Every finding on record at Good Samaritan Society - Albion

Licensure Reference Number 175 NAC 12.006.10(A)(i) Based on observation, record review and interview; the facility failed to assess Resident 8 for safe self-administration of medication. The sample size was 1 and the facility census was 42. Findings are: Findings are:A. Review of the facility policy Resident Self-Administration of Medication with a revision date of 10/31/25 revealed the following:-The purpose of the policy was to determine if the resident could safely self-administer medications.-Before a physician's order was obtained the facility was to complete the Resident Self-Administration of Medications Assessment to determine if the resident could safely self-administer medications.-The resident's ability to continue to safely self-administer medication must be reviewed during the care planning process quarterly and with significant change. B. Review of a Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) for Resident 8 dated 3/25/26 revealed the resident was cognitively intact with diagnoses of diabetes. The resident received insulin injections 7 days. Review of Resident 8's current Care Plan with a revision date of 5/13/26 revealed the resident chose to self-administer insulin medications, the resident demonstrated ability to safely administer insulin and change needles perinterdisciplinary team determination and physician's order. Interventions included the following:-The resident would self-administer insulin and change needles per physician's order.-Medication would be kept in the medication cart/medication refrigerator, and the resident would ask when needing to refill insulin pump.-The resident would document self-administration of medications and report to staff to document in the Medication Administration Record (MAR). Review of Resident 8's Medication Administration Record (MAR) for 5/2026 revealed Resident 8 had the following orders:-The guardian 4 blood sugar transmitter would be changed weekly every Friday. The supplies and directions were on the cabinet on the unit.-The insulin pump would be changed every 3 days and as needed every 6 hours.-Humalog insulin via insulin pump, (maximum of 60 units per day). The resident would notify the staff of the number of units administered per sliding scale and the carbohydrate count after each meal.Review of Resident 8's medical record revealed that no Resident Self-Administration of Medications Assessment was found. An observation on 5/18/26 at 8:30 AM revealed Resident 8 counted the amount of carbohydrates eaten at breakfast meal. The resident then entered the number of carbohydrates into the insulin pump, and the insulin pump injected the amount of insulin needed for the number of carbohydrates entered. The resident notified the staff of the number of carbohydrates eaten and the amount of insulin injected, the staff then documented this in the residents MAR.D. An interview with the Director of Nursing on 5/18/26 at 3:10 PM confirmed that Resident 8 had not been assessed to determine if resident was safe to self-administer insulin.

Licensure Reference Number 175 NAC 12-006.09(I)(i) Based on observation, record review and interview; the facility failed to identify causal factors and to develop and/or revise interventions for the prevention of ongoing falls for 2 (Residents 39 and 18) of 6 sampled residents. The facility census was 48. Findings are: A. A record review of the facility Fall Prevention and Management Policy with reviewed/revised date of 7/29/24 revealed the purpose of the policy was to promote the resident's well-being by developing and implementing a fall prevention and management program. The facility was to identify risk-factors and implement interventions before a fall occurred. If a fall did occur the staff were to complete the following process: -assess the resident for injuries and obtain a set of vital signs including a blood pressure, pulse, respirations, temperature, and pulse oximetry (a non-invasive medical procedure that measures the oxygen saturation of the blood). -if the fall was not witnessed then staff were to perform neurological assessments (a comprehensive evaluation of a person's nervous system, including the brain, spinal cord, and nerves, to identify any abnormalities or damage). -complete an Incident Report. -complete the Fall Scene Huddle Worksheet. -if any teaching was done, it was to be documented in the medical record. -communicate to other staff/shifts that a fall had occurred. -review and update the care plan with any changes or new interventions. B. A record review of the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) for Resident 39 dated 3/11/25 revealed the resident was admitted [DATE] with diagnoses of arthritis, dementia, depression, and psychotic disorder. The following was assessed for Resident 39: -severe cognitive impairment. -required staff assistance with personal hygiene, toileting, dressing, bed mobility and transfers. -2 falls without injury and 2 falls with injury (except major) since previous assessment. -use of bed and chair alarms daily. A record review of the current Care Plan dated 8/5/24 revealed Resident 39 was at risk for falls due to diagnoses of dementia with episodes of confusion, impulsive decision making and no awareness of safety needs, history of falls and psychoactive medication use. The following interventions with their date of development/implementation were identified: -8/5/24 encourage the resident to participate in activities that promote exercise and physical activity. -8/5/24 ensure the resident is wearing appropriate footwear. -8/29/24 toilet before meals and then position in the Commons area for increased supervision. -9/7/24 bolster mattress and extra call light added to the resident's room. -9/16/24 sensor pad (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) to recliner, wheelchair and dining room chair and silent alarm to bed. Ensure alarms are connected to the call light system. A record review of an Incident Report for Resident 39 dated 8/15/24 at 5:53 PM revealed the staff heard the resident's fall alarm and found the resident in their room and lying on their back. The resident reported being in a hurry to go to the evening meal and fell when taking self to the bathroom. New interventions were identified for the resident to be evaluated by Occupational Therapy, Physical Therapy and Speech Therapy; the resident was to be toileted and then positioned in the Commons area prior to the meal service and the resident was no longer to use the 4 wheeled walker. A record review of an Incident Report for Resident 39 dated 8/18/24 at 7:35 PM revealed the staff responded to the resident's call light and fall alarm and found the resident on the floor in front of the recliner. The footrest of the recliner was in the upright/extended position. The resident's medication regimen was reviewed, and a new order was received for Ativan (medication used to treat anxiety) in the early evening when the resident had increased restlessness. A record review of an Incident Report for Resident 39 dated 9/16/24 at 8:00 AM revealed the staff heard a noise from the corridor and found the resident on the bathroom floor. The resident was incontinent and was found without their walker. Further review of the investigation revealed the resident had not been toileted since 9:17 PM on 9/15/24. In addition, the connectors were not secured to the resident's fall alarm, and did not sound when the resident self-transferred. The alarm pad connections were immediately secured so the alarm would come through the call light system. The staff did not address the resident's toileting schedule or provide further investigation as to why the resident had not been toileted since 9:17 PM (10 hours and 42 minutes) the previous evening. A record review of an Incident Report for Resident 39 dated 11/21/24 at 7:06 PM revealed the resident was found on the floor in the Commons area near the public bathroom. The resident indicated needing to have a bowel movement and used the 4 wheeled walker (use was to be discontinued on 8/15/24) to try and get to the bathroom, lost balance and fell . The report indicated staff were to continue current plan of care and interventions as the resident's falls were unavoidable. Further review revealed current interventions were not revised and staff did not develop any new interventions. In addition, the resident continued use of the 4 wheeled walked despite an intervention to no longer use the 4 wheeled walker identified with the resident's fall on 8/15/24. A record review of an Incident Report for Resident 39 dated 1/6/25 at 4:45 PM revealed the resident was found on the floor next to the Nurse's Station. An intervention was identified to change the 4 wheeled walker (use was to be discontinued on 8/15/24) to a front wheeled walker with a basket for the resident's belongings. In addition, staff were to transfer the resident into a wheelchair when restless and then to keep the resident with a staff member for closer supervision. A record review of an Incident Report for Resident 39 dated 1/10/25 at 4:55 PM revealed the resident had been toileted and was ambulating with staff assistance to the recliner. The resident continued use of the 4 wheeled walker which was to have been discontinued on 8/15/24 and on 1/6/25. The resident tried to sit down on the seat of the walker, was too close to the edge and was lowered to the floor by staff. The 4 wheeled walker was removed from the resident's room and was replaced with a front wheeled walker. A record review of an Incident Report for Resident 39 dated 2/12/25 at 9:09 PM revealed the resident was found lying on the floor of the Commons area. The resident's fall alarm was sounding and the resident reported trying to get to my room. An intervention was identified for the physician and the Consultant Pharmacist to review the resident's medications and to have the National Campus Risk Team review the resident's falls. The report indicated the resident's falls were unavoidable and to continue current interventions. Review of the resident's medical record revealed no revision of current interventions or development of new interventions to prevent further falls. A record review of an Incident Report for Resident 39 dated 2/13/25 at 7:28 PM revealed the resident was found on the floor of the Common's area by the Nurse's Station. The resident reported trying to get to the resident's room. An intervention was identified for staff education to ensure the resident was toileted after the evening meal and then the resident was positioned in a recliner and not the wheelchair in the Common's area. A record review of an Incident Report for Resident 39 dated 2/25/25 at 7:00 AM revealed the staff heard the resident's call light and found the resident on the bathroom floor of the resident's room. The resident identified a need to use the bathroom. Further review of the report revealed the resident had last been toileted at 2:30 AM (4 and 1/2 hours prior). The Maintenance Supervisor did review the flooring threshold between the resident's room and the bathroom, but no changes were made. The report indicated the resident's falls were unavoidable due to dementia and to continue the current plan of care. The resident's toileting schedule was not addressed, and no further interventions were developed. Interview with Nurse Aide (NA)-H and NA-I on 4/2/25 at 3:40 PM revealed the resident was to be toileted before and after meals and every 2 hours throughout the evening/night. During an interview on 4/3/25 at 10:21 AM the Director of Nursing (DON) confirmed the following regarding Resident 39's falls: -high risk for falls with impaired safety awareness. -staff were to assess the resident after each fall and complete an Incident Report and a Fall Scene Huddle Worksheet to determine causal factors and to develop or revise interventions to prevent further falls. -with fall on 8/15/24 the Incident Report indicated the resident was no longer to use the four wheeled walker. -with fall on 11/21/24 the Incident Report identified the resident continued use of the 4 wheeled walker. -with fall on 1/6/25 the Incident Report specified the 4 wheeled walker (which was to have been discontinued on 8/15/24) was to be changed to a front wheeled walker. -with the fall on 1/10/25 the resident's 4 wheeled walker was finally removed from the resident's room and was replaced with a front wheeled walker. 51391 C. A record review of Resident 18's MDS dated [DATE] revealed the resident had a diagnosis of non-Alzheimer dementia and unsteadiness on feet. The following was assessed regarding the resident: - severe cognitive impairment. - inattention and disorganized thinking. - hallucination and delusions. - dependent on staff for toileting hygiene, lower body dressing and putting on footwear. -required substantial assistance with upper body dressing and personal hygiene. -required partial assistance with sitting to standing and toilet transfer. - always continent of bowel and frequently incontinent of bladder. - 2 or more falls, 1 with injury and 1 without injury since previous assessment. - bed and chair alarms were used daily. A record review of Resident 18's current Care Plan dated 2/24/24 revealed the resident had an activity of daily living deficit related to history of stroke, dementia, weakness, unsteady gait and history of falls. Nursing interventions with development dates included the following: -2/14/25 assist to lift recliner chair for positioning when in the room. Remote control placed behind chair for staff control. A record review of a Nursing Progress Note dated 3/7/25 at 9:55 PM revealed Resident 18 was observed lying on the resident's back on the floor at the foot of the bed. The resident's alarm was sounding, staff entered the room and observed the resident ambulating independently. Gait belt was placed around the resident's waist, the resident lost balance and was lowered to the floor. A record review of the Incident Report for Resident 18 dated 3/7/25 at 9:50 PM revealed the resident needed to use the bathroom, used the remote to the chair to lower the legs and elevate the seat of the recliner. A record review of the fall review documentation for Resident 18 on 3/21/25 revealed the root cause of the fall was due to the resident ambulating across the room independently, staff responded to the alarm and assisted, but resident lost balance and was lowered to the floor by staff. Further review of the fall review documentation revealed the care plan was reviewed and current interventions in place were correct and applicable for the resident. To continue to use current care plan interventions. No additional interventions were identified. An observation on 4/1/25 at 11:20 AM with NA-K revealed that Resident 18 was transferred with 1 assist, gait belt and front wheeled walker from recliner. The remote to the recliner was behind the recliner, NA-K picked up the remote from behind the recliner that was hanging from an elastic band that was wrapped around the back of the recliner, lowered Resident 18's legs and elevated the recliner to assist the resident to a standing position. An interview on 4/3/25 at 8:30 AM with the DON confirmed the remote for Resident 18's recliner was behind the recliner and was to be screwed into the recliner. Reviewed the investigation report from 3/7/25 with the DON that revealed the resident used the remote to the chair to lower the legs and elevate the seat of the recliner and during the observation on 4/1/25 the remote to the recliner was not screwed into the recliner. An interview on 4/3/25 at 9:00 AM with the Maintenance Manager confirmed that the remote for Resident 18's recliner was on a band wrapped around the back of the recliner. Maintenance Manager confirmed that the recliner remote was connected to the back of the recliner with a screw on 4/3/25 at 8:45 AM. An interview on 4/3/25 at 10:55 AM Thw Director of Nursing confirmed that the cause of Resident 18's fall on 3/7/25 was due to the resident using the remote to the recliner to lower the legs and elevate the seat of the recliner allowing the resident to transfer self independently.

