Every finding on record at Genoa Community Hospital/LTC

Licensure Reference Number 175 NAC 12-006.18 Based on observations, record review, and interviews the facility failed to implement infection prevention measures to prevent the potential spread of infection for Resident 8 during the implementation of Enhanced Barrier Precautions (EBP), cleanliness of facility in the laundry room, and handwashing during the provision of care for Resident 21. The sample size was 14 with a census of 36. Findings are: A. Review of the facility policy EBP with no revision date revealed the following: -EBP refers to an infection control intervention indicated for residents with wounds regardless if wound had an infection, -EBP would be used for chronic wounds including venous stasis ulcers and diabetic foot ulcers, -Personal Protective Equipment (PPE), gown and gloves, was only necessary when performing high-contact care activities, -High-contact resident care activities included: dressing, transferring, providing hygiene cares, changing linens, toileting assistance, and wound care. B. Review of Resident 8's Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 2/26/25 revealed the resident required substantial assistance with transfers and was dependent on staff for toileting hygiene. The resident had a diagnosis of Diabetes and Chronic Venous Insufficiency and had 1 venous ulcer. Review of Resident 8's care plan revealed the resident had a venous stasis ulcer of the left big toe related to chronic venous insufficiency and was on EBP during high contact cares. Review of Resident 8's wound care note dated 5/15/25 revealed Resident 8 had a diabetic toe wound (an open sore that developed on the toe due to complications of diabetes) that had yellow, odorous drainage. There were no measurements for the wound. Review of resident 8's physician order revealed the resident had an order dated 2/11/25 to apply betadine to wound bed on the left big toe 2 times daily, leave open to air at rest, cover with ambulation related to Venous Insufficiency (veins in the legs are unable to return blood to the heart effectively). The following observations were made related to Resident 8: -5/21/25 at 10:00 AM an EBP sticker was on the resident's name tag going into the resident's room. -5/22/25 at 9:15 AM Nursing assistant (NA-B), entered the residents room and put on gloves but no gown. NA-B transferred the resident to the toilet, assisted the resident with toileting cares and then transferred resident back to the wheelchair with only gloves on for PPE. An interview with the Director of Nursing (DON) on 5/28/25 at 12:30 PM confirmed the facility staff did not follow the EBP policy and NA-B should have had gown and gloves on for PPE when completing high contact cares with Resident 8 on 5/22/25. C. Review of the facility policy Environmental Services with no review date revealed the following: - It was the policy of Genoa Medical Facilities to maintain a physical and psychosocial environment that promotes the health, safety and comfort of each resident, -This policy is applied to all facilities staff, included but not limited to housekeeping, nursing, maintenance, dietary and administrative personnel, and -The facility will maintain all areas in a manner that is clean, hazard-free, and compliant with infection control standards. An observation on 5/28/25 at 12:00 PM revealed the clean side of the laundry room had a black fan that blew air on the clean linens. The fan had a thick layer of dust on the fan blades and the fan cover. The fan blew out dust particles on the clean linens. The air conditioner vent above the clean linens had a heavy layer of dust that covered the vents and cold air was blowing out of the vent onto the clean linens. An interview with the head of laundry on 5/28/25 at 12:00 PM confirmed the black fan was blowing dust on the clean linens, the vent above the clean linens had a heavy layer of dust and was blowing onto the clean linens. The cleaning schedule for the laundry room was reviewed with the head of laundry, cleaning the fans and vents were not on the list. 45739 D. Review of the facility policy Hand Hygiene, undated revealed the purpose was to provide guidelines for effective hand hygiene to prevent the transmission of bacteria, germs, and infections. Staff were to: -follow standard precautions, -change gloves and discard after each resident contact, and -change gloves when moving from contaminated body site to a clean body site. Staff were to perform hand hygiene: -before coming on duty, -when hands were soiled, -before each resident encounter, -after coming in contact with resident's skin, -after working on a contaminated body site then moving to a clean body site, -after coming in contact with bodily fluids, dressings, mucous membranes, -always after removing gloves or facemasks, -after toileting, -soap and water must be used when hands were visibly soiled, and -if hands are not visibly soiled, hands could be disinfected with either an alcohol-based hand rub or soap and water. Review of Resident 21's MDS dated [DATE] revealed the resident had cognitive impairment; had impairments to lower extremities on both sides; was dependent with toileting, dressing, mobility and transfers; was always incontinent of bowel and bladder functions; and had dementia. Review of Resident 21's Care Plan last revised 4/7/25 revealed the resident was cognitively impaired and required assistance with dressing, toileting, and transfers. An observation on 5/22/25 at 1245 Medication Aide (MA)-G and MA-H performed hand hygiene, applied gloves and entered Resident 21's room. The resident was in the wheelchair. MA-G brought a sit to stand mechanical lift into the residents room and the MA's hooked the resident up to the lift. The MA's lifted the resident up to standing position. MA-H pulled the residents pants down and removed the brief, and doffed without any concerns. MA-G performed perineal care using pre-moistened wet wipes. While continuing to wear the same pair of soiled gloves, MA-G applied a clean brief to the resident. While continuing to wear the same soiled gloves, MA-G pulled the residents pants up. Both MA's transferred the resident to the recliner. MA-G while continuing to wear the same pair of soiled gloves, covered the resident with a blanket and used the recliner remote control to lift the resident's legs up to a reclined position. MA-G then removed their gloves and performed hand hygiene. An interview on 5/22/25 with MA-G at 1:45 PM confirmed MA-G did not change gloves or perform hand hygiene at appropriate intervals during the provision of care. An interview on 5/28/25 at 10:30 AM with the DON confirmed gloves should be changed and hand hygiene performed when going from a dirty to a clean surface.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to submit a completed investigation of Resident's 139's hip fracture and Resident 26's fall with an ankle fracture to the State Agency in 5 working days. The sample size was 14 and the facility census was 36. Findings are: A. Review of the facility policy Abuse and Neglect revealed the following: -The facility recognized the importance of assuring residents were free from all forms of abuse and implemented safeguards and practices to ensure resident safety. -Potential employees were screened for a history of abuse, mistreatment of residents as allowed by law, including checking with former employers, with appropriate licensing boards, and registries. -Employees were trained on issues related to abuse and what constituted abuse, neglect, mistreatment, and misappropriation. -Events, such as suspicious bruising of residents, occurrences, patterns, and trends that could constitute abuse were identified. -Incidents of suspected of abuse were reported to the Director of Nursing (DON), and/or director of Social Services for investigation. -Investigation results were documented, retained, completed and submitted to the required agencies within 5 working days. B. Review of Resident 139's Admission record revealed the resident was admitted on [DATE] and had dementia, heart disease, high blood pressure, and dizziness. Review of Resident 139's Nursing Admission assessment dated [DATE] revealed the resident had 1-2 falls in the past 90 days, had a change in cognition and displayed behavioral concerns. The resident ambulated with a device, was unstable, at risk for falling and at risk to wander. Review of Resident 139's Care Plan dated 7/13/24 revealed the resident had self-care deficits, confusion, dementia, and impaired balance. In addition, the resident had impaired cognition and thought processes. The resident was admitted to the memory support unit on 7/10/24. Review of Resident 139's Progress note dated 9/4/25 at 2:23 AM revealed the resident was assisted to bed at 8:00 PM and at 9:30 PM (on 9/3/25) staff heard the resident yell Get me out of here at which time the resident reported I twisted my leg when I fell through the roof into the basement. The resident was given Tylenol. At 2:15 AM on 9/4/24 when the resident was assisted to stand and walk into the bathroom, the resident was unable to bear weight on the left leg and the leg was externally rotated. Communication was forward to the Provider asking if an x-ray would be appropriate to check for a pathological fracture (fracture occurring unrelated to trauma or naturally occurring secondary to underlying bone disease). An x-ray was ordered and completed confirming a left hip fracture (The time of the x-ray was not documented). On 9/4/24 at 6:09 PM the provider was at the facility and spoke to the resident's family about the fracture and the family chose hospice care. Review of Resident 139's X-ray report dated 9/4/24 revealed a fracture of the left hip with advanced degenerative arthritis of the hip. Review of Resident 139's Investigation form of the 9/4/24 incident revealed the facility reported the fracture to Adult Protective Services at 12:30 PM on 9/4/24. Additional review revealed the facility conducted an investigation, including staff interviews and the findings determined that abuse had not occurred. There was no evidence the investigation was submitted to the State Agency as required. During an interview on 5/27/25 at 8:36 AM the facility Administrator revealed the facility completed an investigation for Resident's pathological hip fracture, however they had no evidence the investigation was submitted to the State Agency as required. 51391 Record review of a facility Abuse Investigation Report Form dated 10-22-2025 revealed Resident 26 had a fall with resulting in a right ankle fracture on 10/22/24. Review of the facilities Abuse Investigation Report Form revealed that Resident 26's fall with a right ankle fracture occurred on 10/22/24, was reported on 10/22/24 and the investigation report was submitted to the Health and Human Services Regulation and Licensure on 10/29/24, 6 working days from 10/22/24. An interview on 5/27/25 at 8:30 AM with the Director of Nursing confirmed that the Abuse Investigation Report was submitted on 10/29/24 (day 6) and should have been submitted by 10/28/25 (day 5).

Licensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview; the facility failed to ensure Resident 26's Activity of Daily Living (ADL) needs and Resident 1's Post Traumatic Stress Disorder (PTSD) triggers were identified in the resident care plans. The sample size was 14 and the facility census was 36. Findings are: A. Review of the undated facility Care Plan Policy revealed the facility provided individualized, interdisciplinary plans of care for all resident that were appropriate to the resident's needs, strengths, and results of diagnostic limitations and goals. Results of assessment were used to develop, review, and revise the care plan. Services provided met professional standards of quality including culturally competent and trauma-informed care. Review of the undated facility policy Trauma Informed Care revealed that all residents received care in a manner that recognized and responded to the effects of trauma in accordance with federal regulation which required facilities to provide trauma informed care that met professional standards of practice. Care was delivered in a safe, empathetic, and supportive environment that avoided re-traumatization and fostered recovery and empowerment. Residents were assessed upon admission and during care plan development for a history of trauma, and care plans were individualized and included strategies to minimize triggers and promote safety. B. Review of Resident 1's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans dated 3/5/25 revealed the resident had psychiatric diagnosis including anxiety, depression, a psychotic disorder, schizophrenia, and PTSD. Review of Resident 1's Care Plan with a revision date of 10/31/24 revealed the resident had depression, anxiety, a personality disorder, schizophrenia, and PTSD secondary to childhood abuse, however there were no interventions/approaches to direct the staff caring for the resident on what triggered the residents PTSD or how to respond to potential re-traumatization symptoms. During an interview on 5/28/25 at 10:24 AM The Care Plan/MDS RN confirmed PTSD triggers and interventions directing staff responses for Resident 1 were not identified or included in the plan of care. 51391 C. Review of Resident 26's MDS dated [DATE] revealed that the resident was dependent on staff for tub transfers, required supervision with bathing cares and walking 150 feet or more, set up assistance with eating, oral hygiene, toileting hygiene, dressing and personal hygiene and was independent with footwear, transfers and bed mobility and walking up to 50 feet with 2 turns. The following observations were related to Resident 26: -On 5/21/25 at 9:45 AM Resident 26 attended an activity off of the memory care unit, after the activity the resident was assisted back to the memory care unit and ambulated to own room independently with a steady gait. -On 5/21/25 at 12:20 PM the resident was ambulating independently out of the bathroom, resident stated that he just went to the bathroom, gait was steady. On 5/22/25 at 8:10 AM an interview with Nursing Assistant, NA-B, revealed that the resident required directions and cues with cares and ambulated independently. NA-B confirmed that staff are able to review the resident care plans if unsure how much assistance resident required with cares. The care plan for Resident 26 was reviewed with no interventions in place for how much assistance resident needed for dressing, toileting, bathing, transfers, ambulation, bed mobility and eating. On 5/28/25 at 8:15 AM the Long-Term Care Coordinator confirmed that there were no interventions on the care plan stating how much assistance was needed for dressing, toileting, bathing, transfers, ambulation, bed mobility and eating for the resident.

