Every finding on record at Fairview Manor

License Reference Number 175 NAC 12-006.04(H)(ii)(1) Based on record reviews and interviews, the facility failed to ensure the DS (Dietary Supervisor) had the required credentials. This had the potential to affect 38 residents who ate food prepared in the kitchen. The facility had a census of 38. Findings are: An interview on 9/30/24 at 12:25 PM with DS revealed [gender] had not taken classes for their CDM (Certified Dietary Manager) and that the administrator was going to set up the classes. An interview with the Administrator on 10/1/24 at 7:26 AM revealed DS was not a CDM and the RD was not currently employed full time at the facility. An interview with the RD on 10/1/24 at 10:00 AM revealed the RD works in the facility 8 hours a week and remotely to equal 25-30 total hours a week. The RD oversaw the dietary supervisor. A record review of the facility's undated Dietary Manager Job Description revealed a Performance Requirement stating the Dietary Manager was to have completed the requirements for education as outlined in State and Federal guidelines and was to participate in ongoing continuing education.

Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview; the facility failed to code the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) assessment to reflect the resident's status for 1 (Resident 18) of 5 sampled residents. The facility census was 38. Findings are: A record review of Resident 18's August 2024 Medication Administration Record (MAR) revealed that Resident 18 was receiving clopidogrel (an antiplatelet medication used to prevent blood from forming a clot) 75 milligrams (mg) daily. A record review of Resident 18's MDS dated [DATE], revealed the use of antiplatelet medication was coded No. A record review of the MDS 3.0 RAI (Resident Assessment Instrument) User's Manual v1.18.11, dated October 2023, revealed the following guidance: -Antiplatelet: check if an antiplatelet medication (e.g. clopidogrel) was taken by the resident at any time during the 7-day observation period. In an interview on 10/02/24 at 1:02 PM, the MDS nurse confirmed that Resident 18 did have an order for an antiplatelet medication and that the medication was received as ordered in August 2024. The MDS nurse further confirmed that the use of the antiplatelet medication was not coded correctly on the MDS and should have been marked Yes.

Licensure reference number 175 NAC 12-006.17 Based on observation, interviews, and record review; the facility failed to ensure that staff washed their hands with soap and water for at least 20 seconds to prevent the potential for cross contamination during wound care for 1 (Resident 8) of 1 sampled resident. The facility census was 38. Findings are: Record review of Resident 8's Face Sheet dated 10/1/24 revealed the resident was admitted to the facility on [DATE] and had a diagnosis of non-pressure chronic ulcer of skin or other sites with unspecified severity. Record review of Resident 8's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 7/18/24 revealed in: Section C: a Brief Interview for Mental Status (BIMS) score of (-) indicating that the resident was rarely/never understood. Section GG: the resident required maximum assistance with rolling left and right (The ability to roll from lying on back to left and right side and return to lying on back on the bed). Section M: the resident was at risk for pressure ulcers and had one Stage 1 pressure ulcer (an observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence) and one unstageable deep tissue injury. Record review of Resident 8's physician orders dated 10/1/24 revealed an order for the following treatment to their bilateral [NAME] hip ulcers: wash with soap and water, apply Flagyl powder and Xeroform to black areas then cover with Mepilex. The order stated to change the wound dressing three times per week to reduce the smell and promote comfort. An observation on 10/2/24 at 8:34 AM of Resident 8's wound cares with Licensed Practical Nurse (LPN). LPN stated Resident 8 had received pain medication prior to the dressing change. LPN performed hand hygiene with soap and water for 20 seconds and donned gloves. LPN removed the left hip dressing, which revealed a brownish drainage on the dressing and a strong odor was noted. LPN placed the old dressing in a red trash bag and removed their gloves. LPN performed hand hygiene with ABHR gel and donned new gloves. LPN cleansed the wound with antibacterial soap, rinsed and dried. LPN sprinkled [NAME] powder onto the wound, then the xeroform dressing was applied and the wound was covered with a Mepilex dressing. LPN removed their gloves and performed hand hygiene by washing their hands with soap and water for 12 seconds, then donned new gloves. LPN repositioned Resident 8 and then removed the right hip dressing, which had brownish drainage and odor present and placed the dressing into the red trash bag. LPN then removed their gloves and performed hand hygiene with ABHR gel and donned new gloves. LPN cleansed the right hip wound with antibacterial soap, rinsed and dried. LPN sprinkled [NAME] powder onto wound, then the xeroform dressing was applied and the wound was covered with a Mepilex dressing. LPN removed their gloves, repositioned Resident 8 again, and placed a blanket on the resident. LPN performed hand hygiene with soap and water for 7 seconds, donned new gloves and removed the trash from the room. An interview on 10/2/24 at 8:55 AM with LPN revealed that [gender] should have washed [gender] hands for 20 seconds when using soap and water. An interview on 10/2/24 at 10:47 AM with the DON confirmed that hand washing with soap and water should be done for 20 seconds. Record review of the facility's undated Handwashing policy revealed the purpose of the policy was to prevent the spread of infection. The policy also contained guidance to perform the following tasks: 3. Apply soap and work into lather, 4. Rub all surfaces of the hands, between fingers, under nails and 2 of the wrists together continuously for 20 seconds. (2 minutes at the beginning of the shift and end of each shift).

Based on record review and interview; the facility failed to prevent the possibility of the transmission of COVID 19 by not ensuring that visitor screening was completed. This has the potential to affect all residents. The facility identified a census of 36 at the time of survey. Findings are: A record review of an undated visitor screening log revealed there were blank entries. On 08/23/22 at 10:34 AM interview with the Medical Records Coordinator confirmed that the Medical Records Coordinator was to check the visitor screening sheets everyday while at work. The nurses check the sheets when visitors come in during the evening, on weekends and on holidays. When a visitor comes to visit the first time, they need to fill out a screening sheet. The Medical Records Coordinator confirmed the sheet was not dated and incomplete at times. The information was then transferred to a tracking form for each visitor. 08/24/22 10:29 AM Interview with the Infection Preventionist confirmed all the sign in sheets for the visitors should not have blanks on them. They should all be double checked. A record review of the Coronavirus Surveillance Policy, date Implemented 3/16/22: Screening for visitors and staff for signs and symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptom of coronavirus in the last 14 days, has had contact with someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Visitors will be denied entry into the facility if they exhibit any of the criteria listed above. They may be directed to the Infection Preventionist, Director of Nursing, or nurse manager on duty if they have any questions.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1 Based on observation, interview, and record review; the facility failed to monitor the temperatures for the medication refrigerator on the east hallway. This had the potential to affect any resident with medication which required refrigeration on the east hallway. The facility census was 36. Findings are: Observation of the east medication refrigerator on 8/24/2022 at 2:30 PM revealed multiple medications were being stored in the refrigerator including insulin. Interview with RN-A (Registered Nurse) on 8/24/2022 at 2:30 PM revealed there were multiple days with no documentation of refrigerator temperatures on the log posted above the east hall medication refrigerator. Interview with the Administrator on 8/24/2022 at 3:03 PM revealed a discussion with staff had already occurred to ensure daily monitoring of medication temperatures was completed. Record review of the east hall refrigerator log revealed only 5 temperatures were documented for the month of June and 5 temperatures for the month of July. The 4 days in August prior to observation on 8/24/2022 were also not documented. Record review of an undated Policy and Procedure titled, Medication and Storage in The Facility. Heading k. of the document states, Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow temperature monitoring.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09B Based on observations, record reviews, and interviews, the facility failed to code the MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment for the use of a restraint for 1 resident (Resident 12). Facility census was 36. Findings are: Record review of Resident 12's History and Physical completed 6/14/2022 revealed the resident was admitted to the facility in 2016. Among the medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 12 was also identified as having contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right hand and left upper arm. Record review of Resident 12's Annual MDS dated [DATE] identified the resident as having no trunk restraint in place while in the chair. Observation of Resident 12 on 8/22/2022 at 10:23 AM revealed the resident was sitting in a tilted wheel chair with a seat belt clasped across the waist. Observation of the resident on 8/24/2022 at 10:20 AM revealed the resident had a seat belt clasped across the waist while sitting in the wheel chair. Interview with the DON (Director of Nursing) on 8/24/2022 at 10:35 AM revealed Resident 12 was not able to remove the waist belt without assistance. Interview with the MDS Coordinator on 8/24/2022 at 10:43 AM revealed Resident 12 was not able to remove the waist belt without assistance and the resident should have been coded as having a restraint in place. Record review of Resident 12's MDS section P related to restraints revealed the following, Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D9 Based on observation, interview, and record review; the facility failed to ensure thickened fluids were available in the room for 1 resident (Resident 28). Findings are: Review of Resident 28's care plan dated 7/28/2022 revealed the resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] is due to abnormal brain development, often before birth). The resident was also identified as utilizing thickened fluids due to history of aspiration. Review of Resident 28's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment dated [DATE] revealed the resident required supervision and setup for drinking. Observation of Resident 28 on 8/22/2022 at 12:59 PM revealed the resident was sitting in the room watching television. No thickened fluids were present on Resident 28's side of the room. Observation of Resident 28 on 8/24/2022 at 11:00 AM revealed the resident was sitting in the wheel chair in the room. There was no drink observed on Resident 28's side of the room. Interview with NA-B (Nursing Assistant) on 8/24/2022 at 2:23 PM revealed the resident can drink without assistance and uses a lidded cup and liquid thickener. The resident has not had drinks available in the room for at least the past year. Interview with Resident 28 on 8/25/2022 at 9:58 AM revealed the resident shakes head yes when asked if the resident would like to have water available in the room. Interview with the MDS Coordinator on 8/24/2022 at 3:20 PM revealed the facility did not have drinks available in the room for residents on thickened fluids.

