Every finding on record at Gateway Vista

Licensure Reference Number 175 NAC 12-006.04 (E)Based on record review and interview, the facility failed to notify the State Agency within five working days of a change in Director of Nursing. This had the potential to affect all residents who resided at the facility. The facility census was 68. A record review of the Change of Administrator or Director of Nursing Notification Form revealed that the Director of Nursing (DON) was changed on 9/13/25. A record review of the facility faxed letter sent to Dept. of Health and Human Services (DHHS) revealed a fax date of 9/29/25. An interview on 12/23/25 at 1:30 PM with the Administrator confirmed that the Change of Administrator or Director of Nursing Notification form was not submitted to DHHS within the required the five working days and it should of been submitted to DHHS within 5 working days.

Licensure Reference Number 175 NAC 12-006.09(H)Based on record review and interview, the facility failed to implement, monitor, and revise interventions to manage pain for 1 (Resident 1) out of 3 sampled residents for pain control. The facility census was 76 at the time of survey. Findings are:Record review of the facility's policy Pain Management dated December 2023, revealed the facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice. In order to help a resident attain his/her highest practicable level of physical, mental and psychosocial well-being and to manage pain, the facility will:- Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated.- Evaluate the resident for pain and the cause upon admission, and during ongoing assessments.- Manage pain, consistent with current professional standards of practice, and the resident's goals and preferences. If the pain re-assessment findings indicate pain is not adequately controlled, the pain management regimen will be revised as indicated.Record review from Core Principles of Pain Management from Geriatric pain.org dated May 2023 revealed pain is a subjective experience and the individual is the best judge of his or her own pain, and the expert on each pain treatment's effectiveness on him/herself. Further review also revealed that every older adult deserves adequate pain management. Record review of Resident 1's admission record revealed the resident was admitted to the facility on [DATE] with a diagnosis of pain and low back pain.Record review of Resident 1's progress notes dated 9/9/25 revealed order for Acetaminophen (Tylenol) 650 milligram (mg- unit of measurement for medications) every 6 hours as needed for pain.Record review of Resident 1's History and Physical from hospital date of service of 9/5/2025 revealed this resident has chronic back pain and is on chronic opioids (Dilaudid 2 milligram {mg- a dosage of a medication} 5 times a day) with a history of spinal surgeries. Record review of Resident 1's Brief Interview for Mental Status (BIMS) dated 9/10/2025 revealed a score of 13 which indicated intact cognitive function, meaning the resident has normal thinking and memory and is not experiencing a significant level of cognitive impairment.Record review of facility's pain book (educational staff resource) revealed facility used a Pain and Function Assessment Tool with a use of a 0-10 scale (0 = No Pain, 10= Worst Possible Pain) for residents to rate their own pain. Record review of Resident 1's Order Summary dated 9/14/2025 revealed an order for Hydromorphone (Dilaudid) tablet- two milligrams (mg) take one table by mouth five times daily for five days for diagnosis of pain with a start date of 9/7/2025 and a stop date of 9/13/2025.Record review of Resident 1's September 2025's Medication Administration Record, Pain Level Summary and Progress notes revealed:Monday, 9/8/2025 at 4:14 PM Resident rated pain as a 6. No documentation of the site of Resident's pain. No documentation that other pain medications were administered to resident. No documentation of facility's use of Non-Pharmacological Interventions (NPI).Monday, 9/8/2025 at 8:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA (not applicable) Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Tuesday, 09/9/2025 at 8:00 AM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA (not applicable) for use of Non-Pharmacological Interventions (NPI).Tuesday, 09/9/2025 at 11:00 AM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA (not applicable) for use of Non-Pharmacological Interventions (NPI).Tuesday, 09/9/2025 at 2:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was NA. Facility documented NA (not applicable) for use of Non-Pharmacological Interventions (NPI).Tuesday, 09/9/2025 at 5:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA (not applicable) for use of Non-Pharmacological Interventions (NPI).Tuesday, 09/9/2025 at 8:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as right leg. Resident rated pain was a 7. Facility documented rest for use of Non-Pharmacological Interventions (NPI). Resident 1 continued to rate pain a 7 at 8:42 PM, 8:57 PM, and at 10:15 PM. No documentation of any revision to the pain management regimen. No documentation of any additional use of Non-Pharmacological Interventions besides rest. Wednesday, 09/10/2025 at 8:00 AM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was NA. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Wednesday, 09/10/2025 at 11:00 AM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Wednesday, 09/10/2025 at 2:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Wednesday, 09/10/2025 at 5:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Wednesday, 09/10/2025 at 8:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as legs. Resident rated pain was a 10. No documentation that other pain medications were administered to resident. Facility documented rest for use of Non-Pharmacological Interventions (NPI). Resident 1 continued to rate pain a 7 at 8:32 PM, and rated pain as a 3 at 10:43 PM. No documentation of any revision to the pain management regimen. No documentation that other pain medications were administered to resident or Non-Pharmacological Interventions were used besides rest. Thursday, 09/11/2025 at 8:00 AM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as back. Resident rated pain was a 10. Facility documented rest for use of Non-Pharmacological Interventions (NPI). Resident 1 continued to rate pain a 10 at 9:02 AM and at 10:06 AM. No documentation of any revision to the pain management regimen. No documentation of any additional use of Non-Pharmacological Interventions besides rest. No documentation that other pain medications were administered to resident. Thursday, 09/11/2025 at 11:00 AM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as right hip. Resident rated pain was a 8. Facility documented rest for use of Non-Pharmacological Interventions (NPI). Resident 1 continued to rate pain a 8 at 11:43 AM, and as a 10 at 12:53 AM. No documentation of any revision to the pain management regimen. No documentation of any additional use of Non-Pharmacological Interventions besides rest. No documentation that other pain medications were administered to resident. Thursday, 09/11/2025 at 2:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as right hip. Resident rated pain was a 5. Facility documented rest for use of Non-Pharmacological Interventions (NPI). No facility documentation to assess or reassess pain/effectiveness of Dilaudid.Thursday, 09/11/2025 at 5:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as right hip. Resident rated pain was a 5. Facility documented rest for use of Non-Pharmacological Interventions (NPI). No facility documentation to assess or reassess pain/effectiveness of Dilaudid.Thursday, 09/11/2025 at 8:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as right hip. Resident rated pain was a 4. Facility documented rest for use of Non-Pharmacological Interventions (NPI).Friday, 09/12/2025 at 8:00 AM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Friday, 09/12/2025 at 11:00 AM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI). Resident 1 rated pain a 10 at 12:08 PM. No documentation of any revision to the pain management regimen. No documentation of any additional use of Non-Pharmacological Interventions. No documentation that other pain medications were administered to resident.Friday, 09/12/2025 at 2:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Friday, 09/12/2025 at 5:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Friday, 09/12/2025 at 8:00 PM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Saturday, 09/13/2025 at 8:00 AM Resident 1 received Dilaudid 2 mg as ordered. Pain site documented as NA. Resident rated pain was a 0. Facility documented NA for use of Non-Pharmacological Interventions (NPI).Record review of Resident 1's Electronic Medical Record revealed resident's last dose of Dilaudid 2 mg was administered on Saturday, 9/13/2025 at 8:00AM.During an interview on 9/17/2025 at 3:54 PM Resident 1's family member confirmed that the resident had been taking Dilaudid for approximately 2 decades for back pain and that it had been abruptly discontinued while at the facility. Record review of Resident 1's Medication Administration Record (MAR) revealed the resident refused the pain medication on 9/13/2024 at 11:00 AM. Pain rating at that time was a 0 (zero-meaning no pain).Record review of Resident 1's Pain Assessments for 9/13/2025 (Saturday) revealed at 1:54 PM the resident rated pain at a 10. No documentation of any revision to the pain management regimen. No documentation of any use of Non-Pharmacological Interventions. No documentation that other pain medications were administered to resident.Record review of Resident 1's Pain Assessments, Progress Notes, and Electronic Medical Record dated 9/14/2025 (Sunday) revealed:9:18 AM- Pain was a 9. No documentation of any revision to the pain management regimen. No documentation that other pain medications were administered to resident. No documentation of any use of Non-Pharmacological Interventions. 10:28 AM-Pain was a 9. Pain was constant, generalized, aching, non-radiating (not spreading) Facility documented Non- medication interventions refused or did not provide relief.11:37 AM- General complaints of pain was rated a 7, which is considered severe and demands a person's full attention. Facility documented refusal of Non-Pharmacological Interventions. Resident 1 accepted Tylenol 650 mg for pain.12:20 PM- Pain was a 10, which signifies the worst, most severe pain imaginable. It is pain so intense that it is completely incapacitating and dominates all thoughts and sensations.Facility documented that PRN administration (Tylenol) was ineffective.Record review of Resident 1's electronic medical record revealed the resident complained of a pain rating of 9 on Sunday, 9/14/2025 at 9:18 AM, then the nurse called Resident 1's medical provider on 9/14/21 at 10:21 AM. Further record review revealed the nurse never received the order from the medical provider to continue the Dilaudid and never called the medical provider back to ask to resend the faxed order. The fax was later located in the closed business office still on the fax machine on Monday, 9/15/2025. During an interview on 9/18/2025 at 12:26 PM Registered Nurse (RN)-A confirmed that the nurse never received the Dilaudid order, did not follow up with the provider and did not give the medication before the resident discharged from the facility. RN-A also confirmed that the facility had three Dilaudid 2 mg pills in the narcotic drawer for Resident 1. Record review of Resident 1's nurses notes dated 9/14/2025 at 2:35 PM revealed that resident's daughter removed Resident 1 from the facility against medical advice (AMA) because Resident 1 went 24 hours without Dilaudid (pain medication) and is taking them home to medicate (gender) and will not be returning to the facility. During an interview on 9/17/2025 at 3:45 PM with Licensed Practical Nurse (LPN) - B confirmed that Resident 1 came from the hospital with an order for Hydromorphone (Dilaudid) for five days and it was scheduled to be stopped during the weekend and when residents come with a stop date on pain meds, the facility will reassess their pain and address it from there. LPN-B further confirmed the facility did not have a plan for when Resident 1's five day scheduled order for Dilaudid was discontinued, and there was no plan to taper (gradually reduce) the medication. Record review of Resident 1's Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) with a focus area dated 9/9/25, revealed the resident had chronic pain with a goal of adequate relief of pain, interventions included to identify previous pain history and management of that pain, administer analgesics, and document response.During an interview on 9/18/25 at 1:37 PM with Director of Clinical Operations (DCO) confirmed there was no documentation of the resident pain assessment or condition between 12:20 PM and 2:35 PM for Resident 1 on 9/14/2025, the day of discharge. The DCO also confirmed that pain is subjective (subjective means pain is described and reported based on the individual's perception and interpretation).Record review of Resident 1's Minimum Data Set (MDS - this comprehensive assessment evaluates each resident's functional capabilities) dated 9/14/2025 revealed the resident discharged from the facility on 9/14/2025.During an interview on 9/18/2025 at 3:43 PM with the Director of Nursing (DON) confirmed that Resident 1's pain was not under control, based on the pain assessment, when the resident was discharged .

