Every finding on record at Emerald Nursing & Rehab Columbus

Licensure Reference Number 175 NAC 12-006.18ABased on observations, record review and interviews, the facility failed to ensure resident room walls were free from moisture and a black/gray substance in rooms B-4, B-6 and B-8; failed to ensure walls were free of gouges and bubbling paint in rooms B-2, B-6 and B-12; and failed to ensure walls in room B-10 were clean. The facility census was 69. Findings are: An observation on 5/27/26 at 11:00 AM revealed the following: B-2, dirty vents, with cracks and a small gouge (into the drywall) in the wall. B- 4, outside wall was moist with the grayish color stain appropriately 1 feet by 1 feet resembling mildew or a mold like substance.B- 6, outside wall was moist with a black/gray substance resembling mildew and had several bubbles and cracks in the paint.B-8, outside wall felt moist to touch with a blackish/gray substance appropriately 2 feet by 2 feet resembling mildew or a mold like substance.B- 10, streak/stains going down the outside wall. B-12, cracks in the drywall and streaks down the wall with bubbling paint. A record review of the Tel's (a program to report issues to the maintenance director) revealed there was no report regarding the resident walls for the past 6 months. An environmental tour on 5/28/2026 at 1:00 PM with the Administrator and Maintenance Director confirmed:B-2, dirty vents, with cracks and a small gouge (into the drywall) in the wall. B- 4, outside wall was moist with the grayish color stain appropriately 1 feet by 1 feet resembling mildew or a mold like substance.B- 6, outside wall was moist with a black/gray substance resembling mildew and had several bubbles and cracks in the paint.B-8, outside wall felt moist to touch with a blackish/gray substance appropriately 2 feet by 2 feet resembling mildew or a mold like substance.B- 10, streak/stains going down the outside wall. B-12, cracks in the drywall and streaks down the wall with bubbling paint.An interview with the Administrator on 05/28/2026 at 1:00 PM confirmed that the moisture on the walls in the resident's room have been there for a while and it should have been reported by staff who see's the wall daily. Administered went on to state that this was the first time the walls had been brought to the Administrator and Maintenance Directors' attention.

Licensure Reference Number 175 NAC 12-006.09Based on record reviews, observations and interviews, the facility failed to ensure that medications were administered as ordered by a health care provider for 1 of 3 sampled residents and failed to administer insulin injections per professional standards for 1 of 2 sampled residents The census at the time of the survey was 75. Findings are: ARecord review of the facility's policy titled Medication Administration dated 05/2017 revealed that the purpose of the policy is to ensure that residents are given the correct medication and dosage, at the scheduled time and by the right route (by mouth, injection, in eyes, nose, ears, etc.). Number 15 revealed that documentation of administration must be entered into the Medication Administration Record (MAR) as soon as medication is given and if the medication is not given, a reason for the omission must be documented. Record review of the facility's policy titled Medication Errors dated 11/17/2024 revealed that for each medication that are not administered document the rational as to why medication not administered.Record review of Resident 5's admission Record revealed that the resident was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes (a common form of diabetes that develops especially in adults and most often in obese individuals and that is characterized by high blood sugar resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).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) revealed in Section C-Cognitive Patterns that Resident 5 has a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15 indicating the resident is cognitively intact.Record review of Resident 5's Order Summary (a summary of the resident's medication and treatment orders) dated 04/28/2026 revealed an order for Mounjaro injection (a GLP-1 medication used to treat type 2 diabetes) 15MG to be administered subcutaneously (beneath the skin) every 7 days with a start date of 11/13/2025.Record review of Resident 5's Electronic Medication Administration Record (EMAR, a record of the medication administered during a specified time period) with a print date of 04/28/2026 revealed that Mounjaro injections were not administered on 2 separate dates: 03/12/2026 and 04/02/2026. Interviews on 04/28/2026 at 10:50AM with Resident 5 confirmed that on at least 2 occasions Resident 5 did not receive the Mounjaro injections as ordered. Resident 5 voiced concerns regarding the missing doses as this medication was started after a different diabetes medication was discontinued. Resident 5 reports concerns about a possible increase in blood glucose levels (BGL). Resident 5 reports no confirmation on an increase of BGL as the resident has not been seen by a Primary Care Partitioner (PCP) since the 2 missed injections. Record review of Resident 5's progress notes dated 04/28/2026 revealed no progress notes related to the missed Mounjaro injections for 03/12/2026 and 04/02/2026. Record review of the facility's incident log revealed no medication errors were documented in the facility from 01/28/2026 to 04/28/2026. Interview with the Director of Nursing (DON) on 04/29/2026 at 11:26AM confirmed that Resident 5 did not receive the scheduled Mounjaro injections on 03/12/2026 and 04/02/2026, confirmed that there was no documentation in the resident's progress notes regarding the missed injections for either date, confirmed that the resident's PCP was not notified of missed injections and confirmed that no incident report or medication error report was filed at the time of the incident. The DON revealed future plans for securing all GLP-1 medications as missing medications appear to be an issue. BRecord review of the facility's undated clinical performance check list titled Administer Insulin via Insulin Pen revealed the steps required to administer insulin to residents using an insulin pen (a pen that has been prefilled with insulin). Steps in the checklist revealed that after attaching a new needle onto the insulin pen, the pen is to be primed (a process of removing air bubbles from the needle prior to injection to ensure an accurate dose) by turning the dosage knob (knob used to dial up the correct units of insulin) to the 2 unit indicator. With the pen pointed up, push the knob down to dispense the 2 units. If no insulin is noted from the needle, repeat the primming process. Instructions on how to administer the injection into the resident revealed that after cleansing the injection site, insert the needle with a quick motion, slowly push the injection knob down and hold the pen at the site for 6-10 seconds and then pull the needle out. Observation on 04/28/2026 at 7:35 AM revealed the Licensed Practical Nurse (LPN) gathering the supplies needed to administer insulin to Resident 8. Record review of Resident 8's Order Summary dated 04/28/2026 revealed that Resident 8 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes and revealed orders for 13 units of long-acting insulin to be given every morning and 25 units of the long-acting insulin to be given at night. A short acting insulin is ordered to be given before meals and at bedtime. The order is written as sliding scale and is based on the resident's blood glucose level (BGL) prior to the injection. The LPN verified the number of units ordered for both the long-acting insulin and the short acting insulin based on the resident's BGL. The LPN cleaned the rubber stoper with an alcohol wipe prior to inserting the needle, dialed up the correct doses: 13 units for the long-acting insulin and 7 units for the short acting insulin. The LPN entered the resident's room, cleaned the injection site on the resident's right upper arm, injected the long-acting insulin, pulling the pen out immediately after pressing the plunger down. The LPN then repeated the process with the short acting insulin. The LPN did not prime either of the insulin pens prior to injecting them into the arm of Resident 5 and did not hold either of the insulin pens at the injection site for 6-10 seconds before removing them.Interview with the LPN on 04/28/2026 at 8:27 AM confirmed that neither of the insulin pens were primed prior to dialing up the ordered number of insulin units and confirmed that neither of the insulin pens were held at the injection site for 6-10 seconds after administration. Interview with the DON on 04/29/2026 at 11:26 AM confirmed that it is the facility's expectation that insulin pens be primed prior to use and that the pens are held in place for at least 10 seconds after the plunger injects the insulin to ensure an accurate dose is given.

