Every finding on record at Falls City Care Center

Licensure Reference Number 12-006.04(F)(i) Based on record review, and interview, the facility failed to notify the resident's physician of a change in condition, and failed to notify family representative for 1 resident (Resident 2) of 5 sampled residents a change in condition. The facility census was 56.Findings are: A record review of the admission Record revealed Resident 2 was admitted to the facility on [DATE] with the diagnosis of Age-related osteoporosis without current pathological fractures (occurs when bones naturally lose density and mass as you age, becoming weak), Dementia, psychotic disturbance, mood disturbance and anxiety (describes a cognitive decline (such as memory loss and impaired problem-solving) occurring without psychiatric or physical symptoms like aggression, wandering, or anxiety) , Depression (persistent sadness, loss of interest, and a lack of energy), Atrial Fibrillation (rapid quivering in the heart's upper chambers (atria), causing an irregular and often fast heartbeat), Hypertension (high blood pressure), Dizziness and Giddiness (feelings of lightheadedness, faintness, or unsteadiness). A record review of the facility policy Incidents and Accidents with a date (reviewed/revised) of 7/2026 revealed:9) The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies). 11) The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital12) The nurse will enter the incident/accident information into the appropriate form/system within 1 hours of occurrence and will document all pertinent information A record review of Resident 2 progress notes revealed that an late entry dated 6.27.26 at 1:24 PM noting that Resident was being pushed down the hallway in a wheelchair where Resident 2 dropped (gender) right foot off the foot pedal and Resident 2 right leg bend backwards under the wheelchair. A record review of Resident 2 progress notes revealed that on 6/27/26 at 8:30 PM Resident 2 complained of pain to Resident 2's right foot/ankle when touched. A record review of Resident 2 progress notes revealed that there was no progress notes on 6/28/26 for day shift, evening shift or night shift. A record review of Resident 2 progress notes revealed that on 6/29/26 at 1:04 PM that if there is touch to the right ankle Resident 2 will yell out in pain. An appointment was made to see primary physician for the right ankle/foot pain. A record review of Resident 2 progress notes revealed that on 6/29/26 at 2:15 PM Resident 2 yells out in pain with just touching the right ankle. At 4:20 PM a PRN (when needed) Tylenol was given and charted effective. A record review of Resident 2 progress notes revealed that on 6/30/26 at 3:00 PM Resident 2 returned to facility and seeing medical provider and was diagnosed with a right fibular fracture (a break in the smaller, outer bone of the lower leg). The Director of Nursing (DON) was unable to produce documentation that the physician or family representatives had been notified of the incident with the right foot/ankle when a change of condition occurred. An interview on On 7/20/26 at 11:00 AM the DON confirmed that the physician was not notified of the incident of the right ankle/foot being bent-over for Resident 2 until Tuesday (6/30/26), the day of Resident 2's appointment. The DON stated the facility did not do a change of condition to the physician nor did the facility notify family representatives due to nothing was out of the ordinary with Resident 2 . DON confirmed that Resident 2 did complaint of pain with touching of the right ankle but when asked why Resident 2 was screaming Resident 2 stated (gender) didn't know. The DON confirmed that this incident happened on 6/27/26 and Resident 2 was seen by the physician on 6/30/26 where x-rays were done and Resident 2 found to have a right fibular fracture. The DON confirmed that a change of condition should of been done and the physician and family representative should of been updated when the incident had happened and the physician and the family representatives had not been notified.

Licensure Reference Number 175 NAC 12-006.09 (C)(ii) Based on record reviews and interviews, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities within 14 days of a significant change for 2 (Resident 2 and 3) of 5 residents sampled. The facility census was 56.Findings are:A.A record review of the admission Record revealed Resident 2 was admitted to the facility on [DATE] with the diagnosis of Age-related osteoporosis without current pathological fractures (occurs when bones naturally lose density and mass as you age, becoming weak), Dementia, psychotic disturbance, mood disturbance and anxiety (describes a cognitive decline (such as memory loss and impaired problem-solving) occurring without psychiatric or physical symptoms like aggression, wandering, or anxiety) , Depression (persistent sadness, loss of interest, and a lack of energy), Atrial Fibrillation (rapid quivering in the heart's upper chambers (atria), causing an irregular and often fast heartbeat), Hypertension (high blood pressure), Dizziness and Giddiness (feelings of lightheadedness, faintness, or unsteadiness). A record review of progress notes 6/30/26 for Resident 2 revealed that Resident 2 had an injury to Resident 2's right foot/ankle and and x-ray revealed a right fibular fracture (a break in the smaller, outer bone of the lower leg). A record review of the MDS revealed that there was no SCSA done for Resident 2's fracture within the 14 day of the change in condition.The Director of Nursing (DON) was unable to provide a policy or documentation on when and how a significant change is to be done on a MDS.An interview at 2:47 PM 7/20/26 with the DON and Licensed Practical Nurse (LPN)-A confirmed that a SCSA MDS was not completed after Resident 2 fracture and it should have been done. LPN-A confirmed that (gender) thought it had been done. The LPN-A confirmed that (gender) is the one who does the MDS for the facility.B.A record review for Resident 3 admission Record revealed that Resident 3 was admitted to the facility on [DATE] with the diagnosis of Mental Disorders due to known Physiological conditions (a psychiatric syndrome directly caused by an underlying medical or neurological disease), Transient Ischemic Attack (little strokes), Cerebral Infarction (stroke) without residual deficits, Hypothyroidism, Absence of right and left legs above the knee, Dementia, A record review of progress notes dated 12/1/25 revealed Resident 3 had an x-ray revealing a fracture to the left elbow.A record review of the Clinical documentation for the MDS revealed that there was no significant change done for Resident 3 within the 14 day of the change in condition.The DON was unable to provide a policy or documentation on when and how a significant change is to be done on a MDSAn interview at 2:47 PM on 7/20/26 with the DON and Licensed Practical Nurse (LPN)-A confirmed that a SCSA MDS was not completed after Resident 3's fracture and it should have been done.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on record review and interview the facility failed to identify causative factors for one (Resident 1) of 5 sampled residents and the facility failed to put in new interventions to prevent falls for one (Resident 1) of 5 sampled residents. The facility census was 56Finding are: A record review of admission Record revealed Resident 1 was admitted to the facility on [DATE] with the diagnosis of Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Injuries of left hip, Hypertension (high blood pressure), Dementia, and Fracture of Superior Rim of left Pubis (pelvic fracture). A record review of Resident 1's progress notes dated 7/14/26 revealed Resident 1 had a fall. Upon assessment resident is lying on left side next to (gender) bed in fetal position. Floor is clean and clutter free, walker is within reach, call light within reach but not in use at time of fall and resident has bare feet. Resident 1 was sent to ER where the x-rays revealed Resident 1 had a nondisplaced left superior pubis ramus fracture. A record review of Resident 1's Care plan (a written instruction needed to provide effective and person centered care of the resident that meet professional standards of quality care) with last completed dated 3/18/2026 revealed that Resident 1 had actual fall with interventions with dates of 3/05/2025, 3/7/2026, 3/16/2026, 3/17/26. There was no new interventions in place for fall on 7/14/26. A record review of the risk management forms revealed that predisposing section was marked as other with no explanation, and the predisposing situation factors marked other with no explanation to determine the causative factor of the fall for Resident 1. A record review of the facility's Fall prevention and Response Policy dated April 2025 revealed:7) The care plan will be updated with any new or updated fall interventions A record review of the facility's policy Care Planning dated March 2019 revealed:5) Interventions act as the means to meet the individual's needs (not to continue outmoded institutional practices). The recipe for care requires active problem solving and creative thinking to attain, and clearly delineates who, what, where, when and how the individual residents goals are being addressed and met. An interview on 7/20/26 at 2:30 PM with the Director of Nursing (DON) confirmed that interventions had been put in place and had thought that revising old interventions was enough. The DON confirmed that the fall and fracture had not been added to the care plan and it should of been.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record reviews and interviews, the facility failed to report an allegation of abuse to the State Agency within the required timeframe for Resident 2. This affected 1 of 3 residents reviewed for abuse. The facility census was 56.Findings are:A record review of the facility's Abuse Prevention Plan last revised February 2023 revealed that the Administrator (ADM), Director of Nursing (DON), or Nursing Supervisor would make sure that a report was filed and an initial investigation begun immediately. The policy also stated that any allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of resident property should be reported to the State Agency immediately, within two hours if the event that caused the allegation included abuse or there was serious bodily harm, and within 24 hours if abuse was not involved and there was no serious bodily harm.A record review of Resident 2's Order Summary dated 06/25/2026 revealed the facility admitted the resident on 12/01/2025, and the resident did not have a diagnoses of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities).A record review of Resident 2's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 06/03/2026 revealed a Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function. The test is scored from 0-15, and the higher the score, the higher the cognitive function) of 13, indicating the resident was cognitively intact.A review of a Grievance/Concern Report Form dated 05/27/2026 revealed that Resident 2 had filed the grievance to report that the nurse stole medications from Resident 2.An interview on 06/25/2026 at 1:22 PM with Resident 2 confirmed that when they came back from the appointment with their provider, they had a new medication order for Metamucil (a fiber supplement used to promote bowel regularity). Resident 2 stated they stopped at the nurse's desk to give them the paperwork from the appointment and told Licensed Practical Nurse (LPN) A they had a bottle of Metamucil in the basket of the walker and would take care of it. The resident stated LPN A started to open the basket to take the Metamucil and the resident said no, but the LPN kept opening the basket and hitting the resident's hands. Resident 2 reported that their left hand was bruised and the right middle finger would not bend all the way, and that their hands hurt terribly at first, but they were almost healed now. Resident 2 denied having seen a provider for their hands.An interview on 06/25/2026 at 2:17 PM with LPN A confirmed that on 05/27/2026 the LPN had removed Resident 2's medications from the basket of the resident's walker.An interview on 06/25/2026 at 4:11 PM with the Director Of Nursing (DON) confirmed that the incident involving Resident 2 occurred on 05/27/2026. The DON further confirmed that the Resident 2 had stated that LPN A stole (gender's) medications.An interview on 06/25/2026 at 4:30 PM with the Administrator confirmed that the facility should have reported the allegation to the State Agency and did not.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interviews, the facility failed to investigate an allegation of abuse for Resident 2. This affected 1 of 3 residents reviewed for abuse. The facility census was 56.Findings are:A record review of the facility's Abuse Prevention Plan last revised February 2023 revealed that the facility would investigate all incidences such as falls, bruises, medication errors, and resident complaints.A record review of the facility's Skin Program Policy last revised March 2019 revealed that when a bruise or a skin tear was noted, a thorough assessment or comprehensive wound assessment sheet should be completed and documented.A record review of Resident 2's Order Summary dated 06/25/2026 revealed the facility admitted the resident on 12/01/2025, and the resident did not have a diagnoses of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities).A record review of Resident 2's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 06/03/2026 revealed a Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of a resident's cognitive function. The test is scored from 0-15, and the higher the score, the higher the cognitive function) of 13, indicating the resident was cognitively intact.A record review of Resident 2's Progress Notes from 05/01/2026 to 06/25/2026 revealed the only documentation on 05/27/2026 was of the resident's return from an appointment and new orders. There was no mention of the resident's mention of hand pain, or assessment of the hands for injuries. Further review revealed a Skin Issues Progress Note dated 05/31/2026 at 3:54 PM that documented purple bruising to left hand base of middle finger extending to palm of hand. There was no documentation of investigation done regarding how the bruising occurred.An interview on 06/25/2026 at 1:22 PM with Resident 2 confirmed that when they came back from the appointment with their provider, they had a new medication order for Metamucil (a fiber supplement used to promote bowel regularity). Resident 2 stated they stopped at the nurse's desk to give them the paperwork from the appointment and told Licensed Practical Nurse (LPN) A they had a bottle of Metamucil in the basket of the walker and would take care of it. The resident stated LPN A started to open the basket to take the Metamucil and the resident said no, but the LPN kept opening the basket and hitting the resident's hands. Resident 2 reported that their left hand was bruised and the right middle finger would not bend all the way, and that their hands hurt terribly at first, but they were almost healed now. Resident 2 denied having seen a provider for their hands.An interview on 06/25/2026 at 4:11 PM with the Director of Nursing (DON) confirmed that on 05/27/2026 the DON had worked the evening shift and overheard another staff member who stated Resident 2 said that Licensed Practical Nurse (LPN) A had hurt Resident 2. The DON confirmed they had not gone to assess Resident 2 for injury at that time. The DON further confirmed there was no documentation that an investigation was done for the bruising documented on 05/31/2026.