Based on record review and interview, the facility failed to ensure behavior monitoring was completed to indicate duplicate mood/behavior medications were necessary for Resident 21 and 31. The sample size was 5. The facility census was 36. FINDINGS ARE: A. A record review of the Active Orders report ran on 8/22/22 revealed Resident 21 to be taking the following medications that affect mood and behaviors: *olanzapine (an antipsychotic medication) tablet 2.5 mg (milligrams) Oral Twice a day. *[MEDICATION(S)] (an antidepressant medication) tablet 50 mg Oral At bedtime. *temazepam (a sedative/hypnotic medication) capsule 15 mg Oral At bedtime. *lorazepam (used to treat anxiety) tablet 0.5 mg Oral Every 6hours as needed. A record review of the Progress Notes dated 6/23/22 through 8/23/22 revealed no documentation of any negative behaviors being displayed by Resident 21 over the last 60 days. A record review of the document titled Behavior Analysis Report (CareAssist only) dated 6/23/22 through 8/23/22 revealed no negative behaviors had been displayed. An interview on 8/24/22 at 10:23 AM with the facility Nurse Mentor, after review of the Behavior Analysis Report (CareAssist only) dated 6/23/22 through 8/23/22 confirmed that the behavior documentation did not reflect Resident 21's need for the use of 4 medications that affect mood and behavior with no dose reduction attempts. An interview with NA (Nurse Aide)-C on 8/24/22 at 12:15 PM confirmed that the options for negative behaviors to document were not specific to individual residents but were the same for all residents within the facility. B. A record review of the Active Orders report ran on 8/22/22 revealed Resident 31 to be taking the following medications that affect mood and behaviors: -[MEDICATION(S)] (an antianxiety medication) tablet 0.5 mg Oral Three times a day. -[MEDICATION(S)] (an antidepressant medication) tablet 30 mg Oral At bedtime. -[MEDICATION(S)] (an antidepressant medication) tablet 50 mg Oral Every day. A record review of the document titled Point of Care Mood Category Report (MDS 3.0) and dated 7/21/22 through 7/29/22 revealed a list of behaviors listed as follows; Little Interest/Pleasure Doing Things, Mood Symptom Presence, Appearing Down/Hopeless, Trouble Sleeping/Sleeping Too Much, Feeling Tired/Having Little Energy, Poor Appetite or Overeating, Feels Bad About Self, Trouble Concentrating, Moves Slow or Fidgety/Restless, Harms Self/Wants to Die, Short Tempered/Easily Annoyed which the NA's had documented a YES on one isolated entry and NO all remainder of the days for Resident 31. A record review of the Progress Notes for Resident 31 dated 8/18/22 through 8/23/22 revealed the nursing staff would document episodes of restlessness and anxiety which did not correlate with the behavior charting completed by the nursing assistants. An interview on 8/24/22 at 10:23 AM with the facility Nurse Mentor, after review of the NA behavior charting confirmed that the behavior documentation did not reflect Resident 31's display of behaviors, most likely due to staff accepting the behaviors as normal behavior for Resident 31. The interview confirmed that the documentation did not support the use of 3 medications that affect mood and behavior, and no dose reduction attempts. An interview with NA-D on 8/24/22 at 12:13 PM confirmed that the options for negative behaviors to document were not specific to individual residents but were the same for all residents within the facility.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to A) notify the physician of signs and symptoms related to a [CONDITION(S)] which resulted in delay of treatment and a hospitalization for 1 resident (Resident 1), B) notify the physician of a change in condition related to hypersensitivity to touch for 1 resident (Resident 1); and C) notify the physician of weight loss for 1 resident (Resident 1). The facility census was 37. Findings are: A) Record review of Resident 1's Admission MDS (Minimum Data Set- a federally mandated comprehensive assessment completed for developing a comprehensive plan of care) revealed the following: -Section A Identification Information revealed, Resident 1 admitted on [DATE]. -Section I Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Section K Swallowing and Nutrition revealed, Resident 1 was 200 pounds and had no weight loss or gain. Record review of Resident 1's PO (Physician Orders) revealed, no order for an iron supplement for Resident 1. Record review a Timeline provided by the DON (Director of Nurses) for Resident 1's stool color revealed Resident 1 had a change in stool color on 12/21/20: 12/15- loose liquid green stool - Appointment with Provider 12/16- watery, loose stools, notified Primary Provider of orthopedic appointment. 12/17- Order obtained for stool culture 12/18 - green mucous stool - sample sent to lab for processing 12/19 - green mucous stool - Initiated [MEDICATION(S)] 12/21- thick, tarry stool - Provider addressed lab 12/22- green mucous stool, House Shakes were initiated three times a day, notified POA (Power of Attorney) 12/24-large brownish black loose stool educated resident on need to drink more fluid. 12/25 - No involuntary stools 12/26-soft, tarry, bowel movement 12/27-black stool with thin consistency-family at bedside and updated on resident status. 12/28-Dark loose stool - Notified PCP (Primary Care Physician) of [MEDICATION(S)] completion and request for follow up stool culture 12/29 - black tarry stool- void of odor 12/30-No involuntary stool, Care Conference where incidences of tarry stool shared with Representatives who report this was resident baseline stool at home. Family did not want further intervention at this time. Facility monitors for further signs and symptoms of bleeding 12/31 - Loose black stool 1/1- Nurse called to Representative to report change in condition; POA presents to facility, did not want us to send to ER (emergency room ) until (gender) had come to facility to assess. On-Call Provider notified prior to family arrival. Provider waited until family assessed resident; and family did want resident evaluated in ER. 1/1/- Resident then admitted for deep [CONDITION(S)] ulcer that is not actively bleeding according to transfer records. Record review of PN (Progress Notes) dated 12/13/20 revealed, Resident 1 had a loose stool. Record review of PN dated 12/15/20 revealed, Resident 1 had a loose liquid foul green mucous stool. Lungs with crackles on left. Record review of Physician Visit record for the Orthopedic Surgeon dated 12/15/20 revealed, Resident 1 having crackles in lungs, reluctant to participate with therapy. Doctor noted doing well, continue same regimen. Record review of a Provider Fax dated 12/16/20 for Resident 1 revealed, communication of orthopedic appointment. Provider informed of liquid stool. On 12/17/21 the Provider for Resident 1 ordered a stool panel. Record review of PN dated 12/18/2020 revealed, Resident 1 continued to have green foul liquid stools. Resident 1's stool sample was collected and sent to lab. Record review of PN dated 12/19/20 revealed, Resident 1 had loose green mucous stool. [MEDICATION(S)] had been ordered for 7 days. Record review of PN dated 12/20/20 revealed, Resident 1 continued to have loose stools. Record review of PN dated 12/21/20 revealed, Resident 1 had thick tarry stools three times. Record review of PN dated 12/24/20 revealed Resident 1 had a dark brown black stool. Resident 1 had foul smelling stool. Record review of PN dated 12/26/20 revealed Resident 1 had a large soft tarry stool. Record review of PN dated 12/27/20 revealed Resident 1 had a dark black very thin consistency medium stool twice over night. Record review of PN dated 12/28/20 revealed Resident 1 continued to have dark loose stools. Record review of PN dated 12/29/20 revealed Resident 1 continued to have dark tarry stools. Record review of PN dated 12/30/20 revealed Resident 1 had a care plan entry documented on 1/7/21 as a late entry and it was discussed about the recent completion of [MEDICATION(S)] medication and incidences of tarry stools, mixed with formed stools. Will monitor for signs or symptoms of bleeding. Record review of PN dated 1/1/21 at 4:45 AM revealed the resident had a very dark large loose stool. Record review of PN dated 1/1/21 at 1:39 PM revealed, Resident 1 was ashen color and reported not feeling well. Blood pressure was 71/41 and 78/68 and repeated a third time was 73/51. Resident 1 was incontinent of liquid black stool. The POA requested Resident 1 be transferred if needed. POA wanted a hemoglobin completed prior to being sent. The Provider was notified and reported the resident could be seen in the emergency room . Record review of PN dated 1/1/21 at 2:37 PM revealed, POA was going to contact the clinic for a CBC prior to contacting the on-call provider. A Resident Representative was informed of Resident 1's medical condition and was very concerned and requested the resident be seen in the ER. The POA was in agreement. Record review of PN dated 1/1/21 at 7:42 PM revealed, Resident 1 was admitted to the hospital for low hemoglobin. Record review of Hospital Documents for Admission of Resident 1 on 1/1/21: -Resident 1 was admitted to the hospital on 1/1/21. -Resident 1's chief complaint was tarry stools and [CONDITION(S)]. The nursing staff noted low blood pressures. Resident was on [MEDICATION(S)] and [MEDICATION(S)]. -Resident 1 Admission assessment revealed: Upper Gastrointestinal (GI) bleed; currently anticoagulated with a hemoglobin of 7.4. Admit with a surgical consult. Provider had placed Resident 1 on [MEDICATION(S)] IV. All oral medications were held including anticoagulants. -Record dated 1/2/21 revealed Resident 1 had 2 units of blood transfused overnight and the hemoglobin was up to 8.9. Resident 1 still had some black tarry stools. Record dated 1/5/21 the admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge condition was improved. Hospital Course Summary revealed, Resident 1 had admitted to the hospital and was noted to have black tarry stools at the nursing home. Resident 1's hemoglobin was not too bad but was transfused related to actively bleeding. The hemoglobin dropped more post transfusion but was about where Resident 1 was when they were admitted . The hemoglobin did go up slowly. Resident 1 continued to have black stools but hemoglobin's remained stable. Resident 1 was treated with [MEDICATION(S)]. Resident 1 showed a deep [CONDITION(S)] ulcer that was not bleeding. [MEDICATION(S)] was added to the regimen. The resident was stable and ready for discharge. Record review of a Physician notification related to the change in stool color which began on 12/21/20 revealed, the facility was unable to provide documentation of provider notification of the change in stool color for Resident 1. An interview on 8/2/21 with the DON confirmed, Resident 1 had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported according to the hospital note dated 1/5/21 Resident 1 had continued to have black stools, but was not bleeding actively at that time. Tarry stool. Merriam-Webster.com Medical Dictionary, Merriam-Webster, https://www.merriam-webster.com/medical/tarry%20stool. Accessed 4 Aug. 2021 revealed