Every finding on record at Emerald Nursing & Rehab Brookside LLC

Licensure reference number 175 NAC 4-006.12(D)(i) Based on observations, interviews, and record review, the facility failed to ensure all medications were stored and locked in a secure manner to provide resident safety. The facility census was 92. Findings are:An observation on 05/18/2026 at 8:02 AM revealed three medication carts in the three hundred hall were left unattended and unlocked with two of the carts having had computer screens left open with resident information displayed.An interview on 05/18/2026 at 8:05 AM with Licensed Practical Nurse-B (LPN-B) revealed that all three medication carts were left unattended and unlocked, and that two of the computer screens were open with resident information displayed. LPN-B confirmed that the medication carts should always be locked with resident information hidden.An observation on 5/18/26 at 9:56 AM revealed an unlocked and unattended medication cart outside of Resident 2's room with a piece of paper that contained resident information on top.An interview on 5/18/26 at 9:57 AM with the Director of Nursing (DON) confirmed that the medication carts should have been locked when left unattended and resident information should be concealed.Record review of facility's Medication Storage & Security policy that was undated, revealed medication carts were to be locked when not in use and access was limited to authorized personnel.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3)Based on record review and interview, the facility failed to perform or document skin assessments for Resident 1. This affected 1 of 4 residents reviewed for skin protection. The facility census was 92.Findings are:A record review of Resident 1's admission Record printed 05/18/2026 revealed the facility admitted the resident on 04/09/2026.A record review of Resident 1's Discharge Summary with effective date 04/26/2026 revealed that the facility discharged the resident on 04/21/2026.A record review of a Progress Note from 04/21/2026 at 11:22 AM revealed Resident 1 went to a doctor's appointment and was transferred to the hospital from there.A record review of Resident 1's admission Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 04/15/2026 revealed the resident was frequently incontinent (lacking control) of both bladder and bowel. Further review of the MDS revealed that the resident required substantial to maximal assistance (the helper does more than half of the effort for care) with toileting hygiene (cleaning themselves up and adjusting clothing before and after urinating or having a bowel movement).A record review of Resident 1's Nursing admission Data Collection dated 04/09/2026 revealed in Section 2, Skin Conditions, that on admission the resident had bruising to both arms, scabs to both knees, had redness to the skin in the abdominal folds and under the breasts, and had an area described as bottom red, not open. There were no measurements or further descriptions of any of these areas. Further review revealed in Section 14, Interim Care Plan/Baseline (a plan of care for the resident that includes the minimum information needed to provide effective, person-centered care immediately upon admission), Part C, Skin, that the resident was identified as being at risk for impaired skin integrity.A review of Resident 1's Progress Notes revealed there were Skilled Observations completed 04/10/2026, 04/11/2026, 04/12/2026, 04/13/2026, 04/14/2026, 04/15/2026, 04/16/2026, 04/18/2026, 04/19/2026, and 04/20/2026. The areas reviewed on these assessments were as follows:04/10 - Cardiac/Circulatory (Heart) and Respiratory (Breathing)04/11 - Respiratory, Pain Management and Psych/Mood/Behavior04/12 - Respiratory, Pain Management and Psych/Mood/Behavior04/13 - Respiratory, Pain Management and Psych/Mood/Behavior04/14 - Respiratory, Pain Management, Psych/Mood/Behavior, and Infection04/15 - Respiratory, Pain Management, and Psych/Mood/Behavior04/16 - Respiratory, Pain Management, Psych/Mood/Behavior, and Infection04/17 - not done04/18 - Respiratory, Pain Management, Psych/Mood/Behavior, and Infection04/19 - Respiratory, Pain Management, Psych/Mood/Behavior, and Infection04/20 - Respiratory, Pain Management, and Psych/Mood/Behavior.There was no documentation of skin observations in any of the Skilled Observations.Further review of Resident 1's Progress Notes revealed documentation of the resident refusing incontinence cares on 04/10/2026, 04/12/2026, and 04/16/2026.A record review of Resident 1's bathing record revealed documentation that the resident was bathed on 04/15/26 and 04/18/26.A record review of Resident 1's Electronic Health Record revealed a Skin/Wound Weekly Observation dated 04/16/2026 that stated the resident had refused the skin assessment. The form was created 04/23/2026.An interview on 05/19/2026 at 8:37 AM with Nurse Aide (NA) D confirmed that whoever provides a bath to a resident should report any skin integrity issues to the nurse.An interview on 05/19/2026 at 8:39 AM with NA E confirmed that whoever provides a bath to a resident should report any skin integrity issues to the nurse.An interview on 05/19/2026 at 10:10 AM with the Director of Nursing confirmed that it was the expectation for staff performing a bath or toileting a resident to look at skin and report any skin integrity issues to the nurse. The DON further confirmed that the nurse should follow up on a red area that was present on admission, and that the nurse should look at a wound every shift with a full assessment done weekly. The DON further confirmed there was no documentation of Resident 1's skin being observed or assessed between 04/09/2026 and 04/21/2026.