Licensure Reference Number 175 NAC 12-006.02(8) Based on interview and record review, the facility failed to report a serious injury to the State Agency within the required time frame for 1 resident (Resident 12). The sample size was 1 and the facility census was 52. Findings are: A. Review of the facility policy Abuse and Neglect dated 7/6/23 revealed the following: -Ensure employees are knowledgeable of reporting and investigating procedures related to abuse and neglect allegations. -Ensure the facility has an effective system in place. -Ensure that all identified incidents of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated. -Designated agencies will be notified in accordance with state law, including the State Agency and Adult Protective Services (APS). If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and/or there is serious bodily injury then it will be reported immediately, but not later than two hours. B. Review of Resident 12's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/9/24 revealed the resident was admitted on [DATE], had no cognitive impairment, and required substantial assistance with transfers and toileting. Further review revealed diagnoses of cancer, heart failure, diabetes and peripheral vascular disease (narrowing of blood vessels situated away from the heart or brain). C. During an interview with Resident 12 on 3/26/24 at 1:15 PM, the resident indicated [gender] was scheduled for surgery the next day related to a fracture of the right foot second toe. When the resident was asked how the fracture occurred, [gender] stated [gender] was not sure and I could have bumped it on something and didn't know because I have no feeling in my feet. The resident also indicated staff were made aware of the injury at the time it was discovered a couple of weeks ago. Review of a physician progress note dated 3/8/24 revealed Resident 12 had an injury of the second toe of the right foot and x-ray showed dislocation with lateral deviation with a referral was then made to a podiatrist. Review of the Podiatrist's clinical note dated 3/19/24 revealed Resident 12 had a right foot 2nd digit fracture dislocation with exposed bone of an indeterminate time, up to 1 month. Further review revealed a recommendation for amputation of the toe. Review of the facility investigation reports between 3/21/23 and 3/26/24 revealed no evidence facility staff had reported Resident 12's injury to the state agency and/or APS as required. During an interview with the Director of Nurses (DON) on 3/28/24 at 12:55 PM, the DON confirmed Resident 12 had a dislocation of the right foot 2nd toe that was identified on 3/8/24, the resident required surgical intervention, and this was considered a serious injury. The DON also confirmed the incident had not been reported to the State Agency within the required time frame.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, interview and record review, the facility failed to prevent the potential for accidents related to Resident 20, who had an episode of coughing/choking during the meal service. The sample size was 1 and the facility census was 52. Findings are: Review of Resident 20's Minimum Data Set (MDS- a mandatory comprehensive assessment tool used for care planning) dated 1/23/24 revealed the following about the resident: -cognitition was intact; -diagnoses of lung disease, heart failure, pneumonia, and dysphagia (difficulty swallowing); -ate meals independently with set up help; -had a mechanically altered diet (consists of foods that can be safely and successfully swallowed); and -coughing or choking during meals was indicated. Review of Resident 20's care plan with a print date of 4/1/24 revealed the resident was at risk for nutritional problems related to dysphagia, malnutrition, weakness, anxiety, depression, abnormal weight loss, poor meal intake, and modified diet. Interventions included: -Resident prefers to dine in room during meals/resident at risk for choking. Resident educated on risk for choking and recommended supervision and is encouraged to come out for meals. Does frequently refuse. -Adaptive equipment of plastic silverware and divided plate. -Requires a regular/soft and bite size diet with transitional foods/thin liquids. -Allowed mixed consistencies at regular texture/bite size pieces. -Allowed breads and baked goods at regular texture. -Set up meals, independent with food and fluid intake. -Extra gravy and sauces. -Requested small portions. -Offer yogurt daily and a banana as available. -When resident requests foods outside of her modified diet texture, explain the risk, let nursing know to document. An observation of Resident 20 on 3/26/24 at 12:55 PM revealed the resident was seated in [gender] room and was heard coughing excessively. There were no staff present in the room or in the hallway outside of the room. The resident continued to have a harsh cough and was asked if [gender] was okay. The resident nodded to indicate yes but continued to cough excessively for approximately 3 to 5 minutes. The resident was asked if the coughing was caused by the food and [gender] softly stated a piece of fish got stuck. The resident was observed with a plate of food with small bite size pieces of fish, sweet potatoes (mashed consistency) and green vegetables (mashed consistency). An unidentified nursing staff member was summoned to the resident's room and informed of the coughing/choking episode. Observation of Resident 20 in [gender] room on 3/27/24 at 12:00 PM. The resident stated [gender] planned to eat the noon meal inside [gender] room independently. The resident indicated [gender] preferred to eat in [gender] room for meals due to feeling weak from a recent respiratory illness. Observation of Resident 20 inside the room on 4/1/24 at 0730 AM. The resident stated [gender] planned to eat the breakfast meal inside [gender] room. An interview with Speech Therapist (ST)-R on 4/1/24 at 11:00 AM confirmed the resident had a diagnosis of dysphagia and was at risk for choking/aspiration with recommendations for a specialized diet of soft and bite size foods. ST-R also indicated the resident had requested to eat regular foods such as a hamburger, pizza and bread. The resident was educated about the risks of choking/aspiration and allowed to consume the requested regular food items as indicated. An interview with the administrator on 4/1/24 at 11:20 AM confirmed the resident was at risk for choking/aspiration related to difficulty swallowing. The administrator was not able to verify the resident had been closely monitored by staff members when [gender] ate in [gender] room independently in order to prevent potential choking accidents.

Licensure Reference Number 175 NAC 12-006.05(4) Based on record review and interviews, the facility failed to ensure the choice to refuse the Covid-19 vaccine booster for Resident 18 was followed. The sample size was 1 and the facility census was 46. Findings are: Review of Resident 18's medical record revealed the following: -the resident's cognition was moderately impaired and a legal representative had been appointed to make medical and financial decisions for the resident; -on 5/23/22 the resident's legal representative signed a Covid-19 Vaccine Consent form that indicated the offered vaccine was refused; and -on 5/24/22 the resident was administered the Covid-19 vaccine booster. During an interview with Resident 18's legal representative on 03/15/23 at 02:08 PM confirmed the offered Covid-19 vaccine booster had been refused and it was still given to the resident after the refusal. During an interview with the administrator on 3/21/23 at 08:15 AM, the administrator confirmed, Resident 18 was administered the Covid-19 vaccine booster on 5/24/22 and it should not have been given after the resident's legal representative had refused the offered vaccine on 5/23/22.

Licensure Reference Number 175 NAC 12-006.09B Based on observations, interviews and record review, the facility failed to ensure the Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) for Resident 37 was coded to reflect the resident's ADL (Activities of Daily Living) status related to bladder elimination. The facility census was 46. Findings are: A. Review of Resident 37's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of kidney failure, anemia, asthma, arthritis, macular degeneration (an eye disease that can blur your central vision) and progressive neuropathy (a condition that affects the nerves outside your brain or spinal cord). The following was assessed regarding the resident: -cognition mildly impaired; -required extensive assistance with toileting and dressing, limited assistance required with bed mobility, transfers and personal hygiene; and -the resident had an indwelling urinary catheter (a flexible tube inserted into a person's bladder used to drain urine into a collection bag outside of the body.) Observations of the resident ambulating from [gender] room to the dining room on 3/20/23 at 07:45 AM revealed no evidence the resident had a urinary catheter. During an interview with Medication Assistant (MA)-B on 3/20/23 at 08:15 AM, MA-B indicated the resident did not have a urinary catheter and required little assistance with toileting cares. During an interview with the Director of Nurses (DON) on 3/21/23 at 12:15 PM, the DON confirmed the following regarding Resident 37: -the resident did not have an indwelling urinary catheter and has not had one since [gender] was admitted to the facility on [DATE]; -the resident's MDS assessment dated [DATE] under section H (Bowel and Bladder), indicated the resident had an indwelling urinary catheter; and -the assessment was not coded accurately related to the resident's bladder elimination status and should be modified to indicate the resident had no urinary appliances.

Licensure Reference Number NAC 12-006.09C1c Based on observations, record review and interview, the facility failed to review, revise and/or update care plans regarding fall interventions for Residents 22 and 18. The sample size was 3 and the facility census was 46. Findings are: A. Review of Resident 22's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/9/23 revealed the resident was admitted [DATE] with diagnoses of Parkinson's disease, history of a stroke with hemiplegia (paralysis of 1 side of the body), anxiety, depression and Chronic Obstructive Pulmonary Disease (COPD-lung disease which causes difficulty or discomfort with breathing). The following was assessed regarding the resident: -cognition moderately impaired; -extensive assistance required with bed mobility, transfers, dressing and toilet use; -unsteady and only able to stabilize with human assistance with transfers; -frequently incontinent of bowel and bladder; and -1 fall with injury (except major) since previous assessment. Review of Resident 22's current care plan dated 9/7/22 revealed the resident was at risk for falls related to Parkinson's disease, hemiplegia on the left side, weakness, balance problems and memory loss. The care plan indicated the resident had falls on 9/23/22, 11/16/22, 12/9/22 and on 2/2/23. The care plan identified the following fall prevention interventions: -resident not to be left alone while using the toilet; -remind the resident not to bend over to pick up dropped items; -ensure wearing appropriate footwear; -keep personal items within reach; -sign in room to remind resident to use the call light to seek assistance; and -when administering 2:00 AM pain medication, assist the resident with stretching left leg. Review of an Incident Report dated 12/9/22 revealed the resident had a fall at 9:45 AM. The report identified the resident was assisted into the bathroom and was left sitting on the toilet at 9:00 AM. The resident had been left on the toilet a significant time. The resident failed to utilize the call light, self-transferred off the toilet and fell . An intervention was identified for the resident not to be left alone in the bathroom and on the toilet. Review of an Incident Report dated 2/2/23 revealed the resident had a fall at 2:51 AM. The resident had stood up next to the bed to use the urinal and leaned on the bed to maintain balance. While leaning on the bed, the resident accidentally activated the bed controls causing the bed to lower. The resident then lost balance and fell . An intervention was identified to place the bed controls to the opposite side of the bed to prevent a reoccurrence. Review of the resident's current care plan revealed no evidence the care plan had been updated regarding this new intervention. During an observation of toileting cares on 3/20/23 from 10:24 AM to 10:55 AM the following was observed: -10:24 AM Medication Aide (MA)-C entered the resident's room with the sit-to-stand lift (mechanical device which allows the resident to be transferred from a seated position to a standing position. Designed to support the upper body and requires the resident to have some weight bearing capability). MA-C transferred the resident with the lift out of a wheelchair and into the bathroom. The resident was transferred onto the toilet. -10:36 AM MA-C advised the resident to use the call light when done, exited the resident's bathroom, closed the door and then entered the corridor after closing the resident's room door. The resident was left alone and unsupervised in the bathroom; -10:46 AM (10 minutes later) the resident's bathroom call light was answered by Nurse Aide (NA)-N. NA-N assisted the resident out of the bathroom and back into the wheelchair. During an interview on 3/20/23 at 2:44 PM, the Director of Nursing (DON) confirmed the following regarding Resident 22: -fall on 12/9/22 at 9:45 AM related to staff leaving the resident alone in the bathroom and unsupervised. New intervention developed not to leave alone on the toilet; -facility had recently assessed the resident was no longer safe to be transferred as a pivot transfer and the decision was made to use the sit-to-stand lift to transfer the resident; -staff had been leaving the resident alone in the bathroom since use of the lift; -the resident's care plan had not been reviewed and/or revised regarding the intervention for the resident to remain supervised in the bathroom; and -the resident's care plan was not updated with new intervention regarding bed controls from the fall on 2/2/23. 