Licensure Reference Number 175 NAC-006.09 Based on record review and interviews; the facility failed to address Resident 1's diagnosis of Post Traumatic Stress Disorder (PTSD) through evaluation and care planning of potential triggers or situations that could lead to re-traumatization. The sample size was 1 and the facility census was 36. Findings are: Review of the undated facility policy Trauma Informed Care revealed that all residents received care in a manner that recognized and responded to the effects of trauma in accordance with federal regulation which required facilities to provide trauma informed care that met professional standards of practice. Care was delivered in a safe, empathetic, and supportive environment that avoided re-traumatization and fostered recovery and empowerment. Residents were assessed upon admission and during care plan development for a history of trauma, and care plans were individualized and included strategies to minimize triggers and promote safety. Review of Resident 1's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans dated 3/5/25 revealed the resident had psychiatric diagnosis including anxiety, depression, a psychotic disorder, schizophrenia, and PTSD. Review of Resident 1's Care Plan with a revision date of 10/31/24 revealed the resident had depression, anxiety, a personality disorder, schizophrenia, and PTSD secondary to childhood abuse, however there were no interventions/approaches to direct the staff caring for the resident on what triggered the residents PTSD, or how to respond to potential re-traumatization symptoms. During an interview on 5/28/25 at 08:37 AM the Director of Nursing confirmed the facility had not completed a trauma-based assessment related to resident 1's diagnosis of PTSD, or identified triggers that could induce a negative resident response to a situation. During an interview on 5/28/25 at 10:24 AM The Careplan/MDS RN confirmed PTSD triggers and interventions directing staff responses for Resident 1 were not identified or included in the plan of care.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to ensure 1) food was stored under sanitary conditions and 2) outdated food was not available for consumption to prevent the potential development of food borne illness. This had the potential to affect all residents. The facility census was 36. Findings are: Review of the undated facility policy Food Storage revealed all food will be stored off the floor and leftover food is clearly labeled and dated. In addition, leftover food is to be used within 3 days of the date prepared or discarded. Observation during the initial kitchen tour on 5/8/24 at 8:40 AM revealed the following: -Walk-in cooler had 2 large trays of macaroni salad in Styrofoam bowls with plastic wrap covering the trays. There was no label or date on the trays. -Walk-in cooler had a large bowl of orange colored Jello labeled with a date of 4/15/24 (23 days ago). -Walk-in freezer had 3 stacks of food in packages sitting directly on the floor of the freezer. An interview with the Dietary Manager on 5/8/24 at 8:40 AM confirmed the leftover macaroni salad in the walk-in cooler was not labeled or dated and should have been discarded previously. The Dietary Manager also confirmed the 3 stacks of food packages stored in the walk-in freezer should not have been stored directly on the floor.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to report a fall with significant injury to the state agency within the required time frame for Resident 15. The sample size was 4 and the facility census was 36. Findings are: Review of the facility policy Abuse and Neglect, undated, revealed the following: -when an incident or suspected incident of abuse was reported to the Director of Nursing (DON) or Director of social services or his/her designee they would investigate the incident which included interviews with the resident, staff, family, and any witness, a review of the medical record, and a review of all circumstances surrounding the incident, -any alleged violations would be reported to the state agency and all other agencies as required, and -the results of the investigation would be documented and submitted to the State Agency within five working days. Review of Resident 15's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 2/28/24 revealed the following: -the resident had severe cognitive impairment, -diagnoses of neurocognitive disorder (a progressive dementia disorder that leads to a decline in thinking, reasoning, and independent functioning), -the resident required moderate assistance with toileting, dressing, and personal hygiene, and -the resident received antipsychotic medication (a type of psychoactive medication which alters the chemicals in the brain to effect changes in behavior, mood, and emotion), antianxiety, antidepressant, and hypnotic (a sleep-inducing medication) medications. Review of the facility form Abuse Investigation Report Form for an incident that occurred on 3/8/24 at 5:48 PM involving Resident 15 revealed the resident was found lying on the hallway floor, the resident was lethargic, and had red liquid drainage on the floor surrounding the resident's head which was identified to be from a cut above the right eyebrow. The resident was sent to the emergency room and received ten stitches. The incident had no witnesses. The facility reported the incident on 3/9/24 (no time indicated) which was more than the two-hour required time frame reporting for a significant injury to Adult Protective Services (APS). Interview with the DON and the Administrator on 5/13/24 at 2:58 PM confirmed the injury was not witnessed, the resident had an injury that required emergency treatment and APS was not notified within 2 hours.

Licensure Reference Number 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to provide a written notice of transfer to 1 resident (Resident 24) or the resident's legal representative upon transfer to the hospital. The facility census was 36. Findings are: Review of the undated facility policy Notice of A Transfer and/or Discharge revealed the facility would provide a 30 day written notice of transfer or discharge to a resident and/or the resident's representative, except when an immediate transfer or discharge is required by the resident's urgent medical needs. The following information will be provided: -the reason for the transfer or discharge; -effective date of transfer or discharge; -the location the resident is transferred to; -the name, address, and telephone number of the state long-term care ombudsman; -the name address, and telephone number of each individual or agency responsible for the protection of mentally ill or developmentally disabled; and -the name, address, and telephone number of the state health department agency that handles appeals of transfer and discharge notices. Review of Resident 24's Nursing Progress Note dated 5/3/24 revealed the resident was transferred to the local hospital emergency room (ER) for manic (showing wild, apparently deranged, excitement and energy) behaviors that were unable to be controlled. The resident was then transferred and admitted to Faith Regional Behavioral Health Unit for psychosis and mania later on the same day. Review of the Resident 24's medical record on 5/14/24 revealed no evidence a written notice of transfer was provided to the resident or the resident's legal representative after the resident was transferred to the local ER. An interview with the administrator on 5/14/24 at 10:45 AM confirmed Resident 24 was transferred to the localER on [DATE] and the facility had not provided a written notice of transfer to the resident or the resident's representative.

Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide Resident 24 or the resident's representative, written bed hold information when the resident was transferred to the hospital emergency room (ER). The sample size was 1 and the facility census was 36. Findings are: Review of the undated facility policy Holding Bed Space revealed the facility will inform residents and/or resident representatives of the bed-hold policy upon admission and prior to a transfer for hospitalization or therapeutic leave. The Bed Hold Policy Notification and Acknowledgement will be completed at the time the bed hold is needed. Review of Resident 24's Nursing Progress Note dated 5/3/24 revealed the resident was transferred to the local hospital emergency room (ER) for manic (showing wild, apparently deranged, excitement and energy) behaviors that were unable to be controlled. The resident was then transferred and admitted to Faith Regional Behavioral Health Unit for psychosis and mania on the same day. Review of the Resident 24's medical record on 5/14/24 revealed no evidence a written bed hold notice was provided to the resident or the resident's legal representative when the resident was transferred to the hospital. An interview with the administrator on 5/14/24 at 10:45 AM confirmed Resident 24 was transferred to the local hospital on 5/3/24 and the facility had not provided a written bed hold notification to the resident or the resident's representative upon hospitalization .

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure there was an approved diagnosis for the use of an antipsychotic medication (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood, and emotions) for Resident 33. The sample size was 5 and the facility census was 36. Findings are: Review of the facility policy Psychotropic Medication Usage, undated, revealed the following: -psychotropic drugs included antipsychotics, -attending physicians would certify that a psychotropic medication was necessary to treat a specific condition/behavior, and -the consulting pharmacist would report any irregularities to the Medical Doctor or Director of Nursing (DON) which included not having an adequate indication for use. Review of Resident 33's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 4/22/24 revealed the following: -the resident had severe cognitive impairment, -had diagnoses of heart failure, anxiety, and depression, and -required moderate assistance with toileting, dressing the lower half of the body, putting on and taking off footwear and personal hygiene. Review of Resident 33's Care Plan last reviewed 4/30/24 revealed the following: -the resident had behavior problems due to a history of Alzheimer's Dementia, anxiety, hallucinations, schizophrenia, and schizoaffective disorder, and -the resident had impaired cognitive function and impaired thought processes. Review of Resident 33's Order Review Sheet revealed the resident had an order for Haloperidol (an antipsychotic medication) 1 milligram (mg) 1 tablet (tab) orally by mouth twice daily for Alzheimer's Disease ordered 4/26/24 , and Haloperidol 5mg give 1 tab by mouth every evening with supper for Alzheimer's Disease ordered 4/26/24. Review of the Medication Administration Records (MARs) revealed in April 2024 the resident received 16 doses of Haloperidol 1mg, and 8 doses of 5mg Haloperidol. In May 2024 the resident received 1mg Haloperidol 26 times, and 5mg Haloperidol 12 times. Interview on 5/13/24 at 2:58 PM with the DON confirmed the resident's diagnosis for the use of Haloperidol was Alzheimer's Disease. Further interview confirmed Alzheimer's Disease was not an acceptable diagnosis for the antipsychotic medication.