Licensure Reference Number 175 NAC 12-006.18Based on observations, record review, and interviews, the facility failed to follow infection control standards of practice during wound care for Resident 2 and during wound care and resident care for Resident 4. This affected 2 of 4 residents reviewed for wound care. The facility census was 92.Findings are:A record review of the facility's Infection Control: Standard Precautions policy revised 01/2024 revealed that hand hygiene was to be performed: -before and after contact with the resident-before performing an aseptic task-after contact with items in a resident's room-after removing PPE -Gloves were to be changed as necessary or during the care of a resident to prevent cross-contamination (when moving from a dirty site to a clean one) from one body site to another.-Gloves were to be removed promptly after each use and before touching non-contaminated items and environmental surfaces.-Gowns were to be worn to protect skin and to prevent soiling of clothing during procedures and resident care activities that were likely to generate splashes or sprays of blood, body fluids, secretions, excretions, or cause soiling of clothing. A. An observation on 05/18/2026 at 9:51 AM revealed Licensed Practical Nurse (LPN) B performing wound care to Resident 2. The LPN performed hand hygiene on the way into the room prior to putting on gloves. After washing Resident 2's wounds, the LPN changed gloves without performing hand hygiene and completed the treatment to the wounds. An interview 05/18/2026 at 9:58 AM with LPN B confirmed the LPN should have performed hand hygiene when changing gloves and did not. B. Record review of facility policy titled Infection Control: Standard Precautions revised 01/2024 revealed hand hygiene was to be performed: -before and after contact with the resident-before performing an aseptic task-after contact with items in a resident's room-after removing PPE -Gloves were to be changed as necessary or during the care of a resident to prevent cross-contamination (when moving from a dirty site to a clean one) from one body site to another.-Gloves were to be removed promptly after each use and before touching non-contaminated items and environmental surfaces.-Gowns were to be worn to protect skin and to prevent soiling of clothing during procedures and resident care activities that were likely to generate splashes or sprays of blood, body fluids, secretions, excretions, or cause soiling of clothing. An observation on 5/19/2026 at 6:58 AM of the DON and RN-A in Resident 4's room revealed them at the bedside in the act of a complete bed change without a gown on. An observation of wound care completed on 05/19/2026 from 7:34 AM to 7:44 AM revealed Registered Nurse-A (RN-A) performing wound care on Resident 4. Present in the room was also the Director of Nursing (DON). During observation: -RN-A was at the resident bedside, with a gown and gloves on.-Resident 4 independently rolled to the left side, exposing their buttock with no dressing in place.-RN-A cleaned the wound with a Vasche (a wound cleansing solution) soaked gauze, three separate times. A new gauze was used each time the wound was cleaned. Each time the used gauze was placed on the disposable pad on the bed.-RN-A doffed (removed) gloves, then performed hand hygiene.-RN-A donned (applied) new gloves.-RN-A touched the residents foot with clean gloves but did not change gloves.-RN-A then packed the wound (a technique used where gauze is gently stuffed into an open wound, so the body can heal from the inside out).-RN-A used the same gloves and reached into their pocket for scissors (on a key chain) to then cut the excess gauze off from the wound bed. RN-A then placed the used scissors on the disposable pad on Resident 4's bed.-RN-A doffed the gloves and then performed hand hygiene.-RN-A donned new gloves.-RN-A then placed the used scissors back in their pocket with the clean gloves on. -RN-A then touched the clean Mepilex (a soft foam dressing used to treat open wounds) and applied it to the buttock wound.-RN-A doffed the gloves, and no hand hygiene was completed.-RN-A touched Resident 4's glasses, bedside remote, call light, and pillow. RN-A then removed the dirty garbage bag with their bare hands, then touched the box of clean gloves by the top (touching the clean gloves inside the box) and carried clean supplies out of the room; placing them outside of the door. - RN-A removed the gown and performed hand hygiene. An interview with RN-A on 5/19/2026 at 8:09 AM revealed that neither the DON nor RN-A had a gown on when observed completing Resident 4's bed change that morning around 6:58 AM. RN-A also confirmed that the wound had been cleaned during the bed change. RN-A revealed the wound was exposed and not covered, confirming a gown should have been on with direct patient care. RN-A confirmed that the dirty scissors were removed from their pocket with clean gloves then used during wound care without being cleaned, and that no hand hygiene was completed at the end of wound care prior to touching the resident items, surfaces, and clean supplies. An interview with the DON on 5/19/2026 at 8:13 AM confirmed that the expectation was for staff to use personal protective equipment (PPE, includes clothing, gloves, face shields, goggles, facemasks, respirators, and other equipment to protect front-line workers from injury, infection, or illness) with Resident 4 who was on Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) and that PPE's were not used for the entirety of the complete bed change. The DON confirmed that there was cross contamination during wound cares to the buttock on Resident 4.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interviews, the facility failed to notify the Guardian and or Power of Attorney of 2 (Resident 5 and Resident 8) of 5 sampled residents of leaving the facility against medical advice (AMA) and the facility failed to notify the physician of 5 of 5 sampled residents (Residents 5, 6, 7, 8, and 9) of the resident's leaving the facility AMA with no services. The facility census was 98.Findings are:A record review of facility's Policy: Transfer and Discharge (including AMA) created 11-17 revealed:-A. The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternative to both. The physician should be notified and encouraged to speak with the resident. -B. Documentation of this notification should be entered in the nurses notes by the nursing department. The Social Services designees should document any discussion with the resident/family in the social services progress notes. -C. Notify Adult Protection Services or other entity, as appropriate if self-neglect is suspected. Document accordingly. A.A record review of the admission Record with the printed date of 5/11/26 revealed Resident 5 was admitted to the facility on [DATE] with the diagnosis of Osteomyelitis, Upper arm (a serious infection of the bone that causes inflammation, swelling, and pain, often leading to bone tissue death (necrosis) if not treated promptly), Osteomyelitis of Vertebra, Sacral, and Sacrococcygeal Region (a serious infection of the bone that causes inflammation, swelling, and pain, often leading to bone tissue death (necrosis) if not treated promptly), Quadriplegia C5-C7 incomplete (results from damage to the lower cervical spine, affecting all four limbs but leaving some sensation or motor function below the injury site), and Hypertension (high blood pressure).A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated March 24, 2026 for Resident 5 revealed a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored 0-15, the higher the score, the higher the cognitive function) with a score of 13 meaning cognitively intact. A record review of the admission Record with a printed date of 5/11/26 revealed that Resident 5 had a court appointed Guardian dated March 16, 2026. A record review of the progress notes dated 4/23/26 revealed that Resident 5 had signed a AMA (against medical advice) form and left the facility at 4:23 PM with their personal belongings.A record review of Resident 5's progress notes dated 4/23/26 revealed no documentation of the Guardian being notified of Resident 5 leaving the facility AMA.An interview with Resident 5's Guardian on 5/11/26 at 9:30 AM confirmed that the facility did not notify them (the Guardian) that Resident 5 left (discharged from) the facility AMA. Guardian confirmed that (gender) had a voice message to call the facility, but the facility did not leave a message as to what it was regarding. Guardian confirmed that they found out about Resident 5 leaving the facility AMA from Resident 5's sister who had called them (the Guardian) the next day on 4/24/26. Guardian confirmed that the hospital had called (gender) regarding Resident 5 being in the emergency room on 5/1/26 for cares of Resident 5's wounds, catheter (a thin, flexible tube inserted into the bladder to drain urine when a patient cannot do so independently), a colostomy bag (a lightweight, waterproof pouch attached to the abdomen to collect waste from the colon through a surgically created opening called a stoma),and that Resident 5 was discharged back to Resident 5's apartment. An interview on 5/11/26 at 12:30 PM with Social Services (SS) confirmed that they did not document that they left a message with the Guardian regarding Resident 5 until 4/24/25 when (gender) left a message to call the facility. SS confirmed that they did not call the police department that Resident 5 left the facility AMA and that Resident 5 had a legal guardian.An interview on 5/11/26 at 12:30 PM with the Administrator confirmed that the Guardian should have been notified that Resident 5 was leaving the facility AMA and the Guardian was not notified. Administrator confirmed that the facility should have made several attempts to notify the Guardian and the facility did not. The Administrator confirmed that the facility did not notify the police department because (gender) was told by a police officer not to be calling the police department with issues they would not be able to do anything about. The Administrator was unable to provide any documentation regarding the conversation that took place with the police officer. B.A record review of the admission Record with the printed date of May 11, 2026 revealed Resident 8 was admitted to the facility on [DATE] with the diagnosis of Severe Protein-Calorie Malnutrition (a life-threatening condition resulting from acute or chronic deficiencies in protein and energy intake, often and frequently associated with underlying illnesses like cancer or chronic disease), Hepatic failure (liver failure) is a life-threatening condition where the liver rapidly or gradually loses its ability to function, often due to toxins, viruses, or chronic disease), Alcohol Abuse (considered a pattern of drinking that results in harm to one's health, relationships, or ability to work, often characterized by an inability to control consumption despite negative consequences), Chest Pain, Osteoarthritis (degenerative joint pain, stiffness, and reduced mobility as cartilage breaks down over time), falls (an unintentional, sudden descent to the ground or lower level).A record review of the admission Record with the printed date of May 11, 2026 revealed Resident 8 had a Power of Attorney for Healthcare. A record review of the Resident 8's progress notes revealed on 12/26/25 at 1:15 PM that Resident 8 left the facility against medical advice (AMA).A record review of the Resident 8's progress notes revealed there was no documentation of Resident 8's Power of Attorney notification of Resident 8 leaving the facility AMA.An interview on 5/11/26 at 3:00 PM with the Administrator confirmed that there was no documentation of the Power of Attorney for Resident 8 leaving AMA and there should have been documentation of the Power of Attorney being notified of Resident 8 leaving the facility AMA. C.A record review of the admission Record with the printed date of 5/11/26 revealed Resident 5 was admitted to the facility on [DATE] with the diagnosis of Osteomyelitis (a serious infection of the bone that causes inflammation, swelling, and pain, often leading to bone tissue death (necrosis) if not treated promptly)-Upper Arm, Osteomyelitis of Vertebra, Sacral, and Sacrococcygeal Region, Quadriplegia C5-C7 incomplete (results from damage to the lower cervical spine, affecting all four limbs but leaving some sensation or motor function below the injury site), and Hypertension (high blood pressure).A record review of Resident 5's progress notes dated 4/23/26 revealed that Resident 5 had signed a AMA (against medical advice) form and left the facility at 4:23 PM with Resident 5 personal belongings.A record review of Resident 5's progress notes dated 4/23/26 revealed no documentation of the Physician being notified of Resident 5 leaving the facility AMA.An interview with Resident 5's PA-C (Certified Physician's Assistant -a licensed, nationally certified medical professional who diagnoses illnesses, develops treatment plans, and prescribes medication, usually working in collaboration with a physician) on 5/11/26 at 1:30 PM confirmed that (gender) had not been notified of Resident 5 leaving the facility AMA until 4/24/26 when (gender) came to the facility to do rounds on the residents.An interview on 5/11/26 at 3:00 PM with the Administrator confirmed that Resident 5's progress notes had no documentation of the Physician being notified on 4/23/26 of Resident 5 leaving the facility AMA and there should have been notification to the Physician of Resident 5 leaving the facility AMA. D.A record review of the admission Record with the printed date of 5/11/26 revealed Resident 6 was admitted to the facility on [DATE] with the diagnosis of Metabolic Encephalopathy (brain dysfunction caused by non-traumatic, systemic issues like organ failure, infection, or chemical imbalances), Atrial Fibrillation (characterized by a rapid, chaotic, and irregular heartbeat), Emphysema (a chronic, progressive lung disease and a major form of Chronic Obstructive Pulmonary Disease (COPD)), Alcohol Dependence (chronic disease characterized by a physical and psychological need for alcohol), Ischemic Cardiomyopathy (a type of heart muscle disease where the heart's main pumping chamber (left ventricle) becomes weakened and enlarged due to reduced blood supply, typically from coronary artery disease or a heart attack), Aortocoronary Bypass Graft (a procedure used to treat severe coronary artery disease by creating a new path for blood to flow around a blocked artery).A record review of Resident 6's progress notes dated 1/18/26 at 12:55 PM revealed Resident 6 had been overheard on the phone stating Resident 6 was leaving for church and that Resident 6 wasn't coming back. Resident 6 notified the Medication Aid (staff member) that they were leaving for church and would be back around 1:30 PM and Resident 6 signed out of the facility. A record review of Resident 6's progress notes dated 1/18/26 at 2:36 PM revealed Medication Aide stated to nurse coming on shift that Resident 6 was at church and would be back by 1:30 PM.A record review of Resident 6's progress notes revealed there is no documentation that Resident 6 did or did not return to the facility. A record review of the progress notes revealed there is no further documentation of Resident 6 not returning to the facility and no documentation of the Physician being notified that the Resident left the facility AMA.An interview on 5/11/26 at 3:00 PM with the Administrator confirmed that Resident 6 progress notes had no documentation of the Physician being notified on 1/18/26 or 1/19/26 of Resident 6 leaving the facility AMA and there should have been notification to the Physician of Resident 6 leaving the facility AMA. E.A record review of the admission Record with the printed date of 5/11/26 revealed Resident 7 was admitted to the facility on [DATE] with the diagnosis of Type 2 diabetes (when the body becomes resistant to insulin or fails to produce enough, causing high blood sugar (glucose) levels), Dementia (or a decline in cognitive function-including memory, language, and problem-solving-severe enough to impair daily life), and Hypertension (high blood pressure). A record review of the progress note dated 2/10/26 revealed Resident 7's family was transferring Resident 7 to another facility, and due to same day discharge, Social Services was unable to get discharge orders, so the family signed AMA paperwork.A record review of the progress notes revealed that there is no documentation of the Physician being notified of Resident 7's AMA status.An interview on 5/11/26 at 3:00 PM with the Administrator confirmed that Resident 7's progress notes had no documentation of the Physician being notified on 2/10/26 or 2/11/26 of Resident 7 leaving the facility AMA and there should have been notification to the Physician of Resident 7 leaving the facility AMA. F.A record review of the admission Record with the printed date of May 11, 2026 revealed Resident 8 was admitted to the facility on [DATE] with the diagnosis of Severe Protein-Calorie Malnutrition (a life-threatening condition resulting from acute or chronic deficiencies in protein and energy intake, often and frequently associated with underlying illnesses like cancer or chronic disease), Hepatic failure (liver failure- is a life-threatening condition where the liver rapidly or gradually loses its ability to function, often due to toxins, viruses, or chronic disease), Alcohol Abuse (considered a pattern of drinking that results in harm to one's health, relationships, or ability to work, often characterized by an inability to control consumption despite negative consequences), Chest Pain (can indicate serious conditions like a heart attack, pulmonary embolism, or aortic dissection), Osteoarthritis (degenerative joint pain, stiffness, and reduced mobility as cartilage breaks down over time), falls (an unintentional, sudden descent to the ground or lower level).A record review of the progress notes revealed on 12/26/25 at 1:15 PM Resident 8 left the facility against medical advice (AMA).A record review of Resident 8's progress notes revealed there is no documentation of Resident 8's Physician being notified of Resident 8 leaving the facility AMA.An interview on 5/11/26 at 3:00 PM with the Administrator confirmed that there was no documentation of the Physician for Resident 8 leaving AMA and there should have been documentation of the Physician being notified of Resident 8 leaving the facility AMA. G.A record review of the admission Record with the printed dated of May 11, 2026 revealed Resident 9 was admitted to the facility on [DATE] with the diagnosis of Acute Respiratory Failure (a life-threatening, sudden inability of the lungs to oxygenate blood or remove carbon dioxide, often causing severe shortness of breath, confusion, and dizziness), Type 2 Diabetes with polyneuropathy (a common, chronic complication where high blood sugar damages peripheral nerves, affecting up to 50% of diabetics), Chronic Kidney Disease Stage 2 (mild kidney damage with a slightly decreased), Substance abuse (The use of illegal drugs or the use of prescription or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts), Methicillin Susceptible Staphylococcus Aureus Infection (MRSA-caused by a type of staph bacteria that's become resistant to many of the antibiotics).A record review of the progress notes dated 1/3/26 at 10:38 PM revealed that Resident 9 left the facility to spend the night with brother.A record review of the progress notes revealed that there is no documentation that Resident 9 did or did not return to the facility.A record review of the progress notes revealed that there is no documentation that Resident 9 Physician was notified of Resident 9 not returning to the facility.An interview on 5/11/26 at 3:00 PM with the Administrator confirmed that there was no documentation of the Physician for Resident 9 not returning to the facility and there should have been documentation of the Physician being notified of Resident 9 not returning to the facility.