Licensure Reference Number 175 NAC 12-006.04(D) The facility failed to provide a minimum of three nurse aides on each shift per the facility assessment and to ensure call lights were answered to meet the needs of the residents. This had the potential to affect all residents that resided in the facility. The total facility census was 49. Findings are: A record review of the Facility assessment dated [DATE] revealed the facility has an average daily census of 55 that requires 1-3 licensed nurses, 3-9 nurse aides, and 1-3 other nursing personnel. A record review of the facility's Posted Daily Staffing dated 05/04/2025 revealed three licensed nurses and no nurse aides on the day shift. A record review of the facility's Posted Daily Staffing for May 1st- May 31st, June 1, 2, and 3, 2025 revealed two nurse aides staffed on the night shift. A record review of the facility's Schedule Sheet dated May 2025 revealed two NA's scheduled for night shift every night. A record review of the facility's Past Calls for resident room [ROOM NUMBER] dated 12/1/2024-1/14/2025, all shifts, revealed 31 times the call lights were on more than 30 minutes with the longest time of one hour and 21 minutes on 01/01/2025 at 3:30 AM. A record review of the facility's Past Calls for resident room [ROOM NUMBER] dated 05/05/2025-06/03/2025, all shifts, revealed 23 times the call lights were on more than 30 minutes with the longest time of 59:26 minutes on 05/12/2025 at 6:08 AM. A record review of the facility's Past Calls for resident room [ROOM NUMBER] dated 05/05/2025-06/03/2025, all shifts, revealed 10 times the call lights were on more than 30 minutes with the longest time of 1:20 (1 hour and 20 minutes) on 05/09/2025 at 9:35 AM. A record review of the facility's Bathing Schedule dated May 2025 revealed Resident 34 had two baths, one on 05/07/25 and one on 05/15/2025. A record review of the un-named facility's bath log dated 04/25/2025-05/29/2025 revealed Resident 34 received a bath on 04/30/2025 and 05/07/2025. An observation on 06/04/2025 at 9:00 AM of Resident 4 revealed the call light was on and not answered until 9:36 AM. A record review of the facility's Past Calls dated 06/04/2025 for Resident 4 revealed the call light was on for 38:29 minutes. An interview on 06/02/2025 at 11:03 AM with Resident 34 confirmed that the resident had not had a bath for at least a month. The resident confirmed it was because the facility was short of staff. Resident 34 confirmed that the resident's bathing preference is weekly. The resident confirmed there was a wound on the resident's leg and was told by staff that a bath would help, but there was no one to give the resident a bath. An interview with the Administrator (Adm) on 06/02/2025 at 11:25 AM confirmed the Facility Assessment staffing plan on page 13 is a range of nursing staff needed for each shift. An interview on 06/03/2025 at 7:32 AM with Resident 15 confirmed the facility is short of staff on weekends. An interview with the Nursing Assistant (NA)-A confirmed the NA giving the bath will ask the resident's preference, but baths have not been done in a long time due to being short staffed. NA-A confirmed that baths should be done weekly. An interview on 06/04/2025 at 10:15 AM with NA-E confirmed the call lights should be answered within 5-6 minutes but often it takes much longer. NA-E confirmed that the facility could use more staff but are doing the best they can. An interview on 06/04/2025 at 1:10 PM with NA-F confirmed the expectation for answering call lights is 5-10 minutes but this does not always happen. NA-F confirmed that staffing is general okay but depends on who is working. An interview on 06/04/2025 at 1:15 PM with NA-G revealed the facility could use more help. NA confirms the facility only allows two NA's at night and that is not enough when one NA is on the memory care unit. An interview on 06/05/2025 at 8:38 AM with the DON confirmed the facility does not complete call light logs for tracking, nor do they have action plans to address the long call light response times. The DON states that they just talk to the staff. An interview on 06/04/2025 at 2:41 PM with the Adm confirmed that 30 minutes for a call light response time is not acceptable. An interview on 06/04/2025 at 2:41 PM with the DON confirmed the facility assessment requires a minimum of three NA's on night shift but they only staff with two NA's. The DON confirmed the expectation of 10-15 minutes for call light response time but states this is not always possible.

Licensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review, the facility failed to provide bathing per resident preference for 2 (Resident 34 and Resident 10) of 2 sampled residents. The total facility census was 49. Findings are: A. A record review of Care Plan with an admitted [DATE] for Resident 34 revealed diagnoses of polyneuropathy (multiple peripheral nerves become damaged that affects the nerves in the skin, muscles, and organs, leading to symptoms such as numbness and burning pain) and restless leg syndrome (a neurological disorder that is characterized by an uncomfortable feeling in the legs). Resident 34 required extensive assistance for bed mobility and transfers but did not reveal interventions for bathing. A record review of Resident 34's Minimum Data Set (MDS)(this comprehensive assessment evaluates each resident's functional capabilities) dated 04/29/2025 revealed that the resident requires maximum assistance for bathing. The MDS revealed a brief interview for mental status (BIMS) 15 of 15 which indicated that the resident was cognitively intact. A record review of the facility's Bathing Schedule dated May 2025 revealed Resident 34 had two baths, one on 05/07/25 and one on 05/15/2025. A record review of facility's Social Service Routine assessment dated [DATE] for Resident 34 revealed no assessment for bathing preferences. A record review of the un-named facility's bath log dated 04/25/2025-05/29/2025 revealed Resident 34 received a bath on 04/30/2025 and 05/07/2025. An interview on 06/02/2025 at 11:03 AM with Resident 34 confirmed that the resident had not had a bath for at least a month. The resident confirmed it was because the facility was short of staff. Resident 34 confirmed that the resident's preference is to have a bath weekly. The resident confirmed there was a wound on the resident's leg and was told by staff that a bath would help, but there was no one to give the resident a bath. An interview with the Administrator (Adm) on 06/03/2025 at 3:38 PM confirmed there was no other resident assessments for Resident 34 bathing preferences other than what was already provided. An interview with the Nursing Assistant (NA)-A confirmed that the NA giving the bath will ask the resident's preference, but baths have not been done in a long time due to being short staffed. NA-A confirmed that baths should be done weekly. An interview with Licensed Practical Nurse (LPN)-B confirmed that the facility was a little behind on baths, but they will get caught up. LPN-A confirmed that baths should be done weekly. An interview with the Director of Nursing (DON) on 06/03/2025 confirmed that the facility's bath logs are thrown away after they are documented in the Electronic Medical record (EMR) and the residents should have a bath at least weekly. The DON stated that they are trying to complete baths weekly but sometimes get behind. An interview with the Adm on 06/04/2025 at 2:40 PM confirmed the facility did not have a specific bathing policy. 45613 B. An observation on 06/02/25 at 10:42 AM revealed Resident 10 laying in bed with hair that appeared oily and shiny. During an interview on 06/02/25 at 10:43 AM Resident 10 revealed that (gender) cannot remember the last time (gender) had a bath or washed (gender) hair. An observation on 06/04/25 at 2:28 PM revealed Resident 10 lying in bed with hair that appeared oily and shiny. During an interview on 06/04/25 at 2:29 PM Resident 10 confirmed (gender) would like a bath at least once a week but cannot remember the last time (gender) took a bath or washed (gender) hair. Record review of Resident 10's Admission Record revealed that the resident was originally admitted to the facility on [DATE]. Record review of Resident 10's Significant change Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 5/11/2025 revealed that 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 8, that the resident requires supervision or touching assistance with ADL's and bathing. Record review of Resident 10's bathing task log from 4/1-6/5/2025 revealed bathing was documented on: -4/9/25 -5/14/25 -5/21/25 Record review of un-named facility bath log 4/25-5/29/25 revealed that Resident 10 had baths documented on: -5/5/25 -5/21/25 Record review of Resident 10's progress notes from 4/1/2025- 6/5/2025 revealed no documentation of bed baths given or resident refusals. Record review of Resident 10's Comprehensive Care plan focus date initiated on 3/12/2024 revealed an ADL (activities of daily living) self care deficit and no bathing interventions or preferences listed. During an interview on 6/4/25 at 2:40 PM the Administrator confirmed they do not have a facility bathing policy. During an interview on 06/05/25 at 8:31 AM Licensed Practical Nurse (LPN) - D confirmed there was not a bath aide scheduled daily. During an interview on 06/04/25 at 2:58 PM the Director of Nursing confirmed the following: -It is the facility's expectation that every resident should receive at least 1 bath a week and that baths are based on resident preferences. -Resident 10 only received 1 bath in the month of April and 2 baths in the month of May. -All baths, including bed baths, and refusals should be documented under the bathing task. -Upon admission to the facility, residents are asked their bathing preferences and bathing preferences should be care planned. -Currently the facility does not have a full time bath aide. If there are 4 nursing assistants scheduled, then 1 assistant is assigned to provide the resident baths. -Staffing does not always allow for a nursing assistant to be assigned to provide resident baths.

Licensure Reference Number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN-a form that lists the items or services that the facility expects Medicare will not pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay) and the Notice of Medicare Non-Coverage (NOMNC, a required notice allowing the resident to appeal the facility decision to end Medicare Part A coverage) was given to a beneficiaries at least two days prior to the end of covered services which affected 1 (Resident 9) of 4 sampled residents. The facility census was 49. Findings are: A review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by the facility for Resident 9 revealed that the resident's Last Covered Day (LCD) for Medicare Part A services was 04/30/2025, and the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. A further review of the form revealed the facility provided a SNF ABN, and a NOMNC to Resident 9. A record review of Resident 9's SNF ABN revealed it was signed electronically by the Resident 9 with a date of 04/30/2025, and initialed electronically by the Social Services Director (SSD) with no date. A record review of Resident 9's NOMNC revealed it was signed electronically by the Resident 9 with a date of 04/30/2025, and initialed electronically by the Social Services Director (SSD) with no date. An interview on 06/05/2025 at 8:32 AM with the SSD confirmed that the SNF ABN and NOMNC for Resident 9 were not signed within the required time frame prior to the LCD.

