AM revealed the resident was on the floor between the resident's bed and bathroom. The resident was barefoot at the time of the fall and feces was observed on the resident's brief and in the bathroom. The report indicated new orders dated 5/23/26 related to the start of Trazadone (medication used to treat depression and insomnia) 25 mg daily at bedtime, Melatonin 5 mg at bedtime as needed and Alprazolam (medication used to treat anxiety) 0.5 mg for insomnia and increased verbal/physical aggressive behaviors. In addition, the facility requested the resident's provider review the resident's medications. Further review of the resident's medical record revealed no evidence the facility had implemented, and/or revised the bowel and bladder program to address the resident's incontinence of bowel. Review of an Incident Report dated 5/25/26 at 7:15 AM revealed the resident was found on the floor between the bed and the dresser. The report indicated there were no lights on in the resident's room and the resident was not wearing shoes or socks. A new fall prevention intervention was identified for the provider to review the residents' medications. Further review revealed no evidence the facility addressed the lack of lighting in the room, and the resident's refusal to wear gripper socks or shoes when ambulating. Review of a Progress Note dated 5/27/26 at 10:52 AM revealed an order to extend the Alprazolam 0.25 mg daily for 7 days and to start Seroquel (antipsychotic medication) 12.5 mg daily. Review of an Incident Report dated 6/4/26 at 1:51 AM revealed the resident was found on the floor next to the resident's bed. The resident had removed gripper socks and told the staff the resident was on the way to the bathroom when the resident fell. Interventions were identified for a video monitor to the resident's room, and sensor alarms to the resident's bed, wheelchair and recliner. However, there was no evidence the facility addressed the lack of lighting in the room, and the residents' refusal to wear gripper socks or shoes when ambulating. During an interview on 6/23/2026 10:20 AM, the Director of Nursing confirmed the following regarding the residents' falls:-4/30/26 at 2:07 PM no casual factors identified. New intervention for a sign on the resident's wall to remind to call for help. Verified the resident's cognition was severely impaired and reminding the resident to wait for staff assistance was not an effective intervention.-5/4/26 at 6:50 PM the resident reported trying to move the walker as a causal factor for the fall, however the walker was not by where the resident fell. No other causal factors identified. A new intervention was listed for a medication review by the Consultant Pharmacist. -5/25/26 at 1:20 AM the resident was found on the floor between the resident's bed and the bathroom. Feces was found in the bathroom and the resident's incontinence brief. No evidence the facility reviewed/revised the resident's toileting program.-5/25/26 at 7:15 AM the resident was found on the floor between the bed and the dresser. No lights were on in the room and the resident was barefoot. No evidence the facility addressed the low level of lighting in the room or the resident's refusal to wear gripper socks or shoes.-6/4/26 at 1:15 AM the resident was found on the floor by the bed. The resident had removed gripper socks and told the staff the resident was on their way to the bathroom before falling. New interventions were implemented for a video monitor and fall alarms however, the facility failed to address the residents' toileting schedule and refusal to wear gripper socks.

Licensure Reference Number 175 NAC 12-006.17 Based on record review and interview; the facility failed to implement an opportunistic waterborne pathogens plan, to prevent the growth of Legionella and other opportunistic waterborne pathogens in the facility's water system. This had the potential to affect all facility residents. The facility census was 27. Findings are: Reviewed the facility Legionella Management Policy dated 1/18 with a revision date of 1/24 revealed the following; the facility defined and controlled the management of Legionella bacteria in the water systems within the facility, the facility Legionella management team included the facility Administrator, the facility Maintenance Director, and the facility Infection Preventionist and or Quality Assurance Coordinator, the facility used a description of the water system using a flow diagram to identify areas where Legionella bacteria could grow, identified actions to prevent the growth and spread of Legionella and identified who was responsible for maintaining areas and cleaning frequencies. Record review revealed no evidence the facility had identified areas of potential concern through mapping of the facility water system. During an interview on 2/8/24 at 1:00 PM the facility Maintenance Supervisor confirmed no awareness of a facility plan to prevent the growth of waterborne bacteria in the facility water system. In addition, the maintenance department was not aware of any potential areas that had been identified as a potential for stagnant water to occur, or any knowledge of where to test the water system in the event a waterborne illness identified in the facility. In addition, the Maintenance Supervisor was unaware of what waterborne bacteria was, and how to prevent stagnant water from occurring in the facility water system. During an interview on 2/12/24 at 11:12 AM the Infection Preventionist (IP) confirmed the IP was unaware of the facility Legionella policy, had no knowledge of a mapping of the water system to identify potential waterborne illness, and was unaware of any plan for testing the system, should Legionella be identified. Further interview confirmed the IP was not aware what if any measures were in place to identify or prevent stagnant water in the facility water system.

Licensure Reference Number 175 NAC 12-006.09A Based on record review and interview; the facility failed to ensure a new PASARR (Pre-Admission Screening and Resident Review- a tool used to ensure residents receive the care they require for mental illness) screen was completed related to a mental health diagnosis for 1 (Resident 4) of 1 sampled resident. The facility census was 27. Findings are: Review of the facility policy PASARR dated 2017 revealed the following: -the facility would coordinate assessments with the PASARR, -the purpose was to develop guidelines related to those with mental illnesses to ensure they received the care and services they needed in the most appropriate setting, and -the facility would refer all residents with newly evident or possible serious mental illness disorders for a Level II review. Review of Resident 4's Quarterly Minimum Data Set (MDS-a comprehensive assessment tool used in Care Planning) dated 12/5/23 revealed the resident had diagnoses of: Cerebrovascular Accident, Depression, Chronic Lung Disease and Psychotic Disorder; and no documentation that the resident was taking an antipsychotic medication (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood and emotion. Review of the resident's Annual MDS dated [DATE] revealed the resident did not have a PASARR Level II determination and the resident was receiving an antipsychotic medication routinely. Review of Resident 4's PASARR screen dated 6/25/18 revealed on the resident's screen, it was marked no to the question that asked if the resident had a serious mental illness such as psychotic disorder. Review of Resident 4's Care Plan last revised 12/31/23 revealed no documentation that the resident had a Level II screen completed. Review of the facility facsimile (fax) to Resident 4's physician revealed a diagnosis dated 1/24/23 for Psychosis in absence of Dementia. Interview on 2/8/24 at 2:20 PM with the Director of Nursing (DON) confirmed the resident had a diagnosis of psychosis in absence of dementia and a new PASARR should have been completed.

Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview; the facility failed to ensure all newly hired staff had the required background screenings were completed for 4 out of 5 employee files reviewed. The facility census was 27. Findings are: Review of the facility policy: Abuse, Neglect, and Exploitation dated 12/21/23 revealed the facility screened potential employees for a history of abuse through background, reference, and credential checks; and the facility would maintain documentation of proof that the screening occurred. Review of employee file for Nursing Assistant (NA)-C revealed NA-C was hired 11/2017 and left the position on 4/10/23. NA-C was re-hired on 10/10/23. Further review revealed no documentation that a background check, Nebraska Adult Protective Services (APS) Central Registry/Nebraska Child Abuse and Neglect (CAN)Central Registry check, or a Sex Offender Registry check was completed upon NA-C's rehire. Review of the nursing schedule for February 2024 revealed that NA-C was currently working as a Nursing Assistant. Review of employee files revealed no documentation that the Nurse Aide Registry was checked upon hire for the following employees: -Staff-P who was hired on 12/6/23, -Staff-Q who was hired on 12/28/23, and -Staff-R who was hired 12/29/23. Interview with the Director of Nursing (DON) on 2/12/24 at 12:50 PM confirmed the Nurse Aide Registry was not checked for Staff-P, Staff-Q, and Staff-R upon their hire. Further interview with the DON on 2/13/24 at 7:00 AM confirmed NA-C did not have a new background check, an APS/CAN check, or Sex Offender Registry check completed upon their rehire.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review; the facility failed to implement infection control practices to prevent potential cross contamination including the spread of COVID-19 related to: 1) performing hand hygiene at appropriate intervals during the provision of incontinence cares for Resident 5; and 2) failure to develop/implement interventions for unvaccinated staff to assure mitigation of COVID-19. This had the potential to affect all residents in the facility. The total sample size was 24 and the census was 27. Findings are: A. Review of the facility policy Hand Hygiene Procedure dated 9/22 revealed it was the policy of the facility to educate and to provide work practices to aid in the prevention of the spread of infection. Hand hygiene was considered the most important factor in preventing and controlling the spread of infection. The following was identified regarding when staff were to wash hands: -before each resident contact; -after touching a resident or handling their belongings; -whenever hands were soiled; -after any contact with body fluids; -after handling contaminated items; and -before and after gloving. B. Observations of incontinence cares for Resident 5 on 1/24/23 from 9:48 AM to 10:12 AM revealed the following: -Nursing Assistant (NA)-F and NA-K washed hands in the resident's bathroom and placed on clean gloves; -Resident 5 was transferred with a full lift from the resident's wheelchair and into the resident's bed; -NA-K indicated the resident's slacks were soiled with urine and feces. NA-K removed the resident's slacks and placed into a disposable bag to take to the laundry; -without removing soiled gloves, NA-K took clean wash cloths into the resident's bathroom, placed into the bottom of the hand washing sink and saturated the cloths with warm water. NA-K used the soiled gloves to remove excess water from the cloths and then took the cloths to the resident's bedside; -NA-K and NA-F removed the resident's urinary incontinence brief which was heavily soiled with urine and feces. NA-K proceeded to use the washcloths to provide the resident with incontinence cares. NA-K used a clean surface of the washcloth each time the resident was wiped, until all surfaces were soiled. NA-K without use of a barrier, placed the soiled cloths directly onto the resident's bed linens; -without removing soiled gloves, NA-K and NA-F placed a clean incontinence brief on the resident, repositioned the resident in bed and placed a pillow behind the resident's back; -NA-F positioned the pendant call light on the resident while NA-K lowered the resident's bed and placed a blanket on the resident; and -NA-F and NA-K removed soiled gloves but failed to complete hand hygiene before exiting the resident's room. During an interview on 1/24/23 at 10:26 AM, NA-F confirmed staff should perform hand hygiene before putting on clean gloves and when removing soiled gloves. In addition, NA-K failed to follow good infection control practices when touching clean items in the resident's room with soiled gloves and placing soiled wash clothes on the resident's bed linens. C. Interviews and observations on 1/22/23 from 8:00 AM to 10:30 AM revealed the following: -Registered Nurse (RN)-A was unvaccinated and was a contracted staff member. RN-A had been COVID-19 tested twice a week since starting at the facility as this was the facility policy. RN-A reported no additional interventions had been put into place. RN-A was not wearing any personal protective equipment (PPE); -Licensed Practical Nurse (LPN)-B was vaccinated and was a full-time employee at the facility. LPN-B indicated all staff were being tested twice a week per facility policy. LPN-B wore no PPE; -NA-D was a full-time employee at the facility and had not been vaccinated. NA-D confirmed being COVID tested twice a week per facility policy. NA-D reported no additional interventions despite staff's vaccination status and NA-D wore no PPE; and -NA-K, NA-I, and NA-F were all fully vaccinated, were all tested twice a week and were not wearing PPE. During an interview with RN-M the Infection Preventionist on 1/24/23 at 1:16 PM, the following was confirmed: -the facility staff and visitors did not have to wear masks unless the Community Transmission level was high; -the Community Transmission level was currently substantial; and -the facility should have additional interventions in place for the unvaccinated staff to prevent the potential spread of COVID-19.

Based on record review and interview; the facility failed to ensure 3 (Residents 21, 23 and 77) of 5 sampled residents were offered and/or received Pneumococcal vaccinations. The facility census was 27. Findings are: A. Review of the facility policy Pneumococcal Vaccine Series (undated) revealed upon admission, each resident and/or representative were to receive the Vaccination Information Statement (VIS) for pneumococcal vaccines. The staff were to review all the resident's vaccinations and provide/document education on the benefits and potential side effects of the vaccinations for which the resident was eligible. If the resident/representative consented to the vaccine staff were to obtain a physician order, obtain written consent, obtain/document temperature and complete screening questions prior to administering the vaccine then administer the vaccine. B. Review of an Immunization Report dated 1/23/23 revealed no evidence the VIS regarding the Pneumococcal Vaccination was provided, vaccination histories were reviewed to determine eligibility for the Pneumococcal Vaccination, or an attempt was made to obtain consent from residents/representatives for Residents 21, 23 and 77 to administer the vaccine to the residents. C. Interview with the facility Interim Director of Nursing (DON) on 1/23/23 at 1:03 PM verified the facility failed to assess Residents 21, 23 and 77's pneumococcal immunization status upon admission, and the residents had not been offered an/or administered the pneumococcal vaccination during their stay at the facility.