Licensure Reference Number 175 NAC 12.007.04(D) ventilation systemBased on observation, interview, and record review, the facility failed to have functional bathroom ventilation in 15 resident rooms (rooms 105, 110, 111, 112, 114, 201, 205, 206, 216, 218, 311, 312, 313, 318, and 413) out of 77 rooms surveyed. The facility census was 77.Findings: An observation on 8/27/2025 at 8:50 AM during the initial tour, rooms 105, 110, 111, 112, 114, 201, 205, 206, 216, 218, 311, 312, 313, 318, and 413 revealed bathroom vents were not functioning when tested with one ply tissue. An observation on 9/02/2025 at 6:45 AM revealed room [ROOM NUMBER]'s bathroom vent was not functioning. An observation on 9/02/2025 at 6:47 AM revealed room [ROOM NUMBER]'s bathroom vent was not functioning. An observation on 9/02/2025 at 6:51 AM revealed room [ROOM NUMBER]'s bathroom vent was not functioning. An observation on 9/02/2025 at 6:54 AM revealed room [ROOM NUMBER]'s bathroom vent was not functioning. An observation on 9/02/2025 at 9:20 AM during the environmental tour with the maintenance supervisor (maintenance), revealed rooms 110, 111, 112, and 114 bathroom vents were not functioning when tested with one ply tissue. In an interview on 9/2/2025 at 9:20 AM with maintenance confirmed the bathroom vents were not functioning in rooms 110, 111, 112, 114 when tested with one ply tissue. In a record review of the facility's Logbook Documentation dated 9/2/2025 and a print time of 4:07 PM revealed a process inspecting the facility's ventilation system. In a record review of the facility's Work History Report dated 9/3/2025 and a print time of 6:29 AM revealed monthly exhaust fan inspections being completed and documented as functioning. In an interview on 9/3/2025 at 8:00 AM with maintenance confirmed there is an issue with the bathroom vents not functioning and they are being worked on.

Licensure Reference Number 175 NAC 1-005.06(F)Licensure Reference Number 175 NAC 12-006.18(B)Based on record review, observations, and interviews, the facility failed to ensure that staff followed principles of infection control and prevention related cleaning of respiratory equipment for Resident 46. This affected 1 of 2 Residents sampled for respiratory care, The facility 77. Findings are:A record review of Resident 46's admission Record printed 08/28/2025 revealed the resident was admitted on [DATE] and had diagnoses of Parkinson's disease (a progressive brain disorder that affects movement, leading to symptoms like tremors, stiffness, and slowness of movement), chronic obstructive pulmonary disorder (COPD-group of lung diseases that block airflow and make it difficult to breathe), heart disease, irregular heartbeat, high blood pressure, dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and obstructive sleep apnea (OSA-a condition where a blockage or narrowing in your airway keeps air from moving through your windpipe when you're asleep). Further review of the admission Record revealed that the resident had a guardian (a legal representative appointed by a court to take care of an individual who is unable to take care of themselves).A record review of Resident 46's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 07/25/2025 revealed a Brief Interview for Mental Status (BIMS-a screening tool used to assess cognition [relating to the mental process involved in knowing, learning, and understanding things]; the BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points indicates severe cognitive impairment; 8 to 12 points indicates moderate cognitive impairment; and 13 to 15 points indicates that cognition is intact) score of 15. Further review of the MDS revealed that in Section O Special Treatments, Procedures, and Programs, question G1 Non-invasive Mechanical Ventilator was check marked as having been performed during the last 14 days, and while the resident was in the facility.A record review of Resident 46's Order Summary Report printed 08/28/2025 revealed the resident had an order to wear a Positive Airway Pressure (PAP-a treatment that uses a machine to deliver pressurized air through a mask or nasal pillows during sleep) device every evening, and an order for staff to check to make sure the resident was wearing oxygen or the PAP mask every two hours. A record review of Resident 46's Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) revealed there was no mention of the resident's PAP machine, including cleaning the mask. A record review of the facility's Noninvasive Ventilation (CPAP,BiPAP, Trilogy) policy with date implemented of 2023 revealed no directions for cleaning or storage of the machine or equipment. The policy stated the facility would follow the manufacturer's instruction for use of the machine.A record review of the manufacturer's website (https://www.resmed.com/en-us/sleep-health/resources/cleaning-cpap-equipment/) revealed that directions for cleaning your CPAP mask cushion, frame & headgear were: Unplug your CPAP machine from the power source.Disconnect the mask and air tubing from the CPAP machine.Disassemble your mask into 3 parts (headgear, cushion and frame).In a sink or tub, clean your mask cushion and headgear to remove any oils. Gently rub with a mild liquid detergent and warm, drinking-quality water. Avoid using stronger cleaning products as they may damage the mask or leave harmful residue.Rinse again thoroughly with warm, drinking-quality water.Place the cushion and frame on a flat surface, on top of a towel, to dry. Avoid placing them in direct sunlight.Please note: cushion should be cleaned daily, headgear and frame should be cleaned weekly.An observation on 08/27/2025 at 1:48 PM revealed Resident 46's PAP machine on the nightstand with the mask lying on top of machine. The mask had scattered black and brown particles in it.An observation on 08/28/2025 at 7:30 AM revealed the PAP machine is a Resmed Aersense II Autoset. The PAP mask was lying on the nightstand next to the machine with scattered black and brown particles in it.An observation on 09/02/2025 at 1:51 PM revealed the PAP mask was lying on the nightstand next to the machine with scattered black and brown particles in it.An interview with Resident 46 on 08/28/2025 at 7:30 AM confirmed the resident wore the PAP mask every night.An interview on 09/02/2025 at 1:51 PM with Licensed Practical Nurse (LPN) A confirmed the PAP mask was dirty and needed to be washed. LPN A confirmed they did not know how often the mask should be washed and who was responsible for washing it. The LPN further confirmed that the resident was unable to put on or take off the mask independently, and that there was no order for cleaning the mask present in the resident's orders.An interview on 09/02/2025 at 3:25 PM with the Director of Clinical Operations (DCO) confirmed that Resident 46's PAP mask should be cleaned every time it was taken off.An interview on 09/02/2025 at 3:44 PM with the DCO confirmed Resident 46 did not have directions for cleaning the PAP mask in their orders.