Nebraska Licensure reference: 175 NAC 12-006.19Based on observation and interview, the facility failed to maintain a sanitary, orderly and comfortable interior. All residents who reside at this facility have the potential to be affected by these deficient practices.The facility census was 94. Findings are: Observations of Unit 1 on 04/14/2026 at 12:30 PM revealed: - strong urine odor in the carpeted hallway of Unit 1 -carpet of hallway of Unit 1 had over a dozen stains of various sizes and colors ranging from cream color to black throughout the unit. -wall of the doorway of the shared bathroom between room [ROOM NUMBER] and 15 was flaking with pieces broken away and framing visible beneath. Over a dozen pieces of material from the crumbling wall were on the floor. The remaining wall was rough and uncleanable in this area Observations of Unit 3 on 04/14/2026 at 12:45 PM revealed: -resident refrigerator/freezer contained spills of brown, white and yellow colored substances -mounting of sink in the ice machine room was coming apart with sharp edges exposed An Interview on 4/14/2026 at 12:40 PM with Resident A and Resident B residing in room [ROOM NUMBER] revealed that there was not hot water available to them. Resident 301B stated the water had been cold for 2 months.An Interview of CNA A on 4/14/2026 at 12:50 PM revealed that the water on Unit 3 is very slow to warm up. CNA A further shared that a pipe recently burst and there is no hot water due to that issue. An observation of Ice Machine Room on Unit 3 on 04/14/2026 at 1:00 PM revealed: -brown unidentifiable substance along the inner door of the Ice machine -rubber seal on the underside of the ice maker door was missing -hard white substance noted on the floor behind the ice maker -ice maker unit shows an orange indicator light that states Clean; all other indicator lights on the unit were green. -garbage can overflowing with trash that was touching the icemaker lid An observation of Unit 2 on 04/14/2026 at 1:30 PM revealed stains of various sizes on the hallway carpet. Stains were tan, red, brown and black.Interview with Corporate Consultant (CC) on 04/14/2026 at 3:00 PM revealed that facility management was aware of a broken pipe and that the pipe had since been repaired. CC further stated that no one on the management team had been notified that there was an issue with hot water on Unit 3. CC stated that Facility Maintenance staff would be notified.Further interview of CC on 04/14/26 at 3:20 PM revealed that Facility Maintenance had been notified and Maintenance was currently restoring the hot water to Unit 3.An observation of water temperature in bathroom of room [ROOM NUMBER] was conducted on 04/15/2026 at 8:15 AM. Hot water ran for 2 minutes in sink prior to checking water temperature with digital thermometer. Temperature reached 80.2 degrees FahrenheitAn observation of water temperature in bathroom of room [ROOM NUMBER] was conducted on 04/15/2026 at 8:18 AM. The hot water was turned on and ran for over a minute in sink prior to checking water temperature with digital thermometer. Temperature reached 83.5 degrees Fahrenheit. Observation on 04/15/2026 at 8:25 AM of Ice Machine room on Unit 3 revealed: -full garbage can was touching the ice maker -orange Clean light remained lit on icemaker unit -dried white substance remained behind unit. -resident refrigerator/freezer unit contains spills to both refrigerator and freezer portion of the unit. An interview with CC on 4/15/26 at 10:35 AM confirmed that the hallway carpets in Unit 1 and Unit 2 were stained and dirty.An interview with the Director of Nursing on 04/15/2026 at 10:45 AM in the ice maker room on Unit 3 revealed confirmation by the DON that the resident refrigerator on Unit 3 was not clean. The DON also confirmed that the ice maker and surrounding area were not clean.

Licensure Reference Number 175 12-007.04 (D) The facility failed to ensure resident bathroom ventilation was functional in four resident rooms (room's 308, 502, 504, and 505) out of 14 resident rooms sampled. The facility census was 95 at the time of the survey. Findings are: An observation during the initial tour on 2.8.2026 at 8:00 AM revealed the bathroom ventilation was not functioning in resident rooms 100, 308, 315, 318, 319, 502, 504, and 505 when tested with a one-ply tissue. An observation during a facility tour on 2.10.2026 at 7:13 AM with the Administrator (Adm) revealed the bathroom ventilation was not functioning in resident rooms 308, 502, 504, and 505 when tested with a one-ply tissue During an interview on 2.10.2026 at 7:30 AM with the Adm, it was confirmed that the bathroom ventilation was not functioning in resident rooms 308, 502, 504, and 505 and it should have been. During a record review of the facility's undated Inspect exhaust fans for proper operation and clean if necessary document revealed: task completion was marked done on time on 12.29.2025, 9.29.2025, 6.19.2025, and 3.25.2025. The process included the following areas: Check all exhaust fans in bathrooms, shower rooms, soiled and clean utility rooms, janitor closets, kitchen, and sink and laundry areas, and oxygen rooms. Ensure the airflow is sufficient to hold a piece of paper to the vent when operating. Clean vents using a vacuum and air compressor, when needed to remove all dust. Remove dust and grease from motor, wheel and housing. During an interview on 2.11.2026 at 10:00 AM the Adm confirmed the facility did not have a specific bathroom ventilation policy, and it was included with the document that was already provided with the task completion dates.

Based on record review and interviews, the facility failed to transmit a Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) record to the Centers for Medicare and Medicaid Services (CMS) within the prescribed time frame for 1 (Resident 88) of 1 sampled residents. The facility census was 95 at the time of survey. Findings are:Record review of the Resident Assessment Instrument (RAI) manual revealed the facility is required to transmit the MDS within 14 days of completion.Record review of Resident 88's MDS revealed that the resident had an entry MDS on 9/5/2025 and discharge return not anticipated MDS on 9/13/2025 that was completed by the facility but not transmitted to CMS.Record review of Resident 88's progress notes revealed that the resident entered the facility on 9/5/2025 and then left the faciity on 9/13/2025.During an interview on 02/09/2026 at 9:54 AM MDS - C Registered Nurse stated that the Discharge MDS should have been separate from the Medicare 5 day MDS. It was not transmitted because it was a Medicare assessment. During an interview on 02/9/2026 9:56 AM MDS - D Registered Nurse confirmed that they (the facility) had missed submitting/transmitting the MDS and the MDS nurse will do a modification and then submit it to CMS. During an interview on 02/09/2026 2:44 PM the Administrator confirmed they used the RAI manual to ensure MDS accuracy.During an interview on 02/10/2026 7:12 AM the Administrator confirmed that the facility does run Validation Reports from the state, but the MDS nurses hadn't logged into the state site since September 2025.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observation, interviews, and record review, the facility failed to provide assistance with nail care for one (Resident 10) of three sampled residents. The facility census was 95.Findings are:A review of the facility, Activities of Daily Living (ADLs) policy, dated 1/2024, revealed the following:-3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.A review of Resident 10's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 1/29/26, revealed the following:-Resident 10 readmitted from the hospital on 1/23/26-Required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with personal hygiene.-Had a diagnosis of diabetes mellitus (DM- a condition that happens when someone's blood sugar is too high)A review of Resident 10's electronic health record (EHR), from 1/23/26-2/11/26, revealed no documentation of nail care being provided or refusals of nail care.A review of Resident 10's POC (Plan of Care) Response History, ADL-Bathing, from 1/12/26-2/10/26, revealed that Resident 10 was bathed on 1/14/26, 1/16/26, 1/28/26, and 2/5/26.A review of Resident 10's comprehensive care plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) revealed no task/intervention related to diabetic nail care.An observation on 2/8/26 at 1:30 PM revealed Resident 10's fingernails, on both hands, approximately 1/8 to 1/4 centimeter (cm) past the tip of [gender] fingers, with some nails having a jagged shape.An observation on 2/9/26 at 11:30 AM revealed no change in Resident 10's fingernails as the previous observation.In an interview on 2/9/26 at 11:30 AM Resident 10 revealed that [gender] could not remember the last time [gender] fingernails were trimmed, but [gender] felt as though they needed to be trimmed and that staff provide fingernail care for [gender].In an interview on 2/9/26 at 1:35 PM the Medication Aide (MA)-A revealed that the bath aide provides nails care to the residents that are not diabetic on their bath day. MA-A further revealed that if a resident is diabetic that a nurse would trim their nails.In an interview on 2/9/26 at 1:54 PM the Director of Nursing (DON) confirmed that the nurses are to trim diabetic resident's fingernails on their bath days.An observation on 2/11/26 at 7:57 AM Resident 10's fingernails remained in the same condition as the observation on 2/9/26 at 11:30 AM. In an interview on 2/11/26 at 7:57 AM Resident 10 revealed that [gender] fingernails bother [gender] due to their length.In an interview on 2/11/26 at 8:12 AM Registered Nurse (RN)-B revealed that nurse's usually complete diabetic nail care on bath days. RN-B will look at the bath list to know what residents have baths that day. RN-B will also complete nail care if [gender] is notified that a resident's nails need to be trimmed.An observation on 2/11/26 at 8:18 with the DON revealed no change in Resident 10's fingernails.In an interview on 2/11/26 at 8:18 AM the DON revealed that Resident 10 had been in and out of the hospital and [gender] would refuse cares at time. The DON revealed that [gender] refusals to have [gender] fingernails trimmed were probably not documented anywhere. The DON confirmed that Resident 10's fingernails were too long and needed to be trimmed.

