Every finding on record at Emerald Nursing & Rehabilitation Mercy

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2).Based on observation, interview and record review the facility failed to perform treatment for pressure ulcers according to the practitioner's orders for Resident 509, failed to accurately complete and score the Braden Scale for Resident 4 and 509, and failed to evaluate, implement and monitor interventions to prevent pressure ulcer development and to promote wound healing for 4 (Resident 4, 502, 506, and 509) of 4 residents on sample. The facility census was 79.The findings are:Record review of the facility's policy titled Risk Assessment-Braden-Weekly Data Collection dated 01-2024 revealed the purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing skin issues, new pressure injuries or worsening of existing pressure injuries. The purpose of the skin risk assessment is to identify all risk factors and then determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. Risk factors that increase a resident's susceptibility to develop pressure injuries or to not heal pressure injuries include but are not limited to:-under nutrition, malnutrition, and hydration status;-impaired/decreased mobility and decreased functional ability;-the presence of previously healed pressure injuries;-the presence of an existing pressure injury;-exposure of skin to urinary and fecal incontinence or other source of moisture;-elevated body temperature;-altered skin status over pressure points;-impaired perfusion, oxygenation or circulation deficits, for example generalized atherosclerosis or lower extremity arterial insufficiency;-conditions such as end-stage renal disease (ESRD), thyroid disease or diabetes mellitus;-drugs such as steroids that may affect healing;-advanced age;-impaired sensory perception;-cognitive impairment; and-resident refusal to some aspects of care and treatment.The risk assessment should be conducted as soon as possible after admission, but no later than 8 hours after admission is completed. A comprehensive skin data collection will be completed on admission, readmission, weekly and with significant change in condition to obtain a risk assessment. Once the data collection is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure injuries. Repeat the risk assessment (Braden) weekly for the first four weeks, if there is significant change in condition, or as often as is required based on the resident's condition. Record review of the facility's policy titled Prevention of Pressure dated 06-07-2024 revealed the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific factors. Under the section titled Preparation revealed the facility staff were to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Under the section titled Risk Assessment revealed the facility staff are to assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment (Braden) weekly and upon any changes in condition. Under the section titled Skin Assessment revealed the facility staff are to conduct a comprehensive skin assessment upon admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. During the skin assessment inspect: for the presence of redness, temperature of skin and soft tissue and edema. Inspect the skin daily when performing or assisting with personal care and:-Identify any signs of developing pressure injuries, such as non-blanching (reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device) redness. For darkly pigmented skin, inspect changes in skin tone, temperature and consistency.-Inspect pressure points to the sacrum, heels, buttocks, coccyx, elbows, etc.-Wash skin after any episodes of incontinence, using pH balanced skin cleanser.-Moisturize dry skin daily.-Reposition the resident as indicated on the care plan.-Keep the skin clean and hydrated.-Clean promptly after episodes of incontinence.-Avoid alkaline soaps and cleansers.-Use a barrier product to protect the skin from moisture.-Use incontinence products with high absorbency.-Do not rub or otherwise cause friction on skin that is at risk of pressure injuries.-Use facility approved protective dressings for at risk individuals. Under the section titled Mobility/Repositioning revealed the facility staff are to reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary team. Choose a frequency for repositioning based on the resident's risk factors, in accordance with current clinical guidelines. Teach residents who can change positions independently the importance of repositioning, provide support devices and assistance as needed. Remind and encourage residents to change positions. Select appropriate support surfaces for pressure redistribution based on the resident's risk factors, in accordance with current clinical practice guidelines from the facility supply contracted company. Staff are to evaluate, report and document potential changes in the skin and review the interventions and strategies for effectiveness on an ongoing basis. Record review of the facility's Braden Scale evaluation revealed a score of less than 16 facility staff were to initiate skin integrity interventions. Further review of the Braden Scale showed a score of less than 9 indicated the resident was at severe risk for pressure ulcer development; a score of 10-12 indicated the resident was at high risk; a score of 13-14 indicate thee resident was at moderate risk; and a score of 15-18 indicate the resident was at mild risk. A. Record review of Resident 502's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 6. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment.-Had a diagnosis of dementia and adult failure to thrive. -Required moderate assistance with toileting, lower body dressing and hygiene.-Required touching assistance for transfers.-Was frequently incontinent of bladder.-Had an unplanned weight loss of 5% or more in 1 month or 10% or more in 6 months. -Was at risk of developing a pressure ulcer/injury. -Had moisture associated skin damage (MASD) such as incontinence-associated dermatitis, perspiration or drainage. Record review of Resident 502's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) dated 05-29-2024 revised on 03-06-2026 revealed Resident 502 had the potential for pressure ulcer development related to decreased mobility, weakness and incontinence, the goal was Resident 502's skin would remain intact, and the intervention listed was to provide pressure reducing/relieving device to the bed and wheelchair. Further review of the CCP revealed Resident had an actual impairment of skin integrity related to malnutrition, decreased mobility, weakness and incontinence and on 06-24-2026 Resident 502 had an unstageable deep tissue injury (DTI) dated 05-29-2024 revised on 06-30-2026. The goal was Resident 502 would have no complications related to the skin injury to the buttocks through the review date. Interventions dated 06-24-2026 were: air mattress, Enhanced Barrier Precautions (EBP) and provide the treatment to the buttocks DTI as ordered by the provider. Record review of Resident 502's Skin/Wound Weekly Observation (SWWO) dated 05-16-2026 revealed Resident 502 had a current skin issue. The SWWO did not identify the type, size or characteristics of the skin issue and under the section new interventions revealed a treatment was in place for the buttocks and was completed without difficulty. Record review of Resident 502's SWWO dated 05-23-2026 revealed Resident 502 had a current skin issue. The SWWO did not identify the type, size or characteristics of the skin issue and under the section new interventions revealed a treatment was in place for the buttocks and was completed without difficulty. Record review of Resident 502's SWWO dated 05-30-2026 revealed Resident 502 had a current skin issue. The SWWO did not identify the type, size or characteristics of the skin issue and under the section new interventions revealed a treatment was in place for the buttocks and was completed without difficulty, no drainage noted. Record review of Resident 502's Treatment Administration Record (TAR) for June 2026 revealed an order dated 11-06-2025 for Calmoseptine ointment (a moisture barrier used to soothe and protect the skin), wash wounds with normal saline, apply Calmoseptine and cover with a mepilex daily. Further review of the TAR for June 2026 revealed the Calmoseptine treatment had been discontinued on 06-16-2026. Record review of Resident 502's SWWO dated 06-06-2026 revealed Resident 502 had a current skin issue. The SWWO did not identify the type, size or characteristics of the skin issue and under the section new interventions revealed a treatment was in place for the buttocks and was completed without difficulty. There was no pain or discomfort voiced. Record review of Resident 502's Physician Round Form (PRF) dated 06-12-2026 revealed the facility staff requested to discontinue all orders for Calmoseptine as all areas are healed. Record review of Resident 502's SWWO dated 06-13-2026 revealed Resident 502 had a current skin issue. The SWWO did not identify the type, size or characteristics of the skin issue and under the section new interventions revealed a treatment was in place for the buttocks and was completed without difficulty, no pain or discomfort voiced. Record review of Resident 502's SWWO dated 06-20-2026 revealed Resident 502 had a current skin issue. The SWWO did not identify the type, size or characteristics of the skin issue and under the section new interventions revealed a treatment was in place for the buttocks and was completed. Record review of Resident 502's Skin/Wound New Observation (SWNO) dated 06-24-2026 revealed Resident 502 had a DTI to the right gluteal fold measuring 6 centimeters (cm) in length by 8 cm in width and the wound bed was completely covered with eschar (dead tissue that is hard or soft in texture and is usually black, brown or tan in color). Record review of Resident 502's SWWO dated 06-26-2026 revealed Resident 502 had an unstageable pressure injury to the right buttock measuring 3.97 cm in length by 4.29 cm in width and the left buttock had a stage 3 pressure ulcer measuring 4.05 cm in length by 4.62 cm in width. The SWWO dated 06-26-2026 also revealed the pressure ulcer to the left buttock was a new wound. Record review of Resident 502's Progress Notes (PN) dated 06-27-2026 revealed Resident 502's previously unstageable pressure ulcer was exhibiting purulent drainage, and the wound practitioner was notified and gave orders to send Resident 502 to the hospital for further evaluation and treatment of the pressure ulcer. Record review of Resident 502's Acute Care and Emergency General Surgery Hospital Note (ACEGHN) dated 06-27-2026 revealed Resident 502 was found to be in septic shock and had a large sacral wound with foul smelling brown purulent discharge. Record review of Resident 502's Surgical Procedure Note dated 06-27-2026 revealed Resident 502 had undergone an incision, drainage and debridement of the sacral wound of a stage 4 pressure ulcer. After debridement the wound cavity measured 6 cm in length by 5 cm in width by 4 cm in depth and the bone at the base of the wound. An interview conducted on 06-16-2026 at 9:00 AM with the Assistant Director of Nursing (ADON) A revealed (gender) had looked at Resident 502's skin to the buttocks and there was no skin issues before requesting to discontinue the Calmoseptine ointment on 06-12-2026 and confirmed that the SWWO's before and after 06-12-2026 had identified a skin issue to the buttocks and Resident 502 did not receive the treatment after 06-15-2026 until the DTI to the right gluteal fold was identified on 06-24-2026. B. Record review of Resident 4's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-BIMS was scored as an 11. According to the MDS Manual a score of 8 to 12 indicated moderate cognitive impairment. -Had a diagnosis of PVD, ESRD, and diabetes mellitus.-Was at risk of pressure ulcer development.-Had MASD.-Was receiving dialysis services. Record review of Resident 4's CCP dated 09-10-2024 revised 06-23-2026 revealed Resident 4 had an actual impairment of skin integrity to the left lower extremity related to PVD and diabetes. The goal was that the resident will have no complications related to skin injury through the review date. Interventions listed were:-Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short dated 09-10-2024.-Educate resident/family/caregivers of causative factors and measures to prevent skin injury dated 09-19-2024.-Keep skin clean and dry. Use lotion on dry skin dated 09-19-2024.-Use caution during transfers and bed mobility to prevent injury dated 09-10-2024.-Pressure reducing cushion to the wheelchair dated 12-29-2025.-Pressure reducing mattress in place dated 12-29-2025.-EBP dated 06-23-2026.-Needs protective garments-Prevalon Boots dated 06-23-2026. Record review of Resident 4's EMR under the section Census revealed Resident 4 went to the hospital on [DATE] and returned to the facility on [DATE]. Record review of Resident 4's PN dated 06-23-2026 revealed Resident 4 was being sent to the emergency room (ER) from the dialysis center for a blood pressure of 224/116 and nausea. Record review of Resident 4's PN dated 06-24-2026 revealed Resident 4 had returned from the hospital. Record review of Resident 4's readmission Progress Note (RPN) revealed Resident 4 was readmitted with no skin concerns. Record review of Resident 4's Braden Scale dated 06-25-2026 revealed under the question Is the Braden score 16 or below the box was checked no. Record review of Resident 4's TAR for June 2026 revealed an order to complete a skin check and document in the forms section every Wednesday and indicated the dates to be completed were: 06-03-2026, 06-10-2026, 06-17-2026 and 06-24-2026. Record review of Resident 4's SWWO dated 06-10-2026 revealed Resident 4 had no skin issues. Record review of Resident 4's SWWO dated 06-22-2026 revealed Resident 4 had a DTI to the right heel measuring 3 cm in length by 2.5 cm in width and was covered with eschar. The SWWO also revealed that the practitioner had been notified and ordered Skin Prep apply to the right heel daily, may leave open to air and Prevalon boots while in bed. Record review of Resident 4's EMR progress notes and forms section revealed no skin evaluations for any of the 12 days between 06-10-2026 and 06-22-2026. Record review of Resident 4's PN dated 07-02-2026 revealed Resident 4 did not have Prevalon boots in the room. An observation conducted on 07-13-2026 revealed Resident 4 was lying in bed and had a green heel protector that wrapped around Resident 4's right ankle. An observation conducted on 07-13-2026 at 1:50 PM revealed Resident 4 was in bed and had the same green heel protector on the right foot. An observation conducted on 07-14-2026 at 6:00 AM revealed Resident 4 was in bed and had the green heel protector to the right foot. An observation conducted on 07-15-2026 at 6:00 AM revealed Resident 4 was in bed and had no heel protector on the right foot. An observation conducted on 07-15-2026 at 8:35 AM revealed Resident 4 was in bed and had no heel protector on the right foot. An observation conducted on 07-15-2026 at 10:30 AM revealed Nursing Assistant (NA) E was in the room applying the green heel protector to the right foot. An interview was conducted on 07-15-2026 at 10:35 AM with NA E confirmed the green heel protector had not been on Resident 4's right foot and should have been. An observation conducted on 07-15-2026 at 10:45 of ADON A providing wound care to Resident 4's right heel revealed a DTI that was covered with black eschar measuring approximately 2.5 cm in length and 2 cm in width. During the interview, ADON A confirmed that the green heel protector was a Prevalon boot. An interview conducted on 07-15-2026 at 11:30 AM with the ADON A confirmed the green heel protector was not a Prevalon boot and the Nurse Practitioner (NP) was aware of the use of the green heel protector and was ok with it. An interview conducted on 07-15-2026 at 12:30PM with NP B who revealed the facility staff requested an order for Prevalon boots and NP B ordered what was requested and stated the little green heel protectors are fine with me. An interview was conducted on 07-16-2026 at 11:30 AM confirmed the Braden Scale conducted on 06-25-2026 should have been scored as a 12 and the box indicating the score was 16 or less should not have been checked no. An interview conducted on 07-20-2026 at 11:00 AM with ADON A confirmed a SWWO was not completed between 06-10-2026 and 06-22-2026 when the DTI was identified. C. Record review of Resident 506's Electronic Medical Record (EMR) under the section titled Census revealed Resident 506 went to the hospital on [DATE] and returned to the facility on [DATE]. Record review of 506's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-BIMS was scored as a 4. According to the MDS Manual a score of 0 to 7 indicated severe cognitive impairment.-Had a diagnosis of PVD and DM. -Required touching assistance with upper body dressing.-Required partial assistance with toileting, lower body dressing and hygiene.-Required substantial assistance with tub or shower transfers.-Required total assistance with bathing. -Was not at risk for pressure ulcer development. Record review of Resident 506's CCP dated 08-02-2024 revised 06-24-2026 revealed Resident 506 had an actual impairment of skin integrity related to wounds to the right lateral ankle and left foot. The goal was Resident 506 would have no complications related to skin injury through the review date. Interventions listed on the care plan dated 08-02-2024 were:-Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short.-Educate resident/family/caregivers of causative factors and measures to prevent injury. -Pressure reducing cushion to the wheelchair.-Pressure reducing mattress.-Prevalon boot (a specialized medical boot used primarily for non-ambulatory patients to completely offload the heel) while in bed. -Use caution during transfers and bed mobility to prevent injury. Interventions listed after 08-02-2024 were:-EBP dated 06-11-2026.-Treatment in place to the right ankle and left foot per provider order. Record review of Resident 506's Braden Scale dated 06-24-2026 revealed a score of 13 which indicated moderate risk of pressure ulcer development. Record review of Resident 506's Nursing readmission Assessment under section Skin Conditions revealed on 06-24-2026 a 2.5 cm in length by 2 cm in width diabetic wound was noted to the left foot. Record review of Resident 506's Tissue Analytics Evaluation ([NAME]) dated 06-26-2026 revealed Resident 506 had a stage 2 pressure ulcer to the left heel measuring 0.85 cm in length by 1.28 cm in width and 0.1 cm in depth while in the hospital. Record review of Resident 506's TAR for June 2026 revealed an order for treatment of the pressure ulcer to the left foot dated 06-26-2026, 2 days after the wound was identified and 3 days after readmission. The TAR also revealed an order for a Prevalon boot to the right foot while in bed as needed that had not been administered during the month of June 2026. An observation conducted on 07-13-2026 at 11:10 AM revealed Resident 506 was in the wheelchair in the hallway outside of the room, observation of the room revealed a pressure relief mattress on the bed and the absence of a Prevalon boot in the room and closet. An observation conducted on 07-13-2026 at 12:45 PM revealed Resident 506 was lying in bed and had a positioning wedge under the left knee and the left heel was resting on the mattress and no prevalon boot on either foot. An observation conducted on 07-14-2026 at 10:05 AM resident was lying in bed with a wedge under the left leg. The left heel was still touching the mattress and no Prevalon boot to either foot. An observation conducted on 07-15-2026 at 1:50 PM revealed Resident 506 had a pressure ulcer to the left heel that was approximately 1 cm in length and 0.5 cm in width, the skin surrounding the wound was intact and dry. No drainage or odors were observed. An interview conducted on 07-16-2026 at 12:00 PM with ADON A confirmed Resident 506 had not been wearing a Prevalon boot and was uncertain whether the positioning wedge was to be used instead. An interview conducted on 07-16-2026 at 12:10 PM with ADON A confirmed the practitioner had not ordered the pressure relieving wedge and confirmed Prevalon boot was listed as an intervention on the care plan. D. Record review of Resident 509's Care Area Assessment Worksheet (CAAW) dated 01-19-2026 revealed Resident 509 had admitted to the facility with a stage 4 pressure ulcer to the left buttocks. Record review of Resident 509's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Had a diagnosis of quadriplegia (the partial or total loss of motor and sensory function in all four limbs and the torso).-BIMS was scored as 14. According to the MDS Manual a score of 13 to 15 indicated a person is cognitively intact. -Required moderate assistance with oral hygiene.-Required maximal assistance with upper body dressing.-Required total assistance with toileting, bathing, lower body dressing, rolling right to left, and transfers. -Was not at risk of developing pressure ulcers. Record review of Resident 509's CCP dated 01-20-2026 revised on 07-06-2026 revealed Resident 509 had actual skin impairment of skin integrity related to weakness, impaired mobility, quadriplegia and history of pressure ulcer to the left buttock, and stage 2 pressure ulcers to the right and left plantar foot. The goal was Resident 509 would have no complications related to skin injuries. Interventions listed on the CCP were:-Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short dated 01-20-2026.-Educate resident/family/caregivers of causative factors and measures to prevent skin injury dated 01-20-2026. -Keep skin clean and dry. Use lotion on dry skin dated 01-20-2026. -Pressure reducing cushion in wheelchair dated 01-24-2026. -Pressure reducing mattress in place 01-20-2026. -Use caution during transfers and bed mobility to prevent injury dated 01-20-2026.-Enhanced Barrier Precautions (EBP) dated 06-12-2026.-Left plantar (bottom of the foot) foot: wound care treatment order in place dated 07-02-2026. -Right plantar foot: wound treatment order in place dated 07-02-2026. Record review of Resident 509's Braden Scale dated 04-21-2026 revealed a score of 11 which indicated Resident 509 was at high risk of pressure ulcer development. Record review of Resident 509's Order Summary (OS) printed on 07-13-2026 revealed orders to complete a skin assessment and document findings on SWWO form located under the forms tab every Wednesday for monitoring and a treatment of the pressure ulcers to the plantar surface of the bilateral feet as follows: -Left plantar foot, wash area with wound cleanser, and pat dry, paint all around the wound with skin prep and allow to dry, apply a small amount of Silvadene to the wound bed only, apply a small piece of aquacel to the wound cut to fit the size and shape of the wound and cover with a mepilex change every Monday, Wednesday and Friday and as needed for soiling, saturation or accidental removal. Remove the dressings for showers or bathing. -Right plantar foot, wash area with wound cleanser, and pat dry, paint all around the wound with skin prep and allow to dry, apply a small amount of Silvadene to the wound bed only, apply a small piece of aquacel to the wound cut to fit the size and shape of the wound and cover with a mepilex change every Monday, Wednesday and Friday and as needed for soiling, saturation or accidental removal. Remove the dressings for showers or bathing. Record review of Resident 509's Braden Scale dated 07-15-2026 revealed Resident 509 had no sensory impairment and had scored a 17 which indicated a mild risk for pressure ulcer development. An observation conducted on 07-14-2026 at 6:00 AM revealed Resident 509 was lying in bed without pressure-relieving boots and the plantar surfaces of both feet were touching the mattress. An observation conducted on 07-15-2026 at 6:00 AM revealed Resident 509 was lying in bed without pressure-relieving boots and the plantar surface of both feet were touching the mattress. An observation conducted on 07-15-2026 at 10:05 AM of Licensed Practical Nurse (LPN) G and the Assistant Director of Nursing (ADON) B providing wound care to Resident 509 revealed both wounds were washed with wound cleanser and patted dry, silvadene cream was placed in the wound bed and Opticell AG dressing was cut to size and placed in the wound beds and then covered with a bordered gauze. During this observation Resident 509 did not want the Mepilex dressing used because it rolls and comes loose with muscle spasms and wanted the bordered gauze dressing used instead because it stays in place. An interview conducted on 07-16-2026 at 9:43 AM with ADON B confirmed the physician's order was not followed and confirmed the use of Opticell AG dressing for the wound care instead of Aquacel dressing that was ordered. An interview conducted on 07-16-2026 at 10:15 AM with ADON C confirmed upon review of Resident 509's Braden Scale Score of 17 dated 07-15-2026 indicating mild risk for pressure ulcer development was incorrect as it indicated the resident had no sensory impairment. ADON C further confirmed Resident 509 was quadriplegic and had sensory impairment and had developed pressure ulcers to both feet. The interview also revealed that ADON C was uncertain what interventions were put into place when the left plantar foot pressure ulcer was identified to prevent further pressure ulcer development before the right plantar foot pressure ulcer developed. An interview conducted on 7-16-2026 at 11:30 AM with Nurse Practitioner (NP) N confirmed the Opticell AG dressing and Aquacel dressing were not the same and were not interchangeable.

