Every finding on record at Elwood Care Center

Licensure Reference Number 175 NAC 12-006.09(B)Based on record review and interview the facility failed to accurately code the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for 5 residents (Resident 2, 3, 25,16, and 29) of 12 sampled residents. The facility census was 30.Findings are:A. A record review of a 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 4/24/26 for Resident 2 revealed under: -Section A states Resident 2 had a readmission from a hospital on 3/10/26. -Section C reveals Resident 2 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: 3/15 whereas 0-7: reveals the resident has a severe impairment. -Section N reveals Resident 2 took the following high risk drug class medications during the look back period of the last 7 days until the date of the MDS of 4/24/26: -Antipsychotic (medications used to treat psychosis (delusions/hallucinations), schizophrenia, bipolar disorder, and severe depression.) -Antidepressant (medications used to treat depression, anxiety, PTSD, and chronic pain.) -Anticoagulant (medications that prevent harmful blood clots from forming or growing by inhibiting clotting factors.) -Antibiotic (medications that treat bacterial infections by killing bacteria or inhibiting their growth.) -Diuretic (medications that reduce high blood pressure, heart failure, and edema by aiding the kidneys in removing excess sodium and water via increased urination.) -Hypoglycemic (medication that rapidly raises blood sugar.) A record review of an Order Summary dated 5/4/26 for Resident 2 reveals an order for: Clonazepam (a medication used to treat anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it) and/or a seizure disorder) tablet; 0.5 milligram (mg); amout:1 tablet; oral three times a day 8:30 AM, 12:00 PM, 8:00 PM with an order start date of 12/11/2025. An interview with the Assistant Director of Nursing (ADON) on 5/6/26 at 11:50 AM revealed not knowing how to identify the medication Clonazepam on the MDS, therefore not listing it on the high-risk drug class medication being taken by Resident 2. B. A record review of an MDS dated [DATE] for Resident 3 revealed under: -Section A states Resident 3 had a readmission from a hospital on [DATE]. -Section C reveals Resident 3 retains a BIMS score of 15/15 whereas 13-15: reveals the resident is cognitively intact -Section N reveals Resident 3 took the following high risk drug class medications during the look back period of the last 7 days until the date of the MDS of 4/24/26: -Antidepressant -Anticoagulant -Diuretic -Hypoglycemic (medication that rapidly raises blood sugar) -Opioid (medication used for moderate-to-severe pain) A record review of an Order Summary dated 5/4/26 for Resident 3 reveals an order for: -gabapentin (an anticonvulsant medication used to treat partial seizures and neuropathic pain) capsule; 300 milligram (mg); amount: 1 capsule every morning 5:00 AM and Gabapentin capsule; 400 mg; amount: 1capsule; oral twice a day 3:00 PM, 9:00 PM with an order start date of 4/30/25. An interview with the ADON on 5/6/26 at 11:50 AM revealed not knowing how to identify the medication Gabapentin on the MDS, therefore not listing it on the high-risk drug class medication being taken by Resident 3. C. A record review of an MDS dated [DATE] for Resident 25 revealed under: -Section A states Resident 25 had an admission from a hospital on [DATE]. -Section C reveals Resident 25 retains a BIMS score of 10/15 whereas 8-12: reveals the resident is moderately impaired. -Section N reveals Resident 25 took the following high risk drug class medications during the look back period of the last 7 days until the date of the MDS of 3/27/26: -Antipsychotic -Antidepressant -Diuretic -Hypoglycemic -Opioid A record review of an Order Summary dated 5/4/26 for Resident 25 reveals an order for: -gabapentin capsule; 100 mg; amount: 1 capsule oral three a day 7:30 AM, 12:00 PM, 5:00 PM with an order start date of 4/9/26. A record review of a Medication Administration Review (MAR; a legal record of the medications administered to a patient at a facility by a health care professional) for Resident 25 dated 3/1/26 through 3/27/26 revealed an order for gabapentin capsule; 300 mg three times a day with a start date of 10/13/25-4/9/26. Medications were administered as ordered. An interview with the ADON on 5/6/26 at 11:50 AM revealed not knowing how to identify the medication gabapentin on the MDS, therefore not listing it on the high-risk drug class medication being taken by Resident 25. D. Record review of the Quarterly MDS with the Assessment Reference Date of 03/13/2026 revealed Resident 16 had an initial admission date to the facility of 07/14/2025. The MDS was coded that the resident did not receive an anticonvulsant medication during the look back period for the MDS. Record review of Resident 16's Orders on 05/05/2026 revealed that Resident 16 had an order for Gabapentin (an anticonvulsant medication) with instructions to give 300 milligrams at bed time, with an order start date of 08/12/2025. Record review of Resident 16's Medication Administration Record (MAR) for the month of March 2026 revealed Resident 16 was administered the Gabapentin medication as prescribed every day of the month. All of the administrations were signed as completed by facility staff. In an interview completed on 05/06/2026 at10:16 AM with the facility Assistant Director of Nursing (ADON) who acts as the MDS Coordinator (the individual responsible for compiling and entering data into the MDS), the ADON confirmed that Resident 16 received the Gabapentin medication every day during the month. The ADON confirmed that the Quarterly MDS dated [DATE] was not coded correctly and should have been coded that the the resident received the anticonvulsant medication and was not. E. Record review of the facility policy titled Comprehensive Care Plans (a written interdisciplinary comprehensive plan to meet the resident's needs that are identified in the resident's comprehensive assessment) dated 2/11/25 revealed that the facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be used in developing the plan of care. Record review of the MDS assessment dated [DATE] for Resident 29 revealed that Resident 29 admitted into the facility on 9/25/25. The MDS revealed that Resident 29 had a diagnosis of atrial flutter (A type of abnormal heart rhythm (arrhythmia) where the upper chamber of the heart beats too fast. This condition can lead to other problems, like a stroke or heart attack. Atrial flutter medications include anticoagulants (blood thinners) to prevent blood clots that can cause a stroke or heart attack). The MDS section for documenting current resident medication types revealed that anticoagulant was not marked as a medication that Resident 29 was taking. The MDS revealed that antiplatelet (A medication that prevents platelet blood cells from sticking together and clumping. Antiplatelets work by a different mechanism than anticoagulants) was a medication that Resident 29 was taking. Record review of the Medication Administration Record (MAR) (a legal record of the medications administered to a resident at a facility by a health care professional) for the month of February 2026 for Resident 29 revealed that Resident 29 had a physician's order for Xarelto (a prescription anticoagulant to prevent blood clots) 15 milligrams daily. Staff documented administration of the Xarelto daily as ordered for 2/1/26 through 2/28/26. Record review of the Care Plan for Resident 29 dated 5/4/26 revealed that Resident 29 takes medications with a Black Box Warning (prescription medications with severe, life-threatening, or permanently disabling adverse reactions). The care plan revealed that Resident 29 requires care for the black box medication Xarelto. The care plan intervention dated 1/5/26 revealed that if anticoagulation must be discontinued, consider coverage with another anticoagulant. Interview on 5/6/26 at 11:17 AM with the facility Assistant Director of Nursing (ADON) confirmed that the MDS for Resident 29 was coded incorrectly. The ADON confirmed that Resident 29 takes an anticoagulant. The ADON confirmed that Resident 29 does not take an antiplatelet. The ADON confirmed that the MDS should be marked that Resident 29 is taking an anticoagulant and not marked as taking an antiplatelet medication.

Licensure Reference Number 175 NAC 1-005.06(D)Licensure Reference Number 175 NAC 12-006.18(B)Based on observation, record review, and interview the facility failed to ensure that staff performed hand sanitization (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among residents and health care personnel) between resident contacts to prevent the potential for cross contamination. This affected 12 of 12 residents observed (Residents 9, 31, 10, 3, 17, 30, 25, 2, 22, 23, 14, and 26). The facility census was 30.Findings are:Record review of the facility policy titled Hand Hygiene (hand sanitization) dated 1/22/25 revealed that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene will be performed between resident contacts, after handling contaminated objects, after handling items potentially contaminated with body fluids and secretions/excretions, and when in doubt. Observation on 5/4/26 at 2:55 PM on the facility 200 hallway revealed that Nurse Aide-D (NA-D) exited the room of Resident 9 with a used water mug and sat it on the 3 shelf cart in the hall. NA-D did not perform hand sanitization. NA-D entered the room of Resident 31 and then exited with a used mug and sat it on the 3 shelf cart. NA-D did not perform hand sanitization. NA-D entered the room of Residents 10 and 3 (roommates). NA-D exited the room with 4 used mugs cradled against their uniform top with the left arm. NA-D sat the mugs on the 3 shelf cart. NA-D did not perform hand sanitization. NA-D entered the room of Residents 17 and 30 (roommates). NA-D exited the room with used mugs and placed them on the 3 shelf cart. NA-D did not perform hand sanitization. NA-D entered the room of Resident 25 and then exited the room with a used mug. NA-D sat the mug on the 3 shelf cart. NA-D did not perform hand sanitization. NA-D entered the room of Resident 2. NA-D exited the room with a used mug and sat it on the 3 shelf cart. NA-D did not perform hand sanitization. NA-D pushed the 3 shelf cart from the 200 hallway to the 100 hallway. Observation on 5/4/26 at 2:57 PM on the facility 200 hallway revealed that Nurse Aide-E (NA-E) pushed a 3 shelf cart with mugs of water to the doorway of Resident 6. NA-E carried a mug into the room of Resident 6. NA-E exited the room and went to the 3 shelf cart. NA-E did not perform hand sanitization. NA-E removed a mug from the 3 shelf cart and carried it into the room of Resident 9. NA-E exited the room and returned to the 3 shelf cart. NA-E did not perform hand sanitization. NA-E removed a mug from the 3 shelf cart and carried it into the room of Resident 31. NA-E sat the mug on the overbed table in the room. Resident 31 was laying in the bed. NA-E picked up the blanket partially covering Resident 31 and recovered the resident with the blanket. NA-E explained to Resident 31 that NA-E brought fresh water. NA-E exited the room and returned to the 3 shelf cart. NA-E did not perform hand sanitization. NA-E pushed the cart toward the room of Residents 10 and 3 (roommates). NA-E removed two mugs from the 3 shelf cart and carried them into the room of Residents 10 and 3 (roommates). NA-E exited the room and returned to the 3 shelf cart. NA-E did not perform hand sanitization. NA-E removed two mugs and carried them into the room of Residents 17 and 30 (roommates). NA-E exited the room and returned to the 3 shelf cart. NA-E did not perform hand sanitization. NA-E pushed the 3 shelf cart towards the room of Resident 25. NA-E removed a mug from the 3 shelf cart and carried it into the room of Resident 25. NA-E exited the resident room and returned to the 3 shelf cart. NA-E did not perform hand sanitization. NA-E picked up a mug from the 3 shelf cart and carried it into the room of Resident 2. NA-E exited the room and returned to the 3 shelf cart. NA-E did not perform hand sanitization. NA-E pushed the 3 shelf cart from the 200 hallway into the 100 hallway. NA-E picked up two mugs from the cart and carried them into the room of Residents 22 and 23 (roommates). NA-E exited the room. NA-E did not perform hand sanitization. NA-E pushed the cart towards the room of Residents 14 and 26 (roommates). NA-E removed two mugs from the cart and carried them into the room of Residents 14 and 26. NA-E assisted Resident 14. NA-E exited the resident room and returned to the 3 shelf cart. NA-E did not perform hand sanitization. Observation on 5/5/26 at 2:23 PM on the facility 200 hall revealed that NA-E pushed a 3 shelf cart to room of Resident 6. NA-E entered the room and exited with a used water mug. NA-E did not perform hand sanitization. NA-E entered the room of Resident 9 and exited with a used water mug. NA-E did not perform hand sanitization. NA-E pushed the 3 shelf cart down the hall to the next set of rooms. NA-E went into the room of Residents 10 and 3 (roommates) and exited with used water mugs. NA-E did not perform hand sanitization. NA-E went into the room of Resident 31 and exited with used water mug. NA-E did not perform hand sanitization. NA-E continued to enter and remove used water mugs from the rooms of Residents 17, 30, 25, and 2 without performing hand sanitization. Interview on 5/6/26 at 9:39 AM with the facility Assistant Director of Nursing (ADON) confirmed that all staff are expected to perform hand hygiene on exit from a resident room. The ADON confirmed that hand sanitization should have been performed by staff between resident rooms during water pass.

Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview, the facility failed to document that the residents or resident representatives were educated in advanced about the risks, benefits, and alternate interventions of psychotropic medications when new medications were prescribed or current medications were increased for 2 residents (Resident 9 and Resident 20), of 5 sampled residents. The facility census was 30. Findings are:A. Review of the Minimum Data Set (MDS) (a standardized assessment tool used in long-term care settings, that serves as a comprehensive screening and assessment instrument that collects essential information about residents' clinical and functional status and assists in determining care needs, guiding treatment plans, and facilitating reimbursement processes for skilled nursing facilities) created on 3/27/2026 revealed Resident 9 was admitted to the facility on [DATE]. Resident 9 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated normal thinking and memory. The MDS also revealed that Resident 9 had diagnoses of Alzheimer's disease, non-Alzheimer's dementia, malnutrition, anxiety disorder, depression, and insomnia. Record review of the facility policy dated 4/20/2020 Behavioral Health Services revealed it is the policy that all residents receive necessary behavioral healthcare and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. The policy further stated the facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The process included the use of ongoing monitoring of mood and behaviors, care plan development, implementation, and evaluation. Pharmacological interventions shall only be used when non-pharmacological interventions are ineffective or when clinically indicated. Record review of an email sent to the facility from the facility's consulting pharmacist on 10/01/2025 revealed that the pharmacist wanted to touch base with the facility about issues that other facilities had been having with their annual surveys. The consulting pharmacist revealed the following: Essentially any new psychotropic order or change to a current psychotropic (either dose increase or decrease) must have consent documented prior to that order being initiated. This means documentation is required before the first dose is given. But please note, the written/signed consent form is not required here since that is typically not feasible before the first dose/ A simple progress note saying consent was received via telephone with family is perfectly acceptable at first, but it just needs to be before that first dose. The consulting pharmacist then forwarded the actual verbiage from the Centers for Medicare and Medicaid Services (CMS) as it related to the use of psychotropic medications (drugs that affect mood, behavior, thoughts, or perception, primarily by altering brain chemistry) and informing the resident or resident representative about the risks and benefits of a dose increase, decrease, or when a new psychotropic medication is started. Record review of the document titled (Facility Name) Psych April 2026 for Resident 9 revealed that the resident was admitted to the facility with the orders for Abilify (an psychotropic medication (drugs that affect mood, behavior, thoughts, or perception, primarily by altering brain chemistry) used for the diagnosis of major depressive disorder) on 4/15/2025. There was an order for a gradual dose reduction on 6/24/2026 that the family refused at that time. Then on 1/19/2026 another GDR was documented to reduce the medication. The document also revealed that the resident was admitted with the medication Zoloft (a medication for depression) and had a gradual dose reduction completed 9/23/2025 which failed and the medication was then increased on 2/3/2026. Trazadone (an antidepressant) was added as an antidepressant on 3/5/2026. on 3/16/2026, Remeron (an antidepressant) was added to stimulate the appetite. Record review of the Physician Orders printed on 5/6/2026 revealed that Resident 9 takes the following psychotropic medications: 1. Aripiprazole (a psychotropic medication that affects brain function, particularly the activity of neurotransmitters such as dopamine and serotonin, which regulate mood, behavior, and thought processes and used for severe depression) 2 milligrams (mg) once daily for major depressive disorder without psychotic features 2. Mirtazapine (an antidepressant medication) 7.5 mg for moderate protein calorie malnutrition. 3. Sertraline (an antidepressant medication) 150 mg for major depression without psychotic features. 4. Trazadone (an antidepressant medication) 50 mg for insomnia. Review of the Nursing Progress Notes printed on 5/6/2026 revealed there was no documentation of the actual risks and benefits about the psychotropic medications ordered for Resident 9 when the resident entered the facility, when medications were increased, when medications were increased, or when new medications were added. Notes from the progress notes included the following: 6/25/2025; There is an entry in the Nursing Progress Notes that revealed there was information given to the resident representative as to why the facility wanted to try to do a gradual dose reduction (decrease the medication) of aripiprazole, but the resident representative refused. Nothing was documented about the risks or benefits revealed about the aripiprazole medication. 9/23/2025; Received order from PCP in regard to pharmacy review. Order to decrease Sertraline to 100mg QD. Resident Representative notified. 1/9/2026: There is an entry in the Nursing Progress Notes that revealed there was an order to change the aripiprazole, and the staff spoke at length about risks and benefits of decreasing medication. Ensured POA that monitoring for side effects such as change in mood, sleep, and appetite for example are documented if updates to Primary Care Physician need to be done. 2/3/2026; Received order from PCP to increase. Sertraline to 150mg QD. Resident Representative notified 2/17/2026; Documentation that staff received an order to start Trazadone 25mg for sleep on an as needed basis when Resident 9 requests something for sleep. Resident Representative notified. 3/5/2026; Received order from Primary Care Physician make Trazodone 50 mg routine per resident request and give every night at bedtime per Resident 9's request. 3/16/2026; Fax sent from Primary Care physician with new orders: Remeron (mirtazapine) 15 mg- 1/2 tablet at bedtime. Resident Representative notified. In a confirmation interview with the Director of Nursing (DON) on 5/5/2026 at 11:40 AM it was confirmed that although there is information in the progress notes that the residents and families are notified of the medication changes, it is not documented that there is anything related to the actual risks of adding or discontinuing the medications or the risks associated with the medications. The DON also confirmed that there is not an actual document used by the facility to document the risks and benefits of psychotropic medications. In a confirmation interview with the Assistant Director of Nursing (ADON) on 5/5/2026 at 11:42 AM revealed that the care plan (a written plan of care that describes how a facility will care for an individual resident) contains the information as it relates to the risks and benefits but that what is discussed with the residents or resident representatives at the care plan meetings representatives is not documented on the care plan as the facility staff only document that residents and families are told about the medication changes in the progress notes but what specifically is discussed is not documented. ADON stated that the facility is working on documentation and trying to improve that throughout the facility. B. Record review of a Resident Face Sheet for Resident 20 revealed that the facility admitted Resident 20 on 03/23/2026 with diagnosis of generalized anxiety disorder (a persistent, excessive, and uncontrollable worry about everyday things that often causes significant distress, physical symptoms, and interferes with daily life), and major depressive disorder (a serious, common mental health condition characterized by persistent, severe low mood, loss of interest, and low energy that affect daily functioning). Record review of Resident 20's comprehensive 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) with an Assessment Reference Date (ARD) of 03/27/2026 revealed the MDS was coded to reflect that the resident received routine antipsychotic (a psychotropic mood altering drug) and antidepressant (a psychotropic mood altering drug) medications on a routine basis during the look back period. Record review of a untitled document dated 03/11/2026 revealed the residents name and a listed medication order of Quetiapine 25 milligram tablet to be administered at bed time and Citalopram 20 milligram tablet to be administered in the morning. Record review of Resident 20's Medication Administration Record for the month of March 2026 revealed documentation that Resident 20 received the Quetiapine (an antipsychotic psychotropic medication) and Citalopram (an anti-depressant psychotropic medication) medications every day since admission to the facility. Record review of Resident 20's Progress Notes revealed no documentation that the resident or their representative was educated about the risks, benefits, and alternate interventions used for Resident 20 due to receiving the Antipsychotic, and Anti-Depressant medications. Record review of Resident 20's Electronic Medical Health Record revealed no documentation that that the resident or their representative was educated about the risks, benefits, and alternate interventions used for Resident 20 due to receiving the Antipsychotic, and Anti-Depressant medications. In an interview completed on 05/05/2026 at 11:40 AM with the facility Director of Nursing (DON), the DON confirmed that there was no documentation that the resident or their representative were educated about the risks, benefits, and alternate interventions used for Resident 20 for the use of the psychotropic medications that the resident had been receiving since admission to the facility.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(4) Based on record review and interview, the facility failed to ensure that comprehensive person-centered care plans were developed and implemented with measurable goals and objectives to meet the required needs of each resident for 2 residents (Resident 9 and Resident 35) of 14 sampled residents. The facility census was 30. Record review of the facility policy dated 4/1/2024 Comprehensive Care Plans revealed the policy is to develop and implement a comprehensive person-centered care plan (a detailed document that outlines a patient's medical history, current health status, and the coordinated care needed to meet their health needs) for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The definition of person-centered was to focus on the resident as the locus (center) of control and support the resident in making their own choices and having control over their daily lives. The policy explanation and compliance guidelines started that the care planning process revealed the following: 1.) The care planning process would include an assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing goals of care. 2.) The plan would be developed within 7 days after the completion of the Minimum Data Set (MDS) assessment (a standardized, federally mandated evaluation of a nursing home resident's health, functional status, and care needs, used to guide care planning and determine reimbursement) and all areas triggered by the MDS would be considered in the formation of the plan of care. Other factors identified by the interdisciplinary team or in accordance with the resident's preferences would be addressed. 3.) The comprehensive care plan would include at a minimum the following: a. The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services as a result of Preadmission Screening and Resident Review (PASARR) (a federally mandated assessment to ensure individuals with serious mental illness or intellectual disabilities are appropriately placed in nursing facilities and receive the services they need.) d. the resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans as appropriate. F. Resident specific interventions that reflect the resident's needs and preferences. 5.) The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment and as appropriate as changes arise. 6.) The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs, and the objectives will be utilized to monitor the resident's progress. A.Review of the Minimum Data Set (MDS) (a standardized assessment tool used in long-term care settings, that serves as a comprehensive screening and assessment instrument that collects essential information about residents' clinical and functional status and assists in determining care needs, guiding treatment plans, and facilitating reimbursement processes for skilled nursing facilities) created on 3/27/2026 revealed Resident 9 was admitted to the facility on [DATE]. Resident 9 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated normal thinking and memory. The MDS also revealed that Resident 9 had diagnoses of Alzheimer's disease, non-Alzheimer's dementia, malnutrition, anxiety disorder, depression, and insomnia.Record review of the facility policy dated 4/20/2020 Behavioral Health Services revealed it is the policy that all residents receive necessary behavioral healthcare and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. The policy further stated the facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The process included the use of ongoing monitoring of mood and behaviors, care plan development, implementation, and evaluation. Pharmacological interventions shall only be used when non-pharmacological interventions are ineffective or when clinically indicated.Record review of the Comprehensive Care Plan last reviewed and revised on 04/27/2026 revealed that Resident 9 was taking medications with a black box warning (the FDA's most serious safety alert, indicating that a drug carries risks of severe or life-threatening adverse effects) which included: Remeron (an antidepressant) also called mirtazapine, Trazadone (an antidepressant), Abilify (a psychotropic medication) also called aripiprazole, Lasix (a medication that increases urine production to help remove excess salt and water from the body), sertraline (a medication from depression), Synthroid (a medication that replaces or supplement the naturally occurring thyroid hormone produced by the body), and Tylenol also called acetaminophen. One goal listed for all the medications stated, Resident 9 will not have any adverse reactions to medications by the next care plan meeting. The following approaches and specific goals and objectives were documented for the following medications; Remeron - approach; being used for appetite stimulation, monitor for clinical signs of mood changes, suicidality or unusual chances in behavior. No specific measurable goals and objectives were created for this medication. Trazadone - approach; drug may increase risk of suicidal thinking. Monitor patients for signs or symptoms of increased suicidal thinking. No specific measurable goals and objectives were created for this medication. Abilify (aripiprazole) - approach; monitor patients for worsening or emergence of suicidal thoughts and behaviors. No specific measurable goals and objectives were created for this medication. Lasix - approach; drug is a potent diuretic and can cause severe diuresis (too much fluid loss) with water and electrolyte depletion. Monitor patient closely and adjust dose carefully. No specific measurable goals and objectives were created for this medication. Sertraline- approach - warning for clinical worsening and suicide risk, suicidal thoughts and behaviors. No specific measurable goals and objectives were created for this medication. Tylenol - approach; drug can cause acute liver failure which may require a liver transplant or cause death. Most cases of liver failure are associated with drug doses exceeding 4000 milligrams (mg)/day and often involve more that on acetaminophen containing product. Many over-the-counter and prescription products contain acetaminophen, be aware of this when calculating total daily dose. No specific measurable goals and objectives were created for this medication. There were other approaches as they related to Resident 9. The Abnormal Involuntary Movement Score (AIMS) (a 12-item clinician-rated scale to assess severity of involuntary facial movements in patients taking psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications was to be completed as scheduled, but no identification of when these were to be scheduled. The consulting pharmacist was to do gradual dose reductions of the psychotropic medications as required but no indication as to what that timeline was.Interview on 5/5/2026 at 10:58 AM with Nurse Aide (NA) A revealed that nurses let us (nurse aides and medication aides) know in report when there is someone that we have to be monitoring for behaviors. Then they will also tell us the last day we have to observe for behaviors. We chart what we observe about the residents in the electronic medical record. We have a category for behaviors that we - as a CNA - chart in. We watch for anything abnormal and we see anything, we just let the charge nurse know. As for Resident 9, I will need to check with the charge nurse because I don't think we are monitoring Resident 9 for anything anymore.Interview with the Assistant Director of Nursing (ADON) on 5/5/2026 at 11:04 AM who revealed that the behaviors are charted in the Progress notes.Interview with the Director of Nursing (DON) on 5/5/2026 at 11:05 AM who revealed that the progress notes are the only place that we chart a resident's behaviors. We chart when there is a medication change for a period of 30 days. This includes new starts for medications or a discontinuance of a medication. We also chart for 30 days when there is a witnessed change in behaviors.Interview with the ADON on 5/5/2026 at 11:08 AM who revealed that the behaviors are also charted with the MDS if they occur in the look back period - a period of about 5 days when we are doing that assessment - but we always include them in the care plans.Interview with the DON on 5/5/2026 at 11:35 AM revealed that the care plans used to be too long and nobody would take the time to read them. What looks to be all about the medications is mostly just the information for the black box warnings. There is a part of the care plan document that tells more about behaviors and moods. The staff document changes in the medications and moods for a total of 30 days. That includes the decreases of medications for a period of 30 days and when there are any increases in the medications. They do have this captured in the care plan. However, it is broad. The facility staff are going to work on narrowing this in the care plan to be more specific as it relates to each of the medications or at least insert the information as it correlates to the moods into the other aspects of the care plan. The moods and behaviors should be in a different area of the care plan. We will work on creating measurable goals and objectives, so they are more clearly understood for those using the care plan to care for the residents.In a confirmation interview with the ADON on 5/5/2026 at 11:35 AM who revealed that some goals and objectives are buried in other portions of the care plan. The ADON confirmed that the goals do not have measurable and objective goals related to each medication identified and are not person-centered as it would relate only to this resident.B.Record review of the quarterly MDS dated [DATE] revealed Resident 35 was admitted on [DATE]. Resident 35 wore glasses, had a BIMS score of 7 ( a score that indicated severe cognitive impairment, suggesting significant difficulty with memory, orientation and thinking skills), used a walker for ambulation, needed minimal to moderate assistant with activities of daily living such as toileting, bathing, dressing, and oral cares, was occasionally incontinent of urine, had medically complex issues including hypertension (high blood pressure), renal insufficiency (kidney were starting to work inefficiently), diabetes, difficulty speaking, an anxiety disorder, asthma or chronic obstructive pulmonary disorder (difficulty with breathing), anemia (a deficiency of healthy red blood cells or hemoglobin, leading to insufficient oxygen delivery to the body's tissues), and difficulty swallowing, and was at risk of developing pressure ulcers but currently had no skin conditions or open areas of the skin.Record review of the Physician admission Orders dated 10.2.2025 revealed that Resident 35 was admitted with diagnoses of atrial fibrillation (Irregularly irregular heart rhythm), high blood pressure, and hypothyroid (low thyroid).Record review of the Office Clinic Notes dated 12/22/2025 revealed that Resident 35 was seen for failure to thrive (FTT) (a syndrome of physical, cognitive, and functional decline, often marked by weight loss, poor nutrition, decreased activity, and social withdrawal.). FTT was added to Resident 35's list of diagnoses.Record review of the Office Clinic Notes dated 01/26/2026 revealed the office visit was a follow up to Resident 35's edema (swelling from extra fluid in the body), weakness, loss of appetite, and leg pain. Added to Resident 35's list of diagnoses was chronic kidney disease (long term disorder of the kidneys not working properly to secrete urine), pitting edema in which the provider added furosemide (a diuretic medication that helps the kidneys produce more urine to eliminate extra bodily fluids via the kidneys),and leg pain in which the provider order acetaminophen with codeine (codeine is an opioid medication for more severe pain).Record review of the inhouse visit with an Advanced Practice Registered Nurse (APRN) dated 02/03/2026 revealed that the facility staff wanted Resident 35 to be seen for a sore on the right ankle, sores to both buttocks, and weight loss. The staff also asked for an order to have Hospice re-evaluate Resident 35. After seeing Resident 35, the diagnosis included congestive heart failure (CHF) (a chronic condition in which the heart cannot pump blood efficiently, leading to fluid buildup and symptoms like shortness of breath and swelling), blisters and cellulitis with skin breakdown on both buttocks. The APRN ordered doxycycline (an antibiotic medication for infections) for the infection control.Record review of the inhouse facility visit dated 02/12/2026 with an APRN revealed the facility staff wanted Resident 35 to be seen for a follow up about Resident 35's congestive heart failure, blisters that had turned into sores on a foot, the right foot which was purple and cold to touch, edema in both legs, shortness of breath with activities, and lack of appetite. The APRN added levothyroxine to the daily medications, and changed the medication being used for pain control.Record review of the comprehensive care plan last reviewed and revised on 01/28/2026 revealed that that care plan had not been updated to include the addition of the opioid medication given for pain, did not include the addition of the medication Lasix for the Resident 35's edema and congestive heart failure, did not address concerns and goals for the failure to thrive, there were no updates about the skin issues that included blisters, sores, and areas of breakdown and infection on the buttocks, legs and feet, and there were no updates.In a confirmation interview with the ADON on 5/5/2026 at 11:35 AM confirmed that the care plan goals do not have measurable and objective goals related to each medication identified and are not person-centered as it would relate only to this resident.

