Every finding on record at Community Memorial Health Center

Licensure Reference Number 175 NAC 12-006.11(D)Based on record review, observation, and interview, the facility failed to obtain temperatures for all food items prepared by the dietary department and ensure that temperatures of food or drink items were at a palatable safe level. This had the potential to affect all of the residents' receiving food or drink items from the dietary department. The facility census was 59.Findings are:Record review of the Federal Food Code dated 2022 revealed Microwave cooked items should be heated to a temperature of at least 165 degrees Fahrenheit.Record review of a facility policy titled Record of Food Temperatures dated 10/2025 revealed Food temperatures will be checked on all items prepared in the dietary department. Ready to eat foods that require heating before consumption should be heated to at least 135 degrees Fahrenheit.A.In an observation completed on 02/24/2026 at 12:30 PM Dietary Aide I (DA-I) removed a cellophane covered plate with a grilled cheese sandwich on it from the mobile hot cart and placed it in the serving area. The DA removed the cellophane from the item and placed it on the serving tray. Another staff member then took the tray with the grilled cheese sandwich on it to the dining room and served it to a resident. The temperature of the grilled cheese sandwich was not checked prior to serving it to the resident for consumption.In an observation completed on 02/24/2026 at 12:41 PM the Dietary Manager (DM) placed a single serving clear plastic wrapped item containing macaroni and cheese into the microwave in the meal service area and started the microwave. When the microwave sounded the [NAME] removed the clear plastic container with the macaroni and cheese from the microwave and emptied it onto a plate on a serving tray and handed the tray to a nursing staff member. The nursing staff member then took the tray with the food item on it to the dining area and served it to a resident. The temperature for the microwaved food items (the macaroni and cheese) were not checked prior to it being served to the resident for consumption.In an observation completed on 02/24/2026 at 12:50 PM DA-I placed a plate with hot dogs on it and covered in clear cellophane into the microwave and started the microwave. After the microwave sounded the DA removed the plate and placed it on a serving tray and handed the tray to a nursing staff member. The nursing staff member then took the tray and placed the food items on the table in front of a resident. The temperature for the microwaved food items (the hot dogs) were not checked prior to it being served to the resident for consumption.In an interview completed on 02/24/2026 at 12:55 PM with the Cook, the [NAME] confirmed that they did not check the temperature on the grilled cheese, macaroni and cheese, and hot dogs. In an interview completed on 02/24/2026 at 1:05 PM with the DM, The DM confirmed that the facility policy stated that all items served by the dietary department temperatures should be checked. The DM confirmed that the food items served temperatures were not checked.B.In an observation completed on 02/24/2026 at 12:06 Dietary Aide H(DA-H) was observed to be serving drinks to residents from a plastic black wheeled cart in the dining area.In an observation completed on 02/24/2026 at 12:43 PM DA-H returned to the meal service area with the wheeled cart containing clear plastic pitchers of drinks. The DA removed the lid from clear plastic pitcher that contained apple juice and placed it under the juice dispenser. The container was observed to have approximately 1/4 of apple juice remaining in it. The DA depressed the button on the juice dispenser and began to dispense more apple juice back into the container.In an interview completed on 02/24/2026 at 12:44 PM with DA-H, DA-H stated that after serving drinks to the residents sitting in the dining area they refilled the pitchers with more juice and placed them into the refrigerator to be used at the next meal. The DA stated that the actual pitchers are cleansed and changed every 3 days (72 hours) but after serving the drinks in the dining area the pitchers are just refilled with more drinks. The DA stated that they do not check the temperature of the drinks prior to refilling the pitchers with more of the fluids they just add to what is left in the pitcher.In an observation completed on 02/24/2026 at 12:44 PM DA-H checked the temperatures of the fluids in the pitchers, and the following results were obtained:-Apple Juice had a temperature of 45 degrees Fahrenheit-Grape Juice had a temperature of 46 degrees Fahrenheit-Orange Juice had a temperature of 46 degrees Fahrenheit-Milk had a temperature of 43 degrees Fahrenheit-Tomato Juice had a temperature of 45 degrees FahrenheitIn an observation completed on 02/24/2026 at 12:45 AM with DA-H, DA-H stated that cold items including liquids (the juice and milk) should be served/kept at 41 degrees Fahrenheit. The DA confirmed that the fluids were not maintained at 41 degrees Fahrenheit and should have been.In an interview completed on 02/24/2026 at 12:46 AM with the Dietary Manager (DM), the DM confirmed that the fluids (juices and milk) were not maintained at the recommended temperature or lower and should have been.

Licensure Reference Number 175 NAC 12-006.11Based on observation, record review, and interview, the facility failed to ensure hair restraints were worn to keep hair from possibly contacting food and food service items and failed to utilize the approved technique when completing hand hygiene during meal preparation. This had the potential to affect all of the resident's receiving food from the kitchen. The facility census was 59.Findings are:A.Record review of a facility policy titled Dietary Employee Personal Hygiene dated 10/2025 revealed all dietary staff must wear hair restraints (eg., hair net, hat and or beard restraint) to prevent hair from contacting food.In an observation completed on 02/23/2026 at 9:00 AM, Dietary Aide J (DA-J) was observed to be rinsing dishes and placing them in the automatic dish machine. DA-J was observed to have blue hair cap covering their head. The DA had a full beard and did not have a beard covering on- preventing the beard hair from possibly contacting food or food surfaces.In an observation completed on 02/24/2026 at 9:03 AM DA-J was observed to be putting away clean dish items in the main kitchen area. The DA was walking around the main kitchen area with exposed food items holding clean food service items. The DA had blue hair cap covering on their head. The DA had a full beard and did not have a beard covering on.In an observation completed on 02/24/2026 at 10:10 AM Dietary Aide H (DA-H) was observed to be putting away dish items in the main kitchen area. DA-H had a blue hair cap covering on their head. The covering only covered the top 1/4th of their head leaving exposed loose hair while walking around the main kitchen area were exposed food items were present.In an observation completed on 02/24/2026 at 12:06 Dietary Aide H(DA-H) was observed to be serving drinks to residents in the main dining area. DA-H had a blue hair cap covering their head. The covering only covered the top 1/4th of their head leaving exposed loose hair while walking around the main dining area serving drinks to residents from a black wheeled cart.In an interview completed on 02/24/2026 at 1:05 PM with the Dietary Manager (DM), the DM confirmed that DA-J should have a beard covering on while doing dishes and putting away dishes in the main kitchen area and did not. The DM confirmed that DA-H blue hair cap or covering was not worn correctly in the main kitchen area and while serving drinks to the residents in the main dining area and should have been.B.Record review of a facility policy titled Hand Hygiene dated 12/15/2025 revealed hand hygiene technique when using soap and water with instructions to rub hands together vigorously for approximately 20 seconds.In an observation completed on 02/24/2026 at 9:06 AM the [NAME] completed hand hygiene using soap and water. The cook applied soap to their hands and rubbed their hands for only 10 seconds prior to rinsing the soap off.In an observation completed on 02/24/2026 at 9:10 AM the [NAME] completed hand hygiene using soap and water. The cook applied soap to their hands and rubbed their hands for only 10 seconds prior to rinsing the soap off.In an observation completed on 02/24/2026 at 9:19 AM the [NAME] completed hand hygiene using soap and water. The cook applied soap to their hands and rubbed their hands for only 8 seconds prior to rinsing the soap off.In an observation completed on 02/24/2026 at 9:22 AM the [NAME] completed hand hygiene using soap and water. The cook applied soap to their hands and rubbed their hands for only 4 seconds prior to rinsing the soap off.In an observation completed on 02/24/2026 at 9:36 AM the [NAME] completed hand hygiene using soap and water. The cook applied soap to their hands and rubbed their hands for only 7 seconds prior to rinsing the soap off.In an observation completed on 02/24/2026 at 9:45 AM the [NAME] completed hand hygiene using soap and water. The cook applied soap to their hands and rubbed their hands for only 10 seconds prior to rinsing the soap off.In an observation completed on 02/24/2026 at 10:15 AM the [NAME] completed hand hygiene using soap and water. The cook applied soap to their hands and rubbed their hands for only 10 seconds prior to rinsing the soap off.In an observation completed on 02/24/2026 at 10:20 AM the [NAME] completed hand hygiene using soap and water. The cook applied soap to their hands and rubbed their hands for only 10 seconds prior to rinsing the soap off.In an interview completed on 02/24/2026 at 1:10 PM with the Cook, the [NAME] confirmed that they did not rub their hands vigorously with soap for 20 seconds when completing hand hygiene and should have.In an interview completed on 02/24/2026 at 1:05 PM with the Dietary Manager (DM), the DM confirmed that hand hygiene should be completed by vigorously rubbing the hands with soap for 20 seconds and the [NAME] did not complete hand hygiene using the approved method.

Licensure Reference Number 175 NAC 12-006.09(F)(i)Licensure Reference Number 175 NAC 1-005.026(D)Based on observation, record review, and interview the facility failed to ensure that staff performed hand sanitization (hand hygiene- washing the hands using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among residents and health care personnel) between resident rooms during laundry delivery for 4 residents (Residents 54, 41,13, and 66); failed to ensure that laundry was carried in a sanitary manner to prevent the potential for cross-contamination (this had the potential to affect 15 of 15 residents); and failed to ensure that gloves were changed between contaminated surfaces and hand hygiene between glove changes for 1 resident. (Resident 17). The facility census was 59.Findings are: A. Record review of the facility policy titled Hand Hygiene dated 12/15/25 revealed that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed between resident contacts, after handling contaminated objects, before and after handling clean or soiled linens, and after handling items potentially contaminated. Observation on 2/23/26 at 9:04 AM on the facility 100 hall revealed that Laundry Aide-G (LA-G) removed clothing on hangers from inside the laundry cart. LA-G carried the clothing into the room of Resident 2. A sign on the wall inside the room of Resident 2's room revealed that Resident 2 was on Enhanced Barrier Precautions (EBP) (gown and glove use for residents known to be colonized or infected with a multi-drug resistant organism and for residents at increased risk). LA-G exited the room of Resident 2 (a resident on enhanced barrier precautions) with used empty hangers and placed them into the laundry cart. LA-G did not perform hand sanitization. LA-G removed clothing on hangers from inside the laundry cart and carried the clothes into the room of Resident 54. LA-G exited the room of Resident 54 with used empty hangers and placed them into the laundry cart. LA-G did not perform hand sanitization. LA-G removed clothing on hangers from inside the laundry cart and carried the clothes into the room of Resident 41. LA-G exited the room of Resident 41 with used empty hangers and placed them into the laundry cart. LA-G did not perform hand sanitization. LA-G removed a stack of clothing from inside the laundry cart and carried the clothing into the room of Resident 13. LA-G exited the room of Resident 13 and returned to the laundry cart. LA-G did not perform hand sanitization. LA-G removed clothing on hangers from inside the laundry cart and carried the clothes into the room of Resident 66. LA-G exited the room of Resident 66 with used empty hangers and placed them into the laundry cart. LA-G did not perform hand sanitization. Interview on 2/23/26 at 9:13 AM with LA-G revealed that a bottle of hand sanitizer is in the tub on the bottom of the laundry cart. LA-G confirmed that hand sanitization should be performed after exiting resident rooms prior to getting clothing out of the cart for the next resident. LA-G confirmed that hand sanitization had not been completed as required. LA-G performed hand sanitization after pushing the laundry cart further down the 100 hall. Interview on 2/25/26 at 2:25 PM with the facility Director of Nursing (DON) confirmed that all staff are required to perform hand sanitization after exiting resident rooms. The DON confirmed that hand sanitization is required between resident rooms during laundry pass. B. Record review of the facility policy titled Infection Prevention and Control Program dated 12/12/25 revealed that all staff are responsible for following all policies and procedures related to the program. The section titled Linens revealed that laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. Observation on 2/25/26 at 8:28 AM in the facility dining room revealed that LA-G entered the dining room from the facility laundry area. LA-G carried a stack of clothing protectors cradled against their shirt as they walked through the dining room and into the 300 hallway. Interview on 2/25/26 at 2:25 PM with the facility Director of Nursing (DON) confirmed that clothing and linens are to be carried away from the uniform to prevent the potential for cross-contamination. C. Record review of Resident 17's profile revealed an admission date of 1/12/2021 and the following diagnoses: -Hypothyroidism (underactive thyroid) -Diabetes Mellitus (metabolic disorder resulting from inadequate insulin production) -Basal Cell Carcinoma of skin (common form of skin cancer) -Candidiasis, unspecified (fungal infection) -Urinary Tract Infections -Excoriation (Skin-picking) Disorder Observation on 2/25/2026 at 7:29 AM of medication pass with Resident 17 revealed the Licensed Practical Nurse-(E) (LPN-E) did not perform hand hygiene between glove changes. Observation also revealed LPN-E applied topical medications to Resident 17 without changing gloves or performing hand hygiene after touching wheelchair, medication cart, and tablet used for charting. Record Review of facility policy for hand hygiene revealed The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of facility policy for hand hygiene revealed hand hygiene is to be performed after handling contaminated objects, before performing resident care procedures, before preparing or handling medications, when, during resident care, moving from a contaminated body site to a clean body site . Interview on 2/26/2026 at 9:02 AM with the Infection Preventionist (IP) confirmed staff are expected to perform hand hygiene after removing dirty gloves and before donning clean gloves.

