Every finding on record at Florence Home

Based on interview and record review, the facility failed to ensure residents were protected from potential abuse by allowing an employee who was accused of abuse by Resident 5, to finish their shift. This had the potential to affect Residents in rooms 201-205 and 219-220 on the 200 hall. The facility had a census of 80.Findings are:An interview on 9/24/25 at 1:00pm with the Director of Nursing (DON) revealed the following:On 7/13/2025 the resident (Resident 5) made a statement that they did not want the Nurse Aide (NA-C) to change the resident because the NA throws the resident against the wall. Licensed Practical Nurse D (LPN) assigned another employee to care for the resident for the rest of the evening. The DON confirmed they were not aware of the incident until 7/14/1025 when they read Resident 5's progress notes from the evening before. The DON confirmed they contacted LPN D who wrote the progress note and received a verbal report from LPN D about the incident on 7/14/2025.The DON confirmed LPN-D should have contacted the DON immediately after the incident and LPN-D had not done so.The DON confirmed that LPN-D did not send NA-C home after LPN-D was informed of the incident and should have done so. The DON confirmed they had educated LPN-D verbally about informing management immediately of any accusations of abuse, but the DON had not documented the verbal education. An interview on 9/25/25 at 3:27 PM with the DON revealed NA - C worked on the 200 hall from 6-10 PM covering rooms 201-205 and covering rooms 201-204 and 219-220 from 2-6 PM. The DON confirmed NA-C would have had the potential to affect the residents in these rooms on 7/13/2025.A record review of a progress noted dated 7/13/2025 by LPN D revealed the following:Resident (5) refuses care from their assigned NA - C because they throw me against the wall, nurse educated resident that NA-C will be in the room to help spot the replacement NA since the resident requires 2 people during transfers. LPN-D witnessed brief change and NA-C did not overexert any strength during the brief change.A record review of the facility's Abuse Policy dated 1/28/2025 revealed the following: The policy stated the residents' rights to be free from verbal, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees of the Organization recognize its residents, regardless of cognitive ability, to be vulnerable and will take action to protect and prevent mistreatment, abuse, neglect, and misappropriation of resident property within the facility by:intervening in the situationReporting the situation to the proper authoritiesInvestigating the allegationPreventing abuse, neglect, and misappropriation while the investigation is in process.Document evidence that the Organization intervened, reported, prevented abuse/neglect/misappropriation, and investigated.Not employing individuals who have been:Found guilty of abusing or mistreating individuals by a court of law.Entered into the State Nurse Aide Registry concerning abuse, neglect, and mistreatment of residents or misappropriation of their property.Reporting any knowledge, it has of actions by a court of law against an employee for service as a Nurse Aide to the State Nurse Aide Registry of Licensing Authorities.The facility procedure consists of Pre-hire screening, Volunteer screening, employee and volunteer training, prevention, identification, reporting, immediate intervention, and investigation.

Licensure Reference Number 175 NAC 12-006.09 (H). Based on record review and interview the facility failed to hold a blood pressure medication according to the prescribed blood pressure parameters for 1 (Resident 19) of 6 resident's sampled. The facility census was 80. The findings are:Record review of Resident 19's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-25-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13-15 indicates a person cognitively intact. - required extensive assistance with hygiene, and bed mobility.-required total assistance with dressing, toileting, bathing and transfers.-had a pressure ulcer. Record review of Resident 19's Medication Administration Record (MAR) for August 2025 revealed an order for Midodrine 5 milligram (mg) tablet take 1 tablet 3 times a day, hold if Systolic Blood Pressure (SBP: the top number of a blood pressure reading) was above 120. The following entries revealed a SBP of above 120.-08-15-2025 at 8:00 AM Blood Pressure (BP) was 127/79 and documented as administered.-08-25-2025 at 8:00 AM BP was 125/84 and documented as administered. Record review of Resident 19's MAR for September 2025 revealed an order for Midodrine 5 mg take 1 tablet 3 times a day, hold if SBP was above 120. The following entries revealed a SBP of above 120.-09-18-2025 at 8:00 AM BP was 133/82 and documented as administered.-09-21-2025 at 8:00AM BP was 122/69 and documented as administered.-09-12-2025 at 12:00 PM BP was 121/75 and documented as administered.-09-22-2025 at 12:00 PM BP was 127/72 and documented as administered-09-18-2025 at 5:00 PM BP was 133/82 and documented as administered.-09-22-2025 at 5:00 PM BP was 132/79 and documented as administered. An interview conducted on 09-25-2025 at 1:40 PM with Director of Nursing confirmed that Midodrine 5mg should have been held for the dates identified in August and September. Record review of the facility policy titled Following Physician's Orders dated 08-2025 revealed the purpose of this policy is to provide guidelines for following physician's and non-physician provider orders. If a physician order is present and is failed to be administered according to specific orders, it may result in a medication discrepancy.

Licensure Reference Number 175 NAC 12-006.05(E). Based on interview and record review the facility failed to provide baths according to preference for 2 (Resident 8 and 12) of 2 residents sampled. The facility census was 80. The findings are:A.Record review of Resident 8's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 08-27-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -required limited assistance with upper body dressing and bed mobility.-required extensive assistance with bathing.-required total assistance with toileting, lower body dressing and transfers. Record review of the facility grievance log revealed the following concerns voiced by Resident 8:-06-23-2025 Resident 8 was concerned because it had been over a week since (gender) had a shower.-07-07-2025 Resident 8 was concerned that staff did not provide a shower on 07-04-2025.-07-25-2025 Resident 8 reported (gender) did not get a bath this week. An interview conducted on 09-23-25 at 7:30 AM with Resident 8 revealed Resident 8 wanted 2 baths or showers a week and was not getting them.Observation on 09-23-2025 at 7:35 AM revealed a white board in Resident 8's room that indicated Resident 8 was to get a bath on Monday and Wednesday.Record review of Resident 8's bathing record for July 2025 revealed a shower was given on 07-25-2025. Resident 8 should have received 9 showers in July.Record review of Resident 8's bathing record revealed the following for August 2025:-08-04-2025 shower-08-11-2025 shower-08-19-2025 shower-08-25-2025 showerResident 8 should have had a shower on 08-06-2025, 08-14-2025, 08-20-2025, and 08-28-2025. Record review of Resident 8's bathing record revealed the following for September 2025:-09-03-2025 shower-09-15-2025 showerResident 8 should have had a shower on 09-01-2025, 09-08-2025, 09-10-2025, 09-17-2025, 09-22-2025 and 09-24-2025. Record review of Resident 12's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-BIMS score was 14. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-required extensive assistance with hygiene and bed mobility.-required total assistance with toileting, bathing, dressing and transfers. B.Record review of Resident 12's Comprehensive Care Plan (CCP) dated 11-04-2024 revealed Resident 12 would like 2 baths a week.An interview conducted with Resident 12 on 09-22-2025 at 10:02 AM revealed a preference of 2 baths a week but doesn't always get 2.Record review of Resident 12's bathing record for July 2025 revealed the following:-07-03-2025 shower-07-08-2025 bath-07-29-2025 bathResident 12 should have received a bath or shower on 07-01-2025, 07-10-2025, 07-15-2025, 07-17-2025, 07-22-2025, 07-24-2025 and 07-31-2025. Record review of Resident 12's bathing record for August 2025 revealed the following:-08-12-2025 bed bath-08-19-2025 showerResident 12 should have received a bath or shower on 08-05-2025, 08-07-2025, 08-14-2025, 08-21-2025, 08-26-2025 and 08-28-2025. Record review of Resident 12's bathing record for September revealed the following:09-18-2025 bed bathResident 12 should have received a bath or shower on 09-02-2025, 09-04-2025, 09-09-2025, 09-11-2025, 09-16-2025 and 09-23-2025. An interview conducted with the Director of Nursing (DON) on 09-25-2025 confirmed baths were not provided according to preference and Resident 8 and Resident 12 should have had 2 baths a week.

Based on interview and record review the facility failed to report an allegation of abuse against Resident 5 within the required timeframe. The facility had a census of 80. Findings are:An interview on 9/24/25 at 1:00 PM with the Director of Nursing (DON) revealed the following:On 7/13/2025 the resident (Resident 5) made a statement that they did not want the Nurse Aide (NA-C) to change the resident because the NA throws the resident against the wall. Licensed Practical Nurse D (LPN) assigned another employee to care for the resident for the rest of the evening. The DON confirmed they were not aware of the incident until 7/14/1025 when they read Resident 5's progress notes from the evening before. The DON confirmed they contacted LPN D who wrote the progress note and received a verbal report from LPN D about the incident on 7/14/2025.The DON confirmed LPN-D should have contacted the DON immediately after the incident and LPN-D had not done so.The DON confirmed that LPN-D did not send NA-C home after LPN-D was informed of the incident and should have done so. The DON confirmed they had educated LPN-D verbally about informing management immediately of any accusations of abuse, but the DON had not documented the verbal education. An interview on 9/25/25 at 3:27 PM with the DON revealed NA - C worked on the 200 hall from 6-10 PM covering rooms 201-205 and covering rooms 201-204 and 219-220 from 2-6 PM. The DON confirmed NA-C would have had the potential to affect the residents in these rooms on 7/13/2025.A record review of a progress noted dated 7/13/2025 by LPN D revealed the following:Resident (5) refuses care from their assigned NA - C because they throw me against the wall, nurse educated resident that NA-C will be in the room to help spot the replacement NA since the resident requires 2 people during transfers. LPN-D witnessed brief change and NA-C did not overexert any strength during the brief change.A record review of the facility's Abuse Policy dated 1/28/2025 revealed the following: The policy stated the residents' rights to be free from verbal, physical and mental abuse, corporal punishment, and involuntary seclusion. The administration and employees of the Organization recognize its residents, regardless of cognitive ability, to be vulnerable and will take action to protect and prevent mistreatment, abuse, neglect, and misappropriation of resident property within the facility by:intervening in the situationReporting the situation to the proper authoritiesInvestigating the allegationPreventing abuse, neglect, and misappropriation while the investigation is in process.Document evidence that the Organization intervened, reported, prevented abuse/neglect/misappropriation, and investigated.Not employing individuals who have been:Found guilty of abusing or mistreating individuals by a court of law.Entered into the State Nurse Aide Registry concerning abuse, neglect, and mistreatment of residents or misappropriation of their property.Reporting any knowledge, it has of actions by a court of law against an employee for service as a Nurse Aide to the State Nurse Aide Registry of Licensing Authorities.The facility procedure consists of Pre-hire screening, Volunteer screening, employee and volunteer training, prevention, identification, reporting, immediate intervention, and investigation.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(a). Based on observation, interview and record review the facility failed to ensure ready to hang tube feeding was not in use beyond 24 hours for 1 (Resident 12) of 1 residents sampled. The facility census was 80. The findings are:Record review of the facility policy Gastric Tube Feeding Via Pump revealed the purpose of the policy is to provide nutritional support for residents who are unable to obtain nourishment orally. Furthermore, tube feeding and tubing can hang up to 24 hours.Record review of Resident 12's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-BIMS score was 14. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-required extensive assistance with hygiene and bed mobility.-required total assistance with toileting, bathing, dressing and transfers.-had a feeding tube.Observation on 09-22-2025 at 9:00 AM revealed Resident 12 was in the room and tube feeding was disconnected from Resident 12 and the bottle and tubing were still hanging on the tube feeding pole. The bottle was Jevity 1.5 dated 09-22-2025 at 3:50 AM.Observation on 09-23-2025 at 9:30 AM revealed the tube feeding had been disconnected from Resident 12 and a bottle of Jevity 1.5 dated 09-22-2025 at 3:50 AM was still hanging on the tube feeding pole. An interview on 09-23-2025 at 2:15 PM with Registered Nurse (RN) E revealed the bottle of Jevity 1.5 dated 09-22-2025 at 3:50 AM was still running at 6:00 AM on 09-23-2025 and confirmed the bottle of Jevity 1.5 should have been changed at or before 3:50 AM on 09-23-2025. An interview with the Director of Nursing (DON) on 09-25-2025 at 10:55 AM confirmed ready to hang tube feeding should not be used beyond 24 hours.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1 & 2). Based on observation, interview and record review, the facility failed to conduct weekly skin evaluations to prevent the potential for pressure ulcer development and failed to evaluate and monitor a new wound for 1 (Resident 19) of 2 sampled residents. The facility census was 80. The findings are:Record review of the facility policy titled Pressure Ulcer Prevention and Interventions dated 08-2025 revealed any resident with a Braden Scale (a tool healthcare professionals use to assess a patient's risk of developing a pressure ulcer) score of 16 or below will be assessed by a nurse every week with individualized skin interventions based on the Braden score. Record review of the facility policy titled Skin Protocol dated 02-2024 revealed the purpose of the policy was to provide clear expectations regarding reporting and subsequent documentation of skin issues. Weekly skin checks are to be done on all residents by a nurse. Anytime a new skin concern is found the nurse wo is on duty is responsible for: assessing the skin condition, including measurements and description. Record review of Resident 19's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-25-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13-15 indicates a person cognitively intact. - required extensive assistance with hygiene, and bed mobility.-required total assistance with dressing, toileting, bathing and transfers.-had a pressure ulcer. Record review of Resident 19's Electronic Health Record (EHR) revealed a Braden Scale dated 09-17-2025 scored at a 14, which indicated a mild risk of pressure ulcer development. Record review of Resident 19's Electronic Health Record revealed weekly wound evaluations but no weekly skin evaluations. An observation on 09-24-2025 at 10:00 AM of Registered Nurse (RN) B and the Assistant Director of Nursing (ADON) performing wound care for Resident 19 which revealed a large stage 4 pressure ulcer to the right buttock approximately 8 centimeters (cm) length by 3 cm width by 3 cm depth. The observation also revealed another wound to the right buttock that was approximately 4 cm in length by 2 cm in width by 0.1 cm in depth with yellow slough present in the wound bed. Record review of Resident 19's wound evaluations for 09-07-2025 and 09-14-2025 revealed only one wound to the right buttock, not 2. Interview with the ADON on 09-25-2025 at 2:00 PM revealed the second wound on the right buttock was identified by the facility staff on 09-15-2025 and confirmed the wound was not assessed or monitored since 09-15-2025 and should have been upon discovery and weekly going forward. An interview with the Director of Nursing (DON) on 09-25-2025 confirmed weekly skin evaluations were not conducted for Resident 19 and should have been.

