Every finding on record at Emerald Nursing & Rehab Lakeview

Licensure Reference Number 175 NAC 12-006.09Based on record review and interview the facility failed to ensure that the resident choice for Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) matched the physician signed advanced directive for 2 of 24 residents reviewed (Residents 47 and 71). This had the potential for the facility to not follow the resident preference for CPR in the event of cardiac arrest. The facility census was 74. The facility Administrator was notified on [DATE] at 5:15PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Findings are: A.Record review of the facility policy titled Advance Directive Policy and Procedure dated 1/2024 revealed that it is the policy of the facility to establish, implement, and maintain written policies and procedures for advanced directive. The resident has the right, and the facility will assist, the resident to formulate an advance directive at their option. The facility will educate and inform the resident of their rights and formulate an advance directive. Resident choices will be incorporated into treatment, care, and services. All advance directive document copies will be obtained and located in the resident chart. Resident wishes will be communicated to the staff and the resident's physician. During quarterly resident assessment process and with any significant changes of condition, the facility staff will identify, clarify, and review the existing care instructions and whether the resident wishes to change or continue instructions from the advance directive. The section titled Cardiopulmonary Resuscitation (CPR) revealed that the facility will provide basic life support, including CPR, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to the physician order and resident choice indicated in the resident's advanced directives. Nurses and other care staff are educated to initiate CPR unless the resident has a valid Do Not Resuscitate Order in place. Record review of the admission Record dated [DATE] for Resident 47 revealed that Resident 47 admitted into the facility on [DATE]. Diagnoses included Cardiac Arrhythmia (an abnormal heart rhythm where the heart beats too fast, too slow, or has an irregular pattern causing risk of cardiac arrest or stroke) and Intracranial Hemorrhage (a critical, life-threatening medical emergency involving bleeding inside the skull, which can rapidly destroy brain cells by causing pressure and oxygen deprivation). Record review of the progress note for Resident 47 dated [DATE] at 2:02 AM revealed that at approximately 1:35 AM the nurse aide informed the nurse that Resident 47 was less responsive. The nurse assessed Resident 47. Resident 47 was lethargic and unable to be aroused. Breathing was shallow with periods of apnea (temporary stoppage of breathing) lasting approximately 15 seconds. Use of accessory muscles (extra muscles recruited to aid in breathing in addition to the typical muscles used for breathing when the normal muscles are not working sufficiently for breathing) was noted with breathing. The on-call provider ordered that Resident 47 be sent to the emergency room. Resident 47 was transported to the hospital emergency room by emergency services. Record review of the progress note for Resident 47 dated [DATE] at 11:10 AM revealed that the hospital provided the update that Resident 47 was still admitted with a diagnosis of hypoxia (low levels of oxygen in the body tissues that can be life-threatening).Record review of the progress note for Resident 47 dated [DATE] at 1:00 PM revealed that Resident 47 returned to the facility. Record review of the Advance Directive Code (Resuscitate) Status form dated [DATE] for Resident 47 revealed the choice of Full Code- I understand that if my heart stops beating or is inadequate, or that if I stop breathing or my breathing is inadequate, all resuscitation procedures will be initiated. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR. The form was signed by the medical provider on [DATE]. Record review of the Care Plan Report dated [DATE] for Resident 47 revealed that the resident has the following Advanced Directive: Full Code (CPR).Record review of the Advance Directive section of the admission Record dated [DATE] for Resident 47 revealed Do Not Resuscitate (DNR) (A type of advance directive in which health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops), Do Not Intubate (DNI) (a medical directive instructing healthcare providers not to insert a breathing tube). (This contradicts the current choice of Resident 47 to have CPR).Record review of the electronic medical record for Resident 47 revealed that the resident care profile page dated [DATE] showed a code status of DNR, DNI for Resident 47. (This contradicts the current choice of Resident 47 to have CPR).Interview on [DATE] at 1:57 PM with Licensed Practical Nurse-G (LPN-G) confirmed that for a resident in cardiac arrest, LPN-G would determine the resident code status from the resident care profile page in the electronic health record. LPN-G would have someone call 911 and call the doctor for a resident that was a full code. LPN-G revealed that the facility has an Automated External Defibrillator (AED) (a portable, life-saving medical device used to treat sudden cardiac arrest by analyzing the heart's rhythm) on each hall. LPN-G revealed that the crash cart (a wheeled container carrying medicine and equipment for use in resuscitation efforts) is by the fax machine. Interview on [DATE] at 2:16 PM with Registered Nurse-C (RN-C) confirmed that RN-C would check the resident code status on the resident care profile page for a resident in cardiac or respiratory arrest. Interview on [DATE] at 2:30 PM with the facility Social Services Director (SSD) revealed that on admission the SSD reviews the Advance Directive Code Status form with the resident and family and records their choice for CPR or DNR on the form. The SSD revealed that the SSD faxes the form to the doctor for signature and puts the form in the mailbox for the Director of Nursing (DON). The SSD revealed that the DON ensures that the form is received back signed from the doctor and then ensures that the resident choice for CPR or DNR is entered into the electronic medical record for the resident. Interview on [DATE] at 2:52 PM with Licensed Practical Nurse-H (LPN-H) revealed that LPN-H has worked in the facility over the past 3 months. LPN-H confirmed that the facility did not provide any orientation related to resident code status. LPN-H confirmed that LPN-H would determine the resident code status from the resident care profile page in the electronic health record. Interview on [DATE] at 3:07 PM with the facility Director of Nursing (DON) revealed that the facility considers the newly admitted resident as a full code until the Advance Directive Code Status form is received back from the physician with the signature. The DON revealed that when the Advance Directive Code Status form is returned to the facility the resident care plan is updated, the resident care profile is updated, and the order for the resident code status is put into the resident medical record. The DON revealed that the Advance Directive Code Status form is then scanned into the resident electronic medical record. The DON revealed that the resident code status is reviewed at care plan meetings and if the resident wants to change their choice, a new form is completed and sent to the physician for signature. The DON confirmed that the resident care profile for Resident 47 showed Resident 47 was a DNR. The DON confirmed that the Advance Directive Code Status form signed by the physician noted Resident 47 as a full code. The DON confirmed that the resident code status of DNR on the resident care profile was not correct and did not match the resident choice for CPR to be performed in the event of cardiac arrest. B.Record review of the admission Record dated [DATE] for Resident 71 revealed that Resident 71 admitted into the facility on [DATE]. Diagnoses included End Stage Renal Disease (the final, permanent stage of chronic kidney disease (CKD) where kidney function drops to less than 15% of normal, necessitating dialysis or a transplant for survival. At this stage, kidneys fail to filter waste, toxins, and fluids from the blood effectively, leading to critical health complications throughout the body); Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs that prevents airflow to the lungs causing breathing problems); and Chronic Diastolic Heart Failure (stiffness of the left heart muscle causing low blood flow).Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated [DATE] for Resident 71 revealed that Resident 71 receives dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to).Record review of the American Heart Associaton study titled Risk Assessment for Sudden Cardiac Death in Dialysis Patients dated [DATE] revealed that sudden cardiac death is the single most common form of death in dialysis patients.Record review of the progress note for Resident 71 dated [DATE] at 2:06 PM revealed that Resident 71 was hospitalized for fistula (a surgically created connection between an artery and a vein, usually in the arm, which provides durable, high-flow access for dialysis) revision. Record review of the progress note for Resident 71 dated [DATE] at 2:20 PM revealed that Resident 71 returned to the facility from the hospital and signed a full code status. Fax was sent to the doctor and waiting for response. Record review of the Advance Directive Code (Resuscitate) Status form dated [DATE] for Resident 47 revealed the choice of Full Code- I understand that if my heart stops beating or is inadequate, or that if I stop breathing or my breathing is inadequate, all resuscitation procedures will be initiated. This process can include chest compressions, intubation, and defibrillation and is referred to as CPR. The form was signed by the medical provider.Record review of the Care Plan Report dated [DATE] for Resident 71 revealed that Resident 71 has the Advanced Directive DNR/DNI. (This contradicts the current choice of Resident 71 to have CPR).Record review of the Advance Directive section of the admission Record dated [DATE] for Resident 71 revealed DNR/DNI (Do Not Resuscitate, Do Not Intubate). (This contradicts the current choice of Resident 71 to have CPR).Record review of the electronic medical record for Resident 71 revealed that the resident care profile page showed a code status of DNR/DNI for Resident 71. (This contradicts the current choice of Resident 71 to have CPR).Interview on [DATE] at 1:57 PM with Licensed Practical Nurse-G (LPN-G) confirmed that for a resident in cardiac arrest, LPN-G would determine the resident code status from the resident care profile page in the electronic health record. LPN-G would have someone call 911 and call the doctor for a resident that was a full code. LPN-G revealed that the facility has an Automated External Defibrillator (AED) (a portable, life-saving medical device used to treat sudden cardiac arrest by analyzing the heart's rhythm) on each hall. LPN-G revealed that the crash cart (a wheeled container carrying medicine and equipment for use in resuscitation efforts) is by the fax machine. Interview on [DATE] at 2:16 PM with Registered Nurse-C (RN-C) confirmed that RN-C would check the resident code status on the resident care profile page for a resident in cardiac or respiratory arrest. RN-C revealed that RN-C could also check the paper report sheet for the code status of Resident 71. RN confirmed that the paper report sheet documented the code status of Resident 71 as DNR. Interview on [DATE] at 2:30 PM with the facility Social Services Director (SSD) revealed that on admission the SSD reviews the Advance Directive Code Status form with the resident and family and records their choice for CPR or DNR on the form. The SSD revealed that the SSD faxes the form to the doctor for signature and puts the form in the mailbox for the Director of Nursing (DON). The SSD revealed that the DON ensures that the form is received back signed from the doctor and then ensures that the resident choice for CPR or DNR is entered into the electronic medical record for the resident. Interview on [DATE] at 2:52 PM with Licensed Practical Nurse-H (LPN-H) revealed that LPN-H has worked in the facility over the past 3 months. LPN-H confirmed that the facility did not provide any orientation related to resident code status. LPN-H confirmed that LPN-H would determine the resident code status from the resident care profile page in the electronic health record.Interview on [DATE] at 3:07 PM with the facility Director of Nursing (DON) revealed that the facility considers the newly admitted resident as a full code until the Advance Directive Code Status form is received back from the physician with the signature. The DON revealed that when the Advance Directive Code Status form is returned to the facility the resident care plan is updated, the resident care profile is updated, and the order for the resident code status is put into the resident medical record. The DON revealed that the Advance Directive Code Status form is then scanned into the resident electronic medical record. The DON revealed that the resident code status is reviewed at care plan meetings and if the resident wants to change their choice, a new form is completed and sent to the physician for signature. The DON confirmed that the resident care profile for Resident 71 showed Resident 71 was a DNR. The DON confirmed that the Advance Directive Code Status form signed by the physician noted Resident 71 as a full code. The DON confirmed that the resident code status of DNR on the resident care profile was not correct and did not match the resident choice for CPR to be performed in the event of cardiac arrest. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.The facility Abatement Plan statement dated [DATE] was provided to this surveyor on [DATE] at 5:19 PM. The Abatement Plan revealed that the facility took immediate corrective action and the code status for Resident 47 and Resident 71 was reviewed and corrected. Preventive measures implemented to prevent recurrence of similar issues included an enhanced review process, staff training, new process, and periodic audits. The enhanced review process revealed that the DON or responsible party will review current resident signed code status with the physician orders. The staff training revealed that the DON or responsible party will educate all licensed nursing staff and nurse managers on code statuses. Training will include accuracy of the resident care profile related to the signed code status . If residents choose to change code status, Social Services will be notified to redo the form and notify the DON/ADON (Assistant Director of Nursing) to update the order in the electronic medical record. Nurses in the facility were educated immediately. All remaining facility nurses will be educated upon arrival of next scheduled shift. The new process revealed that Social Services will ensure code status will be completed on new admissions and reviewed for all readmissions and at quarterly care plans for accuracy. Social Services will be notified of any requested change in code status orders to ensure the form is updated with the provider's signature, care plan, and resident care profile. Hospital orders and discharge paperwork related to code status does not apply to the facility. Social Services will obtain all code status updates for new admissions, readmissions, or code status changes when requested by the resident or resident representative. The periodic audits revealed that the DON or designee will audit code statuses against the orders, care plan, and the saved signed document once a week for 4 weeks, then monthly thereafter for 3 months to ensure sustained compliance. Results will be taken to the Quality Assurance Process Improvement monthly for review.At the time of exit, the severity of the deficiency was lowered to the D level.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1)Based on record review and interview the facility failed to ensure that nurse aides and medication aides completed at least 12 hours of continuing education annually as required for 5 of 5 sampled staff. The facility census was 74.Findings are:A.Record review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides dated 1/2024 revealed that it is the policy of the facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. The facility will provide at least 12 hours of in-service training annually based on the employment date and not on the calendar year. Documentation of in-services will be forwarded to the Human Resources Director and maintained in the employee's personnel file. In-service training will be provided by qualified personnel and will be based on the needs of the residents in the facility. Minimum training will include: Effective communication; Dementia management and care of the cognitively impaired; Abuse, neglect, and exploitation prevention; Elements and goals of the facility's Quality Assurance Process Improvement program; Resident rights and responsibilities; Written standards, policies, and procedures for the facility's infection prevention and control program, Requirements under the facility's compliance and ethics program; Safety and emergency procedures; and Behavioral health. Record review of the untitled and undated list of facility employees revealed that Medication Aide-I (MA-I) had a hire date of 9/11/08.Record review of the facility provided training documents for the last full year based on hire date (9/11/24-9/11/25) for MA-I revealed that the documents contained no amount of time allotted for the education. (No amount of hours of education completed could be calculated).Interview on 1/29/26 at 2:10 PM with the facility Director of Nursing (DON) confirmed that facility nurse aides and medication aides are required to complete a minimum of 12 hours of continuing education annually based on the staff member's hire date. The DON confirmed that the facility had no documentation that MA-I completed 12 hours of education as required. B.Record review of the untitled and undated list of facility employees revealed that Medication Aide-J (MA-J) had a hire date of 11/21/21.Record review of the facility provided training documents for the last full year based on hire date (11/21/24-11/21/25) for MA-J revealed that the documents contained no amount of time allotted for the education. (No amount of hours of education completed could be calculated).Interview on 1/29/26 at 2:10 PM with the DON confirmed that facility nurse aides and medication aides are required to complete a minimum of 12 hours of continuing education annually based on the staff member's hire date. The DON confirmed that the facility had no documentation that MA-J completed 12 hours of education as required. C.Record review of the untitled and undated list of facility employees revealed that Medication Aide-K (MA-K) had a hire date of 4/29/23.The facility had no documented training for MA-K for the last full year based on hire date (4/29/24-4/29/25). (MA-K did not complete 12 hours of education as required).Interview on 1/29/26 at 2:10 PM with the DON confirmed that facility nurse aides and medication aides are required to complete a minimum of 12 hours of continuing education annually based on the staff member's hire date. The DON confirmed that the facility had no documentation of any continuing education for MA-K for the last full year. The DON confirmed that MA-K had not completed 12 hours of education as required. D.Record review of the untitled and undated list of facility employees revealed that Medication Aide-L (MA-L) had a hire date of 11/12/23.Record review of the facility provided training documents for the last full year based on hire date (11/12/24-11/12/25) for MA-L revealed that the documents contained no amount of time allotted for the education. (No amount of hours of education completed could be calculated).Interview on 1/29/26 at 2:10 PM with the DON confirmed that facility nurse aides and medication aides are required to complete a minimum of 12 hours of continuing education annually based on the staff member's hire date. The DON confirmed that the facility had no documentation that MA-L completed 12 hours of education as required. E.Record review of the untitled and undated list of facility employees revealed that Medication Aide-M (MA-M) had a hire date of 1/15/24.Record review of the facility provided training documents for the last full year based on hire date (1/15/24-1/15/25) for MA-M revealed that the documents contained no amount of time allotted for the education. (No amount of hours of education completed could be calculated).Interview on 1/29/26 at 2:10 PM with the DON confirmed that facility nurse aides and medication aides are required to complete a minimum of 12 hours of continuing education annually based on the staff member's hire date. The DON confirmed that the facility had no documentation that MA-M completed 12 hours of education as required.