Based on record review and interview; the facility staff failed to implement assessed interventions to prevent significant injury for 1(Resident 35) of 4 sampled residents. The facility staff identified a census of 68. Findings are: Record review of Resident 35's Comprehensive Care Plan (CCP) with an initiation date of 3/14/2023 revealed Resident 35 had Activities of Daily Living (ADL's) self-care performance deficit related to the diagnosis of Parkinson Diseases. Further review of Resident 35's CCP with a initiation date of 3/14/2024 revealed Resident 35 was at a high risk for falls related to confusion, de-conditioning and gait/balance problems. The goal identified on Resident 35's CCP was Resident 35 would not sustain a serious injury. Interventions identified to meet the goal revealed the following: -Anticipated and meets Resident 35's needs. -Assistive devices in place with mobility. -Audio monitor in room to be turned on at night. -Bedside table with needed items within reach. -Ensure gait belt (also known as a transfer belt) is in place with transfers and ambulation. -Follow facility fall protocol. A record review of Resident 35's Minimum Data Set (MDS, a federally mandated assessment tool used foe care planning) dated 3/12/2024 revealed the facility staff assessed Resident 35 as needing partial to moderate assistance with toilet transfer. A record review of Physical Therapy (PT) notes for Resident 35 dated 4/23/2024 revealed Resident 35 had a history of falls. According to The PT notes dated 4/23/2024 revealed Resident 35 felt unsteady when walking and was worried about falling. Further review of the PT note for Resident 35 revealed the root cause of Resident 35's fear of falling was due to the Parkinson causing the resident to be unable to employ stepping strategies to maintain balance. A record review of a Gateway Vista Restorative Program sheet dated and signed by a Occupational Therapist dated 9/18/2023 for Resident 35 revealed when transferring Resident 35, staff were to use a gait belt and the assistance of 1 staff member. A record review of Resident 35's Progress Note (PN) dated 4/30/2024 with a time of 3:56 PM revealed Nursing Assistant (NA)-B was assisting Resident 35 from the toilet when Resident 35 took 2 steps forward. According to Resident 35's PN dated 4/30/2024 NA-B held onto Resident 35 as Resident 35 fell with NA-B falling with Resident 35. Resident 35's PN dated 4/30/2024 revealed NA-B's lower extremities may have fallen onto Resident 35 with resulting in a transfer to the hospital. A record review of Resident 35's PN dated 4/30/2024 at 7:29 PM revealed a Hospital Nurse called and reported Resident 35 had sustain a left side superior Pubic Ramus fracture (commonly known as a pelvic fracture). A record review of a Witnessed Fall sheet dated 4/30/2024 revealed Resident 35 was being transferred by NA-B when Resident 35 fell resulting in emergency services being called and Resident 35 transferred to the hospital. A record review of a facility investigation reported dated 5/03/2024 revealed Resident 35 required 1 person assistance with the use of a gait belt and a walker for ambulation and ADL's. Further review of the facility investigation report dated 5/03/2024 revealed Resident 35 sustain a left side superior Pubic Ramus fracture. On 6/12/2024 at 8:30 AM an interview was conducted with the Director of nursing (DON). During the interview the DON confirmed NA-B did not use a gait belt when transferring Resident 35 from the toilet. The DON further reported re-educating nursing staff on the floor Resident 35 resided on and some float staff. When asked was all of nursing re-educated on the use of gait belts, the DON stated no.