Licensure Reference Number 175 NAC 12-006.18Based on observation, record review and interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP - an infection control strategy that focuses on prevention of the spread of Multidrug Resistant Organisms (MDRO's) in nursing homes) were followed when cares were provided to 1 out of 3 sampled residents, and the facility failed to ensure hand hygiene with glove changes for 2 out of 3 sampled residents, and the facility failed to clean and sanitize glucose monitor machine when used between 2 residents. The facility census was 75. Findings are:Record review of facility policy dated 1/2024 titled PPE Enhanced Barrier Precautions revealed EBP requires the use of gown and gloves for high-contact resident care activities.Record review of facility policy, titled Infection Control Standard Precautions - Handwashing, dated last revised 1/2024 revealed for staff to perform hand hygiene before and after contact with residents, and before applying gloves and after removal of gloves.A.An observation on 4/28/2026 at 11:03 AM of an EBP sign outside Resident 6's door instructed staff to wear gloves and gown for high contact resident care activities including when providing hygiene and changing briefs.An observation on 4/28/2026 at 11:04 AM Nursing Assistant (NA) - B removed a cylinder from under Resident 6's penis. The resident then rolled to the side and the NA removed the bedpan with gloves on. Peri cares were performed. NA - B did not wear a gown.An observation on 4/28/2026 at 11:05 AM revealed a 3 drawer tub inside Resident 6's room with gowns and gloves available.During an interview on 4/28/2026 at 11:05 AM NA - B revealed (gender) was unaware if it was needed to have on a gown or not when providing pericares for Resident 6.Record review of skin/wound assessment dated [DATE] for Resident 6 revealed Moisture Associated Skin Damage (MASD) to areas on the back of the resident's thighs.Review of Resident 6'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) date initiated 4/2/2024 revealed a history of Methicillin Resistant Staphylococcus aureus (MRSA) and MDRO infection.Record review of Resident 6's CCP revealed an intervention date initiated 7/2/2024 revealed staff to wear gowns and gloves during high-contact resident care activities.During an interview on 4/29/2026 at 9:47 AM Registered Nurse (RN) - A and Infection Preventionist (IP) nurse confirmed that staff do not have to wear gowns when doing peri cares for a resident with EBP for wounds.During an interview on 4/29/2026 at 10:57 AM NA -C confirmed that (gender) does consider peri cares as high contact care but did not think that oral cares would be considered high contact care.During an interview on 4/29/2026 at 10:59 AM NA - D confirmed that (gender) did not know which residents were on EBP or why.During an interview on 4/29/2026 at 11:08 AM RN IP - A confirmed that peri cares would be considered high contact care activities and that staff should wear gowns and gloves when performing peri cares for residents on EBP. During an interview on 4/29/2026 at 1:07 PM Resident 6 confirmed that staff do not wear a gown when they perform pericares, or when they transfer (gender) from the bed to the wheelchair.B.Record review of online facility staff education regarding hand washing and hand hygiene was dated 3/6/2025 and 2/26/2026. An observation on 4/28/2026 at 8:05 AM in the East Dining room revealed MA - E put on gloves and no hand hygiene was performed.During an interview on 4/28/2026 at 8:08 AM MA - E confirmed that (gender) should have washed (gender) hands before putting on gloves.An observation on 4/28/2026 at 8:18 AM MA - F put on gloves to give insulin and no hand hygiene was performed and then changed gloves and no hand hygiene was performed. During an interview on 4/28/2026 at 8:19 AM MA - F confirmed that (gender) should have performed hand hygiene before putting on gloves and when changing gloves.C.An observation on 4/28/2026 at 11:33 AM NA - G and MA - H transferred Resident 7 to toilet and peri cares were performed and the resident's brief was changed. No hand hygiene was performed before putting on gloves or when changing gloves.During an interview on 4/28/2026 at 11:34 AM NA - G confirmed there is not hand sanitizer in the resident's rooms and (gender) did not have any.D.An observation on 4/28/2026 11:42 AM of MA - H put gloves on to perform an accucheck for Resident 7. No hand hygiene was performed.During an interview on 4/28/2026 at 11:44 AM MA - H confirmed that (gender) should have washed (gender) hands before putting gloves on.During an interview on 4/29/2026 at 9:53 AM Administrator (Adm) confirmed there are no EBP or hand washing audits completed with staff.During an interview on 4/29/2026 at 1:29 PM RN Infection Preventionist - A confirmed that it is the facility's expectation for all staff to complete hand hygiene before and after all resident cares, before and after gloving and with glove changing and that hand washing should be completed for at least 20 seconds.E.Record review of the facility's policy titled Blood Sampling-Capillary (Finger Sticks) Level 111 with a revised date of 08/2011 revealed the steps to be taken while obtaining a sample of the resident's blood to be used to measure the resident's blood glucose level (BGL, the amount of sugar in the blood). Steps in the Procedure number 6 revealed Following the manufacturer's instructions, clean and disinfect the glucose monitoring device (glucometer, a small handheld machine used to measure BGL) after each use with 10% bleach preparation. Record review of the facility's policy titled Glucometer Disinfection dated 05/2019 revealed the steps required to properly clean and disinfect a glucometer including using a disinfectant wipe to cleanse the glucometer and allowing at least 5 minutes for the disinfectant to dry. The policy revealed that the purpose of the procedure guide is to prevent the transmission of bloodborne diseases to the residents and the employees.Observations on 04/28/2026 at 7:75AM revealed the Licensed Practical Nurse (LPN) preparing to administer morning medications to Resident 8. The LPN proceeded to obtain Resident 8's BGL after administering the oral medications. The LPN applied gloves, inserted a BG test strip into the glucose monitor, placed a lancet (a small disposable needle used to poke a tiny hole in the skin) to Resident 8's finger and drew blood. The LPN then applied the drop of blood to the test strip. After obtaining Resident 8's BGL, the LPN placed the glucose monitor on top of the medication cart located in the hall and administered the required insulin to Resident 8. The LPN did not clean or disinfect the blood glucose monitor after use with Resident 8. The LPN then proceeded to gather medication for Resident 11, including the dirty, un-sanitized blood glucose monitor. The LPN repeated the steps used with Resident 8 to obtain a BGL for Resident 11, at no time cleaning or disinfecting the monitor between residents as required. After obtaining the BGL, the LPN placed the un-sanitized glucometer in the top drawer of the medication cart. Interview with the LPN on 04/28/2026 at 8:27 AM confirmed that at no time was the glucometer cleaned or disinfected and should have been. Interview with the Director of Nursing (DON) on 04/29/2026 at 11:26 AM revealed that it is the facility's expectation that the glucometers are cleaned and disinfected between each resident use to help prevent the spread of bloodborne illnesses.

Based on observation, record review and interviews, the facility failed to ensure that the Daily Nurse Staff Posting was posted as required. This had the potential to affect all residents residing in the facility. The facility census was 75.Findings are:Record review of the facility policy titled Nurse Staff Posting and dated 1/2024 revealed the nurse staffing information will contain the following information:facility namethe current datefacilities current censusthe total number and actual hours workedThe facility will post the nurse staffing total at the beginning of each shift, and the posted information will be maintained for 18 months.An observation on 4/28/2026 at 9:37 AM during a facility walk through revealed no daily nursing staff posting in the facility.During an interview on 4/28/2026 at 9:37 the Director of Nursing (DON) confirmed the daily nurse posting was not posted anywhere and should have been. During an interview on 4/28/2026 at 9:40 DON confirmed that the facility census was 75 and there is 1 nurse on the floor scheduled for the dayshift and 1 nurse scheduled for the nightshift. During an interview 4/28/2026 at 12:48 PM Regional Nurse Consultant (RNC) confirmed the facility did not perform the required daily staff posting due to turnover in the scheduler position and that it had not been completed for the last 2 weeks.During an interview 4/29/2026 at 8:10 AM Scheduling Coordinator (SC) confirmed that (gender) started in the position on 4/8/2026 and was unaware the daily nurse staffing was to be completed or posted.

Based on observations, interviews, and record reviews, the facility failed to provide comfortable and safe water temperatures in 4 shared bathroom sinks down East Hall. This had the potential to affect the 7 residents who live in rooms 1, 3,5, and 7. The facility census was 85. Licensure Reference Number 175 NAC 1-009.04 (D)(i) An observation and interview conducted with the Maintenance Director on 08/19/2025 at 7:28 AM using a thermometer supplied by the facility revealed water temperatures from the bathroom sinks to be more than 120 degrees Fahrenheit (F, a temperature scale where water freezes at 32 degrees and boils at 212 degrees) in the following bathrooms down East Hall: The shared bathroom between rooms [ROOM NUMBERS] revealed a water temperature of: 126.1 degrees F. The shared bathroom between rooms [ROOM NUMBERS] revealed a water temperature of: 126.9 degrees F. The shared bathroom between rooms [ROOM NUMBERS] revealed a water temperature of: 131 degrees F. The shared bathroom between rooms [ROOM NUMBERS] revealed a water temperature of: 126 degrees F. An interview with the Maintenance Director on 08/19/2025 at 7:35 AM revealed: The facility had installed a new hot water heater about 6 months ago that supplies hot water to both the East and North halls. The Maintenance Supervisor reported that a mixing valve was not placed on the new hot water heater at the time of installation. The water would be hotter in the morning because it hasn't been used yet and that it's coming fresh from the hot water tank. That if the water temperature were to be turned down, it would not be warm enough later in the day. Confirmed that the water temperature should not be hotter than 120 degrees F in the bathroom sinks. The hot water temperatures are tested daily and there is a log but there is no time when the temperatures were taken listed the log. An interview on 08/19/2025 at 8:15 AM with Nursing Assistant (NA-A) revealed that the residents in rooms 3,5, and 7 down East Hall were all able to go into the bathroom unassisted and use the sink. These 3 residents have a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score between 13 and 15, revealing that they are cognitively intact and able to self-protect from the potential injury from hot water. NA-A confirmed that the 4 remaining residents would need staff assistance to access the bathroom. An interview with the Maintenance Director on 08/19/2025 at 9:00 AM stated that the company that installed the new hot water heater was scheduled to come out today to install the mixing valve. A record review of the facilities' Domestic Water Temperature Log daily check on 08/21/2025 at 7:19 AM, dated 03/03 2025, through 08/18/2025, revealed water temperatures ranging between 101.3 degrees F and 116.6 degrees F. The log did not specify exact resident room numbers, only halls (North, laundry, M kitchen, ACU, NE, NAIF) and no time listed as to when the temperatures were taken. No water temperature documentation noted on Saturdays or Sundays between 03/03/2025, and 08/25/2025. An interview on 08/21/2025 at 11:23 AM with the Maintenance Director confirmed that water temperature checks should be done daily in reference to the facility's daily check log and confirmed that they are only done Monday through Friday and not completed on the weekends.