Licensure Reference Number 175 NAC 12-006.05 (D&E)Based on interview and record review, the facility failed to ensure resident and resident POA (Power of attorney who can make decisions for Resident if Resident is unable)/or their personal representative was informed of the risks and alternate treatment available before initiating antipsychotic/psychotropic medications (medications used to treat psychotic/behavior disorders). This affected 4 of 5 sampled residents (Residents 41, 4, 7, and 24), and the facility failed to notify the resident POA when a change in skin condition occurred for 1 resident (Resident 24). The facility census was 59. Findings are:A. Record Review of Resident 41's admission Record dated 2/23/2026 revealed that the resident was admitted on [DATE] with listed diagnoses: -Delusional Disorders (Mental illness characterized by one or more persistent, false beliefs) -Restlessness and Agitation -Dementia -Anxiety Disorder Record review of Resident 41's admission record revealed a Power of Attorney (POA) for healthcare. Record review of Resident 41's order summary report dated 2/24/2026 revealed orders for: -Risperidone (an antipsychotic medication used primarily to treat schizophrenia or bipolar disorder) Oral tablet 0.25 milligrams (mg) 3 tablets by mouth three times a day related to Delusional Disorder: Order date 10/28/2025 -Depakote (a psychotic medication used to stabilize mood and bipolar disorders) Oral Tablet Delayed Release 125 mg give 250 mg by mouth three times a day related to Unspecified Dementia, Unspecified severity, with other behavioral disturbance: Order date 11/11/2025 Record review of facility policy 'Use of Psychotropic Medication' revised 10/12/2025 states Residents and/or representatives shall be educated via care plans on the risks and benefits of psychotropic drug use, as well as alterative treatments/non-pharmacological interventions. Record review of Resident 41's care plan meeting notes dated 1/8/2026, 10/2/2025, 7/3/2025, 4/3/2025, and 1/2/2025 revealed Resident 41 was prescribed psychoactive medications and yes for Family/Resident Educated. The meeting notes contained no details of any risks and benefits or alternative treatment options) Record review of Resident 41's progress notes from 10/16/2025 through 2/22/2026 revealed no documentation of education provided to Resident POA for risks, benefits, side effects, or alternative treatment options given for prescribed Risperidone and Depakote. An interview on 2/25/2026 at 1:49 PM with Resident 41's POA confirmed the facility did not provide education on risks, benefits, side effects, or alternative treatment options for prescribed psychoactive medications. An interview on 2/25/2026 at 12:40 PM with the facility's Director of Nursing (DON) confirmed that the facility discusses psychoactive medications at care plans (care plan meetings) but DON has a specific form regarding education of the resident or representative on the risk and benefits of the medications. The DON confirmed that the facility has no documentation of risks, benefits, side effects, or alternative treatment options for use of antipsychotic/psychotropic medications being provided to the resident or representative. B. Record review of a facility policy titled Use of Psychotropic (a medication used to treat psychotic/behavior disorders) Medication and dated 10/12/2025 revealed the resident and or their representative shall be educated on the risks and benefits of psychotropic drug use as well as alternative treatments/non-pharmacological interventions. Record review of an admission Record revealed the facility admitted Resident 4 on 09/30/2020 and had diagnosis of anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life) and bipolar disorder (a chronic mental illness characterized by extreme mood swings, alternating between intense highs and deep lows). Record review of Resident 4's Order Summary revealed the resident had provider orders for Risperdal (an antipsychotic medication used to treat schizophrenia or bipolar disorder) 0.5 milligrams(mg) twice daily and Xanax (an antianxiety medication) 0.25 mg twice daily. A record review of Resident 4's medical health record revealed no documentation that Resident 4 or their responsible party were educated on the risks or benefits or the alternative treatment/non-pharmacological interventions for the Risperdal or the Xanax medications. In an interview conducted on 02/25/2026 at 12:40 PM with the facility Director of Nursing (DON) the DON stated that the residents' medications are reviewed with the resident or responsible party during the care plan meeting. The DON stated that there is no documentation of the resident or their responsible party being provided risk and benefits or the alternative treatments/non-pharmacological interventions for the use of the Risperdal and Xanax medications. C. Record review of an admission Record revealed the facility admitted Resident 7 on 06/14/2023 with diagnosis of Major Depressive Disorder (a serious common mood disorder characterized by persistent sadness, loss of interest, and fatigue that impairs daily life). Record Review of Resident 7's Order Summary revealed the resident had provider orders for Mirtazapine (an antidepressant medication) 7.5 mg at bed time. A record review of Resident 7's medical health record revealed no documentation that Resident 7 or their responsible party were educated on the risks or benefits or the alternative treatment/non-pharmacological interventions for the Mirtazapine medication. In an interview conducted on 02/25/2026 at 12:40 PM with the facility Director of Nursing (DON), the DON stated that the residents' medications are reviewed with the resident or responsible party during the care plan meeting. The DON stated that there is no documentation of the resident or their responsible party being provided risk and benefits or the alternative treatments/non-pharmacological interventions for the use of the Mirtazapine medication. D. Record review of Resident 17's admission Record dated 2/24/26 revealed that the resident was admitted to the facility on [DATE] with listed diagnoses - unspecified dementia, unspecified severity, with other behavioral disturbance (cognitive decline where the specific type/severity is not determined, but accompanied by symptoms like sleep issues, disorientation, and confusion, or other behavioral changes) - unspecified dementia, moderate, with psychotic disturbance (cognitive decline where daily tasks are difficult, including memory loss, disorientation, and confusion, necessitating management of behavior and safety) - major depressive disorder, recurrent, in remission, unspecified (a history of, or a pattern of, depressive episodes with no current significant symptoms) - unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive impairment who remain calm and stable) - bipolar disorder, unspecified (a mental health diagnosis used when a person exhibits clear, distressing, and disruptive manic or depressive symptoms that do not meet the clinical criteria for bipolar disorder) Record review of Resident 17's admission Record dated 2/24/26 revealed that Resident 17 had a POA for healthcare. Record Review of Resident 17's Order Summary Report dated 2/25/26 revealed daily prescribed medications: - Olanzapine (antipsychotic medication primarily used to treat schizophrenia and bipolar disorder) oral tablet 2.5 milligram (MG) give 1tablet by mouth in the evening, order date 4/19/23 and Olanzapine oral tablet 5 MG give 5 mg by mouth one time a day, order date 4/15/25. Record review of Resident 17's Nursing Notes from 4/01/25 through 4/30/25 revealed no documentation the POA of Resident 17 was informed of the new antipsychotic medication prescription dated 4/15/25, side effects or risks, and was not given alternative options for treatment. Interview with the facility DON (Director of Nursing) on 2/24/26 at 3:00 PM revealed that the POA was not notified of Resident 17's new prescribed treatment dated 4/15/25 for Olanzapine's side effects, risks, benefits and was not given alternative options for treatment. The DON revealed notification to the POA was provided during care plan meetings after the medication was prescribed and dispensed. Care plan meeting notes for Resident 17 dated: 3/13/25, 8/14/25, and 11/13/25. All care plan meeting notes reveal Resident 17's POA attended all care plan meetings. The meeting notes reveal the POA did not participate in the development of the plan of care however, the family was notified of psychoactive medications and educated at the time of the care plan meeting. E. Record review of Resident 24's admission Record dated 2/26/26 revealed that the resident was admitted to the facility on [DATE] with listed diagnoses: - personal history of other mental and behavioral disorders (a diagnosis of past mental health condition that has resolved or is in remission) - dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive decline caused by an underlying medical condition where no additional psychiatric or behavioral symptoms are present) - major depressive disorder, recurrent, in remission, unspecified (a history of, or a pattern of, depressive episodes with no current significant symptoms) Record review of Resident 24's admission Record dated 2/26/26 revealed that Resident 24 had a POA for healthcare. Record Review of Resident 24's Order Summary Report dated 2/26/26 revealed daily prescribed medications: - Ativan (an antianxiety, used to treat anxiety disorders), 1.5 milligram (mg), Benadryl (antihistamine used to temporarily relieve symptoms of allergies), 25mg/Haldol (antipsychotic medication used to treat schizophrenia, acute psychosis, Tourette's syndrome, and severe behavioral issues or agitation) 3mg, apply to wrist/back of neck topically three times a day and Ativan 1.5mg/Benadryl 25mg/Haldol 3mg, apply to Neck/Wrist topically every day shift every Wed, Sat, order date 10/2/24. Interview with the facility DON (Director of Nursing) on 2/24/26 at 3:00 PM revealed that the POA was not notified of Resident 24's prescribed treatment for Ativan 1.5mg/Benadryl 25mg/Haldol 3mg's side effects, risks, benefits and was not given alternative options for treatment prior to being prescribed and dispensed. The DON revealed notification to the POA being provided during care plan meetings. Care plan meeting notes for Resident 24 dated: 12/5/24, 3/6/25, 6/5/25, 8/28/25, and 12/4/25. All care plan meeting notes reveal Resident 24's POA attended all care plan meetings. The meeting notes reveal the POA did participate in the development of the plan of care, the POA was notified of psychoactive medications and educated at the time of the care plan meeting. F. An interview with the POA for Resident 24 revealed not being aware of any current skin issues with Resident 24. A record review of Resident 24's Progress Notes dated 2/4/2026, revealed new skin issue #1, location right dorsum 1st digit, new skin issues #2 location left dorsum 1st digit. A record review of Wound History dated 2/26/26 revealed several skin issues noted for Resident 24 beginning on 2/4/26 on several areas of both feet, and right heel. An interview with Licensed Practical Nurse (LPN)-F on 2/26/26 at 10:00 AM confirmed finding no communication with the POA for Resident 24 's foot wounds and any interventions listed or communicated on the wounds.

Licensure Reference Number 175 NAC 12-00609(H)Based on record review, interview, and observation the facility failed to replace respiratory equipment for 1 resident (Resident 7) of 1 sampled resident. The facility census was 59.Record review of a facility policy titled CPAP/BiPAP (which is a non-invasive ventilator used to treat breathing difficulties by delivering pressurized air through a mask) Cleaning dated 02/25/2026 revealed it was the policy of the facility to replace equipment routinely to prevent the occurrence or spread of infection. The face mask and tubing should be replaced once every three months and the head gear, non-disposable filters, and humidifier once every six months.Record review of an admission Record revealed the facility admitted Resident 7 on 06/14/2023 with diagnosis of obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts because throat muscles relax, causing the airway to collapse during sleep).Record review of Resident 7's Order Summary on 02/25/2026 revealed Resident 7 had a provider order for a BiPAP to be applied every night.In an interview completed on 02/23/2026 at 10:50 AM with Resident 7, Resident 7 stated that they utilize a BiPAP every night when they sleep. The resident stated that staff provide care and maintenance of the equipment due to the resident not being able to self-manage the tasks. The resident stated they are not sure when their equipment (Mask, Tubbing, and Filters) get changed or replaced. The resident stated the mask that they were using was the same mask they received at the appointment when they received the equipment and had not been changed to their knowledge.Record review of a document titled Diagnostics & Consultants and dated 10/02/2025 revealed for supplies (needed to be replaced): Water chamber every 6 months, Tubing every 3 months, and face mask every 3 months.In an observation completed on 02/23/2026 at 10:50 AM Resident 7's mask and tubbing connected to their BiPAP machine to be lying on there bed with the mask lodged between the mattress of the bed and the 1/4 side rail attached to the bed.In an observation completed on 02/24/2026 at 9:50 AM Resident 7's mask and tubbing connected to their BiPAP machine to be lying on their bed. The mask was observed to be cloudy with dried white spots visible on the mask.In an observation completed on 02/25/2026 at 8:15 AM Resident 7's mask and tubbing connected to their BiPAP machine to be lying on their bed with the mask lodged between the mattress of the bed and the 1/4 side rail attached to the bed.In an interview completed on 02/25/2026 at 8:20 AM with Licensed Practical Nurse E (LPN-E), LPN-E stated that the central supply staff member manages the changing of the resident's respiratory equipment and how frequently it is changed. In an interview completed on 02/25/2026 at 8:21 AM with the Central Supply (CS) staff, the CS stated that they were unaware that Resident 7 utilized a BiPAP at bedtime. The CS stated that they had not ordered or changed the resident's respiratory equipment as they were unaware of the resident using this equipment and device.In an interview completed on 02/25/2026 at 3:45 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 7's respiratory equipment had not been changed as outlined in the facility policy or as recommended by the residents provider as outlined in the Diagnostics and Consultants form.