Licensure Reference Number 175 NAC 12-006.19(A)Licensure Reference Number 175 NAC 12-006.19(B) Based on record review, observation, and interview the facility failed to maintain a sanitary, orderly, and comfortable interior and exterior for 16 of 74 residents (Resident 1, 5, 7, 9, 10, 13, 19, 21, 24, 32, 36, 48, 58, 71, 75, and 85.) Facility census was 74. Findings are: Record review of the facility's undated admission Agreement included a copy of Federal-Resident Rights, upon which the resident and/or resident representative signs and dates in agreement that the facility will provide the following:Safe Environment: The resident has the right to a safe, clean, comfortable, and homelike environment, including ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. A.An observation with the Facility Administrator (FA), Maintenance Supervisor (MS), and the Housekeeping Supervisor (HS) on 01/29/26 at 10:30 AM in the room of Resident 1 and Resident 48 confirmed the bathroom toilet paper holder was broken and the bathroom threshold was soiled with a dark buildup. B.An observation with FA, MS, and HS on 01/29/26 at 10:30 AM in the bathroom of Resident 32, Resident 13 and Resident 24 confirmed the toilet contained dark soiling around the base, the threshold of the bathroom to room revealed dark soiling buildup, and the ventilation revealed a grey fuzzy buildup. C.An observation with FA, MS, and HS on 01/29/26 at 10:40 AM in the dining room for 100 hall contained an outside door to the courtyard revealing cobwebs, yard waste, trash, and bird poop. HS revealed they do not clean outdoors until the warmer weather, leaving the buildup until such time. D.An observation with FA, MS, and HS on 01/29/26 at 10:45 AM in the room of Resident 9 and Resident 58 confirmed cobwebs outside of the room (in the hallway) covering the call light, and a soiling buildup on the threshold at the rooms entrance. E.An observation with FA, MS, and HS on 01/29/26 at 10:50 AM in the room of Resident 19 and Resident 10 confirmed a loose baseboard heater vent cover, bathroom threshold buildup of dark soiling, flooring pulled loose between the toilet and wall and worn toilet seat creating an uncleanable surface. F.An observation with FA, MS, and HS on 01/29/26 at 10:50 AM in the main dining room between 200 and 300 hall at the service counter facing the main kitchen revealed a sink covered with a tray and taped up with blue masking tape. MS confirmed the sink was not in operation. MS further revealed the tape was to prevent others from using the sink. FA confirmed that the way the sink was constructed to avoid being used was not appealing. G.An observation with FA, MS, and HS on 01/29/26 at 10:55 AM in the 300 hallway confirmed the overhead light was not lit. MS pushed the light fixture, opened the cover and revealed the ballast (an electrical device that regulates voltage for lamps) needed to be replaced.An undocumented (date and timed) interview with Registered Nurse (RN)-B revealed the 300-hall overhead light has been out for a month or more and makes it difficult to see necessary items while working. H.An observation with FA, MS, and HS on 01/29/26 at 11:00 AM in the room of Resident 36 and Resident 75 confirmed the base heater cover was loose, partially hanging off the unit and was soiled; further confirmed the molding/strip outside of the bathroom was peeling off the walls. I.An observation with FA, MS, and HS on 01/29/26 at 11:00 AM in the room of Resident 21 and Resident 71 confirmed missing tile on the bedroom flooring and a buildup of black scratches all around the edges of the room between 1.5 to 3 feet in height. J.An observation with FA, MS, and HS on 01/29/26 at 11:00 AM in the room of Resident 5 confirmed the toilet is not sealed to the floor, sitting on spacers/risers, visible under the toilet between missing tiles and the base of the toilet, and a buildup of black scratches all around the edges of the room between 1.5 to 3 feet in height. K.An observation with FA, MS, and HS on 01/29/26 at 11:05 AM in the room of Resident 7 revealed missing paint from the door exposing other layers of colored paint. L.An observation with FA, MS, and HS on 01/29/26 at 11:05 AM in the 400-hall revealed an area where a wheelchair scale and an outside door remains revealed a base heater falling off of the wall and peeling wallpaper. Additionally, between the Business Office and entrance to rooms [ROOM NUMBERS] reveal a 10 inch diameter round loose chrome floor covering. M.An observation with FA, MS, and HS on 01/29/26 at 11:10 AM in the bathhouse on 500 hall, and confirmed by FA, that the floor was stained; that cleaning was needed of the grout, the metal heater unit and tiles (due to build up) through out the shower stalls. N.An observation with FA, MS, and HS on 01/29/26 at 11:05 AM in the unoccupied room of 508 and confirmed by FA , that the bathroom ventilation was not operational and ceiling tiles with water stains need replaced. O.An observation with FA, MS, and HS on 01/29/26 at 11:15 AM in the front of the building, FA confirmed the pest box needs a replacement due to weathering, soiling and a build up of debris.

Licensure Reference Number 175 NAC 12-007.04(D) Based on observation and interviews the facility failed to ensure the ventilation system was in working order in 12 resident bathrooms (rooms 501,502,503, 504, 505, 506, 508, 510, 511, 512, 513, 514) of 24 sampled resident rooms. Findings are:A. An observation with the Facility Administrator (FA), Maintenance Supervisor (MS), and the Housekeeping Supervisor (HS) on 1/29/26 at 11:15 AM a walk through of 500-hall room [ROOM NUMBER] bathroom ventilation system was not pulling when a 1-ply tissue was pressed upon the ventilation system, confirming the vent was non-operational. FA and MS confirmed the ventilation was not working, and that there is no window in the bathroom. During an interview on 1/29/26 at 11:20 AM the MS reveals that no one checks the ventilation system and this is not part of the maintenance program. During an interview on 1/29/26 at 11:20 AM the MS was unaware that ventilation system was not working and that no one alerted (gender) the ventilation system was not working. During an interview on 1/29/26 at 11:20 AM the FA revealed being unaware the ventilation system was not working. An interview with the FA on 1/29/26 at 11:28 AM did not deny the ventilation in rooms 501,502,503, 504, 505, 506, 508, 510, 511, 512, 513, and 514 were not operational. During an interview on 1/29/26 at 3:00 PM the Regional Director of Operation (RDO) revealed the facility did not have a policy on ventilation monitoring.

Licensure Reference Number 175 NAC 12-006.18(B)Based on observation, interview, and record review, the facility failed to ensure staff donned (put on) and doffed (took off) the required PPE (personal protective equipment) during cares for a resident that requires staff to wear PPE for EBP (enhanced barrier precautions), to prevent the potential spread of microorganisms. This affected 1 resident (Resident 4) of 1 sampled resident. The facility failed to clean glucometers per manufacturer recommendations after use affecting 1 resident Resident 76 of 2 sampled residents, and failed to change disposable medical care equipment as ordered for 1 resident Resident 2 of 1 sampled residents. The facility census was 74. Findings are: A. Record review of a document titled Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings dated 2007 from the Centers from Disease Control revealed IV.E.1. the facility is to establish policies and procedures for containing, transporting, and handling patient-care equipment and instruments/devices that may be contaminated with blood or body fluids. Record review of a document titled Evencare ProView blood glucose monitoring system users guide page 6. dated 2018 revealed when using this system always follow the recognized procedures for handling objects that are potentially contaminated with human material. In an observation completed on 1/28/2026 at 11:45 AM Registered Nurse B (RN-B) used a glucometer to obtain resident 76 blood sugar using a drop of blood. The nurse then returned to the medication cart placed the disposable items in the trash can and the test strip from the glucometer with blood visibly on it into the sharps container on the side of the medication cart. The Nurse then placed the glucometer into the top drawer of the medication cart in a divided off space in the drawer. In an interview completed on 1/28/2026 at 11:50 AM with RN-B, RN-B stated that glucometers are not shared between residents and each resident utilized an individual machine and their machine is stored in the medication cart in the residents designated slot separate from the other residents' items. The RN stated that the glucometer is only cleaned when visibly soiled. In an interview completed on 1/28/2026 at 12:15 PM with Registered Nurse C (RN-C) RN-C stated that the glucometer is to be cleaned after each use. The RN confirmed that each resident had used their own glucometer and glucometers were not shared between residents. In an interview completed on 1/28/2026 at 2:10 PM with the facility Director of Nursing (DON), the DON stated they were not aware of a cleaning policy or procedure for the glucometers when they were not shared with other residents. Reviewed with the DON RN-B and RN-C stated cleaning and non-cleaning practices. DON confirmed that nurses were not doing the same thing and should be. In an interview completed on 1/28/2026 at 2:10 PM with the facility Clinical Nurse Consultant (CNC), the CNC confirmed that the facility did not have a policy for glucometer cleaning when the glucometers were not shared between residents. B. Record review of a facility policy titled Care and Treatment of Feeding Tubes dated 01/2024 revealed to use infection control precautions and related techniques to minimize the risk of contamination. Review of Resident 2's physician orders revealed an order stating for night shift to provide a new cup for flushing and piston syringe every night shift and to write date and initials on each item. Review of Resident 2's electronic medication administration record for the Month of January 2026 revealed documentation that this order had been completed each night of the month. In an observation completed on 1/28/2026 at 12:35 PM of medication administration via gastric tube, which is a tube that is surgically placed in a resident's digestive system and used for nutrition, hydration, and medication administration. RN-B prepared medications for Resident 2 using liquid forms of medication pored into clear graduated medication cups. The Nurse administered each medication separately into the resident's gastric tube using gravity and a piston syringe. The nurse then flushed the syringe and the gastric tube with clear water and placed the piston syringe back on a towel placed on an over bed table. It was observed that in black marker written on the piston syringe was the date 1/25/26 and initials. In an interview completed on 1/28/2026 at 12:40 PM with RN-B, RN-B confirmed that the piston syringe is to be changed every night on night shift and per the date written on the syringe it had not been changed as ordered. In an interview completed on 1/28/2026 at 1:15 PM with the facility Director of Nursing (DON), the DON confirmed that the piston syringe is to be changed every night by night shift. The DON confirmed that with the date written on the syringe it had not been changed since 1/25/2026 and was ordered to be changed nightly. C. Record review of Resident 4's admission Record dated 1/27/2026 revealed Resident 4's admission date on 10/06/2025. Also listed on the record are diagnosis, revealing: -pressure ulcer of right buttock, stage 2 (partial-thickness skin loss, appearing as a shallow, open pink/red ulcer or an intact/ruptured blister, affecting the epidermis and dermis layers) -morbid obesity -pressure ulcer of unspecified site, stage 3 (a serious, full-thickness wound extending through the skin to reveal subcutaneous fat, appearing as a deep crater) -cellulitis of left lower limb (bacterial skin infection affecting the skin's deeper layers and underlying tissue, often causing rapid-spreading redness, swelling, warmth, and pain) -lymphedema (chronic condition characterized by swelling, caused by a buildup of protein- fluid due to a damaged or obstructed lymphatic system) Record review of Resident 4's Order Summary Report dated 1/27/2026 reveal a practitioner's order to irrigate a foley catheter (a flexible, indwelling tube inserted through the urethra into the bladder to drain urine) every 30 days and as needed. A record review of the facility's Infection Prevention and Control Program dated 1/2017 with a revision date of 1/2024 reveal it is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Registered Nurses (RN) and Licensed Practical Nurses (LPN) supervise direct care staff in daily activities to assure appropriate precautions and techniques are observed, assess the resident's isolation needs, initiate appropriate precautions in accordance with our established policies and current CDC Infection Control Isolation Guidelines. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO; bacteria or other microorganisms that have developed resistance to at least one or more classes of antimicrobial agents, rendering standard treatments ineffective) that employs targeted gown and glove use during high contact resident care activities' are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. An observation on 1/26/2026 at 9:40 AM a door sign is posted on the door of Resident 4's room stating: Stop, contact precautions; everyone must: -clean their hands, including before entering and when leaving the room. Providers and staff must also: -wear gloves and a gown for the following high-contact resident care activities. -dressing -bathing/showering -transferring -changing linens -providing hygiene -changing briefs or assisting with toileting -device care or use: central lines, urinary catheter, feeding tube, tracheostomy -wound care: any skin opening requiring a dressing Do not wear the same gown and gloves for the care of more than one person. An observation on 01/27/2026 at 2:50 PM Resident 4 is assisted with daily cares and transferred from the bed to the wheelchair. Prior to transfer assisting Resident 4, Nurse Aide (NA)-Q and Medication Aide (MA)-R were not observed washing hands, rather donning gloves, no other PPE were used. Staff member MA-R prepared by cutting several briefs to place on areas of the body that are weeping, as directed by Resident 4. MA-R grabbed a white canister and placed it on the resident's left side. The canister was opened and the resident lifted their leg with use of a gait belt and MA-R began putting cream on the underside of the left leg which had the appearance of raised red round open areas with shiny moist in appearance about 3-5 centimeter (cm) clusters in diameter from creases of the thigh area to the buttock area. MA-R took off one glove and replaced it with another since the glove was covered in white cream. The resident was then assisted to put on an edema sleeve over the left leg from the ankle to the mid-thigh area. The resident was then assisted to turn to the right side of the body, MA-R then put additional cream on the left hip area, which was also covered in raised red round open areas with shiny moist in appearance about 3-5 centimeter (cm) clusters in diameter; then placing a cut brief over the clusters. MA-R was then observed sliding a sling under the resident's body and assisted the resident in turning on the left side. NA-Q then pulled the sling and brief out from under the resident to cover the resident's backside. The resident was then placed on their back; and the sling was pulled up from between the legs of the resident. Licensed Practical Nurse (LPN)-N, was observed coming into the room donning gloves only with a Hoyer lift (a mechanical, portable, or fixed device designed to safely transfer individuals with limited mobility between beds, wheelchairs, or toilets, reducing caregiver strain). NA-Q maneuvered an electric wheelchair and placed into the room while the lift was situated over Resident 4 and secured to the lift. The resident was lifted from the bed and placed into the wheelchair. LPN-N took the lift out of the room and placed it in the hallway. The lift was not sanitized after use. Both MA-R and NA-Q were observed to use hand sanitizer after leaving Resident 4's room. An interview on 1/27/2026 at 3:45 PM with MA-R and NA-Q revealed not knowing that a gown is necessary. An interview on 1/27/2026 at 3:45 PM with LPN-N revealed not thinking it was necessary unless doing catheter cares. An interview with the Assistant Director of Nursing (ADON) on 1/27/2026 at 3:55 PM revealed staff need to wear a gown and gloves when completing transfers and cares for Resident 4.