Licensure Reference Number 175 NAC 12.006.02(8) Based on interview and record review, the facility failed to complete and submit a written investigation to the state agency related to a fall with a fracture for Resident 22 and a resident to resident altercation for Resident 11. The total sample size was 18 and the facility census was 37. Findings are: A. Record review of the facility policy dated 8/12/16 titled Abuse and Neglect Prevention Policy revealed the following; -all allegations of abuse (the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish) and/or neglect (failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness) would be investigated, -all staff would be trained annually, -knowledge provided for prevention included assessment, care planning and monitoring of residents with needs and behaviors that might lead to conflict or neglect; such as history of aggressive behaviors and entering other resident's rooms, -all unusual occurrences needed to be reported to immediate supervisor for an investigation, -Residents would be separated or moved to a place of safety away from a harmful or abusive situation to prevent a reoccurrence and for their own protection, -the reporting of alleged abuse and/or neglect would be done according to state and federal guidelines, -the administrator would maintain investigation results in a confidential file, -any alleged mistreatment, neglect, physical, mental, verbal, or sexual abuse needed to be reported to the administrator and the proper authorities, -report alleged incidents to all local/state/federal agencies within 24 hours of the allegation and after conducting an internal investigation submit a report of all investigation results to the state within 5 working days, -allegations of resident to resident abuse that were not isolated, were preventable, and/or foreseeable would be reported regardless of injury or not, -all resident to resident altercations would be investigated, and -any accident that results in serious resident injury (such as a fracture) would be reviewed and also be reported to the state and local law enforcement. Record review of Resident 22's Electronic Health Record (EHR) Progress Notes revealed the following; -on 2/6/23 the resident had a fall and complained of right-hand discomfort, -on 2/7/23 the resident's right arm was swollen, bruising was noted to the palm of the hand and the hand hurt, -on 2/9/23 the resident's right hand still had swelling and bruising, -on 2/10/23 the resident's right hand was still swollen and bruised with swelling to the upper arm. The resident was seen by the Physician and an Xray was ordered. The Physician updated the facility that fractures were noted on the 4th and 5th metacarpals (long bones in the hand), -on 2/21/23 the resident had a splint placed to the right hand. Record review of documentation by the Director of Nursing (DON) on the facility form titled Individual Injury dated 2/7/23 revealed due to the resident being able to explain the injury with no reason to suspect abuse or neglect, no state report was completed. Record review of Resident 22's EHR revealed a fall risk assessment dated [DATE] with a score of 80 which indicated the Resident 22 was a high fall risk. Record review of Resident 22's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 3/11/23 revealed the Resident had moderate cognitive impairment and a fall with major injury. Record review of Resident 22's Care Plan last revised on 4/10/23 revealed the following; -the resident required assistance with dressing, toilet use, and transfers, and -diagnoses of generalized muscle weakness, need for assistance with personal care, lack of coordination, unsteadiness on feet, unspecified dementia, and malaise and fatigue. Interview with Resident 22 on 4/5/23 at 1:30 PM revealed resident had fallen not too long ago and the fall resulted in a right-hand fracture. Interview on 4/6/23 at 12:00 PM with the facility Administrator revealed the facility did not have any reported incidents for 2023. 42679 B. Record review of Resident 11's MDS dated [DATE] revealed the resident was cognitively impaired and required assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The MDS identified Resident 11 had the following diagnoses; dementia, anxiety and Post Traumatic Stress Disorder (PTSD- a disorder that develops in some people who have experienced a shocking, scary, or dangerous event.) Record review of Resident 139's care plan revealed the resident was cognitively impaired, required extensive assistance with Activities of Daily Living (ADL's) and had diagnoses of dementia, psychotic disturbance, mood disturbance and anxiety. Review of Resident 139 EHR nursing progress note dated 2/20/23 at 2:02 AM revealed the following; -Licensed Practical Nurse (LPN)-P heard a loud commotion from Resident 11's room, entered the room and observed Resident 139 standing over the occupied bed of Resident 11 and was screaming an unknown person's name at the resident. -Resident 11 then shouted out [gender] name to Resident 139, while LPN-P tried to explain to Resident 139 [gender] was not who the resident thought. -Resident 139 made a forward motion towards the resident (Resident 11) lying in the bed at which time LPN-P stepped in between and stopped Resident 139's hands by putting self in front of Resident 139. -Resident 139 then verbally threatened to hit LPN-P and tried to lunge forward through LPN-P bringing [gender] arms up towards the resident (Resident 11) lying in bed. -LPN-P and an unidentified staff member had to physically hold onto Resident 139's hands and arms to prevent [gender] from harming the resident (Resident 11) lying in the bed. -Resident 139 then struck out at LPN-P and the unidentified staff member multiple times and began to escalate. Additional staff were called for assistance to remove Resident 139 from the room and [gender] was transferred to the emergency room for evaluation and treatment related to the aggressive behaviors. Record review of Resident 11's medical record revealed no evidence Resident 11 was evaluated by a nurse for potential physical or psychological harm after Resident 139 was removed from the resident's room. Record review of the facility's investigation reports since 1/12/22 revealed no evidence the incident on 2/20/23 was investigated and reported to the state agency as required. Interview conducted on 4/11/23 at 10:50 AM with the DON revealed the following; -an altercation occurred between Resident's 139 and 11, in Resident 11's room on 2/19/23 at approximately 09:30 PM (the incident was documented on 2/20/23); -Resident 139 was unsupervised in Resident 11's room prior to the loud commotion that was heard; -Resident 139 was physically aggressive during the altercation and was transferred to the ER for evaluation and treatment after the incident; -Resident 11 should have been evaluated by a nurse for potential physical and/or psychological harm following the altercation with Resident 139 and there was no evidence this was completed; and -the incident should have been investigated further and reported to the state agency as required.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, record review, and interviews; the facility failed to protect Resident 25 from potential adverse effects from weather extremes and or potential accidents related to going outside unattended by facility staff, failed to review falls for causal factors and implement measures to prevent potential falls for Residents 8, 20, 21, and 23. The sample size was 7 and the facility census was 33. Findings are: A. The facility policy Elopement (Wandering Residents) with a revision date of 12/2021 revealed the following: -The purpose was to ensure the safety of residents. -The definition of elopement was when a resident, identified as needing supervision, left the facility or safe area unsupervised. -the definition of Wandering was aimless or undirected movement, often repetitive. -Residents residing in the Special Care Unit or determined to be an elopement risk would have family or staff with them at all times when off the unit. -Exiting is when a resident leaves the unit but does not leave the building. B. Review of Resident 25's Minimum Data Set (MDS-federally mandated comprehensive assessment tool used for care planning) dated 11/12/21 revealed the following; The resident had severe cognitive impairment, dementia, and wandered daily. Review of Resident 25's Care Plan dated 1/9/22 revealed the following; -the resident was an elopement/wander risk due to disorientation to place, had a history of attempts to leave the facility unattended, and wandered aimlessly, -the resident should not leave the facility unattended, -the staff were to disguise exits, and distract the resident from wandering by offering pleasant diversion, structured activity, food, conversation, television, or books, -the resident could go on daily walks in the secured courtyard to meet the residents desire to be outside and to prevent the resident from going out alone, and -staff were to ensure the resident was appropriately dressed for weather conditions and not go outside when it was raining, lightening, less than 30 degrees Fahrenheit or more than 100 degrees Fahrenheit. Review of Resident 25's Wander Risk assessment dated [DATE], 3/10/21, 6/10/21, and 9/10/21 revealed the resident was at high risk to wander. Review of Resident 25's Progress Notes revealed the following; -on 9/5/21 at 1:11 PM the resident was resisting cares and barricading self in room. -on 9/6/21 at 2:54 PM the resident was restless and going around in circles in the memory unit. -on 9/11/21 at 11:09 AM the laundry staff notified the nursing team that they found a big tear on the resident's denim pants, the tear was big and ran across the right leg section of the pants, from the groin area to the side pocket. The staff were to monitor closely for wandering and escaping behaviors. -on 9/16/21 at 4:07 AM the resident was up most of night wandering. -on 9/25/21 at 6:25 PM the resident had been trying to exit the Memory Support Unit. -on 9/28/21 at 6:43 AM the resident was up most of the night wandering, -on 10/08/21 at 4:43 AM the resident walked out of Memory Support Unit around 11:00 PM with eyes closed, and the staff facilitated a place for the resident in a recliner in the TV room. -on 10/16/21 at 11:52 PM the resident was up wandering. -on 11/15/21 at 3:50 PM the resident was up wandering and trying to exit. -on 11/27/21 at 8:35 PM the resident was pacing back and forth from the south exit to the east exit. -on 12/11/21 at 3:54 PM the resident received a small skin tear to the left hand from a door while trying to come in from outside. -on 12/24/21 at 5:46 PM the resident had been exit seeking all day, and pushed staff as the staff tried trying to redirect the resident. -on 1/1/22 at 5:26 AM the resident was up and down several times throughout the night trying to go outside through the unit exit door. -on 1/4/22 at 5:40 AM the resident did not sleep and wandered all night. Observation of Resident 25 revealed the following; -on 1/6/22 at 10:57 AM The resident wandered the halls of the Special Memory Unit (an enclosed wing or hallway which specializes in the care of residents with dementia or Alzheimers disease) wearing unlined gloves, a light jacket (unzipped) and light weight flannel pants. -on 1/6/22 at 11:04 AM The resident, while wearing a light jacket that was unzipped, unlined gloves, and light weight flannel pants, exited the facility through the facility exit located within the facility Special Memory Unit that exits into the facility outside courtyard. The resident stood outside the door for approximately 1 minute then re-entered the facility. No staff were in the vicinity and no audible alarm sounded. The outside temperature was 2 degrees Fahrenheit. -on 1/10/22 at 2:30 PM The resident was standing in the doorway of the resident room wearing a light jacket, light weight flannel pants, and light weight gloves. The resident repeatedly opened and shut the room door. On 1/6/22 at 11:08 AM an interview with Licensed Practice Nurse (LPN)-E confirmed the facility had an exit from the Special Memory Unit that is not locked, and residents are allowed to go outside unsupervised and without the staff's knowledge. The exit door does not alarm when the residents exit. On 1/6/22 at 11:16 AM an interview with the Director of Nursing (DON) confirmed the facility exit for the Special Memory Unit is not locked during the day and does not alarm when unlocked. The door locked at 10:00 PM nightly. Resident 25 exits the door routinely throughout the day. Further interview with the DON confirmed that a resident going outside in light weight clothing with an outside temperature of 2 degrees Fahrenheit would not be acceptable. On 1/6/22 at 12:55 PM an interview with the facility Administrator confirmed the facility did not lock the Special Memory Unit exit door to the outside courtyard during the day and the door does not alarm when opened if unlocked. The residents were allowed to go outside into the courtyard unattended. Further interview confirmed that a resident dressed in a light weight jacket, light weight gloves, and flannel pants should not go outside when the temperature is 2 degrees Fahrenheit. The immediate jeopardy identified on 1/6/22 was reported to the facility on [DATE] at 1:11 PM at which time it was identified the facility had an unsecured exit from the Special Memory Unit to the enclosed courtyard and Resident 25 who resided on the Special Memory Unit had been observed exiting the building into the outdoor courtyard dressed in light weight gloves, an unzipped light weight jacket, and light weight flannel pants. The outdoor temperature was 2 degrees Fahrenheit. An abatement statement abating the deficient practice to a scope and severity of E was received from the facility at 1:30 PM on 1/6/22 with the following identified corrective actions; -the doors leading to the outdoor courtyard from the Special Memory Unit were immediately locked, -the Fire Marshal was consulted and had no issues with the locking of the exit door as previously approved life safety locks had been installed, -an alternate door from the Special Care Unit dining room was locked and this door has a coded door alarm, -the door alarms were tested to ensure proper function, and -the facility reported that the exit door alarm must be manually silenced so staff would know if anyone exited the building from either door out to the courtyard. C. Review of the facility policy Assessing Falls and Their Causes dated 5/20/14 revealed the following; -the purpose was to assess residents after a fall and to assist staff in identifying causes of falls. -to review the resident's Care Plan to assess for any special needs of the resident, -to identify the resident's current medication and active medical conditions, -within 24 hours of a fall, the nursing staff would begin to try to identify possible or likely causes of an incident until a cause is identified, or it is determined that the cause could not be found, and -when a resident falls documentation should include-appropriate interventions to prevent future falls. Review of the facility policy Falls and Fall Risk Management dated 5/20/14 revealed the following; -if falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remains relevant. -if underlying causes could not be readily identified or corrected, staff would try various interventions, based on assessment of the nature/category of falling, until falling was reduced or stopped, or until the reason for the falling was identified as unavoidable. D. Review of Resident 23's MDS dated [DATE] revealed the following; -the resident had diagnoses of [CONDITION(S)], Alzheimers Dementia, anxiety and depression, -had severe cognitive loss -was provided extensive assistance with bed mobility, transfers, dressing, toileting, and eating, -had a chair/floor arm used, and -had fallen 2 or more times. Review of Resident 23's Care Plan with a revision date of 12/8/21 revealed the following; -the resident had a history of falling, -had a goal to be free of injuries from falling, -had a chair alarm and bed alarm, -had a new wheel chair with a wider and longer seat, -staff were to check to pad alarm every shift to make sure it was plugged in, -staff were to determine causative factors of falls, -no evidence that staff were to place a fall mat beside the resident's bed, and -no evidence of Care Plan revision following falls on 12/8/21, 9/29/21, 9/28/21, or 9/23/21. Review of Resident 23's Progress Notes revealed the following; -on 9/23/21 at 10:53 AM the resident rolled out of the bed and onto the mat that was beside the bed. -on 9/28/21 at 12:57 AM the bed alarm sounded and the resident was found on knees next to the bed on the floor mat.