Every finding on record at Good Samaritan Society - Atkinson

Licensure Reference Number 175 NAC 12-006.04(D)Based on record review and interview; the facility failed to ensure sufficient staffing to ensure call lights were answered in a timely manner. This had the potential to affect all facility residents who utilized a call device. This had the potential to effect all residents in the building. The facility census was 28.Findings are: A. Review of the facility policy Call Light, last revised 7/8/25 revealed the following:-the purpose was to ensure resident had a method of calling for assistance and to promptly answer the resident's call lights;-when resident's call lights were observed, staff were to go to the resident's room promptly, -staff were to respond to the request as soon as possible, turn the call light off and inquire about the resident's request;-when leaving a room, staff were to place call lights within easy reach of the resident;-for resident's unable to use a call light, appropriate interventions would be care planned; and-each facility was responsible for having an alternate method of communication during a loss of power or call light system failure. B. Review of the facility policy Nursing Services, last revised 10/14/25 revealed the purpose was to provide appropriate staff for resident care and revealed the following:-the facility must have sufficient nursing staff with the appropriate competencies and skills to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment;-the facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans;-the Director of Nursing Services responsibilities would include and be delegated as appropriate which included implementation of day-to-day resident care practices within the nursing department, ensuring equality of care was provided and working with the medical director to ensure that medical needs of residents were met; and-the facility would use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. C. Review of the Device Activity Report (record of call light activations and responses from 2/6/26-2/9/26) revealed the following call light response times greater than 20 minutes:-2/9/26 at 10:06 PM answered at 22 minutes, 16 seconds;-2/9/26 at 9:08 PM answered at 45 minutes, 31 seconds;-2/9/26 at 7:51 PM answered at 21 minutes, 30 seconds;-2/9/26 at 5:06 PM answered at 39 minutes, 22 seconds;-2/9/26 at 3:23 PM answered at 22 minutes, 28 seconds;-2/9/26 at 2:26 PM answered at 29 minutes, 0 seconds;-2/9/26 at 1:37 PM answered at 26 minutes, 26 seconds;-2/9/26 at 1:32 PM answered at 28 minutes, 55 seconds;-2/9/26 at 1:30 PM answered at 22 minutes, 7 seconds;-2/9/26 at 11:52 AM answered at 24 minutes, 0 seconds;-2/9/26 at 11:30 AM answered at 27 minutes, 15 seconds;-2/9/26 at 11:30 AM answered at 26 minutes, 42 seconds;-2/9/26 at 9:21 AM answered at 24 minutes, 29 seconds;-2/9/26 at 8:09 AM answered at 52 minutes, 9 seconds;-2/9/26 at 8:08 AM answered at 31 minutes, 32 seconds;-2/9/26 at 7:40 AM answered at 37 minutes, 7 seconds;-2/8/26 at 8:52 PM answered at 39 minutes, 37 seconds;-2/8/26 at 8:52 PM answered at 39 minutes, 47 seconds;-2/8/26 at 8:44 PM answered at 42 minutes, 46 seconds;-2/8/26 at 6:22 PM answered at 30 minutes, 14 seconds;-2/8/26 at 5:14 PM answered at 48 minutes, 49 seconds;-2/8/26 at 5:05 PM answered at 30 minutes, 12 seconds;-2/8/26 at 3:39 PM answered at 55 minutes, 14 seconds;-2/8/26 at 3:30 PM answered at 22 minutes, 56 seconds;-2/8/26 at 3:29 PM answered at 25 minutes, 10 seconds;-2/8/26 at 1:34 PM answered at 34 minutes, 57 seconds;-2/8/26 at 1:08 PM answered at 21 minutes, 23 seconds;-2/8/26 at 11:05 AM answered at 22 minutes, 37 seconds;-2/8/26 at 11:04 AM answered at 21 minutes, 5 seconds;-2/8/26 at 8:39 AM answered at 44 minutes, 54 seconds;-2/8/26 at 8:08 AM answered at 55 minutes, 47 seconds;-2/8/26 at 8:06 AM answered at 32 minutes, 56 seconds;-2/8/26 at 8:06 AM answered at 41 minutes, 28 seconds;-2/8/26 at 8:06 AM answered at 24 minutes, 58 seconds;-2/8/26 at 7:51 AM answered at 21 minutes, 5 seconds;-2/8/26 at 7:47 AM answered at 42 minutes, 25 seconds;-2/8/26 at 7:41 AM answered at 26 minutes, 10 seconds;-2/8/26 at 7:22 AM answered at 26 minutes, 26 seconds;-2/8/26 at 7:18 AM answered at 49 minutes, 51 seconds;-2/7/26 at 7:40 PM answered at 29 minutes, 12 seconds;-2/7/26 at 1:42 PM answered at 25 minutes, 36 seconds;-2/7/26 at 1:17 PM answered at 21 minutes, 47 seconds;-2/7/26 at 8:36 AM answered at 29 minutes, 57 seconds;-2/7/26 at 7:49 AM answered at 35 minutes, 11 seconds;-2/6/26 at 10:02 PM answered at 20 minutes, 14 seconds;-2/6/26 at 9:31 PM answered at 26 minutes, 26 seconds;-2/6/26 at 9:09 PM answered at 90 minutes, 52 seconds;-2/6/26 at 7:02 PM answered at 49 minutes, 19 seconds;-2/6/26 at 4:06 PM answered at 21 minutes, 47 seconds;-2/6/26 at 2:45 PM answered at 53 minutes, 21 seconds;-2/6/26 at 2:36 PM answered at 31 minutes, 22 seconds;-2/6/26 at 2:18 PM answered at 21 minutes, 16 seconds;-2/6/26 at 11:00 AM answered at 35 minutes, 11 seconds;-2/6/26 at 9:03 AM answered at 130 minutes, 25 seconds;-2/6/26 at 8:58 AM answered at 71 minutes, 38 seconds;-2/6/26 at 8:48 AM answered at 35 minutes, 7 seconds;-2/6/26 at 8:46 AM answered at 45 minutes, 55 seconds;-2/6/26 at 8:43 AM answered at 25 minutes, 55 seconds;-2/6/26 at 8:42 AM answered at 74 minutes, 32 seconds;-2/6/26 at 8:10 AM answered at 29 minutes, 13 seconds;-2/6/26 at 8:06 AM answered at 33 minutes, 8 seconds;-2/6/26 at 8:02 AM answered at 46 minutes, 37 seconds;-2/6/26 at 7:55 AM answered at 63 minutes, 12 seconds;-2/6/26 at 7:25 AM answered at 29 minutes, 55 seconds;-2/6/26 at 7:24 AM answered at 26 minutes, 48 seconds; and-2/6/26 at 7:01 AM answered at 21 minutes, 45 seconds. D. Interview on 2/10/26 at 9:10 AM with the Administrator revealed call lights were expected to be answered within 20 minutes and after reviewing the facility Device Activity Report confirmed multiple resident call light (66 activations) response times for 2/6/26 through 2/9/26 exceeded the 20-minute expectation.