Licensure Reference Number 175 NAC 12-006.17 Based on observations, interview and record review, the facility failed to ensure the nasal cannula was not on the floor for 1 out of 8 sampled residents (Resident 51) to prevent cross contamination. The facility census was 85. Findings are: Record review of Resident 51's admission record dated 8/19/25 revealed resident's admission to the facility was on 7/31/25. Record review of Resident 51's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 8/6/25 revealed:-Section C: BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 15 indicating the resident was cognitively intact.-Section G: uses walker and wheelchair. Needs set up for eating, supervision assists with oral, personal hygiene, toileting hygiene, upper dressing, lower dressing, and footwear. Upper body needs moderate assist, independent with repositioning, and supervision for transfers and walking. Needs moderate assist with bathing. -Section O: O2 (Oxygen) continuous.Record review of Resident 51's Physician's Orders dated 8/19/25 revealed: Oxygen at 2 Liters via nasal cannula continuously to keep sats (saturation) above 90% at all times every shift for shortness of breath -Start Date- 8/06/2025. -Change oxygen cannula and tubing-date and initial as needed for patent -Start Date- 8/06/2025. Observation on 8/19/25 at 8:10 AM Resident 51's oxygen concentrator on and the oxygen tubing was hanging onto the oxygen bottle next to the concentrator. Resident 51 was out of the room. Observation on 8/19/25 at 11:30 AM Resident 51's oxygen concentrator was off and the nasal cannula was laying on the floor beside the concentrator. Resident 51 was out of the room. Observation on 8/19/25 at 1:40 PM Resident 51's oxygen concentrator was off and the nasal cannula was laying on the floor beside the concentrator. Resident 51 was out of the room. An interview on 8/20/25 at 1:00 PM with the Director of Nursing confirmed the oxygen tubing cannula should not be on the floor. Record review of oxygen administration policy dated 9/2024 revealed: The purpose of this procedure is to provide guidelines for safe oxygen administration.-Remove any [NAME] blankets, nylon, and/or [NAME] clothing, etc., from the immediate area where oxygen is to be administered.-Instruct the resident, his/her family, visitors and roommate (if any) of the oxygen safety precautions. Provide the resident with a written copy of the oxygen safety handout. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Record review of Resident 51's care plan dated 8/19/25 revealed:-The resident has functional deficit with current ADL's related to orthostatic hypotension, pain in right hip joint Date Initiated: 8/02/2025.-Resident's needs will be met through anticipation and standards of care daily through next review. Date Initiated: 8/02/2025 Target Date: 10/30/2025-Ambulation: 1 assist with staff-Bed mobility: 1 assist with staff-Wheelchair mobility: 1 assist with staff-Transfer: 1 assist with staff Date Initiated: 8/02/2025, Revision on: 8/05/2025. Record review of Resident 51's diagnoses dated 8/19/25 revealed: Obstructive sleep apnea (a sleep disorder where your airway repeatedly becomes blocked during sleep, causing breathing to pause, often accompanied by loud snoring and gasping), hypoxemia (condition characterized by abnormally low levels of oxygen in the blood), and orthostatic hypotension (a drop in blood pressure that occurs when standing up from a sitting or lying down position).-The resident has oxygen therapy, ineffective gas exchange Date Initiated:8/07/2025 Revision on: 8/13/2025-The resident will have no signs or symptoms of poor oxygen absorption through the review date. Date Initiated: 8/13/2025, Target Date: 10/30/2025-Change residents' position as needed to facilitate lung secretion movement and drainage. Date Initiated: 8/13/2025.-Position resident to facilitate ventilation/perfusion matching: Use upright, high- Fowler's position whenever possible to allow for optimal diaphragm, when on side, the good side should be down (e.g., damaged lung should be up). Date Initiated: 8/13/2025.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, record review, and interview; the facility failed to: 1) utilize the required Personal Protective Equipment (PPE-can include items such as gowns, gloves, masks, goggles, face shields, and foot coverings) when performing direct cares for Residents 3 and 4 who were on Enhanced Barrier Precautions; and 2) complete hand hygiene (hand washing using soap and water or an alcohol based hand rub) and gloving techniques during the provision of a treatment to prevent potential cross contamination during the provision of wound care for Resident 3. The sample size was 5 and the facility census was 79. Findings are: A. Review of the facility policy PPE-Enhanced [NAME] Precautions (EBP) with a revision date of 1/24 revealed EBP are an infection control intervention designed to reduce transmission of resistive organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with wounds or indwelling medical devices. EBP requires the use of gown and gloves only for high-contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care and/or use and wound care). B. Review of the facility policy Handwashing/Hand Hygiene with a revision date of 1/24 revealed the facility considered hand hygiene the primary means to prevent the spread of infections. Handwashing and hand hygiene was to be completed for the following: -when hands were visibly soiled, -before and after coming on duty, -before preparing or handling medications, -before putting on and when taking off gloves, and -before moving from a contaminated body site to a clean body site during resident cares. C. During an observation of resident cares on 8/13/24 at 10:35 AM, Resident 3 was positioned in a wheelchair in the resident's room. A sign on the doorframe of the resident's room indicated the resident was on EBP. Nurse Aide (NA)-D and Medication Aide (MA)-E entered the room to transfer the resident into bed for a dressing change. Both staff completed hand hygiene and placed on gloves but failed to put on gowns. MA-E removed the soiled linens and then proceeded to place clean linens on Resident 3's bed. The full lift (mechanical device that allows residents to be transferred between a bed and a chair using hydraulic power and requires no weight bearing assistance from the resident) was positioned in front of the resident and still without putting on the required PPE, NA-D and MA-E transferred the resident out of the wheelchair and onto the resident's bed. Registered Nurse (RN)-F entered the resident's room, washed hands in the resident's handwashing sink, then placed on a gown and gloves. RN-F removed the dressing from the resident's coccyx area and discarded. Without changing gloves, RN-F sprayed the resident's pressure ulcer with a wound wash, patted dry with gauze and dispensed a moderate amount of barrier cream from the container directly to soiled gloves. RN-F then applied a thick layer of the barrier cream directly to the wound bed. Still without removing soiled gloves, RN-F opened a clean dressing and placed over the coccyx wound. RN-F removed soiled gloves and without washing hands or completing hand hygiene, proceeded to assist MA-E with placing a clean disposable urinary incontinent brief on the resident and adjusting the resident's clothing. D. Observations of resident cares on 8/14/24 at 8:45 AM revealed Resident 4 was lying supine in bed. Resident 4 had a sign on the doorframe of the resident's room which indicated the resident was on EBP. NA-M entered the resident's room washed hands and placed on a clean pair of gloves. NA-M assisted the resident with dressing, transfer into the bathroom, toileting/hygiene cares and changing the resident's urine soiled bed linens without the use of a disposable gown. E. During an interview on 8/14/24 at 2:00 PM, the Director of Nursing (DON) confirmed the following: -Resident 3 was on EBP as the resident had a pressure ulcer to the coccyx. -NA-D and MA-E should have worn a gown as well as gloves when changing the Resident 3's bed and transferring the resident from the wheelchair to the bed. -RN-F should have removed soiled gloves after removing the dressing and applying barrier cream to Resident 3's coccyx, washed hands and placed on clean gloves before putting the clean dressing on the resident's pressure ulcer. -Resident 4 was on EBP due to a pressure ulcer to the resident's right lower leg. -NA-M should have worn gloves and a gown when assisting Resident 4 with direct cares.

Licensure Reference Number: 175 NAC 12-006.09(H)(iii)(2) Based on observation, record review and interview; the facility failed to follow practitioner's orders regarding a dressing change for 1 (Resident 2) of 5 sampled residents. The facility census was 79. Findings are: Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/10/24 revealed the resident was admitted [DATE] with diagnoses of anemia, high blood pressure, diabetes, anxiety, manic depression, and chronic obstructive pulmonary disease. The following was assessed regarding Resident 2: -short- and long-term memory loss with severely impaired decision-making skills, -required total assistance with bed mobility, transfers, dressing, personal hygiene, and toilet use, -feeding tube which provided 51 percent (%) or more of total calories and 501 cubic centimeters (cc) per day or more of average fluid intake, and -had two unhealed stage 3 pressure ulcers (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) on admission. Review of the resident's current Care Plan dated 7/4/24 revealed the resident had actual impairment of skin integrity to the resident's coccyx and bilateral heels as the resident had been bedridden for 28 days in the hospital prior to admission. Review of an Order Summary Report for Resident 2 as of 8/12/24 revealed the resident had an order dated 7/3/24 to cleanse the resident's pressure ulcer to the coccyx with a wound cleanser, and then to apply Triad paste (topical zinc-oxide based paste for wounds with light to moderate levels of drainage which promotes a natural process that uses the body's own enzymes to breakdown dead tissue in wounds) every day and every evening. During an observation of wound care on 8/13/24 at 9:05 AM, Licensed Practical Nurse (LPN)-G washed hands and placed on a clean pair of gloves. No dressing was observed to the resident's pressure ulcer to the coccyx. The pressure ulcer measured approximately 1.5 centimeters (cm) by 2.5 cm with white tissue to the wound bed and pink healing tissue to the outer edges of the wound. LPN-G sprayed a cleanser to the wound bed and patted the area dry. LPN-G applied skin prep (skin protectant that prepares damaged skin for adhesive dressing or protects skin from incontinence or wound drainage) to the edges of the wound and allowed to dry. LPN-G then applied a small amount of Medi-honey (gel/ointment with antibacterial, anti-inflammatory, and debriding effects) directly to staff's glove and placed onto the wound. LPN-G removed gloves and washed hands in the resident's bathroom. During an interview on 8/13/24 at 9:25 AM, LPN-G confirmed completing the wrong dressing change to Resident 2's coccyx pressure ulcer.