Licensure Reference Number 175 NAC-12-006.06 Licensure Reference Number 175 NAC-1-005.04Based on record reviews and interviews, the facility failed to ensure that the Grievance Official (GO, a designated staff member responsible for receiving, investigating and resolving formal complaints regarding resident care) responded to and followed up on concerns of cold food recorded at 6 different Resident Council (RC, a group of residents who meet monthly to discuss the care provided by the facility) meetings. This had the potential to affect all residents who receive meals from the kitchen. The census at the time of the survey was 95. Findings are: Resident interviews conducted by the survey team on day one of the facility's annual survey revealed concerns about meals being served cold. Interviews with Resident 2, Resident 4, Resident 6, Resident 7, Resident 8, and Resident 33 revealed an overall frustration with cold food being served even after complaints and grievances had been filed with the facility. An interview with Resident 2 on 02/08/2026 at 1:02 PM revealed that food is served cold. An interview with Resident 6 on 02/08/2026 at 8:27 AM revealed that the most meals are served cold, coffee is cold, and that dinners are the worst. An interview with Resident 7 on 02/08/2026 at 8:53 AM revealed that the food is horrible and always cold. Resident 7 revealed that complaints have been made to the social workers, but they do not care. An interview with Resident 4 on 02/08/2026 at 11:00 AM revealed that food is always cold. An interview with Resident 8 on 02/08/2026 at 8:32 AM revealed that food this is meant to be hot is often served cold. An interview with Resident 4 on 02/10/2026 at 1:29 PM confirmed that today's lunch was cold and that this complaint has been brought up in resident council every month. An interview with Resident 33 on 02/08/2026 10:45 AM revealed a complaint of food being received cold regardless of location being served. Resident 33 have received cold food in both the resident's room and in dining room. Interviews conducted at the RC meeting on 02/09/2026 at 9:21 AM revealed similar complaints of cold food by the RC President, Resident 50. Resident 50 revealed that at the start of their RC meetings, all prior month's concerns are reviewed, and cold food complaints are almost always in the minutes from the previous meeting. Record review of Resident Council Minutes under the Dietary section revealed that on: 04/09/2025 the residents reported ice cold food. 05/07/2025 Resident feel they are not getting anywhere with them (dietary), Frozen buns, Cold food. 06/04/2025 the residents reported that Food is cold at times. 07/02/2025 the residents reported that . Still getting cold food. 08/06/2025 the residents reported .Items not hot. 10/08/2025 the residents reported .Items not hot when we get them. And on 02/13/2026 under New Business revealed the resident's concerns that complaints and grievances were not being addressed or followed up on. An interview with the Administrator (Admin) on 02/11/2026 10:15 AM revealed that the facility is unable to provide the RC minutes for the months of: September, November, and December of 2025. Record review of the Grievance Tracking logs (a log of all grievances received by the facility) for the months of: April. May, June, July, August, and October of 2025, reveal no mention of the RC complaints regarding cold food being served. An interview on 02/11/2026 at 7:37 AM with the Social Services Director (SSD) and Social Services Assistant (SSA) revealed that they attend the monthly RC meetings, take notes, and assume the responsibilities of the Grievance Official. The SSD and the SSA confirmed that the RC meeting minutes for: 04/09/2025, 05/07/2025, 06/04/2025, 07/02/2025, and 10/08/2025 had complaints about cold food and on 02/13/2025 a complaint was voiced that grievances were not being followed up on. The SSD and the SSA confirmed that the Grievance Logs for the months of: April. May, June, July, August, and October of 2025 did not have the grievances logged as reported by the RC and that they should have been. The SSD and the SSA revealed that when grievances are brought to their attention, they will pass the information on to the appropriate departments and, if necessary, file a formal grievance. If a frequent complaint is identified, they will refer it to the Quality Assurance and Performance Improvement committee (QAPI) and the facility may initiate a Performance Improvement Plan (PIP). Record review of the facility's Clinical Management Grievance Policy dated 05/17/2024 revealed that the facility will ensure prompt resolution to all grievances, keeping the resident and resident representatives informed throughout the investigation and resolution process. Record review of section D of the facility's Grievance Policy titled Resident Council revealed that all grievances identified during RC meetings will be submitted immediately to the GO for investigation and resolution and the outcome will be given to the RC. During an interview on 02/08/2026 at 1:02 PM Resident 2 revealed the food is always cold. During an interview on 02/10/2026 at 1:33 PM Resident 2 confirmed that (gender) has brought up the cold food at Resident council before but it doesn't do any good. During an interview on 02/08/2026 at 11:00 AM Resident 4 revealed that (gender) usually eats in (gender) room and that the food is always cold. During an interview on 02/10/2026 at 1:29 PM Resident 4 confirmed that lunch was cold and that (gender) has brought it up in resident council every month but nothing changes. Record review of the facility policy dated last reviewed 1/2024 and titled Grievance Policy revealed the facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by a designated Grievance Official who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigation, maintaining the confidentiality of all information associated with grievances, communicate with residents throughout the process to resolution and coordinate with other staff. During an interview on 02/11/2026 11:19 AM the Administrator confirmed there was not an official job description for the Grievance Official.

Licensure Reference Number 175 NAC 12-006.04(I)(i)Based on interviews and record reviews, the facility failed to employ a qualified social worker on a full-time basis. This had the potential to affect all residents residing at the facility. The facility census was 95.Findings are:A review of the Emerald Nursing and Rehab Brookside LLC, Facility Assessment, dated 2/6/26, revealed that the facility is licensed to provide care for 173 residents.A review of the Social Work Consultant Job Summary-Brookside, signed and dated 6/15/25 by the Social Worker Consultant (SW-C) and the administrator (Adm), revealed the following:-a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and/or psychology is required-is responsible for providing guidance and counseling to facility social service team members.-advocates for the facility, residents, and family members to ensure needs are met in accordance with federal, state, and facility regulations.In an interview on 2/9/26 at 11:10 AM, the Social Services Assistant (SSA) revealed that [gender] does not have a bachelor's degree in social work or in a human services field. The SSA revealed that the facility has a SW-C that comes to the facility anywhere from once a week to every other week but at least two to three times a month.In an interview on 2/9/26 at 11:11 AM, the Social Services Director (SSD) revealed that [gender] does not have a bachelor's degree in social work or in the field of human services.In an interview on 2/9/26 at 1:38 PM, the SW-C revealed that [gender] goes to the facility once a week or once every other week and at least two to three times a month. The SW-C revealed that [gender] has a bachelor's degree in social work. The SW-C confirmed that [gender] is not a full-time employee at the facility.

Licensure Reference Number 175 NAC 12-006.18Based on observation, record reviews and interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP- an infection control strategy that focuses on the prevention of the spread of multi-drug resistant organisms [MDRO]) were followed when wound care was provided and failed to ensure hand hygiene was completed between glove changes for 1 (Resident 1) of 5 sampled residents. The facility's census was 106. A record review of an admission Record printed on 10/06/2025 revealed that Resident 1 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus Type 2 (DMT2 a common form of diabetes mellitus that develops especially in adults that is characterized by high blood sugar levels, resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). This condition can lead to poor blood flow to the feet resulting in a diabetic ulcer (a slow-healing, open wound).A record review of Resident 1's Order Summary dated 10/06/2025 reveals a wound care order for bilateral toe wounds. The order is to apply Medi Honey and Band-Aid daily, with a start date of 09/20/2025.An observation on 10/02/2025 at 8:30 AM revealed LPN (Licensed Practical Nurse) performing wound care on Resident 1. The LPN first gathered supplies including gauze, Medi Honey, and Band-Aids. The LPN placed gloves in scrubs (uniform) pocket, next performed hand hygiene with hand sanitizer and entered the resident's room. The LPN greeted the resident, applied gloves, removed old Band-Aids from the toes on the resident's right foot. The LPN then removed the dirty gloves and replaced them with new gloves. The LPN cleaned off the open wounds with the gauze and applied the Medi-Honey to each of the open wounds. The LPN then covered each wound with a clean Band-Aid. The LPN disposed of soiled bandages and performed hand hygiene.At no time during this wound care process did the LPN don (to put on) a gown as required for Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).A record review of the facility's Infection Control MDRP PPE (Personal Protective Equipment) Enhanced Barrier Precautions policy dated 03/20/2024 revealed that EBP is to be used during routine cares of residents with chronic wounds including but not limited to those with diabetic foot ulcers. An interview with the LPN on 10/02/2025 at 8:40 AM revealed that the LPN was under the impression that EBP was only used during catheter cares and tube feedings and not for wound cares. An interview with Director of Nursing on 10/02/2025 at 2:00 PM confirmed Resident 1 was in Enhanced Barrier Precautions and it is the facility's expectation for staff to use EBP, including applying a gown before performing wound cares and that hand hygiene should be performed before donning (applying) or after doffing (removing) gloves.

Licensure Reference Number 175 NAC 12-006.02 (H) The facility failed to report an allegation of abuse on two residents (Resident 1 and Resident 2), out of four sampled residents. The facility census was 102. Findings: A.A record review of Resident 1's Clinical Census revealed an admission date of 5/16/2023. A record review of Resident 1's Minimum Data Set (MDS) (this comprehensive assessment evaluates each resident's functional capabilities) dated 6/03/2025 revealed a brief interview for mental status (BIMS) score of five which indicated the resident had severe cognitive impairment. A record review of Resident 1's Care Plan with an admission date of 5/16/2023 and a revision date of 3/26/2025 revealed a diagnosis of dementia, psychotic disturbance, mood disturbance, adjustment disorder, anxiety, and depressed mood and a focus area to include mood problem relating to dementia. Interventions included redirecting/separating from another resident. A record review of Resident 1's Progress Notes dated 6/16/2025 at 5:30 PM revealed that Resident 1 was found standing next to own bed, pulling pants up while Resident 2 was lying on Resident 1's bed. Resident 1 and resident 2 were separated. Resident's not able to give much information about incident due to confusion and medical history. B.A record review of Resident 2's Clinical Census revealed an admission date of 12/12/2024. A record review of Resident 2's MDS dated [DATE] revealed a BIMS score of zero which indicated the resident had severe cognitive impairment and required supervision or touch assist to ambulate 150 feet. A record review of Resident 2's Care Plan with an admission date of 12/12/2024 revealed a diagnosis of Alzheimer's disease, depression, and dementia with agitation. A focus area with a revision date of 12/16/2024 included impaired cognitive function or decision making. Interventions included observing for any changes in cognitive function: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, inattention, disorganized thinking, and mental status changes. A record review of Resident 2's Progress Notes dated 6/16/2025 at 5:20 PM revealed Resident 2 was found in Resident 1's room, on the bed with pants/brief down. Resident 1 was standing next to the bed, in the process of pulling up own pants. Writer stated, Residents not able to give details of the incident due to mental status/ medical history of dementia. Resident 1 and Resident 2 were separated and assisted to the dining room for supper. A record review of Resident 2's progress notes dated 6/16/2025-9/15/2025 revealed no resident assessment completed regarding the incident on 6/16/2025 at 5:20 PM. In an interview on 9/15/2025 at 11:00AM with the administrator (ADM), confirmed there had been issues with the charge nurse and inaccurate documentation. ADM stated there was no contact between Resident 1 and Resident 2 and the incident did not need to be reported. In an interview on 9/15/2025 at 1:40 PM with the assistant director of nursing (ADON), confirmed there was no body assessment completed on Resident 2 after the incident on 6/16/2025. Due to the completion of the investigation, it was determined there was no contact and no need to report the incident. An interview on 9/16/2025 at 10:00 AM with medication aide (MA)-A confirmed the details of the incident on 6/16/205 at approximately 5:00 PM with Resident 1 and 2: Resident 1 and Resident 2 were both sitting outside holding hands. The staff separated Resident 1 and 2. A while later, while passing medications, it was noted that Resident 2 was not in own room. Another nurse aide (NA)-B requested me to come to Resident 1's room quick, and I assumed that Resident 1 had fallen. When I arrived at Resident 1's room, NA-B stated that Resident 1's door was mostly closed. While opening the resident's door, Resident 2 was found with pants and brief pulled down, on top of Resident 1, who was fully dressed. MA-A confirmed witnessing Resident 1 leaving the room and Resident 2 pulling up pants. Charge nurse was notified immediately of the event. On 6/17/2025, Resident 2 was found in resident 1's room, again with pants down. Resident 1 was in room, but no interaction was observed. This occurred at approximately 7:00 PM and was reported to the charge nurse. MA-A confirmed the actions of Resident 1 and Resident 2 were inappropriate and could not understand why it took so long to move Resident 1 to another unit. MA-A confirmed Resident 1 was transferred to another unit about one week later. In a record review of the Facility's Abuse, Neglect, and Exploitation policy dated 11/2017 and a revision date of 1/2024 revealed: Each resident has the right to be free from abuse. Residents must not be subject to abuse by anyone, including, but not limited to other residents. Alleged Violation refers to a situation or occurrence that is observed or reported by staff or others but has not yet been investigated. Any investigation of an allegation of resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A facility is required to investigate and protect a resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. Investigation of alleged abuse or reports of abuse, an investigation is immediately warranted. Document the entire investigation chronologically. Residents must be protected after the alleged abuse. Suspected abuse will be reported, and an investigation will be initiated immediately. In an interview with the ADM upon survey entrance on 9/15/2025 at 9:00 AM, a list of the facility reportable events was requested. There was no record of a report involving Resident 1 and Resident 2 on 6/16/2025.