Licensure Reference Number 175 NAC 12-006.04(D)Based on record review and interview; the facility failed to ensure 8 hours of consecutive Registered Nurse (RN) coverage in a 24-hour period 7 days per week as required. This had the potential to affect all facility residents. The facility census was 28.Findings are: A. Review of the facility policy Nursing Services, last revised 10/14/25 revealed the purpose was to provide appropriate staff for resident care and revealed the following:-the facility must have sufficient nursing staff with the appropriate competencies and skills to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment;-the facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans; and -the facility would use the services of a registered nurse for at least eight consecutive hours a day, seven days a week. B. Review of the Nursing Staff Schedule for August 2025 revealed no documentation of 8 hours of RN coverage on 8/9, 8/10, 8/30, and 8/31.C. Review of the Nursing Staff Schedule for January 2026 revealed no documentation of 8 hours of RN coverage on 1/3 and 1/4.D. Interview on 2/10/26 at 10:05 AM with the Director of Nursing confirmed the facility did not have 8 hours of consecutive RN coverage on 8/9, 8/10, 8/30, and 8/31 in August 2025 and 1/3 and 1/4 in January of 2026.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, record review, and interview; the facility failed to prevent the potential for cross contamination as the staff failed to utilize the required Personal Protective Equipment (PPE-items such as gowns, gloves, masks, goggles, face shields, and foot coverings) when performing personal/catheter cares for Resident 7 who was on Enhanced Barrier Precautions (EBP-use of PPE to reduce the transmission of multi drug-resistant organisms (MDRO- organisms resistant to at least one or more classes of antimicrobial agents) between residents) and to ensure ongoing surveillance of infections. The total sample size was 20 and the facility census was 28. Findings are: A. Review of the facility policy Standard, Enhanced Barrier, and Transmission-Based Precautions with a revised date of 7/7/25 revealed the following: -standard precautions were a group of infection prevention practices that applied to all residents in any setting in which healthcare was delivered, to prevent the spread of infection. -standard precautions included hand hygiene, the use of PPE, respiratory hygiene/cough etiquette, cleaning, and disinfection practices, laundry handling, and safe injection practices. -EBP expanded the use of PPE beyond situations in which exposure to blood and body fluids was anticipated and referred to the use of gloves and gown during high-contact resident care activities that provide opportunities for transfer pf multi-drug resistant organisms (MDRO- germ that is resistant to many antibiotics) -an order for EBP would be obtained for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. -PPE use for EBP was only necessary when performing high-contact care activities which included dressing, transferring, providing hygiene, changing briefs or linens, toileting assistance, and wound care. -EBP should be used for the duration of the affected residents' stay. For a resident on EBP for a wound or an indwelling medical device only, the precautions could be discontinued when the wound is resolved or the device was removed. B. During an observation of personal/catheter care for Resident 7 on 2/9/26 at 11:19 AM the following was identified: -an 8 inch by 10 inch laminated sign was posted on the outside of the resident's room door which indicated the resident was on EBP. On the outside of the bathroom door was an isolation caddy which contained disposable gloves/gowns and clear plastic bags. A covered trash receptacle was positioned inside of the resident's room with a sign that indicated the receptacle was for disposal of PPE. -the resident was lying in bed with the head of the bed elevated. -Nurse Aide (NA)-I and Licensed Practical Nurse (LPN)-A entered the resident's room, performed hand hygiene, and put on clean gloves. -NA-I, without use of a gown or goggles, placed a plastic measuring container underneath of the resident's urinary catheter drainage bag, opened the drainage tube, and emptied the urine into the container. NA-I clamped the drainage tube and took the container with urine into the bathroom and emptied into the toilet. NA-I returned to the resident's bedside, used an alcohol wipe t cleanse the drainage tube and then placed back into the holder on the side of the drainage bag. -NA-I removed gloves, performed hand hygiene, and placed on clean gloves. Still without use of a disposable gown, NA-I and LPN-A removed the resident's disposable urinary incontinent brief after an involuntary loose stool and proceeded with the provision of incontinence/catheter cares. -NA-I and LPN-A repositioned the resident from side to side, cleansed the resident's groin, and perineal area which including the foley catheter insertion site. NA-I removed gloves, performed hand hygiene, and then put on new gloves. The resident was positioned onto right side and NA-I provided hygiene to the resident's buttocks which were covered with feces. Staff removed soiled gloves, performed hand hygiene, and positioned the sling for the full lift underneath the resident. -11:32 AM NA-I exited the resident's room and then re-entered with the lift. NA-I placed on clean gloves but did not utilize a disposable gown. -the resident had complaints of nausea from staff turning the resident from side to side. LPN-A opened the room door and walked into the corridor and then re-entered the room with an emesis basin. LPN-A placed on clean gloves but did not put on a gown. Resident 7 indicated the resident no longer wanted to get up as the resident was still having nausea and discomfort. -11:42 AM LPN-A removed gloves and performed hand hygiene, then again exited the room to get a clean soaker pad for the resident. LPN-A re-entered the room and assisted NA-I to position the resident for comfort, placed a clean incontinence brief on the resident and covered the resident with bed linens. NA-I and LPN-A removed gloves, washed hands, and left the resident's room. During an interview on 2/10/26 at 7:44 AM, the Director of Nursing (DON) confirmed due to use of an indwelling urinary catheter the resident was on EBP. When staff provided the resident with any kind of direct cares such as dressing, repositioning, incontinence care or catheter cares, the staff were to wear a gown and gloves. In addition, the DON confirmed the resident had an isolation caddy on the outside of the bathroom door which held PPE supplies, a receptacle next to the exit door to dispose of used PPE and a sign on the outside of the resident's room which indicated the resident was on EBP. During an interview with Resident 7 on 2/10/26 at 9:42 AM, the resident verified the staff were supposed to wear gowns/gloves when providing the resident cares as the resident was on EBP. The staff do forget to use the PPE on occasion, and the resident will have to remind them before they utilize. C. Review of the facility policy Surveillance, last revised 9/30/25 revealed the purpose was to systematically identify, track, and control infectious diseases and healthcare-associated infections (HAIs) to protect residents, employees, and visitors. The policy revealed the following: -infection surveillance was an ongoing, systematic collection, analysis, interpretation, and dissemination of data to detect and monitor infectious diseases, identify outbreaks, evaluate the effectiveness of prevention efforts, and implement interventions to control the spread of infections; -a two-tiered approach may be utilized to provide a comprehensive strategy for preventing the spread of infection and included: Process Surveillance was the review of practices by employees directly related to resident care to identify whether employees complied with infection prevention and control procedures, and Outcome Surveillance was the review of resident data to identify and report evidence of a suspected/confirmed HAI or communicable disease using standardized definitions of infections; and -the Infection Preventionist (IP) would complete ongoing infection surveillance activities selected by the location. The process of infection surveillance may include: -selection of process and outcome surveillance events based on the resident population and healthcare setting; -utilize standardized definitions of infections to ensure accurate and valid comparisons of surveillance data; -utilize a data collection tool to collect surveillance data for process and outcome surveillance events (sources included the medical record, laboratory results and employee interviews); -analyze surveillance data to identify patterns or trends, evaluate for potential causes of infections, and identify areas for improvement; and -report infection surveillance findings to the interdisciplinary team and develop corrective action as needed. D. Review of the facility infection surveillance on 2/10/26 revealed no evidence that infections and antibiotic use had been tracked for January and February 2026. E. Interview on 2/10/26 at 11:55 AM with the IP confirmed the facility did not have evidence of ongoing infection surveillance for January and February of 2026.

Licensure Reference Number 175 NAC 12-006.05(I)Based on record review and interview; the facility failed to implement their Quality Assessment and Performance Improvement (QAPI) plan to maintain a system to prevent repeat deficient practices including accidents, weight loss, sufficient staffing, unnecessary medications and Emergency Preparedness. This had the potential to affect all facility residents. The facility census was 28. Findings are: Review of the facility policy Quality Assurance and Performance Improvement (QAPI) dated 5/20/25 revealed the facility implemented and maintained an ongoing comprehensive data driven program to address the unique needs of those served and a full range of care and services provided.-The program was ongoing and addressed the complexity and uniqueness of the care and services provided. -The quality program measured, analyzed, and tracked quality indicators, adverse events, and other aspects of performance that enabled assessment of care, services and operations. -The Governing body provided oversight through plan implementation and evaluation. -The QAPI program utilized data to monitor the effectiveness and safety of the services and quality of care; identified and prioritized problems and process improvement opportunities and took action to address areas in need of improvement.-Problem areas were defined as areas where procedures or processes had historically produced unsatisfactory results. Review of the facility QAPI information reviewed during the survey on 2/10/26 revealed no evidence the facility was meeting at least quarterly and/or evaluating current data to ensure identified performance improvement concerns and or previously cited areas on non-compliance were being monitored or addressed. During an interview on 2/10/2026 at 10:32 AM the facility Administrator confirmed the facility had no evidence the facility QAPI team was meeting at least quarterly and the QAPI program had failed to maintain a plan to prevent repeat deficient practices including accidents, weight loss, sufficient staffing to ensure prompt response to call lights, unnecessary medications and Emergency Preparedness.

