Every finding on record at Douglas County Health Center

Licensure Reference Number 175 NAC 12-006.10(D). Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 3 (Resident 1, 4 and 5) of 5 residents sampled. The facility census was 233. The findings are:Record review of the facility's policy dated 02-22-2022 titled Medication Administration revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Staff are to obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Staff are to compare the medication source (bubble pack, bottle) with the Medication Administration Record (MAR) to verify resident name, medication name, form, dose, route and time. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities), high risk drug classes include antipsychotics, hypnotics, anticoagulants, opioids, and diuretics (a medication that increases the production and excretion of urine) and residents taking these medication categories are at risk of side effects that can adversely affect, health, safety and quality of life. A.Record review of Resident 1's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 09-16-2025 revealed the facility staff assessed the following about the resident:-The resident was admitted to the facility on [DATE].-The resident had a traumatic hemorrhage of the cerebrum (bleeding that occurs within the brain tissue).-Brief Interview of Mental Status (BIMS) was scored as a 2/15. According to the RAI Manual, a score of 0-7 indicated severe cognitive impairment. Record review of Resident 1's Transition Orders and Information for the Continuation of Patient Care (TOICPC) dated 09-10-2025 revealed an order for apixaban (an anticoagulant medication used to keep blood from clotting) 5 milligrams (mg) twice a day, wait to take this medication until your doctor or other care provider tells you to start again. The TOICPC also indicated Resident 1 had an appointment with neurology with a follow up head Computed Tomography scan (CT scan: a test used to diagnose blood clots or internal bleeding) on 09-19-2025. Record review of Resident 1's MAR for September 2025 revealed an order for apixaban 5mg tablet take 1 tablet by mouth for atrial fibrillation. Hold until neurosurgery restarts. The MAR also revealed apixaban 5mg was administered twice a day at 9:00 AM and 9:00 PM from 09-19-2025 through 09-28-2025 and apixaban 5mg was administered on 09-29-2025 at 9:00 AM for a total of 21 doses. Record review of Resident 1's Office Visit in Neurosurgery (OVN) dated 09-29-2025 revealed Resident 1 was to return to the office in 1 week for a new CT scan of the head to determine if there is any worsening in the subdural hematoma or subdural hygroma and to revisit operative intervention at that point if appropriate. Record review of Resident 1's OVN dated 10-07-2025 revealed the current imaging indicated a progression of the left sided subdural hematoma. Record review of Resident 1's Physician's Orders dated 10-08-2025 revealed an order to consult hospice for evaluation and treatment for an increased brain hemorrhage. Record review of Resident 1's Medication Error Report (MER) dated 09-10-2025 revealed Resident 1's family representative had changed the neurology appointment from 09-19-2025 to 09-29-2025 and had accompanied Resident 1 to the appointment. Furthermore, the family representative brought the medication error to the facility's attention after the neurologist pointed out the apixaban had not been held at the appointment on 09-29-2025. Further review of the MER revealed the pharmacy had filled the label out as the following: hold until neurosurgery appointment instead of not filling it at all and was not correct as to what the actual orders read on the TOICPC which was a simple Hold order. The medication should not have been filled by the pharmacy at all. The medication should not have been sent to the floor at all. The medication should not have been chart checked or confirmed as per nursing did with such a tenuous and delayed start date. The medication should not have been confirmed as written to prevent administration of the medication. An interview conducted on 10-30-2025 at 11:30 AM with Unit Manager (UM) B confirmed Resident 1 received 21 doses of apixaban in error. According to Bristol [NAME] Squibb, the manufacturer of apixaban, apixaban's serious side effects include increased bleeding which can be serious and may lead to death and is contraindicated for individuals with pathological bleeding. B.Record review of Resident 4's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-BIMS was scored at an 11/15. According to the RAI Manual, a score of 8-12 indicated moderate cognitive impairment.-The resident required limited assistance with dressing and hygiene.-The resident required extensive assistance with toileting, bathing, bed mobility and transfers. Record review of Resident 4's Progress Notes (PN) dated 10-01-2025 revealed Resident 4 had orders for medication changes to discontinue gabapentin (a medication for nerve pain), Spiriva (a medication used to keep airways open) and budesonide nebulizer medication (a medication that reduces swelling in the airways). Record review of Resident 4's Office Visit Neurology Clinic (OVNC) dated 10-03-2025 revealed an order to stop gabapentin since Resident 4 was already taking Lyrica (a medication used for nerve pain). Record review of Resident 4's MAR for October 2025 revealed gabapentin 100 mg capsule was discontinued on 10-01-2025. The MAR also revealed Lyrica 150 mg by mouth twice a day was placed on hold starting 10-03-2025 at 9:00 PM and remained on hold through 10-07-2025 for a total of 9 doses held. Record review of Resident 4's PNs dated 10/6/2025 revealed the resident had been observed to be anxious the last couple of mornings. Later the same day, it was documented that the resident was having an episode of confusion and having difficulty finding their words. Record review of Resident 4's PN dated 10/7/2025 revealed the resident was having continued confusion. Record review of Resident 4's PN dated 10/8/2025 revealed Resident 4 does not seem to be having any issues now that Lyrica was restarted. Record review of Resident 4's MER dated 10-07-2025 revealed Resident 4 returned from a neurology appointment on 10-03-2025 with orders to discontinue the gabapentin, and the orders were faxed to the pharmacy. Furthermore, on 10-03-2025 the pharmacist put a hold on the Lyrica, we called on that date about the hold and the pharmacy did not address, we called again on 10-06-2025 and tried to explain the Lyrica was not discontinued and should not have been held. Today, 10-07-2025 the resident is presenting more confused and not eating. The resident was in withdrawals from having gabapentin and Lyrica stopped abruptly. An interview with UM-D on 10-30-2025 at 12:57 PM confirmed Resident 4's Lyrica was held from 10-03-2025 through 10-07-2025 for a total of 9 doses without an order to do so. C.Record review of Resident 5's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-The resident had a diagnosis of Congestive Heart Failure.-BIMS was scored as a 13/15. According to the RAI Manual, a score of 13 to 15 indicates a person is cognitively intact. -The resident required extensive assistance with bed mobility and transfers.-The resident required total assistance with eating, dressing, toileting, bathing and dressing.-The resident was receiving an opioid medication (a medication to help moderate-to-severe pain).-The resident was taking a hypnotic medication (a class of psychoactive medications primarily used to induce and maintain sleep). Record review of Resident 5's PN dated 10-03-2025 revealed Resident 5 had no sign of a reaction after the medication error that morning. Record review of Resident 5's MER dated 10-03-2025 revealed temazepam (a sedative-hypnotic medication used to treat insomnia) 15 mg capsule was scheduled to be given at bedtime and was given at 9:00 AM. An interview conducted on 10-30-2025 at 11:55 AM confirmed Resident 5 received temazepam at 9:00 AM in error. Record review of Resident 5's MAR for October 2025 revealed an order for Buprenorphine 10 micrograms (mcg)/hour patch (an opioid medication used to manage severe or chronic pain). Apply topically every 7 days on Sundays for chronic pain. Record review of Resident 5's PN dated 10-12-2025 revealed Resident 5's Buprenorphine 10mcg/hour patch was changed on 10-12-2025. The patch found on the resident's chest was dated 09-30-2025 and was to be changed on 10-07-2025. Record review of Resident 5's MER dated 10-12-2025 revealed Buprenorphine 10 mcg/hour patch was omitted on 10-07-2025, a new patch was placed on 10-12-2025 and the MAR was updated to reflect the new dates to change the patch going forward. An interview with UM-F on 10-30-2025 at 11:55 AM confirmed Resident 5's Buprenorphine 10mcg/hour patch was not changed on 10-07-2025 and should have been. Record review of Resident 5's PN dated 10-17-2025 revealed Resident 5 received the wrong medications. Record review of Resident 5's MER dated 10-17-2025 revealed Resident 5 had received another resident's medications at 9:00 AM. An interview with UM-F on 10-30-2025 at 2:55 PM confirmed Resident 5 received the following medications in error:-apixaban 5mg (an anticoagulant medication used to keep blood from clotting),-Hydrochlorothiazide 12.5mg (a thiazide diuretic medication used for high blood pressure and swelling),-Losartan 100mg (a medication to treat high blood pressure), and-Olanzapine 5 mg (an antipsychotic medication used to treat schizophrenia or bipolar disorder). Record review of Resident 5's MAR for October 2025 revealed an order for Entresto Oral Tablet 24-26 mg, give 1 tablet twice a day for Congestive Heart Failure, hold if Systolic Blood Pressure (SBP: the top number of a blood pressure reading) is less than 90. Review of this order also revealed an SBP of 86 on 10-03-2025 and the Entresto was documented as administered, and an SBP of 85 on 10-29-2025 and the Entresto was documented as administered. An interview with UM-F on 10-30-2025 at 2:55 PM confirmed Resident 5 had received Entresto 24-26mg on 10-03-2025 and 10-29-2025 when it should have been held according to the practitioner's orders and was administered in error.

Licensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review the facility failed to administer pain medication according to the practitioner's orders for 2 (Resident 4 and 5) of 5 residents sampled. The facility census was 233. The findings are:A.Record review of Resident 4's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 08-27-2025 revealed the facility staff assessed the following about the resident:-BIMS was scored at an 11/15. According to the MDS Manual, a score of 8-12 indicated moderate cognitive impairment.-The resident required limited assistance with dressing and hygiene.-The resident required extensive assistance with toileting, bathing, bed mobility and transfers. Record review of Resident 4's Progress Notes (PN) dated 10-01-2025 revealed Resident 4 had an order to discontinue their gabapentin (an anticonvulsant medication used to treat nerve pain). Record review of Resident 4's Office Visit Neurology Clinic (OVNC) dated 10-03-2025 revealed an order to stop gabapentin since Resident 4 was already taking Lyrica (a medication used for nerve pain). Record review of Resident 4's MAR for October 2025 revealed their order for gabapentin 100 mg capsule for pain was discontinued on 10-01-2025. The MAR also revealed Lyrica 150 mg by mouth twice a day for pain was placed on hold starting 10-03-2025 at 9:00 PM and remained on hold through 10-07-2025 for a total of 9 doses. Record review of Resident 4's Medication Error Report (MER) dated 10-07-2025 revealed Resident 4 returned from a neurology appointment on 10-03-2025 with orders to discontinue the gabapentin, and the orders were faxed to the pharmacy. Furthermore, on 10-03-2025 the pharmacist put a hold on the Lyrica, we called on that date about the hold and the pharmacy did not address, we called again on 10-06-2025 and tried to explain the Lyrica was not discontinued and should not have been held. Today, 10-07-2025 the resident is presenting more confused and not eating. The resident was in withdrawals from having gabapentin and Lyrica stopped abruptly. An interview with Unit Manager (UM) D on 10-30-2025 at 12:57 PM confirmed Resident 4 was receiving Lyrica for pain and was held from 10-03-2025 through 10-07-2025 for a total of 9 doses without an order to do so. B. Record review of Resident 5's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-The resident had a diagnosis of Congestive Heart Failure.-BIMS was scored as a 13/15. According to the MDS Manual, a score of 13 to 15 indicates a person is cognitively intact.-The resident required extensive assistance with bed mobility and transfers.-The resident required total assistance with eating, dressing, toileting, bathing and dressing.-The resident was receiving an opioid medication (a medication to help moderate-to-severe pain).-The resident was taking a hypnotic medication (a class of psychoactive medications primarily used to induce and maintain sleep). Record review of Resident 5's MAR for October 2025 revealed an order for Buprenorphine 10 micrograms (mcg)/hour patch (an opioid medication used to manage severe or chronic pain). Apply topically every 7 days on Sundays for chronic pain. Record review of Resident 5's Progress Note (PN) dated 10-12-2025 revealed Resident 5's Buprenorphine 10mcg/hour patch was changed on 10-12-2025. The patch found on the resident's chest was dated 09-30-2025 and was to be changed on 10-07-2025. Record review of Resident 5's MER dated 10-12-2025 revealed Buprenorphine 10 mcg/hour patch was omitted on 10-07-2025, a new patch was placed on 10-12-2025 and the MAR was updated to reflect the new dates to change the patch going forward. An interview with UM-F on 10-30-2025 at 11:55 AM confirmed Resident 5's Buprenorphine 10mcg/hour patch was not changed on 10-07-2025 and should have been.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview and record review the facility failed to utilize beard restraints while preparing food in facility kitchen. This had the potential to affect 231 of the 235 residents in the facility. The facility census was 240. The findings are: Record review of the Nebraska Food Code 2-402.11 revealed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service items. Observation on 05-07-2025 at 7:30 AM revealed Dietary Aide (DA)-R was at the cold side of the service line assisting with plating food without a beard net in place and DA-R had a goatee that was approximately an inch long. Observation on 05-08-2025 at 8:49 AM revealed DA-R at the cold side of the service line, plating food without a beard net and DA-R had a goatee. Furthermore, Dietary [NAME] (DC)-Q was at the short-order grill preparing eggs without a beard net and DC-Q had a mustache and goatee that was approximately 1 and a half inch in length. An observation on 05-13-2025 at 7:00 AM revealed DA-R was at the service line assisting with plating room trays and DC-Q was at the short-order grill cooking an omelet both were not wearing hair nets and both had facial hair. An interview with the Dietary Manager (DM) on 05-13-2025 at 7:30 AM confirmed both DA-R and DC-Q had facial hair that required a beard restraint. Record review of the facility policy titled Dress Code Policy dated 07-03-2024 revealed the purpose of the policy was to promote a safe work environment and a positive image to others, giving attention to infection control and safety requirements. Furthermore, under the dietary section of the policy, sideburns, mustaches and beards are to be trimmed and groomed. Beards greater than ½ inch in length shall be covered with a beard net.

Licensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview, the facility failed to identify and monitor target behaviors for the use of an antipsychotic medication for 1 (Resident 97) of 2 sampled residents. The facility identified a census of 240. Findings are: A record review of Resident 97's diagnoses revealed the resident had a diagnosis of dementia (a term used for diseases that affect memory, thinking and the ability to perform daily activities). A record review of Resident 97's physicians orders revealed the resident had an order for Quetiapine Fumarate (an antipsychotic medication used to treat a variety of mental health conditions) 100mg (milligram - a unit of measurement) twice a day and an order for Quetiapine Fumarate 50mg at noon for dementia. Further record review of Resident 97's physicians orders revealed a physician's order dated 7/27/2023, which stated to monitor the resident for behaviors daily. There were no time values present on the order. A record review of Resident 97's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2025 revealed target behaviors (specific, observable actions or patterns of behavior that are chosen as the focus of an intervention or behavior change plan) were not identified and there was no indication on the MAR or TAR for staff to record behavior monitoring for the use of Quetiapine Fumarate. A record review of Resident 97's care plan copied on 5/8/2025 revealed there were no target behaviors identified. An interview on 5/13/2025 at 2:45 PM with Registered Nurse (RN)-D confirmed target behaviors were not identified for Resident 97 and prompts to complete behavior monitoring were not present on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). A record review of the facility's policy Use of Psychotropic Medications last modified on 4/29/2025 revealed the following: Policy Explanation and Compliance Guidelines: 14. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: d) In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturers specifications and the residents comprehensive plan of care.

Licensure Reference Number 175 NAC 12-006.02(H) St 28-372 Based on record reviews and interviews, the facility failed to report to Adult Protective Services and the Department of Health and Human Services an alleged verbal altercation between 2 residents within the prescribed time frame. This had the potential to affect 1 (Resident 218) out of 2 residents sampled. The facility census was 240. Findings are: A record review of Resident 218's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) revealed the resident admitted to the facility on [DATE]. The MDS revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 12/15. The MDS manual states a score of 8-12 is considered moderately impaired. Section I of the MDS revealed the resident was diagnosed with non-traumatic brain dysfunction, non-Alzheimer's dementia, and psychotic disorder (other than schizophrenia). A record review of the facility progress note dated 04/04/2025 at 10:00 AM revealed Resident 218 had an argument with an unnamed resident in the dining room on the unit. No residents were harmed, the unnamed resident used racial slurs, derogatory words and threatened to beat up Resident 218. Resident 218 attempted to grab the walker and charge the unnamed resident. Staff intervened and removed both residents from the dining room. No residents were hurt. An interview was conducted with Unit Manager (UM)-H on 05/08/2025 at 1:17 PM regarding the incident on 04/04/2025 between the unnamed resident and Resident 218. UM-H didn't feel the incident was reportable because verbal altercations happen all the time on the unit. UM-H stated the situation was not reportable because the derogatory remarks were not considered verbal abuse. An interview was conducted on 05/08/2025 at 3:05 PM with Resident 218 regarding the incident on 04/04/2025 when Resident 218 was called a derogatory name, Resident 218 stated feelings of shock and remembrance of the Ku Klux [NAME] (KKK) and did not feel safe. An interview was conducted on 05/08/2025 at 3:55 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the incident with Resident 218 and another resident on 04/04/2025. The DON and ADON didn't feel that the verbal remarks were reportable or that there was a need to further investigate the incident to determine if it was reportable. An interview was conducted on 05/08/2025 at 4:10 PM with the Administrator and after reading the progress note from 04/04/2025 in Resident 218's chart the Administrator agreed that the event was reportable. A record review of the facility's Policy Suspected Resident Abuse or Neglect Including Misappropriation of Resident Property dated 03/11/2025. -Residents must not be subjected to abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers or other agencies serving the resident . Purpose 1. To take steps to prevent abuse/neglect/misappropriation/exploitation of resident property 2. To ensure residents' safety and rights are protected 3.To investigate reports of suspected abuse, neglect or misappropriation/exploitation of property so that corrective action can be taken. 13. the Nurse Manager, House Supervisor, Nursing Administration or appropriate Administrative Staff Member, will report the alleged abuse/neglect suspicion of a crime immediately upon receiving the information as follows: Report the incident within 2 hours to: A. APS B. Sheriff (NOTE: follow the above reporting process regardless of the alleged abuse/neglect or crime was felt to be inflicted by an employee, another resident, a visitor, a student, volunteer or a contractor) 14. information that should be given when a report of abuse/neglect or a suspicion of a crime is made includes: A. initial telephone report B. Written report of alleged crime/abuse/neglect and investigation C. Additional written information if requested 16. The internal investigation will be completed and a formal report sent to the State and APS within 5 working days of the notification of the allegation.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record reviews, interviews and observations, the facility failed to investigate an alleged verbal altercation between Resident 218 and an unnamed resident. This had the potential to affect 1 (Resident 218) out of 2 residents sampled. The facility census was 240. Findings are: A record review of Resident 218's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) revealed the Resident admitted to the facility on [DATE]. The MDS revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 12/15. The MDS manual states a score of 8-12 is considered moderately impaired. Section I of the MDS revealed the resident was diagnosed with non-traumatic brain dysfunction, non-Alzheimer's dementia, and psychotic disorder (other than schizophrenia). A record review of the facility progress note dated 04/04/2025 at 10:00 AM revealed Resident 218 had an argument with an unnamed resident in the dining room on the unit. No residents were harmed, the unnamed resident used racial slurs, derogatory words and threatened to beat up Resident 218. Resident 218 attempted to grab the walker and charge the unnamed resident. Staff intervened and removed both residents from the dining room. No residents were hurt. An interview as conducted 05/08/2025 at 10:09 AM interview with Unit Manager (UM)-H regarding Resident 218 and the alleged altercation on 04/04/2025. UM-H revealed that an unnamed resident called Resident 218 a derogatory name using the N word, UH-M stated that it was evident that Resident 218 was devastated. An interview was conducted with UM-H on 05/08/2025 at 1:17 PM regarding the incident on 04/04/2025 between the unnamed resident and Resident 218. UM-H didn't feel the incident was reportable because verbal altercations happen all the time on the unit. UM-H stated the situation was not reportable because the derogatory remarks were not considered verbal abuse. An interview was conducted on 05/08/2025 at 3:55 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the incident with Resident 218 and another resident on 04/04/2025. The DON and ADON didn't feel that the verbal remarks were reportable and that there was no need to further investigate the incident to determine if it was reportable. An interview was conducted on 05/08/2025 at 4:10 PM with the Administrator and after reading the progress note from 04/04/2025 in Resident 218's chart the Administrator agreed that the event was reportable. A record review of the facility's Policy Suspected Resident Abuse or Neglect Including Misappropriation of Resident Property dated 03/11/2025. -Residents must not be subjected to abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers or other agencies serving the resident . Purpose 1. To take steps to prevent abuse/neglect/misappropriation/exploitation of resident property 2. To ensure residents' safety and rights are protected 3.To investigate reports of suspected abuse, neglect or misappropriation/exploitation of property so that corrective action can be taken. 13. the Nurse Manager, House Supervisor, Nursing Administration or appropriate Administrative Staff Member, will report the alleged abuse/neglect suspicion of a crime immediately upon receiving the information as follows: Report the incident within 2 hours to: A. APS B. Sheriff (NOTE: follow the above reporting process regardless of the alleged abuse/neglect or crime was felt to be inflicted by an employee, another resident, a visitor, a student, volunteer or a contractor) 14. information that should be given when a report of abuse/neglect or a suspicion of a crime is made includes: A. initial telephone report B. Written report of alleged crime/abuse/neglect and investigation C. Additional written information if requested 16. The internal investigation will be completed and a formal report sent to the State and APS within 5 working days of the notification of the allegation.