Licensure Reference Number 175 NAC 12-006.09(I)Based on observation, interview and record review, the facility failed to provide an environment free of accidents and hazards for 2 residents (Resident 17 and Resident 24) of 2 residents sampled. The facility census was 59. Findings are:An observation on 2/23/26 at 9:50 AM revealed Resident 17 and Resident 24 are roommates residing in a secure unit within the facility for concerns related to dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and or wandering tendencies. During the observation of the environment, the bathroom designated to be used by Resident 17 and Resident 24 was found to contain the following prescribed medications:- Diclofenac Sodium External Gel 1 % (percent) (Topical) prescriber order date 11/26/25- Eucerin External Cream (Skin Protectant) Apply to feet topically prescriber order date 11/26/25- Miconazole Nitrate Powder (Topical) Apply to abdominal folds topically prescriber order date 2/5/24- Triamcinolone Cream to red/patchy areas to right and left hands twice a day (BID) prescriber order date 2/4/25 A record review for Resident 17 revealed no Self Administration of Medication (SAM; self-administration is the process where a patient independently prepares and takes their own medication, including oral, topical, or injections without direct staff assistance) on file for the previously listed medications. A record review for Resident 24 revealed no SAM on file for the previously listed medications. An interview with the facility DON (Director of Nursing) and the IDON (Interim Director of Nursing) on 2/26/26 at 11:00 AM confirmed medications should be locked in the medication cart and/or locked in the nurse office in the secure unit. Further interviews confirmed that all medications, creams, powders and topicals prescribed from a practitioner are not to be left out under any circumstance.

Licensure Reference Number 175 NAC 12-006.09Based on record review, interview, and observation, the facility failed to ensure dosing information is included in prescribed medications for 1 (Resident 17) out of 5 sampled residents. Facility census was 59. Record review of Resident 17s admission Summary Revealed an admission date of 1/12/2021 with the following diagnoses-Cervicalgia (medical term for pain localized in the neck)-Unspecified osteoarthritis, unspecified siteRecord Review of Resident 17's order summary dated 2/25/2026 revealed Diclofenac Sodium External Gel 1% apply to neck, back topically every day and night shift related to primary osteoarthritis (Diclofenac Sodium Gel (or Voltaren) is a non-steroidal anti-inflammatory drug used to help relieve arthritic pain).Record review of manufacturers instructions for Diclofenac sodium topical gel revealed The proper amount of Diclofenac gel should be measured using the dosing cards supplied in the drug product carton. One dosing card should be used for each application of drug product. The gel should be applied within the oblong area of the dosing card up to the2-gram or 4-gram line. total dose should not exceed 32 grams per dayObservation on 2/25/2026 at 7:29 AM of medication application of Diclofenac gel revealed LPN-E used an unmeasured amount of topical gel to apply to Resident 17's neck. Interview on 2/26/2026 at 9:20 AM with Facility Interim Director of Nursing (IDON) confirmed that medication orders should include resident name, medication dose, time of administration, route of administration and prescriber name. IDON also confirmed that medication orders from a physician are placed in PCC by a nurse and double checked with a second nurse. IDON confirmed medication orders noted to be missing any information require notification to nursing and then to pharmacy and are to be changed to include all required information. Review of prescription label for Diclofenac sodium topical gel for Resident 17 with IDON confirmed the label was missing dose information. IDON also confirmed that manufacturer's instructions are included in the medication box as well as the dosing card necessary for administering ordered dose.

Licensure Reference Number 175 NAC 12-006.09(F)(i)Based on record review and interview the facility failed to ensure that a written summary of the baseline care plan (a written plan required to be developed within 24 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) was reviewed and provided to the resident/resident representative as required for 2 of 2 residents (Residents 37 and 60); and the facility failed to ensure that a baseline care plan was developed within 24 hours for 1 of 2 residents (Resident 60). This prevented the resident/resident representative from identifying additional resident needs and goals for the resident care plan. The facility census was 59.Findings are: A.Record review of the facility policy titled Interim/Baseline Care Plan dated 9/17/25 revealed that the facility will develop and implement an interim baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be available within 24 hours of a resident's admission. The admitting nurse shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative if applicable. Initial goals shall be established that reflect the resident's stated goals and objectives. Record review of the facility policy titled Comprehensive Care Plans dated 9/17/25 revealed that within 24 hours of admission to the facility an Interim Care Plan for the resident will be completed. The comprehensive care plan (a written interdisciplinary comprehensive plan to meet the resident's needs that are identified in the resident's comprehensive Minimum Data Set assessment) will be developed within 7 days after the completion of the comprehensive MDS assessment (Minimum Data Set (MDS) a mandatory comprehensive assessment tool used for care planning). The comprehensive care plan will be prepared by an interdisciplinary team including the resident and/or the resident's representative to the extent practicable. Record review of the admission Record for Resident 37 dated 2/24/26 revealed that Resident 37 admitted into the facility from the hospital on [DATE]. Diagnoses included stroke, difficulty swallowing after stroke, and surgery on the circulatory system.Record review of the Interim (baseline) Care Plan dated 10/7/25 for Resident 37 revealed that it contained no documentation of resident/resident representative participation or review of the baseline care plan. Record review of the resident medical record for Resident 37 revealed the comprehensive admission MDS assessment dated [DATE]. (Comprehensive care plan required to be developed by 10/21/25).Record review of the comprehensive care plan dated 2/23/26 for Resident 37 revealed that it was developed on 10/21/25 with a focus area of Resident requires long term care due to decreased mobility and weakness due to medical diagnoses that requires assistance with transfers, toileting, and activities of daily living (ADLs) (basic everyday tasks including bathing, eating, dressing, getting in and out of bed, and toileting). Record review of the Care Plan Minutes for Resident 37 dated 10/23/25 revealed that it was for the first care plan meeting after admission into the facility. (This meeting occurred 2 days after the completion of the comprehensive care plan for Resident 37. This did not allow the resident/resident representative to participate in the development of the baseline care plan and comprehensive care plan).Record review of the medical record for Resident 37 revealed that it contained no documentation of a written summary of the baseline care plan being provided to the resident/resident representative as required.Interview on 2/25/26 at 3:22 PM with the facility Director of Nursing (DON) confirmed that the facility did not complete a written summary of the baseline care plan for Resident 37 as required. The DON revealed that the facility discusses the baseline care plan on admission with the resident and/or family but does not have them sign anything. The DON confirmed that a written summary of the baseline care plan was not offered to the resident or representative since the facility does not complete a written summary. B.Record review of the admission Record for Resident 60 dated 2/24/26 revealed that Resident 60 admitted into the facility on [DATE]. Diagnoses included Parkinson's Disease, visual hallucinations, and urinary tract infection.Record review of the progress note for Resident 60 dated 10/30/25 at 10:15 AM revealed that Resident 60 arrived at the facility and was able to walk with a walker. Resident 60 walks with neck bent over and is shaky due to Parkinson's. Record review of the Interim (baseline) Care Plan for Resident 60 revealed it was dated 11/1/25 at 8:37 AM (over 48 hours after admission into the facility on [DATE]). (The baseline care plan was not developed within 24 hours as required). The Interim Care Plan for Resident 60 revealed that it contained no documentation of resident/resident representative participation or review of the baseline care plan. Record review of the resident medical record for Resident 60 revealed the comprehensive admission MDS assessment dated [DATE]. (Comprehensive care plan required to be developed by 11/13/25).Record review of the Care Plan Minutes for Resident 60 dated 11/14/25 revealed that it was for the first care plan meeting after admission into the facility. (This meeting occurred after the completion of the comprehensive care plan for Resident 60. This did not allow the resident/resident representative to participate in the development of the baseline care plan and comprehensive care plan).Record review of the medical record for Resident 60 revealed that it contained no documentation of a written summary of the baseline care plan being provided to the resident/resident representative as required.Interview on 2/25/26 at 3:22 PM with the facility Director of Nursing (DON) confirmed that the facility is required to develop a baseline care plan within 24 hours of admission for each resident. The DON confirmed that the facility did not complete a written summary of the baseline care plan for Resident 60 as required. The DON revealed that the facility discusses the baseline care plan on admission with the resident and/or family but does not have them sign anything. The DON confirmed that a written summary of the baseline care plan was not offered to the resident or representative since the facility does not complete a written summary.

Licensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview, the facility failed to ensure that a PRN (when needed) order for antipsychotics (psychiatric medications primarily used to treat psychosis, schizophrenia, bipolar disorder, and severe agitation by regulating brain neurotransmitters) were limited to 14 days and the practitioner evaluated the resident for renewal of the PRN medication. This affected 1 resident (Resident 34) of 5 residents sampled. The facility census was 59. Findings are:Record review of a facility policy titled, Use of Psychotropic Medication, dated 10/12/2025 revealed, residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).-9. PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days).- a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall indicate the duration for the PRN order. A record review of Resident 34's admission Record dated 2/24/26 revealed and admission date on 1/29/26. Further review revealed the following diagnosis for Resident 34:- dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance (cognitive decline caused by an underlying medical condition including symptoms like verbal/physical aggression, combativeness, shouting, and potential wandering)- non-st-elevation myocardial infarction (serious heart attack)- Parkinson's disease with dyskinesia, with fluctuations (a progressive neurodegenerative movement disorder involving involuntary movements (dyskinesia))-depression, unspecified (diagnosis for those experiencing significant depressive symptoms that cause distress or impairment) A record review of Resident 34's Order Summary Report dated 2/24/26 revealed an order for Zyprexa (an antipsychotic medication primarily used to treat schizophrenia, bipolar disorder, and treatment-resistant depression) oral tablet 5 milligram (mg) give 1 tablet by mouth every 6 hours as needed for agitation/outbursts related to dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance order date 2/6/26. An interview with the Director of Nursing (DON) and Interim Director of Nursing (IDON) on 2/26/26 at 11:00 AM confirmed no end date listed on the orders for Resident 34's PRN antipsychotic medication Zyprexa order dated 2/6/26 and confirmed there were no physician notes revealing a review of the PRN antipsychotic medication prescribed.

Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interviews, the facility failed to ensure residents and or family members had a method to file grievances anonymously and were provided on information on how to file grievances anonymously. This had the potential to affect all the residents residing in the facility. The facility census was 59.Findings are:Record review of an undated facility policy titled Resident and Family Grievances revealed information on how to file a grievance or complaint will be available and a grievance may be filed anonymously.Record review of an undated admission Agreement revealed in section 6 letter M the resident is encouraged to voice their grievances and suggestions to the administrator, director of nursing, social service director, or to the resident council. There is no information provided on how to file grievance anonymously.In an interview completed on 02/26/2026 at 10:45 AM with the facility Social Services Director (SSD), the SSD confirmed that they are the facility's grievance officer. The SSD stated that if a resident or family wished to file a grievance, they would notify a staff member, and the staff member would assist them with the process. The SSD stated they were not sure how a resident would file a grievance anonymously unless they slid it under their office door. The SSD confirmed the policy of the facility that contained the statement guideline that a grievance may be filed anonymously. The SSD stated that residents and families are educated on the grievance process while completing their admission paperwork and sign off on this in the admission paperwork. The SSD confirmed there was not education or instruction provided on how to file a grievance anonymously.In an interview completed on 02/26/2026 at 3:30 PM the Facility Administrator (FA) stated the facility had an open-door policy in regards to grievances. The FA confirmed that residents and families are encouraged to notify facility staff with grievances.

