Every finding on record at Eventide Lincoln Care Center

Licensure Reference Number NAC 175 12-006.09(H)Based on record review and interviews, the facility failed to follow physician orders for 1 (Resident 2) out of 3 sampled residents. The facility census was 134. Findings are:Record review of the facility's policy titled Medication Errors dated 2/26 revealed that a medication error is defined as a discrepancy between what was prescribed and what was administered.According to the American Medical Association (AMA), good nursing practice and nursing standards of care require nurses to act as independent professionals who execute physician orders responsibly.Record review of Resident 2's admission MDS dated [DATE] revealed an entry date to the facility on 5/18/2026 with a BIMS of 15 (indicates Resident 2 is cognitively intact) and a diagnosis of osteomyelitis (a bone infection) and type 2 diabetes mellitus (a chronic metabolic condition where the body fails to produce enough insulin to help regulate blood sugars) with foot ulcer.Record review of Resident 2's Comprehensive Careplan dated 5/19/26 revealed: -MRSA (methicillin-resistant Staphylococcus aureus - a type of bacteria that resistant to many common antibiotics and making the infection harder to treat) with an intervention to give antibiotic therapy as ordered. -diagnosis of osteomyelitis to left ankle and foot with an intervention of IV (intravenous which means into a vein) antibiotic as ordered and wound vac (a medical treatment that uses controlled suction to help severe or hard to heal wounds close faster) with treatment as ordered.Record review of Resident 2's current physician orders included IV Ampicillin/sulbactam (commonly known as Unasyn, an antibiotic used to treat bacterial infections) with a start date of 5/18/2026.Review of Resident 2's Medication Error report dated 6/13/26 revealed the wrong IV antibiotic was given to this resident. IV Ertapenem (also known as Invanz, a broad spectrum antibiotic used to treat serious bacterial infections) was given to the resident.Record review of a physician order dated 6/14/26 for Resident 2 revealed that the Infectious Disease (ID) doctor needed to be notified of the medication error.During an interview on 7/9/2026 at 4:46 PM RN (Registered Nurse) - A and Resident Care Manager (RCM) confirmed that Infectious Disease (ID) was not notified of the medication error and should have been because they were the ones that ordered the IV antibiotic for the resident's infection.During an interview on 7/9/26 RN - B and RCM revealed that if an order is not completed on the shift that it was received, the order should be communicated to the oncoming nurse. In this instance, the night nurse should have communicated with the oncoming day shift nurse.During an interview on 7/9/2026 at 5:15 PM LPN (Licensed Practical Nurse) - C confirmed that (gender) was the nurse on the next dayshift on 6/14/2026 and was not made aware of the new order to notify the Infectious Disease doctor.During an interview on 7/9/2026 at 5:32 PM the Administrator (Adm) confirmed that ID was not notified and should have been and that the physician orders were not followed.

Licensure Reference Number 174 NAC 12-006.11 (A) Based on record review and interview, the facility failed to provide the correct therapeutic diet for one resident (Resident 3) of 5 sampled residents. The facility census was 142.Findings are: A record review of the admission Record with the printed date of June 25th, 2026 revealed that Resident 3 was admitted to the facility on [DATE] with the diagnosis of Pneumonitis due to inhalation of food and vomit, Dementia (a decline in mental abilities severe enough to interfere with daily life), and dysphagia (difficulty swallowing food or liquids). A record review of the Care Plan (Comprehensive Care Plan that is a written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) revealed the focus: Nutrition, increased risk of suboptimal nutrition ( occurs when your body receives adequate calories but fails to get the specific balance of macronutrients, vitamins, or minerals it needs to function optimally) related to medical conditions and advanced age. Interventions: Diet General, minced and moist, mildly thick liquids dated 6/17/2026. A record review of the Physician's orders dated 4/17/26 revealed Resident 3 was admitted to the facility on a pureed diet and advanced with speech therapy to minced and moist on 5/20/26. A record review of the Progress notes dated 6/7/26 revealed that Resident 3 was choking in the dining room where staff were performing the Heimlich and was sent to the hospital. A record review of hospital's History and Physical dated 6/7/26 revealed that Resident 3 had been choking on a piece of chicken that was approximately 8 centimeters (equal to approximately 3 inches). A record review of the facility's menu for the day of 6/7/26 revealed that Baked Chicken was being served for lunch. An interview on 6/25/26 at 1: 30 PM with the Nutritional Culinary Director confirmed that Resident 3 had been given a regular diet for lunch that consisted of regular chicken and that Resident 3 was supposed to have a minced & moist diet. An interview on 6/25/26 at 2:30 PM the Director of Nursing confirmed that Resident 3 choked on a piece of regular chicken that was served to Resident 3 confirming Resident 3 was served the wrong diet. An interview on 6/25/26 at 2:30 PM with the Nutritional Culinary Director and the Director of Nursing confirmed that after the incident with Resident 3 choking the facility put in the following: -Meal service audits initiated focusing on modified diets to ensure no other residents were affected with incorrect diet being served. Dietician completed audit of meal tickets to ensure tickets matched doctor's orders -Plan Change: 2-step verification process implemented to ensure accurate diet is being served.1) Culinary to plate and verify served diet matches plated meals2) Server to deliver plate and verify served diet matches plated meals -Prevention:Education initiated on the 2-step verification and responsibilities in the dining roomEducation initiated on how to identify residents at risk for chokingEducation initiated on IDDSI diet (International Dysphagia Diet Standardization Initiative is texture-modified foods and thickened liquids designed for individuals with swallowing difficulties (dysphagia)). 2-step verification and IDDSI diet education added to new hire experience -Monitoring:1) Continued audits on modified diets weekly times 6 weeks starting 6/15/26 to ensure 2-step verification process is completed. Results brought to QA for review.

Based on record review and interview, the facility failed to revise post fall care plan interventions for Resident 2, Resident 5, and Resident 6 of five residents sampled . The facility reports a census of 141.A. A review of an admission Record indicated the facility admitted Resident 1 on 06/08/2026 with diagnoses that included dementia and repeated falls. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2026, revealed Resident 1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. A review of Resident 1's Progress Notes revealed fall documentation for 06/08/2026 and 06/22/2026. Review of Resident 1' s Care Plan initiated on 06/08/2026, revealed the resident had a potential for falls and had fallen on 06/08/2026 and 06/22/2026. Interventions included moved Resident 1 to a room closer to the nurses station, initiated on 06/08/2026 and no new interventions were identified for 06/22/2026 fall. During an interview with Director of Nursing (DON) and Licensed Practical Nurse (LPN) on 06/25/2026 at 1:45 PM to 2:05PM when discussing Resident 1's Care Plan in the electronic medical record (EMR) confirmed Resident 1 did not have revised interventions for fall on 06/22/2026 and should have. B. A review of an admission Record indicated the facility admitted Resident 5 on 03/04/2024 with diagnoses that included dementia and repeated falls. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/2026, revealed Resident 5 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had moderate cognitive impairment. A record review of the facility Incidents by Incident Type, dated 06/25/2026 revealed Resident 5 had fallen on 06/08/2026. Review of Resident 5's Progress Notes revealed Resident 5 fell on [DATE], 06/08/2026 and 06/24/2026. Review of Resident 5' s Care Plan initiated on 03/04/2024 revealed the resident was a high risk for falls and had fallen on 05/28/2026. New interventions were identified in the Care Plan for Resident 5's 05/28/2026 (added anti roll back to wheelchair) and 06/24/2026 (staff to stay in Resident 5's room while using the bathroom) falls. No new fall interventions were identified for the 06/08/2026 fall. During an interview with Director of Nursing (DON) and Licensed Practical Nurse (LPN) on 06/25/2026 at 1:45 PM to 2:05 PM when discussing Resident 5's Care Plan in the EMR confirmed Resident 5 did not have revised interventions for fall on 06/08/2026 and should have. C. A review of an admission Record indicated the facility admitted Resident 6 on 06/10/2026 with diagnoses that included repeated falls and post hip replacement surgery. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/2026, revealed Resident 6 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident had severe cognitive impairment. A record review of the facility Incidents by Incident Type, dated 06/25/2026 revealed Resident 6 had fallen on 06/12/2026, 06/13/2026, 06/14/2026 and 06/20/2026. Review of Resident 6' s Care Plan initiated on 06/10/2026 revealed the resident was at risk for falls and had fallen on 06/12/2026, 06/13/2026, 06/14/2026, and 06/20/2026. New interventions were identified in the Care Plan for Resident 6's 06/12/2026 (do not leave Resident 6 awake in room alone), 06/14/2026 (mat on floor next to bed) and 06/20/2026 (per Resident 6's request in bed at 8:00 PM) falls. No new fall interventions were identified for the 06/13/2026 fall. During an interview with Director of Nursing (DON) and Licensed Practical Nurse (LPN) on 06/25/2026 at 1:45 PM to 2:05 PM when discussing Resident 6's Care Plan in the EMR confirmed Resident 6 did not have revised interventions for fall on 06/13/2026 and should have.

Licensure Reference Number 175 NAC 12-006.11(E), 12-007.01(A) Based on observations, record review and interview, the facility failed to ensure foods stored were not expired, had been sealed and dated when opened, and the facility failed to prevent cross-contamination between spices and the meat products. This had the potential to affect all residents who had meals from the kitchen. The facility census was 140. Findings are: A. An observation of the kitchen on 4/27/26 at 7:30 AM revealed: In the prep refrigerator -a bag of flour tortilla opened with no date on the bag and the bag had slits on the front of the bag -Caesar dressing opened with no date on the bottle. An observation of the freezer on 4/27/26 at 7:35 AM revealed: - a bag of sweet potatoes fries opened with no date and not sealed, - a bag of mixed vegetables opened with no date, - a bag of potatoes chunks with no date on it, - a bag of Broccoli opened not sealed with no date, -a bag of chopped onions with no date on it, - a bag of celery opened not sealed with no date, - a bag of carrots 2 bags opened not sealed with no date, -Frozen pasta [NAME] 2 bags open without dates, -Roselia Cesar shredded cheddar opened, no sealed, no date, An observation of the dry storage area on 4/27/26 at 7:45 AM revealed: -2 bags of hot dogs buns opened with no date, - a bag of Chinese noodles in sandwich bag with no date, -a bag of ritz crackers in sandwich bag with no date, -3 bags of noodles opened with no date, - a 25 lb. bag of carrot cake mix opened not sealed no date, - a bag of raspberry gelatin mix opened with no date, -Soy Sauce, 1 gallon, opened but not dated. A record review of the Storage Hierarchy with no date revealed: All foods must be covered, labeled, and dated. No prepared foods past 5 days, Resident meals 2 days. A record review of the Food Storage Guidelines with no date revealed: Any foods in the cooler that aren't labeled or dated need discarded immediately. 04/27/2026 8:51 AM An interview with the Nutrition and Culinary Director confirmed that (genders) expectations are that the cooks and kitchen staff open, seal and date items used and put pack in the refrigerator or freezer and it was not. The Nutrition and Culinary Director confirmed that there was expired foods in the dry storage area and there was food that had been opened and not dated or sealed and it should have been. The Nutrition and Culinary Director confirmed that (gender) was getting ready to box the expired items up and take to the food bank. B. Observation of the facility's frozen and refrigerated storage on 4/27/2026 at 7:35 AM revealed: Two bags of frozen pasta open without dates. A box with loose French fries spilled in the bottom but otherwise empty. An unsealed bag of chopped onion with no date. Two bags of opened carrots in unsealed bags with no date. A container of celery opened and not sealed without date. A box of sliced red onions with the bag opened and not dated. An opened container of shredded cheddar, not sealed, not dated. A box of broccoli, opened and not sealed, not dated. A bag of chopped potatoes opened but not dated. Observation of the facility's dry storage room revealed: Six 67-ounce [NAME] Traditional Jars expired 12/7/25. Seven cans of 14.5-ounce Hunts stewed tomatoes expired 4-25-25. Plus, one full box of 12 cans in package expired 4-25-25. [NAME] Hines Chewy [NAME] Brownie Mix 18.3-ounce expired 12-12-25. [NAME] Hines Devil's food cake 12 boxes oz 15.25-ounce expired 4-19-25. [NAME] Hines Butter [NAME] Cake mix 15.25 oz expired 12-18-26 x 5 boxes. Van [NAME] and Beans 15-ounce, 16 cans expired 11-7-24. Six Miracle Whip 12-ounce containers expired 4-22-26. Soy Sauce, 1 gallon, opened but not dated. Canned 11-ounce mandarin oranges expired 12-7-24, 1 loose plus full box of 24 expired 12-7-24. Three 33.8-ounce bottles of espresso syrup, expired 9/24. Four 25.1-ounce bottles of peppermint syrup, expired 9-19-25. Small box of Jello instant banana cream pudding expired. Case of small boxes of Jello instant chocolate pudding with many individual packages, all expired. Small box of Jello instant pistachio pudding 1 full case plus one single box all expired. Record review of facility's food Storage Hierachy policy (undated) revealed that all foods must be covered, labeled, dated and that foods that aren't labeled or dated need discarded immediately. Interview with Nutrition and Culinary Director (NCD-E) at 8:51 AM on 04/27/26 confirmed that all expired items need to be removed and that all opened items need to be rewrapped and dated.

Licensure Reference Number NAC 175 12-006.07(C) Based on interviews and record review, the facility failed to reevaluate and revise the plan of corrective action to prevent recurrence of past performance issues. This had the potential to affect all residents residing in the facility at the time of the survey. The facility census was 140. Findings are: A record review of the facility provided, undated Current List of Active Performance Improvement Plans (PIP's) on 4.27.2026 included Client Satisfaction, Skin/Wound Documentation, Psychotropic Medications, and Falls. A record review of the facility's Statement of Deficiencies dated 12.17.2024 revealed deficient practice areas including care planning, medication errors, and infection control practices. A record review of the Medication Administration facility task for the survey ending 4.30.2026 revealed a medication error rate of 12.82%, according to Centers for Medicare and Medicaid Services (CMS), the acceptable rate for medication errors is <5%. A record review of the facility citations for the survey ending 4.30.2026 revealed deficient practice including infection control, free of medication error rate, and develop/implement comprehensive care plan. During an interview on 4.30.2026 at 8:28 AM with the Quality Assurance/Infection Control Coordinator (QA/IFC Coord) it was confirmed the Quality Assurance (QA) committee reviews the facility's previous Plan of Correction (POC) for areas of improvement opportunities. It was also confirmed that care planning, medications errors, and infection control practices were previous deficient practices and continue to be a concern. During an interview on 4.30.2026 at 8:45 AM with the Executive Director (ED), it was confirmed the previous POC concerns relating to care planning, medication errors, and infection control had not been corrected and continue to be a facility issue.