Licensure Reference Number 175 NAC 12-006.09(B) Based on record reviews and interviews, the facility failed to ensure that the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) comprehensive assessment identified Post Traumatic Stress Disorder (PTSD) for 1 (Resident 135) of 2 sampled residents. The facility census was 240. Findings are: A record review of Resident 135's MDS revealed Resident 135 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, anxiety disorder and post-traumatic stress disorder (PTSD). Resident 135 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 10/15. The MDS manual identified a score of 8-12 was moderately impaired. Further record review of Resident 135's MDS revealed an admission Assessment was completed on 03/18/2025 and revealed non-Alzheimer's dementia and anxiety listed as current diagnoses but did not indicate a diagnosis of PTSD in Section I. An interview was conducted on 05/08/2025 at 1:07 PM with MDS-G to discuss the omission of PTSD in Section I of the MDS. MDS-G stated a diagnosis is not added based on a history of and the diagnoses found in the Point Click Care (PCC) computer system used by the facility are not used for the MDS. MDS-G stated that the diagnoses used for Section I are dependent upon the resident's appointment with the mental health provider. The appointment with the mental health provider was 04/08/2025, which was after the MDS was completed. An interview was conducted on 05/13/2025 at 10:09 AM with the lead Minimum Data Set Coordinator (MDSC)-F regarding the diagnosis of PTSD confirmed that the diagnosis of PTSD should have been on the admission assessment in Section I as Resident 135 had a diagnosis of PTSD.

Licensure Reference Number 175 NAC 12-006.09(E)(i) Based on record reviews and interviews, the facility failed to develop a person-centered comprehensive care plan to meet the mental and psychological needs of 1 resident (135) out of 2 sampled. The facility census was 240. Findings are: A record review of Resident 135's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed Resident 135 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, anxiety disorder and post-traumatic stress disorder (PTSD). Resident 135 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 10/15. The MDS manual identified a score of 8-12 was moderately impaired. A review of facility progress notes written by Licensed Practical Nurse (LPN)-I on 05/02/2025 and 05/03/2025 revealed that Resident 135 was being confrontational and hallucinating about the war. A record review of Resident 135's MDS revealed an admission Assessment was completed on 03/18/2025 and revealed non-Alzheimer's dementia and anxiety listed as current diagnoses but did not indicate a diagnosis of PTSD in Section I of the MDS. An interview was conducted on 05/13/2025 at 10:09 AM with the lead Minimum Data Set Coordinator (MDSC)-F regarding the diagnosis of PTSD. MDSC-F confirmed that the diagnosis of PTSD should have been on the admission assessment in Section I as Resident 135 had a diagnosis of PTSD. A record review of Resident 135's undated care plan revealed no evidence of the resident's PTSD diagnosis being addressed. An interview was conducted with Social Worker (SW)-E on 05/08/2025 at 11:52 AM regarding the diagnosis of post-traumatic stress disorder (PTSD) for Resident 135. SW-E confirmed that the PTSD diagnosis was not addressed on Resident 135's comprehensive care plan. Record review of the facility's Interdisciplinary Plan of Care Policy dated 04/23/2024 revealed: The resident's entire medical record is part of the resident's interdisciplinary plan of care. Interdisciplinary (ID) care plan meetings are conducted in the following manner: 1. Prior to each meeting members of the ID team gather data to assess the residents' needs, to re-evaluate the residents' discharge plan as indicated; to make a list of areas to be addressed as identified by the MDS, and CAA's (care area assessments) to prioritize their list of needs and to evaluate a current plan of care. 5. Each problem identified on the care plan will include a goal, a target date for achievement, and a plan of care/steps to be taken to assist the resident in goal achievement. Record review of the facility's policy DCHC Trauma Informed Care dated 3/3/2025 revealed: Policy Explanation and Compliance Guidelines: 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the residents about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessments, and others. 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (psychologists and mental health professionals) to develop and implement individualized care plan interventions.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3). Based on observation, interview and record review, the facility failed to evaluate and monitor open lesions for 1 (Resident 65) of 4 residents sampled. The facility census was 240. Findings Are: Record review of Resident 65's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-24-2025 revealed the facility staff assessed the following about the resident: -A Brief Interview of Mental Status (BIMS) was not scored for this resident. -The resident required extensive assistance with lower body dressing, bed mobility and transfers. -The resident required total assistance with toileting and bathing. Record review of Resident 65's Comprehensive Care Plan (CCP) printed on 05-13-2025 revealed a focus area of risk for impaired skin integrity due to impaired mobility, bowel and bladder incontinence, and anemia. The goal was that Resident 65's skin will remain intact. Interventions for the staff to use were: -assist bars/side rails to help resident with self-mobility and steadiness with transfers, -blue boots to bilateral feet as needed, -ensure nails are clipped, -evaluate skin integrity, -pressure reduction cushion on bed and in the wheelchair, and -weekly skin assessments and as needed and to notify the provider as needed for skin concerns. An interview on 05-07-2025 at 4:15 PM with Resident 65 revealed they had wounds on the buttocks. Record review of Resident 65's weekly skin assessments revealed the following: -04-21-2025 Skin issue: #001 skin issue had not been evaluated, the location was the right gluteus. Issue type-open lesion. Wound acquired in-house. It is unknown how long the wound has been present. No measurements had been included in the assessment. Skin issue #002 skin issue has been evaluated, the location was the buttocks and the description stated it was reddened. The wound was acquired in-house and it was unknown how long the wound had been present. -04-28-2025 Skin issue: #001 skin issue has been evaluated and the location was the right gluteus. Issue type stated it was an open lesion. Wound was acquired in-house and the reason measurements were not documented was because measurements were not taken during the assessment. Skin issue #002 had been evaluated, the location was the buttocks, issue type stated reddened. -05-05-2025 Skin issue #001 skin issue had not been evaluated. The location was right gluteus, issue type stated open lesion. Wound acquired in house, and no measurements were included in the assessment. Skin issue #002 has not been evaluated to the buttocks of generalized redness. -05-12-2025 Skin issue #001 has not been evaluated to the right gluteus, issue type was an open lesion, wound acquired in-house and no measurements were included in the assessment. An observation on 05-13-2025 at 8:33 AM of Nursing Assistant (NA)-P performing a brief change for Resident 65 revealed 2 open wounds to the left buttock, one was approximately 2 centimeters (cm) length by 1 cm width and the other open wound was approximately 1 cm length by 0.5 cm width. The right buttock had an open wound that was approximately 1 cm in length and 0.5 cm in width. The upper right thigh near the gluteal fold had an open wound that was approximately 3 cm in length by 0.5 cm in width. All wound beds were pink in color and had a scant amount of pink drainage. An interview was conducted on 05-13-2025 with NA-P at 8:55AM which revealed the areas observed on Resident 65's buttocks were not new, but the NA did not know what the treatment for the wounds were. An interview was conducted with the Unit Manager (UM)-C on 05-13-2025 that confirmed the wounds had not been measured weekly and should have been. Record review of the facility policy titled Skin Assessment/Wound Care dated 04-10-2025 revealed it is the facility's policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes procedural guidelines for performing the full body skin assessment. -A full body, or head to toe, skin assessment will be conducted by a licensed nurse upon admission, readmission, and weekly thereafter. -Documentation of the skin assessment will include the date and time of the assessment, document observations, such as skin conditions, document the type of wound, describe the wound with measurements, color, type of tissue in the wound bed, drainage, odor or pain.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on observation, interview and record review the facility failed to implement interventions to offload heels to prevent the potential for pressure ulcer development for 1 (Resident 236) of 3 sampled residents. The facility census was 235. The findings are: Record review of Resident 236's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-19-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -The resident required extensive assistance with upper body dressing and bed mobility. -The resident required total assistance with transfers, toileting, bathing, and lower body dressing. -The resident currently had a pressure ulcer. Record review of Resident 236's Order Summary Report (OSR) printed on 05-07-2025 revealed an order dated 04-24-2025 to offload heels while the patient is in bed, as tolerated. Record review of Resident 236's Comprehensive Care Plan printed on 05-07-2025 revealed a focus area pressure ulcer to sacrum will show signs of healing and the resident will be free of further skin breakdown, and pressure injuries. Interventions listed included: -administer treatments as ordered and monitor for effectiveness. -follow facility policies/protocols for the prevention/treatment of skin breakdown. -if resident refuses treatment, confer with the resident, family and the interdisciplinary team to determine why and try alternative methods to gain compliance. Document the alternative methods. There was no evidence of interventions specific to preventing pressure to the resident's heels. An observation on 05-12-2025 at 7:16 AM revealed Resident 236 was lying in bed on back with heels resting on the mattress without being offloaded. An observation on 05-12-2025 at 9:33 AM revealed Resident 236 was lying in bed on back and heels were not offloaded. An interview conducted with Resident 236 on 05-12-2025 at 1:05 PM revealed that while Resident 236 was in the hospital, their feet were offloaded by placing a pillow under the lower leg to allow the heels to float, but the staff didn't do that at the facility. An observation on 05-12-2025 at 1:25 PM of Resident 236 lying in bed on back without heels offloaded. During this observation Registered Nurse (RN)-M entered the room to perform wound care and confirmed the heels were not offloaded and should have been. Record review of the facility policy titled Pressure Injury Prevention and Management dated 03-27-2025 revealed the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Listed under interventions for prevention and to promote healing: -Section c. Evidence based interventions for prevention will be implemented for all resident who are at risk or have a pressure injury present. Basic or routine care interventions include but are not limited to: redistribute pressure (such as repositioning, protecting or offloading heels, etc.)