Licensure reference number 175 NAC 12-006.12(D)(i) Based on record reviews, observations and interviews, the facility failed to store medications properly in medication rooms and medication carts for 2 (Resident 5 and Resident 14) of 2 sampled residents. The facility census was 96. Findings are: A. Record review of Resident 5's Clinical Census record dated 6/1/25 revealed admission to the facility was 7/18/24. Record review of Resident 5's Diagnosis record dated 6/1/25 revealed diagnosis of Alzheimer's disease (a progressive brain disorder that leads to memory loss, thinking difficulties, and behavioral changes), and unspecified dementia (a general term for a group of brain disorders that cause a decline in memory, thinking, and reasoning skills). Record review of Resident 5's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 4/16/25 revealed: -Section C -Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment, scored 0 indicating severe impairment. -Section GG- Uses walker and wheelchair, needs supervision with eating, maximum assistance with toileting hygiene, bathing, and lower body dressing. Needs moderate assistance with upper body dressing. Dependent assistance with oral hygiene, footwear, personal hygiene, rolling left and right in bed, and transfers. Record review of Resident 5's Care plan dated 6/1/25 revealed: The resident has impaired cognitive function or impaired decision making related to Alzheimer's disease, dementia. Date Initiated: 07/18/2024 Revision on: 01/15/2025 -Staff to ask resident if need assist with toileting every 2 hours related to cognition, decision making ability, memory/mental status. Date Initiated: 11/20/2024 Revision on: 11/20/2024 Date Initiated: 07/18/2024 Revision on: 08/05/2024 -Provide consistent caregivers and routines in a home like environment (Specify: resident prefers) to minimize confusion Date Initiated: 07/18/2024, Revision on: 07/26/2024. Observation on 6/2/25 at 6:45 AM with MA-E performing peri-cares on Resident 5 revealed MA-E put gloves on without performing hand hygiene. MA-E assisted resident to sit up in bed, placed a gait belt on around resident's waist and transferred resident to wheelchair. MA-E pushed the wheelchair to the bathroom and assisted [gender] to stand and removed the disposable brief, then assisted resident to pivot and sit onto the toilet. When Resident 5 was finished with using the toilet, MA-E changed gloves without performing hand hygiene and placed several cleansing wipes onto a paper towel on the sink. MA-E assisted putting disposable pullups into resident's legs, then cleansed resident's left groin with 2 different cleansing wipes. MA-E cleansed the right groin area using 2 different cleansing wipes. MA-E did not dry the groin area. MA-E changed gloves without performing hand hygiene. MA-E stated, there is some Nystatin powder in this cup that someone left on the toilet, I can tell that it's Nystatin powder, I will use it since [gender] groins are red. MA-E poured some of this powder onto [gender] gloved hands and rubbed onto groin areas. MA-E assisted resident's legs into the slacks while sitting on toilet. MA-E assisted Resident 5 to stand and cleaned the peri-area with several different wipes, then cleansed their buttocks with several different wipes. MA-E changed gloves without performing hand hygiene. MA-E assisted Resident 5 to the wheelchair, applied deodorant, and shirt. MA-E removed gloves and combed resident's hair without performing hand hygiene. Interview on 6/2/25 at 8:40 AM with MA-E confirmed [gender] should not use the powder that was on the toilet unless [gender] brought it in from the cart prior to starting this procedure. Interview on 6/2/25 at 8:55 AM with the Director of Nursing confirmed that the staff should not store medicine in residents' room or use the powder that was on the toilet unless it was brought in from the cart prior to starting this procedure. The facility did not have a medication storage policy. B. Record review of Resident 14's admission Record dated 6/1/25 revealed admission to the facility was on 9/15/24. Record review of Resident 14's Diagnosis dated 6/1/25 revealed bipolar disorder, personal history of suicide behavior, depression, other psychoactive substance abuse, personal history of other mental and behavioral disorders. Observation on 6/2/25 at 10:30 AM in Resident 14's room, a medication cup with cream colored ointment sitting on the bedside table. Record review of Resident 14's Physician Orders dated 6/1/25 revealed: Nystatin/Triamcinolone Cream, apply topically to affected area twice daily (Indications for Use: skin care). Record review of Resident 14's Physician orders dated 6/1/25 revealed no orders for the resident to self-administer medications. Record review of Resident 14's assessment records dated 6/1/25 revealed there was no evaluation to self-administer medication. Record Review of Resident 14's MDS dated [DATE] revealed: Section C -Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment, scored 11 indicating moderate cognitive impairment. Section GG - limited ROM on one side upper and lower, uses wheelchair, independent with eating, max assist with oral cares and personal hygiene, dependent with all other cares. Interview with RN-C on 6/2/25 at 10:33 AM revealed the night shift nurse puts some Nystatin cream in a medication cup and places it on Resident 14's bedside table for the nurse to put it on the next morning. Observation on 6/2/25 at 10:58 AM with RN-C applying Nystatin/Triamcinolone Cream to groin areas. NA's performed peri-cares prior to RN-C applying cream. RN-C came into Resident 14's room with gloves on and the tube of Nystatin/Triamcinolone Cream. RN-C threw the medication cup of Nystatin/Triamcinolone Cream that was on the bedside table prior to RN-C arriving and put it in the trash. RN-C then applied Nystatin/Triamcinolone cream to both groins and peri-area. RN-C took gloves off, picked up the Nystatin/Triamcinolone cream tube and left the room without performing hand hygiene. Interview on 6/2/25 at 11:05 AM with Director of Nursing confirmed that the nurse should wash hands prior to leaving the room and should not store medications in the room. The facility did not have a medication storage policy.