Licensure Reference Number 175 NAC 12-006.04C3a Based on record review and interviews, the facility failed to: 1) notify Resident 1's legal representative of a change in condition related to respiratory complications that required evaluation at the emergency room (ER) and a significant change with the resident's urinary status, and 2) notify Resident 181's legal representative of a change in condition related to the development of wounds on the resident's feet with subsequent hospitalization . The total sample size was 24. The facility census was 27. Findings are: A. Review of the facility's Policy and Procedure Notification of Changes with Resident dated 9/4/2015 revealed: It is the policy of the facility to immediately inform the resident, the resident's legal guardian or family member if known, and the resident's physician when there is a significant change with the resident's physical, mental or psychosocial status (such as a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications) a need to alter treatment significantly (such as a need to discontinue an existing form of treatment). The facility must also promptly notify the resident, and the resident's legal guardian or family member if known when there is a change in room or roommate assignment. B. Review of the facility's policy Ulcer and Wound Management and Prevention dated 2/2012 revealed the following: - All residents will be assessed for pressure ulcer risk upon admission, readmission and quarterly and with a significant change in condition. All residents' skin will be checked for condition changes on admission, readmission, weekly and as needed by a nurse. Any skin issues will be addressed upon identification and notification made to the physician and family as soon as possible. - Upon finding new skin issues the nurse will create an incident report and a wound/skin assessment sheet. The nurse finding the skin issue will notify the physician as soon as possible during their shift. The infection control nurse, assessment coordinator, dietary staff and the family will be notified. The nurse will measure and describe skin issues on the Comprehensive Skin Assessment sheet weekly, provide treatment per the physician's orders and document on the Treatment Administration Record (TAR). The nurse will discontinue treatment/cares when skin issues are closed or resolved and document this on the TAR and the wound/skin assessment sheet. C. Review of Resident 181's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 8/4/22 revealed diagnoses of diabetes, heart failure, high blood pressure, and anemia. The assessment indicated the resident's cognition was moderately impaired and required limited assistance with bed mobility, transfers, toileting, dressing and personal hygiene. In addition, assessment of the resident's skin revealed no skin issues were indicated. Review of Resident 181's medical record revealed the following: - A nursing progress note dated 10/21/22 at 5:09 PM, indicated the resident had an open area to the right foot on top of the 2nd toe. There was no evidence the resident's legal representative or the physician was notified of the wound. - A nursing progress noted dated 10/25/22 at 9:58 AM, indicated the resident had an open area to the resident's left foot on the 4th toe with a small amount of pussy drainage present. There was no evidence the resident's legal representative was notified of the wound. - A Non-pressure Skin Condition Report dated 11/23/22 at 1:45 AM, indicated the toes on the resident's right foot were scabbed with a small amount of bleeding. Further review revealed no evidence the resident's legal representative and/or the physician was notified of the wounds. Review of Resident 181's Non-pressure Skin Condition Reports revealed the resident had several skin issues on the right foot: - On 11/24/2022 the top of the right foot 2nd toe was described as a bruise that measured [0.5 centimeters (cm) long by 0.8 cm wide]. There was no evidence the resident's legal representative and/or the physician was notified on this date. - On 11/24/2022 the right foot on the side of the 3rd toe was described as a popped blister that measured [1.1cm (L) X 0.6cm (W)]. On 11/26/22 the report indicated the wound had increased in size [1.5cm (L) X 0.8cm (W)] and had slough (the yellow/white material in a wound that consists of dead cells that accumulate in wound drainage) present. There was no evidence the resident's legal representative or the physician was notified on this date. - On 11/24/22 the right foot on the side of the 4th toe was described as a popped blister that measured [0.9cm (L) X 0.5cm (W)] with a scant amount of clear drainage noted. There was no evidence the resident's legal representative or the physician was notified on this date. Review of Resident 181's medical record revealed the following: - On 12/5/22 the resident was seen by the physician and was prescribed an oral antibiotic (Keflex 500 milligrams (mg) daily for 10 days) for wounds to the resident's right foot and made a referral to the wound clinic for further evaluation. - On 12/7/22 the resident was seen at the wound clinic and subsequently admitted to the hospital for an infection to the right foot. D. During an interview with the resident's legal representative on 1/25/23 at 10:40 AM, the resident's legal representative indicated [gender] had not been notified of the resident's foot wounds until [gender] visited the resident at the facility on 12/5/22. The legal representative also confirmed the resident was admitted to the hospital from the wound clinic on 12/7/22 for an infection to the resident's foot. E. During an interview with the administrator on 1/24/23 at 2:40 PM, the administrator confirmed there was no evidence the Resident 181's legal representative was notified of the foot wounds on 10/21/22, 11/23/22, and 11/24/22 and should have been. The administrator also confirmed the resident was subsequently admitted to the hospital on 12/7/22 for an infection to the resident's foot. 29638 F. Review of Resident 1's MDS dated [DATE] revealed diagnoses of bilateral amputation of lower extremities, anemia, anxiety, depression, legally blind and urinary tract infection (UTI) in the last 30 days. The following was assessed regarding Resident 1: -cognitively intact; -verbal behaviors directed at others and rejection of cares during assessment period; -received extensive to total staff assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; and -indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). Review of the resident's Nursing Progress Notes dated 8/3/22 revealed the following: -3:24 AM the staff reported to the Charge Nurse the resident was short of breath and was wheezing. The resident's oxygen saturation level was 90 percent (%). The resident was hot to the touch with chills; and -4:00 AM the resident's respirations and pulse were rapid. The resident was sent to the ER for evaluation and then admitted to the hospital. Review of the resident's medical record revealed no evidence the resident's representative/family were notified regarding the resident's change in condition and need for hospitalization . Review of Nursing Progress Notes dated 8/13/22 revealed the following: -9:53 AM the resident's indwelling urinary catheter was removed; -11:08 AM the resident was upset regarding removal of the catheter and requested to have re-inserted; and -4:13 PM indwelling urinary catheter was replaced, and bright red blood clots were noted to the catheter. The catheter was removed with moderate amounts of bright red blood along with several clots. Triage nurse at the hospital was notified and indicated clotting was normal, to monitor and to re-insert the catheter. Review of a Progress Note dated 8/16/22 at 2:57 PM revealed an indwelling urinary catheter was inserted with bright red blood clots at the insertion site. Review of the resident's medical record revealed no evidence the resident's representative/family were notified of the removal of the urinary indwelling catheter and the issues encountered when the catheter was replaced. During an interview on 1/22/23 at 12:50 PM the resident's representative indicated the facility did not always notify the representative when the resident had new orders or a change in condition. During an interview on 1/25/23 at 10:55 AM, the Interim Administrator confirmed the resident's responsible party should have been notified regarding the resident's change of condition and need for hospitalization on [DATE] and of the issues with the resident's indwelling urinary catheter which started 8/13/22.