Licensure Reference Number NAC 175 12-006.18 Based on record review and interview; the facility failed to implement their legionella water management policy to prevent the potential for water-borne illness. This had the potential to affect all residents. The facility census was 73. Findings are: Review of the facility policy: Legionella (bacteria that causes pneumonia like illness) Water Management Program, last revised 1/2024 revealed the following: -the water management team would consist of at least the infection preventionist, the administrator, the medical director, the director of maintenance, and the director of environmental services, -the purpose was to identify areas in the water system where Legionella bacteria could grow and spread, and to reduce the risk of Legionnaire's disease (severe form of pneumonia), and -the water management program would include the following: a. an interdisciplinary water management team, b. a detailed description and diagram of the water system, c. identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria and the identification of situations that could lead to legionella growth such as stagnation, d. specific measures used to control the introduction and/or spread of Legionella, e. the parameters that were acceptable and were monitored, f. a diagram of where control measures were applied, g. a system to monitor control limits and the effectiveness of control measures, h. a plan for when control limits were not met and/or control measures were not effective, and i. documentation of the program, and j. the water management program would be reviewed at least once a year. Interview on 7/18/24 at 10:50 AM with the Maintenance Director revealed maintenance was not performing any measures to prevent the growth of legionella. Interview on 7/18/24 at 11:45 AM with the Infection Preventionist revealed that the maintenance department was in charge of performing the measures for the preventing the growth of legionella. Interview on 7/18/24 at 2:05 PM with the Administrator confirmed the facility had no documentation that they were taking measures to prevent the growth of legionella and had not implemented their water management policy.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure the kitchen environment, food storage, and preparation equipment were maintained in a manner to prevent the potential for food borne illness. This had the potential to affect all facility residents who ate food prepared by the facility kitchen. The facility census was 73. Findings are: Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -4-602.13 Nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue. -4-601.11(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. -4-601.11(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. -4-903.11(A) cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (2) Where they are not exposed to splash, dust, or other contamination. -6-2-01.11 Cleanability, Floors, Walls, and Ceilings. Except as specified under 6-201.14 and except for anti-slip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. During the initial brief tour of the primary kitchen on 7/15/24 at 7:15 AM the following was identified: The kitchen floor was covered in a sticky substance causing shoes to stick to the floor when walking. -the grout in the floor tiles was covered in food debris, especially on the floor just in front of the steam table in which food is served from. -the floor beneath the refrigerators, working and food prep surfaces, below the ovens, dishwasher, sinks, and all equipment/table legs and the floor base where they sat, were coated with a thick black substance and food debris. The floor beneath the ovens had a thick layer of food debris present. -The surface of the fire suppression system just above the oven was coated in thick brown sticky substance and the paint was peeling away from the metal surface. -The oven doors were coated with burnt on food and the insides of the ovens had a thick layer of black burnt food. -The inside surface, outside door and below the food steamer were coated in a white substance and one steamer was dripping water into a pan beneath the steamer; the water was full to the top of the pan and cloudy colored. -The walls above and adjacent to the oven was covered in a brown colored sticky substance that had been dripping down the walls. -The wall behind a second fire suppression system located above the food steamer also was coated in the brown dripping sticky substance as was one side of the fire suppression system. Pans used for baking food were located directly below the wall and fire suppression system where the sticky substance was seen. -All the facility cooking pots located on a shelf were coated in a thick layer of black carbon build up on the outside surfaces of the pots extending 1/2 way up the pots. -The air return covers throughout the kitchen had chipping paint and rust spots present. -Just below a pan catching the drippings from the food steamer, was a bin of flour and a bin of sugar. The flour bin was noted to have a brown substance dripping inside of the bin from the pan above it, onto the flour turning the flour a brown color. -The sink in the dishwasher room was dripping at a constant slow trickle, the piping beneath the sink was dripping, and a pan was beneath the sink drain catching the dripping water. The water in the pan was milky and cloudy in appearance. -the doors of the reach-in refrigerators were covered in handprints/smears and the lower portions of the refrigerator surfaces were coated with food debris. -The bottom shelf of the reach-in freezer had frozen orange colored liquid present and a box of vegetables (Okra) stuck in the frozen substance. -The dry food storage area had 4 boxes of unpacked food sitting directly on the floor. -The walk-in freezer had 2 boxes of food stored directly on the floor. -Two food service carts used for transporting food within the kitchen were covered in food crumbs and stuck on food debris. -A food cart with a toaster on it was also heavily covered with food debris and crumbs. -Any/all equipment or items with wheels had heavily soiled wheels. During an initial tour of the secondary kitchen on 7/15/24 at 7:55 AM the following was revealed: -The floor in the secondary kitchen was also sticky and the grout was heavily soiled. -The floor beneath the refrigerators, below the steam table, anywhere legs of equipment were on the floor, and the surrounding areas were heavily soiled. -The lid to the ice machine was hanging down on one side and the surfaces of the ice machine was soiled with a white substance and evidence of dripping water. -The ice machine also had chipping paint on the side of it. -The dishwashing room floor and surfaces were also covered in lime build up and the sink drains were heavily coated in a brown substance. During an interview on 7/15/24 at 7:40 AM with the Dietary Manager (DM) revealed the DM had no current certification but was enrolled in classes. The DM confirmed the facility had no evidence they were completing routine cleaning of the environment and the facility equipment. In addition, the DM confirmed the facility sink in the dishwashing room had been leaking for a least 6 months and a request had been submitted to the maintenance department for repair. The DM confirmed that often the deep cleaning was not getting completed due to staffing concerns. During an interview on 7/15/24 at 8:00 AM with Dietary Staff (DS)-A confirmed cleaning often did not happen, as staff did not have time to clean equipment during the course of a work shift. During a tour of the kitchens on 7/15/24 at 10:30 AM the facility Administrator confirmed the condition of the kitchen walls, floors, food preparation/storage equipment, leaking faucets and drains and fluid dripping into the flour bin from the food steamer was not acceptable. In addition, the Administrator confirmed the DM had not completed the required training and was cooking frequently, not allowing for time to ensure the environment and equipment was being adequately maintained. During an interview on 7/18/24 at 2:45 PM the facility Administrator confirmed the Dietary Manager was not certified, was cooking most of the time, and had the facility had no evidence the kitchen environment and equipment was being cleaned on a routine basis.

Licensure Reference Number 175 NAC 12-006.19 (A) Based on observation, and interview, the facility failed to maintain the cleanliness and condition of walls, floors, and a baseboard in 5 (rooms: Northwest 7 and 10, Northeast 4, East 7 and [NAME] 5) of 68 occupied resident rooms and the Northwest corridor between rooms [ROOM NUMBERS]. The facility census was 73. Findings are: Observations on 7/18/24 from 11:30 AM to 12:06 PM, during the environment tour, revealed the following concerns with the facility environment: Northwest corridor -missing base board in the hallway between rooms [ROOM NUMBERS], -room [ROOM NUMBER] with scrapes and gouges and a hole in the drywall approximately 4 by 10 inches underneath of the air conditioning unit and the adjacent wall with gouged/scraped areas, -room [ROOM NUMBER] in the resident's bathroom above the stool was a hole/gouged area in the drywall which measured approximately 4 by 6 inches. Northeast Corridor -room [ROOM NUMBER] had an area underneath of the window with a patch panel that had been screwed into the wall which measured approximately 20 by 32 inches. East Corridor -room [ROOM NUMBER] next to the resident's bed was a hole/gouged area in the drywall which measured approximately 4 x 6 inches. West Corridor -room [ROOM NUMBER] with a transition stop strip between flooring in the resident's room and the corridor. Right side of the strip was loose and no longer affixed to the floor with exposed flooring having a black discoloration with dirt/debris. An interview with the Administrator on 7/18/24 at 11:42 AM confirmed the areas identified on the environment tour needed to be cleaned and/or repaired. During an interview on 7/18/24 at 12:30 PM, the Maintenance Director (MD) indicated the patch panel had been affixed to the wall in room [ROOM NUMBER] on the Northeast corridor as the wall had caved in . The MD reported a Maintenance Request Log was kept on a clip board at the Nurse's Station, but the areas of concern had not been identified prior to the environmental tour of the facility.

Licensure Reference Number 175 12-006.04(H) Based on observation, interview, and record review; the facility failed to ensure they employed a Certified Dietary Manager (CDM) and staffing sufficient to clean the kitchen environment, food preparation equipment and storage equipment in a manner to prevent potential food borne illness. This had the potential to affect all residents who ate food prepared by the facility. The facility census was 73. Findings are: Review of the facility Job Description for Manager of Dining Services dated 10/1/16 revealed the following: -The Dietary Manager managed the operation of the dietary department to include staff, food ordering and preparation, food delivery and clean-up in accordance with facility policies, physician's orders, patient care plans and appropriate regulations. -Ensured food was nutritional, appetizing, prepared per menu and recipes and served in a timely manner. -Ensured equipment and work areas were clean, safe and orderly, ensured strict adherence to procedures regarding cleaners and or hazardous materials or objects, ensured universal precautions and infection control, isolation, fire, safety and sanitation practices and procedures were followed and promptly addressed any hazardous conditions or equipment. During the initial brief tour of the primary kitchen on 7/15/24 at 7:15 AM the following was identified: The kitchen floor was covered in a sticky substance causing shoes to stick to the floor when walking. -the grout in the floor tiles was covered in food debris, especially on the floor just in front of the steam table in which food is served from. -the floor beneath the refrigerators, working and food prep surfaces, below the ovens, dishwasher, sinks, and all equipment/table legs and the floor base where they sat, were coated with a thick black substance and food debris. The floor beneath the ovens had a thick layer of food debris present. -The surface of the fire suppression system just above the oven was coated in thick brown sticky substance and the paint was peeling away from the metal surface. -The oven doors were coated with burnt on food and the insides of the ovens had a thick layer of black burnt food. -The inside surface, outside door and below the food steamer were coated in a white substance and one steamer