Licensure Reference Number 175 NAC 12-006.01(A) Based on observations, record reviews, and interviews, the facility management failed to utilize its resources to attain or maintain the highest practicable physical and psychosocial well-being of each resident as identified by the deficient practices cited. The facility staff identified a census of 79. Findings are:A record review of the facility's Job Description And Performance Standards Administrator dated 04/22/2025 revealed the Administrator's position was responsible for establishing and maintaining systems in an effective and efficient manner and operate the facility in a manner to safely meet the needs of the residents in compliance with federal, state, and local requirements. The Administrator' job functions included ensuring staff identified and reviewed resident's incidents, accidents, complaints, concerns, and provision of resident care and service and take action to alleviate problems and prevent reoccurrence. The Administrator was responsible for the facility quality assurance performance improvement committee and to review, discuss, and implement recommendations on resident care. The Administrator would consult with the department supervisors regarding staffing, in-service attendance, and the overall effectiveness of each department. The Administrator would oversee the hiring, orientation, and training of nursing staff, communicate with physicians and families of residents regarding notable changes of the resident's status, and provide direction and monitoring for nurses and medication aides on an ongoing basis with input from the Director of Nursing (DON) and nurse managers. The Administrator was responsible for the review of nursing guidelines annually with input from the DON and Medical Director and implement changes accordingly. The Administrator would review therapeutic diets as ordered by the resident's physician. A record review of the facility's Job Description And Performance Standards Director of Nursing dated 04/22/2025 revealed the DON was responsible for the oversight, coordination, and facilitation of all nursing services to ensure that quality care of each resident was provided while maintaining compliance with all local, state, and federal regulations and facility policies and procedures. administering the nursing program in a long-term care facility to maintain standards of resident care. The DON was responsible to oversee all staff interactions and provide direction as needed to ensure staff issues do not effect quality of care for the residents. The DON was to regularly inspect facility and nursing practices for compliance with federal. State and local standards and regulations. The DON would review nursing procedures manual periodically and maintain working knowledge of current procedures. The DON would follow universal precautions and observe infection control policies, including personal protective equipment (PPE) and hand-washing. A record review of the facility's Job Description And Performance Standards Assistant Director of Nursing (ADON) dated 04/22/2025 revealed the ADONs' essential job duties were to assist the DON with all the functions of the nursing department. The ADONs were to ensure compliance with federal, state, and local laws and regulations governing the facility. The ADONs were to assure regulatory compliance on updated care plans as needed, identify areas for improvement based on audits results and work with the nursing staff to modify the processes and educate the staff, and to follow up on dietary recommendations. The ADONs were to provide education and coaching to the nursing staff as needed to improve residents' outcomes. A record review of the facility's undated Job Description And Performance Standards Medical Director revealed that the Medical Director was responsible for overseeing the clinical care provided to residents, guiding facility-wide health policies and protocols, and ensuring regulatory compliance. On the revisit survey with an exit date of 07/20/2026, the survey team identified the repeat deficiencies of F657, F693, F880, and F689 from the previous complaint surveys, and identified the additional deficiencies of F726, F835, and F867. F657: The facility failed to review and revise 1 (Resident 102) of 3 sampled resident's care plan related to all nutrition and hydration taken by mouth (PO) instead of enteral feeding (by tube inserted into the stomach) and failed to update the care plan for pressure ulcer (wound) prevention and treatment for 3 (Resident 4, 506, and 509) of 4 sampled residents. An observation conducted on 07-13-2026 at 11:12 AM revealed Resident 4 was in bed and there was no fall mat next to the bed. An observation conducted on 07-13-2026 revealed Resident 4 was lying in bed and had a green heel protector that wrapped around Resident 4's right ankle. An interview conducted on 07-15-2026 at 12:30PM with NP B who revealed the facility staff requested an order for Prevalon boots and Nurse Practitioner (NP) B ordered what was requested and stated the little green heel protectors are with me. An interview conducted on 07-16-2026 at 12:30 PM with the Regional Nurse Consultant (RNC) confirmed Resident 4's care plan for falls had not been revised and should have been and interventions on the care plan should reflect the correct type of pressure reducing device used for pressure ulcer prevention. An observation conducted on 07-13-2026 at 11:10 AM revealed Resident 506 was in the wheelchair in the hallway outside of the room, observation of the room revealed a pressure relief mattress on the bed and the absence of a Prevalon boot in the room and closet. An interview conducted on 07-16-2026 at 12:10 PM with ADON A confirmed the practitioner had not ordered the pressure relieving wedge and confirmed Prevalon boot was listed as an intervention on the care plan. A record review of Resident 102's Care Plan Report with an admission date of 05/15/2025 revealed the resident required enteral feeding related to the resident revisited eating. The resident had weight loss since admission and had diarrhea (loose stools) with the tube feeding. An intervention was the resident was dependent with tube feeding and water flushes. See Doctor of Medicine (MD) orders for current feeding orders. In an interview on 07/15/2026 at 7:14 AM, the DON confirmed that Resident 102's care plan had not been revised to reflect that Resident 102 was receiving all nutrition and hydration by mouth and not receiving enteral feedings or percutaneous endoscopic gastrostomy (PEG, a tube inserted directly into the stomach to administer nutrients and medications) tube flushes. The DON confirmed the DON called the ADON-A for the resident's floor, and the ADON confirmed the care plan was not revised to indicate the resident was 100% intakes by mouth instead of enteral feedings. An interview conducted on 07-16-2026 at 12:00 PM with ADON A confirmed Resident 506 had not been wearing a Prevalon boot and was uncertain whether the positioning wedge was to be used instead. An interview conducted on 07-16-2026 at 12:10 PM with ADON A confirmed the practitioner had not ordered the pressure relieving wedge and confirmed Prevalon boot was listed as an intervention on the care plan. F693: The facility failed to administer the correct amount of enteral nutrition (liquid formula containing nutrients) per the provider's order on 1 (Resident 103) of 3 sampled residents, ensure flush orders were obtained for 1 (Resident 102) of 3 sampled resident's PEG tube, and ensure 2 (Residents 103 and 101) of 3 sampled resident's enteral nutrients were refrigerated after opening the container per the manufacturer's recommendations. An observation on 07/13/2026 at 2:02 PM revealed Licensed Practical Nurse (LPN)-G did not administer the correct amount of enteral nutrition. In an interview on 07/14/2026 at 1:25 PM, the DON confirmed LPN-G should have used a graduate to measure Resident 103's Glucerna 1.5 but did not. An observation of Resident 102's PEG tube cares on 07/13/2026 at 1:10 PM revealed LPN-J entered the room and cleaned and applied a new split sponge to the resident's peg tube site but that was all LPN-J done. The PEG tube contained a dark brown, crusty substance inside the PEG tube. In an interview on 07/14/2026 at 1:25 PM, the DON confirmed that Resident 102's PEG tube should have been flushed per best practice but was not completed. An observation on 07/13/2026 at 2:02 PM with the DON revealed Licensed Practical Nurse (LPN)-G entered Resident 103's room, completed the resident's enteral feeding using an opened, partially used, 1000 milliliters (mL) container of Glucerna 1.5 ready to hang (RTH) bottle that was sitting on the dresser, placed the cap back on Glucerna 1.5 and placed the container back on dresser. In an interview on 07/16/2026 at 8:25 AM, the DON confirmed the staff leaves the opened bottles of enteral nutrients in the resident's rooms between enteral feedings. The DON confirmed the staff does not refrigerate the 1000 mL bottles of enteral nutrition after they have been opened. The DON confirmed the Osmolite 1.5 RTH and the Glucerna 1.5 RTH should have been refrigerated after opened per the manufacturer's data sheets. An observation on 07/16/2026 at 8:11 AM with LPN-M revealed an opened, partially used, warm to the touch, 1000 mL bottle of Glucerna 1.5 RTH sitting on the resident's bedside table. The bottle was dated 07/15/2026 at 9:30 PM. In an interview on 07/16/2026 at 8:25 AM, the DON confirmed the staff leaves the opened bottles of enteral nutrients in the resident's rooms between enteral feedings. The DON confirmed the staff does not refrigerate the 1000 ml bottles of enteral nutrition after they have been opened. The DON confirmed the Osmolite 1.5 RTH and the Glucerna 1.5 RTH should have been refrigerated after opened per the manufacturer's data sheets.In an interview on 07/16/2026 at 11:22 AM, the facility's NP-N confirmed the enteral feeding nutrients should have been refrigerated after opening.F689 - the facility failed to perform treatment for pressure ulcers according to the practitioner's orders for Resident 509, failed to accurately complete and score the Braden Scale for Resident 4 and 509, and failed to evaluate, implement and monitor interventions to prevent pressure ulcer development and to promote wound healing for 4 (Resident 4, 502, 506, and 509) of 4 residents sampled.An observation conducted on 07-14-2026 at 6:00 AM revealed Resident 509 was lying in bed without pressure-relieving boots, and the plantar surfaces of both feet were touching the mattress.An observation conducted on 07-15-2026 at 10:05 AM of LPN G and the ADON B providing wound care to Resident 509 revealed both wounds were washed with wound cleanser and patted dry, silvadene cream was placed in the wound bed and Opticell AG dressing was cut to size and placed in the wound beds and then covered with a bordered gauze. During this observation Resident 509 did not want the Mepilex dressing used because it rolls and comes loose with muscle spasms and wanted the bordered gauze dressing used instead because it stays in place.An interview conducted on 07-16-2026 at 9:43 AM with ADON B confirmed the physician's order was not followed and confirmed the use of Opticell AG dressing for the wound care instead of Aquacel dressing that was ordered.An interview conducted on 07-16-2026 at 10:15 AM with ADON C confirmed upon review of Resident 509's Braden Scale Score of 17 dated 07-15-2026 indicating mild risk for pressure ulcer development was incorrect as it indicated the resident had no sensory impairment and Resident 509 was quadriplegic and had sensory impairment and had developed pressure ulcers to both feet. The interview also revealed that ADON C was uncertain what interventions were put into place when the left plantar foot pressure ulcer was identified to prevent further pressure ulcer development before the right plantar foot pressure ulcer developed.An interview conducted on 7-16-2026 at 11:30 AM with NP N confirmed the Opticell AG dressing and Aquacel dressing were not the same and were not interchangeable.F867 - The facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program identified and addressed concerns related to deficient practice identified on the survey and ensure correction for repeat deficient practice from previous surveys were maintained. This had the potential to affect all residents that resided in the facility. In an interview on 7/20/26 at 12:38 PM with the RNC when asked if the issues being cited should have been identified by the facility prior to the visit it was reported [they] would be remiss in saying they did everything perfectly and they should have caught it. Further interview revealed they were looking at specifics in the audits being completed and not the regulation as a whole, and they need to do better. F686 - The facility failed to treatment for pressure ulcers according to the practitioner's orders for Resident 509, failed to accurately complete and score the Braden Scale for Resident 4 and 509, and failed to evaluate, implement and monitor interventions to prevent pressure ulcer development and to promote wound healing for 4 (Resident 4, 502, 506, and 509) of 4 residents on sample. An interview conducted on 06-16-2026 at 9:00 AM with the ADON A revealed (gender) had looked at Resident 502's skin to the buttocks and there was no skin issues before requesting to discontinue the Calmoseptine Ointment on 06-12-2026 and confirmed that the Skin/Wound Weekly Observation (SWWO)'s before and after 06-12-2026 had identified a skin issue to the buttocks and Resident 502 did not receive the treatment after 06-15-2026 until the Deep Tissue Injury (DTI) to the right gluteal fold was identified on 06-24-2026. An observation conducted on 07-15-2026 at 10:45 of ADON A providing wound care to Resident 4's right heel revealed a DTI that was covered with black eschar measuring approximately 2.5 centimeters (cm) in length and 2 cm in width. During the interview, ADON A confirmed that the green heel protector was a Prevalon boot. An interview conducted on 07-15-2026 at 11:30 AM with the ADON A confirmed the green heel protector was not a Prevalon boot and the Nurse Practitioner was aware of the use of the green heel protector and was ok with it. An interview was conducted on 07-16-2026 at 11:30 AM confirmed the Braden Scale conducted on 06-25-2026 should have been scored as a 12 and the box indicating the score was 16 or less should have not been checked no. An interview conducted on 07-20-2026 at 11:00 AM with ADON A confirmed a SWWO was not completed between 06-10-2026 and 06-22-2026 when the DTI was identified. An observation conducted on 07-14-2026 at 10:05 AM resident is lying in bed with wedge under the left leg and left heel is still touching the mattress and no Prevalon boot to either foot. In an interview conducted on 07-16-2026 at 12:00 PM with ADON A confirmed Resident 506 had not been wearing a Prevalon boot and was uncertain whether the positioning wedge was to be used instead. An interview conducted on 07-16-2026 at 12:10 PM with ADON A confirmed the practitioner had not ordered the pressure relieving wedge and confirmed Prevalon boot was listed as an intervention on the care plan. An interview conducted on 07-16-2026 at 9:43 AM with ADON B confirmed the physician's order was not followed and confirmed the use of Opticell AG dressing for the wound care instead of Aquacel dressing that was ordered. An interview conducted on 07-16-2026 at 10:15 AM with ADON C confirmed upon review of Resident 509's Braden Scale Score of 17 dated 07-15-2026 indicating mild risk for pressure ulcer development was incorrect as it indicated the resident had no sensory impairment and Resident 509 was quadriplegic and had sensory impairment and had developed pressure ulcers to both feet. The interview also revealed that ADON C was uncertain what interventions were put into place when the left plantar foot pressure ulcer was identified to prevent further pressure ulcer development before the right plantar foot pressure ulcer developed. An interview conducted on 7-16-2026 at 11:30 AM with NP N confirmed the Opticell AG dressing and Aquacel dressing were not the same and were not interchangeable. F726 - The facility failed to ensure licensed nurse's received competency evaluations for enteral tube feedings, wound care and Enhanced Barrier Precautions (EBP) for 3 of 3 nurses employed at the facility. Record review of LPN G's employee filed revealed LPN G was hired on 05-13-2020 and the absence of competency evaluations for enteral tube feedings, wound care (other than negative pressure wound therapy), or EBP. Record review of ADON A' s employee file revealed ADON A was hired on 05-18-2026 and the absence of competency evaluations. Record review of ADON B's employee file revealed ADON B was hired on 03-26-2019 and the absence of competency evaluations. An interview conducted with the RNC on 07-20-2026 at 2:00 PM confirmed competency testing had not been completed for ADON A and ADON B. In an interview on 7/20/26 at 12:38 PM, the RNC when asked if the issues being cited should have been identified by the facility prior to the visit it was reported [they] would be remiss in saying they did everything perfectly and they should have caught it. Further interview revealed they were looking at specifics in the audits being completed and not the regulation as a whole, and they need to do better.

Licensure Reference Number 175 NAC 12-006.07(C) Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance (QAPI, . It is a data-driven, proactive program required by the Centers for Medicare and Medicaid Services for healthcare facilities like nursing homes to continuously track and elevate patient care safety and quality) program identified and addressed concerns related to deficient practice identified on the survey and ensure correction for repeat deficient practice from previous surveys were maintained. This had the potential to affect all residents that resided in the facility. The facility census was 79. Findings are:A record review of facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership with a created date of 1-2024 revealed the following:Policy: The Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI committee, which reports its findings, actions, and results to the Administrator and governing body.Policy Interpretation and Implementation1. The Administrator, whether a member of the QAPI committee or not, is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body.2. The governing body is responsible for ensuring that the QAPI program:a. Is implemented and maintained to address identified priorities;b. Is sustained through transitions of leadership and staffing;c. Is adequately resourced and funded, including the provision of money, time, equipment, training and staff coverage sufficient to conduct the activities of the program;d. Is based on data, resident and staff input, and other information that measures performance; and e. Focuses on problems and opportunities that reflect processes, functions and services provided to the residents. 11. Governance and leadership-a. The governing body and/or executive leadership is responsible and accountable for the QAPI program.b. Governing oversight responsibilities include, but are not limited to the following: i. Approving the QAPI plan annually and as needed. ii. Ensuring the program is ongoing, defined, implemented, maintained, and addresses identified priorities.iii. Ensuring the program is sustained during transitions in leadership and staffing.iv. Ensuring the program is adequately resourced, including ensuring the staff time, equipment, and technical training as needed.v. Ensuring the program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information.vi. Ensuring that corrective actions address gaps in systems and are evaluated for effectiveness.vii. Setting clear expectations around safety, quality, rights, choice, and respect. During the recent survey with an exit date of 07/20/2026 the following deficiencies and repeat deficiencies were identified: F657 The facility failed to review and revise Resident 102's care plan related to 100 % PO (oral intake) instead of enteral intakes and failed to update the care plan for pressure ulcer prevention and treatment for Resident 4, 506 and 509.F686- The facility failed to provide treatment for pressure ulcers according to the practitioner's orders for Resident 509, failed to accurately complete and score a Braden's scale for Resident 4 and 509, and failed to evaluate, implement and monitor interventions to prevent pressure ulcer development and to promote wound healing for Resident 4, 502, 506, 509.F689 The facility failed to ensure fall interventions were in place according to the plan of care for Resident 4.F693 The facility failed to administer the correct amount of enteral nutrition per the provider's order for Resident 103, ensure flush orders were obtained for Resident 102's PEG tube, and ensure Resident 103 and 101's enteral nutrients were refrigerated within 1 hour of opening the container per manufacturer's recommendations. A record review of the facility's last standard survey results from the 03/20/2025 survey revealed the facility was cited for:F580-Notify of Changes (Injury/Decline/Room Change);F677-ADL Care Provided for Dependent Residents;F684-Quality of Care;F686-Treatment/Services to prevent/heal Pressure Ulcer-Repeat;F689-Free from Accident Hazards/Supervision/Devices -Repeat;F756-Drug Regimen Review;F758-Free from Unnecessary Psychotropic Meds/PRN (as needed) use; andF812-Food Procurement, Store/Prepare/Serve-Sanitary. A Record review of the facility survey results from a revisit survey on 3/18/26 revealed the following were cited:F657-Care Plan Timing and Revision-Repeat; andF686-Treatment/Services to prevent/heal Pressure Ulcer-Repeat. A Record review of the facility survey results from a complaint survey on 3/24/26 revealed the facility was cited for:F689-Free from Accident Hazards/Supervision/Devices -Repeat. A record review of a facility survey from a complaint survey on 4/9/26 revealed the facility was cited for:F689-Free from Accident Hazards/Supervision/Devices -Repeat. A record review of a facility survey from a complaint survey on 5/7/26 revealed the facility was cited for:F689-Free from Accident Hazards/Supervision/Devices- Repeat; andF693-Tube Feeding Management/Restore Eating Skills- Repeat. A record review of a facility survey from a complaint survey on 6/16/26 revealed the facility was cited for:F657-Care Plan Timing and Revision -Repeat; andF689-Free from Accident Hazards/Supervision/Devices- Repeat In an interview on 7/20/26 at 12:38 PM with the Regional Nurse Consultant when asked if the issues being cited should have been identified by the facility prior to the visit it was reported [they] would be remiss in saying they did everything perfectly and they should have caught it. Further interview revealed they were looking at specifics in the audits being completed and not the regulation as a whole, and they need to do better.

Licensure Reference Number 175 NAC 12-006.04(B)(ii). Based on record review and interview the facility failed to ensure licensed nurse's received competency evaluations for enteral tube feedings, wound care and Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) for 3 of 3 nurses employed at the facility. The facility census was 79. The findings are:Record review of Licensed Practical Nurse (LPN) G's employee filed revealed LPN G was hired on 05-13-2020 and the absence of competency evaluations for enteral tube feedings, wound care (other than negative pressure wound therapy), or EBP. Record review of Assistant Director of Nursing (ADON) A' s employee file revealed ADON A was hired on 05-18-2026 and the absence of competency evaluations. Record review of ADON B's employee file revealed ADON B was hired on 03-26-2019 and the absence of competency evaluations. An interview conducted with the Administrator on 07-20-2026 at 10:30 AM revealed ADON A and B had transferred to the facility from another facility in the organization and was requesting competency evaluations for the other facility. An interview conducted with the Regional Nurse Consultant (RNC) on 07-20-2026 at 2:00 PM confirmed competency testing had not been completed for ADON A and ADON B.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to report two allegations of potential misappropriation to the State Agency within the required timeframe for 1 (Resident 501) of 1 sampled resident. Facility staff identified a census of 83.Findings are:Record review of facility policy entitled Abuse, Neglect and Exploitation revised 01/2024 revealed: - 9. Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: - f. Contact the State Agency and the local Ombudsman office to report the alleged abuse. - 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: -a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or (sic) resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents (sic) that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (sic)(including the State Survey Agency and adult protected services where state law provides jurisdiction in long-term care facilities) in accordance with State law. - 14. The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies.Record review of Resident 501's admission Record revealed the facility admitted the resident on 01/09/2026. Further review of the admission record identified Resident 501 had diagnoses of major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies) and anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it).Record review of Resident 501's 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 01/15/2026 identified Resident 501 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a score of 14 indicated the resident had intact cognition.Record review of Resident 501's Progress Notes (PN) dated 03/09/2026 revealed an entry that Resident 501 alleged a facility nurse was wearing the resident's necklace. Resident 501 reported the facility nurse stole the necklace. Further review of the progress note identified the nurse had worked at the facility for approximately two years and the necklace was seen in all past photos taken in the facility.Record review of an e-mail dated 03/20/2026 from the Ombudsman (a state official who works with nursing home and assisted living residents who helps answer resident concerns and complaints and advocates for resident rights and their well-being) to the Social Services Director (SSD) identified Resident 501 had brought forth concern of a stolen necklace to the Ombudsman and reported to the Ombudsman that they had filed a grievance directly with the facility.Record review of Resident 501's PN dated 04/22/2026 revealed an entry that Resident 501 reported another resident who resided on a different floor came to Resident 501's room and stole a phone charger. Further review of the progress note showed the resident from the other floor was interviewed and denied taking the charger and the charger was not located.During an interview on 06/16/2026 at 8:39 AM, the SSD reported they were unable to locate a grievance related to the concerns of stolen items dated 03/09/2026 and 04/22/2026. The SSD confirmed the PN entries dated 03/09/2026 and 04/22/2026 were allegations of potential misappropriation and further confirmed allegations of misappropriation should be reported to the State Agency. The SSD reported they were unaware of the allegation dated 04/22/2026.During an interview on 06/16/2026 at 10:52 AM, the facility Administrator (ADM) reported facility management were unaware of the allegation dated 04/22/2026. The ADM confirmed the facility did not have evidence that the allegation on 03/09/2026 and 04/22/2026 were reported to the State Agency.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to complete an investigation and submit the investigation to the State Agency within 5 working days for two allegations of potential misappropriation for 1 (Resident 501) of 1 sampled resident. Facility staff identified a census of 83.Findings are:Record review of facility policy entitled Abuse, Neglect and Exploitation revised 01/2024 revealed: - 7. Investigation of Alleged Abuse, Neglect and Exploitation. - When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is care for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: -a. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. -b. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident. -c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. -d. Document the entire investigation chronologically. - 9. Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: - c. Initiate an investigation immediately. - i. Document actions taken in steps above in the medical record. - 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: - b. Have evidence that all alleged violations are thoroughly investigated. - d. Report the results of all investigation to the administrator or his or her designated representative and to the other official in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. - 14. The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies.Record review of Resident 501's admission Record revealed the facility admitted the resident on 01/09/2026. Further review of the admission record identified Resident 501 had diagnoses of major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies) and anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it).Record review of Resident 501's 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 01/15/2026 identified Resident 501 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a score of 14 indicated the resident had intact cognition.Record review of Resident 501's Progress Notes (PN) dated 03/09/2026 revealed an entry that Resident 501 alleged a facility nurse was wearing the resident's necklace. Resident 501 reported the facility nurse stole the necklace. Further review of the progress note identified the nurse had worked at the facility for approximately two years and the necklace was seen in all past photos taken in the facility.Record review of an e-mail dated 03/20/2026 from the Ombudsman (a state official who works with nursing home and assisted living residents who helps answer resident concerns and complaints and advocates for resident rights and their well-being) to the Social Services Director (SSD) identified Resident 501 had brought forth concern of a stolen necklace to the Ombudsman and reported to the Ombudsman that they had filed a grievance directly with the facility.Record review of Resident 501's PN dated 04/22/2026 revealed an entry that Resident 501 reported another resident who resided on a different floor came to Resident 501's room and stole a phone charger. Further review of the progress note showed the resident from the other floor was interviewed and denied taking the charger and the charger was not located.Record review of facility investigations dated March 2026 through May 2026 revealed no evidence of a completed investigation for the allegation dated 03/09/2026 and 04/22/2026.During an interview on 06/16/2026 at 10:52 AM, the Administrator (ADM) confirmed there was no evidence an investigation was completed regarding Resident 501's allegations of potential misappropriation dated 03/09/2026 and 04/22/2026.

Licensure Reference Number 175 NAC 12-006.09(F)(iii)Based on record review and interview, the facility failed to revise the care plan to reflect resident risk for leaving the facility without signing out, without a destination, and time of return, or of potential locations the resident could be located for 1 (Resident 501) of 3 residents sampled. Facility staff identified a census of 83.Findings are: Record review of facility policy entitled Care Plan Process revised 09/2019 revealed: -A care plan will: -a. Incorporate identified problem areas -i. Onset date -b. Incorporate risk factors associated with identified problems -i. 'Related to' factors (risk factors)- why the problem exists or may exist -ii. All risk factors must be care planned -iii. Build on the resident's strengths -iv. Reflect treatment goals and objectives -viii. In measurable outcomes, such as evidenced by -what does the resident do, or what issue to improve, or maintain what function, etc. Record review of Resident 501's admission Record revealed the facility admitted the resident on 01/09/2026. Further review of the admission record identified Resident 501 had diagnoses of absence of left and right legs below the knee. Record review of Resident 501's Progress Notes (PN) dated 01/17/2026 identified Resident 501 exited the facility without informing facility staff. Facility staff contacted Resident 501's emergency contact (EC) who reported the resident frequents a specific apartment complex in Omaha and did not have a cell phone. Record review of Resident 501's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) printed on 06/15/2026 revealed the facility did not identify the resident was at-risk for leaving the facility without informing staff, or interventions to be implemented when the resident did not return from an outing. During an interview on 06/15/2026 at 4:43 PM, the Director of Nursing (DON) reported the interdisciplinary team meets to discuss resident's departure from the facility. The DON confirmed the CCP should be updated to reflect the resident's risk for leaving the facility without communicating with staff their destination or expected return time to the facility. B. In an interview with the administrator on 6/16/26 at 9:00 AM it was confirmed the facility had not care planned Resident 501would leave the community at times without signing out and they should have.