the following definition of tarry stool: An evacuation from the bowels having the color of tar (dark brown or black) caused especially by hemorrhage in the stomach or small intestine. B) Record review of Resident 1's Admission MDS revealed: -Section A Identification Information revealed, Resident 1 admitted on [DATE]. -Section I Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Baseline Care Plan revealed, nursing orders for: -Assess comfort level -Observe for nonverbal indications of pain grimacing, moaning, irritability, withdrawal from activities/ADL's (Activities of Daily Living), and guarding. -Administer and monitor for the effectiveness of medications per order, -Utilize nonmedical interventions when appropriate distraction activity, warm or cold packs, and whirlpools. -Notify the Provider of ineffective pain management. -Educate resident/family on pain management. Record review of PN dated 01/01/2021 for Resident 1 revealed, Resident is hypersensitive to any touch being done i.e. to do vitals, dressing changes, repositioning etc. Facial grimacing and moaning. Resident 1 had been admitted to the hospital for a Gastro-intestinal bleed. Record review of Hospital Documents for Admission of Resident 1 on 1/1/21: -Resident 1 was admitted to the hospital on 1/1/21. -Resident 1's chief complaint was tarry stools and [CONDITION(S)]. The nursing staff noted low blood pressures. Resident was on [MEDICATION(S)] and [MEDICATION(S)]. -Resident 1 Admission assessment revealed: Upper GI bleed; currently anticoagulated with a hemoglobin of 7.4. Admit with a surgical consult. Provider had placed Resident 1 on [MEDICATION(S)] IV. All oral medications were held including anticoagulants. -On 1/2/21 revealed Resident 1 had 2 units of blood transfused overnight and the hemoglobin was up to 8.9. Resident 1 still had some black tarry stools. Record review of PN dated 1/5/21 through 1/16/21 revealed, no documentation of Resident 1 being hypersensitive to touch. Record review of PN dated 01/16/2021 for Resident 1 revealed, continued to be hypersensitive to any touch i.e. Blood Pressure being taken and moving their arm. Record review of PN dated 01/16/2021 at 2:00 PM for Resident 1 revealed, continued to be very hypersensitive to any touch i.e. blood pressure taken and arm moved. Additional documentation submitted on 8/3/21 of a Vitals Report for Pain for Resident 1 revealed an entry for 01/13/21 at 4:48 PM with no pain documented. Additional documentation submitted on 8/3/21 of a Vitals Report for Pain for Resident 1 revealed missing documentation for the days of 1/14/21 and 1/15/21. Record review of PN dated 01/16/2021 at 9:37 PM for Resident 1 revealed, very hypersensitive to touch. Additional documentation submitted on 8/3/21 of a Vitals Report for Pain for Resident 1 revealed missing documentation for the days of 1/16/21, 1/17/21, and 1/18/21. Record review of PN dated 01/19/2021 at 12:05 AM for Resident 1 revealed, continued to be very hypersensitive to touch or anticipation of being touched. Additional documentation submitted on 8/3/21 of a Vitals Report for Pain for Resident 1 revealed missing documentation for the day of 1/19/21. Record review of PN dated 01/20/2021 at 1:37 PM for Resident 1 revealed, remained hypersensitive to touch to all surfaces of his body. Additional documentation submitted on 8/3/21 of a Vitals Report for Pain for Resident 1 revealed an entry for 01/20/21 at 6:44 PM with no pain documented. Record review of PN dated 01/21/2021 at 2:28 AM for Resident 1 revealed, was noted to be hypersensitive to anticipated touch, but calmed quickly and was cooperative with cares. Additional documentation submitted on 8/3/21 of a Vitals Report for Pain for Resident 1 revealed missing documentation for the day of 1/22/21 Record review of PN dated 01/23/2021 at 1:22 PM for Resident 1 revealed, Hypersensitive to all touch and c/o (complaints of) pain with each touch/movement. Provider notification dated 1/23/21 Resident 1 c/o hurting and hypersensitive to minimal touch or anticipation of being repositioned. Grimaces and calls out with vital signs. Resident 1 saw wound provider on 1/22/21 with addition of wound care, wash wounds BID with soap and water, Santyl to all wounds in am and Therabond to all wounds in the evening, Lotrimen to bilateral feet, Prafo boot at all times to right foot and prevlon boot right foot at all times. Resident continues to refuse to eat, refused to work with therapy, night shift was unable to get comfortable. [MEDICATION(S)] 5/325 1 tab at 11:38 PM (family would prefer (gender) not get it.). Repositioned multiple times, resident refused heels up and pillow under legs. Transferred to recliner and back to bed. Resident had roommate put call light on for resident. Nurse reported pain may be from leg wounds. Resident was receiving [CONDITION(S)] boots, ensure, med pass and ProSource. Orders for [MEDICATION(S)] 100mg oral at night. Follow up on 3/4/21. Additional information submitted on 8/3/21 of Medication Administration Records for January 2021 revealed, During the time frame of hypersensitive to touch was noted 1/16/21 thru 1/23/21 Resident 1 received, Acetaminophen 325mg (milligrams) 2 tablets every 4-6 hours as needed, 8 doses were given and 7 doses on the night shift and 1 dose during the day shift. [MEDICATION(S)] 5/325mg take 1 tablet by mouth every 4 hours as needed for pain Resident 1 was given 3 doses all given on the night shift. An interview on 8/2/21 with the Nurse Mentor who delivered the Provider Notification confirmed the document was the notification to the provider of Resident 1's hypersensitive to touch. A statement signed by the DON dated 8/3/21 revealed; -- Resident 1 was admitted [DATE] with Potential for Alteration in Comfort r/t surgical incision/procedure, wound/wound cares, vascular issues identified on Admission. -- During the course of Resident 1's stay at facility, pain continued to be a potential problem and resident was assessed every shift for pain, during skilled stay, and more frequently as needed- Resident was offered interventions upon each incidence of pain presence, and resident pain status was reviewed frequently by PCP and/or attending specialists upon regular intervals and during times of noted increased pain, upon each specialty visit and recertification visits. -- For instance. Resident was first identified with the phrase hypersensitivity to touch on 1/1/21 prior to transfer to the ER. The Provider reviewed this progress note with transfer paperwork. Resident did not return with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] --This terminology was later identified by an RN (Registered Nurse) on 1/18/21 and was offered regular intervention to relieve presence of pain. The physician was notified of increased pain incidence via fax on the early morning of 1/23/21 and [MEDICATION(S)] was initiated, while PRN (as needed) [MEDICATION(S)], repositioning/ food, fluids, wound care, quiet milieu/ etc. were continuously offered as Non-pharmacological interventions. Resident has had these interventions in place since admission. --It was dually worth noting that hypersensitivity to touch was never diagnosed by a physician although chronic and acute pain were identified and treated, and that resident pain status was continuously evaluated. Resident pain was an on-going problem despite his refusal for common Interventions. When incidences of pain were discussed with resident POA, they did state reluctance for routine [MEDICATION(S)] in fear of further suppressing Resident 1's appetite. There were barriers to therapeutic pain relief due to resident reluctance and family reluctance to utilize the care planned interventions. C. Record review of Resident 1's Admission MDS (Minimum Data Set- a federally mandated comprehensive assessment completed for developing a comprehensive plan of care) revealed: -Section A Identification Information revealed, Resident 1 admitted on [DATE]. -Section I Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Section K Swallowing and Nutrition revealed, Resident 1 was 200 pounds had no weight loss or gain. Record review of PN dated 12/03/20 revealed no admission weight was documented in the PN. Record review of Vitals Record-Weights for Resident 1 revealed the following dates and weights: Admission weight - none documented, 12/5/20 was 201 12/28/20 was 173 1/7/21 was 182, 1/8/21 was 176, 1/9/21 was 178, 1/14/21 was 174, 1/15/21 was 174, 1/23/21 was 171, 1/30/21 was 167. Record review of meal intakes for Resident 1 from 12/5/21 through 12/28/21 revealed: -69 opportunities for meals -Intakes with 0% taken 16 meals refused, -Intakes with 1-25 % taken for 18 meals -Intakes with 26-50% taken 13 meals -Intakes with 51-75% taken 4 meals -Intakes with 76-100% taken 13 meals -Total meal intakes documented were 64. Record review of a Daily Report document revealed, Resident 1 had weight of 200 lbs but had refused naked weight. Reweigh was requested of a naked weight. Record review of an email from the RD (registered Dietician dated 12/22/21 revealed; The RD was concerned related to Resident 1 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Recommended a Product called Banatrol Plus. Requested for house shakes to be started with each meal. The RD reported Resident 1's preference to ice-cream. Record review of a Provider Fax for Resident 1 dated 12/28/21 revealed, information related to weight loss had not been addressed. Record review of Provider notification dated 12/28/21 revealed, the facility was unable to provide notification related to the decrease in weight from 201 on 12/5/20 to 173 on 12/28/20. Record review of a Provider note for Resident 1 dated 1/14/21 an order was received for weight loss- [MEDICATION(S)] 400mg, [MEDICATION(S)] Patch 9.5mg, addressed a Stage II Pressure Lt (left) medial and distal buttock -Order for Allevyn change every 3 days- ROHO (Pressure relieving cushion used to prevent pressure sores) and repositioning every 2 hours. Record review of Weekly Weight Reports for Resident 1 with the following dates revealed, 0/02/21 thru 01/09/21 loss of 22 lbs in 1 month 11.0 %, 01/10/21 thru 01/15/21 loss of 26 lbs in 1 month 13.0% and, 01/16/21 thru 01/23/21 loss of 29 lbs in 1 month 14.5%. An interview on 7/29/21 at 3:08 AM with the DON revealed the resident refused meals on a daily bases. Resident 1's weight was 200 with the Hoyer Lift. The DON reported the staff were doing daily weights that the facility was not documenting in the medical record, at this time was unable to locate the daily weights. The DON confirmed Resident 1 had a weight of 200 lbs (Pounds) on 12/5/21 at the facility and on 12/28/21 was 173 lbs. The DON reported that the resident had Prafo boots and a splint for the humerus fracture. The resident refused a naked weight. An interview on 8/2/21 at 11:18 AM with the DON confirmed, weight loss should be reported to the provider at the time of the weight loss. The DON reported Resident 1 had refused to get a naked weight. Resident 1 had Prafo boots and a plastic arm immobilizer related to a fracture those would not have caused a 28 pound difference in weight. The DON reported there was a discrepancy between the hospital weights and the nursing home weights.