was dripping water into a pan beneath the steamer; the water was full to the top of the pan and cloudy colored. -The walls above and adjacent to the oven was covered in a brown colored sticky substance that had been dripping down the walls. -The wall behind a second fire suppression system located above the food steamer also was coated in the brown dripping sticky substance as was one side of the fire suppression system. Pans used for baking food were located directly below the wall and fire suppression system where the sticky substance was seen. -All the facility cooking pots located on a shelf were coated in a thick layer of black carbon build up on the outside surfaces of the pots extending 1/2 way up the pots. -The air return covers throughout the kitchen had chipping paint and rust spots present. -Just below a pan catching the drippings from the food steamer, was a bin of flour and a bin of sugar. The flour bin was noted to have a brown substance dripping inside of the bin from the pan above it, onto the flour turning the flour a brown color. -The sink in the dishwasher room was dripping at a constant slow trickle, the piping beneath the sink was dripping, and a pan was beneath the sink drain catching the dripping water. The water in the pan was milky and cloudy in appearance. -the doors of the reach-in refrigerators were covered in handprints/smears and the lower portions of the refrigerator surfaces were coated with food debris. -The bottom shelf of the reach-in freezer had frozen orange colored liquid present and a box of vegetables (Okra) stuck in the frozen substance. -The dry food storage area had 4 boxes of unpacked food sitting directly on the floor. -The walk-in freezer had 2 boxes of food stored directly on the floor. -Two food service carts used for transporting food within the kitchen were covered in food crumbs and stuck on food debris. -A food cart with a toaster on it was also heavily covered with food debris and crumbs. -Any/all equipment or items with wheels had heavily soiled wheels. During an initial tour of the secondary kitchen on 7/15/24 at 7:55 AM the following was revealed: -The floor in the secondary kitchen was also sticky and the grout was heavily soiled. -The floor beneath the refrigerators, below the steam table, anywhere legs of equipment were on the floor, and the surrounding areas were heavily soiled. -The lid to the ice machine was hanging down on one side and the surfaces of the ice machine was soiled with a white substance and evidence of dripping water. -The ice machine also had chipping paint on the side of it. -The dishwashing room floor and surfaces were also covered in lime build up and the sink drains were heavily coated in a brown substance. During an interview on 7/15/24 at 7:40 AM with the Dietary Manager (DM) revealed the DM had no current certification but was enrolled in classes. The DM confirmed the facility had no evidence they were completing routine cleaning of the environment and the facility equipment. In addition, the DM confirmed the facility sink in the dishwashing room had been leaking for a least 6 months and a request had been submitted to the maintenance department for repair. The DM confirmed that often the deep cleaning was not getting completed due to staffing concerns. During an interview on 7/15/24 at 8:00 AM with Dietary Staff (DS)-A confirmed cleaning often did not happen, as staff did not have time to clean equipment during the course of a work shift. During a tour of the kitchens on 7/15/24 at 10:30 AM the facility Administrator confirmed the condition of the kitchen walls, floors, food preparation/storage equipment, leaking faucets and drains and fluid dripping into the flour bin from the food steamer was not acceptable. In addition, the Administrator confirmed the DM had not completed the required training and was cooking frequently, not allowing for time to ensure the environment and equipment was being adequately maintained. During an interview on 7/18/24 at 2:45 PM the facility Administrator confirmed the Dietary Manager was not certified, was cooking most of the time, and had the facility had no evidence the kitchen environment and equipment was being cleaned on a routine basis.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i) Based on observations, record review and interviews; the facility failed to implement fall interventions and to revise current interventions and/or develop new intervention to prevent ongoing falls for Resident 69. The sample size was 5 and the census was 73. Findings are: A. Review of the facility policy Falls Management with a revision date of 1/24 revealed the residents were to be assessed to determine fall risk and then the interdisciplinary team (IDT) were to identify and implement appropriate interventions to reduce the risk of falls or injuries. The following procedures were indicated: -assess the resident's fall risk at admission, quarterly, with a change in condition or a fall. -implement goals and interventions based on the individual's needs. -communicate interventions to the team. -educate the staff, resident, and responsible party regarding interventions. -provide training to staff as needed and document. B. Review of Resident 69's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/26/24 revealed diagnoses of adult failure to thrive, previous heart attack with rapid, irregular heartrate and pain. The following was assessed regarding the resident: -cognition was moderately impaired, -displayed behaviors which included verbal and physical behaviors directed at others, other behavioral symptoms (hitting or scratching self, pacing, rummaging, public sexual acts, throwing or smearing food or bodily wastes or verbal/vocal sounds) not directed at others and rejection of cares, -dependent with dressing, bed mobility and transfers, and -one fall without injury since the previous assessment. Review of Fall Scene Investigation Reports for Resident 69 revealed the following: -4/22/24 at 12:30 AM the resident was found sitting on the foot pedals of the wheelchair in the resident's room. Interventions in place included the resident's call light was in reach and the resident wore non-skid footwear. The resident indicated wanting to go to bed and had tried to transfer self. A new intervention was identified to ask the resident earlier in the shift if ready to go to bed and to provide assist when ready. -5/9/24 at 9:51 AM the resident was found on the floor next to the resident's bed. The call light was in reach and the resident wore gripper socks. Interventions to place the resident's bed in the lowest position and for a fall mat to be placed next to the bed were identified. -5/21/24 at 8:20 AM the resident was found on the floor next to the bed. The investigation indicated an alarm was sounding at the time of the fall, the resident's call light was in reach and the resident was wearing non-skid footwear. Further review of the investigation revealed no evidence the fall mat was on the floor next to the resident's bed or if the bed had been placed in the lowest position. A new intervention was identified for positioning bars to be placed on the bed. -5/31/24 at 5:24 AM the resident was found on the floor in the resident's room between the bed and the bathroom. Further review of the investigation revealed no documentation to indicate if the resident's bed had been placed in the lowered position, if the repositioning bars were placed on the bed, and if an alarm and/or the fall mat were utilized. In addition, there was no documentation to indicate a new intervention was developed to prevent further falls. -6/18/24 at 5:42 AM the resident was lying on the floor next to the bed in the resident's room. The report indicated the bed had not been placed in the lowered position and there was no evidence the fall mat was in place at the time of the fall. There were no revisions of current interventions or evidence additional interventions were developed. -6/23/24 at 4:35 PM the resident was found on the floor between the nightstand and the resident's bed. The report identified a fall alarm was to be placed on the resident's bed (investigation dated 5/21/24 at 8:20 AM indicated an alarm was in place and sounding) and a Medication review was to be conducted. Observations of Resident 69 in the resident's room revealed the following: -7/15/24 at 10:11 AM, 10:25 AM and 11:45 PM the resident was seated in the wheelchair. A sensor pad fall alarm (electronic pressure sensitive pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) was positioned on the resident's bed and a second alarm had been placed on the bedside dresser. No alarm had been placed on the resident's wheelchair. The resident's call light cord was pooled on the floor behind the resident and not within reach for the resident to utilize. -7/15/24 at 2:05 PM the resident was lying in bed. The bed had been placed in the lowered position, a sensor pad fall alarm was in place as well as repositioning bars to the bed and the call light was in reach. However, no fall mat was in place on the floor next to the resident's bed. -7/16/24 at 11:00 AM the resident was seated in a wheelchair to the left side of the resident's bed with the sensor pad fall alarm in place. The call light was secured to the positioning bar which was located on the right side of the bed and was not in easy reach of the resident. Interview with Nurse Aide (NA)-S on 7/16/24 at 11:40 AM revealed the resident was to have the call light within reach and was to have the sensor pad fall alarm always on to prevent further falls. NA-S was uncertain as to use of the fall mat and confirmed there was no fall mat in the resident's room. Interview with the Director of Nursing (DON) on 7/17/24 at 2:13 PM verified the following: -new interventions were developed for use of a fall mat next to the resident's bed and for the resident's bed to be placed in the lowered position after the resident's fall on 5/9/24 at 9:51 AM. -no new interventions were developed after the resident's fall on 5/31/24 at 5:24 AM. At some point, the DON had removed the fall mat from the resident's room as the DON felt this was too great of a trip hazard for the resident. However, there was no documentation as to when the fall mat was removed. -the resident's bed had not been placed in the lowered position prior to the resident's fall on 6/18/24 at 5:42 AM. There was no documentation to determine if the staff had received education regarding implementation of the intervention. No further fall interventions were developed and/or implemented.

Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications related to long term use of an antibiotic medication for Resident 22. The antibiotic did not specify a duration and had no supporting documentation for clinical use based on laboratory results. The sample size was 2 and the facility census was 73. Findings are: A. Review of the facility Antibiotic Stewardship Policy dated 11/17 revealed the following: -the purpose of the program was to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. -antibiotic stewardship was to be part of the Infection Control Program. -the facility was to track antibiotic use daily. -all nurses were to be educated regarding proper assessment for infection prior to calling a physician. -the facility was to ensure the pharmacy reviewed all antibiotic usage for appropriateness. -the facility would monitor for any adverse reactions/outcomes related to use of antibiotics. B. Review of Resident 22's medical record revealed the following: -4/5/23 at 10:35 AM the resident was seen by the urologist due to use of an indwelling Foley catheter. Urine in the drainage bag appeared cloudy and a new order was received to start Cefadroxil (antibiotic used to stop the growth of bacteria) 500 milligrams (mg) daily indefinitely. -4/25/23 at 11:28 PM the indwelling Foley catheter was removed per order of the urologist. -4/26/23 at 8:10 AM the resident was out of the facility at the urologist. Further review revealed no evidence the urologist addressed the continued use of the Cefadroxil 500 mg daily. -5/22/23 the consultant pharmacist completed a monthly medication review and requested the resident's physician address the continued daily use of the Cefadroxil 500 mg daily. -6/5/23 the resident's primary physician indicated use of the Cefadroxil should be addressed at the resident's urology appointment on 7/12/23. -7/12/23 the resident was seen by the urologist. Review of the resident's medical record revealed no evidence the continued use of the Cefadroxil 500 mg daily was assessed. -3/7/24 at 12:18 PM a Nursing Progress Note indicated the resident had a urinalysis collected due to