LICENSURE REFERNCE NUMBER 175 NAC 12-006.17 Based on observation, record review, and interview the facility failed to use proper hand sanitization during the application and removal of personal protective equipment and use the recommended personal protective equipment when providing care for residents with a communicable disease to prevent the potential for cross contamination and Covid-19 which had the potential to affect all facility residents; and the facility failed to perform peri care in a manner to prevent the potential for cross contamination for 2 Residents (Resident 33 and 12) The facility census was 33. Findings are: A. Interview on 03/06/2024 at 8:35 AM with the Director of Nursing (DON) revealed the facility was currently in COVID-19 out break and had four residents that were currently positive for COVID-19 requiring isolation precautions. Observation on 03/06/2024 at 8:45 AM on the facility 200 hall revealed the following: -room [ROOM NUMBER] signage on the door stated Red Zone applying Personal Protective Equipment (PPE) must be done outside of the room. Step 1 put on your gown fasten ties at the top and the bottom. Step 2 remove your surgical mask. Sanitize your hands. Apply N95 mask, which is a respirator mask that is designed to achieve a very close fit and very efficient filtration of air borne particles. Make sure you tighten the nose piece to snuggly fit your face. Sanitize your hands. Step 3 apply goggles or face shield. Step 4 apply gloves. Removal of PPE. Step 1 remove gloves and gown inside the room. Sanitize your hands. Step 2 exit the room. Remove face shield or goggles and then remove your N95. Sanitize your hands. Step 3 apply surgical mask. Sanitize your hands. -room [ROOM NUMBER] signage on the door stated Red Zone applying Personal Protective Equipment (PPE) must be done outside of the room. Step 1 put on your gown fasten ties at the top and the bottom. Step 2 remove your surgical mask. Sanitize your hands. Apply N95 mask. Make sure you tighten the nose piece to snuggly fit your face. Sanitize your hands. Step 3 apply goggles or face shield. Step 4 apply gloves. Removal of PPE. Step 1 remove gloves and gown inside the room. Sanitize your hands. Step 2 exit the room. Remove face shield or goggles and then remove your N95. Sanitize your hands. Step 3 apply surgical mask. Sanitize your hands. In an interview on 03/07/2024 at 9:15 AM with the Assistant Director of Nursing (ADON) who acts also in the role of the facilities infection preventionist it was revealed that an additional resident had tested positive for COVID-19. In an observation on 03/07/2024 at 11:07 AM Nurse Aide (NA-A) was applying PPE in the hallway outside room [ROOM NUMBER]. NA-A removed their surgical mask and placed on an N95 mask. NA-A then applied a gown and tied the gown in the back then completed alcohol-based hand sanitization and applied gloves to both hands. NA-A did not put goggles on or follow the correct listed procedure for putting on PPE. In an interview on 03/07/2024 at 11:45 with the ADON it was revealed that staff should be wearing goggles and following the directions posted on the residents' doors for what PPE to wear. The ADON confirmed staff should not be wearing surgical masks either over or under their N95 masks. ADON stated the facility followed both Infection Control Assessment and Promotion Program (ICAP) and Centers for Disease Control (CDC) guidelines for infection prevention. In an interview on 03/07/2024 at 1:30PM with NA-A it was stated that staff know how to put on and take off their PPE and know what PPE to use by the signs posted on the outside of the door to the resident's room. In an observation on 03/11/2024 at 11:15 AM on the 200 hall it was observed that NA-J was walking in the hall with a yellow surgical mask over their N95 mask. In an observation on 03/11/2024 at 11:40 AM outside of room [ROOM NUMBER] it was observed that NA-J was exiting room [ROOM NUMBER] with a N95 mask over a yellow surgical mask and had no goggles on. In an observation on 03/11/2024 at 12:30 PM it was observed that Medication Aide-K (MA-K) was applying PPE in the hallway outside of room [ROOM NUMBER]. MA-K applied a N95 mask then applied a gown and tied it in the back. MA-K then placed their goggles on and then gloves on both hands. MA-K did not perform hand sanitization between any of the application of the PPE as listed on the door outside of the room before entering the room. In an observation on 03/11/2024 at 1:05 PM it was observed that MA-K was applying PPE outside of room [ROOM NUMBER] in the hallway. MA-K applied a gown, removed their surgical mask and applied a N95 mask and then applied gloves to both hands. MA-K did not perform hand sanitization between any of the application of the PPE as listed on the door outside of the room before entering the room. In an interview on 03/12/2024 at 8:32 AM Nurse Aide-D (NA-D) stated staff follow the directions for applying and removing PPE by reading the signs on the doors of the resident's room and completing the steps step by step. In a record review of facility supplied policy labeled Infection Prevention and Control Program dated 06/06/2023 revealed under isolation protocol that the facility will follow current CDC guidelines when caring for a resident with a communicable disease that is placed on transmission-based precautions. In a record review of CDC document labeled sequence for putting on PPE and not dated listed Step 1 put on gown, Step 2 put on mask or respirator, Step 3 apply goggles or face shield, and Step 4 apply gloves. In a record review of CDC document labeled sequence for removal of PPE and not dated listed Step 1 remove gloves wash your hands or use an alcohol based hand sanitizer, Step 2 remove goggles or face shield wash your hands or use an alcohol based hand sanitizer, Step 3 remove gown wash your hands or use an alcohol based hand sanitizer, Step 4 remove mask or respirator wash your hands or use an alcohol based hand sanitizer. In a record review of ICAP document labeled Zones, PPE and Testing dated 09/29/2022 under staff PPE listed full PPE, respirator, eye protection, isolation gown and gloves. In a record review of ICAP document labeled summary of recommendations for COVID-19 in a long term care facility dated 05/11/2023 under PPE required for care of residents with COVID-19 stated staff entering the room of a resident with COVID-19 should adhere to standard precautions and use respirator (N95), gown, gloves, and eye protection. In a record review of ICAP document not dated listed PPE removal perform hand sanitization, remove gown and gloves, perform hand sanitization, remove eye protection, perform hand sanitization, remove N95, perform hand sanitization. 50253 B. Record Review of the policy entitled Catheter: Insertion, Removal, Care, Irrigation, Instillation dated 3/2014 states to Position the bag to avoid urine reflux into the bladder, kinking, or gross contamination of the bag. Keep the bag below the level of the bladder at all times to prevent the backflow of urine and decrease the risk for infection. Do not leave the bag laying on the floor. Record Review of the Policy and Procedure titled Perineal Care revised 6/1/2005 and signed and dated 7/11/2005 by the then acting Director of Nurses is the current policy and procedure used for perineal care. There have been no further updates or revisions to this policy. Record Review of Annual Competencies dated 1/23/2024 Identified what each newly hired nursing staff is trained on for direct resident care and what all direct care employees review annually. Competencies included Incontinence Care Female, Urinary Catheter Care, Oral Care, and Denture Care. Observation on 3/11/2024 at 07:02 AM in Resident 33 room. Nursing Assistant-D (NA-D) came in as soon as the nursing staff had left after removing the patient indwelling foley catheter. NA-D came in to dress the resident for breakfast, but the resident wanted to sleep longer. NA-D used Alcohol Based Hand Sanitizer (ABHS) to perform hand hygiene and left the room. Observation on 03/11/24 at 07:16 AM in Resident 33 room. NA-D used ABHS to perform hand hygiene and donned gloves. NA-D encouraged the resident to get dressed as it is time for breakfast. No peri care was done. NA-D began the process of dressing Resident 33 putting on clean underwear, pants, socks, and shoes while Resident 33 was still lying in bed. NA-D then assisted Resident 33 to a sitting position and removed pajama top, applied deodorant, and then dressed resident in a clean shirt. NA-D then helped Resident 33 put on glasses and donned the gait belt. NA-D removed gloves. No hand hygiene was done. Resident 33 was assisted to a standing position and NA-D pulled up underwear and pants the rest of the way while resident was standing at bedside. Resident 33 ambulated to the bathroom with standby assist of NA-D. In the bathroom, Resident 33 is coached to use the grab bars to sit on the toilet. NA-D performed hand washing for 20 seconds with soap and water, dried the hands thoroughly, and donned new gloves. NA-D then assisted the resident with warm wash cloth to clean face with soap and water. NA-D made bed and placed dirty linen bag beside the bathroom door then helped resident blow the resident nose. NA-D obtained clean peri pad from the closet, placed new peri pad, in underwear, rinsed dentures, gave them to the resident, and assisted the resident to place the dentures. NA-D used 4 disposable cleansing cloths for peri care. From the back, NA-D wiped front to back, only between the labia, and towards the back, folded the disposable cloth, wiped front to back with the same cloth, and disposed of the cloth. NA-D then used one cleansing wipe and wiped the patient front to back only once, discarded the wipe, took the final disposable cleansing cloth, wiped front to back once, and discarded the wipe. NA-D didn't clean thighs, didn't clean the area between the perineum and the thighs, didn't clean the buttocks, and therefore, did not clean the entire peri area. Resident 33 was assisted off the toilet, ambulated to room door, and care was transferred to the Physical therapist who had interrupted NA-D three different times. NA-D then gathered the bags of trash and laundry. NA-D removed gloves, used ABHS, and left the room with the bags of laundry and trash. Interview on 3/11/2024 at 2:45 PM with DON. This surveyor questioned the DON about expectations of peri care. First, nursing staff should encourage the residents to do as much as possible by themselves. Otherwise, if the resident is not able to perform peri care, we will help them. When asked how they teach them to clean the resident if they are standing up, the DON confirmed that the staff should clean front to back. The DON also revealed that the entire perineum should be cleansed including the front and the groin area. The DON confirmed that there should be a change of gloves when going from dirty to clean with hand sanitized with an ABHS if hands appear clean and washed with soap and water if hands are visibly soiled. Education of nursing staff and new hires are done upon hire and then annually. These records are kept for future reference. Audits for hand hygiene are done annually with competencies. C: Observation on 03/11/24 at 07:50 AM in Room of Resident 16. NA-D uses ABHS to perform hand hygiene, dons gloves, gown, N95, and goggles prior to entering the double occupancy room with COVID precautions. NA-D states it is difficult to see through the goggles, and notes that another staff member is using the good safety glasses. At resident bedside, it is noted that the Resident 16's brief has stool leaking out both sides on the front side. Resident lying on their back with head of bed (HOB) elevated. Resident has a G-Tube (a flexible hollow tube inserted through the belly that brings nutrition directly to the stomach so that the individual can obtain the needed fluids and caloric intake needed daily) and is visibly clean and dry. NA-D pulled down the brief at the front, rolled and tucked the brief between the resident legs. NA-D then removed the resident's leg braces, positioned resident for cleaning, gathered several clean wipes and started wiping what NA-D could from front to back. NA-D was not able to spread the resident legs for cleaning. NA-D stated again that NA-D can barely see out of the goggles. NA-D did not call for assistance on the radio each staff member carried to request help when needed. NA-D then rolled Resident 16's brief under the left side as far as possible, and then assisted the resident to their left side. NA-D used one cleaning cloth and wiped both buttocks, then placed it on the dirty brief. NA-D then touched the resident's right thigh with a dirty, soiled glove. NA-D used several disposable cleansing cloths and wiped front to back multiple times each time disposing of the dirty cleansing cloth on the dirty brief that remained under the resident. NA-D about it being difficult to see through the goggles. NA-D rolled up the dirty brief and continued to wipe off the resident. NA-D reached into the bag of disposable cleaning cloths numerous times with the dirty gloves to obtain a clean cloth. When there were no more clothes, NA-D reached for a new pack of wipes, continued to use more disposable cleansing cloths, reaching into clean cloth package with dirty gloves, until NA-D felt the resident was cleaned of all stool. NA-D still did not request assistance with Resident 16. NA-D placed a new chux (a kind of ultra-absorbent incontinence products that are designed to be placed on the top of a bed, wheelchair, or any surface you want to protect) under the resident, tucked it under Resident 16 right side, rolled the Resident 16 to the right side, pulled the clean chux and brief under the patient, and then rolled resident back to a supine (lying on one's back) position. NA-D cleaned the thighs and stated there is a spot of stool that was missed on the right thigh and again complained of the goggles being difficult to see through. Before NA-D fastened the brief NA-D identified more BM that had been missed on the front peri area. NA-D obtained more cleansing wipes from container with the dirty gloves and cleaned the front peri area, fastened the brief and covered Resident 16. While the cleaning process had taken place, NA-D had also touched the G-Tube extension with dirty gloves. NA-D removed the soiled and dirty gloves, used ABHS only, and donned new gloves. At this point, NA-D used the radio to call for assistance. Nurse Aide-J (NA-J) entered the room, assisted NA-D to boost Resident 16 up in bed, and then dressed Resident in socks, leg braces, and clean pants. NA-J assisted Resident 16 to a sitting position, changed the resident's shirt, then assisted with the placement of the Hoyer Lift (a specialized lift for individuals who are not able to ambulate) sling. Another staff member brought the Hoyer lift to the resident door. NA-J and NA-D were then able to position the Hoyer lift (a mobility tool used to help seniors with mobility challenges get out of bed) and the resident wheel chair to get Resident 16 out of bed. Both NA-D and NA-J continued working without changing gloves or doing any hand hygiene (hand washing using soap and water or using ABHS to remove germs to reduce the risk of infection transmission among patients and health care personnel). NA-J rinsed Resident 16's dentures, obtained a warmed washcloth, cleansed the resident's face, and helped the resident put in their dentures. NA-J gathered the dirty linens and the trash from the room, removed the gown and gloves at the doorway per protocol, then asked where the dirty laundry and trash needed to be taken. NA-J walked down the hall and did not change NA-J's mask. No hand hygiene was done by NA-J. NA-J had on only her regular glasses without safety sides or goggles. (Protocol posted on Resident 16 door stated that the staff entering were to wear goggles.) NA-D removed their gown and gloves at the door per the protocol, used ABHS prior to leaving the room, then removed their N95 mask (a respiratory protective mask designed to protect the wearer from respiratory diseases), cleansed the hands with ABHS only, and donned a new mask. Interview on 3/11/2024 at 2:45 PM with DON. DON confirmed that in a situation such as a resident with a feeding tube and a large bowel movement such as had been encountered, the Staff member should call for additional assistance to care for the resident.

Licensure Reference Number 175NAC 12-006.18E3a Based on observation, record review, and interview the facility failed to monitor and record facility hot water temperatures to protect residents from the potential for burns/scalding for 4 of 16 sampled residents (Residents 21, 11, 26, and 29). The facility census was 33. Findings are: A. Record review of the facility Resident Rights dated 2016 revealed that the resident has the right to a safe, clean, comfortable, and homelike environment. The nursing facility must provide a safe, clean, comfortable, and homelike environment ensuring the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Provide comfortable and safe temperatures. Observation on 3/6/24 at 12:18 PM in the room of Residents 21 and 11 (roommates) revealed that the hot water at the bathroom sink measured with a thermometer read a temperature of 127.2 degrees Fahrenheit. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 21 dated 1/12/24 revealed that Resident 21 is able to stand from a sitting position independently. Resident 21 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 7. (A score of 0-7 indicates the resident has severe cognitive impairment). Record review of the current Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 3/7/24 for Resident 21 revealed that Resident 21 may not always call for assistance. Resident 21 doesn't need physical assistance for transfers unless Resident 21 is not feeling well. Interview on 3/6/24 at 12:31 PM with Nurse Aide-A (NA-A) revealed that Resident 21 uses the bathroom on their own. Observation on 3/11/24 at 11:02 AM in the room of Resident 21 revealed that Resident 21 ambulated into the bathroom unassisted. Interview on 3/6/24 at 12:45 PM with the Maintenance Supervisor (MS) revealed the facility process for monitoring the hot water temperatures is to go to the boiler room each morning. MS revealed that MS observes the thermometer for water coming out of the hot water heater and also the thermometer for the hot water temperature as it leaves the mixing valve. MS revealed if the hot water temperature exiting the mixing valve is 120 degrees Fahrenheit or above, MS increases the cold water. MS confirmed that the maximum temperature allowed for hot water is 120 degrees Fahrenheit. MS confirmed that the morning check is a visual check and the temperatures are not documented. MS revealed that the facility had legionella (a water borne bacteria that can cause pneumonia type illness) in the water system months ago and turned the hot water as high as it would go at around 180 degrees Fahrenheit to try to treat the legionella. MS revealed that the plumber told them the mixing valve would likely not be right after running the high temperatures. MS revealed that the facility did random checks of hot water temperatures previously but stopped doing that about 6 months ago when they started doing the daily visual check of the hot water heater and mixing valve. This surveyor requested the documentation of the last 3 random checks performed. Record review of the facility Tracking Tool (Water Temp, Ventilation) dated 5/31/23 revealed hot water temperatures from resident rooms and the public restrooms all in required range. The Tap Water Temperature Checks dated 4/24/23 and 3/2/23 revealed random room hot water temperatures documented. All in required range. Interview on 3/6/24 at 2:20 PM with the MS confirmed no documented temperature checks of hot water had been performed after 5/31/23. B. Record review of the Face Sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) for Resident 11 revealed that Resident 11 admitted into the facility on [DATE]. Diagnoses included dementia. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/19/24 for Resident 11 revealed that Resident 11 had a BIMS score of 10. (A score of 8-12 indicates moderate cognitive impairment). Record review of the Care Plan for Resident 11 dated 3/7/24 revealed that Resident 11 uses a wheelchair for mobility. Observation on 3/6/24 at 12:18 PM in the room of Residents 21 and 11 (roommates) revealed that the hot water at the bathroom sink measured with a thermometer read a temperature of 127.2 degrees Fahrenheit. Interview on 3/7/24 at 12:18 PM with Nurse Aide-A (NA-A) revealed that Resident 11 is assisted to the bathroom and is able to wash their hands. C. Record review of the Face Sheet for Resident 26 dated 3/12/24 revealed that Resident 26 admitted into the facility on [DATE]. Diagnoses included dementia and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 1/19/24 for Resident 26 revealed that Resident 26 had a BIMS score of 10. (A score of 8-12 indicates moderate cognitive impairment). Record review of the Care Plan dated 3/12/24 for Resident 26 revealed that Resident 26 will use the walker to walk short distances. Observation on 3/06/24 at 12:15 PM in the room of Resident 26 revealed that the hot water at the bathroom sink measured with a thermometer read a temperature of 123.9 degrees Fahrenheit. Interview on 3/06/24 at 12:30 PM with Resident 26 revealed that the resident does use the bathroom sink to wash hands. Resident 26 revealed that staff assist the resident into the bathroom. D. Record review of the Face Sheet for Resident 29 dated 3/12/24 revealed that Resident 29 admitted into the facility on [DATE]. Diagnoses included constipation and enlarged prostate. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 2/2/24 for Resident 29 revealed that Resident 29 had a BIMS score of 99. (A score of 99 indicates the resident was unable to cognitively complete the assessment). Record review of the Care Plan dated 3/12/24 for Resident 29 revealed that Resident 29 is incontinent of urine and does not allow staff to assist the resident with toileting. Observation on 3/06/24 at 12:12 PM in the room of Resident 29 revealed that the hot water at the bathroom sink measured with a thermometer read a temperature of 120.3 degrees Fahrenheit. Interview on 3/6/24 at 12:31 PM with NA-A revealed that Resident 29 goes to the bathroom on their own and is independent in the room.