Licensure Reference Number 175 NAC 12-006.16B Based on interview and record review, the facility failed to ensure weights for 2 (Resident 1 and 2) of 4 sampled residents were documented in the resident medical record. The facility had a total census of 37 residents. The findings are: A. A review of Resident 2's electronic medical record revealed an admitted [DATE] and a discharge date of [DATE]. A review of a weight record for Resident 2 revealed the following: -12/11/20 - 156.5 lbs -12/21/20 - 147.5 lbs -1/04/21 - 148 lbs -1/08/21 - 150 lbs -1/15/21 - 152 lbs -1/23/21 - 151 lbs -1/30/21 - 150.5 lbs A review of a facility shift report sheet dated 12/3/20 revealed a weight of 157.2 lbs was documented next to Resident 2's name. A review of the facility's Vital Sign and Weight Monitoring Policy, dated 11/30/18, revealed the following: -Policy: (Facility Name) will monitor vital signs and weights to maintain the overall health of its residents. -Policy explanation and compliance guidelines: -1. (Facility Name) will obtain/record/monitor resident's vital signs upon admission and monthly thereafter and weight upon admission and weekly thereafter. -2. Vital signs and weight monitoring frequency may be adjusted by the resident's provider or at nurse's discretion. In an interview on 8/2/21 at 11:12 AM, the DON (Director of Nursing) reported an admission weight was obtained for Resident 2 on 12/3/21 and was recorded on a shift report sheet from that date. The DON confirmed the admission weight for Resident 2 was not documented in Resident 2's medical record, but should have been. B. Record review of Admission record revealed Resident 1 was admitted on [DATE]. Record review of Vitals Record-Weights for Resident 1 revealed the following dates and weights: Admission weight not documented 12/5/20 was 201 12/28/20 was 173 1/7/21 was 182 1/8/21 was 176 1/9/21 was 178 1/14/21 was 174 1/15/21 was 174 1/23/21 was 171 1/30/21 was 167 Record review of a document presented by the DON of weights not recorded in the medical record for Resident 1 revealed, the following weights: 1/5/21 Readmission from the hospital 182.6 1/8/21 no clothing 176 and 178.6 shower 1/9/21 with clothes 178 1/10/21 with cloths 177.8 1/11/21 with cloths 174 1/12/21 with cloths 173 without clothes 172 1/13/21 with cloths 173 1/14/21 with cloths 174 1/15/21 with cloths 173 1/16/21 with cloths 174 1/17/21 with cloths 173 1/18/21 no documentation 1/19/21 without cloths 166 1/20/21 with cloths 171 1/21/21 with cloths 171 1/22/21 no documentation 1/23/21 with cloths 166 1/24/21 with cloths 167.4 1/25/21 with cloths 167.4 1/26/21 without cloths 163 1/27/21 with cloths with cloths 1/28/21 no documentation 1/29/21 with cloths 166.8 An interview on 7/29/21 at 3:08 PM with the DON revealed the resident refused meals on a daily bases. Resident 1's Weight was 200 with the Hoyer Lift and this was not documented in Vitals Record . The DON reported the staff were doing daily weights that the facility was not documenting in the medical record, at this time was unable to locate the daily weights. The DON confirmed Resident 1 had a weight of 200 lbs (Pounds) on the 12/5/21 and on 12/28/21 was 173 lbs. The DON reported that the resident had Prafo boots and a splint for the humerus fracture. The resident refused a naked weight.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, interview and record review, the facility failed to ensure proper cleaning and storage of the nebulizer treatment [a drug delivery device used to administrator medication in the form of a mist inhaled into the lungs] equipment for Resident 13. The sample size was 16. The facility identified a census of 33. FINDINGS ARE: A record review of the facility policy titled Nebulizer Therapy and dated 11/2018 revealed the following steps related to the cleaning and storage of nebulizer treatment equipment: - Step 1p: staff are to disassemble and rinse the nebulizer with sterile or distilled water and allow to air dry. - Step 2c disassemble parts after every treatment - Step 2d rinse the nebulizer cup and mouthpiece with sterile or distilled water - Step 2e shake off excess water - Step 2f air dry on absorbent towel - Step 2g once completely dry, store nebulizer cup and mouthpiece in a zip lock bag An interview with Resident 13 on 05/03/21 at 01:57 PM revealed aerosol treatments [ a medical treatment used to treat a variety of breathing conditions] were scheduled and provided four times daily. An observation on 05/03/21 at 01:57 PM revealed a nebulizer kit and equipment for Resident 13 laid on the floor in the residents room. An observation on 05/04/21 at 08:41 AM revealed the nebulizer kit dated 5/3/21, for Resident 13, rested on the nebulizer machine with the kit in the assembled condition. An observation on 05/04/21 at 01:40 PM revealed Resident 13's nebulizer kit rested in the holding place on the machine. The kit was observed to be wet with liquid inside. An observation on 05/04/21 at 08:09 AM revealed the nebulizer kit dated 5/3/21 rested on the nebulizer machine, in assembled condition and was moist inside and not in a zip-lock bag. An observation on 05/04/21 at 08:14 AM of the room and bathroom for Resident 13 revealed no sterile or distilled water in room and no visible towel/drying area for the nebulizer kit. An interview on 05/04/21 at 08:09 AM with Licensed Practical Nujrse [LPN] A, regarding the care and process for aerosol treatments, revealed the practice had been that kits were stored with the machine when not in use. The interview did not reveal any steps related to the cleaning or sanitization of the equipment. An interview on 05/05/21 at 3:00 PM with the facility Director of Nursing confirmed the facility policy related to nebulizer equipment cleaning and storage had not been followed and could create the potential for contamination of the respiratory equipment.