Based on observation, record review and interview, the facility staff failed to utilize hand hygiene and gloving, failed to ensure clean surface for treatment supplies,failed to clean scissors prior to wound care and failed to perform wound care in a manor to prevent potential cross contamination for 1 (resident 109) of 1 sampled resident. The facility staff identified a census of 68. Findings are: A record review of a Order Summary report dated 6/11/2024 revealed Resident 109 admitted to the facility on [DATE] with the diagnoses of Hypertension, surgical amputation, falls, Osteomylitis and Non-displaced type ll dens fracture (neck fracture). Further review of Resident 109's Order Summary Report dated 6/11/2024 revealed Resident 109's practitioner ordered a treatment to be completed to Resident 109's right 2nd amputated toe area that consisted of paint the wound with betadine, allow the betadine to air dry, then dress the wound with xereform (type of dressing), apply gauze and then wrap the area with ace wrap. An observation on 6/12/2024 at 10:40 AM of wound care and a transfer revealed Registered Nurse (RN)-C entered Resident 109's room and did not complete hand hygiene. RN-C removed resident's foot from [gender] wheelchair in preparation of a transfer. RN-C obtained and applied a gait belt (also known as a transfer belt) around Resident 109's waist and cued the resident for the transfer and transferred the resident into a recliner. RN-C removed the gait belt and explained to Resident 109 of the need to complete a treatment to the resident right toe area. RN-C without completing hand hygiene, left the residents room, obtained the required treatment supplies and returned to Resident 109's room. Further observation revealed upon entering Resident 109's room with treatment supplies, RN-C placed the treatment supplies on a corner room shelf without a barrier. The scissors that were included with the treatment supplies slid off the stack of the supplies onto the bare surface of the shelf. RN-C without completing hand hygiene donned (put on) gloves and removed Resident 109's right shoes and unwrapped the Ace wrap around Resident 109's right foot and lower right leg, RN-C removed the previous dressing revealing the wound to have stitches that measured approximately 2 centimeters in length. RN-C removed the soiled gloves, completed hand hygiene and donned clean gloves. RN-C then obtained a breadline swab and wiped downwards multiple times on the wound without changing the site on the swab. RN-C obtained the un-sanitized scissors and cut a portion of xereform dressing and placed the dressing onto Resident 109's right 2nd toe amputation site with the remainder of the xereform dressing placed back into the package. RN-C placed a 2 by 2 gauze dressing over the zereform dressing and without changing the gloves and completing hand hygiene wrapped Resident 109's right foot and leg with the Ace wrap and applied the resident shoe. RN-C removed the soiled glove and used hand sanitizer to clean the hand and scissors and placed the scissors into RN-C pocket. On 6/12/2024 at 11:00 AM an interview was completed with RN-C. During the interview RN-C confirmed soiled gloves had not been change and hands washed, soiled scissors were used and not sanitized after use and clean barrier for wound supplies was not used during the treatment on 6/12/2024 at 10:40 AM. On 6/12/2024 at 3:32 PM an interview was conducted with the facility Infection Control Preventionist (ICP). During the interview the ICP reported hand hygiene is to be completed before and after glove use, when using a betadine swab, the site on the swab needs to be changes with each swipe, a clean barrier needs to be in place for wound supplies and scissors need to be sanitized before and after use. A record review of the facility policy dated 2/2024 for Hand hygiene revealed the following: -Guidelines: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personal, residents and visitors. This applies to all staff working in all locations within the facility. -6.a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of 1 (Resident 42) of 7 sampled resident's Minimum Data Set (MDS, a comprehensive resident assessment of a person's functional, medical, and mental function). The facility census was 68. Findings are: A record review of the Centers for Medicare and (&) Medicaid Services' Long-Term Care Resident Assessment Instrument User's Manual dated October 2023 revealed Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(XVIII), (g), and (h) require that (1) the assessment accurately reflects the resident's status. A record review of Resident 42's Clinical Census dated 06/11/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 42's Medical Diagnosis dated 06/11/2024 revealed the resident had diagnoses of Chronic Inflammatory Demyelinating Polyneuritis (an abnormal immune response that can lead to nerve swelling and irritation), Anemia (low red blood cells), Acute Kidney Failures, Unspecified, Multifocal Motor Neuropathy (a rare and progressive disorder that affects motor neurons and cause muscle weakness in the extremities), and Thyrotoxicosis, Unspecified Without Thyrotoxic Crisis Or Storm (too much thyroid hormone). A record review of Resident 42's MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 5 of 15 which indicates the resident was severely cognitively impaired (confused). The resident was independent with oral and personal hygiene (cleaning), and upper body dressing. The resident needed supervision or touching assistance with toileting, lower body dressing and putting on footwear. The MDS revealed the resident was on Dialysis (a treatment that removes waste and excess fluid from the blood when the kidneys are not functioning properly). A record review of Resident 42's Care Plan did not reveal the resident was on Dialysis. An observation on 06/11/2024 at 11:12 AM revealed Resident 42 did not have a visible Dialysis catheter (a tube inserted into a vein) in the resident's chest, neck, or arm. In an interview on 06/11/2024 at 11:12 AM, Resident 42 confirmed the resident was not on Dialysis, but did have a procedure done every 2 weeks to separate the blood. Resident 42 confirmed the resident did not have a Dialysis catheter. A record review of the facility's MDS Resident Matrix dated 06/11/2024 did not reveal that Resident 42 was on Dialysis. In an interview on 06/12/2024 at 8:30 AM, The Director of Nursing confirmed Resident 42 was on Plasmapheresis (a process of removing the blood from the body, separating it into plasma and cells, and transfusing the cells back into the bloodstream) and was not on Dialysis. In an interview on 06/12/2024 at 8:58 AM, the MDS Coordinator-A confirmed Resident 42 was not on Dialysis and the MDS dated [DATE] was not accurate and Dialysis should not have been marked.

Based on observation, record review and interview; the facility staff failed develop a Basline Care Plan (BLC,a plan of care that is developed to meet the residents basic needs until a comprehensive care plan can be established) for 1 (Resident 109) of 1 residents. The facility staff identified a census of 68. Findings are: A record review of a Order Summary report dated 6/11/2024 revealed Resident 109 admitted to the facility on [DATE] with the diagnoses of Hypertension, surgical amputation, falls, Osteomylitis and Non-displaced type ll dens fracture (neck fracture). Further review of Resident 109's Order Summary Report dated 6-11-2024 revealed Resident 109's practitioner ordered Resident 109 to have a cervical collar on at all time when upright or mobilizing. An observation on 6/11/2024 at 3:25 PM revealed Resident 109 was seated up-right in a wheelchair and had the cervical Collar in place. Record review of Resident 109's BLC initiated on 6-03-2024 revealed the use of the cervical collar was not identified on the plan. On 6/12/2024 at 3:30 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed the sue of the cervical collar was not identified on Resident 109's BLC.

Based on observation, interview, and record review, the facility failed to ensure Plasmapheresis (a process of removing the blood from the body, separating it into plasma and cells, and transfusing the cells back into the bloodstream) and the arteriovenous (AV) fistula (a surgical connection between an artery and a vein that creates a stronger entry point for needles necessary for residents that require Dialysis or Plasmapheresis) were identified on 1 (Resident 42) of 7 sampled resident's Care Plan. The facility census was 68. Findings are: A record review of the facility's Care Plans Guideline with a Date Implemented of 2023 revealed the care planning process would include an assessment of the residents needs and would incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the care plan. The care plan would describe the services that would be furnished to attain or maintain the resident's highest practicable (able to be done) physical, mental, and psychosocial (relating to thought and behavior) well-being. A record review of Resident 42's Clinical Census dated 06/11/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 42's Medical Diagnosis dated 06/11/2024 revealed the resident had diagnoses of Chronic Inflammatory Demyelinating Polyneuritis (an abnormal immune response that can lead to nerve swelling and irritation), Anemia (low red blood cells), Acute Kidney Failures, Unspecified, Multifocal Motor Neuropathy (a rare and progressive disorder that affects motor neurons and cause muscle weakness in the extremities), and Thyrotoxicosis, Unspecified Without Thyrotoxic Crisis Or Storm (too much thyroid hormone). A record review of Resident 42's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 04/02/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 5 of 15 which indicates the resident was severely cognitively impaired (confused). The resident was independent with oral and personal hygiene (cleaning), and upper body dressing. The resident needed supervision or touching assistance with toileting, lower body dressing, and putting on footwear. A record review of Resident 42's Care Plan did not reveal the resident was on Plasmapheresis or had an AV fistula. A record review of Resident 42's Progress Note dated 03/09/2024 revealed an admission notes that the resident was on Plasmapheresis. A record review of Resident 42's Clinical Physician Orders dated 06/11/2024 revealed orders for: -Dialysis Fistula: No blood pressures (BP's), labs, jewelry or heavy lifting in extremity having fistula in right arm. every day and evening shift for hemodialysis (HD) catheter and fistula in right arm -Assess fistula site right arm. Palpate thrill (vibration felt when fingers are placed on AV fistula) and auscultate bruit (a sound that indicated how well an AV fistula is functioning) and note any concerns. Assess fistula appearance and document any concerns. Update/notify medical doctor (MD) as needed (prn) abnormal findings. every shift for fistula A record review of the facility's undated Daily Duty Sheet - 3rd Floor did not reveal the resident was on Plasmapheresis or had an AV fistula and required special precautions need related to the right arm AV fistula. An observation on 06/11/2024 at 3:21 PM revealed Resident 42's right arm had an AV fistula located on the inner elbow. In an interview on 06/11/2024 at 3:21 PM, Resident 42 confirmed the resident did leave the facility to have a procedure done every 2 weeks to separate the blood and did have an AV fistula located in the inner elbow of the right arm. The resident was not sure what the name of the procedure was. In an interview on 06/12/2024 at 8:30 AM, The Director of Nursing confirmed Resident 42 was on Plasmapheresis (a process of removing the blood from the body, separating it into plasma and cells, and transfusing the cells back into the bloodstream) and had an AV fistula in the right arm. In an interview on 06/12/2024 at 8:58 AM, the MDS Coordinator (MDS)-A confirmed Resident 42 had Plasmapheresis done every 2 weeks, had a AV fistula in the right arm. MDS-A confirmed Resident 42's Plasmapheresis and AV fistula was not on the Care Plan and should have been.

