Every finding on record at Community Pride Care Center

Licensure Reference Number 175 NAC 12-006.18Based on observation, record review and interview, the facility failed to implement their water management policy to prevent the potential growth of bacteria such as Legionella (bacteria naturally found in fresh water and can grow in man-made water systems and can cause serious lung infections) in the facility water system and failed to COVID test Resident 6 when the resident had signs and symptoms of a respiratory illness. This had the potential to affect all facility residents. The facility census was 45. Findings are: A. Review of the undated facility Legionella Management Policy revealed the following: -The facility defined the control and management of Legionella bacteria in water systems within the facility. -The Legionella management team consisted of the Administrator, Maintenance Director, Safety Officer, and Infection Control. -If staff found control limits such as temperature levels, disinfection levels or manufacturer recommendations were not met, staff took corrective actions to return conditions back to acceptable ranges. During an interview on 12/31/25 at 12:59 PM the Maintenance Director confirmed being unaware of a facility specific water management plan, any mapping of the facility water system, any identified area of concerns or conditions that would make growth of water borne illness likely, or any mitigation plan in place to reduce the likelihood of waterborne illness in the facility. During an interview on 12/31/25 at 1:19 PM Housekeeper-L denied having any training or knowledge of a plan to run water in unoccupied facility rooms or any training on the facility Legionella Mitigation plan. During an interview on 2/31/25 at 1:21 PM the facility Housekeeping Supervisor -M denied any training or knowledge in the facility Legionella Management plan or any known requirement for mitigation of water borne illness. During an interview on 12/31/25 at 1:28 PM the Director of Nursing confirmed the facility has no documented evidence of implementation of the Legionella management plan. During an interview on 12/31/25 at 2:01 PM the facility Administrator confirmed being unaware of any mitigation plan for Water Borne Illness in the facility, and/or any roles required of the environmental services department, or knowledge of any facility map of the water system that would identify areas of concerns or risk related to waterborne illnesses. B. Review of the facility policy Covid-19 Testing last revised 6/24/25 revealed the purpose was to prevent Covid-19 from entering the nursing home, detecting cases quickly, and stopping transmission. The procedure included the following: -Residents with signs and symptoms must be tested. C. An observation on 12/29/25 at 10:15 AM revealed that Resident 6 had sinus congestion. An observation on 12/30/25 at 7:45 AM revealed that Resident 6 had clear sinus drainage and dry cough. Review of Resident 6's Physician's Order fax form dated 12/30/25 revealed that the physician was notified of the resident being congested. An order was received for Claritin (antihistamine)10 milligrams daily as needed for allergy symptoms and Mucinex (relieves cough) 2 times daily for 10 days. There was no order to complete a Covid-19 test. Review of nursing documentation for Resident 6 from 12/25/25 to 12/31/25 revealed no documentation of congestion, cough or sinus drainage. An interview with the DON on 12/31/25 at 2:00 PM confirmed that when a resident had symptoms of Covid the physician was to be notified, and an order was to be received to test the resident for Covid. Resident 6's physician was not asked to complete a Covid test when the resident was showing potential symptoms of Covid.

Licensure Reference Number 175 NAC 12-006. Based on record review and interview, the facility failed to have documented duration of use for all prescribed antibiotics or documented rationale to continue antibiotics indefinitely for Residents 15, 31 and 37. The sample size was 8 and the facility census was 45. Findings are: A. Review of the facility policy Antimicrobial Stewardship Program dated November 2017 revealed the following: -The goal of the Antimicrobial Stewardship Program (ASP) was to promote the appropriate use of antimicrobials in order to maximize treatment outcomes and minimize unintended consequences of antimicrobial therapy. The ASP aimed to improve antibiotic prescribing practices through the development and implementation of antibiotic use protocols and a system to monitor antibiotic use. -An Antimicrobial Stewardship Committee had been established to provide support and oversee activities of the ASP. The ASP was part of the infection Prevention and Control Program (IPCP) and reported activity and outcomes the QAPI (Quality Assurance Performance Improvement) Committee). -Responsibilities included ensuring appropriate antibiotic use, monitoring antibiotic use, antibiotic resistance patterns, and compliance with the ASP. B. Review of the undated Core Elements for Antibiotic Stewardship in Nursing Homes information packet provided to residents at the time of admission to the facility revealed the following: -Antibiotic stewardship referred to the set of commitments and actions designed to make sure patients received the right dose, of the right antibiotic, for the right amount of time: and only when truly necessary. -Improved antibiotic use ensured life saving medications were effective and available when needed. C. Review of Resident 15's After Visit Summary (Discharge orders from the hospital/admission orders to the Nursing facility) dated 10/3/25 revealed an order for Nitrofurantoin (Antibiotic) 50 milligrams (mg) 1 capsule daily with no ordered duration for use. Review of Resident 15's Physician's orders revealed an order for Macrodantin (nitrofurantoin) 50 mg 1 capsule daily at bedtime dated 10/7/25 with no evidence how long the resident was to continue taking the medication. Review of Resident 15's Care Plan dated 10/16/25 revealed the resident was incontinent of urine but no indication the resident was taking antibiotic medication or no clinical indication for the use of a continuous antibiotic. During an interview on 12/30/25 at 2:28 PM The Director 0f Nursing (DON) confirmed Resident 15's Antibiotic Macrodantin had been given daily since admission to facility on 10/3/25 without an ordered duration for use or documented clinical indication for continued use. D. Review of the current medication orders for Resident 31 dated 6/16/25 revealed an order for Nitrofurantoin/Macrodantin (antibiotic medication) 100 mg capsule take one capsule by mouth twice daily for recurrent urinary tract infection. There was no ordered duration of use for the Antibiotic medication. Review of Resident 31's Care Plan with a revision date of 7/15/25 revealed the resident had incontinence and decreased bladder capacity, took medication for an overactive bladder and the antibiotic medication for prevention of urinary tract infections. There was no evidence the facility was monitoring for adverse effects of continuous use of antibiotics or a clinical rationale to continue antibiotics indefinitely. Review of Resident 31's physician documentations revealed no evidence of a documented clinical rationale for continuous use of an antibiotic. During an interview on 12/30/25 at 2:28 PM The DON confirmed Resident 31's antibiotic medication Macrodantin had been given daily since May 2025 without an ordered duration for use or documented clinical indication for continued use. E. Review of Resident 37's Physician's orders revealed an order for Azithromycin (antibiotic) 250 mg 3 times per week dated 10/31/25 with a clinical indication for use of Chronic Obstructive Pulmonary Disease (COPD)(lung disease that makes it hard to breathe). No evidence of how long the resident was to continue taking the medication. Review of Resident 37's Care Plan dated 10/31/25 revealed the resident had COPD with a cough, low energy level and shortness of breath but no indication the resident was taking an antibiotic medication or no clinical indication for the use of a continuous antibiotic. During an interview on 12/31/25 at 1:00 PM with Registered Nurse (RN)-N confirmed Resident 37's antibiotic Azithromycin had been given 3 times weekly since 10/31/25 without an ordered duration for use or documented clinical indication for continued use.

Licensure Reference Number 175 NAC175 12-006.(D)(vi) Based on observation, record review and interview; the facility failed to date a multi-dose medications for Resident 2 and 21 after medication was opened or accessed to ensure manufacturer recommendations and professional standards were followed. The sample size was 3 and the facility census was 45.Findings are:A. Review of the facility policy titled Labeling of Medication Containers revised [DATE], revealed all drugs and medications maintained in the facility would be properly labeled in accordance with state and federal regulations.The Policy interpretation and implementation revealed that labels for individual drug containers must include the expiration date.B. An observation on [DATE] at 7:20 AM revealed Registered Nurse (RN)-G, prepared Resident 2's Ozempic (anti-diabetic agent) 0.25 milligrams(mg). The Ozempic syringe was not dated when opened or when expired and there were 2 doses that had been administered out of the syringe. Review of Resident 2's [DATE] Medication Administration Record (MAR) revealed an order for Ozempic 0.25 mg 1 time per week on Tuesday. An observation on [DATE] at 11:30 AM revealed Resident 21's Ozempic syringe was not dated when opened or expired and there were 3 doses that had been administered out of the syringe. Review of Resident 21's [DATE] MAR revealed an order for Ozempic 1 mg 1 time per week on Thursday. On [DATE] at 11:30 AM the Director of Nursing (DON) confirmed that the Ozempic syringe for Resident 2 and Resident 21 should have an expiration date on them after the first dose was administered.