Licensure Reference Number 175 NAC ,d+[DATE].09D7, ,d+[DATE].09D7b(1), ,d+[DATE].09D7b(3), ,d+[DATE].09D7b(4) Based on record reviews and interviews the facility failed to ensure a resident was supervised during the provisions of cares for toileting for 1 resident (Resident 1), who was identified as a high fall risk, had previous falls with injury and required motion alarms that resulted in a fall and death. The facility to investigate, develop root cause and review and implement and/or revise interventions for further fall prevention for 2 residents (Resident 3 and 4) after a fall of 3 resident reviewed. The facility census was 35. Findings are: Record review of Progress Note dated: [DATE] revealed; the nurse was called to Resident 1's room. Resident 1 was lying on their back. There was a large pool on the floor. Staff sat Resident 1 up to find the gash on the back of (genders) head mid right side 2 cm x .5 cm the area was cleaned. It was determined (gender) would need staples or stitches. ROM (Range of Motion) was done denied pain Neurological checks were started. Resident 1 wanted to eat some supper before they went to ER (emergency room ). Record review of Care Planned interventions for the fall dated [DATE] revealed; was bed in low position. Record review of facility investigation dated [DATE] revealed; Resident 1 had a laceration on the head after a fall to the floor next to the recliner. Medical Treatment require: Resident 1 was sent to the emergency room received 3 staples to the head. Interventions were: silent alarms were placed in the recliner and the wheelchair during room quarantine. What fall/accident intervention were identified on the plan of care ambulate with staff member and gait belt and walker, wheelchair for mobility. Interventions to prevent accidents from reoccurring revealed silent alarms to recliner and wheelchair and increased room checks. Record review of Quarterly MDS (Minimal Data Set- a federally mandated comprehensive evaluation used to develop a comprehensive care plan) dated [DATE] for Resident 1 revealed; 1) Section C Cognition: BIMS (Brief Interview Mental Status a structured evaluation aimed at aspects of cognition in elderly score was 3. Section G 0010 I 1 ADL's(Activities of Daily Living) for toileting revealed; Resident 1 require extensive assist of one for toileting. Section I Active Diagnosis revealed; Resident 1 had Non-Alzheimer's Dementia and [CONDITION(S)]. Record review of Progress note dated [DATE] 10:15 PM revealed; Resident 1 had fallen on the floor. Resident 1 was near the food of the bed. Resident 1 had the following injuries: had 2 skin tears to top of L) hand. #1 skin tear measures 0.5 cm, #2 skin tear measures 1 cm. Both skin tears were cleaned & steri strips applied. Resident 1 had a large bump to L) side of the head just above temple area. Ice pack was applied to head after the assessment was completed. Resident 1 was noted to have confusion at the time of fall. Res. stated 'I was turning around to sit on the toilet' when asked what happened. Record review of Care Planned intervention for the fall dated [DATE] revealed; silent bed and chair alarms added as had fall with head injury to notify staff when getting up independently. Record review of Fall Risk Evaluation dated [DATE] revealed; Resident 1 had intermittent confusion, poor vision, required the use of assistive devices, and was ambulatory and incontinent. Resident 1 took antidepressants, antihistamines and [MEDICATION(S)]. Resident 1 had one or 2 falls in the last 3 months. Resident 1's conditions were neuromuscular functional, psychiatric or Cognition, and Orthopedic. Resident 1's fall risk score was 21. Plan of Care revealed; Resident 1 had a fall in the past quarter. The care plan was adjusted after each fall to promote safety and prevent future falls. Record review of Provider note: dated [DATE] revealed; Diagnosis of: 1. Dementia with behavior disturbance. 2. Delusional disorder. 3. [CONDITION(S)]. 4. [CONDITION(S)] with sequela of pathological fracture. 5. Displaced fracture of left femur with routine healing. 6. Displaced fracture of left medial condyle with routine healing. 7. Displaced comminuted fracture of left femur with routine healing. Resident 1 continued to heal. The Provider did change Resident 1's diagnosis code for the [CONDITION(S)] from M8 1.0 which is [CONDITION(S)] without current fracture to the M80.052S which is [CONDITION(S)] with sequela of pathological fracture. We're not treating the [CONDITION(S)] at this time, but we know that Resident 1 was a fall risk and a risk for fracture again. Due to Resident 1's age; the provider did not think starting treatment at this time was necessary but Resident 1 was on calcium with Vitamin D which was felt appropriate. 8. [CONDITION(S)]. 9. Allergic rhinitis. 10. Shortness of breath. 11. Major depressive disorder. Record review of Resident 1's Progress note dated 0 revealed; Resident 1 had been alert, able to make needs known, normal confusion noted. Resident 1 conversed with the nurse throughout the afternoon without difficulty. Noting nothing was out of the normal for the Resident. Covid screening was completed on Resident 1 at start of shift & all was WNL (within normal limits). Resident 1 used the call light to go to bathroom this afternoon, assisted Resident 1 with a gait belt and use of walker without difficulty. Resident 1 had dinner in room and ate 75% of meal without difficulty. Resident 1 was given HS (Night time) medications as ordered. Resident 1 used the call light for assistance to bathroom, staff member helped Resident 1 to the bathroom with the use of a walker and then told Resident 1 to call when done in bathroom. Resident 1 pulled the call light in the bathroom, but did not wait for staff to come. Resident 1 got off toilet, had not pulled up (genders) pull up or pants and walked out of the bathroom by self-using a walker. Resident 1's pull up and pants were around their ankles. Staff heard a noise from Resident 1's room as they were in the room next door, Resident 1's roommate pushed the call light as well. Staff ran to Resident 1's room at around 7:45 PM, staff entered the room, they found Resident 1 on floor, laying on their back, arms to the sides and legs straight out. Staff notified this nurse, the nurse entered the room, did quick assessment. It was noted that Resident 1 was gray in color, AP (Apical Pulse)-60, R (Respirations) - ,d+[DATE], SPO2 (Oxygen Saturation)-84% on room air, then SPO2 started to drop into the 70's. Unable to arouse Resident 1, even with sternum rub, calling name, and shaking Resident 1's shoulders. Eyes & pupils were fixed, non-reactive. Residents respirations were 6, unable to obtain blood pressure, oxygen was applied via O2 (Oxygen) mask. Resident 1 took 2 more breaths about 10 seconds apart. At about 7:54 PM no breathing noted, no heartbeat, unable to obtain blood pressure. Resident 1 had hit head on either foot board of roommate's bed or on the floor. Resident 1 had small amount of blood to the back of head and a small bump noted. Call placed to Resident 1's POA (Power of Attorney)/emergency contact family member at 8:08 PM, informed of events and Resident 1's had passed. Family instructed the nurse to do what they needed to do the family member would contact other family. A call was placed to PCP (Primary Care Provider) at 8:20 PM the on call Provider returned the call at 8:23 PM, informed of events and Resident 1 had passed. Received TO (Telephone Order) okay to release body to mortuary. A call was placed to the Mortuary at 8:32 PM, the Mortuary came to facility at 9:20 PM to pick up the body. Record review of fall investigation dated [DATE] revealed; on [DATE] Staff had taken Resident 1 to the bathroom and was told to use the call light. Resident had pulled call light, but did not wait for staff and staff heard a noise from Resident 1's room and roommate put on their light. Staff entered room to find Resident 1 on the floor. Charge nurse was notified, vitals were attempted, and assessment was completed. Equipment/Causal factors potentially involved: Resident did not wait for staff, Resident had not pulled up pants, and pants were around ankles. Interventions to prevent accident from happening again: Resident 1 expired. Were alarms in use: Yes Resident 1 had bed and chair alarms. AN interview on [DATE] at 2:53 PM with the MDS Coordinator confirmed; the staff left Resident 1 on the toilet unsupervised as this was a part of her routine. Resident 1 had been instructed to pull the call light. The MDS coordinator confirmed Resident 1 had a BIMS score of 3, but had been able to use the call light. The MDS Coordinator reported that the call light was on when the fall occurred, Resident 1 had not waited for staff. The MDS coordinator reported the facility failed to create a clear picture of what Resident 1's normal routine. An interview on [DATE] at 3:00PM with the MDS coordinator confirmed; Resident 1 had attempted to ambulate with pants on around the ankles and this was an increased risk for falls, and reported that this was unlike the resident who would insist the pants be in place and on at all times. An interview on [DATE] at 3:05 PM with the Administrator reported the call logs revealed; Resident 1 had placed the call light on at 7:34 PM in the bathroom and the roommate had placed the call for help for Resident 1 on at 7:38 PM. The time lapse was 4 minutes. The call reports had been set to a time zone that showed the times were 8:34 and 8:38 PM. An interview on [DATE] at 3:13 PM with the Administrator confirmed; according to the care plan Resident 1 had bed alarms to alert staff of rising from the bed and chair, and Resident 1 was unaware at times of (genders) surroundings and limitations. The Administrator confirmed; according to Resident 1's care plan the resident would not be safe to be unsupervised during the provision of toileting cares. An interview on [DATE] at 3:35 PM with LPN (Licensed Practical Nurse) A, reported that they had worked with Resident 1. LPN reported that Resident 1 was confused most of the time with some clear times. An interview on [DATE] at 4:51 PM with the Administrator confirmed; the cause of death for Resident 1 was head trauma post fall. B. Record review of Quarterly MDS dated [DATE] for Resident 3 revealed, 1)Section C BIMS (Brief Interview Mental Status a structured evaluation aimed at aspects of cognition in elderly score was 12. 