Licensure Reference Number 175 NAC 12.006.09(H) Based on observation, interview, and record review, the facility failed to ensure compression stockings were applied and weekly weights were completed per the provider's orders for 1 (Resident 89) of 4 sampled residents and failed to monitor and treat 1 (Resident 49) of 4 sampled resident's lower extremity edema. The facility census was 80. Findings are:A record review of the facility's Following Physician's Orders policy with a revised date of 08/2025 revealed all aspects of physician or non-physician practitioner's order must be followed in their entirety. A record review of the facility's Ace Wraps, Compression Stockings (TED HOSE, [NAME] STOCKINGS, SUPPORT HOSE, etc.) guideline revealed the staff were to apply ace wraps or stockings to the resident per the provider's order. A.A record review of Resident 89's Profile Face Sheet dated 09/24/2025 revealed the resident was admitted to the facility 02/28/2025. The resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Orthostatic Hypotension (decrease of blood pressure on standing), and Cerebellar Ataxia (lack of muscle coordination and balance). A record review of Resident 89's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 08/20/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware. The resident required limited assistance for bed mobility, transfer, and toilet use and was independent for eating. The resident was not on therapy. A record review of Resident 89's Care Plan dated 03/20/2025 - 11/20/2025 revealed the resident was at risk for impaired skin integrity related to age, diagnoses, and decreased mobility, but did not reveal interventions for compression stockings (garments worn on the legs to apply pressure, promote blood flow, and reduce swelling). A record review of Resident 89's Physician's Orders dated 09/24/2025 revealed an order for compression stockings or equivalent on in AM (morning), off on PM (afternoon) for fluid overload. A record review of Resident 89's Grievance/Complaint Report dated 08/12/2025 revealed the resident told the Veteran's Administration (VA) staff that the residents TED hose had not been put on every day and the VA staff notified the facility. An observation on 09/22/2025 at 10:17 AM revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had significant swelling from edema (a condition where excess fluid builds up in the body causing swelling) in the bilateral lower extremities (BLE)(both legs and feet). The observation did not reveal the resident had compression stockings on but did reveal 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. An observation on 09/22/2025 at 3:12 PM revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had edema in the BLE with not compression stockings on but there were 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. An observation on 09/24/2025 at 8:11 AM revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had edema in the BLE. The observation did not reveal the resident had compression stockings on but did reveal 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. An observation on 09/25/2025 at 9:06 AM revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had edema in the BLE. The observation did not reveal the resident had compression stockings on but did reveal 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. An observation on 09/25/2025 at 9:12 AM with Licensed Practical Nurse (LPN)-A that was the charge nurse revealed Resident 89 was seated in a wheelchair in the resident's room and the resident had edema in the BLE. The observation did not reveal the resident had compression stockings on but did reveal 2 pairs of compression stockings hanging on a walker in the northwest corner of the room. In an interview on 09/22/2025 at 10:17 AM, Resident 89 confirmed the facility's staff had not offered to put the resident's compression stockings on for the last 2 days. In an interview on 09/25/2025 at 9:06 AM, Resident 89 confirmed the facility's staff had not offered to put the resident's compression stockings on and the resident had been out of bed since 6:30 AM. In an interview on 09/25/2025 at 9:12 AM, LPN-A confirmed the resident did not have compressions stockings on and should have had. The compression stockings should be put on when the nursing assistants (NA) assist Resident 89 out of bed in the mornings. B.A record review of Resident 89's Physician's Orders dated 09/24/2025 revealed an order for Document Weight Weekly to be done every week per the resident's physician. A record review of Resident 89's Medication Record For 08/2025 - 09/2025 dated 08/2025 and 09/2025 revealed weekly weights were not completed 08/15/2025, 08/29/2025, and 09/12/2025. A record review of Resident 89's Resident Weight Tracking System Report dated 09/25/2025 revealed the resident had not been weighed 08/15/2025, 08/29/2025. In an interview on 09/25/2025 at 12:15 PM, the facility's Director of Nursing (DON) confirmed Resident 89's weights were not being completed weekly and should have been. C.A record review of Resident 49's Profile Face Sheet dated 09/25/2025 revealed the resident was admitted to the facility 06/12/2025. The resident had diagnoses of Malignant Neoplasm Of Intrathoracic Nodes (cancer in the lymph nodes in the chest), Malignant Neoplasm Of Liver And Bile Duct, Atherosclerotic Heart Disease (plaque buildup in the arteries of the heart), Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus (uncontrolled blood sugars) and Hypothyroidism (underactive thyroid gland). A record review of Resident 49's MDS dated [DATE] revealed the resident had a BIMS of 15 which indicated the resident was cognitively aware. The resident was independent with dressing, eating, toileting and mobility. The resident required setup or clean-up assistance with bathing, personal hygiene (cleaning) and footwear. The resident was not on therapy. The resident was not on hospice and was not on a diuretic. A record review of Resident 49's Care Plan dated 03/20/2025 - 11/20/2025 revealed the resident was at risk for impaired skin integrity related to age, diagnoses, and decreased mobility, and had an intervention to notify the medical doctor of any areas of impaired skin and skin check per facility protocol. but did not reveal interventions for compression stockings (garments worn on the legs to apply pressure, promote blood flow, and reduce swelling. The resident had cancer and was receiving chemotherapy (cancer treatment). A record review of Resident 49's Physician's Orders dated 09/24/2025 revealed an order for weekly skin assessment but did not reveal and order for edemawear or a diuretic (a medication used to eliminate excess fluid from the body). A record review of Resident 49's Medication Record dated 07/2025 - 09/2025 revealed weekly skin assessment marked completed 7/16/2025, 07/30/2025, 08/27/2025, 09/03/2025, and 09/17/2025. Refused 07/09/2025, 07/23/2025, 08/06/2025, 08/20/2025, and 09/24/2025. The medication records were marked the resident was out of the facility 07/02/2025, 08/13/2025, and 08/10/2025. A record review of the facility's Skin Evaluation Form dated 07/01/2025 - 09/25/2025 revealed two evaluations done, 1 on 07/30/2025 and only skin concern was a great toenail concern 07/30/2025 and no issues on 08/27/2025. An observation on 09/22/2025 at 9:41 AM revealed Resident 49's right ankle and foot had edema and was red on the top from above the ankle and entire foot and scab on the lateral side (outside). An observation on 09/22/2025 at 12:12 PM revealed Resident 49's left lower extremity (LLE)(left lower leg and foot) had edema. The resident did not have compression stockings on or in the room. An observation on 09/23/2025 at 2:54 PM with Registered Nurse (RN)-B revealed the resident had BLE swelling with 3 plus (+) pitting edema in the LLE and cellulitis (skin infection) on the right lower extremity (RLE). In an observation on 09/24/2025 at 8:28 AM revealed edema in BLE and RLE appeared to have improved in color. No compressions stockings on resident or in the room. In an observation on 09/25/2025 at 9:06 AM revealed edema in BLE and RLE appeared to have improved in color. No compressions stockings on resident or in the room. In an observation on 09/25/2025 at 9:25 AM with the DON revealed edema in BLE. No compressions stockings on resident or in the room. In an interview on 09/23/2025 at 3:16 PM, RN-B confirmed Resident 49 did have BLE edema and resident had 3+ pitting on LLE that was not being treated. RLE had cellulitis and that was being treated with and antibiotic. RN-B confirmed RN-B seen the resident earlier in the morning and RN-B did not notice the LLE edema. In an interview on 09/25/2025 at 9:06 AM, LPN-A confirmed RN-B had contacted hospice regarding LLE edema on 09/23/2025, but Resident 49's physician had not been contacted, and no treatment changes had been made. In an interview on 09/25/2025 at 9:37 AM the DON confirmed the resident had BLE edema and treatment was not being completed for the LLE and should have been. The DON confirmed the staff were not doing weights and skin assessments as ordered.

Licensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure all food in the facility's refrigerators, freezers, and dry storage were sealed, labeled, and/or dated and failed to clean and maintain the kitchen's fixtures and equipment to prevent the potential for cross contamination and foodborne illness. This had the potential to affect 77 residents that consumed food from the kitchen. The facility census was 79. Findings are: A. A record review of the facility's undated Food Storage (Dry, Refrigerated, and Frozen) Guideline & Procedure Manual revealed all food items would be labeled. The label must include the name of the food item and the date by which it should be sold, consumed, or discarded. Raw animal foods such as eggs should be wrapped properly. Never leave any food item uncovered and not labeled. An observation on 07/29/2024 at 6:15 PM revealed the following: The reach-in refrigerator in the dining room contained 7 chocolate covered cakes in clear plastic containers not labeled or dated. The walk-in freezer contained: -1 opened bag of mixed vegetables not labeled or dated -1 bag of 2 breaded yellow items not labeled or dated The walk-in refrigerator contained: -26 small clear cups with lids that contained a white substance not labeled or dated -1 steam pan of a yellow substance not labeled or dated -1 steam pan of a green substance not labeled or dated -1 steam pan of a white substance not labeled or dated -1 steam pan of a red substance not labeled or dated -The walk-in refrigerator on the back south wall contained -1 bag of a shredded green substance not labeled or dated -1 open bag of green chucks not labeled or dated -2 steam pans covered with aluminum foil not labeled or dated on a cart -1 open bag of a yellow shredded substance not labeled or dated -1 bag of a white shredded substance not labeled or dated -1 open clear container with yellow square slices not labeled or dated -1 steam pan with 10 white ovals not labeled -2 steam pans with a white cream not labeled -1 opened gallon Hellmann's Real Mayonnaise without an open dated -2 plastic containers of blue round items not dated -1 gallon Sysco French Dressing without an open date -1 green rectangular object in plastic wrap not labeled or dated -1 clear container with a green lid not labeled or dated -1 clear container with green round items not labeled or dated -1 steam pan covered with plastic wrap not labeled -1 open pack of meat slices not sealed or dated -2 sandwiches not labeled or dated -1 uncovered steam pan of white ovals, 1 broke oozing yellow not sealed not labeled or dated -1 large clear plastic bin with an orange substance not labeled or dated -2 small clear containers with small white chunky substances not labeled -1 small clear covered container with an orange substance not labeled -1 small clear covered container with a dark brown substance not labeled The dry storage contained: -1 open bag yellow crispy flakes not sealed, labeled, or dated -1 bag of orange logs not labeled or dated -1 large clear container of a yellow liquid substance not labeled or dated In an interview on 07/31/2024 at 6:05 AM, the Dietary Manager (DM) confirmed that all items in the facility's refrigerators and freezers should have been sealed, labeled, and/or dated. B. A record review of the facility's undated Cooks Weekly Clean List revealed the cooks were to sweep and mop the storeroom daily, clean underneath shelves in the cooks area daily, delime the steam table as needed, clean the hot box once a week, clean the ovens and tops when needed, clean the range/grill/stove daily, and sweep and mop the kitchen daily. A record review of the facility's undated Aide-PM Cleaning Checklist revealed the steam table was to be wiped down after each meal service, all carts were to be wiped down after each meal service, and sweep and mop the steamtable area daily. An observation on 07/29/2024 at 6:15 PM revealed -The ice maker had gray fuzzy substance on exterior vents above the door and a black slimy substance on interior surfaces in the front. -The steam table had brown crusty substance between the warmer pans -The toaster had light brown crumbs in and under it -The walk-in freezer floor was sticky. -The inside edge of the front of the hood had a gray fuzzy substance along the edge. The range/oven front vertical surfaces contained white and brown dried splatters and the oven handle was sticky. -The [NAME] double ovens had brown food splatters on the front and inside the doors and the top had scattered black crusty substances -The hot box vertical Flavor holding cart had white and brown dried on splatters down front and on inside lower warmer around door seal and bottom ledge. -The vent on the hot box had a thick coating of a gray fuzzy substance -The dry storage and kitchen floor had scattered crumbs and debris throughout and a black sticky substance around a floor electrical box under the prep table An observation on 07/31/2024 at 6:05 AM with the DM revealed the items listed above had not been cleaned. A record review of the Cooks Weekly Clean List dated July 2024 revealed the refrigerators sweep and mop had not been completed, the storeroom sweep and mop was only done 07/07/2024, the cleaning underneath shelves in cook's area was only done 07/03/2024 and 07/07/2024, delime the steam table had not been done, the hot box had not been cleaned, the ovens and tops had not been cleaned, the ice machine had not been cleaned, the range/grill/stove had not been cleaned, the daily floor sweep and mopping was only done 07/03/2024, 07/07/2024, and 07/21/2024. In an interview on 07/31/2024 at 6:05 AM, the Dietary Manager (DM) confirmed that all items listed above were not clean and should have been.