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on interview and record review; the facility failed to report, investigate and then to submit the investigation to the State Agency within the required time frame an elopement for Resident 180 and to submit an investigation related to an allegation of potential staff to resident abuse for Resident 1. The sample size was 3 and the facility census was 27. Findings are: A. Review of the facility policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated 10/22 revealed in response to allegations of abuse, neglect, exploitation, misappropriation or mistreatment, the facility must: -assure allegations are reported immediately, but not later than 2 hours after the allegation is made if bodily injury or not later than 24 hours if events do not result in serious bodily injury; -conduct an investigation, preventing further potential abuse and/or neglect while the investigation is in the process; and -report the results of the investigation to the State Agency within 5 working days of the incident. B. Review of Resident 180's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 6/29/22 revealed the resident was admitted [DATE] with diagnoses of cancer, anemia, hip fracture, high blood pressure, renal insufficiency and arthritis. The following was assessed regarding the resident: -cognition was moderately impaired; -no behaviors; -required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; and -occasionally incontinent of urine and frequently involuntary of bowel. Review of Resident 180's Nursing Progress Notes dated 8/26/22 revealed the following: -7:38 PM the resident eloped out the North door and the resident was found in the parking lot. The resident told the staff the resident was going home. The resident was not wearing a wander-guard (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door) and the door did not alarm; and -7:50 PM the resident refused to be assessed and the resident indicated feeling trapped. The resident's physician was notified, and the resident was sent to the emergency room (ER) for evaluation due to the resident's unusual behavior. Review of facility investigations from 9/28/21 through 1/22/23 revealed Adult Protective Services (APS) were notified of the resident's elopement on 8/29/22 (3 days after the resident eloped on 8/26/22) at 4:30 PM. Further review of facility investigations revealed an investigation was completed and was then sent to the State Agency on 9/5/22 (10 days after the resident's elopement) at 1:21 PM. During an interview on 1/24/23 at 8:45 AM, the Interim Administrator confirmed Resident 180's elopement was not reported, the investigation completed and then submitted within the required time frames. C. Review of Resident 5's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of malnutrition, anxiety and respiratory failure. The following was assessed regarding the resident: -cognition was moderately impaired; -other behavioral symptoms not directed at others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming or disruptive sounds) which occurred daily; and -required limited to extensive assistance with dressing, bed mobility, transfers, toilet use and personal hygiene. Review of facility investigations from 9/28/21 through 1/22/23 revealed an APS report was completed 10/26/22 at 3:14 PM. Resident 5 reported to the staff about a month ago a staff member had pushed the resident into bed. The resident could not recall the staff but could point them out if the resident saw them again. The report indicated an investigation was ongoing. Further review of facility investigations revealed no evidence an investigation was completed and/or submitted to the State Agency. During an interview on 1/23/22 at 11:30 AM, the Interim Administrator verified an investigation was initiated but the Administrator failed to complete and to submit the results of the investigation as required to the State Agency.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to provide ongoing assessment and monitoring to prevent skin breakdown for Resident 181 who developed foot wounds and was subsequently hospitalized . The sample size was 1 and the facility census was 27. Findings are: A. Review of the facility's policy Ulcer and Wound Management and Prevention dated 2/2012 revealed the following: - All residents will be assessed for pressure ulcer risk upon admission, readmission and quarterly and with a significant change in condition. All residents' skin will be checked for condition changes on admission, readmission, weekly and as needed by a nurse. Any skin issues will be addressed upon identification and notification made to the physician and family as soon as possible. - Upon finding new skin issues the nurse will create an incident report and a wound/skin assessment sheet. The nurse finding the skin issue will notify the physician as soon as possible during their shift. The infection control nurse, assessment coordinator, dietary staff and the family will be notified. - The nurse will measure and describe skin issues on the Comprehensive Skin Assessment sheet weekly, provide treatment per the physician's orders and document on the Treatment Administration Record (TAR). The nurse will discontinue treatment/cares when skin issues are closed or resolved and document this on the TAR and the wound/skin assessment sheet. B. Review of Resident 181's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 8/4/22 revealed diagnoses of diabetes, heart failure, high blood pressure, and anemia. The assessment indicated the resident's cognition was moderately impaired and required limited assistance with bed mobility, transfers, toileting, dressing and personal hygiene. In addition, assessment of the resident's skin revealed no skin issues were identified. Review of Resident 181's medical record revealed the following: - A nursing progress note dated 10/21/22 at 5:09 PM, indicated the resident had an open area to the right foot on top of the 2nd toe. There was no evidence the resident's legal representative or the physician was notified of the wound and no evidence of additional nursing assessment and monitoring of the wound or if the wound had healed. - A nursing progress noted dated 10/25/22 at 9:58 AM, indicated the resident had an open area to the resident's left foot on the 4th toe with a small amount of pussy drainage present. There was no evidence of additional nursing assessment and monitoring of the wound or if the wound had healed. - A nursing progress note dated 11/20/22 at 1:12 PM, indicated the resident had increased swelling to [gender] lower legs, feet and toes. Further review revealed the skin was shiny and tight and the resident also had multiple scattered scratches to [gender] upper right calf, middle left calf, front of both thighs, chest and abdomen. There was no evidence of documentation there were wounds on the resident's feet or toes. - A Non-pressure Skin Condition Report dated 11/23/22 at 1:45 AM, indicated the toes on the resident's right foot were scabbed with a small amount of bleeding. There was no evidence of interventions implemented to prevent additional skin breakdown. - A Non-pressure Skin Condition Report dated 11/24/2022, identified a wound to the resident's right foot on the side of the 3rd toe described as a popped blister that measured [1.1cm (L) X 0.6cm (W)]. On 11/26/22 the report indicated the wound had increased in size [1.5cm (L) X 0.8cm (W)] and had slough (the yellow/white material in a wound that consists of dead cells that accumulate in wound drainage) present. There was no evidence the resident's legal representative or the physician was notified on this date. Further review revealed no evidence of documentation after 11/26/22, related to ongoing nursing assessment and monitoring of the 3rd toe wound. - A Non-pressure Skin Condition Report dated 11/24/2022, identified a wound to the top of the right foot 2nd toe described as a bruise and measured [0.5 centimeters (cm) Length (L) by 0.8 cm Width (W)]. There was no evidence the resident's legal representative and/or the physician was notified on this date. On 12/6/22 the wound had increased in size [1.2cm (L) X 0.8cm (W)] and had slough present. - A Non-pressure Skin Condition Report dated 11/24/2022, identified a wound to the right foot on the side of the 4th toe described as a popped blister that measured [0.9cm (L) X 0.5cm (W)] with a scant amount of clear drainage noted. There was no evidence the resident's legal representative or the physician was notified on this date. On 12/6/22 the wound measured [1.0cm (L) X 0.7 cm (W)] and had black/brown eschar (a collection of dry, dead tissue within a wound). - On 12/5/22 the resident was seen by the physician and prescribed an oral antibiotic (Keflex 500 milligrams (mg) daily for 10 days) for wounds to the resident's right foot. In addition, the physician made a referral to the wound clinic for further evaluation of the foot wounds. - On 12/7/22 the resident was seen at the wound clinic for the foot wounds and was subsequently admitted to the hospital for an infection to the right foot. C. During an interview with the resident's legal representative on 1/25/23 at 10:40 AM, the resident's legal representative indicated [gender] was unaware of the resident's foot wounds until [gender] visited the resident at the facility on 12/5/22 and requested the resident be evaluated at the wound clinic. In addition, the legal representative indicated [gender] was at the appointment with the resident on 12/7/22 and subsequently admitted to the hospital for an infection to the resident's foot. D. During an interview with the administrator on 1/24/23 at 2:40 PM, the administrator confirmed the following: - nursing staff are expected to document any new skin issues upon discovery, notify the physician and the resident's representative and document the resident's skin/wound assessments weekly; - there was no evidence of documentation of ongoing skin/wound assessments for the resident's foot wounds identified on 10/21/22 and 10/25/22; - there was no evidence the physician was notified of the resident's foot wounds on 10/21/22, 11/23/22, and 11/24/22 and should have been; - there was no evidence of additional skin/wound assessment documentation for the resident's right foot 3rd toe wound after 11/26/22; and - the resident was admitted to the hospital on 12/7/22 for an infection to the resident's foot.