Licensure Reference Number 175 NAC 12-006.08(B)(i)Based on record review and interview the facility failed to ensure that the physician performed the resident initial 30 day visit as required for 1 of 3 residents reviewed (Resident 47). The facility census was 74.Findings are: Record review of the facility policy titled Physician Services dated 1/2026 revealed that the medical care of each resident is under the supervision of a licensed physician. The physician will visit the resident at appropriate intervals. Physician visits are provided in accordance with current regulations and facility policy. The resident must be seen at least once every 30 days for the first 90 days after admission. Record review of federal regulation statute 483.30(c) Table 1 revealed that the Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist may not perform the initial Comprehensive Visit (required 30 day visit) in place of the physician. Record review of the admission Record dated 1/26/26 for Resident 47 revealed that Resident 47 admitted into the facility on 8/15/25. The admission Record revealed that care providers for Resident 47 included the physician, a physician assistant, and a nurse practitioner.Record review of the Attending Provider notes dated 10/9/25 for Resident 47 revealed that Resident 47 was seen on 10/9/25 for the 30 day follow-up. The attending provider was the physician assistant. Interview on 1/29/26 at 2:10 PM with the DON confirmed that the initial 30 day visit after admission is to be completed by the physician. The DON confirmed that the initial visit for Resident 47 was completed by the Physician Assistant and not by the physician as required.

Licensure Reference Number 175 NAC 12-006.09Based on record review and interview the facility failed to thoroughly assess a resident after a possible/probable accident/incident and failed to notify a resident's provider after a possible/probable incident/accident that could result in deterioration of health and need to alter treatment for 1 (Resident 83) of 1 sampled resident, and the facility failed to follow practitioner orders of providing medications as prescribed for 1 (Resident 89) of 1 sampled resident. The facility census was 74. Findings are:A. Record review of a facility policy titled Notification of Changes and dated 01/2024 revealed it is the policy of the facility that changes in a residents' condition or treatment are immediately reported to the physician. Requirements for notification were defined as a significant change including deterioration in health and a need to alter treatment due to adverse consequences. Record review of an admission Record revealed the facility admitted Resident 83 on 06/21/2023 with diagnosis of dementia a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior). Record review of Resident 83's Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 12/09/2025 revealed the resident required supervision or touching assistance with the activity of daily living of eating. The MDS did not reveal the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months. Record review of Resident 83's Progress Notes revealed documentation that on 12/27/2025 at 12:22 PM the resident had a choking episode during breakfast meal and appeared to be putting too much food in their mouth during the meal. The documentation stated that a trial of soft foods would be trialed. The note revealed no documentation of an assessment of the residents' condition after the choking episode. No notification of the resident's provider of the choking episode or the need/change of the resident's diet. Record review of Resident 83's Progress Notes revealed documentation on 12/27/2025 at 3:10 PM that the resident's responsible party was notified that the resident was having increased difficulty with swallowing and breathing. Documentation stated that the resident was declining supplemental oxygen use and wanting to go and be evaluated at the emergency room. The responsible party agreed to the residents' wishes. The note revealed no documentation of an assessment of the resident's condition being performed. Record review of Resident 83's Progress Notes revealed documentation on 12/27/2025 at 5:03 PM that the resident was found to not have a blood pressure or pulse. Record review of Resident 83's Vital Signs documentation revealed no documentation of the residents' vital signs on the date of 12/27/2025. In an interview completed on 01/27/2026 at 1:59 PM with Licensed Practical Nurse N (LPN-N), LPN-N confirmed that a resident having a choking incident during a meal would signify a change in condition and the resident would need a full assessment including vital signs and lung sounds documented in the resident's progress notes and the resident's provider should be notified. In an interview completed on 01/27/2026 at 2:05 PM with Registered Nurse O (RN-O) confirmed that a resident having a choking incident during a meal would signify a change in condition and the resident would need a full assessment including vital signs and lung sounds documented in the resident's progress notes and the resident's provider should be notified. In an interview completed on 01/27/2026 at 2:20 PM with the facility Director of Nursing (DON), the DON confirmed that there was no documentation in Resident 83's medical health record that they were fully assessed after the choking episode on 12/27/2025 and that the resident's provider was not notified of the incident, and the resident was later found deceased . The DON confirmed that an assessment of the resident's condition, including vital signs and a minimum of lung sounds, should have been completed after the choking episode and the resident's provider should have been notified and were not. B. Record review of an admission Record for Resident 89 revealed an admission date of 1/21/2026 with a diagnosis of congestive heart failure (condition where the heart cannot pump enough blood), fluid overload (excessive accumulation of fluids in the body, causing swelling), chronic obstructive pulmonary disease (copd; inflammatory lung disease), and type 2 diabetes (a condition where the body doesn't produce enough insulin or doesn't use insulin properly). Record review of Resident 89's Order Summary Report revealed the following orders: -insulin lispro injectable 100/milliliter (ml) inject 'subcutaneous (sq) per sliding scale before meals and at bedtime with parameters set at: if blood glucose less than 150= 4 units; 150-199=6 units; 200-249=8 units; 250- 299=10 units; 300-349=12 units; 350-400=14 units; greater than 400=call clinic (max 42 units/day) for type 2 diabetes mellitus with other circulatory complications; order date: 1/21/2026 -Tresiba flex injectable 100 unit, inject 7 units subcutaneously daily for type 2 diabetes mellitus with other circulatory complications; order date: 1/21/2026 Record review of Resident 89's Progress Notes revealed documentation that on 1/22/2026 at 4:02 PM Tresiba flex injectable medication was not administered. Record review of Resident 89's Progress Notes revealed documentation that on 1/24/2026 at 8:45 AM insulin lispro injectable medication was not administered. Record review of Resident 89's Medication Administration Report (MAR; a document used to track the scheduled and administered medications) for January 2026 reveals insulin lispro injectable was not provided to Resident 89 on 1/22/2026 before all three meals and at bedtime, on 1/23/2026 before all three meals and at bedtime, and on 1/24/2026 before breakfast at 7:00 AM. Additional record reviews revealed Tresiba flex injectable was not administered to Resident 89 on 1/22/2026. In an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 1/28/2026 at 10:45 AM, DON confirmed Resident 89 did not have medications insulin lispro or Tresiba flex injectable. The DON further revealed reasons for not having the medication available was because of a prior authorization needed as well as needing parameters. The DON confirmed the physician was not aware that Resident 89 had not received insulin lispro or Tresiba and that the physician should have been notified.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(2)Based on observation, interview, and record review the facility failed to provide treatment and services to maintain or restore a resident's level of functional ability for 1 (Resident 2) of 1 sampled resident. The facility census was 74.Findings are:Record review of a facility policy titled Activities of Daily Living (ADL's) and dated 1/2024 revealed the facility will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome.A record review of an admission Record revealed the facility admitted Resident 2 on 1/02/2026 with a diagnosis of a stroke, which is the blockage of blood circulation to one or more areas of the brain, affecting the left side of the resident's body.The admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 1/08/2026 revealed Resident 2 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14, indicating the resident was cognitively intact. The MDS revealed documentation that the resident was dependent on staff assistance for transfers and toileting assistance and required substantial or maximum assistance for bed mobility.In an interview completed on 01/26/2026 at 2:04 PM with Resident 2, Resident 2 stated they were admitted to the facility for rehabilitation services after hospitalization. The resident stated that they plan to receive therapy and then return to their home. The resident confirmed that they have only had therapy services a couple of times since admitting to the facility at the beginning of the month and feels like they are losing strength since admission to the facility and not getting better. The resident voiced that at one of their therapy sessions, they had verbal outburst with the therapist and were told therapy would not work further with the resident until they (the resident) could improve their behavior. The resident stated again their desire to get better and return to their home and felt like they were just left in their bed to rot.Record review of a facility supplied document titled Continuum of Care Transfer Report and dated 01/02/2026 revealed under Instructions after discharge that Physical therapy was to evaluate and treat the resident with their rehabilitation potential being good, occupational therapy to evaluate and treat with their rehabilitation potential of being good, speech therapy to evaluate and treat with their rehabilitation potential of good. Also a physical therapy note dated 12/31/2025 revealed the resident needed stand by assistance with bed mobility from lying flat to a sitting position, minimal assistance for bed mobility from a sitting position to a lying position, transfer assistance from a sitting to a standing position of contact guard or stand by assistance, and that the resident walked 120 feet one time and 60 feet one time with the therapist.In an interview completed on 01/27/2026 at 9:45 AM with Nurse Aide D (NA-D), the nurse aide stated that Resident 2 was not receiving therapy or restorative services that they were aware of. NA-D stated that the resident was dependent on staff assistance with all activities of daily living and had difficulty standing with 2 staff assistance to pivot and transfer out of their bed. The CNA stated that the resident only gets out of bed to bathe and does not walk.In an interview completed on 01/28/2026 at 1:17 PM with the facility Director of Rehab (DOR), the DOR stated that the resident was evaluated by physical, occupational, and speech therapy after admission to the facility. The DOR stated that the resident was rude and demeaning to the physical therapist at evaluation and told the therapist to get out of their room. The therapist returned a time later and the resident again became verbal with the therapist. The therapist made the determination, due to the residents behavior and refusal to cooperate with the evaluation, physical therapy would not see the resident on therapy services. The DOR stated that occupational therapy was able to complete an evaluation with the resident and worked with the resident a few times. The DOR stated that the resident would wish to do things that the therapist could not comply with (leave room and was on isolation precautions so could not leave the room) and would get upset and have verbal behavior towards the therapist when their request was not met. The DOR stated that due to this, the resident was discharged from occupational therapy services. The DOR stated that the resident continued to work with speech therapy at this time. The DOR stated that when a resident is discharged from therapy services it is the regular practice to set up the resident with a restorative or exercises program to maintain level of functioning for the resident. The DOR stated that when Resident 2 was discharged from physical and occupational therapy services a restorative or exercise program was not completed for Resident 2 and should have been to maintain level of function and prevent decline.In an interview completed on 01/28/2026 at 2:11 PM with the facility Director of Nursing (DON), the DON confirmed that the resident was not receiving physical or occupational therapy services to maintain or improve their level of functioning. The DON stated that physical and occupational therapy services were discontinued due to the residents' behaviors towards therapists. The DON confirmed that it was the normal practice of the facility to implement a restorative or exercise program for residents discharged from therapy services and this was not done for Resident 2. The DON confirmed that no program or intervention was in place to prevent decline or maintain level of function for Resident 2.