Licensure Reference Number 175 NAC ,d+[DATE].18(B) Based on observation, interview, and record review; the facility failed to implement the required Personal Protective Equipment (PPE-items such as gowns, gloves, face shield that are worn to protect care givers) during the provision of cares for Resident 12 for Enhanced Barrier Precautions (EBP-involve 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) as well as those at increased risk for MDRO, residents with wounds or indwelling medical device/s). The sample sizes was 4 with a census of 42. Findings are: Review of the EBP sign posted on Resident 12's room door, from the U.S. Department of Health and Human Services Center for Disease Control and Prevention revealed the following: For EBP Everyone Must: -Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: -Wear gloves and a gown for the following High Contact Resident Care Activities: Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting -Device care or use of the following: A central line, urinary catheter, feeding tube, or tracheostomy. Wound Care for any skin opening requiring a dressing. Review of Resident's 12 Minimum Data Set (MDS-federally mandated comprehensive assessment use to develop resident care plans) dated [DATE] revealed the resident had 2 ulcers and infection of the foot. The resident had medically complex condition, coronary artery disease (CAD- a disease in which there is a narrowing or blockage of the coronary arteries) and peripheral vascular disease (PVD-a chronic condition that occurs when the arteries that supply blood to the legs or arms narrow or become blocked). Review of Resident's 12 Care Plan with a revision date of [DATE] revealed the resident had a diagnosis of PVD and osteomyelitis (a bone infection that causes inflammation and swelling of the bone tissue) to both feet, left and right 5th toes were amputated on [DATE]. The resident had daily skin treatments to right and left 5th toes, and was seen by the wound clinic weekly or as ordered. The resident was on EBP, and staff were to wear gown and gloves with all resident direct contact. During an observation of the provision of care for Resident 12 on [DATE] at 9:50 AM, Nurse Aide (NA-0) and Med Aide (MA-N), entered Resident 12's room to get the resident out of bed, toileted and dressed for the day. Staff did not put on gown or gloves when entering the room. NA-O and MA-N washed their hands, put on disposable gloves, and attempted to wake resident up. The resident would not open eyes, staff removed gloves, washed hands, and stated that they would return later. During an observation of the provision of care for Resident 12 on [DATE] at 11:20 AM, NA-O and MA-N, entered Resident 12's room to get the resident up and dressed. Staff washed their hands and put on disposable gloves, and no gown, assisted the resident to dress and sit up on the edge of the bed then transferred resident with a sit-to-stand mechanical lift into a wheelchair. The resident was then assisted to the bathroom, a brief was removed that was heavily soiled with urine, staff then sat resident on the toilet. Staff removed their disposable gloves, washed their hands, made the bed, and tidied the room. MA-N and NA-O then washed their hands, put on disposable gloves, and stood resident up with use of mechanical standing lift and sat the resident in a recliner per the resident request. The episode of care was provided without wearing the required gown. During an observation of the provision of care for Resident 12 on [DATE] at 2:25 PM, Registered Nurse, (RN-P), entered Resident 12's room to complete cares to resident's right and left 5th toes. RN-P applied hand sanitizer and disposable gloves, no gown, then set out the dressing supplies on a barrier. RN-P removed resident's shoes, sock, and old dressing from the right foot, then removed the disposable gloves, applied hand sanitizer and reapplied clean disposable gloves. There was some clear drainage on the dressing. The wound was then treated as ordered and covered with a dressing. RN-P removed disposable gloves, washed hands, put on disposable gloves, and then removed the dressing from the left foot 5th digit. RN-P then treated the area as ordered. RN-P completed the entire treatment while not wearing the required gown. During an interview on [DATE] at 1:20 PM, MA-N verified that the Resident 12 was on EBP, gown and gloves should have been worn during high contact resident care and confirmed that no gown was worn when completing cares with resident. During an interview on [DATE] at 1:30 PM, NA-0 verified that Resident 12 was on EBP, gown and gloves should have been worn with high contact resident cares and confirmed that no gown was worn when completing cares with resident. During an interview on [DATE] at 2:45 PM, RN-P verified that Resident 12 was on EBP, confirmed that gown and gloves should have been worn when the treatment to feet was completed and confirmed that no gown was worn when treatment was completed. During an interview on [DATE] at 2:15 PM, the Director Of Nursing (DON), verified that Resident 12 was on EBP, a gown and gloves should have been worn when completing high contact resident cares that required staff to touch the resident.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record review and interview the facility failed to ensure the safety of Resident 1 during bathing resulting in an injury. The sample size was 4 and the facility census was 44. Findings are: Review of the facility undated policy and procedure Shower/Tub Bath revealed the staff were to stay with the resident throughout bathing and never to leave a resident unattended, however there was no indication the policy addressed making sure the safety belt was used to secure residents in the bathing chair. Review of Resident 1's Progress note dated 3/19/24 at 11:52 AM revealed the resident was in a bathing chair outside of the tub and as the Bathing Aide reached to grab a towel the resident reached to the side and leaned out of the bathing chair and fell to the floor hitting (gender) head on the leg of a full body mechanical lift. The Bathing Aide immediately called for a nurse to assist. The nurse responded finding the Bathing Aide on the floor supporting the resident's head. The resident's forehead was lacerated. The resident's physician was contacted, and the resident was sent to the emergency room (ER) for evaluation. Further review revealed no evidence the resident had been secured in the bathing chair with a safety belt. Review of Resident 1's Care Plan dated 1/23/24 revealed the resident was at risk for falling, needed assistance with activities of daily living and was dependent for bed mobility, grooming, dressing, bathing, toileting, and transferring. In addition, the resident had mental debility, abnormal brain function and was unable to make decisions. Further review revealed the Care Plan was revised on 3/20/24 indicating the resident had fallen while in the bathhouse and staff were to make sure the bathing straps were in place when in the bathing chair, and 2 staff members were to be in attendance for cares while in the bath house. During an interview on 4/1/24 at 8:50 AM with Nurse Aide (NA)-B revealed the NA had bathed residents in the past and was not aware of any requirement to use the safety belt for all residents while bathing. During an interview on 4/1/24 at 9:00 AM with Medication Aide (MA)-D revealed the MA infrequently gave residents baths. The MA reported being aware of an incident of Resident 1 falling from the bathing chair recently and reported being educated on the need to have 2 staff members present during bathing or sitting in the bath chair for this resident. Further interview revealed the MA was not aware of any previous requirement to secure all residents in the bathing chair with a safety belt. During an interview on 4/1/24 at 10:45 AM MA-H revealed having bathed many residents while working at the facility. MA-H was not aware of any requirement to secure all residents in a safety belt while bathing, however the MA did report securing some residents if they had difficulty sitting securely upright. During a phone interview on 4/1/24 with NA-K at 12:10 PM revealed the NA had bathed Resident 1 on 3/19/24 when the resident fell from the bathing chair. In addition, NA-K confirmed that Resident 1 was not secured in the bathing chair with a safety belt during or after bathing. During an interview on 4/1/24 at 12:15 PM with the Director of Nursing (DON) confirmed the facility did not have a policy for securing all residents in the bathing chairs during bathing and had no evaluation process in place to evaluate the safety of individual residents while bathing. Further interview confirmed Resident 1 tended to lean forward at times when in a sitting position. The DON confirmed the facility staff did not secure Resident 1 in the bath chair during or after bathing on 3/19/24 resulting in a fall from the bath chair in which the resident sustained a laceration to the forehead requiring sutures (skin closure involving stitches) and evaluation for a head injury in the ER.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview the facility failed to complete a thorough investigation following a fall with injury for Resident 1. The sample size was 4 and the facility census was 44. Findings are: Review of the facility undated policy Accidents and Incidents -Investigating and Recording revealed the e Charge Nurse or Department Director would conduct an immediate investigation of accidents/incidents including the circumstances surrounding the accident/incident. Review of the facility undated policy and procedure Shower/Tub Bath revealed the staff were to stay with the resident throughout bathing and never to leave a resident unattended, however there was no indication the policy addressed making sure the safety belt was used to secure residents in the bathing chair. Review of Resident 1's Care Plan dated 1/23/24 revealed the resident was at risk for falling, needed assistance with activities of daily living and was dependent for bed mobility, grooming, dressing, bathing, toileting, and transferring. In addition, the resident had mental debility, abnormal brain function and was unable to make decisions. Further review revealed the Care Plan was revised on 3/20/24 indicating the resident had fallen while in the bathhouse and staff were to make sure the bathing straps were in place when in the bathing chair, and 2 staff members were to be in attendance for cares while in the bath house. Review of Resident 1's Progress note dated 3/19/24 at 11:52 AM revealed the resident was in a bathing chair outside of the tub and as the Bathing Aide reached to grab a towel the resident reached to the side and leaned out of the bathing chair and fell to the floor hitting (gender) head on the leg of a full body mechanical lift. The Bathing Aide immediately called for a nurse to assist. The nurse responded finding the Bathing Aide on the floor supporting the resident's head. The resident's forehead was lacerated. The resident's physician was contacted, and the resident was sent to the emergency room (ER) for evaluation. Further review revealed no evidence the resident had been secured in the bathing chair with a safety belt. Review of the Facility Reported Incident dated 3/19/24 revealed Resident 1 fell from a bathing chair at 11:17 AM and sustained a laceration to the forehead which required evaluation in the emergency room (ER). The diagnoses listed on the After Visit Summary included, fall, head injury, and laceration of forehead. The Physician Visit Record indicated the resident was to see the Primary Care Physician (PCP) in 5 days for suture (stitches) removal. The revisions dated 3/20/24 listed on the resident Care Plan indicated the facility would provide 2 person assists for transfers and cares while in the bath house and make sure the safety strap was in place. Further review revealed no indication the facility conducted an investigation to determine if the safety strap was in place during the resident's bath on 3/19/24 or following the bath when the resident fell . The report submitted to the State Agency did not include a determination that the safety strap on the bathing chair was not in use. During an interview on 4/1/24 at 8:50 AM with Nurse Aide (NA)-B revealed the NA had bathed residents in the past and was not aware of any requirement to use the safety belt for all residents while bathing. During an interview on 4/1/24 at 9:00 AM with Medication Aide (MA)-D revealed the MA infrequently gave residents baths. The MA reported being aware of an incident of Resident 1 falling from the bathing chair recently and reported being educated on the need to have 2 staff members present during bathing or sitting in the bath chair for this resident. Further interview revealed the MA was not aware of any previous requirement to secure all residents in the bathing chair with a safety belt. During an interview on 4/1/24 at 10:45 AM MA-H revealed having bathed many residents while working at the facility. MA-H was not aware of any requirement to secure all residents in a safety belt while bathing, however the MA did report securing some residents if they had difficulty sitting securely upright. During a phone interview on 4/1/24 with NA-K at 12:10 PM revealed the NA had bathed Resident 1 on 3/19/24 when the resident fell from the bathing chair. In addition, NA-K confirmed that Resident 1 was not secured in the bathing chair with a safety belt during or after bathing. During an interview on 4/1/24 at 12:15 PM with the Director of Nursing (DON) confirmed the facility did not have a policy for securing all residents in the bathing chairs during bathing and had no evaluation process in place to evaluate the safety of individual residents while bathing. Further interview confirmed the DON did not question the staff responsible for bathing Resident 1 regarding utilization of the safety belt in the bathing chair, when investigating following Resident 1's fall.