Licensure Reference Number 175 NAC 12-006.10(D)Based on observations, record reviews, and interviews, the facility failed to ensure their medication error rate was less than 5%. There were 39 opportunities for error and five errors observed, for a total medication error rate of 12.82%. The facility census was 140.Findings are:A record review of the facility's Medication Administration and Storage policy dated 02/16/2026 revealed that medications will be considered as given at the correct time if administered one hour before or one hour after the scheduled time. A. An observation on 04/28/2026 at 8:52 PM revealed Medication Aide (MA) C administering the following medications to Resident 54: Pravastatin (a cholesterol medication) 10 mg (milligrams). A record review of Resident 54's Medication Administration Record (MAR) revealed an order for pravastatin tab 10 mg take 1 tablet by mouth every evening. The time scheduled for administration was 7:00 PM. An interview on 04/28/2026 at 8:54 PM with MA C confirmed that the Pravastatin was administered late. B. An observation on 04/28/2026 at 9:20 PM revealed MA C providing the following medications to Resident 78: LiquaCel (a protein supplement used to encourage wound healing) 30 cc (cubic centimeters); and Juven (a nutritional supplement used to encourage wound healing) 1 packet. A record review of Resident 78's MAR revealed an order for Liquacel + Juven two times a day 30 cc liquael [sic] mixed with 1 packet juven [sic] in 240 cc fluid of choice with morning and evening medication administration. The times scheduled for administration were 8:00 AM and 7:00 PM An interview on 04/28/2026 at 9:38 PM with MA C confirmed the LiquaCel and Juven were provided late. C. An observation on 04/29/2026 at 7:37 AM revealed Licensed Practical Nurse (LPN) D administering the following medication to Resident 8: Humalog (a fast acting mealtime insulin used to control high blood sugars) Kwikpen (a multi-dose, prefilled, single-patient-use injection device used for insulin administration) 4 units injected subcutaneously (under the skin). The resident did not have a meal or other food at the time of administration. An observation on 04/29/2026 at 7:50 AM revealed Resident 8 did not have food. An interview on 04/29/2026 at 8:15 AM with LPN D revealed the LPN did not know how quickly food should be provided after giving fast acting insulin. An observation on 04/29/2026 at 8:18 AM revealed staff delivering Resident 8's meal tray. A record review of Resident 8's MAR revealed an order for Humalog KWPN [Kwikpen] inject 4 units subcutaneously before meals. The morning dose was scheduled for 7:00 AM. A record review of the facility's Insulin-Subcutaneous policy and procedure dated 02/16/2026 revealed no information about the timing of administration related to meals. A record review of the [NAME] Lilly Humalog Prescribing Information revised 01/2026 revealed that the medication should be given within 15 minutes before a meal or immediately after a meal. An interview on 04/29/2026 at 1:48 PM with the Director of Nursing (DON) confirmed that Humalog should be given within 15 minutes before receiving a meal or immediately after eating and that Resident 8's insulin was administered too long before the meal. D. During an observation on 04/28/2026 at 7:20 AM Medication Aide (MA-G a certified professional who safely administers routine medications in nursing homes, assisted living, and home care settings under nurse supervision). MA-G performed hand hygiene for 20 seconds, then verified medication with EMAR (electronic medication administration record is a digital, often mobile-enabled system that replaces paper record for documentation medication administration in healthcare facilities). MA-G administers Acetaminophen (over the counter analgesic and antipyretic drug to treat mild-to moderate pain) 500 milligrams 2 tablets orally every 6 hours (6 AM, 1200 PM, 6 PM, and midnight). MA-G administers Acetaminophen at 7:30 AM. MA-G is also unable to locate Ingrezza (a prescription medication used to treat adults with tardive dyskinesia characterized by uncontrollable movements) 80 milligrams 1 capsule orally daily. MA-G double checked the medication cart, also looked in the pharmacy reorder binder and confirmed the medication had not come in from the pharmacy. MA-G then reordered the medication. During an interview on 04/29/2026 at 11:00 AM MA-G confirmed that the scheduled Acetaminophen should have been given at 6 AM and not 7:30 AM. During an interview on 04/29/2026 at 11:58 AM with the DON (Director of Nursing) confirmed that Acetaminophen should have been given at 6:00 AM and not at 7:30 AM.

Licensure Reference Number 175 NAC 12-006.12(D)(i)(1)Based on record reviews, observations, and interviews, the facility failed to store medications securely for Residents 5, 7, 14, 26, 43, 54, 55, 78, 83, 96, 108, and 154; and the facility failed to ensure medication carts were kept locked when unattended. The facility census was 140.Findings are: A record review of the facility's Medication Administration and Storage policy and procedure dated 02/16/2026 revealed that medications should be stored in a designated and secured (locked) area. A. An observation on 04/28/2026 at 8:04 PM revealed Medication Aide C walked away from the medication cart with the cart unlocked and multiple medication cards, topical creams, and eye drops left on top of the cart. There were no other staff around the cart. A review of the medication cards, topical creams, and eye drops left unattended on the cart revealed the following list of medications and residents: Resident 5 Sertraline (an antidepressant) 25 mg (milligrams) tablets. One card containing 14 tablets. Memantine (a medication for dementia) 10 mg tablets. Two cards containing 14 tablets each. Resident 7 Omeprazole (a medication to reduce stomach acid) 20 mg capsules. One card containing 15 capsules. Resident 14 Memantine 10 mg tablets. Two cards containing 30 tablets each. Resident 26 Calmoseptine ointment (a cream used as a skin protectant and moisture barrier). One 4 ounce (oz) tube. Resident 43 Diclofenac 1% (a medication applied to the skin to treat pain). One 3.53 oz tube. Resident 54 Amlodipine (a medication for high blood pressure) 5 mg tablets. One card containing 14 tablets. Potassium (a supplement) 20 mEq (milliequivalent) ER (extended release) tablets. One card containing 14 tablets. Resident 55 Eliquis (a blood thinner) 5 mg tablets. Two cards of 14 tablets each. Donepezil (a medication to treat confusion and memory loss) 5 mg tablets. One card containing 14 tablets. Resident 78 Metoprolol (a medication for high blood pressure) 25 mg ER tablets. One card containing 14 half tablets Multivitamin Men 50 (a multivitamin designed for men over 50) tablets. One card containing 14 tablets. Pantoprazole (a medication to reduce stomach acid) 40 mg tablets. One card containing 14 tablets. Atorvastatin (a cholesterol medication) 40 mg tablets. One card containing 14 tablets. Metformin (a medication to control blood sugars) 500 mg tablets. Two cards containing 28 tablets each. Duloxetine (an antidepressant) 60 mg capsules. One card containing14 capsules. Tamsulosin (a medication used to treat symptoms of an enlarged bladder, such as difficulty urinating) 0.4 mg capsules. One card containing 14 capsules. Sitagliptin (a medication to control blood sugars) 100 mg tablets. One card containing 14 half tablets. Melatonin (a medication to help with sleep) 1 mg tablets. One card containing 14 tablets. Midodrine (a medication for low blood pressure) 5 mg tablets. One card containing 30 tablets. Pregabalin (a medication used to treat nerve pain) 25 mg capsules. One card containing 42 capsules. Olopatadine (treatment for itching eyes) 0.1% eye drops. One 5 ml (milliliter) bottle. Dorzolamine/timolol (used to lower high pressures in the eyes) 2-0.5% eye drops. One 10 ml bottle. [NAME] tears (treatment for dry eyes) 0.5% eye drops. One 15 ml bottle. Latanoprost (used to lower high pressures in the eyes) 0.005% eye drops. One 125mcg(microgram)/2.5mL bottle. Brimonidine (used to lower high pressures in the eyes) 0.2% eye drops. One 10 ml bottle. Resident 83 Alendronate (a weekly medication used to increase bone density) 70 mg tablets. One card containing 4 tablets. Refresh Plus (treatment for dry eyes) 0.5% eye drops. One box of 30 single use vials, 0.01 fluid oz each. Resident 108 Pantoprazole 40 mg tablets. One card containing 14 tablets. Eucerin Skin Cream Calming (a moisturizing skin cream). One 8 oz tube. Resident 154 Amlodipine 2.5 mg tablets. One card containing 14 tablets. Solifenacin (a medication used to treat bladder problems) 5 mg tablets. One card containing 14 tablets. An interview on 04/28/2026 at 8:20 AM with MA C confirmed they should not have left the medication cart unlocked and unattended and further confirmed they should not have left medications on top of the medication cart unsecured and unattended. B. An observation on 04/28/2026 at 6:27AM revealed an unattended medication cart that was unlocked and accessible to residents on the first-floor resident hallway until 6:31AM. An observation on 04/28/2026 at 10:19AM revealed Medication Aide- I (MA-I) walked away from the medication cart, left it unattended, and entered a patient room. The cart was unlocked and unattended on the first-floor hall until 10:22AM, MA-I returned to lock the cart and walked away. An interview with MA-I at 10:26AM confirmed that they left the medication cart unlocked and unattended. They confirmed that the expectation was that the medication cart should not be left unlocked and unattended. They revealed that there are controlled medications (controlled medications carry a risk of misuse and dependence) locked within the medication cart that should be double locked. An interview on 04/29/2026 at 7:13AM with Licensed Practical Nurse-J (LPN-J) confirmed that the expectation when leaving the medication cart unattended was to lock the cart, close the screen or put in privacy mode, not leave any medications sitting out, and hide all confidential information. They confirmed controlled medications were locked in a locked box within the medication cart. An interview on 04/29/2026 at 7:40AM with Resident Care Manager-H (RCM-H) confirmed that their expectation of the medication cart when left unattended, was to be locked with no medications on top, the screen should be down and minimized with no patient information visible. Record review of Policy and Procedure: Medication Administration and Storage revealed that medications would be stored in a designated and locked area. Controlled substances would be locked in a permanently fixed compartment and double locked. C. Record review of Resident 96's electronic medical record revealed that they were admitted to the facility on [DATE] with diagnoses of encephalopathy (a disorder impacting brain function which may lead to altered mental status), epilepsy (a disorder of the brain causing seizures due to abnormal electrical activity in the brain), acute kidney failure (a sudden loss of kidney function), hypertensive heart disease with heart failure (a heart condition caused by high blood pressure) and sleep apnea (a disorder characterized by interruptions in breathing during sleep). Observation of Resident 96's room on 04/27/2026 at 8:40 AM revealed that 4 medications were left on his bedside table: Mupirocin ointment Brimonidine eye drops Latanoprost eye drops Dorzolamide eye drops During this observation, it was noted that no lock box for medication storage in a resident room was found in Resident 96's room. During interview of Resident 96 at 8:40 AM, they stated that they do not self-administer their own medications and did not know why those (pointing toward medications) were left in the room. Observation of Resident 96's room at 1:25 PM on 04/27/2026 revealed Dorzolamide 10mg eye drops remained in box at bedside but the other 3 medications previously laying on bedside table were no longer present. Observation of Resident 96's room at 2:45 PM revealed that Dorzolamide eye drops remained on bedside table. Record review of Resident 96's physician orders on 04/27/26 at 3:15 PM revealed no order for or assessment for self-administration of medications. Self-administration of medications was not included in the baseline care plan. Resident 96's initial Minimum Data Set (MDS, a comprehensive assessment used in Long-term care facilities to evaluate residents' needs) was not complete at time of record review. A Brief Interview for Mental Status (a tool to evaluate cognitive function) is included on the MDS but the result of this evaluation was not available at time of record review. Record review of facility's Medication Self Administration policy, dated 02/16/2026, revealed that that residents should be assessed to determine if they desired to self-administer medications and are able to fulfill the policy criteria. If a resident was able to qualify for medication self-administration, a lock box would be provided for the medications to be stored in their room. Record review of Resident 96's electronic medical record did not reveal that Resident 96 had received an evaluation for self-administration. Record review of facility's Medication Administration and Storage policy, dated 02/16/2026, revealed that medications will be stored in a designated and secure area. Observation of resident 96's room on 04/29/26 at 7:20 AM revealed that 3 medications were left on the bedside table (Mupirocin ointment, Brimonidine eye drops and Latanoprost eye drops). A vial of Dorzolamide eye drops was on the floor between bed and nightstand. No lockbox for Resident 96's medications was observed in the room. Observation of Resident 96's room on 4/29/26 at 8:35 AM revealed that 4 medications (Mupirocin ointment, Brimonidine eye drops and Latanoprost eye drops and Dorzolamide eye drops) were found on the bedside table. Interview with LPN-J on 4/29/26 at 8:35 AM confirmed Resident 96 does not self-administer medications. LPN-J also confirmed that these medications should be locked up in the medication cart. At this time, LPN-J was observed removing the 4 medications from Resident 96's room and locking them in the medication cart.

Licensure Reference Number 175 NAC St. 71-6022(2) Based on record review and interview, the facility failed to notify the Ombudsman (an independent official who investigates complaints against organizations-typically government agencies or specific industries like healthcare-to resolve disputes and protect rights) of the hospitalizations on 2/8/26, 3/9/26, 4/4/26 and 4/17/26 for Resident 123, and 2/27/2026 for Resident 5, out of 28 residents sampled. The facility census was 140. Findings are: Findings are: A. A record review of the Clinical Census for Resident 5 revealed an admission date of 12.15.2025. A record review of Resident 5's Minimum Data Set (MDS) (this comprehensive assessment evaluates each resident's functional capabilities) with a target date of 3.10.2026 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident had moderate cognitive impairment. A record review of the Clinical Census for Resident 5 revealed a Hospital Leave on 2.27.2026. A record review of the progress note for Resident 5 dated 2.27.2026 at 9:49 PM revealed Resident 5 was transferred to the hospital for further evaluation due to a fall. A record review of the Policy and Procedure Notice of Transfer or Discharge dated 2.16.2026 revealed: the notice of transfer or discharge will include the name, address, and telephone number of the State Long-Term Care Ombudsman (an independent official, appointed by the government, corporations, or organizations, who investigates, mediates, and resolves complaints from individuals regarding unfair treatment, administrative failures, or policy violations) During an interview on 4.29.2026 at 2:02 PM with the Director of Nursing (DON) confirmed the State Long-Term Care Ombudsman was not notified of Resident 5's transfer to the hospital on 2.27.2026 and should have been. B: A record review of the admission Record with the printed date of April 29th 2026 revealed that Resident 123 was admitted to the facility on [DATE] with the diagnosis of Acute Chronic Systolic Congestive Heart Failure (causes fluid backup (congestion) in the lungs and body, resulting in fatigue, shortness of breath, and swelling), Acute Kidney Failure (a sudden, often reversible, loss of kidney function), Hypotension (abnormally low blood pressure) , Anxiety Disorder (health conditions characterized by excessive, persistent fear or worry that interferes with daily life) , and Shortness of Breath (sensation of not being able to get enough air). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated Feb. 19, 2026 revealed Resident 123 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15. A record review of the Progress notes revealed that Resident 123 was admitted to the hospital on [DATE] for Acute heart failure, 3/9/26 for Congestive Heart Failure, 4/4/26 for renal failure and 4/17/26 for chest pain and low blood pressure. A record review of the February 26 and March 26th of notification to the Ombudsman revealed that in the month of February and March there was no notification of Resident 123 being discharged to the hospital. A record review of eventide Policy and Procedure Notice of Transfer or discharge date d 2.16.26 revealed: 3)The notice of Transfer or Discharge will include the following: The name, address, and telephone number of the State Long-Term Care Ombudsman. An interview on 4/29/26 at 7:06 AM with the Director of Nursing confirmed that the facility was unable to locate a notification to the Ombudsman for the discharge to the hospital for Resident 123 on 2/8/26, 3/9/26, 4/4/26 and 4/17/26 and the Director of Nursing confirmed that the Ombudsman should of been notified of the discharges to the hospital for Resident 123.