Licensure Reference Number 175 NAC 12-006.17(E)(ii)Based on record review and interview, the facility failed to notify the local state ombudsman of resident transfers in and out of the facility for 1 resident (Resident 75), and failed to provide the resident or their responsible party written information regarding bed hold at the time of transfer for 1 resident (Resident 75). The facility census was 74.Findings are:Review of an admission Record revealed the facility admitted Resident 74 on 01/13/2022 with diagnosis of cerebral palsy, which is a group of permanent movement, muscle tone, or posture disorder caused by abnormal brain development or damage, and functional quadriplegia, which is a medical condition defined by complete immobility due to severe physical frailty or advanced cognitive impairment without underlying brain or spinal cord injury. Review of Resident 47's Census record revealed the resident was transferred out of the hospital on paid hospital leave on 08/09/2025, 11/05/2025, and 11/15/2025. A.Record review of a facility supplied document titled Nursing Facility Transfer or Discharge and dated 04/04/2024 revealed the facility would send a copy of the notice of transfer or discharge to the state ombudsman.In an interview completed on 01/27/2026 at 4:32 PM with the facility Business Office Manager (BOM), the BOM confirmed that they were the individual responsible for compiling information of residents that transferred into and out of the facility. The BOM stated that they were behind on sending/communicating this information to the state ombudsman as outlined in regulations. The BOM confirmed that the facility was not in compliance with the regulations of notification of the state ombudsman of resident transfers into and from the facility.B.Review of a facility policy titled Bed Hold Prior to Transfer and dated 01/2024 revealed prior to transferring a resident to the hospital the facility will provide written information to the resident and or the resident representative regarding bed hold.Review of Resident 47's Progress Notes revealed documentation that the resident was transferred from the facility to the hospital on [DATE]. The documentation revealed no evidence that the resident or their responsible party were notified regarding bed hold at the time of the transfer.Review of Resident 47's Progress Notes revealed documentation that the resident was transferred from the facility to the hospital on [DATE]. The documentation revealed no evidence that the resident or their responsible party were notified regarding bed hold at the time of the transfer.Review of Resident 47's Progress Notes revealed documentation that the resident was transferred from the facility to the hospital on [DATE]. The documentation revealed no evidence that the resident or their responsible party were notified regarding bed hold at the time of the transfer.Review of a facility supplied document titled with the facility name and dated 08/09/2025 revealed documentation that Resident 47 was transferred to the hospital. The document stated that each resident or legal representative would be informed by the facility staff of the facility's bed hold policy upon admission and when the resident leaves the facility for hospitalization and to contact the facility for more information and to review the attached bed hold policy document. The document was signed by the BOM only.Review of a facility supplied document titled Nursing Facility Transfer or Discharge Notice and Resident 47 name and not dated revealed that Resident 7 was transferred on 11/15/2025 to the hospital. The reason for the transfer or discharge was documented as necessary for the residents' welfare and needs could not be met in the facility.In an interview completed on 01/27/2026 at 4:32 PM with the facility BOM, the BOM stated that they complete the resident bed hold paperwork when they are in the office and notified of the transfer. The BOM stated they call the resident' responsible party and mail the bed hold notification to them. The BOM stated this is not completed at the time the resident is transferred consistently. If the BOM is not present at the time of the transfer, the nursing staff would be responsible for completion of the bed hold paperwork and the notification and this should be documented in the resident's health record. The BOM confirmed that Resident 47 was transferred out of the hospital on [DATE], 11/05/2025, and 11/15/2025 and there was no documentation in the resident's medical health record that they or their responsible party were notified of the facilities bed hold policy at the time of the transfer.In an interview completed on 01/27/2026 at 4:45 PM with the facility Director of Nursing (DON), the DON confirmed that there was no documentation that Resident 47 or their responsible party were notified at the time of the resident being transferred from the facility of the facility's bed hold policy.

Licensure Reference Number 175 NAC 12-006.05(S)Based on record review, observation, and interview the facility failed to ensure resident dignity by not storing incontinent products out of public sight and for not ensuring residents' body parts were covered for 2 residents (Resident 2 and Resident 5) of 2 sampled residents. The facility census was 74.Findings are:Record review of a facility policy titled Facility Responsibilities dated 01/2024 revealed the residents have a right to a dignified existence, the facility must treat each resident with respect, dignity, and care for each resident in a manner and environment that promotes or enhances their quality of life.A.A record review of an admission Record revealed the facility admitted Resident 2 on 1/02/2026 with a diagnosis of a stroke, (which is the blockage of blood circulation to one or more areas of the brain) affecting the left side of the resident's body.The admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 1/08/2026 revealed Resident 2 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15, which indicated the resident was cognitively intact. The MDS revealed documentation that the resident was dependent on staff assistance for toilet use and personal hygiene, was always incontinent of bowel and did not have a toileting program.An observation completed on 1/26/2026 at 2:06 PM revealed on top of the dresser, sitting at the foot of Resident 2's bed was a blue and white opened package of incontinence products. The door to the resident's room was open and this was visible while walking down the hallway.An observation completed on 1/27/2026 at 9:35 AM revealed on top of the dresser, sitting at the foot of Resident 2's bed was a blue and white opened package of incontinent products. The door to the resident's room was open and this was visible while walking down the hallway.An observation completed on 1/27/2026 at 3:16 PM revealed on top of the dresser, sitting at the foot of Resident 2's bed was a blue and white opened package of incontinent products. The door to the resident's room was open and this was visible while walking down the hallway.An observation completed on 1/28/2026 at 11:10 AM revealed on top of the dresser, sitting at the foot of Resident 2's bed was a blue and white opened package of incontinence products. The door to the resident's room was open and this was visible while walking down the hallway.An observation completed on 1/28/2026 at 1:40 PM revealed on top of the dresser, sitting at the foot of Resident 2's bed was a blue and white opened package of incontinent products. The door to the resident's room was open and this was visible while walking down the hallway.In an interview conducted on 01/28/2026 at 2:20 PM with Registered Nurse C (RN-C), RN-C confirmed that resident incontinence products should be stored out of sight of the public.B.A record review of an admission Record revealed the facility admitted Resident 5 on 5/10/2019 with a diagnosis of type 2 diabetes, a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production, and mild cognitive impairment a condition causing noticeable memory or thinking problems that exceed normal aging. The Quarterly MDS dated [DATE] revealed Resident 5 had a BIMS score of 15, indicating the resident was cognitively intact and was dependent on staff assistance for toilet use and personal hygiene and was occasionally incontinent of bowel with no bowel toileting program.An observation completed on 1/26/2026 at 11:30 AM it was observed that Resident 5 was sitting in their wheelchair in front of their open room door. Visible between the back of the wheelchair and the seat of the wheelchair was the resident buttock and incontinence product. Also visible at the foot of the resident's bed sitting on top of the foot of the bed was a white and blue plastic package of incontinence products. In an observation completed on 1/27/2026 at 9:00 AM it was observed that Resident 5 was sitting in their wheelchair in front of their open room door. Visible between the back of the wheelchair and the seat of the wheelchair was the resident buttock and incontinence product. The resident was observed to be wearing a hospital gown with a T-shirt underneath it. The hospital gown was observed to have dried fluid spills to the front of it going down the mid chest area. At the foot of the resident's bed ,on top of the residents edema wear, was a white and blue plastic package of incontinence products. In an observation completed on 1/27/2026 at 3:17 PM it was observed that Resident 5 was sitting in their wheelchair in front of their open room door. Visible between the back of the wheelchair and the seat of the wheelchair was the resident buttock and incontinence product. The resident was observed to be wearing a hospital gown with a T-shirt underneath it. At the foot of the resident's bed, on top of the residents edema wear, was a white and blue plastic package of incontinence products. In an interview completed on 1/27/2026 at 3:18 PM with Resident 5, Resident 5 stated that they wear the hospital gown over their T-Shirt for their comfort. The resident stated that they would like their hospital gown to be changed at least daily but sometimes the facility does not have any so they will wear the same one till one comes available to change into. The resident confirmed there was a spill stain to the front of their gown and stated they had spilled their milk at breakfast.In an observation completed on 1/28/2026 at 4:30 PM it was observed that Resident 5 was sitting in their wheelchair in front of their open room door. Visible between the back of the wheelchair and the seat of the wheelchair was the resident buttock and incontinence product. The resident was observed to be wearing a hospital gown with a T-shirt underneath it. The hospital gown was observed to have additional orange dried fluid spills to the front the gown. At the foot of the resident's bed, on top of the resident's edema wear, was a white and blue plastic package of incontinent products. In an observation completed on 1/29/2026 at 9:40 AM it was observed that Resident 5 was sitting in their wheelchair in front of their open room door. Visible between the back of the wheelchair and the seat of the wheelchair was the resident buttock and incontinence product. The resident was observed to be wearing a hospital gown with a T-shirt underneath it. The hospital gown was observed to have clear and orange dried fluid spills and brown dried food particles to the front the gown.In an interview completed on 1/29/2026 at 9:55 AM with Medication Aide A (MA-A), MA-A stated that resident's clothing should be changed daily or when it is visibly soiled. The MA confirmed that Resident 5 preferred to wear a hospital gown when in their room for comfort and this should be changed at the same frequency as it was part of the residents' clothing. The MA stated they were not aware of any shortage of gowns for the residents hindering the frequency of changing the residents' gown. The MA confirmed that residents' incontinent products should be stored in a drawer or closet out of sight of the public. The MA confirmed that the resident's shirt should be pulled down in the back covering their incontinent product and body part and was not.In an interview completed on 1/29/2026 at 1:16 PM with the facility Assistant Director of Nursing (ADON), the ADON confirmed that resident incontinence products were to be stored out of sight, residents clothing should be changed daily and when soiled, and resident incontinence products and or body parts should not be visible by the public.

Licensure Reference Number 175 NAC 1-009.01 Based on observation and interview, the facility failed to ensure the facility was neat clean and in good repair. This affected 11 of 69 facility residents. Facility stated a census of 69. Findings are: On 12/02/2024 a walk through was completed from 10:00 AM to 10:32 AM where the following was observed. -Cobwebs with debris visible in the windows of the Activities room of the secured care unit. -Chipped and peeling paint exposing unsealed wood on the door frames of resident rooms 411, 404, 405, 403, 207, 209, 102, 107, 108, and room [ROOM NUMBER]. -Missing light fixture cover on a light located in the ceiling of the Activities room on the secured unit. -In room [ROOM NUMBER] bathroom [ROOM NUMBER] pieces of material in different shades of white attached with black screws to the ceiling surrounding the vent located in the ceiling of the bathroom. -In the hallway of the secured care unit inside of the main double doors multiple pieces of white material secured to the ceiling with writing on them. One piece of the material on the edge is wavy and warped not fully secured to the ceiling. -A wooden rocking chair in the Activities Room on the secured unit with out cushion to the seat of the rocking chair exposing the brown cloth material that is frayed and not secured to the frame of the rocking chair. An interview on 12/04/2024 at 1:26 PM with the Facility Administrator (FA), confirmed that the paint was peeling and chipped from the door frames of the rooms listed, the areas in the ceiling of room [ROOM NUMBER] and the secured care unit hall were not sealed appropriately, there was no cushion to the rocking chair, and cobwebs with debris were present in the window of the Activities room of the secured unit. The FA confirmed that there was no current written action plan to address the repair, cleaning, or maintenance of these areas of soiling and disrepair.

License Reference Number 175 NAC 12-006.11 Based on record review, observation, and interviews, the facility failed to ensure the menus were followed as written and that use of the correct size serving spoons were used when meals are served resulting in less than required caloric intake. This affected 13 (Residents 40, 65, 22, 223, 6, 54, 44, 49, 43, 221, 222, 55, and 59) of 15 residents served meals. The facility census was 69. Findings are: An interview on 12/02/2024 at 8:00 AM with the facility [NAME] reveled the cook reviewed the menu for the week. The cook also took the time to discuss the serving spoons that are used in the facility when serving meals. The serving spoons all had different colors and were in separate containers by serving size. The 8 ounce serving spoons were stored together and were orange and green in color. Record review of the Menu titled Dietary Spreadsheet for week 3 used by the dietary department for meal planning. The document copyright date was 2024. The meal served at noon on 12/03/2024 was scheduled for Day 17 and included the following items: -Chicken pot pie - 8 ounces -Lima Beans - 4 ounces -Peanut butter cookie - 2 cookies -Beverage - 8 ounces An observation on 12/03/24 at 12:10 PM revealed food from the kitchen was delivered to the 500 hallway by Dietary Aide (DA-B) on a steam table to serve the individual residents who requested room trays. Chicken Pot pie was served with a white 6-ounce scoop. Each residents plate had one cookie served on a single plate. An interview on 12/03/2024 at 12:36 PM with DA-B revealed that the white scoop was used to serve meals as that is what had been provided in plastic wrap to serve the meals. An interview on 12/03/24 at 12:38 The facility [NAME] confirmed a white 6-ounce scoop was used by the dietary personnel to serve the chicken pot pie during the noon meal.

Licensure Reference Number 175NAC 12-006.19(C)(i) Licensure Reference Number 175NAC 12-006.18(B) Based on observation, interview, and record review, the facility failed to ensure that staff performed laundry delivery to residents in a manner to prevent the potential for cross-contamination for 20 of 20 residents observed (Residents 57, 10, 15, 26, 7, 27, 37, 11, 30, 36, 31, 223, 22, 54, 6, 60, 59, 43, 55, and 41). The facility census was 69. Findings are: Record review of the facility Infection Prevention and Control Program dated 5/20/17 revealed that the facility will establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Laundry and direct care staff will handle, store, process, and transport linens so as to prevent the spread of infection. The section titled Hand Hygiene Protocol revealed that all staff shall wash their hands between resident contacts and after handling contaminated objects. Observation on 12/3/24 at 1:38 PM on the facility 300 hall revealed that Laundry Aide-D (LA-D) removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 14. LA-D exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-D did not perform hand sanitization. LA-D removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 57. The clothing was held rubbing against the front of the emerald green uniform of LA-D. LA-D exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-D did not perform hand sanitization. LA-D removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 10. LA-D exited the resident room and returned to the laundry cart. LA-D did not perform hand sanitization. LA-D removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 15. LA-D exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-D did not perform hand sanitization. LA-D removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 26. LA-D exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-D did not perform hand sanitization. LA-D removed clothing on hangers from inside the laundry cart and carried them to the closed room door of Residents 7 and 27 (roommates). The clothing rubbed against the front of the uniform of LA-D. An unidentified staff cracked open the door and told LA-D that they were working with a resident in the room. LA-D carried the clothing back to the laundry cart and placed the clothing back inside the laundry cart. LA-D removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 37. The clothing rubbed against the front of the uniform of LA-D. LA-D exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-D did not perform hand sanitization. LA-D removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 11. LA-D exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-D did not perform hand sanitization. LA-D removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 30. LA-D exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-D did not perform hand sanitization. The time was now 1:45 PM. This surveyor asked LA-D if they are to do any sanitization between resident rooms. LA-D responded yes. LA-D did not perform hand sanitization. LA-D removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Residents 36 and 31 (roommates). LA-D exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-D did not perform hand sanitization. Observation on 12/4/24 at 3:47 PM on the facility 500 hall revealed that Laundry Aide-E (LA-E) pushed the covered laundry cart onto the 500 hall. LA-E removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 44. LA-E exited the resident room and returned to the laundry cart. LA-E did not perform hand sanitization. LA-E removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Residents 223 and 22 (roommates). LA-E exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-E did not perform hand sanitization. LA-E removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 54. LA-E exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-E did not perform hand sanitization. LA-E removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 6. LA-E exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-E did not perform hand sanitization. LA-E removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Resident 60. LA-E exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-E did not perform hand sanitization. LA-E removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Residents 59 and 43 (roommates). LA-E exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-E did not perform hand sanitization. LA-E removed clothing on hangers from inside the laundry cart and carried the clothing into the room of Residents 55 and 41 (roommates). LA-E exited the resident room carrying used empty clothes hangers and placed them inside the laundry cart. LA-E did not perform hand sanitization. This surveyor asked LA-E if they are to do any sanitization between resident rooms. LA-E responded that they are to use the hand sanitizer after coming out of each room. LA-E did not perform hand sanitization. LA-E opened the laundry cart and began to rearrange a blanket and linens on the bottom shelf of the laundry cart. Interview with the facility Director of Nursing (DON) on 12/5/24 at 1:03 PM confirmed that the expectation is for all facility staff to perform hand sanitization after exiting a resident's room to prevent cross contamination. Interview with the facility Infection Preventionist (IP) on 12/5/24 at 1:03 PM confirmed that staff should not carry clothing or laundry against their uniform due to the potential for cross contamination.