Licensure Reference Number 175 NAC 12-006.05(D)(E)Based on record review and interviews; the facility failed to obtain informed consent for the use of psychotropic medications and/or information for alternate treatment options for Residents 3, 6, 24, and 30. The sample size was 5 and the facility census was 28. Findings are: A. Review of the facility policy Psychotropic Medications with a revision date of 12/9/25 revealed the following: -The purpose was to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary medications. - A consent form must be signed for the use of psychotropic medications. - If a resident was admitted on psychotropic medications or returned from the hospital on new psychotropic medications, the reduction committee was informed, the family/legal representative and resident were notified, Permission for Use of Psychotropic Medications form was to be completed, and the family/representative and/or resident were informed of the risks and benefits of the medication. -With a change of psychotropic medication, the Permission for Use of Psychotropic Medications was to be completed. B. Review of Resident 3's Medication Administration Record (MAR) dated February 2026 revealed the resident was taking the psychotropic medication Celexa (antidepressant) 10 milligrams (mg) daily with a start date of 7/15/22. Review of Resident 3's Care Plan with a revision date of 12/3/25 revealed the resident had quadriplegia secondary to a spinal cord syndrome following a fall on the ice. In addition, the resident had a mood disorder for which Celexa was being taken and the facility monitored for adverse effects. Review of Resident 3's Electronic Medical Record (EMR) revealed no evidence the resident and/or the resident's representative were informed of the benefits, risks, potential side effects or alternative treatments of the medication Celexa. During an interview on 2/10/26 at 11:41 AM the Director of Nursing (DON) confirmed the facility did not obtain the required informed consent or provide the resident/representative alternative treatment options for Resident 3's antidepressant medication Celexa. C. Review of Resident 24's MAR dated February 2026 revealed the resident had orders for the psychotropic medication Lorazepam (antianxiety) 0.5 mg's every 4 hours as needed with a start date of 2/2/25. Review of Resident 24's had an anxiety disorder, had impaired cognition including delirium and hallucinations. The resident had a diagnosis of vascular dementia. The resident was to be monitored for the side effects of psychotropic medication use. Review of Resident 24's Electronic Medical Record (EMR) revealed no evidence the resident and/or the resident's representative were informed of the benefits, risks, potential side effects or alternative treatments to the antianxiety medication Lorazepam. During an interview on 2/10/26 at 11:41 AM the Director of Nursing (DON) confirmed the facility did not obtain the required informed consent or provide the resident/representative alternative treatment options for Resident 3's antianxiety medication Lorazepam. D. Review of Resident 30's Minimum Data Set (MDS-a federally mandated assessment tool used in Care Planning) dated 1/14/26 revealed the resident was admitted on [DATE] with a diagnoses of Non-Alzheimer Dementia, Anxiety and Depression; had severe cognitive impairment; required substantial assistance with dressing, transfers and bed mobility; was dependent on staff for toileting hygiene; and received an antipsychotic medication. Review of Resident 30's Care Plan with a revision date of 1/26/26 revealed the resident required extensive assist with dressing, transfers, bed mobility, was dependent on staff for toileting and received Seroquel (an antipsychotic medication) for a diagnosis of Dementia with Agitation. Review of Resident 30's January 2026 MAR revealed the resident received Seroquel 25 mg one time daily for a diagnosis of Dementia with Behaviors with a start date of 1/8/26 and a stop date of 1/16/25. On 1/16/26 Seroquel was increased to 25 mg two times daily for a diagnosis of Dementia with Behaviors. Review of Resident 30's Permission for use of Psychotropic Medications revealed no documentation of consent for the Seroquel increase on 1/16/26 had been obtained prior to administration or alternative treatments of the medication Seroquel. Interview on 2/9/26 with Registered Nurse (RN)-O confirmed that the facility did not obtain the required informed consent or provide the resident/representative alternative treatment options for Resident 30's antipsychotic medication Seroquel. E. Review of Resident 6's MAR dated February 2026 revealed the resident was taking the antipsychotic Seroquel (medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) 25 mgs to be taken at bedtime for diagnosis of major depressive disorder. Review of Resident 6's Care Plan with a revision date of 7/25/25 revealed the resident had diagnosis of anxiety, major depressive disorder, and agitation with an order for Seroquel and the facility monitored for potential side effects of the antipsychotic medication. Review of Resident 6's EMR revealed no evidence the resident and/or the resident's representative were informed of the benefits, risks, potential side effects, or alternative treatments of the Seroquel. During an interview on 2/9/26 at 2:22 PM the DON confirmed the facility had no documentation to indicate the required informed consent was received from the resident's representative or that the representative was provided information regarding alternative treatment options for Resident 6's antipsychotic medication Seroquel.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i)(1)Based on record review and interview; the facility failed to implement nutritional interventions to address a weight loss for 1 (Resident 28) of 2 sampled residents. The facility census was 28.Findings are:A. Review of the Weight and Height Policy with a reviewed/revised date of 9/30/25 revealed the purpose of the policy was to ensure residents maintained an acceptable parameter of nutritional status, accurately measure weights and monitored weight loss or gain in residents. The facility was to inform the resident, the resident's representative, the Primary Care Physician (PCP), and the Registered Dietician (RD) when there was a significant change in the resident's weight. The policy further indicated if a weight varied by more than 3 percent (%) staff were to reweigh the resident. B. Review of Resident 28's Minimum Data Set (MDS, federally mandated comprehensive assessment tool used to develop resident care plans) dated 10/22/25 revealed diagnoses of diabetes, cancer, end stage renal disease, parastomal hernia with obstruction (incisional hernia that allows protrusion of abdominal contents through the abdominal wall/ostomy), anxiety, bipolar disorder, and depression. Further review of the assessment revealed the resident's cognition was intact, the resident required setup assistance and supervision with eating/drinking, did not have a condition or a chronic disease that could result in a life expectancy of less than 6 months and the resident's weight was 142 pounds (lbs.). The resident had a weight loss of 5 percent (%) in the last month or loss of 10% or more in the last 6 months. Review of Resident 28's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature, and pulse) revealed the following weights:-7/22/25 149 lbs.-8/21/25 144 lbs.-9/30/25 142 lbs. Review of a Mini-Nutritional assessment dated [DATE] at 9:57 AM revealed the resident's score was a 6.0 indicating the resident was malnourished. Further review revealed the resident had a decline in food/fluid intakes, had a weight loss greater than 7 lbs. in the last 3 months and the resident had severe dementia or depression.Review of Weights and Vitals Summary Sheet revealed the resident's weight on 10/25/25 was 133 lbs.Review of a Nutritional Status Dietician assessment dated [DATE] at 11:19 AM revealed the resident was at risk for malnutrition. The resident had a recent hospitalization for small bowel obstruction and had a history of breast cancer with metastasis to the bone. Due to these diagnosis the residents' intakes varied. To continue to provide the resident supplement of choice 120 cubic centimeters (cc) twice a day.Review of Weights and Vitals Summary Sheet revealed the following weights for Resident 28:-11/23/25 131 lbs.-12/26/25 131 lbs. Review of a Mini-Nutritional assessment dated [DATE] at 10:57 AM revealed the resident remained at risk for malnutrition. Review of a Nutritional Progress Note by the Registered Dietician (RD) dated 1/27/26 at 1:54 PM revealed the resident's weight on 1/16/26 was 131 lbs., indicating a severe weight loss of 12% in 180 days as weight on 7/22/25 was 149 lbs. The resident was identified as receiving nutritional supplement of choice due to weight concerns. The RD made a recommendation to discontinue the current nutritional supplement and to start Med Pass 2.0, 120 cc to provide more calories and protein to the resident. Review of a Facsimile (fax) Communication to the Physician form dated 1/27/26 revealed the resident's PCP was notified of the resident's weight and per the RD's recommendation a request was made to discontinue the supplement of choice and to start Med Pass 2.0, 120 cc twice a day. Further review of the form revealed the PCP failed to address the RD's request to change the nutritional supplement to prevent further weight loss for the resident. Review of Weights and Vitals Summary Sheet revealed the following weights for Resident 28:-2/3/26 121 lbs.-2/10/26 123 lbs. During an interview on 2/10/26 at 7:58 PM, the Director of Nursing (DON) confirmed the following regarding Resident 28's weight loss:-the resident has had ongoing weight loss. -the resident has received treatment for cancer and when taking these medications, will have a decline in intakes.-concerns with the scales at the facility and having to get scales fixed/calibrated as do not feel all the resident's weights have been correct.-the resident has been receiving a nutritional supplement but on 1/27/26 the RD made a recommendation to change the supplement to one with additional calories and protein. The PCP was notified of the residents' weight loss and the RD's recommendations but the PCP had failed to address the RD's recommendations.

Licensure Reference Number 175 NAC 12-006.05(S) Based on observations, record review, and interviews; the failed to ensure Resident 7 was treated with respect and dignity during the provision of personal cares. The sample size was 1 and the facility census was 28.Findings are: A. Review of the Resident's Rights for Skilled Nursing Facilities (undated) policy revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. B. During an observation of personal/catheter care for Resident 7 on 2/9/26 from 11:19 AM to 11:42 AM, the following was identified:-the resident was lying in bed with the head of the bed elevated. The resident's bed was positioned directly next to a large picture window and the curtains had been left open. No shades or blinds were in place to the window. In addition, there was no privacy curtain in the semiprivate room.-Nurse Aide (NA)-I and Licensed Practical Nurse (LPN)-A entered the resident's room, performed hand hygiene, and put on clean gloves. NA-I removed Resident 7's bed linens and gathered the resident's gown underneath the resident's breast. The resident was involuntary of stool and NA-I and LPN-A removed the resident's disposable urinary incontinent brief and proceeded with the provision of incontinence/catheter cares. The resident's torso and lower extremities were exposed and the window next to the resident's bed remained open and the resident was visible to anyone walking outside by the resident's room.-NA-I and LPN-A repositioned the resident from side to side, cleansed the resident's groin, and perineal area which included the indwelling catheter insertion site. Staff positioned the sling for the full lift underneath the resident. -11:32 AM NA-I exited the resident's room to retrieve the full lift. Staff failed to drape the resident and the resident remained exposed as staff opened the door and the resident was visible to any staff, visitors, or other residents in the corridor.-11:34 AM NA-I opened the room door again while the resident remained exposed and entered the room with the lift.-the resident had complaints of nausea from staff turning the resident from side to side. LPN-A opened the room door and walked into the corridor and then re-entered the room with an emesis basin. The resident continued to have torso and lower extremities uncovered. Resident 7 indicated the resident no longer wanted to get up as the resident was still having nausea and discomfort.-11:42 AM LPN-A exited the room to get a clean soaker pad for the resident. The resident remained uncovered with lower body and torso visible to anyone in the corridor outside the resident's room. LPN-A re-entered the room and assisted NA-I to position the resident for comfort, placed a clean incontinence brief on the resident and covered the resident with bed linens. During an interview on 2/10/26 at 7:44 AM, the Director of Nursing (DON) indicated the staff should always pull the curtains closed or if available should close blinds or shades to the residents' windows when providing cares for the resident. In addition, the staff should not open a resident's room door if the resident is exposed. The resident should always be covered or else the privacy curtain and window curtains were to be closed to prevent exposing the resident. During an interview on 2/10/26 at 9:42 AM, the resident indicated it upset the resident when the staff left the curtains open during cares. The resident stated this did not happen all the time but it did happen occasionally.