Licensure Reference Number 175 NAC 12-006.09C Based on observation, record review, and interview the facility failed to develop comprehensive Care Plans to accurately reflect the current status for 4 of 12 sampled residents (Resident 2's infection, and use of antianxiety medications, Resident 32's skin integrity, Resident 37's edema (fluid retention of tissue), and Resident 36's Hospice (end-of life) care). The facility census was 41. Findings are: A. Review of the facility policy Care Plan-Comprehensive dated 8/15/23 revealed the following; -The facility developed a comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs. -the interdisciplinary team in coordination with the resident, his/her family or representative, developed and maintained a comprehensive care plan for each resident, -the care plan was designed to identify problem areas, initiate goals, incorporate risk factors, build on resident strengths, reflect measurable outcomes, identify services responsible for each element of care, prevent decline in resident functional statuses, and enhance optimal functioning of the residents. -care plans were revised as changes dictated, and -the care plans were intended to promote continuity of care, communication among staff, increased resident safety, and safeguard against adverse events. B. Review of Resident 2's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 8/26/23 revealed the resident had dementia and was severely impaired cognitively, required extensive assistance with bed mobility, transfers, dressing, and toileting, was occasional incontinent of bowel and bladder, had no special treatments or procedures, and took antidepressant medication. Review of Resident 2's Progress Notes revealed the following; -On 8/31/23 at 10:02 AM the Attending physician was updated on cyst like area on right arm pit and treatment was started with betadine (anti-infective solution) twice daily and warm moist packs to the area 3 times daily. -On 9/1/23 at 4:00 PM the right arm pit cyst like area was red, and firm. The area had no drainage and Betadine was applied and the area was covered with Mepilex (foam dressing) for protection. -On 9/3/23 at 10:04 AM the small firm raised area to right axilla remained, there was no increased warmth, redness, or drainage noted. Betadine was applied. -On 9/20/23 at 10:37 AM a second raised firm area of skin with pinpoint red area was noted in the right armpit and the physician was notified. -On 9/22/23 at 12:18 PM the cyst like area to right armpit firm area remained. There was no drainage or redness. The area was thought to be chronic and the Betadine and warm packs were discontinued. -On 10/13/23 at 2:29 PM the cyst like area to right armpit was open, had moderate purulent (pus) drainage. The area was cleaned, betadine was applied, and the area was covered with a bandaid, and would be monitored daily. -On 10/16/23 at 10:21 AM a wound culture (collection of drainage for the area to determine the type of bacteria present) was obtained from right armpit area. -On 10/18/23 at 5:10 PM the staff were updated that the arm-pit wound was positive for Methicillin Resistant Staphlococcus Aureus (MRSA-bacteria that is resistant to many antibiotics), and the staff placed the resident in Contact Precautions (precautions intended to prevent the transmission of infectious agents) for dressing changes. Review of Resident 2's undated Physician's Orders revealed the resident was on the following medications with the following start dates, and -9/5/23 Lorazepam (anti-anxiety medication) daily as needed, -9/7/23 Buspirone HCL (anti-anxiety medication) twice daily, and -10/16/23 Doxycycline Hyclate (antibiotic typically susceptible to MRSA infections), twice daily, and -additional review revealed diagnoses for MRSA, and an anxiety disorder. During an observation of care for Resident 2 on 11/1/23 at 7:27 AM Nurse Aid (NA)-M entered the resident's room, washed hands, put on gloves and a gown, and helped the resident get up for breakfast. During the provision of care the resident was noted to have an adhesive foam dressing intact to the right armpit. NA-M placed soiled linen in a linen basket in the room and trash in red trash bag lined bin in room. NA-A then removed the gown and gloves and placed in red bag, hand sanitized and assisted resident to the dining area. During an observation of care for Resident 2 on 11/1/23 at 11:30 AM the resident was in the bath house. RN-P entered the bath house to perform a dressing change to the right armpit. RN-P washed hands and put on gloves and a gown, removed a dressing which was clean and dry from the right armpit, and a small slightly pink area was visible in right armpit. There was no open area and no drainage. RN-P disposed of the dressing, removed gloves, hand sanitized, measured the area (1cm), and applied a clean foam dressing. RN-P then removed the gown and gloves and hand sanitized. Review of Resident 2's Care Plan with a revision date of 10/25/23 revealed the following; -the resident needed assistance with ADL's, physical debility, dementia, cognitive loss, difficulty with self-expression, potential for fluid volume deficit, was a fall risk, was positive for MRSA, and had a wound to the right armpit. The resident was on Universal Precautions (precautions taken on all residents to prevent the spread of infection). The resident had diagnosed hallucinations, depression, anxiety, potential for impaired skin integrity, used antidepressant medication, mixed incontinence, and altered vision. There was no evidence the resident was on Contact Precautions. Further review revealed no evidence the resident had additional precautions in place to prevent the spread of MRSA and no evidence the resident was taking antianxiety medication. An interview on 10/31/23 at 2:25 PM with Registered Nurse (RN)-P revealed Resident 2 did have a MRSA positive abscess (collection of pus) on the right armpit that was currently not open or draining. Staff were to put on gloves and a gown during cares involving dressing and undressing, for potential contact with a wound dressing and during treatments of the abscess. An interview on 11/01/23 at 11:12 PM the Director of Nursing (DON) confirmed that Resident 2's Care Plan did not address the additional Contact Precautions in place for treatment of the resident's active MRSA infection. During an interview on 11/02/23 at 9:54 AM the DON confirmed resident 2's Care Plan failed to address the use of antianxiety medications. C. Review of Resident 32's MDS dated [DATE] revealed the resident received extensive assistance with bed mobility, dressing and toileting and was dependent for transfers, the resident had diagnosis of spinal cord dysfunction, was paraplegic, had a bladder catheter (used to empty urine from the bladder), and had no skin breakdown. Review of Resident 32's Care Plan with a revision date of 9/22/23 revealed the resident had a potential for infections due to a history of wound infections and was at high risk for impaired skin integrity. There was no evidence the resident had or was receiving treatment to the skin integrity loss to the buttocks or surrounding skin. Review of Resident 32's Progress Notes revealed the following; -On 10/5/23 at 5:20 PM the residents left buttock area skin was sloughing (shedding a dead layer of skin), and the surrounding skin has some pinkness. -On 10/5/23 at 5:21 PM the right buttock top layer of skin was shearing off, and visible pink tissue was noted underneath. -On 10/5/23 at 5:47 PM the right buttock abrasion was cleaned with with Puracyn (wound cleaner), allowed to dry, allowed to sit for 2-3 minutes, rinsed again and a foam dressing was applied to wound bed -On 10/5/23 at 5:48 PM the left buttock abrasion was cleaned with Puracyn, allowed to sit for 2-3 minutes, rinsed again with Puracyn and Skin Prep (substance that protect the skin from incontinence, wound drainage, and/or friction) was applied. -On 10/6/23 at 1:26 PM the right buttocks wound bed was pink, had no drainage, warmth, or redness and the left buttock skin had shearing, a pink wound bed of the surrounding tissue, and had no drainage, warmth, or redness. -On 10/7/23 at 4:12 PM a foam dressing was intact to both sides of the resident's buttock abrasion, and was clean, dry and intact. During an observation of care for Resident 32 on 10/31/23 at 10:57 AM Medication Aid (MA)-K and Nurse Aide (NA)-G entered the Resident's 32's room, hand sanitized, put on gloves and transferred the resident using a full body mechanical lift from the wheelchair to the bed. MA-K removed a soiled brief then positioned the resident on the left side. The resident had scaly discolored skin above and around buttock. NA-G cleaned the resident's skin, removed the soiled gloves and hand sanitized. During an interview on 11/01/23 at 11:12 PM the DON confirmed that Resident 32's had skin integrity concerns to the buttocks, however the Care Plan did not address the resident's skin integrity concerns specific to current problems and did not accurately reflect the resident's current treatment needed. D. Review of Resident 37's Care Plan with a revision date of 7/10/23 revealed the resident had a potential for fluid volume deficit or dehydration but no evidence the resident had edema or wore edema wear. Review of Resident 37's Progress Notes revealed the following; -On 9/16/23 at 10:22 AM the resident had edema of both lower legs. -On 9/17/23 at 7:54 PM the resident had edema of the lower legs, feet, and ankles. -On 9/18/23 at 8:14 PM the resident had edema wear on both legs. -On 9/26/23 at 4:28 PM the resident had left and right ankle and foot edema. -On 10/6/23 at 9:19 PM the resident had edema of the lower legs and feet. -During an observation on 10/30/23 at 10:28 AM Resident 37 was sitting in a in recliner with feet elevated, the call light was in reach, and the resident was wearing orthopedic sandals and edema wear. -During an observation on 10/31/23 at 7:56 AM Resident 37 was sitting in a wheelchair in the dining room wearing orthopedic sandals and edema wears. -During an observation on 10/31/23 at 11:08 AM Resident 37 was sitting in a recliner wearing orthopedic sandals and edema wear. -During an observation on 10/31/23 at 1:55 PM NA's G and H assisted the Resident 37 to the bathroom. The resident was wearing orthopedic sandals and edema wear. During an interview on 10/31/23 at 02:14 PM NA-G revealed the Resident 37 had edema of both lower legs all the time, wore edema wear (leg covering used to treat edema) and special sandals the resident's family provided. During an interview on 11/01/23 at 1:04 PM the DON confirmed Resident 37's Care Plan did not address the resident's edema or treatment plan associated with the edema such as the use of edema wear. E. Review of the facility policy Hospice Program dated March 2001 revealed the following; -The facility contracted for Hospice (Medicare service provided to person's with end-of-life diagnoses) for residents who wished to participate in such programs. -The hospice agreements were to ensure hospice services were available for those who wished to participate, -Residents who participated in the hospice program would have a coordinated plan of care between the facility, hospice agency and the resident and included directives for pain management and other symptoms, -The hospice agency retained overall professional management responsibility for directing and implementing the care plan related to the terminal illness and related conditions. F. Review of Resident 36's MDS dated [DATE] revealed the resident had diagnoses of pneumonia, cholangitis (inflammation of the gall bladder,) and dementia. In addition, the resident was receiving Hospice care. Review of Resident 36's Care Plan dated 9/11/23 revealed the resident was terminally ill with end-stage dementia and was receiving Hospice care, however there was no evidence of the services Hospice was providing related to the end-of-life diagnosis. Review of Resident 36''s Progress Notes revealed the following; -On 9/4/23 at 1:47 PM the resident had fever and chills and was taken to the ER (emergency room ) for evaluation and at 6:27 PM the facility was notified that the resident was admitted to the hospital for pneumonia. -On 9/8/23 at 4:13 PM the resident was readmitted to the facility from the hospital. During an interview on 11/1/23 at 8:56 AM the DON confirmed Resident 36 was hospitalized following an acute illness with fever and was readmitted to the facility on Hospice services. During an interview on 11/01/23 at 1:04 PM the DON confirmed the Resident 36's Care Plan did not address or define Facility and Hospice roles in the care of the resident.