the resident's complaints of pain and burning with urination. -4/19/24 a facsimile (fax) was sent to the resident's primary physician regarding the continued use of the Cefadroxil since 2023. -4/22/24 the resident's primary physician again refused to address use of the Cefadroxil indicating the medication had been ordered by the urologist. -5/22/24 at 11:15 AM the resident was seen by the urologist. The urologist was asked if continued use of the Cefadroxil was warranted and if so, what diagnosis should be used. Review of the Physician Visit form revealed the urologist did not address the diagnosis or the continued use of the Cefadroxil but indicated a urine culture was pending. -6/4/24 a new order was received for Amoxicillin (antibiotic used to treat bacterial infections) 875 mg take 1 tablet twice a day for 14 days. Review of the resident's Medication Administration Record (MAR) dated 7/24 revealed the resident continued to receive the Cefadroxil 500 mg daily indefinitely which was ordered 4/6/23 for history of urinary tract infections. An interview with the Infection Preventionist dated 7/18/24 at 10:01 AM confirmed the following: -the resident was started on the Cefadroxil 500 mg daily by the urologist 4/5/24. At the time the resident was seen by the urologist, the resident had an indwelling Foley catheter and at the appointment, the resident's urine was cloudy. However, there was no urinalysis completed at the office prior to the initiation of the antibiotic. -per the urologist the resident's indwelling catheter was discontinued 4/25/23. -5/22/23 the consultant pharmacist reviewed the resident's medications and made a recommendation to address the long-term use of the antibiotic based on the potential harm associated with long-term use. -6/5/23 the resident's primary physician indicated the resident should continue the antibiotic and use of the medication should be addressed by the urologist. -seen by the urologist 7/12/23 and use of the antibiotic was not addressed by the urologist. -the resident had a urinalysis completed 3/7/24 due to complaints of burning when the resident voided but there was no evidence of an infection. -4/19/24 the consultant pharmacist again addressed use of the antibiotic. -4/22/24 the primary physician refused to address use of the antibiotic and indicated use should be reviewed by the urologist. -5/22/24 seen by the urologist and a urinalysis was obtained. Though the facility asked about the continued use of the Cefadroxil, the urologist again failed to address and indicated the office was waiting for the culture report. -6/3/24 the facility had not heard any information regarding the impending culture of the urinalysis obtained 5/22/24 and attempted to contact the urologist. -6/4/14 a new order was received for Amoxicillin 875 mg take 1 tablet every 12 hours for 14 days. -the resident continued to receive the Cefadroxil without a stop date.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5 percent (%). Observations of 27 medications administered revealed 6 errors resulting in an error rate of 22.22%. The medication errors were related to 3 (Residents 5, 19 and 68) of 6 residents. The facility staff identified a census of 73. Findings are: A. Review of the facility policy Medication Errors with a revision date of 1/24 revealed the facility was to ensure residents were free of medication error rates of 5% or greater. A medication error was defined as the observed or identified preparation or administration of medications which were not in accordance with the prescriber's order or the manufacturers specifications regarding the preparation and administration of the medication. B. Review of Resident 5's Medication Administration Record (MAR) dated 7/2024 revealed the resident had an order dated 4/13/23 for Metformin (medication used to treat diabetes) 1000 milligrams (mg) to take 1 tablet twice a day with food. Observations on 7/17/24 revealed the following: -7:45 AM Licensed Practical Nurse (LPN)-G administered the Metformin to Resident 5 in the resident's room. The resident was not offered food when the medication was administered. -8:30 AM (45 minutes later) the resident was in the dining room and was served the breakfast meal. C. Review of Resident 19's MAR dated 7/2024 revealed the following orders: -Glimepiride (medication used to treat diabetes) 4 mg 1 tablet daily to take with food ordered 10/27/22, -Metformin 100 mg take 1 tablet daily with food ordered 10/27/22, -Potassium Chloride 20 milliequivalents take 1 tablet with a full glass of water and take with food ordered 11/28/22, and -Aspirin 81 mg take 1 tablet daily with food ordered 11/28/22. Observations on 7/17/24 revealed the following: -7:23 AM LPN-P administered the Glimepiride, Metformin, Potassium Chloride, and the Aspirin to Resident 19 in their room. The medications were not administered with food and the resident did not receive a full glass of water with the medications. -8:43 AM (1 hour and 10 minutes later) the resident was in the dining room and was served the breakfast meal. D. Review of Resident 68's MAR for 7/2024 revealed the resident had an order dated 5/23/24 for Meloxicam (anti-inflammatory medication used to treat arthritis) 15 mg 1 tablet daily. The order further indicated the medication was to be taken with food. Observation on 7/17/24 revealed the following: -7:15 AM LPN-P administered the Meloxicam to Resident 68 in the resident's room. The resident was not offered food at the time the medication was administered. -8:35 AM (1 hour and 15 minutes later) the resident was served their breakfast meal in the dining room. E. During an interview on 7/17/24 at 1:58 PM, the Director of Nursing (DON) verified Residents 5, 19, and 68 should have received their medications with food and staff should have administered during the breakfast meal.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to ensure room trays were palatable and served at the proper temperature. This affected 2 (Residents 34 and 66) of 4 residents served a breakfast room tray. The facility staff identified a census of 73. Findings are: A. Review of the facility Beginning Food Cooking Temperatures log (form used to document food temperatures before each meal service) revealed the serving temperatures of all hot food was to be a minimum of 140 degrees Fahrenheit (F) before serving to the residents. Further review of the log revealed on 7/15/24 at the breakfast meal the scrambled eggs had a temperature of 182 degrees. B. Observations on 7/15/24 revealed the following: -8:10 AM a serving cart was positioned next to the Nurse's Station by the [NAME] corridor. The cart contained 4 breakfast room trays with a thermal cover over each of the plates. -8:50 AM (40 minutes later) Nurse Aide (NA)-S approached the cart, removed one of the trays and deliver the room tray to Resident 34. NA-S removed the thermal covering and revealed a serving of scrambled eggs. -9:00 AM Dietary Aide (DA)-dd obtained a temperature of 78 degrees F for the scrambled eggs. -9:02 AM Resident 66 had also received a breakfast room tray which contained scrambled eggs which had a temperature of 74 degrees F. An interview with DA-dd on 7/15/24 at 9:10 AM confirmed the scrambled eggs should have been a minimum of 140 degrees F before being served to the residents. DA-dd reported the breakfast room trays had been prepared somewhere between 7:30 AM to 7:45 AM that morning and the kitchen staff then placed them by the Nurse's Station for the Nursing staff to distribute. .

Licensure Reference Number NAC 175 NAC 12-006.04C Based on record review and interview; the facility failed to provide sufficient nursing staff for the provision of bathing for Residents 1, 4, and 5. The sample size was 3 and the facility census was 73. This had the potential to affect all residents. Findings are: A. During confidential Resident interview conducted on 4/30/24 at 10:20 AM the resident revealed not receiving baths on a regular schedule. Further interview revealed the resident had gone 3 weeks without a bath in February and the resident told the facility they would like to have 2 baths weekly. When the resident complained, the resident was told the bath aide was on vacation and that staff had called in. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated tool used in care planning) dated 3/21/24 revealed the resident had severe cognitive impairment; had diagnoses of aphasia (language disorder caused by brain damage that affects the ability to understand or express speech), stroke, seizure disorder, anxiety, and psychotic disorder; and required total assistance with bathing. Review of Resident 1's Care Plan last revised 7/12/23 revealed the resident had a bathing preference of once a week and required 1-2 assist. Review of Resident 1's Bathing Documentation 11/1/23 through 4/30/24 revealed the following bath time frames were greater than 7 days apart: -11/4/23 through 11/15/23 (11 days apart), -11/15/23 through 11/30/23 (15 days apart), -11/30/23 through 12/9/23 (9 days apart), -12/9/23 through 12/30/23 (21 days apart), -12/30/23 through 1/28/24 (29 days apart), -1/28/24 through 2/10/24 (13 days apart), -2/24/24 through 3/9/24 (13 days apart), -3/9/24 through 3/19/24 (10 days apart), -3/19/24 through 3/27/24 (8 days apart), -3/27/24 through 4/6/24 (10 days apart), -4/6/24 through 4/16/24 (10 days apart), and -4/20/24 through 4/30/24 (10 days since last bath). C. Review of Resident 4's MDS dated [DATE] revealed the resident was cognitively intact; had diagnoses of Cerebral Palsy, depression, and pain; and required moderate assistance with bathing. Review of Resident 4's Care Plan last revised 7/19/23 revealed the resident required assistance of 1 with bathing and preferred a shower once a week. Review of Resident 4's Bathing Documentation 11/1/23 through 4/30/24 revealed the following bath time frames were greater than 7 days apart: -11/15/23 through 12/6/23 (21 days apart), -12/20/23 through 1/3/24 (14 days apart), -1/10/24 through 1/24/24 (14 days apart), and -2/7/24 through 2/28/24 (21 days). D. Review of Resident 5's MDS dated [DATE] revealed the resident had severe cognitive impairment, was dependent with bathing, and diagnoses of type 2 Diabetes, high blood pressure, Alzheimer's disease, dementia, anxiety, and depression. Review of Resident 5's Care Plan last revised 9/19/22 revealed the resident required 1 assist with bathing and preference to receive a shower once a week. Review of Resident 5's Bathing Documentation 11/1/23 through 4/30/24 revealed the following bath time frames were greater than 7 days apart: -11/4/23 through 11/14/23 (10 days apart), -11/14/23 through 11/25/23 (11 days apart), -12/2/23 through 12/16/24 (14 days apart), -12/16/24 through 12/30/23 (14 days apart), -1/6/24 through 1/27/24 (21 days apart), -1/27/24 through 2/10/24 (14 days apart), -3/23/24 through 4/6/24 (14 days apart), -4/6/24 through 4/16/24 (10 days apart), and -4/20/24 through 4/30/24 (10 days since last bath). E. Review of the untitled facility form for the nursing assignments from 11/1/23 through 4/30/24 revealed the following dates did not have a bath aide scheduled: -11/3/23, 11/17/23, 11/20/23, 11/3/24, -12/1/23, 12/5/23, 12/10/23, 12/21/23, 12/23/23, 12/24/23, 12/26/23, 12/27/23, 12/28/23, -1//24, 1/2/24, 1/8/24, 1/9/24, 1/12/24, 1/13/24, 1/20/24, 1/21/24, -2/3/24, 2/4/24, 2/14/24, 2/16/24, 2/18/24, -3/3/24, 3/8/24, 3/16/24, 3/17/24, 3/22/24, 3/30/24, 3/31/24, and -4/5/24, 4/13/24, 4/14/24, 4/18/24, 4/19/24, 4/27/24, 4/30/24. Review of the nursing assignments on the day sheets revealed the following dates had 2 or more staff did not report to work: -11/6/54, 11/7/24, 11/10/24, 11/12/24, 11/13/24, 11/16/24, 11/19/24, 11/22/24, 11/23/24, 11/24/24, 11/26/24, 11/27/24, 11/28/24, -12/2/24, 12/3/24, 12/4/24, 12/6/24, 12/9/24, 12/10/24, 12/13/24, 2/15/24, 12/16/24, 12/17/24, 12/20/24, 12/21/24, 12/25/24, 12/26/24, -1/1/24, 1/3/24, 1/10/24, 1/11/24, 1/12/24, 1/13/24, 1/14/24, 1/15/24, 1/20/24, 1/21/24, 1/24/24, 1/30/24, -2/3/24, 2/6/24, 2/23/24, 2/24/24, -3/3/24, and -4/20/24, 4/29/24. F. Interviews completed from 4/30/24 from 10:10 AM through 2:55 PM with Licensed Practical Nurse (LPN)-C, Medication Aide (MA)-D, MA-E, LPN-F, Nursing Assistant (NA)-G, MA-H, LPN-I, NA-J, and NA-K revealed that residents were to be getting baths at least once every 7 days but that was not always happening due to staffing. Interview on 5/1/24 at 10:40 AM with the Administrator confirmed the expectation was that residents were to be getting baths weekly and residents 1, 4, and 5 were not getting baths completed weekly. Further interview revealed that if 2 or more staff called in then the bath aide was pulled to the floor.