Licensure Reference Number 175 NAC 12-006.09(H)(v) Based on observation, record review and interview; the facility failed to reevaluate wheelchair positioning, ensure foot pedals were in place and head rest was positioned to support the head for 1 (Resident 164) of 2 sampled residents. The facility census was 240. Findings are: Record review of Resident 164's clinical census report revealed Resident 164 was admitted to the facility on [DATE] and to Hospice on 11/29/24. Record review of Resident 164's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 2/10/25 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 0/15. The MDS manual identified that a score of 0-7 indicated severe cognitive impairment. The MDS identified that Resident 164 was dependent on staff for all Activities of Daily Living (ADLs) (tasks related to personal care, such as dressing, eating, and mobility). The MDS identified that Resident 164 used a manual wheelchair for locomotion and utilized hospice services while a resident. Record review of hospice physician orders for Resident 164 dated 11/29/24 revealed an order for a tilt in space wheelchair and leg rests to go on the wheelchair. The wheelchair and leg rests were delivered to the facility on [DATE] for Resident 164. Observation on 05/07/25 at 11:57 AM revealed Resident 164 seated in a tilt in space wheelchair. No leg rests were attached to the wheelchair and Resident 164's legs dangled from the chair with no support provided. The head rest attached to the chair was positioned in contact with the top of the shoulders with the head left unsupported. Observation on 05/07/25 at 02:00 PM revealed Resident 164 seated in a tilt in space wheelchair. No leg rests were attached to the wheelchair and Resident 164's legs dangled from the chair with no support provided. The head rest attached to the chair was positioned in contact with the top of the shoulders with the head left unsupported. Observation on 05/08/25 at 10:07 AM revealed Resident 164 seated in a tilt in space wheelchair. No leg rests were attached to the wheelchair and Resident 164's legs dangled from the chair with no support provided. The head rest attached to the chair was positioned in contact with the top of the shoulders with the head left unsupported. Observation on 05/08/25 at 2:15 PM revealed Resident 164 seated in a tilt in space wheelchair. No leg rests were attached to the wheelchair and Resident 164's legs dangled from the chair with no support provided. The head rest attached to the chair was positioned in contact with the top of the shoulders with the head left unsupported. Observation on 05/12/25 between 11:55 AM and 12:20 PM revealed Nursing Assistant (NA)-A and NA-B knocked and entered Resident 164's room. Unit Manager (UM)-C entered the room also to observe. NA-A and NA-B proceeded to transfer the resident into the tilt in space wheelchair. NA-A tried to position the headrest to support the residents head, but it kept falling and come into contact with the residents upper shoulders. NA-A stated, It wont stay so we just use it to support (gender) back. UM-C left the room and returned a minute later with leg rests. NA-B placed the leg rests into position on the wheelchair and placed the residents feet onto the foot pedals. The residents legs were very long, and the foot pedals were shorter than the residents legs which caused the residents knees to be up in the air and not in contact with the seat of the wheelchair. UM-C then positioned the head rest on the wheelchair behind the residents head and tried to tighten the head rest so that it would stay in that position. The head rest stayed in that position until the resident was moved into the dining area. The head rest then fell back down and rested against the resident upper shoulders. No staff attempted to reposition the residents headrest. The residents right leg had slipped off of the foot pedal after being transported into the dining area, and the right leg dangled unsupported by the foot rest. No staff attempted to reposition the residents right leg onto the foot pedal. Observation on 05/13/25 at 8:54 AM revealed Resident 164 in the wheelchair in the main dining room. Foot pedals were in place on the wheelchair with both feet on the pedals. The residents knees were up in the air due to the short wheelchair pedals and were not supported by the wheelchair seat. The headrest was positioned against the residents upper back and not in a position to support the head. Interview on 05/13/25 at 8:57 AM with UM-C revealed that the hospice company had provided Resident 164 with the wheelchair and foot pedals. UM-C confirmed that the wheelchair pedals should have been in place on the wheelchair to provide support to the legs and the head rest should have been positioned to support the head. UM-C confirmed that the facility had not contacted the hospice agency to reevaluate the wheelchair. The UM-C confirmed that the facility had not reevaluated the wheelchair because it was a hospice-provided wheelchair. The UM-C stated that the hospice provided the wheelchair and they go by height and weight to determine what size of wheelchair was provided.

Licensure Reference Number 12-006.09(H)(vi)(3)(g) Based on observation, interview and record review, the facility failed to obtain and implement orders for a non-invasive ventilator including settings and daily, weekly, and monthly cleaning for 1 (Resident 55) of 4 sampled residents. The facility census was 235. The findings are: Record review of Resident 55's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 04-18-2025 revealed the facility staff assessed the following about the resident: -The resident was admitted to the facility on [DATE]. -A Brief Interview of Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) was scored as a 14/15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -The resident required extensive assistance with lower body dressing, bed mobility, and transfers. -The resident required total assistance with toileting and bathing. -The resident had diagnoses of congestive heart failure and obstructive sleep apnea (a condition where breathing repeatedly stops and starts while asleep). -The resident required a non-invasive mechanical ventilator. -The resident had impairment in range of motion to one of the upper extremities. Record review of Resident 55's Order Summary Report (OSR) printed on 05-08-2025 revealed no orders for the use of a non-invasive ventilator, such as a BiPAP machine. Record review of Resident 55's Comprehensive Care Plan dated 04-11-2025 revealed a focus area of BiPAP Therapy with an initiation date of 04-11-2025 with a goal that Resident 55 would adhere to the BiPAP regimen, and interventions listed for the staff to use was to encourage Resident 55 to use the BiPAP. An observation on 05-07-2025 at 3:09 PM revealed a BiPAP machine on Resident 55's bedside table. An interview was conducted on 05-12-2025 at 3:34 PM with the Unit Manager (UM)-L which confirmed BiPAP settings were not obtained because the BiPAP machine that was in use was Resident 55's home machine and confirmed that daily, weekly and monthly cleaning were not implemented until 05-11-2025. Record review of the facility policy CPAP/BIPAP Care dated 07-03-2024 revealed the following: -CPAP/BIPAP Daily Care: Clean mask/cushion pillow with warm, soapy water, rinse and air dry. -CPAP/BIPAP Weekly Care: Wash headgear, tubing, mask, cushion/pillows in warm soapy water, rinse and air dry. Wipe CPAP/BIPAP unit off with a damp cloth. Rinse water chamber with vinegar, rinse with water and air dry. -CPAP/BIPAP Monthly Care: Remove filter from the unit and replace with a new one. Your mask cushions, and/or nasal pillows may be disinfected by soaking for 5 to 10 minutes in a 1:1 vinegar/water solution.

Based on record review and interview, the facility failed to assess for pain prior to administering scheduled pain medication and failed to monitor for the effectiveness of pain medication for 1 (Resident 19) of 2 sampled residents. The facility had a census of 240. Findings are: A record review of the facility's Pain Management Policy which was last modified on 3/20/2025 revealed the following policy statement: -A resident will be assessed for the presence/absence of pain on admission, at least quarterly at the time of the MDS (Minimum Data Set - a federally mandated standardized assessment tool used in nursing homes to gather information about resident's health, functional status, and preferences) assessment and when there is a change in the resident's condition and any time a resident is receiving pain medication. A record review of Resident 19's physicians orders revealed Resident 19 has an order for scheduled Tramadol HCL (a medication used to relieve moderate to moderately severe pain) 50 MG (milligrams - a unit of measurement) tablet. 1 tablet three times a day for pain. A record review of Resident 19's MDS (Minimum Data Set - a federally mandated, standardized assessment tool used in Medicare and Medicaid certified nursing homes and skilled nursing facilities to evaluate residents' functional capabilities and identify health problems) dated 3/25/2025, Section J pain assessment revealed Resident 19 had frequent pain that had limited their day-to-day activities. Resident 19's pain was assessed at an 8 on a zero to ten scale with zero being no pain and ten as the worst pain you can imagine. A record review of Resident 19's Medication Administration Record (a document used to track and document the medications administered to a patient) for May 2025 revealed it does not include pain level assessments (a tool used to understand and quantify a persons' pain when the scheduled pain medication was administered). A record review of Resident 19's Physicians order summary revealed there is no order to assess the residents' pain. A record review of Resident 19's Care Plan (a written document that outlines a person's individual needs, goals, and the specific services and support they will receive to support those needs), copied 5/8/2025 revealed an intervention (the act or fact of taking action about something in order to have an effect on its outcome) dated 10/15/2024 which stated, Evaluate the effectiveness of pain-relieving interventions (non-medication and medication). An interview on 5/12/2025 at 2:45 PM with Registered Nurse (RN)-D confirmed the resident did not have an order for pain assessments or to monitor the effectiveness of the scheduled pain medication administered.