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review, the facility failed to provide an assessment by a licensed professional nurse for 1 (Resident 23) of 1 sampled residents with symptoms of a potential respiratory infection. The facility identified a census of 69. Findings are: A record review of Resident 23's Order Summary dated 12/2/24 reveal diagnoses of Allergic Rhinitis (an allergic reaction that causes sneezing, congestion and sore throat) entered on 06/08/23 and Chronic Sinusitis (an inflammation of the sinus or nasal passages occurring for more than 12 weeks at a time) entered on 07/25/24. The Order Summary dated 12/2/24 also revealed an order entered on 10-16-2024 for Mucinex (a medication that helps loosen congestion in the chest and throat, making it easier to cough out through the mouth) for the indication of cough. Instructions for the medication stated the medication should be administered as needed twice a day. The order did not include a stop date. A record review of Medication Administration Record (MAR) for the month of November 2024 revealed that Resident 23 received Mucinex 22 days out of 30. The MAR revealed that Mucinex was administered and followed up for effectiveness each time by a Medication Aide. Record review of Resident 23's progress notes revealed no documentation of respiratory assessments or nursing attention being directed towards Resident 23's cough. An observation on 12/2/24 at 3:35 PM in Resident 23's room revealed Resident 23 to be lying in bed with the head of the bed elevated approximately 30 degrees. Resident 23 was noted to have a cough that sounded deep and productive (producing mucus). An interview with Resident 23 on 12/2/24 at 3:35 PM revealed that the cough had been present for a while, however, within the last two weeks it had worsened. Resident 23 states that they made nursing staff aware of its worsening but was unable to recount the names of staff members notified. Resident 23 revealed that [gender] stay mostly in bed, including meals, and gets out of bed two-three times a day for toileting purposes. Resident 23 revealed [gender] take walks approximately four times a week with the restorative aide. An interview with LPN-H (Licensed Practical Nurse-H) on 12/04/24 at 9:57 AM revealed LPN-H was aware Resident 23 had a cough but was unaware Resident 23 had concerns about cough worsening. LPN-H confirmed that they are the full-time day shift nurse for Resident 23 and states [gender] were not notified that the Medication Aide was administering the as needed Mucinex and performing a follow-up on the medication's effectiveness. LPN-H confirmed that there had not been a respiratory assessment completed by a nurse. An interview with DON (Director of Nursing) on 12/04/24 at 10:52 AM confirmed that there was no policy on what as needed medications should be followed up by the nurse as opposed to the Medication Aide. The DON confirmed there was no policy detailing procedures for performing focused assessments related to acute conditions. The DON confirmed it is best practice to perform focused assessments for acute symptoms or conditions. The DON stated resident does have diagnosis of chronic sinusitis but confirmed that Mucinex was ordered for an indication of cough, which Resident 23 did not have a chronic diagnosis for.

Licensure Reference Number 175 NAC 12.006.09(H)(iii)(2) Based off observation, interview, and record review, the facility failed to routinely assess a pressure ulcer (a localized area of damaged skin or tissue that can occur when pressure is applied to an area for a prolonged period) and monitor the effectiveness of the treatment for the wound for 1 (Resident 26) of 1 sampled residents. The facility identified a census of 69. Findings are: A record review of Resident 26's Minimum Data Set (MDS, a federally mandated tool used to assess the health of nursing home residents who are enrolled in Medicare or Medicaid) dated 10/30/24 revealed that Resident 26 was fully dependent on nursing staff for all activities of daily living (ADLs). The MDS further revealed a diagnosis of Pressure Ulcer of Other Site, Unspecified. A record review of Resident 26's Order Summary dated 12/4/24 revealed the following diagnoses: Spastic Quadriplegic Cerebral Palsy; Contractures of Muscle, Right Upper Arm; Other forms of Scoliosis, Lumbar Region; Contractures of Muscle, Left Upper Arm; Severe Intellectual Disabilities; Contractures of Right Knee; Contractures of Left Knee; Pressure Ulcer of Other Site, Unspecified Stage. A record review of Resident 26's Order Summary dated 12/4/24 revealed the following orders regarding wound care: -An order dated 6/13/24: To right knee wounds, remove old dressings and wash areas with warm soapy water. Rinse and pat dry or cleanse with saline and pat dry, then apply Derma blue cut to fit. Cover with an abdominal pad. Secure with Kerlix and tape. Change three times per week on bath days; one time a day every Tuesday, Thursday, and Saturday for wounds. -An order dated 11/15/24: Nursing Order Wound care of Left Foot, 1st toe: Apply skin prep to area and cover with silicone foam dressing. Apply skin prep and change foam dressing every Tuesday, Thursday, and Saturday for Fluid Filled Blister of Left Foot, 1st toe. -An order entered on 5/6/24: Weekly Skin Assessment, please complete weekly skin integrity review V1 on Bath Day every day shift every Sat for Skin integrity. A record review of Weekly Skin Assessment for the month of November 2024 revealed no wound descriptions or measurements. A record review of a wound consultation with a wound care clinic dated 11/1/24 revealed that Resident 26's wounds were followed by the clinic and Resident 26 was seen once a month. Consult revealed diagnosis of Skin Ulcer of right knee with fat layer exposed (HCC). The providers documentation revealed I do have some concerns today with the right medial knee ulceration measuring slightly larger with some seropurulent drainage (a type of wound drainage that can be a sign of infection or inflammation). I am going to go ahead and start Resident 26 on oral antibiotics for cellulitis of this wound. Document further describes Open wound to medial knee is covered in 100% red moist tissue with moderate amount of seropurulent drainage noted. The Provider's measurements of the wound were 1.8 x 2.5 x 0.1. An interview with Director of Nursing (DON) on 12/5/24 at 8:26 AM revealed that the facility expectation was that nurses are responsible for obtaining wound measurements and descriptions during the Weekly Skin Assessment. DON confirmed that wound measurements and descriptions were not being documented on skin assessment days or at any other time other than monthly with wound care nurse. A record review of the facility policy titled Skin and Wound Management dated 1/2024 revealed that the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, depth, and presence of exudates or necrotic tissue.

Licensure Reference Number 175 NAC 12-006.09(h)(v) Based on observation, interview, and record review, the facility failed to implement interventions to prevent the potential worsening of a contractures for 1 (Resident 23) of 1 sampled resident. The facility identified a census of 69. Findings are: A record review of Resident 23's face sheet dated 12/2/24 revealed an admitted [DATE] and a diagnosis of contractures, (a permanent tightening of the muscles, tendons, skin, or nearby tissues that limits the range of motion of a joint or body part) of the left hand was added on 06/08/23. A record review of the undated Care Plan revealed no documentation for a contractures of the left hand or interventions for the contractures. A Record review of Resident 23's admission Minimum Data Set (MDS, a federally mandated tool used to assess the health of nursing home residents who are enrolled in Medicare or Medicaid) dated 04/22/2021 revealed no documentation of a contractures. A Record review of MDS dated [DATE] revealed no documentation of a contractures. The MDS did reveal Resident 23 requires partial to moderate assistance from staff with all activities of daily living. An observation on 12/2/24 at 3:35 PM in the room of Resident 23 revealed a contractures of the Resident's left hand in which four of five fingers were noted to be bent inwards towards the palm. Fingernails were untrimmed with the tips of fingernails touching the skin of the Resident's palm. An interview with Resident 23 on 12/2/24 at 3:35 PM revealed that the contractures was present prior to admission and caused pain, discomfort and interfered with activities of daily living. Resident 23 revealed the facility staff do not provide assistance with cleaning under fingers or placing towel roll in between fingers and palm. An interview with Occupational Therapist (OT) on 12/04/24 at 9:07 AM revealed Resident 23 received services from 03/18/22 to 04/11/22. Services were discontinued because Resident 23 reached their maximum potential with skilled services. Record review of the OT Discharge Note dated 04/11/22 revealed that Resident 23 was unable to tolerate range of motion (ROM) exercises however was able to complete gentle self-stretching exercise of left hand. The Discharge Note also revealed that Resident 23 is unable to tolerate splint, however, is able to keep small towel roll as barrier in left hand. The Discharge Note revealed that Resident 23 and caregiver (nursing home staff) training included exercise program, compensatory strategies, self-care/skin checks, and splinting/orthotic schedule. An interview with the Director of Nursing (DON) on 12/04/24 at 8:55 AM confirmed that Resident 23 did receive services from OT in 2022 and did receive Botox (a nerve blocking medication that prevents muscles from contracting) injections in 01-2024 to assist with both pain and range of motion of fingers. Injections were not successful and Resident 23's financial power of attorney did not wish to continue treatment. The DON confirmed that the facility implemented no further interventions after that point including self-care or rolled towel to palm intervention. A Record review of the facility ADL policy revised 1/2024 revealed: the facility will maintain individual objectives of the care plan and periodic review and evaluation

Licensure Reference Number 175 NAC 12-006.10 (D) Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% with an observed medication error rate of 7.41% (27 administrations and 2 errors). This affected 2 (Residents 14 and 17), of 10 sampled residents. The facility stated census of 69. Findings are: A. Record review of a facility policy titled Clinical Management Medication Administration dated 05-2017 revealed to verify the pharmacy prescription label on the drug and the medication administration record or the physician orders. If there is a discrepancy check the original physician order and notify the pharmacy do not give the medication until clarified. In an observation completed on 12/03/2024 at 12:15 PM Medication Aide G, (MA-G), obtained a box labeled with Resident 17's name and Ultra Eye Preservative Free Drop 0.4-0.3% with directions to instill one drop into both eyes every 2 hours as needed for dry eyes. MA-G then proceeded to administer the eye drop to Resident 17. In an interview on 12/03/24 12:32 PM with MA-G, MA-G stated that the resident received the eye drop on a routine basis and not on an as needed basis. The MA confirmed that the label read for the eye drop to be administered on an as needed basis not routinely. Record review of Resident 17's Medication Administration Record dated 12/03/24 revealed a physician order for Ultra Eye Preservative Free Drop 0.4-0.3% with directions to instill one drop into both eyes four times a day. In an interview on 12/03/2024 at 1:05 PM with the Director of Nursing (DON) confirmed that Resident 17's Ultra Eye Preservative Free Drop 0.4-0.3% label read to administer the eye drop every 2 hours as needed and the physician order read to administer the eye drop four times a day. The DON confirmed that the physician order and the label did not match. B. In an observation completed on 12/03/2024 at 12:30 PM MA-G obtained a white tube of medication labeled Diclofenac Gel 1% apply 4 GM (Grams) to knees four times daily. MA-G walked to Resident 14's room, knocked on the door, acknowledged the resident and then entered the resident's room. The MA informed Resident 14 they were going to apply the residents pain cream and asked the resident if they would like the cream applied to their back or their knees. Resident 14 stated they would like the cream applied to their back. The MA then applied the gel to the resident's back. Record review of Resident 14's Medication Administration Record dated 12/03/2024 revealed that Resident 14 had a physician order for Diclofenac Gel 1% to apply 4 Grams to the knees four times a day. In an interview on 12/03/2024 at 12:32 PM with MA-G, MA-G confirmed that the label on the tube of medication read for the gel to be applied to the residents knees and the physician order read for the gel to be applied to the resident knees and that the order did not reflect that the gel was to be applied to the residents back or knees per the residents choice. In an interview on 12/03/2024 at 1:05 PM with the DON confirmed that Resident 14 did not have an order for Diclofenac Gel to be applied to their back. The order only indicated it was to be applied to the resident's knees. The DON confirmed that the gel should only be applied as directed in the order.