Licensure Reference Number 175 NAC 12-006.09 (H) iii Based on observation, record review, and interview, the facility failed to complete skin assessments per facility policy and standards of practice for 1 resident (Resident 3), of 4 sampled residents. The facility census was 62. Findings are: A record review of a document from the Wound Care Education Institute and titled Best Practices for Wound Assessment and Documentation dated 04/17/2025 revealed that a foundational element of wound assessment is accurate wound measurements using a standardized method like length, width, and depth. To be time sensitive and consistent documenting the wound assessment at consistent intervals based on facility protocol. A record review of a facility policy titled Skin Assessment and dated 06/12/2025 revealed it is the facility policy to perform skin assessment weekly if the resident has a notable wound or has a Braden assessment score deemed as high risk. Review of an admission Record revealed the facility admitted Resident 3 on 03/05/2024 with diagnoses of chronic kidney disease (a condition where the kidneys are damaged and can not filter blood as well as they should), and actinic keratosis (a rough, scaly patch or bump on the skin caused by damage from ultraviolet radiation, typically from the sun). The Comprehensive (MDS), a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 03/22/2025 revealed Resident 3 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13 indicating that the resident was cognitively intact. In an observation completed on 06/12/2025 at 11:15 AM Resident 3 was observed to have a discolored area to their right cheek. This area in the center was purple black fading into shades of maroon then fading into yellowing and light red color. The area covered the entirety of the upper half of the resident's cheek and had a small oval Band-Aid present at the center. In an interview completed on 06/12/2025 at 11:50 with Resident 3, Resident 3 when asked about their right cheek stated they were told by their provider that they, the resident, was applying their cream too hard in this area and that had probably caused the discolored area to their cheek and the cream was discontinued at this time. The residents denied incident, accident, or trauma to the area. In an interview completed on 06/12/2025 at 1:55 PM with Registered Nurse B (RN-B), RN-B stated that the resident had been self-administering a steroid cream to the Right cheek and the staff were applying an Urea cream (a cream that helps soften dry, rough or thick skin). The RN stated the resident developed the discoloration to the Right cheek and the provider was notified and the creams were discontinued. The RN confirmed that the facility completed skin assessments with documentation of alterations in skin integrity on a weekly basis. The RN stated these assessments are documented on the facility document titled Non-Pressure Skin Condition Report. A record review of a facility supplied document titled Non-Pressure Skin Condition Report and labeled with Resident 3 name on 06/12/2024 at 2:05 PM revealed on 05/05/2025 documentation including measurements and brief description of resident having a 4 centimeter (CM) circle on the right side below the resident's ear and a 1 CM X 3 CM area to the resident's right cheek that was documented as being dark red/purple in color. On 05-12-2025 documentation was present that the area behind the resident's ear was resolved. There was no documentation present for the area to the resident's right cheek. A record review of a facility supplied document titled Progress Notes revealed on 05/21/2024 documentation of the resident having bruising to most of the right side of the resident's face without rash. There was no documentation of measurements for this area. A record review of a facility supplied document titled Non-Pressure Skin Condition Report and labeled with Resident 3's name revealed on 05/26/2025 and 06/02/2025 documentation including measurements of right cheek. On 06/09/2025 documentation of discoloration and bruising to right face. There is no documentation of measurements for this area. In an interview completed on 06/12/2025 at 2:30 PM with the Director of Nursing (DON) the DON confirmed that a skin assessment is completed on residents with alterations in skin integrity weekly. The DON stated that the discoloration to Resident 3 right cheek was from an incident that occurred on 05/01/2025. The DON confirmed the initial documentation of this area on the 05/05/2025 Non-Pressure Skin Condition report, 05/21/2025 Progress Note, 05/26/2025, 06/02/2025, and 06/09/2025 Non-Pressure Skin Condition reports. The DON confirmed there was no documentation on this area from 05/05/2025 to 05/21/2025 and this time frame was greater than one week. The DON also confirmed that there were no measurements for this area present on the 06/09/2025 assessment.