Licensure Reference Number 175 NAC 12-006.09C Based on observation, record review, and interview the facility failed to develop a Comprehensive Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) to include resident care needs for Resident 30 and Resident 28; to include interventions to prevent skin alterations for 2 residents (Resident 3 and 12); to address specific targeted mood and behaviors for psychotropic medications for Resident 3; to include accurate diagnosis for Resident 6; and for indwelling foley catheter for Resident 33. This had the potential to for 6 of 12 sampled residents. The facility census was 33. Findings are: A. Record review of the facility Admission Agreement dated 12/20/21 revealed that Plan of Care means a care plan for nursing care, activities, restorative and rehabilitative services and psychosocial care offered by the facility as identified in the resident's plan of care established by the facility in collaboration with the resident/resident representative. Record review of the facility Resident's Rights dated 2016 revealed that the nursing facility must include an assessment of the resident's strengths and needs in the planning process. Record review of the facility Care Plan Meeting Notice dated 6/22/23 revealed that care plan goals are developed from the resident's needs. Record review of the facility policy titled Baseline Care Plan dated 10/12/20 revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Initial goals shall be established that reflect the resident's stated goals and objectives. Interventions shall be initiated that address the resident's current needs including: any health and safety concerns to prevent decline or injury such as elopement, fall, or pressure injury risk; any identified needs for supervision, behavioral interventions, and assistance with activities of daily living; any special needs such as for intravenous (IV) therapy, dialysis, or wound care. Once established, goals and interventions shall be documented in the designated format. Record review of the Face Sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) dated 3/7/24 for Resident 28 revealed that Resident 28 admitted into the facility on [DATE]. Diagnoses included malignant neoplasm of the prostate (prostate cancer), malignant pleural effusion (A condition in which cancer causes an abnormal amount of fluid to collect between the thin layers of tissue lining the outside of the lung and the wall of the chest cavity), and pain. Record review of the Physician Order Report for Resident 28 dated 3/12/24 revealed an order to monitor dressing to PleurX drain (a thin, flexible tube that's placed in your chest to drain fluid from your lungs) dated 10/10/23. An order to drain PluerX drain as needed with symptoms of cough or chest discomfort dated 12/6/23. Observation on 3/12/24 at 1:39 PM in the room of Resident 28 revealed a gauze dressing covered with a tegaderm dressing (a transparent medical dressing) over the pleurX drain on the right mid abdomen. Interview on 3/11/24 at 3:10 PM with Registered Nurse-B (RN-B) confirmed that Resident 28 has a pleureX drain that drained as needed. RN-B revealed you can tell when it needs drained as Resident 28 begins coughing a lot. Record review of the current Care Plan for Resident 28 dated 3/7/24 revealed that it did not contain any goals or interventions for care of Resident 28's pleurX drain for the excess fluid caused by the malignant pleural effusion. Interview on 3/12/24 at 8:47 AM with Medication Aide-M (MA-M) revealed that MA-M reviews the resident care plan for resident specific care and interventions. Interview on 3/12/24 at 9:40 AM with Nurse Aide-N (NA-N) revealed that NA-N provides care for Resident 28. NA-N was unsure about the pleurX drain or any care interventions for the drain or dressing. NA-N revealed that NA-N refers to the resident care plan to know what cares are required by the resident. Interview on 3/12/24 at 1:08 PM with the facility Director of Nursing (DON) confirmed that Resident 28 has cancer and a pleurX drain for the resident's pleural effusion. The DON confirmed that the expectation was that the care plan for Resident 28 should include the pleurX drain and interventions for staff to follow in caring for the drain. The DON confirmed that the care plan for Resident 28 did not have a goal or interventions for the resident's pleurX drain. B. Record review of the Face Sheet dated 3/7/24 for Resident 30 revealed that Resident 30 admitted into the facility on [DATE]. Diagnoses included dysuria (discomfort, pain, or burning when urinating), heart failure, and abnormal weight loss. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 30 dated 8/4/23 revealed that Resident 30 received an antibiotic on all 7 days of the 7-day lookback period. Interview on 3/11/24 at 12:26 PM with the facility Assistant Director of Nursing (ADON) confirmed that Resident 30 started a prophylactic antibiotic (an antibiotic taken to prevent an infection) due to chronic urinary tract infections. Record review of the Care Plan for Resident 30 dated 3/7/24 revealed that it did not contain any goals or interventions for Resident 30's history of urinary tract infections. Interview on 3/12/24 at 1:08 PM with the DON confirmed that goals and interventions for monitoring for urinary tract infection and preventive interventions are expected to be on the resident care plan. The DON confirmed that a goal and interventions for urinary tract infection was not found on the care plan for Resident 30 and should be on the care plan. 50105 C. A review of Resident 6's Care Plan dated 07/30/2020 with a problem start date of 1/30/2020 the category for medications revealed Risperidone for Schizophrenia (a serious mental illness in which people interpret reality abnormally). A review of Resident 6's Continuity of Care Document dated 03/12/2024 showed a listing of current medications including frequency, instructions, diagnosis associated, start date, end date, and last administered. The medication Risperidone 0.5 mg (milligram), oral one tablet by mouth twice a day. The diagnosis used for the medication revealed adjustment disorder with mixed anxiety and depressed mood. The Continuity of Care Document dated 03/12/2024 reveals last administered dose for Risperidone on 03/12/2024 at 7:27:34 AM. A review of Resident 6's active diagnoses list signed by the physician dated 02/26/2024 did not reveal a diagnosis of Schizophrenia. A review of Resident 6's Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 02/23/2024 pages 25, 26, and 27 Section I lists active diagnoses. The record reveals under psychiatric/mood disorder, anxiety and depression are listed, none other. During an interview on 03/12/2024 at 09:10 AM, the Director of Nursing (DON) stated Resident 6's Care Plan has indicated Risperidone use for Schizophrenia and should not. The DON confirmed that Resident 6 does not have an active diagnosis of Schizophrenia. 50253 D. Record review of the Basic Care Plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) for Resident 33 dated 1-18-2024 revealed an indwelling foley catheter (a flexible plastic hollow tube inserted into the bladder to continuously drain urine) present at admission. Record review of the Comprehensive Care Plan (CCP) dated 2/19/2024 for Resident 33 revealed the following: Category: Skin. Resident 33 is at risk for skin breakdown. Braden score and use of foley catheter. Resident 33 likes to lay in bed throughout the day and needs staff assistance for sufficient movement throughout the day and at night. Resident 33 also has a foley catheter that could cause skin irritation. She wears underwear only during the day and night. Skin is assessed weekly. If staff notice skin breakdown, notify charge nurse. For all treatments see TAR. The CCP contained no interventions to direct staff on the care required for the foley catheter. Observation on 03/11/2024 at 06:47 AM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) are in the room of Resident 33 preparing to remove the catheter. Explanation given to Resident 33 about the procedure as resident was told resident would now need to use the bathroom for toileting as there would no longer be a tube draining the bladder. The staff removed and discarded the catheter. Record Review on 3/12/2024 of the CCP for Resident 33 dated 2/19/2024 shows no further updates to the area of skin after removing the foley catheter on 3/11/2024. Interview on 3/12/2024 at 10:00 AM with the DON confirmed that the DON is unable to identify an area on the CCP which discusses only the catheter or interventions for catheter care. When asked about when and how facility focus on areas on the CCP are created, the DON revealed the ADON does all of the care planning. The DON called the ADON and remained in the room. The DON put the phone on speaker. Interview on 3/12/2024 at 10:12 AM with the ADON via phone. This surveyor asked the ADON about the CCP and why the urinary catheter, diagnosis, and interventions are not included on the CCP. We had a care plan meeting and were told to combine areas when we could. The ADON confirmed that there is no individual care plan or interventions for the specifically for the foley catheter. The ADON confirmed I have not changed the care plan since the catheter was pulled yesterday and I am not in the office today. That will be updated when I return to the facility.

Licensure Reference Number 12.006.09D3 Based on record review, observations, and interviews, the facility failed to ensure the indwelling foley catheter was discontinued for 1 resident (Resident 33) of 1 sampled resident to prevent the potential for urinary problems including infection. The facility census was 33. Findings are: Record review of the admission record dated 1/18/2024 for Resident 33 revealed the resident was admitted to the facility 01/18/2024 with an indwelling foley catheter (tube inserted directly into the bladder for urine drainage) after the resident obtained a left fracture of the acetabulum (left pelvis). Resident 33 did not have surgery for the fracture. Record review of the nursing progress notes for Resident 33 dated 1/24/2024 revealed Resident 33 was seen on 01/24/2024 by the Primary Care Provider (PCP). On that date, the orders were that facility nursing staff were to leave the indwelling foley catheter (catheter) in place until able to ambulate and toilet with 1 assist. Record review of the Physical Therapy (PT) progress note dated 2/13/2024 revealed PT documented patient is ambulatory with 1 assist with therapy. Record review of Resident 33's Progress Note dated 2/21/2024 revealed Resident 33 was able to ambulate to the dining room with one assist from Physical Therapy (PT). Resident 33 is now ambulatory with 1 assist. Record review of nursing communication with the PCP on 2/29/2024. Assistant Director of Nursing (ADON) faxed Resident 33 has an indwelling catheter, but we do not have a DX (diagnosis) for a catheter. Please select an appropriate DX. There was a selection for Neurogenic Bladder or Obstructive Uropathy. The PCP's answer was returned by fax and stated: Patient has catheter due to post op status and decreased mobility. Neither DX is appropriate. Review of the nursing progress note dated 3/5/2024 at 4:00 PM the catheter was removed based on the order from 1/24/24. (This was 21 days after Resident 33 was able to ambulate with 1 assist). Review of the nursing progress note dated 3/06/2024 at 9:15 AM the catheter was replaced due to inability to void. A new order was received from Physician. Occupational Therapy began a 5-day bladder training program. Observation in Resident 33 room [ROOM NUMBER]/06/2024 at 9:10 AM revealed Resident 33 was assisted to bed by the Medication Aide-H (MA-H). MA-H assisted Resident 33 to a lying position and the catheter bag was lifted above Resident 33 before placing it on the edge of the bed where it was then touching the floor. Observation on 03/11/2024 at 6:47 AM, revealed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) removed Resident 33's catheter. Observation in the Dining Room on 03/11/2024 at 12:05 PM revealed Resident 33 was sitting at their assigned table area for meal calling out for help and voiced a need for help. When approached, Resident 33 voiced they needed to use the bathroom. MA-H was informed Resident 33 needed to use the bathroom. Observation in the Dining room on 03/11/2024 at 12:14 PM revealed Resident 33 remained at their table sitting in the chair and did have an feeding assistant next to them. Resident 33 had not been taken to the bathroom. Interview with the DON on 3/12/2024 at 10:00 AM revealed the facility nursing staff had requested a diagnosis for the catheter and was told only that Resident 33 had the catheter in place until the resident was able to ambulate with the assistance of one person. Resident 33 did not have a diagnosis for the Urinary Catheter upon admission. We did try to get a diagnosis for urinary retention, but the physician said 'no'. The DON revealed the facility did have Provider orders to remove the catheter once the resident was ambulatory with one assist and could sit to toilet. The DON, ADON, and Registered Nurse-B (RN-B) had tried multiple times to pull the catheter but the facility Occupational Therapist and Physical Therapist declined. Interview on 03/12/2024 at 10:12 AM with the ADON via a phone call revealed [gender] was aware of the order to remove Resident 33's catheter when the resident was able to ambulate and toilet with one assist. The ADON revealed therapy had informed nursing staff to not pull the catheter.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, record review, and interview; the facility failed to ensure that contingency measures (additional precautions intended to mitigate the transmission and spread of COVID-19) for all staff who were not fully vaccinated were in place. This had the potential to affect all facility residents. The facility census was 31. Findings are: Record review of the facility policy titled COVID-19 Vaccine Mandate Policy dated 5/3/22 revealed that all employees (staff) are required to receive vaccinations as determined by the Centers for Medicare and Medicaid Services (CMS), unless an exemption is approved and the employee accepts reasonable accommodation (additional precautions to mitigate the transmission and spread of COVID-19). The policy revealed that up to date employees are individuals that have received all doses in the primary COVID-19 vaccination series and one booster vaccination when eligible. The policy revealed that the facility will implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not up to date for COVID-19 vaccination including but not limited to: wearing a mask during all close proximity to residents and staff and submit to regular testing according to the county community transmission level for COVID-19. The policy revealed that when the community transmission level is low (blue) no testing, regardless of vaccination status, will be completed. Record review of the COVID-19 Staff Vaccination Matrix (a list of all facility staff documenting each staff member's COVID-19 vaccination status) completed by the facility on 5/3/22 revealed that 30 facility staff were not up to date for COVID-19 vaccination. The record revealed that 3 facility staff had a non-medical exemption approved. Record review of the COVID-19 Staff Vaccination Matrix revealed that Nursing Assistant-D (NA-D) was not up to date on COVID-19 vaccination. Observation on 5/3/22 at 1:58 PM near the nurse's station revealed that NA-D wore a light blue surgical mask. Interview on 5/3/22 at 1:58 PM with NA-D revealed that NA-D was vaccinated for Covid-19 but had not received the booster dose (NA-D was not up to date on COVID-19 vaccination). NA-D confirmed that NA-D was not being tested by the facility when the county community transmission level was low. NA-D revealed that no staff were tested when the county community transmission level was low. NA-D revealed that all facility staff (up to date and those not up to date) wear the same type of mask, a surgical mask. Record review of the COVID-19 Staff Vaccination Matrix revealed that Medication Aide-E (MA-E) was not up to date on COVID-19 vaccination. Observation on 5/3/22 at 2:05 PM on the facility 200 hall revealed that MA-E wore a light blue surgical mask. Interview on 5/3/22 at 2:05 PM with Medication Aide-E (MA-E) confirmed that MA-E had not received a booster dose vaccination for Covid-19 (MA-E was not up to date on COVID-19 vaccination). MA-E revealed that MA-E was not being tested by the facility for COVID-19 before the county community transmission level changed from blue (low) to red (high). Record review of the COVID-19 Staff Vaccination Matrix revealed that Medication Aide-C (MA-C) was up to date on COVID-19 vaccination. Observation on 5/3/22 at 1:56 PM at the nurse's station revealed that MA-C wore a light blue surgical mask. Record review of the COVID-19 Staff Vaccination Matrix revealed that Medication Aide-A (MA-A) was up to date on COVID-19 vaccination. Observation on 5/3/22 at 2:03 PM on the facility 200 hall revealed that MA-A wore a light blue surgical mask. Interview on 5/3/22 at 2:39 PM with the Facility Administrator (FA) revealed that the county community transmission level for COVID-19 was blue (low) until 4/25/22. The FA confirmed that the facility did not perform COVID-19 testing while the county community transmission level was blue on any staff, unless they are symptomatic. The FA confirmed that the mitigation for staff not up to date on COVID-19 vaccination included that those staff wear a surgical mask. The FA confirmed that all staff, those that are not up to date on vaccination and those that are up to date on vaccination, all wear a surgical mask. The FA confirmed that there was no difference in the type of mask worn by both the up to date staff and the not up to date staff. The FA confirmed that the facility was not requiring any additional mitigation measures of the not up to date staff during low county community transmission level.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A1 Based on observation, interview, and record review; the facility staff failed to follow the menu during meal service for the residents. This affected 29 of 31 residents who were served the lunch meal, Residents 29, 4, 28, 32, 27, 23, 21, 14, 6, 1, 31, 22, 12, 3, 20, 7, 83, 5, 8, 2, 19, 11, 9, 25, 30, 17, 26, 16, and 10. The facility identified a census of 33 at the time of survey. Findings are: Observation of the facility kitchen on 12/02/21 at 10:18 AM revealed DC-B (Dietary Cook) prepared a ham and scalloped potatoes casserole. DC-B washed their hands and placed a pan liner in a large pan and sprayed the liner with non-stick cooking spray. DC-B donned gloves and opened 2 bags of freeze dried scalloped potato casserole mix. DC-B poured 2 bags in the pan and poured water into the pan per the package directions. DC-B stirred then added another bag for 3 bags total. DC-B then got a bowl of shredded ham out of the refrigerator and scooped the ham into the pan with the potatoes with a large spoon. DC-B stirred the potatoes and ham together and added the remainder of the water required for the dried potatoes. DC-B then covered the pan with foil and the DM (Dietary Manager) put the pan into the convection oven at 10:38 AM. The potatoes were 20.35 ounce bags. DC-B did not measure or weigh the ham. The ham and scalloped potatoes casserole mix had the appearance of 50/50 portions of ham and potatoes. Observation of the facility kitchen on 12/02/21 at 11:19 AM revealed DC-B prepared the pureed meal. DC-B said 1 resident received pureed food, Resident 30. DC-B pureed the green beans first then placed them in a metal pan and put foil over it and placed them into the oven. DC-B got a different food processor container and placed one 4 ounce gray scoop of the ham/scalloped potato casserole mixture into the processor. DC-B pureed the ham/scalloped potato casserole and added warm milk to moisten it. DC-B then scraped the ham/scalloped potato pureed mixture into a metal pan, covered it with foil, and placed it in the oven. Observation of the scoop DC-B used to scoop the ham/scalloped potato casserole revealed it was a gray #8 scoop that was labeled 4 ounces. Observation of the facility dining room on 12/02/21 at 12:00 PM revealed DC-B served the noon lunch meal to the residents. DC-B served each resident one gray 4 ounce scoop of ham/scalloped potato casserole. DC-B served Resident 16, Resident 4, Resident 29, and Resident 8. DC-B then served Resident 21 and Resident 28; Resident 83 and Resident 7; Resident 5 and Resident 27; Resident 2, Resident 22, Resident 11, Resident 14, Resident 20, Resident 19 and Resident 25. At 12:17 PM DC-B served the pureed food to Resident 30 which consisted of 1 gray 4 ounce scoop of pureed scalloped potato/ham casserole. At 12:19 PM, DC-B served Resident 17 and Resident 26. DC-B then served Resident 31, Resident 23, and Resident 6. All received 1 gray 4 ounce scoop of the ham/scalloped potatoes casserole. DC-B then prepared the room trays. DC-B placed 1 gray 4 ounce scoop of scalloped potato/ham casserole on each plate that was then taken to the residents in their rooms: Resident 3, Resident 1, Resident 9, Resident 12, and Resident 10 all received rooms trays with 1 gray 4 ounce scoop of the ham/scalloped potato casserole. At 12:39 PM Resident 24 was observed in their room with no food. Interview with RN-A at this time revealed Resident 24 had refused lunch and was not served. At 1:23 PM Resident 32 received a room tray with 1 gray 4 ounce scoop of scalloped potato/ham casserole and was observed eating. Resident 15 and Resident 18 received sandwiches for lunch. Resident 13 was not in the facility and was not served. Review of the untitled facility menu for Thursday Week 4 revealed the following was listed for the 2nd meal of the day: 8 ounces Scalloped Potatoes & Ham; 1/2 cup green beans; 1 slice bread; 1/2 cup apple crisp. On 12/06/21 at 3:02 PM the recipe for the scalloped potato/ham casserole was requested from the DM. Review of the untitled recipe for the scalloped potato/ham casserole received from the DM at 12/06/21 at 3:18 PM revealed the amount of potatoes and ham to be used for the casserole and the serving size was not listed on the recipe. The recipe called for a bag of frozen potatoes and 2 cans of ham [NAME]. The recipe also called for a homemade béchamel sauce and the addition of bell papers which were not included in the recipe DC-B had prepared. Interview with the DM at this time revealed the facility did not have any frozen potatoes so they used the bagged ones. The DM reviewed the menu and confirmed DC-B should have served 2 four ounce scoops of the ham and scalloped potato casserole to each resident instead of 1. The DM confirmed the cooks were expected to follow the menu. Review of the facility policy Menus dated December 2008 revealed the following: Menus shall meet the nutritional needs of residents; be prepared in advance; and be followed.