Licensure Reference Number 175 NAC 12.006.18(B) Licensure Reference Number 175 NAC 12.006.18(D) Based on observation, interview, and record review, the facility failed to ensure the staff donned (put on) the correct personal protective equipment (PPE) in COVID-19 isolation rooms, doff (take off) gowns and gloves inside the resident's COVID-19 isolation rooms, ensure COVID-19 isolation residents room doors remained closed, and perform hand hygiene (cleaning) during glove changes to prevent cross contamination when performing peri-care on 2 (Residents 56 and 44) of 3 sampled residents. The facility census was 79. Findings are: A. A record review of the facility's Infection Control Policy Coronavirus (COVID-19), February 2024 dated February 2024 revealed trash cans were to be near the exit inside any resident room to make it easy for employees to discard PPE. A record review of the facility's undated Donning and Doffing Guideline and Audit revealed the purpose was to help prevent the spread of infection. Staff should have had a N-95 mask (a mask the filters out very small particles of bacteria) on at all times in COVID positive resident's isolation rooms. An observation on 07/29/2024 at 9:03 PM revealed a Nursing Assistant (NA) exited COVID-19 isolation room [ROOM NUMBER] in gown, gloves, and eye protection and doffed the PPE in the 2nd floor hallway and placed in the dumpster in the hallway. An observation on 07/29/2024 at 9:17 PM revealed Unit Manager (UM)-H exited COVID-19 isolation room [ROOM NUMBER] with a gown, gloves, and eye protection on, doffed in the 2nd floor hallway, and disposed of PPE in the dumpster in the hallway. An observation on 07/30/2024 at 8:28 AM revealed NA-J entered COVID-19 isolation room with a surgical mask on, not a N-95 mask. An observation on 07/30/2024 at 8:28 AM with UM-H revealed NA-J was in COVID-19 isolation room with a surgical mask on, not a N-95 mask, and was within 6 feet of a COVID-19 positive resident. In an interview on 07/29/2024 at 9:23 PM, NA-J confirmed that there were trash cans in the COVID-19 isolation rooms and PPE should have been removed in the room. In an interview on 07/30/2024 at 8:34 AM UM-H confirmed NA-J should not have been in COVID-19 isolation room without a N-95 mask on. In an interview on 08/01/2024 at 7:23 AM, the Director of Nursing (DON) confirmed the staff should have removed PPE before exiting a positive for COVID-19 resident's room and not in the hallway. B. An observation on 07/29/2024 at 8:52 PM revealed a NA exited COVID-19 isolation room [ROOM NUMBER] and left the resident's door open. An observation on 07/29/2024 at 9:03 PM revealed a NA exited COVID-19 isolation room [ROOM NUMBER] and left the room door open. An observation on 07/30/2024 at 2:57 PM revealed the door to COVID-19 isolation room [ROOM NUMBER] was partially open and the resident was in the room taking a nebulizer treatment (a mist used to deliver medications to the lungs). In an interview on 07/30/2024 at 3:05 PM, the facility's Administrator confirmed the staff was to keep the doors to COVID-19 isolation rooms closed when not entering or exiting. 50106 C. Record review of Resident 44 Profile Face Sheet revealed an admitted [DATE]. Resident 44 diagnosis include: Alzheimer's disease, unspecified dementia, cognitive communication deficit, and need for assistance with personal cares. Record review of Resident 44's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 6/12/2024 revealed the resident was unable to participate in an interview for Brief Interview for Mental Status (BIMS, a brief screener to determine resident's cognition) as the resident is rarely/never understood. Staff assessment for Mental Status revealed the resident did not seem or appear to recall after 5 minutes nor did the resident seem or appear to recall the long past. Section GG revealed functional abilities of Resident 44 were eating-substantial/maximal assistance, toileting, bed mobility and transfers-total assistance. Section H revealed Resident 44 was always incontinent of bowel and bladder. Section O Special Treatments, Procedures, and Programs revealed the resident received hospice services while a resident. Observation on 7/31/24 at 07:18 AM of Nursing Assistant (NA)-D and NA-E planned to performed peri-care on Resident 44 revealing NA-D explained to Resident 44 what the NA's were planned to do (peri-care). NA-D removed the tabs on the soiled brief and pushed it down between the resident's legs. NA-D using a clean washcloth wipe first under the abdominal fold, down each side of the groin and down the middle of the peri-area between the labia. NA-D removed the soiled gloves and without benefit of hand hygiene (HH) applied clean gloves and continued with peri-care. Both NA-D and NA-E roll the resident to the left side and removed the soiled brief. NA-D continued to do peri-care to the buttocks by wiping both buttock and then the anal area using a clean washcloth with each wipe. After the area was clean, NA-D removed the soiled gloves applied clean gloves without the benefit of HH. NA-D applied barrier cream to Resident 44's buttocks, removed the soiled gloves and applied clean gloves without benefit of HH. Interview with NA-D on 7/31/24 at 8:05 AM confirmed HH should have been performed with each glove change. Interview with Director of Nursing (DON) on 7/31/2024 at 12:05 PM confirmed HH should be performed with every glove change. D. Record review of Resident 56's Profile Face Sheet revealed the resident was admitted on [DATE]. Diagnosis listed: Cerebral Infarction (stroke), aphasia (doesn't speak), dysphagia (difficulty swallowing), chenille on dominant side (right), and contractures of right wrist. Record review of Resident 56's MDS revealed the resident is rarely or never understood and was unable to perform the interview for mental status. The staff assessment of mental status revealed the resident does not seam or appear to recall after 5 minutes but does seem or appear to recall long past. Section GG/functional abilities revealed Resident 56 does not eat but receives his nutrition through a gastrointestinal tube (G-tube), dependent for toileting and transfers, and requires substantial/maximal assist with bed mobility. Section H revealed that Resident 56 is always incontinent of bowel and bladder. Observation on 7/31/2024 at 11:24 AM of personal cares revealed NA-F and NA-G donned a gown and gloves in preparation of personal care for Resident 56. NA-F and NA G transferred Resident 56 from the wheelchair and into bed using a mechanical lift. Further observation on 7/31/2024 at 11:24 AM revealed NA-F and NA-G remove a sling from under residents 56, removed the gloves and donned another pair of gloves. NA-F and NA-G did not completed HH. NA-G removed the tabs on the adult brief and push the brief between Resident 56's legs. Further observation on 7/31/2024 at 11:24 AM revealed Resident 56 had a large lose bowel movement and was saturated. NA-G cleaned the front of the resident beginning of the groin, scrotum and penis. NA-G removed the soiled gloves applied clean gloves without HH. NA- F rolled Resident 56 on to the left side and NA-G removed the soiled brief. NA-G cleansed Resident 56's buttock, removed the soiled gloves and without completing HH,donned a clean pair of gloves. Interview on 7/31/24 at 11:30 AM with NA-G confirmed HRH should have been performed with every glove change. Interview on 7/31/24 at 12:05 PM with the DON confirmed HRH should have been performed with every glove change. E. Record review of Facility Policy Peri-care dated 01/2024 revealed the following: -Purpose: -The purpose of the guideline is to provide direction for proper peri-care. -Knock and announce yourself upon entering the room. -Identify resident and explain what you will be doing. -Don appropriate Personal Protective Equipment (PPE), if indicated. -Assemble equipment: Gather gloves, peri-wash, extra trash bags, and washcloths. Apply gloves prior to wetting the washcloths. Wet the washcloths thoroughly with warm water (do not allow the washcloths to touch the sink or the faucet) and place in plastic bag. Take to the bedside. -Perineal cleanser may be pumped on to each individual cloth or washcloths in the plastic bag. -Perform hand hygiene and put on gloves. -Fold down bed linens, exposing only the peri area. Be sure to cover the resident's upper body with a towel or sheet to prevent the feeling of overexposure. -If there is stool present, remove, and dispose of in toilet or trash bag. Remove gloves and perform hand hygiene. -For a female resident: Separate the labia and wash around the urinary meats first, wiping downward from front to back and from inside toward outside. Never wash upward from the anal area. Be sure to use a clean washcloth for each wipe or anytime the washcloth becomes contaminated. Place dirty washcloths in an empty plastic bag. With a clean washcloth, continue to wash between and outside the labia using downward strokes alternating from side to side and moving outward toward the thighs. Pat area dry in the same direction used for washing. -For male resident: If uncircumcised, pull foreskin back from head of penis. Use a washcloth to wash the urinary meats first, working down the penis, scrotum, and thighs. Be sure to wash all skin folds thoroughly, using a clean washcloth for each wipe. Place dirty washcloths in a plastic bag. Return the foreskin to the natural position if uncircumcised male. Pat area dry in the same direction used for washing. -Take gloves off, perform hand hygiene, and apply new gloves. -Keeping the resident covered, ask the resident to assist you in turning to side. -With buttocks exposed. Wash the buttocks first and then the anal area, wiping front to back, using a different washcloth for each wipe. Place dirty washcloths in a plastic bag. Pat the skin dry with dry clean towel and dispose of it in plastic bag. -Remove gloves and dispose into trash. Perform hand hygiene. -If applying moisture barrier product. Perform hand hygiene. Apply clean gloves. Apply product using same technique as cleansing (front to back) Secure brief on resident, and re-dress resident. -Position resident per their preference. -Dispose of soiled supplies and perform hand hygiene. -If PPE was used, remove, and perform hand hygiene. -Report any unusual appearances in the resident's skin to charge nurse/supervisor.

Licensure Reference Number 175 NAC 12.006.02(09(H)(v) Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 30) of 1 sampled resident was placed on the Restorative Nursing Program (RNP)(a program to prevent or improve a resident's abilities) following discharge and recommendation from Occupational Therapy (OT) and Physical Therapy (PT). The facility census was 79. Findings are: A record review of the undated [NAME] Home Guideline Restorative Program revealed residents will be identified as candidates for the Restorative Nursing Program (RNP) based on therapy referrals and facility screenings. Residents identified as candidates would be placed on a RNP. The RNP would focus on range of motion, communication, ambulation, wheelchair mobility, splint application, use of adaptive devices, and restorative dining. A record review of Resident 30's Profile Face Sheet dated 07/31/2024 revealed the resident was originally admitted to the facility on [DATE]. A record review of Resident 30's Med A (Medicare Part A) Resident assessment dated [DATE] revealed the resident had diagnoses of Encephalopathy (damage or disease that affects the brain), Parkinson's Disease With Dyskinesia (a progressive neuromuscular disorder), Epilepsy (a brain disorder that can cause seizures), Chronic Diastolic (congestive) Heart Failure. Chronic Kidney Disease, Stage 3, and Morbid Obesity (severely overweight). A record review of Resident 30's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 06/12/2024 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) 14 of 15 that indicated the resident was cognitively aware. The resident was dependent on staff with toileting, bathing, and dressing, needed partial/moderate assistance with eating and oral hygiene (cleaning), and substantial/maximal assistance with personal hygiene. Resident 30 had impairment on 1 side in range of motion (ROM) of the upper and lower extremities (arms and legs). A record review of Resident 30's Care Plan dated of 06/01/2024 revealed the resident was on a restorative program to maintain the resident's flexibility. The resident had interventions to do the program 3-6 days per week for at least 15 minutes each category, Restorative nursing evaluations would be done monthly, the staff would document changes in activity tolerances, and cue and assist the resident as needed with grooming. A record review of Resident 30's OT Discharge Summary dated 06/03/2024 revealed OT discharged the resident on 06/03/2024 with Restorative Programs, and they were established/trained. A record review of Resident 30's PT Discharge Summary dated 06/03/2024 revealed PT discharged the resident on 06/03/2024 with a Restorative ROM Program. ROM Program was established/trained: the resident is currently able to move feet up and down, rotate the feet in and out, and rotate the legs inward and outward. The resident would be able to move feet up and down, move legs up and down, rotate feet in and out, and rotate legs in and out by performing the following Restorative Nursing interventions: encourage resident to assist with the ROM, encourage the resident to participate, never force the extremity ranging and passive motion. A record review of Resident 30's Interdisciplinary (all staff) Notes dated 07/30/2024 did not reveal the resident was getting a RNP. A record review of Resident 30's Electronic Medical Record and hard chart did not reveal the resident was getting a RNP. An observation on 07/29/2024 at 8:51 PM revealed Resident 30 had difficulty moving both upper and lower extremities on both sides and demonstrated the challenge. An observation on 07/30/2024 at 3:05 PM revealed Resident 30 had difficulty moving all extremities. In an interview on 07/29/2024 at 8:51 PM, Resident 30 confirmed the resident had difficulty moving all extremities. Resident 30 confirmed the resident was not currently receiving OT, PT, or any staff assistance with exercising the resident's extremities. The resident confirmed the resident would do the exercises if offered. In an interview on 07/30/2024 at 8:01 AM, the Director of Nursing confirmed Resident 30 did not get put on the RNP when OT and PT made the recommendations and he should have been placed on a RNP.

Licensure Reference Number 175 NAC 12-006.09 (F)(iii) Based on record review and interview, the facility failed to revise 1 (Resident 56) of 1 resident Care Plan related to NPO (nothing by mouth)status. The facility census was 79. Findings are: Record review of Resident 56's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 6/19/2024 revealed the resident's admitted was 2/21/2024. Resident 56's Brief Interview of Mental Status (BIMS, a brief screener to determine cognitive status) revealed Resident 56 was unable to complete the BIMS due to Resident 56 rarely to never being understood (Resident 56 does not speak). The staff assessment for Mental Status revealed short-term memory problem and appeared to recall long past. According to the MDS, Resident 56 had a stroke/Cardiovascular Accident (CVA) affecting his dominant side. Resident 56 also has diagnoses of aphasia (non-speaking) and dysphagia (difficulty swallowing) due to the CVA. His functional ability to eat-resident does not eat; Resident 56 gets nothing by mouth (NPO). Resident 56 is fed via a gastrointestinal tube (g-tube) for all nutrition and medications due to his dysphagia caused by the CVA. Record review of Resident 56's Physician Orders dated 1/4/2022 revealed an order Jevity ( nutritional formula) 1.5 Cal via feeding pump at a rate of 65 milliliters (ml) per hour continuously for 24 hours for CVA, NPO. Record review of Resident 56 Care Plan dated 5/8/2024 revealed Resident 56's care plan identified Resident 56's nutritional status was to remain stable with no significant weight loss and to tolerate tube feedings. The following interventions were identified: assist with meals as needed, monitor meal intake, and provide snacks and supplements as ordered (Resident 56 is NPO and would not be eating meals nor be given snacks or supplements). Interview with Director of Nursing (DON) on 7/31/24 at 1:31 PM confirmed the interventions on the care plan dated 5/8/24 would be confusing as resident is NPO, does not eat meals, does not need assistance at mealtimes, and snacks and supplements would not be ordered. Resident is dependent upon the nursing staff to provide his nutrition 100% by g-tube.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(1) Based on observation, interview, and record review, the facility staff failed to provide catheter care for 1 (Resident 5) of 3 sampled residents. The facility identified a census of 79. Findings are: A record review of Resident 5's face sheet revealed an admitted [DATE]. A record review of hospital records dated 05/13/2024 indicated that Resident 5 had an orthopedic surgery and was referred to a Skilled Nursing Facility for 24 hour care. A record review of Resident 5's Minimum Date Set (MDS-a federally mandated comprehensive assessment tool dated 6/4/24 revealed the Resident was admitted to the facility with diagnoses of chronic kidney disease (CKD), Chronic Atrial Fibrillation (A-Fib), Diabetes Mellitus (DM), Spinal stenosis with prior spinal fusion, status post revision of T7-L3 laminectomy and fusion, and Chronic Diastolic Congestive Heart Failure. The MDS also indicated no indwelling catheter was in place and Resident 5 was always incontinent of bladder and bowel A record review of lab results from Physician Laboratory Services the resident revealed a Urinary Tract Infection (UTI) on 07/01/2024 was identified. The culture and sensitivity report revealed the organism (a bacterium that normally lives inside human intestines, where it doesn't cause disease. If K. pneumoniae gets into other areas of the body, it can lead to a range of illnesses, including pneumonia, bloodstream infections, meningitis, and urinary tract infections.) to be Klebsiella pneumoniae. A record review on the Resident's Physician Orders for 07/20/2024 revealed as of 07/04/2024 facility staff were to complete catheter cares twice daily. A record review of Resident 5's Care Plan dated 07/07/2024 revealed staff were to perform Foley (catheter) cares per protocol. A record review of progress notes revealed that Resident 5 has an appointment with the Urologist (A doctor that studies and treats conditions affecting the kidneys, ureters, bladder, and urethra). The appointment with the Urologist is on 08/13/2024 at 10:30 AM. A record review of the Guidelines and Audit tool for Foley Care, dated 2024 revealed that during peri care the catheter should be cleansed and rinsed from insertion site to approximately 4 inches outward. An observation on 7/29/24 at 7:30 PM revealed Resident 5 was sleeping with a catheter bag hanging from the bed. An observation on 07/31/2024 at 7:14 AM with Licensed Practical Nurse (LPN)-C and a Nursing Assistant (NA)-B revealed they gathered the supplies to complete catheter cares. LPN-C had a gown on and washed hands before putting gloves on. The NA also had a gown on and placed gloves following hand washing. LPN-C announced to Resident 5 that LPN-C and NA-B were going to be completing catheter care. NA-B pulled the blankets back and began to unfasten Resident 5's brief. The LPN-C using wash cloths completed front peri care for Resident 5. Further observation on 07/31/2024 at 7:14 AM revealed LPN-C and NA-B completed providing personal care task without completing catheter care. An interview on 7/31/24 7:7:23 AM was completed with LPN-C. During the interview LPN-C confirmed catheter care had not been completed for Resident 5.

Based on record review and interview; the facility failed to ensure its admission policy did not waive the potential liability for losses of a resident's personal property for Resident 2, 4, and 5. This had the potential to affect all residents in the facility. The facility census was 77. Findings are: Review of the facility, Admission Agreement, revised 01/24, revealed the following: -XIV. Personal Property: The Home shall not be liable for loss or damage to any personal property belonging to the resident and kept at the Home. Review of the facility, Personal Property policy, updated 1/2024, revealed the following: -[NAME] Home shall not be liable for loss or damage to any personal property belonging to the resident and kept at [NAME] Home, nor will [NAME] Home be responsible for replacing, lost, damaged or stolen items. Review of Resident 2's Admission Agreement, dated 9/18/09, revealed acknowledgement of the Personal Property agreement by Resident 2's resident representative. Review of Resident 4's Admission Agreement, dated 1/18/23, revealed acknowledgement of the Personal Property agreement by Resident 4. Review of Resident 5's Admission Agreement, dated 6/22/23, revealed acknowledgement of the Personal Property agreement by Resident 5's resident representative. An interview on 2/21/24 at 9:27 AM, the Social Services confirmed that the facility's Admission Agreement and Personal Property policy did waive the liability of the facility for losses of resident's personal property and that the agreement is signed upon admission by the resident or the resident's representative.

Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to maintain walls, safety stop strips, doors, fixtures, ceiling tiles and baseboards in good condition in 16 ( Rooms 202, 203, 206, 207, 208, 210, 211, 212, 213, 214, 215, 217, 221, 225, 232 and 233) of 31 occupied resident rooms on the second floor of the facility. The facility had a total of 52 occupied resident rooms. The facility census was 78. Findings are: Observation on 6/8/23 between 9:00 AM and 10:00 AM with the facility Administrator and the [NAME] President of Facilities Management (VPFM) during an environmental tour of the facility revealed the following environmental concerns: - Scratches / gouges on several walls in resident rooms and bathrooms: rooms 202, 203, 211, 215, 217, 221, 225, and 233. - Stop strips pulled away from the floor in front of the toilet in the bathroom and bed in room [ROOM NUMBER]. - Greenish colored corrosion around the water faucets in resident bathrooms in rooms [ROOM NUMBER]. - Scratches / gouges on the exterior room doors in rooms 202, 208, 210, 213, 214, 217 and 221. - Cracked and brown stained caulking surrounding the base of toilets in resident bathrooms in rooms 207, 217, 225, and 232. - Caulking between the sink and the wall cracked and pulled away from the wall in the resident bathroom in room [ROOM NUMBER]. - Ceiling tiles broken in resident bathrooms in rooms [ROOM NUMBERS]. - Ceiling tile had brown water stains present in resident bathroom in room [ROOM NUMBER]. - Linoleum baseboard loose and pulled away from the wall in resident bathroom room [ROOM NUMBER]. Interview on 6/8/23 at 10:05 AM with the VPFM confirmed the issues identified with walls, stop strips for safety, faucets, doors, caulking around the base of toilets and sinks, ceiling tiles and baseboards. Interview on 6/8/23 at 10:56 AM with the VPFM confirmed that there were no work orders for the concerns identified during the environmental tour and that those concerns had not been identified by facility staff prior to the environmental tour of the facility.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on observation, interview, and record review, the facility failed to notify the physician of a change in daily weights for 1 (Resident 24) of 1 resident reviewed. The facility had a total census of 78 residents. Findings are: Record review of Resident 24's Face Sheet, printed 6/7/23, revealed Resident 24 was admitted to the facility on [DATE] and their diagnoses included Congestive Heart Failure (a chronic condition where the heart doesn't pump blood as well as it should - this can cause fluid buildup in the feet, arms, lungs, and other organs) and Chronic Kidney Disease (a condition where the kidneys are damaged and cannot filter blood as well as they should - this can cause excess fluid and waste from the blood to remain in the body). Observation on 6/8/23 at 9:23 AM revealed Resident 24 was dressed and lying on their bed. Further observation at this time revealed Resident 24's bilateral lower legs were very edematous (swollen). Record review of Resident 24's May 2023 MAR (Medication Administration Record) revealed an order to document Resident 24's weight daily, with a start date of 5/26/23. The following weights were recorded for May 2023: -5/26/23 - 183.9 lbs (pounds) -5/27/23 - no weight recorded -5/28/23 - no weight recorded -5/29/23 - 174.7 lbs -5/30/23 - 178.8 lbs -5/31/23 - 179.5 lbs Record review of Resident 24's June 2023 MAR revealed an order to document Resident 24's weight daily. The following weights were recorded for June 2023: -6/1/23 - 180.1 lbs -6/2/23 - no weight recorded -6/3/23 - 180.7 lbs -6/4/23 - 182.2 lbs -6/5/23 - 184.6 lbs -6/6/23 - 185.7 lbs -6/7/23 - no weight recorded Record review of Resident 24's Interdisciplinary Notes revealed the following: -5/26/23 - Resident 24 was noted to have increased swelling in bilateral lower legs. Resident 24's physician was notified, and new orders were received. -5/29/23 - Resident 24's physician was sent an update regarding Resident 24's weights and new orders were received. Record review of Resident 24's Weight Tracking Record printed 6/8/23 revealed Resident 24 weighed 174.7 lbs on 5/29/23 and 185.7 lbs on 6/6/23, for a total weight gain of 11 lbs in 8 days' time. Record review of Resident 24's electronic medical record on 6/8/23 did not reveal Resident 24's physician was updated regarding Resident 24's weight gain from 5/29/23 - 6/6/23. Interview on 6/8/23 at 2:13 PM, the DON (Director of Nursing) confirmed Resident 24's physician had not been updated since 5/29/23 regarding Resident 24's weight gain. The DON also confirmed when the order for daily weights was written, parameters were not established for when to notify Resident 24's physician. The DON reported the standard the facility generally used for daily weight monitoring was to notify the provider if a weight gain of 3 pounds or more was noted in 24 hours or if a weight gain of 5 pounds or more was noted in 7 days. The DON further reported they had reached out to Resident 24's physician and confirmed that was the parameter Resident 24's physician wanted to implement for Resident 24's daily weight monitoring.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to implement pain management interventions for 2 (Resident 1 and 2) of 4 sampled residents. The facility staff identified a census of 68. Findings are: A. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 4-19-2022 revealed the facility staff assessed the following about Resident 1: -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manuel, a score of 13 to 15 indicates a person is cognitively intact. -Required extensive assistance with personal hygiene and eating. -Required total assistance with bed mobility, transfers, toilet use and dressing. -Received pain medication and had pain indicators. Record review of Resident 1's Comprehensive Care Plan (CCP) printed on 5-4-22 revealed Resident 1 was at risk for pressure ulcers and currently had a pressure ulcer to the coccyx area. Further review of Resident 1's CCP revealed Resident 1 had pain medications scheduled and as needed. The goal identified for Resident 1 was to have pain managed. Interventions to meet this goal included pre-medicating Resident 1 as needed to optimize participation in cares and activities. Record review of a Physician Visit Form sheet printed on 5-04-2022 revealed Resident 1's practitioner ordered medications that included Acetaminophen 1000 milligrams (mg) three times a day and [MEDICATION(S)] 5 mg every 4 hours as needed for acute pain. Record review of a History and Physical (H&P) sheet dated 4-13-2022 revealed Resident 1 had a laminectomy ( A laminectomy is a type of back surgery used to relieve compression on the spinal cord) at C3-C6 (neck area). Observation on 5-4-22 of wound care to Resident 1's coccyx starting at 7:40 AM revealed Licensed Practical Nurse (LPN) B obtained the treatment supplies for the treatment, went into Resident 1's room and placed the wound supplies onto the tray table with a barrier. LPN B with Nursing Assistant (NA) C assisting, repositioned Resident 1 onto the right laying side. During the repositioning Resident 1 moaned and groaned with LPN B stating I know it hurts. We'll be done soon. LPN B unfastened an adult brief Resident 1 was wearing and removed a soiled dressing to the coccyx area. Resident 1 moaned and groaned and stated Oh man with a deep breath. LPN B stated I know it hurts, I'll get you something when we are done. LPN B cleansed the coccyx wound with Resident 1 moaning and groaning. LPN B inserted a medicated packing material into the coccyx wound causing Resident 1 to yell out and moan and groan. LPN B stated I know it hurts, we are almost done. LPN B applied a clean covering dressing to the coccyx area. Further observations of wound care revealed Resident 1 had a new pressure ulcer to the left heel. LPN B applied barrier ointment to the left heel. Resident moaned and groaned when the left leg was lifted. LPN B stated I know it hurts, we are almost done. On 5-04-2022 at 7:52 AM an interview was conducted with Resident 1. During the interview when asked on a scale of 0 to 10 what was Resident 1's pain, Resident 1 reported a level of 3 to 4. When asked if a level 3 to 4 was intense pain, Resident 1 stated yes. On 5-04-2022 at 8:01 AM an interview was conducted with LPN B. During the interview LPN B confirmed Resident 1 had been in pain throughout the treatment. When asked if Resident 1 had been pre-medicated prior to starting the treatment to the coccyx and left heel, LPN B stated no. When asked if the treatment should have been stopped and Resident 1 provided pain management, LPN B stated Yes, I should have done that. On 5-04-2022 at 8:04 AM an interview was conducted with NA C. During the interview NA C confirmed Resident 1 had been in pain. On 5-04-2022 at 10:55 AM an interview was conducted with the facility Advanced Registered Nurse Practitioner (ARNP) D. During the interview ARNP D reported it is very important to manage Resident 1's pain and to pre-medicate prior to starting the treatments. On 5-4-2022 at 1:25 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported the expectation was the nurse should have stopped the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] B. Resident 2 was admitted to the Skilled Nursing Facility on 4/14/2022 from a hospital. The discharge orders from the hospital included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 1 patch TransDermal every 72 hours for chronic pain. The patient information package from the hospital stated a 75mcg [MEDICATION(S)] patch was applied to left upper back on 4/13/22 prior to resident discharging to Skilled Nursing Facility. A record review of the Nursing admission note on 4/15/22 revealed the resident allowed Registered Nurse (RN) to perform brief assessment but was too tired to be messed with too much' Nurse at the hospital stated [MEDICATION(S)] patch was placed today. Orders faxed to pharmacy and Primary Care Physician and awaiting confirmation. There are no further nurse notes noted. The nurse did not state that they saw the [MEDICATION(S)] patch on Resident 2. A weekly skin assessment was charted as done 4/16. An undated skin assessment sheet did not reference skin patch or any skin issues other than bruising after IV therapy. A record review of the narcotic delivery sheet dated 4/15/2022 confirmed the delivery of 2 [MEDICATION(S)] patches from the pharmacy to the skilled nursing facility for the resident in room [ROOM NUMBER]-1. A record review of the facility Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] A record review of facility physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date 4/20/22. An interview with the DON at 2:32PM on 05/04/2022 confirmed Resident 2 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed that patch was not changed on 4/16/22. DON confirmed that 2 patches were delivered for Resident use on 4/15/22. The DON stated that when pain medication is received from the pharmacy it is taken to the med cart on the floor where the resident is and is locked in the narcotic drawer. The DON confirmed that if patches were delivered on 4/15/22 for the resident they would have been available to use. The DON confirmed that it is the expectation when pain medication is given to a resident the effectiveness of that medication is measured and charted. A record review of Resident 2's medication record revealed Resident 2 was given the pain medication Acetaminophen-[MEDICATION(S)] #3 as ordered on 4/15/22 at 19:07, 4/16/22 at 17:58, 4/17/22 at 16:23 and 4/19/22 at 15:40. A record review of Resident 2's medication record revealed the resident had a 75mcg [MEDICATION(S)] patch placed on 4/17/22 at 23:49. The DON confirmed that these medications were not assessed for effective pain relief for Resident 2. The DON confirmed that the expectation is to perform a skin check on Residents on admission. The DON confirmed that this was not done on Resident on admission. The DON confirms that pain patch could have been noted on skin if skin assessment had been done on admission.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12E1a Based on observation and interview; the facility staff failed to ensure 2 medication storage carts were secured on the 2nd floor of the facility. This had the potential to affect all residents who reside on the second floor of the facility. Findings are: A. Observation on 5-04-2022 at 9:27 AM revealed the medication storage cart on the second floor south 200 hall was unlocked and unattended. Observation on 5-04-2022 at 10:40 AM revealed the medication storage cart on the second floor south 200 hall was unlocked and unattended. On 5-04-2022 at 10:40 AM an interview was conducted with Licensed Practical nurse (LPN) B. During the interview LPN B confirmed the medication storage cart on the second floor south hall was unlocked and unsecured. LPN B reported the medication cart should be locked when not in use. B. Observation on 5-04-2022 at 1:12 PM revealed the medication storage cart on the second floor north 200 hall was unlocked and unattended. On 5-04-2022 at 1:13 PM an interview was conducted with Registered Nurse (RN) A. During the the interview RN A confirmed the medication storage cart was unlocked and unattended. RN A reported when not in use the medication storage cart is to be locked.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observations, record review and interview; the facility staff failed to utilize handwashing and gloving techniques to prevent the potential for cross contamination during treatments for 1 (Resident 1) of 4 sampled Residents and failed to clean a glucometer ( device used to check blood sugar levels) for 1(Resident 5) of 1 sampled Residents. The facility staff identified a census of 68. Findings are: A. Observation on 5-4-22 of wound care to Resident 1's coccyx starting at 7:40 AM revealed Licensed Practical Nurse (LPN) B obtained the treatment supplies for the treatment, into Resident 1's room and placed the wound supplies onto the tray table with a barrier. LPN B washed hands and donned gloves. LPN B and with the assistance of NA C positioned Resident 1 onto a right side. LPN B pulled down an adult brief Resident 1 was wearing, removed gloves and did not complete handwashing. LPN B donned another pair of gloves removed the soiled dressing and a medicated packing material from Resident 1's wound. LPN B removed the soiled gloves, did not complete hand hygiene and donned another pair of gloves. LPN B cleansed the wound and applied a new medicated packing material into the wound. LPN B removed the soiled gloves and did not complete hand hygiene. LPN B donned another pair of gloves obtained a dressing to cover the wound and applied to Resident coccyx area. LPN B removed the soiled gloves and did not complete hand hygiene. On 5-04-2022 at 8:01 AM an interview was conducted with LPN B. During the interview LPN B confirmed hand hygiene was not complete when removing the soiled gloves and should have been. Record review of the facility Hand Hygiene Guideline dated 5 revealed the following information: -Purpose: -Hand hygiene is the single most important factor in preventing the spread of infection to residents, visitors and staff. -Note section: Employees should always complete the hand hygiene task: b. Before gloving to perform procedures and after removing gloves. B. Observation on 5/4/2022 at 07:00 AM of Registered Nurse (RN) A obtaining the glucometer (a device that measures blood sugar) from a tote and placing a glucose strip into the device. RN A entered the room of Resident 5 and obtained the blood sugar. RN A placed the glucometer on the medication cart and obtained a disinfectant wipe from the drawer of the cart. RN A wiped the glucometer with the disinfecting wipe and placed the glucometer back into the tote. Review of the Blood Glucose Monitoring Guideline dated 7/16 revealed to ensure the glucose machine has been cleaned and disinfected with a sani cloth bleach wipe premoistened with a stabilized bleach solution 1:10 dilution. Place on clean paper towel. Let the machine dry. The machine must be cleaned and disinfected using this method between each resident. Interview conducted with the Director of Nursing (DON) on 5/4/22 at 1:08 PM confirmed the glucometer should have been cleaned and placed on a clean paper towel to dry.

Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure the floors, the ice maker vents, the top of the ice maker, and ventilation system vent above the food warmer/serving station had been maintained in a clean and safe operating condition and that the garbage can was covered in the serving area to prevent the potential for food-borne illness. This had the potential to affect the 62 residents that consume food from the kitchen. Total census was 65. Findings are: Record review of the 2017 United States Food and Drug Administration Food Code for United States Public Health Service, Section 4-6002.13 revealed: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Observation on 02/16/2022 at 09:10 AM revealed the vents and the top of the ice maker were coated with a gray, sticky, fuzzy substance. There was a large amount of dirt and debris (scattered pieces of waste or remains) under and behind the oven. The trash can in the serving area was full of garbage and did not have a cover on it. The ventilation system vent above the serving table was covered with a gray fuzzy substance. Observation with Director of Dining (DD) on 02/16/2022 at 09:10 AM revealed the DD seen the vents and the top of the ice maker were coated with a gray, sticky, fuzzy substance, that there was a large amount of dirt and debris under and behind the oven, the trash can in the serving area was full of garbage and did not have a cover on it, and the ventilation system vent above the serving table was covered with a gray fuzzy substance. Interview with the Director of Dining on 02/16/2022 at 09:10 AM confirmed the vents and the top of the ice maker were coated with a gray, sticky, fuzzy substance. The DD confirmed there was a large amount of dirt and debris under and behind the oven. The DD confirmed the trash can in the serving area was full of garbage and did not have a cover on it. The DD Confirmed the ventilation system vent above the serving table was covered with a gray fuzzy substance. Interview with the Director of Nursing confirmed that 62 of 65 residents consume food from the kitchen.

Licensure Reference Number 175 NAC 12-006.18A(1) Based on observation and interview, the facility failed to maintain walls, ventilation systems, equipment, floors and baseboards in clean and good condition in 15 (rooms 202, 203, 214, 217, 222, 229, 231,301,303, 304 305, 306, 314, 316 317) of 45 occupied resident rooms and bathrooms. The facility census was 65. Findings are: Observation on 02/23/22 between 8:35 AM and 09:20 AM with the facility Director of Maintenance revealed the following environmental issues in the facility: - Ventilation covers were coated with a gray fuzzy substance that resembled dust in resident bathrooms 202, 203, 214, 217, 222, 301, 303, 304, 305 and 317. - Scratches and gouged areas were present on the walls in rooms and bathrooms in rooms 202, 203, 214, 229, 231 and 317. - Food and liquid spills and drips were present on walls near the bed by the door in room 202. - A light bulb was out in the bathroom of room 202. - Drywall patches which had not been painted were present in rooms 214 and 314. - The linoleum was loose from the wall and floor in the bathroom behind the toilet of room 303. - The base of the toilet had broken, brown stained caulking present in the bathroom of room 305. - The base board was loose from the wall and floor near the closet in room 229 and in the hall outside of rooms 304 and 306. - Transition stop strips were loose with the corners peeled away from the floors in resident rooms and bathrooms in rooms 203, 217, 303 and 316. Interview on 02/23/22 at 09:25 AM with the Director of Maintenance confirmed the issues identified during the environmental tour of the facility. Interview on 02/23/22 at 01:32 PM with Director of Maintenance confirmed that there were no work orders present for any of the environmental concerns identified on the 2nd and 3rd floors of the facility.

Based on observations, interviews and record review, it was determined the facility failed to prevent one (Resident 31) of four sampled residents from suffering a fall that resulted in a [MEDICAL CONDITION] which required stitches. Four sampled residents were investigated for falls. Findings are: Resident 31 had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) assessment, dated 06/18/20, documented the resident was severely impaired in cognition, required extensive assistance for activities of daily living, and had sustained no falls since the last assessment. The resident's care plan documented the resident was at risk for falls. Interventions included: use a lift for transfers, keep bed in low position with a fall mat beside the bed, keep personal items within reach, place a body pillow beside the resident while in bed, and assist with locomotion while resident was in wheelchair. The care plan also documented the resident had a fall on 10/29/20 during a transfer and fell /rolled out of bed on 04/18/19. No injuries were incurred with the two falls. A facility incident report, dated 07/29/20, documented the nurse was called to the shower room at 10:00 AM. The nurse observed the resident on the floor, on the resident's left side; the resident was bleeding from a laceration on the forehead that measured 3.5 cm (centimeters) x 1 cm x 0.5 cm. The note documented pressure had been applied to the laceration to stop the bleeding and a dressing was applied. Range of motion and neurological checks were initiated. All were within normal limits. The resident was returned to (gender) room via wheelchair and placed in bed. The physician was notified, and a new order was issued to transfer the resident to a local emergency room for evaluation and sutures. The resident's family was also notified. The note also documented transportation arrived at 11:30 AM and the resident left the facility at 11:45 AM. A Neurological Assessment Flow Sheet, dated 07/29/20 at 10:00 AM, documented neurological checks had been initiated and the results were within normal limits. A hospital emergency room record, history and physical (H&P), dated 07/29/20, documented the resident had fallen from a wheelchair in the shower room at the nursing home. The H&P documented the resident was unable to recall the episode and the laceration to the forehead would require sutures. The report documented the resident had not suffered any additional injuries. A facility, Personal Education form, dated 07/29/20 at 5:00 PM, documented the bath aide, Certified Nurse Aide (CNA)-G, had provided a statement via telephone. The form also documented CNA-G was aware of the procedures and steps involved in providing a tub bath to a resident; however, CNA-G had just forgotten to strap the resident into the tub chair. The report also documented the CNA had been re-educated and reported to (gender) agency. On 08/03/20 at 10:28 AM, the resident was observed to have forehead sutures from a laceration. An unsuccessful attempt was made to interview the resident about the injury. Resident 31 was unable to respond appropriately. On 08/05/20 at 2:39 PM, Registered Nurse (RN)-A was asked to describe the resident's fall on 07/29/20. RN-A stated the resident had fallen out of a bath chair in the bathtub. The bath aide, CNA-G, was with the resident in the bathroom providing the resident with a bath. The nurse was called to the bathroom and upon arrival, the resident was on the floor bleeding from a laceration on the forehead. RN-A had done a full assessment, put pressure on the laceration and applied a dressing. Neurological checks were initiated, the resident was returned to the room, and the physician was notified. Arrangements were made to transfer the resident to a local emergency room . The resident's family had been notified and was going to meet the resident at the hospital. On 08/05/20 at 5:30 PM, an attempt was made to contact CNA-G. The CNA did not answer the phone. A voicemail was left, but the CNA did not return the call. On 08/06/20 at 8:30 AM, the Director of Nurses (DON) and Administrator were interviewed. They stated an investigation of the fall had been initiated. They stated CNA-G had failed to secure the resident's seat belt on the tub chair during provision of a bath, and the resident had fallen forward, striking (gender) head on the bath house floor. They stated the CNA was the only one bathing the resident; two CNAs had transferred the resident to the tub. They had counseled, in-serviced the CNA, and reported the incident to the agency. They added they were in-servicing all the staff on bath safety.

Licensure Reference Number: 175 NAC 12-006.09D7 Based on observation, record review and interviews the facility failed to ensure residents were supervised to prevent the potential for harm related to elopement for 1 of 3 residents (Resident 2) reviewed. The facility census was 90. Findings are: Review of Resident 2's face sheet revealed Resident was admitted on [DATE] with the following Diagnosis: -Dementia with behavior disturbance -Cerebral Infarction -Memory Deficit Review of Resident 2's interdisciplinary (ID) notes dated 2/3/2020 revealed on the date of admission Resident 2 did attempt several times to get on the elevator, stated wanting to go home and refused supper meal stating would eat when home. Wander-guard (device used to alert staff if resident attempts to leave the facility) was placed at that time. Review of ID notes dated 2/18/2020 revealed Resident 2 wandering into other resident rooms, verbally and physically aggressive with staff and attempted to open stairwell doors. Review of ID notes dated 2/20/2020 Resident 2 was threatening to hit staff and having delusions (false thinking). Review of the facility investigation dated 3/2/20 revealed Resident 2 exited the facility when some visitors left. The Wander-guard system did lock the door as designed to do however Staff-A unlocked the door for the visitors and Resident 2 left at that time. Staff-A did not realize Resident 2 had left. Nursing staff were not aware Resident 2 was gone until receiving a call from a private citizen that recognized Resident 2 stating Resident 2 was at a local grocery store. Observation on 3/2/2020 of the outside of the building revealed resident had to cross a four lane heavily traveled street that runs in front of the facility and several residential streets to arrive at the grocery store. Interview on 3/2/2020 at 4:30 PM with the Assistant Director of Nursing revealed the camera shows Resident 2 exiting the facility at 3:45 PM. The facility received a call from a private citizen around 4:45 PM that Resident 2 was at the local grocery store and staff attempted to locate Resident 2 immediately. At 5:00 PM the police were notified due to the staff being unable to locate Resident 2. Review of Resident 2's ID note dated 3/2/2020 revealed Resident 2 was located at 7:30 by Resident 2's family member at a friend's house sitting on the porch waiting for the friend to arrive home. Review of a search on the website MapQuest.com of Resident 2's friend's address revealed Resident 2 was 5.7 miles from the facility when located. Review of Progress notes dated 3/2/2020 revealed Resident 2 stated Resident 2 hitched a ride. Observation on 3/5/2020 at 4:00 PM revealed heavy traffic on the 4 lane street in front of the facility. Review of Resident 2's care plan dated 2/4/2020 revealed Resident 2 had the following issues making Resident 2 at risk for injury while outside of the facility: -Impaired physical mobility related to a history of fracturing both knees, one leg shorter than the other with a built up shoe -Wandering at times into other rooms -Potential for falls related to new environment, use of cane, lift shoe -Increased bleeding related to Anticoagulant (blood thinner) use -Dizziness, fatigue, increased risk for falls related to antihypertensive (high blood pressure) medications Review of Resident 2's progress note dated 3/2/2020 revealed the administrator explained to Resident 2 that the facility staff were worried and it was the facility responsibility to keep Resident 2 safe. Interview on 3/2/2020 2:05 PM with the Administrator revealed resident had not attempted to elope and was not an exit seeker. Resident was placed on a wander-guard due to cognitive function. During the facility investigation the facility found that Resident had a history of elopement and exit seeking that the facility was not aware of on admission. As outlined by the administrator of the facility on 3/2/2020 at 5:30 PM the facility initiated the following plan to address the immediacy of the situation. The facility will re-educate all staff on the Wander-guard system, place Wander-guard checks on the treatment sheets, terminate Staff A, refer Resident 2 for alternate placement, and ask specific questions regarding risk for elopement during admission screening. With the above interventions initiated the immediacy was removed.