42679 B. Review of Resident 18's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of heart failure, anemia, high blood pressure, diabetes, stroke, Parkinson's, asthma, peripheral vascular disease (a slow and progressive circulation disorder), chronic pain syndrome, and delusional disorders. The following was assessed regarding the resident: -cognition severely impaired; -extensive assistance required with bed mobility, transfers, dressing, toileting and personal hygiene; -unsteady and only able to stabilize with human assistance with transfers; -scheduled toileting program had not been trialed since admission; -frequently incontinent of bladder; -condition or chronic disease that may result in a life expectancy of less than 6 months; and -1 fall with injury (except major) since previous assessment. An observation of Resident 18 on 3/15/23 at 09:02 AM in the resident's room revealed the following: -the resident was alone in the room and seated in the wheelchair next to the recliner, then moved closer to the side of the bed; -the resident stood up from the wheelchair unassisted and transferred [gender]self from the wheelchair to the bed; -an alarm sounded and an unidentified staff member responded within a couple of minutes; -the resident was already on the bed when the staff member entered the resident's room; and -the staff member reset the sensor pad alarm and exited the room. Review of Resident 18's current care plan with a print date of 3/20/23 revealed the resident was at risk for unavoidable falls related to Parkinson's disease, history of left hip replacement with chronic left leg pain, unaware of safety needs, use of antidepressant medication, irregular heart rhythm, balance problems, shuffling gait, attempts self-transfers, non-compliant with call light use, memory loss, impulsive movements, turns off safety alarms by self, refuses to wear non-skid socks when transferring self from bed, has delusional thoughts and hallucinations. The care plan indicated the resident had falls on 1/5/22, 2/9/22, 2/16/22, 3/6/22, 3/13/22, 5/24/22; 6/16/22, 6/27/22, 9/8/22, 9/12/22, 9/13/22, 10/11/22, 12/03/22, 2/1/23, and 3/11/23. The care plan identified the following fall prevention interventions: -9/15/21, monitor for significant changes in cognition, safety awareness, gait, mobility, positioning device; -9/21/21, keep room free of clutter, frequently used items close in reach; -2/16/22, leave wheelchair locked next to bed at night; -6/7/22, falling star sign placed in bathroom. Do not leave on toilet unattended; -6/28/22, sensor alarm pad to bed, under shoulder, to wheelchair and recliner. Automatic locking brakes on wheelchair. Sign put in bathroom and room as visual reminders to call for assistance for transfers; -7/7/22, scoop mattress (mattress with raised edges on the sides) on bed; -10/13/22, ensure appropriate footwear, encourage to wear gripper socks at night; -12/3/22, hospice consulted about assisting with prevention of falls and increase hospice visits; -2/1/23, hospice to review meds due to anxiety/poor sleep pattern and poor decision making; and -3/11/23, fall care plan reviewed. Resident interventions all being followed at the time of this fall, continue current plan of care and MD does note that falls are unavoidable due to non-compliance and diagnoses. Will continue and involve family and hospice as resident allows. Review of an Incident report dated 9/8/22 revealed the resident had a fall at 4:45 PM. The resident had self-transferred from the recliner in [gender] room. The wheelchair was not within reach. The chair alarm sounded through the call light system and staff were assisting other residents. The resident indicated [gender] slid to the floor when trying to get to the bathroom without assistance. Staff were educated to keep the resident's wheelchair close to [gender] when in the recliner or bed. Review of the resident care plan revealed no evidence fall prevention interventions had been updated or revised following this fall. Review of an incident report dated 9/12/22 revealed the resident had a fall at 7:00 PM. The resident had self-transferred from the chair/wheelchair and was found on the floor. Staff indicated the resident's fall was unavoidable due to cognition and Parkinson's. There was no evidence causal factors related to the fall were identified. Review of the resident's care plan revealed no evidence fall prevention interventions had been updated or revised following this fall. Review of an incident report dated 9/13/22 revealed the resident had a fall at 09:20 AM. The resident had self-transferred from the wheelchair to the toilet. The resident indicated [gender] did not lock the brakes on the wheelchair or put the call light on for assistance. Review of the resident's care plan revealed no evidence fall prevention interventions were updated or revised following the resident's fall. During an interview with the administrator on 3/21/23 at 12:10 PM, the administrator confirmed the following related to Resident 18's falls: -9/8/22 at 4:45 PM, the resident had a fall when [gender] self-transferred from the recliner in [gender] room. Staff were educated to keep the resident's wheelchair close to [gender] when in the recliner or bed. There was no evidence fall prevention interventions had been updated or revised following this fall. -9/12/22 at 7:00 PM, the resident had a fall when [gender] self-transferred from the chair/wheelchair. Staff indicated the resident's fall was unavoidable due to cognition and Parkinson's. There was no evidence causal factors were identified and no evidence fall prevention interventions had been updated or revised following the resident's fall. -9/13/22 at 09:20 AM, the resident had a fall when [gender] self-transferred from the wheelchair to the toilet. There was no evidence fall prevention interventions were updated or revised following the resident's fall.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observations, interviews and record review; the facility failed to implement fall interventions for Resident 22 and failed to identify causal factors of falls, and to develop and/or revise fall prevention interventions for the prevention of ongoing falls for Resident 18. The sample size was 3 and the facility census was 46. Findings are: A. Review of the facility policy Fall Prevention and Management with a revision date of 3/30/22 revealed the purpose of the policy was to identify risk factors and implement interventions before falls occurred, to give prompt treatment after a fall occurred and to prevent further injury. The following process was indicated if a resident would have a fall: -complete the Fall Scene Huddle Worksheet (form used to document potential causal factors related to the fall) as soon as possible; -implement immediate interventions; -update the resident's care plan with interventions as appropriate; and -continue to monitor the resident's condition and the effectiveness of the interventions. B. Review of Resident 22's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/9/23 revealed the resident was admitted [DATE] with diagnoses of Parkinson's disease, history of a stroke with hemiplegia (paralysis of 1 side of the body), anxiety, depression and Chronic Obstructive Pulmonary Disease (COPD-lung disease which causes difficulty or discomfort with breathing). The following was assessed regarding the resident: -cognition moderately impaired; -extensive assistance required with bed mobility, transfers, dressing and toilet use; -unsteady and only able to stabilize with human assistance with transfers; -frequently incontinent of bowel and bladder; and -1 fall with injury (except major) since previous assessment. Review of Resident 22's current care plan dated 9/7/22 revealed the resident was at risk for falls related to Parkinson's disease, hemiplegia on the left side, weakness, balance problems and memory loss. The care plan indicated the resident had falls on 9/23/22, 11/16/22, 12/9/22 and on 2/2/23. The care plan identified an intervention dated 12/9/22 for the resident not to be left alone while using the toilet. Review of an Incident Report dated 12/9/22 revealed the resident had a fall at 9:45 AM. The report identified the resident was assisted into the bathroom and was left sitting on the toilet at 9:00 AM. The resident had been left on the toilet a significant time. The resident failed to utilize the call light, self-transferred off the toilet and fell . An intervention was identified for the resident not to be left alone in the bathroom and on the toilet. During an observation of toileting cares on 3/20/23 from 10:24 AM to 10:55 AM the following was observed: -10:24 AM Medication Aide (MA)-C entered the resident's room with the sit-to-stand lift (mechanical device which allows the resident to be transferred from a seated position to a standing position. Designed to support the upper body and requires the resident to have some weight bearing capability). MA-C transferred the resident with the lift out of a wheelchair and into the bathroom. The resident was transferred onto the toilet. -10:36 AM MA-C advised the resident to use the call light when done, exited the resident's bathroom, closed the door and then entered the corridor after closing the resident's room door. The resident was left alone and unsupervised in the bathroom; -10:46 AM (10 minutes later) the resident's bathroom call light was answered by Nurse Aide (NA)-N. NA-N assisted the resident out of the bathroom and back into the wheelchair. Interview with the Director of Nursing (DON) on 3/20/23 at 2:44 PM confirmed the resident remained at risk for ongoing falls. The DON verified the resident had a history of falling when unsupervised in the resident's bathroom and the care plan indicated the resident should not have been left alone on the toilet and in the bathroom. 42679 C. Review of Resident 18's MDS dated [DATE] revealed the resident was admitted on [DATE] with diagnoses of heart failure, anemia, high blood pressure, diabetes, stroke, Parkinson's, asthma, peripheral vascular disease (a slow and progressive circulation disorder), chronic pain syndrome, and delusional disorders. The following was assessed regarding the resident: -cognition severely impaired; -extensive assistance required with bed mobility, transfers, dressing, toileting and personal hygiene; -unsteady and only able to stabilize with human assistance with transfers; -scheduled toileting program had not been trialed since admission; -frequently incontinent of bladder; -condition or chronic disease that may result in a life expectancy of less than 6 months; and -1 fall with injury (except major) since previous assessment. An observation of Resident 18 on 3/15/23 at 09:02 AM in the resident's room revealed the following: -the resident was alone in the room and seated in the wheelchair next to the recliner, then moved closer to the side of the bed; -the resident stood up from the wheelchair unassisted and transferred [gender]self from the wheelchair to the bed; -an alarm sounded and an unidentified staff member responded within a couple of minutes; -the resident was already on the bed when the staff member entered the resident's room; and -the staff member reset the sensor pad alarm and exited the room. Review of Resident 18's current care plan with a print date of 3/20/23 revealed the resident was at risk for unavoidable falls related to Parkinson's disease, history of left hip replacement with chronic left leg pain, unaware of safety needs, use of antidepressant medication, irregular heart rhythm, balance problems, shuffling gait, attempts self-transfers, non-compliant with call light use, memory loss, impulsive movements, turns off safety alarms by self, refuses to wear non-skid socks when transferring self from bed, has delusional thoughts and hallucinations. The care plan indicated the resident had falls on 1/5/22, 2/9/22, 2/16/22, 3/6/22, 3/13/22, 5/24/22; 6/16/22, 6/27/22, 9/8/22, 9/12/22, 9/13/22, 10/11/22, 12/03/22, 2/1/23, and 3/11/23. The care plan identified the following fall prevention interventions: -9/15/21, monitor for significant changes in cognition, safety awareness, gait, mobility, positioning device; -9/21/21, keep room free of clutter, frequently used items close in reach; -2/16/22, leave wheelchair locked next to bed at night; -6/7/22, falling star sign placed in bathroom. Do not leave on toilet unattended; -6/28/22, sensor alarm pad to bed, under shoulder, to wheelchair and recliner. Automatic locking brakes on wheelchair. Sign put in bathroom and room as visual reminders to call for assistance for transfers; -7/7/22, scoop mattress (mattress with raised edges on the sides) on bed; -10/13/22, ensure appropriate footwear, encourage to wear gripper socks at night; -12/3/22, hospice consulted about assisting with prevention of falls and increase hospice visits; -2/1/23, hospice to review meds due to anxiety/poor sleep pattern and poor decision making; and -3/11/23, fall care plan reviewed. Resident interventions all being followed at the time of this fall, continue current plan of care and MD does note that falls are unavoidable due to non-compliance and diagnoses. Will continue and involve family and hospice as resident allows. Review of an Incident report dated 9/8/22 revealed the resident had a fall at 4:45 PM. The resident had self-transferred from the recliner in [gender] room. The wheelchair was not within reach. The chair alarm sounded through the call light system and staff were assisting other residents. The resident indicated [gender] slid to the floor when trying to get to the bathroom without assistance. Staff were educated to keep the resident's wheelchair close to [gender] when in the recliner or bed. Review of the resident care plan revealed no evidence fall prevention interventions had been updated or revised following this fall. Review of an incident report dated 9/12/22 revealed the resident had a fall at 7:00 PM. The resident had self-transferred from the chair/wheelchair and was found on the floor. Staff indicated the resident's fall was unavoidable due to cognition and Parkinson's. There was no evidence causal factors related to the fall were identified. Review of the resident's care plan revealed no evidence fall prevention interventions had been updated or revised following this fall. Review of an incident report dated 9/13/22 revealed the resident had a fall at 09:20 AM. The resident had self-transferred from the wheelchair to the toilet. The resident indicated [gender] did not lock the brakes on the wheelchair or put the call light on for assistance. Review of the resident's care plan revealed no evidence fall prevention interventions were updated or revised following the resident's fall. During an interview with the administrator on 3/21/23 at 12:10 PM, the administrator confirmed the following related to Resident 18's falls: -9/8/22 at 4:45 PM, the resident had a fall when [gender] self-transferred from the recliner in [gender] room. Staff were educated to keep the resident's wheelchair close to [gender] when in the recliner or bed. There was no evidence fall prevention interventions had been updated or revised following this fall. -9/12/22 at 7:00 PM, the resident had a fall when [gender] self-transferred from the chair/wheelchair. Staff indicated the resident's fall was unavoidable due to cognition and Parkinson's. There was no evidence causal factors were identified and no evidence fall prevention interventions had been updated or revised following the resident's fall. -9/13/22 at 09:20 AM, the resident had a fall when [gender] self-transferred from the wheelchair to the toilet. There was no evidence fall prevention interventions were updated or revised following the resident's fall.