Licensure Reference Number 175 NAC 12-006.05(E)(i) Based on interview and record review the facility failed to ensure the individualized care plans covered the psychotropic (affects mental status) medication and discharge planning for 2 (Residents 26 and 48) of 4 sampled residents. The facility census was 49 Findings are: A record review of the facility's Care Planning policy and procedure with the revision date of 03/2019 revealed individual resident-centered care planning begins when the resident is admitted and doesn't end until the resident is discharged . The goal for the care plan is directly related to the resident's discharge plan. The physician's orders which include the resident medications are part of the care plan. Care plans should be updated between care conferences to reflect current care need of the individual resident as changes occur. A. A record review of Resident 26's Clinical Census dated 05/13/2025 revealed the resident was admitted to the facility on [DATE] A record review of Resident 26's Medical Diagnosis dated 05/13/25 revealed the resident had diagnoses of Hypertension (increased blood pressure), Diabetes Mellitus (increased blood sugar), Diabetic Neuropathy (pain and numbness in legs and feet), Major Depressive Disorder, Muscle Weakness, Permanent Atrial Fibrillation (irregular, often rapid heartbeat), Acute Kidney Failure (kidneys can't filter waste from the blood). A record review of Resident 26's Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) dated 05/19/2025 revealed Resident 26 had a Brief Interview for Mental Status (BIMS) (a score of a resident's cognitive abilities) of 13 of 15 which indicated the resident is cognitively oriented. The resident needed moderate to extensive assist with oral and personal hygiene, upper and lower body dressing, transferring and putting on footwear. A record review of Resident 26's Physician orders dated 05/13/2025 revealed the resident was on Celexa (antidepressant) and Remeron (antidepressant) daily for depression. A record review of Resident 26's Care Plan dated 05/19/2025 did not reveal that the antidepressant medication was addressed on the care plan. In an interview with the Director of Nursing (DON) on 06/04/2025 at 1:04 PM confirmed that each department is responsible for their own areas on the care plan. The DON is responsible for the resident's sections involving addressing the medication on the care plan. The DON confirmed there was not medications addressed on Resident 26's care plan and should have been. B. A record review of Resident 48's Clinical Census revealed an admission of 07/08/2024 and a discharge date of [DATE]. A record review of Resident 48's Medical Diagnosis dated 07/08/2024 revealed the resident has diagnoses of Hypertension (high blood pressure), low back pain, muscle weakness, unsteadiness on feet, difficulty with walking, and disease of esophagus (moves food and fluid from mouth to stomach). A record review of Resident 48's Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) dated 04/01/2025 revealed a Brief Interview for Mental Status (BIMS) (a score of a resident's cognitive abilities) was a 15 of 15 indicating Resident 48 is cognitively intact. A record review of Resident 48's Physician Order dated 03/31/2025 revealed order for Resident 48 to discharge from the current facility to an Assisted Living Facility on 04/01/2025. A record review of Resident 48's Care Plan dated 03/25/2025 did not reveal the care plan addressed the discharge plan for Resident 48. In an interview with the Social Service Director (SSD) on 06/04/2025 the SSD confirmed Resident 48's discharge plans were not on the Care Plan and should have been.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interview the facility failed to update the Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) to accurately reflect the fall interventions for 1 (Resident 10) of 3 sampled residents. The facility census was 49 at the time of survey. Findings are: Review of the facility's policy titled Fall Prevention and Response Policy dated revised April 2025 revealed that when a fall occurs the care plan will be updated with any new or updated fall interventions. Review of the facility's policy titled Care Planning dated revised March 2019 revealed that careplanning is constantly in progress and it begins the moment the resident is admitted to the facility and doesn't end until discharge or death. Record review of Resident 10's Admission Record revealed that the resident was originally admitted to the facility on [DATE]. Record review of Resident 10's Significant change Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 5/11/2025 revealed that 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 8, which indicated a moderate cognitive impairment, that the resident had diagnosis of history of fall with fracture, that the resident requires assistance with ADL's, and that the resident had a fall without injury. Record review of Resident 10's fall risk evaluation dated 5/5/25 revealed that the resident had a history of falls in the last 3 months. Record review of Resident 10's progress notes dated 5/7/2025 revealed that the resident rolled off the bed and hit (gender) head and was sent to the emergency room . Record review of facility provided incident report dated 5/7/2025 revealed that Resident 10 fell on [DATE] and that no new fall interventions were identified. Record review of Resident 10's CCP revealed: -Fall Prevention focus dated last revised 4/27/2025 -Most recent fall intervention dated 6/26/2023 During an interview on 06/03/25 at 12:08 PM the Director of Nursing (DON) confirmed there were no new fall interventions on the resident's CCP after the 5/7/2025 fall and there should have been.

Licensure Reference 175 NAC 12-006.09(H)(i)(3) Licensure Reference 175 NAC 12-006.09(H)(iv)(3) Based on observations, interviews, and record reviews the facility failed to provide timely repositioning and incontinence care for 1 (Resident 2) of 2 sampled residents for dependent cares. The facility census was 49 at the time of survey. Findings are: Record review of facility policy titled Repositioning Policy and dated [DATE] revealed that repositioning is critical for a resident who is immobile or dependent upon staff for repositioning, for residents who are in bed should be on a every 2 hour repositioning schedule or alternate schedule based on resident assessment, and residents with a stage 1 or above pressure ulcer the every 2 hour repositioning schedule maybe inadequate. An observation on 06/02/25 at 10:02 AM revealed Resident 2 lying in bed on (gender) back with eyes closed and curtains closed and lights off. An observation on 06/03/25 9:13 AM revealed Resident 2 lying in bed on (gender) back with eyes closed and curtains closed and lights off. An observation on 06/04/25 08:15 AM revealed Resident 2 lying in bed on (gender) back with eyes closed and curtains closed and lights off. An observation on 06/05/25 08:02 AM revealed Resident 2 lying in bed on (gender) back with eyes closed and curtains closed and lights off. Record review of Resident 2's quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 5/26/25 revealed that the resident was admitted to the facility on [DATE], 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 0 which indicates severely impaired cognitive skills, the resident is dependent for ADL's, and a stage 2 pressure ulcer was not present on admission. Record review of Resident 2's diagnosis revealed a diagnosis of Cerebral Infarction, Dementia, Mood Disturbance, and Anxiety. Record review of Resident 2'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: -the resident has a pressure ulcer related to immobility date initiated on 11/24/2024 -intervention dated 5/9/2025 the resident needs to be turned/repositioned at least every 2 hours, more often as needed. -intervention dated 5/9/2025 the resident requires 1-2 staff to turn and reposition in bed. Record review of Resident 2's wound care consultation notes from visit dated 5/1/25 revealed an order to apply Therabond to wound on back and cover with mepilex. Record review of Resident 2's Braden Scale risk assessment dated [DATE] revealed a score of 13, which indicates the resident is at risk for skin breakdown and that the resident's skin is often moist. An observation on 06/04/25 at 10:55 AM Licensed Practical Nurse (LPN) - H repositioning Resident 2 and removing the resident's brief in order to perform wound care and pericares. An observation on 06/04/25 at 11:02 AM of Resident 2 lying in bed with brief noted to be heavily saturated with dark yellow urine and with a foul odor. During an interview on 06/04/25 at 11:04 AM Nursing Assistant (NA) - E confirmed that the resident had not been checked, changed or repositioned since before 6 am when the night shift left, and that 5 hours was too long for a resident not to be checked, changed or repositioned. Observation on 6/5/2025 at 8:25 AM of Resident 2 lying in bed with an incontinent brief on was noted to be heavily saturated with dark yellow urine and had a foul odor. During an interview on 06/05/25 at 8:27 AM interview with NA - A confirmed that they (facility staff) have not checked or changed or repositioned the Resident 2 since they got to the facility at 6 AM. It was also confirmed that they do walking rounds at 6 am when they get here with the night shift before they leave, the night shift always tells them that the last time the resident was checked or changed or repositioned was between 5 and 5:30 AM. It was also confirmed that 3 hours is too long for a resident not to be checked, changed or repositioned. Record review of Resident 2's undated nursing care sheet revealed that peri cares should be provided after each incontinence episode. During an interview on 06/04/25 at 4:29 PM the DON confirmed there is no facility wound care policy. During an interview on 6/5/2025 at 1:12 PM the DON confirmed that all residents especially those with wound issues should be checked, changed and repositioned every 2 hours and that all refusals of care should be documented.

Licensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review the facility failed to use proper hand hygiene (cleaning) and use of personal protective equipment (PPE) when providing wound care for one (Resident 8) of two sampled residents. The facility census was 49. Findings are: A record review of the Handwashing/Hygiene policy and procedure with revision date of 01/2020 revealed hand hygiene needs to be completed before and after direct physical contact with a resident, before and after handling any dressing, and objects soiled during or after resident care. Hand hygiene should have been completed immediately after or as soon as possible following contact of such body areas with blood or other potentially infectious material. The use of gloves does not replace handwashing/hand hygiene. A record review of Glove Use with Resident Cares: Policy and Purpose with revision date of 03/2019 revealed the purpose was to provide guidelines for the use of gloves for resident and employee protection. The staff should remove soiled undergarments following performing or assisting with peritoneal (peri)-care. When peri-care were completer staff was to remove gloves and wash hands. Apply clean gloves and assist/place clean undergarments, brief, clean clothing or pajamas. A record review of the facility Policy and Procedure implemented 08/2024 revealed, Enhanced Barrier Precautions (EBP) was an infection control intervention to reduce transmission of multi-resistant organisms (MDRO's) in nursing facilities which involved staff wearing gloves and gown during high-contact residents infected with MDRO's during care, such as wound care. The EBP Policy Explanation and Compliance guidelines dated 08/2024 revealed gowns and gloves should be available near or outside of the resident's room. A gown and gloves should be donned (put on) prior to high-contact resident activities involving the changing of the resident's briefs or assisting with toileting and wound care requiring a dressing. EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that place them at higher risk. A record review on 06/04/2025 of Resident 8's Clinical Census revealed an admitted [DATE]. A record review of Resident 8's Medical Diagnosis dated 01/02/2025 revealed: Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) without complications, Hypothyroidism, unspecified, Acquired absence of left leg above knee, Mild cognitive impairment of uncertain or unknown etiology, Other specified mental disorders due to known physiological condition, Senile (decrease in ability to think or remember) degeneration of brain, not elsewhere classified, Muscle weakness generalized, Peripheral Vascular Disease (PVD) the reduced circulation of blood to a body part), Absence of right leg above knee. A record review of Resident 8's dated 01/02/2025 Minimum Data Set (MDS) (a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 01/02/2025 revealed the resident was at risk for pressure ulcers. A record review of the MDS for review dated 3/27/2025 revealed Resident 8 as being at risk for a pressure ulcer. A Brief Interview for Mental Status (BIMS) a brief screener that aids in detecting cognitive impairment score) is at 99 which explains Resident 8 is unable to complete the interview. The MDS areas revealed Resident 8 was dependent on staff for all cares and needed substantial/maximum assist for turning and repositioning. Resident 8 is frequently incontinent of bowel and bladder had no pressure ulcer A record review of Resident 8's Progress Note dated 05/27/2025 at 8:54 PM revealed the nursing skin assessment evaluated the left buttock pressure ulcer injury (breakdown of skin from pressure) had partial thickness of skin loss with exposed dermis (second layer of skin). The wound was acquired in-house (in facility). A record review of the Resident 8's Care Plan revealed: The resident has STAGE 2 pressure ulcer left buttock related to history of ulcers, Immobility The residents Pressure ulcer will show signs of healing and remain free from infection by/through review date. Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. last to get up, first to lay down The resident needs to turn/reposition at least every 2 hours, more often as needed or requested. An observation on 06/03/2025 at 2:45 PM of Licensed Practical Nurse (LPN)-B, and LPN -C performed wound care for Resident 8. LPN-C provided the treatment for Resident 8 without donning a gown. LPN-C washed hands prior to providing treatment as follows: - place the Optifoam (foam waterproof dressing) Gentle on barrier on bedside table along with clean med cup. - LPN-C pulled the dirty brief down from back of Resident 8's buttock which exposed the urine and stool in it and took off the dirty dressing from left buttock wound which was the Optifoam with a Therabond (dressing that draws extra fluid from open wound) piece in it. - LPN-C left Resident 8's bedside and went into the bathroom to moisten the Therabond. During this time Resident 8 turned onto (genders) back exposing uncovered wound to the dirty brief. - LPN-C washed (genders) hands and replaced gloves. - LPN-C then returned from the bathroom with the Therabond in the cup. LPN-C assisted Resident 8 back onto (genders) right side. - LPN-C cleaned Resident 8's wound with a washcloth with soap and water and then used a second washcloth and rinsed and dried the wound. - LPN-C using the same gloves from cleaning the wound then placed the moistened Therabond into Resident 8's clean wound and covered it with a clean Optifoam Gentle. - LPN-C then using the same gloves took the moist peri wipes and cleaned Resident 8's buttocks of stool and placed clean brief on Resident 8 with the same soiled gloves on. - LPN-C assisted Resident 8 onto genders back and cleaned pubic area and with the same gloves on assisted Resident 8 to turn onto left side for clean brief to be positioned. - LPN-C continued with the same dirty gloves as used with peri care took Resident 8's right hand to get (gender) to release grip from the bedside positioning bar and turned Resident 8 onto (genders) back. - Resident 8 was positioned on the left side with pillow to position. - LPN-C then washed their hands after removing gloves. An interview on 06/03/2025 at 3:15 PM with LPN-C revealed: - LPN-C confirmed that (gender) did not put on gown prior to providing Resident 8's wound treatment or dressing change and confirms they should have. - LPN-C confirmed that (gender) should have changed gloves and washed hands after cleaning stool from Resident 8's buttocks and peri area. - LPN-C confirmed Resident 8's mid left buttock wound should not have been exposed until after the peri care and cleaning of Resident 8's buttocks was done. An interview on 06/03/2025 at 3:15 PM with LPN-B revealed: - LPN-B confirmed that (gender) did not don a gown prior to resident care and should have. - LPN-B confirmed Resident 8's mid left buttock wound should not have been exposed until after the peri care and cleaning of buttocks was done.

Licensure Reference Number 175 NAC 12-006.04C2 Based on record interview and record review; the facility failed to ensure sufficient staffing related to 8-hour daily RN (Registered Nurse) coverage, this had the potential to affect all residents who reside in the facility. The facility identified a census of 52. Findings are: A record review of the staffing schedules for 5/1/24 through 5/20/24 revealed no 8-hour RN coverage on 5/12/24 and 5/16/24, but did reveal there was only 4 hours of RN coverage on 5/12/24. An interview with the facility Administrator on 05/23/24 at 8:07 AM confirmed that after pulling timecards it was found that the facility did not have RN coverage on 5/6/24 and 5/12/24 and only 4 hours of RN coverage on 5/11/24. A record review of the documents titled Facility Assessment Tool (used to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies) dated 6/5/23 revealed the following guidance related to RN coverage: Staffing plan 3.2 Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Licensure Reference Number 175 NAC 12-006.04 Based on record review and interviews; the facility failed to ensure that 5 of 5 reviewed nursing assistants (NA's) had completed 12 mandatory education hours annually, this had the potential to affect all residents who reside in the facility. The facility identified a census of 52. Findings are: A record review of the continuing education hours for 5 employees hired more than one year ago revealed that the following staff had received or completed the following education hours; -NA-K had 6.7 hours of continuing education completed in the last 12 months. -NA-L had 0.50 hours of continuing education completed in the last 12 months. -NA-M had 5.05 hours of continuing education completed in the last 12 months. -NA-N had 0.50 hours of continuing education completed in the last 12 months. -NA-O had 1.75 hours of continuing education completed in the last 12 months. An interview with the facility Administrator on 05/21/24 at 3:20 PM confirmed that Nursing Assistants who had been employed in the facility for more than 1 year had not completed 12 hours of continuing education hours and should have. An interview on 05/22/24 at 10:15 AM with NA-N revealed [gender] was not aware of the need for 12 hours of continuing education annually. A record review of the documents titled Facility Assessment Tool (used to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies) dated 6/5/23 revealed the following guidance related to NA training; Training All required federal and state trainings will be completed including and along with the following: These trainings will be completed by all Associates, and Contractual Staff: Abuse, neglect, and exploitation - Training includes: (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention. The following trainings will be completed by NA's: The above-mentioned trainings and these required in-service training for nurse aides: Continuing competence of nurse aides, at least 12 hours per year. For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

Licensure Reference Number 175 NAC 12.006.09D2 Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 47) of 3 sampled resident's wound care was completed as ordered by the provider. The total facility census was 52. Findings are: A record review of Resident 47's Clinical Census dated 05/22/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 47's Medical Diagnosis dated 05/22/2024 revealed the resident had diagnoses of Type 2 Diabetes Mellites With Diabetic Chronic Kidney Disease (uncontrolled blood sugars that resulted in kidney disease), Secondary Malignant Neoplasm of Bone (bone cancer) Weakness, and lung disorders. A record review of Resident 47's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 05/02/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 12 of 15 which indicates the resident was moderately cognitively impaired. The resident needed partial/moderated assistance putting on footwear, supervision or touching assistance with toileting and dressing, and setup or clean-up assistance with eating and oral hygiene. The MDS revealed the resident was at risk for developing pressure ulcers/injuries but did not have any at the time of the MDS. A record review of Resident 47's Care Plan did not reveal the resident had wounds to the BLE. A record review of Resident 47's Wound - Initial (New) Documentation Form (one wound per form) - V 1 dated 04/27/2024 revealed Resident 47 had an abrasion (damage by scraping or wearing away of skin) to the front of the left lower leg that was 1.7 centimeter (cm) long, 1.6 cm wide, and 0 deep that has a scant (small) amount of clear drainage. A record review of Resident 47's Progress Note dated 05/17/2024 revealed the resident had fluid filled blisters that remained to the bilateral lower extremities (BLE, both lower legs) and treatment in place as ordered. A record review Resident 47's Skilled Status Evaluation - V 5 dated 05/20/2024 revealed the resident had scattered intact (not damaged) and nonintact blisters that remained to the BLE and treatment remained in place as ordered. A record review of Resident 47's Physician's Orders dated 05/15/2024 revealed the facility was to use Betadine Paint (an antiseptic liquid that kills germs/bacteria) to BLE blistered areas, cover with Telfa (a non-adherent dressing) and army battle dressing (ABD, used to absorb discharges from draining wounds) 2 times per day (BID) and apply Triple Antibiotic Ointment (TAO) to any ulcerated area (open sore) on BLE after applying Betadine. An observation on 05/21/2024 at 10:37 AM revealed Licensed Practical Nurse (LPN)-A performed handwashing, got on the floor, gloved and applied Povidone-Iodine swab stick (an antiseptic liquid that kills germs/bacteria) to the front of Resident 47 BLE but did not paint the blistered areas on the sides of the lower legs. In an interview on 05/22/2024 at 8:43 AM, LPN-A confirmed LPN-A thought the order was to paint the open area, not the blisters, I misread it. LPN-A confirmed the blisters on Resident 47's BLE did not get painted with Betadine per the provider's order.

Licensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.006.17D Based on observations, interviews, and record review; the facility failed to ensure all infection control measures were followed during wound care for 1 (Resident 47) of 3 sampled residents, ensure 1 (Resident 54) of 1 sampled resident's nebulizer kit (used to deliver liquid medication to the lungs) and mask were cleaned after each treatment, and failed to perform hand hygiene between gloves changes while providing catheter cares for 1 (Resident 41) of 1 sampled resident. The total facility census was 52. Findings are: A. A record review of the facility's Handwashing/Hygiene policy with a revision dated of Jan. 2020 revealed hand hygiene needed to be completed before donning (putting on) and after removal of gloves. A record review of Resident 47's Clinical Census dated 05/22/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 47's Medical Diagnosis dated 05/22/2024 revealed the resident had diagnoses of Type 2 Diabetes Mellites With Diabetic Chronic Kidney Disease (uncontrolled blood sugars that resulted in kidney disease), Secondary Malignant Neoplasm of Bone (bone cancer) Weakness, and lung disorders. A record review of Resident 47's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 05/02/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 12 of 15 which indicates the resident was moderately cognitively impaired. The resident needed partial/moderated assistance putting on footwear, supervision or touching assistance with toileting and dressing, and setup or clean-up assistance with eating and oral hygiene. The MDS revealed the resident was at risk for developing pressure ulcers/injuries but did not have any at the time of the MDS. A record review of Resident 47's Care Plan did not reveal the resident had wounds to the BLE. A record review of Resident 47's Progress Note dated 05/17/2024 revealed the resident had fluid filled blisters that remained to the bilateral lower extremities (BLE, both lower legs) and treatment in place as ordered. A record review of Resident 47's Wound - Initial (New) Documentation Form (one wound per form) - V 1 dated 04/27/2024 revealed Resident 47 had an abrasion (damage by scraping or wearing away) to the front of the left lower leg that was 1.7 centimeter (cm) long, 1.6 cm wide, and 0 deep that has a scant (small) amount of clear drainage. A record review Resident 47's Skilled Status Evaluation - V 5 dated 05/20/2024 revealed the resident had scattered intact (not damaged) and nonintact blisters that remained to the BLE and treatment remained in place as ordered. A record review of Resident 47's Physician's Orders dated 05/15/2024 revealed the facility was to use Betadine Paint (an antiseptic liquid that kills germs/bacteria) to BLE blistered areas, cover with Telfa (a non-adherent dressing) and army battle dressing (ABD)(used to absorb discharges from draining wounds) 2 times per day (BID) and apply Triple Antibiotic Ointment (TAO) to any ulcerated area (open sore) on BLE after applying Betadine. An observation on 05/21/2024 at 10:37 AM revealed Licensed Practical Nurse (LPN)-A performed handwashing, got on the floor, put on gloves, and applied TAO on Resident 47's ulcerated areas on the front of both of the resident's lower legs, removed and discarded the gloves, and applied a new pair of gloves, but the observation did not reveal that LPN-A performed hand hygiene between changing gloves. LPN-A placed 2 dressing pads on the residents left leg, but as LPN-A started to wrap the resident's lower leg with Kerlix (a stretch dressing), 1 of the dressing pads fell on the carpeted floor, wound side down. LPN-A picked up the dressing pad and placed it back on Resident 47's left lower leg over the wound and continued to wrap the leg with Kerlix. The same side of the dressing pad the touched the carpet was the same side that was applied to the blisters. In an interview on 05/22/2024 at 8:43 AM, LPN-A confirmed hand hygiene should have been completed between glove changes during Resident 47's wound care to the BLE. In an interview on 05/22/2024 at 9:02 AM, LPN-A confirmed the dressing pad that fell on the floor during Resident 47's wound care to the left lower leg should have been discarded following touching the carpeted floor and a new one applied prior to being wrapped with kerlix. B. A record review of the facility's Nebulizer Cleaning Policy with a revision date of March 2019 revealed the nebulizer kit and mask would be cleaned after each use and placed upside down on a paper towel to dry. A record review of Resident 54's Clinical Census dated 05/21/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 54's Medical Diagnosis dated 05/22/2024 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Personal History Of Other Malignant Neoplasm of Bronchus And Lung (lung cancer), Other Forms Of Dyspnea (shortness of breath), Emphysema, Unspecified (lung disease), and Anxiety Disorder, Unspecified. A record review of Resident 54's MDS dated [DATE] revealed the resident had a BIMS of 15 of 15 which indicated the resident was cognitively aware. The resident needed minimal assistance with all activities of daily living (ADLs). A record review of Resident 54's Care Plan did not reveal the resident was on nebulizer treatments. A record review of Resident 54's Order Summary Report dated 05/22/2024 revealed the provider had ordered Arformoterol Tartrate Inhalation Nebulization Solution (liquid medication for the lungs) BID, Budesonide Inhalation Suspension (liquid steroid) BID, and Albuterol Sulfate Inhalation Nebulization Solution (a liquid medication to open the lungs) every 2 hours as needed. A record review of Resident 54's Medication Administration Record (MAR) dated May 2024 revealed the resident was administered nebulizer treatments at least every morning and every evening. In an observation on 05/20/2024 at 10:35 AM revealed Resident 54's nebulizer kit and mask were laying on the resident's bedside table by the resident's recliner. The nebulizer kit had a residual (small, left over) amount of fluid in the nebulizer kit and facial oils on the mask. In an observation on 05/21/2024 at 10:42 AM revealed Resident 54's nebulizer kit and mask were laying on the resident's bedside table by the resident's recliner. The nebulizer kit had a residual amount of fluid in the nebulizer kit and facial oils on the mask. In an observation on 05/21/2024 at 1:56 PM revealed Resident 54's nebulizer kit and mask were laying on the resident's bedside table by the resident's recliner. The nebulizer kit had a residual amount of fluid in the nebulizer kit and facial oils on the mask. In an interview on 05/20/2024 at 10:35 AM, Resident 54 confirmed the staff did not clean the nebulizer kit and mask after each treatment. In an interview on 05/21/2024 at 1:56 PM, Resident 54 confirmed the staff did not clean the nebulizer kit and mask after each treatment. In an interview on 05/21/2024 at 2:50 PM, LPN-A confirmed the staff was to rinse the nebulizer kit after each treatment and confirmed it had not been done. 42861 C. A record review of the document titled Admission Record dated 3/21/24 revealed Resident 41 had been re-accepted into the facility on [DATE] with a primary diagnosis of Acute Congestive Heart Failure (CHF, a long-term condition that happens when your heart can't pump enough blood). An observation on 05/21/24 at 9:20 AM of catheter cares completed by Nurse Aide (NA)-J revealed that NA-J had cleansed Resident 41's genetalia and groin area and then donned (put on) a new pair of gloves without completing any hand hygiene. The observation on 05/21/24 at 9:20 AM of catheter cares completed by Nurse Aide (NA)-J revealed that NA-J then cleansed down the catheter tubing and then donned new pair of gloves without completing any hand hygiene. The observation on 05/21/24 at 9:20 AM of catheter cares completed by Nurse Aide (NA)-J revealed that NA-J then began to assist Resident 41 with (gender) clothing and had not completed hand hygiene. An interview on 05/21/24 at 9:59 AM with NA-J confirmed that hand hygiene had not been completed between glove changes when providing catheter cares to Resident 41 and should have been. An interview on 05/21/24 at 10:10 AM with the facility DON (Director of Nursing) confirmed that the facility expectation was that hand hygiene was to be done between glove changes. A record review of the facility policy titled Catheter Cares with a revision date of October 2022 revealed the following guidelines and procedure steps: -Wash the resident's genitalia and perineum thoroughly with soap and water or perineal wipes. Rinse the area well and towel dry. -Place soiled linen into designated container -Remove gloves and discard into the designated container. Wash and dry your hands thoroughly. -Put on gloves -Provide privacy -Use a clean washcloth with warm water and soap or clean perineal wipe to cleanse and rinse the catheter from insertion site to approximately four inches outward -Check drainage tubing and bag to ensure that the catheter is draining properly -Discard disposable items into the designated containers. Remove glove and discard into designated container. Wash and dry your hands thoroughly.

Licensure Reference Number 175 12-007.04D Based on observation and interview, the facility failed to ensure the ventilation systems were operational in 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) occupied resident's bathrooms on the 300 hallway of the facility. The facility identified a census of 55. Findings are: Observation on 5/22/23 at 9:00 AM of room [ROOM NUMBER]'s bathroom revealed the vent did not draw a 1 square ply of toilet paper when tested for ventilation. Observation on 5/22/23 at 9:10 AM of room [ROOM NUMBER]'s bathroom revealed the vent did not draw 1 square of ply of toilet paper when tested for ventilation Interview on 5/23/23 at 10:54 AM with Maintenance Director revealed room [ROOM NUMBER] and 304 bathroom ventilation systems were not functioning. Interview on 5/23/23 at 10:54 AM with the Administrator confirmed the ventilation system was not functioning in room [ROOM NUMBER] and 304 bathrooms.

Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview, the facility failed to maintain the cleanliness and condition of the exterior of the stove and oven, stove backsplash, microwave and cupboards in a manner to prevent the potential for food borne illness. This had the potential to affect 52 residents that ate foods prepared in the facility kitchen. The facility census was 54. Findings are: Record review of the Nebraska Food Code dated July 2016 section 4-602.12 revealed that non-food contact surfaces of equipment shall be cleaned at a frequency necessary to prevent the accumulation of soil residues. Observation on 2/6/22 between 10:00 AM and 10:15 AM and on 2/8/22 at 10:18 AM with the Dietary Manager (in training) (DM) Q revealed the following sanitation concerns in the food preparation areas of the facility kitchen: - Burned food and liquids on the back splash of stove and around the edges of the stove and oven. - Food particles and a buildup of grease on top of the oven. - Finish worn off areas of the interior of the microwave. - Finish worn off the front surfaces of the cupboards and exterior of the drawers under 2 prep tables in the kitchen. Interview on 02/08/22 at 10:19 AM with the DM Q confirmed the burned on areas on the backsplash, stove and oven, the buildup of grease and food particles on the top of the stove, the finish worn off the interior of the microwave and the finish worn off the fronts of the cupboards and exterior of the drawers under the food prep tables. The DM confirmed that particles from those areas could potentially fall into food being cooked which could cause food borne illness. Interview on 02/08/22 at 03:20 PM with the facility Interim Director of Nursing E confirmed that all residents in the facility except 2 ate foods prepared in the facility kitchen.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assessment Performance Improvement Plan (QAPIP) failed to identify ongoing issues relevant to F 623, F 641, F 644, F 657, F 677, F 684, F 732, F 812, F 880, F 882, F 887, F 921 and a State Licensure deficiency and implement plans of action to identify and correct the deficient practice. This deficient practice had the potential to affect all residents who resided in the facility. The facility had a census of 54. Findings are: Record review of the facility QAPIP dated 2/22/21 revealed the Administrator is responsible for the oversight of the QAPI program. Members included are: The Administrator, all department managers, the Director of Nursing, the Infection and Prevention Officer, Medical Director, Consulting Pharmacist and 3 additional staff. The QA team draws ideas for Quality Improvement from several sources and select high risk, high volume, problem prone and high cost issues. The QAPI process utilizes performance improvement teams and utilize root cause analysis to ensure that the root cause is identified and contributing factors have been identified. Interview on 2/9/22 between 10:23 AM and 10:35 AM with the facility Administrator D confirmed that the QAPI Process had not been effective and the following citations identified during the annnual survey 2/6/22 through 2/9/22 had not been identified by the QAPI process. No plans of actions were previously implemented by the facility to identify and correct the deficient practices. - F 623: Notice requirements before transfer / discharge. - F 641: Accuracy of Minimum Data Set Assessments. - F 644: Refer for new PASARR assessment. - F 657: Care plan revisions. - F 677: bathing provided for dependent resident. - F 684: Labs obtained as ordered. - F 732: Posted nurse staffing information accessible - F 812: Cleanliness of kitchen equipment. - F 867: QAPI program not effective - F 880: Infection prevention and control. - F 882: No specialized training in infection prevention and control. - F 887: no education or opportunity to accept or decline COVID 19 vaccination. - F 921: Cleanliness of the laundry room. State licensure tag 0128: No qualified Food Service Director.