-on 12/8/21 at 3:36 AM the resident was found lying on the floor on the mat beside the bed. -on 9/29/21 at 5:12 AM the resident was found on floor during rounds by staff. The resident was lying on right side with head towards corner of wall and had missed the fall mat almost completely. The bed alarm was flashing but not sounding. -on 12/8/21 at 3:36 AM the resident was found lying on the floor on the mat beside the bed. Observations of Resident 23 revealed the following; - on 1/05/22 at 2:50 PM the resident was resting in a recliner in their room with eyes closed and the call light cord was draped over the bed and out of the resident's reach. - on 1/10/22 at 9:22 AM Nurse Aids (NA's)- F and H assisted the resident to the bathroom using the mechanical lift, then assisted the resident into a recliner, positioned the resident for comfort and covered the resident with a blanket. There was no evidence the staff applied a fall alarm to the resident chair. - on 1/10/22 at 2:32 PM the resident was lying in bed with a call light within reach, but no fall mat placed on the floor next to the bed. The fall mat was leaning against an adjacent wall. -on 1/11/22 at 10:05 AM the resident was sitting in a wheel chair in the dining room. There was no alarm present on the wheel chair. -on 1/10/22 at 9:28 AM an interview with NA-I revealed the staff member was aware the resident was at risk for falling, but reported the resident did not have a fall alarm for use in the wheelchair. Further interview revealed that NA-I was unsure if an alarm was to be used in the resident's bed or recliner, however did report that a fall mat was to be placed on the floor bedside the bed if the resident was in bed. -on 1/11/22 at 10:06 AM an interview with Medication Aide (MA)-F confirmed the resident did not have a fall alarm in the wheel chair and the MA was not aware the resident was to have a chair alarm. -on 1/11/22 at 10:12 AM an interview with the DON confirmed that Resident 23's Care Plan indicated the resident was to have a chair alarm, however the DON was unsure that this was accurate and a current intervention; further interview confirmed Resident 23 was to have a fall mat in use when in bed, however the use of the fall mat was not on the residents current Care Plan. Further interview confirmed that Resident 23's falls on 9/23/21, 9/28/21, 9/29/21, and 12/8/21 had not been reviewed for causal factors and the Care Plan did not have revised fall prevention interventions implemented. E. Review of Resident 8's MDS (Minimum Data Set- a federally mandated comprehensive assessment tool used for care planning) dated 10/02/21 revealed the following; -diagnoses unspecified dementia without behavioral disturbance, major depressive disorder, and [CONDITION(S)] disease, -2 or more falls with major injury, -a BIMS (Brief interview for Mental Status- a tool used to assess cognition) score of 00 which indicated severe cognition loss, -inattention and disorganized thinking, -the resident was provided with extensive assist with bed mobility, transferring, toileting and dressing, and -used a floor/mat alarm. Record review of Resident 8's Progress Notes revealed the following entries; -on 12/2/21 at 5:21 AM staff found the resident sitting on the floor beside the bed mat with the left arm on the mattress, -on 12/10/21 at 10:30 AM the resident fell , and -on 12/12/21 9:30 AM resident 8 tried to wiggle out of the recliner. Another resident was trying to assist resident 8 with standing. Both residents lost their balance and fell . Resident 8 was able to move all extremities without difficulties. Record review of Resident 8's Incident Audit Report section's for Immediate Action Taken for falls dated 12/2/21, 12/10/21 and 12/12/21 revealed no immediate interventions were put into place to prevent future falls. Record review of Resident 8's Morse Fall Scale (a tool used to assess fall risk) completed on 12/12/21 revealed a score of 30 (Moderate risk for falling). Record review of Resident 8's Care Plan revised on 10/19/21 revealed a focus of being high risk for falls related to gait imbalance and that Resident did not know own limits with a goal to remain free of minor injury. Interventions in place for this focus included; -alarm fall mat beside bed while in bed, -be sure the Residents call light was within reach, and encourage the resident to use it for assistance as needed, the resident needed prompt response to all requests for assistance, and - ensure that the resident was wearing appropriate footwear when ambulating or mobilizing in a wheelchair. A review of Resident 8's Care Plan with a revision date of 12/10/21 revealed the resident had falls on 12/2/21 and 12/10/21 with the following interventions; -assist the resident to recliner after meals, -staff were not to place the resident near transfer bars, -floor alarm used when in bed, -staff were to determine and address causative factors of falls, -the resident was to remain in the living room in front of the nursing station after meals, -staff were not to leave the resident unattended in the wheelchair in resident room, -signs were in the resident's room to remind the resident to not get up without help, and to use the call light to ask for assistance, -fall alarms were to be used when up out of bed, and no indication of immediate interventions put into place after falls on 12/2/21, 12/10/21 or 12/12/21. An interview with the DON on 11/11/21 at 09:22 AM confirmed no immediate interventions were implemented to prevent future falls for the falls on 12/2/21, 12/10/21, or 12/12/21. F. Review of Resident 20's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's disease, Non-Alzheimer's dementia and agitation. The MDS further revealed the following regarding Resident 20: -severe cognitive impairment; -behaviors including hallucinations, delusions, physical and verbal behaviors directed at others and rejection of cares; -required extensive assistance with transfers, bed mobility, dressing, personal hygiene and toileting; -frequent bowel and urine incontinence; and -history of falls with 2 or more falls without injury since the previous assessment. Review of a Morse Fall Scale (assessment form used to identify risk for falls) dated 7/2/21 at 10:12 AM revealed the resident had a history of falls prior to Nursing Home admission. The assessment identified the resident was at high risk for falls. Review of Resident 20's Nursing Progress Notes revealed the following: -7/4/21 at 7:00 PM the resident's family was notified the resident had an unwitnessed fall. The note further indicated the resident had been transferred to the emergency room for x-rays of the resident's coccyx; and -7/7/21 at 2:46 AM x-ray report indicated no acute fracture and/or injury. Further review of the resident's medical record revealed an intervention was put into place for the resident to have a TAB's alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound) when positioned in the living room area. Review of an Incident Report dated 7/14/21 at 6:40 AM revealed the resident had an unwitnessed fall in the resident's room. The resident sustained a 17 millimeter laceration beside the left eyebrow. A new intervention was identified for a floor pressure alarm (mat which triggers an alarm when pressure applied to the surface). Review of an Incident Report dated 8/7/21 at 7:35 PM revealed the resident's fall alarm went off and before staff made it to the resident, the resident fell forward out of the chair. Review of the resident's medical record revealed no evidence the resident's current fall interventions were revised or that a new intervention had been developed to prevent further falls. Review of an Incident Report dated 8/9/21 at 9:30 PM revealed the resident had an unwitnessed fall from a recliner in the living room area. The report identified the resident had been anxious earlier in the evening. No new interventions were identified to prevent ongoing falls. Review of an Incident Report dated 8/19/21 at 1:44 PM revealed the resident had removed the TAB's alarm, then slid off the seat of the wheelchair onto the floor. Further review revealed no causal factors were identified and no new interventions were put into place to prevent further falls. Review of an Incident Report dated 8/26/21 at 8:59 PM revealed the resident had an unwitnessed fall in the resident's room. The resident was found on the floor between a wheelchair and the closet. The resident reported trying to reach something out of the closet. No new fall prevention interventions were identified. Review of an Incident Report dated 8/30/21 at 9:10 AM revealed the resident had a fall out of the wheelchair by the Nurse's Station. The resident had been agitated at the time of the fall and the staff were attempting to administer [MEDICATION(S)] (medication used for anxiety and agitation) and the resident was resistive. Review of the resident's medical record revealed no documentation to indicate current fall interventions were reviewed and/or revised or that a new fall intervention had been developed to prevent further falls Review of an Incident Report dated 9/9/21 at 10:18 PM revealed the resident had been found on the floor by the Nurse's Station. No causal factors and no additional fall interventions were identified. Review of an Incident Report dated 9/16/21 at 3:05 PM revealed the resident had a fall in the dining room. The resident was attempting to sit down in a wheelchair without locking the brakes and the chair moved out from under the resident. No additional fall interventions were identified. Review of an Incident Report dated 9/17/21 at 5:43 AM revealed the resident was on the floor of the living room area. The resident's TAB's alarm was in place but did not alarm as the batteries were dead. New batteries were put into place so the alarm was functional. Review of an Incident Report dated 9/23/21 at 8:22 PM revealed the resident had a fall out of the wheelchair. No causal factors were indicated and fall interventions were not revised or new interventions put into place to prevent further falls. Review of an Incident Report dated 9/29/21 at 7:53 PM revealed the resident had a fall out of the wheelchair and sustained a 7.5 centimeter (cm) by 0.5 cm skin tear to the left forearm and a 3 cm by 0.5 cm skin tear above the left elbow. No causal factors were identified and no new fall interventions developed. Review of an Incident Report dated 10/23/21 at 5:50 PM revealed the resident was found on the floor. No causal factors were listed, current fall preventions were not revised and no new interventions were developed. Review of an Incident Report dated 11/4/21 at 9:00 AM revealed the resident was found on the floor next to the resident's bed but the resident was not laying on the floor fall mat. No causal factors and/or new fall interventions were identified. Review of an Incident Report dated 11/23/21 at 1:30 AM revealed the resident had been seated in a wheelchair folding a blanket. The resident leaned to the left and tipped over the wheelchair. No additional fall interventions were identified. Review of an Incident Report dated 12/26/21 at 8:40 AM revealed the resident was found on the floor of the resident's room. The resident identified a need to use the bathroom. No new fall prevention interventions were identified. Review of an Incident Report dated 12/28/21 at 2:11 PM revealed the resident had rolled out of bed when trying to get to the bathroom. No fall interventions were developed in an effort to prevent ongoing falls. G. Review of Resident 21's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of pneumonia, urinary tract infection in the last 30 days, Non-Alzheimer's dementia and [CONDITION(S)]. The MDS further revealed the following regarding Resident 21: -severe cognitive impairment; -required extensive assistance with transfers, bed mobility, dressing and toileting; and -1 or more falls without injury since admission. Review of a Morose Fall Scale dated 10/28/21 at 2:01 PM revealed the resident had a history of falls and the resident had impaired safety awareness. The resident was identified at high risk for falls. Review of Resident 21's current undated Care Plan revealed the resident was at risk for falls due to weakness and a decline related to disease process. An intervention was identified to monitor the resident closely to prevent potential falls. Review of an Incident Report dated 10/28/21 at 8:29 PM revealed the resident had a fall out of bed. An intervention dated 10/30/21 was developed for a floor fall mat next to the resident's bed. Review of an Incident Report dated 12/28/21 at 1:15 PM revealed the resident was heard calling out for help and was found on the floor. Further review of the report revealed no causal factors were identified, current fall interventions were not revised and no new interventions were developed to prevent further falls. H. During an interview on 1/6/22 at 9:13 AM, LPN-A confirmed the following: -causal factors were to be determined for each fall to identify need for revision of current fall prevention interventions or development of new interventions; -both Resident 20 and 21 were at high risk for falls with multiple ongoing falls; and -staff failed to determine causal factors after each of Resident 20's and 21's falls to help determine revision of current fall interventions or to develop new interventions to prevent ongoing falls and potential injuries.