Licensure Reference Number 175 NAC 12-006.05(G) Based on record review and interview; the facility failed to ensure Resident's 6's medication regimen was free from unnecessary medications due to failure to monitor for potential side effects of a psychotropic medication. The sample size was 5 and the facility census was 28.Findings are: A. Review of the facility policy Psychotropic Medications with a reviewed/revised date of 12/9/25 revealed the purpose of the policy was to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate the use of unnecessary medications. Each resident had the right to be free from any chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical signs and symptoms. Each resident's drug regimen was to be free from unnecessary drugs. An unnecessary drug was any drug when used:-in excessive dose including duplicative drug therapy.-for excessive duration.-without adequate monitoring.If the Primary Care Provider (PCP) prescribed an antipsychotic for the resident. a Registered Nurse (RN) was to complete an Abnormal Involuntary Movement Scale (AIMS). Throughout the administration of psychotropic medications, the facility was to monitor potential side effects, or if a side effect occurred, worsening of the side effect. The AIMs assessment was to be completed every 6 months. If there was a change in the assessment, the PCP, and the family/legal representative must be notified and documented in the medical record. B. Review of Resident 6's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 11/26/25 revealed the resident was admitted with diagnoses of non-traumatic brain dysfunction, diabetes, Alzheimer's disease, Non-Alzheimer's dementia, anxiety, and depression. The following was assessed regarding the resident:-impaired cognition.-no behaviors or mood indicators.-required substantial to maximal assistance with dressing, personal hygiene, bed mobility, and transfers.-condition or a chronic disease that may result in a life expectancy of less than 6 months.-use of antipsychotic, antidepressant, antianxiety and opioid medication. Review of Resident 6's Nursing Progress Notes revealed the following:-7/25/25 at 4:13 PM the resident refused to let the staff obtain a blood pressure reading and yelled, it hurts, it hurts.-7/27/25 at 9:42 PM the resident was seated in the lobby area sleeping. When staff attempted to awaken for bed the resident swatted at staff.-7/29/25 at 8:41 AM the resident spit out medications.-7/29/25 at 8:31 PM the resident slapped the staff when the staff attempted to prepare the resident for bed.-8/3/25 at 7:31 PM the resident spit out medications with 3 attempts to administer.-8/7/25 at 8:46 PM the resident's Primary Care Physician (PCP) was at the facility and ordered Seroquel (antipsychotic medication used to treat schizophrenia, bipolar disorders, and major depressive disorder) 25 milligrams 1 daily before bedtime. Review of the resident's Electronic Medical Record (EMR) revealed no evidence that the facility staff had completed an AIMs assessment prior to administering the Seroquel 25 mg daily. Review of a Recommendations for Nursing Staff Only form dated 9/5/25 revealed the Consultant Pharmacist (CP) had identified antipsychotic medications had the capacity to cause tardive dyskinesia (involuntary movement disorder caused by use of antipsychotic medications) and other movement disorders. The CP made a recommendation to complete an AIMS test now and every 6 months to monitor for potential side effects of the medication. Review of a Recommendations for Nursing Staff Only form dated 10/7/25 revealed a second recommendation for the facility to complete the AIMs assessment due to continued use of the Seroquel. Review of the resident's EMR revealed an AIMs Assessment was completed 11/4/25 (2 months after the recommendation by the CP) at 3:52 PM. During an interview with the Director of Nursing (DON) on 2/9/26 at 2:22 PM, the DON confirmed the resident was started on Seroquel 25 mg daily on 8/9/25. Staff failed to complete an AIMs assessment when the medications was first initiated. The CP made recommendations on 9/5/25 and on 10/7/25 to complete the assessment to monitor for potential side effects of the medication but an assessment was not completed until 11/4/25, 3 months after the medications was started and 2 months after the CP first recommended completion.

Licensure reference: 175 NAC 12-006.02(H)Based on record review and interview: the facility failed to report an allegation of potential staff to resident abuse and to send the results of an investigation to the State Agency within the required timeframes for Resident 7. The sample size was 2 and the facility census was 28. Findings are:A. Review of the facility Abuse and Neglect policy with a revision date of 4/7/25 revealed the purpose of the policy was to:-ensure the staff were knowledgeable regarding the reporting and investigative process of abuse and neglect allegations. -ensure the location had an effective system in place that, regardless of the source, prevented mistreatment, neglect, exploitation and misappropriation of their property. -ensure residents were not subjected to abuse by anyone including but not limited to employees, other residents, consultants, volunteers, employees of other agencies, family members or legal guardians, friends, or other individuals. -ensure all identified events of alleged or suspected abuse/neglect including injuries of unknown origin were promptly reported and investigated.-ensure a complete review by the investigation team to identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse to determine the direction of the investigation. Alleged or suspected violations involving any mistreatment, neglect, exploitation, or abuse, including injuries of unknown origin, were to be reported immediately to the administrator or designee with the following actions taken:-intervene in any situation to protect the residents. -remove any individual from the location if necessary for the protection of residents or employees including but not limited to employees, visitors, contractors, or family members.-call local law enforcement or assistance with interventions necessary for the protection of residents or employees. -an investigation was completed and the results of all investigations were to be reported to the Administrator and to other officials in accordance with state law, including the state survey and certification agency within 5 working days of the event. B. Review of Resident 7 's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 10/29/25 revealed the resident was admitted with diagnoses of traumatic brain injury, high blood pressure, diabetes, depression, and anxiety. The following was assessed regarding the resident:-cognitively intact.-required extensive to total staff assistance with bed mobility, transfers, dressing, toilet use and personal hygiene.-always incontinent of bowel and had an indwelling urinary catheter.-almost constant pain rated at an 8 out of 10 which limited day to day activities. Review of a facility Grievance dated 8/15/25 (no time) revealed the resident had a concern regarding Nurse Aide (NA)-I. Resident 7 had requested assistance as the resident was involuntary of bowel. Initially NA-I had refused to provide the resident assistance with cares. NA-I did relent and provided assist but was very rough with the resident's catheter and was short tempered. The resident indicated the staff member slammed things around and staff did not clean the resident or do cares very well. When the resident had asked NA-I not to empty the urinary catheter drainage bag into the resident's handwashing sink, the staff had asked the resident what are you going to do about it. The resident had stated the resident did not want NA-I in the resident's room anymore. Review of facility investigations of potential abuse/neglect from 1/15/25 through 2/5/26 revealed no evidence Resident 7's allegations of NA-I treating the resident roughly and speaking to the resident rudely was reported to the State Agency. The facility did do an investigation of the resident's allegation and NA-I was directed not to provide care assistance to Resident 7. There was no evidence the investigation was then submitted to the State Agency within the required timeframe. During an interview on 2/10/26 at 9:46 AM, the Social Service Director (SSD) confirmed the grievance by Resident 7 on 8/15/25 was not reported and even though an investigation was completed, the results of the investigation were never submitted to the State Agency.

Licensure Reference Number 175 NAC 12-006.05(A)Based on record review and interview; the facility failed to notify the Ombudsman of facility discharges for Residents 1 and 34. The sample size was 2 and the facility census was 28. Findings are: A. Review of the facility policy Discharge and Transfer dated 1/15/26 revealed the facility ensured discharges and/or transfers were documented in the medical record and appropriate information was communicated to the receiving health care provider. The facility allowed each resident to remain in the facility unless discharge or transfer was necessary for the resident's welfare and/or the resident's needs could not be met, and the discharge was appropriate. The facility provided sufficient preparation and orientation to residents to ensure safety and orderly transfer or discharge. With a transfer or discharge the facility sent a copy of an approved discharge form to the office of the State Long-Term Care Ombudsman. B. Review of Resident 1's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and discharged on 1/31/26. There was no evidence the facility notified the State Ombudsman of the resident discharge. C. Review of Resident 34's EMR revealed the resident was admitted to the facility on [DATE] and discharged on 12/7/25. There was no evidence the facility notified the State Ombudsman of the resident discharge. D. During an interview on 2/9/26 at 4:07 PM the facility Administrator confirmed the facility had no evidence of Ombudsman notifications of facility discharges for Residents 1 or 34.