Licensure Reference Number 175 NAC 12-006.17A and 12-006.17B Based on observation, interview, and record review, the facility failed to prevent the spread of COVID-19 as evidenced by: -1. Failure to change and dispose of PPE (Personal Protective Equipment) to prevent cross-contamination. -2. Failure to identify required PPE for residents on transmission-based precautions. -3. Improper usage of N95 respirators by facility staff. The facility also failed to ensure ongoing surveillance was conducted of infections. These failures had the potential to affect all residents residing in the facility. The facility had a total census of 54 residents. The findings are: A. A review of an undated facility timeline revealed 23 facility staff and 14 facility residents tested positive for COVID-19 from 1/10/22 - 1/31/22. In an interview on 2/6/22 at 10:35 AM, LPN (Licensed Practical Nurse) - H reported the facility had 2 red zones (Isolation zone - for residents with positive COVID-19 tests) at the end of the 500 and 600 halls. LPN - H stated the rest of the facility residents were in a yellow zone (Quarantine zone - asymptomatic residents who may have been exposed to COVID-19). LPN - H reported full COVID PPE (N95 respirator, eye protection, isolation gown, and gloves) was required in all resident rooms. Observations on 2/6/22 from 9:30 AM to 6:00 PM throughout the facility revealed no signage to indicate what colored zone (red, yellow, green, gray) residents were in. Four resident room doors had signage indicating a mask, face shield, gown, and gloves were required to enter. No other resident room doors had signage related to the required PPE to enter the resident's room. Observations during this time also revealed bins for trash and linen in all 4 resident-occupied hallways of the facility used by facility staff for disposal of used PPE. No doffing stations were observed in resident rooms during this time. An observation on 2/6/22 at 11:40 AM revealed MA - C donned an isolation gown, performed hand hygiene and entered room [ROOM NUMBER] to answer a call light. MA - C exited room [ROOM NUMBER] still wearing the gown, carrying some dirty dishes. MA - C stopped at the nurses' station and dumped the liquid from the dirty cups into the sink. MA - C then collected the dirty dishes and continued down the 200 hall, through the dining room, and into the kitchen area. MA - C returned to the 200 hall, doffed the gown into a container in the hallway and then performed hand hygiene. An observation on 2/6/22 at 11:42 AM revealed Nurse Aide (NA) - G exited room [ROOM NUMBER] wearing an isolation gown and carrying a bag of trash. NA - G walked to the utility room on the 600 hall and disposed of the trash. NA - G then doffed the gown into a container in the 600 hall and walked to the nurses' station and washed their hands. An observation on 2/6/22 at 11:52 AM revealed LPN - J exited room [ROOM NUMBER] wearing an isolation gown and gloves. LPN - J doffed the gloves in the trash bin in the 200 hall, performed hand hygiene, doffed the gown in the linen container in the 200 hall, performed hand hygiene, cleaned their face shield, and then performed hand hygiene one more time. An observation on 2/6/22 at 11:54 AM revealed NA - G exited room [ROOM NUMBER], doffed their isolation gown in the dirty linen container in the 200 hallway, then walked to the central nurses' station and washed their hands. An observation on 2/6/22 at 12:29 PM revealed LPN - H exited room [ROOM NUMBER] with a room tray, wearing an isolation gown. An interview with LPN - H at this time revealed LPN - H had been assisting the resident in room [ROOM NUMBER] with the noon meal. LPN - H walked to the dining room and delivered the tray of dirty dishes to the kitchen, then walked back to the 200 hallway. LPN - H doffed the gown, placed it in the dirty linen bin in the hallway, and then performed hand hygiene. An observation on 2/6/22 at 12:38 PM revealed NA - G donned an isolation gown and entered room [ROOM NUMBER] with a tray of food. NA - G exited room [ROOM NUMBER] still wearing the isolation gown and doffed it into a container in the 200 hallway. An observation on 2/6/22 at 12:39 PM revealed MA - C exited room [ROOM NUMBER] wearing an isolation gown and carried a tray of dirty dishes. MA - C walked down the 200 hallway, through the dining room and delivered the tray of dirty dishes to the kitchen. MA - C returned to the 200 hallway, doffed the isolation gown and placed it in a container in the hallway. An observation on 2/06/22 at 12:45 PM revealed NA - G donned an isolation gown, performed hand hygiene, and then donned gloves. NA - G delivered lunch trays to rooms [ROOM NUMBER] without changing the isolation gown or gloves. An observation on 2/06/2022 at 12:45PM revealed Activity Director (AD) - I wearing an isolation gown and gloves. AD - I delivered drinks and silverware to room [ROOM NUMBER], then room [ROOM NUMBER] without changing the isolation gown or gloves. In an interview on 2/6/22 at 5:00 PM, the Administrator reported the facility was working with Nebraska Infection Control Assessment and Promotion Program (ICAP) and following their direction. The Administrator reported staff were supposed to wear an N95 respirator, face shield, isolation gown, and gloves in every resident room. The Administrator stated staff were supposed to change the isolation gown and gloves in between each resident room and that doffing/donning stations had been set up for staff to do that in the hallways. A review of the facility's SNF (Skilled Nursing Facility) Isolation Guidance for Admit, Readmit, Testing, Visitation, last revised 1/17/22, revealed the following information: -How to safely remove Personal Protective Equipment (PPE) Example 1: -There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials. Here is one example. Remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. -How to safely remove Personal Protective Equipment (PPE) Example 2: -Here is another way to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials. Remove all PPE before exiting the patient room, except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door. In an interview on 2/7/22 at 10:54 AM, the Administrator reported they had contacted ICAP last evening to clarify PPE disposal procedures. The Administrator confirmed staff were supposed to be doffing isolation gowns and gloves in resident rooms, prior to entering the hallway. In an interview on 2/07/22 at 4:00 PM, the Administrator confirmed there was currently no signage on resident doors to indicate what PPE was required to enter the resident's room. B. An observation on 2/6/22 at 12:07 PM revealed Medication Aide (MA) - C wore an N95 respirator with only the top strap behind their head. The second strap could not be observed. An interview with MA - C at this time confirmed only the top strap was behind MA - C's head. MA - C reported the second strap was tucked inside of the mask. An observation on 2/09/22 at 9:20 AM revealed MA - C sitting at the nurses' station desk, which was open to all facility hallways. MA - C wore an N95 respirator with only the top strap behind their head. The bottom strap could not be observed. In an interview on 2/8/22 at 12:20 PM the administrator confirmed facility staff were expected to wear N95 respirators with both straps behind their heads. A review of the facility's SNF (Skilled Nursing Facility) Isolation Guidance for Admit, Readmit, Testing, Visitation Policy, last revised 1/17/22, revealed the following information related to N95 respirators: -Sequence for Putting on Personal Protective Equipment (PPE) -2. Mask or Respirator -Secure ties or elastic bands at middle of head and neck C. A review of the facility's infection surveillance logs revealed no documentation from July 2021 - February 2022. A review of the facility's Infection Prevention and Control Program Overview Policy, last revised March 2019, revealed the following information: -Major activities of the program: -A. Surveillance of infections with implementation of prevention of infections and control measures. -There is on-going monitoring and identifying infections and communicable diseases among residents, personnel, visitors and others providing services at the facility; subsequent documentation and investigation of infections that occur. -Analysis of data is done on-going and documentation is completed and reported to the infection prevention committee. In an interview on 2/9/22 at 8:50 AM, the Administrator confirmed no infection surveillance had been completed since the facility's previous DON (Director of Nursing) left in July 2021.