2) Section G 0010 I 1 Activities of Daily Living for toileting revealed; Resident 3 require extensive assist of two for toileting. Record review of Resident 3's DX revealed: Unspecified open wound of abdominal wall, left upper quadrant without penetration into peritoneal cavity, subsequent encounter(Primary, Admission), Unspecified [CONDITION(S)], Chronic diastolic (congestive) heart failure, Unspecified severe protein-calorie malnutrition, Other malaise-debility and deconditioning, Psoas muscle abscess, Abscess of intestine-colonic abscess related to the fistula, Overactive bladder, Pain, unspecified, [CONDITION(S)], unspecified, [CONDITION(S)]. Record review of Care Plan for falls for Resident 3 revealed; Care Plan: Problem Start Date: [DATE] Category: Falls Resident 3 was a high risk for falls due to (genders) weakness, vague confusion related to her dementia, poor safety awareness and essential tremors as well as medications she takes Long Term Goal Target Date: [DATE] Will have no fall related injuries Approach Start Date: [DATE] Silent bed and chair alarms to notify staff if trying to get up independently. Approach Start Date: [DATE] Due to uncertainty of Resident 3's weight bearing status with pivot transfer using gait belt and ,d+[DATE] assist to chair, bed etc. Approach Start Date: [DATE] Continue to encourage and remind Resident 3 to call for assistance with all mobility and repositioning Approach Start Date: [DATE] Wheel Chair was the primary mode of mobility, 1 transfer assist with gait belt: be aware that (genders) legs give out at times and the resident was unaware of when this would happen. Record review of Resident 3's Safety Event dated [DATE] revealed; on [DATE] at 2:06 PM Resident 3 had a fall in the resident's room. Resident 3 denied pain. Resident 3 had no injury. Neurological checks: Alert Wakefulness. Facial muscles strong. Left and right upper extremities were weak. Left and right lower extremities are strong. Pupils were 3mm, round brisk for both eyes. Clear word. Resident responds to pain/environment. Possible factors: Recent decline in ADLS. Drug review: antihypertensive. Progress note: Resident 3 was sitting on the floor next to the tall dresser in (genders) room. ROM (Range of Motion) was done. Denies pain. Resident 3 stated I did bump my head on the dresser. Started Neurological checks per policy. Staff asked Resident 3 what was had happen (gender) reported, I was trying to get my w/c. Staff reminded the resident they need to ask for help. Resident 3 had self-transferred early today, called and talked with Family and them, stated, that the resident does get very confused when K+ levels are low. Faxed a noted to Provider about fall. Record review of Care Planned intervention for fall dated [DATE] revealed; the facility was unable to provide documentation of the intervention placed on the care plan. Record review of Fall Huddle dated [DATE] revealed; Resident 3 had attempted a self-transfer to the wheelchair. The call light was not within reach. Resident had increased confusion. The cluttered area was due to the wheelchair and wound vac tubing. Resident 3 had glasses and socks/shoes on. Root Cause: call light was not within reach, increased confusion. Interventions Chair alarm and place call light in reach. Record review of fall Safety event dated [DATE] revealed; Resident 3 had a fall in the resident's bathroom. Resident 3 denied pain. Resident 3 had bruising. Neurological checks: Alert Wakefulness. Facial muscles strong. Left and right upper extremities were strong. Left and right lower extremities are strong. Pupils were 5mm, round brisk for both eyes. Resident responded to their name. Possible factors: Recent decline in ADLS (Activities of Daily Living), cardiac/respiratory disease, other essential tremors. Drug review: antihypertensive and analgesics. Notify Physician of BP >180 and <90, diastolic >110. Record review of a Progress Note dated [DATE] at 5:44 PM Staff called to Resident 3's room at 5:15 PM and noted Resident 3 was on the floor, beside the toilet, in the bathroom. Resident 3 was under the sink and rested against the wall. Laying on back with arms and legs straight. Shoes and socks on. The w/c was parked in bathroom doorway. Questioned Resident 3 what they were doing and they voiced that (gender) they were getting off the toilet. The NA's reported that Resident 3 had gotten on the toilet by them self as they had not assisted the resident there. Noted moderate amount of clear yellow urine present in the toilet. Resident 3 had been restless throughout the afternoon with ongoing confusion. Resident 3 was difficult to redirect at times. Resident 3 had bruising to right calf and different area of bruising to bilateral upper extremities. Unknown if bruising is from fall today or fall yesterday. No bumps or discoloration noted to Resident 3's head, but head resting against the wall and neurological assessments initiated per protocol. Neuro check WNL (Within Normal Limits). ROM (Range of Motion)-WNL. Denies pain related to fall. VS (Vital Signs).98.2,57,18,,d+[DATE],97% on room air. Phone call placed to the Clinic and spoke with the Nurse would notify the Provider of the fall. Informed of low BP (Blood Pressure) and recommended that staff complete orthostatic BP's tomorrow morning and fax to the Provider. Notified that neurological checks were initiated and were WNL. Informed that lab draw and UA (Urinalysis) completed today per order, for ongoing confusion. Continued to monitor Resident 3's condition and return phone call if changes occurred. Record review of fall huddle dated [DATE] revealed; the facility was unable to provide a fall huddle with root cause analysis and interventions for [DATE]. Record review of Resident 3's Care Plan for a fall dated [DATE] revealed; the facility was unable to provide documentation of care planned intervention. Record review of Resident 3's Safety Event dated [DATE] revealed; on [DATE] at 2:54 PM revealed the event was not completed. Record review of a Progress Note dated [DATE] 01:40 PM Resident 3 had a fall while ambulating to BR with staff this morning. The NA (Nurse Aides) called this RN (Registered Nurse) to the resident room at 101 Set resident on floor. Resident stated they had became weak and fell sideways. Noted 4 x 3 cm bruise to right temple and golf ball [NAME] lump to occipital lobe. No further injury noted. Notified PCP (Primary Care Provider) and PDA (Durable Power of Attorney) and Neurological checks Initiated per protocol. Resident 3 denied further discomfort and did rest comfortably at this time. Record review of fall huddle dated [DATE] at 10 20 AM revealed; staff was walking Resident 3 to the restroom. Resident was on their back, legs and arms to the front. Resident 3 had nonskid socks on. Root Cause: Staff had Resident 3 making sure (gender) would not loose balance the walker slid away from Resident 3 and staff tried to keep the resident from falling. Interventions: Staff will have wheelchair in reach during ambulation was on the interventions and crossed through with error written on it. There were no other interventions. Record review of Resident 3's Fall Care Plan revealed; No fall intervention on the care plan for Resident 3 dated [DATE]. Record review of fall Safety event dated [DATE] revealed; Resident 3 had a fall in the resident's room. Resident 3 reported pain at a 3 on a scale of ,d+[DATE]. Resident 3 had bruising, skin tear, and swelling. Neurological checks: Alert Wakefulness. Facial muscles strong. Left and right upper extremities were strong. Right lower extremities are strong. Pupils were 3 mm (millimeters), round brisk for both eyes. Resident 3 had clear speech. Resident 3 responded to name, pain and environment. Resident 3 was confused. Drug review: antihypertensive, anticonvulsants, diuretics and analgesics. Interventions: Bed alarm and first aid. Record review of Progress note dated [DATE] revealed; Resident 3 noted to be sitting on the floor, leaned against the wall, near the bathroom at 0745. Staff responded and noted resident with moderate amount of bleeding from both elbows. Range of motion was within normal limits. Resident 3 assisted up and into w/c via 3 assist. Cleansing of skin tear areas to elbows completed and steri-strips, [MEDICATION(S)], and Coban applied to cover areas. Skin tears to left elbow measure 1)5 cm (centimeters) x 2.5 cm 2)0.9 cm x 0.7 cm Right elbow skin tear measures 8 cm x 5 cm. Questioned resident 3 about what they were doing. Resident 3 reported getting up to make coffee and go pee. Resident 3 was ambulating independently with walker to bathroom at time of fall. Neurological assessment initiated per protocol. Resident 3 then assisted with dressing and noted dark red bruising to left mid back which measures 11,5 cm x 8 cm with mild amount of swelling to area. Phone call to the clinic to notify of fall and injuries. Informed of increased confusion on arise. Received telephone order for UA (Urinalysis) with triggered Culture and Sensitivity. Clean catch UA completed and results faxed to Provider. Resident 3 requested and received PRN (As needed) Tylenol prior to lunch for back discomfort with voiced effectiveness. Bed and chair alarms applied and in place, Will continue to monitor. Currently resting in recliner with call light in reach. Record review of fall Huddle dated [DATE] revealed; Resident 3 had been up to make coffee and use the bathroom. Resident 3 was found on the floor in a sitting position, the room was dark, and the lights were off. Root Cause: Resident 3 got up unassisted, the call light was not on. Interventions were Bed and Chair alarm back in place. Record review of Resident 3's Fall Care Plan revealed; the intervention identified for the fall on [DATE] was already in place on the care plan and dated [DATE]. An interview on [DATE] at 4:00PM with the MDS Coordinator confirmed; Resident 3 had a fall that did not have a fall huddle completed in April. The MDS Coordinator also confirmed Resident 3 did not have interventions after falls on [DATE], [DATE], [DATE], and [DATE] and the fall on [DATE] was not a new intervention. C. Record review of Resident 4's diagnosis revealed; Dementia with [NAME] bodies (Primary), Presence of left artificial hip joint, Pain, unspecified, Difficulty in walking, not elsewhere classified, [CONDITION(S)] disease, Hereditary and idiopathic [CONDITION(S)], Dementia in other diseases classified elsewhere with behavioral disturbance, Restlessness and agitation, Muscle weakness (generalized), Repeated falls, Personal history of (healed) traumatic fracture-left femur/hip, Impulse disorder, unspecified, Abnormal posture, Paraphilia, unspecified. Record review of Resident 4's Care Plan revealed; Problem Start Date: [DATE] Category: Falls Resident 4 continued to be at risk for falls: (gender) no longer ambulated and required a mechanical lift for transfers and with (genders) dementia had no safety awareness: continued to display increased restlessness at times with attempts to get up and out of chair or thinking (gender) can walk. Short Term Goal Target Date: [DATE] Resident 4 would be free from injury from falls. Approach Start Date: [DATE] If extremely restless may try the geri-chair (Reclining chair) NA, Nursing Approach Start Date: [DATE] Low bed and floor mats to each side of bed, recliner chair removed from room as either in w/c or bed. Approach Start Date: [DATE] Fall risk assessment quarterly and with significant change and PRN Nursing Approach Start Date: [DATE] Continue to anticipate Resident 4's needs: (Gender) had no safety awareness related to dementia Nursing Approach Start Date: [DATE] Resident 4 needed total assistance with all ADL's. Approach Start Date: [DATE] Resident 4 required the mechanical lift for transfers with assistance of 2. Resident 4 no longer bears weight. Make sure that you explain what you are doing prior to getting (gender) ready for the lift and to transfer. Approach Start Date: [DATE] OT has reworked Resident 4's w/c and provided (gender) with a low hip belt that reminds (gender) to maintain proper