Licensure Reference Number 175 NAC ,d+[DATE].11E Based on observation, record review, and interview, the facility failed to provide clean and sanitary conditions for food preparation and failed to prevent the potential for food borne illnesses due to expired food and beverages in the refrigerator. The failure had the potential to affect all 63 residents receiving meals from the kitchen and kitchenettes. The facility identified a census of 63 and sample size was 18. Findings are: The initial tour of the main kitchen on [DATE] at 6:00 PM revealed a cart with containers that were not upside down, there was grease on the floor by the stove and the front of the oven was dirty. The observation also revealed that the water and gasoline pipes in-between the stove and oven were exposed and were covered with grease and dust. The shelf containing clean trays had dust and lint on it as well as the shelf above the clean prep sink had a thick layer of dust and debris covering the surface. There was a dust pile and debris on the floor in storage room. The initial tour of the second floor kitchenette on the [DATE] at 07:05 PM revealed the freezer had two open tortilla packages without dates on them. The initial tour of the third floor kitchenette on [DATE] at 6:55 PM revealed outdated orange juice in a pitcher dated [DATE] and preparation date was [DATE]; a pitcher of apple juice did not have an expiration date on it and the preparation date was [DATE]; and a bag of cereal had no open date. The initial tour of the fourth floor kitchenette on [DATE] at 6:35 PM revealed that the steam table was dirty; a tray under the steam table was dirty; the microwave was dirty with food debris; and the storage room floor had water stains that went from the floor under the sink and into the food storage room. There was an orange juice concentrate in the refrigerator with an expiration date of [DATE] and two cereal packages were open and not dated. Observation also revealed the the resident refrigerator in the kitchenette corridor had undated and unlabeled drinks and a medication pass supplement. There was a container of opened food and beverage thickener that was not dated. There was an uncovered and unlabeled dish of ice-cream in the freezer door with a metal spoon in it and two uncovered pans of cake observed sitting on the counter in the kitchenette corridor with missing pieces. At 6:45 PM, an interview with Culinary Services Employee A, confirmed the outdated drink and food items. On [DATE] at 10:45 AM a second observation of the main kitchen with the Registered Dietician (RD) and the Culinary Certified Dietary Manager (CDM), Dietetic Technician Registered (DTR) present, revealed the water and gasoline pipes in-between the stove and oven were exposed and covered with grease and dust; the shelf underneath the steamer had dirt and debris on it which had a stack of large stainless steel bowls lying face down on the dirty shelf; the shelf containing clean trays with dust and lint on it; there was a dust pile and debris on the storage room floor; and the shelf above the clean prep sink where pureed food was prepared had a thick layer of dust and debris covering its surface. Interview on [DATE] at 10:45 AM with the RD, CDM, and DTR confirmed the water and gasoline pipes in-between the stove and oven were exposed and covered with grease and dust; the shelf underneath the steamer had dirt and debris on it which had a stack of large stainless steel bowls lying face down on the dirty shelf; the shelf containing clean trays with dust and lint on it; there was a dust pile and debris on the storage room floor; and the shelf above the clean prep sink where pureed food was prepared had a thick layer of dust and debris covering its surface.

Licensure Reference Number 175 NAC 12-006.09C Based on interviews and record reviews; the facility failed to develop care plans to address pain for 2 (Resident 64 and Resident 50) of 4 sampled residents. The facility census was 63 with 18 sampled residents. Findings are: A. Record review of Resident 64's face sheet dated 4/5/22 as date of admission revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the resident on 4/19/22 at 9:00 AM revealed the resident frequently rates (gender) pain greater than 5 and that the resident has to request the [MEDICATION(S)] be put on before therapy but most of the time the patch does not get put on in time for therapy. This morning I did not get my pain patch and Occupational Therapy was very painful to me. Record review of Resident 64's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (a medication used to treat nerve pain) 300mg capsule by mouth three times a day. -[MEDICATION(S)] PA Patch 4% (a patch used for pain) apply topically and change daily (on 12 hours, off 12 hours). -Acetaminophen 325 milligrams (mg) take 2 tablets by mouth every 8 hours. -Assess pain every shift, have resident rate pain if present. -Occupation therapy, physical therapy and speech therapy to evaluate and treat. -Wear right shoulder sling immobilization at all times. Record review of Resident 64's care plan revealed that pain was not addressed on the care plan. The care plan addressed limited physical mobility related to weakness and fracture. Interview with Registered Nurse (RN) Clinical Nurse Coordinator (CNC) for Unit 1 on 4/22/22 at 9:25 AM confirmed that pain, pain medications, and non-pharmacological interventions were not addressed on Resident 64's care plan and that Resident 64's pain assessment on 4/19/22 day shift revealed Resident 64's pain to be rated at a 6. B. Record review of Resident 50's face sheet dated 3/26/2022 as date of admission revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the resident on 4/19/22 at 9:10 AM revealed that the resident was grimacing when attempting to sit up in bed independently and holding left leg. Interview with the resident on 4/19/22 at 9:11 AM revealed that the resident has a lot of pain in the left leg after the stroke and today the the resident would rate the pain at an 8 on a scale of 1 to 10. Resident 50 also verbalized that (gender) asked for heat several times but had never received it and that (gender) might have to wait an hour to get a (PRN: as needed or requested medication) pain medication when requesting it. Record review of Resident 50's physicians orders revealed the following orders; -Pain assessment every shift, rate pain on a 1 to 10 scale. -[MEDICATION(S)] (a medication used to treat nerve pain) 100 milligrams (MG) orally three times a day. -[MEDICATION(S)] PA Pad 4% (a patch used to treat pain) apply 2 patches topically and change daily (on 12 hours, off 12 hours). -[MEDICATION(S)] tab (a narcotic used to treat moderate pain) 50 MG 1 tablet orally every 6 hours as needed (PRN). Record review of Resident 50's comprehensive care plan revealed an identified Behavior problem showing a BIMS of 14, indicating resident is cognitively intact and alert/oriented and able to make choices. The Care Plan also revealed that pain, [MEDICATION(S)] and non-pharmacological interventions were not addressed on the care plan. The care plan had an identified problem for medications with a black box warning and to monitor for undesirable side effects and a problem for limited physical mobility. Record review of Resident 50's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN CNC for Unit 2 on 4/22/22 at 9:15 AM confirmed that [MEDICATION(S)] and [MEDICATION(S)], and any other non-pharmacological interventions for pain were not on the care plan.