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on interview and record review; the facility failed to address Resident 28's nutritional status and risk for weight loss on the resident's comprehensive plan of care and failed to involve Resident 12's legal guardian in the development of the resident's care plan. The total sample size was 20 and the facility census was 28. Findings are: A. Review of the Care Plan Policy with a revised/reviewed date of 12/1/25 revealed the purpose of the policy was to develop a comprehensive care plan using an interdisciplinary approach. A comprehensive care plan was to include measurable objectives, and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Each resident was to have an individualized person-centered, comprehensive plan of care that included measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, emotional, psychosocial, and educational needs. Any problems, needs, and concerns identified were to be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI- a comprehensive, standardized, and mandatory system used in skilled nursing facilities to evaluate the functional, medical, and psychosocial status of residents) and review of physician orders. A baseline care plan was to be developed on admission according to federal and state regulations. The facility must provide the resident and the resident representative with a written summary of the baseline care plan and document the meeting with the resident and the representative and any significant discussion that occurred. The care plan was to be modified to reflect the care currently required/provided for the resident. The resident, family and/or the legal representative were to have the opportunity to participate in the planning of their care to the extent practicable. B. Review of Resident 28's Minimum Data Set (MDS, federally mandated comprehensive assessment tool used to develop resident care plans) dated 10/22/25 revealed diagnoses of diabetes, cancer, end stage renal disease, parastomal hernia with obstruction (incisional hernia that allows protrusion of abdominal contents through the abdominal wall/ostomy), anxiety, bipolar disorder, and depression. Further review of the assessment revealed the resident's cognition was intact, the resident required setup assistance and supervision with eating/drinking, did not have a condition or a chronic disease that could result in a life expectancy of less than 6 months and the resident's weight was 142 pounds (lbs.). The resident had a weight loss of 5 percent (%) in the last month or loss of 10% or more in the last 6 months. Review of a Mini-Nutritional assessment dated [DATE] at 9:57 AM revealed the resident's score was a 6.0 indicating the resident was malnourished. Further review revealed the resident had a decline in food/fluid intakes, had a weight loss greater than 7 lbs. in the last 3 months and the resident had severe dementia or depression. Review of Resident 28's comprehensive care plan with a revision date of 11/3/25 revealed the resident had impaired cognitive function and/or thought process with confusion and memory loss related to anxiety, bipolar and schizophrenic disorders. The resident had been diagnosed with breast cancer with secondary cancer to the bone. The resident was independent with eating but required verbal cues to ensure adequate intakes. Review of a Mini-Nutritional assessment dated [DATE] at 10:57 AM revealed the resident remained at risk for malnutrition. Review of a Nutritional Progress Note by the Registered Dietician (RD) dated 1/27/26 at 1:54 PM revealed the resident's weight on 1/16/26 was 131 lbs., indicating a severe weight loss of 12% in 180 days as weight on 7/22/25 was 149 lbs. The resident was identified as receiving nutritional supplement of choice due to weight concerns. The RD made a recommendation to discontinue the current nutritional supplement and to start Med Pass 2.0 120 cubic centimeters (cc) to provide more calories and protein to the resident. Further review of Resident 28's care plan revealed no evidence the facility had addressed the resident's risk for altered nutrition and the resident's current weight loss interventions. During an interview on 2/10/26 at 7:58 AM, the Director of Nursing (DON) confirmed Resident 28's current care plan did not address the resident's nutritional status and did not identify any interventions developed/implemented for the resident's weight loss. C. Review of Resident 12's Minimum Data Set (MDS-a federally mandated assessment tool used in Care Planning) dated 1/14/26 revealed the resident was admitted on [DATE] with a diagnoses of Congestive Heart Failure (CHF), and Stroke; was cognitively intact; hearing was highly impaired, resident had no speech; was independent with dressing, toileting cares, transfers/ambulation, bed-mobility; hospice care; and received an antidepressant medication. Review of Resident 12's Care Plan revealed the resident was cognitively intact; diagnosis of CHF and stroke; was independent with dressing, toileting cares, transfers/ambulation, bed mobility; received hospice care; and received an antidepressant medication. The resident had a communication problem related to deafness evidenced by unable to hear, used sign language, read lips, used gestures and white board to communicate. Review of facility form Care Plan Review Log revealed that Resident 30's Care Plan was reviewed on 1/9/26. An interview on 2/5/26 at 1:19 PM with Resident 12's Legal Guardian/Sister revealed that family had not been invited to a Care Plan meeting for over a year. An interview on 2/9/25 at 4:45 PM with Social Services Director confirmed that there was not any facility documentation to confirm that the Legal Guardian/Sister had been invited to Resident 12's Care Plan meetings or who attended the resident's Care Plan meetings when the meetings occurred.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i)(3) Based on record review and interview; the facility failed to revise current fall interventions and/or develop new interventions to prevent ongoing falls for Resident 6. The sample size was 6 and the facility census was 28.Findings are: A. Review of the Fall Prevention and Management policy with revised/reviewed date of 10/14/25 revealed the purpose of the policy was to promote resident well- being by developing and implementing a fall prevention and management program, identifying risk factors, and implementing interventions before a fall occurs. If a resident fall occurs, the following procedure was identified:-assess the resident and perform a full body examination.-notify the Primary Care Physician (PCP) and the resident's representative.-complete a Fall Scene Huddle Worksheet to determine causal factors and fall interventions.-document the incident in the Safe Event-Incident Report. B. Review of Resident 6's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11/26/25 revealed the resident had diagnosis of non-traumatic brain dysfunction, diabetes, Alzheimer's disease, Non-Alzheimer's dementia, anxiety, and depression. The resident's cognition was impaired and the resident required substantial to maximal assistance with personal hygiene, toileting hygiene, dressing, bed mobility, and transfers. The resident used bed/chair alarms daily. Review of a Safe Event-Incident Report dated 10/22/25 at 6:30 AM revealed the resident was found on the floor of the resident's room. Review of a Fall Huddle Worksheet dated 10/22/25 revealed the resident was barefoot at the time of the fall. New intervention was developed for the resident to always wear gripper socks. Review of a Safe Event-Incident Report dated 11/19/25 at 11:30 AM revealed the staff heard the resident's fall alarm and the resident was found on the floor of the resident's room. Review of a Fall Huddle Worksheet dated 11/19/25 revealed the resident had self-transferred, lost balance, and fell. The resident was wearing gripper socks; the fall alarm was in place and functional; and the resident's assistive devices were in reach. Further review revealed no new fall interventions were developed and current interventions were not revised. Review of a Safe Event-Incident Report dated 11/30/25 at 7:15 PM revealed the staff heard a muffled fall alarm sounding and when the resident was checked, the resident was on the floor. Review of a Fall Huddle Worksheet dated 11/30/25 revealed the staff had assisted the resident from the dining room to the resident's room after the evening meal. Staff received education to assist the resident to the bathroom immediately after meals. Review of a Safe Event-Incident Report dated 12/9/25 at 12:30 PM revealed the resident was found on the floor and facing the recliner with the floor mat moved out of reach. The resident indicated a need to use the bathroom. Review of a Fall Huddle Worksheet dated 12/9/25 revealed the staff received re-education on making sure the residents' fall alarms were in place and functional. There was no evidence which staff received the education and how the information was provided to the remainder of the staff. Review of a Safe Event-Incident Report dated 12/13/25 at 11:30 AM revealed the resident was found on the floor outside of the bathroom and the resident indicated a need to use the bathroom. Review of a Fall Huddle Worksheet dated 12/13/25 revealed the resident's chair alarm was not underneath the resident and had not been plugged in. Further review revealed no new fall interventions were developed and current interventions were not revised. Review of a Safe Event-Incident Report dated 12/18/25 at 2:30 PM revealed the resident was found lying on the bathroom floor of the resident's room. The resident had removed the chair alarm from the wheelchair and then used the wheelchair to transfer into the bathroom. Review of a Fall Huddle Worksheet dated 12/18/25 revealed the resident had been toileted 30 minutes prior but was now incontinent of bowel and bladder. No additional fall interventions were identified to prevent further falls. Review of a Safe Event-Incident Report dated 2/8/26 at 4:15 PM revealed the resident was found on the floor of the resident's room. Review of a Fall Huddle Worksheet dated 2/8/26 revealed the facility had the family bring in new slippers as current slippers had no tread and increased the resident's risk for falls. During an interview on 2/9/26 at 1:41 PM with the Director of Nursing (DON) and the Registered Nurse Consultant verified the following regarding the residents' falls: -10/22/25 at 6:30 AM a new intervention was developed to make sure the resident was always wearing gripper socks or slippers.-11/19/25 at 11:30 AM the fall investigation revealed the resident's alarm was working at time of the fall, the walker was in place and the resident was wearing gripper socks. No new fall interventions were listed. -11/30/25 at 7:15 PM a new intervention was identified to assist the resident to the bathroom before and after meals. -12/9/25 at 12:30 PM the staff received re-education to make sure the residents' fall alarms were in place and functional. No evidence who received this re-education and how all the staff were re-educated.-12/13/25 at 11:30 AM review of the investigation revealed the resident's fall alarm had not been placed under the resident and was not plugged into the sensor box. No new interventions were developed and current interventions were not revised. -12/18/25 at 2:30 PM discussed the resident's toileting schedule with the staff but no documentation if any new interventions.-2/8/26 at 4:15 PM family brought new slippers in for the resident.