LICENSURE REFERENCE NUMBER 12-006.09D7 Based on record reviews and interviews; the facility failed to: 1) ensure interventions were in place for the prevention of further elopements (when a resident leaves the premises or a safe area without authorization and/or supervision) for Resident 180; and 2) assess causal factors and develop and/or revise interventions to prevent ongoing falls for Resident 5. The sample size was 4 and the facility census was 27. Findings are: A. Review of Resident 180's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 6/29/22 revealed the resident was admitted [DATE] with diagnoses of cancer, anemia, hip fracture, high blood pressure, renal insufficiency and arthritis. The following was assessed regarding the resident: -cognition was moderately impaired; -no behaviors; -required limited to extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; -occasionally incontinent of urine and frequently involuntary of bowel; -history of falls with a fall in the last month prior to admission which resulted in a fracture; and -surgical repair of hip fracture. Review of a Wandering Risk Scale dated 6/22/22 at 2:00 AM revealed the resident had no history of wandering. The resident was alert and orientated with no desire to leave the facility until the resident was recovered from hip fracture. The resident was identified as low risk for wandering. Review of Resident 180's Nursing Progress Notes revealed the following: -8/9/22 at 3:02 PM the resident's representative was notified the resident had been self-transferring to the bathroom. The resident had been re-educated on the need to call for and then wait for staff assistance, but the resident continued to refuse; -8/19/22 at 2:26 PM the resident's representative was notified Resident 180's roommate had tested positive for COVID-19. Resident 180 tested negative but was moved to a different room; -8/25/22 at 10:40 AM the resident again tested negative for COVID-19; -8/26/22 at 7:38 PM the resident eloped out the North door and indicated the resident was going home. The resident was found in the parking lot. The resident was not wearing a wander-guard (a bracelet/signaling device is worn by the resident and sounds an alarm if the resident comes within a certain distance of the door) and the door did not alarm; and -8/26/22 at 7:50 PM the resident refused to be assessed and the resident indicated feeling trapped. The resident's physician was notified, and the resident was sent to the emergency room (ER) for evaluation due to the resident's unusual behavior. Review of a Resident/Employee Incident/Accident Reporting Form dated 8/26/22 revealed the following observation; at 7:30 PM: Nurse Aide informed staff the resident was exit seeking and staff were to watch Resident 180. Dietary staff to the resident's room to remove the evening meal tray and the resident was not in the room. The resident was then found in the parking lot. Further review of the report revealed there was no documentation to indicate what actions were put into place to prevent a reoccurrence. Review of an additional Resident/Employee Incident/Accident Reporting Form dated 8/26/22 at 7:45 PM revealed the resident was very confused and agitated. The report identified the need for placement of a wander-guard as an intervention to prevent reoccurrence but indicated there were none in the building. Review of a facility investigation dated 9/5/22 regarding the resident's elopement on 8/26/22 at 7:30 PM revealed the following new interventions to prevent further potential elopements; -resident moved to a different room away from the exit doors; and -15-minute checks to be completed on the resident. Review of a 15 Minute, Visual Checks form used to document the checks the staff completed on Resident 180 revealed the checks were not initiated until 8/31/22 (5 days after the resident's elopement). During an interview with the Interim Administrator on 1/23/23 at 3:15 PM the following was confirmed: -staff had witnessed the resident at the exit door and the resident was attempting to open the door however, no increased supervision was provided despite the resident's exit seeking behaviors; -the resident was sent to the emergency room to be evaluated as behavior was not typical for the resident. The resident returned to the facility the same night; -the resident was moved to a different room, but there was no documentation as to what room the resident was moved to or when the move had occurred; -there was no evidence in the resident's medical record to indicate the 15-minute checks were started until 8/31/22 which was 5 days after the resident's elopement; and -the facility did have a supply of wander-guard bracelets, but the bracelets were stored in the Social Service Director's office. No education was provided to the staff regarding B. Review of the facility Fall Prevention Program Policy (undated) revealed each resident was to be assessed for risk of falling and was to receive care and services in accordance with the level of risk to minimize the likelihood of falls. Residents with an assessment score of 10 or above would be considered at high risk for falls and would be placed on the facility's Fall Prevention Program. When any resident experienced a fall the facility would: -assess the resident; -complete a post fall assessment; -complete an incident report; -review the resident's care plan and update as indicated; and -document all assessments and actions. C. Review of Resident 5's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of anemia, diabetes, Alzheimer's disease, dementia, anxiety, malnutrition and dementia. The following was assessed for Resident 5: -short-and long-term memory loss with severely impaired decision-making skills; -required total staff assistance with dressing, bed mobility, transfers, toilet use and personal hygiene; -always incontinent of urine and frequently involuntary of bowel; and -at risk for falls with 2 falls without injury since the previous assessment. Review of the resident's Care Plan dated 1/19/22 revealed the resident was at risk for falls with the following interventions: -tilt-n-space (wheelchair which shifts its position on its frame as one unit, while maintaining the angle of the hips, knees and ankles) chair for positioning and comfort; -staff educated on need to tilt wheelchair slightly when resident alone in room; -fall mat next to the bed; -offer frequent toileting; and -assist with lying on the floor per resident's request. Review of a Fall Risk Evaluation dated 4/18/22 at 1:59 PM revealed the resident scored a 20 which indicated the resident was at high risk for falls. Review of Nursing Progress Notes dated 6/3/22 revealed the following: -10:42 AM at approximately 10:10 AM, the resident was found face down on the floor of the resident's room. The resident had pain with range of motion to the right leg and was sent to the ER for evaluation; and -12:36 PM the resident returned to the facility with no injuries identified. Review of the resident's medical record revealed no evidence the resident was assessed for causal factors, a new intervention was developed, or current interventions revised to prevent further falls. Review of Nursing Progress Notes dated 6/8/22 revealed the following: -1:39 PM the resident's representative was notified the resident was on the floor this morning; and -4:08 PM the resident did climb out of the wheelchair and onto the floor at 9:00 AM. Alarms/mats were in place. Review of the resident's medical record revealed no evidence the resident's fall was assessed for causal factors or that fall interventions were changed and/or developed. Review of a Nursing Progress Note dated 8/13/22 at 1:20 AM, revealed the resident was heard crying and staff found the resident face down on the ground next to the resident's bed. Causal factors were not assessed, and interventions were not revised/developed for further fall prevention. Review of a Nursing Progress Note dated 8/27/22 revealed at 4:28 AM, the resident was found by the mattress on the floor. No injuries were identified. In addition, no causal factors or revised interventions were identified to prevent further falls. Review of a Nursing Progress Note dated 8/31/22 at 8:00 PM revealed the resident was on the floor, lying on the fall mat next to the resident's bed. Review of the resident's medical record revealed no evidence the facility determined causal factors or developed new interventions for ongoing falls. Review of Nursing Progress Notes dated 10/17/22 at 2:47 AM revealed the resident was on the floor, lying face down on the fall mat. No injuries were identified. The resident was assisted into bed and the call light was placed within reach. The resident's bed was in the lowered position and the fall mat was on the floor next to the bed. No additional interventions were identified. Review of a Nursing Progress Note dated 10/19/22 at 11:26 PM revealed at 10:45 PM, the resident was lying on the floor, on the fall mat next to the resident's bed. Review of a Post Fall assessment dated [DATE] at 11:51 AM revealed no causal factors were assessed, current interventions were not revised, and no additional interventions put into place. Review of a Nursing Progress Note dated 11/2/22 revealed when staff entered the resident's room at 9:15 PM, the resident was seated on the fall mat on the floor next to the resident's bed. Review of a Nursing Progress Note dated 11/3/22 at 11:56 AM revealed a scoop mattress (a special type of mattress with raised sides which may be employed as a fall prevention measure) and an air mattress overlay were placed on the resident's bed to prevent further falls. Review of a Nursing Progress Note dated 11/6/22 at 12:35 AM revealed the resident was found lying on the floor. Review of the resident's Care Plan revealed a new fall intervention dated 11/13/22 (7 days after the resident's fall on 11/6/22) to position a body pillow when the resident was in bed. Review of a Nursing Progress Note dated 11/14/22 (8 days after the resident's fall on 11/6/22) revealed the facility discontinued and removed the air mattress overlay on Resident 5's bed to prevent further falls. During an interview on 1/25/23 at 12:59 PM, the Interim Administrator confirmed the staff failed to complete an Incident Report and a Post Fall Evaluation after each of Resident 5's falls. In addition, causal factors were not assessed, fall interventions were not revised and/or new interventions implemented in a timely manner to prevent further falls.

Licensure Reference Number 175 NAC 12-006.17A Based on interview and record review; the facility failed to prevent the potential spread of COVID-19 as the facility failed to perform a COVID-19 test for Residents 1 and 14 who had reported signs and symptoms. The total sample size was 24 and the census was 27. Findings are: A. Review of the facility's Infection Prevention and Control Program Policy with an effective date of 9/22 revealed residents who had signs or symptoms of Covid-19 (fever, cough, sore throat, stomach pain, respiratory distress, diarrhea or other symptoms unusual to their normal bodily function) must be tested and placed on isolation precautions pending test results. B. Review of Resident 14's Nursing Progress Notes revealed the following: -10/9/22 at 9:39 PM the resident was noted to have a harsh cough. The resident had a wheeze to bilateral upper lobes of the resident's lungs; -10/10/22 at 9:02 AM the resident had a harsh, productive cough with yellow colored drainage and the resident continued with a slight wheeze to lungs; and -10/12/22 at 1:50 AM the resident complained of coughing all night the previous evening. Review of Resident 14's medical record revealed no evidence the resident received a COVID test despite the residents ongoing potential symptoms from 10/9/22 to 10/12/22. C. Review of Resident 1's Nursing Progress Notes revealed the following: -10/2/22 at 11:45 PM the resident's temperature was 102.4 degrees Fahrenheit (F); -10/3/22 at 12:49 AM the resident's temperature was 100 degrees F; and -10/3/22 at 8:19 AM indicated at 6:00 AM, the resident's temperature was 100.9 degrees F. The resident was lethargic and drooling and was unable to hold food in mouth from the breakfast meal. Review of Resident 1's medical record revealed no evidence the resident received a COVID test despite the resident's elevated temperature and increased lethargy. D. Interview with Registered Nurse (RN)-M on 1/24/23 at 1:16 PM confirmed RN-M was the facility Infection Preventionist. Further interview revealed the facility should have COVID tested both Residents 1 and 14 when the resident's began displaying potential symptoms of COVID-19.