Licensure Reference Number 175 NAC 12-006.09(I)Based on record review and interview, the facility failed to have a comprehensive and consistent process to identify when alert and oriented residents would return to the facility after leave and steps to take if the resident failed to return for 2 (Resident 501 and 503) of 4 residents sampled. Facility staff identified a census of 83.Findings are: A. Record review of Resident 501's admission Record revealed the facility admitted the resident on 01/09/2026. Further review of the admission record identified Resident 501 had diagnoses of absence of left and right legs below the knee. Record review of Resident 501's 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 01/15/2026 identified Resident 501 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a score of 14 indicated the resident had intact cognition. Further review of the MDS revealed the resident required substantial assistance with transfers and was independently mobile in a manual wheelchair. Record review of Resident 501's Progress Notes (PN) revealed the following: -On 06/10/2026 at 5:14 AM, a note showed the resident was out of the facility throughout the night shift. At 3:42 PM, the emergency contact (EC) reported Resident 501 was at a friend's house and was doing fine and would plan to return the next day. -On 06/11/2026, the administrator (ADM) sent a text message to the EC at 11:10 am and 3:59 PM asking if they knew when the resident would return to the facility with no answer. A telephone call was made by the ADM to the EC at 2:49 PM with no answer. At 6:31 PM, the EC stated the resident would return on 6/12/2026. -In a note dated 06/12/2026, the Social Services Director (SSD) reported they attempted to contact Resident 501's EC on 06/11/2026 at 12:00 PM and 3:00 PM with no response. On 06/11/2026 at 3:30 PM the SSD responded to areas the resident frequented but did not locate the resident. On 06/11/2026 at 6:30 PM, the residents EC contacted the SSD and reported the resident would be back to the facility on [DATE]. -On 06/12/2026, the SSD responded to areas the resident frequented. The SSD located Resident 501. The resident agreed to come back to the facility and transportation was arranged. The resident later reported that they did not want to come back to the facility and signed discharge against medical advice paperwork. Record review of a Visitor/Resident Sign In/Out Sheet revealed Resident 501 signed themselves out on 06/09/2026 at 12:10 PM with destination of friends. There was no expected time of return, physical destination, or contact number left for the facility. During an interview on 06/15/2026 at 4:07 PM, Licensed Practical Nurse (LPN)-A reported they were assigned to Resident 501's care on 06/09/2026. LPN-A reported the resident left the facility around 11:00 AM and returned to the facility approximately 30 minutes later. LPN-A further reported Resident 501 left again on 06/09/2026. LPN-A reported they were unaware of the time the resident left. LPN-A further reported when a resident does not return to the facility when expected, or if the resident leaves without facility knowledge, LPN-A would call the contact number left on the sign out form. If the resident was unable to be reached using the contact number or if no number was left, LPN-A reported they would inform facility management and follow management's instructions. LPN relayed facility staff became aware of a resident not being in the facility when medications and treatments are due. LPN-A reported steps taken would be documented in the resident's progress notes. During an interview on 06/15/2026 at 4:20 PM, the Director of Nursing (DON) reported there was no set time frame for when the facility staff should call and check on the resident. The DON further reported that facility staff would attempt to contact the resident when medications and treatments were due if the resident had not returned to the facility at an expected return time, if a return time was not listed, or if facility staff were unaware of the cognitive resident's departure from the facility. The DON relayed if facility staff were unable to contact the resident they would continue to try until contact is made and an updated plan for return was provided to the facility. The DON reported facility staff would also try the emergency contact number listed in the resident's chart. The DON communicated if facility staff was unable to contact anyone at all, they would report the resident's absence to the local police department and Adult Protective Services (APS). During an interview on 06/15/2026 at 5:08 PM, the facility administrator (ADM) reported the facility would report to APS and the local police department not over 24 hours from the time a resident was supposed to return to the facility. The administrator confirmed a delay in reporting to APS due to belief Resident 501's EC was at work. The administrator confirmed APS was not notified until approximately 6:15 PM on 06/11/2026. B. Review of a facility Document titled Staff education signing out created 6/12/2026 at 6:35PM revealed the following: All resident's must sign out of the facility at the nurse's station on the resident's floor. All residents who are not allowed to go outside without supervision will be noted in their Care Profile. When a resident signs out (not an Elopement) the resident will be asked the approximate time of return and will be educated that if they do not return at that time, the facility will do the following: 1. Attempt to call the resident. If not able to reach the resident, move onto the next step. 2. Notify the Administrator and/or Director of Nursing. 3. Notify the Emergency Contact/Family. 4. Document attempts. 5. Adult Protective Services will be notified by the Administrator and/or Director of Nursing. 6. Police will be notified. 7. Physician and/or Nurse Practitioner will be notified. In an interview with the Administrator on 6/16/26 at 10:25 AM, it was revealed that all staff were sent the above education on 6/16/26 though the electronic system the facility uses for payroll. Further interview confirmed that not all staff members had signed the education at this time. Record review of Resident 503's Minimum Data Set(MDS, a federally mandated comprehensive assessment tool used to determine a residents functional capabilities and helps nursing home staff identify health problems) with an assessment reference date (ARD) of 4/1/26 revealed the a Brief Interview for Mental Status (BIMS, a tool used to screen and identify the cognitive status of residents in nursing facilities) of 13/15 which according to the MDS manual a score of 13-15 suggests intact cognition. Further review revealed Resident 503 they were independent in a motorized wheelchair(w/c) once seated in the w/c. Record review of facility form titled Release of responsibility for Leave of Absence reveled the following 'I, the undersigned, hereby accept complete responsibility for [Resident 503] while away from emerald Nursing and Rehab Mercy and absolve the management of said facility, it's personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident is away. I understand the bed will be reserved for the above-named resident when he returns on or before the appointed time. Authorization must be signed by the resident or by the nearest relative in case the resident is physically or mentally incompetent. We do ask that a cell phone number is provided with each Leave of Absence. By signing this the resident and/or representative is acknowledging that if the representative does not return at the expected time the facility staff will attempt to contact the resident and/or representative and obtain an updated anticipated return date/and time. If the facility staff are unable to reach the resident and/or representative the facility will Notify the Emergency Contact/Family, Document attempts, Adult Protective Services will be notified, Police will be notified and the Physician and/or Nurse Practitioner will be notified.' Further review of the document revealed Resident 503 signed out on 6/13/26 at 1:30 PM stating the resident was going to 'ex-wife' with nothing marked in approximate date/time of return. The sign in on the form was dated 6/15/26 at 11:15 AM. Record review of Resident 503's progress notes reveled and entry on 6/13/26 at 1:38 PM stating 'Resident signed out of facility'. Record review of Resident 503's Progress Note dated 6/14/26 at 6:05 AM revealed 'resident did not return to facility last night. Call placed to resident's cell phone and ex-wife, no answer from either'. Record review of Resident 503's Progress Note dated 6/14/26 at 4:00 PM revealed 'This nurse placed a call to the resident and the resident's ex-wife to inquire about the residents expected time of return to the facility. No answer was received from either party at this time. Voicemails were unable to be left. Facility will continue to attempt contact and monitor for residents return. Record review of resident 503's progress note dated 6/14/26 at 8:24 PM reveled At approximately 4:45 PM resident sent Director of Social Services (DSS) a text the [gender] was at [gender] ex-wife's and [gender] electric wheelchair (w/c) would not stay charged. Resident 503 stated they would wait for transportation to bring them back to the facility on 6/15/26. In an Interview with the Administrator on 6/16/26 at 8:55 AM The Administrator confirmed steps 1-4 of the process were completed when the facility was unable to reach Resident 503, but no evidence was provided of notification of APS the Police or Physician and/or Nurse Practitioner was contacted when Resident 503 did not return to the facility and the facility was unable to reach the resident or the Emergency Contact.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(c)Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(a)Based on observation, interview, and record review, the facility failed to administer the correct amount of enteral nutrition (liquid formula containing nutrients) per the provider's order on 1 (Resident 103) of 3 sampled residents, ensure flush orders were obtained for 1 (Resident 102) of 3 sampled resident's percutaneous endoscopic gastrostomy (PEG, a tube inserted directly into the stomach to administer nutrients and medications) tube, and ensure 2 (Residents 103 and 101) of 3 sampled resident's enteral nutrients were refrigerated after opening the container per the manufacturer's recommendations. The facility census was 79.Findings are:A.A record review of the facility's Care and Treatment of Feeding Tubes with a revision date of 1-2024 revealed the staff would ensure that the administration of enteral nutrition followed the practitioner's orders.A record review of the facility's Competency Assessment Enteral Tube Feeding via Syringe (bolus: a large, concentrated dose over a short period of time) with a revised date of November 2018 revealed staff would verify there was a physician's order for the procedure and verify the type, amount, method, and rate of administration. The staff would administer only full-strength feeding tube formulas. Do not add water. The staff would attach a 60 milliliter (ml) syringe to the tube and fill the syringe with the prescribed amount of enteral feeding to be given. The staff was to follow the enteral feeding with the ordered flush of warm water. A record review of Resident 103's Clinical Census dated 07/15/2026 revealed the resident was admitted to the facility 03/05/2026.A record review of Resident 103's Medical Diagnosis dated 07/15/2026 revealed the resident had diagnoses of cerebral infarction (stroke), encephalopathy (damage or malfunction of the brain), type 2 diabetes mellitus (uncontrolled blood sugar), personal history of other infectious and parasitic diseases (history of bacterial, viruses, fungi, or parasitic infections), gastrostomy status (had a PEG tube).A record review of Resident 103's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 06/19/2026 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a resident's cognitive abilities) of 00 which indicated the resident was cognitively impaired. The resident was dependent on staff for all activities of daily living, mobility, and transfers. The resident did not attempt eating. The resident had a feeding tube and received 51 percent (%) or more calories and 501 cubic centimeters (cc) per day of the fluid intake through the feeding tube. A record review of Resident 103's Care Plan Report with an admission date of 03/05/2026 revealed the resident required enteral feeding related to the resident's brain injury. The resident had weight loss since admission and had diarrhea (loose stools) with the tube feeding. An intervention was the resident was dependent with tube feeding and water flushes. See Doctor of Medicine (MD) orders for current feeding orders.A record review of Resident 103's Order Summary Report dated 07/15/2026 revealed the resident had an enteral feed order for the enteral nutrition Glucerna 1.5, bolus, 240 ml five times per day for a total of 1200 ml per 24 hours.An observation on 07/13/2026 at 2:02 PM with the Director of Nursing (DON) revealed Licensed Practical Nurse (LPN)-G entered Resident 103's room, performed hand hygiene, put a barrier towel on overbed table, got the enteral feeding supplies, measured water in a graduate (a container with measurements on it), and applied gloves. LPN-G put a towel under the resident's PEG tube. LPN-G removed gloves and regloved with no hand hygiene, got a stethoscope, and checked the PEG tube's residual (remaining amount of stomach contents), applied a 60 cc syringe, flushed the PEG tube with 35 mL water, opened a bottle of Glucerna 1.5 ready to hang nutrients and poured an unmeasured amount of Glucerna 1.5 into a Medline ribbed 9 ounce disposable plastic cup and poured the nutrients into syringe on the PEG tube. LPN-G administered 2 full 60 cc syringes of Glucerna 1.5, then topped off the syringe with approximately another 30 cc's because the syringe had not completely emptied, then topped off the syringe again with another unmeasured amount of Glucerna 1.5. LPN-G poured in the remaining 35 mL of water before the Glucerna 1.5 completely drained from the 60 cc syringe. LPN-G then closed the PEG tube port, removed the 60 cc syringe from the PEG tube, placed the cap back on Glucerna 1.5 and placed the container back on the dresser. When questioned on the amount administered, LPN-G filled the Medline 9 oz plastic cup with water to the line that LPN-G thought they filled the Glucerna 1.5 to and poured the water into a graduate. The amount was centered on the 200 ml mark of the graduate.In an interview on 07/13/2026 at 2:02 PM the DON confirmed the amount of water from the ribbed plastic cup that LPN-G poured into the graduate was 200 mL.In an interview on 07/13/2026 at 2:02 PM LPN-G confirmed LPN-G filled the plastic cup to a certain line on the plastic cup. LPN-G confirmed LPN-G filled the 60 cc syringe 3 or 4 times. LPN-G confirmed the fluid was 200 cc and that would have been the amount of Glucerna 1.5 that was given to Resident 103.In an interview on 07/14/2026 at 1:25 PM, the Director of Nursing (DON) confirmed LPN-G should have used a graduate to measure Resident 103's Glucerna 1.5 but did not.In an interview on 07/15/2026 at 7:45 AM, the facility's Regional Nurse Consultant (RNC) confirmed LPN-G used a plastic cup for Resident 103's enteral feeding. The RNC confirmed that was not LPN-G's regular practice for measuring enteral feeding, but the Assistant Director of Nursing (ADON) instructed LPN-G to use a ribbed plastic cup.B.A record review of the facility's Care and Treatment of Feeding Tubes with a created date of 11-17; 1-2024 revealed the facility would utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding tubes would be utilized in accordance with physician's orders which typically include the frequency of flush. Direction for staff on how to provide the frequency of and volume used for flushing, including flushing for medication administration, and what to do when a prescriber's order does not specify.A record review of the undated National Library of Medicine's Chapter 17 Enteral Tube Management revealed to prevent enteral tubes from clogging, it is important to flush feeding tubes at a minimum of once per shift. https://www.ncbi.nlm.nih.gov/books/NBK593216/A record review of Resident 102's Clinical Census dated 07/14/2026 revealed the resident was admitted to the facility 08/18/2025.A record review of Resident 102's Medical Diagnosis dated 07/15/2026 revealed the resident had diagnoses of cerebral palsy (neurologic disorder affecting a person's ability to move, maintain balance, and hold posture), paraplegia (paralysis of the lower half of the body), hypokalemia (electrolyte imbalance), iron deficiency, unspecified severe protien-calorie malnutrition (body lacks sufficient calories and protein), and gastrostomy status.A record review of Resident 102's MDS dated 04/28/2026 revealed the resident had a BIMS of 13 which indicated the resident was cognitively aware. The resident required setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with upper body dressing and was dependent on staff for toileting hygiene, bathing, and personal hygiene. Ther resident needed substantial/maximal assistance with rolling in bed and was dependent on staff for positioning and transfers. The resident had a feeding tube and received 26-50 % or more calories and 501 cc per day of the fluid intake through the feeding tube. A record review of Resident 102's Care Plan Report with an admission date of 05/15/2025 revealed the resident required enteral feeding related to the resident resisted eating. The resident had weight loss since admission and had diarrhea with the tube feeding. An intervention was the resident was dependent with tube feeding and water flushes. See MD orders for current feeding orders.A record review of Resident 102's Order Summary Report dated 07/13/2026 revealed the resident had an enteral feed order of Nutren 1.5 three times per day, give 220 ml, flush with 200 ml of water. It did not reveal a separate order for PEG tube flushes.A record review of Resident 102's Clinical Physician Orders dated 07/13/2026 revealed the resident's enteral feed order of Nutren 1.5 three times per day, give 220 ml, flush with 200 ml of water was on hold with a last revision date of 05/17/2026. It did not reveal a separate order for the PEG tube flushes to be continued.A record review of Resident 102's Nutrition Follow Up Visit dated 06/09/2026 revealed the resident's Registered Dietician (RD) recommended the resident transition to 100% oral feedings but did not reveal a recommendation to continue to flush the PEG tube.A record review of Resident 102's Physician Round Form dated 07/01/2025 revealed the facility completed the form with a chief complaint of the resident's RD-P recommended the resident transition to 100% by mouth (PO) eating and the enteral feeding was on hold. The new orders were: No new order, continue to follow up closely with the facility RD dated 07/08/2026. There was no discussion that the resident's PEG tube flush orders were part of the enteral feeding order that was put on hold, and there was not a separate order to flush the resident's PEG tube.An observation of Resident 102's PEG tube cares on 07/13/2026 at 1:10 PM revealed LPN-J entered the room and cleaned and applied a new split sponge to the resident's peg tube site but that was all LPN-J had done. The PEG tube contained a dark brown, crusty substance inside the PEG tube.In an interview on 07/15/2026 at 11:30 AM, the facility's RD-Q confirmed Resident 102 seen RD-P at the resident's doctor's office and RD-P is no longer at the resident's doctor's office. RD-Q confirmed RD-Q is now the dietician seeing the resident. RD-Q confirmed that RD-Q was watching the resident's weight closely, if the resident continues to decline, they would have to put the resident back on an enteral feeding in the mornings, if the resident agreed. RD-Q was not aware that the resident's PEG tube was not being flushed because the flush orders were included in the enteral feeding order that was placed on hold.In a telephone interview on 07/15/2026 at 2:57 PM, Resident 102's physician's LPN-R confirmed that LPN-R and the resident's doctor were not aware that the resident's PEG tube flushes were not being completed because the flushes were included in the enteral feeding order that RD-P placed on hold. LPN-R confirmed the facility had not contacted the physician's office to request an order for PEG tube flushes. LPN-R confirmed the resident's physician would not have been OK with the resident's PEG tube not being flushed, and the physician still wanted the PEG tube to be flushed so that it did not get occluded (plugged). The physician did not have any plans to discontinue the PEG tube until they know the resident will be able to maintain the resident's weight.In an interview on 07/14/2026 at 1:25 PM, the DON confirmed that Resident 102's PEG tube should have been flushed per best practice but was not completed.C.A record review of the facility's Care and Treatment of Feeding Tubes with a revision date of 1-2024 revealed the staff would use infection control precautions and related techniques to minimize the risk of contamination. The facility would ensure that the selection and use of enteral nutrition was consistent with manufacturer's recommendations.A record review of [NAME] Laboratories' Glucerna 1.5kcal (kilocalorie) manufacturer's data sheet dated November 2019 with the DON revealed that once opened, unused product should be covered and stored in a refrigerator. https://www.abbottnutrition.ie/downloads/6-Glucerna-1_5kcal-datasheet-pending-GMS-[NAME]-Version-1-November-2019.pdfA record review of Resident 103's Order Summary Report dated 07/15/2026 revealed the resident had an enteral feed order for the enteral nutrition Glucerna 1.5, bolus, 240 ml five times per day for a total of 1200 ml per 24 hours.An observation on 07/13/2026 at 2:02 PM with the Director of Nursing (DON) revealed Licensed Practical Nurse (LPN)-G entered Resident 103's room, completed the resident's enteral feeding using an opened, partially used, 1000 ml container of Glucerna 1.5 ready to hang (RTH) bottle that was sitting on the dresser. LPN-G placed the cap back on Glucerna 1.5 and placed the container back on the dresser.An observation on 07/14/2026 at 7:14 AM revealed an opened, partially used, 1000 ml bottle of Glucerna 1.5 RTH sitting on the resident's dresser.In an interview on 07/16/2026 at 8:15 AM, LPN-L confirmed the staff does not refrigerate Resident 103's Glucerna 1.5 between tube feedings.In an interview on 07/16/2026 at 8:25 AM, the DON confirmed the staff leaves the opened bottles of enteral nutrients in the resident's rooms between enteral feedings. The DON confirmed the staff does not refrigerate the 1000 ml bottles of enteral nutrition after they have been opened. The DON confirmed the Osmolite 1.5 RTH and the Glucerna 1.5 RTH should have been refrigerated after opened per the manufacturer's data sheets.In an interview on 07/16/2026 at 9:50 AM, RD-Q confirmed the enteral feeding nutrients should have been refrigerated after opening.In an interview on 07/16/2026 at 11:22 AM, the facility's Nurse Practitioner (NP)-N confirmed the enteral feeding nutrients should have been refrigerated after opening.D.A record review of the facility's Care and Treatment of Feeding Tubes with a created date of 11-17; 1-2024 revealed the staff would use infection control precautions and related techniques to minimize the risk of contamination. The facility would ensure that the selection and use of enteral nutrition was consistent with manufacturer's recommendations.A record review of [NAME] Laboratories' Osmolite 1.5kcal manufacturer's data sheet dated November 2018 with the DON revealed that once opened, unused product should be covered and stored in a refrigerator. https://www.proconnect.[NAME]/content/dam/an/hcpproconnect/uk/en/product-content/adult/Osmolite_1.5kcal_datasheet.pdf.coredownload.pdfA record review of Resident 101's Order Summary Report dated 07/14/2026 revealed the resident had an enteral feed order for the enteral nutrition Osmolite 1.5, 350ml with 100ml Flush (Bolus) four times a day for caloric intake.An observation on 07/13/2026 at 11:56 AM revealed there was an opened and dated 1000 ml bottle of Osmolite 1.5 RTH on Resident 101's bedside table.An observation on 07/13/2026 at 12:25 PM revealed Registered Nurse (RN)-S took an opened, partially used, 1000 ml bottle of Osmolite 1.5 RTH off the bedside table and measured 350 ml of the Osmolite in a graduate and administered the nutrients to Resident 101.An observation on 07/16/2026 at 7:03 AM revealed an opened, partially used, warm to the touch, 1000 ml bottle of Glucerna 1.5 RTH sitting on the resident's bedside table. The bottle was dated 07/15/2026 at 9:30 PM.An observation on 07/16/2026 at 8:11 AM with LPN-M revealed an opened, partially used, warm to the touch, 1000 ml bottle of Glucerna 1.5 RTH sitting on the resident's bedside table. The bottle was dated 07/15/2026 at 9:30 PM.In an interview on 07/16/2026 at 8:11 AM, LPN-M confirmed there was an opened, partially used, warm to the touch, 1000 ml bottle of Glucerna 1.5 RTH sitting on the resident's bedside table. The bottle was dated 07/15/2026 at 9:30 PM.In an interview on 07/16/2026 at 8:15 AM, LPN-L confirmed the staff does not refrigerate 1000 ml bottles of enteral nutrients between tube feedings.In an interview on 07/16/2026 at 8:25 AM, the DON confirmed the staff leaves the opened bottles of enteral nutrients in the resident's rooms between enteral feedings. The DON confirmed the staff does not refrigerate the 1000 ml bottles of enteral nutrition after they have been opened. The DON confirmed the Osmolite 1.5 RTH and the Glucerna 1.5 RTH should have been refrigerated after opened per the manufacturer's data sheets.In an interview on 07/16/2026 at 9:50 AM, RD-Q confirmed the enteral feeding nutrients should have been refrigerated after opening.In an interview on 07/16/2026 at 11:22 AM, the facility's NP-N confirmed the enteral feeding nutrients should have been refrigerated after opening.