Licensure Reference Number 175 NAC 12-006.09(F) Based on observation, record review, and interview; the facility failed to implement and/or revise Residents 1, 29, 54, and 59's current care plans to reflect the resident's current status. The sample size was 22 and the facility census was 58. Findings are: A. Review of the facility policy Comprehensive Care Plans with a revision date of 12/14/2022 revealed the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs. The care planning process will include resident's strengths and needs, -The care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) assessment, -The care plan will describe services that are to be furnished to attain or maintain the resident's physical, mental, and psychosocial well-being, -The care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, B. Review of Resident 29's MDS dated [DATE] revealed the resident was cognitively intact; was dependent with dressing, transfers, bed mobility, and toileting; had diagnoses of dementia, Parkinson's Disease, anxiety, and depression; received antipsychotic and antidepressant medications; was at risk for pressure ulcers, had pressure relieving devices for their chair, bed, and was on a turning/repositioning program. Review of Resident 29's Care Plan last revised 10/3/24 revealed the resident received antidepressant medications (Sertraline and Trazodone), antipsychotic medications (Quetiapine), and was dependent with bed mobility, dressing, transfers, and toileting. The resident was at risk for skin breakdown and staff was to follow treatments as ordered on the Treatment Administration Record (TAR). There was no documentation on the Care Plan that the resident had any Pressure sores or was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of Multi-Drug Resistant Organisms [MDRO's]). Review of Resident 29's TAR for November 2024 revealed orders for: -change foam heel cup every Tuesday for deep tissue injury (damage to the soft tissue beneath the skin caused by pressure or shear forces) ordered 9/24/24, and -paint left and right heel wounds with betadine, allow to dry, and then apply skin prep to site twice a day until healed, then place heel protector over site ordered 10/14/24. Observations of 11/18/24 at 11:10 AM an EBP sign was located on Resident 29's Bathroom door. Observation on 11/20/24 with Licensed Practical Nurse (LPN-M) at 7:30 AM revealed LPN-M performed hand hygiene and donned a gown and gloves. LPN-M uncovered the resident and placed a pad to soak up drainage underneath the resident's legs. LPN-M removed the foam heel cup from both of the resident's heels. LPN-M stated the resident had sores to both heels that had black eschar (a dark, hard, dry covering) to both areas. LPN-M completed the treatment as ordered, then applied lotion to the resident's legs. LPN-M removed their gown and gloves, and hand hygiene was performed without identified concerns. Interview on 11/19/24 at 11:30 AM with LPN-M revealed Resident 29 had EBP for on-going heel wounds. Interview on 11/20/24 at 3:10 PM with the MDS Nurse confirmed the residents pressure areas and EBP were not implemented onto Resident 29's Care Plan. Interview on 11/20/24 at 3:55 PM with the Director of Nursing (DON) confirmed Resident 29's care plan did not include pressure areas and that the resident was on EBP. 51391 C. Review of Resident 59's MDS dated [DATE] revealed the following regarding the resident: -resident was dependent on staff for toileting cares, bathing, lower body dressing, personal hygiene, and no transfer was attempted -resident required substantial assistance with upper body dressing, -resident required moderate assistance with brushing teeth and set up assistance with eating meals, -resident was always incontinent of bowel and had constipation, -resident had an indwelling catheter, -resident received pain medications and frequently had pain that constantly affected day to day activities, -resident had a stage 3 pressure ulcer with pressure ulcer care, and -resident had a diagnosis of an MDRO and arthritis. Observation of the provision of care for Resident 59 on 11/18/24 at 10:30 AM, LPN-E and Nurse Aide (NA)-D entered Resident 59's room to complete peri-cares, catheter cares and to reposition the resident. An EBP sign was on the wall of Resident 59's room. LPN-E and NA-D washed their hands and put on disposable gowns and gloves. Resident 59 was incontinent of a small bowel movement and the staff completed catheter cares and peri cares. LPN-E did not remove or change gloves after completing peri cares or catheter cares. LPN-E and NA-D changed the residents bottom sheet and put on a clean incontinence brief. LPN-E removed the disposable gown and gloves and washed hands but failed to reapply gloves or a gown. LPN-E assisted to reposition the resident, adjusted the bed linens, pillows, and the catheter tubing without use of the required gown and gloves. Review of Resident 59's care plan dated 11/1/24 revealed that there was no care plan initiated for Activities of Daily Living (ADL's), Indwelling Catheter (a tube inserted into the bladder to drain the urine), falls, pressure ulcer, Hospice Care, Pain, and Constipation. Interview with MDS Nurse on 11/21/24 at 9:30 AM verified that no constipation care plan was in place for Resident 59. D. Review of Resident 54's MDS dated [DATE] revealed the following regarding the resident: -resident was dependent on staff for oral hygiene, toileting cares and bathing, -resident required substantial assistance with eating, dressing, footwear and transfers, -resident required moderate assistance with bed mobility, -resident was occasionally incontinent of bowel, -resident was frequently incontinent of urine, and -resident received antipsychotic and antianxiety medications. Review of Resident 54's care plan with a revision date of 9/7/24 revealed that nursing care plans regarding the above ADL's had not been reviewed/revised since 6/24/24. A interview with the MDS Nurse on 11/19/24 at 2:45 PM revealed that the care plan for Resident 54 had not been reviewed/revised since 6/24/24. E. Review of Resident 1's MDS dated [DATE] revealed the following regarding the resident: -resident required substantial assistance with toileting cares, lower body dressing, footwear, personal hygiene, transfers and walking short distances, -resident required moderate assistance with oral hygiene, bathing cares, upper body dressing, -resident was independent with wheelchair mobility, -resident was always continent of bowel, -resident had an indwelling catheter, and -resident felt down and depressed, had trouble sleeping, was tired and had trouble concentrating. Review of Resident 1's care plan revealed that resident had a diagnosis of anxiety, depression, psychotic disorder, schizophrenia, and MRSA. Resident 1's care plan last revised 8/10/24 revealed that there were no interventions in place for impaired cognition and activities care plans. The nursing care plan goals had not been reviewed and updated since 8/10/24 and MDRO was not on the care plan. Quarterly MDS was completed 10/23/24. During an observation of the provision of care for Resident 1 on 11/19/24 at 10:30 AM LPN-L completed suprapubic catheter cares (tube that goes into the bladder through the abdominal wall which drains urine from the bladder, cares include washing and drying the skin around the catheter site). EBP sign was on the wall when entering the room. LPN-L washed hands and put on a disposable gown and gloves then removed the sponge dressing from around the supra-pubic catheter which was heavily soiled with urine. LPN-L cleansed and dried the skin around the catheter and applied a clean sponge dressing to the insertion site. LPN-L then removed soiled gloves and washed hands. A interview with the MDS Nurse on 11/19/24 at 2:45 PM confirmed the Falls, ADL, Pressure Ulcer and Indwelling Catheter care plans for Resident 59 were initiated on 11/19/24 and they should have been in place by 11/1/24. The MDS Nurse confirmed Resident 54's care plan had not been reviewed or updated after the care plan meeting from 9-7-24 and MDRO is not on Resident 1's care plan. Interview with MDS Nurse on 11/20/24 at 2:30 PM confirmed that care plans were to be reviewed and revised after each MDS assessment.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to ensure meals served in the Special Care Unit (SCU) were palatable and served at the proper temperature. This had the potential to affect all 16 residents that resided on the SCU. The facility census was 58. Findings are: A. Review of the facility policy Record of Food Temperatures (undated) revealed it was the policy of this facility to record food temperatures daily to ensure food was served at the proper temperature. The following guidelines were to be followed: -food temperatures were to be recorded on all items prepared in the dietary department. -hot food items were to be maintained at 135 degrees Fahrenheit (F) or higher. -potentially hazardous food that was cooked and then cooled was to be reheated so that all parts of the food reached an internal temperature of 165 degrees (F) for at least 15 seconds before service. -ready to eat foods that required heating before consumption were to be taken directly from a sealed container of an intact package from an approved food processing source and heated to at least 135 degrees (F) before holding for hot service. B. Education to the staff working on the SCU regarding food temperatures out of the Hot Boxes (undated) revealed the following process to follow: -staff were to take the temperature of one food item from the first and the last plate served to ensure palatable food temperatures were maintained. -all hot items being held for service needed to have a temperature of 135 degrees (F) or greater. -with the first plate, staff were to pick any one item on the plate and obtain a temperature by holding the thermometer in place for 10-15 seconds to give the digital read out time to finishing temping. The food item needed to reach 135 degrees (F). -if the temperature was below 135 degrees (F), staff were to place the plate in the microwave until the temperature came up to 165 degrees (F) for a total of 15 seconds. If the first plate does not have a temperature of 135 degrees (F) you will most likely need to heat all other plates to ensure a palatable food temperature. -document the name of the food item and the temperature on the food log and sign yes or no if corrective action (reheating the food in the microwave) was taken. -staff were to repeat this process for the last plate using the same food item used for the first plate. -if the food did not maintain the correct temperature, staff were to notify the cook or the Dietary Manager (DM) so they could identify and resolve the problem. C. Interview with the DM on 11/19/24 at 1:59 PM revealed the kitchen staff were to check food temperatures from food held on the steam table. Each food item needed to be at least 135 degrees (F) before plating and packaging in the Hot Box for the SCU. Observations on 11/21/24 from 8:00 AM to 8:40 AM revealed the following: -8:10 AM the Hot Box was delivered by the dietary department and was left in the SCU dining room. -8:13 AM the Director of Nursing (DON) removed the first tray from the Hot Box and removed the thermal covering from the plate. The DON used a digital thermometer to perform a temperature check of ground sausage. The ground sausage had a temperature of 131 degrees (F). The DON placed the plate into the microwave for 45 seconds, removed and obtained a temperature of 138 degrees (F) for the ground sausage. The plate was again returned to the microwave for 40 seconds. The DON removed the plate and checked temperature of the ground sausage and obtained a temperature of 143 degrees (F). -8:18 AM the DON placed the plate back into the microwave for the third time and finally obtained a temperature of 165 degrees (F) for the ground sausage. -observations from 8:18 AM to 8:40 AM revealed no further temperature checks were completed for the breakfast meal. Observations on 11/21/24 at 12:36 PM on the SCU revealed the following food temperatures were obtained from a test tray after completion of the noon meal service: -cheesy potatoes had a temperature of 136 degrees (F). -ham slice had a temperature of 134 degrees (F). -diced carrots had a temperature of 131 degrees (F). -spaghetti had a temperature of 133 degrees (F). -mashed potatoes had a temperature of 133 degrees (F). -puree ham had a temperature of 133 degrees (F). -puree carrots had a temperature of 132 degrees (F). -ground ham had a temperature of 134 degrees (F). D. Review of food temperatures logs from the SCU from 11/1/24 to 11/20/24 revealed the following: -for the breakfast meal there was no evidence food temperatures were documented on 11/1, 11/2, 11/3, 11/4, 11/9, 11/10, 11/16 and 11/17 (8 out of 20 days). -for the noon meal there was no evidence food temperatures were documented on 11/1, 11/3, 11/4, 11/6, 11/9. 11/10, 11/16. and 11/17 (8 out of 20 days) -for the evening meal there was no evidence food temperatures were documented on 11/5, 11/9, 11/10, 11/15 and 11/17 (5 out of 19 days). During an interview on 11/21/24 at 9:30 AM, the DM confirmed the SCU staff were not always completing temperature checks of the food items served from the Hot Box. In addition, the DM indicated food should not be served below 135 degrees (F) to ensure the food was palatable.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18(B), and 175 NAC 12.006.18(D) Based on observations, record review and interview: the facility staff failed to utilize gloves and to wash hands and/or perform hand hygiene at appropriate intervals during the provision of toileting and catheter cares for Residents 1, 26 and 54 and to implement enhanced barrier precautions when providing direct cares for Residents 29 and 59. The total sample size was 22 and the facility census was 58. Findings are: A. Review of the facility policy Hand Hygiene (undated) revealed hand hygiene was defined as the general term for cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub also known as alcohol-based hand rub (ABHR). Hand hygiene was to be completed when: -hands were visibly soiled with blood or other body fluids. -between resident contacts. -after handling contaminated objects. -before applying and after removing personal protective equipment (PPE), including gloves. -before preparing or handling medications. -before performing resident care procedures. -after handling items potentially contaminated with blood, body fluids, secretions, and excretions. -when during resident care, moving from a contaminated body site to a clean body site. -before and after proving cares to residents in isolation. B. Review of the facility policy Infection Prevention and Control Program (undated) revealed gloves were to be worn to prevent the spread of infection and to protect hands from potentially infectious materials and defined use in the following situations: -when touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin. -when employees hands had any cuts, scrapes, wounds, chapped skin, or dermatitis. -when cleaning up spills or splashes of blood or body fluids. -when cleaning potentially contaminated items. -whenever in doubt. C. Review of the facility policy Enhanced Barrier Precautions (EBP-involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organism (MDRO-bacteria that have become resistant to certain antibiotics) reviewed/revised 6/3/24 revealed it was the policy of the facility to implement EBP for the prevention of transmission of MDRO's. The policy indicated an order would be obtained for EBP for residents based on the following criteria: -Chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers, and -Indwelling medical devices such as central lines, urinary catheters and feeding tubes, even if the resident was not known to be infected or colonized with an MDRO. Personal Protective Equipment (PPE-items such as gowns, gloves, face shield that are worn to protect care givers) for EBP was only necessary when performing high-contact care activities: -Dressing -Bathing -Transferring -Providing Hygiene -Changing Linens -Changing Brief or assisting with toileting cares -Device care or use: central lines, urinary catheters, feeding tubes. -Wound care: any skin opening requiring a dressing. D. During an observation of nursing care on 11/19/24 at 7:52 AM, Medication Aide (MA)-H provided toileting assistance for Resident 26. MA-H entered the resident's bathroom and without washing hands or using hand sanitizer, assisted the resident with ambulation into the bathroom. Without use of gloves, MA-H removed the resident's slacks and disposable urinary incontinent brief and positioned the resident on the toilet. Still without performing hand hygiene, MA-H exited the resident's room. When the resident activated the call light, MA-H returned to the resident's bathroom. MA-H placed on a clean pair of gloves without completing hand washing or hand hygiene and provided perineal hygiene for the resident. MA-H placed a small amount of barrier cream directly to the staff's gloved fingers and applied to the resident's buttocks. While still wearing soiled gloves, MA-H assisted the resident to stand, adjusted the resident's incontinent brief and slacks and directed the resident to start ambulating toward the dining room. MA-H removed soiled gloves when assisting the resident to the dining room but failed to complete hand hygiene or to wash hands when leaving the resident's room. During an interview on 11/19/24 at 9:00 AM, MA-H confirmed the following: -staff should have washed hands or completed hand hygiene when entered the resident's room and before providing cares for the resident. -staff should have worn gloves when removing the urinary incontinence brief as the resident was occasionally incontinent of urine. -staff should have washed hands before putting on clean gloves. -staff should not have worn soiled gloves to adjust the resident's incontinence brief and clothing. -staff should have completed hand hygiene after removing soiled gloves and before leaving the resident's room. Interview on 11/21/24 at 9:00 AM with Licensed Practical Nurse LPN-K, Infection Preventionist revealed the direct care staff had received ongoing training related to use of gloves and performing hand hygiene and/or handwashing. 51391 E. During an observation of the provision of care for Resident 1 on 11/19/24 at 10:30 AM, LPN-L, entered Resident 1's room to complete supra-pubic catheter cares (tube that goes into the bladder through the abdominal wall which drains urine from the bladder, cares include washing and drying the skin around the catheter site). LPN-L washed hands and put on a disposable gown and gloves, then removed the sponge dressing from around the supra-pubic catheter which was heavily soiled with urine. LPN-L, without changing gloves, cleansed and dried the skin around the catheter and applied a clean sponge dressing to the insertion site. LPN-L then removed soiled gloves, gown, and washed hands. During an interview on 11/19/24 at 12:45 PM, LPN-L, verified that Resident 1 was on EBP, indicated that a gown and gloves need to be worn when completing suprapubic catheter cares and emptying urine from the catheter bag. LPN-L verified that gloves should have been changed when completing suprapubic catheter cares when taking the old sponge dressing off. F. During an observation of the provision of care for Resident 54 on 11/19/24 at 9:20 AM, MA-M, entered Resident 54's room to assist the resident to the bathroom. MA-M did not wash hands or put on gloves. MA-M pulled down the resident pants and incontinence brief which was soiled with urine. MA-M put on gloves, changed the resident's soiled brief, assisted the resident to a standing position and completed incontinence cares. Without removing gloves, MA-M pulled up the resident's pants and assisted the resident into the wheelchair. MA-removed disposable gloves and assisted the resident with washing hands. MA-M then washed hands, transferred the resident into bed, assisted with covering the resident and placed items within reach of the resident. MA-M did not wash hands before leaving the room and then sat down at the computer to chart. G. Review of Resident 59's Care Plan dated 11/19/24 and Treatment Administration Record dated 11/2024 revealed the resident was on EBP and had a diagnosis of Extended-spectrum beta-lactamase (ESBL-an enzyme produced by some bacteria that makes them resistant to many antibiotics). During an interview on 11/18/24 at 9:25 AM, LPN-E, verified that Resident 59 was on EBP due to a foley catheter (a thin tube that drained urine from the bladder into a collection bag), and indicated a gown and gloves needed to be worn when completing catheter cares and emptying urine from the catheter bag. During an observation of the provision of care for Resident 59 on 11/18/24 at 10:30 AM, LPN-E and Nurse Aide (NA)-D entered Resident 59's room to complete peri-cares, catheter cares and to reposition the resident. LPN-E and NA-D washed their hands and put on disposable gowns and gloves. Resident 59 was incontinent of a small bowel movement and the staff completed catheter cares and peri cares. LPN-E did not remove or change gloves after completing peri cares or catheter cares. LPN-E and NA-D changed the residents bottom sheet and put on a clean incontinence brief. LPN-E removed the disposable gown and gloves and washed hands but failed to reapply gloves or a gown. LPN-E assisted to reposition the resident, adjusted the bed linens, pillows, and the catheter tubing without use of the required gown and gloves. During an observation of the provision of care for Resident 59 on 11/19/24 at 8:10 AM, LPN-L and MA-F, entered Resident 59's room to reposition the resident and to get the resident ready for breakfast. LPN-L and MA-F washed their hands, put on a disposable gowns and gloves, and completed peri cares and catheter cares. LPN-L changed gloves and LPN-L and MA-F changed the resident's soiled brief. LPN-L removed the disposable gown and changed gloves. LPN-L then changed the sheet and blanket covering the resident, repositioned the resident to the resident's right side and adjusted pillows and the catheter tubing without wearing the required gown. During an interview on 11/19/24 at 12:05 PM, MA-O verified Resident 59 was on EBP and a gown and gloves needed to be worn when completing cares on Resident 59 that require any contact with the resident. During an interview on 11/19/24 at 12:40 PM, LPN-L verified Resident 59 was on EBP, and indicated a gown and gloves only needed to be worn when completing catheter cares and emptying urine from the catheter bag for Resident 59. 45739 H. Review of Resident 29's MDS dated [DATE] revealed the resident was cognitively intact, was dependent with dressing, transfers, bed mobility, and toileting, had diagnoses of dementia, Parkinson's Disease, anxiety, and depression, received antipsychotic and antidepressant medications, was at risk for pressure ulcers, and had pressure relieving devices for their chair, bed, and was on a turning/repositioning program. Review of Resident 29's Care Plan last revised 10/3/24 revealed the resident received antidepressant medications, antipsychotic medications, and was dependent with bed mobility, dressing, transfers, and toileting. The resident was at risk for skin breakdown and staff were to follow treatments as ordered on the Treatment Administration Record (TAR). There was no documentation on the Care Plan that the resident had any pressure sores or was on EBP. Review of Resident 29's TAR for November 2024 revealed orders for: -change heel cup every Tuesday for deep tissue injury (damage to the soft tissue beneath the skin caused by pressure or shear forces) ordered 9/24/24, and -paint left and right heel wounds with betadine, allow to dry, and then apply skin prep to site twice a day until healed, then place heel protector over site ordered 10/14/24. Observations of 11/18/24 at 11:10 AM a sign was located on Resident 29's Bathroom door that the resident had EBP implemented. Observation on 11/19/24 at 11:30 AM with MA-M and MA-N. Both MA's performed hand hygiene and started to gown up in the resident room. LPN-L entered Resident 29's room and told the MA's they did not need to gown up because the resident's wounds were covered. The MA's removed their gowns, and applied gloves only. The MA's uncovered the resident and rolled the resident to remove their pants, then removed the resident's soiled brief. MA-N performed peri cares without any identified concerns. MA-N removed their gloves, performed hand hygiene then applied new gloves and applied a clean brief to the resident. MA-M rolled the resident to the other side and hooked the brief to the resident. Both MA's, still not wearing gowns assisted the resident to sit on the edge of the bed and hooked the resident up to the sit to stand lift. The MA's transferred the resident to the wheelchair using the sit to stand lift. Once the resident was in the wheelchair, both MA's removed their gloves and performed hand hygiene. The MA's removed the lift from the resident, MA-N, without wearing gloves assisted with personal hygiene and MA-M made the residents bed without wearing gloves or a gown and the bedspread touched MA-M's scrub top. MA-M removed the trash from the room and disposed of, then removed the sit to stand lift from the resident room and cleaned the lift. MA-N took the resident to the dining room. Both MA's performed hand hygiene upon exiting the resident room. Interview on 11/19/24 at 11:30 AM with LPN-L revealed Resident 29 had EBP for heel wounds but PPE was only needed when working with the resident's heels. If the heels were covered then PPE was not required. LPN-L stated EBP could possibly be discontinued because the resident did not have any drainage. Interview on 11/19/24 at 11:35 AM with MA-M and MA-N revealed they wear PPE in the morning when getting the resident up for the day because the socks could have come off, but PPE was not required when the heel wounds were covered. Further interview confirmed PPE was not required while performing high-contact cares unless the wounds were uncovered. Interview on 11/20/24 at 3:10 PM with the MDS nurse confirmed the residents pressure areas and EBP were not implemented onto Resident 29's Care Plan. Interview on 11/20/24 at 3:55 PM with the Director of Nursing (DON) confirmed EBP should be followed, and PPE worn during all high contact care times such as toileting, dressing, and transferring for residents with on-going wounds.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04(F)(i)5 Based on record review and interview; the facility staff failed to notify the primary care practitioner (PCP) and the Registered Dietician (RD) of weight loss for 2 (Residents 27 and 12) of 3 residents reviewed. The facility identified a census of 58. Findings are: A. Review of the facility policy Notification of Changes with a revision date of 12/220/22 revealed the purpose of the policy was to ensure prompt notification to the resident's physician and the resident's representative when there was a change requiring notification. Circumstances which required notification included: -accidents resulting in injury or physician intervention. -significant change in the resident's physical, mental, or psychosocial condition. -circumstances that required a need to alter treatment. -a transfer or discharge from the facility. -a change in the resident's rights. -a change in the resident's roommate. B. Review of a Weights and Vitals Summary Sheet (form used to document a resident's weights, blood pressure, respirations, temperature, and pulse) revealed the following weights for Resident 27: -4/30/24 weight was 152 pounds. -5/27/24 weight was 148 pounds (down 4 pounds in 1 month). -6/27/24 weight was 140 pounds (down 8 pounds or a 5% loss in 1 month). -7/29/24 weight was 139 pounds. -8/22/24 the resident's weight was 130 pounds (down 9 pounds in 1 month or a 6% loss in 30 days). Review of the resident's electronic medical record revealed no evidence the RD or the PCP were notified of the resident's ongoing significant weight loss. An interview with the Dietary Manager on 11/19/24 at 1:59 PM confirmed the following regarding Resident 19: -6/27/24 the resident had a weight loss of 8 pounds or a 5% loss in 1 month. -8/22/24 the resident had a weight loss of 9 pounds or a 6% loss in 30 days. -the RD and the PCP were not notified of Resident 27's ongoing weight loss. C. Review of a Weights and Vitals Summary Sheet for Resident 12 revealed the following: -9/29/24 weight was 149 pounds. -10/31/24 weight was 132 pounds (down 17 pounds or a 11% weight loss in 30 days). During an interview on 11/20/24 at 4:04 PM, the DM confirmed the resident's PCP, and the RD were not notified after the resident's weight on 10/31/24 revealed a 17 pound or an 11% loss in 1 month.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview; the facility failed to ensure antibiotics were given in accordance with the facility Antibiotic Stewardship Program (ASP-program for optimizing treatment of infections and reducing adverse events from the use of antibiotics) for Resident 16. The sample size was 5 and the facility census was 58. Findings are: A. Review of the facility undated Antibiotic Stewardship Program policy revealed the following: -It was the policy of the facility to implement and Antibiotic Stewardship Program (ASP) as part of the facilities overall infection prevention and control program. -The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. -The Infection Preventionist, with oversight from the Director of Nursing served as the leader of the Antibiotic Stewardship Program and received support from the Administrator and other governing officials of the community. -The Medical Director, Consultant Pharmacist, and Attending Physicians supported the ASP through active participation in developing, promoting, and implementing a facility wide system for promoting, and implementing a facility-wide system for monitoring the use of antibiotics. -Antibiotic use protocols including nursing assessment prior to physician notification, laboratory testing in accordance with practice standards, criteria to determine whether to treat infection with antibiotics, and ensuring all antibiotics specified dosing, duration, and indication for use. Review of Resident 44's Minimum Data Set (MDS-federally mandated assessment used to development resident Care Plans) dated 9/28/24 revealed the resident received antibiotics in the preceding 7 days. Review of the Note to Attending Physician Form sent to the physician from the Consultant Pharmacist dated 1/16/24 revealed the Consultant Pharmacist sent a recommendation letter to the physician requesting clarification of the Bactrim DS order. The document stated the resident had been taking the Bactrim DS since 6/12/23. Further review revealed the physician included a diagnosis of Pneumonitis (inflammation of the lungs) and checked a box to continue the medication but documented no clinical rationale or supporting evidence to support the continued use of an antibiotic. Review of Resident 44's Physician's Orders dated 11/20/24 revealed the following medication: - Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 MG (Bactrim DS) Give 1 tablet by mouth two times a day every Monday, and Thursday. During an interview on 11/20/24 at 2:22 PM the Director of Nursing confirmed the resident continued routine use of the antibiotic Bactrim DS without a stop date, and the provider had not documented a clinical rationale in accordance with the facility Antibiotic Stewardship Program for continued use of an antibiotic without a stop date or predetermined course duration.