Licensure Reference Number 175 NAC 12-006.09D Based on interview and record review; the facility failed to administer scheduled pain medication at the scheduled time for 1 (Resident 64) of 4 residents sampled, which resulted in Resident 64 having pain. The facility identified a census of 63. Findings are: Record review of Resident 64's face sheet dated 4/5/22 as date of admission revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the resident on 4/19/22 at 9:00 AM revealed the resident frequently rates the resident's pain greater than 5 and that the resident has to request the [MEDICATION(S)] be put on before therapy but most of the time the patch does not get put on in time for therapy. This morning I did not get my pain patch and Occupational Therapy was very painful to me. Interview also revealed that the resident will not lift right arm or move right arm as it causes too much pain. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/19/22 it was administered at 10:23 AM and on 4/21/22 the [MEDICATION(S)] 4% was administered at 11:01 AM. Record review of therapy notes on 4/22/22 confirmed that Resident 64 had two therapy sessions on 4/19/22 and 4/21/22. Interview with Resident 64 on 4/22/22 at 10:54 AM confirmed that therapy is done every morning and afternoon. Record review of Resident 64's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 10 being the worst pain. Interview with Registered Nurse (RN) Clinical Nurse Coordinator (CNC) for Unit 1 on 4/22/22 at 9:25 AM confirmed that Resident 64's pain assessment on 4/19/22 day shift revealed Resident 64's pain to be rated at a 6. Interview on 4/21/22 at 9:10 AM with the Therapy Manger revealed that there was no schedule for therapy. Further discussion revealed that the patient was responsible for asking for pain medication prior to therapy and therapy does not call nursing to let them know when the patient's therapy will be occurring. Interview on 4/22/22 at 7:30 AM with RN E confirmed that nursing is rarely notified when therapy is going to see the residents in order to give pain medication. Interview on 4/21/22 at 10:20 AM with RN F confirmed that if therapy goes to see a resident and the resident is having pain, they will ask the nurse to give pain medication and therapy will come back anywhere from ½ hour to 2 hours later to do therapy. Record review of Resident 64's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (a medication used to treat nerve pain) 300mg capsule by mouth three times a day. -[MEDICATION(S)] PA Patch 4% (a patch used for pain) apply topically and change daily (on 12 hours, off 12 hours). -Acetaminophen 325 milligrams (mg) take 2 tablets by mouth every 8 hours. -Assess pain every shift, have resident rate pain if present. -Occupation therapy, physical therapy and speech therapy to evaluate and treat. -Wear right shoulder sling immobilization at all times. Interview with the Director of Nursing on 4/22/22 at 3:00 PM confirmed the [MEDICATION(S)] was administered over 2 hours late on 4/19/22 and that Resident 64 rated (gender) pain at a 6.

Licensure Reference Number 175 NAC 12-006.10A2 Based on observation, record review, and interview, the facility failed to ensure residents received medication in accordance with prevailing standards and physician orders for 2 residents (Residents #64 and #52.) The facility census was 63 current residents. The sample size was 18 residents. Findings are: A. A review of the complete medical record for Resident #52 revealed the resident was admitted on [DATE]. Continued review revealed the resident had orders for: 1) Metoclopram (a medication utilized in the treatment for gastroentestinal reflux disease)10mg (milligrams) tablet; 1 tablet by mouth four times daily. Give 30 minutes before a meal*; and 2) [MEDICATION(S)] (a medication utilized in the treatment for constipation) 24mcg (micrograms) 1 capsule by mouth twice daily. *Take with food, Do not crush* An observation on 4/21/2022 at 08:55 AM revealed RN-F (Registered Nurse-F) prepared medications for Resident #64. 1 tablet of Metoclopram and 1 capsule of [MEDICATION(S)] were among the medications prepared for administration to the resident. Resident #64 was sitting in a personal recliner in the residents own room. RN-F offered the medications to Resident #64 and the resident consumed the medications. On 4/21/2022 at 08:55 AM an interview with Resident #64 revealed the morning meal had been consumed at least 30 minutes ago. An interview with RN-F revealed Resident #64 had eaten breakfast approximately 30 minutes prior to receiving the morning medications. B. A review of the complete medical record for Resident #52 revealed the resident was admitted on [DATE]. Continued review revealed the resident had orders for: 1) [MEDICATION(S)] (a medication utilized in the treatment for heart disease) 3.125mg 1 tablet by mouth twice daily. Take with food*; and 2) [MEDICATION(S)] Sulfate (a medication utilized in the treatment of [CONDITION(S)][low blood iron])1 tablet by mouth twice daily with meals. An observation on 04/21/22 at 09:10 AM revealed RN-F prepared medications for Resident #52. 1 tablet of [MEDICATION(S)] 3.125mg and 1 tablet [MEDICATION(S)] sulfate 325mg were among the medications prepared for administration to the resident. Resident #52 was sitting in a personal recliner in the residents own room. RN-F offered the medications to Resident #52 and the resident consumed the medications. On 4/21/2022 at 09:10 AM an interview with Resident #52 revealed the resident had eaten breakfast at approximately 08:20 AM. An interview with RN-F revealed Resident #52 had eaten breakfast approximately 45 to 50 minutes prior to receiving the morning medications On 4/21/2022 an interview with Administrator verified medications had not been administered as ordered to Resident #52 and Resident #64. An interview with the nurse consultant vereified medications had not been administered as ordered to Resident #52 and Resident #64.