Licensure Reference Number 175 NAC 12-006.09(H)Based on record review and interview, the facility failed to follow the plan of care for transfers resulting in significant injury and failed to complete a post-fall evaluation for 1 (Resident 100) of 3 sampled residents. The facility staff identified a census of 103.Findings are:Record review of facility policy entitled Falls Management dated revised 01/2024 revealed the facility would implement goals and interventions with the resident and family for inclusion in the comprehensive care plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) and communicate interventions to the care giving teams. Further review of the policy revealed in the event of a fall, the licensed nurse should complete a head-to-toe assessment to check for breaks in the skin and other abnormal findings. The policy further revealed vital signs to include blood pressure, pulse, pulse oximetry (device used to measure the percentage of oxygen in the blood), and respirations.Record review of Resident 100's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 04/12/2026 revealed Resident 100's transfer status was dependent.Record review of Resident 100's CCP revealed Resident 100 required a mechanical lift and two staff assistance for transfers with an initiated date of 08/15/2024 and revised 04/16/2026.A. Record review of an Abuse, Neglect, Misappropriation investigation with an incident date of 4/12/2026 revealed Nurse Aide (NA)-A attempted to transfer Resident 100 with a mechanical lift from the wheelchair to the bed without any assistance on 04/09/2026. NA-A reported after lifting the resident from the wheelchair and turning to the bed, [gender] attempted to turn the mechanical lift and one of the wheels got stuck. NA-A attempted to free the wheel which caused the mechanical lift to tilt and Resident 100 fell to the floor. NA-A acknowledged a mechanical lift transfer required two staff members.Further review of the investigation revealed NA-A left the room and informed Medication Aide (MA)-B and Licensed Practical Nurse (LPN)-C of the incident and all three staff members returned to Resident 100's room. LPN-C reported [gender] asked Resident 100 about pain, but performed no further assessment and NA-A, MA-B, and LPN-C assisted Resident 100 into bed. Resident 100 had verbalized no complaints on 04/10/2026. On 04/11/2026, Resident 100 had complaints of pain to the right knee and facility staff observed swelling. Facility staff notified Resident 100's medical practitioner on 04/11/2026 and the facility received an order to perform an x-ray of the right knee. The facility was notified on 04/12/2026 of the x-ray results which showed an acute appearing right femur fracture. Resident 100 was subsequently sent to the hospital for evaluation and treatment. The facility investigation concluded the root cause of the incident was failure to follow established care plan interventions requiring the use of a mechanical lift with 2 staff assist for resident transfer. Staff involved did not adhere to the resident's documented status per care plan, resulting in an unsafe transfer process and subsequent resident injury.Record review of Resident 100's Electronic Health Record (EHR) including progress notes, forms, and scanned documents lacked evidence a post-fall evaluation to include absence of recorded vital signs and absence of a head-to-toe assessment.Interview on 05/07/2026 at 10:03 AM with the Director of Nursing (DON) confirmed at the time of Resident 100's fall, the care planned transfer status was dependent with mechanical lift and two staff members. The DON reported Resident 100 was transferred by mechanical lift and one staff member, and Resident 100 sustained a fall with a fracture.In a follow-up interview on 05/07/2026 at 10:56 AM, the DON confirmed a post-fall evaluation was not completed by the licensed nurse. The DON reported a post-fall evaluation should have completed at the time of the fall.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interview, the facility failed to notify the medical practitioner of omitted body weight measurements for 2 (Residents 101 and 102) of 3 sampled residents. The facility staff identified a census of 103.Findings are:A. Record review of Resident 101's admission Record (AR) revealed the facility admitted the resident on 01/22/2024. Further review of the AR revealed Resident 101 had diagnoses of dysphagia (difficulty swallowing) and presence of a gastrostomy tube (g-tube, tube inserted through the abdomen into the stomach to receive nutrition and hydration).Record review of Resident 101's Annual 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 02/13/2026 revealed the resident had a feeding tube while a resident at the facility.Record review of Resident 101's Order Summary Report (OSR) revealed an order for weekly weights every Wednesday on day shift for weight loss dated 01/10/2026.Record review of Resident 101's Weights revealed the last recorded weight was dated 04/1/2026.Record review of Resident 101's Electronic Treatment Administration Record (eTAR) revealed the following: -04/08/2026 no weight was recorded; -04/15/2026 no weight was recorded; -04/22/2026 no weight was recorded; and -04/29/2026 no weight was recorded.Record review of Resident 101's Electronic Health Record (EHR) including progress notes, eTAR, and scanned documents revealed no evidence that Resident 101's medical practitioner was notified of the facility's inability to capture the resident's weight.During an interview on 05/07/2026 at 12:29 PM the Director of Nursing (DON) confirmed there was no evidence of the provider being notified of the omitted weight measurements and further confirmed facility staff should have notified the provider.B. Record review of Resident 102's AR revealed the facility admitted the resident on 10/19/2021. Further review of the AR revealed Resident 102 had diagnoses of severe protein-calorie malnutrition and presence of a g-tube.Record review of Resident 102's OSR revealed an order for weekly weights every Friday related to nutritional deficiency dated 08/05/2025.Record review of Resident 102's weights revealed no record of weight from 03/20/2026 until 05/06/2026.Record review of Resident 102's eTAR dated March, April, and May 2026 revealed the following: -03/06/2026 resident refused weight measurement. -03/27/2026 there was no documentation on the eTAR. -04/03/2026 resident refused weight measurement. -04/10/2026 there was no documentation on the eTAR. -04/17/2026 resident refused weight measurement. -04/24/2026 resident refused weight measurement. -05/01/2026 there was no documentation on the eTAR.Record review of Resident 102's Progress Notes dated 03/01/2026 to 05/06/2026 revealed a note dated 03/06/2026 that Resident 102 would allow staff to weigh [gender] on 03/07/2026. There was no evidence the facility staff followed up on 03/07/2026 to attempt to obtain a weight measurement.Record review of Resident 102's EHR including progress notes, eTAR, and scanned documents revealed lack of evidence Resident 102's medical practitioner was notified of refusal of weights and omission of weights.During an interview on 05/07/2026 at 12:29 PM with the DON confirmed there was no evidence of the provider's notification of the omitted or refused weight measurements and further confirmed the facility staff should have notified the provider.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to report an allegation of potential neglect within the required timeframes for Resident 100. The facility staff identified a census of 103.Findings are:Record review of facility policy entitled Abuse, Neglect and Exploitation dated revised 01/2024 revealed: - 13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: -a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or [sic] resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents [sic] that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State law.Record review of Resident 100's Comprehensive Care Plan (CCP) with an intervention dated 4/16/2026 revealed Resident 100 was depended for transfers , need the use of a Hoyer (mechanical) lift and 2 staff assisting with the transfer. Record review of an Abuse, Neglect, Misappropriation investigation with an incident date of 4/12/2026 revealed Nurse Aide (NA)-A transferred Resident 100 with a mechanical lift from the wheelchair to the bed without any assistance on 04/09/2026. NA-A reported after lifting the resident from the wheelchair and turning to the bed, [gender] attempted to turn the mechanical lift and one of the wheels got stuck. NA-A attempted to free the wheel which caused the mechanical lift to tilt and Resident 100 fell to the floor.Further review of the investigation revealed NA-A left the room and informed Medication Aide (MA)-B and Licensed Practical Nurse (LPN)-C of the incident and all three staff members returned to Resident 100's room. LPN-C reported [gender] asked Resident 100 about pain, but performed no further assessment and NA-A, MA-B, and LPN-C assisted Resident 100 into bed.Record review of Resident 100's Electronic Health Record (EHR) including progress notes, scanned documents, and forms showed there was no evidence of a post-fall evaluation regarding Resident 100's fall on 04/09/2026.Record review of Abuse and Neglect Policy Acknowledgement forms revealed the following: -NA-A acknowledged the facility policy on 12/18/2025. -MA-B acknowledged the facility policy on 01/28/2026. -LPN-C acknowledged the facility policy on 11/06/2025.Record review of a sign-in sheet entitled Resident's Rights & Abuse dated 02/13/2026 revealed LPN-C's signature.Interview on 05/07/2026 from 10:56 AM to 11:24 AM with the Director of Nursing (DON) confirmed the events within the investigation dated 04/12/2026. The DON further confirmed there was no documentation to support a post-fall evaluation was completed at the time of the incident. The DON confirmed NA-A, MA-B, and LPN-C were all previously trained on abuse, neglect, and misappropriation reporting procedures. The DON reported LPN-C's failure to complete a post-fall evaluation was considered potential neglect and should have been reported to facility management and the State Survey Agency at the time of occurrence.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(a)Based on record review, observation, and interview, the facility failed to have complete tube feeding orders, failed to date and time tube feeding equipment, and failed to account for amount of infused tube feeding for 2 (Residents 101 and 102) of 3 sampled residents. The facility staff identified a census of 103.Findings are:Record review of facility policy entitled Care and Treatment of Feeding Tubes dated Revised 01/2024 revealed: -It was the facility's policy to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. -7. Direction for staff on how to provide the following care would be provided: -e. Frequency of and volume for flushing, including flushing for medication administration, and what to do when a prescriber's order does not specify.A. Record review of Resident 102's admission Record (AR) revealed the facility admitted the resident on 10/19/2021. Further review of the AR identified Resident 102 had diagnoses of severe protein-calorie malnutrition and unspecified nutritional deficiency.Record review of Resident 102's (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 01/28/2026 identified Resident 102 received 26-50 percent (%) of calories and 501 cubic centimeters (cc) or more through the feeding tube daily.Record review of Resident 102's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) identified Resident 102 required assistance with tube feeding and water flushes and to refer to MD (Medical Doctor) orders.Record review of Resident 102's Order Summary Report revealed the following orders: -200cc water flush three times a day dated 06/03/2025. -Nutren 1.5 Full Strength to be delivered via gastrostomy (g-tube, tube inserted through the abdomen into the stomach to deliver food, hydration, and medications) via pump at a rate of 55 milliliters (mL) per (/) hour (hr) for 12 hours nightly plus packet of liquacel (protein supplement). Goal rate of 55mL/hr. Add 200 cc water flush TID dated 06/10/2025.Observation on 05/06/2026 at 7:10 AM revealed Nutren 1.5 was running at 55mL/hr with a 30mL/hr water flush. Observation on 05/07/2026 at 8:10 AM with Registered Nurse (RN)-E revealed the tube feeding pump was running and instilling Nutren 1.5 at 55mL/hr with a 30 mL/hr water flush.Interview on 05/06/2026 at 9:10 AM with Licensed Practical Nurse (LPN)-D confirmed Nutren was running at 55 mL/hr and a water flush of 30mL/hr. LPN-D reported the tube feeding rate and the flush rate are determined by physician's orders. LPN-D was unable to locate an order for the 30 mL/hr water flush and was further unable to report what to do if a physician's order did not specify flush amounts.Interview on 05/06/2026 at 9:37 AM and 12:52 PM with the Director of Nursing (DON) confirmed there was no order for 30 mL/hr water flush. The DON revealed the facility followed the standards of practice related to feeding tubes.Interview on 05/07/2026 at 8:10 and 8:20 AM with RN-E confirmed the tube feeding pump was set to administer 55 mL/hr of tube feeding and 30 mL/hr of water. RN-E reported if there was no flush order during the continuous tube feed they would notify the APRN. RN-E confirmed there was no flush order for the continuous tube feeding. Follow up interview on 05/07/2026 at 8:44 AM with the DON revealed the facility had no written standards of practice related to feeding tubes available for review.B. Record review of Resident 102's April 2026 Electronic Treatment Administration Record (eTAR) revealed a total tube feeding administered recorded on 04/02/2026, 04/03/2026, 04/04/2026, and 04/05/2026. The rest of the dates were marked off or on and did not record the amount of tube feeding or water flush administered.Record review of Resident 102's May 2026 eTAR revealed total tube feeding administered was recorded on 05/02/2026 and 05/03/2026. Off was written for 05/01/2026, 05/04/2026, and 05/05/2026 and did not record the amount of tube feeding or water flush administered.Interview on 05/06/2026 at 9:37 AM with the DON revealed staff should verify on the pump the ordered amount of tube feeding and water flush was administered but did not need to be recorded.Interview on 05/06/2026 at 12:52 PM with the DON revealed the facility did not have a tube feeding competency available to review and reported the facility follows standards of practice.Interview on 05/07/2026 at 8:20 AM with RN-E reported without clearing the pump and recording the amount, there was no way to confirm the resident received the required nutrition and hydration.Follow up interview on 05/07/2026 at 8:44 AM with the DON revealed the facility had no written standards of practice related to tube feeding administration available for review.C. Observation on 05/06/2026 at 8:10 AM with LPN-D in Resident 102's room revealed Nutren 1.5 was being administered continuously. The tube feeding bag and water bag were not labeled with the date and time of first use.Observation on 05/07/2026 at 8:10 AM with RN-E in Resident 102's room revealed Nutren 1.5 was being administered continuously. The tube feeding bag and water bag were not labeled with the date and time of first use.Interview on 05/06/2026 at 8:11 AM with LPN-D confirmed the tube feeding supplies were not labeled with date and time of first use and should have been.Interview on 05/07/2026 at 8:20 AM with RN-E confirmed the tube feeding supplies were not labeled with date and time of first use and should have been.D. Record review of Resident 101's AR revealed the facility admitted the resident on 01/22/2024. Further review of the admission record identified Resident 101 had diagnoses of anoxic brain injury (lack of oxygen to the brain) and dysphagia.Record review of Resident 101's MDS dated [DATE] identified Resident 101 utilized a feeding tube and received 51 percent (%) or more of total nutrition and 501 milliliter (mL) or greater of hydration through the feeding tube daily.Record review of Resident 101's Order Summary Report revealed: -Enteral feed order every hour Osmolite 1.5, 60 mL/hr continuous feed with 100 mL/hr water flush dated 02/18/2026.Observation on 05/05/2026 at 12:54 PM revealed the ordered tube feeding and flush was administered at the ordered rate. The tube feeding bag and the water flush bag were not labeled with the date and time of first use.Interview on 05/07/2026 at 10:56 AM with the Director of Nursing confirmed the tube feeding was not labeled with date and time of first use and further confirmed should have been done.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(6)Licensure Reference Number 175 NAC 12-006.17(A)(v)Based on record review and interview, the facility staff failed to document a post-fall evaluation for 1 (Resident 100) of 3 sampled residents. Facility staff identified a census of 103.Findings are:Record review of facility policy entitled Falls Management dated revised 01/2024 revealed: - 6. Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement, palpating and examining all areas for breaks in the skin and/or other abnormal findings. -7. Obtain vital signs: blood pressure, pulse, pulse oximetry, and respirations. -8. Obtain neurological checks (neuro-checks)per policy for any unwitnessed fall or any fall with evidence of injury to head. -9. If no obvious injury move resident to a comfortable position. If injury, severe pain or abnormal assessments observed, call 9-1-1 for transfer. -10. The nurse will complete documentation, to include vital signs.Record review of an Abuse, Neglect, Misappropriation investigation with report date 04/15/2026 identified Resident 100 sustained a fall while being transferred with one-staff member and mechanical lift on 04/09/2026. The investigation identified the medical record lacked evidence of an evaluation of Resident 100 at the time of the fall.Record review of Resident 100's Electronic Health Record (EHR) which included progress notes, forms, and scanned documents lacked evidence of an evaluation of Resident 100 at the time of the fall.Interview on 05/07/2026 at 10:56 AM with the Director of Nursing (DON) confirmed there was no post-fall evaluation noted in Resident 100's EHR.

Licensure Reference Number 175 NAC 12-006.18(B)Based on record review, observation, and interview, the facility failed to change a tube feeding pump set at the required intervals to prevent the potential for cross contamination for 1 (Resident 101) of 3 sampled residents. The facility staff identified a census of 103.Findings are:Record review of facility policy entitled Care and Treatment of Feeding Tubes dated revised 01/2024 revealed: - 7. Direction for staff on how to provide the following care will be provided. - d. Use of infection control precautions and related techniques to minimize the risk of contamination.Record review of Kangaroo ePump Enteral Feed and Flush Pump with Pole Clamp, Programmable dated Revised 04/2020 revealed: - The pump set usage warning indicator will blink on the running screen if a pump set has been used for 24 or more hours (hours actually running). It is recommended to replace pump sets after this length of usage.Observation on 05/05/2026 at 12:54 PM revealed Resident 101's Kangaroo ePump was running at the ordered rate. The machine display blinked Set Use > (greater than) 24 hrs (hours).Observation on 05/06/2026 at 6:26 AM revealed Resident 101's Kangaroo ePump was running at the ordered rate. The machine display blinked Set Use > 24 hrs.Interview on 05/06/2026 at 11:27 AM with Registered Nurse (RN)-E confirmed the Kangaroo ePump displayed set use greater than 24 hours. RN-E reported the pump set should be changed each time the tube feeding bag was replaced.Interview on 05/07/2026 at 12:50 PM with the Assistant Director of Nursing confirmed potential for cross contamination if the tube feeding pump set is not changed every 24 hours.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(1). Based on interview and record review the facility failed to implement interventions to prevent a significant injury for 1 (Resident 6) of 3 residents sampled and failed to investigate and implement interventions for falls for 1(Resident 3) of 3 residents sampled. The facility census was 117. The findings are:A.Record review of the facility's policy titled Accidents and Incidents reveals the facility strives to ensure that residents/patients, visitors, and/or volunteers will not experience undue discomfort and/or have their health and safety placed in jeopardy due to an unusual occurrence (accident/incident). The facility defines an accident/incident as an event, occurrence, or happening that may produce an actual or potential undesirable outcome. Should an accident occur facility strives to prevent such an occurrence from happening again. A thorough investigation and follow-up will be completed within 5 working days. B. Record review of Resident 6's admission Notification E-mail (ANE) dated 03-25-2026 revealed Resident 6 was admitted to the facility on [DATE] and Resident 6 had a diagnosis of dementia and required moderate to maximum assistance of 2 for function and mobility. Record review of a After Visit summary with a date of 3/25/2026 revealed the under the section identified as Activity Instructions revealed the instructions as follows:-Activity as tolerated.-Up with assistance, gait belt, walker and 2 people assisting. Record review of Resident 6's Nursing admission Data Collection (NADC) dated 03-25-2026 revealed the following about the resident:-admitted to the facility on [DATE].-Was alert and oriented to self only. -Had limited range of motion and weakness in all four extremities.-Had poor muscle control and balance. -Was dependent on 2 assistants for transfers. -Had a recent change in cognitive status within the last 90 days.-Vision was severely impaired. Record review of Resident 6's Baseline Care Plan (BCP) dated 03-26-2026 printed 04-06-2026 revealed Resident 6 had a functional deficit with current Activities of Daily Living (ADL) and the goal was Resident 6 would maintain current level of ADL function. The interventions listed included assistance with ambulation, bed mobility, wheelchair mobility and transfers but did not indicate how much assistance was to be provided. The BCP revealed Resident 6 was at risk for falls and the goal was Resident 6 would not sustain a serious injury. The interventions listed were Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat if indicated and Resident 6's safety insight was poor at this time and staff are to conduct routine visual rounding to determine additional safety queuing.Record review of Resident 6's Visual/Bedside Kardex printed on 04-06-2026 revealed no instruction on how much assistance Resident 6 required with ambulation, bed mobility, wheelchair mobility, or transfers. Record review of Resident 6's Progress Notes (PN) dated 04-05-2026 revealed Resident 6's left foot was extremely swollen, discolored and painful and the left knee was rotated inward and Resident 6 was sent to the hospital emergency room for evaluation. Record review of Resident 6's Hospital Orthopedic Physician Consult Note (HOPCN) dated 04-05-2026 revealed Resident 6 had a left total hip dislocation. An interview conducted on 04-06-2026 at 2:40 PM with Nursing Assistant (NA) E revealed Resident 6 was a pivot transfer and it helps if you have a second person. An interview conducted on 04-07-2026 at 5:45 AM with NA D revealed NA D had worked with Resident 6 on the shift prior to being sent to the hospital on [DATE] and NA D had transferred Resident 6 that morning alone. An interview conducted on 04-07-2026 at 11:50 AM with NA C revealed NA C always transferred Resident 6 with the assistance of 2 staff, one day it took 2 to 3 of us to transfer Resident 6. An interview conducted on 04-07-2026 at 12:00 PM with the Director of Nursing (DON) revealed the staff refer to the Visual Bedside Kardex for information on how residents are to be transferred. An interview conducted on 04-07-2026 at 12:50 AM with the Assistant Director of Nursing (ADON) revealed if a resident transfer status was maximum assistance of 1 and the resident had a diagnosis of dementia the expectation is that staff transfer with 2 assist.An interview conducted on 04-09-2026 at 7:15 AM with the DON confirmed Resident 6 was a maximum assist of 2-3 people for transfers, the visual/bedside Kardex had not been completed and Resident 6's transfer status had not been identified on the Kardex prior to 04-05-2026 when Resident 6 was found to have a dislocated left hip and should have.C. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had diagnosis of Diabetes Mellitus type 2. -Brief Interview of Mental Status (BIMS) was scored as a 6. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment.- required substantial assistance with upper body dressing, and bed mobility.-required total assistance with toileting, bathing, lower body dressing and transfers.Record review of Resident 3's Comprehensive Care Plan (CCP) dated 12-12-2025 revealed Resident 3 was at risk for falls related to weakness, impaired mobility, diabetes and psychotropic medications, the goal was Resident 3 would not sustain serious injury through the review date. Interventions listed were Physical and Occupational therapy to evaluate and treat and resident's safety insight is poor, and staff will conduct routine visual rounding to determine additional safety queuing. Record review of Resident 3's Progress Notes (PN) dated 12-13-2025 revealed Resident 3 had fallen at 6:15 AM and 7:20 AM and had been sent to the hospital for evaluation.Record review of Resident 3's CCP revealed no additional fall interventions were implemented after the falls on 12-13-2026.Record review of Resident 3's Electronic Health Record (EHR) including forms, evaluations and progress notes revealed no fall evaluation dated 12-13-2025 and no new intervention to prevent further falls. An interview conducted with the ADON on 04-08-2026 at 10:30 AM confirmed Resident 3's falls on 12-13-2025 were not investigated, and new interventions were not implemented and should have been.

Licensure Reference Number 175 NAC 12-006.09(H). Based on observation, interview and record review the facility failed to evaluate, monitor and implement interventions for severe pain and failed to ensure pain medications were available for use for 1(Resident 3) of 3 residents sampled. The facility census was 117. The findings are:Record review of the facility's policy titled Pain Management dated 01-2024 revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility utilizes a systematic approach for recognition, assessment, treatment and monitoring of pain. Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to:-change is gait-loss of function-decline in activity level-resisting care, striking out-bracing, guarding, or rubbing-fidgeting, increased or recurring restlessness-facial expressions: grimacing, frowning, fear, grinding teeth.-change in behavior: depressed mood, decreased participation in usual daily living.-loss of appetite-sleeping poorly-sighing, groaning, crying, breathing heavily.If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had diagnosis of Diabetes Mellitus type 2. -Brief Interview of Mental Status (BIMS) was scored as a 6. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment.- required substantial assistance with upper body dressing, and bed mobility.-required total assistance with toileting, bathing, lower body dressing and transfers. -had pain almost constantly.-had pain that frequently effected sleep.-had pain that almost constantly interfered with therapy. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 12-22-2025 revealed Resident 3 had the potential for pain related to diabetic neuropathy in bilateral feet and lower back pain. The goal was Resident 3 would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions listed to achieve the goal were:-The resident is able to: call for assistance when in pain, reposition self, ask for medication, and tell you how much pain is experienced, and what increases or alleviates the pain.-the resident prefers to have pain controlled by medication.-provide non-pharmacological interventions to assist with pain management: redirection, distraction, and repositioning. Record review of Resident 3's Order Summary printed on 04-06-2026 revealed Resident 3 had the following orders for pain:-Aspercreme with 4% lidocaine, apply topically to feet twice a day for neuropathic pain -Diclofenac gel 1% apply to each knee 3 times a day.-Lidocaine pain patch 4% apply 1 patch to the right thigh and 1 patch to the back daily-12 hours on and 12 hours off. -pregabalin 150 milligram (mg) capsule, take one capsule twice daily. -acetaminophen 500 mg tablet take 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident 3's Treatment Administration Record (TAR) for April 2026 revealed the aspercreme with lidocaine 4% was not available and not administered to Resident 3 and acetaminophen 500 mg give 1 tablet as needed every 6 hours for pain had not been administered for the month of April 2026. Further review of the TAR revealed the lidocaine patch 4% was to be applied at 8:00 AM and removed at 8:00 PM. Record review of Resident 3's Progress Notes (PN) revealed the following about aspercreme with lidocaine 4%:-04-05-2026 reordered medication-04-06-2026 medication on order from pharmacy-04-07-2026 on order from pharmacy-04-07-2026 medication reordered awaiting pharmacy to deliver.-04-08-2026 called pharmacy they will deliver the medication tonight-04-08-2026 medication on order, awaiting delivery.-04-09-2026 called pharmacy again they stated the medication would be delivered tonight. An observation conducted on 04-08-2026 at 10:00 AM revealed Licensed Practical Nurse (LPN) A had entered Resident 3's room to administer Diclofenac cream to Resident 3's knees, LPN A asked Resident 3 to rate the pain and Resident 3 responded 10 and its throbbing, LPN A applied cream to bilateral knees revealing there was no lidocaine patch on the right leg, and left the room. An interview conducted on 04-08-2026 at 10:05 AM with Resident 3 revealed Resident 3 had not had the lidocaine 4% patch applied to the right thigh and back that was due at 8:00AM. An interview conducted on 04-08-2026 at 11:25 AM with Resident 3 revealed Resident 3 had not received the Lidocaine 4% patch to the right thigh and back. An interview conducted on 04-08-2026 at 11:30 AM with LPN A revealed LPN A confirmed that Resident 3 had not received the lidocaine pain patch. An interview conducted on 04-08-2026 at 11:35 AM with MA B confirmed Resident 3 had not yet received the Lidocaine 4% patch to the right thigh and back and confirmed that even though the patch would be applied late the next shift would remove the patch at the assigned time. An observation conducted on 04-08-2026 at 12:45 PM revealed Resident 3 was lying in bed and Resident 3 had a lidocaine patch on the right thigh dated 04-08-2026. An interview conducted on 04-08-2026 at 12:50 PM with MA B confirmed Resident 3's lidocaine patch 4% to the right thigh and back had been applied at 12:45 PM. An interview conducted with the Assistant Director of Nursing on 04-09-2026 at 11:35 AM confirmed Resident 3 would not receive the full dose of the lidocaine patch because it was applied late. An observation on 04-09-2026 at 2:15 PM revealed Resident 3 was in bed and LPN A asked if the Diclofenac cream was effective for Resident 3's knee pain. Resident 3 replied it brought the pain to a 3 which was acceptable but my feet are a 10. An interview conducted on 04-09-2026 at 2:20 PM with Resident 3 revealed Resident 3 had not received aspercreme with lidocaine cream to bilateral feet. An interview conducted on 04-09-2026 at 2:25 PM with LPN A confirmed Resident 3's pain was a 10 on 04-08-2026 at 10:00 AM and confirmed LPN A did not offer non-pharmacological pain interventions, did not return and re-evaluate Resident 3's pain, did not administer any as needed pain medications and did not contact Resident 3's practitioner and should have. LPN A also confirmed Resident 3 had not received aspercreme with lidocaine to the bilateral feet yet this week because it was unavailable.