LICENSURE REFERENCE NUMBER NAC 175 12-006.10A(1)(2) Based on observation, interview and record review, the facility failed to ensure medications were kept secured for Resident 42 and that expired medications were not available for use for Resident 20. The total sample size was 23. The facility census was 48. Findings are: A. Review of the facility's policy on Medication Administration with a revised date of 4/6/2021, revealed medications were not to be left at the resident's bedside or at the table unless there was a specific physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy on the storage of medications with a revised date of 12/28/2020, revealed staff should routinely check medication storage areas for expired medications and dispose of them in accordance with state/pharmacy regulations. Review of the facility's policy titled Resident Self-Administration of Medication with a revised date of 10/15/21, revealed the purpose of the policy was to determine if residents could safely self-administer medications and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . B. An observation of Resident 42 on 12/16/21 at 09:38 AM, revealed the resident had a medicine cup with 2 tums on the bedside table. Resident 42 confirmed the medication was tums and they had been at the resident's bedside table for several hours. Resident 42 also indicated there had been 3 tums in the medicine cup initially and that [gender] had taken 1 of them earlier in the day without staff in the room. An interview with RN-H on 12/16/21 at 09:40 AM, revealed RN-H had not given Resident 42 the tums during the shift and the resident did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 42's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . C. An observation of the medication cart on 12/16/21 at 10:30 AM, revealed Resident 20 had a bottle of Milk of Magnesia that was labeled as opened on 6/11/20 and should have been discarded after 1 year from the date opened. D. Interview with the DON on 12/16/21 at 10:30 AM confirmed staff administering medications should not leave them with residents unless they have been assessed as safe to self-administer medications and have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also confirmed expired medications should not be stored in the medication cart and Resident 20 had an expired bottle of Milk of Magnesia located in the cart that should have been disposed of after 6/11/21.

Licensure Reference Number 175 NAC 12-006.17 Based on observations, interviews, and record reviews; the facility failed to ensure infection control practices were in place to prevent the potential spread of COVID-19 related to residents not wearing masks in common areas in which they had the potential and/or were within 6 feet of others. This had the ability to affect all residents. The total sample size was 33 and the facility census was 55. Findings are: A. Review of the Long-Term Care COVID-19 Phasing Guidance dated 6/15/20 revealed facilities could move to Phase 3 if they met certain criteria. Further review revealed certain mitigation steps were to be implemented in Phase 3. The guidance revealed: - Communal dining was allowed with residents social distancing at least 6 feet apart or with appropriate barriers in place. - Limited group activities were allowed and expanded group activities were allowed with appropriate social distancing and the use of a cloth face covering or facemask. - Universal source control pertained to everyone in the facility. Residents and visitors were to wear cloth face coverings or facemasks, if able to tolerate and wear safely. B. On 8/24/20 at 7:30 AM 3 residents were seated together watching television in the day area. The residents (Residents 40, 21, and 17) were seated less than 6 feet apart and none of them were wearing a face covering or facemask. On 8/24/20 at 7:45 AM Residents 40, 21, and 17 remained in the day area watching television less than 6 feet apart without face coverings or facemasks on. No staff were observed encouraging/assisting residents to put on face coverings or facemasks. C. On 8/24/20 at 7:41 AM Resident 49 was observed pushing Resident 51 to the breakfast table. Resident 49 then assisted Resident 51 with putting on a clothing protector. The residents were less than 6 feet apart and neither resident had a face covering or facemask on. D. On 8/24/20 at 7:52 AM Resident 36 went up to Resident 27 (who was seated in a wheelchair in the hallway with eyes closed). Resident 36 got within 6 feet of Resident 27 and encouraged the resident to wake up and head out to breakfast. Neither resident had a face covering or facemask on. A staff member walked by and thanked Resident 36. No staff were observed encouraging/assisting residents with face coverings or facemasks and/or social distancing. E. Interview with the Director of Nursing (DON) on 8/24/20 at 11:45 AM confirmed the facility had transitioned to Phase 3. F. Observations on 8/24/20 from 7:30 AM to 8:40 AM revealed the following: - At 7:33 AM Resident 35 was seated in a wheelchair and was assisted from the resident's room out to the Nurse's Station by Medication Aide (MA)-D. Resident 35 was not wearing a mask; - At 7:47 AM Resident 43 self-propelled wheelchair from the resident's room, down the corridor and into the main dining room for the breakfast meal. Resident 43 was not wearing a mask. Resident 43 passed directly by Resident 35 who remained seated at the Nurse's Station and remained without a mask; - At 7:52 AM Resident 1 ambulated independently from the resident's room, down the corridor to the main dining room and was not wearing a mask. Resident 1 ambulated directly by Resident 35 who remained at the Nurse's Station; - At 7:55 AM Resident 41 was assisted out of the resident's room by MA-D and positioned across from Resident 35 in the corridor. Neither of the residents were wearing masks. MA-E was standing at the medication cart which was parked next to where the residents were seated. MA-E passed by both Resident 35 and 41 multiple times while passing medications but made no attempts to assist the residents with putting on a mask; - At 7:56 AM Resident 15 without wearing a mask ambulated out of the resident's room, down the length of the corridor and out to the main dining room. Resident 15 walked by both Resident 35 and Resident 41 who remained by the Nurse's Station without masks; - At 8:03 AM MA-D assisted Resident 35 from the Nurse's Station and out to the main dining room, the resident remained without a mask. MA-D passed by Resident 41 but failed to assist the resident with putting on a mask; - At 8:06 AM Resident 4 ambulated independently from the resident's room to the sitting area at the end of the hallway by the entrance to Memory Lane. The resident was not wearing a mask; - At 8:07 AM MA-D assisted Resident 19 out of the resident's room and then to the main dining room. The resident's wheelchair was propelled directly by Resident 41. Neither of the residents were wearing masks; and - At 8:38 AM Resident 41 propelled self out of the main dining room, through the corridors and back to the Nurse's Station on the resident's hallway. Resident 41 passed directed by MA-E who was at the medication cart. Resident 41 was not wearing a mask and MA-E failed to cue or to assist the resident with putting on a mask. During an interview on 8/24/20 at 9:37 AM, MA-D confirmed residents were to wear a mask when out of their rooms except when sitting in the dining room for meals. MA-E further confirmed staff should assist residents with placement of masks or should cue the residents to make sure masks were in place. G. Observation of Resident 3 on 8/20/20 at 10:30 AM revealed the resident was riding a stationary bike located in the common entry way area to Memory Lane and the resident was wearing a surgical mask below the chin and not covering the mouth and nose. Observation of Resident 14 on 8/20/20 at 1:05 PM revealed the resident sitting in a wheelchair and being pushed down the hall of Memory Lane by a nurse aid and not wearing a mask. Observation of Resident 28 on 8/20/20 at 1:12 PM revealed the resident was self-propelling a wheel chair down the hall of Memory Lane not wearing a mask. Observation of Resident 16 on 8/24/20 at 8:00 AM revealed the resident sitting in the hallway of Memory Lane in a wheel chair and not wearing a mask. Observation of Resident 6 on 8/24/20 at 8:05 AM revealed the resident sitting in a chair in the lobby area of Memory Lane reading a newspaper and not wearing a mask. Observation of Resident 28 on 8/24/20 at 8:05 AM revealed the resident sitting in a wheel chair within 2 feet of another resident having a conversation with another resident who was seated at a table preparing for breakfast. Resident 28 was not wearing a mask. Observation of Resident 3 on 8/24/20 at 9:00 AM revealed the resident wheeling through the hallway and between 2 tables set up for breakfast with one resident present at each table finishing breakfast. Resident 2 was not wearing a mask. Interview with Resident 24 on 8/20/20 at 1:30 PM confirmed that the resident was not aware that masks should be worn outside of resident rooms and the resident was not encouraged by staff to wear a mask when outside of resident rooms.

License Reference Number: 175 NAC 12-006.17B Based on observations, record reviews and interviews; the facility failed to implement infection control precautions to prevent the spread of COVID-19 as 1) staff failed to follow transmission based precautions for 4 (Residents 1, 2, 6 and 7) of 7 sampled residents; and 2) staff failed to ensure forms were completed for staff screening. This had the ability to affect all of the facility residents. The total sample size was 7 and the census was 54. Findings are: A. Review of the facility policy for Transmission Based Precautions (undated) revealed staff were to wear a mask, face shield, isolation gown, and gloves when entering the room of a resident on isolation precautions. The following sequence for placing on Personal Protective Equipment (PPE) was identified: -complete hand hygiene; -put on a gown ensuring torso is fully covered from neck to knees, arms to end of wrists and wrapped around the back. The gown should then be fastened in back of the neck and waist; -put on mask with ties or elastic bands at middle of head and neck, fit flexible band to nose-bridge and ensure a snug fit to face and below chin; -place goggles or face shield over face and eyes and adjust to fit; and -put on gloves ensuring the gloves extend to cover wrist of isolation gown. The following instructions were identified for removal of PPE: -remove gloves; -remove gown; -exit the resident's room; -perform hand hygiene; -remove the face shield/goggles; and -perform hand hygiene. B. Review of a the facility form titled COVID-19 Unit-Outside the patient's room with a revision date of 4/14/20 revealed the following procedure for re-use of a face shield: -sanitize hands; -put on a pair of clean gloves; -place a disinfectant wipe on table as a barrier; -remove face shield and position on barrier; -use a disinfectant wipe to cleanse the front and the back of the shield, the elastic band and the foam band; -place shield upside down to dry; -remove gloves; and -hand sanitize. C. Observations on 6/29/20 of the 100 corridor during the noon meal revealed the following: -12:20 PM Nursing Assistant (NA)-C positioned a cart with room trays outside of Resident 6's room. Signs posted outside of the room indicated the resident was in the Gray Zone and was on isolation. NA-C was wearing a surgical mask and a face shield. Without performing hand hygiene, NA-C placed on a pair of clean gloves. NA-C removed the face shield and placed the shield directly on the shelf of a cabinet located outside of the residents' room. NA-C donned an isolation gown and placed the face shield back on. NA-C entered the resident's room and delivered the meal tray. After completion of task, NA-C removed gloves and isolation gown before leaving the resident's room. NA-C failed to cleanse the face shield or to complete hand hygiene; -12:22 PM NA-C propelled the room tray cart to Resident 1's room. A sign outside of the room indicated the resident was in the Gray Zone and was on isolation. Without completing hand hygiene, NA-C entered the resident's room and placed on an isolation gown then, stepped out of the room and placed on a clean pair of gloves from an isolation cart. NA-C brought a meal tray into the room and positioned the tray on a bedside table. The bedside table contained various items including a television remote, a covered thermal cup, a Kleenex box and a can of soda. NA-C attempted to move items to accommodate the meal tray and dropped the remote on the floor then proceeded to pick up. Items on the table were rearranged so that food was within the resident's reach. NA-C assisted the resident with meal set-up and with putting on a clothing protector. Upon leaving the resident's room, NA-C removed gloves and gown and completed hand hygiene. NA-C failed to cleanse the face shield; -12:25 PM NA-C positioned the room tray cart outside of Resident 7's room. Signs outside of the resident's room indicated the resident was on isolation as the resident was in a Gray Zone. NA-C removed face shield and placed directly on the top shelf of the isolation cart outside of the room without benefit of a barrier. NA-C placed on an isolation gown and secured, then replaced the face shield. Without any hand hygiene, NA-C put on clean gloves. After delivery of the meal tray to the room, NA-C removed gown and gloves and performed hand hygiene but failed to clean the shield; and -12:28 PM NA-C propelled the room tray cart to Resident 2's room. Signs outside of the room indicated the resident was in the Gray Zone and was on isolation. NA-C donned an isolation gown and gloves. NA-C delivered the room tray and removed gown and gloves before leaving the resident's room. NA-C removed the face shield and placed on the top of the isolation cart without benefit of a barrier. NA-C proceeded to cleanse the shield with disinfectant wipes, placed the shield back on, performed hand hygiene and returned to the dining room. During an interview with the Director of Nursing (DON) on 6/30/20 at 2:20 PM, the DON verified the following regarding NA-C: -hand hygiene should have been completed before placing on PPE and entering the resident's rooms; -NA-C's face shield should have been placed on a clean barrier and cleansed with a disinfectant wipe. This task should have been completed each time NA-C exited a resident room; and -hand hygiene should have been performed after removal of PPE to prevent the potential for cross contamination. D. An observation on 6/29/20 at 10:15 AM showed an area located at the facility entrance for screening with a sign stating, Upon arriving to work: sanitize your hands, put on your mask, social distance while you are waiting to be screened and get screened (temp taken, answer questions). Review of the facility's Employee Screening Logs from 3/11/20 - 5/11/20 revealed the logs were documented on paper. The logs were to include the date, the names of the employee being screened and the employee's temperature. In addition, employee responses to screening questions to determine potential COVID-19 symptoms and risks of exposure were included. Further review of the screening logs revealed the following: -3/25/20 no temperatures were documented on 2 line entries; -1 temperature was not documented on 3/30/20, 4/3/20, 4/6/20, 4/13/20, 4/16/20, 4/28/20 and 5/1/20; and -4/18/20 no temperature and no responses to symptoms were documented on 1 line entry. Review of the facility's Dietary Deliveries Log dated 3/12/20 - 4/10/20, had 20 line entries without temperatures documented but had the word no written under the column Do you have a fever? Review of 2 forms titled COVID-19/Coronavirus Disease 2019 Employee Screening Documentation updated 3/12/20 showed the forms did not include the date screening was completed. An interview on 6/30/20 at 3:00 PM with the DON and Administrator confirmed the screening logs were missing documentation.