Based on record review and interview; the facility failed to ensure to accurately code Resident 23's Preadmission Assessment and Annual Resident Review (PASARR) status on the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) and Care Plan the results. The total sample size was 12 and the facility census was 41. Findings are: Review of the facility policy PASARR, last revised 2/12/22 revealed the following: -PASARR was a federal requirement to ensure individuals were not inappropriately placed in nursing homes, and -when a level II PASARR was found, the facility would update the individuals Care Plan. Review of Resident 23's annual MDS dated [DATE] and a quarterly MDS dated [DATE] revealed the following: -in section A, the resident not marked to have been evaluated by Level II PASARR, -the resident was not marked to have a serious mental illness, -diagnoses of anxiety, depression, and schizophrenia, and -the resident took antipsychotic medication (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood, and emotions) on a routine basis. Review of Resident 23's PASSAR screen completed on 2/14/23 revealed the following: -a level II PASSAR evaluation was completed on 2/14/23, -the resident was found to have a serious mental illness, -the resident was appropriate for nursing facility services, and -specialized services were not required. Review of Resident 23's Care Plan revealed no documentation that the resident had a level II PASARR determination. Interview on 11/1/23 at 1:53 PM with the Director of Nursing (DON) and the MDS Coordinator confirmed the resident did have a level II PASSAR evaluation completed. Further interview with the DON confirmed that the PASSAR was not correctly coded on the annual MDS, and the level II determination had not been included in the residents Care Plan.

Licensure Reference Number NAC 12-006.02(8) Based on record review and interview, the facility failed to thoroughly investigate Resident 192's potential misappropriation related to missing money in order to prevent further incidents. The total sample size was 17 and the facility census was 41. Findings are: Review of the undated facility policy titled Abuse, Neglect, and Misappropriation of Property revealed the following; -the purpose of the policy supported a 'zero tolerance' related to resident abuse, neglect and/or misappropriation of property; and -misappropriation was defined as; the deliberate misplacement, exploitation, or use of a resident's belongings or money without the resident's consent. Record review of a facility investigation report revealed on 2/5/23, Resident 192 reported missing bingo money from the resident's dresser drawer. There had been a search of the resident's room for the money, but staff were unable to locate it. The activity staff member and resident's family member confirmed the resident had $5.10 from bingo winnings in [gender] possession. The facility reported the incident to Adult Protective Services and indicated the incident would be investigated, staff would be educated and the money would be reimbursed to the resident. There was no evidence staff members working prior to and on the day of the incident were interviewed about the missing money. In addition, there was no evidence other residents had been interviewed regarding misappropriation of personal belongings/money. An interview with the Administrator on 11/2/23 at 9:05 AM, confirmed facility had not interviewed other staff members or residents related to the missing money during the investigation of the incident on 2/5/23 and staff should have conducted more interviews related to potential misappropriation to prevent further incidents.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09A Based on record review and interview, the facility failed to ensure a new PASARR (Pre-Admission Screening and Resident Review - used to determine if people with serious mental illnesses that require nursing facility services are placed in the appropriate setting) assessment had been completed after a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 43. Findings are: Review of Resident 37's PASARR dated 10/11/2018 revealed there was no indication Resident 21 had a serious mental illness. The PASARR also indicated if changes occurred a new screen must be submitted. Review of Resident 37's Admission MDS (Minimum Data Set - a comprehensive assessment tool used to develop a resident's plan of care) dated 12/15/2018 revealed the resident was admitted to the facility on [DATE]. The resident had the following diagnoses; Anxiety Disorder, Depression, [CONDITION(S)] and [CONDITION(S)] (a serious mental illness). Review of Resident 37's medical record revealed the resident was seen by a mental health physician on 12/17/18 and the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the physician added an antipsychotic medication ([MEDICATION(S)] 100 milligrams (mg) twice a day. During an interview with the Director of Nurses (DON) on 9/14/22 at 3:10 PM, the DON confirmed Resident 37 had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) related to Resident 15's bladder elimination, reflected the resident's status at the time of the MDS assessment. The sample size was 18. The facility census was 43. Findings are: A. Review of the updated facility matrix dated 9/12/22, indicated Resident 15 had an indwelling urinary catheter (flexible tubing that is inserted into a person's bladder used to continuously drain urine into a collection container). B. Review of Resident 15's MDS dated [DATE], revealed section H (assessment pertaining to a resident's bowel and bladder elimination status) identified the resident had an indwelling urinary catheter and was incontinent of urine. Review of Resident 15's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . C. An interview on 9/15/22 at 9:05 AM with the Director of Nurses, confirmed Resident 15 did not have an indwelling urinary catheter currently and had not had one since January 2022. An interview with the MDS coordinator on 9/15/22 at 9:10 AM, confirmed Resident 15's most recent MDS assessment dated [DATE] was not an accurate reflection of the resident's urinary status at the time of the assessment and should have been updated after the indwelling catheter was discontinued in January 2022.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on observations, record review and interview; the facility failed to implement interventions and to revise and/or develop new interventions to prevent ongoing falls for Resident 30 and failed to ensure staff were trained and implemented fall prevention interventions for Resident 33. The sample size was 7 and the census was 38. Findings are: A. Review of the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/1/21 revealed the following related to Resident 30: -moderately impaired cognition; -required extensive staff assistance with ambulation, transfers, dressing, toileting and personal hygiene; -occasionally incontinent of urine; and -had 2 or more falls with no injury since the previous assessment. Review of an Incident Report dated 11/22/20 revealed at 2:00 PM the resident was found on the floor of the resident's bathroom. The resident indicated ambulating independently to the bathroom and stated the Physical Therapist (PT) was allowing the resident to be independent with toileting. A new intervention was put into place for the resident to call staff for assistance to the bathroom until the staff was able to clarify ambulation status with PT. An undated note at the bottom of this report indicated therapy had not cleared the resident to be independent with toileting and ambulation. Further review of the resident's medical record revealed no evidence an intervention was developed to prevent further falls. Review of an Incident Report dated 12/13/20 at 3:15 PM revealed the resident was observed on the floor of the resident's room. The resident had been seated in a recliner and slid out while attempting to reach for the walker. A Dycem (non-slip material) pad was placed underneath the cushion in the seat of the recliner. Review of a Fall Investigation form dated 12/26/20 revealed the resident had a fall in the resident's room at 10:30 AM. The resident had been looking out the window, started walking backwards away from the window, tripped over feet and fell . The resident was provided education to always walk forward and to call for staff assistance as needed. Review of an Incident Report dated 2/3/21 revealed at 3:50 PM staff heard a loud noise from the resident's room. The resident was found seated on buttocks on the floor in front of the resident's recliner. The resident identified PT had tested the resident the previous day and the resident could ambulate independently in room and did not have to use the walker. PT went over safety precautions with the resident and verified independence, but only when using the walker. Review of an Incident Report dated 2/8/21 revealed at 4:20 PM, the resident was found on the floor in front of the resident's closet. The resident identified removing clothing from the closet, losing balance and then falling. An intervention was developed for the staff to assist the resident every afternoon with removing clothing from the closet for the next day. Review of an Incident Report dated 4/17/21 revealed at 9:20 AM the resident was observed on the floor of the resident's room. The resident had slid to the floor while self-transferring from the recliner to the wheelchair. A new intervention was identified for staff to assist the resident with ambulation to and from the bathroom. Review of a Fall Investigation form dated 4/19/21 at 1:00 PM revealed the resident had a fall when attempting to transfer from the wheelchair to the recliner. The resident had failed to lock the brakes of the wheelchair before attempting to transfer. Staff were to assure the resident's walker was in reach and the resident was encouraged to use the wheelchair for longer distances only. Review of a Fall Investigation form dated 4/19/21 at 7:40 PM revealed the resident had leaned forward and slid out of the chair. The causal factor was determined to be the resident's positioning in chair. An intervention was developed for staff to dipstick (test used to identify potential infection) the resident's urine. Review of a Fall Investigation form dated 4/22/21 revealed at 6:45 PM the resident was found on the floor. The form listed the resident was having a behavior as a causal factor and staff were awaiting urine culture results as a new intervention to prevent ongoing falls. Review of a Fall Investigation form dated 4/27/21 at 6:35 PM revealed the resident slid to the floor in front of the recliner. The resident's walker was across the room and out of reach for the resident. Behaviors were again listed as a causal factor with an intervention for staff to visit with family about moving the resident to a room closer to the Nurse's Station for more supervision. Review of Resident 30's current Care Plan with revision date 5/5/21 revealed the resident was at risk for falls related to a history of falls with fractures to the right humorous (long bone of the upper arm), the right radius (long bone in the forearm), the right elbow and the right hip. The care plan identified the resident had falls on 11/22/20, 12/13/20, 12/26/20, 2/3/21, 2/8/21, 4/17/21, x2 falls on 4/19/21, 4/22/21 and 4/27/21. Nursing interventions included the following: -Dycem pad placed between the cushion and the seat of the recliner; -keep items in the same place and call light within reach; -encourage resident to call for assistance as needed with transfers, ambulation and toileting and to use gait belt (a belt placed around a resident's waist to provide a secure and safe hand hold for caregiver) when transferring or ambulating