Licensure Reference Number 12-006.09(J)(i)(1). Based on observation, interview and record review the facility failed to accurately record meal intakes, implement interventions to prevent a significant weight loss, and failed to implement practitioner orders to ensure adequate nutrition after a bariatric surgery for 1 (Resident 3) of 1 residents sampled. The facility census was 117. The findings are: A. Record review of the facility policy titled Weight Monitoring dated 10-06-2025 revealed based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this not possible or resident preferences indicate otherwise. Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. Weight analysis will be completed by the Registered Dietician or designee. A significant change in weight is defined as: 5% change in weight in 1 month, 7.5 % change in weight in 3 months, and 10% change in weight in 6 months. The interdisciplinary team including the Registered Dietician, Dietary Manager, Activities, Social Work and Nursing meets weekly for a Nutrition meeting. The Registered Dietician or Dietary Manager should assist with interventions, and actions are to be recorded in the nutrition progress notes. The Interdisciplinary plan of care communicates care instructions to the staff. B. Record review of maintenance logs for the facility scales revealed the fourth-floor scale needed a new battery on 02-23-2026, that was replaced and revealed the fourth-floor scale had been calibrated for accuracy by the facility staff on 02-28-2026 and 03-31-2026 and an outside company calibrated the scale on the fourth floor on 04-02-2026.C. Record review of Resident 6's Nutrition admission Data Collection (NADC) dated 12-22-2025 revealed Resident 6 had a gastric bypass in June of 2025 and the Registered Dietician (RD) recommended adding ensure nutritional supplement 3 times a day as Resident 6 had been taking that prior to admission to the facility. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had diagnosis of Bipolar Disorder and Anxiety Disorder -Brief Interview of Mental Status (BIMS) was scored as a 6. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment.- required substantial assistance with upper body dressing, and bed mobility.-required total assistance with toileting, bathing, lower body dressing and transfers. -weight was 240 pounds (lb). Record review of Resident 3's Comprehensive Care Plan (CCP) dated 12-22-2025 revised 03-11-2026 revealed Resident 3 had a nutritional problem or potential nutritional problem related to having had a gastric bypass and decreased appetite. The goal was Resident 3 would maintain adequate nutritional and hydration status. Interventions listed were to provide a regular diet, supplements per practitioner orders and to monitor weights and meal intakes dated 12-22-2025. Record review of Resident 3's Electronic Health Record (EHR) under the section Weights and Vitals revealed Resident 3 weighed 240 lbs on 02-01-2026 and weighed 188.0 lbs on 02-24-2026 indicating a loss of 52 lbs or 21.6% weight loss. Record review of Resident 3's Dietary Progress Notes (DPN) dated 03-01-2026 revealed Resident 3's weight was down 58 lbs., Resident 3 ate 50-100% of meals, and Resident 3 had an order for ensure nutritional supplement 3 times a day but does not always take the supplement. No new interventions were identified to prevent further weight loss. Record review of Resident 6's CCP revealed no additional nutritional interventions. Record review of Resident 6's DPN dated 03-11-2026 revealed the RD had reviewed Resident 6's weight and changed the nutritional supplement from ensure to boost breeze related to indicators of loose stools. Record review of Resident 6's CCP revealed an intervention dated 03-14-2026 to change ensure supplement to boost breeze 3 times a day. Record review of Resident 3's Office Visit Notes (OVN) dated 03-17-2026 revealed an order to resume bariatric vitamins (specialized high potency nutritional supplement designed for individuals who have undergone weight loss surgery). Record review of Resident 3's Order Summary (OS) printed on 04-06-2026 revealed the bariatric vitamins were not identified. Record review of Resident 3's Medication Administration Records (MAR) for March 2026 and April 2026 revealed the bariatric vitamins were not administered. Record review of Resident 3's DPN dated 03-22-2026 revealed Resident 3's practitioner had not replied to the RD's update on weight loss and the RD would update the practitioner again and request weekly weights. Record review of Resident 3's DPN dated 03-25-2026 revealed the RD followed up with a second update on weight loss for Resident 3's practitioner. Record review of Resident 3's DPN dated 04-01-2026 revealed Resident 3's practitioner ordered weekly weights for closer monitoring. Record review of Resident 3's EHR under section Weights and Vitals revealed no weekly weight was obtained on 04-08-2026. An observation conducted on 04-08-2026 at 8:15 AM revealed the facility staff had delivered breakfast to Resident 3, consisting of scrambled eggs, 2 slices of bacon, a banana and a large orange juice. Resident 3 was in bed with eyes closed and the breakfast tray was left on the bedside table. An observation conducted on 04-08-2026 at 9:00 AM revealed Nursing Assistant (NA) H entered Resident 3's room to pick up the breakfast room tray and saw that Resident 3 was asleep and walked back out of the room without attempting to encourage or assist the resident with breakfast. A continuous observation conducted on 04-08-2026 from 9:20 to 10:00 AM revealed the staff had not come into to encourage or monitor Resident 3's breakfast intake. An observation conducted on 04-08-2026 at 10:00 AM revealed Licensed Practical Nurse (LPN) A had entered Resident 3's room to perform a treatment and asked the resident if Resident 3 was done eating and Resident 3 stated yes, all I want is the banana. LPN A then placed the banana on the bedside table and took the room tray out of the room. LPN A did not encourage Resident 3 to eat or offer to provide a substitute. An interview conducted with the Maintenance Director (MD) on 04-09-2026 revealed the scale on the fourth floor has been functioning properly since 02-24-2026. An interview conducted with LPN A on 04-09-2026 at 11:55 AM confirmed Resident 3 did not eat anything for breakfast on 04-08-2026, and confirmed LPN A had not offered Resident 3 a substitute on 04-08-2026 and should have. Record review of Resident 3's EHR under tasks revealed the intake for breakfast on 04-08-2026 was 75-100% of the meal was consumed. An interview conducted with the Director of Nursing (DON) on 04-09-2026 at 12:00 confirmed the documentation in Resident 3's EHR for breakfast on 04-08-2026 was 75-100% and confirmed that documentation was not accurate. An interview conducted with the Assistant Director of Nursing (ADON) at 2:45 AM confirmed the orders received on 03-17-2026 for bariatric vitamins had not been implemented and should have. The ADON further confirmed that if the meal intakes in the EHR are incorrect the RD would not be able to assess Resident 3's nutrition accurately.

Licensure Reference Number 175 NAC 12-006.09. Based on observation, interview and record review the facility failed to monitor daily fluid intake, and failed to ensure medications and treatments were coordinated with the provision of dialysis services for 1 (Resident 5) of 1 residents sampled. The facility census was 117. The findings are:A.Record review of the facility policy titled Special Needs-Dialysis Policy dated 01-2024 revealed the policy is to outline care and services for dialysis residents in order to reduce the risk of infections, complications, and to provide for ongoing monitoring and interventions. An assessment of the resident will be performed on admission and quarterly and will include the location of the dialysis shunt, when dialysis is performed and where, and what to monitor. This information will be included as part of the resident's plan of care. The facility will ensure medications and meals are provided as ordered. Physician referral may be needed in order to adjust medication times or obtain an order to hold medications on dialysis day. B.Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-22-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored as a 14. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required supervision and set up with eating and oral hygiene.-required partial assistance with upper body dressing, bed mobility and transfers.-required substantial assistance with toileting and lower body dressing.-had a diagnosis of End Stage Renal Disease (ESRD), Diabetes and Glaucoma.-was receiving dialysis.-was legally blind. Record review of Resident 5's Comprehensive Care Plan dated 03-17-2026 revealed Resident 5 had ESRD and receives dialysis, the goal was Resident 5 would not experience any unavoidable complications from dialysis through the review date. Interventions listed were:-if bleeding from the vascular access is not controlled, apply direct pressure, call the dialysis team/nephrologist to determine the need for the resident to be transported emergently to the emergency room (ER).-Resident has dialysis, the location of services, the days of the week and time of services were not on the CCP.-monitor/document/report any signs or symptoms of infection to the access site such as redness, swelling and warmth.-monitor/document/report any signs or symptoms of renal insufficiency such as changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Record review of Resident 5's Order Summary (OS) printed on 04-07-2026 revealed Resident 5 had an order for dialysis treatments 3 times a week on Monday, Wednesday, and Friday at Dialysis Omaha at 5:45 AM. Record review of Resident 5's Medication Administration Record (MAR) for March 2025 revealed the following medications were not given because Resident 5 was out of the facility for dialysis:-March 18th 2026 at 8:00 AM- hydralazine 25 milligram (mg) tablet,-carvedilol 25mg tablet-nifedipine 30 mg Extended Release tablet, -losartan potassium 100 mg tablet,-simvastatin 40 mg tablet, -venlafaxine 150 mg Extended Release tablet, -Xarelto 20 mg tablet, -Gabapentin 300 mg tablet-Insulin Glargine 100 units per milliliter (ml) inject 35 units, -atropine sulfate 1% eye drops 1 drop in the right eye,-brimonidine 0.2% eye drops instill 1 drop in the right eye, -dorzol/timol 2-0.5% eye drops instill 1 drop in the right eye, -prednisolone 1% eye drops instill 2 drops into the right eye. March 20, 2026 at 8:00AM--losartan potassium 100 mg tablet, -simvastatin 40 mg tablet, -venlafaxine 150 mg extended-release tablet, -Xarelto 20 mg tablet, -Gabapentin 300 mg tablet-Ferrous sulfate 325 mg tablet-Insulin Glargine 100 units per milliliter (ml) inject 35 units, -atropine sulfate 1% eye drops 1 drop in the right eye,-brimonidine 0.2% eye drops instill 1 drop in the right eye, -dorzol/timol 2-0.5% eye drops instill 1 drop in the right eye, -prednisolone 1% eye drops instill 2 drops into the right eye. -Nepro nutritional supplement -blood sugar check Record review of Resident 5's Electronic Health Record under the section Census revealed Resident 5 was at the hospital from [DATE] to 04-03-2026. Record review of Resident 5's Hospital Discharge Orders (HDO) dated 04-03-2026 revealed an order to limit fluids to 1500 ml per day. Record review of Resident 5's MAR for April 2026 revealed the following medications were not given due to resident being out of the facility for dialysis:-April 6, 2026 between 6:00 and 10:00 AM-losartan potassium 100 mg tablet, -carvedilol 25 mg tablet-venlafaxine 150 mg extended-release tablet, -Eliquis 5 mg tablet, -Gabapentin 300 mg tablet-Ferrous sulfate 325 mg tablet-atropine sulfate 1% eye drops 1 drop in the right eye,-brimonidine 0.2% eye drops instill 1 drop in the right eye, -dorzol/timol 2-0.5% eye drops instill 1 drop in the right eye, -prednisolone 1% eye drops instill 2 drops into the right eye. -Nepro nutritional supplement -treatment to the right abdominal fold- cleanse wound and apply triad paste and cover with a dressing -treatment to the right and left buttock-cleanse area and apply triad paste to wound beds. Record review of Resident 5's MAR for April 2026 did not have the order to limit fluids to 1500 ml a day. Record review of Resident 5's Progress Notes (PN) from 04-03-2026 revealed no record of fluid monitoring and no documentation that Resident 5 had a fluid restriction of 1500 ml per day. An interview conducted on 04-09-2026 at 8:30 AM with Resident 5 revealed Resident 5 did not know about the 1500 ml fluid limit per day. An interview conducted with the Assistant Director of Nursing (ADON) on 04-09-2026 at 1:05 PM confirmed Resident 5's medications and treatments should be scheduled around dialysis treatments and not be omitted and confirmed the 1500 ml fluid limit per day was not implemented and should have been.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5). Based on interview and record review the facility failed to update the resident's representative of changes in condition for 1(Resident 3) of 3 residents sampled. The facility census was 117. The findings are:A.Record review of the facility policy titled Notification of Changes Policy dated 01-2024 revealed it is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and reported to the attending physician or delegate. The resident and/or resident representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. The objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician and immediate notification to the resident and/or resident representative when there is a change in the resident's condition, or an accident that may require physician intervention. Requirements for notification of resident, the resident representative, and their physician:-an accident involving the resident, which results in injuiry and has the potential for requiring physician intervention.-a significant change in the resident's physical, mental or psychosocial status in either life-threatening conditions or clinical complications.-a need to alter treatment significantly such as a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. Notification is provided to residents and/or resident representatives to promote the resident's right to make choices about care and treatment and to keep them informed of the resident's current health status. B.Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had diagnosis of Diabetes Mellitus type 2. -Brief Interview of Mental Status (BIMS) was scored as a 6. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment.- required substantial assistance with upper body dressing, and bed mobility.-required total assistance with toileting, bathing, lower body dressing and transfers.Record review of Resident 3's Progress Notes (PN) dated 12-13-2025 revealed Resident 3 had fallen at 6:15 AM and 7:20 AM and had been sent to the hospital for evaluation. The progress note did not indicate Resident 3's representative had been notified of the falls or being sent to the hospital. Record review of Resident 3's Dietary Progress Notes (DPN) dated 03-11-2026 revealed Resident 3 had lost 68 lbs which was a 28% weight loss in 30 days which was a significant weight loss. The progress notes did not indicate Resident 3's representative had been notified of the significant weight loss. An interview conducted with the Assistant Director of Nursing (ADON) on 04-08-2026 at 10:30 AM confirmed Resident 3's representative had not been notified of the 2 falls on 12-13-2025 with transfer to the hospital or the significant weight loss identified on 03-11-2026 and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to evaluate, monitor and implement interventions for pressure ulcer prevention and to promote wound healing for 2 (Resident 2 and 3) of 2 residents sampled. The facility census was 115. Findings are:A.Record review of the facility's policy titled Skin and Wound Management dated 01-2024 revealed 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, document and report the following:-a full assessment of the pressure ulcer including location, length, width and depth, presence of exudate or necrotic (dead) tissue. Under the section Treatment and Management the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. Under the section Monitoring the staff are to evaluate, report and document potential changes in the skin and review the interventions and strategies for effectiveness on an ongoing basis. B. Record review of the Matrix ALAL Mattress System quick reference guide revealed instructions to calibrate the mattress to the patient's body weight using 35-pound (lb) increments. C.Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 01-04-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored as 13. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -Required extensive assistance with toileting, bathing, dressing, hygiene, bed mobility, and transfers,-was at risk of developing a pressure ulcer,-had 2 venous ulcers. Record review of Resident 2's Electronic Health Record (EHR) under the section census revealed Resident 2 was at the hospital from [DATE] to 03-04-2026. Record review of Resident 2's Hospital Wound Ostomy Nurse Consult (HWNC) dated 02-26-2026 revealed the following:-an unstageable pressure ulcer to the right lateral ankle measuring 2.0 centimeters (cm) in length and 2.5 cm in width that was black and brown in color.-an unstageable pressure ulcer to the right lateral foot measuring 3.5 cm in length and 6.0 cm in width, that was black and brown in color.-an unstageable pressure ulcer to the right 5th toe measuring 3.0 cm in length and 2.5 cm in width, that was black and brown in color.-a pressure ulcer to the right heel that was 5.0 cm in length and 7.0 cm in width that was red in color and non-blanchable (a skin condition where red, purple, or brown spots do not fade or turn white when pressed) and was questionable if the wound was a stage 1 pressure ulcer (According to the MDS Manual a stage 1 is an early, reversible sign of skin damage over a bony prominence, characterized by intact skin with non-blanchable redness) or a deep tissue injury (DTI: a serious, often rapidly evolving wound caused by intense/prolonged pressure or shear). Record review of Resident 2's Transition Orders and Information for the Continuation of Patient Care (TOIPC) dated 03-04-2026 revealed Resident 2 had two open wounds on both the right and left buttocks, an incision to the left below the knee amputation (BKA) site, an unstageable pressure ulcers to the right lateral ankle, the right lateral foot, the right lateral 5th toe, and the right heel. Record review of Resident 2's readmission assessment dated [DATE] under the section skin conditions revealed Resident 2 had unmeasured pressure ulcers to the right outer ankle, right lateral foot and the right 5th toe. Record review of Resident 2's Order Summary (OS) printed on 03-16-2026 revealed the absence of orders for the treatment of the unstageable pressure ulcers on the right lateral ankle, the right heel, the right lateral foot, the right lateral 5th toe. Record review of Resident 2's Treatment Administration Record for March of 2026 revealed no evidence of a treatment for Resident 2's unstageable pressure ulcers. Record review of Resident 2's Skin/Wound Weekly Observation (SWWO) dated 03-11-2026 revealed Resident 2 had Maceration Associated Skin Damage (MASD) to the right and left buttocks and a diabetic wound to the left outer ankle and no mention of the left BKA site or wounds to the right foot and ankle. An observation conducted on 03-17-2026 at 2:30 PM with the Wound and Infection Nurse (WIN) and Assistant Director of Nursing (ADON) B assessing Resident 2's wounds to the right foot and ankle revealed the following pressure ulcers:-A denuded area to the top of the right foot measuring 4 cm in length and 5 cm in width.-Right lateral ankle black area measuring 2 cm in length and 2 cm in width.-Right heel a black area measuring 5 cm in length and 7 cm in width.-Black skin in between all 5 toes.-Right lateral 5th black area measuring 2 cm in length and 2 cm in width.-Right anterior ankle black area measuring 2 cm in length and 2 cm in width. An interview with the WIN on 03-18-2026 at 2:20 PM confirmed the pressure ulcers to the right foot had not been treated from 03-04-2026 to 03-17-2026 for a total of 13 days. D.Record review of Resident 3's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE]-had a diagnosis of mononeuropathies of the bilateral lower limbs (damage affecting single nerves in both leg simultaneously causing weakness, numbness and pain).-BIMS was scored at 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -Required limited assistance with bed mobility and upper body dressing,-required total assistance with toileting, bathing, lower body dressing, and transfers,-was at risk of developing a pressure ulcer,-had no pressure ulcers,-weight was 145 lbs. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 01-19-2026 revealed Resident 3 had an actual impairment of skin integrity related to fragile skin, impaired mobility, incontinence and malnutrition. The goal was Resident 3 would maintain intact skin. The interventions listed were:-avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short.-Educate resident, family and caregivers of causative factors and measures to prevent skin injury,-keep skin clean and dry. Use lotion on dry skin,-pressure reducing cushion to wheelchair,-pressure reducing mattress in place,-use caution during transfers and bed mobility to prevent injury. Record review of Resident 3's SWWO dated 01-30-2026 revealed Resident 3 had a DTI to the right heel measuring 3.9 cm in length and 4.2 cm in width and a DTI to the left heel measuring 4.4 cm in length by 3.9 cm in width. A new intervention that was listed was a new treatment order for skin prep to both heels. Record review of Resident 3's CCP dated 01-19-2026 revealed no new interventions on or after 01-30-2026 for Resident 3's pressure ulcers to the bilateral heels. Record review of Resident 3's Treatment Administration Record (TAR) for January 2026 revealed no new treatment initiated for the pressure ulcers to the bilateral heels. Record review of Resident 3's TAR for February 2026 revealed the following order dated 02-02-2026 for Resident 3's pressure ulcers to the bilateral heels:-wash with facility cleanser and pat dry,-paint entire heel with skin prep and allow to dry,-may leave open to air,-protect heels at all times with Prevalon boots (a specialized medical device designed to prevent heel pressure ulcers by floating the heel, providing total offloading and maintaining a neutral 90-degree foot position), offloading or floating. Record review of Resident 3's SWWO dated 03-12-2026 revealed Resident 3 had a new unstageable pressure ulcer to the right bottom foot measuring 1.8 cm in length and 2.1 cm in width that was 100% covered with eschar (dead skin). Record review of Resident 3's CCP printed on 03-16-2026 revealed no new interventions on or after 03-12-2026 for the pressure area to the bottom of the right foot. Record review of Resident 3's OS printed on 03-16-2026 revealed the absence of an order for treatment of the right bottom foot. Record review of Resident 3's TAR for March 2026 revealed the absence of treatment for the right bottom foot. Observation on 03-16-2026 at 11:00 AM revealed Resident 3 was lying in bed on an air mattress set at 8 which equals 315 lbs. and wearing green heel protectors (a heel boot that pads the heel and ankle and does not float the heel). Observation on 03-17-2026 at 6:00 AM revealed Resident 3 was lying on the back in bed on an air mattress set at 8 with green heel protectors on bilateral feet. Observation on 03-17-2026 at 8:05 AM revealed Resident 3 was in bed with the Head of Bed (HOB) elevated on an air mattress set at 8 and green heel protectors to bilateral feet. Observation on 03-17-2026 at 9:30 AM with Licensed Practical Nurse (LPN) C providing wound care revealed Resident 3 had the following pressure ulcers:-left heel measuring 4 cm in length and 5.5 cm in width that was black in color.-right heel measuring 7 cm in length and 7 cm in width that was black in color.-right medial bottom foot measuring 3 cm in length and 3 cm in width that was black in color.-right lateral foot was a non-blanchable dark pink/purple area measuring 3 cm in length and 2 cm in width. An interview conducted with LPN C on 03-17-2026 at 10:00 AM confirmed the green heel protectors did not provide protection for the entire foot and the heel protector to the left foot had moved up the foot and was not relieving pressure to the wound to the left heel. An interview conducted with the WIN on 03-17-2026 at 11:00 AM confirmed Resident 3 was to be wearing Prevalon boots to both feet, not the green heel protectors. An interview conducted with LPN C on 03-17-2026 at 11:30 AM confirmed a setting of 8 would be correct for a patient weighing 315 lbs and could cause more pressure for Resident 3 who weighed 145 lbs. An interview with ADON A on 03-18-2026 at 10:30 AM confirmed the air mattress had not been set up correctly for Resident 3. ADON A confirmed that the correct air mattress setting for Resident 3 should be a 3. ADON A further confirmed that Resident 3 was not receiving treatment to the right bottom foot as ordered. An interview with the WIN on 03-18-2026 at 2:20 PM confirmed the treatment order for Resident 3's right bottom foot was not transcribed onto the TAR to ensure the treatment was performed.

Licensure reference: 175 NAC 12-006.10(D) Based on record review and interview, the facility failed to ensure medications were provided in accordance with physician's orders for 2 [Resident 4 and 6] of 6 sampled residents. The facility had a total census of 92. Findings are:A.A review of Resident 6's admission Record revealed Resident 6 was admitted to the facility on [DATE] with a diagnosis of pneumonia and type 1 diabetes mellitus with diabetic polyneuropathy [a complication of diabetes that involved nerve damage in the arms, hands, legs, and feet]. A review of Resident 6's 7/2025 MAR [Medication Administration Record] revealed Resident 6 was not administered the following medications on 7/18/25:-Cefdinir [an antibiotic] 300 mg, 1 capsule every 12 hours scheduled for 8 PM.-Lantus insulin [long acting] 25 units subcutaneously at bedtime scheduled for 6 PM. A review of Resident 6's Progress Note dated 7/19/25 at 1:11 AM revealed Resident blood sugar was 349 when checked with glucometer. According to Resident 6's Progress Note, the on-call provider was notified with no new orders. A review of Resident 6's Progress Note dated 7/19/25 at 12:58 PM revealed insulin orders were received for sliding scale insulin. The 7/19/25, 12:58 PM note stated that Resident 6 was administered 4 units of insulin before lunch for blood sugar of 346. A review of Resident 6's Progress Note dated 7/19/24 at 4:15 PM revealed Resident 6's family member reported Resident 6 had a blood sugar of 400 on Dexcom and wanted Resident 6 to go to the hospital. A review of American Diabetes Association on 7/31/25 website revealed the following target blood sugar:-Before a meal: 80-130-1-2 hours after beginning of the meal: less than 180 mg/dl A review of Resident 6's Progress Note dated 7/20/25 revealed Resident 6 was admitted to the hospital with a diagnosis of diabetic ketoacidosis [a life-threatening complication of diabetes that develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy]. In interviews on 7/28/25 at 12:11 PM, 4:15 PM, and 4:29 PM, the DON [Director of Nursing] confirmed Resident 6 did not get medications ordered for evening of 7/18/25. The DON confirmed that Lantus insulin was available in the emergency medication kit and Resident 6's orders were entered between 5-6 PM therefore not providing the insulin would be a significant medication error. Further, the DON reported Resident 6's Cefdinir had been delivered to the facility at 7:52 PM on 7/18/25 and not administering it to Resident 6 would be considered a significant medication error. - A review of Resident 4's admission Record revealed Resident 4 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus and dependence on renal dialysis. A review of Resident 4's 7/2025 MAR revealed orders for sliding scale insulin 3 times per day at scheduled times of 8 AM, 12 PM, and 5 PM per the following sliding scale: 150-200=1 unit; 251-300=3 units; 301-350=4 units; 351-400=5 units; 401-450=6; greater than 450=7 units and call provider. A review Resident 4's 7/2025 between 7/1/25 and 7/28/25 revealed Resident 4's sliding scale insulin not provided at 5 PM on the following days:-Wednesday 7/2/25 noted to be out of facility,-Monday 7/7/25 noted to be out of the facility,-Wednesday 7/9/25 noted to out of facility,-Friday 7/11/25 blank,-Wednesday 7/16/25 out of facility,-Friday 7/18/25 blank,-Monday 7/21/24 out of the facility,-Wednesday 7/23/25 blank,-Saturday 7/26/25 blank. In interviews on 7/28/25 at 12:23 PM, 2:50 PM, and 4:08 PM, the DON reported Resident 4 goes to dialysis around 1 PM and comes back around dinner time. The DON reported an expectation that Resident 4's blood sugar be checked and sliding scale insulin provided after Resident 4 returned from dialysis. The DON confirmed not administering Resident 4's sliding scale insulin would be considered a significant medication error.