Licensure Reference Number 175 NAC 12-006.09D1c Based on record review and interview; the facility failed to provide bathing services for Residents 1, 4, and 5. The sample size was 3 and the facility census was 73. This had the potential to affect all residents. Findings are: A. Review of the facility policy Activities of Daily Living (ADL's), last revised 1/2024 revealed the following: -the facility would ensure a resident's ADL's would not deteriorate unless deterioration was unavoidable which included bathing, dressing, grooming, transferring, ambulate, toilet use, eating and speech, and -a resident who was unable to carry out ADL's would receive the necessary services to maintain good nutrition, grooming, personal hygiene, and oral hygiene. B. During a confidential Resident interview conducted on 4/30/24 at 10:20 AM the resident revealed not receiving baths on a regular schedule. Further interview revealed the resident had gone 3 weeks without a bath in February and the resident told the facility they would like to have 2 baths weekly. When the resident complained, the resident was told the bath aide was on vacation and that staff had called in. C. Review of Resident 1's Minimum Data Set (MDS-a federally mandated tool used in care planning) dated 3/21/24 revealed the resident had severe cognitive impairment; had diagnoses of aphasia (language disorder caused by brain damage that affects the ability to understand or express speech), stroke, seizure disorder, anxiety, and psychotic disorder; and required total assistance with bathing. Review of Resident 1's Care Plan last revised 7/12/23 revealed the resident had a bathing preference of once a week and required 1-2 assist. Review of Resident 1's Bathing Documentation 11/1/23 through 4/30/24 revealed the following bath time frames were greater than 7 days apart: -11/4/23 through 11/15/23 (11 days apart), -11/15/23 through 11/30/23 (15 days apart), -11/30/23 through 12/9/23 (9 days apart), -12/9/23 through 12/30/23 (21 days apart), -12/30/23 through 1/28/24 (29 days apart), -1/28/24 through 2/10/24 (13 days apart), -2/24/24 through 3/9/24 (13 days apart), -3/9/24 through 3/19/24 (10 days apart), -3/19/24 through 3/27/24 (8 days apart), -3/27/24 through 4/6/24 (10 days apart), -4/6/24 through 4/16/24 (10 days apart), and -4/20/24 through 4/30/24 (10 days since last bath). D. Review of Resident 4's MDS dated [DATE] revealed the resident was cognitively intact; had diagnoses of Cerebral Palsy, depression, and pain; and required moderate assistance with bathing. Review of Resident 4's Care Plan last revised 7/19/23 revealed the resident required assistance of 1 with bathing and preferred a shower once a week. Review of Resident 4's Bathing Documentation 11/1/23 through 4/30/24 revealed the following bath time frames were greater than 7 days apart: -11/15/23 through 12/6/23 (21 days apart), -12/20/23 through 1/3/24 (14 days apart), -1/10/24 through 1/24/24 (14 days apart), and -2/7/24 through 2/28/24 (21 days). E. Review of Resident 5's MDS dated [DATE] revealed the resident had severe cognitive impairment, was dependent with bathing, and diagnoses of type 2 Diabetes, high blood pressure, Alzheimer's disease, dementia, anxiety, and depression. Review of Resident 5's Care Plan last revised 9/19/22 revealed the resident required 1 assist with bathing and preference to receive a shower once a week. Review of Resident 5's Bathing Documentation 11/1/23 through 4/30/24 revealed the following bath time frames were greater than 7 days apart: -11/4/23 through 11/14/23 (10 days apart), -11/14/23 through 11/25/23 (11 days apart), -12/2/23 through 12/16/24 (14 days apart), -12/16/24 through 12/30/23 (14 days apart), -1/6/24 through 1/27/24 (21 days apart), -1/27/24 through 2/10/24 (14 days apart), -3/23/24 through 4/6/24 (14 days apart), -4/6/24 through 4/16/24 (10 days apart), and -4/20/24 through 4/30/24 (10 days since last bath). F. Interviews completed from 4/30/24 from 10:10 AM through 2:55 PM with Licensed Practical Nurse (LPN)-C, Medication Aide (MA)-D, MA-E, LPN-F, Nursing Assistant (NA)-G, MA-H, LPN-I, NA-J, and NA-K revealed that residents were to be getting baths at least once every 7 days but that was not always happening due to staffing. Interview on 5/1/24 at 10:40 AM with the Administrator confirmed the expectation was that residents were to be getting baths weekly and residents 1, 4, and 5 were not getting baths completed weekly.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, record review and interview, the facility failed to ensure interventions were implemented to prevent a potential burn injury from a hot liquid spill for 2 residents (Resident 1 and 2). The sample size was 3 and the facility census was 77. Findings are: A. Review of Resident 1's electronic medical record revealed the following: -The resident was admitted to the facility on [DATE], was cognitive, independent with eating and had diagnoses of Diabetes Mellitus, Chronic Kidney Disease, weakness and Nutritional Deficiency. -Progress Note dated 9/17/23 at 11:41 PM, revealed the resident spilled a cup of hot tea onto self during breakfast. The resident had several areas of blisters located on both inner thighs that required a treatment of Silvadene Cream (a topical antimicrobial drug use for the prevention and treatment of wound infections in patients with second- and third- degree burns) twice a day. -The undated Care Plan indicated there was an itervention for lids to hot liquids initiated on 9/17/23. Review of Resident 1's diet card dated 10/4/23 indicated the resident should have lids for all hot liquids. An observation of Resident 1 in the dining room on 10/4/23 at 8:35 AM, revealed the resident was seated at the table with a mug that was 3/4 empty and no lid was on the mug or located on the table. The resident also confirmed [gender] had hot tea in the mug. An interview with Nurse Aide (NA)-E on 10/4/23 at 8:37 AM confirmed Resident 1 was served hot tea and there was no lid on the mug. NA-E also confirmed the resident's diet card indicated the resident should have had a lid on the mug. B. Review of Resident 2's undated Care Plan revealed the resident was at risk for Hot Liquid Injury related to impaired cognition and upper extremity weakness with a revised date of 6/20/23. There was also an intervention that indicated the resident was to have lids on all hot liquid containers. Review of Resident 2's diet card dated 10/4/23 revealed the resident was to have a 2 handled cup with llids for all HOT liquids. An observation of Resident 2 on 10/4/23 at 08:45 AM, revealed the resident was seated in the dining room and had a mug with a hot beverage on the table in front of the resident without a lid. An interview with dietary cook-A on 10/4/23 at 08:45 AM confirmed Resident 2 was served hot coffee and did not have a lid on the mug. Cook-A also confirmed the resident's diet card indicated [gender] should have had a lid for the hot coffee.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record reviews, interviews, and record review, the facility failed to provide a safe environment to prevent resident-to-resident abuse which involved 2 (Resident #44 and Resident #45) of 4 residents reviewed for abuse. Findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, created May 2017, revealed, It is the policy of (Facility) that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. A review of Resident #45's Admission Record indicated the facility admitted the resident on 03/16/2021 with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety, abnormalities of gait and mobility, and age-related osteoporosis without current pathological fracture. Review of Resident #45's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/17/2023, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had verbal behavioral symptoms directed toward others for one to three days during the assessment period. A review of Resident #45's care plan with an initiated date of 03/16/2021 and a revision date of 08/04/2023, revealed the resident had the potential for a decline in mood and behavior. An intervention initiated on 06/24/2022, directed the staff to remove the resident from crowded areas or public spaces if the resident called other people names and provide an alternative activity or distraction of the resident's preference. An intervention initiated on 04/20/2023, directed the staff to redirect the resident from wandering into other residents' rooms. A review of Resident #44's Admission Record indicated the facility admitted the resident on 04/07/2023 with diagnoses that included anxiety disorder and major depressive disorder. Review of Resident #44's admission MDS, with an ARD of 04/14/2023, revealed Resident #44 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not exhibit any behavioral symptoms during this assessment period. A review of Resident #44's care plan with an initiated date of 04/07/2023, revealed the resident had impaired cognitive function/dementia or impaired thought processes and had poor short term memory. A review of a Resident to Resident, document dated 04/27/2023, indicated on 04/20/2023 at 7:15 PM, Resident #45 was being wheeled around in their wheelchair by another resident (who was not involved in the altercation) and was wheeled into Resident #44's room, which caused Resident #44 to become agitated. Per the document, Resident #44 hit Resident #45 with a closed fist on the left side of their face. Medication Aide (MA) A was present in the room at the time, attempted to intervene by redirecting Resident #45 out of Resident #44's room just prior to the hit in the face, but was unable to separate the residents fast enough. MA A got between Resident #44 and Resident #45 and removed Resident #45 from the room. Charge Nurse, Licensed Practical Nurse (LPN) F, was alerted to the area. Resident #45's face was examined by LPN F, and there were no signs/symptoms of injury noted. According to the document, this was an isolated event and the immediate steps taken to protect the residents included the separation of both residents, assessment for injury, residents kept in separate areas for the rest of the evening, and a stop sign placed on Resident #44's door to discourage other residents from entrance. A review of a Resident to Resident, dated 08/02/2023, indicated on 07/27/2023, Resident #45 was in the commons area, near the kitchenette, when Resident #44 came out of their room for another cup of coffee. MA A filled Resident #44's cup with coffee. When MA A turned back to Resident #44 and Resident #45, Resident #44 was in front of Resident #45, about an arm's length away, and Resident #44 raised their arm with the coffee cup spilled some of the coffee on top of Resident #45's leg purposefully, which had a temperature of 102 degrees Fahrenheit. MA A took the coffee cup from Resident #44 and asked them to leave the area. Resident #44 left and went to their room. MA A then rolled up Resident #45's pants and checked the resident's leg. MA A wiped Resident #45 and called LPN E. MA A asked Resident #45 if it hurt, and Resident #45 responded, no, that it was okay, and commented on their wet pants. Resident #44 left their room and told MA A it was an accident. LPN E assessed Resident #45 leg, and no injuries were noticed. According to the document, the immediate steps taken to protect the residents included the removal of the cup of coffee from Resident #44, the separation of the residents for the rest of the evening and night, the cleanup of spill, and assessment of the