Every finding on record at Continental Falls

175 NAC 12-006.18Based on observations, record reviews, and interviews: the facility failed to utilize Personal Protective Equipment (PPE-equipment such as gowns, gloves, masks, goggles, that creates a barrier against germs and hazards) when performing high contact cares for Residents 8 and 41 who were on Enhanced Barrier Precautions (EBP-an infection control measure involving the use of gowns and gloves for high contact care to prevent spreading organisms), failed to perform hand hygiene and glove changing at appropriate intervals during toileting for Resident 7, and failed to clean re-usable resident care equipment used for transfers for Residents 8, 30, and 52. The sample size was 10 and the facility census was 46. Findings are: A. Review of the facility policy Enhanced Barrier Precautions dated 2024 revealed the facility implemented EBP for the prevention of transmission of Multidrug-Resistant Organisms (MDRO's-organisms that are resistant to multiple antibiotics) that employed targeted gown and glove use during high contact resident care activities. The facility promptly identified need, and initiated EBP's which included the following: -all staff received training on EBP upon hire and annually and were expected to comply with all designated precautions.-The facility had gloves and gowns available near or immediately outside the resident's room.-PPE for EBP was necessary when performing high-contact care activities.-EBP were used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. B. During an observation on 1/11/26 at 8:00 AM a sign titled Enhanced Barrier Precautions (EBP) was posted on the wall directly outside Residents 8 and 41's Room (roommates) which indicated staff were to clean their hands before entering and leaving the resident room. In addition, Providers and Staff were to wear gloves and a gown for the following High-Contact Resident Care Activities; Dressing, Bathing, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or assisting with toileting, Device care or use (central lines, urinary catheters, feeding tubes, or tracheostomy), and/or Wound care for any skin opening requiring a dressing. C. Review of Resident 41's Care Plan with a revision date of 9/2/25 revealed the resident had a diagnosis of the MRDO Methicillin Resistant Staphylococcus Aureus (MRSA), was incontinent at times and staff were to offer assistance as needed with toileting needs. During an observation of care for Resident 41 on 1/12/26 at 8:10 AM Nurse Aide (NA)-C entered the resident room and then bathroom. NA-C put on gloves but not a gown and proceeded to assist the resident in the bathroom with changing a soiled brief and providing peri-cares. NA-C performed hand hygiene and exited the room with the soiled brief in a garbage bag. D. Review of Resident 8's Care Plan with a revision date of 11/4/25 revealed the resident was Resistant to Vancomycin (VRE-antibiotic resistant bacteria). During an observation of the care for Resident 8 on 1/12/26 at 8:25 AM, NA-C entered the room, put on gloves, but no gown and assisted Resident 8 with changing of a soiled brief, while the resident was lying in bed. The brief was removed, placed in a garbage bag and a new brief was applied all while not wearing a gown. E. During an interview on 1/12/26 at 8:33 AM, NA-C revealed the NA was not aware Residents 41 and 8 were on Enhanced Barrier Precautions. In pointing out the sign on the outside of the room, NA-C continued to deny being aware either resident was on EBP because they don't have catheters, and or don't go to dialysis. NA-C was not aware of other criteria that would require the use of EBP. F. During an interview on 1/12/26 at 12:47 PM the Director of Nursing (DON) confirmed the facility expected staff to implement the use of gown and gloves during high contact care episodes for residents who had targeted MRDO's including VRE and MRSA. This included Resident's 41 and 8. G. Review of the facility policy Cleaning and Disinfection of Reusable Equipment, undated revealed the following: -the purpose was to ensure reusable equipment was cleaned and disinfected in a manner that reduced the risk of infection transmission and supported a safe environment for individuals served, staff, and visitors; -reusable equipment would be cleaned and disinfected between uses, and as needed, using approved methods to prevent cross contamination; -all cleaning practices would be performed in accordance with manufacturer's recommendations, accepted infection prevention standards, and organizational procedures; -reusable equipment were items intended for use on more than one individual or for repeated use (such as medical devices, assistive devices, shared equipment); -staff were responsible for cleaning and disinfecting equipment after use and prior to reuse; -reusable equipment would be cleaned and disinfected between individual uses, when visibly soiled, and according to routine schedules; and -clean equipment would be stored in a manner that prevents contamination. H. Review of Resident 8's Minimum Data Set (MDS- a federally mandated assessment tool used in Care Planning) dated 12/18/25 revealed the resident was admitted on [DATE] with diagnoses of Heart Failure and Kidney Disease; the resident had moderate cognitive impairment; and required assistance with toileting, dressing, hygiene, and transfers. I. Review of Resident 8's Care Plan, last revised 1/6/26 revealed the resident required assistance with bed mobility, dressing, hygiene, toileting, and transfers and had diagnoses of Left Artificial Knee joint, Kidney Failure, Adjustment Disorder with Depressed Mood; Obsessive-Compulsive Disorder, Bipolar Disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function), and Unspecified Mood Disorder. J. An observation on 1/13/26 at 8:15 AM with Medication Aide (MA)-I and NA-C wore PPE appropriately while dressing Resident 8 while the resident was lying in bed. Both MA-I and NA-C removed their PPE, performed hand hygiene and applied new gloves, but no gowns. MA-I and NA-C assisted the resident to sit on the edge of the bed and their clothing touched the bed linens. The aides applied the sit to stand lift pad behind the resident and hooked the pad to the machine, then transferred the resident to the wheelchair. NA-C removed their gloves, performed hand hygiene then applied new gloves. NA-C then made the resident's bed and the bed linens were touching NA-C's clothes. MA-I moved the sit to stand lift into the hallway. The lift was not observed to be cleaned after use. There was a bag on the handle of the lift, but no cleaning materials were noted to be in the bag. MA-I removed the trash from the room, removed their gloves and performed hand hygiene upon leaving the room. MA-C removed their gloves, exited the room and performed hand hygiene upon exit. K. An interview with the DON confirmed Resident 8 was on EBP, PPE should be worn with high-contact care activities including transfers and bed-making and the sit to stand lift should be cleaned after each use to prevent cross-contamination. L. During an observation on 1/11/26 at 1:29 PM, NA-X assisted Resident 52 to the resident's room per the wheelchair. NA-X was wearing a sweatshirt over the staff's uniform. NA-X washed hands and placed on clean gloves then lifted the sweatshirt to reveal a gait belt. NA-X removed the gait belt from their person and placed it directly on the resident. The resident was pivoted transferred from the wheelchair into the bathroom. When the resident had finished toileting, staff stood the resident, completed hygiene cares, adjusted the resident's clothing and brief and transferred the resident back into the wheelchair. NA-X removed the gait belt from the resident and after lifting the staff's sweatshirt, placed the gait belt back onto their person. NA-X failed to clean and/or disinfect the gait belt prior to and after use with the resident. During an observation of toileting cares on 1/12/26 at 10:38 AM, NA-C and NA-D approached Resident 52 who was seated in a recliner in the front commons area. NA-D removed a gait belt the staff member was wearing around their waist and placed it directly on the resident. The resident was transferred into a wheelchair and was assisted to the resident's room and into the bathroom. Once Resident 52 was positioned on the toilet, NA-D removed the gait belt from the resident and draped the belt across the top of the tank of the toilet. The resident then had clothing changed before the gait belt was removed from the toilet and placed back onto the resident for the transfer into the wheelchair. After the resident was positioned safely in the wheelchair, NA-D removed the gait belt from the resident and placed the belt back onto NA-D's waist. NA-D failed to clean and/or disinfect the gait belt prior to and after use with the resident. During an interview on 1/12/2026 at 10:58 AM, NA-C and NA-D confirmed the direct care staff reuse the gait belt from resident to resident without cleaning/disinfecting. The staff wear the gait belt so that they always have available. M. During an observation of care for Resident 30 on 1/13/26 at 10:45 AM, NA-J and NA-D washed hands and put on a disposable gown and gloves and used the full lift (mechanical device designed to help care givers move a resident who are unable to bear weight) to transfer Resident 30 from the bed to the recliner. Once in the recliner, the staff removed the lift from the resident and proceeded to exit the room with the lift and positioned the device in the corridor for use with the next resident. Staff failed to clean and to disinfect the lift before and after use on Resident 30 who remained on EBP. During an interview on 1/13/26 at 11:30 AM, NA-J confirmed the following: -staff did not clean the lift before bringing it into the resident's room or when removing it from the room. -the lift was used for transferring multiple residents and was not exclusively used for transferring Resident 30. -Resident 30 remained on EBP due to positive diagnosis of HIV. N. Review of the facility policy titled Handwashing/Hand Hygiene revised October 2023 revealed the following: -Hand hygiene was the primary means to prevent the spread of healthcare-associated infection. -Hand hygiene was to be completed for the following: - After contact with body fluids or contaminated surfaces. - After touching a resident and the resident's environment. - Before moving from work on a soiled body site to a clean body site on the same resident. - Immediately after glove removal. O. Record review of Resident 7's quarterly Minimum Data Set (MDS) (a federally mandated assessment utilized to determine a resident's functional capabilities and care) dated 12/07/25 revealed the following: -The resident was occasionally incontinent of urine. -The resident refused to transfer to the toilet and was dependent on staff for perineal hygiene. -The resident was dependent on staff for transferring from bed to chair and chair to bed. -The resident required extensive assistance with dressing upper and lower extremities and putting on shoes. An observation of provision of care for Resident 7 on 1/13/26 at 10:15 AM revealed Nurse Aide (NA)-D and NA-J completed hand hygiene and put on gloves. NA-D had a gait-belt around the waist. Resident 7 was lying in bed and requested to be dressed and complete perineal hygiene in bed. NA-J changed the residents socks and put on pants and shoes for the resident. NA-D completed perineal hygiene cares, removed the wet brief and wet sheet from the bed. NA-D (did not change gloves or wash their hands) and NA-J put a clean brief on the resident. NA-D changed gloves (did not wash hands), sat resident on edge of bed, assisted resident with putting on shirt, the gait-belt was removed from around NA-D's waist and put around the resident's waist. The resident was then transferred to the wheelchair. NA-D and NA-J removed the gloves and washed their hands with soap and water. An interview with the DON on 1/13/24 at 2:45 PM confirmed that staff were to wash their hands when gloves were removed and staff should change gloves and wash hands when going from a dirty task to a clean task. Further interview confirmed staff should not be wearing a gait belt around their waist. P. Record review of Resident 31's January 2026 Treatment Administration Record (TAR) revealed the following treatment orders: -Soak the right and left great toes in epsom salt-soaked gauze for 15 minutes daily, then cleanse with wound cleanser, swab with betadine, apply a strip of iodoform gauze (sterile, medicated gauze strips) packing to the wound bed, cover great toe's with gauze and secure with tape. -Cleanse the right and left posterior thighs with soap and water using wipes then pat dry. Combine 1 packet of collagen particles with 15 milliters (ml) of A&D ointment, apply to open areas, cover with a silicone superabsorbent dressing and change daily. Record review of Resident 31's January 2026 Medication Administration Record (MAR) revealed the following treatment: -Cleanse abdominal folds and groin with soap and water, pat dry, apply Calmoseptine (ointment that protects, soothes, and promotes healing) then apply cornstarch over the Calmoseptine 2 times daily and as needed. -Cleanse the forehead and face rash with saline, apply Triamcinolone (steroid) ointment to rash twice daily and as needed for itching. An observation of provision of care revealed Licensed Practical Nurse (LPN)-L, washed their hands with soap and water, put on a gown and gloves and set up a table with a clean surface and treatment supplies. The treatment was completed to both great toes as ordered (LPN-L did not change gloves or wash hands) then washed the residents face with saline soaked gauze and applied Triamcinolone ointment to the rash. LPN-L mixed the A&D ointment with 1 packet of collagen particles, washed the groin and abdominal folds with soap and water, then patted skin dry and applied Calmoseptine to the abdominal folds and groin. LPN-L removed their gloves (did not wash their hands) and put cornstarch over the Calmoseptine. LPN-L changed gloves, (did not wash hands), positioned resident on their side and cleaned the residents bottom using wipes, changed their gloves (did not wash hands) cleaned wounds to back of right and left leg with use of wipes, soap and water, patted areas dry and applied cream mixture of A&D and collagen then covered wounds with a dressing. (LPN-L did not change gloves or wash their hands) Then removed the gauze from the residents great toes, cleaned great toes with wound cleanser and painted them with betadine, applied a strip of Iodoform gauze packing to the wound bed and secured packing with tape. An interview on 1/12/26 at 1:45 PM with LPN-K confirmed that LPN-L should have been washing hands when changing gloves and should have changed gloves and washed hands when going from one treatment area to another.

Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview; the facility failed to notify the resident and/or their representative of potential risk or benefits prior to initiation of pf psychoactive medications for 3 (Residents 2, 5, and 8) of 5 sampled residents. The facility staff identified a census of 46.Findings are:A. Review of the facility policy Psychotropic Medication Use, last revised February 2025 revealed the following:-residents would not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record;-medications included antipsychotics, antidepressants, antianxiety, and hypnotics/sedatives were subject to prescribing, monitoring, and review requirements specific to psychotropic medications;-psychotropic medication management involved the resident, family and/or representative;-residents who had not used psychotropic medications were not prescribed or given those medications unless the medication is determined to be necessary to treat a specific condition that was diagnosed and documented in the medical record;-prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and the physician would review the following with the resident/representative prior to obtaining documented consent or refusal: non pharmacological alternatives, the indication and rationale for the recommendation, the potential risks and benefits, and the representative right to accept or decline the treatment. B. Review of Resident 2's Minimum Data Set (MDS-a federally mandated assessment tool used in Care Planning) dated 12/3/25 revealed the resident was admitted [DATE] with diagnoses of Cirrhosis (scar tissue of the liver which make it hard to function), Kidney Disease, Diabetes, and Anxiety; was cognitively intact; was independent with dressing, transfers, bed mobility, and toileting; and received antianxiety and antidepressant medications.Review of Resident 2's Care Plan, last revised 9/5/25 revealed the resident was independent with dressing, ambulation, bed mobility and toileting; received psychotropic medications for anxiety and insomnia; and had diagnoses of Diabetes, Chronic Kidney Disease, Insomnia, and Anxiety.Review of Resident 2's Order Summary Report with active orders revealed the resident was receiving Buspirone (an antianxiety medication) 5 milligrams (mg) three times daily for a diagnosis of Anxiety with a start date of 8/18/25; and Zolpidem (a sedative/hypnotic medication) 5mg at bedtime for a diagnosis of Insomnia with a start date of 8/18/25.Review of Resident 2's Consent for Use of Psychoactive Medications revealed no documentation that consent for the Buspar and the Zolpidem had been obtained by the facility prior to administration of the medications. C. Review of Resident 5's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of Renal Disease, Bipolar Disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function), Post-Traumatic Stress Disorder and Chronic Lung Disease; was cognitively intact; was independent with ambulation, dressing, and bed mobility, and required assistance with toileting; and received antipsychotic, antianxiety and antidepressant medications.Review of Resident 5's Care Plan last revised on 10/13/25 revealed the resident was independent with dressing, transfers, bed mobility and required assistance with toileting; received antipsychotic and antidepressant medications; and had diagnoses of Bipolar Disorder, Post-Traumatic Stress Disorder, Borderline Personality Disorder, and Insomnia.Review of Resident 5's Order Summary Report with active orders revealed the resident was receiving Vraylor (an antipsychotic medication) 3mg at bedtime for a diagnosis of Bipolar Disorder with a start date of 3/25/25; and Amitriptyline 100mg at bedtime for a diagnosis of Depression with a start date of 4/16/25.Review of the facility facsimile (fax) dated 3/25/25 revealed Resident 5 received an increase of Vraylor to 3mg and Amitriptyline to 50mg.Review of Resident 5's Progress Note dated 4/17/25 revealed the resident had an increase in Amitriptyline to 100mg at bedtime and the resident (self-responsible) was aware (1 day after the start of the Amitriptyline, and not in advance).Review of Resident 5's Consents for Use of Psychoactive Medications revealed no documentation consent for the Vraylor and Amitriptyline increase on 3/25/25 had been obtained prior to administration. D. Review of Resident 8's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of Anemia, Heart Failure, Bipolar Disorder, and Schizophrenia (a brain disorder causing disruptions in thought, emotions, and behaviors); had moderate cognitive impairment; required assistance with toileting, hygiene, dressing, and transfers; and received antipsychotic and antidepressant medications.Review of Resident 8's Care Plan last revised 1/6/26 revealed the resident required assistance with bed mobility, dressing, hygiene, toileting, and transfers; received psychotropic medications; and had diagnoses of Schizophrenia, Adjustment Disorder with Depressed Mood, and Obsessive-Compulsive Disorder.Review of Resident 8's Order Summary Report with active orders revealed an order for Fluvoxamine 100mg 1 tablet in the morning, and 2 tablets at bedtime for a diagnosis of Schizoaffective Disorder (combination of Schizophrenia symptoms and Bipolar Disorder symptoms) with a start date of 8/1/25.Review of Resident 8's Consents for Use of Psychoactive Medications revealed no documentation that consent for Fluvoxamine was obtained prior to administration. E. Interview on 1/14/26 at 2:10 PM with the Director of Nursing confirmed the facility did not have documentation to show consents for Resident 2's Buspar and Zolpidem, Resident 5's Vraylar and Amitriptyline, and Resident 8's Fluvoxamine were obtained prior to the medications being administered.