Based on record reviews and interviews, the facility failed to ensure trauma survivors received trauma-informed care to eliminate triggers that may cause re-traumatization for 1 (Resident 135) of 2 sampled residents. The facility census was 240. Findings are: A record review of Resident 135's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed Resident 135 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, anxiety disorder and post-traumatic stress disorder (PTSD). Resident 135 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 10/15. The MDS manual identified a score of 8-12 as having moderately impaired cognition. A record review of progress notes written by Licensed Practical Nurse (LPN)-I on 05/02/2025 and 05/03/2025 revealed Resident 135 was confrontational with cares and hallucinating about the war. A record review of Resident 135's medical record revealed no PTSD or trauma informed care assessment had been completed. An interview was conducted with Social Worker (SW)-E on 05/08/25 at 11:52 AM regarding the diagnosis of post-traumatic stress disorder (PTSD) for Resident 135. SW-E confirmed that the diagnosis was not addressed on Resident 135's care plan. SW-E also confirmed there was no assessment completed to determine what triggers would affect the resident. A record review of the facility's policy DCHC Trauma Informed Care dated 03/03/2025 revealed: Policy: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Definitions: Trauma Informed Care is an approach to delivering care that involved understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Policy Explanation and Compliance Guidelines: 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as [gender] cultural preferences. This will include asking the residents about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessments, and others. 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (psychologists and mental health professionals) to develop and implement individualized care plan interventions.

Based on record reviews and interviews, the facility failed to ensure 3 (Resident 218, 135, 226) of 7 residents had a physician conduct a face-to-face visit within the first 30 days after admission. The facility census was 240. Findings are: A. A record review of Resident 218's admission record revealed an admission date of 07/30/2024. A review of Resident 218's records revealed there was no evidence of a physician visit within the first 30 or 60 days after admission. Record review revealed Resident 218 was seen by a nurse practitioner (NP) on 08/09/2024 to establish care and on 09/20/24 for recertification. B. A record review of Resident 135's admission record revealed an admission date of 03/11/2025. A review of Resident 135's records revealed there was no evidence of a physician visit within the first 30 days after admission. A record review revealed Resident 135 was seen by an NP on 03/11/2025 for admission history and physical. C. A record review of Resident 226's admission record revealed an admission date of 04/15/2025. A review of Resident 226's records revealed there was no evidence of a physician visit within the first 30 days after admission. A record review revealed Resident 226 was seen by an NP on 04/15/2025 for an admission history and physical. An interview was conducted on 05/12/25 at 8:02 AM with the Compliance Officer, who stated there was no policy on physician visits for the facility. On 05/12/25 at 11:38 AM an interview with the Medical Director (MD) was conducted regarding initial admission assessments for new admissions. The MD stated the initial visit was not conducted by the MD and stated the NPs completed the initial admission assessments within 24 hours since they were assigned to the facility. The MD stated the notes were available for review and if the NP had concerns, MD would be available to visit on site.

Licensure Reference Number 175 NAC 12-006.18(B) & 1-005.06 Based on observation, interview and record review the facility failed to secure a catheter bag for 1 (Resident 221) of 2 residents and failed to secure oxygen tubing with cannula for 1 (Resident 108) of 5 residents sampled in a manner to prevent the potential for cross contamination. The facility census was 240. The findings are: A. Record review of Resident 221's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-12-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was not conducted because Resident 221 was not able to complete the interview. -The resident required extensive assistance with dressing and personal hygiene. -The resident required total assistance with bed mobility, toileting and bathing. -The resident had an indwelling urinary catheter (a tube inserted into the bladder to collect urine). An observation on 05-07-2025 at 9:10 AM revealed Resident 221 was lying in bed and their urinary catheter drainage bag was lying on the floor without a cover or barrier. An observation on 05-12-2025 at 7:02 AM revealed Resident 221 was lying in bed and their urinary catheter drainage bag was lying on the floor without a cover or barrier. An interview on 05-12-2025 at 7:15 AM with Nursing Assistant (NA)-N confirmed the catheter drainage bag was on the floor and it should not have been. B. Record review of Resident 108's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as 0/15. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -The resident required extensive assistance with transfers, and personal hygiene. -The resident required total assistance with toileting, bathing, and dressing. -The resident was receiving oxygen. An observation on 05-07-2025 at 12:39 PM revealed Resident 108 was in the dining room and in the resident's room, their oxygen concentrator was running with the oxygen tubing and cannula on the floor. An observation on 05-13-2025 at 7:30 AM revealed Resident 108 was sitting in the dining room and in the resident's room the oxygen tubing and cannula were lying on the floor. An interview on 05-13-2025 at 7:35 AM with NA-O confirmed the oxygen tubing and cannula were lying on the floor and should not have been. Record review of the facility policy titled Infection Prevention and Control Program dated 07-30-2025 revealed the facility has established and maintains an infection control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. All staff are responsible for following all policies and procedures related to the program. Under section 11 titled Supplies Protocol all non-sterile items are stored and maintained as clean.

Licensure Reference Number 175 NAC 12-006.04(f)(i)(5) Based on observation, record review and interview; the facility failed to ensure follow up was completed with the physician to obtain x-rays after complaints of pain were made by Resident 1 and failed to ensure x-ray recommendations were followed timely for Resident 1. X-rays showed that Resident 1 sustained a fracture of the right shoulder. The facility census was 239. Findings are: Record review of Resident 1's Face Sheet revealed a admitted [DATE] with diagnoses that included restlessness and agitation, altered mental status, schizophrenia, psychosis and mood affective disorder. Record review of Resident 1's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 4/30/24 revealed a BIMS (Brief interview for mental status, a brief screener that aids in detecting cognitive impairment) score of 15, which indicated that Resident 1 was cognitively intact. The MDS showed that resident 1 was independent with all activity of daily living needs and had no falls since the previous assessment in January 2024. A Fall Risk Assessment was completed on 4/26/24 with a score of 2. This score identified that Resident 1 was at low risk for falls. Record review of Resident 1's Progress Notes revealed the following: - 5/15/24 09:45: Fax to [resident physician] due to resident wants [gender] shoulder x-rayed, stating it hurts. - 5/17/24 14:44: continues to ask about arm X-ray. Dr was faxed 2 days ago, no bruise but says it hurts. - 5/17/24 15:08: x-ray orders to do Monday [5/20/24] [Scheduled by outside Hospital for 5/21/24] - 5/21/24 08:30: went to have shoulder x-ray with NA [nursing assistant] - 5/30/24 16:39: Results from bilateral shoulder x-rays results faxed to [Resident 1's physician]. - 6/19/24 12:52: [Resident 1's physician] faxed over asking when is [Resident 1's] repeat X-ray scheduled? - 6/21/24 08:30: Resident went out for an x-ray of the right shoulder at the [outpatient radiology center]. Resident was accompanied by staff - 6/27/24 11:11: x-ray results from 2 view shoulder completed on 6/21/24 faxed to [Resident 1's physician]. - 6/27/24 16:45: APS [ Adult Protective Services] called at this time due to: healing non-displaced right greater tuberosity fracture. - 6/27/24 17:40: POA [power of attorney] made aware of x-ray results showing healing non-displaced right greater tuberosity fracture. - 6/27/24 17:51: [Resident 1] was interviewed and asked if [gender] knew possible causative factors for [gender] right greater tuberosity fracture. [Resident 1] verbalized not knowing how [gender] could had fractured self. Record review of X-ray results dated 5/21/24 revealed a possible non displaced right greater tuberosity fracture. Recommendation by the Radiologist read: : Follow-up radiographs in 10-14 days could be obtained for further evaluation. Record review of X-ray's completed on 6/21/24 and faxed to the facility on [DATE] revealed healing non-displaced right greater tuberosity fracture right shoulder. Record review of Resident 1's Electronic Medical record [EMR] including doctor orders, progress notes and miscellaneous records revealed no follow up with Resident 1's physician had been attempted by the facility staff between 5/15 and 5/17 to try to obtain x-rays for Resident 1's right shoulder. Record review of Resident 1's Progress Notes on 5/15/24 and 5/17/24 indicated that Resident 1 was having continued pain to the right shoulder. Record review of Resident 1's Mediation Administration Record dated May 2024 revealed that Resident 1 received the following scheduled pain medication: - Acetaminophen 500 mg 1 tab three times daily for headache / mild pain with a start date of 4/1/24. - Acetaminophen with Codeine #3 1 tab twice daily for Migraine with a start date of 4/29/24. Record review of Resident 1's Doctor orders and Progress note dated 6/19/24 revealed the following: - When is [Resident 1] scheduled for [gender] repeat x-ray at [outside hospital]. Patient needed a follow up per radiologist 10-14 days. Orders were sent to [phone number]. Record review of Resident 1's Electronic Medical record [EMR] including doctor orders, progress notes and miscellaneous records revealed no attempts to follow up with Resident 1's physician regarding the recommendations for follow up x-rays within 10 - 14 days. Observation on 7/17/24 at 11:45 AM revealed Resident 1 standing in [gender] room shaving at the mirror. The resident was using the right arm to shave and had good range of motion with the right arm. Resident 1 exhibited no signs of pain or discomfort during the observation. Interview on 7/17/24 at 11:48 AM with Resident 1 stated that x-rays showed [gender] had a broken right shoulder and the resident didn't know how that had happened. The resident stated that there was no pain now and it was healed. Interview on 7/17/24 at 10:06 AM with the Assistant Director of Nursing [ADON] confirmed that Resident 1 had sustained a fracture to the right shoulder and exhibited pain on 5/15/24 when Resident 1 approached the nurse and complained of right arm pain and wanted an x-ray done. The ADON confirmed that there was no follow up attempts to reach Resident 1's physician between 5/15 and 5/17 when the resident re-approached the staff and continued to complain of right arm pain. The ADON confirmed that the staff should have tried to call the physician on 5/16/24 after 24 hours had gone by with no response from the physician. Interview on 7/17/24 at 10:47 AM with Registered Nurse (RN) A Nurse Manager confirmed that that there had been no attempts to follow up with Resident 1's physician after the X-ray report dated 5/21/24 was received by the facility. RN A confirmed that the X-ray radiologist recommended a follow up X-ray within 10-14 days and the 14 th day would have been 6/4/24. RN A confirmed that facility staff did not follow up with Resident 1's physician about the recommendation by the radiologist until they received a question from Resident 1's physician regarding a follow up X-ray and an order for a new X-ray on 6/19/24. RN A confirmed that this was a total of 15 days elapsed with no follow up after the recommended time frame for the follow up x-rays and a total of 30 days between the X-ray on 5/21/24 which showed a possible fracture and 6/21/24 that showed a healing fracture for Resident 1. Interview on 7/17/24 at 2:39 PM with the facility Director of Nursing [DON] confirmed that after Resident 1's initial report of pain and physician notification on 5/15/24. According to the DON the staff should have tried to contact the physician the following day, 5/16/24, because the physician hadn't gotten back to them. The DON stated I would expect my staff to follow up due to continued reports of pain by the resident. I would expect my staff to call and clarify if the physician wanted a follow up X-ray after we saw the X-ray results on 5/21/24 with the radiologist recommendations. This didn't happen and Resident 1 went an additional 2 weeks after the recommended 14 days to get a follow up X-ray completed. Record review of a facility policy and procedures entitled Guidelines for Physician Notification dated 12/27/23 revealed the following: - Immediate notification: Any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change (more severe) in relation to usual symptoms and signs or, unrelieved by measures already prescribed. - X-ray: report immediately to the physician new or unsuspected finding (e.g. fracture). Old or long standing findings with no change report next working day. - Falls/ injury: with any suspected serious injury (e.g.Fracture), any hip pain or more then minor pain elsewhere report immediately to the physician. - Fracture and dislocations: Any suspected fracture or dislocation report immediately to the physician. - Pain: New severe pain or marked increase in chronic pain report immediately to the physician. Increase in frequency or severity of pain report to the physician the next working day.