Licensure reference number 175 NAC 12-006.18(D) Based on record reviews, observations and interviews, the facility failed to ensure staff performed hand hygiene prior to applying gloves and in between glove changes during peri-cares for 1 (Resident 5) of 2 sampled residents, and failed to perform hand hygiene prior to applying gloves and in between glove changes during peri-cares and catheter care, and wear a gown for 1 (Resident 14) of 2 sampled residents to prevent potenial cross contamination. The facility census was 96. Findings are: A. Record review of the facilities Infection Control-Handwashing Policy revised 1/2024 revealed: Policy Statement - This policy considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after contact with residents -Before moving from a contaminated body site to a clean during resident care -After removing gloves The use of gloves does not replace hand washing/hand hygiene. Applying and removing gloves -Perform hand hygiene before applying non-sterile gloves. Record review of Resident 5's Diagnosis dated 6/1/25 revealed diagnosis of overactive bladder, Alzheimer's disease (a progressive brain disorder that leads to memory loss, thinking difficulties, and behavioral changes), unspecified dementia (a general term for a group of brain disorders that cause a decline in memory, thinking, and reasoning skills), and urinary tract infection (occur when bacteria enter the urinary tract and cause inflammation). Record review of Resident 5's Clinical Census record dated 6/1/25 revealed admission to the facility was 7/18/24. Record review of Resident 5's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 4/16/25 revealed: -Section C -Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment, scored 0 indicating severe impairment. -Section GG- Uses walker and wheelchair, needs supervision with eating, maximum assistance with toileting hygiene, bathing, and lower body dressing. Needs moderate assistance with upper body dressing. Dependent assistance with oral hygiene, footwear, personal hygiene, rolling left and right in bed, and transfers. Record review of Resident 5's Care plan dated 6/1/25 revealed: The resident has bladder incontinence related to Disease Process-Alzheimer's Disease, Dementia, need for assistance with cares and transfers. Dx (Diagnosi): overactive bladder Date Initiated: 07/26/2024 Revision on: 01/15/2025 -The resident will remain clean and dry through the next review date. Date Initiated: 07/26/2024 Revision on: 05/05/2025 -Incontinent: Routine Check and change every 2-3 hours and as required for incontinence. Date Initiated: 07/26/2024 Revision on: 07/26/2024 -Brief use: The resident uses disposable briefs. Change every 2-3 hours and prn (as needed). Date Initiated: 07/26/2024 Revision on: 07/26/2024 The resident has potential impairment of skin integrity to reoccurring MASD (Moisture-associated skin damage refers to inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture. -The resident will maintain intact skin through the next review date. Date Initiated: 08/05/2024 Revision on: 05/05/2025 -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated: 08/05/2024 Observation on 6/2/25 at 6:45 AM revealed MA-E performed peri-cares on Resident #5. MA-E put gloves on without performing hand hygiene. MA-E assisted resident to sit up in bed, placed a gait belt on around resident's waist and transferred to wheelchair. MA-E pushed the wheelchair to the bathroom and assisted [gender] to stand and removed the disposable brief, then assisted resident to pivot and sit onto the toilet. When Resident 5 was finished with using the toilet, MA-E changed gloves without performing hand hygiene and placed several cleansing wipes onto a paper towel on the sink. MA-E assisted putting disposable pullups into resident's legs, then cleansed resident's left groin with 2 different cleansing wipes. MA-E cleansed the right groin area using 2 different cleansing wipes. MA-E did not dry the groin area. MA-E changed gloves without performing hand hygiene. MA-E stated, there is some Nystatin powder in this cup that someone left on the toilet, I can tell that it's Nystatin powder, I will use it since [gender] groins are red. MA-E poured some of this powder onto [gender] gloved hands and rubbed onto groin areas. MA-E assisted resident's legs into the slacks while sitting on toilet. MA-E assisted Resident 5 to stand and cleaned the peri-area with several different wipes, then cleansed the buttocks with several different wipes. MA-E changed gloves without performing hand hygiene. MA-E assisted Resident 5 to the wheelchair, applied deodorant, and [gender] shirt. MA-E removed gloves and combed resident's hair without performing hand hygiene. Interview on 6/2/25 at 8:40 AM with MA-E confirmed [gender] should have washed hands before putting on gloves, in between changing gloves, dry the areas after cleaning, and not use the powder that was on the toilet unless [gender] brought it in from the cart prior to starting this procedure. Interview on 6/2/25 at 8:55 AM with the Director of Nursing confirmed that staff should wash hands before donning gloves, in between glove changes, dry areas after cleaning, and not use the powder that was on the toilet unless they brought it in from the cart prior to starting the procedure. B. Record review of the facilities MDRO (Multidrug-Resistant Organisms) PPE (Personal protective equipment) -Enhanced Barrier Precautions revised 1/2024 revealed: -Enhance Barrier Precautions (EBP) are an infection control interventions designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. -EBP may be indicated for residents with any of the following- wounds or indwelling medical devices, regardless of MDRO colonization status. -For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: providing hygiene, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Record review of the facilities Infection Control-Handwashing Policy revised 1/2024 revealed: Policy Statement - This policy considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or alternately, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after contact with residents -Before moving from a contaminated body site to a clean during resident care -After removing gloves The use of gloves does not replace hand washing/hand hygiene. Applying and removing gloves -Perform hand hygiene before applying non-sterile gloves. Record review of Resident 14's admission Record dated 6/1/25 revealed admission to the facility was on 9/15/25. Record review of Resident 14's Diagnosis dated 6/1/25 revealed urinary tract infection. Record review of Resident 14's Physician Orders dated 6/1/25 revealed: Foley Catheter: Indwelling Size:16 French, Diagnosis: Urinary retention, Change Catheter and Drainage bag(s) Every 30 Days and as needed. Record review of Resident 14's Physician Orders dated 6/1/25 revealed: Nystatin/Triamcinolone Cream, apply topically to affected area twice daily (Indications for Use: skin care). Record Review of Resident 14's MDS dated [DATE] revealed: -Section C -Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment, scored 11 indicating moderate cognitive impairment. -Section GG - limited range of motion on one side of upper and lower extremity, uses wheelchair, independent with eating, maximum assistance with oral cares and personal hygiene, dependent cares with all other cares. -Section H - has an indwelling catheter Record Review of Resident 14's care plan dated 6/1/25 revealed: The resident has (Foley) Catheter related to multiple sclerosis Date Initiated: 05/18/2025 Revision on: 05/26/2025 -The resident will be/remain free from catheter-related trauma through review date. Date Initiated: 05/18/2025 -The resident will show no s/sx of Urinary infection through review date. Date Initiated: 05/18/2025 -CATHETER: The resident has (18 French) Foley Catheter. Position catheter bag and tubing below the level of the bladder Date Initiated: 05/18/2025 Revision on: 05/26/2025 Observation on 6/2/25 at 10:50 AM with NA-A and NA-B performing peri-cares and catheter cares on Resident 14's. NA-A and NA-B put gloves on without performing hand hygiene and did not put a gown on. NA-A cleansed Resident 14's external genitalia with cleansing disposable wipes while NA-B handed NA-A a clean wipe after each swipe of cleaning an area. NA-A held onto the catheter tubing near the external urethral opening and cleansed tubing from opening to 6 inches down the tube using 2 different wipes. NA-A did not dry the area after cleansing. NA-A and NA-B changed gloves without performing hand hygiene. The NA's assisted resident to turn to [gender] left side. NA-A cleansed buttocks and anal area with cleansing wipes as NA-B handed new wipes to NA-A. NA-A and NA-B assisted resident to back and then both NA's performed hand hygiene for 20 seconds. Observation on 6/2/25 at 10:58 AM with RN-C applying Nystatin/Triamcinolone Cream to groin areas. RN-C came into Resident 14's room with gloves on and the tube of Nystatin/Triamcinolone Cream. RN-C threw the medication cup of Nystatin/Triamcinolone Cream that was on the bedside table prior to RN-C arriving and put it in the trash. RN-C then applied Nystatin/Triamcinolone cream to both groins and peri-area. RN-C took gloves off, picked up the Nystatin/Triamcinolone cream tube and left the room without performing hand hygiene. Interview on 6/2/25 at 11:05 AM with Director of Nursing (DON) confirmed that the staff should wash hands prior to applying gloves, perform hand hygiene between glove changes, wear a gown, and the nurse wash hands prior to leaving the room. DON confirmed Resident 14 was in Enhanced Barrier Precautions.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure that 4 Minimum Data Sets (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) were coded correctly related to falls for 3 (Residents 1, 3, and 5) out of 5 sampled residents for falls. The facility census was 98. Record review of facility policy and procedures, titled Expanded Assessment Areas last updated 1/2024 revealed: -the facility shall prepare an interdisciplinary comprehensive assessment of the resident required by the Resident Assessment Instrument (RAI) using the Minimum Data Set (MDS) 3.0 and evidence based discipline assessment tools. -the assessment and the MDS information will be used to develop a comprehensive, person-centered careplan. Record review of the RAI manual dated October of 2024 revealed the definition of fall with injury to include abrasions, fractures or any fall related injury that causes the resident to complain of pain. During an interview on 4/3/2025 at 9:07 AM the Director of Nursing (DON) confirmed that the facility uses the RAI manual to ensure the MDS accuracy. Record Review of Resident 1's Annual MDS dated [DATE] revealed that the resident was admitted to the facility on [DATE]. A. Record review of Resident 1's progress notes dated 3/23/2025 revealed the resident fell in their room and was sent to the hospital and had a C1 fracture (a break in the first vertebra of the cervical spine, located at the base of the skull). Record review of Resident 1's Discharge MDS dated [DATE] was not marked as fall with injury. During an interview on 4/3/2025 at 11:21 AM the MDS - A nurse coordinator confirmed that Resident 1's fall with injury was not marked correctly on the Discharge MDS dated [DATE] and should have been. B. Record review of Resident 1's fall data collection assessments revealed that the resident had falls on 1/28/2025, 2/9/2025, 2/11/2025 the resident had an abrasion, 2/13/2025 the resident complained of pain, and 2/17/2025. Record review of Resident 1's Annual MDS dated [DATE] revealed was marked with falls with no injury. An interview on 4/3/2025 at 11:22 AM interview with MDS - A nurse coordinator confirmed Resident 1's fall with the abrasion and the fall with complaints of pain were not marked correctly on the MDS dated [DATE] and should have been marked as falls with injury. C. Record review of Resident 3's Annual MDS dated [DATE] revealed that the resident was admitted to the facility on [DATE]. Record review of the facility provided Matrix revealed Resident 3 has had a fall with injury. Review of Resident 3's Quarterly MDS dated [DATE] revealed resident has had falls with major injury. Record review of Resident 3's fall data collection assessments revealed no current fall risk assessment completed. Record review of Resident 3's progress notes dated 3/10/25 through 3/28/2025 revealed no falls. Record review of Resident 3's Comprehensive Careplan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) dated 3/27/2024 did not reveal any falls. During an interview on 4/3/2025 at 8:55 AM the DON confirmed that the resident's last fall was on 1/29/2022. During an interview on 4/3/2025 at 9:04 AM the MDS - A nurse coordinator confirmed that Resident 3's last MDS dated [DATE] was marked incorrectly and should not have been marked for falls. D. Record review of Resident 5's Quarterly MDS dated [DATE] revealed that the resident was admitted to the facility on [DATE]. Record review of facility provided incident report dated 2/18/2025 revealed that Resident 5 had an unwitnessed fall on 2/18/2025. Record review of Resident 5's MDS dated [DATE] revealed no falls indicated. During an interview on 4/3/2025 at 4:41 PM the MDS - A nurse coordinator confirmed that no falls were marked on the Quarterly MDS dated [DATE] and should have been.

Licensure Reference Number 175 NAC 12-006.10 Based on observation, interview and record review the facility failed to follow the physician's orders for 1 (Resident 6) of 3 sampled residents. The facility identified a census of 92. Findings are: A record review of the admission record reviewed on 3/3/25 revealed that Resident 6 had been admitted into the facility on [DATE] with a primary diagnosis of severe protein calorie malnutrition. A record review of the significant change 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 1/2/25, revealed Resident 6 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15 indicating the resident had no cognitive impairment. A record review of the Order Summary for Resident 6, reviewed on 3/3/25, revealed the indication for use of the Omeprazole was Gastro-Esophageal Reflux Disease (GERD, a chronic digestive disease where the liquid content of the stomach refluxes into the throat) dated 11/18/23. An observation on 3/3/25 of the medication administration completed by Medication Aide (MA)-D revealed the following medications were administered to Resident 6 at 7:45 AM: -Tylenol (an over the counter pain reliever) 650 milligrams (mg) (2 tablets of 325mg) by mouth (po) three times daily (TID), -HZD-2 Estradiol (a hormone supplement) 2 mg po every day, -Hyoscyamine (a medication used for gastrointestinal disorders) 0.375 mg extended release (ER) po every day, -Omeprazole (a medication used for gastrointestinal disorders) 20 mg po every day, give 60 minutes before breakfast, -Probiotic (live bacteria and yeasts that have beneficial effects on your body) 1 tablet po every day, -Spironolactone (a medication used to treat fluid retention) 25 mg po BID with food, -Tab-a-vite with iron (a multivitamin) with morning meal, -Vitamin D3 (a vitamin supplement) 400 mg po every day, -Pregabalin (a medication used to treat nerve pain and control seizures) 50 mg po every day, -Miralax (a stimulant laxative) 17 grams (gm) mix with 4-8 ounces of liquid po every day, -Tums (an antacid) 1 tablet po every morning. An observation on 3/3/25 revealed that the Station 2 breakfast trays had arrived at 7:54 AM. An observation on 3/3/25 at 8:01 AM revealed Resident 6 had been given (gender) breakfast tray and began eating at this time. An interview on 3/3/25 at 8:03 AM with Medication Aide (MA)-D confirmed that Resident 6 had been given (gender) breakfast tray and had begun eating 18 minutes after receiving the Omeprazole which was ordered to be given one hour prior to breakfast. MA-D confirmed that it had not been an hour as ordered since taking the Omeprazole. On 3/3/25 at 11:36 AM, when a copy of the facility medication administration policy was requested, a Medication Administration check list was provided by the Corporate Nurse Consultant (CNC) who voiced that this was what the facility used. A record review of the document titled Medication Administration revealed that under the category titled Med Admin consisted of the step titled Correct dose time. An interview on 3/3/25 at 11:36 AM revealed that the CNC had contacted the facility pharmacist regarding the Omeprazole instructions to give 60 minutes prior to breakfast. The CNC voiced that the pharmacist had stated that 30 minutes prior to breakfast would also be sufficient. When informed that it had been given 18 minutes prior to Resident 6 eating breakfast, the CNC confirmed that 18 minutes was not sufficient.

Licensure Reference Number 175 NAC 12-009.11(A) Based on observation and interview; the facility failed to ensure a bathroom floor was maintained in a clean and sanitary manner for 1 (Resident 1) of 3 sampled residents. The facility census was 97. Findings are: In an observation on 1/21/25 at 3:27 PM of Resident 1's bathroom floor revealed the following: -4 cracked tiles in front of the toilet with one tile having a missing area -Large brown stained area out from base of toilet -Caulking around base of toilet with cracks and brown stains around the front of the toilet In an observation on 1/22/25 at 8:08 AM of Resident 1's bathroom floor revealed the same concerns as listed above. In an interview on 1/22/25 at 8:08 AM, the Administrator confirmed that the above-mentioned areas were present and confirmed that Resident 1's bathroom floor was not maintained in a clean and sanitary manner.