Based on record review and interview, the facility failed to ensure that a required bed hold notification was provided to the resident/resident representative for 3 residents (Residents 26, 28, and 13) of 3 residents reviewed. This prevented the resident /resident representative from making an informed decision to either request a bed hold (a reservation that allows a resident to return to the facility) or release the resident bed. The facility census was 33. Findings are: A. Record review of the facility policy titled Readmission-Bed Hold Policy and Notice dated 2/6/20 revealed that 1) the policy is to be given to the Resident and or Resident Representative at the time of transfer or therapeutic leave (when a resident temporarily leaves the facility for a family-type setting). 2) Emergency Transfer/Bed-hold notice: Complete Emergency notice then have Resident and or Resident Representative select either Request for Bed hold or Release of Bed, then sign the notice. If the Resident and or Resident Representative are not present at the time of transfer (for instance in an emergency transfer) notice must be given within 24 hours of transfer with documentation of multiple attempts made to reach the Resident Representative. The section titled Types of Bed Hold revealed that in the event that a Resident eligible for Medicare Part A (Medicare insurance coverage that pays for a resident's stay in the facility for a limited time) is transferred to or readmitted to a hospital, Medicare Part A eligibility will be terminated on the day the Resident is admitted to the hospital. The Resident's bed will be reserved at the Basic Rate if the Resident or Resident Representative elects to hold the bed and agrees to make bed hold payments to the Facility. Record review of the Face Sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) for Resident 26 revealed that the resident admitted to the facility on [DATE] with the latest return into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Progress Note for Resident 26 dated 8/12/21 at 8:41 revealed that Resident 26 felt like the resident's lungs were filling up with fluid. The resident's lung sounded moist (indicating excess fluid in the lungs). Record review of the Progress Note for Resident 26 dated 8/12/21 at 4:38 PM revealed that an order was received to admit Resident 26 to the hospital emergency room for evaluation. Record review of the Progress Note for Resident 26 dated 8/13/21 at 9:27 AM revealed that the resident was admitted to the hospital. Record review of the Progress Note for Resident 26 by the facility Social Services Director (SSD) dated 8/13/21 at 2:36 PM revealed that the spouse of Resident 26 requested that the SSD call the hospital for an update on the resident. The hospital nurse revealed that the resident had pneumonia and [CONDITION(S)]. The nurse gave the SSD the phone number for Resident 26 so the spouse would be able to talk with Resident 26. The note contained no documentation that a bed hold was discussed. Record review of the Progress Note for Resident 26 dated 8/17/21 at 1:15 PM revealed that Resident 26 readmitted to the facility from the hospital. Record review of the resident health record for Resident 26 revealed no documentation of bed hold notification occurring for the resident's hospitalization from [DATE] through 8/17/21. Interview on 12/7/21 at 11:20 AM with the facility Social Services Director (SSD) confirmed that the facility had no documented bed hold notification for Resident 26 for the hospital stay beginning on 8/12/21. The SSD confirmed that a bed hold notification should have been completed. Interview on 12/7/21 at 11:35 AM with the Facility Administrator (FA) revealed that the bed hold forms are sent with a resident in the packet that is sent with the resident to the hospital. The FA confirmed that the facility had no documented bed hold notification for some residents sent to the hospital. The FA revealed that the facility found some issues related to bed hold notifications after this surveyor brought it to their attention. The FA revealed that the facility will update the process for bed hold notifications to ensure that bed hold notifications are completed. B. Record review of the Face Sheet for Resident 28 revealed that the resident admitted to the facility on [DATE] with the latest return into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Progress Note for Resident 28 dated 8/13/21 at 11:30 AM revealed that when the medical records staff attempted to open the door to the medical records office Resident 28 was found lying on the resident's back with the head towards the door. Resident 28 was unresponsive. The ambulance was called and the resident's representative was notified. The resident's physician was notified. The note contained no documentation that a bed hold was discussed with the resident's representative. Record review of the Progress Note for Resident 28 dated 8/13/21 at 4:00 PM revealed that the facility received a call from the hospital notifying them that Resident 28 was being admitted to the hospital. Record review of the Progress Note for Resident 28 dated 8/14/21 at 10:20 AM revealed that Resident 28 returned to the facility accompanied by the resident's representative and was readmitted to the facility. The note contained no documentation that a bed hold was discussed. Record review of the resident health record for Resident 28 revealed no documentation of bed hold notification occurring for the resident's hospitalization from [DATE] through 8/14/21. Interview on 12/7/21 at 11:20 AM with the facility Social Services Director (SSD) confirmed that the facility had no documented bed hold notification for Resident 28 for the hospital stay beginning on 8/13/21. The SSD confirmed that a bed hold notification should have been completed. Interview on 12/7/21 at 11:35 AM with the Facility Administrator (FA) revealed that the bed hold forms are sent with a resident in the packet that is sent with the resident to the hospital. The FA confirmed that the facility had no documented bed hold notification for some residents sent to the hospital. The FA revealed that the facility found some issues related to bed hold notifications after this surveyor brought it to their attention. The FA revealed that the facility will update the process for bed hold notifications to ensure that bed hold notifications are completed. C. Record review of the Face Sheet for Resident 13 revealed that the resident admitted to the facility on [DATE] with the latest return into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident health record for Resident 13 revealed that Resident 13 was hospitalized on [DATE] through 10/30/21, 11/2/21 through 11/8/21, and on 12/1/21 through 12/2/21. Record review of the Progress Note for Resident 13 dated 10/29/21 at 5:23 AM revealed that Resident 13 stated that the resident did not feel good and complained of an upset stomach. Resident 26 had a loose foul smelling bowel movement that smelled like old blood. Record review of the Progress Note for Resident 13 dated 10/29/21 at 9:36 AM revealed that a call was placed to the physician of Resident 13 to update the physician on the resident. Record review of the Progress Note for Resident 13 dated 10/29/21 at 3:30 PM revealed that the facility received a call from the medical provider that Resident 13's labs were low and that the resident would require blood if the family wished for the resident to be treated. A call was placed to the resident's representative and the representative requested that the resident be treated. Resident 13 was transferred to the hospital emergency room by ambulance. The note contained no documentation that a bed hold was discussed. Record review of the Progress Note for Resident 13 dated 10/29/21 at 7:08 PM revealed that Resident 13 was admitted to the hospital. Record review of the Progress Note for Resident 13 dated 10/30/21 at 9:05 AM revealed that a nurse from the hospital called the facility to inform them that Resident 13 was being discharged back to the facility today. The hospital nurse informed the facility that Resident 13 had a [CONDITION(S)] (bleeding in the digestive tract). Record review of the Progress Note for Resident 13 dated 10/30/21 at 11:35 AM revealed that Resident 13 returned to the facility. Record review of the resident health record for Resident 13 revealed no documentation of bed hold notification occurring for the resident's hospitalization from [DATE] through 10/30/21. Record review of the Progress Note for Resident 13 dated 11/2/21 at 8:00 AM revealed that Resident 13 was out of the facility to an appointment with the primary care provider after returning from the hospital on Saturday (10/30/21). Record review of the Progress Note for Resident 13 dated 11/2/21 at 10:45 AM revealed that the medical provider called the facility from the clinic to inform them that Resident 13's hemoglobin (a protein in red blood cells) was lower today than it was before the blood transfusion that the resident received on Friday (10/29/21). The provider revealed that the resident's representative would need to decide if the resident should be sent for treatment or brought back to the facility on comfort cares. The resident representative wanted Resident 13 to be treated. The note contained no documentation that a bed hold was discussed with the resident's representative. Record review of the Progress Note for Resident 13 dated 11/2/21 at 11:22 AM revealed that Resident 13 was being admitted to the hospital for treatment. Record review of the Progress Note for Resident 13 dated 11/8/21 at 11:00 AM revealed that Resident 13 returned to the facility from the hospital. Record review of the resident health record for Resident 13 revealed no documentation of bed hold notification occurring for the resident's hospitalization from [DATE] through 11/8/21. Record review of the Progress Note for Resident 13 dated 11/23/21 at 3:14 PM revealed that Resident 13 was scheduled for debridement (the removal of dead, damaged, or infected tissue to improve healing) of the resident's right below the knee amputation stump (the area of the leg left after removal of the lower leg) and placement of a wound vac (a medical device that provides vacuum-assisted closure of a wound to help wounds heal) on 12/1/21. Record review of the Progress Note for Resident 13 dated 12/1/21 at 1:24 PM revealed that Resident 13 was out of the facility for the procedure at the hospital. Record review of the Progress Note for Resident 13 dated 12/1/21 at 4:18 PM revealed that Resident 13 would be staying overnight at the hospital. The resident representative was notified. The note contained no documentation that a bed hold was discussed with the resident's representative. Record review of the Progress Note for Resident 13 dated 12/2/21 at 1:54 PM revealed that Resident 13 returned to the facility from the hospital. Record review of the resident health record for Resident 13 revealed no documentation of bed hold notification occurring for the resident's hospitalization from [DATE] through 12/2/21. Interview on 12/7/21 at 11:20 AM with the facility Social Services Director (SSD) confirmed that the facility had no documented bed hold notification for Resident 13 for the hospital stays beginning on 10/29/21, 11/2/21, and 12/1/21. The SSD confirmed that a bed hold notification should have been completed for each of the hospital stays. Interview on 12/7/21 at 11:35 AM with the Facility Administrator (FA) revealed that the bed hold forms are sent with a resident in the packet that is sent with the resident to the hospital. The FA confirmed that the facility had no documented bed hold notification for some residents sent to the hospital. The FA revealed that the facility found some issues related to bed hold notifications after this surveyor brought it to their attention. The FA revealed that the facility will update the process for bed hold notifications to ensure that bed hold notifications are completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review, the facility failed to ensure duplicate antipsychotic medications were not administered at the same time for 1 of 5 sampled residents, Resident 30. The facility identified a census of 33 at the time of survey. Findings are: Review of Resident 30's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 9/17/2021 revealed an admitted [DATE]. Resident 30 had a BIMS (Brief Interview for Mental Status) score of 0 which indicated severe cognitive impairment. Resident 30 required extensive assistance from staff for bed mobility, transfer, dressing, toilet use, and bathing, locomotion on the unit, eating, and personal hygiene. Antipsychotic medication was received 7 days of the 7 day MDS look back period. Review of Resident 30's Physician Order Report for 6/1/2021 to 12/6/2021 revealed the following orders: ABH gel; 1/25/1; ([MEDICATION(S)] 1 mg (antianxiety)/[MEDICATION(S)] 25 mg (antihistamine)/[MEDICATION(S)] 1 mg(antipsychotic) topical three times a day PRN as needed with a start date of 6/8/2021. [MEDICATION(S)] ([MEDICATION(S)]) tablet; 1 mg; 1 tablet by mouth three times a day as needed for anxiety with a start date of 6/1/2021. [MEDICATION(S)] ([MEDICATION(S)])(antipsychotic) tablet 5 mg; 1 tablet by mouth every morning at 7:30 AM . [MEDICATION(S)] ([MEDICATION(S)])(antipsychotic) tablet; 100 mg; 1 tablet by mouth at bedtime at 8:00 PM . Review of Resident 30's Medication Administration Record for June, July, August, September, October, November, and December 2021 revealed the ABH and [MEDICATION(S)] were administered at the same time or within a 4 hour time frame of each other: June 2021: 6/12/2021 ABH was administered at 7:04 AM; [MEDICATION(S)] was administered at 9:56 AM. ABH and [MEDICATION(S)] were both administered at 11:40 AM on 6/15/2021. Resident 30 also received routine [MEDICATION(S)] at 8:00 AM and 8:00 PM. July 2021: 7/13/2021: ABH and [MEDICATION(S)] were both administered at 5:54 PM on the 15th. [MEDICATION(S)] was administered at 3:25 AM and ABH was administered at 6:10 AM on 7/25/21. Resident 30 also received [MEDICATION(S)] 25 mg at 8:00 AM. August 2021: 8/28/2021 [MEDICATION(S)] was administered at 9:40 AM and ABH was administered at 9:42 AM; [MEDICATION(S)] was administered at 12:12 PM and ABH was administered at 4:32 PM on the 30th. ABH was administered at 12:17 PM and [MEDICATION(S)] was administered at 8:54 AM and 4:40 PM on the 31st. Resident 30 also received [MEDICATION(S)] 5 mg at 7:30 AM from 8/13 to 8/31, [MEDICATION(S)] 100 mg at 8:00 PM every night from 8/1/2021 to 8/31/2021 and [MEDICATION(S)] 25 mg at 7:30 am from 8/1 to 8/12/21. September 2021: [MEDICATION(S)] was administered at 8:52 AM and ABH was administered at 12:27 PM on the 5th. [MEDICATION(S)] and ABH were both administered at 11:26 AM on 9/13/2021. [MEDICATION(S)] was administered at 11:21 AM and ABH was administered at 2:01 PM on the 14th . Resident 30 also received [MEDICATION(S)] 5 mg at 7:30 AM every am. October 2021: [MEDICATION(S)] was administered at 4:32 AM and ABH was administered at 6:45 AM on the 18th. [MEDICATION(S)] was administered at 4:47 AM and 11:41 AM and ABH was administered at 7:05 AM on 10/20/2021. ABH was administered at 2:17 PM and [MEDICATION(S)] was administered at 3:21 PM on 10/27/2021. Resident 30 also received 5 mg of [MEDICATION(S)] at 7:30 AM every AM. November 2021: [MEDICATION(S)] was administered at 12:52 PM and ABH was administered at 2:37 PM on 11/1/2021. Review of Resident 30's Physician Order Report for 6/1/2021 to 12/6/2021 revealed no documentation the medical provider had given an order for the ABH and [MEDICATION(S)] to be administered at the same time. Review of Resident 30's Progress Notes revealed the following documentation of the Medication Regimen Reviews: 11/29/2021 04:19 PM MRR (Medication Regimen Review)- See note to MD 10/22/2021 12:30 PM MRR- NO RECOMMENDATIONS 09/19/2021 12:56 PM MRR-see note to nursing. 08/17/2021 03:51 PM MRR-see note to MD. 07/19/2021 02:45 PM MRR-no recommendations. 06/14/2021 03:16 PM MRR-see note to MD. 05/13/2021 04:14 PM MRR-see note to MD. 04/16/2021 04:09 PM MRR-see note to MD. 03/19/2021 04:49 PM MRR-no recommendations. Review of Resident 30's Progress Notes revealed no documentation the medical provider had given an order to administer the PRN ABH and [MEDICATION(S)] at the same time. Interview with the DON (Director of Nursing) on 12/06/21 at 3:40 PM confirmed the staff should not have been administering the [MEDICATION(S)] and the ABH gel at the same time since the ABH gel had [MEDICATION(S)] in it. Reviewed Resident 30's MARs with the DON and the ABH and [MEDICATION(S)] doses that were given at the same time or within 4 hours of each other. The DON agreed the staff should have followed the standard for medication administration: TID (Three times a day)-8 hours apart. The DON also revealed the facility staff had requested from the provider an order for the ABH topical antipsychotic medication because Resident 30 would spit out the oral [MEDICATION(S)]. The DON revealed the ABH and [MEDICATION(S)] were not intended to be given at the same time; the staff should have administered either one or the other, not both. Review of the facility policy Medication Administration Schedule dated 7/19/2005 revealed the following: When specific time spread required between specific medications a time given will be put on MAR with the first medication given. Review of the https://app.healthcarefirst.com/help/Homecare/Patients/MAR_(Medication_Administration_Record)/MAR_Administration/As_Needed_(PRN)_Medications.htm revealed the following: BID, TID, and QID As Needed (PRN) Medications When a medication is ordered with a Frequency of BID (Twice a Day), TID (Three Times a Day), or QID (Four Times a Day) selection, and marked As Needed (PRN), MAR will utilize a 24 hour day period to calculate the available dosage for the Frequency to verify that dosage in any interval is not exceeded. BID uses a 12 hour time period for dosage, TID uses an 8 hour time period for dosage, and QID uses a 6 hour time period for dosage.