Licensure Reference Number 175 NAC 12-006.17A Based on interview and record review; the facility failed to maintain an infection control program, educate staff regarding infection control and prevention measures, and complete resident, staff, and contractor/visitor screenings for COVID-19, to prevent the potential spread of infections. This had the potential to affect all facility residents. The facility census was 27. Findings are: A. Review of the facility Novel Coronavirus Prevention and Response Policy (undated) revealed the following; -the facility Infection Preventionist (person/s trained to provide direction and monitoring of infections and or potential infections to prevent infections and the spread of infections within the facility) would assess the facilities risk associated with COVID-19, -staff would be alert to resident signs of COVID-19 (fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea), and -the facility would have interventions in place to prevent the introduction of respiratory germs into the facility, including assessing visitors and healthcare personnel for symptoms of COVID-19 through individual screening. B. Review of the facility policy and procedure Infection Control (undated) revealed the following; -the facility would establish and maintain and infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, -maintain a system for preventing, identifying, reporting, investigation and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, -would designate one individual as the Infection Prevention and Control Officer (IPCO), for whom infection prevention and control would be their major responsibility, and IPCO would have specialized training in infection prevention and control beyond their initial professional degree. C. Review of the facility Contractor Screening logs (log to be used for those person's entering the facility whom were not employed by the facility but visiting or providing services through other agencies) revealed the following; -on 7/22/22 10 persons names were entered on the log, 3 persons entered their full names, 7 persons entered their body temperatures, 8 persons indicated for which contract agency they represented, and 9 persons entered the reason for their visit. -on 7/25/22 4 persons names were entered on the log, and 1 person entered their full name. -on 8/4/22 8 persons names were entered on the log, 6 persons entered which contract company they represented, and 7 persons entered their body temperature. -on 8/5/22 4 persons entered their names on the log, and 3 persons entered their body temperature. D. Review of the facility Coronavirus Screening Forms revealed the following; - an undated form revealed the form contained a name, did not contain a date, and had no answers to the screening questions to assess for signs and symptoms of COVID-19), no answer about vaccine status, fever, cough, sore throat, breathing difficulties, body aches, muscle aches, headache, congestion, runny nose, nausea, vomiting, or diarrhea, and contact with someone with COVID-19. - an undated form contained a name (not a full name), was not dated, and indicated the person filling out the form had, a cough, congestion/runny nose, nausea/vomiting or diarrhea, had been in contact with someone with or under investigation for COVID-19, and no evidence the facility restricted the person from entering the facility, -form dated 8/1/22 revealed the form had a first name listed and no last name, and no answers to the screening questions to assess for signs and symptoms of COVID-19, -form dated 8/1/22 had a full name and date, but no answers to the screening questions to assess for signs and symptoms of COVID-19, -form dated 8/1/22 had a name (not a full name), but no answers to the screening questions to assess for signs and symptoms of COVID-19, -form dated 8/4/22 had a full name and body temperature, but no answers to the screening questions to assess for signs and symptoms of COVID-19, and E. Review of all sampled resident's medical records revealed no evidence the facility was conducting daily screening for s/s of COVID-19. F. Review of the facility Staff Education records revealed no evidence the facility had provided staff with education regarding proper screening of staff, residents, and or contractors/visitors for COVID-19. G. An Interview on 8/11/22 at 1:45 PM with and agency (not employed directly by the facility but contracted through an outside agency to provide services) RN (Registered Nurse) -A revealed the RN had been told by the facility DON (Director of Nursing) at the time of orientation that daily COVID resident screenings to assess the residents for signs and symptoms of COVID-19, were not done at this facility, and the NA's (Nurse Aids) would check resident temperatures and oxygen saturations daily. H. An Interview on 8/11/22 at 1:47 PM with agency Licensed Practical Nurse (LPN) - F revealed the LPN had been told by the facility DON (Director of Nursing) at the time of orientation, that daily COVID resident screening to assess the residents for signs and symptoms of COVID-19, were not done at this facility, and the NA's (Nurse Aids) would check resident temperatures and oxygen saturations daily. reported that she was told by the facility DON when she first started covering shifts for the facility that daily COVID screening were not done at this facility and the Nurse Aids would check resident temperatures and oxygen saturations daily. I. An interview on 8/11/22 at 1:50 PM with agency Nurse Aide (NA)- I revealed the NA was unaware that resident's temperatures and oxygen saturations were to be checked and documented daily. J. An interview on 8/11/22 at 1:50 PM with agency NA-J revealed the NA was unaware that resident's temperatures and oxygen saturations were to be checked and documented daily. K. An interview at 1:54 PM with NA-K revealed the nurse aide was aware was aware that a daily temperature and oxygen saturation level was to be completed on each resident daily, however the NA reported that the temperatures and oxygens saturation were not always completed, and not always documented in the resident's medical records. L. An Interview on 8/11/22 at 2:00 PM with the facility Administrator confirmed the following; - the facility Contractor Screening Logs, and the facility Coronavirus Screening forms had not been filled out accurately or completely to identify person's entering the facility or restricting person's entering the facility with potential signs and symptoms of COVID -19. -the facility had no evidence the staff had been educated on proper screening for staff, residents, and contractor/visitors, and - facility residents were not being screened daily for signs and symptoms of COVID 19.