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to assure Resident 56's highest level of well-being related to lack of monitoring and physician notification related to abnormal vital signs. The sample size was 1 and the facility census was 53. Findings are: Review of the facility's procedure titled Change in Condition Evaluation with a revision date of 5/2016 revealed the purpose of the procedure was to improve communication between nurses and a provider when nursing was monitoring a change in condition, to enhance the nursing evaluation of and documentation of a resident who had a change in condition, to provide a standard format to collect pertinent clinical data prior to contacting the provider when there was a change in condition, and to standardize shift to shift communication about a resident's change in condition. Further review revealed nursing judgment should be used when determining the urgency of contacting the provider. Review of the hospital Discharge Documentation dated 3/14/19 revealed Resident 56 was hospitalized for [REDACTED]. The hospital discharge education stated help should be sought right away if the resident had shortness of breath and it continued to get worse. Review of Resident 56's Weights and Vitals Summary revealed on 3/14/19 at 12:24 PM the resident's oxygen level was 91 percent (%) (with a normal range of 90-100%) upon return from the hospital. Review of Resident 56's Progress Notes dated 3/14/19 revealed: - At 2:30 PM, the resident was given a nebulizer treatment for [REDACTED]. - From 5:23 PM to 5:25 PM, the resident's vital signs were taken. The resident's blood pressure was 70/40 (with low blood pressure being below 90/60) and the resident was light headed with standing. The resident respiratory rate was 32 (with a normal rate being between 12 and 20). The resident's oxygen level was 73% (there was no evidence to indicate the physician or family was notified). - At 5:37 PM, the facility gave the resident [MEDICATION NAME] for shortness of breath. - At 5:50 PM and 6:04 PM, the facility documented the nebulizer treatment and the [MEDICATION NAME] had been ineffective as the resident's oxygen saturation was 44% on 7LPM of oxygen (there was no evidence the residents family or physician was notified). - There was no evidence to indicate the resident's vital signs had been reassessed from 6:04 PM to 8:30 PM. - At 8:30 PM, the resident was not responding to staff when sitting in the recliner. A full body lift was used to transfer the resident to bed. - At 8:45 PM, the resident's Power of Attorney (POA) was notified of the resident's condition. The resident's POA requested the resident be transferred back to the hospital. - At 8:57 PM, the facility cancelled the rescue squad as the resident had passed away. During an interview on 4/2/19 at 11:08 AM, Licensed Practical Nurse (LPN)-B confirmed being on duty on 3/14/19 when Resident 56 returned from the hospital, and had worked with the resident until 6:00 PM. LPN-B stated the resident was struggling (with oxygen levels) from the time the resident was readmitted . LPN-B stated nothing seemed to help the resident's oxygen levels. LPN-B stated the oxygen levels would come up to the 60's but then would go back down. LPN-B stated the resident had an order for [REDACTED]. During interviews with the Director of Nursing (DON) on 4/2/19 at 10:15 AM and 4/3/19 at 9:09 AM, the DON confirmed the facility did not have a known oxygen order on file when the resident returned to the facility on 6LPM of oxygen. The facility faxed the physician for an oxygen clarification order (that wasn't returned until the next day after the resident had passed away-and identified an order on the hospital transfer sheet for oxygen at 4LPM). The DON confirmed there was no evidence the resident's family or physician had been contacted regarding the residents abnormal vital signs from the time the resident readmitted (at approximately 12:00 PM) until 8:30 PM. The DON confirmed the nursing staff should have contacted the resident's physician regarding the resident's abnormal vital signs. Further interview confirmed the facility did not investigate or report the resident's death, as the facility had not identified it as unexpected.

Licensure reference number 175 NAC ,[DATE].02(1) Based on interview and record review, the facility failed to ensure a Cardiopulmonary Resuscitation (CPR) certified staff member was available for the residents at all times. This had the ability to affect all residents that had a Resuscitate order (indicating CPR should be initiated if needed). The sample size was 7 and the facility census was 53. Findings are: Review of the facility Cardiopulmonary Resuscitation policy with a revision date of ,[DATE] revealed: - The purpose of the policy was to ensure all licensed nursing staff members were certified in CPR and to ensure CPR was available to residents at all times. - Each facility would assign an employee responsible to ensure all licensed nurses had a current CPR certification. Review of the facility Advanced Directives dated [DATE] revealed 7 residents (Residents 35, 25, 2, 40, 24, 52, and 36) had a resuscitate order. Review of the undated list CPR certification and expiration provided by the facility did not identify the Transportation Aides as being CPR certified. Further review revealed Licensed Practical Nurse (LPN)-A's and LPN-K's CPR certifications had expired ,[DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 10:15 AM, the DON confirmed LPN-A and LPN-K did not have a current CPR certification. During an interview with the Human Resources Coordinator on [DATE] at 10:22 AM, the Human Resources Coordinator confirmed 3 of the Transportation Aides (Transportation Aides G, H, and I) did not have a current CPR certification.

Licensure reference number 175 NAC 12-006.02(8) Based on observation, interview, and record review; the facility failed to investigate and report alleged neglect for Resident 21 and failed to investigate and report an incident of potential neglect for Resident 56. The sample size was 5 and the facility census was 53. Findings are: A. Review of the facility policy Abuse and Neglect with a revision date of 11/2016 revealed the facility would ensure all incidents of alleged or suspected abuse/neglect were promptly investigated and reported. B. Review of a Grievance Form dated 3/15/19 revealed Resident 21 had developed [MEDICAL CONDITION] and was treated in the hospital. The reporting family member felt this could have been prevented with better washing and drying of the resident's foot. The family member felt this was neglect. Review of the facility self-reports from 3/2019 to 4/2019 revealed no evidence the alleged neglect had been reported to the State Agency. An observation of resident care was completed on 4/2/19 at 7:30 AM with Licensed Practical Nurse (LPN)-B and Medication Aide (MA)-C. Resident 21 had just gotten out of the bath tub. LPN-B gave the resident morning medications and MA-C went to apply the dressing to the resident's right foot. MA-C placed dry gauze between the resident's toes (as ordered). MA-C spread the resident's toes gently and revealed open areas between the 2nd and 3rd toes and the 3rd and 4th toes. The area between the resident's toes was still wet when the gauze pads were placed and the resident complained of pain during the treatment. During an interview on 4/2/19 at 7:30 AM, MA-C stated either MA-C or MA-E were usually assigned baths on the 200 wing. MA-C stated the resident had a lot of pain when the resident's feet were cleaned. MA-C stated when cleaning and drying between the resident's toes MA-C would do the best I can but it was difficulty to get between the toes dry due to the resident moving and pain with foot cares. Interview with the Director of Nursing (DON) on 4/2/19 at 10:15 AM, the DON stated the resident's family had voiced concerns previously and they had put some things into place such as weekly foot checks. The DON confirmed the alleged neglect had not been investigated (beyond a discussion with the physician) and had not been reported as the facility did not identify the situation as potential neglect. C. Review of the facility's procedure titled Change in Condition Evaluation with a revision date of 5/2016 revealed the purpose of the procedure was to improve communication between nurses and a provider when nursing was monitoring a change in condition, to enhance the nursing evaluation of and documentation of a resident who had a change in condition, to provide a standard format to collect pertinent clinical data prior to contacting the provider when there was a change in condition, and to standardize shift to shift communication about a resident's change in condition. Further review revealed nursing judgment should be used when determining the urgency of contacting the provider. Review of the hospital Discharge Documentation dated 3/14/19 revealed Resident 56 was hospitalized for [REDACTED]. The hospital discharge education stated help should be sought right away if the resident had shortness of breath and it continued to get worse. Review of Resident 56's Weights and Vitals Summary revealed on 3/14/19 at 12:24 PM the resident's oxygen level was 91 percent (%) (with a normal range of 90-100%) upon return from the hospital. Review of Resident 56's Progress Notes dated 3/14/19 revealed: - At 2:30 PM, the resident was given a nebulizer treatment for [REDACTED]. - From 5:23 PM to 5:25 PM, the resident's vital signs were taken. The resident's blood pressure was 70/40 (with low blood pressure being below 90/60) and the resident was light headed with standing. The resident respiratory rate was 32 (with a normal rate being between 12 and 20). The resident's oxygen level was 73% (there was no evidence to indicate the physician or family was notified). - At 5:37 PM, the facility gave the resident [MEDICATION NAME] for shortness of breath. - At 5:50 PM and 6:04 PM, the facility documented the nebulizer treatment and the [MEDICATION NAME] had been ineffective as the resident's oxygen saturation was 44% on 7LPM of oxygen (there was no evidence the residents family or physician was notified). - There was no evidence to indicate the resident's vital signs had been reassessed from 6:04 PM to 8:30 PM. - At 8:30 PM, the resident was not responding to staff when sitting in the recliner. A full body lift was used to transfer the resident to bed. - At 8:45 PM, the resident's Power of Attorney (POA) was notified of the resident's condition. The resident's POA requested the resident be transferred back to the hospital. - At 8:57 PM, the facility cancelled the rescue squad as the resident had passed away. During an interview on 4/2/19 at 11:08 AM, Licensed Practical Nurse (LPN)-B confirmed being on duty on 3/14/19 when Resident 56 returned from the hospital, and had worked with the resident until 6:00 PM. LPN-B stated the resident was struggling (with oxygen levels) from the time the resident was readmitted . LPN-B stated nothing seemed to help the resident's oxygen levels. LPN-B stated the oxygen levels would come up to the 60's but then would go back down. LPN-B stated the resident had an order for [REDACTED]. During interviews with the Director of Nursing (DON) on 4/2/19 at 10:15 AM and 4/3/19 at 9:09 AM, the DON confirmed the facility did not have a known oxygen order on file when the resident returned to the facility on 6LPM of oxygen. The facility faxed the physician for an oxygen clarification order (that wasn't returned until the next day after the resident had passed away-and identified an order on the hospital transfer sheet for oxygen at 4LPM). The DON confirmed there was no evidence the resident's family or physician had been contacted regarding the residents abnormal vital signs from the time the resident readmitted (at approximately 12:00 PM) until 8:30 PM. The DON confirmed the nursing staff should have contacted the resident's physician regarding the resident's abnormal vital signs. Further interview confirmed the facility did not investigate or report the resident's death, as the facility had not identified it as unexpected.