a resident); and -use of walker in room and staff to follow with the wheelchair when ambulating longer distances. During an observation on 6/2/21 at 8:11 AM, Nursing Assistant (NA)-H ambulated Resident 30 from the resident's room out to the dining room. Resident 30 was not wearing a gait belt. During observations from 6/2/21 at 8:15 AM to 6/3/21 at 8:19 AM there was no Dycem pad positioned between the cushion and the seat of the recliner in the resident's room. During interview on 6/3/21 at 8:14 AM the Director of Nursing (DON) revealed the following: -Resident 30 was at high risk for falls with a history of multiple fractures related to falls; -verified staff were to complete an investigation after each fall to determine causal factors; -the staff were to then revise current fall prevention interventions or develop new interventions based on causal factors to try and prevent further falls; -PT verified the resident had not been cleared to ambulate independently after the resident's fall on 11/22/20. No further interventions were developed to prevent further falls; and -after the resident's falls on 4/19/21 at 7:40 PM and on 4/22/21 at 6:45 PM, no new interventions were implemented or current interventions revised to prevent ongoing falls. B. Review of Resident 33's Care Plan revealed: - On 1/27/21 the resident was lowered to the floor while ambulating with a staff member. A new intervention was initiated for the resident to ambulate with the assistance of 2 staff members. - On 4/18/21 the resident was lowered to the floor while transferring with 1 staff member. A new intervention was initiated for the resident to transfer with the assistance of 2 staff members. On 6/3/21 at 6:55 AM Nursing Assistant (NA)-H and NA-J transferred Resident 33 from the bed to the wheelchair. NA-H then wheeled the resident towards the bathroom. NA-J asked NA-H if NA-H needed help transferring Resident 33 in the bathroom or if NA-H could do it independently, since there was a grab bar in the bathroom. NA-H stated yes, but NA-J then did stay and help transfer Resident 33 in the bathroom. Interview with NA-H on 6/3/21 at 9:15 AM confirmed NA-H thought Resident 33 could be transferred with 1 or 2 staff assist. NA-H stated if the staff were not comfortable then they would use 2 staff to transfer the resident because they did not want the resident to fall. During an interview with Registered Nurse (RN)-B on 6/3/21 at 9:40 AM, RN-B stated Resident 33's assistance needs varied by the day. RN-B stated if the resident was more tired then they would use 2 staff to assist the resident on those days. Interview with the DON on 6/3/21 at 10:10 AM confirmed Resident 33 needed to be transferred with 2 staff and a gait belt at all times.

Licensure Reference Number 175 NAC 12-006.09D Based on observation, interview, and record review; the facility failed to ensure Resident 26's pain was managed on an ongoing basis. The sample size was 1 and the facility census was 38. Findings are: Review of the undated facility policy titled Pain Medication revealed the purpose of the procedure was to establish a protocol for pain management. The guidelines included: - Residents would be evaluated on a routine basis to check for pain levels using a numbered pain scale. - If a resident stated they had on a continuing basis severe pain, notification would be given to all nursing staff that the resident needed to be offered PRN (as needed) medications at each medication pass. - The resident's responsible party and primary care physician would be notified. - Pain would continue to be documented on the Medication Administration Record (MAR) and under pain in Systems/Symptoms. - If a resident stated that they continued to have severe pain, physical and occupational therapies would be notified to do a screen. Review of Resident 26's Care Plan revealed the resident had chronic pain. The resident had pain to the left great toe and back pain. Interventions included: -Allow sufficient time to respond. -Administer pain medications and note effectiveness/adverse effects. -Notify physician of changes. -Monitor restlessness and apply Sore No More cream to back and knees as indicated. -Assist with positioning for comfort, report pain indicators, and provide a quiet environment. Review of Resident 26's Progress Notes revealed: - On 3/22/21 it was noted that the resident was restless and irritable. - On 3/29/21 it was noted that the resident had chronic complaints of back pain. Sore No More cream was applied. - On 4/6/21 the resident had increased confusion. The resident was tearful with complaints of back pain. Pain cream was applied. - On 4/10/21 the resident refused catheter cares. - On 4/15/21 the resident was tearful and upset. The resident stated I have pain it is so bad I am going to die. I am hurting so bad that I am going to cry and yell out. PRN Tylenol given. - On 4/22/21 the resident was tearful about pain. - On 4/30/21 the resident complained of moderate lower back pain. Sore No More cream applied and resident repositioned. - On 5/5/21 the resident attempted to hit the nurse during catheter cares. - On 5/22/21 the resident was irritable with cares. Review of Resident 26's MAR and Treatment Administration Records (TAR) dated 5/2021 revealed the following orders: - Tylenol 650 milligrams (mg) daily for pain. - Tylenol 650mg 2 times daily PRN. - Apply Sore No More cream to lower back and knees 2 times daily. On 6/3/21 from 7:10 AM to 7:20 AM Resident 26's catheters cares were observed. Licensed Practical Nurse (LPN)-I entered the room. Resident 26 complained of continued pain. LPN-I asked if the resident's scheduled Tylenol that was given helped and the resident replied no. The resident continued to repeat complaints of pain. LPN-I indicated the nurse would get the resident something else for pain. Interview with Nursing Assistant (NA)-H on 6/3/21 at 9:15 AM confirmed Resident 26 often had complaints of pain. NA-H stated the resident frequently had complaints of back pain and toe pain. NA-H stated the pain was worse during transfers and better when the resting is in bed. NA-H felt the resident's poor circulation and cold feet was the cause of the frequent foot/toe pain. Interview with the Director of Nursing (DON) on 6/3/21 at 10:10 AM revealed the facility did not complete routine pain monitoring for Resident 26 and did not assess the resident's pain level on the pain scale (as indicated in the facility policy). The DON stated the facility did not follow up on the resident's pain level after giving Resident 26's routine morning Tylenol, even if the resident reported pain when it was given. Interview with LPN-I on 6/3/21 at 12:40 PM confirmed Resident 26 had scheduled Tylenol once a day, PRN Tylenol that could be given twice a day, and Sore No More cream. LPN-I confirmed the resident didn't have any additional pain medication options that could be given if the Tylenol and Sore No More were ineffective.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12 Based on observation, record review and interview; the facility failed to assure outdated medications were not available for use for Residents 33 and 137. The total sample size was 16 and the census was 38. Findings are: A. Review of a policy labeled Storage of Medications (undated) revealed no discontinued, outdated or deteriorated drugs were to be retained for use. All such medications were to be returned to the issuing pharmacy or destroyed in accordance with established procedures governing the destruction of medications. B. Review of the facility reference for use and storage of Insulin (medication used to treat diabetes mellitus) Vials and Insulin Pens (disposable pen-like device to which a disposable needle is attached used for injecting a desired dose of insulin) medications included the following regarding maximum storage conditions: -[MEDICATION(S)] 70/30 was to be discarded 28 days after the vial was opened; and -Novolog insulin pen was to be discarded 28 days after opened. C. During observation of Medication Administration for Resident 33 on 6/2/21 at 7:41 AM, Registered Nurse (RN)-A used an insulin syringe to draw up 6 units of [MEDICATION(S)] 70/30 Insulin 100 units/ (per) ml (milliliter) from the bottle. The bottle of [MEDICATION(S)] Insulin was labeled as opened on 4/20/21. During an interview on 6/2/21 at 7:45 AM, RN-A confirmed the vial of [MEDICATION(S)] Insulin was past the expiration date and verified open vials of insulin were to be disposed of after 28 days. D. During an observation of Medication Storage on 6/2/21 at 7:55 AM an opened pre-filled pen of Novolog Insulin for Resident 137 was not labeled with a date as to when the pen was opened. During an interview on 6/2/21 at 8:00 AM, RN-A confirmed the pre-filled Novolog Insulin pen had been opened and was not labeled with an opened date.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interview; the facility failed to prevent and contain the spread of COVID-19 as the facility failed to: 1) ensure that standards of practice for personal protective equipment (PPE) and isolation procedures for Transmission Based Precautions (TBP) were in place and were being followed; and 2) residents were protected from staff members displaying symptoms of COVID-19. This had the potential to affect all facility residents. The total sample size was 17 and the facility census was 37. Findings are: A. Review of The Center for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality and Oversight Group dated 3/13/20 revealed the following guidance for infection control and prevention of COVID-19: 1). Facilities should regularly monitor the Center for Disease Control (CDC) website for information and resources. 2). Prompt detection, triage, and isolation of potentially infectious residents are essential to prevent unnecessary exposures among residents and healthcare personnel. B. Review of Infection Control Assessment and Promotion Program (ICAP) zone recommendations revealed: - The Red Zone was for residents that were either positive or presumptive positive for COVID-19. PPE requirements included gown, gloves, eye protection, and N95 mask (N95 preferred, if no N95, then a surgical mask with a face shield); and - The Yellow Zone was for residents that were asymptomatic but had been exposed to COVID-19. PPE requirements included gown, gloves, eye protection, and N95 mask (N95 preferred, if no N95, then a surgical mask with a face shield). C. Review of the CMS (Centers for Medicaid and Medicare Services) Clinical Standards and Quality, Safety and Oversight Group dated 3/23/20 revealed additional guidance. Where the patient/resident was sleeping at the health care facility, signage on the patient's room was important to ensuring that all staff were aware of the necessary infection control steps. D. Review of the undated facility policy Isolation Precautions revealed; 1). Droplet Precautions must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the resident coughing, sneezing, talking, or by performance of a procedure. 2). Place the Resident in a private room, or if a private room is not available with a resident with the same infection. 