Based on interview, and record review; the facility failed to implement a care planned intervention for 1 (Resident #2) of 6 residents whose care plans were reviewed. Specifically, following an incident on 04/22/2023 involving Resident #2 and another resident, the facility implemented a new intervention consisting of a magnetic barrier attached to Resident #2's door frame to deter other residents from entering Resident #2's room. This intervention was never discontinued, but the barrier was removed, and additional resident to resident altercations involving Resident #2 and Resident #3 occurred on 10/17/2023 and 11/22/2023, when Resident #3 entered Resident #2's room. Findings included: The facility's policy titled, Interdisciplinary Plan of Care, reviewed on 04/23/2024, indicated, Members of the Interdisciplinary Team are responsible for updating the plan of care, as indicated, as the resident's status changes or as other problems/needs are identified. Interdisciplinary Team members will review and evaluate the plan of care to make recommendations and revisions as needed. The policy further indicated, Record the date the care/treatment/intervention was initiated/evaluated. Include month, day and year. EVALUATION/PROGRESS: Document the team's evaluation of the current problem, plan of care, and progress made. Make certain to note if/when a need is resolved, therefore no longer active. A record review of the Admission Record revealed the facility admitted Resident #2 on 04/13/2023. According to the Admission Record, the resident had a medical history that included diagnoses of dementia with agitation and major depressive disorder without psychotic features. A record review of quarterly Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents), with an Assessment Reference Date (ARD) of 09/18/2023, revealed Resident #2 had a Brief Interview for Mental Status (BIMS, test is used to get a quick snapshot of how well you are functioning cognitively at the moment) score of 6, which indicated the resident had severe cognitive impairment. A record review of Resident #2's care plan included a Focus area, initiated on 04/22/2023 and revised on 10/20/2023, that indicated the resident had the potential to be physically aggressive related to dementia with agitation. Per the care plan, Resident #2 had a history of altercations with other residents, including an incident on 04/22/2023 in which Resident #2 bear hugged another resident from behind and told them to get out of Resident #2's room. The care plan reflected an active intervention initiated on 04/22/2023 that directed staff to apply a magnetic barrier attached to the door frame to deter other residents from entering Resident #2's room. A document from the Chief Nursing Officer (CNO) to the state survey agency, dated 10/19/2023, revealed that on 10/17/2023 it was reported Resident #3 wandered into Resident #2's room, and Resident #2 pushed Resident #3 out of the room with enough force to propel Resident #3 into the hall, causing Resident #3 to fall and hit their head. Per this document, a door net was ordered for Resident #2's room, despite the care plan already reflecting an active intervention for the use of a magnetic door barrier. A record review of Resident #2's care plan Focus area addressing the potential for physical aggression was updated following the incident on 10/17/2023 to reflect Resident #2 pushed peer violently out of room causing a fall in which the other resident (Resident #3) hit their head on the floor. On 10/17/2023, an intervention was added to the care plan that indicated an orange mesh door curtain was ordered to prevent peers from wandering into Resident #2's room, despite the care plan already reflecting an active intervention for the use of a magnetic door barrier. There was no indication any of the listed interventions had been discontinued. A document from the CNO to the state survey agency, dated 11/29/2023, revealed that on 11/22/2023 a resident altercation occurred, involving Resident #2 and Resident #3. Per the document, Resident #3 entered Resident #2's room, and Resident #2 pushed Resident #3 out and yelled at them to leave. The document indicated the force of [Resident #2's] pushing caused [Resident #3] to fall backwards across the hall and strike [his/her] head on the handrail. During an interview on 05/14/2024 at 10:56 AM, Unit Manager I stated Resident #2 had unpredictable, aggressive behavior. During a follow-up interview on 05/14/2024 at 2:35 PM, Unit Manager I stated a magnetic mesh barrier was put up on Resident #2's doorway to prevent residents from entering their room in April 2023, because Resident #2 was territorial when other residents entered their room. Unit Manager I further stated the use of magnetic barriers was subjective based on each resident. Unit Manager I said if staff saw an issue, staff put the barrier up for a period of time, then stated the mesh barrier on Resident #2's door probably came down sometime after it was initially put up in April 2023. During an interview on 05/14/2024 at 3:46 PM, the Compliance Officer stated the facility was remodeling the memory care unit where Resident #2 and Resident #3 resided from 07/26/2023 to 11/10/2023. Per the Compliance Officer, Resident #2's magnetic barrier would have come down during that time for painting, and because the resident was stable at that time, staff did not put the barrier back in place on Resident #2's door. During the interview, the Compliance Officer stated she would review interdisciplinary team notes to see if she could locate any documentation regarding a decision to remove Resident #2's magnetic barrier due to the resident being stable. After reviewing notes, the Compliance Officer returned with documentation related to remodeling the memory care unit but had no documentation related to a decision to discontinue the use of Resident #2's magnetic door barrier. During an interview on 05/15/2024 at 9:50 AM, the Administrator said Resident #2 did not like other people in their space, so staff placed a physical barrier up over the doorframe to Resident #2's room for a while, which staff utilized periodically. Per the Administrator, the use of the physical barriers was dependent on the resident. The Administrator indicated if a resident became stable, the mesh barrier could come down and staff would adjust the care plan accordingly. During an interview on 05/15/2024 at 2:06 PM, Unit Manager I stated interventions listed on a resident's care plan were interventions staff could use and described them as tools in a toolbelt where staff could use them some days and use other interventions different days; however, Unit Manager I stated there was no documentation regarding conversations about removing the mesh barrier or documentation indicating the mesh barrier was discontinued because Resident #2 was stable. During an interview on 05/15/2024 at 4:31 PM, the Assistant Director of Nursing (ADON) stated she expected staff to follow the care plan because care plans were individualized for resident care. The ADON said she could not speak to whether the mesh barrier used on Resident #2's door to keep other residents out of their room was an effective intervention or not. The ADON further stated she did not know if staff would have removed the intervention for the mesh barrier from the care plan if it was taken down. She stated if an incident occurred, staff could look at the care plan to see if there was a useful intervention they could put in place, as opposed to routinely implementing care planned interventions to prevent further incidents. During an interview on 05/15/2024 at 4:42 PM, the Compliance Officer stated anyone who worked on the memory care unit knew Resident #2 could be explosive, depending on the day. The Compliance Officer further stated a care plan was a flexible document but said she expected staff know a resident's care plan and follow it.