Licensure reference number 175 NAC 12-006.09C1a Based on observation, interview, and record review; the facility failed to ensure the baseline care plan (BCP, a plan of care for the resident that includes the minimum information needed to provide effective, person-centered care immediately upon admission) had interventions to address healthcare needs for Resident 125 who had an indwelling suprapubic urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage. The tube is inserted into the bladder through a hole in the lower abdomen) This failure had the potential to affect 1 of 2 sampled residents recently admitted to the facility. The facility census was 147. Findings are: An observation and interview on 04/27/2026 at 07:48AM revealed Resident 125 in their room with a catheter present hung at the side of their chair. They reported that they had a suprapubic catheter for many years due to medical reasons. Record review of the Order Summary Report (a listing of the physician orders for a resident) dated 04/28/2026 for Resident 125 revealed that Resident 125 admitted to the facility on [DATE]. Diagnoses included neuromuscular dysfunction of bladder (occurs when nerve damage from diseases or injuries interrupts signals between the brain, spinal cord, and bladder muscles, causing loss of control, urinary retention, or overactive bladder symptoms) and presence of urogenital implants (medical devices surgically inserted to treat urinary incontinence or structural issues in the genitourinary system). Record review of the admission Orders dated 04/21/2026 revealed that the resident did not have an indwelling urinary device on admission and no orders were placed at that time. Record review indicated that an MDS had not been completed due to Resident 125 being newly admitted . Record review of the Care Plan Report of the BCP revealed that there was no information indicating that Resident 125 had an indwelling urinary device. Review of the Policy and Procedure: Catheter- Suprapubic revealed that the care plan must include the type of catheter and the indication for use. An interview on 04/29/2026 at 2:08PM with the Director of Nursing (DON) confirmed that the BCP did not indicate that Resident 125 had a catheter present on admission. They confirmed that Resident 125 did have an indwelling suprapubic catheter in place upon admission and it was not documented in the BCP but should have been.

Licensure Reference Number 175 12- 0006.09(E) (iii) Based on observations, interviews, and record review, the facility failed to care plan the services that are provided to attain or maintain the resident's highest practicable well-being for two residents (Resident 16 and Resident 110) out of eight residents sampled. The facility census was 140 at the time of the survey. Findings are: A. A record review of Resident 16's Minimum Data Set (MDS) (this comprehensive assessment evaluates each resident's functional capabilities) with a target date of 2.15.2026 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. An observation on 4.27.2026 at 10:24 AM revealed Resident 16 with an oxygen nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen to people with breathing conditions), and a nebulizer machine (a medical device that converts liquid medication into a fine mist for direct inhalation into the lungs) at the bedside. During an interview on 4.28.2026 at 7:50 AM with Medication Aide (MA-K), it was confirmed that Resident 16 received nebulizer treatments and oxygen therapy. A record review of Resident 16's medical diagnosis revealed a history of COVID-19, Obstructive Sleep Apnea (a serious sleep disorder where throat muscles excessively relax, causing airway collapse and repeated breathing interruptions during sleep), and anxiety. A record review of Resident 16's Clinical Physician Orders with a print date of 4.28.2026 at 6:25 AM revealed orders for inhalation therapy (delivers medication directly to the lungs). A record review of the Care Plan (a mandatory, individualized document detailing a resident's medical, physical, and emotional needs, along with specific interventions to address them) with an admission date of 2.9.2026 for Resident 16, did not include a focus area for respiratory care, including the nebulizer machine and oxygen therapy. During an interview on 4.28.2026 at 10:54 AM with the Director of Nursing (DON) confirmed that Resident 16's respiratory orders, nebulizer treatments, and oxygen therapy is not a focus area on the care plan and should be. B. Record review on 04/29/2026 at 7:44 AM of Resident 110's admission record revealed an admission date of 03/04/2024. Record review on 04/29/2026 at 7:45 AM of Resident 110's diagnosis record revealed the following diagnosis: chronic pain, age related osteoporosis with out a current pathological fracture, and unspecified kyphosis (forward rounding of the upper back (thoracic spine) exceeding 50 degrees often called hunchback, causes range from poor posture and abnormal vertebral development to osteoporosis related fractures, injuries or birth defects. Record review on 04/29/2026 at 7:50 AM Resident 110's Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 02/19/2026 revealed a Brief Interview for Mental Status (BIMS-a screening tool used to assess cognition relating to the mental process involved in knowing, learning, and understanding things. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points indicates severe cognitive impairment; 8 to 12 points indicated a moderate cognitive impairment; and 13 to 15 points indicates that cognition is intact) Resident 110's score was a 13. During an observation on 04/27/2026 at 12:36 PM revealed Resident 110 was sitting in recliner and was unable to hold head up straight, Resident 110's neck was leaning on the left shoulder. During an observation on 04/28/2026 at 9:45 AM it was revealed Resident 110 was awake, sitting in recliner, feet are elevated, no complaints of pain and head was leaning on left shoulder with a soft pillow behind head. During an observation on 04/28/2026 at 2:05 PM revealed Resident 110 was sleeping in recliner with gown on and neck was resting on left shoulder. In an interview on 04/29/2026 at 12:10 PM with Resident 110 confirmed that holding (gender) head upright can be tiring. Resident 110 further confirmed how long it had been since having therapy. During an observation on 04/29/2026 at 12:29 PM Resident 110 was propelling self in wheelchair with Resident 110's head leaning on left shoulder. Record review on 04/29/2026 at 12:55 PM of care plan last revised on 02/02/2026 that the facility had not care planned about Resident 110's positioning of neck or interventions to assist with neck positioning. Record review on 04/30/2026 at 7:07 AM of physical therapy notes dated 12/21/2025 revealed that physical therapy had provided Resident 110 with strengthening interventions to do on [gender]'s own. In an interview on 04/29/2026 at 12:37 PM with the Director of Nursing (DON) confirmed that Resident 110 has had therapy, and that facility should have care planned how Resident 110 positions neck with a diagnosis of kyphosis and interventions put in place to assist Resident 110 with proper neck positioning.

Licensure Reference Number 175 NAC 12-006.10 Based on record review and interview, the facility failed to ensure Physicians orders were followed for one (Resident 9) of 3 sampled residents. The facility census was 140. Findings are: A record review of the admission Record with the printed date of 4/27/26 revealed that Resident 9 was admitted to the facility on [DATE] with the diagnosis of Bipolar (a chronic mental health condition characterized by intense, fluctuating mood shifts, including extreme highs (mania/hypomania) and severe lows (depression), Type 2 diabetes (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar) , Essential tremors (involuntary, rhythmic shaking, most commonly in the hands during movement), Post-Traumatic Stress disorder (condition triggered by experiencing or witnessing terrifying events, such as assault, disasters, or combat), Attention-Deficit hyperactivity (characterized by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with functioning), Atherosclerotic Heart Disease of Native coronary artery without Angina Pectoris (where plaque builds up in the heart's original arteries without causing chest pain). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated January 29th 2026 revealed a BIMs (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) for Resident 9 a BIMs score of 15 meaning cognitive intact.A record review of Physicians Visit Record dated 2/25/26 revealed that the physician ordered Quetiapine (antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) 200mg at bedtime to be reduced to Quetiapine 100mg at bedtime for Resident 9 and was noted off by the nurse showing that the nurse completed the order.A record review of the Pharmacist's Recommendation to Prescriber dated 3/18/26 revealed the pharmacy recommendation was to reduce Quetiapine 200 mg at bedtime. A note from the physician written on the Pharmacist's Recommendation to Prescriber form revealed attached is an order from 2/25/26 that was not initiated with the reduction of Quetiapine from 200 mg to 100 mg.A record review of the Medication Record dated February 2026 revealed that Resident 9 received Quetiapine 200mg on Feb. 25, 26, 27, and 28th at bedtime.A record review of the Medication Record dated March 2026 revealed that Resident 9 received Quetiapine 200 mg on March 1, 2, 3 ,4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24,and 25th.A record review of the Medication Record dated March 2026 revealed that Resident 9 was not started on the Quetiapine 100mg till March 26th.An interview on 4/29/26 at 12:12 PM with the Director of Nursing confirmed that the Physicians' orders had not been followed for Resident 9 and the physicians orders should have been followed for Resident 9. The Director of Nursing confirmed that there were no policy and procedure per say when taking off Physicians orders. The Director of Nursing confirms that the nurse has a form called Physicians Visit Record that has a place where pharmacy, care plan, and computer should be marked when completion of the orders and they had not been marked as completed by the nurse for Resident 9.

Licensure reference number 175 12-006.09D3(1) Based on observation, interview, and record review the facility failed to ensure an active physician's order for the continued use of an indwelling suprapubic urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage. The tube is inserted into the bladder through a hole in the lower abdomen) and associated maintenance care was established for 1 (resident 125) of 1 resident reviewed. The facility census was 147. Findings are: An observation and interview on 04/27/2026 at 07:48AM revealed Resident 125 in their room with a catheter present hung at the side of their chair. They reported that they had a suprapubic catheter for many years due to medical reasons. Record review of the Order Summary Report (a listing of the physician orders for a resident) dated 04/28/2026 for Resident 125 revealed that they admitted to the facility on [DATE]. Diagnoses included neuromuscular dysfunction of bladder (occurs when nerve damage from diseases or injuries interrupts signals between the brain, spinal cord, and bladder muscles, causing loss of control, urinary retention, or overactive bladder symptoms) and presence of urogenital implants (medical devices surgically inserted to treat urinary incontinence or structural issues in the genitourinary system). Record review of the Order Summary Report dated 04/28/2026 of active orders for Resident 125 revealed no order for the use of a suprapubic urinary catheter or associated maintenance care. An order for as needed (PRN) dressing changes to the suprapubic insertion site active 04/21/2026 was noted. Record review of the admission Orders dated 04/21/2026 revealed that the resident did not have an indwelling urinary device on admission and no orders were placed at that time. Record review indicated that an MDS had not been completed due to Resident 125 being newly admitted . Record review of the Care Plan Report of the baseline care plan (a plan of care for the resident that includes the minimum information needed to provide effective, person-centered care immediately upon admission) revealed that there was no information indicating that Resident 125 had an indwelling urinary device. Record review of Policy and Procedure: Catheter- Suprapubic revealed that the care plan must include the type of catheter and the indication for use. The electronic treatment administration record (eTAR- an electronic system for documenting or authorizing patient care) entries would be in place for any procedure related to the catheter (irrigation, other treatments ordered, discontinuation). A provider order was needed to replace a suprapubic catheter and would be changed PRN, the drainage bags would be changed every two weeks and PRN. An interview on 04/29/2026 at 07:40AM with Resident Care Manager-H (RCM-H) confirmed that Resident 125 did not have an order for their suprapubic catheter or any associated maintenance care. An interview on 04/29/2026 at 02:08PM with Director of Nursing (DON) confirmed that the Baseline Care Plan and admission Orders did not indicate that the resident had a catheter present on admission. They confirmed that the resident did have a catheter in place upon admission. They confirmed that Resident 125 did not have any physician orders for continued use of an indwelling suprapubic urinary catheter or associated maintenance care.