3). Remove PPE (gloves/gowns) prior to leaving the resident environment. E. Review of the Resident Census on 12/2/20 at 9:15 AM revealed a facility census of 37 with 13 residents being identified as COVID-19 negative and 24 residents being identified as COVID-19 positive. F. Observations on 12/2/20 between 9:45 AM and 10:30 AM revealed: -Resident rooms [ROOM NUMBERS] had both a COVID-19 negative and a COVID-19 positive resident residing in the same room. -No signage was present on the doors of resident rooms 101, 102, 104, 106, 107, 109, 110, 112 and 210 to inform staff of the resident's current COVID-19 status. -Multiple rooms (COVID-19 negative and COVID-19 positive) doors were wide open throughout all resident care halls. -Resident 13 (COVID-19 negative) was observed in the commons area by the nurse's station sitting in a chair with a cloth face mask on. No staff cued or encouraged the resident to return to the resident's room. -9:47 AM Nurse Aide (NA)-B entered room [ROOM NUMBER] (COVID-19 positive) wearing a mask, face shield (no gloves and no gown) and delivered water to the resident's bedside table. NA-B was within 1 foot of the resident. -9:50 AM Licensed Practical Nurse (LPN)-A was passing medications to residents in room [ROOM NUMBER] (COVID-19 positive) wearing a mask, face shield and gloves. LPN-A was not wearing an isolation gown. -9:52 AM NA-C entered room [ROOM NUMBER] (COVID-19 positive) to remove a food tray. NA-C wore a mask, face shield, and gloves. NA-C failed to place an isolation gown on before entering the resident room. -10:05 AM LPN-F exited room [ROOM NUMBER] (COVID-19 positive) carrying a blood pressure wrist cuff. LPN-F had not been wearing an isolation gown. -10:10 AM Resident 12 was assisted to ambulate in the hallway and commons area with staff. Staff wore a mask, face shield, gown and gloves. Resident 12 was COVID negative and walked by numerous resident rooms with doors open that were identified as COVID-19 positive. -10:15 AM Medication Aide (MA)-E assisted a resident through the hall to their room after bathing. MA-E left the resident room in a mask, face shield, gown and gloves. MA-E proceeded approximately 15 feet down the hall before removing the gown and gloves, placing in a trash receptacle and then sanitized hands. -10:20 AM Resident 14 was assisted to ambulate in the hallway and commons area with staff. The staff member wore a mask, face shield, gown and gloves. Resident 14 was COVID negative and walked by numerous resident rooms with doors open that were identified as COVID positive. G. Review of the updated Resident Census on 12/2/20 at 6:30 PM revealed a facility census of 37 with 5 residents being identified as COVID-19 negative and 32 residents being identified as COVID-19 positive. H. Interviews on 12/2/20 between 9:45 AM and 10:30 AM revealed: -9:47 AM LPN-A indicated isolation gowns were rarely used for medication administration with the exception of procedures such as wound care and nebulizer treatments. Further interview with LPN-A revealed gloves were to be worn into all rooms and removed with hand hygiene completed after each resident and/or task, and N95 masks and face shields were to be worn into all rooms with the face shields cleaned if soiled. N95 masks and face shields were not to be changed between rooms unless soiled. -9:55 AM NA-C and NA-D revealed that training for infection control and contact precautions had been provided and staff had been instructed to utilize gowns in rooms throughout the facility only when direct resident contact was anticipated and gowns were not used for answering of call lights, meal delivery and meal pick up. -10:05 AM LPN-F identified gowns were not being used routinely for minimal contact interactions with residents, but masks, face shields, and gloves were being worn. -11:30 AM the Director of Nursing (DON) confirmed: 1) Residents who were COVID-19 negative remained roommates with residents who were COVID-19 positive and were not offered a room change or educated of the risks of contracting COVID-19, 2). resident room doors were not being kept closed to help prevent the transmission of COVID-19, 3). gowns were not being worn in resident rooms at all times, and 4). staff were to remove gowns and gloves in the resident rooms prior to leaving the room. I. Review of the undated facility Screening policy revealed every employee needed another staff member to perform the temperature and symptom check. The employee doing the screening must initial to indicate who the screener was. If there were any abnormal findings the employee would notify the nurse to come assess. The nurse would determine if the employee needed to be sent home or note if the abnormal finding was due to a chronic condition. Review of the Staff Screening Logs and facility COVID-19 Positive Staff list dated 10/1/20 to 12/2/20 revealed no evidence the following staff members had a chronic condition to explain the signs/symptoms and there was no evidence to indicate the staff members were prohibited from working on the following occasions: - On 10/11/20 Staff Member (SM)-H reported cough/congestion/sore throat. - On 10/14/20 SM-I reported yes and no to GI symptoms. - On 10/16/20 SM-F reported a headache. - On 10/17/20 SM-J reported cough/congestion/sore throat. SM-J tested positive for COVID-19 on 10/20/20. - On 11/9/20 SM-K reported a headache. - On 11/13/20 SM-L reported cough/congestion/sore throat and headache/muscle aches. - On 11/15/20 SM-M reported cough/congestion/sore throat and loss of taste/smell. SM-M tested positive for COVID-19 on 11/17/20. - On 11/23/20 and 11/24/20 SM-N reported cough/congestion/sore throat. SM-N tested negative using Point of Care testing on 11/23/20 and 11/25/20. There was no evidence SM-N received a confirmatory PCR test. - On 11/28/20 SM-O reported headache/muscle aches and GI symptoms. - On 11/30/20 SM-P reported cough/congestion/sore throat. SM-P tested positive for COVID-19 on 12/1/20. Interview with the Administrator on 12/2/20 at 8:45 AM revealed all staff were screened at the back entrance by another employee, if the staff member had anything that was a concern then this should be reviewed by the DON or Assistant DON. Interview with the DON on 12/2/20 at 11:45 AM and 12/3/20 at 3:30 PM confirmed SM-N was currently home ill with presumed COVID-19. The DON confirmed that although SM-N had signs/symptoms of COVID-19 a confirmatory PCR test was not completed for SM-N after the point of care (POC) test was negative. As a result of the identified non-compliance the facility administrator was notified on 12/2/20 at 11:58 AM of the Immediate Jeopardy situation. Abatement: The facility submitted an abatement plan that included the following: -All staff were educated on the priority to work with negative residents and the appropriate PPE to use when working with negative residents. -All staff were educated on the appropriate disposal of PPE before leaving a positive resident's room. -Residents that were positive were moved into 2 different red zone hallways (200 and 300 halls) away from negative residents. The doors to rooms and these hallways will be kept shut. -ICAP recommendations and floor plan were again reviewed with ICAP to ensure appropriate separation of positive and negative residents. -All negative residents retested to ensure they were still negative. -Facility will continue with their outbreak testing of staff and residents. The facility's abatement plan was acceptable and the immediacy was removed on 12/2/20 at 1:45 PM. The scope and severity was lowered to an F.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview, and record review; the facility failed to develop, implement, and/or revise interventions to prevent elopement for Resident 1. The sample size was 3 and the facility census was 42. Findings are: A. Review of the facility Elopement policy (undated) revealed precautionary measures to be taken. This included assuring all door alarms were activated and working. B. Review of Resident 1's Elopement Risk assessment dated [DATE] revealed the resident was at HIGH risk for elopement. Review of Resident 1's current Care Plan updated 8/6/20 revealed the resident was at risk for elopement related to confusion and exit seeking. Interventions included checking the wander guard bracelet, offering food and activities, and a supervised area. Further review revealed the resident had eloped on 6/17/20 and 7/26/20. Review of Resident 1's Progress Note dated 6/17/20 revealed the resident eloped out of the facility main entrance door after supper. A new intervention was to be implemented to walk the resident back after meals. Review of Resident 1's Medical Record revealed no documentation that the resident was being walked back after meals. Review of Resident 1's Progress Note dated 6/27/20 revealed after supper Resident 1 was headed down to the Assisted Living and an Assisted Living staff member redirected the resident back to the nursing home side (no evidence to indicate the resident had been walked back from the dining room after supper). Review of an Elopement Incident report revealed Resident 1 eloped on 7/26/20. The resident was discovered to not be in the facility. Upon searching the resident was found outside headed towards the assisted living front doors. The alarm did not activate on the facility front doors as the switched was found to be turned off. The switch was then turned back on. Observation of the facility front doors on 8/11/20 at 10:00 AM revealed a wander guard box was present on the inside set of door (identified by the Director of Nursing as not working) and the outside set of front main doors set off an alarm when opened that alarmed in the main facility area across from the nurses station on a panel. The panel identified which door was alarming and had a plastic box over it so that the alarm could be reset but not turned off. The second panel of door alarm switches did not have a plastic cover over it to ensure that the alarms were not turned off and included door alarms that were on the nursing home side of the facility, this included an exit to the courtyard and a therapy entrance. Review of the facility Wanderguard System Weekly Checklist form dated 1/2020 through 8/2020 revealed the wander guard system to the front entrance was not identified. Further review revealed no evidence to indicate the door alarm system (that alarms anytime someone enters or exits) had been checked on a routine basis to ensure proper functioning. Interviews with the DON on 8/11/20 from 10:00 AM to 11:30 AM confirmed the facility front door wander guard system had quit working. The DON stated now the facility front doors were set to alarm anytime someone went in or out of them and the staff were to determine the source before turning the alarm off. The DON stated that this process change had taken place on 7/15/20. The DON was unable to provide any documentation of training with the staff on the new process to ensure it was being done correctly. The DON confirmed 2 of the doors on the nursing home side (therapy and court yard) were on a separate alarm panel that did not have a plastic box to ensure the alarms were unable to be turned off by staff. Further interview revealed there was no wander guard system to keep nursing home residents from getting into the Assisted Living. The DON confirmed there was no documentation to show Resident 1 had been walked back from meals. The DON felt Resident 1's elopement on 7/26/20 happened because the staff had turned the door alarm system off for the facility main entrance (they were possibly trying to turn the alarm off for the Assisted Living but had flipped the wrong switch) and therefore it didn't alarm when Resident 1 eloped. The DON stated the facility started hourly checks on Resident 1 as a result of the resident's elopement on 7/26/20 but confirmed the facility didn't start those checks until 8/6/20 (11 days later). Interview with the Administrator on 8/11/20 at 11:20 AM confirmed the wander guard system to the facility front doors didn't work. The Administrator was unsure how long this had been broken but felt it hadn't been more than 6 months. Interview with Housekeeper-F on 8/11/20 at 11:40 AM, revealed the housekeeper was unaware that the wander guard system to the front set of exit doors was not functioning. The housekeeper thought the doors would lock down if a resident with a wander guard tried to exit.