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12B (5) Based on interview and record review, the consultant pharmacist failed to identify the irregularity of duplicate therapy when PRN (as needed) antipsychotic (medications used to treat behavior disorders) medications were administered at the same time in addition to routine antipsychotic medications for 1 of 5 sampled residents, Resident 30. The facility identified a census of 33 at the time of survey. Findings are: Review of Resident 30's quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 9/17/2021 revealed an admitted [DATE]. Resident 30 had a BIMS (Brief Interview for Mental Status) score of 0 which indicated severe cognitive impairment. Resident 30 required extensive assistance from staff for bed mobility, transfer, dressing, toilet use, and bathing, locomotion on the unit, eating, and personal hygiene. Antipsychotic medication was received 7 days of the 7 day MDS look back period. Review of Resident 30's Physician Order Report for 6/1/2021 to 12/6/2021 revealed the following orders: ABH gel; 1/25/1; ([MEDICATION(S)] 1 mg (antianxiety)/[MEDICATION(S)] 25 mg (antihistamine)/[MEDICATION(S)] 1 mg(antipsychotic) topical three times a day PRN as needed with a start date of 6/8/2021. [MEDICATION(S)] ([MEDICATION(S)]) tablet; 1 mg; 1 tablet by mouth three times a day as needed for anxiety with a start date of 6/1/2021. [MEDICATION(S)] ([MEDICATION(S)])(antipsychotic) tablet 5 mg; 1 tablet by mouth every morning at 7:30 AM . [MEDICATION(S)] ([MEDICATION(S)])(antipsychotic) tablet; 100 mg; 1 tablet by mouth at bedtime at 8:00 PM . Review of Resident 30's Medication Administration Record for June, July, August, September, October, November, and December 2021 revealed the ABH and [MEDICATION(S)] were administered at the same time or within a 4 hour time frame of each other: June 2021: 6/12/2021 ABH was administered at 7:04 AM; [MEDICATION(S)] was administered at 9:56 AM. ABH and [MEDICATION(S)] were both administered at 11:40 AM on 6/15/2021. Resident 30 also received routine [MEDICATION(S)] at 8:00 AM and 8:00 PM. July 2021: 7/13/2021: ABH and [MEDICATION(S)] were both administered at 5:54 PM on the 15th. [MEDICATION(S)] was administered at 3:25 AM and ABH was administered at 6:10 AM on 7/25/21. Resident 30 also received [MEDICATION(S)] 25 mg at 8:00 AM. August 2021: 8/28/2021 [MEDICATION(S)] was administered at 9:40 AM and ABH was administered at 9:42 AM; [MEDICATION(S)] was administered at 12:12 PM and ABH was administered at 4:32 PM on the 30th. ABH was administered at 12:17 PM and [MEDICATION(S)] was administered at 8:54 AM and 4:40 PM on the 31st. Resident 30 also received [MEDICATION(S)] 5 mg at 7:30 AM from 8/13 to 8/31, [MEDICATION(S)] 100 mg at 8:00 PM every night from 8/1/2021 to 8/31/2021 and [MEDICATION(S)] 25 mg at 7:30 am from 8/1 to 8/12/21. September 2021: [MEDICATION(S)] was administered at 8:52 AM and ABH was administered at 12:27 PM on the 5th. [MEDICATION(S)] and ABH were both administered at 11:26 AM on 9/13/2021. [MEDICATION(S)] was administered at 11:21 AM and ABH was administered at 2:01 PM on the 14th . Resident 30 also received [MEDICATION(S)] 5 mg at 7:30 AM every am. October 2021: [MEDICATION(S)] was administered at 4:32 AM and ABH was administered at 6:45 AM on the 18th. [MEDICATION(S)] was administered at 4:47 AM and 11:41 AM and ABH was administered at 7:05 AM on 10/20/2021. ABH was administered at 2:17 PM and [MEDICATION(S)] was administered at 3:21 PM on 10/27/2021. Resident 30 also received 5 mg of [MEDICATION(S)] at 7:30 AM every AM. November 2021: [MEDICATION(S)] was administered at 12:52 PM and ABH was administered at 2:37 PM on 11/1/2021. Review of Resident 30's Physician Order Report for 6/1/2021 to 12/6/2021 revealed no documentation the medical provider had given an order for the ABH and [MEDICATION(S)] to be administered at the same time. Review of Resident 30's Progress Notes revealed the following documentation of the Medication Regimen Reviews: 11/29/2021 04:19 PM MRR (Medication Regimen Review)- See note to MD 10/22/2021 12:30 PM MRR- NO RECOMMENDATIONS 09/19/2021 12:56 PM MRR-see note to nursing. 08/17/2021 03:51 PM MRR-see note to MD. 07/19/2021 02:45 PM MRR-no recommendations. 06/14/2021 03:16 PM MRR-see note to MD. 05/13/2021 04:14 PM MRR-see note to MD. 04/16/2021 04:09 PM MRR-see note to MD. 03/19/2021 04:49 PM MRR-no recommendations. Review of Resident 30's Progress Notes revealed no documentation the consultant RPh had requested the provider review the duplicate PRN antipsychotic medication administration. There was no documentation the medical provider had given an order to administer the PRN ABH and [MEDICATION(S)] at the same time. Review of Resident 30's Note to Attending Physician/Prescriber dated 11/29/2021, 8/18/2021, and 6/16/2021 revealed no documentation the consultant RPh requested the medical provider to review the duplicate PRN antipsychotic administration. Interview with the consultant RPh (Registered Pharmacist) on 12/06/21 at 2:18 PM revealed they had not identified the irregularity of the ABH and [MEDICATION(S)] being given together or close to each other. The RPh revealed the ABH was being compounded by a different pharmacy. Interview with the DON (Director of Nursing) on 12/06/21 at 3:40 PM confirmed the staff should not have been administering the [MEDICATION(S)] and the ABH gel at the same time since the ABH gel had [MEDICATION(S)] in it. Reviewed Resident 30's MARs with the DON and the ABH and [MEDICATION(S)] doses that were given at the same time or within 4 hours of each other. The DON agreed the staff should have followed the standard for medication administration: TID (Three times a day)-8 hours apart. The DON also revealed the facility staff had requested from the provider an order for the ABH topical antipsychotic medication because Resident 30 would spit out the oral [MEDICATION(S)]. The DON revealed the ABH and [MEDICATION(S)] were not intended to be given at the same time; the staff should have administered either one or the other, not both. Review of the facility policy Medication Administration Schedule dated 7/19/2005 revealed the following: When specific time spread required between specific medications a time given will be put on MAR with the first medication given. Review of the facility policy Medication Regimen Review dated 6/21/2021 revealed the following: The drug regimen of each resident is reviewed at last once a month by a licensed pharmacist and includes a review of the resident's medical chart. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes: Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. Facility staff shall act upon all recommendations according to procedures for addressing mediation regimen review irregularities. Review of the https://app.healthcarefirst.com/help/Homecare/Patients/MAR_(Medication_Administration_Record)/MAR_Administration/As_Needed_(PRN)_Medications.htm revealed the following: BID, TID, and QID As Needed (PRN) Medications When a medication is ordered with a Frequency of BID (Twice a Day), TID (Three Times a Day), or QID (Four Times a Day) selection, and marked As Needed (PRN), MAR will utilize a 24 hour day period to calculate the available dosage for the Frequency to verify that dosage in any interval is not exceeded. BID uses a 12 hour time period for dosage, TID uses an 8 hour time period for dosage, and QID uses a 6 hour time period for dosage.

Based on interview and record review, the facility failed to ensure Resident 25 was seen by the medical provider at least every 60 days. This affected 1 of 5 sampled residents. The facility identified a census of 33 at the time of survey. Findings are: Resident # 25 admitted [DATE] Review of Resident 25's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 11/19/2021 revealed an admitted [DATE]. Resident 25 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 25 required extensive assistance from staff for transfer, walk in room, locomotion on unit, dressing, toilet use, personal hygiene, and bathing. Review of Resident 25's Doctor Visit Sheets revealed documentation Resident 25 was seen by the medical provider 7/29/2021; 6/30/2021; 4/23/2021; 3/24/2021; 2/19/2021 and 12/7/2020. There was no documentation Resident 25 had been seen by the medical provider since 7/29/2021. Review of Resident 25's Progress Notes revealed no documentation Resident 25 had been seen by the medical provider since July 29, 2021. Interview with the DON (Director of Nursing) on 12/07/21 at 10:25 AM revealed they reviewed Resident 25's chart and confirmed there was no documentation Resident 25 had been seen by a medical provider since July 29, 2021. The DON revealed the MR (Medical Records) scheduled the resident appointments. The DON confirmed the residents were to be seen by their medical provider every 60 days. Interview with MR on 12/07/21 at 10:28 AM revealed they had reviewed Resident 25's chart and confirmed Resident 25 had not been seen by the medical provider since July 29, 2021. MR revealed there was no reason for Resident 25 not being seen, such as a resident refusal, the appointments had gotten missed. Review of the facility policy Physician Visit dated 6/8/2005 revealed the following: It is required that the resident's visit they (sic) physician every 30 days for the first 90 days and then every 60 days thereafter.

Licensure Reference Number 175NAC 12-006.09D2b Based on record review and interview, the facility failed to document wound monitoring of a pressure ulcer (A localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) for 1 resident (Resident 3). This had the potential to affect the physician treatment decisions for any changes in the pressure ulcer. The facility census was 33. Findings are: Record review of the Face Sheet for Resident 3 revealed that the resident admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) for Resident 3 dated 10/15/21 revealed that Resident 3 was at risk for developing pressure ulcers. The MDS documented that Resident 3 did not have a pressure ulcer at the time of the assessment. The MDS revealed that Resident 3 required extensive assistance of 2 staff for bed mobility (how the resident turns side to side and positions the body while in bed or alternate sleep furniture) and transfers (how the resident moves between surfaces including to or from the bed, chair, wheelchair, and standing). Record review of the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 3 revealed that Resident 3 was at risk for pressure ulcers related to impaired mobility. The care plan directed staff to report any signs of skin breakdown (sore, tender, red, or broken areas). Record review of the Progress Note for Resident 3 dated 11/2/21 at 8:17 AM revealed that the bath aide reported that the sore to the right buttock of Resident 3 looked worse from last week. The wound measured 2 centimeters round. Stage 2 (an identifier used to describe the type of skin tissues involved in the pressure ulcer wound). The facility will continue with [NAME] (a moisture barrier to promote healing) to protect the wound. A fax was sent to notify the resident's physician. Record review of the fax to the physician of Resident 3 dated 11/2/21 revealed that Resident 3 had a 2 centimeter round stage 2 open area to the right buttock. [NAME] applied to protect. Record review of the health record of Resident 3 revealed that a Pressure Sore (ulcer) Record was initiated by Registered Nurse-A (RN-A) on 11/2/21. The Pressure Sore Record documented that Resident 3 had a stage 2 pressure ulcer on the right buttock with the measurements documented as 2 centimeters round. Record review of the facility policy titled Wound Treatment Management dated 4/1/20 revealed that to promote wound healing of various types of wounds, it is the facility policy to provide evidence-based treatments in accordance with current standards of practice and physician orders. Step 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Step 5. Treatment decisions will be based on: a. Etiology (cause) of the wound b. Characteristics of the wound: i. Pressure injury stage. ii. Size- including shape, depth, and presence of tunneling (a tunnel that extends from the wound base underneath the skin) and/or undermining (a large wound with a small opening at the skin wound surface). iii. Volume and characteristics of exudate (fluid that oozes out of a wound). iv. Presence of pain. v. Presence of infection. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin (the skin surrounding the wound). Step 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound done weekly and PRN (as needed). Considerations for needed modifications include: a. Lack of progress towards healing. b. Changes in the characteristics of the wound. Record review of the health record of Resident 3 revealed that the resident's health record contained no further documentation of the assessment and characteristics of the stage 2 pressure ulcer on the right buttock of Resident 3 after 11/2/21. The health record revealed no documentation of weekly measurements or other assessments of the stage 2 pressure ulcer. Interview on 12/6/21 at 11:29 AM with RN-A revealed that the pressure ulcer on the right buttock of Resident 3 is just a dry skin area at this time. RN-A revealed that the pressure ulcer had not been documented as healed as RN-A likes to continue to monitor the wound area. This surveyor asked RN-A where weekly wound measurements and assessments could be found. RN-A revealed that the facility Director of Nursing (DON) took over performing measurements of wounds in the facility. Record review of the Progress Note for Resident 3 documented on 12/6/21 at 11:29 AM revealed that no open sore to the right buttock was noted this morning. Dry flaky skin was noted. The facility will continue to use aloe with cares. The area is resolved. The DON was notified. Record review of the Progress Note for Resident 3 documented on 12/6/21 at 11:37 AM revealed that the progress note was a late entry documentation for 12/1/21 at 11:35 AM. The progress note revealed that the open area to the right buttock was no longer open. Dry flaky skin was noted. The facility will change from applying [NAME] to the area to applying aloe (a first aid cream) to the area. Interview on 12/6/21 at 11:47 AM with the DON confirmed that the facility expectation is to assess and document weekly measurements and assessment of pressure ulcers to monitor healing or worsening of the pressure ulcer. The DON confirmed that the facility had no documentation that the pressure ulcer on the right buttock of Resident 3 had been measured and assessed weekly.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observations, interviews, and record reviews; the facility staff failed to perform hand hygiene with glucometer (a machine used to check blood sugar levels) checks and insulin administration which affected 3 of 4 sampled residents (Residents 25, 24, and 17); failed to wear gloves with injections which affected 3 of 3 sampled residents (Resident 25, 24, and 17), failed to clean a glucometer after each resident use, which had the potential to affect 3 of 3 residents (Residents 25, 24, and 17); and failed to perform a dressing change to prevent potential cross contamination which affected 1 of 1 sampled residents (Resident 82). The facility identified a census of 82 at the time of survey. Findings are: A. Observation of LPN-E on 9/9/20 at 11:32 AM revealed they donned gloves and took a glucometer into Resident 25's room. LPN-E then lanced Resident 25's finger and placed a drop of blood on the test strip that was inserted into the glucometer. LPN-E touched the glucometer and Resident 25's hand and finger. LPN-E then removed 1 glove and answered the phone that was in LPN-E's pocket. LPN-E then took the other glove off and put the phone back into their pocket. LPN-E took the glucometer out to the treatment cart and placed it into a caddy with another glucometer and the testing supplies including the lancets, test strips, alcohol wipes and cotton balls. LPN-E then drew up Resident 25's insulin, took the insulin into Resident 25's room, and injected the insulin into Resident 25's abdomen. LPN-E did not reapply gloves and with bare un-gloved hands, injected the insulin into Resident 25's abdomen. LPN-E did not clean the glucometer. B. Observation of Resident 17 at 11:43 AM revealed LPN-E took a glucometer, test strip, alcohol wipe, and cotton ball out of the caddy on the treatment cart and took it into Resident 17's room. LPN-E lanced Resident 17's finger and placed a drop of blood onto the test strip that was inserted into the glucometer. LPN-E touched the glucometer and Resident 17's hand and finger. LPN-E then removed their gloves, placed the glucometer into the caddy with the other glucometer, test strips, lancets, alcohol wipes, and cotton balls, and took the caddy out to the cart. LPN-E did not do any hand hygiene. LPN-E then took a wipe out of the container and wrapped it around the glucometer they had used to check Resident 25's blood sugar. LPN-E did not clean Resident 17's glucometer. LPN-E then opened the drawer on the cart and got an insulin pen out. LPN-E took the insulin pen into Resident 17's room, put the needle on it, dialed the dose and injected the insulin into Resident 17's abdomen at 11:47 AM. LPN-E did not wear gloves when administering the insulin injection to Resident 17. LPN-E then took the phone out of their pocket and answered it without doing any hand hygiene. LPN-E then touched the computer and the drawer of the treatment cart and put the insulin pen away. LPN-E then took the phone to LPN-G. C. Observation of Resident 24 on 9/9/2020 at 11:52 AM revealed LPN-E wheeled Resident 24 to their room from the dining room by touching the handles on the wheelchair. LPN-E then came out Resident 24's room and retrieved a pair of gloves out of the box. LPN-E then donned the gloves and took the glucometer, test strip, lancet, alcohol wipe, and cotton ball into Resident 24's room. Resident 17's glucometer that had not been cleaned was in the caddy with all of the supplies including the other glucometer, the test strips, lancets, alcohol wipes, and the cotton balls. LPN-E had not cleaned Resident 17's glucometer machine. LPN-E then lanced Resident 24's finger and placed a drop of blood on the test strip that was inserted into the glucometer. LPN-E touched the glucometer and Resident 24's hand and finger. LPN-E then removed the gloves and did not do hand hygiene. LPN-E then touched the computer screen, unlocked the cart, and opened the drawer. LPN-E took a bottle of insulin out of the drawer and drew up 2 units of insulin into a syringe. LPN-E then took the insulin into Resident 24's room and injected the insulin into Resident 24's right arm. LPN-E did not wear gloves to give Resident 24 the insulin injection and did not perform hand hygiene before or after administering the insulin injection to Resident 24. LPN-E then put the syringe into the sharps container and handled Resident 24's wheelchair handles and wheeled Resident 24 out to the hall. LPN-E then went back to the computer sitting on top of the treatment cart and touched the screen. LPN-E then opened the drawer on the cart and put the box of insulin away after. LPN-E had not performed hand hygiene. NA-D (Nurse Aide) then wheeled Resident 24 into the dining room by handling the wheelchair. D. Observation of Resident 82 on 9/9/2020 at 1:55 PM revealed LPN-E placed a tube of ointment that was in a clear plastic sandwich bag and a dressing onto Resident 82's bedside stand. LPN-E did not put a barrier on the stand before placing the ointment or the dressing on the stand which contained resident personal items. Resident 82 was observed resting in bed on their right side. LPN-E then removed the tube of ointment from the sandwich bag it was in and placed it on the nightstand next to the unopened dressing. There were no wound cleaning supplies observed such as gauze