Licensure Reference Number 175 NAC 12-006Based on record review and interview; the facility failed to ensure the daily staff posting had the required information. This had the potential to affect all facility residents. The facility census was 28.Findings are: Review of the facility policy Nursing Staff Daily Posting, last revised 12/1/25 revealed the purpose was to post the location's daily staff according to federal Centers for Medicare and Medicaid Services (CMS) staff posting requirements and revealed the following:-the facility would post daily the staffing and resident census at the beginning of each shift and update as appropriate (for each shift) and it would include the following information- location name, current date, resident census, total number and actual number of hours worked by categories of registered nurses, licensed nurses, certified nursing assistants and certified medication assistants;-this information must be prominently displayed in a clear and readable format where residents, staff members, and the public may view; and-records must be kept for 18 months or as required by state law, whichever is greater. Review of the facility form Daily Nursing Staffing for January 1 through 31, 2026 and February 1 through 9, 2026 revealed no documentation that the facility census was included on the forms. Interview on 2/9/26 at 5:10 PM with the Director of Nursing confirmed the staff daily posting did not contain the census which was required.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record reviews and interviews; the facility failed to notify Resident 1's practitioner of the residents increased lethargy, decreased appetite, lowered blood glucose levels and staff failure to administer insulin; and Resident 3 and 4's practitioner and/or responsible parties of ongoing falls. The sample size was 5 and the facility census was 33. A. Review of the facility policy Notification of Change with a revision date of 12/23/2024 revealed the purpose of the policy was to identify when regulation required notifications to occur. The policy further revealed the facility must immediately inform the resident, the resident's physician and the resident representative when there was:-an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention.-a significant change occurred in the resident's physical, mental or psychosocial status.-there was a need to alter treatment significantly, a need to discontinue or change an existing form of treatment or to commence a new form of treatment. When making notification to the physician, the facility was to ensure that all pertinent information was available and provided upon request. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/10/25 revealed the resident was admitted [DATE] with diagnoses of traumatic spinal cord dysfunction, osteomyelitis of the vertebra in the lumbar region, atrial fibrillation, coronary artery disease, high blood pressure, end stage renal disease, diabetes, arthritis, and Non-Alzheimer's dementia. The following was assessed for the resident: -cognition was intact. -frequently incontinent bladder. -required staff assistance with personal hygiene, dressing, transfers, toileting hygiene, and bed mobility. -frequent pain which occasionally interfered with day-to-day activities and the resident rated at an 8 out of 10. -one fall without injury since admission. -functional limitation of range of motion to one side of lower extremities. Review of Resident 1's plan of care dated 10/10/25 identified the resident had a diagnosis of diabetes with an intervention to monitor/document/report to the practitioner any signs of hypoglycemia (blood glucose level falls below normal usually below 70). Signs of hypoglycemia were identified as confusion, lethargy, slurred speech, fatigue, and loss of appetite. Review of Resident 1's Nursing Progress Notes revealed the following: -10/8/25 at 5:14 PM the resident's Aspart Insulin (rapid acting insulin used to manage blood sugar levels) was not given as the resident had refused to eat the breakfast and the noon meal. -10/8/25 at 6:56 PM the resident was lethargic. -10/8/25 at 9:14 PM the resident's Glargine insulin (long acting insulin used to manage blood glucose levels) was held as the resident refused the evening meal and the resident's blood sugar was low. -10/9/25 at 8:32 AM the resident's Aspart insulin was again held due to poor meal intake. -10/9/25 at 8:33 AM the resident's Aspart insulin was not administered as the resident continued to refuse to eat. -10/9/25 at 8:45 AM the resident was lethargic, consumed only bites of the breakfast meal, and required 2 staff to assist the resident with transfer into bed. Review of the resident's medical record revealed from 10/8/25 at 8:33 AM to 10/9/25 at 8:33 AM there was no evidence the resident's practitioner was notified of the resident's refusal to eat, lethargy, staff failure to administer the resident's insulin and the resident's need for increased assistance with activities of daily living. During an interview with the Director of Nursing on 10/22/25 at 9:10 AM the following was confirmed: -the resident was admitted [DATE] due to fall at the resident's home with pain related to spinal abscess and osteomyelitis of the lumbar region. -10/8/25 at 5:14 PM to 10/9/25 at 8:45 AM the resident was lethargic and refused to eat or was unable to eat. The facility staff held the resident's ordered Aspart insulin and Glargine insulin due to the resident's poor intake and lowered blood glucose reading. -the staff failed to notify the resident's practitioner of the resident's change in condition and the failure to administer the resident's insulin without ordered parameters. C. Review of a Fall Prevention and Management Policy with a revision date of 10/14/25 revealed if a resident had a fall, the nurse was to assess the resident and perform a full body examination to determine suspected injury. The nurse was to notify the resident's practitioner and representative of the incident and results of the assessment. D. Review of Resident 3's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of previous stroke, coronary artery disease, high blood pressure, end stage renal disease, diabetes, aphasia, Non-Alzheimer's dementia, depression, and schizophrenia. The following was assessed for the resident: -short and long term memory loss with severely impaired decision making needs. -behaviors which included verbal/physical abuse directed at others, other behavioral symptoms not directed toward others, rejection of cares, and wandering. -frequently incontinent of bowel and bladder. -required staff assistance with personal hygiene, dressing, transfers, toileting hygiene, and bed mobility. -use of bed and chair alarms daily. -two or more falls without injury and two or more falls with injury (except major) since the last assessment. Review of Resident 3's Nursing Progress Notes revealed the following: -5/19/25 at 1:37 PM the resident had slurred speech, was cold/clammy and pupils were not responsive. The resident appeared short of breath but refused further assessment. The practitioner indicated the family were to be notified, but there was no evidence the family received notification. -9/11/25 at 8:40 AM the resident had an unwitnessed fall at the south nurse's station. Review of the resident's medical record revealed no injuries were identified and there was no documentation the family was notified. -9/21/25 at 2:35 AM the staff heard the resident's fall alarm and witnessed the resident stumble backwards and fall. No injuries were observed. The resident's physician was notified but there was no evidence the resident's representative received notification. -9/28/25 at 12:34 AM the resident was found on the floor of the bathroom. The fall was reported to the Hospice nurse but there was no indication the residents' physician or representative were made aware of the fall. Interview with the DON on 10/22/25 at 9:20 AM verified the charge nurses were responsible for notifying the resident's representative and the practitioner whenever a resident had a fall. In addition, the DON confirmed on 5/9/25 at 1:37 PM the resident's representative was unaware of the resident's change in condition and was never notified of the resident's falls on 9/11/25 at 8:40 AM, 9/21/25 at 2:35 AM and on 9/28/25 at 12:34 PM or the practitioner was made aware of the fall on 9/28/25 at 12:34 PM. E. Review of Resident 4's MDS dated [DATE] revealed the resident was admitted on [DATE]. Resident had a diagnosis of history of falling, left foot drop, seizure disorder and had weakness to 1 side of the body. The following was assessed for the resident: -required staff assistance with personal hygiene, dressing, transfers, toileting hygiene, and bed mobility. -1 fall without injury and 1 fall with injury (except major) since the last assessment. Review of Resident 4's Nursing Progress Notes revealed the following: - On 9/20/25 at 3:47 PM resident was found on the floor in the bathroom by the toilet. The resident's family had been notified, no evidence that the physician had been notified. -On 10/11/25 at 4:45 AM resident transferred from bed to wheelchair, the wheel chair brakes were not locked and the wheel chair went out from underneath the resident. No injuries were noted. The resident's physician had been notified, no evidence that the family had been notified. Interview with the DON on 10/22/25 at 11:00 AM verified the charge nurses were responsible for notifying the resident's representative and the practitioner whenever a resident had a fall. The DON confirmed that Resident 4's physician was not notified of resident's fall on 9/20/25 at 3:47 PM and the family was not notified of the resident's fall on 10/11/25 at 4:45 AM.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to thoroughly investigate allegations of potential abuse for Residents 1 and 2 and to report an allegation of potential abuse for Resident 2 within the required timeframe. The sample size was 5 and the facility census was 31. Findings are: A. Review of the facility Abuse and Neglect Policy with a reviewed/revised date of 4/7/25 revealed the policy of the facility was to ensure all alleged or suspected violations involving any mistreatment. neglect, exploitation or abuse, including injuries of unknown origin were to be reported immediately to the Administrator or a delegated individual. The purpose of the policy was to: -ensure employees were knowledgeable regarding reporting and investigating the process of abuse and neglect allegations in the facility. -ensure the facility had an effective system in place that, regardless of the source, prevented mistreatment, neglect, exploitation, and abuse of residents and misappropriation of their property. -ensure residents were not subjected to abuse by anyone including but not limited to employees, other residents, consultants, volunteers, employees of other agencies serving the individual, family members or legal guardians. -ensure all identified events of alleged or suspected abuse/neglect including injuries of unknown origin were promptly reported and investigated. -ensure a complete review by the investigation team to identify events such as suspicious bruising of residents, occurrences that may constitute abuse and determine the direction of the investigation, patterns, and trends. The following process was to be followed: -intervene in any situation to protect the residents. -remove any individual as necessary from the facility if necessary to protect the residents and/or employees. -call local law enforcement for assistance with interventions necessary for the protection of the residents/employees. -the facility was to have evidence that all alleged or suspected violations were thoroughly investigated and were to prevent further potential abuse while the investigation was in progress. -results of all investigations were to be reported to the Administrator or designated representative and to other officials in accordance with state law, including the State Survey and Certification Agency within 5 working days of the event. If the alleged or suspected violation was verified, appropriate corrective action was to be taken. B. Review of Resident 1's Nursing Progress Notes dated 4/13/25 revealed the following: -5:32 PM the resident had reported to family members that the resident's leg hurt. The resident further reported the resident had been hurt by a staff member and the resident had let the staff know they had hurt the resident at the time of the injury. When the resident's leg was assessed, the resident flinched and verbalized discomfort. -9:36 PM Adult Protective Services (APS) were notified at 9:10 PM the resident had stated that the resident's leg hurt, and the resident let whoever did this know the resident had been hurt. Review of a Nursing Progress Note dated 4/14/25 at 12:45 AM revealed the resident was walking in the corridor and told the staff the resident needed assistance to the bathroom. The resident reported pain in the resident's right leg because someone (the resident used a hand to make a chopping motion) just whammed the resident's leg. Review of the facility investigation dated 4/14/25 revealed the resident had advanced dementia with confusion. The resident had a history of knee/leg pain, and the facility had no concerns a staff member had any involvement with the resident's complaint of pain. Review of the facility investigation and the resident's medical record revealed no evidence a thorough investigation had been completed regarding the resident's allegation someone had hurt the resident's leg to rule out the potential for abuse. C. Review of Resident 2's Nursing Progress Notes dated 2/22/25 at 2:39 PM revealed the resident had requested a physician appointment as the resident was having a lot of pain from when a staff member had penetrated the resident when assisting the resident with a bath. The resident's roommate was questioned regarding the allegation and the roommate could not confirm or deny the allegation. The facility Administrator was notified of the residents' concerns. Review of a Nursing Progress Note dated 2/24/25 (2 days after the resident's allegation of potential abuse) at 1:57 PM revealed APS was notified of the resident's allegation. Review of the facility investigation revealed the facility did not substantiate the allegation of sexual abuse based on the history of the resident's behaviors. The resident was seen by the provider and no trauma was identified and the resident was diagnosed with a urinary tract infection. Further review of the investigation, however, revealed no evidence of the roommate's interview, or interviews with other residents and/or staff to ensure a thorough investigation. D. An interview with the facility Administrator on 4/22/25 at 2:00 PM confirmed the facility had not completed a thorough investigations regarding Resident 1's allegation of a staff member hurting the resident's leg and Resident 2's allegation of a staff member hurting the resident when assisting the resident with a bath. In addition, the facility failed to report Resident 2's allegation of potential staff to resident abuse within the required timeframe.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report an injury of unknown origin and to submit an investigation to the State Agency within 5 working days for 1 (Resident 3) of 5 sampled residents. The facility identified a census of 31. Findings are: A. Review of the facility Abuse and Neglect Policy with a reviewed/revised date of 4/7/25 revealed the policy of the facility was to ensure all alleged or suspected violations involving any mistreatment. neglect, exploitation or abuse, including injuries of unknown origin were to be reported immediately to the Administrator or a delegated individual. The purpose of the policy was to: -ensure employees were knowledgeable regarding reporting and investigating the process of abuse and neglect allegations in the facility. -ensure the facility had an effective system in place that, regardless of the source, prevented mistreatment, neglect, exploitation, and abuse of residents and misappropriation of their property. -ensure residents were not subjected to abuse by anyone including but not limited to employees, other residents, consultants, volunteers, employees of other agencies serving the individual, family members or legal guardians. -ensure all identified events of alleged or suspected abuse/neglect including injuries of unknown origin were promptly reported and investigated. -ensure a complete review by the investigation team to identify events such as suspicious bruising of residents, occurrences that may constitute abuse and determine the direction of the investigation, patterns, and trends. The following process was to be followed: -intervene in any situation to protect the residents. -remove any individual as necessary from the facility if necessary to protect the residents and/or employees. -call local law enforcement for assistance with interventions necessary for the protection of the residents/employees. -the facility was to have evidence that all alleged or suspected violations were thoroughly investigated and were to prevent further potential abuse while the investigation was in progress. -results of all investigations were to be reported to the Administrator or designated representative and to other officials in accordance with state law, including the State Survey and Certification Agency within 5 working days of the event. If the alleged or suspected violation was verified, appropriate corrective action was to be taken. B. Review of the facility Incident and Accident Log revealed an incident dated 2/27/25 at 3:50 PM for Resident 3 which was identified as an injury of unknown origin. Review of Resident 3's Nursing Progress Notes dated 2/27/25 at 3:50 PM revealed the resident had bruising to bilateral hands which was identified as injury of unknown origin. The left hand third finger had a bruise which measured 1.5 centimeters (cm), and the fourth finger had a bruise which measured 0.2 cm. The resident's right-hand knuckles had a bruise which measured 0.05 cm. Review of facility investigations submitted to the State Agency from 2/1/25 to 4/22/25 revealed no evidence the injury of unknown origin for Resident 3 was reported or that an investigation was conducted and then submitted to the State Agency as required. An interview with the facility Administrator on 4/22/25 at 2:00 PM confirmed the facility had not reported the injury of unknown origin documented in Resident 3's medical record or conducted an investigation related to the injury.