Licensure Reference Number 175 NAC 12-006. 17 Based on interview and record review the facility failed to maintain an employ an Infection Preventionist. This had the potential to affect all facility residents. The facility census was 27. Findings are: A. Review of the facility Novel Coronavirus Prevention and Response Policy (undated) revealed the following; -the facility Infection Preventionist (person/s trained to provide direction and monitoring of infections and or potential infections to prevent infections and the spread of infections within the facility) would assess the facilities risk associated with COVID-19 -staff should be alert to resident signs of COVID-19 (fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea), and -take interventions to prevent the introduction of respiratory germs into the facility, including assessing visitors and healthcare personnel for symptoms of COVID-19 through individual screening. B. Review of the facility policy and procedure Infection Control (undated) revealed the following; -the facility would establish and maintain and infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, -maintain a system for preventing, identifying, reporting, investigation and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, -would designate one individual as the Infection Prevention and Control Officer (IPCO) for whom infection prevention and control was their major responsibility and IPCO would have specialized training in infection prevention and control beyond their initial professional degree. C. An Interview on 8/11/22 at 2:00 PM with the facility Administrator confirmed the facility did not have an Infection Preventionist to maintain and oversee the facility Infection Control and Prevention Program,

Licensure Reference Number 175 NAC 12-006.04C1 and 175 NAC 12-006.04C2 Based on interview and record review; the facility failed to ensure 8 hours of consecutive Registered Nurse (RN) coverage every 24 hours was provided and to designate/employ a full time Director of Nursing. This had the potential to affect all facility residents. The total sample size was 7 and the facility census was 27. Findings are: A. Review of the Director of Nursing (DON) Job Description dated 3/29/21 revealed the DON reported to the facility Administrator. Further review revealed the following essential functions: -develops staffing plans that assure enough qualified, competent nursing staff to meet the resident care needs; -ensures 24-hour availability as nursing administration resource by providing on-call and telephone access or designating an alternate, qualified nursing staff member to do so; -supervises development of in-service education program designed to equip nursing staff with sufficient knowledge and skills to provide nursing and nursing related services to residents; -the primary purpose of the job position was to supervise the day-to-day nursing activities of the facility during the DON's tour of duty. Such supervision would be in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility; and -the DON was responsible for ensuring the highest degree of quality care was always maintained. B. Review of the facility Daily Assignment Sheets from 7/23/22 through 8/11/22 revealed the facility had no RN coverage on 7/30/22, 7/31/22, 8/1/22, 8/5/22, 8/8/22, 8/9/22 and on 8/12/22. In addition, the facility had only 6 hours of consecutive RN coverage on 8/4/22 and on 8/6/22. C. Interview with the Administrator on 8/11/22 from 8:45 AM to 9:20 AM revealed the facility DON's last day was 7/23/22 and the facility had not named an interim DON as acting DON until the position was permanently filled. Further interview on 8/11/22 at 10:00 AM confirmed the facility administration had still not named an interim DON (the facility had now gone 19 days without a DON overseeing the nursing operations of the facility). In addition, the Administrator confirmed the facility currently did not have a RN on their staff roster and from 7/23/222 through 8/11/22 the facility had gone 9 (7/30/22, 7/31/22, 8/1/22, 8/4/22, 8/5/22, 8/6/22, 8/8/22, 8/9/22, and 8/12/22) days without benefit of 8 consecutive hours of RN coverage.

Licensure Reference Number 175 NAC 12-006.18b1 Based on observations, interviews and record review, the facility failed to 1) ensure a bedside call light was within reach and available for 2 sampled residents (Resident's 1 and 2) who required assistance with Activities of Daily Living (ADL's) and 2) ensure call lights were answered in a timely manner. The sample size was 5 and the facility census was 29. Findings are: A. An observation of Resident 1 on 5/4/22 at 2:15 PM, revealed the resident was lying in bed and there was no evidence of a call light in the room or within reach of the resident. The resident reported [gender] has never had a call light available and yelled out loud for staff's attention when needing assistance. An interview with Nursing Assistant (NA)-C on 5/4/22 at 2:15 PM, confirmed Resident 1 was able to call for assistance and make [gender] needs known to staff. NA-C also confirmed the resident did not have a call light available in the resident's room or within reach of the resident. B. An observation of Resident 2 on 5/4/22 at 2:18 PM, revealed the resident was lying in bed and there was no evidence of a call light in the room or within reach of the resident. An interview with NA-C on 5/4/22 at 2:18 PM, confirmed Resident 2 was able to call for assistance when needed and no call light was available or within reach of the resident. C. An interview with the Director of Nurses (DON) on 5/4/22 at 2:20 PM, confirmed Resident 1 and Resident 2 should have had a call light available and within reach of the residents. D. Review of the facility's call light device report, from 4/28/22 to 5/5/22 revealed the following evidence related to call light times that exceeded 30 minutes in duration: -On 4/28/22 at 3:50 AM, room [ROOM NUMBER]B, 40 minutes 12 seconds; - 4/28/22 at 6:04 PM, room [ROOM NUMBER]B, 50 minutes 31 seconds; - 4/29/22 at 6:44 AM, room [ROOM NUMBER], 52 minutes 13 seconds; - 4/29/22 at 6:06 PM, room [ROOM NUMBER], 46 minutes 22 seconds; - 4/29/22 at 6:15 PM, room [ROOM NUMBER]A, 57 minutes 7 seconds; - 4/29/22 at 9:18 PM, room [ROOM NUMBER]A, 56 minutes 55 seconds; - 4/30/22 at 7:06 AM, room [ROOM NUMBER]B, 38 minutes 28 seconds; - 5/1/22 at 4:38 AM, room [ROOM NUMBER]B, 63 minutes 45 seconds; - 5/1/22 at 8:09 PM, room [ROOM NUMBER]A, 69 minutes 52 seconds; - 5/2/22 at 1:57 AM, room [ROOM NUMBER]B, 31 minutes 17 seconds; - 5/2/22 at 4:30 AM, room [ROOM NUMBER], 36 minutes 54 seconds; - 5/2/22 at 12:55 PM, room, 210B, 50 minutes 50 seconds; - 5/2/22 at 12:55 PM, room [ROOM NUMBER], 31 minutes 55 seconds; - 5/2/22 at 7:48 PM, room [ROOM NUMBER]B, 49 minutes, 57 seconds; - 5/2/22 at 8:26 PM, room [ROOM NUMBER]B, 37 minutes 29 seconds; - 5/2/22 at 8:31 PM, room [ROOM NUMBER]A, 31 minutes 53 seconds; - 5/3/22 at 7:33 AM, room [ROOM NUMBER]B, 43 minutes 19 seconds; - 5/3/22 at 7:57 AM, room [ROOM NUMBER]B, 60 minutes 13 seconds; - 5/3/22 at 4:22 PM, room [ROOM NUMBER]B, 32 minutes 47 seconds; - 5/3/22 at 7:15 PM, room [ROOM NUMBER], 34 minutes 12 seconds; - 5/3/22 at 7:26 PM, room [ROOM NUMBER], 39minutes 50 seconds; - 5/4/22 at 12:11 AM, room [ROOM NUMBER]B, 44 minutes 36 seconds; - 5/4/22 at 12:27 AM, room [ROOM NUMBER]B, 38 minutes 6 seconds; - 5/4/22 at 2:03 AM, room [ROOM NUMBER], 43 minutes 20 seconds; - 5/4/22 at 5:55 AM, room [ROOM NUMBER]A, 35 minutes 50 seconds; - 5/4/22 at 2:18 PM, room [ROOM NUMBER]A, 31 minutes 16 seconds; - 5/4/22 at 2:56 PM, room [ROOM NUMBER]B, 47 minutes 26 seconds; - 5/4/22 at 7:11 PM, room [ROOM NUMBER]A, 34 minutes 6 seconds; - 5/4/22 at 7:13 PM, room [ROOM NUMBER]A, 34 minutes 54 seconds; - 5/4/22 at 10:37 PM, room [ROOM NUMBER]B, 37 minutes 10 seconds; and - 5/5/22 at 6:28 AM, room [ROOM NUMBER]B, 47 minutes 55 seconds. E. An interview with the facility's Administrator on 5/5/22 at 2:15 PM, confirmed staff were expected to respond to resident's activated call lights in under 30 minutes.