Licensure Reference Number NAC 175 ,d+[DATE].09D2b Based on record review, interview and observation, the facility failed to implement interventions to promote healing of skin breakdown for 3 of 4 sampled residents (Residents 1, 2 and 4) related to pressure ulcers. The facility census was 54. Findings are: A. Record review of the facility Skin Program Policy dated [DATE] revealed the policy to ensure that a resident who enters the facility without pressure injury does not develop pressure ulcers unless the individuals clinical condition demonstrates that they were unavoidable. Procedures included: Nursing personnel will utilize the results of the physical exam and the Pressure Ulcer assessment tools to determine an individualized pressure ulcer prevention program for each at risk resident. This will include interventions to protect skin against the effects of pressure , friction and shear. Record review of the facility policy for Completing An Accurate Assessment Regarding Pressure Ulcer Injuries Policy dated [DATE] revealed accurate assessments addressing each residents skin status will be conducted by qualified staff and correctly documented in the medical record. Record review of Resident 1's closed record MDS (Minimum Data Set) (is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated [DATE] revealed Resident 1 Resident 1 had one or more unhealed pressure ulcers and required extensive assist of two people for bed mobility, transfers, toilet use, dressing and personal hygiene. Record review of Resident 1's Electronic Medical Record revealed that Resident 1 expired on [DATE]. An interview on [DATE] at 2:15PM with DON (Director of Nursing) revealed that Resident 1 had an Unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough, a layer of dead skin and tissue in the wound bed) wound to the Right Heel that was infected. Resident 1 was on antibiotic therapy. Resident 1 was started on [MEDICATION(S)] then was switched to [MEDICATION(S)] (2 antibiotics that treat different strains of infections). Resident 1 received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . After this was completed, Resident 1 was started on [MEDICATION(S)] Tablet ,d+[DATE] mg give 1 tablet to be given by mouth two times a day for the infected right heel wound for 10 days. This started on [DATE]. Resident 1 was given 2 doses of the [MEDICATION(S)] one on [DATE] at 8:00 PM and the other on [DATE] at 8:00 AM. [MEDICATION(S)] was put on hold on [DATE] from 6:30 PM to [DATE] at 6:30 PM. Record review of Resident 1's Progress Note dated [DATE] revealed the pressure ulcer developed in the facility and was identified on that date. The facility notified the Doctor on that date for orders. Record review of Resident 1's undated Care Plan (a written document that describes specific instructions and preference of how to care for resident) revealed Resident 1 had a pressure injury. The goal was to heal the skin. Interventions included: - Air mattress utilized. -Braden Scale and Skin Assessment and Risk Factor assessments completed as required. -Encourage to keep legs elevated when sitting in recliner. -Liquacel [a liquid protein supplement used for wound healing] 30 milliliters [ml] 2 times a day for wound healing. -Pravalon boots to bilateral heels with pressure injury at all times. -Staff to ensure Resident 1is turned and repositioned to reduce pressure on heels as appropriate. -Treatment as ordered. -Wheelchair had pedals with no posts and backboard for positioning. -Staff to ensure resident cued to reposition. -Pressure redistributing pad in chair. -Pressure reducing mattress, air mattress on bed. -Skin observed at least weekly by nursing staff during bathing process. Record review of Resident 1's Progress Notes revealed the following: - [DATE] 22:05 Skin/Wound Note: Treatment done to heels as ordered, right heel wound declining, increase in amount of black/gray tissue noted. Foul odor noted, Pravalon boots on and heels suspended with pillows. Air mattress in place and functioning. Continue to monitor. - [DATE] 20:43 General Note: Fax received regarding Right heel worsening. New order to culture, [MEDICATION(S)] 500 mg TID x 7 days, appointment with Dr. [NAME]. No other concerns at this time. - [DATE] 22:34 Health Status Note Text: Resident remains on [MEDICATION(S)] for wound care, prophylactic, R/heel had moderate amount of drainage, odor noted. C/o tenderness to touch to heels. Pravalon boots on continuous. Record review of Resident 1's skin sheets revealed the following measurements of the Pressure Ulcer to the right heel: [DATE]: Type of wound: Pressure, Location of wound: Right heel, Measurements: Length 2.6 centimeters cm], width 3.5 cm, Unstageable. [DATE]: Type of wound: Pressure, Location of wound: Right heel, Measurements: Length 3.6cm, Width 3.9, Unstageable. Record review of Resident 1's [DATE] Treatment Sheet [TS] revealed incomplete documentation of turning and use of the Pravalon boot There were noted blank spots in the documentation on the TS related to turning and the use of the Pravalon boot. An interview on [DATE] at 3:00 PM with the DON confirmed that the task charting for turning and the Pravalon boot were on the treatment sheet and that there was incomplete documentation to show those tasks had been performed. B. Record review of Resident 2's MDS (Minimum Data Set) (is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated [DATE]. The resident was admitted to the facility most recently on [DATE] after a recent hospitalization . The resident has resided at the facility since [DATE]. Section G (functional Status) Revealed Resident 2 requires extensive assistance to total dependence for following activities of daily living: bed mobility, transfers, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene. Section H (Bladder and Bowel) Resident 2 had an indwelling catheter (a tube placed in the bladder that drains urine out of the body). Resident 2 has an ostomy (an opening to the stomach wall that connects the intestines to eliminate stool. Section I (Active Diagnosis) Resident 2 has the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Section M ( Skin Conditions) Resident 2 has 1 unhealed pressure ulcer/ injury that is documented as unstageable ( slough and or eschar - cover the wound bed) Slough( dead tissue separating from living tissue especially : a mass of dead tissue separating from an ulcer) ( Eschar- a dry, dark scab or falling away of dead skin). Section N (Medications) Resident 2 received the following medications the last 7 days: anticoagulant (medications used to thin blood) antibiotic (medication used to treat infections), diuretic (medication used to increase water loss). Record review of Resident 2's Care Plan (a written document detailing residents specific care needs and preferences) dated [DATE] revealed the following information: Resident 2 is at risk for skin breakdown due to impaired pressure injury. Date Initiated: [DATE] Revision on: [DATE] -Goals: I want to prevent any further breakdown and I want my skin to remain healed. -Interventions: Bowel, Bladder, Braden Scale, and Skin Assessment & Risk Factors assessments. - Consult with wound nurse as needed. -Resident 2 need total assist with off-loading (reposition while sitting up) while in wheelchair - Use the turning sheet for assisting me with repositioning to help prevent injury to my skin -While up in wheelchair I need to be off-loaded every 15 minutes. - Wound assessment completed weekly. Record review of Resident 2's Intervention task charting titled reposition q (every) 2 hours dated [DATE] - [DATE] revealed resident 2 was only turned 90 times out of 558 times. Record review of Resident 2's intervention task charting titled reposition q (every) 2 hours dated [DATE] - [DATE] revealed resident 2 was turned 38 times out of 558 times. An interview on [DATE] at 3:00PM with DON confirmed documentation for task charting dated ,d+[DATE] and ,d+[DATE] reflects that Resident 2 was not turned according to physicians order. Record review of weekly wound form dated [DATE] revealed Resident 2's pressure wound to left buttocks was measured at 5.1 cm x 2.3 cm x undeterminable depth. Stage- Unstageable. Record review of progress noted dated [DATE] revealed Residents 2's pressure wound had increase in size measurement documented were 6 cm x 4 cm x greater than 4 cm deep. Tunneling present in multiple directions. Record review of progress note dated [DATE] Revealed Resident 2's has a new open area to the right of current pressure ulcer measuring 1.5cm x 1.5 cm with tunneling to the original wound. Record review of progress note dated [DATE] revealed resident 2's new open area had increase in size to 3 cm x 1.5 cm. C. Record review of Resident 4's MDS (Minimum Data Set) (is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated [DATE] revealed Resident 4 was admitted to the facility recently on [DATE]. Section G (Functional Status) Resident 4's Activities of Daily living required extensive to total dependence for level of care and 2 or more persons physical assistance for the following: bed mobility, transfers, locomotion on and off unit, dressing, and personal hygiene. Resident 4 only required supervision and 1 person physical assist for eating. Section H (Bladder and Bowel) Resident 4 is always incontinent of urine and bowel. Resident 4 is not on a toilet program. Section I ( Active Diagnosis) Resident 4 current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section M (Skin) Resident 4 is at risk for developing pressure ulcers/ injuries? Yes Resident 4 currently has an unhealed pressure ulcer. Resident 4 pressure ulcer is documented as unstageable - deep tissue injury. Resident 4 has the following interventions in place for preventing pressure ulcers: pressure reducing device for bed, turning/ repositioning program, nutrition or hydration program to manage skin problems, pressure ulcer/injury care, applications of ointments/ medications other than to feet, application of dressings to fee with or without topical medications. Record review of Resident 4's Care Plan dated [DATE] revealed the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of facility Matrix ( a chart used to show specific resident conditions based on the MDS) Resident 4 lists as having a worsened pressure ulcer. Left leg above knee Amputation (surgical removal of the leg from above the knee to entire foot). Record review of resident 4's weekly wound form dated [DATE] revealed pressure sore to right great toe measurements were 0.2 cm x 0.2cm x 0 and was staged at: suspected Deep Tissue Injury. Record review of Resident 4's weekly wound form dated [DATE] revealed pressure sore to right great toe measurements were 1.0 cm x 0.6 cm x 0 and staged at Deep Tissue Injury. An observation on [DATE] at 4:45PM revealed Resident 4 lying in bed with sheet and blanket covering. Resident 4 had right leg sticking out from sheet. Right leg has multiple red/pink scratches, right great toe has quarter size black area. Heel area has dry skin present. Left leg was amputated above the knee. An interview on [DATE] at 4:45 PM with Resident 4 revealed that resident shakes head yes when asked if right great toe was painful. Resident was also able to raise right leg side to side and up and down. Resident also noted he has pain to left stump. Record review of Care Plan dated [DATE] revealed Resident 4 has the following problem: my skin presents with pressure injury. Pressure injury to right great toe. Goal: Prevent any kind of skin breakdown. Interventions: Complete skin assessments, foot of bed to be positioned away from the wall to prevent skin break down to Right Lower Extremity, I have an amputation to left lower leg. Treatment to off load left heel on pillow as resident will allow. Care plan does not reflect any interventions specific to right great toe pressure injury. An interview on [DATE] with DON confirmed Resident 4's pressure injury is to right great toe and care plan does not reflect any interventions for this problem.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on record review and interview; the facility staff failed to evaluate casual factors and nutritional requirements for pressure ulcer healing for 1 resident ( Resident 57), and failed to evaluate a need for treatment change for 2 residents ( Resident 57 and 20). The facility staff identified a census of 54. Findings are: A. Record review of Resident 57's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 7-02-2015 revealed the facility staff assessed the following about the Resident: -Resident 57 BIM's ( Brief Interview of Mental status) score was an 8. According to the MDS manual, a score of 8 to 12 indicated moderately impaired cognition. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Occasionally incontinent of urine and continent of bowel -No current pressure ulcers. Record review of a Braden Scale ( tool used for predicting pressure sore risk) evaluation form dated 4-02-2015 revealed Resident 57's score was a 16. According to the information on the Braden Scale form, a score of 16 placed Resident 57 in the low risk category for developing a pressure ulcer. Record review of a Braden Scale evaluation form dated 7-01-2015 revealed Resident 57's score was a 16. According to the information on the Braden Scale form, a score of 16 placed Resident 57 in the low risk category for developing a pressure ulcer. Record review of Resident 57's progress note dated 7-14-2015 revealed Resident 57 was .found to have a stage 2 (partial thickness loss of dermis presenting as an ulcer with red pink wound bed without slough (dead tissue) on the coccyx on tail bone measuring 2 cm (centimeters) by 2.5 cm pressure ulcer. Record review of a physician order [REDACTED]. Record review of a Weekly Wound Documentation Form (WWDF) dated 7-14-2015 revealed Resident 57 was identified with a pressure ulcer to the sacrum that measured 2 cm by 2.5 cm and was un-stageable ( full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.). According to the information on the WWDF dated 7-14-2015 the wound base had 50% granulation tissue ( appearance red beefy looking, indicates good tissue development) and 50% slough. No Eschar was identified as part of the pressure ulcer. The WWDF identified there was not any drainage or odor present to the pressure ulcer. Wound edges were intact. Record review of Resident 57's WWDF dated 7-22-2015 revealed Resident 57 pressure ulcer to the coccyx measured 1.7 cm by 1 cm, unable to determine the depth (UTD) and remained a stage 2 pressure ulcer. The wound based was evaluated 35% granulation and 65% [MEDICATION NAME] tissue. There was not any drainage or odor to the wound with the wound edges macerated. According to the WWDF dated 7-22-2015 there was not a decline in the wound. Record review of a WWDF dated 7-30-2015 revealed the pressure ulcer to the coccyx area measured 2.1 cm by 1.2 cm with a depth of less than 0.2 cm and remained a stage 2 pressure ulcer. The wound base was identified as having 50% [MEDICATION NAME], 45% granulation and 5% slough. There was not any drainage or odors present. The wound edges were macerated with a decline in wound progress. Record review of a WWDF dated 8-03-2015 revealed Resident 57 had a pressure ulcer to the coccyx that measured 4 cm by 4 cm and was un-stageable. The WWDF identified a second pressure ulcer to the coccyx that measured 9 cm by 9 cm that was identified as a stage 1(non-blanchable redness of localized area usually over a bony prominence). The pressure ulcer had a scant (small) amount of drainage with an odor present. According to the WWDF the progression of the wound had declined and had progressed to un-stageable. Record review of Resident 57's WWDF dated 8-07-2015 revealed the pressure ulcer to the coccyx measured 5 cm by 3.8 cm and was un-stageable. The wound base was 100% eschar with moderate drainage of a tan color and had an odor. Record review of Resident 57's medical record that included the treatment sheets, WWDF's, nutritional assessment and Comprehensive Care Plan (CCP) did not identify the casual factors of why Resident 57 had developed a pressure ulcer, why the pressure healing declined and did not contain an evaluation of Resident 57's nutritional requirements for pressure ulcer healing. An interview on 8-25-2015 at 12:17 PM was conducted with Licensed Practical nurse (LPN) B. During the interview, LPN B reported (gender) was the facility wound nurse. Review of Resident 57's pressure ulcer development was reviewed with LPN B. When asked if the casual factors identifying why Resident 57 had developed a pressure ulcer had been completed, LPN B stated no'. During the interview, LPN B reported the stage 1 identified on the WWDF dated 8-03-2015 was from tape. LPN B further stated the pressure ulcer was the same ulcer noted in the progress note dated 7-14-2015 and the WWDF dated 7-14-2015. LPN B confirmed the evaluation of the pressure ulcer was not correct. An interview with the Director of Nursing (DON) was conducted on 8-25-2015 at 12:19 PM. During the interview, the DON confirmed there was not an evaluation of Resident 57's nutritional requirements for pressure ulcer healing and should have been done. The DON further confirmed there were no new nutritional interventions implemented until 8-03-2015 B. Resident 20 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the WWDF dated 6/27/15 revealed Resident 20 had open blisters to the left great toe and first toe with scant drainage. Left toe blisters (WWDF does not identify which toe) was measured at .2 cm in length x .1 cm in depth. WWDF stated Resident 20 did holler when shoes and socks were taken off and Resident 20 reported it hurt. A physician order [REDACTED]. A physician's orders [REDACTED]. A review of the WWDF dated 7/2/15 identified Resident 20 had an unstageable pressure sore on the left great toe with 100% Eschar (Necrotic) measuring 2 cm in length and .8 cm in width. WWDF dated 7/2/15 identified Resident 20 had a unstageable pressure sore on left second toe with 100% eschar measuring 1.5 cm in length and 1.0 cm in width. A physician's orders [REDACTED]. A review of the WWDF dated 7/23/15 revealed Resident 20's unstageable pressure sore to left great toe was 10% slough and 90% eschar and measured 1.6 cm in length and .6 cm in width. WWDF dated 7/23/15 for Resident 20's unstageable pressure sore to the left second toe was 100% eschar and measured 1.1 cm in length and .8 cm in width. A review of the Wound Care Nurse evaluation dated 7/30/15 identified Resident 20's pressure sore to the left great toe was unstageable, facility acquired and measured 1.6 cm in length and .8 cm in width. Wound bed was described as 100% yellow slough. Resident 20's pressure sore to left second toe was described as unstageable, facility acquired and measured 2.1 cm in length and 1.0 cm in width. The evaluation identified that that wound was caused by Resident 20's shoes being too tight. Interview with LPN B on 8/25/15 at 12:34 PM revealed the Wound Nurse recommended no treatment changes after the 7/30/15 evaluation had been completed. A review of the WWDF dated 8/21/15 revealed Resident 20's unstageable pressure sore to the left great toe was 100% slough and measured 1.6 cm in length and .8 cm in width. WWDF dated 8/21/15 for Resident 20 ' s unstageable pressure sore to left second toe was 100% slough and measured 2.1 cm in length and .8 cm in width. Treatment orders remained as 7/2/15 physician order [REDACTED].>Observations on 8/25/15 at 10:44 AM revealed treatment with hydrogel completed on Resident 20's great toe and second toe. Both wounds had defined edges with whitish tissue and a small amount of drainage. In an interview on 8/25/15 at 12:34 PM, LPN B confirmed Resident 20 developed the pressures at the facility from the tongue of Resident 20's shoes. LPN B reported hydrogel was started on 7/2/15 and continued ever since. LPN B reported no improvement had been seen in the wound. In an interview on 8/25/15 at 12:34 PM, the Director of Nursing reported that a change of treatment should be implemented after 2 weeks if no improvement was seen. The Director of Nursing reported the Wound Nurse should be contacted for treatment recommendations.