Licensure Reference Number 175 NAC 12-006.19(A)Based on observations, record reviews, and interviews; the facility failed to maintain the cleanliness and condition of resident rooms/bathrooms in 3 (Rooms 206, 505 and 509) of 45 occupied rooms. This had the potential to affect 3 residents who resided in those rooms. In addition, the facility failed to clean and maintain bathhouses, and the windows, flooring and walls in corridors and the dining room. The total sample size was 17 and the facility census was 46. Findings are: A. Review of the undated Maintenance and Housekeeping Policy revealed the purpose of the policy was to ensure the facility was maintained in a safe, clean, functional, and hygienic condition through effective maintenance and housekeeping practices, thereby supporting operational efficiency, safety, and compliance with applicable standards and regulations. This applied to all buildings, infrastructures, equipment, utilities, common areas, and external premises of the facility. The following objectives were identified:-obtain a clean, safe, healthy environment.-prevent equipment and infrastructure deterioration.-ensure compliance with safety, health and environmental regulations.-minimize downtime and maintenance related risks.-promote accountability and continuous improvement.The following roles and responsibilities were identified for the maintenance team -perform preventative corrective and breakdown maintenance.-maintain records of inspections and repairs and servicing.-ensure safe operation of equipment and utilities.The following roles and responsibilities were identified for the housekeeping team:-maintain cleanliness of all designated areas per schedule. High touch and high risk areas were to receive priority cleaning. -use approved cleaning agents and equipment. -follow waste segregation and disposal guidelines.B. Review of the Deep Clean Check Off List revealed the following areas in the residents' rooms which were to be cleaned with documentation when cleaning was completed: -pull out the beds and sweep/vacuum under, wipe down the bed frames and springs.-pull out the dresser and sweep/vacuum underneath, wipe down sides.-dust and wipe down televisions. -clean ceilings, vents, and light fixtures.-clean windowsills and inside of windows.-clean and wipe down heater/radiator units, remove trash from inside of units. -clean and wipe down pictures/prints on the walls.-clean and wipe down garbage cans inside and out.-clean and wipe down all walls (clean out corners with scrapers if needed). -clean and wipe down doors, door jams, and door frames.-clean and wipe down closets and shelving inside and out.-clean and wipe down all tables, nightstands and rolling tables.-clean and wipe down all chairs. -clean and wipe down baseboards/edges.-clean and disinfect floors.-clean and disinfect toilets.-clean and disinfect vents (check for trash inside of vents).-clean and disinfect any wheelchairs in the rooms.inspect curtains for spills or damage and alert management to replace if needed. -clean and disinfect outside of refrigerators.-clean and disinfect phones, remotes, and anything else belonging in room. C. Environmental observations of the residents' rooms on 1/11/26 during the initial pool from 9:00 AM to 2:00 PM revealed the following:-resident room [ROOM NUMBER], the bathroom trash receptacle contained several pre-moistened cleansing cloths and an incontinent brief which were soiled with feces and the room had a feces odor. The window next to the resident's bed was covered with plastic and the window frame was paint chipped.-resident room [ROOM NUMBER], with a urine odor to the room. The mattress on the bed had brown discoloration, and an outline of a urine stain. The bed frame and headboard with heavy layer of dust/debris. The wheelchair in the room had brown spots which covered the wheels and handles of the chair. The vanity underneath the handwashing sink in the resident's room was missing the baseboard to the left side. In addition, there were brown colored stains on the ceiling which extended down the wall directly above the light fixture over the vanity/handwashing sink.-resident room [ROOM NUMBER], personal fan which blew directly across the resident's bed with heavy layer of dust/debris. The baseboard heater in the resident's room behind and to the side of the bed was missing the outside cover. The baseboard underneath the handwashing sink/vanity was still intact but portions were pulled away from the wall. Observations of the facility shower/bathhouses on 1/12/26 at 9:25 AM revealed the following:-300 hall shower room, the ceiling directly above the shower chair had a 5 by 7 centimeter (cm) area of paint which had peeled away from the ceiling and was hanging. The remainder of the ceiling with areas of chipped paint.-500 hall whirlpool room, panel on the lower wall opposite of the tub with a heating/cooling unit. Two prongs extended from the panel which were to hold knobs for adjusting the temperature of the room. The panel with areas of brown discoloration which appeared to be rust. A window directly next to the whirlpool tub was covered with plastic and was secured with 2-3 inch blue masking tape around the perimeter of the window. A ceiling vent above the tub with a heavy layer of dust/debris. Interview with Bath Aide (BA)-A and BA-B on 1/12/26 at 9:35 AM verified the concerns related to the ceiling of the shower room. BA-A and BA-B confirmed the following regarding the whirlpool room:-there were no knobs for the heating/cooling unit in the whirlpool room. The staff would have to get someone from maintenance to come with pliers to adjust the temperature of the room. -the window did not close completely and the plastic wrap and tape helped to keep the cold out.-the ceiling vent above the whirlpool needed to be cleaned. During an environmental tour with the Assistant Social Service Director (SSD) /previous Administrator on 1/13/26 from 10:30 AM to 11:17 AM revealed the following:-room [ROOM NUMBER], the window frame remained paint chipped and was covered with plastic.-desk at the Nurse's Station between the 300 and the 500 corridors, with a wood veneer finish which was faded and worn completely away in areas. -the windows to bilateral sides of the corridor between the dining room and the 500 halls were spotted/soiled and required cleaning. The wall cover was peeled away on bilateral sides of the hall between the fire doors and the windows.-floor of the commons area leading to the 300 hall was scuffed with areas worn away/missing. -floor to the dining room with several scuffed areas underneath the residents' tables/chairs and at the entrance of the dining room by the 300 halls. During an interview on 1/13/26 at 11:20 AM the Assistant SSD/previous Administrator reported the following:-was aware on 1/11/26 the bathroom trash in room [ROOM NUMBER] contained soiled items and there was an odor in the room. The housekeeping staff were instructed to clean the room and remove the trash.-performed a daily check of the resident's room temperature and if a significant drop in temperature from the entrance of the room to the window, would then instruct the maintenance staff to cover the windows with plastic.-replaced the mattress in room [ROOM NUMBER] on 1/12/26 when notified of the strong urine odor.-the windows in the corridor required cleaning and indicated they had not been cleaned since the spring/summer months and the wall covering needed to be repaired. -flooring in the dining room and the hallways needed to be replaced.-desk at the Nurses' Station needed to be repaired. An interview with the Maintenance Supervisor on 1/14/26 at 8:00 AM confirmed the ceiling needed to be repaired in the shower room and knobs needed to be replaced on the heating/cooling unit of the whirlpool room. In addition, the baseboards needed to be repaired in rooms [ROOM NUMBERS] and the baseboard heater in room [ROOM NUMBER] needed a new cover. Interview with the head of House keeping on 1/14/26 at 8:30 AM confirmed the housekeeping staff were to clean the resident's bed frames, personal fans and the ceiling vents in the resident's rooms and the bath houses. If the housekeeping staff notice a resident's wheelchair was soiled then the staff should wipe down and notify nursing.

Based on record review and interview; the facility failed to notify the ombudsman (a state appointed advocate for residents of nursing homes) of resident discharges as required for 3 (Residents 3, 4 and 48) of 3 residents reviewed. The facility census was 46.Findings are: A. Review of the facility policy Transfer and Discharge (undated) revealed it was the policy of the facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. The facility's transfer/discharge notice was to be provided to the resident and the resident's representative in a language and way they could understand. The notice was to include the name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care (LTC) Ombudsman. In addition, the notice was to be provided to the resident, the resident's representative if appropriate and the LTC Ombudsman as soon as practicable before the transfer or discharge. The Social Service Director (SSD) or designee was to provide copies of notices for emergency transfers to the Ombudsman, but they were to be sent when practicable, such as in a monthly list of residents, if the list met all requirements for content of notices. The facility was to then maintain evidence that the notice was sent to the Ombudsman. B. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/7/26 revealed the resident was admitted [DATE] with diagnoses of anemia, coronary artery disease, Non-Alzheimer's dementia, schizophrenia, anxiety, diabetes, bipolar disorder, and chronic obstructive pulmonary disease. Review of Resident's 4's Nursing Progress Notes revealed the following: -6/4/25 at 12:33 AM the resident was found in bed with a large, dark, foul smelling coffee ground emesis. The resident was sent to the emergency room for evaluation. -6/4/25 at 5:01 AM the emergency room was contacted and indicated the resident was admitted to the hospital. -9/4/25 at 7:15 AM the resident complained of weakness with difficulty standing/ ambulating and reported pain with breathing. The resident had a temperature of 102.2 degrees Fahrenheit with a pulse rate of 134 beats per minute. The resident was sent to the emergency room for evaluation. -9/4/25 at 2:16 PM the facility was notified the resident was admitted to the hospital with aspiration pneumonia. -11/24/25 at 4:38 PM the resident was unable to bear weight on the right leg with complaints of pain. The resident's right leg was swollen up to the thigh. The resident was sent to the emergency room for evaluation. -11/24/25 at 11:27 PM the resident was admitted to the hospital with weakness and leg pain. -1/4/26 at 6:40 PM the resident had an emesis and was lethargic. The resident's temperature was 104.4 degrees Fahrenheit and pulse was 122 beats per minute. The resident was sent to the emergency room for Evaluation. The resident was admitted to the hospital for a urinary tract infection. Review of the resident's medical record from 6/4/25 to 1/11/26 revealed no evidence that the Ombudsman had been notified of the resident's discharges to the hospital on 6/4/25, 9/4/25, 11/24/25 and on 1/4/26. Interview with the SSD on 1/13/26 at 8:26 AM confirmed the SSD was responsible for notification to the Ombudsman of resident discharges. The SSD further confirmed the Ombudsman had not been notified of Resident 4's discharges to the to the hospital. C. Review of Resident 48's Medical Record revealed the resident was admitted to the facility on [DATE] and discharged on 10/28/25. There was no evidence that the State Ombudsman was notified of Resident 48's discharge. Additional review revealed the facility had no evidence the facility was submitting a report to the State Ombudsman containing residents discharging from the facility. During an interview on 1/12/26 at 10:15 AM the SSD confirmed the facility had not been submitting the required discharge reports to the State Ombudsman including Resident 48. There was no evidence of reports being submitted in the past 6 months. D. Review of Resident 3's Medical Record revealed the resident was admitted to the facility on [DATE] and admitted to the hospital on [DATE]. There was no evidence that the State Ombudsmen were notified of the resident's discharge to the hospital on [DATE]. An interview on 1/13/26 at 11:30 AM with the SSD confirmed the facility had not notified the State Ombudsmen of the Resident 3 being discharged to the hospital.

Licensure Reference Number 175 NAC 12-006.12(D)(iii)Based on observations, interviews and record review; the facility failed to ensure insulin pens were labeled for all insulin dependent residents, failed to monitor the temperature of refrigerators containing medications, and failed to ensure expired medications were not available for resident use. In addition, the facility failed to ensure Resident 7's bedside medications were securely stored and failed to secure medications in Resident 31's room. The sample size was 17 and the facility census was 46. Findings are: A. Review of the facility policy Medication Storage dated 2024 revealed the following: -The facility ensured all medications housed on the premises were stored in the pharmacy or medication room according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. -All medications were stored in locked compartments (i.e., medications carts, cabinets, refrigerators, medication rooms) and under proper temperature controls,-All medications requiring refrigeration were stored in refrigerators with temperatures maintained within 36-46 degrees. Charts were kept on the refrigerators and temperature levels were recorded daily by the charge nurse or designee. B. Review of the facility information provided through the facility pharmacy dated April 2025 and titled Expired or Not Expired revealed the following: -expiration dating of many products change once the items are removed from their primary packaging and are in use -Once the products were opened, they needed to be used within a specific timeframe to avoid reduced potency and potentially reduced efficacy. -Expiry dates of all medications should be checked on a monthly basis. -Items to watch included insulins, as expiration dates could vary between pens and vials. C. Review of the undated facility list containing information regarding the stability of insulin stored at room temperature revealed the following: Novolog/Aspart (rapid-acting insulin made to control blood sugar in people with diabetes) was stable for 28 days if opened,Humalog/Lispro (rapid-acting insulin made to control blood sugar in people with diabetes) was stable for 28 days if opened,Basaglar (a long-acting insulin made to control blood sugar in people with diabetes) was stable for 28 days if opened, andLantus/Glargine (a long-acting insulin made to control blood sugar in people with diabetes) was stable for 28 days if opened.Revzoglar (a long-acting insulin injection used to improve glycemic control in adults and children with diabetes) was stable for 28 days if opened. Glargine-yfgn (a long-acting insulin made to control blood sugar in people with diabetes) was stable for 28 days once opened. D. During a tour of the facility medication carts and room on 1/12/26 at 2:40 PM the following were observed. -No insulin pens that were opened and on the medication carts, had the required opened (date when the medication was first opened) date to ensure the insulin was not being administered past the recommended use by date. -The following vial of insulin was observed: -Resident 35 had 1 vial of Lantus insulin that was opened on 11/30/25-The following insulin pens were found opened with no date indicating when they were opened: -Resident 19 had Basaglar (glargine) -Resident 23 had Humalog- 2 pens-Resident 31had Lantus- 2 pens and Novolog/Aspart-Resident 37 had Lispro and Lantus-Resident 39 had Aspart and Glargine-Resident 43 had Aspart and Rezvoglar-Resident 59 had Lantus and Rezvoglar E. During an interview at 2:45 with Medication Aide (MA)-R reported being unsure how long insulin could be given once it was opened. The MA thought maybe 2-3 months but did not know for sure. MA-R confirmed that none of the insulins on the cart had dates when opened and thus staff would not know when to stop using them and/or open a new vial or pen. Further interview confirmed the MA had given undated insulin injections to residents. In addition, the MA confirmed giving insulin injections to residents. F. During an observation of a second medication cart revealed the following undated and opened insulin pens on 1/12/25 at 2:50 PM -Resident 2 had Lantus and Aspart-Resident 4 had Aspart and Rezvoglar-Resident 13 had Rezvoglar-Resident 21 had Aspart-Resident 22 had Basaglar-Resident 29 had Lantus-Resident 40 had Lantus (2 pens) and Lispro,and -Resident 54 had Glargine-yfgn G. During an interview on 1/12/26 at 2:55 PM with MA-T reported being unaware insulin pens were to be dated when opened, and in addition confirmed being unsure how long insulin pens could be used once opened I month I think. In addition, the MA confirmed giving insulin injections to residents. H. During a tour of the facility medication room on 1/12/26 at 2:58 PM the following was noted; -2 refrigerators containing resident medications and no evidence the facility had been completing daily temperature checks of the refrigerators to check to see if the medications were being held at appropriate temperatures.The following stock (used for whichever resident may need it) medications -an opened and undated vial of Tuberculin -5 Acetaminophen suppositories that expired on 9/2025-An unopened bottle of Acidophilous that expired on 4/28/25, and 12 unopened bottles of Antacid each containing 150 chewable tablets that expired on 10/2025. I. During an interview at 3:00 PM Registered Nurse (RN)-S confirmed the refrigerator temperature was to be checked daily, and the only temperature log completed was for December 2025, and there was no log for January 2026. In addition, RN-S confirmed that all outdated medications were to be destroyed so they were not available for use by residents. J. Review of the list of Residents taking subcutaneous (injections under the skin) antidiabetic medications revealed the following: -Resident 2 had orders for Lantus, inject 10 units twice daily and Novolog, inject 3 times daily based on the residents' current blood glucose levels. -Resident 4 had order for Lantus inject 15 units in the morning and 5 units in the evening.-Resident 19 had orders for Glargine inject 15 units at bedtime.-Resident 13 had orders for Rezvoglar 18 units at bedtime.-Resident 21 had orders for Aspart inject 13 units 3 times daily, and addition units based on the current blood glucose levels, and Lantus 20 units twice daily. -Resident 22 had orders for Glargine 5 units daily.-Resident 23 had orders for Humalog to be given based on the residents' current blood glucose levels. -Resident 29 had orders for Lantus inject 50 units daily.-Resident 31 had orders for Lantus inject 35 units daily.-Resident 35 had orders for Lantus inject 10 units daily.-Resident 37 had orders for Lantus inject 42 units daily and Lispro inject 3 times daily based on blood glucose levels. -Resident 39 had orders for Basaglar inject 20 units twice daily, and Novolog inject 3 times daily based on the residents' blood glucose levels. -Resident 40 had orders for Lantus inject 45 units daily and Lispro inject 12-16 units 3 times daily based on the resident's blood glucose levels. -Resident 43 had orders for Lantus inject 20 units in the morning and 5 units at bedtime.-Resident 54 had orders for Glargine inject 8 units at bedtime.-Resident 59 had orders for Lispro inject after each meal based on the residents' current blood glucose levels and Rezvoglar 28 units daily. K. During an interview on 1/12/26 at 3:05 PM the Director of Nursing (DON) confirmed that all insulins must be dated when opened, to prevent it from being used beyond manufacturers' recommendations to ensure effectiveness. In addition, all undated insulin present on the medication carts would be discarded and destroyed to prevent further use. In addition, the DON confirmed that the facility had information available to direct staff in how long all types of insulin could be given once opened and all medications that were expired should be discarded/destroyed in accordance with facility policy. Further interview with the DON confirmed the facility was to complete daily checks of the facility refrigerators used for storing medications to ensure those medications requiring refrigeration were being held at appropriate temperatures. L. Review of the facility policy titled Self-Administration of Medications revised in February 2021 revealed the following: -Residents had the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. -Self-administered medications were to be stored in a safe and secure place which was not accessible by other residents. If safe storage was not possible in the resident's room, the medications of residents permitted to self-administer were stored on a central medication cart or in the medication room. A licensed nurse would transfer the unopened medication to the resident when the resident requested. M. Record review of Resident 7's admission record revealed Resident 7 was admitted on [DATE] with a diagnosis of Emphysema (chronic lung disease). Record review of Resident 7's physician orders revealed on 12/30/25 an order for Albuterol Inhaler two puffs every four hours as needed for shortness of breath, cough or wheezing may be kept at bedside. A record review of Resident 7's assessments revealed a Medication Self-Administration Safety Screen was completed on 12/31/2025 revealing the Brief Interview for Mental Status (BIMS-interview used to determine cognition) was 13. According to the MDS (an assessment tool used for care planning) manual as score of 13 to 15 indicates a person is cognitively intact. The screen revealed Resident 7 was safe to self-administer the Albuterol Inhaler. Record review of Resident 7's January 2026 Medication Administration Record (MAR) revealed a physician's order for Albuterol inhaler, inhaling two puffs into lungs every four hours as needed for shortness of breath/cough/wheezing, may keep in room. The following observations were revealed of Resident 7's Albuterol Inhaler: On 1/11/26 at 11:20 AM the Albuterol Inhaler was sitting on top of resident's dresser, not locked up. On 1/12/26 at 9:15 AM the Albuterol Inhaler was sitting on top of resident's dresser, not locked up. On 1/12/26 at 2:15 PM the Albuterol inhaler was sitting on top of resident's dresser, not locked up. An interview on 1/13/26 at 2:45 PM with the DON confirmed that medications that were self-administered by the residents were to be stored in safe and secure place that was not accessible by other residents. N. According to Resident 31's admission record, Resident 31 was admitted to the facility on [DATE] with a diagnosis of Quadriplegia (a paralysis affecting both arms and legs, chest, abdomen, pelvis and back). Record review of Resident 31's January 2026 Medication Administration Record (MAR) revealed an order for Enemeez Mini Enema 5 milliliters (ml) into the rectum at bedtime. The following observations of Resident 31's room revealed the following: -There were three Enemeez Mini Enema's on Resident 31's vanity on 1/11/26 at 9:20 AM making this available to any staff, visitor or resident. -There were three Enemeez Mini Enema's on Resident 31's vanity on 1/11/26 at 12:30 PM making this available to any staff, visitor or resident. -There were three Enemeez Mini Enema's on Resident 31's vanity on 1/12/26 at 8:30 AM making this available to any staff, visitor or resident. Review of Resident 31's assessments from 06/15/2023 through 01/13/2026 did not reveal evidence of an evaluation of Resident 31's ability to self-medicate. An interview on 01/12/26 with Licensed Practical Nurse (LPN-K) confirmed that Resident 31 does not self-administer medications and there should not be any medications in Resident 31's room.

Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review and interview; the facility failed to change gloves and wash hands at appropriate intervals during food preparation and the meal service to prevent the potential for cross-contamination and food-borne illness. This had the potential to affect any resident that consumed food prepared/served by the kitchen. The facility census was 46. Findings are:A. Review of the facility policy Handwashing, undated revealed Dietary Staff would wash their hands before starting work, when returning to work, after smoking, eating, drinking, after visiting restrooms, after handling garbage or poisonous compounds, and at other times hands were soiled. Hand washing facilities should be readily accessible and equipped with paper towels and soap. B. Review of the facility policy Glove Use, undated revealed it was the policy to wear gloves to protect both patrons and employees from contagious and foodborne illnesses. Employees would do the following:-wash their hands thoroughly before and after wearing or changing gloves;-choose the correct size gloves to fit their hands;-change disposable gloves between tasks and not wear them continuously;-change gloves if they rip or become soiled;-change gloves after sneezing, coughing, or touching their hair and/or face;-not use food contact gloves for nonfood tasks including cleaning, handling money, etc.;-remove disposable gloves by grasping at the cuff and peeling them off inside out;-wear gloves with handling salad bar items, fruits, sandwiches, cooked foods, deli meats, cheese, breads, and ice;-wear disposable gloves at all times if they were wearing artificial nails or fingernail polish; and-find gloves conveniently located in racks at hand sinks and near workstations. C. Observation on 1/12/26 at 10:55 AM Cook-F was already wearing gloves when preparing ground meat and puree meal preparation for residents who required those consistency of meals. Cook-F obtained ham with pineapple from the metal container using tongs and placed a sufficient amount in the blender. Cook-F obtained a saucepan off the stove that contained gravy and placed a ladle of gravy in with the ham and pineapple then placed the lid on the blender, held it in place with their left hand and pushed the buttons of the blender with their right hand. When finished Cook-F removed the lid of the blender, Cook-F reached into the blender with their right hand while wearing the same gloves used to touch the food containers, tongs, saucepan handle, ladle, blender lid and buttons grabbed large chunks of ham and ripped them up with their gloved hands and placed them back into the blender. Continuing to wear the same pair of gloves, Cook-F placed the lid back on the blender and pushed the buttons on the blender. Cook-F, while continuing to wear the same pair of gloves opened the blender, then grabbed another chunk of ham with their gloved hands and ripped that piece up. Cook-F replaced the lid, continued to wear the same pair of gloves, and utilized the buttons to puree the ham further to the desired consistency. While still wearing the same pair of gloves, Cook-F transferred the puree ham into a clean metal container using a spatula, then Cook-F removed their gloves. No hand hygiene was observed to have been performed. Cook-F ran the blender container through the dishwasher, then put on new gloves without performing hand hygiene. Cook-F obtained a new pan from the shelf and used the same tongs to place ham into the blender. Cook-F placed the lid on the blender and held it in place using their left hand while pushing the buttons with their right hand. Cook-F removed the blender lid and grabbed large chunks of ham while continuing to wear the same gloves and ripped the ham up. Cook-F replaced the lid on the blender, held it in place and pushed the buttons with their right hand. While continuing to wear the same pair of gloves, Cook-F transferred the ground meat into a new metal pan and covered the pan with a lid. Cook-F removed their gloves and placed the ham containers on a cart. No hand hygiene was observed to have been completed.D. Observation on 1/12/26 at 11:50 AM Cook-F brought the food for the lunch meal from the main kitchen to the serve-out kitchen. Cook-F applied gloves without performing hand hygiene. Cook-F started serving the lunch meal at 11:55 AM. Cook-F placed the pureed ham in a microwaveable bowl and placed the meat in the microwave, then pushed the buttons to warm up the food, and then placed the food back on the steam table. While continuing to wear the same pair of gloves, Cook-F grabbed a loaf of bread from the counter, opened it and placed it on top of the steam table. Cook-F grabbed a slice of bread while continuing to wear the same pair of gloves and placed it on a plate to be served. While continuing to wear the same pair of gloves, Cook-F went to the refrigerator and took out sliced turkey and sliced cheese which were in ziplock bags. Cook-F obtained a plate, and while wearing the same pair of gloves, grabbed 2 slices of bread and placed them on a plate. Cook-F then opened the turkey, grabbed 2 slices and put them on the bread. Continuing to wear the same gloves, Cook-F then opened the cheese, grabbed a piece and placed it on the other slice of bread, then placed the two slices together. Cook-F served the sandwich. Cook-F went to the refrigerator, opened it and grabbed a bag of buns. Cook-F then grabbed a bun out of the bag with the gloved hand and placed it on a plate with ham and served the plate. Cook-F, while continuing to wear the same pair of gloves grabbed a can of chicken noodle soup from a plastic package. Cook-F opened the can and placed it in a bowl, then put it in the microwave, while touching the handle of the microwave and the buttons of the microwave while continuing to wear the same gloves. Cook-F resumed serving from the steam table. No observations of hand hygiene or glove changing was observed. E. Interview on 1/12/26 at 12:35 PM with Cook-F confirmed Cook-F did not perform hand washing and glove changing at appropriate intervals. F. Interview on 1/12/26 at 1:50 PM with the Certified Dietary Manager confirmed hand washing should be completed after removing gloves and gloves should be changed when touching non-food items to touching food items.

Licensure Reference Number 175 NAC 12-006.09(F)(iii)Based on record review and interview; the facility failed to ensure Residents 8 and 41's Care Plans accurately reflected the need to implement Enhanced Barrier Precautions (EBP- the use of Personal Protective Equipment (PPE) during high contact care) during the care of Residents 8 and 41 who had MDRO's (Multi-Drug Resistant Organisms), and the use of Antipsychotic (medication that is used primarily in the treatment of severe mental illness) for Resident 1. The sample size was 17 and the facility census was 46. Findings are: A. Review of the facility policy Care Plans, Comprehensive Resident Centered with a revision date of March 2022 revealed the following; -The facility developed and implemented a comprehensive, person-centered care plan that included objective and timetables to meet the resident's physical, psychosocial and functional needs, -described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being,-reflected currently recognized standards of practice for problem areas and conditions,-and was updated for a significant change in the resident's condition. B. Review of the facility policy Enhanced Barrier Precautions dated 2024 revealed the facility implemented EBP to prevent the transmission of multidrug-resistant organisms that employed targeted gown and glove use during high contact resident care activities. The facility promptly identified need and initiated EBP's which included the following: -all staff received training on EBP upon hire and annually and were expected to comply with all designated precautions.-The facility had gloves and gowns available near or immediately outside the resident's room. PPE for EBP's were necessary when performing high-contact care activities.-EBP's were used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that place them at higher risk. C. During an observation on 1/11/26 at 8:00 AM a sign titled Enhanced Barrier Precautions was posted on the wall directly outside Residents 8's room identifying staff were to clean their hands before entering and leaving the resident room. In additional Providers and Staff were to wear gloves and a gown for the following High-Contact Resident Care Activities; Dressing, Bathing, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or assisting with toileting, Device care or use (central lines, urinary catheters, feeding tubes, or tracheostomy), and/or Wound care for any skin opening requiring a dressing. D. Review of Resident 8's Care Plan with a revision date of 11/4/25 revealed the resident was dependent on staff for meeting physical needs due to cognitive and physical limitations. This included assistance with toileting and related hygiene needs and changing of briefs. Further review revealed the resident was Resistant to Vancomycin (VRE-an MRDO) however, the was no evidence in the plan of care that staff were to use EBP (the use of gowns and gloves during all high-contact resident care). E. During an observation on 1/11/26 at 8:00 AM a sign titled Enhanced Barrier Precautions was posted on the wall directly outside Residents 41's room identifying staff were to clean their hands before entering and leaving the resident room. In additional Providers and Staff were to wear gloves and a gown for the following High-Contact Resident Care Activities; Dressing, Bathing, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or assisting with toileting, Device care or use (central lines, urinary catheters, feeding tubes, or tracheostomy), and/or Wound care for any skin opening requiring a dressing. F. Review of Resident 41's Care Plan with a revision date of 9/2/25 revealed the resident had the MRDO Methicillin Resistant Staphylococcus Aureus (MRSA). Additional review revealed the resident had mild incontinence, wore a brief, and staff were to assist as needed with incontinence care. Further review revealed no evidence staff were to use EBP during all high contact resident care. During an interview on 1/12/26 at 8:33 AM, NA-C revealed the NA was not aware Residents 41 and 8 were on Enhanced Barrier Precautions. In pointing out the sign on the outside of the room, NA-C continued to deny being aware either resident was on EBP because they don't have catheters, and or don't go to dialysis. NA-C was not aware of other criteria that would require the use of EBP. G. Review of the facility policy Psychotropic Medication Use, last revised February 2025 revealed the following: -residents would not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record; -medications included antipsychotics, antidepressants, antianxiety, and hypnotics/sedatives were subject to prescribing, monitoring, and review requirements specific to psychotropic medications; -psychotropic medication management involved the resident, family and/or representative; -residents who had not used psychotropic medications were not prescribed or given those medications unless the medication is determined to be necessary to treat a specific condition that was diagnosed and documented in the medical record; -prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and the physician would review the following with the resident/representative prior to obtaining documented consent or refusal: non pharmacological alternatives, the indication and rationale for the recommendation, the potential risks and benefits, and the representative right to accept or decline the treatment. H. Review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool used in Care Planning) dated 12/8/25 revealed the resident was admitted on [DATE]; was cognitively impaired; required assistance with dressing, hygiene, transfers, and toileting; had diagnoses of Kidney Disease and Non-Alzheimer's Dementia; and received antipsychotic and antidepressant medications. Review of Resident 1's Care Plan last revised 12/15/25 revealed the resident required assistance with dressing, bed mobility, toileting, and transfers; had impaired cognitive function due to Dementia; received antidepressant medications; and was on Hospice Care. There was no documentation that the resident was receiving an antipsychotic medication. Review of Resident 1's Order Summary Report with active medication orders revealed an order for Haloperidol (an antipsychotic medication) 2 milligrams (mg) every 6 hours for a diagnosis of Dementia with a start date of 10/23/25. Review of Resident 1's Medication Administration Record revealed the resident received Haloperidol 108 out of 120 administrations in November 2025, 108 out of 120 administrations in December 2025, and 51 out of 51 administrations in January 2026. I. Interview on 1/14/26 at 1:00 PM with the MDS Coordinator revealed Enhanced Barrier Precautions was not on the Care Plan for Resident 8 and 14, and the antipsychotic was not on the Care Plan for Resident 1. J. Interview on 1/14/26 at 1:20 PM with the Director of Nursing confirmed Enhanced Barrier Precautions was not on the Care Plan for Residents 8 and 14 and the antipsychotic medication for Resident 1 was not on the Care Plan.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(iii)(3)Based on observations, record review, and interview; the facility failed to thoroughly assess bruising and to implement interventions to prevent ongoing bruises for Resident 52. The sample size was 2 and the facility census was 46 Findings are: A. Review of a facility policy titled Pressure Ulcers and Skin Policy with a reviewed date of 8/22 revealed the nursing staff were to examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. When bruising was observed, staff were to ensure appropriate clinical assessment occurred. The assessment was to include the general location, appearance, resident comfort, reported concerns and any reasonable contributing factors. Documentation was to support continuity of care and demonstrate bruising was recognized and addressed with ongoing observation and appropriate follow-up when indicated. Additional follow-up may occur when there was a change in condition, increased bruising, resident concern, or other clinical indicators. B. Review of Resident 52's Nursing Admission/Screening History dated 1/6/26 at 9:27 AM revealed no skin issues were noted.Review of the resident's current Care Plan dated 1/7/26 revealed the resident was admitted [DATE] with diagnoses of spinal stenosis, atrial fibrillation, repeated falls, history of Transient Ischemic Attacks (brief interruption of blood flow to the brain leading to temporary symptoms like those of a stroke), anxiety, and depression. The resident was identified at risk for skin breakdown related to fragile skin and side effects from blood thinner medications. Interventions included the following:-avoid scratching, keep fingernails short and avoid excessive moisture to body parts.-identify/document potential causative factors and eliminate/resolve where possible.-encourage the resident to wear shirts with long sleeves or geri-sleeves (sleeves made with breathable material that contours to the shape of the arm which protects skin from bruising and skin irritation). -keep skin clean and dry, apply lotion to dry skin. Review of a Nursing Progress Notes revealed the following:-1/7/26 at 2:00 AM the resident was found seated on the floor of the resident's room. The resident was barefoot and the right great toenail was bleeding. No further areas of skin breakdown were identified.-1/8/26 at 9:20 AM the resident's skin without bumps, bruises or redness noted. Right great toe with no further bleeding.-1/8/26 at 5:00 PM the resident's skin was without any new bumps, bruises, or redness. The bump to the resident's temple had subsided.-1/8/26 at 9:40 PM the resident was observed laying on the floor of the resident's room. The resident reported striking head and a small bump was noted above/beside the left eye.-1/9/26 at 8:20 PM the resident's skin is without any new bumps, bruises or redness noted. Area above the left eye continues with bruising to small bump.-1/11/26 at 5:45 AM the resident was up all night, repeatedly attempting to get up out of the wheelchair and yelling/hitting at staff. -1/11/26 at 10:59 AM resident noted to have bruises scattered on bilateral arms from fall and bumping items from being active up and down all night. During an observation on 1/11/26 at 11:02 AM, the resident was seated by the Nurse's Station in a tilt-n-space wheelchair (chair which allows the entire seating system to tilt backward while maintaining the user's hip, knee, and ankle angles). Resident 52 was picking things out of the air and attempted to reach down to the floor to pick up items. Resident 52 was wearing a short sleeved shirt and pants were pulled up to the resident's mid shins. The resident had dark purple bruising visible to bilateral arms from mid-bicep to the wrist, bilateral lower legs from the resident's ankle to the mid shin area and a bruise was noted above the resident's left eye. No protective sleeves or long sleeves were observed on the resident's arms. Review of Nursing Progress Notes on 1/12/26 at 8:17 AM revealed a late entry for 1/10/26 (no time) which indicated the resident had been up throughout the day with increased anxiety and multiple attempts to exit seek. The resident was unbalanced and would run into doors/hand railings and was resistive with cares. Several discolored areas were noted to the residents' arms. During an observation on 1/12/26 at 10:38 AM, Nurse Aide (NA)-D and NA-C approached the resident who was seated in a recliner in the front commons area. The resident was wearing gripper socks, a sleeveless night gown and a short sleeved t-shirt. No arm protectors or long sleeves were in place. A gait belt was placed on the resident who was then transferred into a wheelchair and assisted to the resident's room for cares. During an interview on 1/12/2026 at 11:48 AM, Registered Nurse (RN)- AA reported the direct care staff were to notify the Charge Nurse of any new areas of skin breakdown and then the Charge Nurse was responsible for completing and documenting an assessment. The RN further reported typically measuring any new areas of breakdown, including bruising so that the staff can define if the areas are healing or not. Review of a Facsimile (Fax) Communication Sheet dated 1/13/26 at 1:31 PM revealed the resident's Primary Care Provider was notified the resident had scattered bruising to bilateral arms and requested a review of the resident's current medications. Further review of the fax revealed no evidence the bruising to the resident's left eye or bilateral lower legs being identified. During an interview with the Director of Nursing (DON) on 1/12/26 at 11:51 AM, the DON confirmed the Charge Nurses were responsible for completing assessments of any areas of skin breakdown. The DON indicated Resident 52's bruising was extensive and would not expect the staff to measure the areas but would expect to have documentation of all areas of breakdown with descriptions regarding exact location, color, and extent of the bruising to measure if bruises were healing. The DON did verify the resident's care plan identified use of long sleeves or geri-sleeves to be placed on the resident's arms to protect the resident's skin and to potentially prevent further bruising.