Licensure Reference Number NAC 175 12-006.09 and 12-006.09(I) Based on record review, observation, and interviews; the facility staff failed to implement interventions to prevent hot liquid burns for 1 (Resident 1) of 1 sampled residents, and failed to evaluate for potential injuries from a fall prior to moving the resident for 1 (Resident 2) of 3 sampled residents . The facility staff identified a census of 107. The facility Administrator was notified on 10/17/24 at 4:30 PM of an Immediate Jeopardy (IJ) which began on 08/05/24. The IJ was removed on 10/17/24 at 6:30 PM, as confirmed by surveyor onsite verification. Findings are: A. A record review of Admission Record revealed Resident 1 was admitted to the facility on [DATE] with the diagnoses of: -Burn of unspecified body region, unspecified degree, -Type 2 Diabetes Mellitus without complication (a disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), -Muscle Weakness generalized (lack of muscle strength), -Unsteadiness on Feet (when you have trouble walking or maintaining your balance), -Abnormalities of Gait and Mobility (changes to a person's normal walking pattern). A record review of the Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 5/15/24 revealed in section C Cognitive Patterns revealed a Brief Interview for Mental Status, (BIMs, a test used to get a quick snapshot of a resident's cognitive function, scored 0-15, the higher the score, the higher the cognitive function) of 15 meaning cognitively intact. Resident 1 was independent with Activities of Daily Living (ADL's). A record review of the Care Plan (CP, written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 8/15/24 revealed Resident 1 had no care plan addressing skin issues related to burns. A record review of the Admission packet revealed that the facility did not approve or deny items being brought into the facility by the family. A record review of the Progress notes dated 11/3/2023 at 7:58 AM revealed that Resident 1 is storing medication in room. The medications were not removed from the room. Resident 1 family member has a history of bringing in over the counter medications for Resident 1. The family member and Resident 1 have received education on the dangers of this and that it is against facility policy. Both the family member and Resident 1 have acknowledged understanding. The progress note did not reveal other items being brought into the facility that was not allowed. A record review of the Progress notes dated 8/5/24 revealed a Skin/Wound weekly observation of a burn to right foot and right anterior leg. Further review of the medical record did not reveal any further skin/wound documentation. A record review of Provider Notification SBAR (situation, background, assessment, request) dated 6/7/24 revealed documentation of Superficial burn to leg with orders for silvadine (a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of wound sepsis in patients with second- and third-degree burns) twice a day for one week. A record review of the Wound Nurses notes referred areas to right foot/right leg as burns dated 6/24/24, 7/1/24, 7/9/24 and 7/15 24 An interview on 10/17/24 at 10:30 AM with RN (Register Nurse)-1 confirmed that Resident 1 had received burns to Resident 1's right foot and right front leg due to spilling hot coffee from Resident 1's rice cooker. RN-1 confirmed that Resident 1 would use the rice cooker to make coffee, rice and ramen noodles. RN-1 confirmed that Resident 1 received another burn on 10/12/24 on Resident 1 buttocks. RN-1 confirmed that on 10/14/24 Resident 1 was sent to the hospital and was kept overnight due to the burns on Resident 1 buttocks. An interview on 10/17/24 at 11:00 AM with MA (Medication aide)-5 and NA(Nursing assistant)-4 confirmed that staff had knowledge that Resident 1 had the rice cooker in Resident 1's room and that Resident 1 made ramen noodles, coffee, and rice in the rice cooker in Resident 1 room. MA-5 confirmed that (gender) had reported the rice cooker in Resident 1 room and since nothing was done assumed that the rice cooker was allowed. MA-5 confirmed that the rice cooker had been in Resident 1 room for over 6 months. An interview on 10/17/24 at 9:34 AM with S.S (Social Services) revealed that Housekeeping had removed a rice cooker from the Resident 1's room before Resident 1's burn on 10/12/24. S.S confirmed that the previous Administrator who exited the facility on April 5th had educated the family of Resident 1 a couple of times saying that family member could not bring anything into Resident 1 without telling the nurse. An interview on 10/17/24 at 11:00 AM with HK-2 (Housekeeping) confirmed that on 10/14/24 was the first time they had been asked to remove the rice cooker. HK-2 confirmed that (gender) also removed a power strip that was not approved per fire code, and 2 electric blankets. One electric blanket was on the bed and the other electric blanket was in a drawer. An interview on 10/17/24 at 2:30 PM with the DON (Director of Nursing) confirmed that (gender) had no knowledge of the rice cooker that Resident 1 had in (gender) room. The DON confirmed that the rice cooker should not have been in Resident 1's room. The DON confirmed that staff after 10/16/24 was educated on what to do if these items are found in Resident 1 room. The DON confirmed that (gender) was not aware that the wounds on Resident 1 right leg/right foot was from a burn. B. A record review of the facility policy Fall Management dated 4/15, date revised 4/20 and last date revised 1/24 revealed the following: Post fall/Injury resident management. -In the event a resident has fallen and or is found on the ground, a complete head to toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present. Remain with the resident while calling for assistance, if at all possible. A record review of the Admission Record revealed that Resident 2 was admitted to the facility on [DATE] with the diagnoses of: -Malignant Neoplasm of Pancreas (a cancerous tumor that develops in the pancreas), -Type 2 Diabetes Mellitus (a disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), -Depression(a mental health condition that involves a prolonged low mood or loss of interest in activities), -Anxiety Disorder (a feeling of fear, dread, or uneasiness that can be a reaction to stress), -Conduct Disorder (a group of behavioral and emotional problems characterized by a disregard for others), -Weakness (lacking strength). A record review of the MDS dated [DATE] revealed in section C Cognitive Patterns revealed a BIMS score of 6 meaning the resident is severely cognitively impaired. A record review of the CP dated 10/11/24 revealed that Resident 2 was at risk for falls and staff will conduct routine visual rounding. A record review of the Nursing Assistant Task revealed that Resident 2 was a 1 assist with Activities of Daily Living and transfers. An observation on 10/17/24 at 10:00 AM revealed Resident 2 on the floor this surveyor told NA-3 that Resident 2 was on the floor. NA-3 went into Resident 2's room and assisted Resident 2 off the floor using no lift equipment to assist the resident off the floor. An interview on 10/17/24 at 11 AM with the RN-1 confirmed that the NA-3 should not have assisted the resident off the floor before a full body assessment was done. An interview on 10/17/24 at 11 AM with the DON confirmed that the NA-3 should not have gotten Resident 2 off the floor prior to being assessed. The facility implemented the following actions on 10/17/24 to remove the immediacy of the situation and protect the residents: Abatement Statement: skin/wounds Identified opportunity for improvement/Deficient Practice: Facility failed to report skin breakdown/injury due to resident spilling hot liquid: Immediate Corrective Action for those affected by the deficient practice: Residents wound was assessed, Physician notified and orders received. (Completed 10/14/24) Education provided to resident's Power of Attorney (POA) on what resident can/cannot have in room (Complete 10/14/24) Items removed from resident room to be returned to son (Completed 10/14/24) Staff education completed related to items that could potentially cause injury and what to do if items are found. (Education began 10/14/24, all nursing staff will be educated prior to working their next shift) Staff education completed on reporting skin issues to Administrator, DON and or Assistant Director of Nursing (ADON) at time wound is found (Education began 10/14/24, all nursing staff will be educated prior to working their next shift). Process/Steps to identify other having the potential to be impacted by the same deficient practice: Hot Liquid evaluation for Risk Residents completed on all residents started on 10/14/24. (Evaluations will be completed by 10/18/24 Care plans updated on any resident identified as being at risk for potential injury due to hot liquids (by 10/25/24) Measures put into place/systematic changes to ensure the deficient practice does not occur: All residents have hot liquid evaluation completed on admission and quarterly. Nursing staff education related to wound identification who and how to report any potential wounds. All new hires will be educated regarding the skin protocol, potential for injury and process of reporting wounds. Wounds will be discussed daily as part of morning clinical. Residents rooms will be audited weekly for potential hazardous equipment. Affected resident room will be audited daily. Plan to monitor performance to ensure solutions are sustained. Hot liquid eval's will be completed on admission and quarterly. Items that are a potential risk will be identified on admission with personal inventories. The plan of correction will be reviewed by the Quality Assurance and Performance Improvement (QAPI) program committee for the next 3 months. Falls 10/17/24 Identified Opportunity for Improvement/Deficient Practice: Facility failed to ensure staff following protocol for resident falls Immediate Corrective Action for those affected by the deficient practice: Staff education outlining fall protocol: staff to call for nurse to assess resident prior to moving resident to chair or bed, (began 10/17/24, all nursing staff will be educated prior to working their next shift. Process/Steps to identify others having the potential to be impacted by the same deficient practice: High fall risk residents will be identified (begin 10/17/24, completion by 10/18/24). Care plan audited to ensure risk for falls or actual falls identified as a focus with resident centered appropriate interventions in place ( completion by 10/18/24). Residents profiles updated indicating fall risk (completion by 10/18/24). Measures put into place/systematic changes to ensure the deficient practice does not recur: All new admissions fall risk will be identified. Resident centered interventions will be put into place on care plans. All falls will be reviewed daily in morning clinical. Fall packet will be put into place. Fall policy and procedure will be gone over with all new nursing hire by DON/ADON. All staff education on fall policy and procedure will be ongoing with all staff meetings. Post fall huddle will be completed by nursing staff immediately following fall. Random gait belt audits will be done on all nursing staff. Plan to monitor performance to ensure solutions are sustained. Monitoring will be on going. The plan of correction will be reviewed by the Quality Assurance and Performance Improvement (QAPI) program committee for the next 3 months. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to remove the immediacy of the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Licensure Reference Number 175 NAC 12-006.05Q Based on record review and interviews, the facility failed to ensure that residents could access their personal resident fund money on weekends, holidays, or during evening/overnight hours. This affected 65 of 65 residents with a personal fund account. The facility census was 112. An interview on 08/20/2024 at 8:22 AM with Resident 9 revealed Resident 9 had concerns that they were only able to access their money in their personal fund account during business hours when the business office is open, or sometimes when certain front receptionists are working but was unable to get any monies in the evening or on the weekends. An interview with the Business Office Manager (BOM) on 08/21/2024 at 8:17 AM confirmed that residents who have money in a personal fund account at the facility can only access their money Monday through Friday, 8:00 AM to 5:00 PM at the front desk or the Business Office. BOM confirmed that there are 65 residents who have a personal fund account at the facility. A record review of the policy titled Facility Responsibilities, Policy No: ROP-83, Created 1-2024 revealed no evidence that the facility should have access to petty cash on an ongoing basis to honor resident requests to access their money in their personal funds account.