Liscensure Reference Number 175 NAC 12-006.09 Based on record review and interviews; the facility failed to conduct neurological assessments after unwitnessed falls and falls with head injuries for 3 (Residents 1,2, and 4) of 4 sampled residents. The facility census was 101. Findings are: A. Record review of Resident 2's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 10-13-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as an 8. According to the MDS Manual a score of 8 to 12 indicate a person has severe cognitive impairment. -Required total assistance with dressing, toileting, bathing, transfers and bed mobility. Record review of Resident 2's progress notes revealed on 10-23-24 Resident 2 fell out of bed when the nursing assistant rolled [gender] to the left side. Furthermore, Resident 2 had sustained a hematoma (a solid swelling of clotted blood within the tissues) to the right side of the forehead and neurological assessments had been initiated. Record review of the Resident 2's Electronic Health Record (EHR), including assessments revealed the absence of a neurological assessment record. An interview conducted with Licensed Practical Nurse (LPN) A on 11-14-2024 at 11:30 AM revealed LPN A worked on 10-24-2024 with Resident 2 and did not perform neurological assessments. An interview conducted on 11-14-2024 at 2:00 PM with Nursing Assistant (NA) D revealed NA D had worked with Resident 2 on 10-25-2024 and had noticed that Resident 2 was not acting right. Furthermore, NA D revealed Resident 2 had a red and white bump to the forehead and when NA D moved the Resident 2's legs, Resident 2 winced. Record review of Resident 2's progress notes revealed on 10-25-2024 Resident 2 was exhibiting confusion and was unable to follow directions and was sent to the hospital. An interview conducted on 11-14-24 at 2:15 PM with the Interim Director of Nursing (IDON) confirmed that neurological assessments were not performed for Resident 2. B. Record review of Resident 1's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 14. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required extensive assistance with toileting, dressing, and transfers. -required total assistance with bathing. Record review of a list provided by the facility of incidents by incident type dated 11-14-2024 revealed Resident 1 had an unwitnessed fall on 09-08-2024, 09-29-2024, 10-15-2024, 10-19-2024, 10-29-2024. Record review of Resident 1's EHR revealed incomplete neurological assessments for the unwitnessed fall on 09-08-2024, and no neurological assessments for the unwitnessed falls on 09-29-2024, 10-15-2024, 10-19-2024 and 10-29-2024. An interview with the Assistant Director of Nursing (ADON) B conducted on 11-14-2024 at 2:55 PM revealed the facility could not locate any neurological assessments in the EHR or on paper for Resident 1. C. Record review of Resident 4's Care Plan printed on 11-14-2024 revealed the following about the resident: -had diagnosis of Dementia, Diabetes and a left Below the Knee Amputation (BKA). -required extensive assistance with dressing. -required total assistance with bed mobility, transfers, and bathing. Record review of the facility list of incidents by incident type dated 11-14-2024 revealed Resident 4 had an unwitnessed fall on 10-16-2024 and 10-29-2024. Record review of Resident 4's EHR revealed an incomplete neurological assessment for the fall on 10-16-2024 and no neurological assessments for the fall on 10-29-2024. An interview with the Assistant Director of Nursing (ADON) B conducted on 11-14-2024 at 2:55 PM revealed the facility could not locate any neurological assessments in the EHR or on paper for Resident 4. Record review of the facility policy Accidents/Neuro Checks dated 01-2024 revealed the following -Policy: the purpose of this procedure is to provide guidelines for a neurological assessment. -Neurological assessments are indicated: -upon physician order; -following an unwitnessed fall; -following a fall or other accident/injury involving head trauma; or -when indicated by resident's condition. An interview with the Interim Director of Nursing (IDON) on 11-14-2024 at 3:00 PM confirmed that neurological assessments for Resident 1, 2 and 4 were not done or not completed and should have been performed after an unwitnessed fall or a fall with head injury.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record review and interview; the facility staff failed to implement interventions to prevent elopement and failed to implement action plans to identify the location of 1 (Resident 14) of 3 sampled residents. The facility staff identified a census of 94. Findings are: Record review of an undated Policy titled Signing Resident Out revealed the following information: -Policy: -Residents leaving the facility premises will be encouraged to sign out/or inform nursing staff of their plan to leave the facility. -Specific Procedures/Guidance: -Residents and/or the residents representatives will be educated on the facility process for signing-out when the resident leaves the facility premises. -1 a. A resident leaving the premises will be signed out or will notify nursing representative of their plan to leave the premise. -2. A sign out log location will be designed by the facility and accessible to residents. -3. The sign out log will indicate the date and time the resident is leaving the facility premise, general indication of intended location and the residents expected date and time of return. Record review of the facility Elopement/Exit Seeking Policy revised on 9-02-2019 revealed the following information: - Elopement is defined as a resident leaving the physical structure of the facility without the knowledge of facility staff. -10. If an employee discovers that a resident is missing from the facility,he/she shall: -a. Determine if the resident is out on an authorized leave pass. -b. If the resident was not authorized to leave, initiate a search of the building, grounds and surrounding areas. -c. If the resident is not located, notify the Administrator, Director of Nursing, the residents representative, attending physician, law enforcement officials and government agency as indicated. -e. Initiate an extensive search of the surrounding area. Review of the facility Policy for Resident Elopement Follow-up Procedure revised on 9-02-2019 revealed the following: -Policy: -It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Record review of a Admission Record sheet printed on 9-19-2023 revealed Resident 14 admitted to the facility on [DATE] with the diagnoses that included Cellulitis (skin infection) of the left lower limb, Diabetes, Heart Failure, Hypertension and severe Sepsis (the body's extreme response to an infection). Record review of a Functional Abilities sheet dated 9-15-2023 revealed the facility staff assessed the following about Resident 14: -Uses a manual wheelchair. -Dependent for toileting, upper and lower body dressing, and standing and transferring. Record review of Resident 14's Progress Note (PN) dated 9-16-2023 with a time data entry of 1:32 PM revealed at 8:45 AM Resident 14 was observed at the facility elevator with a family member. According to Resident 14's PN dated 9-16-2023 with a data entry time of 1:32 PM revealed the facility nurse asked if Resident 14 was going out to smoke with Resident 14 responding with a wave. Record review of Resident 14's PN dated 9-16-2023 with a data time entry of 3:45 PM revealed Resident 14 had left the unit with a male visitor before 9:00 AM. Resident 14's PN dated 9-16-2023 with a date entry time of 3:45 PM revealed Resident 14's personal belonging were gone and the facility wheelchair Resident 14 was utilzing was in the lobby. The facility staff made calls to Resident 14's contact numbers without any response. Record review of a sign out sheet revealed the sign out sheet had multiple dates of facility residents leaving and returning to the facility. Further review of the sign out sheet revealed Resident 14 was not on the sign out sheet on. On 9-20-2023 at 1:21 PM an interview was conducted with Licensed Practical Nurse (LPN) A. During the interview LPN A reported Resident was at the facility elevator on 9/16/2023 LPN A reported asking Resident 14 if Resident 14 was going out to smoke. LPN A reported Resident 14 waved and did not say anything. LPN A reported after not seeing Resident 14 return after about 30 minutes LPN A looked in the smoking area and did not see Resident 14. LPN A reported looking for the sign out sheet and was not able to locate it. LPN A reported law enforcement or a facility search was not completed. LPN A reported the facility DON was notified of Resident 14 missing and was waiting for instructions. On 9-20-2023 at 1:30 PM an interview was conducted with the Interim Director of Nursing (IDON). During the interview the IDON reported being notified Resident 14 was missing on 9/16/2023. According to the IDON, Resident 14's room was searched and Resident 14's personal items were missing and felt Resident 14 had left the facility Against Medical Advice (AMA). When asked if Resident had spoken about going AMA, the IDON stated no. The IDON confirmed the facility staff did not know where Resident 14 had gone to or where Resident 14 currently is located. The IDON further confirmed law enforcement or an extended search for Resident 14 was not implemented. On 9-20-23 at 10:40 AM a follow up interview was conducted with the IDON. During the interview the IDON reported Resident 14 had not been educated on the Signing Residents Out process and should have been. The IDON reported initially the Signing Residents out had been on admission paper work, however, this information had been deleted and Resident 14 would not have had the information. On 9-19-2023 at 5:24 PM an action plan to remove the Immediate Jeopardy situation was provided as follows: -The facility administrator called local law enforcement about Resident 14. -All residents will be assessed to identify impaired cognitive status by Social Services by 9-19-2023 at 8:00 PM. -All residents who are identified to have impaired cognitive status will have an elopement risk assessment completed by nursing on 9-19-2023 by 10:00 PM. -Wander Guard placement was initiated for residents deemed at risk for elopement/wandering completed by nursing on 9-19-2023 at 10:00 PM. -Wander guard placement and function checks in Point Click Care (PCC) orders were completed for current residents with wander guard in place and identified at risk for elopement by nursing on 9-19-2023 by 10:00 PM. -Care plans of residents identified to be at risk for elopement were reviewed and updated by nursing on 9-19-2023 by 10:00 PM. -The elopement books were reviewed and updated to reflect residents risk for elopement/wandering by Social services on 9-19-2023 by 11:00 PM. -Education will be completed with staff on Signing Resident out and Elopement Policy by DON (Director of Nursing) or designee. Initiated by DON on 9-19-2023 at 5:30 PM. -Education reconciliation completed to ensure staff have received education prior to working by DON/designee stated on 9-19-2023 at 5:30 PM. -The facility will keep Resident sign out book at reception desk, reviewed every 2 hours until process is established. -The facility Administrator will initiate an audit of signing out resident log daily until a process is established. -QAPI (Quality Assessment Process Improvement) meeting regarding elopement completed 9-19-2023 at 3:45 PM with the facility Administrator, DON, Social services Director, Regional consultant, Unit Managers, Activity Director , Therapy Director, Admissions Director and Chief Operating Officer.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on interview and record review; the facility failed to implement measures to prevent a facility acquired pressure ulcer; (a localized injury to the skin and underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction that happens to cause tissue breakdown); for Resident 1 and 6. The facility census was 89. Findings are: A. An Admission Record dated 06/16/2022 was present for Resident #1, with the following diagnoses: unspecified asthma, Type 2 diabetes mellitus with diabetic neuropathy, anemia, proliferate diabetic retinopathy without macular edema, left eye, dissociative identity disorder, Type 2 diabetes mellitus with other diabetic ophthalmic complication, glaucoma, bipolar ll disorder, polyneuropathy, hyperlipidemia , spinal stenosis, obstructive sleep apnea, essential hypertension, schizoaffective disorder, bipolar type, muscle weakness, difficulty in walking, weakness, other reduced mobility. trigger finger, left ring finger, transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of Resident 1's Admission MDS (Minimum Data Set A comprehensive assessment tool used to develop a resident's care plan) dated June 23, 2022 and this resident, was at risk to develop pressure ulcers; but did not currently have any ulcers; and the resident required extensive assistance from 2 staff persons for bed mobility and transfers. Resident could not ambulate. Review of Resident 1's Quarterly MDS dated [DATE]; revealed that resident had an unhealed unstageable (unable to determine the depth of the ulcer due to inability to visualize the wound bed due to the presence of non-viable tissue) pressure ulcer that had not been present upon admission to the facility indicating the pressure ulcers were facility acquired. Both heels were to be off the bed, if the resident did not have prevalon boots on. Record review of a resident focused pressure ulcer root cause analysis form revealed on 8/4/22 resident was noted to have a right and left heel pressure unstageable ulcer; just mushy and unstageable at that time. Record review starting on 9/8/22 revealed TA (tissue analytics) started following skin issue. Both extremities have scabs and redness. Revealed that the resident was not always compliant to prevention worsing of the heel areas. TA revealed on 9/15/22 the left heel was better; the right heel was still unstageable and considered a deep tissue injury on the heels. The right heel had unattached edges, had eschar, serosanquinous, but macerated and foul odor was noted. Was seen by provider. Wound care was skin prep, santyl apply thick nickel layer to wound bed, hydrofera blue. ABD pad, and roll, ace wrap. At all times have resident offloading and pressure relief to bilateral heels. On 9/22/22 the left heel was almost heeled. The right heel was 1 cm in length bigger, 6.83 cm width; continues to be unstageable and have unattached edges, eschar, small serosanquinous and macerated with foul odor. The treatment was discontinued and new treatment was initiated. On 9/29/22 the length was smaller to 5.14; width was 6.17; about the same. Continued with unattached eschar, serosanquinous foul macerated right heel ulcer and treatment of skin prep, ABD pad with ace wrap and prevalon boots, elevate heels, Turn every 2 hours. On 10/13/2022 at 800 AM, record review revealed; the provider was at facility and the resident was transferred to the hospital with right heel pressure ulcer, foul odor, maceration, and Covid-19. Interview on 10/26/22 at 215 PM; with the Director of Nurses revealed, that as the DON did not realize that the staff was not getting the treatment completed; and that it looked macerated, and had foul odor. Interview on 10/27/22 at 1:15 PM with APRN-F, revealed that treatments that are ordered are not getting completed , and the areas are open are not healing, when the APRN-F enters the facility the staff does not complete the treatments that had been ordered; and does not keep APRN F apprised of the condition of the pressure ulcers. 21492 B. Record review of a Wound Evaluation (WE) sheet dated 10-2022 revealed Advanced Practice Register Nurse (APRN) H had assessed Resident 6 with a left Deep Tissue Injury (DTPI) persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). Further review of Resident 6's WE dated 10-20-2022 revealed APRN H ordered a treatment to the left heel as follows: -Wound cleanser of facility choice and pat dry the left heel wound. -Apply skin prep to the left heel and surround skin and allowed to dry. -Prevalon Boots( foot wear that reduces pressure to heels of resident) on at all time. -Air Mattress to Resident 6's bed. Record review of Resident weight dated 10-11-2022 revealed a weight of 231.0 pounds. Observation on 10-26-2022 at 8:40 AM revealed Resident 6 was in bed and did not have the prevalon boots on and the air mattress setting was set for a resident who weighs 350 pounds. According to the setting on the air mattress gave a range of where the air mattress setting should be. Further observations revealed the prevalon boots had been placed on a chair in Resident 6's room. Observation on 10-26-2022 at 9:45 AM revealed Resident 6 was in bed and did not have the prevalon boots on and the air mattress setting was for 350 pounds. On 10-26-2022 at 8:40 AM an interview was conducted with Resident 6. During the interview Resident 6 reported staff had taken the boots off and did not re-apply them. Resident 6 reported being agreeable to wearing the prevalon boots. Observation on 10-26-2022 at the wound treatment to the left heel revealed Resident 6's air mattress setting was set at 350 pounds. On 10-26-2022 at 11:35 PM an interview was conducted with Assistant Director of Nursing (ADON) C. During the interview ADON C confirmed Resident 6 did not have on the prevalon boots until just prior to the observations of the treatment and further confirmed the setting on Resident 6's air mattress was to high and needed to be adjusted to fit Resident 6's weight.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(5) Based on record review and interview; the facility staff failed to evaluate bowel function and implement interventions to prevent a fecal impaction ( hard stool in the large intestine) for 1 (Resident 4) of 1 sampled resident. The facility staff identified a census of 83. Findings are: A. Record review of the the facility undated Routine Bowel Protocol revealed the following information: -Description: -The purpose of a routine Bowel protocol is to facilitate early identification of constipation as indicated by individual resident bowel patterns and documented on the bowel record to reduce episodes of constipation. -Routine Bowel Protocol Interventions: -1. Complete a through bowel assessment. -Review the residents documentation to determine when the most recent bowel movement was recorded. -Complete a bowel assessment noting any abdominal distension, abdominal tenderness, or presence and/or absence of bowel sounds. -2. Consult the physician to implement the following bowel protocol: -Day 3, give Milk of Magnesia. -Day 4, give a suppository. -Day 5, give a fleets enema. -3. Avoid re-occurrence through follow up on strategies with the Physician and/or the Dietitian. B. Record review of Resident 4's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 11-12-2021 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored was a 15. According to the MDS Manuel a score of 13 to 15 indicates a person is cognitively intact. - Required extensive assistance with dressing and eating. -Required total assistance with bed mobility, transfers, toilet use and personal hygiene. -Was frequently incontinent of bowel. -Currently had a pressure ulcer. Record review of Resident 4's bowel record revealed Resident 4 had a medium Bowel Movement (BM) on 11-12-2021. Further review of Resident 4's BM record revealed Resident 4 did not have a BM until 11-19-2021 of a small amount in a 7 day span. According to Resident 4's bowel record, on 11-21-2021 Resident 4 had a small BM. Review of Resident 4's medical record that included Progress Notes (PN), Treatment Administration (TAR) records and Medication Administration Records (MAR) revealed there was no indicators that identified the facility staff had evaluated Resident 4 and implemented interventions to prevent a potential fecal impaction. Record review of Resident 4's PN dated 11-22-2021 revealed a digital check of Resident 4's rectum revealed a large impaction of hard stool. Record review of Resident 4's BM record from 12-27-2021 through 1-01-2022 revealed Resident did not have a BM for 7 days. Review of Resident 4's medical record that included PN ,TAR and MAR from 12-27-2021 though 1-01-2022 revealed there was no evidence the facility staff had evaluated Resident 4 and implemented interventions to prevent a potential fecal impaction. Record review of Resident 4's BM record from 1-08-2022 through 1-13-2022 revealed Resident 4 did not have a BM for a 6 day span of time. Review of Resident 4's medical record that include PN ,TAR and MAR from 1-08-2022 though 1-013-2022 revealed there was no evidence the facility staff had evaluated Resident 4 and implemented interventions to prevent a potential fecal impaction. Review of Resident 4's BM record from 1-18-2022 through 1-21-2022 reveal Resident revealed Resident 4 had a small BM on 1-21-2022. Review of Resident 4's PN dated 1-22-2022 revealed Resident 4 had nausea and vomiting with chills and requested to be sent to the hospital. Record review of a Hospital note dated 1-23-2022 with a time of 6:09 AM revealed the reason for the visit was Resident 4 could not stop throwing up. According to the Hospital note dated 1-23-2022 with a time of 6:09 AM, Resident 4 had multiple emesis (vomiting) throughout the entire exam and the color and consistency of the emesis was concerning for stool verses a bleed. Further review of Resident 4's Hospital note dated 1-23-2022 and timed at 6:09 AM revealed under the section identified an Assessment and Plan, the nausea and vomiting had an unknown origin with the concerns of a bowel obstruction as emesis output resembled stool. Record review of Resident 4's hospital note dated 1-23-2022 with a time of 11:31 AM revealed Resident 4 had a fecal impaction on admission to the hospital with heavy stool burden that was identified on a CAT Scan. On 2-28-2022 at 11:55 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported the expectation was the facility Bowel protocol was followed. The DON confirmed an evaluation of Resident 4's bowel function should have been completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observations, record reviews and interviews; the facility staff failed to identify pressure ulcers, obtain treatments and evaluate causal factors for the development of pressure ulcers for 3 (Resident 4, 14 and 13) of 3 sampled residents. The facility staff identified a census of 83. Findings are: A. Record review of Resident 4's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 11-12-2021 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manuel a score of 13 to 15 indicate a person is cognitively intact. - Required extensive assistance with dressing and eating. -Required total assistance with bed mobility, transfers, toilet use and personal hygiene. -Was frequently incontinent of bowel. -Currently had a pressure ulcer. Record review of Resident 4's Skin sheet (SWA) dated 10-06-2021 revealed there were no skin issues identified. Record review of Resident 4's SWA dated 10-13-2021 revealed Resident 4 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 4's SWA sheet did not identify the size or staging of the pressure ulcers. Further review of Resident 4's WSA sheet dated 10-13-2021 under the section titled Notes revealed Resident 4 had two areas on the coccyx (tail bone area) that opened. Record review of a Resident Focused Pressure Ulcer Root Cause Analysis Form (RFPURCAF) dated 10-13-2021 revealed Resident 4 had a healed coccyx pressure ulcer on 5-21-21. Further review of the RFPURCAF dated 10-13-2021 revealed Resident 4 had a new pressure ulcer to the sacrum area that measured 2.5 centimeters (cm) by 5.2 cm with slough (dead tissue) and was un-stageable (Un-stageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). Record review of an In-House Physician Visit (IHPV) sheet dated 10-15-2021 revealed a treatment was obtained for the buttocks wounds. Record review of a Tissue Analytics (TA, skin specialist) sheet dated 10-13-2021 for Resident 4 revealed the location of the wound was to the buttocks, was un-stageable and new. Further review of the TA sheet dated 10-13-2021 revealed the skin specialist was unable to assess the pressure ulcer wound bed. Review of Resident 4's medical record that included Progress Notes, Practitioner Orders and Comprehensive Care Plan revealed there was not any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 4's TA assessment dated [DATE] revealed Resident 4 had an un-stageable pressure ulcer to the sacrum that measured 2.87 cm by 5.56 cm with a depth of 0.10 cm with 40% slough and ordered a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Observation on 2-28-2022 at 9:30 AM with Licensed Practical Nurse (LPN) B and Registered Nurse (RN) C of Resident 4's treatment to the sacrum revealed the opening of the pressure ulcer was approximately 2.0 cm roundish with whitish wound base. LPN B after cleansing the wound, packed the wound with saturated gauze of a disinfectant solution. Further observations revealed LPN B was able to insert the gauze using a Q tip type of applicator to approximately 1.50 cm. On 2-24-2022 at 2:38 PM an interview was conducted with the facility Administrator. During the interview the facility Administrator provided copies of Resident 4's skin assessments dated 10-13-2022. The facility Administrator confirmed Resident 4's pressure ulcer skin assessment was not completed. On 2-28-2022 at 11:55 AM an interview was conducted with the Director of Nursing (DON). During the interview review of Resident 4's SWA dated 10-13-2021, the RFPURCAF sheet dated 10-13-2021, TA sheet dated 10-13-2021 and the IHPV sheets were reviewed. The DON confirmed the sacrum wound was being identified as multiple different areas and did not have treatments in place. The DON further confirmed the RFPURCAF was not thorough to identify why resident 4 developed the pressure ulcer. B. Record review of Resident 14's Admission assessment dated [DATE] revealed Resident 14 had a pressure ulcer to the sacrum. Further review of Resident 14's Admission assessment dated [DATE] revealed there was not an indication Resident 14 had a pressure ulcer to the heels. Observation on 2-28-2022 at 11:20 AM of wound care with LPN E and RN D revealed the treatment was to Resident 14 buttocks area. LPN E cleansed Resident 14 buttocks and applied the treatment as ordered. Further observation with RN D revealed Resident 14 had an approximately 2.0 round dark area to the left heel. On 2-28-2022 at 11:20 AM an interview was conducted with RN D. During the interview RN D reported not being aware of the area and the area looked new. Record review of the facility Policy and Proceedures for the Prevention of Pressure Ulcers/Injuries dated 7-2017 revealed the following information: -Risk Assessment: -1. Assess the resident on admission (within eight hours) for existing pressure ulcers. -2.0Conduct a comprehensive skin assessment upon admission including, skin integrity including any evidence of existing or developing pressure ulcers. C. A review of Resident 13's admission nursing assessment dated [DATE] revealed a pressure sore to left heel 4 cm in length x 4 cm in width x undetermined dept. The pressure sore was classified as a suspected deep tissue injury. A review of Resident 13's wound evaluation dated 1/26/22 revealed Resident 13 had a 4.76 cm length x 4/41 cm width x .1 cm depth wound to left heel. Resident 13's left heel pressure ulcer was classified as unstageable. The following treatment orders were listed for Resident 13's left heel, cleanser of facility choice and apply skin prep to wound (do not use on open areas) daily and as needed for soiling. A review of Resident 13's 1/22 MAR/TAR [Medication Administration Record/Treatment Administration Record] did not reveal the order for skin prep to left heel daily and as needed for soiling. A review of Resident 13's 2/22 MAR/TAR revealed an order dated 2/3/22 to cleanse left heel and left knee areas with cleanser of choice, apply skin prep to wound daily and as needed. The order was first initialed as completed on 2/7/22. In an interview on 2/28/22 at 2:29 PM, the Director of Nursing confirmed the pressure sore on left heel was present at admission and confirmed there was no documentation that treatment was done to left heel before 2/7/22.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to monitor a change in condition for 1 (Resident 1) of 4 sampled residents. The facility staff identified a census of 74. Findings are: A. According to the Mayo Clinic at Mayoclinic.com symptoms of dehydration included the following, Dry mouth, dry skin, confusion, dry lips and strong urine. B. Record review of Resident 1's Comprehensive Care Plan (CCP) revealed Resident 1 required assistance with Activities of Daily living such as personal hygiene, dressing and mobility. Record review of a Nutritional Risk Assessment (NRA) dated 7-30-2020 revealed the facility Registered Dietician (RD) had assessed Resident 1's daily fluid needs as 1100 to 1650 milliliters of fluid per day. Record review of Resident 1's Progress Note (PN) dated 12-12-2020 at 8:23 PM revealed Resident 1's family member had called the facility wondering if an assessment had been completed as Resident 1 had not ben talkative as is Resident 1's normally is. According to the progress note dated 12-1-2020 Resident 1 had not been eating or drinking. Record review of Resident 1's PN dated 12-12-2020 at 8:25 PM revealed Resident 1's practitioner had ordered medication to treat Thrush ( a fungus type if infection) to the back of Resident 1's throat. Record review of a COMS PN dated 12-13-2020 revealed Resident 1 was identified as having decreased fluid intake, pain with swallowing, mucous membranes were dry with decreased saliva with skin dry to touch. According to the Narrative section of the COMS PN dated 12-12-2020 revealed Resident 1 had difficulty talking due to Resident 1's .mouth is dry and (gender) lips are dry and cracked. Record review of Resident 1's medical record that included progress notes, practitioners orders, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's PN dated 12-15-20 at 11:56 AM revealed Resident 1 was evaluated as being lethargic and not alert, continued to have difficulty swallowing and was being transported to the hospital. On 12-22-2020 at 10:07 AM an interview was conducted with the newly hired Director of Nursing (DON). During the interview review of Resident 1's PN dated 12-13-2020 to 12-15-2020 was reviewed as well as Resident 1 medical record. During the interview the DON confirmed there was not documentation of monitoring of Resident 1's change in health status. The DON reported Resident 1 should had been on alert charting for every shift to monitor Resident 1's condition and that also had not been completed.