Licensure Reference Number 175 NAC 12-006.I(i) Based on observation, interview, and record review; the facility failed to ensure Residents 14 and 16's falls were reviewed for causal factors, fall prevention interventions were based on causal factors, and reviewed and revised to prevent ongoing falls. The sample size was 4 and the facility census was 58. Findings are: A. Review of the facility policy Fall Prevention Program dated 8/3/23 revealed the following: -Each resident was assessed for fall risk and received care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -The facility used standardized risk assessment to determine a resident's fall risk, and initiated interventions that decreased the risk of falling including but not limited to a clear pathway to the restroom, locking of bed wheels, leaving call lights accessible, providing adequate lighting, and keeping equipment in good repair. In addition, the facility implemented routine rounding, monitoring residents for changes in condition, encouraged residents to wear shoes or slippers with non-slip soles, ensured eyeglasses were clean and were being worn, and reassessed fall risk every 90 days. -At Risk for Falls care plans included adequate supervision, consistent with the resident's needs, goals, and current standards of practice to reduce accident risk. -Care Plan interventions were monitored and modified as necessary in accordance with current practice standards. B. Review of Resident 16's Minimum Data Set (MDS-federally mandated assessment used to development resident care plans) dated 9/28/24 revealed the resident had Cancer and received partial assistance with bathing, dressing, hygiene, and mobility. The resident had frequent moderate pain of 5 out of 10. Review of Resident 16's Morse Fall Scale assessments dated 6/7/24 through 9/26/24 revealed the resident was at High Risk for Falling. Review of Resident 16's Incident Reports revealed the following: -On 5/31/24 at 11:08 PM the resident attempted a self-transfer from a wheelchair to a recliner and fell . The resident reported getting feet stuck to the floor. The intervention was Resident is not to wear crocs . -On 6/6/24 at 3:30 PM the resident activated a call for assistance and staff found the resident sitting on the floor in front of a recliner. The resident had removed shoes, had no socks on and the electric recliner was found in the up position. The resident reported sliding off the recliner onto the floor. The intervention was for the resident to wear gripper socks, the recliner remote was to be left out of the resident's reach and a sign was placed in the resident's room for a reminder. -On 6/22/24 at 3:45 PM the resident was found lying on the floor between the recliner and the bed. The intervention was to re-educate staff to keep the recliner remote out of the reach of the resident. - On 8/20/24 at 3:45 PM the resident slipped on a slightly wet floor and was subsequently lowered to the floor. The intervention was to use a gait belt (belt used around the waste for safety and support during transfers) with transfers, unsure the resident wore proper footwear, and ensuring the bathing room floor was dry before transferring. There was no evidence this was not a facility standard already in place. -On 8/23/24 at 10:15 AM the resident attempted to self-transfer was heard calling out and was found in a kneeling position on the floor. The resident reported needing to go to the bathroom. The intervention was the resident agreed to request assistance, there was no evidence this was a new intervention. -On 10/15/24 at 3:00 PM the resident activated a call light in the bathroom and was found sitting on the floor beside the toilet. The intervention was the resident was re-educated to activate call light prior to attempting a self-transfer, staff were to provide continuous reminders, and signs were placed in the resident room and bathroom. There was no evidence this was a new intervention. During an observation of the provision of toileting assistance for Resident 16 on 11/20/24 at 9:18 AM the resident called for assistance to the toilet. Nurse Aide (NA)-O responded and provided assistance to transfer the resident from the wheelchair to the toilet. No gait belt was used. The resident was then transferred back to the wheelchair and into a recliner and again, a gait belt was not used. During an interview on 11/20/24 at 9:20 AM, NA-O revealed having worked in the facility for 4 years. When questioned about fall prevention measures NA-O knew Resident 16 was assisted with transfers and had dycem in the wheelchair. In addition, staff were to monitor for attempts to self-transfer and are aware of the residents fall risk. NA-O was unaware of any other specific fall prevention interventions. Review of the Resident 16's Care Plan with a revision date of 9/24/24 revealed the following problems, interventions, and implementation dates: 1/18/23 -The resident was at risk for falling. 1/18/23 - encourage periods of rest to prevent over tiring, grab bars in the bathroom, keep floor and pathways clear of clutter, call light in place and provide orientation to call light with cares, 6/30/23 - keep door open for observation, 6/30/23 - therapies as needed, 8/26/23 - use of an assistive device per resident's needs, 10/24/23 - Dycem (non-skid mat) on recliner seat, 12/18/23 - Complete Morse Fall Assessment (Assessment used to determine fall risk) upon admission, readmission, quarterly, and as needed. 1/18/24 - call light in place and orientation to call light with cares, 6/12/24 - absolutely no crock shoes, 6/19/24 - non-slip socks and shoes on, 9/5/24 - signage placed in multiple places in room to remind resident to use call light, staff educated to use gait belt, proper footwear and to assure floor is dry before transferring, and 9/24/24 - per family, recliner remote within reach, family aware and educated on risk due to resident having frequent falls related to setting recliner up without assistance and falling. There was no evidence the resident Care Plan was reviewed and/or revised following the resident's falls on 8/20/24, 8/23/24, or 10/15/24 based on causal factors. During an interview on 11/20/24 at 12:33 PM the Director of Nursing (DON) confirmed the resident had fallen several times, and although the facility reviewed falls, they had not identified causal factors with all falls and implemented prevention measures related to the causes and/or or ensured that all fall prevention measures were updated on the resident's care plan. In addition, the DON confirmed staff were to be using gait belts for assisted transfers with Resident 16. C. Review of Resident 14's MDS revealed the resident had 1 fall with no injury. In addition, the resident was severely impaired cognitively, displayed disorganized thinking, inattention, and altered levels of consciousness. The resident received assistance with eating, hygiene, dressing, bathing, transfers, and bed mobility. Diagnoses included dementia, schizophrenia, arthritis, and heart disease. Review of Resident 14's Morse Fall Scales on 6/14/24-10/31/24 revealed the resident was at risk for falling. Review of Resident 14's Incident reports revealed the following: -On 6/19/24 at 6:45 AM the resident was observed on the floor in front of the toilet with regular socks rather than gripper socks on. The intervention was to use gripper sock and a Tabs monitor (alarm with a pull tab secured to the resident that is supposed to alarm and alert staff if the resident tries to get up unassisted), and staff were to check on resident right after morning shift change and get the resident up and dressed. -On 6/26/24 at 3:30 AM the resident was found lying on the floor between the bed and the bathroom door. Staff determined the resident removed the TABS alarm and walked without walker a walker toward the bathroom. The intervention was to ensure the resident's walker was left in reach. It was unclear whether this was a new intervention and was not on the Care Plan. -On 10/9/24 at 3:30 PM the resident was found lying on the floor between the closet and the bed. The resident had been toileted 15 minutes prior but had since removed shoes and did not have on gripper socks. The resident did not use call light for assistance. The resident was determined to be confused and there was no new intervention documented. -On 10/22/24 at 6:30 PM the resident was found on the floor next to the bed. Staff believe she may have been trying to get into the unmade bed. The intervention was to take the resident to the dining room first while they were busy getting other residents to the dining room. In addition, staff were to place 2 wedge cushions on the resident's bed. -On 10/31/24 at 1:30 AM the resident was found on floor on the bedside fall mat. It was determined the wedged were not in place and the intervention was staff education provided. -On 11/16/24 at 8:10 AM the resident was found on the floor of another resident's room. The intervention for to staff to be aware of the resident's location every hour. Review of Resident 14's Care Plan with a revision date of 10/24/24 revealed the following: -6/12/24-The resident was at risk for falling, -6/12/24 the following interventions were added to the care plan (call light in place and orientation to the call light with cares, Morse Fall Scale to be completed with admission/readmission, quarterly and as needed, Encourage rest periods to prevent over tiring, low-bed with bed placed against the wall, never leave alone on the toilet, non-slip sock/shoes on, observe for behaviors and address appropriately, and 1 hour safety checks), -6/19/24 resident to be checked on after morning shift change and dressed if awake during rounds, -10/24/24 fall mat to outer side of the bed, wedges x 2 to outer side of bed, -11/3/24 resident to lie in bed after lunch, toilet around 3:00 PM and place in w/c in hallway for monitoring, -11/12/24 resident will purposefully crawl over wedges and place self on There was no evidence the resident Care Plan was reviewed and or revised following the resident's falls on 6/19/24 (to include the use of a TABS monitor), 10/9/24, or 11/16/24 based on causal factors. During an interview on 11/19/24 at 9:26 AM Nurse Aide-F confirmed that Resident 14 was at risk for falling and knew staff were to ensure the residents needs were met, ensure the resident's bed with in a low position with a bed side fall mat, assist the resident as needed to the toilet, make sure the resident's call light was accessible, and engage the resident in an activity when possible. During an interview on 11/20/24 at 12:33 PM the DON confirmed that although the facility reviewed fall, they did not always identify causal factors and implement prevention measures related to those causes or ensure that all fall prevention measures were updated on the Resident 14's care plan.