sponges or wound cleanser. LPN-E donned gloves and removed the old dressing from Resident 82's sacrum/coccyx area (tailbone). There was an open area observed on Resident 82's sacrum/coccyx. Wearing the same gloves, LPN-E dabbed the area with a tissue or peri-wipe then removed the gloves. LPN-E then donned new gloves. LPN-E did not do hand hygiene after removing the gloves that were worn while LPN-E removed the soiled dressing prior to donning new gloves. LPN-E then squeezed some gel out of the tube onto their gloved finger and put the gel on the open area on Resident 82's sacrum/coccyx. Wearing the same gloves, LPN-E opened the dressing and applied a new dressing to Resident 82's sacrum/coccyx. LPN-E then removed the gloves and put the tube of treatment gel back into the bag. LPN-E did not do hand hygiene after removing the gloves and did not cleanse the wound after removing the old dressing prior to applying the new dressing. Review of Resident 82's Physician's Orders dated 9/5/2020 revealed the following order for treatment to Resident 82's open coccyx wound: cleanse area; hydrogel (ointment); [MEDICATION NAME] (dressing); change twice daily and PRN (as needed). Interview with the DON (Director of Nursing) on 9/10/20 at 7:45 AM revealed gloves were not to take the place of hand washing and hands were to be washed before donning and after removing gloves. The DON revealed it was the expectation that the glucometers be cleaned no matter what, even if it was the residents own machine, especially if the staff put it in the same caddy with the other glucometer machine which is shared with the residents. It is the expectation the nurses would wear gloves when giving injections. They could get contaminated with blood during injections. Interview with the DON on 9/10/20 at 7:59 revealed the facility staff were expected to always put a paper towel down for a barrier or some other sort of barrier to put the dressing change supplies on. The DON revealed Resident 82's pressure area was supposed to be cleaned with wound wash. The DON revealed gloves were to be changed after removing soiled dressings and hand hygiene between glove changes was expected Review of the undated facility Skills Checklist received from the facility Administrator revealed the following. Washes hands with soap and water and puts on gloves. Checks to be sure the right insulin is being given in the right dose to the right person at the right time. Removes gloves and washes hands. Review of the facility Policy for Glucometer cleansing between residents updated 3/19/2020 revealed the following: Purpose: to prevent the spread of infection through use of a single glucometer. Policy: The glucometer will be cleansed after each use with a disposable germicidal cloth per manufacturer's institutions and allowed to dry before the next use. Review of the facility policy Gloves dated 7/2/2005 revealed the following: Non-sterile gloves should be used for invasive procedures to prevent contamination of the employee's hands when providing treatment or services to the resident and when cleaning contaminated surfaces. Wash hands after removing gloves. When to use gloves: When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin. Review of the facility policy Handwashing Policy revision date 10/2011 revealed the following: Purpose: To prevent or minimize the spread of infection. When to Wash Hands (at a minimum): Before and after each resident contact. After touching a resident or handling his or her belongings. Whenever hands are obviously soiled. After contact with any body fluids. After handling any contaminated items. When to use hand sanitizing foam: Only when visible soil is absent. After contact with resident's intact skin. After contact with inanimate objects. Before donning gloves. Before entering the residents' room. Before exiting the residents' room.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below 5% with 3 errors out of 25 opportunities resulting in a medication error rate of 12%. This affected 2 of 13 residents observed during medication administration (Residents 25 and 17). The facility identified a census of 32 at the time of survey. Findings are: A. Observation of Resident 25 on 9/9/2020 at 11:38 AM revealed LPN-E (Licensed Practical Nurse) administered 1 unit of Insulin [MEDICATION NAME] to Resident 25. LPN-E did not offer Resident 25 food, milk, or juice. Observation of Resident 25 on 9/9/2020 at 11:50 AM revealed they were sitting at the dining room table. Resident 25 had a glass of water and a diet Coke (a sugar free cola with no nutritive value). Observation of Resident 25 on 9/9/2020 at 12:00 PM, 12:05 PM, 12:19 PM, and 12:22 PM revealed Resident 25 continued to be observed sitting in the dining room without food, milk, or juice. Resident 25 did not have food, milk or juice 44 minutes after receiving the Insulin [MEDICATION NAME]. Review of the MAR (Medication Administration Record) for September for Resident 25 revealed documentation the insulin was administered to Resident 25. Review of Resident 25's physician's orders [REDACTED]. Humalog Insulin (insulin [MEDICATION NAME]); 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD. If Blood Sugar is 150 to 199, give 1 Units. If Blood Sugar is 200 to 249, give 2 Units. If Blood Sugar is 250 to 299, give 3 Units. If Blood Sugar is 300 to 349, give 4 Units. If Blood Sugar is 350 to 399, give 5 Units. If Blood Sugar is 400 to 499, give 6 Units. If Blood Sugar is greater than 499, call MD. subcutaneous four times a day. B. Observation of Resident 17 on 9/9/2020 at 11:47 AM revealed LPN-E administered 6 units of [MEDICATION NAME]via insulin pen to Resident 17. LPN-E did not prime the insulin pen prior to administering the insulin to Resident 17 or offer Resident 17 food, milk, or juice. Observation of Resident 17 on 9/9/2020 at 12:03 PM, 12:05 PM, and 12:18 PM revealed Resident 17 was sitting in their recliner in their room. Resident 17 did not have any food, milk, or juice. Observation of Resident 17 on 9/9/2020 at 12:22 PM revealed a staff person walked with Resident 17 to the dining room. Resident 17 did not have food, milk, or juice 35 minutes after receiving the [MEDICATION NAME] insulin. Review of the MAR (Medication Administration Record) for September for Resident 17 revealed documentation the insulin was administered to Resident 17. Review of Resident 17's physician's orders [REDACTED]. [MEDICATION NAME] U-100 Insulin [MEDICATION NAME] (insulin [MEDICATION NAME] u-100) solution; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD. If Blood Sugar is 100 to 150, give 4 Units. If Blood Sugar is 151 to 200, give 6 Units. If Blood Sugar is 201 to 251, give 8 Units. If Blood Sugar is 252 to 400, give 9 Units. If Blood Sugar is greater than 400, call MD. subcutaneous before Meals and At Bedtime Interview with the DON (Director of Nursing) on 9/10/20 at 7:45 AM revealed the nurses were expected to follow the manufacturer's directions for the insulin pens. The DON revealed it was their expectation the nurses would follow the manufacturer's instructions for giving insulin in regards to meals. The DON revealed if the resident does not have their meal and was not eating, they were to receive juice or a protein or some sort of snack and it needed to be in front of them. Review of the [MEDICATION NAME] manufacturer's directions for use for the [MEDICATION NAME] dated 9/9/2020 revealed the following: A Guide to Using Your [MEDICATION NAME]: Prepare your pen: Remove the cap. Attach a new needle. Prime your pen: turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Give your injection: select your dose. Give your injection. Review of the FDA (Food and Drug Administration) prescribing information for [MEDICATION NAME] revealed the following: Subcutaneous injections: [MEDICATION NAME] should generally be given immediately (within 5-10 minutes) prior to the start of a meal. [MEDICATION NAME] is an insulin analog with an earlier onset of action than regular human insulin. Because [MEDICATION NAME] has a more rapid onset and a shorter duration of activity than human regular insulin, it should be injected immediately (within 5-10 minutes) before a meal. Review of the Insulin [MEDICATION NAME] Prescribing Information from the manufacturer dated 9/9/2020 revealed the following: Subcutaneous injection (2.2): Administer Insulin [MEDICATION NAME] Injection by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. Review of the undated facility Skills Checklist received from the facility Administrator revealed the following: Checks to be sure the right insulin is being given in the right dose to the right person at the right time. Review of the undated [MEDICATION NAME] directions received from the facility administrator revealed the following: Giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: Turn the dose selector to 2 units. Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop in insulin after 6 times, do not use the [MEDICATION NAME] and contact Novo [MEDICATION NAME].

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on interview and record review, the facility failed to review and revise the care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) after falls and implement additional fall prevention measures to prevent falls for 4 of 16 sampled residents (Residents 20, 29, 23 and 26). The facility census was 32. Findings are: A. Review of Resident 20's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/15/2020 revealed an admission date of [DATE]. Resident 20 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 20 had 2 or more falls with no injury and 1 fall with injury since admission. Review of Resident 20's Events revealed the following: On 7/11/2020 at 11:09 PM it was documented that Resident 20 fell in their room at 6:00 PM. On 7/09/2020 at 6:27 PM it was documented that Resident 20 fell in the hallway at 6:00 PM. Review of Resident 20's comprehensive Care Plan revealed a Problem Start Date: 07/28/2020 for Category: Falls. Review of Resident 20's Baseline Care Plan dated 7/8/2020 revealed Resident 20 had a high fall risk with need for walker and assistance with transfers, toileting, ambulating, and dressing. There was no documentation the baseline care plan was reviewed and revised with a new intervention after Resident 20 fell on [DATE] and 7/11/2020. Interview with the DON (Director of Nursing) on 9/10/20 at 8:15 AM revealed when a resident fell , the charge nurse completed an event form and it was submitted to the DON. The DON reviewed the event form to determine what interventions needed to be implemented and then the event was submitted to the Administrator. The DON revealed the report then went to the MDS Coordinator who reviewed it and documented the interventions on the care plan as part of the MDS process. The DON revealed Resident 20's Comprehensive Care Plan wasn't done yet so the staff couldn't put any interventions on it. The DON confirmed there were no interventions documented on the baseline care plan to prevent falls after Resident 20 fell on [DATE] and 7/11/2020. The DON revealed putting interventions on the baseline care plan prior to the completion of the initial comprehensive care plan was something the facility needed to work on. B. Review of Resident 29's SCSA (Significant Change in Status) MDS dated [DATE] revealed an admission date of [DATE]. Resident 29 had a BIMS score of 5 which indicated sever cognitive impairment. Resident 29 had 2 or more falls without injury since last assessment. Review of Resident 29's Progress Notes dated 8/13/2020 at 7:45 PM revealed Resident 29 was found on the floor laying on their right side. Resident 29 was assisted back into bed after being assessed. Review of Resident 29's Care Plan dated 12/15/2016 revealed a problem for Falls. There was no documentation the care plan was reviewed and revised with a new intervention after Resident 29 fell on [DATE]. Interview with MA-F on 09/09/20 at 4:21 PM revealed they got the information they needed to care for the residents from the care plan. Interview with the DON on 9/10/20 at 8:32 AM confirmed the facility staff did not put new interventions on the care plan after Resident 29 fell on ,[DATE]. Review of the undated facility policy Care Plan Guidance - Implementation and Review revealed the following: A written baseline care plan will be established within the first 48 hours of new admission. The baseline care plan will provide the minimum information that is necessary to care for the resident properly and safely. A written care plan summary will be completed within 7 days of MDS closure. This summary is presented to both resident and representative at time of first care plan meeting (or close to said date). Resident is able to sign summary themselves, unless resident has cognitive impairment, in which case resident representative will give consent (verbally or written signature). A care plan will be implemented into the EHR (Electronic Health Record) within 7 days of MDS completion, as to incorporate appropriate CAA's. Care plans will be reviewed at least quarterly, and more often if needed as situations arise such as significant changes. Care plans are reviewed by MDS Coordinator, Social Service Director, Activities Director, Dietary Manager, and by nursing floor staff (charge nurses and CNA/MA). C. Interview on 9/10/20 at 1:27 PM with the facility Director of Nursing (DON) revealed the expectations of staff after a resident fall. The charge nurse should implement interventions to address the causal factors. The DON reviews the incident report and the report then goes to the facility MDS Coordinator (MDSC) for review of the fall and review of the resident's care plan. Interventions are reviewed to determine if the interventions are effective. The facility is expected to identify a new intervention to prevent falls that addresses the causal factors. The DON updates the care plan with the fall intervention. The DON confirmed that all fall interventions are to be on the resident care plan including the use of fall mats. Record review of the Resident Face Sheet for Resident 23 revealed that Resident 23 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to communicate. [MEDICAL CONDITION] affects a person's ability to express and understand written and spoken language). Record review of the care plan for Resident 23 revealed the fall prevention intervention implemented on 3/25/20 to remind Resident 23 to not transfer without assistance. Record review of the electronic health record for Resident 23 revealed that Resident 23 had a fall on 7/4/20 at 6:31 PM. Resident 23 was found on the floor beside the recliner. The resident had ambulated from the hall to the recliner in the room (without assist) and missed the recliner. The resident had a 10 centimeter round bump to the back of the head with a 5 centimeter scratch in the center. Record review of the care plan for Resident 23 revealed the post fall intervention implemented on 7/6/20 was that Resident 23 was encouraged to call for assistance with transfers. Record review of the electronic health record for Resident 23 revealed that Resident 23 had a fall on 8/18/20 at 8:00 PM. Resident 23 had a fall while self-transferring without assistance. The charge nurse noted that Resident 23 had a laceration to the back right side of the head with a moderate amount of bleeding. A pressure dressing was applied and the resident's physician was contacted. The physician ordered the resident to be transported to the emergency room for evaluation. Record review of the care plan for Resident 23 revealed the post fall intervention implemented on 8/19/20 was that Resident 23 was encouraged to call for help and discouraged to self-ambulate. Interview on 9/09/20 at 3:18 PM with Restorative Aide-B (RA-B) revealed that staff try to anticipate Resident 23's needs. RA-B revealed that Resident 23's cognition declines as the resident becomes more tired as the day goes on and that the resident becomes more forgetful and performs self-transfers. Interview on 9/10/20 at 10:03 AM with Nursing Assistant-C (NA-C) revealed that Resident 23 fall prevention interventions should include a chair alarm (a personal alarm with a sensor pad that emits an alert sound when a resident stands up) due to the resident self- transferring. NA-C confirmed that encouraging Resident 23 to call for assistance and wait for help was not effective to prevent falls. NA-C revealed that current fall interventions for Resident 23 included a fall mat at the resident's bedside at night. Record review of the care plan for Resident 23 identified that the use of the fall mat was not included in the care plan for Resident 23. Interview on 9/10/20 at 2:34 PM with the Facility Administrator (FA) confirmed that for each fall causal factors should be identified and a new intervention for falls initiated and placed on the resident's care plan. The FA confirmed that fall interventions that are ineffective due to change in condition should be reviewed for effectiveness and revised as appropriate. D. Interview on 9/10/20 at 1:27 PM with the facility Director of Nursing (DON) revealed the expectations of staff after a resident fall. The charge nurse should implement interventions to address the causal factors. The DON reviews the incident report and the report then goes to the facility MDS Coordinator (MDSC) for review of the fall and review of the resident's care plan. Interventions are reviewed to determine if the interventions are effective. The facility is expected to identify a new intervention to prevent falls that addresses the causal factors. The DON updates the care plan with the fall intervention. The DON confirmed that all fall interventions are to be on the resident care plan including the use of fall mats. Record review of the Resident Face Sheet for Resident 26 revealed that Resident 26 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the care plan for Resident 26 revealed the fall prevention interventions implemented on 5/29/19 included: Provide proper well-maintained footwear; Provide Resident 26 with an environment free of clutter; Keep personal items and frequently used items within reach; Resident 26 is assisted by staff during ambulation and transfers and is utilizing a walker most of the time and a wheelchair when needed. Record review of the electronic health record for Resident 26 revealed that Resident 26 had a fall on 6/1/19 at 1:47 PM. Resident 26 tried to stand up in the dining room and tripped and fell . The charge nurse noted a laceration on the left side of the head oozing blood for about 2 minutes. Pressure was applied to stop the bleeding. Record review of the care plan for Resident 26 revealed the post fall intervention implemented on 6/1/19 was that staff attempt to supervise the resident while the resident is wandering. Record review of the electronic health record for Resident 26 revealed that Resident 26 had a fall on 6/8/19 at 4:45 PM. Resident 26 was laying on the floor by the patio door in the dining room. The resident was transported