Licensure Reference Number 175 NAC 12-006.09D3 (5) Based on record review and interview, the facility failed to provide bowel elimination management for 3 Residents (Residents 1, 2, 3) of 3 residents reviewed. The facility census was 80. Findings are: [NAME] Review of Resident 1's ID (Interdisciplinary) notes dated 7/9/2019 revealed Resident 1 was transferred to the hospital for a fall resulting in a [MEDICAL CONDITION] and Resident 1 returned to the facility on [DATE]. Review of Resident 1's Discharge paperwork from the hospital revealed Resident 1's last Bowel Movement (BM) in the hospital was on 7/11/2019. Review of Resident 1's ID notes revealed Resident 1 was less mobile than before the fracture and was not eating or drinking fluids well. Review of Resident 1's Medication Adminstration Record (MAR) for (MONTH) 2019 revealed Resident 1 was taking narcotic pain medication. Review of Resident 1's ID notes dated 7/14/2019 revealed Resident 1 was on the bedpan twice during the shift with no results. Review of Resident 1's MAR indicated [REDACTED]. This was Resident 1's third day without a bowel movement. Facility guidelines instructs an assessment of the abdomen by a nurse and a laxative given. Review of Resident 1's bowel tracking log revealed Resident 1 did not have a bowel movement until 7/17/2019 and was not provided a laxative or an abdominal assessment per the facility guidelines. This resulted in Resident 1 having no bowel movement for 6 days. Review of Resident 1's ID notes dated 7/18/2019 revealed Resident 1 complained of increased groin pain despite a medium amount of bowel movement passed. No abdominal assessment documented at this time. Review of Resident 1's ID notes dated 7/19/2019 at 8:40 PM revealed Resident 1 experienced pain in the abdomen and groin area. The nurse assessed Resident 1's abdomen as soft and tender, Bowel sounds were hypoactive (slow). Resident 1 appeared uncomfortable and showing facial grimace. Review of ID notes dated 7/19/2019 revealed Resident 1 was transferred to the hospital and diagnosed with [REDACTED]. Review of the facility Guideline titled Bowel Program dated revised 8/19 revealed the following: - A report is to be pulled at the beginning of each shift and any resident with no BM in 3 days will be considered for a laxative. -The nurse will complete an assessment to include bowel sounds, abdominal distention, and tenderness. -The Medication aide will then be directed to provide resident with bowel care ordered starting with a laxative then suppository and then enema if no results from previous interventions. If no orders for bowel care a call to the physician will be made. Review of Resident 1's MAR indicated [REDACTED]. [MEDICATION NAME] suppository (bowel stimulant) 1 daily as needed for constipation. Both ordered on [DATE] on admission to the facility. No documentation bowel care was provided in July. Review of ID notes dated 7/19/2019 for Resident 1 revealed Resident 1 returned from the hospital after removal of a fecal impaction on 7/19/2019 and was given Milk of magnesia (laxative) on 7/20/2019 with no bowel movement and no abdominal assessment completed. No further intervention was completed until Resident 1 was again given Milk of Magnesia on 7/24/2019 with Medium results. Review of the Bowel tracking log revealed Resident 1 had a medium sized BM on 7/24/2019. Resulting in Resident 1 not having a BM for 4 days after being hospitalized for [REDACTED]. Interview on 8/12/2019 at 3:10 PM with the Unit Manager revealed Resident 1 was not provided with care for bowel elimination according to the facility guidelines after returning from the hospital from a fall with a fracture and using narcotic pain medications that cause constipation and did not follow up with the bowel guidelines after Resident 1 returned from the hospital after a fecal impaction diagnosis. B. Review of Resident 2's Medication Administration Record [REDACTED]. Review of Resident 2's (MONTH) 2019 Bowel tracking revealed Resident 2 had no bowel movement (BM) or Intervention to promote a bowel movement during the following times: (MONTH) 1 -July 6 (5 days) July 19 -July 27 (8 days) July 27 -August 3 (7 days) August 3-August 8 (5 days) Review of Resident 2's care plan revealed the following interventions: - Document Bowel and Bladder habits - Assist to toilet - Anticholesterol (lower cholesterol) medication side effects constipation. Review of Resident 2's (MONTH) 2019 MAR indicated [REDACTED]. Medication was not provided in (MONTH) or (MONTH) 2019 to promote regular bowel movements. The consistency of bowel movements were documented as Hard Interview on 8/12/2019 at 3:15 PM with the Unit Manager revealed Resident 2 was not provided with bowel interventions when bowel movements were over 3 days apart as designated in the facility guidelines for bowel care and no assessments were completed by the nursing staff. Resident 2 should not be having hard stools and should be assessed for use of a stool softener. C. Review of Resident 3's [DIAGNOSES REDACTED]. Review of Resident 3's MAR indicated [REDACTED]. Review of the bowel tracking for Resident 3 revealed Resident 3 went over 3 days without a bowel movement and without assessment or intervention on the following dates: July 18-July 25 (7 days) July 26-July 30 (4 days) Review of Resident 3's MAR for (MONTH) 2019 revealed an order for [REDACTED]. Polyethelene [MEDICATION NAME] 17 gm daily prn (as needed) for constipation. ordered on [DATE] not given in (MONTH) 2019. Review of Resident 3's MAR indicated [REDACTED]. Interview on 8/12/2019 at 11:56 AM with Unit manager revealed all bowel movements should be charted in the Point of Care Documentation. Interview 8/12/2019 at 3:18 PM with the Unit Manager revealed since Resident 3 had a [MEDICAL CONDITION] Resident 3 should have had more regular bowel movements and should not show several days in between and the nurse needs to follow up with nursing assistance immediately and complete an assessment and intervention.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility staff failed to implement assessed interventions and re-evaluate interventions to prevent falls for 1 resident (Resident 7). The facility staff identified a census of 106. Findings are: Record review of Resident 7's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9-23-2013 revealed the facility staff assessed the following about the resident: -Resident 7 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -No behaviors were identified on the MDS. Record review of Resident 7's Comprehensive Care Plan (CCP) updated on 7-08-2013 revealed Resident 7 was at risk for falls related to left side weakness. The goal was Resident 7 would not have fall related injuries. Interventions listed included completing a fall risk assessment and to remind Resident 7 to lock wheelchair brakes and to ring for assistance. A hand written entry dated 7-11-13 revealed Resident 7 was to have a chair alarm. Further review of Resident 7's CCP revealed the sit/stand alarm had a start date of 4-17-13. Resident 7's CCP did not identify any refusal of cares or the use of personal alarms. Record review of a Care Plan Checklist (CPC) dated 7-10-2013 revealed Resident 7's fall risk score was 23. According to information on a Fall Risk Assessment sheet, a score of 15 or above indicated the resident was at risk for falling and to implement a fall risk care plan. Resident 7's CPC section titled Fall Prevention in Place, revealed the yes or no area was not completed. Record review of a CPC dated 10-02-2013 revealed Resident 7 scored a 22 for fall risk. The area titled Fall Prevention in Place was checked "no". Record review of a Fall Risk assessment dated [DATE] revealed Resident 7 scored a 22. Based on the information on the Fall Risk Assessment sheet, Resident 7 remained at risk for falls. Record review of an Fall Incident Report dated 10-24-2013 revealed Resident 7 had a fall from the wheelchair. The information under the section titled Fall Interventions already in place, identified the call light was in place. The area for staff to document what was done immediately to prevent re-occurrence was left blank. The area to identify recommendations to prevent future falls contained documentation that "res. (resident) refused fall alarm". No recommendations for additional interventions to prevent falls was identified on the Fall Report. Record review of a Radiology Report sheet dated 10-26-2013 revealed the results of the x-ray conclusion identified Resident 7 had a "acute left hip fracture". Record review of a facility report dated 10-29-2013 revealed Resident 7 had been sent to the hospital and returned to the facility on [DATE] after having surgery for [REDACTED]. Record review of Resident 7's CCP revealed the interventions to prevent falls continued to identify the sit/stand alarm on the wheelchair was to be used. Observation on 12-09-2013 at 12:34 PM revealed Resident 7 was seated in a wheelchair in (gender) room and did not have a sit/stand alarm or any other type of alarm. Observation on 12-10-2013 at 9:32 AM revealed Resident 7 was seated in a wheelchair in Resident 7's room. No alarms were were being used for Resident 7. An interview on 12-10-2013 at 9:38 AM was conducted with Licensed Practical Nurse (LPN) A. During the interview, visualization of Resident 7 seated in the wheelchair was completed with LPN A. Review of Resident 7's CCP was completed with LPN A. LPN A confirmed that Resident 7 was to use a sit/stand alarm when in the wheelchair. LPN A confirmed the alarm was not being used for Resident 7. Record review of the facility Guidelines for Fall prevention and intervention revealed the following information: -Procedure: -#4. Upon using the Fall Risk assessment tool, residents found to have a score of 15 or above will be considered "High Risk". Those residents with "High Risk" score and a history of a fall in the past 3 months will have additional measures implemented to reduce risk for falls and falls related injuries.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a, 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to follow up on nutritional recommendations to promote wound healing, failed to evaluate causal factors for the development of pressure ulcers and implement interventions to prevent development of pressure ulcers for 3 (Resident 9, 5, and 7) of 19 sampled and 11 non-sampled residents. The facility staff identified a census of 95. Findings are: A. Record review of a Profile Face Sheet dated 2/02/2011 revealed Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 9's Minimum Data Set ( A federally mandated comprehensive assessment tool used for care planning) dated 1/25/2011 revealed the facility staff assessed the following about the resident: -Resident 9 had short and long term memory ability. -Required extensive assistance with bed mobility, transfers, dressing, toileting use and personal hygiene. -Had lower extremity impairment to one side. -had a stage 1(defined area of persistent redness that is non-blanchable...). -Resident 9 was at risk for the development of a pressure ulcer. -Resident 9 was not assessed as having a pressure ulcer on any heels. Record review of a Braden Risk Assessment Scale ( tool used for predicting pressure ulcer risk) sheet dated 1/18/2011 revealed Resident 9 was assessed as having a score of 18. According to the information on the Braden Scale, a score of 16 or less places residents at risk for the development of pressure ulcers. Record review of Resident 9's Comprehensive Care Plan (CCP) dated 2/02/2011 revealed Resident 9 was at risk for skin breakdown. The goal for Resident 9 was to "...Have no skin breakdown..." Record review of Resident 9's Interdisciplinary Notes (IPN) dated 2/04/2011 revealed Resident 9 was assessed as having a stage 2 ( partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater) to the sacrum. According to the IPN note, Caloseptine was applied and the physician notified. Record review of a Fax sheet sent to the residents' physician on 2/04/2011 had informed the physician of the open area. The Resident physician ordered the Caloseptine be applied twice a day and as needed and also to have a nutrition consult. Record review of Residents 9's Nutrition Services Progress Note dated 2/06/2011 revealed the Registered Dietician (RD) O had made recommendations for 206 cookie and 2 cal supplement 60 ml (milliliters), 2 times a day. According to RD O's documentation, the supplement at this time would meet the resident needs. The RD identified that on 2/04/2011 Resident 9 had skin breakdown and made an additional recommendation of starting on a multivitamin every day to address the"... wound healing". Observation on 2/15/2011 at 8:17 AM was conducted of the pressure ulcer during the provision of personal cares. Observation revealed Resident 9 had an open area to the sacrum (coccyx area). The size of the pressure ulcer measured approximately 1 cm (centimeter) by 1 cm. No drainage was noted at this time. The wound bed had the appearance of being red and dry. The surrounding tissue around the wound was slightly redden. Barrier cream was applied. Inspection of Resident 9's heels was conducted with the assistance of Nursing Assistant (NA) O. NA O lifted Resident 9's left heel revealing an open, draining wound to the heel area. NA O stated that (gender) was "not aware of the open area". NA O obtained Licensed Practical Nurse (LPN) Q. LPN Q observed the area to Resident 9's left heel. When asked if this was a new area "LPN Q stated "yes". LPN Q stated the heel ulcer was a " stage 2, caused from pressure". An interview with RD O was conducted on 2/15/2011 at 8:40 AM. During the interview RD O confirmed the recommendation had not been followed through with the resident physician. When asked what the expectation was for follow through, RD O stated "not more than 48 hours". B. Record review of a Profile Face Sheet dated 11/24/2010 revealed Resident 5 was admitted to the facility on [DATE] with the diagnose that included Alzheimer's. Record review of Resident 5's MDS dated [DATE] revealed the facility staff assessed the following about the resident; -Resident 5 had short and long term memory problems. -Required total assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. -Incontinence of bowel and bladder. -Resident 5 was assessed to be at risk for the development of pressure ulcers. -No pressure ulcers were identified at the time of the MDS assessment. Record review of Resident 5's CCP dated 6/04/2010 revealed Resident 5 was at risk for skin breakdown. The goal for Resident 5 was to have " no redness, irritation or skin breakdown". A hand written entry dated 2/01/2011, on Resident 5's CCP revealed the resident had developed a stage 2 pressure area to the coccyx. Observation on 2/14/2011 at 1:12 PM during personal cares revealed Resident 5 had an area of approximately 0.5 cm round pressure area to coccyx. The wound was slightly open, no drainage was noted and the surrounding skin was pink. Inspection of Resident 5's heels was conducted with the assistance of NA H. Observation of the left outer aspect of Resident 5's heel revealed a fluid filled blistered type of area of approximately 0.3 cm. The surrounding skin was red and non-blanchable. An interview with LPN S was conducted on 2/15/2011 at 1:30 PM. During the interview, LPN S stated "no"when asked if casual factors had been evaluated for Resident 5. When asked if ongoing monitoring to the ulcer on the coccyx, LPN S stated "not able to find any". An inspection of the left heel was conducted on 2/14/2011 at 3:00 PM with LPN B. LPN B confirmed Resident 5 had skin breakdown to the left heel. When asked what stage, LPN B stated "stage 2" and when asked if the area was caused from pressure LPN B stated "yes". C. Record review of a information sheet dated 12/15/2010 revealed Resident 7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 7's Minimum Data Set ( A federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 12/14/2010 revealed the facility staff assessed the following about the resident: -Resident 7 had short and long term memory problems. -Required total assistance with toileting. -Required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. -Incontinent of bowel and bladder. -Resident 7 was assessed to be at risk of development of pressure areas and did not have any pressure areas at the time of the completion of the MDS. -Additional [DIAGNOSES REDACTED]. Record review of Resident 7's CCP dated 6/26/2010 revealed Resident 7 was at risk for skin breakdown. Approaches used to prevent skin breakdown included placing a Roho (type of pressure reliving cushion) in the wheelchair and when Resident 7 transfers into a recliner, moving the roho into the recliner. Observations on 2/10/2011 at 2:35 PM, 2/14/2011 at 8:02 AM, 2/15/2011 at 8:55 Am revealed Resident 7 was seated in the recliner with out any pressure reliving cushion, such as the Roho. On 2/15/2011 at 8:55 AM, LPN B was asked to determine if the Roho cushion was under Resident 7 seated in the recliner. LPN B stated "no". Record review of the facility Guideline For The Prevention And treatment of [REDACTED]. -treatment of [REDACTED]. -F, Re-evaluate interventions per risk factors identified. -G, Updated the care plan with skin concerns and interventions as appropriate.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review and interviews; the facility staff failed to provide supervision in the 2nd floor dining room when a hot steam table was present to prevent potential scald. The facility staff identified 7 residents (Residents 42, 43, 44, 45, 46, 47, and 48) who had cognitive deficits and self mobile with wandering behaviors on the 2nd floor and failed to implement an identified intervention to prevent potential food burns for 1 resident (Resident 7) of 7 sampled and 7 non-sampled residents. The facility staff identified a census of 98. Findings are: A. Observation on 6/01/2011 at 9:50 AM revealed the 2nd floor dining room (south solarium) door was open. Inside the dining room was a steam table with 4 compartments, plugged into the wall. No staff or residents were in the room. An interview with Licensed Practical Nurse (LPN) A was conducted on 6/01/2011 at 9:55 AM. During the interview, LPN A was shown the open dining room door. When asked if the door should be locked, LPN A stated "yes". Further inspection of the steam table revealed the knobs were in the off position. The surface was touched revealing the 2 compartment lid to be hot to the touch. LPN A was asked to have the Dietary Service Manager (DSM) come to the 2nd floor dining room. LPN A stated "I'll close this door for safety while I go to the kitchen". On 6/01/2011 at 10:00 AM DSM B entered the 2nd floor dining room. DSM B was requested to obtain the temperature of the liquid inside the steam table. DSM B, using a facility thermometer, obtained the temperature of the liquid in the 2 compartment of the steam table. The liquid temperature was 141 degrees Fahrenheit. DSM B obtained the liquid in the 3rd compartment, which was a temperature of 141 degrees. The 4th compartment liquid was a temperature of 138 degrees. When asked what would happen if a resident spilt the hot liquid on them, DSM B stated "they would get pretty badly burnt". On 6/01/2011 at 11:20 AM, LPN C provided a list of 7 residents on the 2nd floor who were identified as having cognitive deficits with wandering behaviors and who were self mobile. Record review of an information sheet from Antiscald.com revealed that with a exposure to a temperature of 140 degrees Fahrenheit, it would take 3 seconds for a 2nd degree burn and 5 seconds for a 3rd degree burn. B. Resident 7 was admitted to the facility on [DATE] according to the Face Sheet. Resident 7's readmission orders [REDACTED]. A review of Resident 7's MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 5/24/11 revealed supervision assist of one for eating was needed. Incident Report for Resident 7 dated 5/4/11stated the following: "Staff reported to nurse that Res. (Resident) was given (Resident 7's) dinner and told to wait d/t (due to ) it being hot. Res. then attempted to eat (Resident 7's) mashed potatoes and dropped them on (Resident 7's) chest area. Res. does c/o (complaint of) pain & area slightly reddened." The Incident Report listed the following recommended interventions for Resident 7: "Res has clothing protectors available. Ensure that they are on. . ." Observations of the lunch meal between 12:24-12:44 PM on 5/31/11 revealed Resident 7's plate was placed on the table in front of Resident 7. After Resident 7 placed fingers in food and stated "ow", the plate was moved out of Resident 7's reach. Resident 7 was observed to be fed entire meal by staff members. Resident 7 did not have a clothing protector on. Observations of the breakfast meal between 8:55 AM - 9:09 AM on 6/1/11 revealed Resident 7's meal was placed out of Resident 7's reach. Resident 7 was fed entire meal by Nurse Aide D. Resident 7 was not wearing a clothing protector. In an interview at 9:09 AM on 6/1/11 after Resident 7 had eaten approximately 75% of meal, Nurse Aide D reported a clothing protector was not placed on Resident 7 as Nurse Aide D was feeding Resident 7. After interview with Nurse Aide D, another staff member placed a clothing protector on Resident 7. In an interview on 6/1/11 at 11:19 AM, the Director of Nursing confirmed staff members were expected place a clothing protector on Resident 7 at meals.