Licensure Reference Number 175 NAC 12-006.10 (A)(i)Based on record review, observation and interview, the facility failed to evaluate 1 (Resident 31) of 2 sampled residents for self-administration of bedside medications. The facility staff identified a census of 46. Findings are: A. Review of the facility policy titled Self-Administration of Medications revised in February 2021 revealed the following:-Residents had the right to self-administer medications if the interdisciplinary assessed resident's cognitive and physical abilities to determine whether self-administering medications were safe and clinically appropriate for the resident.-If it was deemed safe and appropriate for a resident to self-administer medications, this was documented in the medical record and the care plan. B.According to Resident 31's admission record, Resident 31 was admitted to the facility on [DATE] with a diagnosis of Quadriplegia (paralysis affecting both arms and legs, chest, abdomen, pelvis and back). Record review of a quarterly Minimum Data Set (MDS) (a federally mandated assessment utilized to determine a resident's functional capabilities and care) dated 11/19/25 revealed the Brief Interview for Mental Status (BIMS-interview used to determine cognition) was 15, which indicated the resident was cognitively intact. Record review of Resident 31's Care Plan dated 06/15/23 revealed there was no evidence of a focus issue, goal or interventions regarding self-administration of medication. Record review of Resident 31's January 2026 Medication Administration Record (MAR) revealed an order for Enemeez Mini Enema five milliliters (ml) into the rectum at bedtime. Review of Resident 31's assessments from 06/15/23 through 01/13/26 did not reveal evidence of an evaluation of Resident 31's ability to self-medicate. The observations of Resident 31's room revealed the following:-There were three Enemeez Mini Enema's on Resident 31's vanity on 1/11/26 at 9:20 AM making this available to any staff, visitor or resident.-There were three Enemeez Mini Enema's on Resident 31's vanity on 1/11/26 at 12:30 PM making this available to any staff, visitor or resident.-There were three Enemeez Mini Enema's on Resident 31's vanity on 1/12/26 at 8:30 AM making this available to any staff, visitor or resident. An interview on 01/12/26 at 1:45 PM with Licensed Practical Nurse (LPN)-K confirmed that the facility had not completed an evaluation for Resident 31's ability to self-administer medications and there was no physician order for Resident 31 to self-administer medication.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, record review and interview; the facility staff failed to implement a water management plan to prevent potential illness such as Legionella( a bacteria) and failed to ensure a urinary catheter bag was secured to prevent potential contamination for 1 (Resident 12) of 3 residents. The facility had a census of 52. Findings are: A. Record review of a undated Policy and Procedure for the facility Water Management Program revealed the following information. -1. A water management team has been established to develop and implement the facility's water management program, including facility leadership the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing. a. Team members have been educated on the principles of an effective water management program, including how Legionella and other water-borne pathogens grow and spread. Education is consistent with each team members role. b. The water management team has access to water treatment professionals, environmental health specialists and state/local health officials. -2. The maintenance director maintains documentation that describes the facility's water system. A copy is kept in the water management binder. -3. A risk management assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will consider the following elements: a. Premise plumbing. This includes water system components as described in the documentation of the facility's water system. b. Clinical equipment. This includes medical devices and other equipment utilized in the facility that can spread Legionella through aerosols or aspiration. c. At-risk population: This facility's entire population is at risk. High risk areas shall be identified through the risk assessment process. Supporting documentation of any areas or resident population that exhibit greater risk than the general population shall be kept in the water management program binder. -4. Data to be used for completing the risk assessment may include, but are not limited to a. Water system schematic description b. Legionella environmental assessment c. Resident infection control surveillance data d. Environmental culture results e. rounding observation data f. water temp logs g. water quality reports from drinking water provider. h. community infection control surveillance data. -8. The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will now verify the program activity for which they are responsible. -9. The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data and rounding data shall be utilized to validate the effectiveness. -12. The facility will conduct an annual review of the water management program as part of the annual review of the infection prevention and control program, and as needed, such as when any of the following events occur. -In the event of an update to the water management program, the water management team shall: -a. Update the water system/schematic/description, associated control points, control limits and -14: Documentation of all of the activities related to the water management program shall be maintained with the water management program binder for a minimum of 3 years. An interview on 10/31/2024 at 11:29 AM with the maintenance person K confirmed they could not locate a Water Management Plan or a schematic plan of the facility's water system and meant the facility did not have one. 49164 B. Record review of Resident 12's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 06-30-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 7. According to the MDS [NAME] a score of 0-7 indicates a person has a severe cognitive impairment. -Required extensive assistance with eating -Required total assistance with bed mobility, transfers, toileting, bathing, and dressing. An observation on 10-28-2024 at 2:27 PM of Resident 12 lying in bed with the urinary catheter bag laying face down on the fall mat next to Resident 12's bed. An observation on 10-30-2024 at 7:32 AM of Licensed Practical Nurse (LPN) A and LPN G performing catheter care for Resident 12 revealed the urinary catheter bag was hanging on the bed-frame. After performing catheter care, LPN A lowered the bed frame of the bed to the lowest position allowing the catheter bag to touch the floor. An interview on 10-30-2024 at 8:00 AM with LPN A confirmed the catheter bag was touching the floor. An observation after the interview with LPN A on 10-30-2024 at 8:00 AM revealed LPN A removed the catheter bag from the bed-frame and placed in on the fall mat next to Resident 12's bed. A follow up interview with LPN A confirmed that the fall mat on the floor was dirty and placing the catheter bag on the fall mat could cause cross contamination. An interview conducted on 10-31-2024 at 1:15 PM confirmed the catheter bag should not touch the floor, or the fall mat which is stored and used on the floor due to the potential for cross contamination. Record review of the facility's undated policy titled Catheter Care, Urinary revealed the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The policy directs staff to use aseptic technique when handling or manipulating the drainage system and to be sure the catheter tubing and drainage bag are kept off the floor.

Licensure Reference Number 12.006.11(E) Based on observation and interview the facility failed to ensure the cleanliness of the shelf below the prep table and the stand-up mixer and failed to secure the floor tiles under the convection oven in a manner to prevent build up of dirt and debris. This had the ability to affect 49 of 52 residents who ate from the facility kitchen. The facility census was 52. The findings are: An observation on 10-28-2024 at 8:30 AM of the kitchen revealed food build up and debris on the bottom shelf of the prep table, and the stand-up mixer. An observation on 10-30-2024 at 10:00 AM of the kitchen revealed the floor tiles under the convection oven were no longer secured the underfloor and food debris were collecting underneath. An interview with the Kitchen Manager (KM) on 10-31-2024 at 9:30 AM confirmed the buildup and debris on the bottom shelf of the prep table and the stand-up mixer. Furthermore, the KM confirmed the flooring under the convection oven was coming loose from the underfloor and dirt and build up were collecting underneath.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to provide a written investigation to the State Agency within the required five working days for 1 (Resident 1) of 4 sampled residents. The facility census was 56. Findings are: A. Review of the facility policy Abuse, Neglect, and Exploitation dated 5/8/23 revealed the following: -It is the policy of Continental Springs LLC to protect the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. -The facility will have written procedures that include reporting of all alleged violations to the Administrator/Director of Nurses (DON), a state agency, Adult Protective Services (APS), and all other required agencies within specified time frames; immediately, but no later than 2 hours if the events involve abuse and no later than 24 hours if the events do not involve abuse and/or serious bodily injury. -The Administrator/DON will provide a summary of the investigation to the state agency within 5 business days. B. Review of a facility investigation dated 3/6/24 related to a fall with significant injury for Resident 1 revealed the following: On 2/28/24 the resident was found at the bedside with bleeding on the left side of the face. The resident complained of pain was sent to the hospital for evaluation. The facility staff were notified the resident had a brain bleed and a facial fracture and remained at the hospital. Further review revealed the facility had not submitted the written investigation to the State Agency within the required 5 business days. The facility submitted the written investigation to the State Agency on 3/6/24. An interview with the DON on 3/19/24 at 12:40 PM confirmed Resident 1 had a fall with significant injury that occurred on 2/28/24 and the written investigation was not submitted to the State Agency within the required 5 business days.

Licensure reference number 175 NAC 12-006.11D Based on record review, observations and interviews; the staff failed to maintain food temperatures in a manner to prevent potential food borne illness. This has the potential to effect 52 of 54 residents. The facility staff have identified the census to be 54. The findings are: Record review of facility policy dated April 2019 titled Food Preparation and service: Section Food preparation, Cooking and holding time/temperatures revealed; - The danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness, - Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese, - The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous food (PHF) must be maintained below 41 degrees or above 135 degrees Fahrenheit, - Internal cooking temp for ground meat (beef, pork), ground fish, raw eggs held for service, comminuted meat, injected or mechanically tenderized meats, ratites at 155 degrees Fahrenheit for 15 seconds, - Internal cooking temp for poultry, wild game, stuffed fish, stuffed meats at 165 degrees Fahrenheit for 15 seconds. The policy further revealed ready to eat foods that require reheating are taken directly from the sealed container or intact package from the food processing source and cooked to at least 135 degrees Fahrenheit. The policy revealed mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees Fahrenheit during preparation or they are reheated to 165 degrees Fahrenheit for at least 15 seconds. Record review of facility policy dated April 2019 titled Food Preparation and service: Section Food Service/Distribution revealed the temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff. Observation on 08/22/23 at 12:30 PM revealed room trays were made in the dining from the steam table and placed in an insulated cover on an uninsulated cart. The room trays were on the cart from 12:30 PM-12:45 PM for a total of 15 minutes. At 12:45 PM facility staff took the cart with the room trays for the entire facility and started to pass the room trays on hall 500. Observation on 08/22/23 at 1:08 PM revealed resident #25's room tray being delivered. Observation on 08/23/23 at 8:43 AM revealed room trays were made in the dining room from steam table and placed on uninsulated cart. Observation on 08/23/23 at 8:47 AM revealed Cook A obtained the following temperatures: a sausage patty on a plate was 101 degrees Fahrenheit, scrambled eggs on the steam table were 114 degrees Fahrenheit, and oatmeal on the steam table was 130 degrees Fahrenheit. Observation on 08/23/23 at 9:06 AM revealed the facility staff began passing room trays on halls 500, 300, 100, 200. The facility staff were completed with delivering room trays throughout the facility at 9:25 AM. Observation on 08/23/23 at 9:25 AM revealed delivery of the last room tray on hall 200. A food temperature check was completed on a test tray on hall 200 which revealed the sausage temperature at 77.5 degrees Fahrenheit and oatmeal at 124.2 degrees Fahrenheit. Observation on 08/23/23 at 12:36 PM revealed lunch room trays started being plated and placed on the cart from the steam table in the dining room. Observation on 08/23/23 at 12:50 PM revealed dietary staff took the room trays from the dinning room to pass the room trays throughout the facility. The dietary staff began passing room trays at 12:55 PM and completed at 1:07 PM. Observation on 08/23/23 at 1:07 PM revealed delivery of the last room tray on hall 200. A food temperature check was completed on a test tray on hall 200 was the pork was 129.3 degrees Fahrenheit, potatoes 130.6 degrees Fahrenheit, and mixed vegetables 126.1 degrees Fahrenheit. Interview on 08/23/23 at 8:50 AM with Cook A revealed that Cook A did not remember what the safe serving temperature for food was. Cook A also confirmed the facility does not have logs for food temperatures from the steam table to check the functioning of the steam table and that foods are held at a safe serving temperature. Interview on 08/23/23 at 9:03 AM with Dietary Aide D revealed that Resident #25 complained about cold food. Interview on 08/23/23 at 11:57 AM with Cook A revealed the only time food temperatures are taken was in the kitchen after coming out of the oven prior to serving in the dinning room. Interview on 08/23/23 at 2:42 PM with Resident #1 revealed the food on room trays is not hot enough which is why the resident goes to the dining room for meals. Interview on 08/23/23 at 2:45 PM with Resident #39 revealed food on room trays for all meals are cold and the coffee is warm at best. Interview on 08/23/23 2:48 PM The Administrator confirmed there had been food temperature complaints, and the facility initiated a Performance Improvement Plan (a document that aims to help employees/facility meet job performance goals) on food temperatures. The Performance Improvement Plan (PIP) was started on 7/27/23. The Administrator stated the PIP identified the dietary staff were to pass room trays one hallway at a time then go back to the dining room, and plate the food for the next hallway. The Administrator revealed the dietary staff were to complete that process between each hallway delivery. The Administrator confirmed the PIP was not working as the identified actions were not put into place. Interview on 08/24/23 at 9:10 AM with the Dietary Supervisor revealed the expectation for steam table food temperature should be 145 degrees Fahrenheit and food temperatures for hot food would be to maintain 135 degrees Fahrenheit of all hot food. Dietary Supervisor confirmed the temperatures of food on room trays that were served on 8/23/23 was a concern. Dietary Supervisor confirmed the process for passing room trays was not implemented as identified from the facility PIP regarding room temperatuers. The Dietary Supervisor revealed there are not measures in place to monitor the food temperatures throughout the meal delivery and service.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to serve food in a sanitary manner, wash hands when indicated to prevent cross contamination, and maintain a clean environment and equipment to prevent potential food borne illness. This had the potential to affect all residents who ate from the facility kitchen. The facility census was 46. Findings are: A. Review of the facility policy Food Safety and Sanitation date 2017 revealed the following; -All local, state, and federal standards and regulations would be followed to ensure safe services, -The kitchen would be kept clean, neat, and orderly, and -employees would wash their hands after touching self, others, or surfaces/items with potential contamination. B. Observation made during the survey revealed the following; -during the initial kitchen tour on 7/27/22 at 9:06 AM a ceiling air vent located above the food preparation area was noted to be covered in dust and debris, -during a subsequent kitchen tour on 8/1/22 at 11:00 AM the ceiling air vent located above the food preparation area remained covered in dust and debris, -during the subsequent kitchen tour on 8/1/22 at 11:00 AM 2 uncovered totes, one containing serving scoops and utensils, and one containing measuring devices were located on a shelf below the food preparation area, with all items in the totes stored upside down and downside up, rendering staff unable to obtain items without touching the serving surfaces of other items, -during the subsequent kitchen tour on 8/1/22 at 11:17 AM a countertop ice machine was observed and Dietary Staff -C reported no knowledge of a cleaning procedure or knowledge of a cleaning schedule for the ice machine, - during observation of meal service at 11: 53 AM Cook-A donned disposable gloves for the meal service and touched disposable food containers for room trays on the inside and outside surfaces, a thermometer for checking food temperatures, foil coverings on top of prepared food, oven doors, cabinet drawers, visibly soiled potholders, serving scoops/spoons, a bag of hot dog buns, and the steam table. Without removing the soiled gloves Cook-A removed hot dog buns from the package and placed them in the disposable food service containers for the room trays. Cook-A then obtained a package of sliced cheese from the refrigerator and opened the cellophane covering, removed the cheese from the package and place individual slices of cheese on the buns and continued to wear the same pair of gloves. Cook-A then placed prepared meat on the buns with a serving utensil, but also touched the meat with the gloves, placed French fries in the containers with a serving utensil, also touching the fries with the gloved hands. Cook A- also reached and adjusted goggles and a face mask being worn for COVID-19 precautions, and returned to serving the meal without changing gloves or washing hands. C. Interview with the facility Administrator on 8/1/22 at 2:00 PM confirmed that air vents, and appliances such as the ice maker should have been on a regular cleaning schedule, staff should wash or sanitize their hands prior to putting on gloves, when gloves are changed, and confirmed that ready to eat food should not be handled with gloves used to complete other tasks.

Licensure Reference Number 175 NAC 12-006.17D Based on observations, record review and interview, the facility staff failed to; 1) provide an aerosol generating procedure according to standards of practice for Resident 11, 2) change gloves and perform hand hygiene to prevent cross contamination during incontinence cares for Resident 7, 3) wear gloves while entering the rooms of residents on transmission-based precautions, and 4) wash/sanitize hands at intervals to prevent the spread of infections, including Covid-19. The sample size was 23. The facility census was 46. Findings are: A. Review of the undated facility policy titled Handwashing/Hand Hygiene revealed staff shall perform handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors in the following situations: -before and after coming on duty; -before and after direct contact with residents; -before preparing/handling medications; -before performing any non-surgical invasive procedures; -before and after handling an invasive device (ie. IV access sites); -before donning sterile gloves; -before handling clean or soiled dressings; -before moving from a contaminated body site to a clean body site during resident care; -after contact with a resident's intact skin; -after contact with blood or bodily fluids; -after handling used dressings, contaminated equipment, etc.; -after contact with objects in the immediate area of the resident; -after removing gloves; -before and after entering isolation precaution settings; -before and after eating or handling food; -before and after assisting a resident with meals; and -after personal use of toilet or conducting your personal hygiene. Further review of the Handwashing/Hand Hygiene policy revealed hand hygiene is the final step after removing and disposing of personal protective equipment (ie. gloves, gowns, face masks and eye protection). Additionally, the use of gloves does not replace hand washing/hand hygiene and should be used before procedures, when anticipating contact with blood or body fluids, and when in contact with a resident, the equipment or environment of a resident who is on isolation precautions. B. Review of Resident 7's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting and personal hygiene cares. On 8/2/22 at 10:20 AM observations of Resident 7 revealed the following: -Nurse Aide (NA)-K and NA-L wore isolation gowns, gloves, eye protection and an N95 Mask upon entering the room; -NA-K and NA-L removed the resident's soiled incontinence brief and prepared to clean the resident's perineal (genitals and buttocks) area; -NA-L used disposable cleansing wipes and cleaned the resident's front side first, then NA-K helped to turn the resident on [gender] side to clean the back side; -NA-L then used 3 disposable cleansing wipes to clean the resident's buttocks that had a small amount of feces in the area, but did not remove the soiled gloves or perform hand hygiene after; -NA-L proceeded to assist NA-K with putting on a clean incontinence brief and dressed the resident touching the resident's clothing and arms with the same pair of soiled gloves; -NA-L cleaned the residents face, upper body and hands using additional cleansing wipes while wearing the soiled gloves; -NA-L then cleaned the resident's mouth using a disposable toothette (a tool used for mouth cares) while wearing the soiled gloves; and -NA-L then touched and combed the resident's hair while wearing the same pair of soiled gloves. An interview with NA-L on 8/2/22 at 10:45 AM, confirmed NA-L had not removed the soiled gloves and washed hands immediately after performing incontinence cares on Resident 7 and should have done this before touching the resident. B. Review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR further indicated during a COVID outbreak, the resident's room door was to be closed during the treatment and staff were to wear N95 masks. Observations on 7/28/22 at 12:41 revealed the following regarding Resident 11: -signs had been placed on the door of resident's room which indicated the resident was currently in a Yellow Zone (quarantine zone for residents who had been exposed to COVID-19 and were asymptomatic). The sign further indicated staff were to wear gowns, gloves, eye protection and N95 masks when entering the resident room; and -the door to the resident's room was open and the resident was positioned in a wheelchair in the doorway of the room entrance. The resident was observed receiving a Nebulizer treatment (small handheld device that converts liquid medication into a fine spray of aerosols) and was rolling back and forth in the chair between the doorway and into the corridor while receiving the treatment. During an interview on 7/28/22 at 2:34 PM, the Director of Nursing (DON) confirmed Resident 11 was receiving routine aerosolizing treatments. In addition, the DON confirmed the resident was currently in a Yellow Zone and when the resident received these treatments, the resident was to be in their room with the door closed. C. During an observation on 7/27/22 at 11:30 AM Licensed Practical Nurse (LPN)-I entered resident room [ROOM NUMBER] and announced blood sugar check upon entry. LPN-I had on an N95 face mask, eye protection and gloves but no gown. The resident door sign indicated yellow zone and directed the staff to wear full PPE (personal protective equipment -gown, gloves, eye protection, and an N95 face mask). Gowns, gloves, face masks, and hand sanitizer were available outside the resident room door in a caddy. LPN-I entered the room without a gown; talked to the resident behind a privacy curtain and exited the room with gloves on, then proceeded to the medication cart located across the hall and approximately 15 feet away from room [ROOM NUMBER]. LPN -I did not remove the gloves she had worn into room [ROOM NUMBER], touched the top and drawers of the medication cart, and touched the laptop computer located on the medication cart before removing the gloves. LPN-I removed the gloves, and then placed on a clean pair of gloves and did hand sanitize. LPN-I then returned across the hall to room [ROOM NUMBER] and put on a gown prior to entering the room. LPN-I's gloves, face mask and eye protection were also on. After the episode of care was complete LPN-I exited room [ROOM NUMBER], removed gown and gloves at the doorway, returned to the medication cart, accessed the computer and then used hand sanitizer. D. During an observation on 7/27/22 at 12:38 PM through 12:50 PM of dietary staff (Dietary Aide (DA)-N and DA-O delivering room trays in hall 2 in which all residents were in isolation to prevent the spread of COVID-19, revealed the following; -A resident residing in 302 handed DA-O who was not wearing gloves, a used water pitcher from the resident room, which DA-O filled with water from a clean water pitcher located on the dietary serving cart, DA-O then handed the used water pitcher back to the resident. DA-O did not wash hands or sanitize after touching the used water pitcher from the isolation room, or before touching the clean water pitcher located on the dietary serving cart. The clean water pitcher after being touch by DA-O soiled hands was returned to the clean serving cart and DA-O proceeded down the hall to the next room without washing hands or sanitizing hands. - DA-N entered room [ROOM NUMBER] after putting on a gown, (mask and eye protection were already in place), but no gloves, delivered food tray to room and touched multiple surface, items in the room to place the tray so it was accessible to the resident, exited the room, removed the gown but did not wash or sanitize hands and grabbed the handle of and proceeded down the hall pushing the dietary cart. DA-N then stopped at room [ROOM NUMBER] and hand sanitized. E. During an interview on 7/28/22 at 11:15 AM the Director of Nursing (DON) confirmed that all facility residents were on transmission based precaution (TBP) and in isolation in their rooms to prevent the spread of COVID-19. All staff were to wear full PPE (gown, gloves, approved face mask, and eye protection) when entering all resident rooms and remove the gown and gloves when exiting the rooms. Further interview confirmed staff should always hand wash or sanitized following removal of PPE, and should not enter or re-enter rooms of residents without full PPE.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to complete AIMS (abnormal involuntary movement scale) assessments to detect potential adverse effects of antipsychotic medication use for Resident 18 and 28. The sample size was 5 and the facility census was 46. Findings are: A. Review of Resident 18's Physicians Orders dated 6/29/22 revealed Resident 18 had an order for the antipsychotic medication aripiprozole 5mg daily. Review of Resident 18's Care Plan with a revision date of 7/11/22 revealed the following; the resident took [CONDITION(S)] (affecting mental state) medication and the facility would review medication for adverse reactions. Review of Resident 18's Medical Record revealed no evidence the facility had completed an AIMS assessment to monitor the resident for potential adverse effects of the medication. Interview on 8/2/22 at 1:30 PM with RN-P (Registered Nurse) revealed that all residents taking antipsychotic medication were to have AIMS assessments completed at the time the medication is initiated and every 3 months thereafter. Additional interview confirmed the facility had not completed an AIMS assessment on Resident 18 whom had been taking an antipsychotic medication daily since 6/29/22. B. Review of Resident 28's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 5/6/22, revealed diagnoses of Non-Alzheimer's Dementia, [CONDITION(S)], and [CONDITION(S)] (a person's mental state other than [CONDITION(S)]). The resident also received antipsychotic medications on a routine basis. Review of Resident 28's Physicians Order Summary dated 8/2/22, revealed the resident received the following antipsychotic medications; [MEDICATION(S)] 50 milligrams (mg) twice a day, [MEDICATION(S)] 0.5mg twice a day and [MEDICATION(S)] 9.5mg daily. Review of the resident's electronic health record revealed an AIMS assessment had been completed on 8/9/21, 11/30/21 and 5/13/22. Further review of the resident's medical record revealed no evidence additional assessments had been completed to assure staff were monitoring the resident for potential adverse effects from use of the antipsychotic medication. An interview with RN-P on 8/2/22 at 1:30 PM, confirmed AIMS assessments should have been completed quarterly for Resident 28 and had not been done between 11/30/21 and 5/13/22.