Licensure Reference Numbers 175 NAC 12-006.09D7 Based on observations, record review and interview; the facility failed to assure a safe environment was provided for residents identified at risk for falls as fall prevention interventions were not implemented, revised and/or new interventions developed to prevent ongoing falls for 1 (Resident 29) of 3 sampled residents. Facility census was 53. Findings are: Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/28/18 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The same assessment indicated the resident's cognition was severely impaired and the resident had a behavior of wandering which occurred on a daily basis and placed the resident at risk for getting into a potentially dangerous place. In addition, the assessment indicated the resident required extensive staff assistance with toilet use and dressing. Review of an Incident Report dated 11/25/18 at 5:35 AM revealed staff heard a noise and found the resident kneeling on the floor next to the resident's bed. The resident indicated I am trying to get on the bed. The report identified the resident had removed gripper socks and was barefoot. The resident was provided re-education on use of the call light system to seek staff assistance and about wearing appropriate footwear. Review of an Incident Report dated 12/10/18 at 7:10 AM revealed the resident was found sitting on the floor in the resident's bathroom. The resident had been incontinent of urine on the floor, slipped and fell . Review of a Fall Screen Huddle Worksheet (form used to assess a resident's fall to determine causal factors and to assist with the development of new interventions for fall prevention) revealed the resident had not been toileted since 12:36 AM (6 hours and 34 minutes). The resident had gotten up independently to go to the bathroom, was incontinent and slipped and fell in the urine. A new intervention was identified for a silent bed alarm and for the staff to provide the resident with more frequent toileting assistance through the night. Review of an Incident Report dated 02/01/19 at 9:56 AM revealed the resident was ambulating independently with a walker, lost balance and went down to the resident's knees. Further review of the resident's medical record revealed [REDACTED]. Review of an Incident Report dated 02/04/19 at 9:58 AM revealed the resident was found on the floor of the resident's room. The resident's walker was located across the room from where the resident was lying. An intervention was developed for the Physical Therapist to evaluate the resident and a sign was placed in the resident's room to remind the resident to wear shoes and to take the walker. Review of an Incident Report dated 02/17/19 at 6:53 PM revealed the resident was found sitting on the floor in the Commons Area of the 100 Wing (Memory Lane). Review of a Fall Scene Huddle Worksheet dated 02/17/19 revealed potential causal factors included a change from tile to carpeting on the floor, shuffling gait and increased fatigue from wandering. The resident identified left hip pain and had poor weight bearing. The resident was sent to the emergency room for an evaluation with no acute findings. review of the resident's medical record revealed [REDACTED]. There was no evidence that current fall interventions were revised and/or additional interventions were developed. Review of a Nursing Progress Note dated 02/20/19 at 1:16 PM revealed the resident was wandering with the resident's walker and dragging the resident's left leg. The resident refused to sit down and to rest. Review of an Incident Report dated 03/22/19 at 4:30 PM revealed the resident was ambulating with the walker in the front lobby area with a family member. The resident turned to sit in a chair, the resident's left leg would not move and the resident fell on to buttocks. An intervention was identified for the family to be educated on need to use a gait belt when walking with the resident. Review of an Incident Report dated 03/27/19 at 5:00 PM revealed the resident was found sitting on the floor of the Solarium Area between the 400 (Heart Land) and the 100 Wings. Staff reported the resident had been dragging left foot when seen ambulating with walker earlier in the shift and the resident had increased confusion. The report further identified the resident had difficulty with following directions. An intervention was identified for the staff to encourage the resident to use a wheelchair after 4:00 PM. Review of a Progress Note dated 03/30/19 at 9:52 AM revealed the resident was ambulating with walker and was encouraged by the staff to sit down and rest but the resident refused. Review of a Progress Note dated 03/30/19 at 5:52 PM revealed the resident was seated in a wheelchair. The resident was self-propelling the chair using hands and feet but was having difficulty due to cognition. Staff then witnessed the resident stand from wheelchair and push the wheelchair trying to ambulate. Resident noted to be dragging left leg with ambulation. Observations of Resident 29 on 04/02/19 revealed the following: -9:07 AM, Nursing Assistant (NA)-E ambulated the resident with a gait belt and the resident's walker into the resident's room; -9:11 AM, NA-E provided the resident stand by assist with ambulation out of the resident's room. The resident was no longer wearing a gait belt. NA-E then cued the resident to go to the Activity Room. Resident 29 proceeded to walk independently the length of the center corridor and around the corner to the Activity Room. The resident had a shuffling gait and was noted to drag the left leg with ambulation; -1:12 PM, the resident was seated in an arm chair in the Commons Area of the 100 Wing. The resident stood and began to ambulate with the walker to the public bathroom in the area. Resident 29 struggled to open the bathroom door while holding onto the walker and finally was able to enter the bathroom. No staff was available in the area at this time; -1:45 PM, the resident was ambulated with a gait belt and walker by NA-F out of the bathhouse and to the resident's room; and -1:49 PM, the resident ambulated out of room and into the corridor with walker. The resident was encouraged by Licensed Practical Nurse (LPN)-B to go to the Activity Room and then pointed to the center corridor. The resident proceeded to walk independently with the walker the length of the center corridor and around the corner to the Activity Room. The resident was leaning heavily on the walker and was dragging left leg with ambulation. During an interview on 04/03/19 at 9:59 AM, the Director of Nursing (DON) confirmed the following regarding Resident 29: -the resident was at high risk for falls; -each fall should have been assessed for causal factors and a new intervention was to be developed or current interventions were to be revised in an attempt to prevent ongoing falls; and -staff should have been using the gait belt when walking with the resident or if the resident was resistive, then staff should have provided the resident with stand by assist when ambulating to try and prevent further falls.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on record review and interview, the facility failed to determine causal factors and develop new interventions for the prevention of falls for Resident 42. The facility census was 52 and the sample size was 13. Findings are: Review of Resident 42's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 12/8/17 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had moderate cognitive impairment and had no falls since the previous assessment. Review of Resident 42's Care Plan dated 9/6/17 revealed the resident was at risk for falls, was able to complete toileting tasks independently and was resistive with staff assistance with toileting. The Care Plan further indicated the resident did not like staff to accompany the resident into the bathroom and extensive assistance with perineal care and clothing changes was required at times due to incontinence. Review of a Risk Management Report dated 1/19/18 revealed Resident 42 was found on the floor that day at 12:00 midnight. Documentation further indicated the intervention to prevent another fall was to place a Dycem (a non-slip material placed in the seat of a chair to prevent sliding) between the wheelchair seat and cushion. Review of a Risk Management Report dated 1/13/18 revealed Resident 42 was found sitting on the floor between the bed and the wheelchair at 11:15 AM that day. The resident stated, I was going to go to the bathroom. Documentation indicated the resident was last toileted at 9:30 AM. The intervention to prevent further falls was to request a therapy evaluation (screening) due to the resident's weakness of the lower legs. Review of the Nursing Communications For Therapy Screening (a form used to request a therapy evaluation) dated 1/15/18 (2 days after the resident's fall) revealed Resident 42 had 2 falls in a 4 day period. Documentation on the same form by the Physical Therapist (PT) dated 1/18/18 (5 days following the resident's last fall) revealed a recommendation for Resident 42 to have 1 assist at all times due to fall risk and decreased safety. The PT further indicated Resident 42 might benefit from a toileting schedule due to falls occurring with bathroom mobility. There was no evidence Resident 42 was assessed for a toileting schedule. Review of a Risk Management Report dated 1/19/18 revealed Resident 42 fell at 2:40 PM that day. Documentation indicated the resident was resistive to cares, noncompliant and had poor safety awareness. The resident was incontinent of bowel and it appeared the resident was trying to go to the bathroom right before the fall. The intervention to prevent additional falls was that there was an order for [REDACTED]. Review of a Risk Management Report dated 1/20/18 revealed Resident 42 fell at 10:45 AM that day. Documentation indicated the resident's pants were around the ankles. Further documentation indicted the resident last voided (urinated) at 9:30 AM and a Nursing Assistance observed the resident sleeping in bed around 10:30 AM. The resident was subsequently transferred to the hospital after complaining of severe right hip pain. Interview with the Director of Nurses (DON) and Registered Nurse (RN)-J on 1/24/18 at 1:10 PM revealed the following: - Resident 42 was frequently non-complaint with therapy and assistance with activities of daily living; -The request for a therapy evaluation was not submitted until 1/15/18 (2 days after the last fall) and the therapy evaluation was not completed until 1/18/18 (5 days after the last fall); -Resident 42 was not assessed for a potential toileting schedule; and -Additional interventions for the prevention of falls were not developed following Resident 42's fall on 1/19/18.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3(1)(2) Based on record review and interview, the facility failed 1) to provide care and services for catheter management for Resident 24 and 2) to assess a decline in bowel and bladder continence for Resident 154 and develop a plan to prevent further decline. The sample size was 13 and the facility census was 52. Findings are: A. Review of Resident 154's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/11/17 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. The MDS further indicated the resident was cognitively intact, required extensive assistance for toilet use, and was always continent of bowels and bladder. Review of Resident 154's Care Plan dated 8/1/17 indicated the resident was occasionally incontinent of urine and the nursing intervention was to use a pull-up (an adult incontinent brief). The Care Plan further indicated Resident 154 had a deficit in performance of activities of daily living. Nursing interventions related to toilet use included extensive assistance of 1 with perineal hygiene upon arising, the resident uses the toilet independently throughout the remainder of the day, and the resident requested assistance with toileting at times. Review of the MDS dated [DATE] revealed Resident 154 continued to require extensive assistance for toilet use, was occasionally incontinent of bowel and bladder (this indicated a decline in continence status), and no toileting program (including scheduled toileting, prompted voiding, or bladder training) had been attempted. There was no evidence a Bowel and Bladder Assessment was completed to evaluate causal factors related to the resident's decline in continence status, or that the resident's Care Plan was reviewed and revised to include interventions to manage the incontinence and prevent further decline. During interview on 1/24/18 at 11:15 AM, Medication Aide (MA)-G revealed the following related to Resident 154's incontinence care: -since return from a recent hospitalization the resident was more incontinent of bowel and bladder and required more assistance with toileting; -called for assistance as needed but at times would get up to the bathroom independently before staff responded; and -was not on a scheduled toileting program and staff relied on the resident to ask for assistance to the bathroom. During interview on 1/24/18 at 11:50 AM, the Director of Nursing (DON) verified Bowel and Bladder Assessments were supposed to be completed on admission and quarterly thereafter. The DON further verified a Bowel and Bladder Assessment had not been completed for Resident 154 since admission in 2014. B. Review of Resident 24's current undated Care Plan revealed the resident had a history of [REDACTED]. Interventions were to change the catheter monthly, administer antibiotics as ordered, and to complete catheter cares 2 times daily. Review of a Progress Note dated 1/17/18 revealed Resident 24 had very little urine output from the suprapubic catheter. Review of Resident 24's Medication Record dated 1/2018 revealed an order to flush the resident's suprapubic catheter every Monday. Further review revealed the catheter irrigation was not signed off as completed on 1/15/18 and 1/22/18. Review of Resident 24's Tasks (area where catheter cares would be documented) revealed no documentation to indicate catheter cares had been completed 2 times daily. Interview with Registered Nurse-H on 1/24/18 at 10:14 AM confirmed there was no documentation to indicate catheter cares had been completed according to Resident 24's plan of care.