LICENSURE REFERENCE NUMBER 12-006.09D7 Based on observation, record review and interview; the facility staff failed to utilize the assessed assistive device for transfer for Resident 11 which resulted in a staff assisted fall with fracture and failed to transfer Resident 7 in a safe manner to prevent injury. The sample size was 19 plus 11 non-sampled residents. The facility census was 95. Findings are: A. Observations of Resident 11 on 2/14/11 at 7:05 AM and at 10:25 AM during staff assisted transfers revealed that Resident 11 utilized a Hoyer (a type of full body lift also known as the EZ lift) lift with 2 staff assist for transfers. A picture of an EZ lift was present on Resident 11's nightstand. Record review of Resident 11's Admission Face Sheet dated 1/21/11 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review of Resident 11's Minimum Data Set ( A federally mandated comprehensive assessment tool used for care planning) dated 11/18/2010 revealed that Resident 11 exhibited no short or long term memory problems, no cognitive difficulties, no mood indicators, verbal behavioral symptoms 1 to 3 days per week and daily behavioral symptoms that included verbal or vocal symptoms or disruptive sounds. The MDS for 11/18/2010 revealed that Resident 11 required extensive assistance from staff for transfers. Record reviewed of Resident 11's Comprehensive Care Plan dated 12/8/2011 revealed that Resident 11 was to be transferred using a Hoyer and two staff assist. Record review of Resident 11's Physical Therapy Progress report dated 7/1/10 revealed that Physical Therapy had assessed Resident 11's transfer technique and determined that the safest transfer for Resident 11 was the use of the Hoyer lift with 2 staff assist. This was determined due to the fact that Resident 11 stood and assisted with the EZ stand (a type of lift in which the resident must stand and bear weight to move) inconsistently. Interview per telephone on 2/17/11 at 11:30 AM with the facility Physical Therapy Assistant (PTA)confirmed that Resident 11 was assessed in July of 2010 to need a Hoyer (EZ lift) lift for transfers as Resident 11 was not able to use the EZ stand consistently or safely. The PTA confirmed that the Hoyer EZ lift remained the safest method of transfer for Resident 11. Record review of a facility investigation report for an accident that involved Resident 11 dated 1/31/11 revealed that Resident 11 had experienced a staff assisted lowering to the floor from a EZ stand on 1/31/11. Review of the facility investigation dated 1/31/11 revealed that staff had transferred Resident 11 using an EZ stand instead of the EZ lift to transfer Resident 11 on 1/31/11. The report revealed that Resident 11 had become agitated, let loose of the lift and had raised (gender) arms. Resident 11 was then lowered to the floor by staff. Resident 11 held the left upper arm and complained of pain. Bruising was observed and Resident 11 had decreased range of motion to the left arm. The Dr. was notified and an X-ray was done on the left arm. Record review of a Radiology Report dated January 31, 2011 revealed that Resident 11 had symptoms that included pain from trauma and confirmed a [DIAGNOSES REDACTED]. The facility investigation revealed that each resident had a picture of they equipment they used for transfers and that Resident 11 had a picture of an EZ lift present on Resident 11's nightstand at the time of the investigation. The investigation revealed that both of the staff involved in the transfer were aware to look at the night stand for the picture of the appropriate transfer method. Record review of Resident 11's Physician order [REDACTED]. Interview on 2/14/11 at 9:38 AM with the Director of Nursing (DON) confirmed that staff had not used the correct lift to transfer Resident 11 on 1/31/11. This had resulted in a staff assisted fall with a fracture of Resident 11's left arm. The DON stated that the facility nurse aide involved in the transfer had been trained to use the incorrect lift for Resident 11 by a nurse aide trainer and the other aide involved was a pool aide that had not been oriented to the facility prior to working that shift. The DON confirmed that the accident and subsequent fracture had occurred as a result of staff not using the correctly assessed lift for Resident 11. B. Record review of a information sheet dated 12/15/2010 revealed Resident 7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 7's MDS dated and signed as completed on 12/14/2010 revealed the facility staff assessed the following about the resident: -Resident 7 had short and long term memory problems. -Required total assistance with toileting. -Required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. -Incontinent of bowel and bladder. -Resident 7 was assessed to be at risk of development of pressure areas and did not have any pressure areas at the time of the completion of the MDS. -Additional [DIAGNOSES REDACTED]. Observation on 2/14/2011 between 8:22 AM and 8:40 AM revealed NA G and NA H prepared to transfer Resident 7 from the recliner into a wheelchair. NA G and NA H obtained a mechanical lift ( a sit to stand type) for the transfer. The transfer sling was placed around Resident 7 waist and connected to the lift. The waist of the sling was fastened loosely. NA H and NA G started to lift the Resident. Certified Medication Assistant (CMA) I entered Resident 7's room to assist. NA G and NAH started to lift the resident with the mechanical device. Observation at this time revealed as the NA's lifted Resident 7, Resident 7 did not bare weight and was hanging from the mechanical .The sling slid under Resident 7 underarm area. CMA I instructed NA G and NA H to set Resident 7 back into the recliner. CMA I assisted in repositioning, cuing Resident 7 to stand and assisted Resident 7 into the wheelchair with NA G and NA H. CMA I stated '' That was a terrible transfer". On 2/16/2010 at 7:10 AM was conducted with LPN B. During the interview, the above incident was describe for LPN B. When asked if that would have been a safe transfer for Resident 7, LPN B stated "no".

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 Based on observation, record review and staff interviews; the facility failed to prevent and manage pain for 1 (Resident 11) resident of 14 sampled residents. The facility census at the time of survey was 95. Findings are: Record review of Resident 11's Profile Face Sheet, dated 1-21-11, revealed that Resident 11 was admitted to the facility on [DATE] with diagnoses, including but not limited to: cerebral artery occlusion, Diabetes Mellitus Type II, [MEDICAL CONDITIONS], Essential Hypertension, [MEDICAL CONDITION], and Dysphagia. Resident 11 suffered a stroke and was originally admitted to the facility on [DATE], fell from a transfer lift on 1-31-11 at the facility and suffered a left humerus fracture, (surgery 2-9-11), then scheduled for further surgical repair on 2-23-11, and returning to facility on 3-3-11. Resident 11 currently wore a sling on the left arm at all times except for bathing and was not to apply any weight or have any weight applied to the left arm. Review of Resident 11's MDS (Minimum Data Set, a federally mandated comprehensive assessment used for care planning) dated 2-9-11 revealed that Resident was scored for the following: ? Cognitive score 6/15; ? Mood score 2/27; ? Ability to transfer 4 - 3, total dependence with 2+ person physical assistance; ? Ambulation - 8, activity did not occur; ? Activities of Daily Living (Dressing & Personal Hygiene) - 3-2, extensive assistance with 1 person physical assist; ? Range of Motion - Upper extremity = 1 (impairment on 1 side); and Lower extremity = 0 (no impairment). Resident 11 was ordered [MEDICATION NAME]/APAP 7.5/500 [MEDICATION NAME] PO (orally) 15ml (milliliter) Give Scheduled and 10ml PO QID (4 times daily) + 10ml PO q (every)4 hrs (hours) prn (as needed) pain, on 2-12-11. Observation of wound care for Resident 11's left lateral lower leg took place on 4-26-11 at 9:00 AM and was performed by LPN (Licensed Practical Nurse) E. Resident 11 cried out several times during the treatment. However, when the wound cleansing was done and the wound patted dry. Resident 11 cried out with an "ow" -like sound. The crying stopped when this task was stopped. Observation of Resident 11 transfer from bed to chair on 4-26-11 at 9:25 AM revealed that Resident 11 cried out multiple times during the sling placement under the resident and during the actual transfer and positioning to the wheelchair. NA (Nurse Aide) F asked Resident 11, "Are you in pain?" Resident 11 gave no answer. NA F then asked Resident 11, "Are you scared or in pain?" Resident 11 gave no answer. Observation of Occupational Therapy (OT) visit on 4-26-11 at 10:05 AM revealed that, when OT G began active range of motion (AROM) with Resident 11, Resident 11 loudly cried out for an extended period. When OT G asked Resident 11 if "that hurts?," Resident 11 clearly stated "Yes." Review of Geriatrics Progress Note, dated 3-31-11, stated "Has severe [MEDICAL CONDITION] + (plus) is unable to communicate pain/needs," and "Continues to cry frequently." The note continued "Gender has okay pain control with good mood + no crying @ (at) times but increased with cares." Review of Resident 11's Orthopedic doctor Office Visit note, dated 4-12-11, revealed "Cries out at times no matter where (gender) is touched." Review of Resident 11's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During the month of April, 2011, Resident 11 took the medication as ordered except for 4 instances on 4-8-11 at noon, 4-14-11 at noon and 2000 and 4-16-11 at 2000. Review of Resident 11's PRN MAR for April, 2011 revealed that the [MEDICATION NAME]-APAP 7.5-500 elix ([MEDICATION NAME]) was administered only on the following dates: 4-13-11 at 2330, 4-14-11 (no time documented) and 4-20-11 (twice, 0100 and 2nd time undocumented). Review of facility Pain Evaluation for Process 175 NAC 12-006.09D, dated 3-24-11, for Resident 11 revealed that "Resident's Goal in Relation to pain" was to sleep comfortably and comfort with movement. Interview with LPN E on 4-26-11 at 9:00 AM reviewed pain medication administration and if Resident 11 was administered pain medication prior to wound treatment and/or transfers. LPN E stated that "Resident 11 did not regularly receive pain medication prior to either wound care or transfers." Interview with MA (Medication Aide) H on 4-26-11 at 12:00 PM revealed that no PRN pain medication had been administered to Resident 11 by MA H. When asked in any staff had approached (gender) about Resident 11 being in pain prior to Resident 11 being transferred from bed to wheelchair, MA H stated that NA F had come to talk with MA H about pain meds, and that NA F was told that Resident 11 gets pain meds routinely. Interview with the DON (Director of Nursing) on 4-26-11 at 12:45 PM reviewed the effectiveness of pain medications after 4 or more hours. The DON agreed that pain medications should have been, and continue to be given to Resident 11 for comfort with movement.

LICENSURE REFERENCE NUMBER 12-006.09D Based on observation, record review and interview; the facility staff failed to re-evaluate and implement interventions to prevent and manage pain (Residents 11 and 7) and failed to monitor the condition of a [MEDICAL TREATMENT] fistula site (access site for [MEDICAL TREATMENT]) and resident condition post [MEDICAL TREATMENT] treatment for [REDACTED]. The facility census was 95. Findings are: Pain: A. Record review of Resident 11's Admission Face Sheet dated 1/21/11 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Record review of Resident 11's Minimum Data Set (MDS)(A federally mandated comprehensive assessment tool used for care planning) dated 11/18/2010 revealed that Resident 11 exhibited no short or long term memory problems, no cognitive difficulties, no mood indicators, verbal behavioral symptoms 1 to 3 days per week and daily behavioral symptoms that included verbal or vocal symptoms or disruptive sounds. The MDS for 11/18/2010 revealed that Resident 11 required extensive assistance from staff for transfers, dressing, toilet use and personal hygiene. The MDS dated [DATE] revealed that the Resident pain assessment interview revealed that Resident 11 reported rare pain, that pain had no effect on day to day functioning and that the resident had not been on any scheduled or as needed (PRN) pain medications. Record review of Resident 11's Pain Evaluation and Management Plan dated 1/21/11 revealed that Resident 11 exhibited discomfort in the neck due to immobility. A summary of the pain evaluation revealed no pain and the plan to reassess quarterly or with a significant change in condition/pain Record review of Resident 11's Physician order [REDACTED]. The Physician orders [REDACTED]. Record review of a Radiology report dated January 31, 2011 revealed that Resident 11 had symptoms that included pain from trauma and confirmed a [DIAGNOSES REDACTED]. Record review of Resident 11's Comprehensive Care Plan (CCP) dated 12/08/10 revealed that the CCP did not contain any specific information, measurable goals or interventions to address pain control related to a new fracture for Resident 11. Interview on 2/14/11 at 10:13 AM with the Director of Nursing (DON) revealed that Resident 11 had not had a new pain assessment completed since the fracture of Resident 11's arm. The DON confirmed that the last pain assessment had been completed on 1/21/11 and the fracture had occurred on 1/31/11. The DON stated that Resident 11's pain should have been reassessed as Resident 11 had a change in condition/pain with a new fracture. Interview on 2/14/11 at 5:00 PM with LPN B (Licensed Practical Nurse) confirmed that the facility staff had not completed a new pain assessment for Resident 11 after the [MEDICAL CONDITION] arm had occurred. Record review of Resident 11's Medication Administration Record (MAR) dated for the month of February 2011 revealed that Resident 11 received [MEDICATION NAME] (a narcotic used for pain control) every day at 8 AM, 12 PM, 4 PM and 8 PM. Record review of Resident 11's as needed (PRN) medication sheets revealed that Resident 11 received [MEDICATION NAME] as needed for pain in addition to the regularly scheduled dose. Record review of the back of the February 2011 PRN MAR revealed that Resident 11 had received additional doses of [MEDICATION NAME] on February 1st, February 2nd and February 3rd for complaints of pain to the left arm.. Review of the front side of the PRN MAR revealed that Resident 11 had last received a PRN [MEDICATION NAME] for pain control on 2/8/11. Observations of Resident 11 on 2/14/11 between 7:05 AM and 7:40 AM, with the Assistant Director of Nursing (ADON) present to observe, revealed Resident 11 laying in bed. Nursing Assistants (NA) J and K began dressing Resident 11, touched the left arm, turned side to side to dress Resident 11's lower extremity. Resident 11 began yelling and crying "No don't do it, I quit, my arm hurts, leave my arm alone, Ow my arm is sore". Resident 11 continued to cry and yell out while staff attempted to dress Resident 11 in bed and positioned the full lift sling underneath Resident 11. NA J and K decided to only dress the lower extremities due to the residents complaints of pain and the presence of the sling on the left arm. NA J draped the upper body with a gown. At 7:30 AM, Medication Aide (MA) L entered the room and gave Resident 11 the scheduled dose of [MEDICATION NAME]. Resident 11 took the medication after NA K told Resident 11 that it would help with the pain to make it better. NA J and K continued to position the Hoyer (a type of full body lift) and performed the transfer from the bed to the chair. During the transfer, Resident 11 cried and screamed " Ow, I don't like this, it hurts, my arm hurts." Interview on 2/14/11 at 7:45 AM with the ADON confirmed the observation that Resident 11 was crying out and verbalizing pain in the left arm with movement. The ADON stated that while Resident 11 usually did yell and resist movement, this was the first time the ADON had heard Resident 11 complain of pain specifically in the arm. The ADON stated that Resident 11 did appear to be in pain. Interview on 2/14/11 at 7:50 AM with NA J confirmed that Resident 11 was in pain during the transfer and that the pain was worse since Resident 11 had the arm fracture. NA J stated that prior to the fracture, Resident 11 didn't have any specific area's that that the resident would complain of pain in and that now Resident 11's pain was more specific to the fractured arm. Interview on 2/14/11 at 7:55 AM with MA L revealed that Resident 11 had not received any medication for pain prior to the transfer. MA L stated that Resident 11 had last received a scheduled dose of pain medication at 8 PM on 2/13/11 and had not received any PRN pain medications since 2/8/11. Observation on 2/14/11 between 10:25 AM and 10:30 AM revealed that Resident 11 exhibited symptoms of pain with movement during a staff assisted transfer from the wheelchair to the bed. NA J and K attached the straps on the Hoyer lift, lifted and transferred Resident 11 from the chair to the bed. During the transfer, Resident 11 cried and yelled out "I don't like this, my arm hurts, Ow it hurts." Interview on 2/14/11 at 10:30 AM with NA J confirmed that Resident 11 appeared to be in pain during the transfer from the wheelchair to the bed. Record review of Resident 11's MAR and interview on 2/14/11 at 11:18 AM with MA L confirmed that Resident 11 had not received any PRN medications for pain prior to the transfer on 2/14/11 at 10:30 AM. Interview on 2/14/11 at 5:00 PM with LPN B revealed that (Resident 11)should have been premedicated prior to the transfers on 2/14/11 and that this would have helped make Resident 11 more comfortable during transfers and cares. In an interview on 2/15/11 at 7:10 AM, the DON stated "They needed to medicate (Resident 11) so that (gender)'s comfortable. {Gender) should be medicated 45 minutes to 1 hour before cares are given." [MEDICAL TREATMENT] Monitoring: C. Record review of Resident 14's Admission Physician order [REDACTED]. Observation of Resident 14 on 2/15/11 at 1:35 PM with Licensed Practical Nurse (LPN B) revealed the presence of a [MEDICAL TREATMENT] fistula site (an access site for [MEDICAL TREATMENT]) in the left upper extremity. Record review of Resident 14's CCP dated 1/3/11 revealed that the CCP did not contain any specific information, measurable goals or interventions to address the care and treatment of [REDACTED]. Interview on 2/15/11 at 2:45 PM with the Director of Nursing revealed that the facility had no policies or procedures for the care and treatment of [REDACTED]. The DON stated that the expectation was that upon each day of return from [MEDICAL TREATMENT] treatments, the resident should be assessed for the first 4 hours after return of the condition of the blood pressure, any nausea and vomiting, any abnormalities or bleeding or problems with the fistula site. The DON stated that the assessment and monitoring of the post [MEDICAL TREATMENT] condition and the fistula site should be documented in the nurses notes. Record review of Resident 14's Nurses notes for January and February 2011 revealed inconsistent documentation of the post [MEDICAL TREATMENT] condition of Resident 14 or the post [MEDICAL TREATMENT] assessment of the condition of the [MEDICAL TREATMENT] fistula site. Interview on 2/15/11 at 5:00 PM with the DON confirmed that the assessment and monitoring of Resident 14's condition post [MEDICAL TREATMENT] and of the condition of the fistula site post [MEDICAL TREATMENT] was sporadic and not consistent. The DON confirmed that Resident 14 had been to [MEDICAL TREATMENT] a total of 17 times in January and February and that facility staff had documented Resident 14's condition only 5 times. The DON confirmed that this did not meet the expectations for the assessment and monitoring of the fistula site and the condition of Resident 14 post [MEDICAL TREATMENT]. C. Record review of a information sheet dated 12/15/2010 revealed Resident 7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 7's MDS dated and signed as completed on 12/14/2010 revealed the facility staff assessed the following about the resident: -Resident 7 had short and long term memory problems. -Required total assistance with toileting. -Required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. -Incontinent of bowel and bladder. -Resident 7 was not assessed as having any pain. -Additional [DIAGNOSES REDACTED]. Record review of Resident 7's Occupational Therapy notes dated 1/19/2011 revealed Resident 7 was assessed as having contracture to the left upper extremity. Record review of a pain assessment for Resident 7 dated 12/07/2010 revealed that at the time of the pain assessment, Resident 7 did not have pain. Observation on 2/14/2011 at 8:02 AM revealed Resident 7 was seated in a recliner in a reclined position yelling "help me my hand hurts". Observation at this time revealed Resident 7's face was red and had tears streaming down the face. Observation on 2/14/2011 at 8:13 AM revealed Resident 7 remained in the recliner and was yelling " help me, my hand hurts, I hurt bad". Observation on 2/14/2011 starting at 8:22 AM through 8:40 AM of a transfer revealed NA H brought a mechanical lift (Maxie Stand) into Resident 7's room for the transfer. NA G had entered Resident 7's room to assist with the transfer of Resident 7. Resident 7 was seated in a recliner. The Maxie Lift was placed in front of Resident 7. Resident 7 stated to both NA's "Can I have something, my hand hurts". Observation at this time revealed Resident 7 was tearful. NA G stated to Resident 7, " we will let the nurse know you need something after we get you up". The transfer belt was placed around Resident 7 waist. NA G instructed Resident 7 to hold onto the bars of the lift and placed Resident 7's hands onto the bars. Resident 7 started to cry and stated " My hand hurts". NA G placed a positioning belt around Resident 7's legs that assisted in maintaining Resident 7's feet on the lift for safety. Resident 7 started to scream, I hurt, I hurt, and was observed to cry". NA G started to lift Resident 7 up with the mechanical lift. Resident 7 started to scream and cry "I hurt, I hurt". Certified Medication Assistant (CMA) I, had entered Resident 7's room to assist with Resident 7. Resident 7 became very tearful and started to sob, stating "I hurt, my hand hurts". CMA I instructed NA G to set Resident 7 back into the recliner". CMA I explained to Resident 7 about transferring into the wheelchair and that CMA I would "...get pain medication after the transfer". CMA I, NA G and NA H transferred Resident 7 from the recliner into a wheelchair. Resident 7 stated " I hurt, I hurt" during the transfer. An interview with CMA M was conducted on 2/14/2011 at 8:25 AM. During the interview, CMA M stated "after (gender) was transfered into the wheelchair", when asked when Resident 7 recieved medications for pain. An interview was conducted with NA H and NA G on 2/14/2011at 8:40 AM. Both, NA H and NA G stated "yes" when asked if Resident 7 was always painful in the mornings. NA G stated that Resident 7 "... is always painful, more in the mornings, (gender) hand is contracted". An interview with CMA I was conducted on 2/14/2011 at 9:32 AM. During the interview, CMA I stated that Resident 7"..is always painful". When asked everyday, CMA I stated "yes". An interview on 2/14/2011 at 10:07 AM was conducted with Licensed Practical Nurse (LPN) A. During the interview, LPN A stated Resident 7 "was always painful". LPN A stated Resident 7's "hand is contracted and has a lot of pain". When asked if Resident 7 should be pre-medicated prior to providing cares, LPN A stated "Yes, that would be a good idea".