Licensure reference: 175 NAC 12-006.09C2 Based on record review and interview; the facility failed to ensure a safe discharge plan for 1 (Resident 48) of 1 sampled resident. The facility had a census of 46 residents. Findings are: Review of Resident 48's Minimum Data Set (MDS- federally mandated assessment tool used for care planning) dated 5/13/22 revealed the resident was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility staff assessed the following regarding Resident 48: -cognition was severely impaired; -required extensive assistance with bed mobility, dressing, toilet use and personal hygiene and total assistance with transfers; -functional limitation of range of motion to both lower extremities; -frequently incontinent of urine and always involuntary of bowel; and -no active discharge planning for the resident's return to the community. Review of Nursing Progress Notes dated 5/4/22 revealed the following: -8:40 AM the resident's family was notified the resident had refused to pay the resident's share of the bill for the last few months. A thirty-day notice was to be issued if no agreement was reached; -11:10 AM the resident made verbal threats regarding the Director of Nursing (DON) and the Administrator to cut their throats; -3:26 PM an order was received to transfer the resident to the emergency room for a psychiatric evaluation; and -10:30 PM the resident returned to the facility with no new orders. Review of a Nursing Progress Note dated 5/23/22 at 11:15 AM revealed the resident returned from an outing with family wearing 2 incontinence products which were soiled with urine and feces. Review of a Nursing Progress Note dated 6/7/22 at 1:53 PM revealed the resident indicated trying to buy a house and then living there with a family member. Review of the resident's current Care Plan with revision date of 6/7/22 revealed the resident had a desire to return to the community. However, the resident currently required extensive assistance with activities of daily living and was unable to safely return to the community. The resident had refused to pay the resident's portion of the bill and the family was notified. The facility sent out referrals to other facilities per the resident's request. The resident indicated the resident would be going to live with a family member. However, the family member frequently did not answer phone and was unavailable. Review of a Nursing Progress Note dated 6/14/22 at 1:27 PM revealed the resident attempted to use the electric wheelchair to exit the facility through the laundry room door. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed no documentation the resident's family were notified or that a discharge plan was in place to assure the resident's safety with discharge. Review of a telephone order dated 6/20/22 at 9:49 AM revealed an order to discharge the resident with current medications except for narcotics. Further review of the medical record revealed no documentation to indicate where the resident was going or whom the resident was going with when discharged . Review of a Nursing Progress Note dated 6/20/22 at 9:00 PM revealed the resident had requested staff assist with calling a U-[NAME] truck to pick up the resident's belongings so the resident could leave that night. Review of a Nursing Progress Note dated 6/23/22 at 5:55 PM revealed the resident's family removed most of the resident's belongings from storage at the facility. The resident was prepared to leave with the family, but family corrected the resident stating they were only taking belongings and not the resident. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing Progress Notes dated 6/29/22 revealed the following: -9:33 AM staff assessed the resident and determined the resident was able to make safe decisions about leaving the facility Against Medical Advice (AMA) and knew the risks of leaving; -11:04 AM the resident left the facility after signing AMA paperwork. The resident's physician, family and pharmacy were updated; and -7:49 PM a family member called the facility angry and asked how the facility had let the resident leave with no way to get back to the facility. During an interview on 7/27/22 at 11:27 AM the Social Service Director (SSD) confirmed the resident had been given a 30 day notice due to non-payment of the resident's bill. Initially the resident and family made no attempt to find alternate placement or have a plan for paying the resident's bill. The resident told the facility an apartment was rented, and the resident was going to stay there with family however, the family never confirmed this arrangement. No plan was in place as to when or where the resident was discharging. The resident was non-compliant with use of electric wheelchair, smoking and with use of call light. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The family were called but did not answer so the police were notified. The facility did not feel there was a choice as to allowing the resident to leave.

Licensure Reference Numbers 175 NAC 12-006.09D7 Based on record review and interview; the facility failed to investigate/identify causal factors and to develop and/or revise interventions for the prevention of falls for 1 (Resident 31) of 6 residents reviewed for accidents. The facility census was 46. Findings are: Review of Resident 31's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/16/22 revealed diagnoses of dementia, [CONDITION(S)], and failure to thrive. The same assessment indicated the resident's cognition was severely impaired and the resident required extensive staff assistance with bed mobility, transfers, toilet use, personal hygiene, and dressing. Review of an Incident Report dated 3/26/22 at 5:16 PM revealed the resident was found on the floor at bedside. The resident's bed was in the lowered position. The resident was unable to give a description regarding how the fall occurred. No injuries were identified. Further review of the form revealed staff failed to document the resident's mental status, level of pain, and potential predisposing environmental/situational factors. In addition, no new or revised fall interventions were identified on the assessment to prevent further falls. Review of the resident's current Care Plan with revision date 7/22/22 revealed the resident was at risk for falls due to balance problems, decreased mobility with [CONDITION(S)], history of wandering and poor safety awareness. The Care Plan indicated the resident had subsequent falls on 6/25/22 and on 7/15/22. Interview with the Director of Nursing (DON) on 8/1/22 at 1:37 PM confirmed Resident 31 was at risk for falls. The DON indicated staff were to complete an Incident Report after each resident fall to identify causal factors for the fall and then use the causal factors to revise and/or develop interventions to prevent further falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview; the facility failed to evaluate and/or revise nutritional interventions to address a weight loss for 1 (Resident 16) of 3 sampled residents. The facility census was 46. Findings are: A. Review of a Nutrition (Impaired) Weight Loss policy with revision date 9/2017, revealed the physician and nursing staff were to monitor and document the weight and dietary intake of residents. In addition, they were to monitor an individual's response to interventions and possible complications of such interventions. B. Review of Resident 16's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/18/22 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's weight was 125 pounds (lbs.) with a 5 percent (%) weight loss in the last month or a 10% weight loss in the last 6 months. The resident was not on a physician prescribed weight loss regimen. In addition, the assessment indicated the resident had a loss of liquids/solids from their mouth when eating/drinking and of holding food in mouth/cheeks or had residual food in their mouth after eating. Review of Resident 16's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature, and pulse) revealed the resident's weight on 3/4/22 was 144 lbs. Review of a Nutritional Progress Note dated 3/22/22 at 1:12 PM revealed the resident was consuming 75 to 100 % of food at meals and denied any difficulty with chewing or swallowing food at meals. No recommendations were identified as the resident's intakes were meeting nutritional needs. Review of the resident's Weights and Vitals Summary Sheet revealed the following: -4/7/22 weight was 137 lbs.; and -5/3/22 weight was 124 lbs. (down 13 lbs. or a 9% loss in 1 month). Review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -a new order dated 5/9/22 for Mighty Shake (nutritional supplement with added calories) 120 cubic centimeters (cc) to be given 3 times a day; -from 5/9/22 through 5/18/22, staff failed to document the amount of nutritional supplement the resident had consumed with administration; and -from 5/18/22 through 5/31/22 out of the 42 times the resident was provided the supplement, the resident consumed 50% or less a total of 38 times. Review of a Nutritional Progress Note dated 5/22/22 at 9:45 AM confirmed the resident was drinking only 25-50% of the Mighty Shake nutritional supplement when offered. No additional recommendations were made. Review of the resident's Weights and Vitals Summary Sheet revealed the resident's weight on 6/17/22 was 125 lbs. Review of a Nutritional Progress Note dated 6/23/22 at 2:08 PM revealed the resident continued to consume only 25-50% of the Mighty Shakes provided 3 times a day. A recommendation was made to discontinue the Shakes and to start Ensure Clear (supplement drink with added protein and nutrients) 240 cc twice a day. Review of Resident 16's MAR for 6/2022 revealed from 6/25/22 through 6/30/22 the staff failed to document the amount of supplement the resident consumed when administered at 8:00 AM and at 6:00 PM. Review of Resident 16's MAR for 7/2022 revealed from 7/1/22 though 7/13/22 the staff failed to document the amount of supplement the resident consumed with each administration. Review of the resident's Weights and Vitals Summary Sheet revealed the resident's weight on 7/15/22 was 114 lbs. (down 11 lbs. or a 9% loss in 1 month). Review of a Nutritional Progress Note dated 7/23/22 at 6:17 AM revealed the resident's meal intakes remained poor at 0-25% and intakes of the Ensure Clear varies greatly. No new recommendations were made as weight loss was likely to continue due to poor intake at meals and varied supplement acceptance. Review of a Facsimile Communication from the resident's physician dated 8/2/22 revealed the resident would likely continue to have unavoidable weight loss due to the progression of the resident's chronic medical condition. During an interview on 8/1/22 at 2:27 PM, the Director of Nursing (DON) confirmed the following regarding Resident 16's weight loss: -the resident had poor meal intakes and had ongoing weight loss; -the nursing staff were responsible for administering nutritional supplements and were to document the amount of supplement the resident consumed each time to assure the intervention was effective and to determine if new intervention was required; and -no further nutritional interventions had been developed to address the resident's weight loss.

Based on record review and interview, the facility failed to report a fall with injury for Resident 4 and failed to submit an investigation related to a fall with a major injury for Resident 1 to the state agency. The facility census was 52. Findings are: A. Review of Resident 4's Progress note dated 4/8/2022 revealed at 11:45 AM the nurse heard a bang coming from the shower room. Upon entering the shower room Resident 4 was sitting on the floor. Resident 4 was sent to the emergency room for evaluation. Resident 4 returned to the facility. No injury was diagnosed at that time. Review of a Progress note dated 4/18/2022 revealed Resident 4 continued on scheduled Tylenol and heat packs to Resident 4's hip without adverse effects. Resident 4 continues to state having pain to the area. Resident 4 also continues to need staff assistance for transfers and requests a WC (wheelchair) over a walker, both in the room and throughout the facility. Progress note revealed a Computerized Tomography (CT) scan was completed on 5/4/2022 of the Pelvis due to right hip pain and the fall on 4/8/22. Review of a progress note dated 5/5/2022 revealed the Interdisciplinary Team (IDT) meeting was held to review Resident 4's cares and revealed a recent CT scan identified pelvic fracture. Last fall was on 4/8/22 at facility. Had been utilizing hot packs to right hip along with scheduled Tylenol for pain Review of the facility policy titled Abuse reporting policy and procedure undated revealed if there is reason to suspect or believe in any form of abuse, neglect, has occurred a report will be called in the following timeframe: - Injury; Within 2 hours. -No injury present within 24 hours. -An investigation will be completed and submitted in 5 working days. Interview with the Director of Nursing (DON) on 6/1/2022 at 8:00 AM revealed Resident 4 did fall out of the shower chair when being removed from the whirlpool and Resident 4 was not secured with the safety belt. No injuries were found at the time of the fall and no report was called to the state agency. Stated pelvic fractures were found on 5/8 per CT scan. This injury was not reported. B. Review of Progress noted dated 5/6/2022 at 21:20 revealed Resident 1 was found sitting on the floor drying and holding the left leg stating pain in extremity. Resident 1 was sent to the emergency room and was found to have a fracture. Facility investigation revealed the fall with a major injury was reported to the state agency. However, no investigation was submitted to the state agency to follow up on the incident. Interview on 5/31//2022 at 2:00 PM with the Director of Nursing (DON) revealed the investigation was completed internally but was not sent to the state agency.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assessment Performance Improvement Plan (QAPI) failed to identify ongoing issues relevant to F578, F600, F605, F656, F676, F692, F732, F740, F745, F755, F756, F758, F759, F760 and F812 and implement plans of action to identify and correct the deficient practice. The QAPI failed to ensure repeated deficiencies at F584, F676, F689, and F698 were corrected and the correction maintained. This deficient practice had the potential to affect all residents who reside in the facility. The facility staff identified a census of 50. Findings are: Record review of the facility Policy and Procedure Quality Assessment Performance Improvement (QAPI) also know as Quality Assurance (QA) dated 2021 revealed the following information: -Purpose: -The purpose of the QAPI in our facility is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision that every day is life changing. To do this, all employees will participate in ongoing QAPI efforts which support our mission that compassion is at the heart of our care. -Guiding Principles: #3. In our facility, QAPI includes all employees, all departments, and all services provided. -Governance and Leadership: -A facility-wide training will be conducted to inform everyone the the facility about QAPI plan at Continental Springs. On 4-12-2021 at 11:40 AM an interview was conducted with the Director Of Nursing (DON). During the interview review of the facility QAPI was completed. During the interview the DON reported the facility management was working on developing a QAPI program. The DON reported the facility QAPI has mostly been working on COVID-19 issue and had not reviewed citations from the last certification survey. On 4-12-2021 at 2:05 PM an interview was conducted with Nursing Assistant (NA) K. During the interview NA K reported not knowing what QA was. On 4-12-2021 at an interview was conducted with NA L. During the interview NA L reported not knowing what QA was and what the committee was working on. On 4-13-2021 at 9:10 AN an interview was completed with Licensed Practical Nurse (LPN) M. During the interview LPN M reported not being aware of anything the QA(QAPI) was working on. On 4-13-2021 at 937 AM an interview was conducted with LPN N. During the interview LPN N reported not being aware of what QA (QAPI) was working on.

Licensure Reference Number: 175 NAC 12-006.05(9) Based on record review and interviews, the facility failed to ensure 1 Resident (Resident 26) was free from abuse. The facility census was 50. Findings are: Review of Resident 26's medical record revealed Resident 26 had Delusional disorder, Mood disorder, Autistic disorder. Record review of Resident 26's Progress note dated 6/6/2020 at 12:18 PM revealed Resident 26 had been verbally abusive to staff during the shift. Registered Nurse (RN)-I did not document any interventions to calm Resident 26. RN-I called the on call healthcare provider and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 26's progress note dated 6/6/2020 at 12:25 PM revealed RN-I entered Resident 26's room and told Resident 26 that the healthcare provider ordered a shot because of Resident 26's behaviors. RN-I asked Resident 26 to willingly take the shot and the staff would leave Resident 26 alone. Resident 26 indicated an unwillingness to take the shot by becoming more agitated. RN-I again asked the resident to take the shot willingly and Resident 26 again indicated refusal. NAs then put the resident on the bed and RN-I gave Resident 26 the [MEDICATION(S)] shot without Resident 26's permission. Interview on 04/07/21 at 2:34 PM with the Director of Nursing (DON) revealed if Resident 26 was held down and given a shot it would be abuse. Record review of Resident 26's progress note dated 6/6/2020 at 12:25 PM revealed after RN-I gave the shot to Resident 26, RN-I remained in the resident room and continued to tell Resident 26 that it was illegal for Resident 26 to be aggressive with staff and verbally abusive. Review of a Progress note for Resident 26 dated 6/6/2020 at 2:10 PM revealed RN-I informed Resident 26 that RN-I wasn't going to reply to anything Resident 26 was saying to RN-I because RN-I wasn't going to argue with Resident 26 about anything. Review of a Progress note for Resident 26 dated 7/10/2020 at 9:45 PM revealed that Resident 26 put on call light and asked to talk to RN-I . RN-I entered Resident 26's room. Resident 26 told RN-I that RN-I caused Resident 26 severe trauma for giving me that shot. Review of the facility policy titled Abuse/Reporting Policy and Procedure revealed Physical abuse included controlling behavior through corporal punishment or any impairment of bodily function. Interview on 04/12/21 at 11:16 AM with the Administrator in Training revealed giving the [MEDICATION(S)] shot when the resident refused and holding Resident 26 down to give the shot would be considered abuse.