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(8) Based on observation, record review and interview; the facility failed to assess the use of a seat belt alarm (a belt attached at the sides of a wheelchair with a velcro closure that is secured around the waist of the seated resident; when the velcro closure is released, an alarm sounds to alert staff the resident has removed the seat belt in an attempt to stand up from the wheelchair) as a potential physical restraint (if the resident is not capable of intentionally removing the seat belt, it is considered a physical restraint) for Resident 50. Facility census was 55. Findings are: A. Review of the facility Procedure for Physical Restraints, issued 2/2013, revealed the following: - A physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's own body. - Physical restraints may include, but are not limited to, using devices in conjunction with a chair such as trays, tables or belts, that prevent a resident from rising. - Remove easily was defined as The manual method, device, material or equipment . can be removed intentionally by the resident in the same manner as it was applied by the staff. - Anytime a device, material or equipment is attached or placed adjacent to the resident's body, a determination will be made by a licensed nurse as to whether it is or could be a restraint for the individual resident. - If the device, material or equipment cannot be removed easily by the resident and restricts freedom of movement or normal access to one's own body, then it is a restraint. - If the device, material or equipment is not a restraint for this resident, then the steps taken to make this decision must be documented, and it must be reviewed with a significant change in condition and quarterly in conjunction with the care plan to ensure that it continues to not be a restraint for the resident. B. Review of Resident 50's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used or care planning) dated 6/9/15 indicated the resident had [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe impairment of cognitive skills, and problems with inattention (easily distracted, out of touch, or difficulty following what was said) that fluctuated in frequency and severity. Review of Resident 50's current Care Plan with a target date of 12/16/14 indicated the resident was at risk for falls and had a seat belt alarm in the wheelchair as an intervention for fall prevention. The Care Plan further indicated the resident was to demonstrate how to self release the seat belt every shift. Review of the Medication Administration Record [REDACTED]safety check to make sure resident is able to self release. During observation of nursing care on 8/10/2015 from 11:25 AM until 11:34 AM, Resident 50 was seated in the wheelchair with a seat belt secured at the waist. Licensed Practical Nurse (LPN)-I instructed Resident 50 to release the seat belt. The LPN demonstrated with gestures how the seat belt could be released, but the resident made no attempt to carry out the instructions. During observation of nursing care on 8/10/2015 from 1:15 PM until 1:30 PM, Resident 50 was seated in the wheelchair with a seat belt secured at the waist. Nursing Assistant (NA)-J repeatedly asked Resident 50 to release the seat belt, but the resident made no attempt to follow instructions. During interview on 8/10/2015 at 1:30 PM, NA-J indicated Resident 50's seat belt alarm was initiated because the resident was getting up from the wheelchair and had falls. NA-J further indicated the resident would release the seat belt some days but other days it doesn't sink in. During observation on 8/10/2015 at 1:37 PM, Registered Nurse (RN)-K instructed Resident 50 to release the seat belt. The resident made no attempt to follow instructions. RN-K demonstrated with gestures how the seat belt could be released, attempted to place the seat belt velcro closure in the resident's hands, and repeatedly instructed the resident in this manner. Resident 50 made no attempt to release the seat belt. During interview on 8/10/15 at 1:40 PM, RN-K indicated staff ask Resident 50 to release the seat belt 2 times daily (BID), once on the morning shift and once on the evening shift, and the resident released the seat belt this morning. RN-K further indicated the seat belt alarm was initiated because Resident 50 leans forward in the wheelchair and has had falls in the past. During interview on 8/11/15 between 12:25 PM and 1:40 PM, the Director of Nursing (DON) verified Resident 50's ability to release the seat belt was evaluated BID, and if the resident was not consistently able to demonstrate this, they would reevaluate if the seat belt was needed and/or reassess it as a physical restraint. The DON verified it sometimes required multiple requests during a shift before Resident 50 demonstrated the ability to release the seat belt, and the resident's ability was dependent on mood and time of day. The DON further verified Resident 50's seat belt alarm was reviewed with a significant change in condition and quarterly in conjunction with the care plan to assure it continued to be appropriate and not a physical restraint for the resident. Review of Care Plan Conference Notes and Care Plan Reviews from 9/2014 through 6/2015 revealed no evidence to indicate Resident 50's seat belt alarm was reviewed for appropriateness and/or potential physical restraint except for a Care Plan Review note dated 6/17/15 that indicated wears seatbelt alarm. Is able to show staff every shift (resident) can remove it.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on record review and staff interview; the facility failed to ensure Resident 56 received care and services to prevent complications from the use of a suprapubic catheter (a type of indwelling urinary catheter consisting of a tube which is surgically inserted through the lower abdomen into the bladder to drain urine). The facility census was 55. Findings are: A. Review of facility Procedure for Urogenital (the complex of organs of the urinary system and associated genital structures) Tract Infections dated 6/2012 indicated infections might follow catheterizations. Interventions for prevention included recommendations to Avoid irrigations (a liquid solution is injected into the catheter tubing to relieve a blockage) and catheters should not be changed on a routine schedule. B. Review of Resident 56's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/12/15 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment and used an indwelling urinary catheter. Review of Resident 56's Order Summary Report (physician's orders [REDACTED]. In addition, an order dated 4/30/14 indicated Resident 56's suprapubic catheter was to be changed routinely 1 time a month. Review of the Order Summary Report revealed an order dated 9/3/14 which stated If increased behaviors noted, change catheter and obtain UA (a urinalysis is a laboratory test which determines presence of infection) for culture (laboratory test which determines type of bacteria causing the infection) . The order further indicated this was to be completed .right away. Review of Progress Notes dated 12/5/14 at 1:24 PM revealed Resident 5'suprapubic catheter was changed that morning due to the resident's frequent statements of feeling the need to urinate and urine had a foul smell, was a dark concentrated color and had increased sediment (the presence of cells, debris and other solid matter in the urine). Documentation indicated a urine sample was obtained and sent to the laboratory (lab) for testing. Review of Progress Notes dated 12/8/14 at 7:11 AM revealed a phone call was received from the lab which identified Resident 56 had a [MEDICAL CONDITION] (MRSA-a type of bacteria that is resistant to many antibiotics) infection of the urine. Documentation indicated a facsimile (fax) with the results was sent to the physician and .Awaiting response. Review of a fax dated 12/8/14 revealed a copy of Resident 56's UA results were sent to the physician with a request for a signature. The physician signed the fax but no orders were obtained for treatment of [REDACTED]. Review of Progress Notes revealed the following documentation: -1/1/15 at 9:26 PM-Resident 56 had a poor urine output and urine was .very dark amber color .Catheter irrigated hard but was able to irrigate. Will continue to monitor . -1/3/15 at 1:59 PM-Resident 56 was agitated and .keeps wanting to go to the bathroom. An attempt to irrigate the catheter was unsuccessful and the suprapubic catheter was changed without difficulty. There was no evidence a UA was obtained although the resident had an increase in behaviors. -1/8/15 at 8:23 PM-Resident 56's urine was .very thick, dark amber and full of sediment. Urine also has very foul odor. An attempt to irrigate the catheter was unsuccessful and the catheter was changed. -1/12/15 at 8:30 PM-Resident 56's suprapubic catheter could not be irrigated and at 10:30 PM the suprapubic catheter was changed. -1/13/15 at 2:16 PM- Resident 56's urine was cloudy, dark yellow in color and a UA was sent to the lab. -1/15/15 at 2:27 PM-the lab reported Resident 56's UA was contaminated. Documentation further indicated the resident's suprapubic catheter was changed at that time. -1/16/15 at 10:15 AM-a UA was obtained and sent to the lab for testing. -1/16/15 at 8:06 PM-Orders were received for Bactrim DS (an antibiotic) 1 tablet 2 times daily for 7 days for treatment of [REDACTED]. Review of a fax dated 1/20/15 revealed culture results from the UA obtained 1/16/15 identified Resident 56 [MEDICAL CONDITION] infection of the urine. Review of Progress Notes revealed Resident 56's catheter was irrigated and/or changed as follows: -2/9/15 at 9:50 AM- .Has frequent call out episodes of needing to use the bathroom .Noted small urine output per catheter overnight and no output this morning . The suprapubic catheter was changed. 2/12/15 at 8:24 PM-Resident 56 was yelling, refusing to eat and complaining of severe abdominal pain and discomfort. .Very little urine in drainage bag observed at this time Attempts to irrigate the catheter were not successful and the suprapubic catheter was changed. 2/23/15 at 2:20 PM-Resident 56 had frequent requests to use the bathroom and noted to have no urinary output. The suprapubic catheter was changed. -3/2/15 at 9:00 PM-an attempt to irrigate the suprapubic catheter was unsuccessful and documentation at 10:00 PM indicated the suprapubic catheter was changed. -3/7/15 at 10:40 AM-Resident 56 had behaviors throughout the night and morning and not much urine output. An attempt to irrigate the catheter was unsuccessful and the suprapubic catheter was changed. After the catheter was changed the resident .calms down and is able to rest comfortably in bed. -3/13/15 at 2:14 PM-Resident 56 was restless all shift and had no urine output at the end of the shift. An attempt to irrigate the catheter was unsuccessful and the suprapubic catheter was changed with difficulty and .thick mucousy urine returned. -3/28/15 at 2:50 PM-Resident 56 was hollering, had no urine output and the suprapubic catheter was changed. -4/2/15 at 3:40 AM and 4/6/15 at 10:33 PM-Resident 56's suprapubic catheter was changed after unsuccessful attempts to irrigate the catheter. -4/11/15 at 1:31 PM-Resident 56 was restless and had no urine output. An attempt to irrigate the catheter was unsuccessful and the suprapubic catheter was changed. -4/17/15 at 9:15 AM-Resident 56's suprapubic catheter was Changed due to increased behaviors, yelling out to go to b/r (bathroom). -4/21/15 at 1:30 PM and 4/22/15 at 4:50 AM-Resident 56's catheter was irrigated due to complaints of needing to urinate. -4/25/15 at 8:53 AM-Resident 56's catheter was changed as no urine output and resident was hollering out to use toilet. -4/27/15 at 1:33 PM-Resident 56's catheter was irrigated due to .catheter not draining, abdominal discomfort -4/28/15 at 1:46 PM-The catheter was irrigated as the Resident has been hollering most of this shift to use B/R (bathroom). -5/4/15 at 1:25 PM and 5/17/15 at 9:40 AM-Resident 56's catheter was changed as attempts to irrigate the catheter were ineffective. Review of the Order Summary Report revealed an order dated 5/20/15 to irrigate Resident 56's catheter every week on Monday beginning 5/26/14. Review of Progress Notes from 6/1/15 through 6/30/15 revealed Resident 56's suprapubic catheter was changed a total of 5 times as follows: -6/1/15 at 7:50 AM due to Poor output, hollering out help, I need to go to the toilet. -6/9/15 at 12:41 PM as resident was requesting toilet frequently and no urine output. -6/15/15 at 9:49 PM-as unable to irrigate the catheter -6/24/15 at 6:30 AM-as resident was Hollering out all night. -6/29/15 at 8:52 PM-as unable to irrigate the catheter. There was no evidence a UA was obtained and sent to the lab for testing (from 2/1/15 through 6/29/15) although Resident 56 continued to display increased behaviors related to the need to urinate. There was no evidence the frequency of Resident 56's suprapubic catheter irrigations and catheter changes was assessed/evaluated. Interview with the Director of Nurses (DON) and Registered Nurse (RN)-N on 8/10/15 at 2:28 PM revealed Resident 56 had not been evaluated by the urologist (a physician who specializes in disease of the urinary tract) since the urologist surgically inserted the suprapubic catheter on 11/12/13. During interview on 8/11/15 at 9:50 AM, RN-N indicated Resident 56's catheter was irrigated whenever the resident repeatedly voiced the need to use the bathroom. RN-N further indicated if the irrigation was unsuccessful then the catheter was changed in an attempt to change the resident's behavior. RN-N verified UA's had not been obtained as ordered when Resident 56 displayed increased behaviors.