sitting position. Resident 4 could remove the belt as he desired. Record review of Fall Risk Evaluation for Resident 4 dated [DATE] revealed; Resident 4 was intermittently confused. Resident 4 was visually impaired. Resident 4 required the use of an assistive device for balance and gait. Resident 4 was ambulatory and incontinent. Resident 4's medications were: Cardiovascular - Cardiac [CONDITION(S)] Perceptual - Impaired hearing; Impaired vision; Dizziness/[CONDITION(S)] Neuromuscular/Functional - Loss of limb movement, Decline in functional status; Incontinence; [CONDITION(S)], CVA (Cerebral Vasuclar Accident-stroke); [CONDITION(S)]/[CONDITION(S)] (One side paralysis); [CONDITION(S)]; [CONDITION(S)] Disorder; Syncope; Unsteady gait Psychiatric Or Cognitive - Delirium; Decline in cognitive skills; Manic Depression; Alzheimer's Disease; Other Dementia Orthopedic - Joint pain; Arthritis; Fracture of hip; Missing limb; [CONDITION(S)]. Resident 4's total fall risk score was 21. Plan of Care: Resident 4 had 2 falls in the past quarter. Safety measures remain in place to prevent falls as outlined in (genders) care plan. Will continue to reevaluate fall risk quarterly and make adjustments as necessary. Assessment data retrieved between [DATE] and [DATE]. Record review of Safety Event dated [DATE] revealed; Resident 4 had a fall in the resident's room. Resident 4 denied pain. Resident 4 had no injury. Facial Muscles were strong, Upper Extremities were strong, and Lower extremities were weak. Pupils were 3mm (Millimeter) round sluggish to the left eye and right was 3 mm. Speech was clear. Resident 4 responded to name, pain, and environment. Resident 4 complained of nausea and vomiting prior to the fall. Evaluations revealed: continue in fall program with interventions in place per current care plan. Record review of Progress Note dated [DATE] 02:25 AM Resident 4's silent bed alarm went off at 0100 and nursing staff found resident laying on the floor next to (genders) bed on his right side. Resident 4 was laying on a cushioned floor mat and electric bed was in lowest position. Resident 4 had vomited and was incontinent of bowel at this time. Range of motion was performed to all extremities without limitations. No noted bruising or open areas to the skin noted. Resident 4 stated (gender) did not hit (genders) head and denied discomfort. Resident 4 stated I was trying to get out of bed to find Spouse. Resident 4 was cleaned up and cares performed. Lift sling was placed under resident and was assisted up into the wheelchair by three assist and Hoyer lift. Resident 4 was alert and answered questions sensibly. Vitals were taken an resident was resting in his wheelchair, covered with warm blanket, denied discomfort and nausea, watching television in living room with staff nearby. Provider was faxed and notified of fall. Resident's son and spouse will be informed of fall in the morning. Record review of Fall Huddle dated [DATE] revealed; Resident 4 was getting up to find spouse, found on floor beside bed on floor mat. Resident 4's room was dark. Resident 4 was bare foot wearing a brief. Root Cause: Going to find Spouse. Interventions: All interventions were in place floor mats, call light, bed in low position, pillows beside Resident 4. Record review of Resident 4's Care Plan intervention for fall dated [DATE] revealed; the facility was unable to provide documentation of a new intervention for the fall. Record review of Safety Event dated [DATE] revealed; the event was not completed. Record review of Fall Huddle dated [DATE] revealed Resident 4 was attempting to find spouse. Resident 4 was on buttocks legs extended near bed. Resident 4 slid from bed in low position to the fall mat on the floor. Resident 4 had nonskid socks. Root Cause: Resident 4 was worried about spouse and attempted transfer unassisted. Interventions: Ensure Resident 4's bed was in a low position while in bed. Record review of Safety Event dated [DATE] revealed; Resident 4 had a fall in the resident's room. Resident 4 denied pain. Resident 4 had no injury. Facial Muscles Strong, Upper Extremities were strong, and Lower extremities were strong. Pupils were 3 MM round and brisk. Speech was clear. Resident 4 responded to name, pain, and environment. Resident 4 had antihypertensive, antipsychotic, and sleeping medications. Evaluations revealed: continue in fall program with interventions in place per current care plan. Record review of Resident 4's Care Plan intervention for fall dated [DATE] revealed; the facility was unable to provide documentation of a new intervention for the fall. Record review of PN dated [DATE] at 10:10 PM 98.3, P-63, R-20, B/P.,d+[DATE], SP,d+[DATE]% on room air. Staff found Resident 4 on hands and knees on the floor mat next to bed. The bed was in the lowest position. When staff asked Resident 4 what happened, Resident 4 stated I have things to do down here'. Resident 4 denied hitting head, no injury noted, good ROM. Resident 4 denied any discomfort, and Resident 4 was assisted back to bed without difficulty. Fax sent to PCP to inform and Resident 4's spouse was notified as well. Resident 4 was lying in bed, call light was within reach. Staff will monitor. Record review of Fall Huddle dated [DATE] revealed; Resident 4 was attempting to make love. Resident 4 fell near the bed, the room was dark, on a floor mat. Resident 4 had a bed alarm in place. Resident 4 had gripper sock and a brief on. Root Cause: Not completed Interventions: Not completed. Record review of Resident 4's Care Plan intervention for fall dated [DATE] revealed; the facility was unable to provide documentation of a new intervention for the fall. Record review of Safety Event dated [DATE] revealed; Resident 4 had a fall in the resident's room. Resident 4 denied pain. Resident 4 had no injury. Facial Muscles Strong, Upper Extremities were strong, and Lower extremities were weak. Speech was clear. Resident 4 responded to name, pain, and environment. Possible contributing factors were: neurological disorder, recent decline in ADLs and Orthopedic condition. Resident 4 had antihypertensive and analgesics. Evaluations revealed: continues in fall prevention program with interventions in place per current care plan. Discomfort associated with event has resolved although chronic pain continues. No injury noted related to the event. Care plan reviewed by nursing staff following event. Record review of the Fall Huddle dated [DATE] revealed; Resident 4 did not have a reason they fell , was found on the fall mat next to the bed. Resident was kneeling on the right knee, the room was dark bed was in the low position. Resident 4 had 1 Ted hose on and 1 sock with cushion boot. Resident had a long sleeve shirt and brief on. Staff was alerted to room by the alarm. Root Cause: Resident complaints of pain and was irritable. Interventions to prevent further falls: NO interventions listed. An interview on [DATE] at 2:45 PM with the MDS Coordinator confirmed; that Care Plans should have new interventions placed after a fall related to route cause analysis. An interview on [DATE] at 2:45 PM with the MDS Coordinator confirmed the interventions for fall prevention was were missing on the care plans related to transferring written interventions to the computer program. The MDS the interventions should be written on the care plans. An interview on [DATE] at 5:45 PM with the Administrator revealed; the Administrator would email the additional information related to the care plans. An interview on [DATE] at 8:53 Am with the Administrator confirmed; the facility had no additional information for the interventions for Resident 3 or 4. Abatement Statement dated [DATE] 35 residents have been evaluated individually according to their most recent BIMS score and Fall Risk Assessment, use of bed and/or chair alarms/ history of falls in the previous 6 months and ADL scores for transfers and toileting. 8 residents were identified as at risk for falls in the bathroom. The Administrator and the Nurse Mentor are calling all nursing staff tonight to educate them on who the 8 residents are that need to have a care partner present with them when they are in the bathroom and the criteria that will be used to identify residents at risk in the future. Staff that are present in building this evening will be given verbal education. Care plans are being updated for those residents identified as needing attendance during toileting.

Licensure Referene Number 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to ensure that staff wore hairnets when plating food and entering kitchen areas of neighborhood dining rooms, that hair nets completely enclosed all hair, that food was not touched with bare hands and that utensils and dishes were handled in a manner to prevent the potential for food borne illness. This had the potential to affect all residents who ate food prepared in the main kitchen and neighborhood kitchens. Findings are: [NAME] Observation on 12/30/19 from 11:52 AM-12:40 PM in the 100 hallway Dining Room revealed that Homemaker C was wearing hairnet but didn't cover all hair on left side and back, that NA (Nursing Assistant) D was dishing up salad in kitchen area but did not have a hairnet on, that NA [NAME] was dishing up fruit in kitchen area and did not have a hairnet on and that NA F when picking up a plate was placing thumb over the rim of the plate and was entering the kitchen area when food was being served without a hairnet on. Observation on 01/02/20 from 09:57 AM-10:30AM of food preparation by Dietary I revealed Dietary I to open a cabinet drawer and pick up a spoon by touching the bowl part of the utensil. Observation on 01/02/20 from 11:51 AM-12:10 PM in the 100 hallway Dining Room revealed that Homemaker G was wearing a hairnet but didn't cover all hair in the front and while temping the cold sandwiches touched a hamburger bun with bare hand and that NA H was entering the kitchen area when food was being served without a hairnet on. Record review of the Nebraska Food Code, Effective date 7/21/16, Hair Restraints 2-402.11 Effective revealed; (A) FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENs; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Interview on 01/07/20 at 02:00 PM with Dietary Manager confirmed that hairnets should be worn when plating food, that hairnets when worn, should cover all hair, that staff shouldn't put thumb over rim of plates, that utensils should be picked up by the handles and that food should not be touched directly with bare hands. B) Observation on 12/30/19 at 12:05 PM of the 200 hall dining room revealed NA-H (Nurse Aide), NA-K, and NA-L dishing up food from the steam table and delivering the plate to residents at the tables. NA-H, NA-K, and NA-L were not wearing hair nets, and NA-K did not have beard hair restrained. Observation on 12/30/19 at 5:10 PM of the 200 hall dining room revealed MA-A dishing up food from the steam table and delivering the plate to residents at the tables. MA-A was not wearing a hair net. Interview on 1/7/20 at 1:14 PM with NA-L revealed 16 residents were eating in the 200 hall dining room that day. NA-L revealed the number of residents eating in the dining room would vary day to day depending on resident preferences.