Licensure Reference Number 175 NAC 12-006.05(8) Based on record review and interview, the facility failed to ensure residents are free from chemical restraints for 1 resident (Resident 26). The facility census was 50. Findings are: Appendix PP Nursing Home Federal regulations define the following terms and examples related to a chemical restraint: - Chemical restraint is defined as any drug that is used for discipline or staff convenience and not required to treat medical symptoms. - Discipline is defined as any action taken by facility staff for the purpose of punishing or penalizing residents. - Staff have recommended to the practitioner that a resident be administered a medication in order to prevent a resident from displaying behaviors. Record review of Resident 26's Progress note dated 6/6/2020 at 12:18 PM revealed Resident 26 had been verbally abusive to staff during the shift. Registered Nurse (RN)-I did not document any interventions to calm Resident 26. RN-I called the on call healthcare provider and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [MEDICATION(S)] order for Resident 26 written on 6/6/2020 by the healthcare practitioner did not provide a medical reason for use of [MEDICATION(S)]. Review of Progress notes dated 6/6/2020 at 12:25 PM revealed two NAs accompanied RN-I into Resident 26's room. RN-I explained to Resident 26 that the primary care provider ordered a shot related to Resident 26 becoming physical with staff and showing increased aggression. Review ofa Progress note for Resident 26 dated 7/10/2020 at 9:45 PM revealed Resident 26 told RN-I that RN-I caused Resident 26 severe trauma for giving me that shot. Interview on 04/12/21 at 11:16 AM with the Administrator in Training revealed giving the [MEDICATION(S)] for Resident 26 for a behavior toward staff would be a chemical restraint.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04E3 Based on observations, record review and interviews; the facility staff failed to provide medically related Social Services for indicators of Mental Health Distress for 1 (Resident 18) of 1 sampled resident. The facility staff identified a census of 50. Findings are: Record review of the Facility Social Services job description dated 5-2021 revealed the following information: -Job Summary: -Assist in planning, organizing, implementing, and directing the overall operation of the Social Services department. Operates in accordance with current Federal, State and local standards, guidelines and regulations, and established company policies, and procedures to ensure that medical-related emotional and social needs of the residents are met and maintained on an individual basis. -Essential Functions: -1. Assist in developing preliminary and comprehensive social services needs assessment and plan of care for residents to include identifying resident problems, needs and goals. -3. Provides consultation to members of the facility, community agencies, etc,in an effort to solve the needs and problems of the residents through the development of social service programs. On 4-05-2021 at 12:51 PM an interview was conducted with Resident 18. During the interview Resident 18 was observed to be tearful. Resident 18 reported during the interview having recently had both legs amputated and started to cry. Resident 18 reported wanting counseling. When asked if anyone had discussed arranging counseling services, Resident 18 reported [NAME] had arranged for counseling. Observation on 4-07-2021 at 12:45 PM revealed Resident 18 was in bed and had a sad affect. During the observation Resident 18 reported feeling very lonely as family was not near and reported wanting counseling services. During the observation Resident 18 became tearful and reported frustration of Resident 18's life changes and loss of independence. Record review of Resident 18's Admission Record sheet printed on 2-09-2021 revealed Resident 18 admitted to the facility on [DATE] with the diagnoses that included Major Depressive Disorder, Absences of the right and left leg above the knee. Record review of Resident 18's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning ) signed as completed on 2-10-2021 revealed the following information of Resident 18's response: -Resident Mood Interview questions section of the MDS: -Feeling down, depressed, or hopeless. Symptom was present and the frequency was 12 to 14 days (nearly every day). -Trouble falling asleep or staying asleep, or sleeping to much. Symptom was present and the frequency was 12 to 14 days (nearly every day). -Feeling tired or having little energy. Symptom was present and frequency was identified as 7 to 11 days (half or more of the days). -Poor appetite or over eating was present and frequency was identified as 7 to 11 days (half or more of the days). -Trouble concentrating on things, such as reading the newspaper or watching TV was present and frequency was identified as 7 to 11 days (half or more of the days). -Thoughts that you would be better off dead was present and frequency was identified as 7 to 11 days (half or more of the days). Record review of the MDS worksheet revealed Psyc (psychiatric) services will be offered to resident as needed. Record review of Resident 18's medical record that included Progress Notes, Comprehensive Care Plan and Practitioners orders revealed there was not an indication that Social Services was providing interventions to manage Resident 18's mental health distress. On 4-08-2021 at 7:35 AM an interview was conducted with the facility MDS Coordinator. During the interview the MDS coordinator reported completing a interview with Resident 18. The MDS Coordinator reported Resident 18 was tearful and had a significant loss related to the amputations and wanted to be closer to family. The MDS Coordinator reported not being aware if Resident 18 was receiving any counseling. On 4-08-2021 at 9:50 AM an interview was conducted with Social Services (SS) A. During the interview SS A reported not talking with Resident 18 about Resident 18 loss of both legs and independence. SS A reported the facility wasn't doing anything specifically for Resident 18's mental health. SS A reported Resident 18 does become tearful when SS A talks with Resident 18.

Licensure reference number 175 NAC 12-006.17 Based on observation, interview, and record review; the facility failed to implement infection control practices and Centers for Medicare and Medicaid Services (CMS) guidelines to prevent potential cross contamination including the spread of COVID-19 (A highly contagious virus primarily spread from person to person through respiratory droplets, which can lead to serious illness and even death) related to: 1) staff members unaware of residents on Transmission Based Precautions (the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected with certain infectious agents for which additional precautions are needed to prevent infection) and/or not wearing appropriate PPE (Personal Protective Equipment- can include items such as gowns, gloves, masks, goggles, face shields, and foot coverings) when in rooms of resident's that should have been on Transmission Based Precautions, 2) residents that required Transmission Based Precautions did not have any indication on their rooms to identify this, 3) breaks in gloving and hand hygiene practices, 4) a COVID-19 positive resident leaving the residents room and within 6 feet of another resident without a mask on, 5) residents in the hallway without face masks, 6) cleaning of reusable equipment and facility cleanliness, and 7) symptomatic residents without ongoing monitoring and isolation not initiated at the time that symptoms were first identified. This had the ability to affect all residents. The total sample size was 28 and the facility census was 54. Findings are: A. Review of the Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality, Safety and Oversight Group dated 3/13/20 revealed the following guidance for infection control and prevention of Coronavirus Disease 2019 (COVID-19): -the facility should regularly monitor the CDC (Center for Disease Control) website for information and resources. Per the CDC, prompt detection, triage, and isolation of potentially infectious residents are essential to prevent unnecessary exposures among residents and healthcare personnel; -restriction of all visitors and non-essential healthcare personnel except for certain end of life situations; -cancel all group activities and communal dining; -implement active screening of residents for fever and respiratory symptoms; -screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperatures and document the absence of shortness of breath, new or change in cough and sore throat. If they are ill, have them put on a mask and then self-isolate at home; -the facility should identify staff that work at multiple facilities (such as agency staff) and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk for COVID-19; and -properly clean, disinfect, and limit sharing of medical equipment between residents and areas of the facility. B. Review of the CMS 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. C. Review of Resident 13's Progress Notes revealed the resident was admitted to the facility on [DATE]. Review of the Resident's Progress Notes, Skilled Charting, and Facility Temperature Logs revealed no evidence the resident was screened for COVID-19 symptoms on 5/2/19, 5/3/19, and 5/4/19. Review of Resident 13's Progress Notes revealed the resident was admitted to the hospital on [DATE] for COVID-19. D. Review of the facility form Residents on Isolation Precautions dated 5/12/20 identified Resident 8 as being on Transmission Based Precautions related to a potential exposure. Observation on 5/13/20 at 10:20 AM revealed LPN-A in the resident's room with a mask on but no other PPE. LPN-A was helped move the resident's wheelchair towards the resident's bedside tray table and helped reposition the resident's feet on the base of the table. LPN-A then went and got gloves (didn't complete hand hygiene first) and then assisted the residents roommate (Resident 28) to the bathroom. The curtain was not pulled and the residents passed within 6 feet of each other. E. Review of the facility form Residents on Isolation Precautions dated 5/12/20 identified Resident 11 as being in Transmission Based Precautions due to symptoms (of COVID-19). Observation of Resident 11's room door/entry-way on 5/13/20 at 8:30 AM revealed no indication that the resident was supposed to be on Transmission Based Precautions. The room door/entry-way had no yellow Isolation Door Caddy, no signage, and no table outside of the door for dietary to deliver meals. The divider curtain between the resident and the resident's roommate was open. F. Review of Resident 16's Progress Notes dated 5/1/20 at 12:33 AM revealed the resident was very pleasant with staff, asked for an inhaler and nicotine gum. Then stated the resident was going to go make rounds. The resident then rode around the facility in the resident's wheelchair. Interview with the Administrator on 5/13/20 at 7:50 AM revealed 4 residents had tested positive for COVID-19. This included Resident 16. Observation of Resident 16's room on 5/13/20 from 8:00 AM to 10:00 AM revealed no sign on the door and no yellow Isolation Door Caddy to indicate the need for isolation. Observation of Resident 16 on 5/13/20 from 9:20 AM to 9:25 AM revealed Resident 16 self-propelled down the hallway (east of the dining room) in the resident's wheelchair and through the dining room. Resident 16 had a mask on that was below the resident's mouth and nose. Resident 15 also self-propel down the hallway (east of the dining room) and through the dining room at the same time passing with 3 to 4 feet of Resident 16. Resident 15 did not have a mask on. Resident 16 knocked on the door to be let out to smoke with the other smoking residents. Nursing Assistant (NA)-C opened the door and told Resident 16 that they would have to smoke by themselves and that the resident should have the mask on. NA-A then closed the door. NA-A did not direct Resident 16 back to the resident's room and did not ensure other residents remained over 6 foot from the resident. As NA-A closed the door Resident 16 yelled out loudly. Resident 16 then pulled the mask up covering the resident's mouth and nose. Resident 16 backed up to the side of the hallway outside by the door leading to the smoking area. Resident 15 passed by Resident 16 within 2 to 3 feet and knocked on the door to be let out to smoke. NA-A let Resident 15 outside at that time. Interview with the Director of Nursing (DON) on 5/13/20 at 9:30 AM revealed the resident was non-compliant with isolation and would leave the residents room and go into the hallway. The resident had been given a mask to wear, but would not always wear it. No other interventions had been identified to protect other resident's from Resident 16 related to the resident's non-compliance. Interview with the Administrator and the DON on 5/13/20 at 1:30 PM revealed the facility had attempted to put signage up on Resident 16's door but the resident became angry and removed it as the resident was in denial about being COVID-19 positive. The DON and Administrator revealed no other steps had been taken to ensure staff in all departments knew about Resident 16's need for Transmission Based Precautions when interacting/assisting the resident. G. Review of the facility form Residents on Isolation Precautions dated 5/12/20 identified Resident 4 as being on Transmission Based Precautions due to an exposure to a COVID-19 positive resident. Observation of breakfast meal delivery on 5/13/20 from 8:00 AM to 8:30 AM revealed Dietary Aide (DA)-D delivered drinks to room [ROOM NUMBER], prior to going to room [ROOM NUMBER] DA-D changed gloves but failed to perform hand hygiene after removing gloves. DA-D continued down the hallway changing gloves between residents but not performing hand hygiene when changing gloves. DA-D then got to Resident 4's room. The table outside of the room had PPE setting on top of it. DA-D commented what is going on with Resident 4. Housekeeper-E walked by at that time and said the resident was negative and that this wasn't needed anymore (while moving the PPE off of the table). NA-D then entered Resident 4's room to deliver breakfast drinks, touched items in the resident's room including bedside table, came back out and took a packet of creamer from a plastic baggie with multiple packets in it and took a milk of out the ice bin with multiple individual milks without changing gloves/hand hygiene prior. After completing Resident 4's drinks NA-D changed gloves but didn't complete hand hygiene prior to moving on to the next resident. The gown NA-D was wearing while delivering all meals remained in place after Resident 4's room as well. H. On 5/13/20 at 10:21 AM NA-B entered Resident 18's room with NA-B's face mask not covering the NA's nose (bilateral nares visible) and was within 6 feet of the resident. I. Review of the facility staff/visitor screening logs dated 4/22/20 to 5/12/20 revealed all staff members did not have screening completed related to signs/symptoms of COVID-19. In those cases the staff members' temperature was listed but no indication as to whether the staff had symptoms of COVID-19 was recorded. Further review RN-H did not have documentation of screening for signs/symptoms of COVID-19 on the night of 5/7/20 when the RN worked the over-night shift into 5/8/20. (RN-H was identified as testing COVID-19 positive on 5/9/20) Interview with the Administrator on 5/12/20 at 1:45 PM revealed the staff members had been screening themselves prior to working. J. Review of the Handwashing Sign in Sheet In-service dated 4/9/20 revealed only 14 staff members had completed the competency training. Review of a Staff Meeting Agenda dated 3/12/20 and 4/1/20 confirmed staff were to wear masks. Another review was completed with staff on when to wash hands and how to properly use hand gel. Anyone that entered the building was to be screened, and 99 percent of exposure is not [MEDICAL CONDITION] on hands, but touching face. Review of the facility employee listing revealed the facility had approximately 59 staff employed in the nursing home. K. Confidential resident interview on 5/12/20 at 2:00 PM revealed the resident had a potential exposure with a COVID-19 positive resident. The resident was upset that there was no indication on the other resident's door that this resident shouldn't enter. The resident was upset and felt the facility had put the resident at risk. Review of the resident's Progress Notes dated 3/20/20 to 5/12/20 revealed no evidence that the resident had been educated on not going into other resident rooms. L. Observations made throughout the facility on 5/12/20 from 1:45 PM to 2:00 PM revealed small linen carts with clean linens on them located on the Center and North hallways were completely uncovered. Observations were made of Residents in the hallways throughout the day on 5/12/20. This included Resident 14 who self-ambulated throughout all the hallways in the facility without a mask on and Resident 27 who self-propelled in the resident's wheelchair throughout the Center hallway. (This could have potentially contaminated the clean linens) M. On 5/12/20 at 2:00 PM the facility floors had soiled areas throughout. The North hallway had distinct foot prints on the floor and a white/pink substance near the North wing corridor that was dried with a footprint impression in it. Down the Center and Back hallway were round dried circles of an unknown substance. On 5/13/20 at 7:50 AM noted the facility floor had soiled areas throughout. The North hallway had distinct foot prints on the floor and a white/pink substance near the North wing corridor that was dried with a footprint impression in it remained. Down the Center and Back hallway the round dried circles of an unknown substance remained. Resident 14 noted to be ambulating in the hallways on 5/13/20 at 7:45 AM with gripper socks on and no shoes. Interview with Housekeeper-E on 5/13/20 at 7:50 AM confirmed floor in the hallways should be cleaned daily but wasn't sure if that had happened on 5/12/20. N. On 5/12/20 at 4:20 PM Transportation Staff -F entered the facility from the service wing, without wearing a mask. Transportation Staff-F walked down the Center hall, spoke with another staff regarding a transport, and then walked back out through the service door. O. Further staff interviews revealed: - Interview with RN-I (who was identified as the facility infection preventionist) on 5/12/20 at 2:10 PM revealed RN-I was unaware of who was on isolation. When asked if the residents with yellow Isolation Door Caddies or signage on their doors meant the residents were on transmission-based precautions RN-I stated I don't know I just got here today, when asked when RN-I worked last RN-I stated last night. When RN-I was asked how the staff were cleaning the reusable blood pressure cuff RN-I was unsure and didn't know if it was actually being cleaned between uses. - During an interview with Registered Nurse (RN)-L on 5/12/20 at 2:11 PM (who had keys and was in the medication cart on the back hallway), RN-L stated they were agency and hadn't worked at the facility in over a year and was not sure who was on Transmission Based Precautions. - Interview with the DON on 5/12/20 at 2:45 PM revealed Resident 13 was transferred to the hospital from the wound clinic because the resident was having shortness of breath worse than the resident's usual. When asked if the staff were utilizing N-95 masks when working with residents on isolation the DON stated I can't say that they are. The DON was unsure how the staff were supposed to be cleaning the reusable wrist blood pressure cuff. The DON confirmed RN-I worked Monday through Friday 2:00 PM to 10:00 PM as a charge nurse and was supposed to work on infection control during those shifts, as time allowed. RN-I had no time designated to infection control. -Interview with Housekeeper-E on 5/13/20 at 7:50 AM confirmed their department was not informed of which residents were on Transmission Based Precautions. Housekeeper-E stated there were four of them but wasn't sure which actual residents were involved. Housekeeper-E stated the only way they know if a resident was on Transmission Based Precautions was if they had a sign or a yellow Isolation Door Caddy, if they didn't have one of those items then they would assume they were not on Transmission Based Precautions. -Interview with DA-D on 5/13/20 at 8:10 AM revealed DA-D did not know what residents were currently on Transmission Based Precautions. DA-D stated they looked for signage on the residents' doors to indicate this or an Isolation Door Caddy. DA-D stated they were not supposed to go into any rooms with residents on Transmission Based Precautions, they were to leave the meals on the table outside of the resident's door and then nursing would take it from there. - Interview with the Administrator on 5/13/20 at 12:43 PM revealed the residents that were admitted /readmitted were put into a 14 day quarantine and therefore full PPE was not being required. The administrator confirmed N-95 masks should be worn when entering the room for residents that were positive for COVID-19 or symptomatic. - Interview with the Director of Nursing and Administrator on 5/12/20 at 1:00 PM revealed the facility had 1 resident (Resident 13) who had been transferred to the hospital and had tested positive for COVID-19 and had 2 staff members Dietary Aide-J and Registered Nurse-H who had tested positive for COVID-19. No current residents in the facility with confirmed COVID-19 at that time since Resident 13 was in the hospital. Three resident's had direct contact with Resident 13 and were supposed to be on Transmission Based Precautions now. The facility was supposed to be screening all residents. All staff were to wear masks at all times, and residents had to wear masks when leaving their rooms. The DON reported they had some trouble with compliance of residents and the staff were to remind and educate the residents when they saw this. The staff should encourage residents to return to their rooms. All new admissions were to be put on a 14 day quarantine. (The facility did not indicate residents that had direct contact with RN-H had been identified and placed on Transmission Based Precautions). An abatement plan was provided by the facility on 5/13/20 at 3:45 PM with additional information sent via email on 5/13/20 at 5:17 PM. As part of the abatement plan the facility was to mark all rooms that required transmission-based precautions with either a red stop sign (meaning COVID-19 positive) or a yellow yield sign (meaning the resident was symptomatic of COVID-19, had an exposure, or was a new/re-admission). Additional on-site investigated was completed on 5/19/20 with additional concerns identified. P. Review of the facility COVID-19 Tracking Log sent 5/18/20 revealed a total of 8 staff members and 6 residents had now tested positive for COVID-19. Q. Review of the facility COVID-19 Screening Tool dated 5/15/20 to 5/19/20 revealed: - Not all staff were identified as being screened before working. Transportation Aide-F was not identified as screened prior to working on 5/19/20 (The Administrator confirmed the staff member was working). - From 5/14/20 to 5/19/20 10 staff members didn't address if they did or didn't have symptoms of COVID-19. - From 5/14/20 to 5/19/20 staff members identified 14 times they presented with COVID-19 symptoms. There was no evidence the cause of the symptoms were investigated prior to the staff members being allowed to work and provide care for the residents. -The staff member completing the screening was not identified 48 out of 72 times. Interview with the Administrator and the DON on 5/13/20 at 9:00 AM confirmed the staff were allowed to work with COVID-19 symptoms, the DON stated I currently have symptoms (cough and a sore throat) and don't know if I should be here right now. R. Review of Resident 18's Progress Note dated 5/14/20 at 3:17 PM revealed the resident had tested positive for COVID-19. On 5/19/20 at 1:30 PM NA-M was observed to open Resident 18's room door (coming out of the room) and pushed the mechanical sit to stand lift out of Resident 18's room into the hallway. NA-M had on a face shield, mask, and gown and placed the sit/stand lift in the hallway. NA-M stood in Resident 18's doorway and proceeded to remove the gown, this took multiple tries with NA-M touching multiple surfaces on the outside of the gown with bare hands. NA-M then discarded all of the PPE in a trash bin in the hallway approximately 15 feet from the resident's room. NA-M then re-entered the resident's room with no PPE/no mask on and walked over by the sink in the room, mumbles a few words and exited without washing hands. NA-M then got some hand sanitizer out of the dispenser located outside of the resident's room, hand rubbed for approximately 3-5 seconds and proceeded down the hallway. The mechanical sit to stand lift was not observed to have been cleaned (no wipes present to clean with). Interview with NA-M on 5/19/20 at 1:30 PM confirmed the mechanical sit to stand lift was not cleaned after use. NA-M stated the night shift cleaned the lifts and would need to ask them. S. Review of the facility list provided on 5/12/20 identified Resident 4 as being on Transmission Based Precautions due to a potential exposure. Observation of Resident 4's room on 5/19/20 at 8:30 AM revealed the resident had no signage to indicate the resident should be on Transmission Based Precautions. Interview with the DON revealed the resident had a potential exposure on either 5/7/20 or 5/8/20 with a COVID-19 positive resident (less than 14 days prior). T. Review of a the facility form Residents on Isolation Precautions dated 5/12/20 identified Resident 11 as being in Transmission Based Precautions due to symptoms (of COVID-19). Review of a Progress Note dated 5/13/20 at 4:28 PM revealed the Resident 11 was on droplet isolation precaution related to episodes of loose stools. Observation of Resident 11's room on the 5/19/20 revealed a yield sign on the resident's door name tag. LPN-O was observed on 5/19/20 from 9:20 AM to 9:30 AM in Resident 11's room taking the resident's vital signs (blood pressure, oxygen level, temperature). LPN-O had a mask on but no gloves, face shield, or gown. LPN-O exited the resident's room with the reusable equipment in hand. Observed LPN-O clean the items with Sani Hand Sanitizing Wipes. The items had no visible wet time. LPN-O stated a bleach cleaner was not used on the items as it would discolor or potentially damage the items. LPN-O stated the residents on Transmission Based Precautions should have their own personal equipment. LPN-O was unaware that Resident 11 was supposed to be on Transmission Based Precautions. LPN-O stated they worked for a staffing company and got very little information in report. On 5/19/20 at 9:31 AM, NA-B entered Resident 11's room with clean linens. NA-B had a mask on but no other PPE. NA-B's mask was positioned below the NA's nose (nares visible). On 5/19/20 at 1:05 PM NA-B entered Resident 11's room to shut off the resident's call light and exited the room. NA-B was wearing only a mask and no other PPE. No hand hygiene was observed when NA-B exited the room. U. Review of Resident 1's Progress Note dated 5/13/20 at 12:01 AM revealed the resident had tested positive for COVID-19. Observation of Resident 1's room door on 5/19/20 at 8:10 AM revealed the resident had an Isolation Door Caddy on the room door. The resident's room did not have a room number, name tag, and did not have a red stop sign indicating the resident was on transmission-based precautions. V. Review of Resident 3's Progress Note dated 5/11/20 revealed the resident enjoyed strolling in the hallways of the facility, enjoyed sitting in the back hallway, and enjoyed smoking outside with other residents. Review of Resident 3's Progress Note dated 5/11/20 at 5:13 PM revealed the resident had left the facility for [MEDICAL TREATMENT]. Review of a facility form Residents on Isolation Precautions dated 5/12/20 revealed Resident 3 was on Transmission Based Precautions related to a potential exposure. Observation of Resident 3's room on 5/19/20 at 8:15 AM revealed no signage to indicate the resident was on Transmission Based Precautions. Interviews with the Administrator and the DON on 5/19/20 at 9:30 AM confirmed Resident 3 had a potential exposure to a COVID-19 positive resident and also revealed the [MEDICAL TREATMENT] center had reported a large number of staff and residents at the [MEDICAL TREATMENT] center had tested positive for COVID-19. W. Resident 26 was observed on 5/19/20 at 8:30 AM to be within 2 feet of Resident 9 (the resident's roommate who had symptoms of COVID-19). On 5/19/20 at 9:15 Resident 5 returned from the smoking area to the resident's room without a mask on. Resident 5 passed less than 6 feet from Resident 26 in the hallway. On 5/19/20 at 1:00 PM Resident 5 exited the resident's room into the hallway without a mask on headed towards the smoking area. Resident 26 also entered the hallway. Residents 5 and 26 passed within 2-3 feet of each other in the hallway. Resident 26 had a mask with notable gaps between the mask edges and the resident's nose. Resident 26 used the hand rail along the wall to help move the resident through the hallway. X. Review of an In-Service Training Sign-In Sheet dated 5/13/20 with the topic identified as isolation identification, PPE, Handwashing revealed 11 staff members had been educated. Y. The facility was unable to provide monthly infection control surveillance. Z. Interview with the Administrator on 5/19/20 at 9:30 AM confirmed the only education that had been done in the past week was just what we did when you guys were here. Stated the other staff should have got the information passed along in report. The Administrator stated they had a communication book at the front nurse's station, but confirmed they didn't have one for the back nurse's station. The Administrator did not know if the facility had any policies in place related to COVID-19 and in regards to when employees were safe to return work. The Administrator stated not sure we have anything written on COVID-19 policies but stated that they were always talking about it. When asked about the staff screening process prior to work the Administrator stated the charge nurses should know how to screen the staff. When asking the Administrator about the difference between red stop signs and yellow yield signs on residents' doors and the precautions to be taken the Administrator stated staff needed full PPE on anytime a staff member went into a room with a red stop sign, but a yellow caution sign the staff doing direct care were to wear full PPE and but felt indirect care in the room the staff could use gloves and mask. When asked what constituted direct care for residents in yellow yield sign rooms, such as taking vital signs, the Administrator felt that task would not necessarily warrant full PPE. Stated it would depend on the specifics on the resident and what they had going on. Stated if they were coughing then they should probably wear more PPE and if they weren't coughing then not necessarily. The Administrator stated I honestly don't know what Resident 11 has. Further interview revealed the staff were entering the building through the back entrance and then going through the building to the front entrance to be screened. Interview with the DON on 5/19/20 at 9:40 AM confirmed the facility had initiated staff training the week prior (5/13/20) and thought maybe 10 staff had received that education and confirmed no other documented training had occurred since. The DON stated all reusable resident equipment, including that used to check vital signs should be cleaned using Sani disinfectant wipes, not the Sani hand sanitizing wipes. The DON confirmed yellow yield sign and red stop sign resident should all be treated exactly the same in regards to transmission-based precautions and PPE. When asked when a resident that was in a yellow yield sign room could come out of transmission-based precautions the DON was unsure and stated they shouldn't be taking residents out of precautions that they should remain that way to ensure safety. A determination was made that the facility's noncompliance placed all residents in immediate jeopardy. On 5/19/20, the IJ cited on 5/12/20 remained ongoing. AA. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/25/20 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 17's Nursing Progress Notes revealed the following: -4/14/20 at 2:48 PM the resident was assessed as having a temperature of 100 degrees Fahrenheit with complaints of nausea; -4/17/20 at 8:42 AM the resident's temperature was 99.3 degrees Fahrenheit with complaints of feeling very tired. The resident's physician was notified of these concerns; -4/20/20 at 4:56 PM the resident complained of shortness of breath and of a cough. A new order was received for respiratory treatments every 6 hours as needed for shortness of breath and cough; -4/25/20 at 9:11 PM the resident had complaints of increased congestion; -4/28/20 at 10:52 AM the resident voiced complaint of not feeling well with increased shortness of breath; -4/30/20 at 12:32 AM a facsimile (fax) was received from the resident's physician which identified new orders for [MEDICATION NAME] (antibiotic used to treat bacterial infections) 875 milligrams (mg) twice a day for 10 days and for [MEDICATION NAME] (liquid medication used to treat coughs) 10 cubic centimeters (cc) every 6 hours as needed for cough; -5/5/20 at 1:02 PM the resident complained of still not feeling well at times with continued shortness of breath; -5/7/20 at 11:06 AM the resident was admitted to the hospital with [REDACTED].>-5/12/20 at 6:43 PM the resident was readmitted from the hospital. A perm a- catheter (a catheter placed through a vein into or near the right atrium (one of 2 heart chambers where blood enters into the heart) used for [MEDICAL TREATMENT] (a method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood) in an emergency or until a long-term device is ready to use) was inserted 5/10/20 to the resident's right chest. Further review of the resident's medical record revealed [REDACTED]. An observation on 5/13/20 at 09:20 AM revealed a wheelchair was positioned in the corridor outside of Resident 17's room. Further observation revealed there were several packaged isolation gowns and blue plastic disposable gowns positioned on the seat of the wheelchair. In addition, a box which contained several containers of disposable gloves in various sizes was observed on the foot pedals of the wheelchair. There were no signs on the closed door of the resident's room or on the walls outside of the room to indicate the resident was positive or presumed positive for COVID-19 or that the resident was on Transmission Based Precautions. During an interview on 5/13/20 at 9:25 AM, Medication Aide (MA)-K identified Resident 17 had been readmitted from the hospital the evening of 5/12/20. MA- was unaware if the resident was currently on Transmission Based Precautions but indicated the resident's roommate remained in the room with Resident 17. MA-K was unable to identify which of the facility's current residents were to be on Transmission Based Precautions. Review of Resident 17's Nursing Progress Notes revealed the following: -5/14/20 at 3:25 PM the resident's physician was notified the resident had complaints of shortness of breath and had a temperature of 99 degrees Fahrenheit; -5/14/20 at 6:23 PM a fax was received from the resident's physician with an order to isolate the resident and to monitor closely; -5/15/20 at 1:38 PM the resident left the facility for a [MEDICAL TREATMENT] appointment; -5/19/20 at 6:43 PM the resident was complaining of shortness of breath and body aches. The resident's lung sounds were coarse with a dry cough noted. The resident's temperature was 99 degrees Fahrenheit. An order was received to transfer the resident to the hospital; and -5/19/20 at 7:49 PM the facility received a call from the hospital indicating the resident was now positive for COVID-19. BB. Review of Resident 7's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 7's Nursing Progress Notes revealed the following: -3/25/2020 at 7:59 PM the resident was observed to have rapid respirations. The resident's pulse was 107 beats per minute. The resident's oxygen saturation level (the amount of oxygen in the blood) was 86 percent (%) on room air with lung sounds diminished throughout lung fields. The resident was placed on oxygen per nasal cannula at 2 liters and after several minutes, was less anxious with an oxygen saturation level of 94%; and -3/26/2020 at 3:09 AM the resident was observed to sleep long intervals with eyes closed and remained on oxygen. Further review of t (TRUNCATED)