Based on observations, interviews, and facility policy review, the facility failed to ensure staff stored foods for residents in a sanitary manner. Specifically, staff failed to label and date resident foods brought in by visitors, clear the nourishment refrigerators of spoiled foods, and maintain the temperature logs for the nourishment refrigerators. This had the potential to affect 153 residents who resided in 6 neighborhoods (Wind Song Way, Field of Dreams, [NAME] Way, Tranquility Road, Sunshine Gardens, and Safe Harbor) of 10 total neighborhoods in the facility. Findings included: Review of a facility policy titled, Use and Storage of Food Brought in by Family or Visitors, last modified on 10/21/2019, revealed, Policy: It is the right of the residents of this facility to have food brought in by family or other visitors. However, the food must be handled in a way to ensure the safety of the resident. The policy specified, 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff. Review of a facility policy titled, Cleaning Responsibilities for Nursing Personnel, last modified on 01/31/2020, revealed that Nurses are responsible for cleaning the medication room and refrigerators. On 04/25/2024 at 3:11 PM the Director of Support Services stated there was no facility policy addressing nourishment refrigerators. On 04/25/2024 at 11:10 AM, observation of the nourishment refrigerator for the Windsong Way neighborhood revealed the April 2024 Dietary Refrigerator Temperature log specified, Refrigerator temperatures range: Between 32 and 40 degrees Fahrenheit Refrigerator Temperature MUST be recorded daily. The April 2024 log was missing documentation of temperature checks for 14 days (04/01/2024, 04/02/2024, 04/07/2024, 04/08/2024, 04/09/2024, 04/13/2024, 04/14/2024, 04/18/2024, 04/19/2024, 04/20/2024, 04/21/2024, 04/22/2024, 04/23/2024, and 04/24/2024). The refrigerator contained three plastic sealable food-storage containers labeled for a resident, but there were no dates indicating when they were first stored in the refrigerator. The refrigerator also contained a container of leftover food labeled for another resident, but there was no date to indicate when the item was first stored in the refrigerator. An open container of butter spread that was not labeled with the date it was opened was also observed in the nourishment refrigerator. During an interview on 04/25/2024 at 11:10 AM, Nursing Assistant (NA) J and NA K both revealed that the food items that had been opened should have been dated. On 04/25/2024 at 11:49 AM, observation of the nourishment refrigerator for the Field of Dreams neighborhood revealed the April 2024 Dietary Refrigerator Temperature log was missing documentation of temperature checks for eight days (04/02/2024, 04/08/2024, 04/09/2024, 04/13/2024, 04/14/2024, 04/18/2024, 04/20/2024, and 04/24/2024). During an interview on 04/25/2024 at 11:50 AM, Registered Nurse (RN) L said the dietary department maintained the nourishment refrigerators. On 04/25/2024 at 1:42 PM, observation of the nourishment refrigerator for the [NAME] Way neighborhood revealed the April 2024 Dietary Refrigerator Temperature log was missing documentation of temperature checks for eight days (04/01/2024, 04/07/2024, 04/08/2024, 04/09/2024, 04/18/2024, 04/19/2024, 04/23/2024, and 04/24/2024). On 04/25/2024 at 1:45 PM, observation of the nourishment refrigerator for the Tranquility Road neighborhood revealed the April 2024 Dietary Refrigerator Temperature log was missing documentation of temperature checks for 10 days (04/02/2024, 04/07/2024, 04/08/2024, 04/09/2024, 04/11/2024, 04/12/2024, 04/18/2024, 04/20/2024, 04/23/2024, and 04/24/2024). The refrigerator also contained a bottle of cranberry juice that was opened and undated. On 04/25/2024 at 1:45 PM, observation of the nourishment refrigerator for the Sunshine Gardens neighborhood revealed food items labeled for residents but undated, including a pizza box containing leftover pizza, a package of sliced cheese, and a package of cracker cut cheese. The packages of sliced cheese and cracker cut cheese had a greenish-grey discoloration. During an interview on 04/25/2024 at 1:45 PM, Health Unit Assistant ([NAME]) M for Sunshine Gardens confirmed the sliced cheese and cracker cut cheese were moldy and promptly discarded them. [NAME] M also confirmed the pizza box of leftover pizza was undated, but [NAME] M stated the pizza was received by the resident the day prior. On 04/25/2024 at 2:05 PM, observation of the nourishment refrigerator for the Safe Harbor neighborhood revealed an undated paper bag of food from a fast-food burger restaurant labeled for a resident. There was also an undated and unlabeled bag from a fast-food pizza restaurant and an opened, undated container of salad dressing that was frozen solid due to being stored too close to the freezer section of the refrigerator. During an interview on 04/25/2024 at 2:05 PM, [NAME] N for Safe Harbor revealed they did not know where the bag from the fast-food pizza restaurant came from, and it would have to be discarded. [NAME] N said the undated bag from the fast-food burger restaurant belonged to one of the residents, and [NAME] N then went to ask the resident when it was received so it could be dated. During an interview on 04/25/2024 at 3:11 PM, the Director of Support Services (DSS), including Food Services, revealed food service staff managed the nourishment refrigerators and that it was their responsibility to record the temperatures on the logs. The DSS said any foods brought into residents should be labeled with the resident's name and the date it was received and should be discarded after three days. The DSS also confirmed that it was facility expectation that undated food items be discarded from the nourishment refrigerators, and any spoilt food, including the moldy cheese, should also be discarded. During an interview on 04/26/2024 at 11:01 AM, the Administrator revealed dietary staff were responsible for checking the temperatures of the nourishment refrigerators daily, and nursing staff were responsible for the day-to-day maintenance of the nourishment refrigerators, including cleaning the refrigerators of spoilt or outdated items and labeling and dating residents' foods. During an interview on 04/26/2024 at 11:10 AM, the Assistant Director of Nursing (ADON) revealed the facility expectation was that food brought in from visitors be labeled and dated, that the refrigerator temperatures be logged daily, and for the refrigerators to be checked daily and any outdated, undated, or spoilt food items discarded.