Licensure Reference Number 175 NAC 12-006.09D2a Based on observation, record review and interview, revealed the facility failed to provide preventative skin care to prevent a recurrent pressure ulcer(localized damage of the skin and or underlying soft tissue usually over a boney prominence related to a medical or other device) for 1 resident (Resident 16) of 3 residents reviewed. The facility census was 74. Findings are: Observation on 12/22/2020 at 10:45 AM of the dressing change on Resident 16's right lateral (outside) ankle. During dressing change Resident 16 revealed Resident 16 had pain from the ankle wound. Interview on 12/22/2020 at 10:40 AM with RN-A revealed Resident 16 had a Stage 3 pressure area on the right lateral (outside) ankle. RN-A revealed area is recurrent and is thought to be caused by the prosthesis used for foot drop. Recently after the wound was healed the prosthesis was remade however the wound reoccurred. Review of Resident 16's progress note dated 9/24/2020 from Resident 16's primary physician revealed Resident 16 needed to have a custom AFO brace (a brace used for support) for Resident 16's right leg. Review of Resident 16's progress notes 11/10/2020 revealed Resident 16 complained of discomfort from the new shoe and brace. Review of Resident Progress note dated 11/10/2020 revealed Resident 16 had a new open area to the right lateral (outside) ankle related to the new prosthetic device (brace). Review of Resident 16's progress notes dated 11/11/2020 revealed the brace company added padding to the brace and the brace was placed back on Resident 16. Review of Resident 16's Wound Weekly observation tool dated 11/10/2020 revealed Resident 16 had an open area to the right lateral (outside) ankle measuring 1.2 cm (centimeter)in length, 1.4 cm in width, and 0.1 cm in depth. Review of Resident 16's skin weekly assessment dated [DATE] revealed documentation the wound assessment was not completed due to wound nurse treating area. Review of Resident 16's skin weekly assessment dated [DATE] revealed documentation Resident 13 had no skin issues. Review of Resident 16's Wound Weekly Observation Tool dated 12/16/2020 revealed a Pressure Ulcer stage 3 (Full thickness skin loss due to pressure on the area ) on the right lateral (outside) ankle measuring 3.0 cm in length, 2.1 cm in width, and 0.1 cm in depth. Review of Task documentation dated December 2020 for Resident 16 revealed the right ankle brace to be on in morning and off at bedtime and observe skin integrity to be completed by the NA. Review of treatment sheets dated for November and December 2020 revealed no documentation of nurse monitoring of Resident 16's right lower leg to prevent brace from causing open wound to re-occur. Review of the facility policy titled Pressure Ulcers/Injuries Overview dated July 2017 revealed the definition of Avoidable means that the resident developed a pressure ulcer and that the one or more of the following was not completed: - Monitoring or evaluation of the impact of the interventions, - Revision of interventions as appropriate - Implementation of interventions that are consistent with the resident's needs. Interview on 12/28/2020 at 9:40 AM with the Director of Nursing (DON) revealed monitoring by a nurse should have been completed when the new brace and shoe were initiated to prevent the brace from causing the pressure ulcer to reoccur.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 D9 Based on observation, record review and interview; the facility staff failed to implement interventions to prevent dehydration for 2 (Resident 1 and 15) of 4 residents and failed to obtain weights as ordered for 1 (Resident 1) of 4 sampled residents, The facility staff identified a census of 74. Findings are: A. Record review of the facility policy for Resident Hydration and Prevention of Dehydration dated 10-2017 revealed the following information: Policy: -This facility will strive to provide adequate hydration and to prevent and treat dehydration. -Policy Interpretation and Implementation. -#6. Nurse's Aids (NA) will provide and encourage intake of bedside, snacks and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. NA's will report intake of less than 1200 milliliter (ml) per day to the nursing staff. -#7. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. -#12. Nursing will monitor and document fluid intake and the dietician will be kept informed of the status. B. According to the Mayo Clinic at Mayoclinic.com symptoms of dehydration included the following, dry mouth, dry skin, confusion, dry lips and strong urine. C. Record review of Resident 1's Comprehensive Care Plan (CCP) revealed Resident 1 required assistance with Activities of Daily living such as personal hygiene, dressing and mobility. Record review of a Nutritional Risk assessment dated [DATE] revealed the facility Registered Dietician (RD) had assessed Resident 1's daily fluid needs as 1100 to 1650 milliliters of fluid per day. Record review of Resident 1's Progress Note (PN) dated 12-12-2020 at 8:23 PM revealed Resident 1's family member had called the facility wondering if an assessment had been completed as Resident 1 had not ben talkative as Resident 1's normally is. According to the progress note dated 12-1-2020 Resident 1 had not been eating or drinking. Record review of Resident 1's PN dated 12-12-2020 at 8:25 PM revealed Resident 1's practitioner had ordered medication to treat Thrush ( a fungus type if infection) to the back of Resident 1's throat. Record review of a COMS PN dated 12-13-2020 revealed Resident 1 was identified as having decreased fluid intake, pain with swallowing, Mucous Membranes are dry with decreased saliva with skin dry to touch. According to the Narrative section of the COMS PN dated 12-12-2020 Resident 1 had difficulty talking due to Resident 1's .mouth is dry and (gender) lips are dry and cracked. Review of Resident 1's medical record revealed no documentation the facility staff had implemented intervention to assist Resident 1 with additional hydration. Review of Resident 1's PN dated 12-15-20 at 11:56 AM revealed Resident 1 was evaluated as being lethargic and not alert, continued to have difficulty swallowing and was being transported to the hospital. On 12-22-2020 at 10:07 AM an interview was conducted with the newly hired Director of Nursing (DON). During the interview review of Resident 1's PN dated 12-13-2020 was reviewed as well as Resident 1 medical record. During the interview the DON confirmed there were not interventions implemented to assist Resident 1 with hydration and further confirmed Resident 1's fluid intake had not been monitored and should have been. D. Record review of Resident 15's active orders as of 12-21-20 revealed Resident 15's practitioner ordered Resident 15 to have nectar thick liquid consistency. Record review of Resident 15's Nutritional Risk Assessment (NRA) dated 7-30-2020 revealed the facility RD has assessed Resident 15's minimum fluid needs as 2150 ml per day. Further review of Resident 15's NRA dated 7-30-2020 revealed the facility RD directed Resident 15 be encourage to drink water through out the day. Observation on 12-21-2020 at 2:25 PM revealed Resident 15 was in bed and had a sign posted above Resident 15's that identified Resident 15 like to drink lots of water. Further observation at this time revealed a water pitcher with thickened water was on Resident 15's tray table. The tray table with the water pitcher was out of Resident 15's reach towards the foot of the bed. Observation on 12-21-2020 at 3:32 PM revealed Resident 15 was in bed awake. Resident 15's water pitcher was on a tray table out of of Resident 15's reach, positioned by the end of the bed. Observation on 12-21-2020 at 4:25 PM with the DON revealed Resident 15's water pitcher was not in reach of the resident. On 12-21-2020 at 4:25 PM during the observation with the DON, the DON confirmed Resident 15's water pitcher was not within reach and should have been. 12-22-2020 at 10:55 AM observation with the Assistant Director of Nursing(ADON) revealed Resident 15's water pitcher was not within reach for Resident 15. The ADON was observed to lower Resident 15's tray table with the pitcher of water and placed then within reach of Resident 15. E. Record review of Resident 1's Order Summary Report with active orders as of 12-21-2020 revealed Resident 1's practitioner had order a weekly weight. Record review of a Weights and Vitals summary sheet provided by the facility revealed the following information: -October 2020, 2 weights were obtained for the month and should have been 4. -November 2020, 2 weights were obtained for the month and should have been 4. -December 2020, the first 2 weeks, 1 weight was obtained and should have been 2. On 12-28-2020 at 12:35 PM an interview was conducted with the facility Administrator. During the interview the Administrator reported not being able to locate the weekly weights for Resident 1.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to evaluate and implement interventions to manage pain for 1(Resident 20) of 1. The facility staff identified a census of 59. Findings are: Record review of Resident 20's Care Plan (CP) with an admitted [DATE] revealed Resident 20 had chronic pain related to [CONDITION(S)] and [CONDITION(S)]. The goal identified for Resident 20 was to be free of complaints of pain daily. Interventions identified on Resident 20's CP included administer medications as ordered by the Medical Doctor's. Anticipate the residents need for pain relief and respond immediately to any complaints of pain. Observation on 3-10-2021 at 10:30 AM Revealed Registered Nurse (RN) D obtained the required supplies for wound care, donned PPE and entered Resident 20's room. RN D placed the supplies on the a tray table with a barrier. RN D waited for another staff member to assist with repositioning Resident 20. Nursing Assistant (NA) E entered Resident 20's room to assist with repositioning Resident 20. RN D instructed NA E to position Resident 20 onto the left laying position as the treatment was to Resident 20's bottom. NA E started to remove heel protector boots when Resident 20 yelled out OH and had facial grimacing. NA E stated I know that hurts, I'll be careful. RN D and NA E started to reposition the resident onto the left laying position when Resident 20 yelled out loudly and started to cry. NA E stated I know it hurts , we have to do the treatment. RN D did not stop the treatments, evaluate the resident's pain and implement interventions to manage Resident 20's pain. RN D after having the resident positioned onto the left laying side removed the old dressing to the tailbone area revealing a wound that measured approximately 6 centimeters (cm) roundish and approximately 2 cm's deep. Resident 20 started to cry when the old dressing was removed and had a furrowed brow and facial grimacing. Resident 20 moaned , groaned and had facial grimacing through the cleaning of the wound. RN D applied the ordered treatment to Resident 20's wound area causing Resident 20 to cry out and moan. Resident 20 was positioned onto a back laying position after the wound care was completed. Record review of Resident 20's Pain Tool dated 3-10-2021 and time after the observation as of 11:24 AM revealed the following information: -The description of pain was identified as moaning when turned side to side. -Current pain scale using the face scale was evaluated as Hurts a Whole Lot. According to Resident 20's Pain tool dated 3-10-2021 with a time of 11:24 AM revealed Resident 20's pain at the least using the face scale was identified as Hurts a Whole lot and the worst using the face scale was Hurts a Whole Lot. On 3-10-2021 at 12:25 PM an interview was conducted with RN D. During the interview RN D reported not evaluating if Resident 20 had been pre-medicated for pain prior to conducting Resident 20's treatment. RN D confirmed Resident 20 was in pain during the wound treatment and did not stop and evaluate the need for pain management. Review of the facility Pain Assessment and Management Policy and Procedure dated 3-2015 revealed the following information: -Purpose: -The purpose of this procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. -General Guidelines: -2. Pain Management is defined as the process of alleviating the residents pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. -3. Pain management is a multidisciplinary care process that includes the following: -B. Effectively recognizing the presence of pain. -E. Developing and implementing approaches to pain management. 6. Assess the resident's pain and consequences of pain at least every shift and as needed. -Defining Goals and Appropriate Interventions: 2. Pain management interventions shall reflect the source, type and severity of pain. 3. Pain management interventions shall address the underlying causes of of the resident's pain.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed monitor for the side effects of an antipsychotic medication and failed to follow up with an appointment for indicators of adverse reactions to the use of an antipsychotic medication for 1 Resident 15) of 1 sampled resident. The facility staff identified a census of 74. Findings are: A. According to Drugs.com extrapyramidal symptoms (EPS) are side effect of antipsychotic medications. According to the information from Drugs.com EPS symptoms include severe uncontrolled muscle contractions of the head, neck, trunk ,and limbs. In addition, it can cause uncontrolled movement of the tongue, jaw lips or face. According to information at Healthline.com EPS are also called drug induced movement disorders described the effects caused by the use of certain antipsychotic medication. According to the information from Healthline.com some of EPS could be permanent. Healthline identified Tardive Dyskinesia as a late onset of the EPS involving repetitive , involuntary farcical movements such as tongue twisting, chewing motions and lip smacking. On 12-21-2020 at 3:32 PM an interview was conducted with Resident 15. During the interview as Resident 15 spoke, excessive tongue movement from side to side, up and down and at times out of the mouth were observed. Observation on 12-21-20 at 4:25 PM with the newly hired Director of Nursing (DON) revealed Resident 15 was awake and in bed. During an interview with Resident 15 observations revealed excessive tongue movement from side to side, up and down and at times out of the mouth. Record review of Active Orders sheet as of 12-21-2020 revealed Resident 15's practitioner order medications that included [MEDICATION(S)] ( an antipsychotic medication) 25 milligrams to be taken daily at bed time. Record review of Resident 15's Comprehensive Care Plan (CCP) revealed Resident 15 was receiving an antipsychoic medication and had been admitted to the facility with EPS. According to Resident 15's CCP, the goal for Resident 15 was to be /remain free of [CONDITION(S)] drug related complications including movement disorders. The interventions identified on Resident 15's CCP included administering the [CONDITION(S)] medications and to monitor for the side effects and effectiveness every shift, to complete a Abnormal Involuntary Movement Scale (AIMS, tool used to evaluate the side effect of the use of antipsychotic medication) to be completed every 6 months and as needed. Record review of the AIMS test completed on 4-21-20 revealed had minimal facial expressions and minimal lips and perioral area such as puckering, and lip smacking. Further review of the AIMS evaluation dated 4-21-20 revealed the were no abnormal movements of the tongue. Record review of a AIMS evaluation dated 7-17-20 revealed Resident 15 was evaluated as have no abnormal tongue movement. Record review of a Psychiatric Follow up sheet dated 9-23-20 revealed Resident 15 was positive for abnormal movements related to mental health medications. The Treatment plan identified on the Psychiatric Follow up sheet included ongoing monitoring of current mental health medications for the effectiveness, adverse events and significant changes and to complete ongoing consultation as clinically indicated. On 12-22-2020 at 7:07 AM an interview was conducted with the DON. During the interview the DON confirmed Resident 15 did have excessive tongue movement and reported not being aware of what the plan for management of those movements were. On 12-22-2020 at 10:07 AM a follow up interview was conducted with the DON. During the interview the DON confirmed there had not bee any monitoring for the side effects for the use of the antipsychotic medication and there should have been. The DON further reported any new symptoms should have been reported to the practitioner. B. Record review of a Discharge summary sheet dated 12-4-2020 revealed Resident 15 had been in the hospital for an acute illness. Further review of the discharge summary sheet dated 12-4-2020 revealed revealed Resident 15 had Tardive dyskinesia resolved and psych recommended follow up with a movement disorder specialist . Review of Resident 15's record revealed there was not any indications the facility staff had follow up with assisting Resident 15 with a movement disorder specialist. On 12-28-2020 at 9:10 AM an interview was conducted with the DON. During the interview the DON confirmed the facility staff had not followed up with the recommendation for a movement disorder specialist and should have.

Licensure Reference Number 175 NAC 12-006.10D Based on interview and record review, the facility failed to ensure medication was administered in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility had a census of 86. The findings are: A review of an Ultrasound Requisition dated 12/6/19 revealed an ultrasound performed at the facility indicated Resident 511 had a positive result for a DVT ([CONDITION(S)]-a blood clot that forms in a vein deep in the body) in Resident 511's left lower extremity. A review of a History and Physical for a date of service of 12/6/19 indicated Resident 511 was currently hospitalized for an acute DVT and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The History and Physical also indicated Resident 511 had been on [MEDICATION(S)] (a medication used to help prevent the formation of blood clots), but it had been discontinued on 11/24/19 for an unknown reason. A review of Resident 511's November 2019 MAR (Medication Administration Record) revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 12/16/19 at 3:15 PM, the DON (Director of Nursing) confirmed that the DON put a stop date of 11/24/19 on Resident 511's [MEDICATION(S)] order and that there was no stop date on the [MEDICATION(S)] order prior to that time. In an interview on 12/16/19 at 3:46 PM the DON reported being unable to find an order from 511's physician to discontinue the [MEDICATION(S)] on 11/24/19.