Licensure Reference Number 175 NAC 12-006.04(G) Licensure Reference Number 175 NAC 12-006.04(D) Based on observation, record review, and interview; the facility failed to have sufficient staff to meet the daily living activities of Resident 20; the bathing needs of Resident's 3, 11, 16, and 24; and to ensure timely call light response times. This had the potential to affect all facility residents. The sample size was 20 and the facility census was 31. Findings are: A. Review of the Device Activity Report (record of call light activations and responses) from 1/9/25 through 1/13/25 revealed the following call light response times greater than 15 minutes: -1/12/25 at 9:28 PM answered at 36 minutes 19 seconds, -1/12/25 at 9:27 PM answered at 19 minutes and 12 seconds, -1/12/25 at 8:37 PM answered at 19 minutes 3 seconds, -1/12/25 at 5:51 PM answered at 66 minutes 39 seconds, -1/12/25 at 5:28 PM answered at 47 minutes 52 seconds, -1/12/25 at 5:12 PM answered at 38 minutes 2 seconds, -1/12/25 at 4:52 PM answered at 15 minutes 54 seconds, -1/12/25 at 6:36 AM answered at 26 minutes 52 seconds, -1/12/25 at 6:20 AM answered at 18 minutes 10 seconds, -1/11/25 at 7:21 PM answered at 18 minutes 55 seconds, -1/11/25 at 6:58 PM answered at 26 minutes 8 seconds, -1/11/25 at 6:50 PM answered at 28 minutes 0 seconds, -1/11/25 at 4:46 PM answered at 17 minutes 47 seconds, -1/11/25 at 12:30 PM answered at 29 minutes 23 seconds, -1/11/25 at 13:05 PM answered at 15 minutes 28 seconds, -1/11/25 at 12:01 PM answered at 28 minutes 29 seconds, -1/11/25 at 8:32 AM answered at 16 minutes 26 seconds, -1/11/25 at 8:23 AM answered at 33 minutes 47 seconds, -1/11/25 at 8:00 AM answered at 21 minutes 54 seconds, -1/11/25 at 7:49 AM answered at 33 minutes 47 seconds, -1/11/25 at 1:53 AM answered at 21 minutes 8 seconds, -1/10/25 at 3:13 PM answered at 16 minutes 57 seconds, -1/10/25 at 2:18 PM answered at 22 minutes 35 seconds, -1/10/25 at 9:55 AM answered at 16 minutes 43 seconds, -1/10/25 at 8:32 AM answered at 32 minutes 3 seconds, -1/10/25 at 6:38 AM answered at 15 minutes 48 seconds, and -1/9/25 at 7:39 PM answered at 16 minutes 4 seconds. Interview on 1/13/25 at 2:40 PM with the Director of Nursing (DON) revealed call lights were expected to be answered within 15 minutes. Further interview confirmed the facility did not have a policy related to answering call lights. Interview on 1/13/25 at 4:08 PM with the Administrator confirmed there were long call light time frames (longer than 15 minutes) on 1/9/25 through 1/13/25 and staff were expected to answer within 10-12 minutes. B. Review of Resident 11's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 10/16/24 revealed the resident had severe cognitive impairment; was dependent with toileting, showering, dressing, transfers, and hygiene; and had diagnoses of stroke, dementia, anxiety, weakness of one side of the body, and depression. Review of Resident 11's Care Plan last revised 1/1/25 revealed the resident was cognitively impaired, requested 1 bath per week, and required assistance with bathing, bed mobility, dressing, personal hygiene, toileting, and transfers. Review of Resident 11's Bathing Documentation for October, November, and December of 2024 and January 2025 revealed the resident received baths on: -10/5/24, 10/9/24, 10/17/24 (8 days between baths), 10/24/24, 11/7/24 (14 days between baths), 11/14/24, 11/21/24, 11/28/24, 12/5/24, 12/12/24, a sponge bath on 12/21/24 (9 days between baths), 12/28/24, and a bed bath on 1/3/25. There was no further documentation of a bath in January as of 1/15/25 (12 days since last bath). Interview on 1/15/25 at 10:10 AM with Registered Nurse (RN)-G confirmed Resident 11 did not receive a bath at least weekly. 42360 C. Review of Resident 16's MDS dated [DATE] revealed the resident was cognitively impaired, had Diabetes, had a dementia diagnosis, and received substantial assistance with bathing. Review of Resident 16's Care Plan with a revision date of 12/27/24 revealed the resident had impaired cognitive function and confusion, self-care deficits and requested one bath weekly and needed staff assistance to bathe. Review of Resident 16's Bathing Records from December 1st, 2024, through January 15th, 2025, revealed the following: -Bathing occurred on the following days in December 2024: December 4th, 11th, and 18th. -Bathing occurred on the following days in January 2025: No documented baths as of January 2025. -There was no evidence of bathing from December 18th, 2024, and January 15th, 2025 (28 days). During an interview on 1/15/25 at 10:15 AM RN-G confirmed Resident 16 was not receiving baths at least weekly as care planned. D. Review of Resident 3's MDS dated [DATE] revealed the resident had severe cognitive impairment, had a dementia diagnosis, and was dependent for all Activities of Daily Living (ADL's) including bathing. Review of Resident 3's Care Plan with a revision date of 12/30/24 revealed the resident had self-care performance deficits including being unable to walk, and dependence on the staff for moving in bed, dressing and grooming, eating, oral care, hygiene, toilet use, and bathing. Review of Resident 3's Bathing Records from October 1st, 2024, through January 15th, 2025, revealed the following: -Bathing occurred on the following days in October 2024: October 6th, and October 17th. -Bathing occurred on the following days in November 2024: November 7th, 14th, 21st, and 28th. (20 days between the baths on October 17th and November 7th). -Bathing occurred on the following days in December 2024: [DATE]th, 12th, and 27th. (15 days between the baths on December 12th and December 27th). -Bathing occurred on the following days in January 2025: January 10th. (14 days between the baths on December 27th and January 10th). During an interview on 1/15/25 at 10:15 AM RN-G confirmed Resident 3 was not receiving baths at least weekly as care planned. E. Review of the facility Resident Council Meeting minutes 4/5/24 one concern from a resident about call light response times at the meeting; the resident was not named. The resident reported waiting for an hour. 7/12/24 a non-specific complaint about call lights and not knowing when to call- a resident was not named. In addition, the resident referred to staff on their cell phones during work shifts. 11/1/24 a concern about occasional longer wait times for call lights (no specifics). F. During the Resident Council meeting with the surveyor on 1/15/25 at 9:35 AM Resident 24 reported the facility had ongoing concerns with lack of bathing related to not having enough staff, despite this concern being discussed routinely at Resident Council. It's the one concern that never seem to have any permanent resolution. 51391 G. Review of Resident 20's MDS dated [DATE] revealed the resident received substantial to maximal assistance with toileting cares and transfers and was frequently incontinent of bowel and bladder. The resident had a diagnosis of non-traumatic brain dysfunction, Alzheimer's Dementia with short- and long-term memory loss with severely impaired decision-making skills. Review of Resident 20's Care Plan with a revision date of 11/27/24 revealed the resident required extensive assist to use the toilet, was dependent on staff for perineal hygiene and required extensive assist with transfers. The resident did not recognize the need to use the bathroom, was frequently incontinent of bowel and bladder and the staff were to check the resident for incontinence before and after each meal and as needed (PRN). During an observation of the provision of care for Resident 20 on 1/12/25 at 9:30 AM the resident was sitting in a wheelchair in the dining room, breakfast was completed, and staff then pushed the resident to the aviary area to watch the birds. At 11:30AM the resident continued to sit in the aviary area in the wheelchair. At 12:20 PM staff pushed the resident from the aviary area to the dining room for the noon meal. At 1:40 PM the resident was assisted out of the dining room to the resident's room to complete toileting cares. During an interview on 1/12/25 at 11:00 AM RN-B, verified Resident 20 had been sitting in the aviary area since after breakfast. During an interview on 1/12/24 at 2:00 PM Nursing Assistant (NA-L), verified that Resident 20 was to be assisted to the bathroom with morning cares, before and after meals, in the afternoon and at bedtime and the resident had not been assisted to the bathroom since before breakfast. H. During an interview with Resident 24 on 1/12/25 at 9:40 AM, the resident voiced that weekly baths were not being done by the facility all of the time. Review of Resident 24's MDS dated [DATE] revealed the resident received partial assistance with bathing and supervision with a tub transfer. Review of Resident 24's Care Plan with a revision date of 12/2/24 revealed the resident required extensive 1 assist with taking a whirlpool. Review of Resident 24's Bathing Records from December 16th, 2024, through January 10th, 2025, revealed the following: -Bathing occurred on the following days in December 2025: December 20th -Bathing occurred on the following days in January 2025: January 4th -There was no evidence of bathing on December 27th, 2024, or January 10th, 2025. -There was no evidence of bathing from the facility from 12/21/24 to 1/4/25. During an interview on 1/14/25 at 2:00 PM, NA-C and RN-H, verified that Resident 24 required assistance with bathing. During an interview on 1/14/25 at 2:45 PM, RN-G, verified that the resident had not received a bath weekly from the facility.