Based on record review and interview, the facility failed to ensure advance directives were reviewed on a routine basis for 3 residents (Residents 6, 18, and 27) of 3 residents reviewed. The facility census was 35. Findings are: A) Review of Resident 6's Face Sheet dated 12/31/19 revealed the resident's advance directives included do not resuscitate (DNR) and do not intubate (DNI). Review of Resident 6's Fairview Manor Policy and Procedure for Code/No Code dated 3/23/16 revealed the resident representative selected no code and signed the form on 3/23/16. Review of Resident 6's Care Plan revealed no documentation related to advance directives. B) Review of Resident 18's Face Sheet dated 12/31/19 revealed the resident's advance directives included DNR. Review of Resident 18's Policy and Procedure for Code/No Code dated 10/22/19 revealed the resident's representative selected no code and signed the form on 10/22/19. Review of Resident 18's Care Plan revealed no documentation related to advance directives. C) Review of Resident 27's Face Sheet dated 12/31/19 revealed the resident's advance directives included DNR. Review of Resident 27's MAR (Medication Administration Record) revealed the resident's advance directive is DNR. Review of Resident 18's Care Plan revealed no documentation related to advance directives. Interview on 01/02/20 at 3:37 PM with the SSD (Social Services Director) revealed advance directives were completed and reviewed at admission when a resident and representatives were present, but the advance directives were not reviewed routinely after that time.

Licensure Reference Number 175 NAC 12-006.05(21) Based on observation, record review and interview; the facility failed to ensure that staff called residents by preferred name for 2 residents, (Residents 12 and 22), and failed to ensure that the lift sling was not visible in wheelchair for 1 resident, (Resident 7). The facility census was 35. Findings are: [NAME] Observation on 12/30/19 from 11:52 AM-12:40 PM in the 100 hallway Dining Room revealed NA (Nursing Assistant) A to refer to Resident 12 and 22 as honey when speaking to them. Record review of Care Plan for Resident 12 revealed that honey was not a preferred name to be used. Record review of Care Plan for Resident 22 revealed that honey was not a preferred name to be used. Interview on 01/07/20 at 02:10 PM with RN (Registered Nurse) J confirmed that staff using endearing names to address residents without their permission would be a dignity issue. B) Observations on 12/30/19 at 5:07 PM, on 12/31/19 at 12:00 PM, and 01/06/20 at 12:30 PM of Resident 7 in the dining area revealed the resident's transfer lift sling was present under Resident 7. The straps and slings were exposed and clearly visible in the dining area. Interview on 01/06/20 with the DON (Director of Nursing) revealed Resident 7's sling was present when the resident was up in the wheelchair. The DON revealed the facility previously talked about removing the slings from under residents, but could not remember if any decisions were made. The DON also revealed there was no policy in place, and the resident or resident representative did not express a preference for removing the sling.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to notify the resident's representative prior to being discharged from Medicare Part A for 1 resident (Resident 21) of 3 residents reviewed. The facility census was 35. Findings are: The facility provided information regarding the Beneficiary Notice - Residents discharged Within the Last Six Months revealed Resident 21 was discharged from Medicare Part A services on 01/03/20 but remained in the facility. The facility was unable to provide signed copies of the notices given to the resident and the resident's representative at the time of discharge from Medicare Part A services due to forms being in the mail. Review of Resident 21's Progress note dated 01/06/20 revealed the resident's representative was notified Resident 21's last covered day was 01/03/20 and will resume private pay as of 01/04/20. Interview on 01/06/20 at 2:36 PM with SSD (Social Services Director) confirmed Resident 21's representative was not notified the resident was no longer covered by Medicare Part A prior to coming off on 01/03/20. The SSD revealed the resident's representative was notified on 01/06/20 and the forms were put in the mail to be sent to Resident 21's representative.

Licensure Reference Number 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to provide in writing to resident and resident's representative the reason for transfer to the hospital for 2 residents (Residents 22 and 28). The facility census was 35. Findings are: Review of Progress notes dated 10/04/2019 at 10:22 AM revealed Resident 22 was transferred to the hospital after being seen in physician's office for the following symptoms; temperature of 101.0 degrees, face flushed, complaints of being short of breath, productive cough of yellow sputum and wheezes (a high-pitched or coarse [MEDICATION NAME] sound heard when breathing) throughout lung fields. Review of Progress Notes dated 11/19/2019 at 10:53 AM revealed that Resident 28 was transferred by ambulance after sustaining a fall to the ER (emergency room ) for evaluation and on 11/19/2019 at 02:38 PM facility was notified that Resident 28 was being admitted to hospital for fractured right hip. Interview with SSD on 01/07/20 at 11:40 AM confirmed that no written documentation of reason for hospital transfer was provided to Residents 22 and or 28 or to Resident 22 and 28's Representatives.

Based on record review and interview, the facility failed to ensure the PASRR ( Preadmission Screening and Resident Review - A federal requirement to help ensure individuals are not inappropriately placed in nursing homes for longterm care) reflected the current diagnoses for 2 residents (Residents 21 and 10) of 2 residents reviewed. The facility census was 35. Findings are: A) Review of Resident 21's PASRR revealed dated 4/4/16 revealed no mental health diagnoses were documented under the Diagnoses heading and no medications were documented under the Mental Health Medications heading. Under the Ascend Outcome heading, documentation revealed no Level II assessment was required and if changes occurred or new information refuted these findings a new screen must be submitted. Review of Resident 21's comprehensive MDS (Minimum Data Set - Federally mandated comprehensive assessment tool used for care planning) dated 11/17/19 revealed depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities causing significant impairment in daily life) and [MEDICAL CONDITION] (Severe mental disorder that causes abnormal thinking and perceptions) diagnoses were documented under the Psychiatric/mood disorder heading in section I. B) Review of Resident 10's PASRR dated 4/4/16 revealed no diagnoses under the Serious Mental Health heading. [DIAGNOSES REDACTED]. Diagnoses of Dementia (A group of thinking and social symptoms that interferes with daily functioning, characterized by impairment of at least two brain functions, such as memory loss and judgement) was not documented under the Neurocognitive Disorder/Dementia Heading. The PASRR determination revealed no further screening required unless the individual is later suspected or found to have a mental illness. Review of Resident 10's quarterly MDS dated [DATE] revealed diagnosed including: [DIAGNOSES REDACTED]. Interview on 1/7/20 at 1:55 PM with SSD (Social Services Director) confirmed the PASRR was not updated with current diagnoses for Resident 10 and Resident 21. SSD revealed nursing staff should have reported the changes in diagnoses.

Licensure Reference Number 175 NAC 12-006.09C Based on observation, record review and interview; the facility failed to develop a comprehensive care plan (a comprehensive interdisciplinary plan to ensure the provision of quality care for a resident) to include a [DIAGNOSES REDACTED]. The facility census was 35. Findings are: [NAME] Observation on 12/31/19 at 10:21 AM of Resident 22 sitting up in recliner chair in room revealed right lower extremity [MEDICAL CONDITION]. Review of physician orders [REDACTED]. Review of MDS (Minimum Data Set) (a mandatory comprehensive assessment tool used for care planning) revealed that latest Quarterly dated 8/9/19 and Annual dated 11/8/19 included a [DIAGNOSES REDACTED]. Review of comprehensive care plan (a written interdisciplinary comprehensive plan detailing how to care for a resident) for Resident 22 revealed no problem related to [MEDICAL CONDITION] identified. Interview on 01/07/20 at 2:05 PM with RN J confirmed that Resident 22's care plan did not include [MEDICAL CONDITION]. B) Observation on 12/30/19 at 11:55 AM revealed Resident 6 was sitting in a wheelchair in the Dining room with a lap belt secured around the waist. Interview on 01/02/20 at 2:22 PM with DON (Director of Nursing) revealed Resident 6 has been using the same wheelchair since admission and had always used the lap belt. DON revealed the lap belt was used for positioning since the Resident would slouch and scoot down in wheelchair. Review of Residents 6's care plan revealed an absence of documentation related to the use of a lap belt when in wheelchair. Interview on 01/07/20 at 08:16 AM with DON confirmed lap belt is not documented on Resident 6's care plan.

Licensure Reference Number 175 NAC 12-006.09C1c Based on observation, record review and interview; the facility failed to ensure that the comprehensive care plan (a written interdisciplinary comprehensive plan detailing how to care for a resident) was reviewed and revised to include a skin condition and treatment for 1 resident (Resident 31). The facility census was 35. Findings are: Observation and Interview with Resident 31 on 12/30/19 at 01:47 PM revealed tape on right lower extremity. Right lower extremity appeared reddened with open areas present. Resident 31 states puts the tape on to make skin stronger. Observation and Interview with Resident 31 on 01/02/20 at 02:30 PM reveals Resident 31 sitting up in recliner chair in room, blister observed on Right lower extremity, no tape noted to Right lower extremity, and a container of [MEDICATION NAME] cream noted at bedside. Resident 31 states pats the [MEDICATION NAME] cream on legs once in a while to soften scabs. Record review of physician orders [REDACTED]. [MEDICATION NAME] Gentle 3 inches by 3 inches, apply over [MEDICATION NAME] cream on right leg wounds as needed. Record review of comprehensive care plan reveals an identified risk for pressure ulcer and skin breakdown but no interventions related to right lower extremity skin issue and as needed treatment for [REDACTED]. Interview with RN (Registered Nurse) J on 01/07/20 at 2:30 PM confirmed that Resident 31's care plan had not been reviewed and revised to include the current skin issue to right lower extremity or the as needed treatment that had been ordered by physician.