LICENSURE REFERENCE 175 NAC ,[DATE].11E Based on observations, interviews, review of facility documents, and review of facility policies and procedures, the facility failed to ensure the staff used non-expired test strips to test the sanitizer level of the dishwashing machine, and failed to ensure the water temperature of the dishwashing machine was maintained within an acceptable range for the effective sanitization of kitchen and food-service dishware and utensils. This deficient practice created a likelihood for the occurrence of serious injury, harm, impairment, or death from foodborne illness and placed the 90 residents capable of oral intake in immediate jeopardy. The facility had a census of 93 residents on the first day of the survey. Findings include: During the initial tour of the kitchen, accompanied by the facility's Dietary Manager (DM), on [DATE] beginning at 8:38 AM, observation revealed, and the DM confirmed, that the facility used a low-temp dishwashing machine to clean and sanitize the facility's kitchen ware and food-service ware. At 8:40 AM, observation revealed Dietary Aide (DA)17 checked the water temperature of the dishwashing machine by visualizing the water temperature gauge on the front of the machine below a built-in water reservoir. DA17 reported the water temperature registered 115 degrees Fahrenheit (F). During the observation, the DM confirmed that the water temperature was below the acceptable range of 120 degrees F at the time the temperature was tested . DA17 then tested the level of sanitizer in the water by dipping a test strip into the sanitizing solution collected in the built-in water reservoir on the front of the machine. DA17 reported the sanitizer level as 100 parts per million. At that time, observation of the container of test strips just used by DA17 to test the sanitizer level, revealed the test strips had an expiration date of [DATE]. During an interview at that same time, both DA17 and the DM stated the test strips in the container had been supplied by the vendor that installed the new dishwasher on [DATE], and had been used exclusively since that date to test the sanitizer level of the dishwasher solution. A review of the Dish Machine Log - Low Temp forms posted next to the dishwasher revealed the forms were in a monthly format, and each day of the month was divided into three spaces labeled breakfast, lunch, and dinner. Each of the three daily timeslots had a place to log both the temperature of the water and the sanitizer level. Further review of the (MONTH) 2019 log entries from [DATE] through [DATE] revealed the following information: On [DATE] and [DATE]: No entries were logged for either the water temperatures or the sanitizer levels for any of the three meals on those two dates. On [DATE] and [DATE]: No entries were logged for either the water temperatures or the sanitizer levels for the breakfast and lunch meals on those dates. Supper water temperatures were logged as 100 degrees F, with sanitizer levels within normal limits. On [DATE]: Breakfast and lunch water temperatures were both logged as 100 degrees F, with no water temperature or sanitizer level entries logged for the supper meal. On ,[DATE] /19: Breakfast, lunch, and supper water temperatures were all logged as 100 degrees F, with sanitizer levels within normal limits. On [DATE]: No entries were logged for the breakfast and lunch water temperatures or sanitizer levels. The supper water temperature was logged as 100 degrees F, and the sanitizer level was within normal limits. On [DATE]: No entries were logged for the breakfast and lunch water temperatures or sanitizer levels. The supper water temperature was logged as 115 degrees F, with the sanitizer level within normal limits. On [DATE]: The breakfast water temperature of 115 degrees F, and the sanitizer level of 100 parts per million were logged post-breakfast at 8:50 AM that day. During an interview at the time of the observation, the DM stated he was responsible for ensuring the water temperature was tested prior to cleaning dishes and he failed to monitor the temperature logs for the dishwashing machine during the current month. During an interview with the Grounds Director (GD), the DM, and the Director of Procurement (DOP) on [DATE] at 9:30 AM, the GD stated the water in the building would only be heated to a maximum temperature of 119 degrees F and the dishwashing machine did not have a booster' to increase the temperature to acceptable minimum required temperature for cleaning or rinsing dishes. In addition, the GD stated there had been no work orders submitted for repairs to the dishwashing machine. During an interview on [DATE] at 9:40 AM, the Administrator stated she had not been notified of any problems with the new dishwashing machine and there had been no work order submitted regarding problem with the safe operation of the machine. Review of a facility electronic mail (email) message titled, Dishwasher Replacement, dated [DATE], from the DM to the Administrator, the DOP, and the owners of the facility revealed the DM recommended a High Heat Washer be purchased to replace the facility's dishwasher. The reasons noted by the DM for this recommendation were noted as follows: 1) You wouldn't need a booster due to the machine heating the water which would solve our problem right now, 2) The facility would save money because, you wouldn't need to buy chemicals, and 3) it improves dry times on items washed. A follow-up interview was conducted with the DM on [DATE] at 11:00 AM. The DM confirmed he sent a message to the Administrator, the DOP, and the owners of the facility because there had been problems with inconsistent water temperatures with the facility dishwashing machine and plans were made to replace the machine. A review of a facility's Kitchen Audit, dated [DATE], and conducted by the Registered Dietician (RD) revealed the water temperature noted on the facility's dishwashing machine at the time of the audit was measured as 110 degrees. The audit guidelines noted a low temperature machine's water temperature should be equal to or greater than 120 degrees and should follow the manufacturer's guidelines. The RD's note on the audit reads, temp 110 - replacing dishwasher, An interview with the DOP was conducted on [DATE] at 12:30 PM. The DOP stated he was responsible for the purchase of the new dishwashing machine for the facility. The DOP confirmed he was aware of the recommendations made by the DM to purchase a high temperature dishwashing machine were made on [DATE]. In addition, the DOP confirmed he was aware the facility needed to purchase a new dishwashing machine due to problems with inconsistent water temperatures on the machine. The DOP stated he received a recommendation from a vendor to purchase a low temperature washer and the new dishwashing machine was installed on [DATE]. The DOP did not provide an explanation for why the recommendation to purchase a high temperature dishwashing machine from the DM was not considered and the DOP did not provide an explanation for why a booster was not purchased to increase the temperature of the new machine. An interview was conducted with the Administrator and Regional Administrator on [DATE] at 2:25 PM. The Administrator stated the DOP was responsible for the purchase of a new dishwashing machine for the facility kitchen. The Administrator confirmed she understood the facility needed to purchase a new dishwasher due to inconsistent water temperatures. In addition, the Administrator confirmed she was aware a low temperature dishwashing machine would need a booster to increase water temperatures because the hot water temperatures set in the building would only reach 119 degrees. The Administrator stated she had not been made aware of any problems with the new dishwashing machine and there had been no work orders submitted at the facility related to problems with the operation of the new dishwashing machine since the installation date of [DATE]. The Administrator stated the DOP was responsible for communicating with vendors related to the purchase and would have expected a booster to be purchased at the time the new machine was purchased but could not provide an explanation for the facility's failure to purchase a booster to increase the water temperature for safe operation of the new machine. Observation on [DATE] at 2:35 PM, revealed the manufacturer's guideline and the National Sanitary Foundation requirements were posted on the Data Plate on the front of the dishwasher and read, Wash Temp. - Minimum 120 degrees Fahrenheit, recommended 140 degrees Fahrenheit, Rinse Temp.- Minimum 120 degrees Fahrenheit, recommended 140 degrees Fahrenheit. A review of facility policy titled, Dish Machine Usage, dated ,[DATE], stated the purpose of the policy was, to ensure proper techniques when washing tableware (i.e., dishes, silverware, glasses and cups). The procedure outlined in the policy stated, Wash and rinse tanks should be filled with clear water. Check the temperature of the wash and rinse cycles, verifying that both meet the temperature posted on the dish machine.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.10D Based on record reviews and interviews the facility failed to ensure that residents were free of significant medication errors. This affected one resident (Resident 1). The facility census was identified as 103. Findings are: A. Record review of Resident 1's EMR (Electronic Medical Record) revealed Resident 1 was admitted on [DATE] for the following medical Diagnoses: [REDACTED]. Record review of Resident 1's MAR (Medication Administration Record) for the month of January 2017 revealed the resident was to receive [MEDICATION NAME] (muscle relaxer used to treat spasm, pain, and stiffness) Solution- 1 ml (milliliter) or 10 mg (milligrams) via [DEVICE] (gastrostomy tube) three times a day for muscle spasms. The [MEDICATION NAME] Solution concentration was 10 mg per 1ml. Record review of the facility Medication Regimen report of Incident dated 01/18/2017 revealed that Resident 1 received 19 ml or a total of 190 mg of [MEDICATION NAME] Solution at 5:00 AM on 01/18/2017. It further revealed that the resident was sent emergently to the hospital at 11:30 AM due to the resident vomiting profusely. An interview with the 4th floor charge nurse revealed the resident was to return to the facility from the hospital sometime on 01/23/2017. The resident had been hospitalized for [REDACTED]. An interview with the DON (Director of Nursing and the ADON (Assistant Director of Nursing) on 01/23/2017 at 12:08 PM revealed the nurse involved, RN D (Registered Nurse D), was suspended, educated and then completed a Medication Pass Competency. They further stated that they plan to educate and competency test the rest of the nursing staff. Both of them stated that this was a significant medication error. An interview with RN D on 01/23/2017 at 2:43 PM revealed that RN D confirmed that (gender) had given the medication and that it was the wrong dose. RN D further confirmed that the medication error was a significant medication error.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to implement interventions related to falls for Resident 199 and failed to ensure medications were not left at the bedside for Resident 109. The facility census was 101. Findings are: A. A Review of Resident 199's closed record revealed a Minimum Data Set (MDS - a federally mandated comprehensive assessment tool used for care planning) Assessment, dated 12-8-15 revealed Resident 199 was an extensive assist of one staff member with transferring and revealed that Resident 199 had a history of [REDACTED]. Review of Resident 199's fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Reveal of a Situational Background Assessment Recommendation (SBAR) dated 12-26-15 revealed Resident 199 had an unwitnessed fall. The SBAR revealed that, at 5:45 am, Resident 199 was heard calling for help. When staff arrived in Resident 199's room, staff observed the resident on the floor in front of the resident's wheelchair leaning on to the resident's left side. Resident 199 was assessed and complained of pain in the left knee. The SBAR revealed Resident 199's brief was wet and the resident had failed to use the call light for assistance. Review of Resident 199's Progress Notes revealed that, on 12/26/2015 at 19:14, Resident 199 was complaining of pain to the left knee, the left knee had 4 plus edema (swelling, rated 1= small amount to 4=large amount) and was tender to touch. An order was received to x-ray the left knee to ensure nothing was broken from the Nurse Practitioner (APRN). The facility received the X-ray report and it revealed Resident 199's left femur was fractured. The APRN was notified and gave orders to send Resident 199 to the hospital for evaluation. Review of Resident 199's progress notes revealed no fall interventions in place at the time of Resident 199's fall on 12-26-15. Review of Resident 199's comprehensive care plan revealed no care plan for falls with listed interventions in place until 12-30-16 after the fall occurred. Review of the facility investigation for Resident 199's fall on 12-26-15 revealed no interventions in place at the time of the fall. Interview with the Director of Nursing (DON) on 07/06/2016 at 2:24 PM revealed that they did could not find any evidence of fall interventions in place for Resident 109 prior to the fall on 12-26-15 and there should have been. B. A record review of Resident 109's records revealed Resident 109 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An observation on 06/30/2016 at 9:22 AM revealed there was a medication cup with 2 pink caplets on the bedside table. An interview with Resident 109 on 06/30/2016 at 9:22 AM revealed the caplets were Benadryl Tablets and that (gender) took them separately from the pain medications. An interview with ADON (Assistant Director of Nursing) on 06/30/2016 at 12:19 PM revealed, if medications were left at the bedside and there was no staff present, that would be considered resident self-administration of medications and a self-medication assessment would have to been done as well as a physician order [REDACTED]. The ADON confirmed Benadryl was at the bedside of Resident 109 and that there was no order or assessment for Resident 109 to self-medicate. Record review of the Self-Administration Assessment for Resident 109, dated 2/24/2016, revealed that the Resident 109 was not cleared to be self-medicating.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview; the facility staff failed to ensure 2(Residents 26 and 31) and 3 of 16 sampled and 2 non-sampled residents was free of a significant medication error. The facility staff identified a census of 117. Findings are: Record review of a Discharge Summary sheet dated 11/28/2011 revealed Resident 26 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 26's Nurse's Notes dated 11/14/2011 at 12 AM revealed Resident 26 had complained of chest pain and was transported to the hospital. Record review of a Discharge Summary sheet dated 11/17/2011 revealed Resident 26 had been admitted to the hospital on [DATE]. According to the information in the Discharge Summary sheet dated 11/17/2011, the hospital admitting team had called the facility and discovered Resident 26 had received 130 units of [MEDICATION NAME] in error. Resident 26 was admitted to the hospital for treatment. The final [DIAGNOSES REDACTED]. Record review of a Physician admission orders [REDACTED]. Record review of a verification of Incident investigation/Administrative Summary (VIIAS) form dated 11/15/2011 revealed the following entry:" [MEDICATION NAME] 130 units given to this resident-who is not (on) diabetic medications..." On 12/26/2011 at 9:15 AM an interview with the Director of Nursing (DON) was conducted. During the interview, the DON confirmed Resident 26 had received the [MEDICATION NAME] in error. When asked if this was a significant error, the DON stated " yes, it was very serious". When asked if Resident 26 was insulin dependent, the DON stated "no". A follow up interview was conducted with the DON on 12/26/2011 at 11:00 AM. During the interview, the DON was asked if follow up education after the incident with Resident 26 on 11/15/2011 had occurred with all nurses to ensure insulin would be given correctly. The DON stated "no". Record review of the Nursing 2011 Drug Handbook by Wolters Kluwer, Lippincott, Williams and Wilkins page 1069 revealed the following information: -Onset time of the insulin was 1 hour. -Adverse reaction was listed as [DIAGNOSES REDACTED]. - Nursing considerations identified [DIAGNOSES REDACTED] is the most common side effect of the insulin. B. Record review of Resident 31's closed record Admission Summary dated 10/5/11 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review of a Nurses Note dated 10/19/11 revealed that Resident 31 had been found with fixed pin point pupils, non-reactive to light, confused manner with eyes rolled back into the head when not talking. The physician was called and an ambulance transported Resident 31 to the hospital per physician order. Record review of a hospital Discharge Summary dated 10/25/11 revealed an admission [DIAGNOSES REDACTED]. The Discharge Summary History of Present Illness section dated 10/25/11 revealed, that on the way to the emergency room (ER), Resident 31 had received [MEDICATION NAME] (a drug used to counteract the effects of [MEDICATION NAME]/opiod medication) which resulted in some improvement in Resident 31's mental status. The Discharge summary showed a significant lab finding of [MEDICATION NAME] in Resident 31's blood per Gas Chromatography test.(lab test). The hospital course section of the Discharge Summary dated 10/25/11 described Resident 31's altered mental status as being possibly secondary to opiate intoxication, the urine drug screen was positive for opiates and Resident 31 was given [MEDICATION NAME] 5 times on the day of admission to the hospital. A gas Chromatography test was ordered for Resident 31 and found have [MEDICATION NAME] and [MEDICATION NAME] (an antidepressant, other name is [MEDICATION NAME]) present. A review of Resident 31's current medications listed in the Emergency Department record dated 10/25/11 showed a current medication list that included [MEDICATION NAME] (an antidepressant,formal drug name [MEDICATION NAME]) but no current orders for [MEDICATION NAME]. Record review of Resident 31's admission orders [REDACTED]. Record review of Resident 31's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of a facility Investigation Report completed on 10/21/11 for Resident 31 revealed that Resident 31 had been sent to the ER and had [MEDICATION NAME] present in their system per lab reports. The Summary Review Findings revealed that the facility had done an investigation into the incident with Resident 31. The investigation revealed that the facility staff were unable to determine how Resident 31 had come to have [MEDICATION NAME] discovered in their system. The facility took follow up action and education was provided to the Licensed Nursing staff regarding the 5 rights (of medication pass) and potential outcomes if not followed. Record review of a facility Inservice done on 11/1/11 on the 5 rights of medication pass did not include specific information related to procedures to ensure that the correct medication is being given to the correct resident. Interview on 12/6/11 at 9:30 AM with the facility Administrator confirmed the incident with Resident 31 and that Resident 31 did have [MEDICATION NAME] in their system. Interview on 12/6/11 at 3:00 PM with the DON confirmed that Resident 31 did not have orders for [MEDICATION NAME] but that somehow it had gotten into Resident 31's system while a resident in the facility.

LICENSURE REFERENCE 175-NAC-12-006.09D2a-b Based on observation interview, and record review; the facility failed to evaluate causal factors and evaluate nutritional requirements for wound healing for Resident 1 and 3. The facility census was 111 and the sample size was 23 plus 1 non-sampled resident. Findings are: A. Based on Resident 1's Annual MDS (Minimum Data Set, a government required assessment tool to give a picture of the Resident ) dated 04/3/11, Resident 1 had the [DIAGNOSES REDACTED]. Resident 1 needs extensive assistance of 2 persons to move in bed, or to transfer. Resident 1 had a catheter for urine and is incontinent for bowels. Resident 1 required 2 assistants for elimination needs. Resident 1 was unable to walk. Resident 1 scored 12/15 for cognitive ability, indicating moderate Cognitive Impairment. This MDS assessment also stated that Resident 1 had (two) stage 2 Pressure Ulcers that started on 03/29/11. The MDS defines Pressure Ulcer stages in this way: ? Stage 1 Intact skin with non-blanchable redness of a localized area usually over a bony prominence. ? Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or ruptured blister. ? Stage 3 Full thickness tissue loss Subcutaneous fat may be visible, but bone tendon or muscle is not exposed. Slough may present but does not obscure the depth of tissue loss. May include undermining and tunneling. ? Stage 4 Full thickness tissue loss with exposed bone, tendon or muscle. Per interview on 09/29/11 with Resident 1's Physicians Assistant, Resident 1 had no feeling from the waist down. In an interview on 09/28/2011, at 08:45AM,Wound Nurse LPN-R ( Licensed Practical Nurse) stated that the stage 2 Pressure Ulcers that started March 29,2011, were on the heels, bilaterally. Review of Nurse ' s Notes and dated from 3/09/11-04/09/11, made no mention of the Pressure Ulcers. In the interview on 09/28/11, the Wound Nurse LPN-R, revealed there is a separate set of Skin Nurses Notes and there is also a skin assessment sheet where wounds are documented including measurements. Request was made for all the skin assessment notes regarding the heel wounds. Review of the Skin Assessment Sheet dated 3/28/11 shows there was an open stage 2 Pressure Ulcer discovered on the left heel and the measurements were given. No cause was noted other than saying it was a Pressure Ulcer. When no Skin Nurses Note or Skin Assessment Note was found for the Right Heel Wound until 03/31/2011, the same information was requested again. The first note obtained for the Right Heel Wound was for 03/31/2011, and it contained no initial assessment of cause and no measurements. The Skin Nurses Notes stated skin was assessed and( Pressure Ulcers) on bilateral heels with red granular bases. It mentioned heel lift boots on and said Cont. treatment. One Piece of information given was a report titled Weekly Wound Report -Pressure Ulcers dated 05/01/2011 that stated Resident 1 had stage 2 Pressure Ulcers on the right and left heels that started on 03/29/11. In an interview on 09/28/11 at 08:45,when asked what caused these pressure ulcers, LPN R stated it was pressure, acquired in house (meaning the resident did develop them while living in the facility),but the cause was unknown. LPN-R stated there may be a correlation between the resident having chronic urinary tract infections but the cause was unknown. Review of the Wound Care Plan Showed the concern as being Altered Skin Integrity and the first date entered on the care plan was 06/04/10 and was for the Left Heel Stage 2, and the goal was the Skin will show signs of improvement As Evidenced By decrease in wound size in 30 days. The next dates on the care plan was 03/29/11 for Stage 2 Ulcer on the Left Heel again and also a stage 2 on the right heel. There was also a Pressure Ulcer for the right Isch ( Buttocks) dated 07/07/11. Interventions listed on the care plan for all skin issues were: ? Monitor for s/s of infection ? Notify Doctor of change in wound status ? Monitor nutritional intake ? Monitor lab values ? Treat per Doctors Order For the heels the care plan stated ? 03-29-11 Cleanse right and left heel and with (PVC?) pat dry, apply [MEDICATION NAME], gauze, [MEDICATION NAME] QOD (every other day) In an interview on 10/03/2011 at 12:15 PM with the facility RD-Q ( Registered Dietician-Q) it was revealed that the RD follows the ADA (American Dietetic Association ) recommendations of adding 1.2 grams of protein per kilogram of body weight when a person has a pressure ulcer. The RD stated the facility does alert the RD when there is a Pressure Ulcer, either by the daily sheet that is printed out of Pressure Ulcers, or verbally. Review of the nutritional status progress notes has entries on 07/19/10; 01/09/11; and 06/26/11. The note on 06/26/11 gives a total assessment of nutrition and states the Resident eats 55% of meals for the 30-90 days prior to that. A calculation was made to meet resident needs and a change of diet was written to go from Regular diet to Enhanced Regular Diet and change Prostat ( a protein supplement) 30 ml. daily to 30 ml. twice daily. In an interview on 09/29/11 at 8:55 AM with the DON (Director of Nursing) revealed the expectation was for Dietary to be notified within a week at the latest but the preference was within 24 hours. No information was provided by the facility to indicate the Dietician had been notified prior to the 06/26/2011. The care plan also stated there was a stage 2 Pressure Ulcer to the right buttock. The care plan added 2 new items for interventions for this new Pressure Ulcer ; ? [MEDICATION NAME] /[MEDICATION NAME] to Right Isch ? New cushion eval by Occupational Therapy In an interview with the Wound Care Nurses on 09/28/11 at 8:45 AM, Wound Care LPN-R stated the reason for the wound on the buttocks was not known. Wound Care LPN-R stated Resident 1 has always had a Roho Cushion so its not known why the resident had skin breakdown on the buttocks. ( A Roho cushion is a cushion that fills with air like an inner tube of a bicycle tire and basically made of the same substance. ) No other interventions were added on the Wound Careplan until 08/15/11 when the wound was changed to a stage 3. ( Resident 1 was hospitalized from [DATE] until 08/15/11) .On 08/15/11 the new interventions added were ; ? Air Mattress ? Not up in chair greater then twice a day for 2 hours at a time. ? Prevalon Boots on at all times No nutritional assessment could be found in the medical record to correlate with the Pressure Ulcer discovered on 07/07/11. The first one after that was dated 08/26/11 , in which changes were made back to Enhanced and Prostate twice a day. B. Record review of the Admission and Discharge Summary sheet dated 8/29/2011 revealed Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Nursing Admission assessment dated [DATE] revealed Resident 3 was assessed to have "no open areas" with the left, right and coccyx area being clear. Record review of a laboratory results dated [DATE] revealed Resident 3 had a low serum protein of 4.7 (reference range is 6.0 to 8.1 g(gram)/dl (deciliter) and a low serum [MEDICATION NAME] of 2.4 (reference range 3.3 to 4.8 g/dl). Record review of a Braden Pressure Ulcer Risk assessment dated [DATE] revealed Resident 3 was assessed with [REDACTED]. Record review of a Change of Condition Report-Skin Condition form revealed Occupational Therapy (OT) " noticed open area on coccyx. Skin reddened in area with skin tear apparent. Called wound nurses for assessment". Record review of Resident 3's Nurse's Notes dated 8/15/2011 revealed Resident 3 was identified with an open area to the coccyx with a granular base. The surrounding area had redness and a partial skin flap. MD was informed with treatment orders and "therapy called to get a cushion for the wheelchair". Record review of a Pressure Ulcer Evaluation Record (PUER) dated 8/15/2011 revealed Resident 3 was identified with a stage 2 pressure ulcer ( stage 2 pressure ulcer is a partial thickness loss dermis presenting as shallow open ulcer with red pink wound bed, with out slough. May also present as an intact or open/ruptured serum-filled filled blister) to the coccyx. The area measured 3 centimeter (cm) by 3 cm. The wound area had light drainage with the wound bed having granulation tissue. The evaluation was completed by LPN R. Record review of Resident 3's Nurse's Notes dated 8/22/2011 revealed the coccyx wound bed was identified as being "dark purple/ red base". Resident 3's physician was notified and the facility staff requested laboratory test. The facility also had requested a order for an air mattress and this was applied to Resident 3's bed. Record review of Resident 3's Nurse's notes dated 8/26/2011 revealed the wound to the coccyx was evaluated as having a pink/yellow base. According to the documentation, Resident 3's laboratory result had identified Resident 3's [MEDICATION NAME] was low at 2.4 g/dl and that the Registered Dietician (RD) had been informed of the results. Record review of a PUER dated 8/29/2011 revealed the size of the wound was 1.6 cm by 2.0 cm. The wound bed had granulating tissue with 5% slough (dead tissue). Record review of Resident 3's nurse's Notes dated 9/02/2011 revealed Resident 3's pressure ulcer to the coccyx area was evaluated as having a red/yellow wound base. Record review of Resident 3's Wound Care plan dated 8/15/2011 revealed Resident 3 " heels red". Interventions listed was "float heels off bed at all times" and "Prevalon Boots". Record review of Resident 3's Skin Integrity Care Plan: Prevention dated 8/19/2011 revealed Resident 3 had the "potential for impaired skin integrity R/T (related to) requires assist with turning and reposition, 2 assist" and "history of pressure ulcers". Record review of Resident 3's Wound Care Plan dated 8/20/2011 revealed Resident 3 had fluid filled blisters to both heels. C. Record review of a PUER dated 8/20/2011 revealed Resident 3 had developed a stage 2 right heel blister. The size of the blister was 3 cm by 6 cm. the MD was notified for treatment orders and heel boots were placed on Resident 3's feet. Record review of a PUER dated 8/27/2011 revealed Resident 3's right heel ulcer measured 6.5 cm by 4.0 cm. Record review of a PUER dated 9/03/2011 revealed the pressure ulcer to the right heel measured 6.0cm by 4.0 cm. Record review of Resident 3's Nurse's Notes dated revealed the right heel blister was re-absorbing. Record review of a PUER dated 8/20/2011 revealed Resident 3 had a stage 2 pressure ulcer to the left heel that measured 4 cm by 3 cm. The stage 2 ulcer was evaluated as a blister that was intact. Boots were applied and the MD informed and treatment orders requested and received by the facility staff. Record review of a PUER dated 8/27/2011 revealed the size of the pressure ulcer to the left heel measured 4.0 cm by 5.2 cm with the blister intact. Record review of a PUER dated 9/03/2011 revealed the pressure ulcer measured 4.0 cm by 5.6 cm. The fluid filed blister to the left heel remained intact and no treatment changes were requested from the physician. Record review of Resident 3's Nutrition Screening and Assessment (NSA) form dated 8/22/2011 revealed the facility RD had documented that Resident 3's skin was intact. Review of the Assessment summary and Dietary Plan section of the NSA from did not identify or assess that Resident 3 had 3 pressure ulcers. The assessment did not identify what Resident 3's nutritional requirements would be for wound healing or how that would be completed. Record review of a Nutritional Progress Notes for Resident 3 dated 9/06/2011 revealed the nutritional assessment identified 1 of 2 remaining pressure ulcers. Interview with the facility wound nurses LPN R and LPN S was conducted on 9/28/2011 at 11:40 AM. During the interview LPN R reported that heel boots had been placed on Resident 3 on 9/15/2011 as the heels were red and blanch-able. When asked if the heel boots had been re-evaluated on 8/20/2011 when both of the heels were identified with heel blister, LPN R stated "no". When asked what the causes of the skin breakdown were to the coccyx and both heels, both, LPN R and LPN S stated "We're not sure". On 9/28/2011 at 3:28 PM a interview was conducted with the DON. During the interview the DON was asked what was the time frame for notifying the RD of pressure ulcers. The DON responded that the RD should be notified within 24 hours and 1 week at the most for a nutritional assessment. Review of the RD assessment dated [DATE] was conducted with the DON. When asked if the RD had assessed the nutritional requirements for wound healing for Resident 3, the DON stated "NO''. When asked if there should have been an assessment, the DON stated "yes". When asked when a resident develops a pressure ulcer, should there be an assessment of casual factors, the DON stated "yes". The DON confirmed Resident 3 development of pressure ulcers did not have the casual factors assessed for the resident. A interview with RD T was conducted on 10/03/2011 at 12:00 PM. During the interview review of the Nutritional Progress Notes dated 9/06/2011 was conducted with RD T. RD T confirmed 1 of the 2 pressure ulcers were included in the assessment. When asked if both pressure ulcers were included would have that made a difference. RD T stated "yes, I would have made additional recommendations".

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview; the facility staff failed to ensure 2(Residents 26 and 31) and 3 of 16 sampled and 2 non-sampled residents was free of a significant medication error. The facility staff identified a census of 117. Findings are: Record review of a Discharge Summary sheet dated 11/28/2011 revealed Resident 26 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 26's Nurse's Notes dated 11/14/2011 at 12 AM revealed Resident 26 had complained of chest pain and was transported to the hospital. Record review of a Discharge Summary sheet dated 11/17/2011 revealed Resident 26 had been admitted to the hospital on [DATE]. According to the information in the Discharge Summary sheet dated 11/17/2011, the hospital admitting team had called the facility and discovered Resident 26 had received 130 units of [MEDICATION NAME] in error. Resident 26 was admitted to the hospital for treatment. The final [DIAGNOSES REDACTED]. Record review of a Physician admission orders [REDACTED]. Record review of a verification of Incident investigation/Administrative Summary (VIIAS) form dated 11/15/2011 revealed the following entry: [MEDICATION NAME] 130 units given to this resident-who is not (on) diabetic medications. On 12/26/2011 at 9:15 AM an interview with the Director of Nursing (DON) was conducted. During the interview, the DON confirmed Resident 26 had received the [MEDICATION NAME] in error. When asked if this was a significant error, the DON stated yes, it was very serious. When asked if Resident 26 was insulin dependent, the DON stated no. A follow up interview was conducted with the DON on 12/26/2011 at 11:00 AM. During the interview, the DON was asked if follow up education after the incident with Resident 26 on 11/15/2011 had occurred with all nurses to ensure insulin would be given correctly. The DON stated no. Record review of the Nursing 2011 Drug Handbook by Wolters Kluwer, Lippincott, Williams and Wilkins page 1069 revealed the following information: -Onset time of the insulin was 1 hour. -Adverse reaction was listed as [DIAGNOSES REDACTED]. - Nursing considerations identified [DIAGNOSES REDACTED] is the most common side effect of the insulin. B. Record review of Resident 31's closed record Admission Summary dated 10/5/11 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review of a Nurses Note dated 10/19/11 revealed that Resident 31 had been found with fixed pin point pupils, non-reactive to light, confused manner with eyes rolled back into the head when not talking. The physician was called and an ambulance transported Resident 31 to the hospital per physician order. Record review of a hospital Discharge Summary dated 10/25/11 revealed an admission [DIAGNOSES REDACTED]. The Discharge Summary History of Present Illness section dated 10/25/11 revealed, that on the way to the emergency room (ER), Resident 31 had received [MEDICATION NAME] (a drug used to counteract the effects of [MEDICATION NAME]/opiod medication) which resulted in some improvement in Resident 31's mental status. The Discharge summary showed a significant lab finding of [MEDICATION NAME] in Resident 31's blood per Gas Chromatography test.(lab test). The hospital course section of the Discharge Summary dated 10/25/11 described Resident 31's altered mental status as being possibly secondary to opiate intoxication, the urine drug screen was positive for opiates and Resident 31 was given [MEDICATION NAME] 5 times on the day of admission to the hospital. A gas Chromatography test was ordered for Resident 31 and found have [MEDICATION NAME] and [MEDICATION NAME] (an antidepressant, other name is [MEDICATION NAME]) present. A review of Resident 31's current medications listed in the Emergency Department record dated 10/25/11 showed a current medication list that included [MEDICATION NAME] (an antidepressant,formal drug name [MEDICATION NAME]) but no current orders for [MEDICATION NAME]. Record review of Resident 31's admission orders [REDACTED]. Record review of Resident 31's Medication Administration Record [REDACTED]. Record review of a facility Investigation Report completed on 10/21/11 for Resident 31 revealed that Resident 31 had been sent to the ER and had [MEDICATION NAME] present in their system per lab reports. The Summary Review Findings revealed that the facility had done an investigation into the incident with Resident 31. The investigation revealed that the facility staff were unable to determine how Resident 31 had come to have [MEDICATION NAME] discovered in their system. The facility took follow up action and education was provided to the Licensed Nursing staff regarding the 5 rights (of medication pass) and potential outcomes if not followed. Record review of a facility Inservice done on 11/1/11 on the 5 rights of medication pass did not include specific information related to procedures to ensure that the correct medication is being given to the correct resident. Interview on 12/6/11 at 9:30 AM with the facility Administrator confirmed the incident with Resident 31 and that Resident 31 did have [MEDICATION NAME] in their system. Interview on 12/6/11 at 3:00 PM with the DON confirmed that Resident 31 did not have orders for [MEDICATION NAME] but that somehow it had gotten into Resident 31's system while a resident in the facility.