License Reference Number 175 NAC 12-006.119(A)(iv) Based on record reviews, observations, and interviews, facility failed to provide a physician ordered therapeutic diet with increased protein for 1 (Resident 22) of 1 resident sampled. The facility census was 69. Findings are: Record review of the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents and for use when creating Care Plans) dated 11/10/24 for Resident 22 revealed the resident had a Brief Interview of Mental Status (a short cognitive screening tool used to assess a person's mental abilities in long-term care facilities) score of 14 a score of 13 to 15 means the individual is cognitively intact. Record review on 12/03/24 of the working Care Plan (a document outlining a resident's individual healthcare needs, including medical conditions, personal preferences, and specific care strategies to provide the best possible support and treatment) revealed that Resident 22 was admitted on [DATE], had diagnoses of non-pressure ulcer of the back with necrosis of the bone, pressure ulcer of the sacral region stage 4, severe protein-calorie malnutrition, type 2 diabetes, anemia, and paraplegia. The care plan also revealed that Resident 22 had a nutritional problem related to non-pressure chronic back ulcer, pressure ulcer of the sacral region stage 4, severe protein-calorie malnutrition and anemia. Supplements were to be to be given as ordered. Record Review of the Physician Orders printed on 12/04/2024 revealed dietary orders that Resident 22 was to receive a regular diet, regular texture, regular consistency with double portions of proteins with meals as well as snacks and supplements per the registered dietician's recommendations. Observation on 12/04/24 at 12:10 PM of Dietary Aide (DA-B) who served the resident meals to those who resided on the 500 hallway. DA-B served Resident 22 one scoop of meat and one sandwich to Resident 22. Interview on 12/04/24 at 12:30 PM with DA-B, who stated Resident 22 received two sandwiches instead of just one. Retrieved the dining room meal order ticket to show that Resident 22 is ordered to receive double protein servings. Interview on 12/04/24 at 12:55 PM with Resident 22 revealed Resident 22 that only one sandwich and one portion of protein was served with the noon meal. Interview on 12/04/24 at 12:57 PM with Activity Aide (ACT-A) who repeated the question to Resident 22 for clarification as Resident 22 only speaks Spanish. Resident 22 stated [gender] had uno (one) sandwich and held up one finger. Confirmation from ACT-A that Resident 22 had only one portion of protein during the noon meal. Interview on 12/04/24 at 01:00 PM with the Administrator confirmed Resident 22 has an order for double protein servings at meal time. Interview on 12/04/2024 at 01:15 with DA-B revealed that Resident 22 had not been given the double servings of protein but instead another resident.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review, the facility failed to store and distribute foods and liquids in accordance with the facility policy and to prevent potential cross contamination and foodborne illness. This had the potential to affect 68 of 69 residents. Findings Are: A record review of the facility policy labeled Nutrition Services Food Storage dated 03/14/2014 revealed dry storage room items should be stored to ensure freshness, in bulk, and in tightly covered containers. The policy revealed all containers must be labeled and dated. In addition, scoops for items stored in bins, such as sugar, flour, rice and other items should be covered in a protected area near the food containers. The policy revealed for refrigerated items to be dated, labeled and tightly sealed. All items should include name of item and a use by date. The policy revealed frozen items should be stored in moisture proof wrap and/or containers that are labeled and dated. A. Observation on 10/30/2023 during the initial Kitchen tour from 8:52 AM to 9:20 AM revealed: The walk in refrigerator contained: - A 2% gallon of milk noted to be half full and was not labeled with an open date, - A large industrial size clear plastic bag approximately one fourth full of white shredded cheeses that was closed with a blue plastic disposable glove, - A cardboard box with a opened plastic bag inside that exposed raw chicken wings, - A clear plastic covered rectangular container that contained sliced meat that was not labeled or dated, - A clear plastic covered container that contained cheese slices that was not labeled or dated. ' The walk in freezer contained: - An undated cardboard box labeled Tyson Chicken tenders that was open with the plastic bag inside open and exposed breaded chicken portions, - An undated cardboard box labeled Mixed Vegetables was observed with the plastic bag inside of the box was opened and exposed vegetables, The main kitchen and dry storage area on the lower shelf of silver food prep table a clear plastic container labeled parsley that was approximately one half full was observed with no date written on opened container. A large round clear plastic container labeled flour no date present on label with white plastic measuring cup in container. Noted in cupboard opened containers labeled salt, dill weed, and baking soda all open with no date written on them. Salt and baking soda both in original cardboard containers open, not sealed exposing contents to the air. A large white round plastic container labeled Cheerios and dated 08/09. A industrial size container labeled Jiff peanut butter with date written on lid of 08/22. An interview on 10/30/2023 at 9:20 AM with the Dietary Manager (DM) revealed all items are to be dated when they are opened. An interview on 11/01/2023 at 10:30 AM with the Dietary Cook (DC)-D revealed when items are opened in the kitchen they are to be dated on the package. B. Observation on 11/01/23 at 9:01 AM of the north dining area revealed a metal cart with apple juice and milk placed in a gray plastic tub with a clear liquid on the bottom of the tub. Then, DM poured the milk and apple juice into thermal cups and temperatures were obtained which were: the milk was 46.8 degrees Fahrenheit and the apple juice was 43.8 degrees Fahrenheit. An interview on 11/01/2023 at 9:05 AM with the DM revealed liquids should be 38 degrees Fahrenheit or below. A record review of facility policy labeled Nutritional Services Food Preparation and Handling dated 03/14/2014 section headed cold food temperatures item four states maintain all cold items at a temperature of 40 degrees Fahrenheit or below.

Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to ensure that the bathroom ventilation vents were free from dirt and dust affecting 10 (Residents 6, 16, 35,19, 44, 51, 53, 119, 120, and 121) of 20 sampled residents. The facility census was 68. Findings are: Observation on 10/30/23 between 12:36 PM- 3:19 PM revealed the bathroom vents in the resident rooms that were occupied by Resident 6, 16, 35, 19, 44, 51, 53, 119, 120, and 121 were soiled with a white gray fuzzy substance. Observation on 11/2/23 at 11:30 AM with the facility Administrator and the Maintenance Director confirmed the bathroom vents in the resident rooms that were occupied by Resident 6, 16, 35, 19, 44, 51, 53, 119, 120, and 121 were soiled with a white gray fuzzy substance. The facility Administrator and Maintenance Director revealed the vents needed to be cleaned.

LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].17B LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].17D Based on observation, interview, and record review; the facility staff failed to follow the CMS (Centers for Medicare and Medicaid) guidelines to prevent the potential spread of Covid-19 by failing to follow the guidelines for quarantine of a resident newly admitted to the facility (Resident 11). The failure to follow quarantine guidelines for residents newly admitted to the facility had the potential to affect the 7 residents who had not tested positive for Covid-19 and still had the potential to contract Covid-19 (Residents 17, 18, 1, 19, 20, 8, and 21) and 1 of 2 newly admitted residents who had not been tested for Covid-19 (Resident 11). The facility staff also used the same face shield when entering a resident room under quarantine placing them at risk for cross contamination between Resident 11 and the 7 facility residents who had not contracted Covid-19 (Residents 17, 18, 1, 19, 20, 8, and 21). The facility staff also failed to perform hand hygiene to prevent potential cross contamination during insulin administration which affected 5 of 5 residents (Resident 22, 4, 5, 7, and 10); failed to change gloves and perform hand hygiene during BS (blood sugar) checks which affected 8 of 8 residents (22, 4, 6, 12, 7, 8, 10, and 9); failed to clean the blood glucose monitoring machine between residents to prevent potential cross contamination which affected 8 of 8 residents (22, 4, 6, 12, 7, 8, 10, and 9); failed to perform hand hygiene to prevent potential cross contamination when exiting resident rooms for 6 of 6 residents (Residents 12, 13, 14, 7, 15, and 16), and before putting on gloves and after taking off gloves for 2 of 2 residents (Residents 19 and 20). The facility identified a census of 50 at the time of survey. Findings are: A. Interview with the facility Administrator on [DATE] at 11:09 AM revealed the following: The facility had Covid-19 cases with the facility and the staff in the past. The facility is considered Green right now. The facility nurse consultant was working with the local health department and DHHS (Department of Health and Human Services) on their cases and that determination has been made at this time. The facility did not have any active Covid-19 cases at this time. The administrator revealed the facility currently had a quarantine unit for any residents who returned from the hospital and they resided in quarantine on that unit for 14 days. They are currently not accepting any residents who are confirmed positive for Covid-19. The administrator revealed the entire facility did not have any Covid-19 positive residents at this time. All staff were required to wear masks when entering resident rooms and residents were to wear a mask if they came out of their room. Interview with RN-I (Registered Nurse) on [DATE] at 11:30 AM revealed the 500 unit was the quarantine unit where residents were required to reside for 14 days when they were admitted to the facility. Observation of the quarantine unit on [DATE] at 11:35 AM revealed there were no residents observed residing on that unit. There were signs on some of the doors dated [DATE] that read: 500 Hallway-will be required to wear all PPE (Personal Protective Equipment) which is N95 (a type of mask), gown, gloves, and face shield while working with residents. Interview with the facility Administrator on [DATE] at 12:30 PM revealed 1 resident was scheduled to be admitted to the facility from the hospital tomorrow and they would reside on the quarantine unit for 2 weeks. Interview on [DATE] at 1:06 PM with Resident 1 who was sitting out in the hall in the green Zone in a power wheelchair revealed they had not tested positive for Covid-19. Observation of NA-H (Nursing Assistant) on [DATE] at 8:40 AM revealed they were working on the quarantine unit. Interview with NA-H at this time confirmed they were working on the quarantine unit today. NA-H revealed there was 1 resident who was admitted to the facility after NA-H had left the facility last night. NA-H revealed the procedure for entering the resident's room was that it was their understanding that the staff were protecting the resident from the staff so they just wore a mask and a face shield. NA-H revealed it was their understanding that the resident had a TIA ([MEDICAL CONDITION]) and had been in the hospital for a year before coming to the facility. Interview with NA-H on [DATE] at 8:58 am revealed they did float to other units in the facility to provide care to residents. NA-H revealed they helped get people up this morning on the other units. NA-H revealed no one in the building was considered contagious so NA-H understood they could provide care to the residents on the other units as well as caring for the residents on the quarantine unit. Observation on [DATE] At 9:00 revealed NA-H went into Resident 11's room where the new resident was residing on the Gray or quarantine unit after using hand sanitizer and donning a face shield. NA-H did not don gown or gloves. NA-H was already wearing a surgical face mask. NA-H talked to Resident 11 then left the room, took the face shield off and laid it on top of the PPE cart sitting outside of Resident 11's door and used hand sanitizer for hand hygiene from a dispenser hanging on the wall. Observation on [DATE] at 9:26 AM revealed MA-J (Medication Aide) walked to the doorway of Resident 11. MA-J was wearing a face mask and donned the face shield that was laying on the top of the PPE cart. MA-J did not don a gown or gloves. MA-J then entered Resident 11's room. MA-J then came out of Resident 11's room and put the same face shield on top of the cart, do hand hygiene with hand sanitizer and walked down the hall to the other units in the facility that were Green. Observation of Resident 11's room on [DATE] at 9:00 AM revealed a sign on the door that read: 14 Day Admission Precaution. Staff Mask (May wear face shield). Resident mask when in room. Resident to wear mask when outside of room. There were no other directions for other PPE use or precautions on the sign. Interview on [DATE] at 9:32 with RN-K revealed the quarantine hall Resident 11 was residing on was a Gray Zone. RN-K revealed Resident 11 had been in the hospital for 8 months and the facility felt the staff were to protect that resident from the staff; not protect the staff from the resident. RN-K revealed the facility had tested all of the residents for Covid-19 but not the staff. RN-K revealed the facility had 5 residents who had never tested positive for Covid-19 and they had been directed by the SIP (State Infection Preventionist) to monitor those 5 daily for signs and symptoms of Covid-19. When RN-K was asked if the Resident 11 had been tested for Covid-19 prior to admission RN-K said they did not know and would need to look into that. Interview on [DATE] at 9:54 am with RN-K confirmed Resident 11 did not have a baseline Covid-19 test, or was not tested prior to admission. Interview with RN-K on [DATE] at 11:00 AM revealed the staff were only using a face mask and face shield to enter Resident 11's room as RN-K said Resident 11 was kind of an exception. RN-K revealed the facility typically didn't get a resident who had been 8 months in the hospital. RN-K reported they did not feel Resident 11 could have had any potential exposure as Resident 11 did not come from home. RN-K confirmed the facility still had residents who never tested positive and not all of the staff tested positive either and the staff were leaving the facility and returning ad lib. RN-K revealed the facility as a whole was on the downhill slide of the Covid-19 disease. RN-K revealed they did not feel Resident 11 was a risk for transmission because Resident 11 had been in the hospital for 8 months. RN-K revealed they had not consulted with the health department regarding the situation with Resident 11 and they would do that. Record review of an email sent by RN-K revealed they had sent an email to the SIP (State Infection Preventionist) at 11:27 AM on [DATE] for clarification on required PPE for the facility Gray Zone. Response by the SIP was returned to RN-K at 12:09 PM on [DATE] and indicated the facility needed to follow the Gray Zone guidelines for Resident 11. Facility began mitigation to place Gray Zone in full PPE prior to response from SIP was received. Observation on [DATE] at 12:12 PM Revealed NA-H wearing N95 mask, face shield, gown, and gloves when they took a meal into Resident 11's room. NA-H then removed the gown and gloves and face shield and performed ABHR (Alcohol Based Hand Rub) after they left Resident 11's room. NA-H then donned new gloves and cleaned the face shield. NA-H removed gloves and performed ABHR. NA-H then donned a new gown, face shield, and gloves then delivered a meal to Resident 22 indicating the facility had abated the immediate jeopardy. On [DATE] at 12:20 PM the RDO (Regional Director of Operations) expressed concern with the requirement for staff to wear gloves, gown, mask, and face shield when in the rooms of the newly admitted residents residing in the facility quarantine unit. The RDO revealed that Resident 11 had been hospitalized for [REDACTED]. The RD stated that the facility and staff had put much thought into how to care for the newly admitted residents. The facility administrator was present. At 12:40 PM RN-K revealed that they had e-mailed the SIP for clarification on the required PPE use for newly admitted residents. The email response from the SIP confirmed that any new resident was to be put into a Gray Zone (a transitional or quarantine unit used to monitor residents admitted to the facility for Covid-19 to prevent the potential for spread of Covid-19 in the facility) for 14 days and that the facility was to follow the PPE requirement for a Gray Zone (Gown, Gloves, Eye protection and N95 mask). The facility changed their procedure and all staff will don full PPE (gown, gloves, mask, face shield) when they enter the rooms of newly admitted residents on the Gray Zone. At 12:45 PM the DON revealed that the Gray Zone guidelines were implemented and that the staff was educated. On [DATE] an e-mail was sent to the administrator with a request for the documentation of when they did the transition on the Gray unit and when they educated staff and what this entailed for the corrective action to abate the situation on site [DATE]. The administrator was also asked for a list of staff who had never tested positive to determine if there was still a risk of staff bringing it into the facility or contracting it from another resident in the facility and passing it on to residents including the new resident and the 7 residents who never tested positive. Review of the undated list of staff Covid-19 test results revealed 22 of 117 staff listed tested positive. MA-J was not on the list at all and NA-H was not listed as testing positive so there was the potential they could become infected and spread to the residents in the Gray unit or the other residents in the facility who had not tested positive by working on both the Gray and Green units without using the PPE per guidelines. Review of the staff training dated [DATE] revealed the staff were trained that all admissions will be on a 14 day droplet precautions (Gray Zone). Full PPE is to be worn when in room with resident for droplet precautions. This was documented as completed at 12 PM. Review of the e-mail communication with the SIP dated [DATE] at 12:09 PM revealed the facility was directed to follow the Gray Zone procedure for the new residents on the Gray Zone for 14 days. The SIP directed the facility that Gray Zone PPE should be worn: N95, eye protection (face shield or goggles), gown, gloves. Review of the facility Covid-19 Line Listing report revealed 20 residents who were Covid-19 positive had expired during the time frame from [DATE] to [DATE]. 43 of the residents currently residing in the facility had tested positive for Covid-19 and had recovered. Review of the list of residents who have tested negative identified by the facility as the residents who had never tested positive for Covid-19 were: Residents 17, 18, 1, 19, 20, 8, and 21. These residents had never had Covid-19 or tested positive so they were still at risk for contracting it. Review of the ICAP (Infection Control and Prevention) Review of Zones and PPE (Personal Protective Equipment) revealed the following guidelines for the zones and PPE: Gray Zone: Residents who are being transferred from the hospital/outside facility (but have no known exposure to Covid-19) are usually kept in this Zone for 14 days, and if remains asymptomatic at the end of 14 days will be moved to Green Zone. PPE to be used: Gown, gloves, eye protection and N95 mask (N95 mask preferred if no N95 then surgical mask with face shield). Green Zone (Covid-19 free Zone): Asymptomatic residents without any exposure to Covid-19: PPE to be used: Surgical mask and PPE per standard precautions. The facility abated the Immediate Jeopardy by implementing the Gray Zone precautions and educating staff by 12:00 PM on [DATE]; however, the new resident (Resident 11) and the 7 residents who had not contracted or tested positive for Covid-19 (Residents 17, 18, 1, 19, 20, 8, and 21) were placed at risk for contracting Covid-19 due to the staff failure to follow the Gray Zone precautions and working on both the Gray and Green Zones. Therefore, the Immediate Jeopardy was abated to an E, as the residents were still at risk for contracting Covid-19 due to the 14 day incubation period. B. Observation on [DATE] at 9:00 revealed NA-H went into Resident 11's room where the new resident was residing on the Gray or quarantine unit after using hand sanitizer and donning a face shield. NA-H did not don gown or gloves. NA-H was already wearing a surgical face mask. NA-H talked to Resident 11 then left the room, took the face shield off and laid it on top of the PPE cart sitting outside of Resident 11's door and used hand sanitizer for hand hygiene from a dispenser hanging on the wall. NA-H then walked away from the cart and left the face shield on top of the cart. The face shield was not cleaned. Observation on [DATE] at 9:26 AM revealed MA-J (Medication Aide) walked to the doorway of Resident 11. MA-J was wearing a face mask and donned the face shield that was laying on the top of the PPE cart, which was the same face shield that had been used and not cleaned by NA-H. MA-J then entered Resident 11's room. MA-J then came out of Resident 11's room and put the same face shield on top of the cart, do hand hygiene with hand sanitizer and walk down the hall to the other units in the facility that were designated as green. The face shield was not cleaned. C. Observation of LPN-G (Licensed Practical Nurse) on [DATE] at 11:33 MA revealed LPN-G (Licensed Practical Nurse) was doing BS (Blood Sugar) checks and administering insulin to residents using supplies from a treatment cart with several drawers and the computer was sitting on top of it with a mouse on a mouse pad. Interview with LPN-G at this time revealed the facility residents shared a glucometer (a portable machine used to check BS levels at the bedside). The glucometers LPN-G were using were labeled Assure Platinum. Observation on [DATE] at 11:35 AM revealed LPN-G donned gloves. The glucometer was sitting on top of the cart on a piece of paper. It was not wrapped with a disinfectant wipe. LPN-G gathered an alcohol wipe, cotton ball, lancet and glucometer test strip from the drawer by touching the drawer with the gloved hands, picked up the glucometer and went into Resident 22's room and checked Resident 22's blood sugar. LPN-G pricked Resident 22's finger with the lancet and placed a drop of blood on a test strip that was inserted into the glucometer. LPN-G touched Resident 22's hand with the gloves and the glucometer as well as a cotton ball LPN-G placed on Resident 22's finger after LPN-G lanced it and placed a drop of blood from Resident 22's finger onto the test strip. After the result appeared on the screen of the glucometer, LPN-G left the room, put the lancet into the sharps container, then LPN-G used a Clorox non-bleach wipe and cleaned the glucometer with the wipe and placed it on a paper square on top of the cart. LPN-G wiped the glucometer quickly and discarded the wipe. The glucometer was dry in seconds. LPN-G then used the same gloved hands to open the drawer on the cart and get out an insulin pen that was in a clear plastic bag. LPN-G then opened a drawer and retrieved a pre-packaged insulin pen needle. LPN-G opened the needle, placed it on the insulin pen, primed the pen, dialed the dose, entered Resident 22's room and injected the insulin into Resident 22's arm. LPN-G then came out of the room with the same gloves on, discarded the needle in the sharps container, put the insulin pen in a bag that was lying on top of the cart. LPN-G then removed the gloves and did hand hygiene with ABHR (Alcohol Based Hand Rub). LPN-G then placed the insulin pen in the bag back into the drawer. Observation on [DATE] at 11:40 AM revealed LPN-G donned gloves, opened the drawer and got a test strip, cotton ball, alcohol wipe, and lancet out of the drawer. LPN-G touched the same drawer LPN-G had touched with the gloved hands LPN-G had used for Resident 22. LPN-G picked up the glucometer off the top of the cart and went into Resident 4's room and checked their blood sugar by lancing their finger and placing a drop of blood on the test strip that LPN-G had inserted into the glucometer. LPN-G touched Resident 4's hand while obtaining the blood sample. LPN-G then left Resident 4's room with the glucometer, took a Clorox non-bleach wipe out of the container on the cart, wiped the glucometer, threw the wipe away and placed the glucometer on a barrier on top of the cart. The glucometer was dry in seconds. LPN-G still had the same gloves on. LPN-G documented the BS by touching the computer mouse on top of the cart. LPN-G then used keys to open the cart then opened a drawer on the cart and got Resident 4's insulin pen bag out of the drawer. LPN-G then removed a pre-packaged needle from the drawer, opened it and put it on the insulin pen. LPN-G still has the same gloves on. LPN-G then went in and gave Resident 4 the insulin by injecting it into their left arm. LPN-G then left Resident 4's room and went back to the cart and put the insulin pen back into the bag after discarding the needle into the sharps container. LPN-G then unlocked the cart with their keys. LPN-G then removed the gloves, opened the drawer, and put the bag with the insulin pen back into the drawer. LPN-G then charted on the computer on the cart by touching the mouse and the keyboard. LPN-G then gave keys to the administrator who had come up and requested a set of keys to get into the storeroom. LPN-G did not do hand hygiene after removing their gloves. LPN-G then got gloves out of a box and laid them on top of the cart. LPN-G did hand hygiene with ABHR and put on the gloves. Observation on [DATE] at 11:45 AM revealed LPN-G got a bag containing and insulin pen out of the drawer for Resident 5. LPN-G touched the drawers with the same gloved hands and the bag the insulin was in. LPN-G retrieved a prepackaged insulin pen needle and alcohol swab from the cart. LPN-G opened the needle and placed it on the insulin pen. LPN-G then entered Resident 5's room and wiped their site on their skin with alcohol and injected the insulin using the same gloved hands. LPN-G then left Resident 5's room and put the needle in the sharps container, placed the cap back on the insulin pen, removed gloves, put the insulin pen in the bag, opened the drawer on the cart, put the bag with the insulin pen into the drawer, then touched the computer. LPN-G then did hand hygiene using ABHR hand sanitizer and LPN-G charted touching the computer mouse. Observation on [DATE] at 11:50 AM revealed LPN-G took the glucometer not wrapped and put it into the drawer. LPN-G took the wipes to a different cart and got a glucometer out of the drawer. At 11:53 AM LPN-G donned gloves then got an alcohol wipe, test strip, lancet, and cotton ball out of the drawer. LPN-G took the glucometer into Resident 6's room and checked Resident 6's BS by lancing their finger, placing a drop of blood on the machine then wiping their finger with a cotton ball using the gloved hands. Observation on [DATE] at 11:57 AM revealed LPN-G brought the glucometer out of Resident 6's room, wiped it with the Clorox non-bleach disinfectant wipe and discarded it. The glucometer surface was dry in seconds. LPN-G then removed their gloves and charted touching the computer mouse. LPN-G then did hand hygiene with ABHR. LPN-G then retrieved supplies from the cart out of the drawer including an alcohol wipe, test strip, lancet, and cotton ball. LPN-G then donned gloves and took the same glucometer into Resident 12's room and checked Resident 12's BS at 12:00 PM. LPN-G then took the glucometer out of the room, wiped it with the Clorox non-bleach wipe and discarded the wipe. LPN-G wiped the glucometer very quickly and it was visibly dry in seconds. At 12:02 PM LPN-G took the same glucometer and put a test strip in after donning gloves and opening the drawer to retrieve the alcohol wipe, cotton ball, and lancet. Observation on [DATE] at 12:03 PM revealed LPN-G took the glucometer into Resident 7's room and checked Resident 7's BS. LPN-G came out the room and got keys out of their pocket with the same gloves hands. LPN-G then dropped the keys on the floor then picked them up with the same gloved hands and laid them on top of the cart. LPN-G then changed gloves with no hand hygiene, charted by touching the mouse then opened the drawer and got an insulin pen out that was in a plastic bag. LPN-G then opened another drawer and got a prepackaged needle and put it on the insulin pen, took it into Resident 7 and administered the insulin to Resident 7 at 12:06 PM by injecting them. LPN-G then came out of Resident 7's room and used the same gloved hands to open the drawer after unlocking it with the keys. LPN-G quickly wiped the glucometer with the Clorox bleach free wipe and discarded into their gloves when they removed them. The glucometer was dry in seconds. Observation on [DATE] at 12:10 PM revealed LPN-G discarded an empty alcohol wipe box in trash can on the cart. LPN-G touched the inside of the trash can with their bare hand and did not perform hand hygiene. LPN-G then touched the computer mouse, opened the drawer and retrieved a lancet, alcohol wipe, and cotton ball. LPN-G then donned gloves and took the glucometer into Resident 8's room and checked Resident 8's BS. LPN-G then brought the glucometer out of Resident 8's room at 12:13 PM and wiped it with the Clorox non-bleach wipe and discarded the wipe in their gloves. The glucometer was dry in seconds. Observation on [DATE] at 12:16 PM revealed LPN-G went back to the other cart. LPN-G handled the keys and unlocked the cart. LPN-G then opened the drawer with bare hands that LPN-G had not cleaned and retrieved an alcohol wipe, cotton ball, and lancet from the drawer. LPN-G picked up the glucometer and donned gloves. At 12:17 PM LPN-G took the glucometer into Resident 10's room and checked Resident 10's blood sugar. At 12:18 PM LPN-G brought the glucometer out of Resident 10's room to the cart and wiped the glucometer with the Clorox non-bleach wipe and discarded the wipe. It was dry in seconds. LPN-G then used the same gloved hands to open the drawer and get 2 prepackaged needles and Resident 10's insulin out of the drawer that was in a bag. Using the same gloved hands, LPN-G opened the needles and placed them on 2 insulin pens and took them into Resident 10 and administered the insulin at 12:21 PM. LPN-G came out of Resident 10's room and used the same gloved hands to unlock the cart with their keys, open the drawer and put the bag with the insulin pens back into the cart by opening the drawer. LPN-G then removed the gloves. LPN-G touched the computer mouse to chart then did hand sanitizer. At 12:23 PM LPN-G put a test strip into the glucometer. LPN-G then donned gloves then opened the drawer to get an alcohol wipe, cotton ball and lancet. LPN-G then went into Resident 9's room at 12:24 PM checked their BS using the glucometer. Review of the facility policy Glucometer Disinfection dated ,[DATE] revealed the following: 1. Retrieve disinfectant wipe from container. 2. Cleanse the glucometer with the disinfectant wipe. 3. Discard disinfectant wipe in waste receptacle. 4. Allow device to dry for minimum of five (5) minutes or per manufacturer recommendations. 5. Wash hands or use alcohol gel as appropriate. Review of the facility policy Blood Glucose Sampling-Capillary (Finger Sticks) revised [DATE] revealed the following: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. Steps in the procedure: 1. Wash hands. 2. Don gloves. 3. Place blood glucose monitoring device on clean field. 4. Wipe the area to be lanced with an alcohol pledget. 5. Obtain the blood sample, following the manufacturer's instructions for the device. 6. Discard lancet into the sharps container. 7. Following the manufacturer's instructions, clean and disinfect glucose monitoring device after each use with 10% bleach preparation. 8. Remove gloves, and discard into appropriate receptacle. 9. Wash hands. 10. Replace blood glucose monitoring device in storage area after cleaning. Review of the undated Guidelines for Cleaning and Disinfecting the Assure Platinum Meter revealed the following: To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below. The Assure Platinum Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens. ARKRAY recommends using these wipes to clean and disinfect the Assure Platinum meter: Clorox Healthcare Bleach Germicidal Wipes. Option 1: Obtain a commercially available EPA-registered disinfectant detergent or germicide wipe. Carefully review the manufacturer's instructions. Clean and disinfect the meter following step-by-step instructions. Options 2: Clean the outside of the blood glucose meter with a lint-free cloth dampened with soapy water or [MEDICATION NAME] alcohol. Disinfect the meter by diluting 1 ml of household bleach (,[DATE]% hypochlorite solutions) in 9 ml water to achieve a 1:10 dilution. Use a lint-free cloth dampened with the solution to thoroughly wipe down the meter. Cleaning and Disinfecting Procedures: Open the cap of the disinfectant container and pull out 1 towelette and close the cap. Wipe surface of the meter to clean blood and other body fluids. Carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down. This prevents disinfectant liquid from entering the meter. Dispose of the used towelette in a trash bin. The meter should be cleaned prior to each disinfection step. Pull out 1 new towelette and wipe the entire surface of the meter horizontally and vertically to remove blood borne pathogens. Carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down. This prevents disinfectant liquid from entering the meter. Treated surface must remain wet for recommended contact time. Please refer to wipe manufacturer's instructions. Do not wrap the meter in a wipe. Dispose of the used towelette in a trash bin. Record review of the label on the Clorox non-bleach wipes read the following: Wipe surface to be disinfected. Use enough wipes for treated surface to remain visibly wet for 4 minutes. Interview with RN-K on [DATE] at 12:34 PM revealed staff were expected to throw the face shield away after use and get a new one or clean it and use for 1 staff person only. The staff were not to use the same face shields. The staff were also expected to clean the face shield and wait for the disinfectant for work if they were going to re-use it and for only 1 staff person. RN-K revealed the staff were expected to follow the package directions on the disinfectant for contact or wet set time when cleaning the glucometers. Staff were expected to do hand hygiene after they removed gloves and change the gloves when they were contaminated. Interview with DON-A (Director of Nursing) on [DATE] at 12:34 PM revealed the staff were expected to disinfect the glucometers with the wipes for 5 minutes or whatever it read on the package of the disinfectant. D. Observation on [DATE] at 8:49 AM revealed that Housekeeping Aide-D (HA-D) removed cleaned laundry from the rack on the laundry cart in the hallway. HA-D carried the laundry into the room of Residents 12 and 13 and hung the laundry in the closet. HA-D exited the resident room carrying empty hangers from the resident closet and hung the used hangers on the rack of the laundry cart. HA-D did not perform hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel). HA-D removed cleaned laundry from the rack on the laundry cart and carried the laundry into the room of Residents 14 and 7. Resident 14 took the hanger from HA-D and removed the cleaned laundry item and HA-D carried the empty hanger out of the resident room and hung it on the rack of the laundry cart. HA-D did not perform hand hygiene. HA-D removed cleaned laundry from the rack on the laundry cart and carried the laundry into the room of Residents 15 and 16 and hung the laundry in the closet. Resident 16 told HA-D that the resident had placed several empty hangers on the end of the rack in the closet and requested that HA-D remove the empty hangers. HA-D removed the empty hangers from the closet and exited the resident room and hung the empty hangers on the rack of the laundry cart. Interim Director of Nursing-F (DON-F) walked up to HA-D and told HA-D something that this surveyor was unable to hear. HA-D responded oh, sorry to DON-F and then performed hand hygiene with alcohol based hand rub. HA-D removed cleaned laundry from the rack on the laundry cart and carried the laundry into the room of Residents 2 and 17. HA-D exited the room carrying empty hangers from the resident closet and hung the used hangers on the rack of the laundry cart. HA-D performed hand hygiene using alcohol based hand rub. Record review of the facility policy titled Infection Prevention and Control Program dated [DATE] revealed step 4. Hand Hygiene Protocol: a. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after Personal Protective Equipment (PPE- gloves, gowns, masks) removal, before/after eating, before/after toileting, and before going off duty. Step 10. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens so as to prevent the spread of infection. E. Observation on [DATE] at 1:57 PM revealed that Nursing Assistant-B (NA-B) and Nursing Assistant-C (NA-C) entered the room of Resident 20 with a sit to stand lift (a mechanical assistive device used to transfer a resident with difficulty standing (TRUNCATED)