by ambulance to the emergency room for evaluation of the right hip and knee. Record review of the care plan for Resident 26 revealed the post fall intervention implemented on 6/8/19 was that a walker was provided due to the resident's constant walking and wandering to the point of fatigue causing instability. A walker was already an intervention that was initiated previously on 5/29/19. Record review of the electronic health record for Resident 26 revealed that Resident 26 had a fall on 9/5/19 at 3:24 PM. Resident 26 was found sitting on the floor next to the wheelchair. Resident 26 had a skin tear to the right elbow. Record review of the care plan for Resident 26 revealed the post fall intervention implemented on 9/6/19 was a bed alarm (a personal alarm with a sensor pad placed on the bed that emits an alert sound when a resident stands up from the bed) placed on the resident's bed. Record review of the electronic health record for Resident 26 revealed that Resident 26 had a fall on 10/4/19 at 3:22 PM. Resident 26 was found sitting on the floor in the resident's room by the recliner entangled in the walker. Record review of the care plan for Resident 26 revealed the post fall intervention implemented on 10/7/20 was that rounds will be completed on Resident 26 in the afternoon to assist the resident with toileting. Record review of the electronic health record for Resident 26 revealed that Resident 26 had a fall on 10/17/19 at 7:00 PM in the dining room. Resident 26 was in the dining room after supper watching TV and got up and fell to the floor. Kitchen staff heard a crash and found the resident on the floor. Record review of the care plan for Resident 26 revealed the post fall intervention implemented on 10/21/20 was for the walker to be kept within reach at all times. Record review of the electronic health record for Resident 26 revealed that Resident 26 had a fall on 11/1/19 at 7:30 PM. Resident 26 was found on the floor beside the roommate's recliner. Record review of the care plan for Resident 26 revealed that no post fall intervention was implemented and added to the care plan for the resident's fall on 11/1/19. Record review of the electronic health record for Resident 26 revealed that Resident 26 had a fall on 11/14/19 at 4:52 PM in the facility living room. Resident 26 was reclined on a couch with staff assistance. Resident 26 was unable to get up on own without difficulty and fell . Record review of the care plan for Resident 26 revealed the post fall intervention implemented on 11/15/20 was to educate staff not to put Resident 26 in a reclined position. Record review of the electronic health record for Resident 26 revealed that Resident 26 had a fall on 2/21/20 at 4:05 AM. Resident 26 was observed lying on the resident's back next to the chair in the resident room. The water pitcher from the bedside dresser was noted on the floor. The charge nurse noted a 5 centimeter bump on the back right side of the resident's head. Record review of the care plan for Resident 26 revealed the post fall intervention implemented on 2/21/20 was for staff to offer additional fluids throughout the day and evening as it appeared the resident was getting a drink. Record review of the electronic health record for Resident 26 revealed that Resident 26 had a fall on 2/21/20 at 8:21 AM. The nurse heard a crash and found Resident 26 laying on the floor on the resident's right side. The charge nurse noted a 5.75 centimeter laceration on the top right side of the resident's head, a 2 centimeter long skin tear to the right side of the chin, and a 1 centimeter skin tear to the top of the right eyebrow. Resident 26 was transferred to the emergency room . The charge nurse noted that Resident 26 has dementia with diminished safety awareness and unable to educate the resident. Record review of the care plan for Resident 26 revealed the post fall intervention implemented on 5/11/20 was that Resident 26 needed frequent cuing and reminders to use the walker. Interview on 9/9/20 at 3:12 PM with Medication Aide-A (MA-A) revealed that staff toilet are to toilet Resident 26 every 2 hours and keep the walker in reach of the resident. Interview on 9/9/20 at 3:18 PM with Restorative Aide-B (RA-B) revealed that Resident 26's fall risk is dependent on the resident's motivation and if the resident is motivated to try doing things without assistance. RA-B revealed that fall interventions included that staff are to always keep the walker next to the resident, a fall mat is to be placed at the bedside when Resident 26 is in bed, offer to assist the resident to the bathroom, and offer a drink to the resident. Interview on 9/10/20 at 10:03 AM with Nursing Assistant-C (NA-C) revealed that interventions to prevent falls for Resident 26 included a fall mat at night, and items to be kept close to the resident such as eyeglasses, water, TV remote, and maybe a magazine. NA-C confirmed that Resident 26 transfers are to be with a gait belt and walker. NA-C did not identify the care planned intervention of keeping the walker next to the resident. Record review of the care plan for Resident 26 identified that the use of the fall mat was not included in the care plan for Resident 26. Interview on 9/10/20 at 2:34 PM with the Facility Administrator (FA) confirmed that for each fall causal factors should be identified and a new intervention for falls initiated and placed on the resident's care plan. The FA confirmed that fall interventions that are ineffective due to change in condition should be reviewed for effectiveness and revised as appropriate.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05 (21) Based on observation, interview, and record review; the facility staff failed to provide privacy during blood sugar checks and insulin administration for 3 residents (Resident 25, 17, and 24). This affected 3 of 4 residents observed during blood sugar checks and 3 of 3 residents observed during insulin administration. The facility identified a census of 32 at the time of survey. Findings are: A. Observation of Resident 25 on 9/9/20 at 11:32 AM revealed LPN-E (Licensed Practical Nurse) entered Resident 25's room with the glucometer (a machine used to check blood sugar levels). Resident 25 was sitting in a wheelchair in their room in view of the doorway. LPN-E left the door open and proceeded to lance Resident 25's finger and apply a drop of blood to the test strip on the glucometer. LPN-E announced Resident 25's blood sugar then walked out to the treatment cart. LPN-E then drew up insulin into a syringe and re-entered Resident 25's room. LPN-E pulled up Resident 25's shirt, exposed their abdomen and injected the insulin into Resident 25's abdomen. Resident 25 was still sitting in the wheelchair in view of the door which was open. As LPN-E was injecting the insulin into Resident 25's abdomen, MA-A (Medication Aide) observed that Resident 25 was exposed and closed the door. Resident 25 was visible to passers-by in the hall. B. Observation of Resident 17 on 9/9/2020 at 11:43 AM revealed LPN-E entered Resident 17's room with the glucometer. Resident 17 was sitting in their recliner in view of the door and the window. LPN-E lanced Resident 17's finger and applied a drop of blood onto the test strip that was in the glucometer. LPN-E announced Resident 17's blood sugar. LPN-E took the glucometer out to the treatment cart and retrieved an insulin pen. LPN-E took the insulin pen into Resident 17's room and proceeded to inject the insulin into Resident 17's abdomen after pulling up Resident 17's shirt and exposing their abdomen. The door was open and the window was not covered. Resident 17 was visible to passers-by in the hall and outside of the building. C. Observation of Resident 24 on 9/9/2020 at 11:52 AM revealed LPN-E wheeled Resident 24 to their room from the dining room. LPN-E then took the glucometer into Resident 24's room, lanced Resident 24's finger, and placed a drop of blood on the test strip in the glucometer. LPN-E then announced Resident 24's blood sugar. LPN-E then took the glucometer out to the treatment cart. LPN-E drew up insulin into a syringe for Resident 24 and took it into Resident 24's room. LPN-E then injected the insulin into Resident 24's arm. Resident 24 was sitting in their wheelchair in view of the doorway. LPN-E did not close the door when LPN-E checked Resident 24's blood sugar or injected Resident 24 with insulin. Resident 24 was visible to passers-by in the hall. Interview with the DON (Director of Nursing) on 9/10/20 at 7:45 AM revealed it was their expectation the nurse would close the door and provide the resident privacy if the nurse were giving insulin injections or doing blood sugar checks. Interview with the DON on 9/10/20 at 1:57 PM revealed the facility did not have a privacy policy. The DON revealed the facility staff were expected to follow the residents' rights to privacy which the staff were trained.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interviews and record reviews, the facility failed to ensure the Resident or Personal Representative (PR) received a written summary of the baseline care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) prior to completion of the initial assessment for 7 of 11 sampled residents (Residents 20, 25, 15, 19, 23, 26, and 132). The facility census was 32. Findings are: A. Review of Resident 20's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 7/15/2020 revealed an admission date of [DATE]. Resident 20 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. The MDS completion date was 7/20/2020. The CAA completion date was 7/21/2020. Review of Resident 20's Baseline Care Plan dated 7/8/2020 revealed no documentation a written summary was given to Resident 20's Personal Representative Review of Resident 20's Baseline Care Plan Summary revealed it was documented as verbally consented by POA 7/28/2020, 21 days after Resident 20 was admitted to the facility, and 6 days after the completion of the admission MDS. B. Review of Resident 25's quarterly MDS dated [DATE] revealed an admission date of [DATE]. Resident 25 had a BIMS score of 8 which indicated moderately impaired cognition. Review of Resident 25's admission MDS revealed an ARD of 5/19/2020 and a completion date of 5/26/2020. Review of Resident 25's Baseline Care Plan Summary revealed verbal consent by POA (Power of Attorney) was documented on 5/29/2020, which was day 17 of admission and after the admission MDS completion date. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 October 2019 revealed the following: Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the actual date of admission, regardless of whether admission occurs at 12:00 a.m. or 11:59 p.m., is considered day 1 of admission. o The ARD (Assessment Reference Date) (item A2300) must be set no later than day 14, counting the date of admission as day 1. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the ARD must also cover this time period. For example, if a resident is admitted at 8:30 a.m. on Wednesday (day 1), a completed RAI is required by the end of the day Tuesday (day 14). o Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being. This means it is imperative for nursing homes to assess a resident upon the individual's admission. The IDT (Interdisciplinary Team) may choose to start and complete the Admission comprehensive assessment at any time prior to the end of day 14. Nursing homes may find early completion of the MDS and CAA(s) (Care Area Assessment) beneficial to providing appropriate care, particularly for individuals with short lengths of stay when the assessment and care planning process is often accelerated. o The MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) completion date, but not later than. o The CAA(s) completion date (item V0200B2) must be no later than day 14. o The care plan completion date (item V0200C2) must be no later than 7 calendar days after the CAA(s) completion date (item V0200B2) (CAA(s) completion date + 7 calendar days). Review of the undated facility policy Care Plan Guidance - Implementation and Review revealed the following: A written baseline care plan will be established within the first 48 hours of new admission. The baseline care plan will provide the minimum information that is necessary to care for the resident properly and safely. A written care plan summary will be completed within 7 days of MDS closure. This summary is presented to both resident and representative at time of first care plan meeting (or close to said date). Resident is able to sign summary themselves, unless resident has cognitive impairment, in which case resident representative will give consent (verbally or written signature). A care plan will be implemented into the EHR (Electronic Health Record) within 7 days of MDS completion, as to incorporate appropriate CAA's. Care plans will be reviewed at least quarterly, and more often if needed as situations arise such as significant changes. Care plans are reviewed by MDS Coordinator, Social Service Director, Activities Director, Dietary Manager, and by nursing floor staff (charge nurses and CNA/MA). Interview with the MDSC (Minimum Data Set Coordinator) on 9/10/20 at 8:37 AM revealed they misunderstood the time frame the baseline care plan written summary needed to be provided to the PR. MDSC revealed they had been completing the baseline care plan at the time of admission then writing another care plan summary which they reviewed with the PR at the initial care plan meeting. MDSC revealed they were not giving the PR the written summary of the baseline care plan at the time of admission and prior to completion of the initial MDS assessment. MDSC revealed they were reviewing the care plan with the PR after the initial MDS was completed at the time of the initial care plan meeting to have the PR approve the information that was going to be included on the comprehensive care plan. C. Record review of the undated facility policy titled Care Plan Guidance - Implementation and Review revealed that: A written baseline care plan will be established within the first 48 hours of new admission. The baseline care plan will provide the minimum information that is necessary to care for the resident properly and safely. Record review of the facility Baseline Care Plan Summary form revealed the instructions on the bottom of the form that directed the facility to make a copy of the form. The original goes to the resident/representative. File copy in the medical record. Record review of the Resident Face Sheet (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) for Resident 15 revealed that Resident 15 admitted to the facility on [DATE]. Record review of the Baseline Care Plan Summary for Resident 15 revealed that the form was reviewed and signed by Resident 15 at the care plan meeting on 1/21/20 which was 11 days after the resident admitted to the facility. Interview with the facility MDS Coordinator (MDSC) on 9/10/20 at 8:37 AM confirmed that the facility developed baseline care plans in the first 48 hours after admission and did not share the care plan with the resident and family until the intial care plan meeting. D. Record review of the undated facility policy titled Care Plan Guidance - Implementation and Review revealed that: A written baseline care plan will be established within the first 48 hours of new admission. The baseline care plan will provide the minimum information that is necessary to care for the resident properly and safely. Record review of the facility Baseline Care Plan Summary form revealed the instructions on the bottom of the form that directed the facility to make a copy of the form. The original goes to the resident/representative. File copy in the medical record. Record review of the Resident Face Sheet for Resident 19 revealed that Resident 19 admitted to the facility on [DATE]. Record review of the Baseline Care Plan Summary for Resident 19 revealed that the form was reviewed with the resident representative at the care plan meeting on 7/28/20 which was 20 days after the resident admitted to the facility. E. Record review of the undated facility policy titled Care Plan Guidance - Implementation and Review revealed that: A written baseline care plan will be established within the first 48 hours of new admission. The baseline care plan will provide the minimum information that is necessary to care for the resident properly and safely. Record review of the facility Baseline Care Plan Summary form revealed the instructions on the bottom of the form that directed the facility to make a copy of the form. The original goes to the resident/representative. File copy in the medical record. Record review of the Resident Face Sheet for Resident 23 revealed that Resident 23 admitted to the facility on [DATE]. Record review of the Baseline Care Plan Summary for Resident 23 revealed that the form was reviewed with the resident representative at the care plan meeting on 3/25/20 which was 14 days after the resident admitted to the facility. F. Record review of the undated facility policy titled Care Plan Guidance - Implementation and Review revealed that: A written baseline care plan will be established within the first 48 hours of new admission. The baseline care plan will provide the minimum information that is necessary to care for the resident properly and safely. Record review of the facility Baseline Care Plan Summary form revealed the instructions on the bottom of the form that directed the facility to make a copy of the form. The original goes to the resident/representative. File copy in the medical record. Record review of the Resident Face Sheet for Resident 26 revealed that Resident 26 admitted to the facility on [DATE]. Record review of the Baseline Care Plan Summary for Resident 26 revealed that the form was reviewed with the resident representative and signed by the resident's Power of Attorney at the care plan meeting on 7/3/19 which was 36 days after the resident admitted to the facility. G. Record review of the undated facility policy titled Care Plan Guidance - Implementation and Review revealed that: A written baseline care plan will be established within the first 48 hours of new admission. The baseline care plan will provide the minimum information that is necessary to care for the resident properly and safely. Record review of the facility Baseline Care Plan Summary form revealed the instructions on the bottom of the form that directed the facility to make a copy of the form. The original goes to the resident/representative. File copy in the medical record. Record review of the Resident Face Sheet for Resident 132 revealed that Resident 132 admitted to the facility on [DATE]. Record review revealed that a Baseline Care Plan Summary had not been completed for Resident 132 as of 9/10/20 which was 8 days after the resident was admitted to the facility. Interview on 9/09/20 at 5:28 PM with the facility Social Services Director (SSD) confirmed that the signed baseline care plan summary for Resident 132 had not been completed yet.