Licensure Reference Number 175 NAC ,[DATE].09D Based on record review and interviews, the facility failed to: 1) ensure assessments and ongoing monitoring were completed for Residents 9, 1, 20, 7 and 17 who were positive or presumed positive for COVID-19; 2) implement assessment and monitoring for Residents' 21 and 25 related to diabetic management; and 3) complete assessment and monitoring of Resident 25 related to [MEDICAL TREATMENT] (a method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood) and the resident's multiple potential exposure to COVID-19 from transport and weekly visits to the [MEDICAL TREATMENT] center. The total sample size was 28 and the facility census was 54. Findings are: A. Review of the facility policy Change in a Resident's Condition or Status with revision date ,[DATE] revealed the Charge Nurse was to document in the resident's medical record information relative to a significant change in the resident's medical/mental condition or status. A significant change of condition was identified as a decline in the resident's status which would not normally resolve itself without intervention and/or impacted more than one area of the resident's health status. B. Review of the facility policy [MEDICAL TREATMENT] Access Care with revision date ,[DATE] revealed the following regarding documentation in the resident's medical record: -location of access site; -condition of dressing to the site; -any report from [MEDICAL TREATMENT] nurse post-[MEDICAL TREATMENT] being given; and -observations post [MEDICAL TREATMENT]. C. Review of the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality, Safety and Oversight Group dated [DATE] revealed the following guidance for infection control and prevention of Coronavirus Disease 2019 (COVID-19): -implement active screening of residents for fever and respiratory symptoms. Actively take their temperatures and document the absence of shortness of breath, new or change in cough and sore throat; and -for a medically necessary appointment outside of the nursing home, such as [MEDICAL TREATMENT], the facility should monitor the resident upon return for fever and signs and symptoms or respiratory infection (preferably in a space dedicated for observation of asymptomatic residents). D. Review of Resident 25's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission orders [REDACTED]. Review of Resident 25's Nursing Progress Note dated [DATE] at 3:44 PM revealed while the resident was at [MEDICAL TREATMENT], the resident was transferred to the emergency room related to respiratory complications. A chest x-ray and laboratory screening were completed before the resident returned to the facility. review of the resident's medical record revealed [REDACTED]. Review of [MEDICAL TREATMENT] Flow Sheets (form used to document a resident's pre-[MEDICAL TREATMENT] vital signs which included a blood pressure, temperature, pulse, respirations and an oxygen saturation level) from [DATE] - [DATE] revealed the resident was receiving [MEDICAL TREATMENT] 3 times a week (Mondays, Wednesdays and Fridays). Further review revealed no documentation to indicate a [MEDICAL TREATMENT] Flow record was completed on [DATE], [DATE], and on [DATE]. Review of the resident's Medication Administration Record [REDACTED]. Further review revealed no documentation to indicate the resident's vital signs were monitored upon return from [MEDICAL TREATMENT] on [DATE], [DATE] and on [DATE]. Review of the resident's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED] -at 7:30 AM the resident did not receive the ordered insulin or have blood glucose level checked on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and on [DATE] (11 out of 30 days); -at 11:30 AM the resident did not receive the ordered insulin or have blood glucose level checked on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and on [DATE] (8 out of 30 day). In addition, the resident had blood glucose level checked but did not receive insulin on ,[DATE], ,[DATE] and on [DATE]; and -at 5:30 PM the resident did not receive the ordered insulin or have blood glucose level checked on [DATE]. In addition, the resident had blood glucose level checked but did not receive insulin on ,[DATE] and [DATE]. Review of the resident's Treatment Administration Record (TAR) dated ,[DATE] revealed the resident had an order for [REDACTED]. Documentation revealed staff were charting each shift whether the resident was compliant or non-compliant with the designated fluid restriction. Further review revealed the following: -6AM to 2PM the resident was not compliant with fluid restrictions on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE]. There was no documentation regarding the resident's compliance on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and on [DATE]; -2PM to 10PM the resident was not compliant with fluid restrictions on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and on [DATE]. There was missing documentation of the resident's compliance on [DATE]; and -10PM to 6AM the resident was not compliant regarding fluid restrictions on ,[DATE], ,[DATE] through ,[DATE], ,[DATE], ,[DATE] and on [DATE]. Review of the resident's medical record from [DATE]-[DATE] revealed no evidence the facility had monitored the resident's blood glucose at bedtime or addressed the resident's non-compliance with fluid restrictions. In addition, no further assessment or monitoring was completed despite the facility failure at times to check the resident's blood glucose level and to administer the [MEDICATION NAME]when ordered at 7:30AM, 11:30AM and at 5:30 PM. Review of the facility Resident Screening Log (form used to assess and document any potential signs and symptoms of COVID-19) from [DATE] to [DATE] revealed Resident 25 had no screening completed on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and on [DATE]. Further review of the resident's screening log revealed on ,[DATE], ,[DATE] and on [DATE] through [DATE], the resident had a temperature check but the facility failed to assess/document if the resident had any signs or symptoms and staff failed to document a signature to identify who had completed the resident screening. Review of the resident's MAR for ,[DATE] revealed the following regarding the resident's ordered [MEDICATION NAME]administration and/or blood glucose monitoring from [DATE] through [DATE]: -at 7:30 AM the resident's blood glucose level was not checked and the resident's 30 units of [MEDICATION NAME]was not administered on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] (7 out of 16 days); -at 11:30 AM the resident's blood glucose level was not checked and the resident's order for [MEDICATION NAME]was not administered on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE] (8 out of 16 days); and -at 5:30 PM the resident's blood glucose level was checked but the resident's insulin was not administered on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and on ,[DATE] (6 out of 16 days). Review of the resident's MAR for ,[DATE] revealed from [DATE] to [DATE], staff failed to monitor the resident's pulse, blood pressure, temperature respirations and oxygen saturation level upon return from [MEDICAL TREATMENT] on [DATE], [DATE], [DATE], [DATE] and on [DATE]. Review of the resident's TAR from [DATE]-[DATE] revealed the following regarding the resident's non-compliance with fluid restrictions: -6AM to 2PM the resident was non-compliant on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and on [DATE]. The facility failed to document compliance on ,[DATE], ,[DATE] and on [DATE]; -2PM to 10PM the resident was non-compliant with fluid restriction on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and on [DATE]. The facility failed to document compliance on ,[DATE], ,[DATE] and on [DATE]; and -10PM to 6AM the resident was non-compliant with fluid restriction on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and on [DATE]. The facility failed to document the resident's compliance on ,[DATE], ,[DATE] and on [DATE]. Review of the resident's medical record from [DATE]-[DATE] revealed no evidence the facility had monitored the resident's blood glucose at bedtime or addressed the resident's non-compliance with fluid restrictions. In addition, no further assessment or monitoring was completed despite the facility failure at times to check the resident's blood glucose level and to administer the [MEDICATION NAME]when ordered at 7:30AM, 11:30AM and at 5:30 PM. Review of [MEDICAL TREATMENT] Flow Sheets dated [DATE]-[DATE] revealed no documentation to indicate a [MEDICAL TREATMENT] Flow record was completed on [DATE]. Review of a facsimile (fax) from the [MEDICAL TREATMENT] Center on [DATE] (no time) revealed the center had attempted to call the facility 9 times to multiple extensions' with no answer and a voicemail left. The fax identified an order for [REDACTED]. review of the resident's medical record revealed [REDACTED]. In addition, there is no documentation in the resident's medical record to indicate the reason the medication was ordered or that the facility was monitoring the resident for a potential infection. Review of the resident's Nursing Progress Notes dated [DATE] revealed the following: -8:20 AM the resident was found unresponsive with no pulse present. Cardiopulmonary Resuscitation (CPR) was initiated and the resident was transferred to the hospital; and -11:50 AM the facility was notified the resident had expired at 8:51 AM. E. Review of Resident 7's MDS dated [DATE] revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 7's Nursing Progress Notes revealed the following: -[DATE] at 7:59 PM the resident was observed to have rapid respirations. The resident's pulse was 107 beats per minute. The resident's oxygen saturation level (the amount of oxygen in the blood) was 86 percent (%) on room air with lung sounds diminished throughout lung fields. The resident was placed on oxygen per nasal cannula at 2 liters and after several minutes, was less anxious with an oxygen saturation level of 94. review of the resident's medical record revealed [REDACTED]. Review of Resident 7's Nursing Progress Notes revealed the following: -[DATE] at 8:48 PM the resident was identified as receiving the COVID-19 test; -[DATE] at 11:52 PM the facility was notified Resident 7 had tested positive for Covid-19. Isolation precautions were put into place. The note further indicated staff were to complete vital signs every 4 hours as ordered by the resident's physician; -[DATE] at 3:48 PM the resident's temperature was 99.9 degrees Fahrenheit and the resident's oxygen saturation level was 90% on room air. The resident's lung sounds with rhonchi (coarse rattling respiratory sound somewhat like snoring, usually caused by secretion in [MEDICATION NAME] airways) throughout. A moist cough was noted; -[DATE] at 4:34 PM a fax was sent to the resident's physician regarding positive results for COVID-19; -[DATE] at 8:53 PM the resident's temperature was 101.7 degrees with a pulse of 104 beats per minute and an oxygen saturation level of 87% on room air. Lung sounds with scattered crackles throughout and a moist cough was noted. The resident had refused food and fluids. Shortness of breath was observed with exertion. The resident's physician was notified of the resident's condition; -[DATE] at 9:23 PM a new order was received for Tylenol, [MEDICATION NAME] and to increase oxygen to keep the resident's saturation levels above 90%. The facility was to encourage the resident to stay up in a wheelchair as much as possible to prevent pneumonia. The resident refused the need for hospitalization at this time; -[DATE] at 5:30 PM the resident's temperature was 104 degrees Fahrenheit; -[DATE] at 3:55 PM the resident's temperature was 101.3 degrees Fahrenheit with oxygen saturation level bouncing from 92% to 96% on 3 liters of oxygen. The resident's lung sounds were diminished throughout with wheezing. The resident had complaints of coughing, body aches, headache, sore throat and shortness of breath. The resident requested to be transported to the hospital. review of the resident's medical record revealed [REDACTED]. F. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 17's Nursing Progress Notes revealed the following: -[DATE] at 2:48 PM the resident was assessed as having a temperature of 100 degrees Fahrenheit with complaints of nausea; -[DATE] 8:42 AM the resident's temperature was 99.3 degrees Fahrenheit with complaints of feeling very tired; -[DATE] at 5:21 PM an order was received for the staff to check the resident's oxygen saturation level every shift and to report if the resident's saturation level was below 89%; -[DATE] at 4:56 PM the resident complained of shortness of breath and of a cough. A new order was received for respiratory treatments every 6 hours as needed for shortness of breath and cough; -[DATE] (5 days after the resident first indicated feeling short of breath) at 9:11 PM the resident had complaints of increased congestion; -[DATE] at 10:52 AM the resident voiced complaint of not feeling well with increased shortness of breath; -[DATE] at 12:32 AM a facsimile (fax) was received from the resident's physician which identified new orders for [MEDICATION NAME] (antibiotic used to treat bacterial infections) 875 milligrams (mg) twice a day for 10 days and for [MEDICATION NAME] (liquid medication used to treat coughs) 10 cubic centimeters (cc) every 6 hours as needed for cough; -[DATE] at 1:02 PM the resident complained of still not feeling well at times with continued shortness of breath. Further review of the resident's medical record revealed [REDACTED]. -[DATE] at 11:06 AM the resident was admitted to the hospital with [REDACTED].>-[DATE] at 6:43 PM the resident was readmitted from the hospital. A perm a- catheter (a catheter placed through a vein into or near the right atrium (one of 2 heart chambers where blood enters into the heart) used for [MEDICAL TREATMENT] (a method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood) in an emergency or until a long-term device is ready to use) was inserted [DATE] to the resident's right chest. -[DATE] at 3:25 PM the resident's physician was notified the resident had complaints of shortness of breath and had a temperature of 99 degrees Fahrenheit; -[DATE] at 6:23 PM a facsimile (fax) was received from the resident's physician with an order to isolate the resident and to monitor closely; review of the resident's medical record revealed [REDACTED]. -[DATE] at 1:38 PM the resident left the facility for a [MEDICAL TREATMENT] appointment; -[DATE] (5 days after the resident's physician instructed the facility to monitor the resident closely) at 6:43 PM the resident was complaining of shortness of breath and body aches. The resident's lung sounds were coarse with a dry cough noted. The resident's temperature was 99 degrees Fahrenheit. An order was received to transfer the resident to the hospital; and -[DATE] at 7:49 PM the facility received a call from the hospital indicating the resident was now positive for COVID-19. G. During an interview on [DATE] at 1:30 PM, Licensed Practical Nurse (LPN)-A confirmed the following: -Resident 7 had an elevated pulse, low oxygen saturation level and diminished lung sounds reported on [DATE]. Despite the resident portraying potential symptoms of COVID-19, no further assessment of the resident was completed; -Resident 7 was tested for COVID-19 on [DATE] and on [DATE], the test came back positive; -Resident 7's physician was notified the resident was positive and ordered the resident's vital signs were to be assessed every 4 hours. The facility failed to complete vital signs every 4 hours; -Resident 17 was complaining of shortness of breath on [DATE] with an order to have the resident's oxygen saturation level assessed every shift and to report levels below 89% to the resident's physician. Staff failed to complete oxygen saturation levels every shift as ordered by the resident's physician; -no further assessment of the resident until [DATE] when the resident was again displaying shortness of breath and a cough; -no evidence the resident was assessed again until [DATE]; -[DATE] the resident was started on an antibiotic due to shortness of breath, cough and diminished lung sounds with an occasional temperature; -no further assessment of the resident until [DATE] and on [DATE] the resident was admitted to the hospital for fluid overload; -[DATE] the resident was complaining of shortness of breath and had an elevated temperature. Staff were advised to monitor the resident closely. There were no further assessments documented for Resident 17 until [DATE] when the resident was again transferred to the hospital and tested positive for COVID-19; -Resident 25 went to [MEDICAL TREATMENT] 3 times a week and staff were to complete a full set of vital signs before going and after returning from [MEDICAL TREATMENT]; -missing documentation of assessments before and after returning from [MEDICAL TREATMENT]; -Resident 25 was on a fluid restriction and staff were to document compliance or non-compliance each shift; -missing documentation as to the resident's compliance or non-compliance with fluid intakes each shift; -Resident 25 was a diabetic and staff were to administer [MEDICATION NAME]3 times a day before meals and to obtain a blood glucose level at the same time; -the resident would refuse to eat or would refuse insulin at times or the resident was at [MEDICAL TREATMENT]. The facility did not send insulin or food with the resident when at [MEDICAL TREATMENT]; -the facility was not checking the resident's blood glucose level at bedtime; -the resident's physician was unaware the resident's blood glucose level was not being monitored or the [MEDICATION NAME]administered as ordered by the physician; -the order for Z-Pak received from the [MEDICAL TREATMENT] Center on [DATE] was not noted and/or initiated for the resident; -there was no documentation in the resident's medical record to indicate why the Z-Pak was ordered; and -no assessment of the resident's medical status from [DATE] until [DATE] when the resident was found unresponsive. H. Review of Resident 21's MDS dated [DATE] revealed: -a [DIAGNOSES REDACTED].>-the resident received supervision for dressing, toileting, bed mobility and dressing; and -the resident received insulin injections 6 out of 7 days, with 1 insulin order change. Review of Resident 21's Care Plan dated [DATE] revealed no indication that the resident received insulin, was a diabetic, or required monitoring related to the diabetes. Review of Resident 21's Progress Notes revealed: -[DATE] at 9:32 PM the resident was admitted to the facility. -[DATE] at 9:45 PM the facility faxed the PCP (primary care physician) requesting blood glucose monitoring and reporting parameters. -[DATE] at 4:40 PM (3 days later) the facility received a reply to the fax generated on [DATE] with orders for daily blood glucose monitoring, and an order to submit a blood glucose log to the PCP every 2 weeks. -[DATE] at 11:30 AM the resident was found lying on the bed, unresponsive, diaphoretic (sweating profusely), and having [MEDICAL CONDITION] activity. Resident 21 was determined to have a critically low blood glucose level of 26, was treated with an injection of [MEDICATION NAME] (medication to raise blood glucose levels) and transported to the ER (emergency room ) for further treatment. -[DATE] at 5:12 PM the resident returned to the facility with no new orders. The discharge Patient Education Material recommended blood glucose monitoring for patients at least 2 times daily. -[DATE] at 2:21 PM the resident's family was notified of a potential exposure to a confirmed case of COVID-19. -[DATE] at 9:33 PM the resident was placed in isolation due to possible COVID-19 exposure, exhibiting headaches, body aches, and nausea. The family and physician were notified. -[DATE] at 8:50 PM the resident was tested for COVID-19. -[DATE] at 12:53 AM the resident's COVID-19 test was negative indicating the resident did not have COVID-19. -[DATE] at 3:00 PM the resident had a blood glucose of 32 (critically low) by lunch time, had not eaten breakfast or lunch, and the staff administered [MEDICATION NAME] to raise the resident's blood glucose level. The physician was faxed a request to change or hold the resident's night dose of Basaglar (injectable long acting insulin for treatment of [REDACTED]. -[DATE] at 5:27 AM the resident was found lying on the floor in the bathroom at 4:00 AM with no pulse or blood pressure. Further review of the resident's Nursing Progress Notes revealed: -no evidence the facility assessed the resident's change in status related to low blood glucose levels following an ER visit on [DATE] until [DATE]; -no evidence the facility completed assessments related to symptoms of COVID-19 following the initial documented symptoms of headaches, body aches and nausea on [DATE] at 9:33 PM; -no evidence the facility made additional attempts to obtain a response from the resident's physician on [DATE] or [DATE] regarding changing or holding the resident's night dose of Basaglar; and -no evidence the facility assessed the resident for signs and symptoms of low blood glucose or documented on the resident's condition from [DATE] at 3:00 PM until [DATE] at 4:00 AM when the resident was found on the floor of the bathroom with no pulse or blood pressure. I. Review of Resident 9's MDS revealed: -a [DIAGNOSES REDACTED]. -the resident received supervision for eating and extensive assistance provided for bed mobility, transfers, toileting, and dressing. -the resident had moderate cognitive impairment. Review of Resident 9's Nursing Progress Notes revealed: -[DATE] at 12:25 AM the resident complained of not being able to breath and was given medications for the relief of symptoms. -[DATE] at 3:09 PM the resident's emergency contact was informed of a potential exposure to COVID-19. -[DATE] at 9:25 PM the resident was tested for COVID-19. -[DATE] at 2:00 AM the resident had a body temperature of 103.3 degrees Fahrenheit and an oxygen saturation of 88%. The physician was notified and recommended isolation precautions, continued oxygen, and fever management. -[DATE] at 3:24 PM the facility was notified that resident's COVID test was positive. -[DATE] at 5:09 PM the resident had increased shortness of breath and chest discomfort and was transferred to the hospital and admitted . Further review of the resident's Nursing Progress Notes revealed: -no evidence the facility assessed the resident's change in status from [DATE] at 12:25 AM until [DATE] at 2:00 AM; and -no evidence the facility assessed the resident's change in status from [DATE] at 2:00 AM until [DATE] at 5:09 PM when the resident required admission to the hospital. J. Interview with DON on [DATE] at 2:00 PM confirmed that residents with a condition change should be assessed, and have documented condition assessments every shift until their condition stabilizes. K. Review of Resident 1's Nursing Progress Notes revealed: - On [DATE] the resident tested positive for COVID-19 with vital signs every 4 hours ordered. - No documentation in the Nursing Progress Notes on [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Resident 1's COVID-19 Flow Sheets dated [DATE] to [DATE] revealed: - On [DATE] the resident had vital signs taken at 3:20 PM and 3:40 PM; - On [DATE] the resident had vital signs taken at 8:00 AM and 3:00 PM; - On [DATE] the resident had vital signs taken once (time not indicated) and at 11:45 AM; - On [DATE] the resident had vital signs taken at 3:00 PM; and - On [DATE] the resident had vital signs taken at 11:40 PM. Review of Resident 1's Nursing Progress Notes, Assessments, and Vital Signs section in the Electronic Health Record revealed no additional vital signs had been taken (with the order for vital signs every 4 hours) L. Review of Resident 20's Nursing Progress Notes: - On [DATE] at 3:16 PM, the resident was running a fever of 100 degrees Fahrenheit with a loss of appetite and a headache. - On [DATE] at 6:14 PM, the physician ordered a repeat COVID-19 test. - No documentation in the Nursing Progress Notes on [DATE] and [DATE]. - On [DATE] at 11:15 PM, the physician was notified of the resident having an oxygen level of 83% and a heart rate of 106 beats per minute. The physician advised to start the resident on oxygen at 2 liters per minute. - On [DATE] at 11:50 PM, the resident's oxygen level increased to 90%. - On [DATE] at 4:09 PM (approximately 14 hours since the resident's last set of vital signs), the physician was contacted regarding the resident running a temperature of 102.1 degrees Fahrenheit with oxygen started. - On [DATE] at 6:01 AM (approximately 14 hours since the resident's last set of vital signs), the resident had a heart rate of 114 beats per minute and an oxygen level of 80%. The resident was educated to wear the oxygen at all times. - There was no evidence to indicate the resident's COVID-19 test was repeated.