Licensure Reference Number 175 NAC 12-006.04(B)(ii) Based on interview and record review; the facility failed to provide the required 12 hours of ongoing training for 5 (Medication Aide (MA)-B, MA-E, NA-G, NA-H, and MA-J) of 5 sampled direct care staff. This had the potential to affect all the residents residing in the facility. The facility census was 112. Findings are: Record review of 5 direct care staff files who have been employed a year or more revealed all 5 direct care staff had not completed the required 12 hours of ongoing training. An interview on 8/21/24 at 2:10 PM the Human Resources Director revealed that the 12 hour ongoing training had not been being completed for any direct care staff, confirmed that the 12 hours of ongoing training had not been completed on the 5 sampled direct care staff and should have been.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility failed to ensure a Left Ventricular Assist Device (LVAD-surgically implanted assistive device that allows the heart to not have to work as hard in patients that are in End Stage Heart Failure) was operational by not maintaining power to the device via a working power source for one (Resident 2) of one sampled resident. This resulted in an Immediate Jeopardy past noncompliance. The facility census was 103. Findings are: Record review of Resident 2's electronic medical record revealed that Resident 2 admitted to the facility on [DATE] at 1:00 PM with the following diagnoses: Chronic combined systolic congestive and diastolic congestive heart failure, heart assist device, ischemic cardiomyopathy, atherosclerotic heart disease, and presence of aortocoronary bypass graft. Record review of the Community LVAD Education provided by the Acute Care Nurse Practitioner (ACNP)-B on 5/15/23 revealed the following: -Pump Running Symbol-most important piece to the controller. If both arrows are LIT UP IN GREEN, then the controller and pump are working well. If only one arrow is lit up GREEN, then the controller has changed to back up mode-CALL COORDINATOR. If no arrows are lit in green and instead are BLACK, the pump is off. -Status Symbols: Diamond-Yellow and 15 minutes left on set of battery; 4 Bars-Green and 25% increments; Battery- Red and 5 minutes left on battery set; Broken Heart: RED, low flow or power/patient disconnected; Wrench-Yellow and indicates something is wrong with controller. -External Power Equipment: Batteries will last 12-17 hours based upon the speed of the pump, push the battery button on the battery and it will give you a percentage of how much battery power is left (in 20% increments). Alternating Current (AC) power at night and batteries during the day if up and about. Record review of the undated facility resource binder revealed the following; -VAD (Ventricular Assist Device) Coordinator/Emergency Phone Number. -Pictures of the LVAD equipment. -The LVAD device used 14 Volt lithium-ion batteries that provide up to 17 hours of support. The batteries drain simultaneously and require 4 hours to charge. Five lights on each battery indicate the amount of power remaining. -Parameters for the heart mate 3 included the flow (amount of blood coming out of the heart through pump every minute measured in liters per minute), speed (a set speed that referred to how fast the pump is running in revolutions per minute), and power (measured by the system controller and reflects the wattage required to power the pump). -Notification to the VAD Coordinator for any VAD alarms, any changes in mental status, any light headedness or dizziness. -Notification to the primary care physician for anything that is not VAD related. -Notification to 911: if VAD is not functioning (no green arrows) call 911 first THEN VAD Coordinator. -Obtain all four VAD numbers and document them in the parameter book EVERY DAY and then document it in acticare touch screen daily when you receive from company. -It is very important to perform the daily self- checks on the pocket controller and power module. -It is important to change your back up controller monthly. Record review of the sign in sheet from the education provided to staff on 5/15/23 by ACNP-B revealed Registered Nurse (RN)-C was in attendance and Licensed Practical Nurse (LPN)-D was not in attendance. Record review of the facility's nursing staff schedule, dated 5/18/23, revealed LPN-D worked 2:00 pm to 10:30 pm and RN-C worked 10:00 pm to 6:30 am. Interview on 5/31/23 at 11:40 am, the Regional Nurse Consultant (RNC) revealed that the night nurses, RN-C and LPN-D, had not assessed Resident 2 during the shift worked. RNC confirmed there were no other residents with an LVAD device within the facility. Record review of Resident 2's care plan with a closed date of 5/23/23 did not reveal information regarding Resident 2's LVAD device. Record review of Resident 2's Medication and Treatment Administration record printed 5/31/23 for the month of May 5/1-5/31/23 did not reveal information regarding Resident 2's LVAD device. Record review of Resident 2's electronic health record did not indicate the pump parameters for Resident 2's LVAD device. Interview on 5/31/23 at 1:08 pm, ACNP-B revealed that on 5/15/23 ACNP-B arrived at the facility at 4:00 pm and remained at the facility for one and a half hours to train the staff. ACNP-B revealed that the education included equipment for staff to work with the LVAD hands on and hear the alarms. ACNP-B revealed that a resource binder was provided to the facility as a reference. ACNP-B further revealed that when Resident 2 admitted to the facility on [DATE] ACNP-B and LVAD team were present and provided additional education to facility staff on shift. ACNP-B revealed that Resident 2's battery stated 60% at 2:45 pm when ACNP-B left the facility. ACNP-B confirmed that it is an expectation for the LVAD to be plugged into an AC power source when Resident 2 went to bed. ACNP-B revealed that the process to plug in the LVAD was performed. Interview on 5/31/23 at 1:56 pm, LPN-D revealed that LPN-D had not attended the education on 5/15/23. LPN-D further revealed that upon arrival for LPN-D's shift at 2:00 pm, LPN-E and the LVAD team were in Resident 2's room. LPN-D revealed that LPN-D entered the room and was shown what the alarm sounded like. LPN-D revealed that LPN-D was in Resident 2's room between 7:00 pm to 8:00 pm and had not assessed Resident 2 throughout the shift. LPN-D revealed that no education was provided regarding the need to plug the LVAD in and LPN-D confirmed LPN-D did not plug in the LVAD. Interview on 5/31/23 at 2:13 pm, RN-C revealed that RN-C had not attempted to assess Resident 2 until 2:30 am, at which time RN-C noted Resident 2 was not breathing at which time RN-C plugged in the LVAD and notified the on-call provider for the LVAD team. RN-C revealed that prior to 2:30 am RN-C had only peaked into Resident 2's room. Review of Resident 2's progress note dated 5/19/23 at 3:30 am revealed that the on call for primary care physician was contacted and an order to release Resident 2's body was obtained and that family was present and notified mortuary. The facility did confirm there were no additional residents with LVAD devices in the facility.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to identify, evaluate casual factors and implement interventions for the development of pressure ulcers for 1(Resident 5) of 3 sampled residents. The facility staff identified a census of 107. Findings are: Record review of an Order Summary Report sheet printed on 12-20-2022 revealed Resident 5 was admitted to the facility on [DATE] with the diagnoses that included Cerebral Infarction (commonly known as a stroke) with left side side paralysis. Record review of Resident 5's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning ) dated 11-09-2022 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was a 10. According to the MDS Manuel a score of 8 to 12 indicates a person cognition is moderately impaired. -Required extensive assistance with toilet use, bed mobility and dressing. -Required total assistance with transfers and personal hygiene. -Incontinent of bowel and bladder. -Was at risk for the development of pressure ulcer and currently did not have any. Record review of Resident 5's Comprehensive Care Plan (CCP) dated 8-10-2022 revealed Resident 5 had the potential for pressure ulcer development. The goal for Resident 5 was to have intact skin. Interventions to meet this goal included monitoring, reminding and assisting Resident 5 to reposition at least every 2 hours and more if requested. Record review of a Skin/Wound Weekly Observation dated 12-15-2022 revealed the facility staff had documented Resident 5 did not have any skin issues. Review of Resident 5's medical record that included CCP's, practitioner orders and Resident 5's Progress notes revealed no indications Resident 5 had pressure ulcers. Observation on 12-20-2022 at 11:08 AM with Licensed Practical Nurse (LPN) C revealed LPN C with the assistance of another staff member positioned Resident 5 onto the left laying position. LPN C had unfastened and pulled down an adult brief revealing Resident 5's right buttock with a an approximate quarter sized open area and the left buttock with a wound area of approximately 0.3 centimeters (cm) wide and 2.4 cm long area that was dark purple and non-blanch-able. On 12-20-2022 at 11:08 AM an interview was conducted with LPN C. During the interview LPN C reported not being aware Resident 5 had skin breakdown as there were no treatments for skin breakdown for Resident 5. LPN C reported the areas to Resident 5's left and right buttocks were pressure ulcers. On 12-20-2022 at 11:12 AM an interview was conducted with Resident 5's family member. During the interview Resident 5's family member reported visiting the resident daily and often assist with doing Resident 5's personal cares. Resident 5's family member reported being aware of the open areas for at least 2 weeks and reported having instructed staff to use a cream for the buttock area. Resident 5's family member further reported staff do not always put the cream on. On 12-20-2022 at 1:10 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported not being aware Resident 5 had a pressure ulcer.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on record review and interview the facility failed to ensure that resident abuse resulting in injury was investigated for 1 resident (Resident 87) and the facility failed to ensure that misappropriation of resident property was investigated for 1 resident (Resident 86). Based on record review and interview, the facility failed to ensure incident investigations were submitted to the state agency within 5 working days. This affected 5 residents (Residents 14, 40, 69, 86, and 87) of 10 residents reviewed. The facility census was 123. Findings are: A) Interview with Resident 87 on 9/30/19 at 10:26 AM occurred in the resident room. A splint was observed in place on the resident's right pinky finger. When asked by this surveyor what happened to the resident's right pinky finger the resident responded that the resident (Resident 87) hit another resident in the head when another resident attempted to kiss the resident (Resident87). Resident 87 confirmed that this was reported to facility staff in (MONTH) (2019). Record review of the nurse progress note for Resident 87 dated 3/5/19 at 10:45 PM revealed that the resident had complained of itching to the small right finger earlier in the evening at 9:00 PM. The finger was swollen, reddish purple in color and painful to touch, ice was applied at that time and continuing to monitor for any changes. Record review of the X-Ray report for Resident 87 dated 3/6/19 revealed that the resident had a [MEDICAL CONDITION] digit (pinky finger) of the right hand. Record review of the facility policy titled Abuse Investigations dated (MONTH) 2014 revealed the Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Step 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state or local laws, with five (5) working days of the reported incident. Interview with the Clinical Services Consultant (CSC) on 9/30/19 at 11:07 AM confirmed that a state report was not completed or submitted for the resident to resident altercation that resulted in a [MEDICAL CONDITION] pinky finger for resident 87. B) Record review of the Progress note for Resident 86 dated 5/26/19 10:19 PM revealed that the family reported that the resident's watch was missing and that it was gold in color. Record review of the Progress note for Resident 86 dated 5/31/19 9:59 AM revealed that the resident's family member was here and reported that they bought the resident a new watch, gave the receipt to Social Services for reimbursement of the lost item and stated that it may have been stolen by a former employee. Record review of the facility grievances revealed an email dated 5/31/19 from the facility Social Services Director (SSD J) to the facility Grievance Officer. The email revealed that Resident 86 was missing a watch since 5/26/19. A resident family member bought a new watch for the resident on 5/31/19 and the receipt was submitted to the business office for reimbursement. Record Review of the facility policy titled Reporting Abuse to Facility Management dated (MONTH) 2014 revealed Step 2 definitions: To help with recognition of incidents of abuse, the following definitions of abuse are provided: Step 2 h. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Interview with the facility Administrator on 9/24/19 at 2:55 PM confirmed that if an item is reported as stolen, it is reported right away. If an item is missing, the facility looks for it to try and find it first. The Administrator confirmed that the facility was unable to provide documentation showing that an investigation was completed and submitted to the state agency within 5 working days. C) Review of Abuse/Neglect Investigation Report Form dated 5/30/19 revealed that on 5/25/19 Resident 14 was walking by Resident 40 when Resident 40 reached out and hit Resident 14 on the arm. No documentation related to submission of the investigation report to the state agency within 5 working days was present. Interview on 9/30/19 at 8:23 AM with the DON (Director of Nursing) revealed the facility was unable to provide documentation showing the investigation was submitted to the state agency within 5 working days. D) Review of Abuse/Neglect Investigation Report Form dated 6/12/19 revealed that on 6/7/19 Resident 69 reported NA-C (Nurse Aide) pushed Resident 69 into a wheelchair while being assisted to the bathroom. No documentation related to submission of the investigation report to the state agency within 5 working days was present. Interview on 9/24/19 at 3:24 PM with CSC (Clinical Services Coordinator) revealed the facility was unable to provide documentation showing the investigation was submitted to the state agency within 5 working days.