Licensure reference number 175 NAC 12-006.18(B)(D) Based on observations, interviews and record reviews, the facility failed to ensure proper hand hygiene was completed, glove use during wound care for Resident 6, medication administration for Resident's 54 and 78, and failure to store C-pap(continuous positive airway pressure machine is the primary treatment for obstructive sleep apnea using a mask and steady airflow to keep airways open) to prevent cross contamination for 4 out of 4 sampled resident's. The facility census was 140. Findings are: A. Record review of Resident 96's electronic medical record reveal that they were admitted to the facility on [DATE] with diagnoses of encephalopathy (a disorder impacting brain function which may lead to altered mental status), epilepsy (a disorder of the brain causing seizures due to abnormal electrical activity in the brain), acute kidney failure (a sudden loss of kidney function), hypertensive heart disease with heart failure (a heart condition caused by high blood pressure) and sleep apnea (a disorder characterized by interruptions in breathing during sleep). Observation of Resident 96's room on [DATE] at 8:40 AM revealed that Continuous Positive Airway Pressure or CPAP (a device that delivers continuous air pressure to help individuals with sleep apnea breathe more easily during sleep) tubing and mask were on the floor and under edge of bed. Tubing was not dated. Observation of Resident 96's room at 10:15 AM revealed that CPAP remained on the floor at edge of bed. Interview of Resident 96 at 10:15 AM revealed that Resident 96 does not store CPAP equipment on the floor at their home. Record review on [DATE] at 12:30 PM revealed that CPAP was ordered at the time of admission. Observation of Resident 96's room on [DATE] at 10:00 AM revealed that CPAP equipment is laying on bedside table. Interview of resident 96 at 10:00 AM regarding the placement of the CPAP facemask and tubing, revealed statement at least it is not on the floor. Observation of Resident 96's room on [DATE] at 07:20 AM revealed that CPAP equipment is on floor, pieces had separated and were laying under the bed. Interview of resident 96 at 7:20 AM revealed that it came apart last night and I couldn't fix it. When asked if they called for assistance with the device, Resident 96 stated no, staff never help me with it. Observation of Resident 96's room at 8:35 AM revealed that CPAP remained on the floor. Interview with Charge Nurse (LPN-J) at 8:35 AM on [DATE] revealed that staff are supposed to wash the CPAP chamber each day. LPN-J states that after washing, the equipment is left to dry on a paper towel on the bedside table. LPN-J was asked how the equipment should be stored after drying. LPN-J confirmed that CPAP equipment should not be stored on the floor and further stated that this CPAP equipment should be stored in a bag at the bedside. LPN-J added comment that several of the equipment bags for residents on Unit 1 are missing. LPN-J further stated that they would work on getting those today. Record of Resident 96's Medication and Treatment Administration Records review on [DATE] at 1:00 PM revealed that nursing staff had signed that CPAP was applied to Resident 96 every evening at bedtime. Record review of baseline care plan at 1:00 PM revealed that CPAP is not included on the document. The facility's Policy on Care Plans, dated [DATE], states that the baseline care plan must include the minimum healthcare information necessary to properly care for the resident, including physician orders and clinical monitoring and treatment. This policy further states that the baseline care plan will include a summary of any services/treatments to be administered by the facility. Interview with Director of Nursing (DON) on [DATE] at 1:05 PM regarding training for respiratory therapy and ensuring that staff providing respiratory therapy services have received training to ensure competency revealed that DON stated that all information available had already been provided to a fellow surveyor. This information, training on administration of oxygen, provided to facility staff in [DATE] did not address provision of respiratory therapy, including CPAP administration. However, the training document did state that tubing must be kept off the floor and that tubing must be labeled. DON did not produce any documentation regarding which staff have been trained and were competent to provide respiratory therapy. Observation of Resident 96's room on [DATE] at 2:15 PM revealed that CPAP mask was now laying on resident 96's bedside table but tubing was not dated. B. Record review on [DATE] at 1:30 PM revealed Resident 6 was admitted on [DATE] and is a DNR (order is a legally binding medical document instructing healthcare professionals not to perform CPR (cardiopulmonary resuscitation if a patient's heart stops or they stop breathing). Resident 6's BIMS (brief interview for mental status used in nursing homes and post- acute care to evaluate a resident's cognitive function specifically attention, orientation or memory. Scoring interpretation 13-15 cognitively intact, 8-12 moderately impaired, 0-7severely impaired), Resident 6's BIMS score was a 14. Resident 6's active diagnosis revealed an admission for a displaced comminuted fracture of the shaft to right tibia, with a subsequent encounter for closed fracture malunion. During an observation on [DATE] at 9:40 AM Licensed Practical Nursing (LPN-B) gathered Personal Protective Equipment (PPE- specialized clothing or gear designed to protect workers from physical, chemical, biological or radiological hazards) to complete Resident 6's wound care. LPN-B then exits room with gown and gloves on to obtain a bedside table, LPN-B then takes off gown and placed it in a trash can in lounge area. LPN-B then performed hand hygiene for 22 seconds, LPN-B shuts the water off after drying hands. LPN-B then puts on new gown and reaches for gloves in scrub pocket and puts gloves on. LPN-B then obtained dry gauze, xeroform (sterile non-adherent, and occlusive wound dressing made of the fine mesh gauze impregnated with petrolatum and 3 percent bismuth tribromophenate), scissors from drawer in Resident 6's room. LPN-B then uses scissors to cut brown sticky wrapping (Coban) from right lower extremity. LPN-B then performed hand hygiene for 24 seconds and then reached behind gown and into scrub pocket to obtain a new pair of gloves. LPN-B then cuts a small piece of yellow moist gauze to place on right lower ankle, LPN-B then wraps white kerlix around right lower ankle, uses white tape to date and initial dressing. LPN-B then performs hand hygiene for 23 seconds and puts on a new pair of gloves that were obtained from scrub pocket behind gown. LPN-B then opens a sterile 4x4 white gauze and moistens with normal saline, LPN-B then places wet dressing to right knee, wraps with white kerlix, used white tape to date and initial dressing change. LPN-B then takes gloves, gown and face mask, performed hand hygiene for 20 seconds and placed all unused supplies back in Resident 6's drawer. LPN-B then leaves the room and enters another resident's room with soiled trash from doing wound care. In an interview on [DATE] at 10:13 AM LPN-B confirmed that LPN-B should have cleaned the bedside table, opened wound supplies prior to performing treatment, and that gloves should have been readily available instead of obtaining from scrub pocket behind gown after performing hand hygiene. LPN-B further confirmed that the soiled trash from doing Resident 6's wounds should not go into another resident's room. LPN-B further confirmed that LPN-B should not have exit Resident 6's room with a gown and gloves on and dispose of them in a common area. Record review on [DATE] at 11:15 AM of Hand Hygiene policy last revised on [DATE] stated that hand hygiene should be done before and after resident care, before every clean procedure, after every dirty procedure and as needed. Handwashing consists of: 1.Turn water on in sink 2.Wet hands and wrists thoroughly, keeping hands lower than elbows 3. Apply soap 4. Lather all surfaces of wrists, hands, and fingers 5. Scrub using friction for at least 20 seconds do not rinse during this 6. Rinse all surfaces, keeping hands lower than elbows 7. Use a clean dry paper towel to dry and shut off the faucet 8. Then dispose of the paper towel in the wastebasket 9. Do not touch the inside of the sink Record review on [DATE] at 9:04 AM of Policy and Procedure guidelines for Wearing Gloves last revised [DATE] revealed that gloves must be worn following standard precautions. To prevent the spread of infection and protect employees from potential hazardous materials. Obtain appropriate gloves from utility rooms, resident bathrooms, or other designated areas. Gloves are disposable and should be changed between residents and between dirty and clean procedures on the same resident. Change gloves per policies and procedures. Do not double gloves. Do not carry gloves in your pocket for later use. Always perform hand hygiene before putting on gloves and after removing them. Record review on [DATE] at 2:00 PM of Policy and Procedure Simple Dressing Change last revised on [DATE] revealed that all dressing changes will be completed in a clean and sterile technique as appropriated for wound care ordered by the provider. 1. Review providers order for dressing change. 2. Perform hand hygiene and assemble supplies. 3. Identify the residents and explain the procedure. 4. Put on gloves and clean the working surface with germicidal wipe according to manufacturer's instructions. 5. Place trash receptacle with reach. 6. Remove gloves and perform hand hygiene. 7. Set up supplies on clean surface. 8. Position resident. 9.Remove gloves and perform hand hygiene. 10. Apply gloves 11. Remove dressing. Fold dressings with drainage contained inside and remove gloves inside out. If the dressing is small remove gloves inside over the dressing. 12. Dispose of gloves and soiled dressing in trash. 13. Perform hand hygiene. 14. Apply gloves 15. Cleanse wound as ordered. 16.Remove gloves and perform hand hygiene. 17.Apply gloves. 18. Apply clean dressing as ordered. 19. Ensure dressing is dated. 20. Remove gloves and perform hand hygiene. 21. Assist the resident to a comfortable position. 22. Clean the working surface with germicidal wipe according to manufacturer's instructions. 23.Remove trash from room. 24. Perform hand hygiene 25. Document the dressing change. Record review on [DATE] at 2:18 PM of current orders revealed that wound care to Resident 6's right lower extremity is as follows: 1. Anterior Knee Dressing-Wet to dry dressing applied over anterior knee wound twice a day. moisten gauze with normal saline and place over wound bed, then apply dry dressing over top and secure with kerlix, to remove gently pull gauze off wound, if it's adhered slightly damped the gauze as needed every day and evening for wound care. 2. Medial ankle wound- Change xeroform dressing to ankle wound daily until fully healed. 3. Right calf and left lower extremity ruptured blisters: wash with soap and water, apply xeroform, cover with gauze then ace wrap, only cover with mepilex (soft silicone foam dressing designed for treating chronic and acute wounds), change every 3 days and as needed. In an interview on [DATE] at 2:30 PM with the DON (Director of Nursing) confirmed that LPN-B should not have reached for clean gloves behind LPN-B gown. DON further confirmed that LPN-B should not have taken wound care trash into another resident's room. DON also confirmed that LPN-B should not have exited Resident 6's room with gown and gloves on and disposed of them in a common area. It was further confirmed that LPN-B should have had supplies opened prior to beginning wound care. C. An observation on [DATE] at 8:40 PM revealed Medication Aide (MA) C performed hand hygiene and began to prepare medications for Resident 54. An observation on [DATE] at 8:45 PM revealed MA C knocked over the medication cup and spilled pills onto the medication cart. MA C picked the pills up with their bare hands and put them back in the cup. An interview on [DATE] at 8:54 PM with MA C confirmed that they should not have touched pills with their bare hands to put them back in the medication cup, but should have put gloves on. D. An observation on [DATE] at 8:57 PM revealed MA C performed hand hygiene, put on gloves, and began to prepare medications for Resident 78. The MA opened a bottle of eye drops, then threw away the seal. MA C began looking through the drawers of the cart to find the LiquaCel, touching multiple bottles and the drawers of the cart with their gloved hands. After finding the LiquaCel, MA C removed their gloves and went to another medication cart on the floor to get the Juven. Without performing hand hygiene, MA C put on a new pair of gloves and opened the Juven packet. MA C put the powder into a cup, then threw away the empty packet, touching the trash with their gloved hand. MA C then finished preparing Resident 78's medications. MA C removed their gloves to sign the controlled medication out and then put on new gloves without performing hand hygiene. A record review of the facility's Hand Hygiene policy and procedure dated [DATE] revealed no information about glove use. A record review of the facility's Guidelines for Wearing Gloves policy and procedure dated [DATE] revealed that hand hygiene should be performed before putting gloves on and after removing them. An interview on [DATE] at 8:46 AM with the Director of Nursing (DON) confirmed that staff should perform hand hygiene when changing gloves.

Licensure Reference Number 175 NAC 12-006.09(H)Based on observations, record review and interview, the facility failed to ensure prompt response to call lights to ensure resident needs were being met for 2 (Residents 1 and 6) out of 6 sampled residents. The facility census was 131.A. A record review of admission Record revealed Resident 1 was admitted to the facility on [DATE] with the diagnosis of Cerebral Infarction (brain tissue death (necrosis) from a blocked blood vessel, cutting off oxygen and nutrients, and is the most common stroke type), Hypertensive Heart Disease (heart problems caused by long-term high blood pressure (hypertension), forcing the heart to work harder), Anxiety Disorder (mental health conditions marked by excessive, persistent fear and worry disproportionate to the situation), Major Depressive Disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities), Muscle Weakness (reduced strength, where muscle don't contract normally, caused by temporary issues like fatigue), Retention of Urine (the inability to fully empty your bladder), Incontinent of Bowels (the inability to control bowel movements), Facial Weakness following Cerebral Infarction (happens when blood flow loss damages brain areas controlling facial muscles, usually causing drooping on the opposite side of the face), Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (damage to the left side of the brain, affecting movement control, leading to weakness/paralysis in the right arm, leg, and face). An interview on 12/30/25 at 10:00 AM with Resident 1 confirmed that (gender) feels call lights take a long time to be answered. An observation on 12/30/25 of Resident 7 turning on the call light that was visible above the door with an audible sound (beeping) at 11:30 AM. Continuous observation of call light being on until 11:45 AM when staff member responded to the light. A record review of Resident 1 Full Event List (call light log) revealed: On 12-1-2025 the call light was on from 8:58 AM until 9:17 AM On 12-1-2025 the call light was on from 6:29 PM until 7:09 PM On 12/9/2025 the call light was on from 7:11 AM until 7:37 AM On 12/9/2025 the call light was on from 9:37 AM until 9:56 AM On 12/12/2025 the Call light was on from 1:00 PM until 1:45 PM On 12/13/2025 the call light was on from 10:39 AM until 11:03 AM On 12/13/2025 the call light was on from 6:36 PM until 6:59 PM On 12/20/2025 the call light was on from 7:42 AM until 7:59 AM On 12/20/2025 the call light was on from 12:30 PM until 1:00 PM On 12/24/2025 the call light was on from 9:42 AM until 10:08 AM On 12/26/2025 the call light was on from 11:56 PM until 00:14 AM On 12/26/2025 the call light was on from 10:15 AM until 10:43 AM On 12/26/2025 the call light was on from 1:00 PM until 1:37 PM On 12/28/2025 call light was on from 9:14 AM until 10:08 AM A record review of the facility's Policy and Procedure: Standards of Care with a Revised date of 8/24 revealed: Call lights will be accessible for residents in their rooms. Alternative options are available as needed per nurse's discretion, such as a call bell. Staff will respond to call lights in a timely manner. An interview on 12/30/25 at 6:00 PM with the Executive Director (ED) confirmed that (gender) expectations of call lights being answered in a timely manner is 5 minutes. ED confirmed that Resident 1 call light had not been answered in a timely manner B. A record review of Resident 6's admission Record printed 12/30/2025 revealed that Resident 6 was admitted to the facility on [DATE], and had a diagnosis of Parkinson's disease (a progressive brain disorder that affects movement, leading to symptoms like tremors, stiffness, and slowness of movement). A record review of a Brief Interview for Mental Status (BIMS-a screening tool used to assess cognition [relating to the mental process involved in knowing, learning, and understanding things]. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points indicates severe cognitive impairment; 8 to 12 points indicates moderate cognitive impairment; and 13 to 15 points indicates that cognition is intact) dated 12/24/2025 revealed Resident 6 scored a 14, indicating they were cognitively intact. An interview on 12/30/2025 at 12:00 PM with Resident 6 revealed that the resident had to wait up to half an hour or more for their call light to be answered. A record review of the Full Event List (a record of call light times) for Resident 6 from 12/01/2025 to 12/20/2025 revealed the following call light durations: 12/01/2025 from 7:00 AM to 7:46 AM, 12/01/2025 from 9:00 AM to 9:20 AM, 12/01/2025 from 1:28 PM to 1:58 PM, 12/02/2025 from 6:59 AM to 7:38 AM, 12/03/2025 from 10:26 PM to 10:58 PM, 12/04/2025 from 1:23 PM to 1:50 PM, 12/05/2025 from 10:37 AM to 11:11 AM, 12/06/2025 from 8:28 AM to 9:10 AM, 12/06/2025 from 9:24 AM to 9:49 AM, 12/07/2025 from 7:25 AM to 7:51 AM, 12/07/2025 from 8:11 AM to 8:44 AM, 12/09/2025 from 10:10 AM to 10:28 AM, 12/09/2025 from 6:36 PM to 6:55 PM, 12/12/2025 from 7:48 AM to 8:09 AM, 12/19/2025 from 12:46 AM to 1:07 AM, 12/20/2025 from 9:54 AM to 10:13 AM, 12/23/2025 from 10:24 AM to 10:48 AM, 12/23/2025 from 12:11 PM to 12:27 PM, 12/26/2025 from 8:58 AM to 9:28 AM, 12/26/2025 from 11:37 AM to 11:55 AM, 12/26/2025 from 2:06 PM to 2:25 PM, and 12/28/2025 from 6:12 AM to 6:28 AM. A record review of the facility's Standards of Care policy last revised 08/24 revealed that staff should respond to call lights in a timely manner. An interview on 12/30/2025 at 5:32 PM with Registered Nurse (RN) D confirmed that the expectation was that call lights would be answered within 5 minutes. An interview on 12/30/2025 at 6:00 PM with the Executive Director (ED) confirmed that the expectation for call lights was that they should be answered within 5 minutes.