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.05(9) Based on record review and interviews; the facility failed to protect 3 residents (Residents 100, 21 and 11) from staff to resident coercion and physical abuse. Staff members forced the residents to receive care at a time and manner against resident wishes. The facility census was 77 residents at the time of the complaint investigation with 4 residents selected for sampled review. Findings are: A. Review of the facility's staff training materials on abuse and neglect revealed the following definition of physical abuse and staff responsibility: PREVENTING RESIDENT ABUSE - Your responsibility: to protect all residents from any form of abuse. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Interview with the ED (Executive Director) on 12/8/10 at 10:00 AM confirmed that all staff were trained with the PREVENTING RESIDENT ABUSE training materials when hired by the facility. Record review confirmed that RN-J (Registered Nurse) signed acknowledgment of receiving the PREVENTING RESIDENT ABUSE training on 6/1/10. B. According to the undated RECORD OF ADMISSION, Resident 21 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident 21 resided on the secured memory support unit of the facility. Review of the CARE PLAN revealed that the facility identified Resident 21 as being forgetful and having limited functional abilities. The following were the planned interventions starting on 9/1/10: Help me maintain my dignity. Help me with reminders and cues as needed. Please allow me to do what I am capable of doing, at my own pace in my own way even if it doesn't make sense to you. Please help me make safe choices. Please remember that I am an adult and treat me accordingly. Please speak to me in my reality. Review of an 11/29/10 INVESTIGATIVE FINDINGS of an allegation of staff to resident abuse that occurred on 11/21/10 revealed that 3 staff members alleged that the charge nurse (RN-J) coerced/abused Resident 21 while assisting with toileting. The Witness Statement given on 11/22/10 by NA-E (Nursing Assistant) revealed that Resident 21 was sitting on the toilet when RN-J "grabbed" the resident's wrists and pushed the hands up over the resident's head back towards the wall. NA-E heard something hit the wall. The Witness Statement given on 11/22/10 by NA-K revealed that RN-J grabbed Resident 21's wrists and put the resident's arms above the resident's head and against the wall. NA-K reported hearing a "loud noise" when something hit the wall. Review of the INTERVIEW SUMMARY revealed that RN-J confirmed that Resident 21 hit the head on the wall during the 11/21/10 toileting incident. The SUMMARY OF INVESTIGATIVE FINDINGS documented that RN-J grabbed the hands of Resident 21 and put the hands over the resident's head causing the resident's head to hit the wall. The resident was assessed as having an ecchymotic area on the right inner wrist the following day (11/22/10). RN-J was notified on 11/30/10 via an EMPLOYEE MEMORANDUM that the facility concluded that staff to resident abuse took place on 11/21/10 between RN-J and Resident 21. An interview was conducted with NA-K on 12/8/10 at 2:50 PM regarding the staff to resident abuse between RN-J and Resident 21 on 11/21/10. NA-K confirmed working on 11/21/10 and being a witness to the incident. NA-K reported that two staff were assisting Resident 21 with toileting and a clothing change in an attempt to prepare the resident for bed on 11/21/10. Resident 21 was using "bad language" and hitting at the staff while the resident sat on the toilet. NA-K reported that normally the staff leave Resident 21 alone for a few minutes and return later to re-approach if the resident was hitting. NA-K stated that they could not safely leave Resident 21 sitting on the toilet on 11/21/10 so they summoned RN-J for guidance and assistance. Resident 21 was not allowed to sit in a calm environment and regain composure once RN-J entered the room. RN-J came into the bathroom and grabbed the wrists of Resident 21, pulled the resident's arms above the resident's head and "slammed" the resident's arms against the wall behind the toilet stool. While holding the resident's arms against the wall the resident's back was bent backwards over the tank of the toilet stool and the resident's head possibly hit the wall. C. According to the 11/20/10 ADMISSION RECORD, Resident 11 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident 11 resided on the secured memory support unit of the facility. Review of the CARE PLAN revealed that the facility identified Resident 11 as being at risk for falls. Interventions included assisting the resident with transfers and using a gait belt with transfers. Review of 11/29/10 INVESTIGATIVE FINDINGS of an allegation of staff to resident abuse that occurred on 11/21/10 revealed that 3 staff members alleged that the charge nurse (RN-J) abused Resident 11 while assisting with a transfer from the floor to the wheelchair and a transfer from the bed to the wheelchair. The Witness Statement given on 11/22/10 by NA-E revealed that Resident 11 had fallen in the sitting area. NA-E needed assistance to get the resident safely off the floor and back into the wheelchair so RN-J was summoned for help. RN-J grabbed Resident 11 off the floor and placed the resident into the wheelchair without the use of a gait belt, assistance or a mechanical lift. Later that afternoon, NA-E reported that Resident 11 was in bed, trying to get up. NA-E reported that RN-J came into the room and "yanked" the resident's legs and neck as the resident said "I can't stand. I can't stand." RN-J then "slammed" Resident 11 into the wheelchair and told the resident "Do you want to end up breaking your neck, you're really pissing me off." The Witness Statement given on 11/22/10 by NA-K revealed that RN-J grabbed Resident 21 under the arms "roughly", carried the resident out of bed and "forcefully" put the resident into the wheelchair. Interview with NA-K on 12/8/10 at 2:50 PM revealed that NA-K was working the afternoon of 11/21/10 and found Resident 11 on the floor in front of the resident's wheelchair. NA-K reported being trained to stay with the resident and call for assistance when a resident was found on the floor. NA-K stated that facility policy was to use a mechanical lift to get residents up off the floor. NA-K remained with the fallen resident and summoned help. RN-J reported to render assistance. NA-K confirmed that RN-J leaned over Resident 11 and picked the resident up from the floor and "slammed" the resident into a wheelchair. The SUMMARY OF INVESTIGATIVE FINDINGS documented that RN-J had been rough with Resident 11 and verbally inappropriate on 11/21/10. RN-J was notified on 11/30/10 via an EMPLOYEE MEMORANDUM that the facility concluded that staff to resident abuse took place on 11/21/10 between RN-J and Resident 11. D. Review of the Admission Record for Resident 100, admission to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Care Plan, with a print date of 11/13/2010, revealed the facility identified Resident 100 as showing behaviors and becoming confused, cursing at the staff when assisted and curse at other residents who were in the way. The following were the planned interventions that started on 9/1/2010: -Offer me a quieter setting to help soothe me. -Please listen to me an discuss my concerns when I need to talk, -Schedule care/treatments around my preferences which may change from day to day. If I don't want care now, please try later. -Reinforce my positive behaviors as they occur. -When I am upset, try to involve me in activities or spend time with me one on one. Review of the facility form entitled Facility Progress Notes dated 11/22/2010 at 21:20 (9:20 PM) a late entry for 1530 (3:30 PM) indicated LPN (Licensed Practical Nurse) -R attempted to obtain the UA (urinalysis). The resident was resistive and combative with the procedure. Review of the facility investigation interview with RN-B stated, " I held the RLE (Right Lower Extremity) in abduction to give more visual access and the resident was very combative, quite vocal, very resistive and at times grabbed my fingers."

Based on record review and staff interviews, the facility failed to ensure 2 allegations of abuse toward 2 residents (Residents 11 and 21) by a nurse were reported immediately to the facility administrator in accordance with the facility's abuse policy. The failure to report the first abusive incident enabled the second abusive incident to occur. The facility census was 77 and the survey sample size was 4. Findings are: A. Review of the facility's 7/1/10 policy titled "Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property" revealed: - "Policy: It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws with involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property, are reported immediately to the Executive Director (hereinafter "ED") of the facility". - "Reporting: Any employee who suspects an alleged violation shall immediately notify the ED or his/her designee". B. Review of an ADMISSION RECORD dated 11/20/10 revealed Resident 11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a VERIFICATION OF INVESTIGATION dated 11/29/10 revealed: - "DATE/TIME OF OCCURRENCE 11/21/2010 2-10 shift"; - DESCRIPTION OF EVENT/ALLEGATION was "Reported by nursing staff that (Registered Nurse (RN)-J) had been rough handling resident (Resident 11) when placing in (gender) wheelchair. Also reported that (RN-J) had been using profanity when working with resident"; - "DATE REPORTED 11/21/2010". "TIME REPORTED 2200" (10:00 PM) to the Administrator. During an interview on 12/8/10 at 2:50 PM, Nurses Aide (NA)-K revealed Registered Nurse (RN)-J, on 11/21/10 at about 4:00 PM, had picked up Resident 11 from the floor and "slammed" the resident into the wheelchair. NA-K stated the incident had been reported to the Administrator "that night". During the interview, it was revealed that NA-K had received abuse training on-line, but was not sure who to report the incident to. NA-K revealed the NA was taught to report abusive incidents to the charge nurse, but RN-J was the charge nurse and NA-K did not know who else to report the incident with Resident 11 to since the charge nurse was involved. C. Review of an undated RECORD OF ADMISSION revealed Resident 21 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of a VERIFICATION OF INVESTIGATION dated revealed: - "DATE/TIME OF OCCURRENCE 11/21/2010 2P-10P shift"; - DESCRIPTION OF EVENT/ALLEGATION was "Staff had concerns with the RN (RN-J) and how (the RN) helped the staff in getting (Resident 21) dressed and ready for bed. (Resident 21) was resisting the staff in taking (gender) clothes off and putting (gender) night clothes on. Two (2) staff alleged that the RN (RN-J) had held the residents arms, when the resident struck out at the RN"; - ASSESSMENT OF RESIDENT/DESCRIBE INJURY: "Noted (approximately) 1.5 cm (centimeter) faint ecchymotic (bruised) area to rt (right) inner wrist"; - Reported on 11/21/2010 at 2200 (10:00 PM) to the Administrator. -- RN-J: "I know @ times I might be a little more physical w/ (with) the men because they go after my lady aides. I just try to protect them but I know I have to watch myself & I thought I had been doing okay lately". During an interview on 12/8/10 at 2:50 PM, NA-K revealed RN-J had grabbed each of Resident 21's hands, pulled them up above the resident's head, and slammed them against the wall. NA-K revealed Resident 21's head either hit the back of the toilet or the wall. NA-K described that Resident 21 was bent backwards when RN-J held the resident's hands against the wall. During an interview on 12/8/10 at 11:22 AM, the Director of Nursing (DON) revealed the incident of RN-J roughly handling Resident 11 happened in the afternoon, and the incident when RN-J grabbed and held Resident 21's wrists happened later during the same shift, probably after supper. During an interview on 12/8/10 at 11:22 AM, the Administrator revealed NA-E and NA-K had shared their concerns how RN-J had treated the residents to Medication Aide (MA)-F after they had finished working. The Administrator revealed MA-F encouraged NA-E and NA-K to report their concerns to the Administrator right away. During an interview on 12/8/10 at 12:30 PM, the Administrator revealed NA-E, NA-K, and MA-F were educated about reporting concerns of abuse immediately. The Administrator explained due to the holidays, not all staff were educated or inserviced about the abuse policy's requirement to immediately report any incident of suspected abuse. The Administrator revealed employees would receive education in a written form with their pay checks "next Thursday" (12/9/10). Review of EMPLOYEE EDUCATION forms revealed "TOPIC: Reporting obligations - see policy (abuse policy). *when an event happens report immediately to prevent potential re-occurrence" given to NA-E, NA-K and MA-F on 11/29/10. During an interview on 12/8/10 at 3:10 PM, the Administrator revealed that the facility's abuse policy was attached to each employee's pay check and that each employee was expected to sign a form that indicated receipt of the abuse policy. The Administrator revealed that the employee's signature confirmed they received the abuse policy, but not that the employee had read the policy. Review of the abuse policy received by the employees revealed no additional information that directed the employee's attention to the reporting requirement of the policy. During an interview on 12/8/10 at 11:22 AM, the Administrator revealed if the NAs had reported the abusive incident that involved RN-J and Resident 11 immediately, the RN would have been suspended and the second abusive incident that involved RN-J and Resident 21 would not have happened.