resident by the nurse. Per the document, the preventative measure put into place by the facility revealed the facility purchased a lidded cup for Resident #44 and the education of staff to utilize the cup, monitor the resident while drinking coffee, and the potential for resident to resident altercation. On 08/15/2023 at 3:18 PM, an interview was attempted with Resident #45; however, the resident was not interviewable due to their cognitive status. In an interview on 08/16/2023 at 1:45 PM, Resident #44 stated they did not remember having a confrontation with any resident. During a telephone interview on 08/16/2023 at 8:47 PM, MA A indicated they had just started their shift, and Resident #44 asked for a cup of coffee. MA A indicated they poured Resident #44 a cup of coffee, and during that time, Resident #45 was mouthing off to Resident #44. MA A said they turned their back for two seconds to get Resident #45 a snack to calm them down, and Resident #44 poured coffee over Resident #45's leg. MA A said they asked Resident #44 to leave the area. MA A indicated they rolled up Resident #45's pants leg to check their leg and called LPN E to assess. MA A indicated there was no redness; the coffee was warm. MA A indicated Resident #44 was about an arm's length from Resident #45 and intentionally poured the coffee on Resident #45 as Resident #44 looked at MA A. MA A could not remember the exact date and said the incident happened in July2023. MA A further reported there was another incident between Resident #44 and Resident #45. According to MA A, when the facility admitted Resident #44, the resident hit Resident #45 in the face with their fist. MA A stated they assumed for this incident Resident #44 was startled by Resident #45 while the resident slept. MA A stated they separated the residents, called the charge nurse on duty to assess the residents. During an interview on 08/17/2023 at 3:05 PM, the Director of Nurses indicated it was their expectation resident-to-resident abuse did not happen. During an interview on 08/17/2023 at 3:13 PM, the Executive Director indicated that it was their expectation resident-to-resident abuse should not happen.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, record review and interviews; the facility failed to implement interventions to prevent potential aspiration and to assess causal factors, develop and/or implement interventions to prevent ongoing falls for Resident 42. The sample size was 7 and the facility census was 73. Findings are: Review of Resident 42's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/6/21 revealed diagnoses of dementia, dysphagia (difficulty swallowing) and diabetes. The assessment indicated the resident's cognition was severely impaired, the resident required extensive staff assistance with eating and was on a physician prescribed weight gain regimen. Review of a Speech Therapy Plan of Treatment dated 8/4/20 revealed a bedside swallowing evaluation was completed due to recent hospitalization for dysphagia. The resident refused to participate in the evaluation and due to cognitive impairment and reduced attention to task, a recommendation was made to continue mechanical soft diet (chopped, ground or puree foods for individuals with difficulty chewing or swallowing) with nectar thick liquids (adjustment of fluid thickness to an apricot nectar or thicker cream soups to prevent choking). Review of the resident's current Care Plan with revision date 12/29/20 revealed the resident was at nutritional risk related to dementia, impaired respiratory status with history of aspiration pneumonia (infection related to the introduction of foreign material (including food) from the windpipe into the lungs due to inadequate swallowing mechanism with symptoms of elevated temperature and cough). The following interventions were identified: -magic cup (frozen dessert similar to ice cream with added calories and protein) to be provided twice a day; -monitor weight weekly; -provide diet as ordered (regular/mechanical soft texture with nectar thick liquids); -staff to assist at meals as needed; -Registered Dietician to review as needed; and -super cereal (hot cereal with added butter and brown sugar) at meals as requested. In addition, the resident was identified at risk for falls related to impaired balance, history of falls and cognitive impairment. The following interventions were identified for fall prevention: -to eat in the dining room when able; -fall alarm to bed; -call light within reach; -use of 1-2 staff for transfer with full body lift; and -fall mats to each side of bed. Review of a Nursing Progress Note dated 1/21/21 at 7:00 PM revealed the resident was found on the floor lying on the fall mat next to the resident's bed. Review of a Fall Scene Investigation Report dated 1/21/21 at 7:00 PM revealed the resident had been found lying on the floor of the resident's room and indicated the resident had rolled/slid out of bed. The resident was alone and unattended while eating in bed and at the time of the fall. Staff had visualized the resident 15 minutes prior to the fall and the resident had been sitting up in bed and eating the evening meal. A new intervention was identified for the resident to eat meals in the dining room for increased supervision. Review of Nursing Progress Notes revealed the following: -1/27/21 at 2:35 PM the resident had a temperature ranging from 99.5 degrees Fahrenheit (F) to 100.9 degrees F. In addition, the resident had a productive wet cough; -1/29/21 at 3:24 PM the resident was up in the wheelchair for the noon meal and was coughing; and -2/1/21 at 1:00 PM staff entered the resident's room to remove the resident's room tray and the resident was found on the floor. Review of a Fall Scene Investigation Report dated 2/1/21 at 1:00 PM revealed the resident's fall had occurred in the resident's room. Staff had observed the resident eating the noon meal while positioned in bed 15 minutes prior to the fall. The fall mat had been moved away from the side of the bed so the tray table containing the resident's noon meal could be positioned next to the bed. The resident was alone and unattended while eating in bed and at the time of the fall. The report further revealed the resident had been diagnosed with a urinary tract infection and were waiting for an order for an antibiotic. The report failed to address the resident had been left unsupervised to eat in the resident's bed and that the fall mat had been removed from the side of the resident's bed. Review of Nursing Progress Notes revealed the following: -2/15/21 at 3:50 PM the resident had coughed up thick green mucous during the breakfast and the noon meal; -2/20/21 at 1:40 PM the resident refused the noon meal and indicated not feeling well and was ready to go to the hospital; -2/25/21 at 1:07 PM the resident had a fever of 101.3 degrees F with slight expiratory wheezes; -3/24/21 at 11:50 AM resident with productive coughing. History of coughing and of dysphagia. Lung sounds were congested with expiratory wheezes; -3/30/21 at 5:53 AM the resident reported not feeling good and yelling the resident was going to die. The resident had 3 emesis within 1 hour and had a temperature of 100.8 degrees F. The resident was diagnosed with a urinary tract infection and aspiration pneumonia; -4/5/21 at 10:53 PM the resident with difficulty ingesting fluids, food and medications due to cough. Temperature of 100.2 degrees F and oxygen saturation (level of oxygen in the blood) of 91% (normal range of 95-100%); -4/9/21 at 1:05 PM resident received last dose of antibiotic. Temperature of 100.5 degrees F and oxygen saturation of 92% and continued with productive cough; -4/27/21 at 1:51 PM resident had a productive cough and expiratory wheezes to lungs; -4/29/21 at 2:47 PM resident had a productive cough noted after the noon meal and lung sounds with expiratory wheezes; -5/5/21 at 3:09 PM resident with expiratory wheezes to lungs; -5/10/21 at 9:34 AM resident was coughing and was calling for help. The staff found spit and phlegm in 3 different piles next to the resident's bed; -5/15/21 at 1:51 PM the resident was noted to have wheezing after the noon meal. The note indicated the resident remained on a mechanical soft diet with nectar thick liquids with diagnosis of aspiration pneumonia approximately a month ago; and -5/18/21 at 1:49 PM the resident had an unwitnessed fall in the resident's room. An assessment revealed the resident's oxygen saturation level fluctuated between 88 to 95%. During an observation on 5/19/21 at 12:20 PM the resident was positioned in a wheelchair at a table in the dining room. The resident was served a bowl which contained baked beans and bite sized pieces (not ground) of hotdogs. The resident consumed only bites of the meal due to an occasional wet cough. The resident pushed menu items to the center of the table away from the resident and rested head on the resident's arm. During an observation on 5/20/21 at 8:05 AM the resident was seated in a wheelchair in the dining room. The resident's breakfast meal was pushed away from the resident and the resident reported no appetite. The resident had a repeated cough and indicated not feeling very well. During an observation on 5/24/21 at 1:03 PM the resident was positioned in the dining room at a table. The resident had a plate which contained a serving of roasted chicken which was cut into bite sized pieces (not ground) without gravy, apple crisp and mashed potatoes with gravy. The resident had consumed bites of the chicken and mashed potatoes and had a continued loose cough. Review of the resident's menu ticket for the noon meal on 5/24/21 revealed the resident was to have received ground roasted chicken with gravy. Interview with Nurse Aide (NA)-E on 5/24/21 at 1:10 PM confirmed Resident 42 had received regular chicken without gravy even though the kitchen had sent ground meat with gravy for the resident's noon meal. Interview with the Director of Nursing (DON) and the Unit Coordinator confirmed the following: -the resident was evaluated by the Speech Therapist on 8/4/20 with a recommendation for a mechanically altered diet and nectar thick liquids due to difficulty with swallowing and cognitive deficits; -Resident 42 had a history of falls and of aspiration pneumonia; -the resident had a fall on 1/21/21 at 7:00 PM in the resident's room when eating a meal in bed while unsupervised. A new intervention was developed for the resident to eat meals in the dining room with supervision to prevent falls and due to swallowing problems; -the resident had a subsequent fall on 2/1/21 when the resident had again been left alone in the resident's room to eat the evening meal unsupervised while positioned in bed. In addition, staff had removed the fall mat which was to be in place next to the resident's bed. Fall interventions were not revised or additional interventions developed related to this fall; -the resident had ongoing signs and symptoms of potential aspiration with elevated temperature, wheezes, cough and decreased oxygen saturations and on 3/30/21 was diagnosed with aspiration pneumonia; -the resident continued to have documented symptoms of potential aspiration at meals but the facility failed to have the resident evaluated by the Speech Therapist to determine if current diet remained appropriate; -the resident should not have been served the bites of hotdog on 5/19/21 or the regular chicken without gravy on 5/24/21 as the resident was on a mechanical soft diet and was at increased risk for aspiration.