Licensure Reference Number 175 NAC 12-006.17A (1), 12-006.17B Based on observation, interview and record review the facility failed prevent and contain COVID-19 by A). Failing to identify and separate grey zone (a zone that is used for new admissions and resident who require outside appointments to quarantine for 14 days) and green zone (a zone that is free from exposure from Covid-19 with negative tested residents) residents on 2 floors (1st floor and 2nd floor grey zones). This had the potential to affect all residents on the 1st and 2nd floors in grey zones. B.) The facility failed to ensure the Covid -19 Guideline policy; identified residents who had been removed from quarantine (Green Zone) and provide guidance for care and PPE (Personal Protective Equipment) use for those resident. This had to potential to affect all resident in the facility. C. The facility failed to ensure 2 employees followed COVID guidelines for PPE use in a grey zone. This had the potential to affect all residents on the 1st floor. D. The facility failed to ensure hand hygiene was completed during meal delivery for residents who resided in rooms [ROOM NUMBER]. The facility census was 65. Findings are: A. An observation on 10/28/20 at 7:25 AM of a sign as entered the 1st floor hall identified the hall as a grey Zone. An interview on 10/28/20 at 11:03 AM with the DON (Director of Nurses) confirmed all residents residing on 1st floor were in the grey zone. An interview on 10/28/20 at 3:43 PM with the DON confirmed 18 residents resided on 1st floor. An observation on 10/29/20 at 7:54 AM of 1st floor Grey Zone revealed the following room doors were open; 102, 105, 106, 108, 110, 112, and 123. An observation of a grey zone on 10/28/20 at 10:15 AM of NA (Nurse Aide) A entered room [ROOM NUMBER] without a gown. The RN (Registered Nurse) B donned a gown and gloves after HH (Hand Hygiene) and took a gown in room [ROOM NUMBER] for the NA. An interview on 10/28/20 at 10:27 AM with RN B revealed the resident in 100 was not on quarantine. RN B reported the date written in ink on the door sign was the indication of when a resident would come off quarantine. RN B was unable to verify the zone the resident would be in, if the resident was no longer on quarantine. RN B reported the staff were not required to use a gown when entering the room if a resident was no longer on quarantine. An observation on 10/29/20 at 8:06 AM of floor 2 was a grey zone up to the barrier to the red zone. An observation of a grey zone on 10/29/20 at 10:26 AM of 2nd floor the following room doors were open: 201 and 210. An observation of a grey zone on 10/29/20 at 10:26 AM on 2nd floor revealed a resident ambulated the hallway with the therapist and greeted the Resident in 201 as the door to room [ROOM NUMBER] was open. An interview on 10/29/20 at 11:30 AM with the VPO (Vice President of Operations) confirmed some resident that were on the Gray Zone were off quarantine but kept on the Gray Zone related to appointments. VPO reported the residents who were quarantined were not being ambulated. Residents who were off quarantine the staff knew which residents were no longer quarantined and staff could identify the apporpriate PPE needed for each resident. Record review of a List of Resident who were no longer on quarantine on floor 1 provided by the DON revealed the follow rooms were no longer in isolation: 100, 101, 103, 110, 111, and 118. Residents who remained on quarantine were rooms 102, 104, 105, 106, 107, 108, 109, 112, 113, 114, 116, 120. Record review of a List of Resident who were no longer on quarantine on floor 2 provided by the DON revealed the follow rooms were no longer in isolation: 202, 203, 206, 208, and 216. Residents that who remained on quarantine were rooms 200, 201, 205, and 207. An interview on 10/29/20 at 10:02 AM with the DON confirmed 1st floor was a grey zone if residents were no longer quarantined the residents could ambulate with therapies in the hallway on the grey zone. There was not a green zone- the staff would continue some of the gray zone precautions B. Record review of the facility policy revealed; guidelines for Red Zones, Yellow Zones and Grey Zones. The policy had not addressed resident who were no longer on quarantine (Green Zone) and the required PPE needed during cares. An interview on 10/29/20 at 11:30 AM with the VPO (Vice President of Operations) confirmed some residents in the Gray Zone were no longer in quarantine. C. An observation on 10/28/20 at 7:30 AM of RN C exited a gray zone room, Resident 9, without a face shield or goggles. An interview on 10/28/20 at 7:35 AM with RN C confirmed RN C had not used a face shield or goggles in a grey room related to the resident was difficult to draw blood from. After the interview RN-C retrieved a face shield from behind the nurse's desk. An observation on 10/28/20 at 7:44 AM of RN D entered a resident room on the grey zone with eye glasses on and without goggles or a face shield. An interview on 10/28/20 at 7:35 AM with RN D confirmed RN D understood glasses were okay to wear on the grey unit in place of goggles or face shield. An interview on 10/28/20 at 8:47 AM with the IP (Infection Preventionist) confirmed the COVID-19 guideline for PPE on a grey zone was N95 mask, goggles or face shield and gown. IP confirmed eye glasses were not considered an approved eye protection on a Grey Zone. Record review of Covid -19 Guideline Policy dated 10/21/19 revealed; New Admission Referral and Admission (Gray Zone) Guideline: #9. SNF/ALF (Skilled Nursing Facility/Assisted Living Facility) admissions will initiate droplet precautions at all times. c. An N95 Mask and eye protection will be donned prior to entering the Gray zone. Record review of a CDC (Centers for Disease Control) article, dated 2020/06 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed; Implement Universal Use of Personal Protective Equipment HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also: Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Wear an N95 or equivalent or higher-level respirator, instead of a facemask, for: Aerosol generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings FAQ) and Respirators with exhalation valves are not recommended for source control and should not be used during surgical procedures as unfiltered exhaled breath would compromise the sterile field. For HCP working in areas with minimal to no community transmission, HCP should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. Universal use of a facemask for source control is recommended for HCP. D. An observation on 10/29/20 at 8:07 AM of NA E passed meal trays to residents. NA E retrieved food from the cart enclosed in Styrofoam container, knocked on the door went into the room with food on the gray zone. No HH (Hand Hygiene) was completed. NA E pushed cart down hall to Resident 18's room, NA E retrieved food from the cart enclosed in Styrofoam container, knocked on the door and went into Resident 18's room, closed the door, exited room without HH and took a banana off of the cart and delivered banana to Resident 18. NA E pushed the cart to Resident 17's room, NA retrieved food from the cart enclosed in Styrofoam container, knocked on the door and went into Resident 17's room, exited room without HH and took a banana off of the cart and delivered to Resident 17. An observation on 10/29/20 at 8:09 AM of the RN F informed NA E to perform HH between meal deliveries. An observation on 10/29/20 at 8:14 AM of NA E retrieved food from the cart enclosed in Styrofoam container, knocked on the door and went into Resident 16's room, exited room without HH and took a banana off of the cart and delivered the banana to Resident 16. Record review of HH Policy dated 3/6/20 revealed; Hand hygiene is the single most important way to prevent the spread of infection and disease, therefore it the policy of the company to require employees to adhere to the following hand hygiene policy. PROCEDURE: 1. Proper hand hygiene should occur: a. Before and after scheduled shift. b. Before and after all direct resident/tenant cares which includes both touching intact and non-mtact skin. This also includes between moving from a contaminated body-site to a clean-body site during patient care. c. Before putting on gloves and after taking them off (Remember, wearing gloves is no substitute for good hand washing. Likewise, hand hygiene does not eliminate the need for gloves). d. Before, during, and after food preparation. e. After using the restroom. f. After touching objects that are likely to be contaminated with potentially infectious organisms including but not limited to bedpans, urinals, urine measuring devices, dentures, dressings, used tissues, raw meat and eggs, eating utensils, etc . g, After handling any type of animal. h. After tobacco use. i. After coughing, sneezing, using a handkerchief or disposable tissues. j. After eating. k. Anytime hands are soiled or touch contaminated items including but not limited to garbage.

Licensure Reference Number 175 NAC 12-006.10A1 Based on observations, record review and interview, the facility failed to ensure a resident was assesed and competent to safely self-administer medications and to keep medications at the resident's bedside for Resident 7. This affected 1 of 1 sampled residents. The facility census was 64. Findings are: An observation on 9/20/20 at 12:11 PM revealed Resident 7 had a bottle of Refresh eye drops on the bedside table. An interview with Resident 7 on 9/20/20 at 12:11 PM revealed the resident had been self-administering the Refresh eye drops. Review of the facility policy on Administering Medications dated 10/2011 revealed residents may self-administer their own medications once the physician and the Interdisciplinary Care Planning Team have determined the resident has the decision-making capacity to do so safely. Review of Resident 7's current physician orders dated September 2020 revealed there was no documented order for the resident to self-administer the Refresh eye drops. Review of Resident 7's current undated Care Plan did not address the resident was determined safe to self-administer medications. An interview with Clinical Coordinator (CC)-A on 9/23/20 at 8:10 AM confirmed Resident 7 did not have an assessment completed for self-administration of medications and no physician's order had been obtained for the resident to keep the Refresh eye drops at the bedside.

Based on record review and interview, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review - a federal requirement to help ensure individuals were not inappropriately placed in nursing homes for long term care) was reevaluated after a new [DIAGNOSES REDACTED]. The facility census was 64. Findings are: A. Review of Resident 21's PASRR dated 4/27/17 revealed under Section I: Mental Illness, Question 1: Does the individual have any of the following Serious Mental Illnesses, the checkbox next to No was checked. The checkbox next to the Psychotic/Delusional Disorder was not marked. Review of Section X: Determination and Outcome revealed the resident did not meet criteria for further review at that time. Review of Resident 21's PASRR Determination letter dated 4/27/17 revealed no further screening was required unless the resident was later suspected or found to have a mental illness. Review of Resident 21's EHR (Electronic Health Record) Medical [DIAGNOSES REDACTED]. Review of Resident 21's MDS (Minimum Data Set - a federally mandated process for clinical assessment of all residents) dated 1/28/20 revealed the [DIAGNOSES REDACTED]. Review of Resident 21's MDS dated [DATE] revealed the [DIAGNOSES REDACTED]. Section A - Identification Information - revealed the resident was not currently considered by the state level II PASRR process to have serious mental illness. Interview on 9/23/20 at 7:39 AM with the Director of Case Management confirmed Resident 21's PASRR was not updated after Resident 21's new [DIAGNOSES REDACTED]. The Director of Case Management confirmed the PASRR should have been updated with the new diagnosis. B. Review of Resident 31's PASARR evaluation dated 2/1/19 revealed no serious mental illness with [DIAGNOSES REDACTED]. Review of Resident 31's MDS dated [DATE] revealed the resident had the following diagnoses; Anxiety Disorder and Depression. There was no [MEDICAL CONDITION] identified. Review of Resident 31's MDS dated [DATE] revealed the resident had the following diagnoses; Anxiety Disorder, Depression, and [MEDICAL CONDITION] (other than [MEDICAL CONDITION]). Review of Resident 31's Order Summary dated 9/23/20 revealed the resident was prescribed [MEDICATION NAME] (a medication classified as an antipsychotic) 25 milligrams (mg) at bedtime for [MEDICAL CONDITION] in the absence of dementia related to Unspecified [MEDICAL CONDITION], Not Due to a Substance or Known Physiological Condition. Review of Resident 31's medical record on 9/23/20 revealed the resident had a [DIAGNOSES REDACTED]. An interview with Clinical Coordinator (CC)-A on 9/23/20 at 8:15 AM confirmed Resident 31's most recent PASARR evaluation was dated 2/1/19 and the resident had not had a new PASARR since the new [DIAGNOSES REDACTED]. C. A record review of the level I PASRR for Resident 16 revealed it did not contain two antidepressant medications that Resident 16 had been admitted with. 09/22/20 03:12 PM An interview with the facility DON (Director of Nursing) confirmed that the level I PASRR did not contain two antidepressant medications that Resident 16 had been admitted with.