Licensure Reference Number 175 NAC 12-006.09(H)(iv) Based on interview and record review; the facility failed to ensure Resident 59's Bowel and Bladder management plan was coordinated and addressed in cooperative with the Hospice Care provider. The sample size was 1 with a census of 58. Findings are: A. Review of the undated facility policy Bowel Elimination revealed the following: The facility developed and implemented a process to assure that constipation was prevented/addressed in a timely fashion. Daily documentation of bowel elimination was reviewed. The night shift ran a report showing no Bowel Movement (BM) in the last 48 hours and no BM in the last 72 hours. The following steps were followed for all residents of Community Memorial Health Center: - If no BM in 48 hours the dietary staff was notified and the resident was offered bran flakes, prune juice or both. - If no BM in 72 hours the resident was offered Milk of Magnesia (laxative), 30 cubic centimeters (cc) by mouth. - If no BM for 4 days the resident was offered a Dulcolax Suppository (laxative) Rectally. - If no BM for 5 days the resident was offered a Fleets Enema (injection of liquid into the rectum to cause the intestines to empty). B. Record review of Nursing Assistant (NA), documentation dated 11/1/24 through 11/16/24 revealed no BM was documented. Review of Nursing Note Documentation revealed: -On 11/6/2024 at 1:10 AM Resident 59 was given a fleets enema and had not had a BM for 7 days. The resident had nausea and was given Zofran (Medication for nausea), and the resident was educated about the complications of constipation. -On 11/10/2024 at 11:41 PM The resident had a BM on 11/7/24 and a suppository had been given. -On 11/20/2024 at 2:44 PM bowel management medication was discussed with the hospice nurse and a routine laxative was initiated. Review of the resident's Medication Administration Record (MAR) dated 11/24 revealed that the resident received Milk Of Magnesia on 11/4/24 with no BM, on 11/5/24 the resident refused medications offered, on 11/6/24 the resident received a enema and had a BM, on 11/9/24 the resident received Milk Of Magnesia with no BM, per nursing note documentation resident received a suppository on 11/10/24, on 11/15/24 the resident received Milk Of Magnesia with no BM, on 11/16/24 the resident received a suppository and had a BM. The resident had an order for Polyethylene Glycol Powder 17 gram (Laxative) by mouth every 24 hours as needed for constipation and the medication had not been administered for the month of 11/24. Review of the Hospice Certification and Plan of Care dated 10/16/24 revealed that Resident 59 was admitted to Hospice Care on 10/16/24. Review of Hospice Order dated 10/16/24 revealed: - The Hospice Nurse was to assess and instruct the resident/caregiver on factors that increased the risk of constipation and measures to prevent constipation. The Hospice Goal dated 10/16/24 revealed: -The Resident/Caregiver verbalize understanding of risk factors that increased the risk of constipation and measures to prevent constipation. Review of Resident 59's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/26/24 revealed that the resident had constipation. Review of Resident 59 facility Care Plan dated 11/19/24 revealed no evidence constipation was addressed. During an interview with the Director of Nursing (DON), on 11/20/24 at 7:45 AM, the DON confirmed that Resident 59 received medications as needed for bowels but not routinely, and the resident bowel medications had not been reviewed as the resident did not get out of bed, activity level was limited, and resident's intake was poor. During an interview on 11/20/24 at 2:05 PM with Licensed Practical Nurse, (LPN-Q) from Hospice, confirmed that the facility staff had not voiced any constipation concerns for Resident 59. During an interview on 11/21/24 at 9:30 AM with Registered Nurse (RN-R), confirmed that Resident 59 did not have a constipation care plan in place.

Licensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview; the facility failed to ensure Level 1 Preadmission Assessment and Resident Review (PASARR-screening process required to be completed prior to admission to ensure residents with Serious Mental Illness (SMI), Intellectual Disability(ID), Development Disability(DD) or Related Disorders (RD) met the criteria for Nursing Home admission and had any additional services needed) screens were completed accurately prior to admission for Residents 48 and 44. The sample size was 3 and the facility census was 58. Findings are: A. Review of the facility policy Resident Assessment-Coordination with PASARR Program with a revision date of 7/18/24 revealed the following: -The facility coordinated assessments with the PASARR program under Medicaid to ensure that all individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs. -All applicants to the facility were screened for SMI or ID and RC in accordance with the State's Medicaid rules for screening. -Level 1 screening was completed prior to admission and a negative screen allowed the facility to proceed with admission and ended the PASARR process, a positive screen necessitated level 2 evaluation completed by the appropriate designated authority to determine appropriateness of setting for the individual and any recommendations for specialized services. B. Review of Resident 48's Minimum Data Set (MDS-federally mandated assessment used to development resident Care Plans) dated 10/12/24 revealed the following: -The resident had a level 1 PASARR, -had diagnoses of a Psychotic Disorder and Post Traumatic Stress Disorder (PTSD), and -received antipsychotic, antianxiety, and antidepressant medications. Review of Resident 48's PASARR dated 11/28/23 revealed no evidence the screen included any mental illness diagnosis. Review of Resident 48's Care Plan with a revision date of 5/9/24 revealed diagnoses of Anxiety Disorder, Depression, and PTSD and the resident was at risk for adverse reactions to medication. The resident had hallucinations, delusions, and insomnia. In addition, the resident could become aggressive and resistive to care. During an interview on 11/19/24 at 3:40 PM the Director of Nursing (DON) confirmed the facility had not checked the accuracy of Resident 48's Level 1 PASRR screen at the time of admission to ensure it was completed accurately and to ensure the resident did not need a level 2 (screen completed by an outside source to determine if the resident had SMI/ID/DD/RD in order to establish if the resident needed additional services not routinely provided by nursing facilities) screen. In addition, the DON confirmed the resident did have a diagnosis of a delusional disorder, anxiety disorder, depression and PTSD that was not included on the 11/28/23 Level 1 screen. C. Review of Resident 44's MDS dated [DATE] revealed the resident had a level 1 PASARR screen and had diagnoses of an anxiety disorder and bipolar disorder and took antipsychotic, antianxiety, and antidepressant medication. Reviewed of Resident 44's PASARR level 1 screen dated 5/21/24 indicated the resident had no Major Mental Illness. There was no indication the bipolar disorder or anxiety disorder was included on the level 1 screen. Review of Resident 44's Orders revealed the following: -5/16/24 Buspirone HCl (antianxiety medication) Oral Tablet 10 MG Give 10 mg by mouth two times a day related to a generalized anxiety disorder, -5/17/24 aripiprazole (antipsychotic medication) Oral Tablet 15 MG Give 15 mg by mouth one time a day related to bipolar disorder, and -The resident was taking psychoactive (mind altering) medications with Target Behaviors of agitation, very regimented, easily irritable, health concerns, and impatient. Review of Resident 44's Care Plan with a revision date of 10/29/24 revealed the resident displayed verbal and physical aggression and was at risk for adverse reactions to medications, took antipsychotic, and hypnotic (sleep inducing) medications and was monitored for side effects and effectiveness. During an interview on 11/19/24 at 3:40 PM the Director of Nursing (DON) confirmed the facility had not checked the accuracy of Resident 44's Level 1 PASARR screen at the time of admission to ensure it was completed accurately, and to ensure the resident did not need a level 2 screen. In addition, the DON confirmed the resident did have diagnoses of bipolar disorder and anxiety disorder that was not on the Level 1 screen.

Licensure Reference Number 175 NAC 12-006.12(A) Based on record review and interview; the facility failed to attempt a Gradual Dose Reduction (GDR) of Residents 24, 26, and 29's psychotropic medications (medications which alter consciousness, mood, and thoughts) or to have a documented clinical rationale for continued use. The sample size was 5. The facility census was 58. Findings are: A. Review of the facility policy Use of Psychotropic Medications, implemented on 10/6/23 revealed the following: -a psychotropic drug was any drug that affected brain activities associated with mental processes and behavior. Psychotropic drugs included: antipsychotics, antidepressants, anti-anxiety, and hypnotics, -the indications for the use of the medications would be determined by assessing the underlying condition, current signs, symptoms, expressions, and preferences and goals for treatments, and identifying of underlying causes, when possible, -the attending physician would assume leadership in medication management by developing, monitoring, and modifying the medication regimen, -the indications for use of any psychotic drug would be documented in the medical record, -documentation would include the specific condition as diagnosed by the physician, -residents who used psychotropic drugs would receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs, -the effects of the psychotropic medications would be evaluated on an on-going basis, and -the residents' response to the medications, including progress towards goals and presence/absence of adverse consequences would be documented in the resident's medical record. B. Review of Resident 24's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 9/28/24 revealed the resident had severe cognitive impairment; diagnoses included depressive disorder and anxiety; Resident 24 received antipsychotic and antidepressant medications, and required assistance with dressing, and toileting. Review of Resident 24's Care Plan last revised 11/18/24 revealed the resident had impaired cognition; had dementia; was at risk for elopement; had behaviors of tearfulness, and difficulty redirecting; received medications for antianxiety (Risperdal) and antidepressants (Mirtazapine, Trazodone, Sertraline); and required assistance with bed mobility, dressing, hygiene, and toileting. Review of the facility forms Note to the Attending Physician/Prescriber regarding Resident 24 revealed the following: -on 5/22/24 a GDR was due for Sertraline. The Physician marked the dose reduction was contraindicated due to behaviors noted in the care plan and charting. An area marked Please fill in a patient specific reason as to why reduction is contraindicated was left blank, and -on 7/17/24 GDR's were due for the Risperdal, Mirtazapine, and Trazodone. The Physician marked the dose was contraindicated due to behaviors noted in the care plan and charting for Risperdal. For Remeron and Trazodone, the Physician marked dosage reduction is contraindicated. An area marked Please fill in a patient specific reason as to why reduction is contraindicated was left blank. C. Review of Resident 29's MDS dated [DATE] revealed the resident was cognitively intact, was dependent with dressing, transfers, bed mobility, and toileting, had diagnoses of dementia, Parkinson's Disease, anxiety, and depression, and received antipsychotic and antidepressant medications. Review of Resident 29's Care Plan last revised 10/3/24 revealed the resident received antidepressant medications (Sertraline and Trazodone), antipsychotic medications (Quetiapine), and was dependent with bed mobility, dressing, transfers, and toileting. Review of the facility forms Note to Attending Physician/Prescriber regarding Resident 29 revealed the following: -on 2/14/24 GDR's were due for Quetiapine, Sertraline, and Trazodone. The Physician did reduce the Quetiapine, but marked dosage reduction is contraindicated for Sertraline and Trazodone. An area marked Please fill in a patient specific reason as to why reduction is contraindicated was left blank, and -on 7/17/24 GDR's were due for Seroquel, Trazodone, and Sertraline. The Physician marked dosage reduction is contraindicated due to behaviors noted in the care plan and charting for the Seroquel. Dosage reduction is contraindicated was marked for Trazodone and Sertraline. An area marked Please fill in a patient specific reason as to why reduction is contraindicated was left blank. D. Interview with the Director of Nursing (DON) on 11/20/24 at 11:55 AM confirmed the GDR's did not have rationale's for contraindications documented that was specific to Resident 24 or Resident 29 and there should have been a rationale's documented. 29638 E. Review of Resident 26's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of Parkinson's disease, cancer, anemia, coronary artery disease, renal failure, diabetes, depression, bipolar disorder, and non-Alzheimer's dementia. The resident was assessed as having moderate cognitive impairment, with behaviors of delusions and hallucinations. The resident had physical/verbal behaviors directed toward others, other behavioral symptoms not directed toward others, and rejection of cares. The resident was identified as receiving antipsychotic and antidepressant medications. Review of the resident's Care Plan with a revision date of 1/25/23 revealed the resident had paranoia, hallucinations, delusions, verbal, and physical aggression and indicated the resident received psychoactive medications. Review of the facility form Note to the Attending Physician/Prescriber with a date of 11/15/23 revealed the resident was due for a GDR of the following medications: -Depakote (antiseizure medication used to treat some psychiatric conditions) 125 milligrams (mg) three times a day. -Zyprexa (antipsychotic medication used to treat mental health disorders) 5 mg daily. -Risperdal (antipsychotic medication used to treat mental health disorders) 1 mg twice a day. -Trazadone (medication used to treat depression) 100 mg daily. The note requested the resident's physician evaluate use of these medications for a potential GDR. Further review revealed the physician denied a GDR due to the resident's behaviors. No specific reason was identified as to why the GDR was contraindicated. During an interview on 11/20/24 at 12:05 PM, the DON confirmed Resident 26's physician failed to document a specific clinical rational as to why a GDR of the resident's psychoactive medications were clinically contraindicated.