Licensure Reference Number 175 NAC 12-006.17 Based on observation and interview the facility failed to 1) screen visitors by completing a covid question sheet and taking a temperature for COVID-19 (a mild to severe respiratory illness infection caused by [MEDICAL CONDITION] that can spread from person to person), upon entering the facility and 2) have/ develop a policy for residents with abnormal covid screening results 3) ensure dietary staff wore surgical mask to prevent the spread of Covid-19 4) Staff were performing self screening ( including taking own temperatures and filling out covid screening questions 5) ensure Residents ( Residents 1 and 2) were wearing face covering outside of their rooms. This had the potential to affect all staff and resident in the facility. The facility census was 43. Findings are: 1) A. Observation on 7/13/20 at 11:22 a.m. revealed signs on entrance door to ring door bell, no visitors allowed, and fill out COVID-19 screening sheet (a screening tool for COVID-19 symptoms and exposure), have temperature taken, and complete hand hygiene. Before entering facility. B. An observation upon entering the facility on 7/13/20 at 11:25 a.m. revealed the DON (Director of Nursing) opened facility door for three visitors to come in. DON asked to have hand hygiene completed and stated would complete COVID-19 screening sheets when the three visitors got into conference room. C. Interview with DON on 7/13/20 at 5:30 p.m. confirmed the COVID-19 screening sheets did not get completed on three visitors that entered the facility on 7/13/20 at 11:22 a.m. D. Record view of facility policy titled COVID-19 Phasing Guidance dated June 22,2020 revealed, all visitors must be symptom free and screened according to current guidelines. Under screening heading 100% screening for all persons entering the building and all staff at the beginning of each shift. Temperature checks, and questionnaire about symptoms and potential exposure. 2) Interview on 7/13/20 at 2:10 p.m. with RN/IP (Registered Nurse and Infection Preventioist),revealed that residents get a daily temperature, and ask questions if they have a cough, sore throat, short of breath and record on a paper log and gets handed in to DON (Director of Nursing). RN/IP revealed a temperature of 99.0 or above facility would keep residents in their rooms and keep an eye on them. If they have a roommate the roommate would also stay in room and be monitored. RN/IP stated the facility has two shifts for dining. RN/IP stated that residents are allowed out of their rooms, and are not required to wear a masks at this time. RN/IP stated if a resident would have to go out of the building they would wear a mask or face covering. Interview on 7/13/20 at 2:45 p.m. with Resident 1 revealed that resident goes out of room without a face mask or face covering. Resident 1 stated we can go out of our rooms with out a face mask. Resident 1 stated we only wear a face mask if we go out of the facility. 2) According to CDC (Center for Disease Control and Prevention) (An organization responsible for providing research and education on infections and prevention of illness Worldwide) Document titled Preparing for COVID-19 in Nursing Homes dated June 25, 2020 revealed the following ---Evaluate and Manage Residents with Symptoms of COVID-19. - Ask residents to report if they feel feverish or have symptoms consistent with COVID-19. -Actively monitor all residents upon admission and at least daily for fever (T?1) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below: Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >9 might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. An interview on 7/13/20 at 3:15 PM with DON (Director of Nursing) revealed the facility has no policy or procedure for what to do if resident has an abnormal screening (this includes a temperature over 100.4, or answering yes to cough, fever, sore throat, difficulty breathing. DON stated in the event of an abnormal screening staff would contact residents physician and wait for directions. DON stated on one event they had resident with symptoms resident was placed in isolation with roommate, staff began wearing full PPE and resident and roommate were tested for covid -19. Covid test returned negative. Record review of facility policies revealed no policy for facilities procedure regarding residents with abnormal screenings. 3) An observation on 7/13/20 at 11:50 AM revealed DA (Dietary Aide)- A was wearing a beard net over nose and mask. DA was not wearing a face mask or face shield. An interview on 7/13/20 at 11:50 AM with DA -A revealed (gender) had severe asthma and was unable to wear surgical mask or other types of masks because (gender) was not able to breathe; DA-A is wearing a beard net as an alternative to surgical mask. An interview on 7/13/20 at 11:55 AM with DS (Dietary Supervisor)- B revealed (gender) was aware of DA-A has a problem with not being able to breathe with surgical mask; DA- A has been wearing beard net as an alternative to surgical mask. DS-B states that one time DA-A was sent home due to having an asthma attack. Record review of document Titled COVID-19 Policy not dated revealed under section Universal Source Control and PPE -All facility staff and essential healthcare personnel, regardless of their position, who may interact with resident or enter resident rooms, should wear a surgical. procedural facemask. The facility staff, regardless of their position, who do not provide care to the residents and who have no interaction with resident should wear either a cloth face covering or facemask while in the facility. An interview on 7/13/20 at 3:00 PM with DON confirmed DA-A should be wearing a surgical mask per facility policy. 4) An interview on 7/13/20 at 12:00 PM with Activity Director revealed that when (gender) arrives at work though employee entrance, hand sanitizer is available, then must fill out from screening questions do you have any of the following symptoms of Covid-19? Fever, cough, sore throat, Difficulty Breathing ( circle Yes or No for each). Then take temperature and document temperature. AD states if any screening questions answer yes or have a temperature you need to use walkie and call a nurse to see if you can come into work. An observation on 7/13/20 at 1:50 PM revealed the following NA (Nursing Assistants) -C,D,E preformed self-screening by taking their own temperatures documenting it on screening log and answering covid screening questions by circling yes or no for having cough, fever, sore throat, difficulty breathing. An interview on 7/13/20 at 3:00 PM with DON confirmed that staff are entering the facility performing screening by filling out Covid -screening sheet with the following questions do you have a Fever, cough, sore throat, Difficulty Breathing? ( circle Yes or No for each). Document Temperature. DON stated facility is following CDC guidelines in regard to temperature and notes anything over 100.4. DON stated (gender) reviews logs daily. DON states staff are calling (gender) if they have symptoms or questions about coming to work. Per CMS QSO memo 20-30. All phases require 100% screening of every person entering the building. Ensure all outside persons entering building have cloth face covering or facemask and observation of any signs or symptoms. 5) According to the CDC dated 7/9/20 Implement Universal Source Control Measures Source control refers to use of cloth face coverings or facemask's to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Patients and visitors should, ideally, wear their own cloth face covering (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth face covering, as supplies allow. Patients may remove their cloth face covering when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room. An interview on 7/13/20 at 11:40 AM with Resident 2 revealed (gender) had just moved in about 1 month ago due to having a stroke. Resident 2 has been doing physical therapy and hopes to return home. Resident 2 states he only leaves his room for meals and therapy, Activities have all been held in hallways or individual. Visitors have been allowed thought the window only. Resident 2 states (gender) is receiving baths 2 times per week. Resident 2 was not wearing a mask during interview; Interview took place in communal area; Resident 2 states only wears mask when leaving the facility for appointments. Resident states he has left facility multiple times for appointments in outside community. An interview on 7/13/20 at 3:00 PM with DON confirmed residents should be wearing masks when outside of their rooms and when leaving the facility.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview, the facility failed to ensure interventions were in place to protect residents from potential allegations of verbal and/or physical abuse involving 4 (residents 11, 33, 99 and 100) of 5 sampled residents reviewed for abuse. The facility census was 48. Findings are: [NAME] Review of the facility policy titled Abuse, Neglect, and Misappropriation of Resident Property Policy (Undated) included the following related to Definitions of Abuse and Neglect: -Verbal abuse was the use of oral, written or gestured language that willfully included disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability; and -Physical abuse included hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. B. Review of an Alleged Report of Possible Abuse/Neglect dated 12/26/18 revealed an investigation was conducted regarding an allegation that Nurse Aide (NA)-I was rough when providing cares for Resident 99 and had used inappropriate language in front of Resident 33. The following was revealed: -Resident 33 was admitted with [DIAGNOSES REDACTED]. -Resident 99 was admitted with [DIAGNOSES REDACTED]. -12/22/18 NA-J was assisting NA-I with getting Resident 33 ready for bed. Staff were using the Hoyer Lift (a mechanical device that allows residents to be transferred between a bed and a chair using hydraulic power and requires no weight bearing assistance from the resident) to transfer the resident and the lift was malfunctioning and kept dying. NA-J reported every time the lift quit, NA-I would say this mother [***] ing thing. NA-J further reported Resident 33 kept apologizing as the resident felt the malfunction was the resident's fault; -12/23/18 NA-J assisted NA-I with putting Resident 99 to bed. Resident 99 was seated on the side of the bed and NA-I pushed the resident into the bed. NA-J indicated Resident 99 was almost in tears and complained of shoulder pain and NA-J felt NA-I was rough when putting a night gown on the resident. NA-I then told NA-J the resident had been like this the last 3 nights and NA-I was done with this; -12/24/18 (2 days after the incident of verbal abuse by NA-I related to