Licensure Reference Number 175 NAC 12-006.09(H)Based on record reviews and interviews, the facility failed to assess Resident 6 for a change of condition. This affected 1 of 4 residents sampled for changes of condition. The facility census was 132.Findings are:A record review of Resident 6's admission Record dated 09/30/2025 revealed the resident was admitted to the facility on [DATE] from an acute care hospital and discharged [DATE] to an acute care hospital. Further review of the admission Record revealed the resident had diagnoses of a right leg trimalleolar fracture (a fracture of three of the four ankle bones) that was surgically repaired, localized edema (swelling caused by fluid retention in the tissues), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (CHF-a long-term condition in which the heart is unable to pump enough blood to meet the body's needs), an irregular heart rate, chronic kidney disease (CKD-a gradual loss of kidney function, resulting in the inability to filter waste and excess fluid from the blood), and acute kidney failure (a sudden [within hours or day] loss of the kidneys' ability to filter waste and excess fluids from the blood).A record review of Resident 6's 5-day Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 09/01/2025 revealed the resident had a Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15.A record review of Resident 6's Skilled Nursing Facility Physician admission Orders electronically signed by the physician on 08/28/2025 revealed the resident was in the facility for a Medicare skilled stay.A record review of the Order Summary Report dated 09/30/2025 that listed Resident 6's Active Orders as of 09/05/2025 revealed an order for DRESSING/INCISION CARE: Keep splint C/D/I [clean/dry/intact] until f/u [follow/up] appt. scheduled for every shift with a start date of 08/26/2025.A record review of Resident 6's hospital Discharge Summary dated 08/26/2025 revealed the resident was admitted to the hospital on [DATE] with the right ankle fracture after having fallen at home, and surgery to repair the right ankle was done on 08/20/2025.A record review of Resident 6's admission Assessment dated 08/26/2025 revealed that on admission the resident had strong pulses in both wrists and in the left foot, and a weak pulse in the right foot. Further review revealed the resident also had edema (swelling caused by fluid retention) in both legs. There was no mention of a cast or splint present to Resident 6's right leg.A record review of Resident 6's Progress Notes from 08/26/2025 to 09/30/2025 revealed the following:A Communication note dated 08/26/2025 at 11:00 PM from nursing that did not address edema, the neurovascular status (NV status-checking for pulses, skin temperature, color, and sensation) of the right foot, or the cast/splint on the right leg.A Medicare note dated 08/28/2025 at 3:35 PM from nursing that did not address edema, NV status, or the cast/splint on the right leg.A Nutrition note dated 09/02/2025 at 11:12 AM from the registered dietitian that stated there was no edema documentation noted.A Medicare note dated 09/02/2025 at 3:51 PM from nursing that did not address edema, NV status, or the cast/splint on the right leg.A Labs note dated 09/03/2025 at 11:37 AM from nursing that stated blood had been drawn for labs.A Care Conference note dated 09/03/2025 at 12:12 PM as a late entry from nursing that did not address edema, NV status, or the cast/splint on the right leg. The note did state that the resident had a six pound weight gain since admission.A Medicare note dated 09/03/2025 at 8:33 PM that stated the cast was in place. The note did not address edema or NV status of the right leg.A Medicare note dated 09/05/2025 at 2:54 PM from nursing stated the resident had edema to both legs. The note did not address NV status or the cast/splint to the right leg.A Transfer to ER/Hospital note dated 09/05/25 at 4:28 PM that stated the resident was transferred to the hospital by ambulance due to a change in condition, elevated creatinine (a waste product in the blood that measured how well the kidneys were functioning), weight gain and lethargy (drowsiness and an unusual lack of energy and mental alertness).A Communication note dated 09/06/2025 at 11:17 AM that stated Resident 6 had been admitted to the hospital for acute kidney injury (AKI-also called acute kidney failure).There were no other Progress Notes that addressed Resident 6's physical condition. There were four Medicare notes between admission [DATE] and discharge 09/05/2025.A record review of Resident 6's weight record revealed the following weights, measured in pounds:08/26/2025-none recorded08/27/2025-305.008/28/2025-none recorded08/29/2025-305.008/30/2025-309.008/31/2025-311.009/01/2025-309.509/02/2025-311.009/03/2025-316.409/04/2025-315.009/05/2025-316.4This was a gain of 11.4 pounds in ten days. There was no documentation of the medical provider being notified of Resident 6's weight gain.A review of Resident 6's vital signs (VS-temperature [T], pulse [P], respirations [R], blood pressure [B], and oxygen saturation [O2 sat-a measure of how much oxygen your blood is carrying as a percentage] section of the electronic health record and the Progress Notes revealed a total of 7 sets of VS. Two were done 08/26/2025, and one set each on 08/28/2025, 09/01/2025, 09/02/2025, 09/03/2025, and 09/05/2025.A record review of Resident 6's hospital ED [Emergency Department] Provider Notes dated 09/05/2025 revealed the resident's diagnosis was AKI superimposed (developed in addition to an existing condition) on CKD.A record review of the Lippincott Manual of Nursing Practice, 12th Edition, Copyright 2025 revealed that assessment for a resident with CHF should include heart sounds, lung sounds, and edema. An assessment for a resident with COPD should include heart and breath sounds, O2 sat, and how much effort it takes the resident to breathe. An assessment for a person with CKD should include a thorough physical examination, including vital signs, cardiovascular [heart], pulmonary [lung], GI [gastrointestinal, or stomach and digestive system], neurologic [brain and nervous system], dermatologic [skin], and musculoskeletal [muscles and skeleton] systems. An assessment for a resident who has had surgical repair of a fracture should include monitoring the circulation to the body part farther away from the head than the fracture for decreased or absent pulses, color of the area, skin temperature, and sensation.A record review of the facility's Timeliness of Documentation policy with last review date of 01/08 revealed: Clinical documentation which is handwritten or typed directly into the medical records software will be entered by the end of each shift. A skilled Medicare client requires daily documentation in the Medical record.An interview on 10/01/2025 at 9:57 AM with Registered Nurse (RN) A confirmed that residents who are in the facility for a Medicare skilled stay require daily documentation, and that the documentation should include VS and a full assessment.An interview on 10/01/2025 at 10:13 AM with Resident Care Manager (RCM) B confirmed that Resident 6 was in the facility for a Medicare skilled stay and did not have documentation of daily VS or assessments.An interview on 10/01/2025 at 1:10 PM with the Provisional Administrator (P. ADM) confirmed there was no documentation in Resident 6's Electronic Health Record (EHR) of communication with the medical provider regarding the resident's weight gain.An interview on 10/01/2025 at 4:36 PM with the P.ADM confirmed that with the diagnoses Resident 6 had of CHF, CKD, and a surgical repair of a right ankle fracture, assessments should have included shortness of breath and O2 sats, edema, and NV status of the right foot and that the EHR did not include daily assessments of those.An interview on 10/01/2025 at 4:36 PM with the Director of Nursing (DON) confirmed that with the diagnoses Resident 6 had of CHF, CKD, and a surgical repair of a right ankle fracture, staff should have assessed the resident for respiratory status including shortness of breath and O2 sats, edema, and NV status of the right foot at least daily. The DON confirmed the EHR did not include daily documentation of those assessments and that the required daily Medicare charting was not present.

Licensure Reference Number 175 NAC 12 -006.17(A)(v)Based on record reviews and interviews, the facility failed to maintain a complete and accurate medical record for 1 (Resident 6) of 6 sampled residents. The facility census was 132.Findings are:A record review of Resident 6's admission Record dated 09/30/2025 revealed the resident was admitted to the facility on [DATE] from an acute care hospital and discharged [DATE] to an acute care hospital. Further review of the admission Record revealed the resident had diagnoses of a right leg trimalleolar fracture (a fracture of three of the four ankle bones) that was surgically repaired, localized edema (swelling caused by fluid retention in the tissues), chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), congestive heart failure (CHF-a long-term condition in which the heart is unable to pump enough blood to meet the body's needs), an irregular heart rate, chronic kidney disease (CKD-a gradual loss of kidney function, resulting in the inability to filter waste and excess fluid from the blood), and acute kidney failure (a sudden [within hours or day] loss of the kidneys' ability to filter waste and excess fluids from the blood).A record review of Resident 6's 5-day Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 09/01/2025 revealed the resident had a Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15.A record review of Resident 6's Skilled Nursing Facility Physician admission Orders electronically signed by the physician on 08/28/2025 revealed the resident was in the facility for a Medicare skilled stay.A record review of the Order Summary Report dated 09/30/2025 that listed Resident 6's Active Orders as of 09/05/2025 revealed an order for DRESSING/INCISION CARE: Keep splint C/D/I [clean/dry/intact] until f/u [follow/up] appt. scheduled for every shift with a start date of 08/26/2025.A record review of Resident 6's hospital Discharge Summary dated 08/26/2025 revealed the resident was admitted to the hospital on [DATE] with the right ankle fracture after having fallen at home, and surgery to repair the right ankle was done on 08/20/2025.A record review of Resident 6's admission Assessment dated 08/26/2025 revealed that on admission the resident had strong pulses in both wrists and in the left foot, and a weak pulse in the right foot. Further review revealed the resident also had edema (swelling caused by fluid retention) in both legs. There was no mention of a cast or splint present to Resident 6's right leg.A record review of Resident 6's Progress Notes from 08/26/2025 to 09/30/2025 revealed the following:A Communication note dated 08/26/2025 at 11:00 PM from nursing that did not address edema, the neurovascular status (NV status-checking for pulses, skin temperature, color, and sensation) of the right foot, or the cast/splint on the right leg.A Medicare note dated 08/28/2025 at 3:35 PM from nursing that did not address edema, NV status, or the cast/splint on the right leg.A Nutrition note dated 09/02/2025 at 11:12 AM from the registered dietitian that stated there was no edema documentation noted.A Medicare note dated 09/02/2025 at 3:51 PM from nursing that did not address edema, NV status, or the cast/splint on the right leg.A Labs note dated 09/03/2025 at 11:37 AM from nursing that stated blood had been drawn for labs.A Care Conference note dated 09/03/2025 at 12:12 PM as a late entry from nursing that did not address edema, NV status, or the cast/splint on the right leg. The note did state that the resident had a six pound weight gain since admission.A Medicare note dated 09/03/2025 at 8:33 PM that stated the cast was in place. The note did not address edema or NV status of the right leg.A Medicare note dated 09/05/2025 at 2:54 PM from nursing stated the resident had edema to both legs. The note did not address NV status or the cast/splint to the right leg.A Transfer to ER/Hospital note dated 09/05/25 at 4:28 PM that stated the resident was transferred to the hospital by ambulance due to a change in condition, elevated creatinine (a waste product in the blood that measured how well the kidneys were functioning), weight gain and lethargy (drowsiness and an unusual lack of energy and mental alertness).A Communication note dated 09/06/2025 at 11:17 AM that stated Resident 6 had been admitted to the hospital for acute kidney injury (AKI-also called acute kidney failure).There were no other Progress Notes that addressed Resident 6's physical condition. There were four Medicare notes between admission [DATE] and discharge 09/05/2025.A record review of Resident 6's weight record revealed the following weights, measured in pounds:08/26/2025-none recorded08/27/2025-305.008/28/2025-none recorded08/29/2025-305.008/30/2025-309.008/31/2025-311.009/01/2025-309.509/02/2025-311.009/03/2025-316.409/04/2025-315.009/05/2025-316.4This was a gain of 11.4 pounds in ten days. There was no documentation of the medical provider being notified of Resident 6's weight gain.A review of Resident 6's vital signs (VS-temperature [T], pulse [P], respirations [R], blood pressure [B], and oxygen saturation [O2 sat-a measure of how much oxygen your blood is carrying as a percentage] section of the electronic health record and the Progress Notes revealed a total of 7 sets of VS. Two were done 08/26/2025, and one set each on 08/28/2025, 09/01/2025, 09/02/2025, 09/03/2025, and 09/05/2025.A record review of Resident 6's hospital ED [Emergency Department] Provider Notes dated 09/05/2025 revealed the resident's diagnosis was AKI superimposed (developed in addition to an existing condition) on CKD.A record review of the Lippincott Manual of Nursing Practice, 12th Edition, Copyright 2025 revealed that assessment for a resident with CHF should include heart sounds, lung sounds, and edema. An assessment for a resident with COPD should include heart and breath sounds, O2 sat, and how much effort it takes the resident to breathe. An assessment for a person with CKD should include a thorough physical examination, including vital signs, cardiovascular [heart], pulmonary [lung], GI [gastrointestinal, or stomach and digestive system], neurologic [brain and nervous system], dermatologic [skin], and musculoskeletal [muscles and skeleton] systems. An assessment for a resident who has had surgical repair of a fracture should include monitoring the circulation to the body part farther away from the head than the fracture for decreased or absent pulses, color of the area, skin temperature, and sensation.A record review of the facility's Timeliness of Documentation policy with last review date of 01/08 revealed: Clinical documentation which is handwritten or typed directly into the medical records software will be entered by the end of each shift. A skilled Medicare client requires daily documentation in the Medical record.An interview on 10/01/2025 at 9:57 AM with Registered Nurse (RN) A confirmed that residents who are in the facility for a Medicare skilled stay require daily documentation, and that the documentation should include VS and a full assessment.An interview on 10/01/2025 at 10:13 AM with Resident Care Manager (RCM) B confirmed that Resident 6 was in the facility for a Medicare skilled stay and did not have documentation of daily VS or assessments.An interview on 10/01/2025 at 1:10 PM with the Provisional Administrator (P. ADM) confirmed there was no documentation in Resident 6's Electronic Health Record (EHR) of communication with the medical provider regarding the resident's weight gain.An interview on 10/01/2025 at 4:36 PM with the P.ADM confirmed that with the diagnoses Resident 6 had of CHF, CKD, and a surgical repair of a right ankle fracture, assessments should have included shortness of breath and O2 sats, edema, and NV status of the right foot and that the EHR did not include daily assessments of those.An interview on 10/01/2025 at 4:36 PM with the Director of Nursing (DON) confirmed that with the diagnoses Resident 6 had of CHF, CKD, and a surgical repair of a right ankle fracture, staff should have assessed the resident for respiratory status including shortness of breath and O2 sats, edema, and NV status of the right foot at least daily. The DON confirmed the EHR did not include daily documentation of those assessments and that the required daily Medicare charting was not present.