LICENSURE REFERENCE NUMBER 175NAC 12-006.09C1a The facility failed to complete a baseline Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) within 48 hours that included information necessary to provide care related to the PICC line (a peripherally inserted central catheter that is a form of intravenous access that can be used for a prolonged period of time) for Resident 16 and the PICC line and wound vac (a device that drains seeping liquid from a wound that is used to reduce the incidence of infection and aid in the healing process by forming an airtight cover and pumping the liquid out) interventions for Resident 53. Resident sample size was 16. Facility census was 64. Findings are: A record review of the baseline CCP completed within the first 48 hours revealed it did not contain the PICC line use or care related to the UTI (urinary tract infection) for Resident 16. An interview on 09/22/20 at 03:12 PM with the facility DON (Director of Nursing) confirmed that the baseline CCP for Resident 16 did not contain the PICC line use or care of related to the UTI and should have. A record review of the baseline CCP completed in the first 48 hours did not contain the wound vac care interventions, the PICC line use or the Wound Care Clinic (WCC) visits for Resident 53. An interview on 09/22/20 at 03:12 PM with the facility DON confirmed that the baseline CCP for Resident 53 did not contain the wound vac care interventions, the PICC line or the WCC.

Based on record review and interview, the facility failed to ensure the physician documented a clinical rationale for the contraindication of a GDR (Gradual Dose Reduction) for [MEDICAL CONDITION] medications (a medication capable of affecting the mind, emotions, and behavior) for 1 resident (Resident 21) of 5 residents reviewed. The facility census was 64. Findings are: Review of Resident 21's Order Summary Report dated 9/21/20 revealed Resident 21 was ordered: - [MEDICATION NAME] 20 MG ([MEDICATION NAME] Oxalate - a medication used to treat depression and anxiety) by mouth one time a day for dementia (a group of thinking and social symptoms that interferes with daily functioning) and major [MEDICAL CONDITION] (a mental health disorder characterized by persistently depressed mood or loss of interest in activities) - [MEDICATION NAME] 25 MG (Quetiapine [MEDICATION NAME] - an antipsychotic medication that works by changing the actions of chemicals in the brain) by mouth at bedtime for unspecified [MEDICAL CONDITION], not due to a substance or known physiological condition (a mental disorder characterized by a disconnection from reality). Review of Resident 21's Note to Attending Physician/Prescriber dated 5/11/20 revealed the facility consultant pharmacist identified the resident had been receiving [MEDICATION NAME] and Quetiapine. The pharmacist identified nursing staff would not support a dose reduction due to Resident 21 displaying behaviors disruptive to cares and other residents. The pharmacist identified Resident 21 was a candidate for a trial dosage reduction attempt to find the minimal effective dose. On 6/5/20, Resident 21's healthcare provider noted a dosage reduction was clinically contraindicated, but did not include specific rationale explaining why. The healthcare provider's response was noted by an LPN (Licensed Practical Nurse) on 6/7/20. Interview on 9/23/20 at 7:23 AM with the DON (Director of Nursing) confirmed the healthcare provider's clinical rationale for the contraindication of the GDR should have been documented on the form, but the documentation was not completed.

Based on record review and interview, the facility failed to ensure residents received the notice of transfer in writing when being sent to the hospital. This affected 2 residents (Residents 7 and 44) of 3 residents sampled. The facility census was 72. Findings are: Review of the Bed Hold/Transfer and Re-Admission Policy form revised 11/21/17 revealed the form included blank spots to designate who was contacted about the bed hold policy and the date contacted, the reason for discharge/transfer from the facility in layman's terms, indication of if the resident/representative wanted to hold the bed, and signature lines and dates for the resident/representative and the facility representative. A. Review of Resident 7's Bed Hold/Transfer and Re-Admission form dated 4/18/19 revealed SSW-A discussed the bed hold policy and the reason for transfer from the facility with the resident's representative on 04/18/19. The form indicated the resident's representative did want the resident's bed held, and the signature line revealed via phone with the resident representative's name. Review of progress note dated 4/18/19 revealed SSW-A spoke with Resident 7's representative by phone regarding the facility's bed hold policy. Interview on 5/20/19 at 9:35 AM with CC-B revealed the form was not given to Resident 7 at the time of transfer. B. Review of Resident 44's Bed Hold/Transfer and Re-Admission form dated 4/30/19 revealed SSW-A discussed the bed hold policy and the reason for transfer from the facility with the resident's representative via telephone on 4/30/19. The form indicated the resident's representative did want the resident's bed held. The signature line revealed via phone with the resident representative's name. Review of progress note dated 4/30/19 revealed SSW-A spoke with Resident 44's representative by phone regarding the facility's bed hold policy. Interview on 5/20/19 at 9:35 AM with CC-B revealed the form was not given to Resident 44 at the time of transfer. Interview on 5/20/19 at 9:35 AM with CC-B (Clinical Coordinator) revealed the facility did not provide the Bed Hold/Transfer and Re-Admission Policy form to the resident at the time of transfer. CC-B revealed the social services department would call the resident's representative regarding the bed hold policy and reason for transfer. Interview on 5/20/19 at 3:30 PM with SSW-A (Social Services Worker) revealed the bed hold policy was given to the resident and representatives at the care plan meetings so the resident representatives were aware of the policy, but the form is not given to the resident at the time of transfer. SSW-A revealed if a resident is transferred out of the facility after business hours, the Social Services department would notify the resident's representative the next morning and the House Supervisor would notify the resident's representatives if the resident was transferred on the weekend. SSW-A revealed the resident/representative did not get a copy of the form when it is completed, but it is given to the CMD (Case Management Director) and kept on file

Licensure Reference Number 175 NAC 12.006.11E Based on observation, record review; and interview, the facility failed to ensure that residents personnel refrigerators were being monitored and documentation being done for the temperatures in these refrigerators. This had the potential to affect 3 residents with personal refrigerators, Residents 9, 42, and 35. The facility census was 72. Findings are: Review of the Policy for Personal Food Storage and Personal Food Item Guidelines from Gateway Vista dietary Director, revealed that all refrigeration units will have internal thermometers to monitor temperatures. Units must maintain safe internal temperatures in accordance with state and federal standards for safe food storage temperatures. Staff will monitor and document unit refrigerator temperatures. Observation of the individual refrigeration units on 5/14/19 at 3:00 PM on the 4th floor revealed 3 resident refrigerators for Residents 9 , 35, and 42 did not contain thermometers to ensure temperatures remained in the safe zone for foods. Interview on 5/20/19 at 3:00 PM with E-RN revealed that the resident's refrigerators did not have thermometers for individual refrigerators and did not have any type of documentation for those refrigerator units.