Based on interviews, record review, and facility policy review, the facility failed to invite 1 (Resident #45) of 39 sampled residents whose care plans were reviewed to attend their care conferences. Findings included: A review of a facility policy titled, Interdisciplinary Plan of Care, last modified on 02/03/2021, revealed, Purpose 1. To facilitate an interdisciplinary approach to resident care which is aimed at meeting the many and varied needs of the resident. 2. To promote collaboration of the various disciplines. Procedure The resident's interdisciplinary plan of care is developed and revised through a collaborative effort of an Interdisciplinary Team (IDT), the resident and the resident's guardian/DPOA [durable power of attorney] or representative of his/her choice. The policy further specified, 3. The disciplines discuss their assessments of the resident's needs. The members of the Interdisciplinary Team, the resident, and their family/guardian or representative of his/her choice are encouraged to be actively involved in identifying needs and the planning of care. A review of an Admission Record revealed the facility admitted Resident #45 to the facility on [DATE] with diagnoses that included chronic atrial fibrillation, unspecified intellectual disabilities, Tourette's disorder, and major depressive disorder. A review of an annual Minimum Data Set (MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes.), with an Assessment Reference Date (ARD) of 02/12/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #45's comprehensive care plan revealed a Focus area, initiated on 05/25/2022 and revised on 02/14/2024, that indicated the resident was at risk for self-care deficit due to decreased mobility, intellectual disability, incontinence, and chronic pain. An intervention initiated on 05/25/2022 directed staff to encourage the resident to participate in planning day to day care. During an interview on 04/22/2024 at 11:25 AM, Resident #45 stated they had not been asked to attend their care conferences. Resident #45 said their family member participated in care conferences via phone calls, but the resident also wanted to attend. A review of Resident #45's Multidisciplinary Care Conference documents, dated 06/01/2023 at 9:22 AM, 08/28/2023 at 11:06 AM, 11/30/2023 at 9:46 AM, and 03/04/2024 at 9:41 AM, revealed no documentation that indicated Resident #45 attended any of their care conferences. A review of social services Progress Notes, for the timeframe from 05/25/2023 to 04/23/2024 revealed documentation that the resident's responsible party was invited to the resident's care conferences; however, there was no documentation indicating the resident had been invited to attend. During an interview on 04/25/2024 at 9:30 AM, the Chief Nursing Officer (CNO) revealed it was important for residents to be invited to their care plan meetings so the residents could have a voice in their own care. The CNO stated they expected care plan meetings to be held quarterly and after any significant change in condition. The CNO said they expected residents and their family members to be invited. During an interview on 04/25/2024 at 2:50 PM, Registered Nurse (RN) Y revealed the facility conducted care conferences within 30 days of admission and on a quarterly and annual basis. RN Y said it was mandatory for staff to invite the residents to attend their care conferences. During an interview on 04/26/2024 at 9:28 AM, Social Worker (SW) Z revealed they sent out care conference invitations by way of mail to the resident's responsible party and entered a progress note. SW Z said they had not invited Resident #45 to their care conferences and stated that there had been times that residents were invited to care plan meetings, and it had not gone well. During an interview on 04/26/2024 at 11:25 AM, the Assistant Director of Nursing (ADON) revealed they expected residents to be invited to their care conferences. The ADON indicated residents should be invited to their care conferences to state their concerns, because the residents were the best voice of what was important to them. During an interview on 04/26/2024 at 12:19 PM, the Administrator revealed they expected residents to be invited to their care conferences, regardless of whether they had a responsible party or guardian. The Administrator said residents should be involved in their care plan because it affected them.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to monitor and evaluate causal factors for the development of pressure ulcers for 1 (Resident 177) of 3 resident sampled. The facility staff identified a census of 188. Findings are: Record review of Resident 177's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 12-29-21 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was assessed as a 3. According to the MDS Manuel, as score of 0 to 7 indicates severe cognitive impairment. -Required supervision with eating. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Frequently incontinent of bowel and bladder. - Resident 177 was at risk for pressure ulcers and currently had 1 stage 2 ( Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister). Record review of Resident 177's Comprehensive Care Plan (CCP) with a printed dated of 4-15-2020 revealed Resident 177 had pressure ulcer injuries to the buttocks/sacral area. The goal identified on Resident 177's CCP printed on 4-15-2020 was pressure injuries will improved/heal over and will have no further skin breakdown. Interventions identified on Resident 177's CCP included incontinent care, pressure reducing cushion and mattress, assist with repositioning , encourage being out of the wheel chair and to notify MD, Occupational Therapy (OT) and Dietary for poorly healing wounds. Further review of Resident 177's CCP revealed on 5-26-2021 Resident 177 was identified with an open area to the coccyx (tail bone area) with slough (dead tissue) noted. Record review of Resident 177's Wound assessment (WA) sheet dated 12-21-2021 revealed Resident 177 had a stage 2 pressure ulcer to the left coccyx area measured 0.10 centimeters (cm) by 0.30 cm's. According to the WA dated 12-21-2021 Resident 177 had a pressure ulcer to the posterior coccyx that had healed. Record review of Resident 177's CCP dated 1-05-2022 revealed the pressure ulcer had healed. Review of Resident 177's record did not have information on the condition of Resident 177's skin on 1-05-2022 or location of what pressure ulcer had healed. Record review of Resident 177's Treatment Administration Record (TAR) for January 2022 revealed Resident 177 had a treatment order to the pressure ulcer. The order dated 8-27-2021 instructed nursing to cleanse Resident 177's buttock wounds with soap and water, cut Calcium Alginate (type of dressing) into 1/2 strips by 1 inch. Staff were to insert into the wound the calcium alginate and to cover with a foam dressing and to change the dressing every other day and as needed. Further review of Resident 177's TAR for January 2022 revealed facility staff continued to complete the order as of 1-12-2022. Record review of Resident 177's WA sheet dated 1-12-2022 revealed Resident 177 had a new stage 2 pressure ulcer to the left coccyx area. According to the WA sheet dated 1-12-2022 the stage 2 pressure ulcer measured 1.0 centimeter (cm) by 4.0 cm's. Further review of Resident 177's WA sheet dated 1-12-2022 revealed Resident 177 was identified with an additional stage 2 pressure ulcer to the posterior coccyx that measured 0.30 cm's by 0.20 cm's. Record review of a practitioner's order dated 1-12-2022 revealed the facility staff were to continue the treatment to the open areas on Resident 177's buttocks. Review of Resident 177's record revealed there was no evidence the facility had evaluated casual factors for the development of the new pressure ulcers to the left coccyx area's and the posterior coccyx pressure ulcer. Record review of Resident 177's WA sheet dated 1-19-2022 revealed the left coccyx area measured 2.0 cm's by 0.40 cm's. According to Resident 177's WA sheet dated 1-19-2022 in the section of the WA identified as comments about Wound Status revealed an additional open area on the coccyx that measured 0.1 cm by 0.2 cm's. The stage 2 pressure ulcer to Resident 177's posterior coccyx measured 0.10 cm's by 0.10 cm's. Record review of Resident 177's medical record revealed there was not an evaluation of casual factors for the development of the pressure ulcer that measured 0.1 cm's by 0.2 cm's identified on Resident 177's WA sheet dated 1-19-2022. Record review of Resident 177's WA sheet dated 1-25-2022 revealed the left coccyx wound measured 1.50 cm by 1.20 cm and the posterior stage 2 pressure ulcer measured 1.10 cm by 0.30 cm. Further review of Resident 177's WA sheet dated 1-25-2022 revealed Resident 177 developed a pressure ulcer to the right coccyx area that measured 1.10 cm's by 0.30 cm's. Resident 177's WA sheet dated 1-25-2022 did not evaluate or identify the condition of the pressure ulcer identified on Resident 177's WA sheet dated 1-19-2021 that had measured 0.1 cm's by 0.2 cm's. Review of Resident 177's record revealed there was not an evaluation of casual factors for the pressure ulcer development to the right coccyx area. Record review of Resident 177's WA sheet dated 1-26-2022 revealed the left coccyx stage 2 pressure ulcer measured 1.20 cm's by 1.00 cm's with a depth of 0.20 cm's with the wound bed with slough (dead tissue). The posterior coccyx stage 2 pressure ulcer measured 0.80 cm's by 1.00 cm's with a depth of 0.10 cm's. The wound bed was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 1-31-2022 at 9:42 AM with Licensed Practical Nurse (LPN) T of the treatment to Resident 177's pressure ulcers revealed LPN T removed a soiled dressing revealing Resident 177 had 4 areas to the coccyx/sacrum area. The left coccyx area measured approximately 0.3 to 0.4 cm's roundish with 2 additional areas next to the left coccyx area that measured approximately 0.3 cm's roundish with one of the 2 additional areas with raised white macerated tissue The right pressure ulcer measured approximately 0.50 cm's, had white macerated tissue around the edges and a dark red center. On 1-31-2022 at 9:42 AM an interview was conducted with LPN T. LPN T reported the pressure ulcers looked worse and further confirmed Resident 177 had 4 pressure ulcers. On 2-1-2022 at 7:45 AM a interview was conducted with Registered Nurse (RN) S. During the interview RN S reported being the unit manager for Resident 177. RN S reported during the interview wound assessments are to be completed weekly. RN S confirmed there was not a wound assessment completed on 12-28-2021. Review of the WA sheet dated 1-19-2022 was completed with RN S. RN S confirmed Resident 177 had developed an additional pressure ulcer. RN S stated not sure how that happened. Review of Resident 177's WA sheet dated 1-25-2022 was completed with RN S. RN S confirmed Resident 177 had developed an addition pressure ulcer to the right coccyx area. Review of Resident 177's WA sheet dated 1-26-2022 was completed with RN S. During the interview, RN S confirmed Resident 177's pressure ulcers to the left coccyx, right coccyx and posterior coccyx had slough in the wound beds. RN S reported would not be able to stage the pressure ulcers due to the slough in the wound beds. RN S confirmed the condition of the pressure ulcers had declined. Record review of an undated Nursing Service Policy and Procedure tilted Skin Care Protocol revealed the following information: -Policy: -Maintaining skin integrity is an important aspect of resident care. Individuals with a potential for/or an actual skin integrity will be provided the necessary care and treatments to prevent skin breakdown and/or promote healing. Re-evaluate the treatment plan as soon as any evidence of deterioration is noted. A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to implement assessed interventions and failed to implement additional interventions to prevent falls for 3 (Resident 20, 21 and 23) of 4 residents. The facility staff identified a census of 225. Findings are: [NAME] Record review of Resident 20's Minimal Data Set(MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 6-19-2019 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was a 1. According to the MDS Manuel, a score of 0 to 7 indicated severe cognitive impairment. -Extensive assistance with bed mobility and transfers requiring 2 persons physically assisting the resident. -Total dependence for locomotion on the unit, toilet use and personal hygiene requiring 2 persons to physically assist the resident. Record review of Resident 20's Comprehensive Care Plan (CCP) dated 1-29-2019 revealed Resident 20 was at high risk for falls. The goal identified for Resident 20 was no falls or no falls with injury. The interventions identified on Resident 2's CCP included 2 persons to assist with dressing, hygiene, grooming/bathing and bed mobility. Resident 20's CCP also identified Resident 20 could stand and pivot with assistance. Other interventions included a mat next to the bed and to keep Resident 20's bed in a low position. Record review of a Abuse/Neglect/Misappropriation/Crime Reporting Form (ANMCRF) dated 7-24-2019 revealed Resident 20 had .fell out of bed yesterday ,striking (gender) head on the floor sustaining an abrasion and possible head injury. Record review of a investigation report dated 7-25-2019 revealed the Nursing Assistant (NA) A had been providing care to Resident 20 when Resident 20 fell from bed. Record review of a Documentation form dated 7-24-2019 revealed NA A reported working with Resident 20. According to the Documentation report, NA A reported getting Resident 20 cleaned and dressed and when NA A retrieved Resident 20's wheelchair, Resident 20 fell out of bed. Record review of an undated Fall Root Cause Analysis (RCA) form revealed Resident 20 had sustained a laceration and hematoma to the right side of the face and had altered mental status. According to the RCA, the family chose not to have Resident 20 sent to the hospital. On 8-12-2019 at 1:50 PM an interview was conducted with Registered Nurse (RN) B. During the interview RN review of Resident 20's MDS and CCP were reviewed. RN B confirmed during the interview Resident 20's CCP and MDS indicated Resident 20 was to have 2 people assist with cares. When asked how many staff were assisting Resident 20 when Resident 20 fell on [DATE] resulting in a laceration and hematoma, RN B stated 1 staff was working with (gender). B. Record review of Resident 21's MDS dated as completed on 5-29-2019 revealed the facility staff assessed the following about Resident 21: -BIM's score was a 3. -Required supervision with bed mobility, transfers, walking on the unit and eating. -Required extensive assistance with toilet use and personal hygiene. Record review of Resident 21's CCP dated 3-04-2019 revealed Resident 21 had a fall on 7-30-2019 resulting in a laceration 2 lacerations to Resident 21's forehead. Further review of Resident 21's CCP revealed there were not specific interventions implemented in an attempt to prevent re-occurrence. Record review of Resident 21's progress notes dated 7-31-2019 revealed Resident 21 was seated at a table ,stood up and fell . On 8-12-2019 at 12:25 PM an interview was conducted with RN B. During the interview RN B confirmed no additional interventions had been implemented when Resident 21 fell on [DATE]. C. Record review of Resident 23's MDS signed as dated as completed on 7-03-2019 revealed the facility staff assessed the following about the resident: -BIM's score was a 3. -Required supervision with eating. -Required extensive assistance with transfers, dressing, toilet use and personal hygiene. Record review of Resident 23's CCP dated 12-03-2018 revealed Resident 23 was at risk for fall related to multiple falls and poor safety awareness. Further review of Resident 23's CCP revealed Resident 23 had a fall on 6-30-2019 at 1:45 PM and on 6-30-2019 at 10:30 PM. Review of Resident 23's record revealed there was not evidence the facility had implemented interventions in an attempt to prevent additional fall when Resident 23 fell , twice on 6-30-2019. Record review of Resident 23 progress note dated 7-16-2019 revealed Resident 23 had slipped from the wheelchair sustaining a laceration on the left side of the head. On 8-12-2019 at 4:00 PM a interview was conducted with RN B. During the interview RN B. During the interview review of Resident 23's care plan was completed. During the interview, RN B confirmed additional interventions were not implemented after he falls on 6-30-2019. RN B further confirmed Resident 23 had sustained a laceration to the left side of the head. RN B confirmed additional interventions should have been implemented. Record review of the facility Policy and Procedure for Fall Risk Assessment sheet revised on 9-2005 revealed the following information: -Purpose: -2. To facilitate implementation of preventative measures. -Procedure: -7. Revise the residents care plan to reflect care needs and interventions based on the residents potential for falling. -Key Points: -Interventions must be implemented to aid in the prevention of falls.