Licensure Reference Number 175 NAC 12.006.18(B) Licensure Reference Number 175 NAC 12.006.18(D) Based on observation, interview, and record review, the facility failed to ensure Yellow Zone signs were posted at the entrances to the 100 hallway, ensure [NAME] Zone signs were posted on the entrances of [NAME] and Good Houses, and ensure passive screening education was posted at Good, [NAME], and [NAME] Houses to prevent the spread of COVID-19. This had the potential to affect all residents in the facility. The facility also failed to ensure Enhanced Barrier Precautions (EBP) signs were posted for Residents 18, 54, and 120, ensure staff placed a barrier between the carpeting and staff clothing in a contact isolation room, ensure a mask was worn above the nose and below the chin in a [NAME] Zone, ensure staff wore a gown and gloves in a contact isolation room, ensure hand hygiene and gloves changes were performed between wound sites during wound care on Resident 39, ensure the staff performed hand hygiene during wound cares for Resident 119, ensure staff performed hand hygiene during catheter cares for Residents 114, ensure staff did not use contaminated (dirty) gloves to obtain cleansing wipes from the clean container, and failed to use the required Personal Protective Equipment (PPE) for EBP during wound care for Resident 119 to prevent cross contamination. The facility census was 139. Findings are: A. A record review of the facility's 2024 Infection Prevention & Control Plan dated January 1st, 2024 revealed team members would provide resident's family and visitors education about infection prevention and transmission of communicable disease as appropriate. A record review of the facility's SNF (Skilled Nursing Facility) COVID-19 policy with a date reviewed of 10/16/2024, revealed the facility would provide passive screening education, such as visual postings, to all that enter the facility's buildings. The facility would not restrict visitation but would provide education on recommendations for PPE and/or infection control. In a [NAME] Zone everyone should mask in communal areas of the unit and staff should wear a surgical mask and eye protection. In a Yellow Zone staff would wear a N95 mask (a mask that filters very small particle of bacteria) and eye protection, residents would wear source control when out of the room and restrict communal dining. A record review of the facility's undated Attention All Visitors Respiratory Illness Alert sign revealed it was a passive screening education sign used by the facility that recommended a person delay visitation if they were experiencing any symptoms of a respiratory illness and had instructions if a person must visit. An observation on 12/12/2024 at 1:46 PM did not reveal any passive screening education at the entrances to [NAME], [NAME], or Good Houses. Staff were not wearing masks. An observation on 12/16/2024 at 6:23 AM did not reveal any passive screening education at the entrances to [NAME] or Good Houses. An observation on 12/16/2024 at 6:34 AM did not reveal [NAME] Zone signs at the entrances to [NAME] or Good Houses. An observation on 12/16/2024 at 6:36 AM did not reveal any passive screening education at the entrances to [NAME] House and staff were not wearing masks. An observation on 12/16/2024 from 9:38 AM until 10:01 AM with the facility's Infection Preventionist (IP) revealed there was now a [NAME] Zone sign on the entrances to Good and [NAME] Houses. There was no passive screening education sign on [NAME] House. The observation did not reveal Yellow Zone signs or any sign indicating what PPE should be used on the north entrance and entrance from the main lobby to the 100 hallway. In an interview on 12/11/2024 at 7:00 AM with the [NAME] President of Nebraska Operations confirmed 100 and 300 hallways were in a Yellow Zone due to residents had tested positive for COVID-19 in those areas. In an interview on 12/16/2024 at 6:23 AM with Licensed Practical Nurse (LPN)-B, the charge nurse for [NAME] and Good Houses, confirmed a housekeeping staff member tested Positive for COVID-19 on 12/11/2024 or 12/12/2024 and [NAME] and Good Houses were now in a [NAME] Zone and staff were required to wear masks. In an interview on 12/16/2024 at 2:16 PM with Licensed Practical Nurse (LPN)-B, the charge nurse for [NAME] and Good Houses, confirmed the Nurse Manager (NM)-G just put the [NAME] Zone signs up that morning at the entrances to [NAME] and Good Houses. In an interview on 12/17/2024 at 4:17 PM with the Administrator confirmed there were Yellow Zone signs for 100 hallway, but they were posted at the nurse's station which was by the elevator. Residents were still allowed to eat in the dining room which was between the main entrance to the 100 hallway and the nurse's station. In an interview on 12/16/2024 at 10:24 AM, the IP confirmed the 100 hallway went into a Yellow Zone on 12/11/2024 and [NAME] and Good House went to a [NAME] Zone 12/13/2024. The [NAME] Zone Signs should have been posted at the entrances to [NAME] and Good Houses on 12/13/2024, but the NM's did not work on the weekends and that was why it did not get done. In an interview on 12/16/2024 at 10:05 AM, the IP confirmed the undated Attention All Visitors Respiratory Illness Alert sign should have been at the entrances to [NAME], Good, and [NAME] Houses and was not. The IP confirmed there should have been Yellow Zone signs posted at all entrances to the 100 hallway and there were not. B. A record review of the facility's Enhanced Barrier Precautions policy with a review date of 10/26/2024 revealed EBP was to be used in conjunction with standard precautions and expanded the use of PPE to donning (putting on) a gown and gloves during high-contact resident care activities. Indications for use included residents with wounds, indwelling medical devices (inserted in the body), and infection or colonization (bacteria that live in the body without any problems) with a Multidrug-resistant Organism (MDRO, bacteria that resist treatment with more than one antibiotic). An observation on 12/11/2024 at 11:36 AM revealed Resident 120 was in the resident's room and had a visible urinary catheter bag hanging on side of the bed, but did not reveal an EBP sign in the room or restroom. An observation on 12/11/2024 at 12:05 PM revealed Residents 18 and 54 were in their rooms and had visible urinary catheter bags, but did not reveal an EBP signs in either of the resident's rooms or restrooms. An observation on 12/11/2024 at 12:22 PM revealed Residents 54 was in the resident's room and had visible urinary catheter bag, but did not reveal an EBP sign in the resident's room or restroom. An observation on 12/12/2024 at 1:31 PM revealed Resident 120 was in the resident's room and had a visible urinary catheter bag hanging on side of the bed, but did not reveal an EBP sign in the room or restroom. An observation on 12/16/2024 at 1:22 PM with LPN-B revealed Residents 18, 54, and 120 were in their rooms and had visible urinary catheter bags, but did not reveal an EBP sign in any of the resident's rooms or restrooms. In an interview on 12/16/2024 at 1:22 PM, LPN-B confirmed LPN-B could not find an EBP sign in Residents 18, 54, or 120's rooms and there should have been signs present. C. A record review of the facility's 2024 Infection Prevention & Control Plan dated January 1, 2024 revealed team members would support resident safety by adhering to all policies and procedures related to infection prevention. A record of the facility's undated QAPI (Quality Assurance and Performance Improvement), IPCP (Infection Prevention and Control Program), COVID, ASP (Antibiotic Stewardship Program) PowerPoint for staff revealed Contact Precautions was implemented when the resident had an infection that was spread through contact with the environment or resident. Contact Precautions help keep staff and visitors from spreading germs after touching the resident or their environment. A record review of Resident 88's Medical Diagnosis dated 12/12/2024 revealed the resident had a Stage 3 Pressure Ulcer (a wound that involved a full thickness loss of skin and some damage to the underlying tissue) of the right heel. A record review of Resident 88's Clinical Physician Orders dated 12/12/2024 revealed the resident had an order for wound care to the right heel and Antibiotic Charting: Resident placed on an antibiotic for Methicillin-resistant Staphylococcus Aureus (MRSA, bacteria that is resistant to the antibiotic Methicillin and very hard to treat) to the right heel. Contact precautions in place. A record review of Resident 88's Skin Progress Note dated 12/12/2024 revealed the resident had a Stage 3 Pressure Ulcer to the right heel that was 4.32 centimeters (cm) long and 4.47 cm wide with light exudate of serosanguineous (contains blood and a clear, yellowish liquid) fluid, and less than 25% dressing saturation. In an observation on 12/12/2024 at 12:25 PM revealed the resident's dressing were saturated through the kerlix (dry wrap dressing) at the wound area. Advanced Practice Registered Nurse (APRN)-E was sitting on the floor in front of the resident with APRN's clothing in direct contact with the carpeting in the resident's room. After APRN-E completed evaluating and debriding (removed damaged tissue), LPN-A got dressings and kneeled down in front of the resident to dress the wounds. LPN-A's clothing was in direct contact with the carpeting in Resident 88's room. In an interview on 12/16/2024 at 9:38 AM, the facility's IP confirmed APRN-E and LPN-A should have placed a barrier on the floor prior to getting on the floor during wound care to prevent cross contamination (spread of bacteria) from the resident's carpeting to the staff's clothing. D. A record review of the facility's SNF COVID-19 policy with a date reviewed of 10/16/2024 revealed the facility would provide passive screening education, such as visual postings, to all that enter the facility's buildings. The facility would not restrict visitation but would provide education on recommendations for PPE and/or infection control. In a [NAME] Zone everyone should mask in communal areas of the unit and staff should wear a surgical mask and eye protection. In a Yellow Zone staff would wear a N95 mask and eye protection, residents would wear source control when out of the room and restrict communal dining. An observation on 12/16/2024 from 9:38 AM until 10:01 AM with the facility's Infection Preventionist (IP) revealed there was now a [NAME] Zone sign on the entrances to Good and [NAME] Houses. An observation on 12/16/2024 at 1:17 PM revealed a sign posted by the entrance door to [NAME] House that revealed: Attention, [NAME] Zone, team members - surgical masks and hand hygiene (cleaning) and guests - surgical masks recommended and hand hygiene. An observation on 12/16/2024 at 1:55 PM revealed Supply Chain (SC)-D staff member entered [NAME] House from Good House, walk to the supply closet, and walk back out of [NAME] House to Good House with the entire N95 mask below their chin. SC-D was within 6 feet of staff and residents. In an interview on 12/16/2024 at 2:00 PM, LPN-B, the charge nurse, confirmed SC-D should have had a mask on above the nose and below the chin while in the [NAME] Zone. E. A record of the facility's undated QAPI, IPCP, COVID, ASP PowerPoint for staff revealed Contact Precautions were implemented when the resident had an infection that was spread through contact with the environment or resident. Contact Precautions help keep staff and visitors from spreading germs after touching the resident or their environment. An observation on 12/12/2024 at 1:19 PM revealed Housekeeping Aide (HA)-C entered Resident 88's room with only an N-95 mask on to clean the restroom. There was a sign on the door as you enter the room that said: Attention, Contact Precautions. hand hygiene, gown, and gloves were needed to enter the room. In an interview on 12/12/2024 at 1:22 PM, HA-C confirmed HA-C did not wear a gown or gloves when HA-C entered Resident 88's room and cleaned the restroom. In an interview on 12/16/2024 at 9:46 AM, the facility's IP confirmed HA-C should have donned a gown and gloves before entering Resident 88's room. F. A record review of the facility's Wound and Skin Care Management policy with a date reviewed of 11/11/2023 revealed the facility would provide care and services to promote prevention and management of skin injuries. A record review of Resident 39's Order Summary Report dated 12/16/2024 revealed orders for: Wash right heel, apply Silvadene (antibiotic cream used to treat or prevent infections) and cover with Mepilex (a foam wound dressing). Wash left toe and 4th left toe, apply Silvadene, and cover with bandaids every evening shift for wound care. Vaseline Gauze, 4x4, and wrap with kerlix on skin tear to right lateral (outside) leg every evening shift. An observation on 12/17/2024 at 11:31 AM revealed Resident 88's wound physician examined the resident's right lateral shin wound, debrided left great toe and right heel, and examined the left 4th toe. LPN-F cleansed and dressed the resident's right lateral shin with no concerns. LPN-F then cleansed right heel and left toes with no concerns. LPN-F washed hands for greater than 20 seconds, applied gloves, and went to get Silvadene and there was none in the room or in the medication cart. Resident 88's wound physician ordered to use Xeroform (a petroleum-based antibiotic dressing) instead of the Silvadene. The facility's IP brought in a package of Xeroform and a pair of scissors. LPN-F completed handwashing for greater than 20 seconds, applied new gloves, opened the Xeroform package and cut a piece to the size of the right heel wound, opened the Mepilex dressing and applied it to the right heel, cut 2 more pieces of Xeroform to the size of the wounds on the left toes and applied a dressing to each toe wound, then opened 3 bandages and applied 1 bandage to the left great toe and 2 bandages to the left 4th toe over the Xeroform all without performing hand hygiene and glove changes between wound sites. In an interview on 12/17/2024 at 12:14 PM, LPN-F confirmed LPN-F should have performed hand hygiene and glove changes between body sites during the application of dressings to the wounds. In an interview on 12/17/2024 at 12:19 PM, the facility's IP confirmed LPN-F should have performed hand hygiene and glove changes between wound sites during the application of dressings to the wounds. 47406 G. Record Review of facility policy, Hand Hygiene and Gloving Policy dated 10/26/24 revealed: It is the policy of the facility to utilize appropriate hand hygiene practices to prevent and control the spread of infection. Procedure: 4. For procedures related to hand hygiene, refer to EBSCO, CDC guidelines, or hand hygiene competency. Record review of facility policy Hand Hygiene Competency Policy with revision date of 6/9/24 revealed: 1. Prepare a paper towel if not visible. 2. Turn on the water and wet your hands and wrists while holding your fingertips down, 3. Apply soap and work into a lather. 4. Rub all surfaces of hands, between fingers, under nails, and at minimum 2 inches above the wrists continuously for at least 20 seconds. 5. Rinse hands under running water without touching the sink or faucet, holding fingertips downward. Do not flick or shake fingertips to dry. 6. Dry hands and wrist thoroughly using a paper towel without touching the towel dispenser or sink. 7. Dispose of the paper towel into a waste container. 8. Using a new paper towel, turn the faucet off and dispose of the paper towel into a waste container. Record review of facility policy, Enhanced Barrier Precaution Policy dated 10/26/24 revealed: It is the policy of the facility to follow best practice guidance related to enhanced barrier precautions on a case-by-case analysis of risk factors. Purpose: The purpose of this policy is to decrease the likelihood of transmission of infectious diseases through the use of enhanced barrier precautions. PPE (Personal protective Equipment) Procedure: 1. Use Enhanced Barrier Precautions (EBP) when performing high contact resident care activities for residents who meet the criteria for the use of EBP. b. Hand hygiene upon entering and leaving the room. 2. High-Contact cares may include: d. Providing hygiene h. Wound Care: Any skin opening requiring a dressing. 3. Intended to be uses for the resident's entire length of stay in the facility, or until wound is healed or invasive device is removed. Record review of Resident 119's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 10/6/24 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 119's diagnoses dated 12/12/24 revealed diagnoses of Pressure-Induced Deep Tissue Damage of Right Heel and Pressure Ulcer of left buttock, stage 3. Record review for Resident 119's physician orders revealed: -EBP related to wounds two times a day with a start date of 08/29/2024. -Apply dry Hydrofera blue rope with a little piece out of the wound to left buttocks. Cleanse with soap and water vigorously and change daily. Continue to cover the wound with 4x4 gauze and Tegaderm every day. This order had a start date of 12/4/24. Observation on 12/16/24 at 7:15 AM of Resident 119's wound cares completed by LPN-J. LPN-J performed hand hygiene with soap and water for 15 seconds and donned gloves. LPN-J did not put a gown on. LPN-J removed the old dressing from left upper buttock wound. LPN-J took off their gloves, performed hand hygiene for 14 seconds and donned new gloves. LPN-J sprayed foam cleanser-no rinse needed onto gauze and cleansed the wound. LPN-J removed their gloves, performed hand hygiene for 16 seconds, and donned new gloves. LPN-J applied a small piece of Hydrofera blue rope in wound, covered with dry 4x4 gauze and secured with Tegaderm dressing. LPN-J removed their gloves and performed hand hygiene for 16 seconds. Interview on 12/16/24 at 10:43 AM with LPN-J revealed [gender] should have worn a gown when performing wound cares and washed hands with soap and water for at least 20 seconds. Interview on 12/16/24 at 1:09 PM with NM-K confirmed the staff needs to perform hand washing at least 20 seconds and to wear a gown when doing wound cares. H. Record review of facility policy Perineal Care: Male/Female & Catheter Care Competency dated 6/9/24, revealed staff were to arrange supplies to avoid contaminating clean items. Record review of Resident 114's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 10/12/24 revealed the resident was admitted to the facility on [DATE] and required maximum assistance with their toileting hygiene. Record review of Resident 114's physician's orders dated 12/12/24 revealed an order for catheter cares to be performed every shift. Observation on 12/16/24 at 6:30 AM with MA-L performing catheter cares on Resident 114 in the resident's room. EBP supplies were in a container in the room. MA-L applied a gown and then performed hand hygiene with soap and water for 12 seconds and donned gloves. MA-L took a cleansing wipe from the container and wiped the resident's pubic area, then got another wipe from the container with the same glove and washed both sides of the resident's groin, folding the wipe between sides. MA-L obtained another wipe from the container with the same soiled glove and cleansed the resident's urethral meatus and continued down the catheter tubing several inches. MA-L then removed the soiled gloves, performed hand hygiene with hand sanitizer, and donned new gloves. MA-L changed the resident's brief and cleansed the perineal area. MA-L removed their gown and gloves and washed their hands for 18 seconds. Interview on 12/16/24 at 7:00 AM with MA-L revealed that [gender] should not have placed their dirty glove into the cleansing wipes container and their hands should have been washed with soap and water for at least 20 seconds. Interview on 12/16/24 at 1:07 PM with NM-K confirmed the staff needs to perform hand washing for at least 20 seconds and staff was not to use soiled gloves when getting wipes out of the cleansing wipe container.

Licensure Reference Number 175 NAC 12-006.11(A)(1) Based on observation, interview, and record review; the facility failed to follow recipes when preparing resident meals. This had the potential to affect the 93 residents who received food from the kitchen. The facility identified a census of 139. Findings are: A record review of the recipe titled PU4 Hot Dog Beef 8/1 on Bun (PU4 Hot Dog on Bun) and dated 12/16/24 revealed the following instructions: -Ingredients: Hotdog Beef 8/1 on Bun, 2 each. 1/2 cup of water. 1/2 cup of Low Sodium (LS) Soup Broth Beef/Base. -Puree Bread: Tear or cut bread product into smaller pieces to facilitate blending, then add to blender or food processor. Pour in liquid. Blend until desired consistency is reached. Add additional liquid to achieve desired consistency. -Puree Filling: Place sandwich filling in blender or food processor. Add broth or other liquid. Blend until desired consistency is reached. Add additional liquid if needed to achieve desired consistency. -Sandwich Serving: Place 1 #12 scoop of the filling between 2 #12 scoops of bread. A continuous observation of meal prep being completed that began on 12/16/24 at 9:57 AM by Cook-N and being observed by the Culinary Director, revealed preparation of hot dogs. Cook-N was following a to do list which was lying on the prep table on top of the recipes for the meal. The observation revealed Cook-N grabbing a clear plastic pitcher and scooped water from the pot that the hotdogs were boiling in and poured that water into a blender. Cook-N then added 2 hotdogs, more hot water and a liquid thickener to the blender. When asked how Cook-N knew how much water or liquid to use when pureeing the hot dogs, Cook-N stated I just use whatever is needed. Cook-N was then observed chopping up some hotdogs for the ground consistency meals. The pureed consistency hotdogs was noted to be a watery liquid consistency. Cook-N then placed lids on the bowls of pureed and ground hotdogs and placed them into the warming carts going to the floors for lunch. The observation revealed that no bread or bun had been used for the resident meals. During an interview on 12/16/24 at 9:57 AM with the Culinary Director, it was confirmed that Cook-N did not prepare any buns and did not measure any of the water used, but should have. The Culinary Director also confirmed that Cook-N did not have the recipe out or use it during meal preparation.

Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) related to the use of an anticoagulant (a medication used to prevent and treat blood clots in blood vessels and the heart) for 1 (Resident 30) of 5 sampled residents. The facility census was 139. Findings Are: A record review of the Resident Assessment Instrument (RAI, a manual used to provide instructions on how to complete the MDS and the care plans) User's Manual, with effective date of October 1, 2019, under N0410: Medications Received - Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel. Record review of Resident 30's Quarterly MDS dated [DATE] revealed: -The resident was admitted to the facility on [DATE], -For anticoagulant use under the column is taking anticoagulant was checked. Record review of Resident 30's Medication Administration Record (MAR) for September and October of 2024 revealed no use of an anticoagulant. Record review of Resident 30's Comprehensive Care Plan (CCP, written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed no use of anticoagulant for the resident's cardiovascular status. Interview on 12/17/24 at 10:47 AM with the MDS Director revealed the facility used the RAI manual to ensure MDS accuracy and that anticoagulant should not have been marked for Resident 30.

Based on interviews and record reviews, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR Level II, a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) for 1 (Resident 4) of 4 sampled residents was completed as required. The census of the facility was 139. Findings are: Record review of the facility's undated Preadmission Assessment and Annual Resident Review Screening (PASARR) Policy revealed that all admissions to the facility will have a PASARR completed. For any admission with a Level II screen, the facility will follow the recommendations on the PASARR screen. Record review of Resident 4's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 11/28/24 revealed the resident was admitted to the facility on [DATE]. Record review of Resident 4's diagnoses dated 12/12/24 revealed the following diagnoses: -Generalized Anxiety Disorder (a condition characterized by excessive anxiety and worry about a variety of events or activities that occurs more days than not, for at least 6 months), -Major Depressive Disorder- Recurrent Severe without psychotic features (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 -Bipolar Disorder, unspecified (a condition characterized by dramatic shifts in mood, energy, and activity levels that affect a person's ability to carry out day-to-day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs that are experienced by everyone). Record review of Resident 4's PASARR II (PASRR Level II is a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) dated 3/14/24 revealed: -This resident was found to have a serious mental illness. -This resident did require, and was appropriate for nursing facility services at that time. -The number of days approved was 180. Record Review of Resident 4's medical records revealed no evidence of an additional PASRR Level II evaluation being completed after the initial 180 days had passed. Interview on 12/16/24 at 2:46 PM with Social Worker (SW)-M revealed that Resident 4's PASRR Level II evaluation was due in September 2024 and it had not been done. Interview on 12/17/24 at 7:30 AM with the administrator revealed that Resident 4's next PASRR Level II evaluation was due in September 2024 and that had not been completed.

Licensure Reference Number 175 NAC 12-006.12B Based on observations, interviews, record reviews, and review of policy and procedures, the facility failed to ensure a resident received adequate monitoring for appropriate dosing, indications for use, and adverse (harmful) effects for ophthalmic (administered in the eyes) [MEDICATION(S)] (steroid). This affected one of seven residents (Resident 399) reviewed for unnecessary medications. This deficient practice resulted in Resident 399 receiving [MEDICATION(S)] directly into both the resident's eyes four times a day from 01/10/2020 to 09/10/2020. On 09/11/2020, Resident 399 was diagnosed with steroid induced [CONDITION(S)] (increased pressure inside the eye, which over time causes loss of vision), which led to [CONDITION(S)], mental anguish, inability to cope with the loss of a sense, and depression. The facility census was 149 residents. Findings are: A review of the facility's policy titled, Interdisciplinary Care Planning Resident Assessment Instrument (RAI), dated 06/08/2016, indicated all members of the core team were responsible for reviewing the client's condition and attending each meeting prepared to discuss pertinent information. The policy indicated the Social Worker (SW) was responsible for leading the meeting. The policy indicated a significant change of condition assessment was required to be done within seven days for a decline in condition. The policy defined a significant change of condition as a major change in status that was not self-limiting (resolved itself), impacted more than one health status area, and required Interdisciplinary Team (IDT) review and revision of the care plan. A review of Resident 399's admission record indicated the facility admitted the resident on 04/03/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 399's Minimum Data Set (MDS - a standardized assessment tool for health status), dated 08/05/2020, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated Resident 399 required extensive assistance of one staff member when turning or repositioning in bed, transferring between the bed and chair, toileting, and maintaining personal hygiene. A review of Resident 399's care plan for diabetic retinopathy with macular [CONDITION(S)] (disease of the retina with impaired vision due to a build-up of fluid in the macula, a part of the eye), dated 06/18/2018, indicated interventions to avoid complications included administering eye drops per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 399's care plan for risk for serotonin syndrome (a condition that affects the nervous system and occurs when there is a chemical build-up caused by medications) related to polypharmacy (use of multiple medications), dated 03/29/2019, indicated a goal of preventing adverse drug reactions for Resident 399. The care plan indicated nursing interventions to accomplish this goal included reviewing recommendations made by the CP and following up on them. The care plan also indicated nurses were to review all medications with the physician and/or CP to ensure that no duplicate orders were present and that the medications were properly dosed, timed, and no adverse reactions were present. A review of Resident 399's Order Summary Report, dated 01/08/2020 at 7:08 AM, indicated the resident was receiving [MEDICATION(S)] suspension 1% eye drops: one drop in both eyes four times daily due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Order Summary Report indicated the original order date for the [MEDICATION(S)] was 11/12/2019. A review of Davis' Drug Guide 2020-2021 indicated [MEDICATION(S)] was classified as a corticosteroid (medications used to treat inflammation) The guide indicated the lowest dose should be prescribed for the lowest amount of time. The guide indicated adverse effects which included [CONDITION(S)] and increased intraocular (in the eyeball) pressure. The guide indicated alternate day therapy was preferable for long term use. The guide indicated a precaution advising not to discontinue the medication abruptly. A review of Resident 399's Physician Visit Record, dated 01/13/2020 (no time), indicated the resident was seen by the ophthalmologist that day. The note indicated the resident had ocular (eye) medications that included [MEDICATION(S)] suspension 1% eye drops: one drop in both eyes four times daily. The note did not indicate a follow-up visit or plan. A review of Resident 399's interdisciplinary team (IDT) notes, dated 03/04/2020 at 11:00 AM, indicated the resident would get books through the mail from the library but had not been able to read due to issues with the resident's eyes. The notes did not indicate what actions were taken in response to the eye issues. A review of Resident 399's Order Summary Report, dated 04/01/2020 at 1:40 PM, indicated the resident was still receiving [MEDICATION(S)] suspension 1% eye drops: one drop in both eyes four times daily. A review of Resident 399's pharmacist medication reviews from 01/21/2020 to 04/16/2020 indicated no recommendations were made by the pharmacist regarding the resident's medication order for [MEDICATION(S)] (a steroid) suspension 1% eye drops: one drop in both eyes four times daily. A review of Resident 399's pharmacist medication reviews for May 2020 indicated no medication review was documented. A review of a faxed situation background assessment and recommendation (SBAR) form, dated 05/05/2020 at 3:22 PM, indicated the facility reviewed Resident 399's medication list and was requesting the physician discontinue three medications, one of which was artificial tears. The form did not indicate any documentation about the [MEDICATION(S)] eye drops. The form indicated the physician reviewed the medication list and replied on 05/06/2020 at 11:00 AM with orders to discontinue the artificial tears. The physician did not give orders pertaining to the [MEDICATION(S)] eye drops. A review of Resident 399's IDT notes, dated 05/27/2020 (no time), indicated the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDT notes did not indicate when the last or next eye doctor appointment was. A review of Resident 399's Order Summary Report, dated 06/18/2020 at 9:33 AM, indicated the resident was still receiving [MEDICATION(S)] suspension 1% eye drops: one drop in both eyes four times daily. A review of Resident 399's IDT Notes, dated 08/19/2020 at 10:45 AM, indicated the resident had diabetic retinopathy with macular [CONDITION(S)] (fluid buildup in the colored part of the eye) and was followed by an ophthalmologist. The notes indicated the resident was receiving eye drops as ordered. The IDT notes did not indicate which eye drops. The IDT notes indicated Resident 399 reported the resident's vision was getting worse, and the facility would schedule an appointment. The IDT notes did not indicate when the last or next eye doctor appointment was. A review of Resident 399's medical record indicated the resident did not have a follow-up visit with the ophthalmologist from 01/14/2020 to 09/10/2020. A review of Resident 399's progress note, dated 09/05/2020 at 11:09 AM, indicated the resident was spilling the resident's iced tea and reported it was because the resident was not being able to see. The note indicated LPN AA advised the staff to put lids on Resident 399's cups. The note did not indicate the resident's physician was notified about Resident 399's vision problem. A review of Resident 399's progress note, dated 09/09/2020 at 4:24 PM, indicated the resident's physician called the facility and requested the resident be seen by an ophthalmologist that week because he felt the resident may have had endophthalmitis (inflammation to the fluids in the eye due to infection) due to a urinary infection. The note indicated LPN AA informed the physician the resident had an appointment on 09/14/2020. A review of Resident 399's Physician's Visit Record, dated 09/11/2020 (no time), indicated the resident was seen by the ophthalmologist that day. The notes indicated the ophthalmologist diagnosed Resident 399 with Steroid Induced [CONDITION(S)] (the nerve connecting the eye to the brain is damaged due to steroid use), active stage severe in both eyes. The notes also indicated the ophthalmologist reduced the [MEDICATION(S)] eye drops to twice a day. A review of Resident 399's progress note, dated 09/11/2020 at 4:02 PM, indicated the resident saw an optometrist earlier that day and returned with multiple eyedrop orders, which included a reduction in the frequency of the [MEDICATION(S)] eye drops from four times a day to two. A review of Resident 399's progress note, dated 09/13/2020 at 3:55 PM, indicated the resident required help with eating due to loss of vision. The note indicated the resident was on three different eye drops. The note did not indicate the resident's physician was notified about the resident requiring help with eating due to vision loss. A review of Resident 399's Order Summary Report, dated 09/14/2020 at 6:39 PM, indicated the resident's [MEDICATION(S)] suspension 1% eye drops was reduced to: one drop in both eyes two times daily. A review of Resident 399's pharmacist medication reviews, from 06/16/2020 to 09/17/2020, indicated no recommendations were made by the pharmacist regarding the resident's medication order for the [MEDICATION(S)] eye drops. A review of Resident 399's progress note, dated 09/20/2020 at 2:27 PM, indicated the resident reported not being able to see. The note indicated MDS Coordinator X watched the resident eat unassisted, asked the resident what show they were watching, and asked the resident to grab the bathroom grab bar as a way of assessing the resident's eyesight. The note indicated LPN AA asked Resident 399 how the therapy session went, and Resident 399 informed LPN AA it did not go well because the resident could not see what they were trying to show [the resident]. The note indicated Resident 399 informed the nurse that the therapist was trying to show the resident the exercises but Resident 399 could not see them. The note did not indicate the resident's physician was notified about Resident 399's vision problem. A review of a faxed SBAR form, dated 09/23/2020 at 10:37 AM, indicated the facility was requesting a geriatric counselor for Resident 399 because the resident was displaying sadness due to the loss of vision. The form indicated the physician replied on 09/23/2020 at 5:55 PM and agreed with the need for a counselor. The form also indicated the physician wanted the nursing staff to inform the resident that the vision loss was not permanent per the ophthalmologist note and should resolve over time. A review of Resident 399's Physician's Visit Record, dated 09/26/2020 (no time), indicated the resident was depressed and still adjusting to [CONDITION(S)]. The record indicated the resident was to receive support therapy. A review of Resident 399's progress note, dated 10/01/2020 at 2:59 PM, indicated the resident had a difficult time adjusting since the [CONDITION(S)] diagnosis. The note indicated the resident would become tearful easily and yell out often. A review of Resident 399's progress note, dated 10/04/2020 at 9:30 AM, indicated the resident did not want to leave the resident's bed, eat or drink, and did not want visitors. The note indicated the resident wanted to be left alone to sleep. A review of Resident 399's Order Summary Report, dated 10/06/2020 at 4:50 PM, indicated the resident was no longer receiving the [MEDICATION(S)] eye drops. A review of Resident 399's Physician's Visit Record, dated 10/07/2020 (no time), indicated the physician added a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 399's progress note, dated 10/07/2020 at 4:47 PM, indicated Resident 399's family member was informed that occupational therapy was going to be discontinued. The note indicated the family member was frustrated and asked why the facility was giving up on Resident 399 after only two weeks of therapy. The note indicated the family member expressed how the loss of vision was new and wanted to know what options they had to keep therapy going. A review of Resident #399's physician's visit record, dated 12/08/2020 (no time), indicated the resident's condition was worsening over the last month, and the resident was confused, sleepy, and not eating. The record indicated due to the vision not improving, the family wanted to place the resident on hospice. During an interview on 09/23/2021 at 10:26 AM, the Consultant Pharmacist (CP) stated CP oversaw Resident 399's medication regimen review. The CP stated medication reviews were performed monthly and included reviewing the indications for use, dosing, and appropriateness of use. The CP stated [MEDICATION(S)] eye drops were also required to be reviewed monthly for the duration the resident was taking them. The CP stated the duration for use was dependent on why the resident was receiving the [MEDICATION(S)] eye drops, and CP was not sure why the [MEDICATION(S)] was not addressed. The CP stated CP did not recall her thought process as to why the [MEDICATION(S)] was not reviewed or addressed by CP. During an interview and record review on 09/23/2021 at 10:55 AM, the Director of Nursing (DON) reviewed Resident 399's Physician Visit Record dated 01/13/2020 (no time). The DON stated the physician continued the [MEDICATION(S)] and did not write any instructions for a follow-up visit. The DON stated follow-up visits were usually indicated on the post-visit notes. The DON stated the resident did not see the ophthalmologist until September 2020. The DON stated all medications ordered were reviewed by the physician during each 60-day review, even if ordered by a specialty physician. The DON stated the CP did a monthly review of all medications and provided recommendations. The DON stated that due to COVID-19, the facility pulled back on outside visits, but tele health visits were still available. The DON reviewed Resident 399's Physician Visit Record, dated 09/11/2020 (no time), and stated the ophthalmologist diagnosed the resident with steroid induced [CONDITION(S)], which was because the resident was still on the [MEDICATION(S)] eye drops. The DON stated the [MEDICATION(S)] drops were reduced during the visit and not stopped because steroids could not be abruptly stopped. The DON stated she was not sure why steroids had to be tapered down but knew there could be adverse effects if they were not. The DON reviewed the pharmacy medication reviews for 2020 and confirmed the pharmacy medication review did not address the [MEDICATION(S)] medication, and a medication review was not done in May 2020. The DON stated the [MEDICATION(S)] should have been addressed by the CP because the CP knew the indications for use and potential adverse effects. The DON stated it was the facility's expectations that the CP perform a medication review every month. The DON reviewed all of Resident 399's progress notes from all disciplines (physician, nursing, social work, etc.) from January 2020 to September 2020 and confirmed the [MEDICATION(S)] was not addressed by any discipline in that time frame. The DON stated that on 08/19/2020 during the care plan meeting, Resident 399 complained the resident's vision was getting worse. The DON confirmed no follow-up action was taken. The DON stated on 09/02/2020 that Resident 399 reported not being able to see and felt the actions taken by the nurse to assess the resident's vision were appropriate. The DON stated the nurse made sure the resident could feed self and asked the resident what they were watching, and the resident was able to tell her. The DON could not confirm if the volume of the television was turned off to ensure the resident was only assessing eyesight and not hearing. The DON confirmed the resident also reported not being able to see the exercises the therapist was trying to show the resident. The DON confirmed the physician was not notified and stated she felt the nurse took the appropriate action because the resident was being subjective. The DON stated that on 09/05/2020, Resident 399 was spilling tea because the resident could not see. The DON stated the on-call physician was notified, and the on-call physician stated he would notify the resident's primary physician. The DON confirmed the nurse did not document a follow up call to ensure the primary physician was notified. The DON stated on 09/09/2020, the resident's physician called and stated he wanted the resident seen that week. The DON stated the resident saw the ophthalmologist on 09/11/2020 and the ophthalmologist told the resident that the resident was going blind.