175NAC 12-006.17A(4), 175 NAC 12-006.17B, and 175 NAC 12-006.17D Based on observation, record review and interview; the facility failed to implement infection control practices to prevent potential cross contamination including the spread of Covid-19 related to failure of the facility staff to: 1) complete handwashing at intervals to prevent cross contamination for Resident 8, 2) ensure face masks were worn in a manner to prevent the spread of Covid-19, 3) complete screening of visitors for Covid-19, and 4) implement Transmission Based Precautions in a manner to prevent the potential spread of infection for Resident 1. The total sample size was 15 and the facility census was 33. Findings are: A. Review of the Center for Disease control's (CDC) guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the covid-19 Pandemic updated 9/10/21 revealed the following: -Establish a process to identify anyone entering the facility, regardless of their vaccination status, so they can be properly managed; -screening visitors and staff for symptoms of covid-19 (fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea); -implement Source Control Measures (refers to the use of respirators or well-fitting facemasks to cover a person's mouth and nose to prevent the spread of respiratory secretions); and -healthcare providers should wear a face mask when they are in areas of the facility where they could encounter residents. Review of the facility's Covid Surveillance Policy with a revised date of April 2021 revealed the following: -The facility should screen visitors and staff for signs or symptoms of a respiratory infection, such as fever, new onset of cough, new onset of shortness of breath, or sore throat, chills, muscle pain, headache, new loss of taste or smell, fatigue, congestion or runny nose, nausea/vomiting, and diarrhea; -determine if the staff member has tested positive for Covid-19 in the past 30 days or had an exposure to someone who tested positive for Covid-19 in the past 14 days; and -determine if anyone traveled outside of the continental USA within the last 14 days. Review of the facility's signage posted at the front entrance revealed the following: -Visitors were instructed to read the posted questionnaire that asked if they were experiencing symptoms such as; fever or feel feverish, cough or shortness of breath, or sore throat or if they had any exposures to persons with confirmed or suspected Covid-19; -if visitors answer yes to any of the questions they are not to enter; and -if no symptoms, visitors should take their temperature on the kiosk machine, use hand sanitizer and enter with a mask covering their nose and mouth. An observation of the facility screening area on 1/5/22 at 08:30 AM revealed the following: -A kiosk machine was located at the facility entrance which obtained the person's temperature upon positioning self directly in front of the machine; -no responses to the Covid-19 screening questions or visitor identifying information was requested or recorded; and -the hand sanitizer dispenser was empty and no face masks were available. An observation on 1/5/22 at 08:45 AM of Licensed Practical Nurse (LPN)-A, revealed LPN-A was standing at the nurses station in the hallway with [gender] face mask pulled below the chin exposing both nose and mouth while talking with another staff member. An observation on 1/5/22 at 12:20 PM revealed an unidentified male enter the building without a face mask on, stopped at the kiosk briefly, then proceeded to walk through the dining room where residents were eating and went into the kitchen. An observation on 1/6/22 at 07:25 AM, revealed no hand sanitizer or face masks were available at the screening area and the kiosk took a temperature but did not require any identifying information or responses to the Covid-19 screening questions for visitors entering the facility. An interview with the Director of Nurses (DON) on 1/6/22 at 9:40 AM, confirmed the following: -anyone entering the facility are required to wear a face mask properly; -face masks should have been available at the screening area but were not; -the kiosk machine obtained temperatures of visitors and staff, but visitors had not been required to record any responses to the Covid-19 screening questions or identifying information as part of the screening process; and -hand sanitizer should have been available at the screening area. B. Review of the facility's policy Handwashing/Hand Hygiene with a revised date of 1/11/18 revealed the following related to when employees must wash their hands; - Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least twenty (20) seconds, dry hands thoroughly with paper towels and then turn off the faucets with a clean, dry paper towel. -before and after direct contact with residents, -when hands were visibly dirty or soiled, -before and after assisting a resident with toileting, -after removing gloves; and between glove changes, -if hands are not visibly soiled, use an alcohol based hand rub, -before moving from a contaminated body site to a clean body site during resident care, and -hand hygiene is always the final step after removing and disposing of personal protective equipment. An observation during the provision of care for Resident 8 on 1/10/22 at 10:55 AM revealed Certified Nursing Assistant (CNA)-H did not wash hands for at least 20 seconds, then turned the faucet off with bare hands and used a new paper towel to dry hands. CNA-H and CNA-C assisted Resident 8 to the bathroom. The residents clothes were soiled with feces, were removed and CNA-H provided perineal cares in the front area. CNA-H changed gloves but did not perform hand hygiene in between and feces were observed on the gloves. CNA-H used the same gloves to reach into the resident's closet and grabbed a new brief from the package, then finished dressing the resident. CNA-C performs perineal care on the back side and removed gloves and pulled the resident's clean pants up. CNA-H, was still wearing the same pair of soiled gloves and moved the wheelchair to the bathroom. Both staff members repositioned the resident in the wheelchair and CNA-H started to push the resident to the hallway while still wearing soiled wearing gloves. CNA-H then stops and removes gloves. No hand hygiene performed by either staff member as they left the room. An interview with DON on 1/10/22 at 11:43 AM confirmed hand hygiene was not performed correctly. C. Review of the facility policy Infection Precautions Policy with a revision date of 11/20 revealed Contact Isolation was to be implemented for residents with specific disease processes and for residents with known or suspected infections or evidence of syndromes that may represent an increased risk for contact transmission and outbreaks. Gowns and gloves were required for all health care workers. In addition, staff were to avoid transporting the resident unless medically necessary and all bodily fluids were to be contained to maintain source control. D. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/10/21 revealed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -severe cognitive impairment; -wandering behavior which occurred 1-3 days out of a 7 day look back period; -required limited assistance with walking in the resident's room and in the corridors; and -frequently incontinent of urine and occasionally incontinent of bowel. Review of a Nursing Progress Note dated 11/15/21 at 10:15 AM revealed Resident 1's physician was notified the resident was having more frequent watery stools over the last few days. The note further indicated the stools occurred 5 or more times a day. Review of a Nursing Progress Note dated 12/3/21 revealed the following: -12:24 PM revealed while the resident was walking from the dining room back to the resident's room, the resident had stool running down pants and into shoes and then onto the floor; and -5:18 PM the resident received negative results for C-Difficile (infection of the large intestine caused by [CONDITION(S)] Difficile bacteria which can be spread through contact). Review of a Nursing Progress Note dated 12/9/21 at 1:46 PM revealed a stool sample was collected. Review of a facsimile (fax) titled Lab Results dated 12/9/21 revealed Shiga Toxin-2 (bacteria which causes bloody diarrhea and is ingested by contaminated food and/or water and can be spread easily through contact) was detected and the results were called to the facility on [DATE] at 7:55 PM. The fax further indicated the results were reported to the State Health Department. Review of a Nursing Progress Note dated 12/11/21 at 1:07 PM revealed a facsimile (fax) with laboratory results was received and indicated Shiga Toxin-2 was detected. Review of a Nursing Progress Note dated 12/18/21 at 11:46 AM revealed the facility received a call from the East Central Health District on 12/17/21 at 4:30 PM. The representative indicated the resident should have been placed into contact isolation and the resident was to remain in isolation until a negative stool sample was obtained. The note further indicated Resident 1 was to be placed in Contact Isolation and the resident's roommate was to be transferred to another room. During an interview on 1/10/22 at 9:00 AM the DON confirmed the following regarding Resident 1: -was having multiple loose stools in a day that were not contained by incontinence products; -12/9/21 the resident had a stool sample collected; -12/10/21 at 7:55 PM the facility was notified by the lab the resident's sample was positive for Shiga Toxin-2; and -the resident was not placed into Contact Isolation until 12/18/21 (8 days after the facility was initially notified of positive results). In addition, the resident's roommate remained in the same room with the resident until 12/18/21.