Based on observation, record review and interview; the facility failed to assure Resident 25 and 50 were free from use of unnecessary medications as antipsychotic medications (medication that alters the chemical levels in the brain which impact mood and behavior, and are used to treat psychiatric disorders) were prescribed without indication for use or behaviors to support the use of antipsychotic medications. Furthermore, documentation of the residents' mood and behavior was not completed in order to evaluate the effectiveness and further need for the medications. Facility census was 55. Findings are: A. Review of the facility Policy and Procedure for Unnecessary Medications, issued 9/2012 revealed the following: - Each resident's drug regimen must be free from unnecessary drugs. - An unnecessary drug is any drug when used: a) in excessive dose, b) for excessive duration, c) without adequate monitoring, d) without adequate indications for its use, e) in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or f) any combination of the above reasons. B. Review of the facility Procedure for Psychopharmacological Medications (any medication used for managing behavior, stabilizing mood or treating psychiatric disorders) and Sedative/Hypnotics, revised 3/2015 revealed the following: - Throughout the administration of the psychopharmacological medications, mood and behavior documentation must continue in order to indicate the effect the medication has on the behavior. - The reduction committee will review the need for psychopharmacological medications at least every 3 months and document the rationale for continuing the medication. - The committee will also evaluate the resident's target symptoms and the effect of the medication on the severity, frequency and other characteristics. C. Review of Resident 50's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 6/9/15 indicated the resident had [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe impairment of cognitive skills, problems with inattention (easily distracted, out of touch, or difficulty following what was said) that fluctuated in frequency and severity, and the presence of delusions (misconceptions or beliefs that are firmly held and contrary to reality). Review of Resident 50's Admission Physician's Orders dated 6/7/12 revealed an order dated 6/14/12 for [MEDICATION NAME] (an antipsychotic medication) 0.5 mg (milligrams) every noon and bedtime (hs). Review of Resident 50's Medication Administration Record [REDACTED] - 2/7/14 [MEDICATION NAME] 0.5 mg every evening, and - 2/8/14 [MEDICATION NAME] 1mg every day at noon. Review of Resident 50's current Care Plan dated 6/25/14 revealed the following: - Use of antipsychotic medication, with nursing interventions including to observe for increased mortality in elderly residents with dementia-related [MEDICAL CONDITION]; and potential adverse effects include agitation, anxiety, dizziness and drowsiness. - Mood problem related to dementia and [MEDICAL CONDITION] evidenced by seeking to go home, restlessness and delusions, with nursing interventions to provide encouragement/assistance/support to maintain as much independence and control as possible; administer medications as ordered including [MEDICATION NAME] for [MEDICAL CONDITION]; and when restless, assist resident to a meaningful task or invite to a group activity. - Behaviors related to dementia, anxiety and [MEDICAL CONDITION] evidenced by wandering and exit seeking, with nursing interventions to provide opportunity for positive interaction and attention; prefers diversional activities of bingo, laundry folding, snacks; Behavior #1 (exit seeking): offer an activity such as folding laundry or activity offered that afternoon; and Behavior #2 (wandering): allow to self propel in wheelchair and offer snack. Review of Nursing Progress Notes dated 2/4/15 through 7/7/15 revealed there was no quantitative monitoring and documentation of Resident 50's behaviors. Documentation revealed the following incidents: - 2/10/15 at 10:42 PM-exit seeking behavior; experiences sundowners (periods of extreme agitation and confusion during the late afternoon or early evening hours leading to irritability towards others) during afternoon hours; activities and redirection are often used, along with needs being met; [MEDICATION NAME] (a medication used to treat anxiety) given this afternoon was helpful. - 3/19/15 at 6:17 PM-Care Plan Change: Staff noted Resident 50 wandering 1 time during the care plan assessment period; continues to have delusional thinking and taking [MEDICATION NAME] for [MEDICAL CONDITION]; Typically has increased anxiety in late afternoon; interventions to decrease anxiety and exit seeking provided by staff and family; and Most of the time those interventions are effective. - 5/10/15 at 10:56 AM-Feeds self at meals and will refuse assistance from staff at times. - 6/10/15 at 10:11 AM-gets restless and wants to go home in the evenings - 6/18/15 at 5:37 PM-restless daily; propels wheelchair continuously and rarely sits still - 7/7/15 at 10:33 AM-wanders up and down hallway per usual; no attempts to leave the facility - 7/7/15 at 3:22 PM, 7/8/15 at 9:47 AM, and 7/9/15 at 10:39 AM-no behaviors and/or or exit seeking noted. There was no further documentation of Resident 50's behaviors provided. Furthermore, there was no evidence to indicate Resident 50's use of [MEDICATION NAME] was routinely reviewed and the rationale for continuing the medication provided. During interviews on 8/10/15 the following was revealed: - At 1:30 PM, Nursing Assistant (NA)-J indicated Resident 50's behaviors included verbalizing thoughts of leaving or going home, going in and out of other resident's rooms, sometimes yelling, leaning forward in chair, and thinking another resident is spouse. NA-J indicated interventions to manage behaviors included visiting one-to-one, exercise, food, and/or laying the resident down in bed. - At 1:37 PM, Registered Nurse (RN)-K was not able to identify specific behaviors targeted by use of [MEDICATION NAME], but indicated Resident 50 had increased behaviors in the afternoon and gets worked up. During interview on 8/11/15 at 10:18 AM, RN-L indicated Resident 50's behaviors included wandering, anxiety, relating to the past and wanting to go home. During interview on 8/11/2015 at 12:25 PM, the DON verified there was no further documentation of Resident 50's behaviors. D. Review of Resident 25's MDS dated [DATE] indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS further indicated the resident had severe cognitive impairment and physical behaviors toward staff occurring 1 to 3 days during the 7 day assessment period. Review of Resident 25's current Care Plan dated 4/13/15 indicated the following: - The resident was on antipsychotic medication therapy related to dementia with behavioral symptoms and delusions, and nursing interventions included to monitor behavioral symptoms; monitor symptoms of [MEDICAL CONDITION] such as hallucinations (hearing or seeing things that are not real) or delusions; observe for increased mortality in elderly residents with dementia-related [MEDICAL CONDITION]; and potential adverse effects include agitation, anxiety, dizziness and drowsiness. - The resident has behaviors related to anxiety, depression, and dementia evidenced by disruptive yelling, tearfulness and attention-seeking, and nursing interventions included approach in a calm manner; remove from situation and take to alternate location; minimize potential disruptive behaviors by offering tasks to divert attention such as laundry folding and table talk; Behavior #1 disruptive yelling: assess for pain and provide pain intervention as needed; Behavior #2 tearfulness: provide one-to-one visits, reassure staff is available to help; and Behavior #3 attention seeking: provide diversional activity such as listening to music. Review of Resident 25's MAR indicated [REDACTED]. Review of a Psychiatric Consult Progress Note dated 5/21/15 revealed Resident 25 had symptoms of nervousness and anxiety, tearfulness, persistent hollering and yelling for family members who visit the resident often. Documentation indicated a new pain management program was effective in decreasing some of the resident's behaviors, the resident was being treated for [REDACTED]. Documentation further indicated the resident had a physician's order for [MEDICATION NAME] to be used as needed, however, this is not been (sic) utilized very often, and nursing progress notes indicated that when used it is helpful in treating Resident 25's anxiety. Documentation indicated the resident denied auditory or visual hallucinations, suicidal ideation or paranoid delusions. New physician's orders included [MEDICATION NAME] 0.25 mg 2 times daily and to consider decreasing [MEDICATION NAME] in future. Review of Nursing Progress Notes dated 4/8/15 through 8/8/15 revealed no evidence of quantitative documentation related to Resident 25's behaviors. There was occasional documentation of restlessness, anxiety, tearfulness, hollering or crying out, frequently related to pain and/or relieved with pain medication, antianxiety medication, comfort measures and/or diversional activities. There was no documentation to indicate Resident 25 had delusions and/or psychotic symptoms. Furthermore, there was no documentation to indicate staff evaluated the resident's behaviors as related to pain, or to provide rationale for continuing [MEDICATION NAME]. During interviews on 8/10/15 the following was revealed: - At 1:06 PM, NA-J indicated Resident 25 used to cry a lot related to back discomfort. NA-J indicated the resident doesn't cry as much any more since a new wheelchair was provided, and the resident was much happier and more content. NA-J further indicated Resident 25 will sometimes call out for someone who has already passed, or thinks (resident) is going somewhere with family members. Interventions to manage behaviors included to talk with the resident and provide comfort. - At 1:43 PM, RN-K verified Resident 25's target behaviors for use of [MEDICATION NAME] were yelling out, hollering, repetitive statements, and anxiety. RN-K indicated the resident was receiving [MEDICATION NAME] prior to admission to the facility. - At 10:30 AM, RN-L verified yelling out and hollering were Resident 25's target behaviors for the use of [MEDICATION NAME]. RN-L further verified this behavior was improved since changes in pain management and increase in antidepressant medication. During interview on 8/11/2015 at 12:25 PM, the DON verified there was no further documentation of Resident 25's behaviors.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09 D7 Based on observation, interview and record review; the facility failed to assess one resident's (Resident 24) ability to safely operate a power lift recliner resulting in an accident with injury. The facility census was 55. Findings are: Review of Resident 24's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 6/24/14 revealed this resident required two person assistance for bed mobility, toileting and assistance for transfers. The MDS indicated the resident did not ambulate. According to the MDS the resident had a BIMS (Brief Interview for Mental Status) score of 0/15 indicating severe cognitive impairment. At 4:11 PM on 8/5/14 an interview was conducted with Licensed Practical Nurse E (LPN-E) regarding Resident 24's whereabouts. LPN-E stated that the resident was sent to the hospital that afternoon after falling. LPN stated injuries included a laceration to left forehead and a skin tear to left forearm. LPN-E further indicated that the resident got a hold of the recliner remote and used it to put the chair all the way up and that Resident 24 fell forward out of the chair. Review of an incident report for Resident 24, dated 8/5/14, revealed that, "staff heard alarm sounding (a sensor alarm placed under the resident which alarms when the resident stands up so that staff can monitor movements) and entered room to find resident on the floor in front of recliner ... ....lift chair noted to be in complete upright/standing position. Question if the resident was able to use remote to elevate chair ... ....intervention to promote safety is to keep lift remote out of resident's reach. Provide resident with item such as blanket to fidget with ... ....resident has poor safety awareness and history of impulsivity and attempts to transfer self from bed/chair." Review of Resident 24's care plan revealed a history of falls and indicated the resident remained a fall risk. On 8/6/14 at 8:05 AM the Director of Nursing (DON) confirmed that Resident 24 sustained a laceration to the forehead which required stitches and a got a skin tear to the left arm. On 8/6/14 at 8:30 AM observation was made of Resident 24 at the breakfast table slumped to the left side with bruising to their face and a laceration with stitches to the forehead. On 8/11/14 at 1:56 PM an interview was conducted with the DON. The DON stated that at the time of admission Resident 24 was much more alert and oriented but had had a significant decline in cognition. The DON stated that when a resident first gets a power lift chair that they are instructed on how to use it but that there is no ongoing assessment to determine the resident's ability to safely operate the chair. The DON also indicated during this interview that Resident 24 "liked to fidget with things."

Licensure Reference Number: 175 NAC 12-006.09D4 Based on observation, interview and record review; the facility failed to provide Range of Motion (ROM - the range through which a joint can be moved) exercises to prevent a reduction in ROM abilities for one resident (Resident 51). The facility census was 57 and sample size was 40. Findings are: On 2/27/12 at 5:52 PM when asked if Resident 51 had a contracture (defined as a condition of fixed high resistance to passive stretch of a muscle), RN F stated yes - in the arms and legs. When asked if Resident 51 received ROM services or had a splint device in place, RN (Registered Nurse) F stated no because Resident 51 was comfort measures only. Review of Resident 51's Admission Interdisciplinary assessment dated [DATE] revealed that Resident 51 was admitted on [DATE] with no contractures. Review of Resident 51's Minimum Data Set (MDS - A federally mandated comprehensive assessment tool used for care planning) dated 2/8/11 revealed Resident 51 had no functional limitations in ROM. Review of a later MDS for Resident 51 dated 1/31/12 revealed Resident 51 had a functional limitation in ROM in lower and upper extremities bilaterally. Review of Resident 51's Physician order [REDACTED]. Review of Resident 51's Care Plan dated 2/9/12 revealed, "Self care deficit r/t (related to) DJD ([MEDICAL CONDITION] Joint Disease), stiffness of arms and legs. Goal: Will continue to be clean and well groomed. Interventions did not address the 'stiffness of arms and legs' or the limitations in ROM as mentioned in the MDS assessment. Interview with the Director of Nursing (DON) on 2/29/12 at 10:30 AM revealed that Resident 51 was not on a restorative program and was not receiving any formal ROM exercises. The DON further stated that when staff were questioned about the lack of ROM exercises that staff did not think that Resident 51 qualified due to being on comfort cares. The DON went on to state that ROM exercises are a part of comfort care and that the staff would be educated on this. Observation on 3/1/12 at 9:50 AM of MA (Medication Aide) C and NA (Nurse Aide) D attempting to move Resident 51's joints through their ROM (per request) revealed Resident 51's right elbow and left knee to be stiff and unable to completely straighten. When asked about Resident 51's stiffness NA D reported that Resident 51 was just being resistive. A follow up interview with the DON on 3/5/12 at 10:25 AM revealed that Resident 51 was on a restorative program for mental stimulation when Resident 51 resided on the south side of the building but was not on a restorative program for ROM because Resident 51 was ambulatory at that time. The DON went on to say that Resident 51 has had a lot of decline since moving from the south unit to the north. Interview with RN F on 3/5/12 at 2:09 pm revealed that the unit managers were responsible for assessing the resident's ROM abilities and needs. RN F went on to explain that these assessments were completed upon admission and when a significant change had occurred. RN F further stated that if a change had been noted a referral to OT (occupational therapy) or PT (physical therapy) would be made in order to get recommendations for a restorative program. RN F then confirmed that Resident 51 had limitations in range of motion in Resident 51's extremities as marked on the MDS assessment. Review of Resident 51's medical record revealed that in the previous two years there was one referral made to OT for wheelchair positioning. Review of the Occupational Therapy Evaluation and Plan of Treatment dated 11/28/11 revealed, "Initial Assessment Reason for Referral: W/C (wheelchair) positioning. Tone: Rigid. RUE (Right upper extremity) ROM and LUE (Left upper extremity) ROM: PROM (Passive ROM) impaired (secondary) to rigidity. Review of the facility's policy for Restorative Nursing Care revised February 2005 revealed, "Each resident will receive restorative nursing care to the extent possible, based on individual strengths, needs, and problems as defined in nursing assessments. This restorative care will be outlined in the resident's nursing care plan. Care will include safe measures to prevent complications and deformities, maintain strength and abilities, and restore or adapt to lost functions and capabilities."