Licensure Reference: 175 NAC 12-006.09D8c Based on record review, interview, and observation; the facility failed to evaluate resident weight loss and implement interventions to prevent further weight loss for three residents (Residents 20, 57, and 76). Findings are: A. Resident 76 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the Weights and Vitals Summary, Resident 76 had a weight of 133.8 lbs. (pounds) on 7/26/15 and a weight of 122 lbs. on 8/23/15. Resident 76 had a weight loss of 11.8 lbs. (8.8%) in 28 days. A review of Resident 76's Care Plan dated 8/13/15 revealed Resident 76 was independent in eating with a goal of maintaining independence in eating. Resident 76's weight loss was not identified as a concern on the Care Plan. Observations of breakfast on 8/25/15 between 8:12 AM and 8:35 PM revealed Resident 76 ate half of scrambled eggs, half of bacon, bites of cereal and half of scrambled eggs. A review of Resident 76's meal intake report revealed intakes reported for 39 meals. Record intakes for Resident 76 were as follows: -0-25% intake at 4 meals -25-50% intake at 15 meals -51-75% intake at 15 meals -76-100% intake at 2 meals -Resident not available at 3 meals. Registered Dietitian Nutritional assessment dated [DATE] for Resident 76 identified resident had a weight loss of more than 5% in the last month without being on a prescribed weight-loss regimen with a weight loss of 8% since admission. Resident 76 was identified as having a 0-50% intake. The assessment reported Resident 76 typically skipped breakfast, occasionally skipped lunch, and ate a large meal at supper. Resource juice or Ensure (high calorie supplements) was recommended to increase calorie intake and prevent further weight loss. A review of physician orders and August 2015 Medication Administration Record did not reveal an order for [REDACTED]. In an interview on 8/25/15 at 11:38 AM, the Director of Nursing confirmed Resident 76 had no physician orders for a nutritional supplement and there was no evidence that Resident 76's physician was notified of the Registered Dietitian's recommendation for supplements. B. Resident 20 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident 20's care plan dated 6/11/15 revealed Resident 20 was identified at nutritional risk due to [MEDICAL CONDITION] (stroke) with a goal of weight to remain the same through next quarter. Interventions for Resident 20 included chart meal consumption, provide Resident 20 with carnation instant breakfast made with ice cream 3 times a day, regular diet, and weekly weights. According to the Weights and Vitals Summary, Resident 20 weighed 142.6 lbs. on 5/27/15 and 123 lbs. on 8/22/15. Resident 20 had a weight loss of 19.6 lbs. (13.7%) between 5/27/15 and 8/22/15. The Weekly Wound Documentation Form for Resident 20 dated 8/21/15 identified Resident 20 had an unstageable pressure sore on the left great toe with a length of 1.6 cm (centimeters) and width of .8 cm and an unstageable pressure sore on the left second toe with a length of 2.1 cm and width of .8 cm. Observations of the lunch meal on 8/24/15 between 12:22 PM and 12:52 PM revealed Resident 20 ate 3/4 of pudding and half of a large glass of carnation instant breakfast. Observations of breakfast meal on 8/25/15 between 8:48 AM and 9:24 AM revealed Resident 20 drank 3/4 of large glass of carnation instant breakfast and only bites of hot cereal. A review of the Registered Dietitian Assessment for Resident 20 dated 6/1/15 revealed Resident 20 was on a mechanical diet with thin liquids and needed to be monitored for difficult chewing and swallowing. Resident 20's intake was identified as between 50-75%. Resident 20's admission weight was listed at 142.6 lbs. and usual weight was 132 lbs. Potential for change in food intake and weight was identified for Resident 20 due to depression which was being treated with [MEDICATION NAME]. Plan was to continue to monitor intake, weight, and labs. A fax to Resident 20's physician dated 6/18/15 identified Resident 20 was not eating much but was taking Carnation Instant Breakfast with breakfast 3 times per day and ice cream in between. Resident 20 was identified as not wanting a feeding tube and being depressed and Resident 20 thought breathing treatments helped in the past. Orders were received for the addition of [MEDICATION NAME] (an antidepressant) at bed time and Alberterol breathing treatment every 4 hours as needed. A Nutrition at Risk Interdisciplinary Note dated 7/7/15 identified Resident 20 with significant weight loss and open areas on toes. Resident 20's current weight was 134 lbs. down 6% in 30 days. Weight loss was identified as resulting from decreased swelling. Resident was identified as being at risk for aspiration but declined thickened liquids and did not want a tube feeding. Interventions included carnation instant breakfast mixed with ice cream with meals. A Nutrition at Risk Interdisciplinary Note dated 8/7/15 identified Resident 20 with a current weight of 129.2 lbs. with recent weight loss attributed to very poor intake related to nausea treated with medications. Resident 20 was moved to the assisted dining area for assistance and encouragement due to poor intake. Intake was identified at 0-25%, and [MEDICATION NAME] 2.9. Interventions included adding additional protein powder to instant breakfast shake and to provide assistance and high calorie foods and fluids. A review of Resident 20's progress notes, assessments, and faxes to the physician did not reveal any additional interventions for weight loss were added after Nutrition At Risk Interdisciplinary Note dated 8/7/15. In an interview on 8/25/15 at 9:43 AM, the Dietary Manager reported Resident 20 did not want a pureed diet or thicken liquids. The Dietary Manager reported Resident 20's main intake was the Carnation Instant Breakfast at meals and Resident 20 didn't receive any supplements between meals but could get snacks from the snack cart. In an interview on 8/25/15 at 11:30 AM, the Director of Nursing did not recall discussing a supplement between meals for Resident 20. · · C. Record review of Resident 57's Comprehensive Care Plan (CCP) printed on 8-24-2015 revealed Resident 57 was admitted to the facility on [DATE]. Review of Resident 57's CCP revealed Resident 57 was independent with eating. The goal identified on the CCP for Resident 57 was to maintain independence with eating. The goals included a regular diet and was to be weighed weekly. Record review of Resident 157's weights revealed the following information: -6-15-2015, 129.2 pounds. -7-11-2015, 124.3 pounds, a 4.9 pound loss or 3.79 percent. -7-15-2015, 121.3 pounds, a 7.9 pound weight loss from the 6-15-2015 weight or 6.1 percent. -7-29-2015, 119.1 pounds, an additional loss of 2.2 pound or a 7.1 percent weight loss from the 6-15-2015 weight. Record review of Resident 57's Progress note dated 8-7-2015 revealed the facility Dietician documented the following information: Resident reviewed at nutritional risk due to significant weight loss and an open area on the coccyx. Current weight 119.1 # (pounds). Resident on regular diet. Recently moved to an assisted table to encourage intake. Appetite remains poor. Resident was provided Carnation Instant Breakfast with meals, also started on [MEDICATION NAME] for wound healing. There was not any documentation that Resident 57's nutritional needs were evaluated to ensure nutritional needs were being meet, in addition, there was no evidence provided by the facility that additional interventions were implemented for the significant weight loss identified on 7-15-2015 and again on 7-29-2015. Record review of the facility Policy and Procedure for Weight Assessment, revised on 3-2014, revealed the following information: -Procedures: -3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. -4. The Dietitian will respond within 24 hours of receipt of written notification. -Analysis: -B. Approximate calorie, protein and other nutrient needs compared with the resident's current intake. An interview with the Director of Nursing (DON) was conducted on 8-25-2015 at 12:19 PM. During the interview, the DON confirmed Resident 57 had a significant weight loss and there was no evidence nutritional interventions were implemented to prevent further weight loss.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility Quality Assurance and Performance Improvement (QAPI) committee failed to identify ongoing issue relevant to F157, F242, F279, F314, F325, F329 and F371 and implement effective plans of action to identify and correct the deficient practice. The facility QAPI program failed to ensure the repeated deficiencies at F329 and F371 were corrected and the correction maintained. The facility staff identified a census of 54. Findings are: Record review of an undated information sheet for the facility Quality Assurance and Performance Improvement Committee revealed the following information: QAPI is a data driven, proactive approach to improving the quality of life, care and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions. On 8-25-2015 at 2:03 PM an interview was conducted with the facility Administrator. During the interview was asked if weight loss and pressure ulcers had been identified by the QAPI as a problem that required the attention of the QAPI Committee, the Administrator stated no, that was not identified as a problem area. On 8-25-2015 at 2:18 PM an interview was conducted with Nursing Assistant (NA) A. When asked if NA A knew what the QAPI was and what they were working on, NA A stated no. On 8-25-2015 at 2:19 PM an interview was conducted with NA C. When asked if NA C knew what the QAPI was and what they were working on, NA A stated I'm not sure what that is. An interview was conducted on 8-25-2015 with Registered Nurse (RN) D. During the interview when asked if RN D knew what the QAPI was and what they were working on, RN D reported being aware of the committee and stated I'm not sure what they are working on. An interview was conducted on 8-25-2015 at 2:30 PM with Licensed Practical Nurse (LPN) E. When asked if LPN E knew what the QAPI was and what they were working on, LPN E stated I'm not sure what they are working on.