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to code a pressure ulcer on the Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) for Resident 4. The sample size was 15 and the facility census was 33. Findings are: Review of Resident 4's MDS dated [DATE] revealed the following; -the resident had no unhealed pressure ulcers, -received pressure ulcer care, and -had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 4's Care Plan with an initiation date of 7/27/21 and a revision date of 12/1/21 revealed the following; -the resident had impairment to the skin integrity of the heels, -the resident was to be encouraged to reposition self frequently and as needed, -follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -identify and eliminate potential causal factors where possible, -to assist the resident to apply protective garments, and -no evidence the resident risk for pressure sores was addressed on the Care Plan until 42 days after the first pressure ulcer was identified. Review of Resident 4's Progress Notes revealed the following; -on 4/14/21 at 12:00 PM the resident arrived at facility and had no skin issues. -on 6/15/21 at 1:29 AM the resident had a 40cm by 22cm pressure ulcer below the left ankle and a large popped blister in the same area, and a popped blister 3cm diameter on the sole of the right foot. A dressing and heel boots were applied. -on 7/27/21 at 2:11 PM an x-ray of the left foot was taken to make sure there was no [CONDITION(S)] (bone infection). -on 7/27/21 at 3:36 PM the physician was notified of the resident's complaint of extreme pain to the left lower leg from the knee down to the foot. -on 7/27/21 at 7:22 PM the physician ordered [MEDICATION(S)] (antibiotic) for [CONDITION(S)] of the left heel. -on 8/21/21 at 11:03 AM the physician was informed that the resident's left heel was necrotic (dead tissue) and black at the wound bed, at approximately 170 mm diameter and the area around the wound was dark gray, almost black, and had what appeared to be yellowish drainage underneath the skin. -on 8/29/2021 at 2:37 PM the resident had a blister noted on the bottom of the foot under left big toe which was grayish in color and approximately 12mm x 8mm. The physician was contacted and advised to do the same treatment as with the left heel ulcer. -on 9/2/21 at 4:24 PM new blisters were seen on the resident's left foot, fluid filled approximately 23x 12mm. -on 9/17/21 at 2:04 AM had stage 3 pressure ulcers on both feet. -on 9/23/21 at 11:24 PM the resident refused to allow staff to put prevalon (protective) boots. -on 10/13/21 at 6:48 PM the resident took of the heal protector boots off. -on 10/21/21 at 5::00 PM the left heel was debrided (removal of non-viable and/or dead tissue) at the wound clinic, and it was noted the resident was non-compliant with keeping on profo (protective) boots in the bed and non-compliant with floating (positioning off the mattress) feet. -on 11/8/21 at 12:58 PM There was a noted blackened area on the bottom of the wound edge. -on 11/16/21 at 12:00 PM orders were received from the wound clinic to off load heels at all times, apply daily dressing to the left heel with [MEDICATION(S)] and [MEDICATION(S)], cover with dry gauze and secure with kling (roll gauze) and paper tape and follow up with the Dr. in a week. -on 12/1/21 at 3:09 AM a Stage 2 pressure ulcer was noted on the resident's coccyx (tail-bone area). -on 12/1/21 at 12:40 PM the provider responded and reported that the resident would be seen at 4:00 PM for assessment of the wound. -on 12/4/21 at 4:32 AM the resident's coccyx and area surrounding it was pink and a bandaid was applied to area on the coccyx where the skin had break down. -on 12/5/21 at 12:45 PM the resident's right heel was reported to be healed. -on 12/28/21 1:08 PM the resident was seen at the wound clinic and the left heel was reported to be 5.8cm x 4.3cm x 0.3cm in size (larger than the initial measurements on 6/15/21). -on 12/31/21 11:49 AM the provider ordered the facility to try range of motion and positioning to see if that would help with the resident's leg. Observation of Resident 4 on 1/06/22 at 11:17 AM during the provision of wound care to the left heel by LPN (Licensed Practice Nurse)-E revealed an open wound area that encompassed a large portion of the bottom of the left heel. The wound was beefy red in appearance. The wound was cleansed with soap and water and a clean dressing was applied. Interview on 1/6/22 at 11:20 AM with Licensed Practical Nurse (LPN)-E confirmed that Resident 4 had a stage III pressure ulcer on the left heel that was facility acquired and had not healed. Interview on 1/10/22 at 1:11 AM with the Director of Nursing (DON) confirmed Resident 4's MDS dated [DATE] did not reflect the resident's status of having a stage III pressure ulcer. Further interview confirmed the pressure sore was present at the time of the MDS assessment on 12/17/21 but was not coded on the assessment.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09A Based on record review and interview, the facility failed to ensure a new PASRR (Pre-Admission Screening and Resident Review- review for a mental illness or intellectual disability) had been completed after a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 33. Findings are: Review of Resident 28's Admission PASRR revealed was completed on 3/14/17 as a level 1 and had come with the resident from a the hospital. The rationale documented on the level 1 screen determined that Resident 28 exhibited no evidence to suggest presence or known conditions of mental illness, intellectual disability, or a condition related to intellectual disability. As such, the resident did not meet the criteria for a Level 2 evaluation. The assessment indicated no further evaluation/screening was required unless the individual was later suspected or found to have a mental illness or intellectual disability condition. Review of Nursing Progress Notes revealed the following: -7/1/17 at 11:08 PM the resident was sent to the emergency room for an acute mental status change. The resident was combative, confused, wandering and calling out; -7/4/17 at 12:55 PM the resident returned from the hospital with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -7/11/17 at 6:46 PM the resident received a new order for [MEDICATION(S)] ((medication used to treat certain mental/mood conditions such as [CONDITION(S)], episodes of [CONDITION(S)] and [CONDITION(S)]) 12.5 milligrams (mg) daily; -7/23/17 at 4:17 PM the resident was hallucinating and told staff the resident was a captain and had 3000 soldiers. The resident screamed the staff were trying to poison the resident; -7/25/17 at 4:58 PM the resident was talking about seeing little people and stated the nurses were killing the little people and pushing them outside for the rest of the little people to carry away. The resident remained concerned staff were attempting to poison the resident and felt there were people watching and recording all of the resident's activities; -8/2/17 at 7:08 PM the resident reported seeing bugs and that people were coming to get the resident; -8/9/17 at 11:42 PM the resident was agitated and yelling an astronaut was coming to help the resident escape and talked about food and medications being poisoned; -8/12/17 at 6:30 AM the resident was transferred to a Behavioral Health facility for an in-patient psychiatric evaluation; and -8/22/17 at 1:00 PM the resident was readmitted to the Nursing Home with orders for [MEDICATION(S)] (medication used to treat severe agitation associated with certain mental/mood conditions such as [CONDITION(S)] and [CONDITION(S)]) to be given twice a day. Record review of Resident 28's annual Minimum Date Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 11/23/21 section A1500 for PASRR revealed that Resident 28 was not considered by the State level 2 PASRR process to have a serious mental illness or intellectual disability or a related condition. The MDS further identified Resident 28 had a current psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 28's medical record revealed no evidence a new PASRR had been completed since the resident's admission on 3/15/17 even though the resident had an in-patient stay at a Behavioral Health facility, received ongoing treatment with antipsychotic medications, and had a mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 1/6/22 at 9:35 AM with the facility Administrator confirmed that that a new PASRR had not been completed for Resident 28 since admission to determine if a Level 2 PASRR was indicated.

Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interview, the facility failed to implement, review, and revise care plan fall interventions for Resident 23. The sample size was 15 and the facility census was 33. Findings are: Review of Resident 23's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/3/21 revealed the following; -the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -had severe cognitive loss -was provided extensive assistance with bed mobility, transfers, dressing, toileting, and eating, -had a chair/floor arm used, and -had fallen 2 or more times. Review of Resident 23's Care Plan with a revision date of 12/8/21 revealed the following; -the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -had a goal to be free of injuries from falling, -had a chair alarm and bed alarm, -had a new wheel chair with a wider and longer seat, -staff were to check the pad alarm every shift to make sure it was plugged in, -staff were to determine causative factors of falls, -no evidence that staff were to place a fall mat beside the resident's bed, and -no evidence of Care Plan revision following falls on 12/8/21, 9/29/21, 9/28/21, or 9/23/21. Review of Resident 23's Progress Notes revealed the following; -on 9/23/21 at 10:53 AM the resident rolled out of the bed and onto the mat that was beside the bed. -on 9/28/21 at 12:57 AM the bed alarm sounded and the resident was found on knees next to the bed on the floor mat. -on 9/29/21 at 5:12 AM the resident was found on floor during rounds by staff. The resident was lying on right side with head towards corner of wall and had missed the fall mat almost completely. The bed alarm was flashing but not sounding. -on 12/8/21 at 3:36 AM the resident was found lying on the floor on the mat beside the bed. Interview on 1/10/22 at 9:28 AM with Nurse Aide (NA)-I revealed that the NA was aware that Resident 23 was at risk for falling, required monitoring for falling, and had a floor mat to be used while in bed. The NA was not aware of any additional fall prevention interventions. Interview on 1/11/22 at 10:06 AM with Medication Aide (MA)-F revealed confirmed that Resident 23 did not have a fall alarm in the wheel chair and MA-F was not aware the resident was to have an alarm in the wheel chair. Interview on 1/11/22 at 10:12 AM with the Director of Nursing (DON) confirmed that Resident 23's Care Plan indicated the resident was to have a chair alarm, however the DON was unsure that this was an accurate and current intervention. Further interview confirmed the resident was to have a fall mat in use when in bed, however this intervention was not on the residents current care plan. The DON confirmed that Resident 23's Care Plan was not accurate.

Licensure Reference Number 175 NAC 12-006.09C3 Based on record review and interview, the facility failed to complete a discharge assessment for Resident 33. The sample size was 2 and facility census was 33. Findings are: Review of the undated facility policy Processing a Discharge to Home revealed the following: The facility staff would complete a discharge summary including; - resident's full name and medical record number, - date of admission and discharge date , - name of attending provider, - recap why the resident was here (Primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - what type of support services were being provided at home, - summary of education provided prior to leaving, and - any medications taken with the resident. Review of Resident 33's progress notes revealed on 11/1/21 at 3:03 PM the resident discharged to home with medications and discharge instructions. An interview with the Administrator on 1/11/22 at 11:23 AM confirmed no other documentation for the discharge summary was in the chart, and the Processing a Discharge to Home policy is how a discharge should be documented.

Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility failed to implement interventions to prevent and heal a pressure ulcer for Resident 4. The sample size was 3 and the facility census was 33. Findings are: The facility policy Prevention of Pressure Ulcers dated 5/20/14 revealed the following; -The purpose of the policy was to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. -Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure and decreased circulation. -The common sites for pressure ulcer is where bone is near the surface of the body. -Pressure ulcer can be hard to heal and are a serious skin condition. -For a person in bed determine if the person needs a special mattress of foam, air, gel, or water. -Refer the person to a rehabilitative or restorative nursing program. -The care process should include efforts to monitor the impact of interventions, and modify the interventions as appropriate. The facility policy Pressure Ulcer Treatment dated 5/20/14 revealed the following; -The purpose of the policy was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. -The pressure ulcer treatment program should focus on wound assessment, managing tissue loads, pressure ulcer care, and managing of infection. Review of Resident 4's Minimum Data Set, dated dated dated [DATE] (MDS-federally mandated comprehensive assessment tool used for care planning) revealed the following; -extensive assistance was provided with bed mobility, transfers, toileting, and dressing, - the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - pressure ulcer care had been completed in the past 7 days, and - the resident had limited range of motion to one lower extremity. Review of Resident 4's Braden Scales (Assessment to determine risk for pressure sores) performed on 4/14/21, 4/21/21, 4/28/21, 5/5/21, and 10/2/21 all indicated the resident was at risk for pressure sores. Review of Resident 4's Care Plan with an initiation date of 7/27/21 and a revision date of 12/1/21 revealed the following; -the resident had impairment to the skin integrity of the heels, -the resident was to be encouraged to reposition self frequently and as needed, -follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -identify and eliminate potential causal factors where possible, -to assist the resident to apply protective garments, and -no evidence the resident risk for pressure sores was addressed on the Care Plan until 42 days after the first pressure ulcer was identified. Review of Resident 4's Progress Notes revealed the following; -on 4/14/21 at 12:00 PM the resident arrived at facility and had no skin issues. -on 6/15/21 at 1:29 AM the resident had a 40cm by 22cm pressure ulcer below the left ankle and a large popped blister in the same area, and a popped blister 3cm diameter on the sole of the right foot. A dressing and heel boots were applied. -on 7/27/21 at 2:11 PM an x-ray of the left foot was taken to make sure there was no [CONDITION(S)] (bone infection). -on 7/27/21 at 3:36 PM the physician was notified of the resident's complaint of extreme pain to the left lower leg from the knee down to the foot. -on 7/27/21 at 7:22 PM the physician ordered [MEDICATION(S)] (antibiotic) for [CONDITION(S)] of the left heel. -on 8/21/21 at 11:03 AM the physician was informed that the resident's left heel was necrotic (dead tissue) and black at the wound bed, at approximately 170 mm diameter and the area around the wound was dark gray, almost black, and had what appeared to be yellowish drainage underneath the skin. -on 8/29/2021 at 2:37 PM the resident had a blister noted on the bottom of the foot under left big toe which was grayish in color and approximately 12mm x 8mm. The physician was contacted and advised to do the same treatment as with the left heel ulcer. -on 9/2/21 at 4:24 PM new blisters were seen on the resident's left foot, fluid filled approximately 23x 12mm. -on 9/17/21 at 2:04 AM had stage 3 pressure ulcers on both feet. -on 9/23/21 at 11:24 PM the resident refused to allow staff to put prevalon (protective) boots. -on 10/13/21 at 6:48 PM the resident took of the heal protector boots off. -on 10/21/21 at 5::00 PM the left heel was debrided (removal of non-viable and/or dead tissue) at the wound clinic, and it was noted the resident was non-compliant with keeping on profo (protective) boots in the bed and non-compliant with floating (positioning off the mattress) feet. -on 11/8/21 at 12:58 PM There was a noted blackened area on the bottom of the wound edge. -on 11/16/21 at 12:00 PM orders were received from the wound clinic to off load heels at all times, apply daily dressing to the left heel with [MEDICATION(S)] and [MEDICATION(S)], cover with dry gauze and secure with kling (roll gauze) and paper tape and follow up with the Dr. in a week. -on 12/1/21 at 3:09 AM a Stage 2 pressure ulcer was noted on the resident's coccyx (tail-bone area). -on 12/1/21 at 12:40 PM the provider responded and reported that the resident would be seen at 4:00 PM for assessment of the wound. -on 12/4/21 at 4:32 AM the resident's coccyx and area surrounding it was pink and a bandaid was applied to area on the coccyx where the skin had break down. -on 12/5/21 at 12:45 PM the resident's right heal was reported to be healed. -on 12/28/21 1:08 PM the resident was seen at the wound clinic and the left heel was reported to be 5.8cm x 4.3cm x 0.3cm in size (larger than the initial measurements on 6/15/21). -on 12/31/21 11:49 AM the provider ordered the facility to try range of motion and positioning to see if that would help with the resident's leg. Observation of Resident 4 on 1/06/22 at 11:17 AM during the provision of wound care to the left heel by LPN (Licensed Practice Nurse)-E revealed an open wound area that encompassed a large portion of the bottom of the left heel. The wound was beefy red in appearance. The wound was cleansed with soap and water and a clean dressing was applied. The Resident's left leg was bent at an angle in which the heel nearly touched the buttocks. The resident was not able to straighten the leg more than slightly when asked by the nurse to do so. 01/06/22 11:20 AM an Interview with LPN-E revealed Resident 4 had a left heel pressure ulcer that was facility acquired (occurred after admission to the facility). The resident was non-compliant with leaving on heel protectors and or keeping heels off of the bed, and was unable to straighten out the left leg. Further interview confirmed the resident did not have a therapy program or a restorative nursing plan to address the contracture (a condition of shortening of muscle, tendons, or other tissues often leading to deformity or rigidity of joints) of the left leg. Further interview confirmed the resident did not have a documented or formal plan for range of motion exercises for the left leg or a specialized pressure redistribution mattress. Observation of Resident 4 on 1/10/22 at 10:53 AM revealed the resident resting in bed on back with left leg bent at an angle in which the heel nearly touches the buttock and rested directly on the bed. There were no heel protectors in place. 01/10/22 1:11 PM an Interview with the Director of Nursing (DON) confirmed Resident 4 had a facility acquired stage III ( deep tissue involvement) left heel pressure ulcer, The facility had an order to off-load (remove source of pressure) from the left heel at all times. Further interview confirmed the resident was non-compliant with leaving on heel protectors, however the facility had not implemented additional or alternative measures for offloading the resident's left heel when in bed. Further interview confirmed the resident did not have a professional therapy evaluation or plan, did not have a restorative nursing plan, and had no documented range of motion exercises as recommended, to address the left leg contracture that could contribute to non-healing of the pressure sore.

LICENSURE REFERENCE 175 NAC 12-006.04C3a (6) Based on interview and record review, the facility failed to notify Resident 1's physician and responsible party of changes in condition and Resident 4's responsible party regarding a fall. The sample size was 9 and the facility census was 29. A. Review of the policy Change in Resident's Condition or Status dated 5/20/14 revealed the facility was to promptly notify the resident, their attending physician and the resident's representative of changes in the resident's medical/mental condition and/or status. A significant change in condition was to be defined as a decline or an improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard clinical interventions. In addition, the Charge Nurse was to notify the resident's family or representative when: -the resident was involved in any accident or incident that resulted in an injury including an injury of unknown origin; -there was a significant change in the resident's physical, mental or psychosocial status; -a decision had been made to discharge the resident from the facility; and/or -it was necessary to transfer the resident to a hospital/treatment center. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/11/20 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment further revealed the resident's cognition was severely impaired; the resident required total staff assistance with food and fluid intakes, transfers, bed mobility, dressing, toilet use and personal hygiene; and the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Nursing Progress Note dated 8/29/20 revealed at 3:03 AM, the resident had a witnessed fall. The resident indicated pain to the resident's right elbow, abdominal area and to the leg. Further review revealed at 4:03 AM, the resident's physician was sent a facsimile (fax) regarding the resident's fall. Review of a Nursing Progress Note dated 8/29/20 at 9:14 PM revealed the resident now had deep purple bruising to the right hip and was complaining of pain to the area. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing Progress Notes dated 8/30/20 revealed the following: -2:17 PM the resident was unable to bear weight on the resident's right leg during transfers; and -9:40 PM the resident had increased swelling and bruising to the right hip and remained unable to bear weight. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Progress Note dated 8/31/20 at 5:35 PM revealed the resident was complaining of pain at a 10 out of 10. The resident's physician was notified and an order was received for an x-ray. The resident was transferred to the hospital with a fracture to the right hip. Review of Resident 1's medical record revealed the resident's responsible party/family had not been notified of the resident's fall on 8/29/20 or the resident's increased bruising, swelling and inability to bear weight on 8/30/20. Resident 1's family/responsible party was not notified of the resident's fall and change of status until the resident was transferred to the emergency room for an x-ray and found to have a fractured hip on 8/31/20 at 5:35 PM. Review of a Nutritional Assessment completed by the Registered Dietician (RD) on 9/17/20 at 11:04 AM revealed the resident had a recent significant change of status related to a right [CONDITION(S)] with surgical repair. The assessment indicated the resident's estimated fluid needs were 1955cc to 2346cc of fluids daily to maintain hydration. The assessment further indicated a weight of 172 pounds which was obtained on 8/31/20. Review of documentation of the resident's fluid intakes at meals from 9/17/20 to 9/28/20 revealed the following: -9/17/20 the resident refused fluids at the breakfast and the evening meal and consumed 120cc of fluids at the noon meal; -9/18/20 the resident refused fluids at the breakfast and evening meal and consumed 120cc at the noon meal; -9/19/20 the resident refused fluids at the breakfast and the noon meal and drank 240cc at the evening meal; -9/20/20 the resident refused fluids at the breakfast and noon meal and consumed 260cc of fluid at the evening meal; -9/21/20 the resident refused fluids at the breakfast meal, drank 100cc at the noon meal and 120cc at the evening meal; -9/22/20 the resident refused fluids at the breakfast and the evening meal and drank 120cc at the noon meal; -9/23/20 the resident refused fluids at the breakfast meal, drank 240cc at noon and 120cc at the evening meal; -9/24/20 the resident refused fluids at the breakfast and the noon meal and consumed 120cc at the evening meal; -9/25/20 the resident refused fluids at all 3 meals; -9/26/20 the resident consumed 240cc of fluids at breakfast, 120cc at the noon meal and refused fluids at the evening meal; -9/27/20 the resident refused fluids at breakfast and the noon meal and drank only 60cc at the evening meal; -9/28/20 the resident consumed 480cc of fluid at breakfast and 240cc at the noon meal. Resident 1 refused fluids at the evening meal; and -9/29/20 no fluids were consumed at breakfast and only 120cc of fluids were taken at the noon meal. Review of intake documentation of the resident's Ensure Plus supplement from 9/17/20 to 9/29/20 revealed the following: -9/17/20 the resident consumed 120cc of supplement at each of the meals; -9/18/20 the resident refused the supplement at breakfast and the evening meal and drank 120cc at the noon meal; -9/19/20 the resident drank 120cc of supplement at breakfast. All other supplements were refused; -9/20/20 the resident consumed 120cc at each meal; -9/21/20 the resident refused supplement at breakfast, consumed 60cc at noon and 120cc at the evening meal; -9/22/20 the resident refused breakfast supplement and consumed 120cc at the noon and the evening meal; -9/23/20 the resident refused breakfast and the evening meal supplement and drank 120cc at the noon meal; -9/24/20 the resident refused supplement at breakfast and drank 120cc at the noon and the evening meal; -9/25/20 the resident refused supplement for the breakfast meal and consumed 120cc for the noon and evening meal; -9/26/20 the resident refused the supplement for the evening meal and drank 120cc for breakfast and at noon; -9/27/20 the resident refused the supplement at breakfast, drank 120cc at noon and 60cc for the evening meal; and -9/28/20 the resident consumed 120 cc at breakfast. No further documentation was available for 9/28/20 and 9/29/20. Review of the resident's Weight Summary Form dated 9/28/20 revealed a weight of 154 pounds (a loss of 18 pounds in 1 month). review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON) on 2/16/20 at 1:00 PM indicated the staff did not calculate the resident's total fluid intake daily to evaluate their actual intake and ensure that their hydration needs were met. Further interview confirmed the resident's physician and the resident's family/responsible party had not been notified of the resident's weight loss and declining intakes. C. Review of Resident 4's MDS dated [DATE] revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's cognition was moderately impaired, the resident required limited assist with bed mobility, transfers, dressing and toilet use and was unsteady with balance during transitions and walking. The resident was identified as having 2 or more falls without injury and 2 or more falls with injury (except major) since the previous assessment. Review of a Nursing Progress Note dated 11/13/20 at 1:38 AM revealed the resident was found on the floor between the wheelchair and the wall of the resident's room with the fall alarm sounding. The resident had a 1 centimeter (cm) by 0.5 cm abrasion to the right cheek. Further review revealed no evidence the resident's family and/or responsible party had been notified of this fall. Interview with the DON on 2/16/20 at 1:30 PM confirmed Resident 4's family had not been notified of the resident's fall on 11/13/20 at 1:38 AM.