Licensure Reference Number: 175 NAC ,[DATE].04C1(3) Based on record review and interview, the facility failed to re-educate staff to perform Cardio-Pulmonary Resuscitation (CPR) according to staff policy and standards of practice for one resident (Resident 3). The facility census was 185. Findings are: Review of Resident 3's progress notes dated [DATE] revealed Resident 3 was found unresponsive and without a pulse. Licensed Practical Nurse (LPN) A initiated CPR and sent word for another nurse to call a code and get the crash cart. 911 was called and emergency medical professionals arrived at the facility. Review of the Lincoln Fire & Rescue Patient Care Report dated [DATE] revealed, Inadequate bystander CPR being performed on pt (patient) bed on arrival of LFR (Lincoln Fire & Rescue) crew. Review of the facility's internal investigation dated [DATE] revealed LPN B's statement to be, Upon 911 arriving and taking over the scene, resident was moved to the floor per 911 recommendations. CPR resumed. Interview with Registered Nurse (RN) C on [DATE] at 5:15 PM revealed RN C was the nursing supervisor on duty when CPR was performed on Resident 3. RN B explained that the crash cart was kept on each unit and was equipped with a suction machine, gloves, masks and a back board to be used when performing CPR. RN B further reported that upon entering Resident 3's room on [DATE], staff had already initiated CPR and the crash cart had already been brought to the resident's room. RN B could not say if the back board was in use or not. Interview with LPN A on [DATE] at 4:08 PM revealed staff performed CPR on Resident 3 while Resident 3 was in the bed and no back board was used. Interview with LPN B on [DATE] at 2:15 PM revealed that LPN B took the crash cart to Resident 3's room and began to assist with CPR. LPN B further confirmed that CPR was performed while Resident 3 was lying in the facility bed which was equipped with a standard mattress. LPN B reported that 911 personal did not have any comments regarding the way CPR was being completed by the facility upon their arrival. LPN B reported no training or instruction was given on how staff should improve their process when performing CPR. Interview with the Director of Nursing (DON) on [DATE] at 2:30 PM revealed staff were not provided education on the importance of using the back board when performing CPR. Review of the untitled policy and procedure provided by the facility regarding performing CPR printed on [DATE] revealed, 2. Notify staff of the need to bring emergency equipment or code cart to the patient's room .b. CPR board. 4. Place the patient supine on a firm surface. According to the 2015 American Heart Association Guidelines, patients should be placed on a hard surface in a supine position for the implementation of CPR.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to evaluate causal factors, failed to evaluate nutritional requirements for pressure ulcer healing, failed to monitor a pressure ulcer and failed to follow up with the physician for a treatment change for a pressure ulcer for one resident (Resident 346). In addition, the facility failed to identify a wound as a pressure ulcer, failed to provide ongoing assessments of a pressure ulcer to ensure healing and failed to prevent a pressure ulcer from occurring for Resident 297. The facility staff identified a census of 208. Findings are: Record review of a Diagnosis/History sheet printed on 3-18-2015 revealed Resident 346 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 346's MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated 1-8-2015 revealed the facility assessed the following about the resident: -BIMs (Brief Interview of Mental Status) was a 2. According to the MDS manual, a score of 2 indicated severe cognitive impairment. -The resident required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -No pressure ulcers were identified on the MDS. Record review of Resident 346's Braden Scale (tool used for predicting pressure ulcer risk) Assessment report dated 1-2-2015 revealed Resident 346's score was 12. According to the documentation on the Braden Risk assessment Report, as score of 12 placed Resident 346 at high risk for the development of a pressure ulcer. Record review of Resident 346's Comprehensive Care Plan (CCP) dated 1-17-2014 revealed Resident 346 was at risk for skin breakdown. The goal identified for Resident 346 was to .remain free from skin breakdown. Record review of a Fax sheet dated 2-11-2015 revealed Resident 346's physician was informed that Resident 346 had a pressure ulcer to the Left Shoulder blade area that measured 2.6 cm (centimeter) by 1.4 cm. Record review of a Wound Assessment Report dated 2-10-2015 revealed Resident 346 was identified with a stage 2 (partial thickness skin loss involving epidermis, dermis, or both. The ulcer was superficial and presented clinically as an abrasion, blister or shallow crater) pressure ulcer. The pressure ulcer length was 2.60 cm, width was 1.40 cm and the depth was 0.20 cm. There was not any slough (dead yellowish tissue) or eschar (thick black necrotic tissue). Record review of a Food and Nutrition-Dietitian Assessment (FNDA) dated 1-12-2015 revealed that the stage 2 pressure ulcer had not been identified on the FNDA. Further review of the FNDA revealed there was not an evaluation of Resident 346's nutritional requirements for pressure ulcer healing. Record review of a Fax sheet dated 3-09-2015 revealed Resident 346's Wound on left scapula is not showing signs of healing. Wound has dark sl (slightly) moist red center with 25% eschar et (and) dk (dark) pink edges. According to the information on the fax sheet dated 3-09-2015, Resident 346's physician responded (gender) would try to make a house call this week. Record review of Resident 346's medical record that include physician progress notes [REDACTED]. ulcer not showing signs of healing. Further review of Resident 346's record did not contain any evidence that casual factors for the development of the pressure ulcers had been completed for Resident 346. Record review of a Wound Assessment Report sheet dated 3-18-2015 revealed the pressure ulcer to the left shoulder measured 2.0 cm by 1.0 cm by 0.15 had 60% eschar and was a stage 3 ( Full thickness loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but no through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) pressure ulcer. Observation on 3-18-2015 at 10:58 AM with Licensed Practical Nurse (LPN) Z was conducted of Resident 346 pressure ulcer to the left shoulder. The pressure ulcer to the left shoulder had yellowish gray tissue in the center with blackish surrounding tissue. LPN Z reported the size of the pressure ulcer to be 2.5 cm round. Observation on 3-18-2015 at 9:22 AM revealed Resident 346 was seated in a wheelchair in the dining room for breakfast. Resident 346 was observed to lean to the left leaning onto the handlebar of the wheelchair, placing pressure onto the left shoulder pressure area. There was no pressure relief between Resident 346's left shoulder and the handlebar of the wheelchair. Observation on 3-18-2015 at 11:55 AM revealed Resident 346 was seated in a wheelchair in the Dining room for lunch. Resident 346 was observed leaning to the left placing pressure onto the left shoulder pressure ulcer. The wheelchair did not have pressure relieving device in place to the left shoulder area. An interview was conducted with LPN Z on 3-18-2015 at 10:58 AM. During the interview, LPN Z confirmed the pressure ulcer to Resident 346's left shoulder had necrotic tissue. A follow up interview was conducted with LPN Z on 3-18-2015 at 11:25 AM. During the interview when asked if LPN Z had seen Resident 346 leaning in the wheelchair to the left, LPN stated yes. LPN Z reported that Resident 346 was leaning to the left in the wheelchair onto the pressure ulcer area. An interview was conducted on 3-19-2015 at 11:08 AM with the Director of Nursing (DON). During the interview, the fax sheet dated 3-09-2015 was reviewed with the DON. When asked what the expectation to follow up on faxes when there has not been a response, the DON stated within 24 hours. The DON further confirmed causal factors are to be evaluated when a resident develops a pressure ulcer. The DON confirmed there was not an evaluation of Resident 346's nutritional requirements for pressure ulcers. B. Observation on 3-18-2015 at 10:58 AM with Licensed Practical Nurse (LPN) Z of Resident 346 right heel revealed a pressure ulcer. LPN Z gave the measurement of the heel ulcer as 2.5 cm round. Observation on 3-18-2015 at 2:47 PM with Nursing Assistant (NA) Y of Resident 346's right heel revealed .it's been there a while. Record review of Resident 346's record did not contain any monitoring of the pressure area to the right heel. Record review of Resident 346's CCP dated 1-17-2014 revealed documentation that Resident 346 had a blister to the right heel and that it had resolved on 4-30-2014. An interview was conducted with the DON on 3-19-2015 at 11:08 AM. During the interview, the DON confirmed there was not any monitoring of the pressure ulcer to the left heel. When asked if there should have been monitoring, the DON stated yes with measurement. Record review of a fax sheet dated 3-19-2015 revealed Resident 346's physician was informed of the pressure ulcer to the right heel. The facility requested permission to use their skin protocols that was identified as un-stageable Pressure Ulcer Protocol. C. Review of Resident 297's Braden Risk Assessment Report (an assessment tool to determine one's risk of developing pressure ulcers) dated 1/20/15 revealed, Risk Score: 16. Risk Level: Mild due to slightly limited sensory perception, occasionally moist skin, very limited mobility, a potential problem with friction and shearing and occasional walking of short distances. Review of Resident 297's Care Plan dated 1/20/15 mentioned the following regarding skin integrity: -At risk for complications of diabetes: Monitor skin integrity. -Episodes of urinary incontinence: Monitor skin, Cleanse skin after incontinence. -At risk for further skin breakdown: Notify nurse of redness, Use 2 assist with repositioning, Avoid dragging heels, pressure reducing mattress, foam cushion on w/c (wheelchair), off load heels with pillows in bed, complete Braden scale. Review of Resident 297's Progress Notes revealed the following: -1/20/15 at 11:01 PM; admitted to room [ROOM NUMBER] an 84 y/o (year old) .Body assessment done and results as follows: Right had (hand) noted to have bruising, Right forearm noted to have bruises, right upper lateral shoulder noted to have bruises,. Left hand noted to have several bruises, left forearm noted to have bruises, left upper anterior shoulder has large bruise. Also noted bruising on left lower abdominal area and abdominal bruising on to lower abdominal area. Also noted large bruise to right lateral lower back. Noted a scabbed abraised area to right knee. Noted brownish pigment to lower shins bilaterally. No open areas noted this shift. -1/21/15 revealed Resident 297 complained of pain to the L calf during bath and an ulcer area was observed. Resident and spouse reported area was from resident's [DIAGNOSES REDACTED]. Review of Resident 297's Wound Assessment Report dated 1/27/15 revealed Wound type: Other: eschar (a piece of dead tissue) intact to Left calf. Measuring Length (L) 1.00 cm (centimeters) x Width (W) 1.00 cm x Depth (D) .10 cm with no drainage. Review of Resident 297's dictated Wound Care Clinic notes dated 1/27/15 revealed, This is a patient who I have been asked by (the primary MD) to see in reference to a wound in the posterior aspect of the left leg.The patient has been hospitalized and had been on anticoagulation, so I think there is a definite cause and effect relationship here and probably a pressure ulcer. Attached to the dictated report was a Wound Center Wound Assessment noted by facility staff on 2/3/15 that stated Wound Etiology: Pressure Ulcer Review of Resident 297's Progress Notes dated 2/23/15 revealed, noted on left tip of left great toe a 0.2 cm brown scab like area. Will request (Wound MD) see this also. Review of Resident 297's dictated Wound Care Clinic notes dated 2/24/15 revealed, (Resident 297) had an ulceration on the 2nd toe caused by the first toe. Plan: would clinic will to use Xeroform gauze. This will help keep it dry, but also protect the second toe from the great toe. I think it is from pressure that we give rise to this because of the knuckles or joints of the phalanges. One against the other makes for the ulceration. It does not look to me that any footwear that (Resident 297) would be using would have an inadequate toe box that would be provoking this kind of a wound. Review of Resident 297's Wound Assessment Reports from 2/3/15 to 3/19/15 revealed the pressure ulcer to the left calf was measured by a nursing staff member on a weekly basis. The Wound Assessment Report dated 2/17/15 reported measurements of length (l) was 5.40 cm x width (w) 2.40 cm x depth (D) of .50 cm and was now classified as a pressure ulcer. The Wound Assessment Report dated 3/17/15 revealed measurements of (L) 6.20 cm x (W) 4.20 x (D) .40 cm with moderate purulent drainage (often described as 'milky' in appearance and accompanies infection). Review of Resident 297's Wound Assessment Reports from 2/24/15 to 3/19/15 revealed the pressure ulcer assessment to the Left 2nd toe was not completed. Review of the Progress Notes revealed the following regarding the pressure ulcer to the left 2nd toe: -2/24/15; To 2nd toe left weave [MEDICATION NAME] gauze (a petroleum nonadherent dressing) may cover with gauze, changing daily.left foot and toes [MEDICAL CONDITION] (swollen) (L) .2 cm x (W) .2 cm x (D) .1 cm dark areas noted to left great toe later (lateral) Lt 2nd toe med (medial). -2/27/15; Drsg (dressing) changed to L 2nd toe. Area has some slough (accumulated dead cells typically white or yellow in color) noted to it. (No measurements) -3/1/15; Spouse here visiting, requested to watch dressing changes, 2nd left toe wound is .5 x .4 cm dressed with Xeroform gauze.no drainage present. Wounds are slow to heal. -3/3/15; Continue same treatment to .left toe .02 x .02 x .01 cm dark areas to left great lateral and left 2nd toe med. -3/6/15; Wound to between left great toe and 1st toe looks to be same. -3/10/15; Left 2nd toe dressing CDI (clean, dry and intact). Dr. evaled and treated wound. -3/13/15; Treatment to toe done on left foot as ordered. Area is 1 cm round and is black in color. -3/14/15; Left 2nd toe dressing CDI, toes are rubbing on eachother which is causing slow healing along with hx (history) of diabetes. -3/16/15; Treatment to left second toe done as ordered. (no measurements or assessment documented). Review of the facility's Skin Care Management Program dated 9/17/14 revealed, Purpose: To provide guidelines and protocols for the management of the client's skin integrity including: d. identification and management protocols for pressure, vascular and other types of wounds. Policy: (Facility) will work to ensure a client who enters the facility with out pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that hey were unavoidable and, will provide care and services to: 1. promote the prevention of pressure sore development, 2. Promote the healing of pressure sores that are present, and 3. Prevent development of additional pressure sores. Procedure: All clients will be screened and identified as either low risk or high risk for developing pressure ulcers. Clients will be screened utilizing the Braden scale.Clients with a Braden scale of 18 or less will be identified as HIGH risk for developing pressure ulcers. Pressure Ulcer staging will occur.Clients admitted with or who develop pressure ulcers (all stages) will be assessed by a nurse and documented using the Wound Assessments section of the electronic medical record.Interim pressure ulcer assessments will be completed weekly during the day shift by the assigned Nurse Manager or designee.This assessment will be completed and documented using the Wound Assessment section of the Electronic Medical Record. Nurse Managers will be responsible for ensuring the wound is documented weekly until resolved. During an interview on 03/23/2015 at 1:50 PM Registered Nurse (RN) D was questioned about documentation of ongoing assessments of the toe wounds for Resident 279. RN D proceeded to state that if the Dr. from the wound clinic saw the residents then the staff did not touch or do anything with the wounds. When questioned why the calf on the back of the leg would have weekly assessments by a staff RN in regards to size, stage, drainage, infection or [MEDICAL CONDITION] of the wound but the wound on Resident 279's toe would not, RN D reported the Wound Nurse must have forgot. RN D further stated the wound on the toes was from pressure from the toes rubbing against each other but the wound on the back of the left calf did not require off loading because it was not classified as pressure.