Licensure Reference Number 175 NAC 12-006.09D7 Based on interview and record review, the facility failed to implement interventions and failed to develop and/or revise interventions based on causal factors to prevent falls for 3 residents (Residents 1, 2, and 3) resulting in a a [CONDITION(S)] (Resident 2 and 3), neck fracture (Resident 1) The sample size was 4 and the facility census was 60. Findings are: A. Review of the undated facility policy Accidents and Supervision revealed: -The resident environment was to remain as free of accident hazard(s) and risk(s) as possible and each resident receives adequate supervision and assistive devices to prevent accidents including: -Identifying hazard(s) and risk(s), -Evaluating and analyzing hazard(s) and risk(s), -Implementing interventions to reduce hazard(s) and risk(s), and -Monitoring for effectiveness and modifying interventions when necessary Review of the undated facility policy Fall Prevention Program revealed: -The facility utilized a standardized risk assessment for determining a resident's fall risk. -For program identification the facility utilized high risk and low/moderate risk, using the scoring method designated on the risk assessment. -Upon admission the nurse would complete a fall risk assessment, along with the admission assessment to determine the resident's level of risk. -The nurse would implement interventions on the resident's Baseline Care Plan in accordance with the resident's level of risk. B. Review of Resident 2's MDS (Minimum Data Set- a federally mandated assessment required for all nursing facility residents used to formulate the Resident's plan of care) dated 12/13/19 revealed the resident: - fell within 1 month of admission, - had frequent moderate pain, - was frequently incontinent of bladder, - required extensive assistance with bed mobility, transfers, dressing, and toileting, - was moderately impaired cognitively, and - had a diagnosis of a [CONDITION(S)] and dementia. -The facility Fall Risk Assessment for Resident 2 completed on 12/9/19 indicated Resident 2 was at high risk for falls. Resident 2's Care Plan dated 12/12/19 confirmed the resident had potential for falls related to dementia, anxiety, history of falls, [MEDICATION(S)] (medication used for treatment of anxiety) use, and hypertension with interventions to: -Keep call light in reach, -Educate staff on answering call lights timely, -Monitor blood pressure, -Monitor for side effects of medications, -Shoes or gripper socks on at all times, -Wheelchair to be left in the bathroom when not in use, -Wheelchair with staff assistance for distances, -Walker for pivot transfers, -Wheelchair in bathroom when not in use and gripper socks (added 1/5/20), - Wheelchair out of reach when not occupied (added 1/21/20), - Bed/Chair alarm (added 2/3/20), and - Do not leave unattended on toilet (added 2/21/20). Review of Resident 2's Progress Notes revealed: -Resident 2 fell in the bathroom at 2:00 AM on 1/5/20. Resident 2 was in bed, transferred self to the wheelchair and then to the bathroom. Resident 2 had wet the bed and was going to change. Resident 2 was lying on the bathroom floor on the residnet's back. Resident 2 had pulled the call light in the bathroom while falling and the wheelchair moved from underneath the resident. Resident 2 had bare feet at the time ofthe fall. -Resident 2 fell in bathroom at 12:00 AM on 1/21/20. Staff assisted Resident 2 to the toilet when the alarm of another resident sounded and the staff attending Resident 2 left the room to assist the resident with the sounding alarm. Resident 2 then attempted to transfer self into the wheelchair and fell . -Resident 2 fell in bathroom at 12: 25 AM on 1/26/20. The resident got up to the bathroom and did not use the call light and fell . Resident 2's left hip was externally rotated and pain was present with movement. Resident 2 was transferred to acute care and diagnosed with a [CONDITION(S)]. Interview with the DON (Director of Nursing) on 3/2/20 at 1:00 PM confirmed the facility failed to evaluate causal factors for falls and implement new intervention for Resident 2's falls on 1/5/20 and 1/21/20. C. Review of Resident 1's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. Review of Resident 1's Care Plan revealed the resident was at risk for fall related injury. Interventions included: - 8/16/18- Therapy as needed, - 8/16/18- When rising from a lying position, sit on the side of bed for a few minutes before transferring/standing, - 11/18/19- Gripper socks/shoes as much as possible, - 1/17/20- Call light in reach on the night stand, - 1/17/20- Educate/remind the resident to request assistance prior to getting up, - 1/17/20- Follow the added parameters to the resident's blood pressure medication, - 1/17/20- Uses wheel chair with staff assistance, and - 2/17/20- Keep the resident's bathroom door closed at all times. Resident to be in wheel chair in common areas with bedroom door closed. Review of Resident 1's Morse Fall Scales dated 11/5/19 and 1/20/20 confirmed the resident was at High Risk for Falling. Further review revealed the resident had impaired gait and would overestimate or forget limits. Review of Resident 1's Incident/Accident and Post Fall form dated 11/18/19 revealed the resident had fallen in the resident's bathroom. The resident was bare foot and didn't have the call light on the resident's walker. Interventions were identified for the resident to use gripper socks and to have the call light on the walker. There was no evidence to indicate the resident's toileting needs were addressed. Review of Resident 1's Incident/Accident and Post Fall form dated 12/6/19 revealed the resident fell after a self-transfer. The intervention was to replace a sign on the resident's walker to remind the resident to use the walker. There was no evidence the reason for the self-transfer was addressed. Review of Resident 1's Incident/Accident and Post Fall form dated 1/3/20 revealed the resident fell in the bathroom after a self-transfer. The resident did not have gripper socks on (per plan of care) and the resident's walker was not in reach. The intervention was to have the wheeled walker next to the resident's bed. There was no evidence the resident's toileting needs were addressed. Review of Resident 1's Progress Note dated 1/3/20 revealed the resident suffered a severe humerus fracture from the fall. Review of Resident 1's Progress Notes dated 2/17/20 revealed the resident fell and was found on the floor in the doorway of the resident's bathroom. The resident was bleeding from a wound on the resident's head. The resident continued to complain of neck pain and was sent to the hospital for evaluation Review of Resident 1's Progress Notes dated 2/18/20 revealed the resident had suffered a neck fracture from the fall on 2/17/20. Review of a Written Warning Notification dated 2/17/20 revealed Nursing Assistant (NA)-F put high risk resident on toilet and walked away. During an interview with NA-A on 3/2/20 at 9:27 AM, NA-A stated if a resident used a personal fall alarm or if they would try to self-transfer then that is how the NA would know not to leave that resident alone in the bathroom. NA-A did not mention a pocket care-plan. During an interview with NA-C on 3/2/20 at 9:35 AM, NA-C stated the NA wouldn't leave a resident unattended in the bathroom if the resident was not cognitively aware. NA-C stated the residents' BIMS were listed on the pocket care-plan and could be used to identify if the resident was cognitively aware or not and then what we feel is safe. NA-C did not mention using the portion of the pocket care-pan that identified specifically what residents shouldn't be left unsupervised. During an interview with NA-D on 3/2/20 at 9:37 AM, NA-D stated if a resident had a fall alarm then they were not to be left alone in the bathroom or if they couldn't sit upright on the toilet themselves. NA-D stated knowing who to leave or not leave in the bathroom alone was common sense and you just know, I guess. NA-D did not mention using a pocket care-plan. During an interview with the Administrator on 2/3/20 at 1:00 PM the Administrator confirmed NA-F left Resident 1 unsupervised in the bathroom. Further interview confirmed NA-F had received disciplinary action for leaving a resident that was at high risk for falls (Resident 1) in the bathroom unsupervised. The Administrator confirmed the area on the pocket care-plan that identified specific residents at high risk for falls with instructions to not leave them unsupervised in the bathroom was added after Resident 1's fall on 2/17/20. The Administrator stated that was no evidence to show that any of the other staff members had been educated to use the pocket care-plan when deciding which residents required supervision in the bathroom. D. Review of Resident 3's MDS dated [DATE] revealed diagnoses of [CONDITION(S)], Dementia, Diabetes and history of Urinary Tract Infections. In addition, the resident's mobility was assessed as needing limited assistance with walking and the resident's balance during transitions was steady at all times. Review of an Incident/Accident report dated 11/21/19 at 9:50 PM revealed Resident 3 was observed by a staff member walking with a 2 wheeled walker wearing nonskid slipper socks and fell backwards onto the floor. An immediate intervention was implemented to have the resident continue to wear slipper socks and put shoes on if seen walking. Review of a Progress Note dated 11/22/19 at 11:23 AM revealed Resident 3 was not wanting to bear weight on the left leg and was sent to the hospital for an x-ray. Review of Resident 3's hospital report dated 11/22/19 revealed the resident had a fracture of the left hip. A review of 4 undated Care Plans for Resident 3 confirmed the resident's fall risk and related interventions were not included on 3 of the earlier Care Plans. In addition the current undated Care Plan revealed the resident's fall risk and related interventions were dated 1/6/20 (6 weeks after the resident had fallen). During an interview on 3/2/20 at 11:45 AM with Licensed Practical Nurse (LPN)-H, LPN-H confirmed Resident 3 had been assessed as being at a high risk for falls and was ambulating independently with the use of a walker prior to the resident's fall on 11/21/19. LPN-H also confirmed Resident 3 has had a decline in functional mobility and has not been walking since the fall occurred. During an interview on 3/2/20 at 12:30 PM with the Director of Nursing (DON), the DON confirmed Resident 3 had been identified as being a high risk for falls and according to the Fall Prevention Program the Care Plan should indicate the resident's fall risk and include interventions to prevent potential falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, record reviews and staff interviews; the facility failed to provide supervision and assistance for 1 resident (Resident 1) who sustained a burn injury from a hot coffee spill. Facility census was 48. Findings are: A. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/20/12 and 3/14/13 revealed the resident had short term and long term memory problems and required extensive assistance with eating. Review of Restorative Feeding Progress Notes form dated 12/19/12 and 3/14/13 revealed Resident 1 required cueing and set up help with meals and the resident fed self. Review of Care Plan Minutes dated 12/19/12 revealed Resident 1's placement in the dining room was at a cue/assist table. The 12/19/12 Care Plan Minutes further indicated the resident's "Hot/cold liquid safety" was "ok with staff". There was no further documentation to indicate what type of assessment was used to determine the resident's ability to safely feed self hot food/liquid items. Review of Care Plan Minutes dated 3/20/13 revealed Resident 1's placement in the dining room was at an "Assist Table" and the "Hot/cold liquid safety" was "ok". Review of the current Care Plan (revision date 3/14/13) revealed the resident required supervision with assistance of 1 with eating. The Care Plan also stated the resident would "...forget my limitations regarding my safety. I have episodes of yelling out 'Help' d/t (due to) concerns of being forgot at meal times ..." Review of Incident/Accident Report dated 5/26/13 revealed Resident 1 pulled a cup of coffee to the edge of the table and spilled the cup into lap. Documentation indicated the resident's right inner thigh was reddened in an area that measured 15 centimeters (cm) by 24 cm. The resident's left inner thigh had an area of redness which measured 15 cm by 7 cm with a 4 cm by 2 cm open area where the top layer of skin was removed. Review of the current Care Plan revealed an intervention dated 5/26/13 which indicated the resident was to have "Lid to Hot Liquid cups". Review of the facility investigation report dated 5/29/13 revealed new measures put into place to prevent burns from coffee spills included the use of a travel mug with a lid and closure latch. The report further indicated the resident was moved to an assist table where staff was present and could observe the resident (although the 3/14/13 Care Plan identified this intervention was in place prior to the coffee spill). Review of the current Care Plan revealed an intervention dated 6/10/13 which indicated the resident's family member voiced if Resident 1 did not like a lid on the cup, the coffee could be cooled down with ice and the resident could "spoon it" as the resident "has always done". Review of Interdisciplinary Progress Notes dated 6/10/13 at 7:00 PM revealed Resident 1 was observed "...in Dining room, removing lid from coffee mug. Dietary notified. Lid replaced by staff..." Observations in the Rodeo Dining Room on 6/12/13 from 8:25 AM until 9:07 AM revealed the following: -The temperature of the coffee when served from the coffee machine measured 162 degrees Fahrenheit (F). -Resident 1 was seated at an assisted table and had been served a cup of coffee in a travel mug with a lid. The resident made no attempt to drink from the cup. Interview with Nursing Assistant (NA)-C on 6/12/13 from 9:22 AM until 9:25 AM revealed the resident was supposed to be served coffee in a cup with a lid. NA-C indicated the resident required cueing and encouragement to eat but would not allow staff members to feed the resident. NA-C stated the resident sometimes "tries to take the lid off the coffee cup" because the resident "doesn't like it". Observations in the Rodeo Dining Room on 6/12/13 from 11:57 AM until 12:42 PM revealed the following: -At 11:57 AM, Dietary Aide (DA)-E placed a travel mug filled with coffee in front of Resident 1 who was seated at an assist table. There were no other staff members present in the dining room to assist Resident 1. DA-E added creamer and placed a lid on the mug. -From 12:00 noon until 12:08 PM, Resident 1 remained seated at the table with no staff member present to assist. -At 12:08 PM, DA-E removed Resident 1's coffee mug. The temperature of the coffee was 150 degrees F. -At 12:09 PM, DA-E filled a clean travel mug with coffee and creamer, put a lid on the mug and placed the mug on the table in front of Resident 1. --From 12:09 PM until 12:14 PM (5 minutes), Resident 1 received no assistance or supervision. B. During interview on 6/12/13 from 9:00 AM until 9:10 AM, the Administrator indicated the Care Plan Minutes form served as the resident risk assessment for hot liquid spills, and was evaluated with each care plan meeting. The Administrator further indicated that following Resident 1's coffee burn on 5/26/13, the facility recognized the resident risk assessment for hot liquids " was not adequate " , and a new Restorative Feeding Evaluation form was initiated on 5/27/13. The new form was to be completed for newly admitted residents, and for current residents as their care plan meetings were held. The Administrator indicated all residents would eventually be evaluated for risk for hot liquid spills using the new form. (Surveyor ) C. Interview with the MDS Coordinator on 6/12/13 from 1:15 PM until 1:20 PM revealed the plan was to assess residents with the newly developed Restorative Feeding Evaluation form on admission to facility, with a change of condition, quarterly and annually. The MDS Coordinator indicated Resident 1's Restorative Feeding Evaluation form was to be completed 6/12/13 as the Care Plan was " being done today " . D. Review of Resident 1's Restorative (sic) Feeding Evaluation form revealed it was completed 6/12/13 (17 days after the resident sustained [REDACTED]. Restorative Feeding Progress Notes on the same form dated 6/12/13 (no time indicated) revealed a plan to serve Resident 1 " ...coffee when staff is at assist table in a cup with no lid and put ice in it to cool it down. "