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on interview and record review, the facility failed to: identify causal factors, develop new interventions and/or revise current interventions to prevent ongoing falls for Residents 1 and 4. The sample size was 9 and the facility census was 29. Findings are: A. Review of the facility policy Fall Assessment and Prevention (undated) identified the following regarding the purpose of the policy: -identify the residents at risk for falls and recognize/minimize and/or eliminate factors which contribute to the risk of falls; and -develop individual care plan interventions to prevent/reduce falls and/or injuries related to falls. Fall risk assessments were to be completed at admission to determine risk for falls and appropriate individualized interventions identified in the resident's initial Plan of Care. In addition, a fall assessment was to be completed with a significant change in level of function or if the resident has 2 or more falls in 30 days. If a fall does occur, the resident should be assessed for injuries, and safety measures to protect the resident from harm and further falls should be implemented. An incident report and a fall investigation form would be completed which would include location of fall, behaviors prior to fall, observations related to fall, physical assessment of resident's condition and interventions to prevent further falls. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/11/20 revealed diagnoses of Alzheimer's disease, Non-Alzheimer's Dementia, [CONDITION(S)] and anxiety. The assessment further revealed the resident's cognition was severely impaired; the resident required total staff assistance with transfers, bed mobility, dressing, toilet use and personal hygiene; and the resident had a history of falls. Review of Resident 1's current Care Plan dated 4/22/20 revealed the resident was at high risk for falls related to cognition and dementia. Interventions included the following: -anticipate and meet the resident's needs; -be sure the call light is within reach and encourage the resident to use. The resident was to receive prompt response to all requests for assistance; -frequent visual checks especially at night as the resident was up and down out of bed frequently; and -fall alarm at all times. Review of a Nursing Progress Note dated 6/22/20 at 10:52 PM revealed the resident was lowered to the floor by a Nursing Assistant. No injuries were identified. Further review of the resident's medical record revealed no evidence causal factors for the resident's fall were identified, current interventions were revised or that a new intervention was developed to prevent further falls. Review of a Nursing Progress Note dated 7/7/20 at 7:45 AM revealed the resident had slid out of a recliner in a commons area of the Memory Support Unit. The note further indicated use of fall alarm and a floor alarm due to frequent attempts to self-transfer. Review of the resident's medical record revealed no evidence causal factors were assessed or that a new intervention to prevent falls was developed. Review of Nursing Progress Notes dated 8/29/20 revealed the following: -3:03 AM revealed the resident had a witnessed fall. The resident indicated pain to the resident's right elbow, abdominal area and to leg. The resident was administered a [MEDICATION(S)] as there was no evidence the resident had a bowel movement in the last 3 days. No further interventions were identified for fall prevention; and -9:14 PM the resident had deep purple bruising to the right hip and was complaining of pain to the area. Review of Nursing Progress Notes dated 8/30/20 revealed the following: -2:17 PM the resident was unable to bear weight on the resident's right leg during transfers; and -9:40 PM the resident had increased swelling and bruising to the right hip and remained unable to bear weight. Review of a Nursing Progress Note dated 8/31/20 at 5:35 PM revealed the resident was complaining of pain at a 10 out of 10 and an order was received for an x-ray. The resident was transferred to the hospital with a fracture to the right hip. C. Review of Resident 4's MDS dated [DATE] revealed diagnoses of unspecified dementia without behavioral disturbance, diabetes, Non-Alzheimer's dementia, [CONDITION(S)] disease and depression. The resident's cognition was moderately impaired, the resident required limited assist with bed mobility, transfers, dressing and toilet use and was unsteady with balance during transitions and walking. The resident was identified as having 2 or more falls without injury and 2 or more falls with injury (except major) since the previous assessment. Review of Resident 4's current Care Plan (undated) revealed the resident was at risk for falls and interventions were in place to assist the resident to the resident's recliner after meals and to determine and address causative factors of any falls. Review of a Nursing Progress Note dated 10/9/20 at 9:52 PM revealed the resident had a fall in the resident's room. No causal factors were identified, no new interventions were developed and current fall interventions were not revised. Review of a Nursing Progress Note dated 11/13/20 at 1:38 AM revealed the resident was found on the floor between the wheelchair and the wall of the resident's room with the fall alarm sounding. The resident had a 1 centimeter (cm) by 0.5 cm abrasion to the right cheek. Further review revealed no causal factors were determined and no additional interventions developed to prevent further falls. Review of a Nursing Progress Note dated 1/28/21 at 4:41 PM revealed the resident was found crawling on the floor of the resident's room. Further review of the resident's medical record revealed no evidence current interventions were revised or that new interventions were developed. Interview with the Director of Nurses (DON) on 2/16/21 at 1:30 PM revealed staff were expected to complete an investigation after each resident fall. Investigations were to include causal factors for falls. Staff were then to use the causal factors for the development of new fall prevention interventions or to revise current interventions in an effort to prevent ongoing falls and/or injuries.

Licensure Reference Number 175 NAC 12-006.09D9 Based on record review and interview; the facility failed to ensure that fluid intake was monitored and evaluated to ensure hydration needs were met for 1 (Resident 1) of 9 sampled residents identified at risk for dehydration. The facility census was 29. Findings are: A. Review of the facility Hydration policy dated 5/20/14 revealed the staff and the resident's physician were to identify individuals with a significant risk for subsequent fluid and electrolyte imbalance, for example, those with prolonged vomiting, diarrhea, or fever, or who were not eating or drinking well. Treatment and management of residents with associated risk for dehydration would include supportive measures such as providing fluids. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/11/20 revealed the resident's cognition was severely impaired, the resident required limited staff assistance with food and fluid intake and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's weight was 172 pounds with an identified weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months without a prescribed weight-loss regimen. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a care plan dated 4/22/20 revealed the resident was at risk for impaired hydration/nutrition status. Interventions included the following: -monitor oral intake and weight and notify the physician of significant changes; -9/11/20 the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -9/17/20 due to poor intakes, offer Ensure Plus (nutritional supplement with added calories and protein) 120 cubic centimeters (cc) at all meals. Review of a Nutritional Assessment completed by the Registered Dietician (RD) on 9/17/20 at 11:04 AM revealed the resident had a recent significant change of status related to a right [CONDITION(S)] with surgical repair. The assessment indicated the resident's estimated fluid needs were 1955 cc to 2346 cc of fluids daily to maintain hydration. Review of documentation of the resident's fluid intakes at meals from 9/17/20 to 9/29/20 revealed the following: -9/17/20 the resident refused fluids at the breakfast and the evening meal and consumed 120cc of fluids at the noon meal; -9/18/20 the resident refused fluids at the breakfast and evening meal and consumed 120cc at the noon meal; -9/19/20 the resident refused fluids at the breakfast and the noon meal and drank 240cc at the evening meal; -9/20/20 the resident refused fluids at the breakfast and noon meal and consumed 260cc of fluid at the evening meal; -9/21/20 the resident refused fluids at the breakfast meal, drank 100cc at the noon meal and 120cc at the evening meal; -9/22/20 the resident refused fluids at the breakfast and the evening meal and drank 120cc at the noon meal; -9/23/20 the resident refused fluids at the breakfast meal, drank 240cc at noon and 120cc at the evening meal; -9/24/20 the resident refused fluids at the breakfast and the noon meal and consumed 120cc at the evening meal; -9/25/20 the resident refused fluids at all 3 meals; -9/26/20 the resident consumed 240cc of fluids at breakfast, 120cc at the noon meal and refused fluids at the evening meal; -9/27/20 the resident refused fluids at breakfast and the noon meal and drank only 60cc at the evening meal; -9/28/20 the resident consumed 480cc of fluid at breakfast and 240cc at the noon meal. Resident 1 refused fluids at the evening meal; and -9/29/20 no fluids were consumed at breakfast and only 120cc of fluids were taken at the noon meal. Review of intake documentation of the resident's Ensure Plus supplement from 9/17/20 to 9/29/20 revealed the following: -9/17/20 the resident consumed 120cc of supplement at each of the meals; -9/18/20 the resident refused the supplement at breakfast and the evening meal and drank 120cc at the noon meal; -9/19/20 the resident drank 120cc of supplement at breakfast. All other supplements were refused; -9/20/20 the resident consumed 120cc at each meal; -9/21/20 the resident refused supplement at breakfast, consumed 60cc at noon and 120cc at the evening meal; -9/22/20 the resident refused breakfast supplement and consumed 120cc at the noon and the evening meal; -9/23/20 the resident refused breakfast and the evening meal supplement and drank 120cc at the noon meal; -9/24/20 the resident refused supplement at breakfast and drank 120cc at the noon and the evening meal; -9/25/20 the resident refused supplement for the breakfast meal and consumed 120cc for the noon and evening meal; -9/26/20 the resident refused the supplement for the evening meal and drank 120cc for breakfast and at noon; -9/27/20 the resident refused the supplement at breakfast, drank 120cc at noon and 60cc for the evening meal; and -9/28/20 the resident consumed 120 cc at breakfast. No further documentation was available for 9/28/20 and 9/29/20. Further review revealed no documentation that the resident would be offered or encouraged to drink more fluids. Interview with the Director of Nursing (DON) on 2/16/20 at 1:00 PM indicated the staff did not calculate the resident's total fluid intake daily to evaluate their actual intake and ensure that their hydration needs were met. Further interview confirmed the resident was at risk for dehydration due to recent [CONDITION(S)], impaired cognition and dependence on staff. The DON verified the resident needed encouragement and assistance to take fluids throughout the day with cares, snacks and meals.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview; the facility failed to ensure that residents were transferred safely to prevent injury for one resident, Resident 1. The facility census was 33. Findings are: Review of Resident 1's Care Plan dated 10/30/13 revealed that Resident 1 was admitted with [DIAGNOSES REDACTED]. Care Plan interventions for Resident 1 included: extensive assist with bed mobility, grooming, dressing and use of mechanical lift or two assist with all transfers. Review of the General Population CNA (Nursing Assistant) Worksheet, which is referred to by nursing assistants while at work in the facility, revealed that Resident 1 required two assist with transfers. Review of Nurses Notes for Resident 1 dated 12/1/13 revealed that at 7:15 PM NA (Nursing Assistant) A reported that Resident 1 grabbed the NA's knee during a transfer, causing Resident 1 to lose balance, and NA-A lowered Resident 1 to the floor. Resident 1 complained of pain to left shoulder with movement. Assessment by the nurse at 10:30 PM revealed left shoulder misshapen when compared to right shoulder. Review of a Physician's Visit report dated 12/2/13 revealed Resident 1 had a left Humeral (shoulder) fracture resulting from the fall on 12/1/13. Review of the personnel file for NA-A revealed a hire date of 7/19/13 and that there was no documentation that the Nurse's Aide Skills Proficiency Checklist was completed. The Certified Nurse's Aide Skills Proficiency Checklist included orientation to lifting residents, transfers from bed to wheelchair and wheelchair to toilet. An interview with the DON (Director of Nursing) on 12/16/13 at 4:30 PM revealed that on 12/1/13 NA-A attempted to transfer Resident 1 without the assist of another staff member or the use of a gaitbelt which resulted in Resident 1 being lowered to the floor and sustaining a fracture to the resident's left shoulder. Further interview with the DON confirmed that there was not documentation of NA-A's proficiency with resident transfers.