Licensure Reference: 175 NAC 12-006.07C Based on record review and staff interview, the facility Quality Assurance Plan (QAP) failed to identify ongoing issues relevant to F 221, 226, 253, 279, 280, 309, 314, 323, 329, 332, 371 and 441 and implement effective plans of action to identify and correct the deficient practice. The Quality Assurance Plan failed to ensure the repeated deficiencies at F 253, 280, 309, 314 and 323 were corrected and the correction maintained. The sampled consisted of 19 sampled and 11 non-sampled residents. The facility had a census of 95 residents. Findings are: The overview of the facility Quality Assurance Plan dated 2/10/11 stated the following objectives: - Develop and organized culture that promotes interdisciplinary collaboration for improvement of procedures and outcomes to meet or exceed the needs and expectations of residents, families and other customers. - Implement a strategic, systematic organization wide approach to plan, design, implement, assess and improve resident and family processes and outcomes. A review of a QA issues list from the December 2010 QA Report revealed that the following audits were done in December of 2010: Falls, Incidents, Medication and Treatment sheets, Medication and Treatment errors, Catheters, Urinary Tract Infections, Infection control, Decubidi, Diabetic Monitoring, Critical Chart Documentation and Alarm and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] In an interview on 2/16/10 at 9:55 AM, the Assistant Director of Nursing (ADON) confirmed that these were audits only and that the facility did not have a QA process to address concerns related to F 221, 226, 253, 279, 280, 309, 314, 323, 329, 332, 371 and 441. The ADON stated that there were no QA processes in place currently to address the repeat deficiencies at F 253, 280, 309, 314 or 323. Interview on 2/16/10 at 9:45 AM with the DON confirmed that the QA program had not been monitoring any of the issues found on survey except F 309 related to pain. The DON stated that the pain Plan of Action had not been effective and that the QA program needed to be reviewed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and observations, the facility Quality Assurance committee failed to correct ongoing issues relevant to F280, F309 and F314 and failed to implement effective plans of actions to correct the deficient practice and maintain correction. The survey sample was 14 and the facility staff identified a census of 95. Findings are: Record review of the facility's Quality Assurance Program updated on 3/30/11 revealed the following: -The Quality Assurance (QA) Program will assist the facility in providing on-going evaluation of facility systems, practice standards, and care process to ensure the provision of both quality of care and quality of life. If quality deficiencies are identified, the QA committee will develop and implement plans of action to correct these quality deficiencies. -Members of the QA committee participate in the development and implementation of action plans that correct identified problems and comply with State and Federal regulations. - Committee responsibility: - Identifying quality deficiencies, inappropriate care practices and/or issues which necessitate action. -Develop and implement plans of action to correct identified problems. -Re-evaluate corrective actions as needed. -Maintain systems functioning satisfactorily and consistently including maintaining appropriate current practice standards. The facility had an annual survey completed on 2/16/2011. The facility had areas of deficiencies that required a plan of correction. A re-visit to the facility was completed on 4/26/2011 in regards to their plan of correction for those deficiencies cited on 2/16/2011 inspection. The facility staff did not maintain correction for the regulations that are identified in this report and repeated deficiencies were written.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2a and 12-006.09D2b Based on observation, record review and staff interviews; the facility failed to provide treatment to promote healing of pressure ulcers for 2 (Residents 11 and 12) residents and failed to implement nutritional recommendations for pressure ulcer healing for 1 (Resident 31) resident of 14 sampled residents. The facility census at the time of survey was 95. Findings are: A. Record review of Resident 11's Profile Face Sheet, dated 1-21-11, revealed that Resident 11 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: cerebral artery occlusion, Diabetes Mellitus Type II, [MEDICAL CONDITIONS], Essential Hypertension, [MEDICAL CONDITION], and Dysphagia. Resident 11 suffered a stroke and was originally admitted to the facility on [DATE], fell from a transfer lift on 1-31-11 at the facility and suffered a left humeral fracture, (surgery 2-9-11), then scheduled for further surgical repair on 2-23-11, returning to facility on 3-3-11. Review of Resident 11's MDS (Minimum Data Set, a federally mandated comprehensive assessment used for care planning) dated 2-9-11 revealed that Resident 11was scored for the following: ? Cognitive score 6/15 ? Mood score 2/27 ? Ability to transfer 4 - 3, total dependence with 2+ person physical assistance ? Ambulation - 8, activity did not occur ? Activities of Daily Living (Dressing & Personal Hygiene) - 3-2, extensive assistance with 1 person physical assist ? Range of Motion - Upper extremity = 1 (impairment on 1 side) Lower extremity = 0 (no impairment) ? Bowel and Bladder - 3-3, always incontinent (currently has a foley catheter, however) Record review of Resident 11's medical record revealed a Braden Risk Assessment Scale, dated 3-3-11, totaling a score of 12. This scale assesses areas including moisture, activity, mobility, nutrition, sensory perception and friction and shear. The form states "Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers." Record review of Resident 11's medical record revealed a Resident Assessment, dated 3-3-11, detailing in picture and written description the resident skin condition: ? Stg (Stage) II Sacrum ? The descriptions related to the posterior side of the body are: the sacrum (Stage II), bruising to right wrist and mushy heels (bilateral heals are circled). ? The descriptions related to the anterior side of the body are: Bruise (right medial elbow), dressing to left upper arm/shoulder, sling for left mid-upper arm to mid-forearm and 3+ [MEDICAL CONDITION] to left ankle. Review of Resident 11's medical orders revealed physician orders, dated 3-7-11, to: 1.) Discontinue previous treatments to coccyx. 2.) [MEDICATION NAME] drsg (dressing) to open areas coccyx. Change q (every) 3 days + PRN (as needed) until healed. Review of the Treatment Administration Record (TAR) revealed the following discontinued on 3-7-11, order handwritten: [MEDICATION NAME] cover - apply hydrogel to open area. Change QOD (every other day) PRN (as needed) till healed, 3-3-11. Observation of wound care on 4-26-11 at 9:00AM by LPN E to Resident 11 revealed LPN E stating "the dressing is in the wrong spot," when uncovering Resident 11's buttocks. The foam dressing was noted to be on the left lower gluteal fold. The dressing was not dated or initialed. LPN E removed the gluteal fold dressing and proceeded to cleanse the entire buttocks from the [MEDICATION NAME] cream and washed the sacral wound with normal saline and patted dry with gauze. LPN E then stated that (gender) likes to apply skin prep to the outer edge of dressing area so the dressing will "stick better." This was performed. LPN then applied [MEDICATION NAME] dressing to the sacral wound, dated and initialed the dressing. Interview with the DON on 4-26-11 at 12:50PM discussed Resident 11's wounds. DON referred to the Weekly Status Report, dated 4-22-11 which stated on 3-3-11 "hydrogel/[MEDICATION NAME] started 3-7-11 tx (treatment) changed to [MEDICATION NAME] ......3-24-11 Stg (Stage) II to coccyx size drecrease noted and improvement noted. ....4-8-11 ...and improvements to Sacrum wds (wounds)." The DON agreed that no new physician order [REDACTED]. B. Record review of a Profile Face Sheet dated 4/25/2011 revealed Resident 12 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Weekly Status Report sheet dated 4/22/2011 revealed Resident 12 had a pressure ulcer to the coccyx. Record review of a Skin Assessment Form dated 4/22/2011 revealed that Resident 12's ulcer was assessed as a stage III ( Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but no through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) pressure ulcer. The ulcer was assessed with [REDACTED]. Record review of a Treatment sheet dated 4/01/2011 through 4/30/2011 revealed the treatment for [REDACTED]. Observation on 4/26/2011 at 9:48 AM revealed Licensed Practical Nurse (LPN) A obtained supplies for the treatment to Resident 12's pressure ulcer. LPN A washed hands and donned gloves. LPN A removed the soiled dressing and packing from the pressure ulcer and cleansed around the wound with normal saline. LPN A obtained a cotton tipped applicator, wrapped it with a 4 by 4 piece of gauze and placed it into the area of undermining of the pressure ulcer. LPN A twisted the applicator inside the pressure ulcer several time and then removed the applicator. Observation at this time revealed the tip of the applicator for approximately 2 inches down revealed red blood like drainage from the wound. LPN A obtained the [MEDICATION NAME] and packed the wound. LPN A then covered the wound with an Allyven and Primpore dressing. An interview with LPN A was conducted on 4/26/2011 at 9:55 AM. During the interview, LPN A confirmed the dressing used was not what was ordered. When asked if there was an order to cleanse the ulcer area and insert a gauze wrapped applicator into the wound, LPN A stated "no". When asked if this could cause trauma to the wound, LPN A stated "yes". An interview with the wound nurse LPN C, was conducted on 4/26/2011 at 1:40 PM. During the interview, LPN C confirmed that there was not an order for [REDACTED]. An interview was conducted on 4/26/2011 at 1:47 PM with the Director of Nursing (DON). During the interview the DON stated "yes" when asked if the order to cleanse around and inside the pressure ulcer should have been clarified. C. Record review of a Profile Face Sheet dated 4/11/2011 revealed Resident 31 was admitted to the facility on [DATE]. Record review of a Transfer Form dated 4/11/2011 revealed Resident 31 was admitted to the facility with pressure ulcers. Record review of a Nutrition Services Progress Note dated 4/12/2011 revealed the registered Dietician (RD) evaluated Resident 31's nutritional requirements and recommended to have a"... multivitamin with minerals to address micronutrient needs for wound healing" and that milk would be sent with at all meals for "added protein". Record review of Resident 31's medical record did not contain evidence the recommendation for the multivitamin had been completed. Observation on 4/26/2011 at 12:20 PM revealed Resident 31 was in the dinning room for lunch. Resident 31 did not have milk with lunch. An interview with the Dietary Assistant (DA) D was conducted on 4/26/2011 at 12:32 PM. When asked if Resident 31 was offered milk, DA D stated "no". AN interview with LPN B was conducted on 4/26/2011 at 3:15 PM. During the interview, LPN B confirmed Resident 31's record did not contain evidence on the recommendation for the multivitamin.