Licensure Reference Number 175 NAC 12-006.10A2 Based on observation, interview and record review, the facility staff failed to administer medical treatments in accordance with physician's orders and standards of practice for 2 sampled residents (Resident 3 and Resident 5). This had the potential to cause a decline in the resident's medical conditions. The facility census was 29. Findings are: A. Review of Resident 5's Physician's Order Summary dated 5/5/2022, revealed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of Resident 5 on 5/5/22 at 07:30 AM, revealed the resident was in [gender] room lying in bed with eyes closed and the room was dark. The resident's [CONDITION(S)] machine was located on a small dresser across the room and was not turned on or in use by the resident while lying in the bed with eyes closed. B. Review of Resident 3's medical record revealed the resident had wounds on the left hand with the following treatment orders by the physician: - Monitor Steri-Strips (thin, adhesive strips of tape put across a minor cut) to 2nd finger of the left hand two times a day until healed, dated 4/4/22. - Change [MEDICATION(S)] (thin, transparent adhesive dressing used to cover skin tears) to the back of left hand every 3 days until healed, dated 4/12/22. - Monitor Steri-Strips to the back of left hand two times a day until healed, dated 4/12/22. Review of Resident 3's Nursing Progress Notes revealed the following related to the wound treatments that were observed on the resident's left hand: - On 4/14/22 at 2:59 PM, the resident had some bleeding to the top of left hand and Registered Nurse (RN)-I, cleaned the wound and Steri-Strips were in place. The resident's hand was then wrapped with gauze dressing and Kling (a stretchable gauze material) and Coban (an elastic bandage that adheres to itself that requires caution when applied due to potential for constricting). There was no physician's order for the gauze, Kling and Coban. - On 4/15/22 at 12:39 PM, an unnamed nurse had been alerted by a family member of the swelling to the resident's left thumb. The unnamed nurse documented an observation of the resident's left hand dressing, which consisted of a Curlex dressing (a stretchable gauze material) and Coban wrapped around both hands. The unnamed nurse removed the Coban, Curlex dressing and a non-adherent pad (a dressing referred to as a [MEDICATION(S)] pad, similar to the pad on a Band-Aid) from the resident's left hand. There was no physician's order for the [MEDICATION(S)] pad, Curlex and Coban. C. An interview on 5/5/22 at 08:05 AM with the Director of Nurses, confirmed Resident 5 should have had the [CONDITION(S)] machine on and in use when in bed as it was ordered by the physician. The DON also confirmed Resident 3's left hand wound dressings (non-adherent [MEDICATION(S)] pad and Coban bandage) were placed on the resident and there was no physician's order for the new treatment.

Licensure Reference Number 175 NAC 12-006.09D2(b) Based on observations, record reviews and interviews, the facility staff failed to assess, monitor and provide treatments of a pressure ulcer wound for 1 resident (Resident 1) in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 29. Findings are: A. Review of the facility's undated policy and procedure titled Ulcer and Wound Management and Prevention revealed the following: - Facility staff will manage existing ulcers and wounds by following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - All residents' skin will be checked by a nurse on admission, readmission, weekly and as needed. - Assessment and documentation of pressure ulcers will be done once a week and include; location, stage, type, size including depth, odor, drainage, surrounding tissue, temperature, tunneling (a wound that's progressed to form passageways underneath the surface of the skin), mechanical forces (friction against a surface), nutrition and sensation. - The Director of Nurses (DON), skin nurse, and the assessment coordinator will discuss the healing/worsening of an ulcer to determine treatment effectiveness on a weekly basis. B. Review of Resident 1's Skin and Wound Evaluation record dated 4/21/22, revealed the resident had a Stage 2 (a classification system that identifies the amount of tissue damage related to a pressure wound) Pressure Ulcer located on the Coccyx (the lower tail bone on a person's buttock). Review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Apply Skin-Prep (a liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes/adhesives); - apply [MEDICATION(S)] (a moisture barrier ointment that protects and helps heal skin irritations); and - cover with a foam dressing and change twice a day. An observation of Resident 1 on 5/5/22 at 11:30 AM revealed the following: - Registered Nurse (RN)-I performed wound care treatments to the resident's chest and abdomen per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - RN-I reported the coccyx wound was opened and there should have been a treatment order for the pressure wound, but was unable to locate the order on the resident's medical record; and - RN-I then assisted the resident with putting an incontinence brief back on and dressed the resident to go out to the dining room for the noon meal and did not administer the current treatment that was ordered by the physician. C. During an interview with the DON on 5/5/22 at 1:30 PM, the DON confirmed Resident 5 did have a Pressure Ulcer wound and assessments, monitoring and documentation of the wound should be done on a weekly basis. The DON indicated the facility had a wound care nurse who had been responsible for completing this, but was no longer employed at the facility. The DON also confirmed Resident 5's pressure wound assessment and monitoring, had not been documented or completed since 4/21/22 and should have been done on a weekly basis.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1, and 12-006.12E4 Based on interview, observation and policy review, the facility failed to ensure that medications were secured from unauthorized access. This practice had the ability to affect 15 of 22 residents. The facility census was 22. Findings are: A. Review of the facility policy Medication Storage with a revision date of 7/19/21 revealed all drugs and biologicals were to be stored in locked compartments (medication carts, cabinets, drawers, refrigerators and medication rooms) under proper temperature controls. B. Observation on 9/22/21 at 9:26 AM revealed the door to the Nurse's station was open and 2 medication carts were visualized. No staff were available in the area and one of the medication carts was unlocked. Resident 4 self-propelled the resident's wheelchair to the entrance of the Nurse's station and was looking for a staff member. An interview on 9/22/21 at 9:28 AM with Medication Aide (MA)-D confirmed both the door to the Nurse's station and the medication cart had been left unlocked and the medication carts were usually stored in the Nurse's station. MA-D indicated the medication carts were to be secured at all times. C. Observation on 9/27/21 at 9:16 AM revealed an open door to the Nurse's station and no staff were present in the room. A closet space inside of the Nurse's station was unsecured and there was a green storage container which held a blister pack of medications labeled [MEDICATION(S)] (medication used to treat depression). In addition, there was a yellow basin which held the following medications; [MEDICATION(S)] Sodium (medication used to treat constipation), [MEDICATION(S)] (medication used to treat nausea), Geritussin (medication to treat cough), Aspercreme and Aspercreme with [MEDICATION(S)] (ointments used to treat pain) and a generic pain relieving cream. During an interview on 9/27/21 at 2:15 PM, Registered Nurse (RN)-E confirmed the closet door in the Nurse's station was to be kept closed and locked at all times to prevent the potential for misappropriation of medications.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on interview and record review, the facility failed to protect Resident 3 from potential misappropriation of property. The sample size was 3 and the facility census was 22. Findings are: A. Review of the facility Reporting Alleged Violations policy with a revision date of 7/1/21 revealed the purpose of the policy was to assure alleged violations were reported immediately to the facility Administrator and other officials. All alleged violations which involved abuse, neglect, exploitation or mistreatment were to be reported. This included injury of unknown origin and misappropriation of resident property. When an alleged violation was suspected, staff were to respond to the resident's needs and protect them from further incident. Staff were to monitor and document the resident's condition and were to immediately initiate an investigation. B. During an interview on 9/22/21 at 1:46 PM, Resident 3's family member indicated last week all of the resident's jewelry disappeared. The family reported visiting the facility on 9/13/21 and the resident had 3 necklaces; a gold chain, a heart necklace and a black hills gold necklace which were suspended on a hook hanging on the wall and a pair of gold ball earrings located in a dresser drawer in the resident's room. When the family member returned for a visit on 9/15/21, all of these items were missing. The family member reported the missing items to the Charge Nurse. The family member was contacted the following day by the Social Service Director (SSD) and was told the facility would look into the missing items. Resident 3's family indicated the items had not been located and no further information was provided to the family. Review of facility investigations and grievances for the last 6 months revealed no evidence a grievance had been documented or an investigation had been completed regarding the resident's missing property. Interview with the SSD on 9/23/21 at 9:33 AM confirmed the following: -Resident 3's family had reported the missing items; -no grievance form had been completed; -no facility investigation was initiated; and -SSD had searched for the items but had been unable to locate. Interview with the Administrator on 9/27/21 at 10:41 AM revealed the facility should have investigated the loss of the resident's jewelry to assure no further concerns related to misappropriation of resident property.