Licensure Reference Number 175 NAC 12-006.09D Based on record reviews and interviews, the facility failed to ensure a change of condition was identified, assessments were completed and care was provided for 1 (Resident 1) of 6 sampled residents. The facility census was 57. Findings are: A. Review of an Acute Condition Changes-Clinical Protocol policy and procedure with revision date 12/2012 revealed the physician should be contacted about a resident with an acute change of condition and provide detailed information and pertinent information which included the following: -vital signs; -current level of pain and any recent changes in pain level; -all active diagnoses; and -onset, duration and severity of the resident's change in condition B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/11/20 revealed the resident's cognition was severely impaired with [DIAGNOSES REDACTED]. The assessment indicated the resident required extensive staff assistance of 2 with transfers, bed mobility and toilet use and extensive staff assistance of 1 with personal hygiene and dressing. In addition, the resident was assessed to be always incontinent of bowel and bladder. Review of Resident 1's current Care Plan with revision date 8/21/19 revealed the resident had an activities of daily living self-care deficit related to [DIAGNOSES REDACTED]. The resident was also identified as combative and uncooperative with cares at times. The following interventions were identified: -extensive staff assistance of 1 to turn and reposition the resident in bed; -extensive staff assistance of 1-2 with toileting. The resident was to wear a disposable urinary incontinence brief; and -extensive assistance of 1-2 staff for pivot transfers. Review of Nursing Progress Notes dated 4/2/20 revealed the following: -7:54 AM the facility attempted to call the resident's physician regarding swelling to the resident's left leg; -8:18 AM the on call physician responded to the facility and advised the facility to collect vitals and then call the office of the resident's physician; -8:33 AM the resident's physician office was notified of the resident's current status. The resident's vital signs were within normal limits, the resident's left leg extended outward, was warm to the touch and appeared swollen. The facility was advised they would be contacted shortly; -6:16 PM (9 hours and 46 minutes later) the resident's family were notified of the resident's left leg and the family requested the resident be sent to the emergency room for evaluation; and -11:41 PM the facility was notified the resident was admitted to the hospital with [REDACTED]. Review of a Palliative Care Consult Note dated 4/6/20 at 11:00 AM revealed the resident had been sent to the hospital with reports of a swollen left leg, which was warm to the touch and was externally rotated for 2 days. The resident was found to have a complex [MEDICAL CONDITION] hip. The resident was found to have additional [DIAGNOSES REDACTED]. Review of Investigative Questionnaires (interviews conducted by the Administrator regarding Resident 1's injury to the left leg) dated 4/3/20 from 4:58 PM to 10:39 PM revealed the following: -Dietary Aide (DA)-B indicated on 3/18/20 the resident was assisted out to the dining room. The resident was slumped over in the wheelchair and was making little noises like the resident was hurting. DA-B notified the direct care staff. When the staff adjusted the resident's positioning, the resident let out a big scream; -Nurse Aide (NA)-A identified the resident had been complaining of pain when repositioned in bed for about a month; and -NA-G indicated a concern the resident had been having increased pain to the left hip for the last month and the resident also had a bruise to the left hip. Review of Resident 1's electronic medical record revealed no documentation regarding any bruising to the resident's left hip, no evidence the resident was having increased pain to the left hip or was having difficulty with repositioning related to the hip pain. During an interview on 4/7/20 at 10:45 AM, NA-A verified the following: -over the last month the resident would moan with pain whenever staff provided incontinence cares or repositioned the resident; -observed a large bruise to the resident's left hip about a month ago; and -the bruising and the resident's increased pain to the left hip had been reported to Registered Nurse (RN)-I and to an Agency Charge Nurse but NA-A had never heard that anything had been done for the resident. During an interview on 4/7/20 at 11:45 AM, RN-I identified the following: -the bruising to the resident's left hip should have been assessed and an investigation should have been completed to identify how the injury occurred; and -the resident's increased pain level should have been monitored and reported to the resident's physician with interventions developed to address the increased pain. Interview with the Administrator on 4/7/20 at 1:30 PM confirmed the following: -bruising to the resident's left hip with increased pain was not identified and/or investigated to determine potential causal factors; -no interventions were developed to address the resident's increased hip pain; and -the resident's change in condition was not reported to the physician until 4/2/20 when the resident was hospitalized with a left [MEDICAL CONDITION].