Resident 33 and 1 day after the physical abuse by NA-I related to Resident 99) NA-J reported the above allegations to the Director of Nursing (DON); -12/24/18 at 8:30 AM the DON notified Adult Protective Services of the abuse allegations; -12/24/18 at 9:15 AM, NA-I was suspended pending an investigation; and -12/26/18 NA-I's employment was terminated as the allegations were substantiated. C. Review of the facility Grievance Log revealed on 1/23/19 at 1:00 PM, Resident 100 reported a concern to the Social Service Director (SSD) regarding treatment by Licensed Practical Nurse (LPN)-B. The resident indicated the resident's medications were brought late to the resident's room. When LPN-B brought the medications the resident was on the phone with a friend. LPN-B spoke harshly to the resident and had spoken loudly enough for the resident's friend to overhear the conversation while on the phone with Resident 100. Review of facility investigations from 12/1/18 through 8/1/19 revealed no evidence an investigation was completed regarding the resident's allegation that LPN-B had spoken harshly to the resident or that interventions were put into place to prevent further potential verbal abuse. D. Review of Resident 11's Behavior Progress Notes dated 2/24/19 revealed at 11:27 AM, Resident 11 was coming down the hallway and saw another resident in the way. Resident 11 indicated the other resident was going to have to move. Staff attempted to move the other resident when Resident 11 gave a hard pat to the other resident's left knee to get them out of the way. Staff told Resident 11 this was unnecessary and the resident needed to be more patient. Review of facility investigations from 12/1/18 through 8/1/19 revealed no evidence an investigation was completed regarding the resident to resident altercation with Resident 11 to identify which other resident was involved or that interventions were put into place to prevent further occurrence. Review of the facility Grievance Log revealed on 3/26/19, Resident 11 had voiced a complaint regarding treatment by NA-[NAME] Resident 11 had activated the call light in the resident's room and when NA-A responded, the resident requested assistance with use of the urinal. NA-A wanted the resident to use the bathroom and the resident indicated discomfort with moving and again asked for the urinal. Resident 11 stated NA-A threw the urinal into the resident's lap and then left the resident's room. Review of facility investigations from 12/1/18 through 8/1/19 revealed no evidence an investigation was completed regarding Resident 11's allegation concerning treatment by NA-A or that interventions were put into place to prevent potential further abuse. E. During an interview on 7/31/19 at 2:02 PM, Resident 33 identified NA-I could be pretty mean sometimes. When asked if the resident had reported this, the resident stated everyone knew it. F. Interview with the DON on 8/5/19 at 7:18 AM confirmed the following: -NA-I was scheduled and provided direct resident cares on 12/22/18, 12/23/18 and 12/24/18. NA-J did not report the potential allegation of verbal abuse related to Resident 33 on 12/22/18 or the potential allegation of physical abuse towards Resident 99 which had occurred on 12/23/18 to the DON until 12/24/18; -no education had been provided to NA-J or to the other facility staff regarding the timely reporting of potential allegations of abuse; -the grievances related to Resident 100's concern about how LPN-B spoke to the resident and Resident 11's concern about treatment by NA-A should have been investigated as potential abuse allegations and interventions should have been put into place to assure the residents were protected; and -the DON was never informed a resident to resident altercation had occurred between Resident 11 and another resident. Further interview revealed the DON had determined the other resident involved was Resident 99. No interventions had been put into place to protect Resident 99 or to prevent Resident 11 from involvement of further resident to resident altercations. In addition, no education had been provided to the facility staff to assure timely reporting of potential abuse.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report allegations of potential abuse to the State Agency, to complete investigations and to submit the results of the investigations for 3 (Residents 99, 11 and 100) of 5 residents sampled. The facility census was 48. Findings are: [NAME] Review of the facility Abuse, Neglect, and Misappropriation of Resident Property Policy (Undated) indicated the following: -The facility will report any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state regulations. -The facility will conduct an investigation of such allegations in accordance with state law. -The facility will report all investigation findings to the state in accordance with state regulations. B. Review of the facility Grievance Log revealed on 1/23/19 at 1:00 PM, Resident 100 reported a concern to the Social Service Director (SSD) regarding treatment by Licensed Practical Nurse (LPN)-B. The resident indicated the resident's medications were brought late to the resident's room. When LPN-B brought the medications, the resident was on the phone with a friend. LPN-B spoke harshly to the resident and had spoken loudly enough for the resident's friend to overhear the conversation while on the phone with Resident 100. Review of facility investigations of potential abuse/neglect from 12/1/18 through 8/1/19 revealed no evidence an investigation was completed regarding the resident's allegation that LPN-B had spoken harshly to the resident or that a report had been filed to the State Agency. Review of Resident 11's Behavior Progress Notes dated 2/24/19 revealed at 11:27 AM, Resident 11 was coming down the hallway and saw another resident in the way. Resident 11 indicated the other resident was going to have to move. Before staff could intervene, Resident 11 gave a hard pat to the other resident's left knee to get them out of the way. Staff told Resident 11 this was unnecessary and the resident needed to be more patient. Review of facility investigations from 12/1/18 through 8/1/19 revealed no evidence an investigation was completed of the resident to resident altercation involving Resident 11 and there was no evidence the State Agency had been notified of the incident. Review of the facility Grievance Log revealed on 3/26/19, Resident 11 had voiced a complaint regarding treatment by Nursing Assistant (NA)-[NAME] Resident 11 had activated the call light in the resident's room and when NA-A responded, the resident requested assistance with use of the urinal. NA-A wanted the resident to use the bathroom and the resident indicated discomfort with moving and again asked for the urinal. Resident 11 stated NA-A threw the urinal into the resident's lap and then left the resident's room. Review of facility investigations from 12/1/18 through 8/1/19 revealed no evidence an investigation was completed regarding Resident 11's allegation concerning treatment by NA-A or that a report had been filed with the State Agency. Interview with the DON on 8/5/19 at 7:18 AM confirmed the following: -the grievances related to Resident 100's concern about how LPN-B spoke to the resident and Resident 11's concern about treatment by NA-A should have been reported and investigated as potential abuse allegations and the investigations then sent to the State Agency; and -the DON was never informed a resident to resident altercation had occurred between Resident 11 and another resident. Further interview revealed the DON had determined the other resident involved was Resident 99. The DON indicated the incident should have been reported, an investigation completed and then the results of the investigation sent to the State Agency.

License Reference Number 175 NAC 12-006.17D Based on observations, record review and interviews the facility failed to prevent the potential for cross contamination with appropriate hand hygiene during the provision of medication administration for Residents 16, 8, 38, 22 and 39 and provision of cares for Resident 29. The facility census was 49 Findings are: (A) Observation on 08/5/19 from 7:30AM - 8:15 AM revealed R.N - H ( Registered Nurse) provide morning medications to residents 16,8,28, and 22 without preforming hand hygiene before medication preparation and after medication administration. Observation on 08/5/19 from 8:30AM - 8:40AM revealed R.N -G administer eye drops to resident 39 without completing hand hygiene prior to applying gloves, administering eye drops and then immediately administered nasal spray without changing gloves or completing hand hygiene in between medication administrations. Record review of facility Hand Washing Procedure not dated revealed appropriate 10-15 second hand washing must be performed under the following conditions. Step 4. Before preparing or handling medications. Step 13. Upon completion of duty. Record review of facility procedure titled Eye Drops not dated revealed this procedure may involve potential and/ or direct exposure to blood, body fluids, infectious diseases, air contaminants and hazardous chemicals. Steps in the procedure: 1. Wash your hands thoroughly before beginning the procedure. 10. Put on gloves. 21. Remove gloves and discard in designated container. Wash hands. Record review of facility Nose Medication Procedure not dated revealed steps in the procedure: 1. Wash your hands thoroughly before beginning the procedure. 16. Wash hands. An Interview on 08/05/19 at 2:20 PM with DON confirms hands should be washed or sanitized before medication administration, between eye and nose medications and after medication administration. (B) Resident 29 Observation on 08/01/19 at 2:40-3:00PM resident was in wheelchair heading to restroom, NA -F sanitized hands, assisted resident to stand, used bare hands to pull down residents pants and soiled brief, applied gloves, removed soiled brief and disposed of, proceed to apply new brief weaving it in between residents pant legs, resident was pushing pants down and NA -F told resident was not necessary as she could get brief on, resident then was assisted to stand, NA- F preformed perineal care( cleaning of genitals) and removed soiled gloves and assisted resident to pull up pants, NA- F then washed hands for 9 seconds. Resident was then assisted into bed. NA- F applied hand sanitizer and blew on her hands to dry them quicker. Applied gloves; removed garbage, removed gloves and took garbage bag taken to soiled utility room; NA- F washed hands for 4 seconds. An interview on 08/06/19 at 7:00AM with DON confirmed staff should be washing hands per facility policy for 15-20 seconds and if using hands sanitizer to rub into hands until dry.