Licensure Reference Number 175 NAC 12-006.09(H) Based on observation, record review and interview; the facility failed to meet the Activities of Daily Living (ADL) needs for Resident 20 and the bathing needs for Resident's 3, 11, 16 and 24. The sample size was 20 with a census of 31. Findings are: A. Review of Resident 20's Minimum Data Set (MDS-federally mandated comprehensive assessment use to develop resident care plans) dated 12/12/24 revealed the resident received substantial to maximal assistance with toileting cares and transfers and was frequently incontinent of bowel and bladder. The resident had a diagnosis of non-traumatic brain dysfunction, Alzheimer's Dementia with short- and long-term memory loss with severely impaired decision-making skills. Review of Resident 20's Care Plan with a revision date of 11/27/24 revealed the resident required extensive assist to use the toilet, was dependent on staff for perineal hygiene and required extensive assist with transfers. The resident did not recognize the need to use the bathroom, was frequently incontinent of bowel and bladder and the staff were to check the resident for incontinence before and after each meal and as needed (PRN). During an observation of the provision of care for Resident 20 on 1/12/25 at 9:30 AM the resident was sitting in a wheelchair in the dining room, breakfast was completed, and staff then pushed the resident to the aviary area to watch the birds. At 11:30AM the resident continued to sit in the aviary area in the wheelchair. At 12:20 PM staff pushed the resident from the aviary area to the dining room for the noon meal. At 1:40 PM the resident was assisted out of the dining room to the resident's room to complete toileting cares. During an interview on 1/12/25 at 11:00 AM Registered Nurse (RN-B), verified Resident 20 had been sitting in the aviary area since after breakfast. During an interview on 1/12/24 at 2:00 PM Nursing Assistant (NA-L), verified that Resident 20 was to be assisted to the bathroom with morning cares, before and after meals, in the afternoon and at bedtime and the resident had not been assisted to the bathroom since before breakfast. B. During an interview with Resident 24 on 1/12/25 at 9:40 AM, the resident voiced that weekly baths were not being done by the facility all of the time. Review of Resident 24's MDS dated [DATE] revealed the resident received partial assistance with bathing and supervision with a tub transfer. Review of Resident 24's Care Plan with a revision date of 12/2/24 revealed the resident required extensive assist with taking a whirlpool. Review of Resident 24's Bathing Records from December 16th, 2024, through January 10th, 2025, revealed the following: -Bathing occurred on the following days in December 2025: December 20th -Bathing occurred on the following days in January 2025: January 4th -There was no evidence of bathing on December 27th, 2024, or January 10th, 2025. -There was no evidence of bathing from the facility from 12/21/24 to 1/4/25. During an interview on 1/14/25 at 2:00 PM, NA-C and RN-H, verified that Resident 24 required assistance with bathing. During an interview on 1/14/25 at 2:45 PM, RN-G, verified that the resident had not received a bath weekly from the facility. 42360 C. Review of Resident 16's MDS revealed the resident was cognitively impaired, had Diabetes, had a dementia diagnosis, and received substantial assistance with bathing. Review of Resident 16's Care Plan with a revision date of 12/27/24 revealed the resident had impaired cognitive function and confusion, self-care deficits and requested one bath weekly and needed staff assistance to bathe. Review of Resident 16's Bathing Records from December 1st, 2024, through January 15th, 2025, revealed the following: -Bathing occurred on the following days in December 2024: December 4th, 11th, and 18th. -Bathing occurred on the following days in January 2025: No documented baths as of January 15, 2025. -There was no evidence of bathing from December 18th, 2024, through January 15th, 2025 (28 days). During an interview on 1/15/25 at 10:15 AM RN-G confirmed Resident 16 was not receiving baths at least weekly as care planned. D. Review of Resident 3's MDS dated [DATE] revealed the resident had severe cognitive impairment, had a dementia diagnosis, and was dependent for all ADL's including bathing. Review of Resident 3's Care Plan with a revision date of 12/30/24 revealed the resident had self-care performance deficits including being unable to walk, and dependence on the staff for moving in bed, dressing and grooming, eating, oral care, hygiene, toilet use, and bathing. Review of Resident 3's Bathing Records from October 1st, 2024, through January 15th, 2025, revealed the following: -Bathing occurred on the following days in October 2024: October 6th, and October 17th. -Bathing occurred on the following days in November 2024: November 7th, 14th, 21st, and 28th. (20 days between the baths on October 17th and November 7th). -Bathing occurred on the following days in December 2024: [DATE]th, 12th, and 27th. (15 days between the baths on December 12th and December 27th). -Bathing occurred on the following days in January 2025: January 10th. (14 days between the baths on December 27th and January 10th). During an interview on 1/15/25 at 10:15 AM RN-G confirmed Resident 3 was not receiving baths at least weekly as care planned. 45739 E. Review of Resident 11's MDS dated [DATE] revealed the resident had severe cognitive impairment; was dependent with toileting, showering, dressing, transfers, and hygiene; and had diagnoses of stroke, dementia, anxiety, weakness of one side of the body, and depression. Review of Resident 11's Care Plan last revised 1/1/25 revealed the resident was cognitively impaired, requested 1 bath per week, and required assistance with bathing, bed mobility, dressing, personal hygiene, toileting, and transfers. Review of Resident 11's Bathing Documentation for October, November, and December of 2024 and January 2025 revealed the resident received baths on: -10/5/24, 10/9/24, 10/17/24 (8 days between baths), 10/24/24, 11/7/24 (14 days between baths), 11/14/24, 11/21/24, 11/28/24, 12/5/24, 12/12/24, a sponge bath on 12/21/24 (9 days between baths), 12/28/24, and a bed bath on 1/3/25. There was no further documentation of a bath in January as of 1/15/25 (12 days since last bath). Interview on 1/15/25 at 10:10 AM with RN-G confirmed Resident 11 did not receive a bath at least weekly.

Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on record review and interviews; the facility failed to revise nutritional interventions and/or develop new interventions to address ongoing weight loss for 1 (Resident 14) of 2 sampled residents. The facility census was 31. Findings are: A. Review of the facility policy Weight and Height with a revision date of 10/15/2024 revealed the following regarding weighing the residents and monitoring weight loss. The policy indicated the purpose of weighing the resident was to: -ensure the resident maintained acceptable parameters of nutritional status regarding weight. -report a significant weight change to the physician, family, and resident. -monitor weight loss in a resident. The policy indicated residents at nutritional risk were to be weighed weekly and the facility was to immediately inform the resident, consult with the resident's physician and notify the resident's legal representative when there was a significant change in the residents' weight. The following procedure was identified for weighing the resident: -weigh the resident at the same time of the day using the same type of scale -document the weight in the resident's medical record. -if weight varied by more than three percent (%), the staff were to reweigh the resident, document and report the weight to a licensed nurse. -the licensed nurse was to notify the director of food and nutrition within 24 hours regarding any significant weight change. Significant weight change was defined as 5% in 30 days, 7.5% in 90 days and 10% in 180 days. -the licensed nurse should immediately notify the medical provider regarding any significant weight change. B. Review of Resident 14's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 12/25/24 revealed the resident was independent with eating and drinking. The resident's weight was 140 pounds (lbs.) with a loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The resident had a diagnosis of fractures, anxiety, and depression. Review of Resident 14's Care Plan (undated) revealed the resident ate independently and would usually request a room tray. The following nutritional interventions were identified: -the resident was to be weighed weekly. -the staff were to discuss with the resident positive coping behaviors, alternatives to undereating, feelings related to food and self-image concerns. The care plan identified repeatedly the resident would request something specific to eat then refuse. The facility was to accommodate the resident to the best of their ability. Review of the Weight and Vitals Summary Sheet (form used to document a resident's weights, blood pressure, respirations, temperature, and pulse) revealed the resident's weight on 9/25/24 was 158 lbs. Review of Nursing Progress Notes revealed the following: -9/27/24 at 4:58 PM the physician was notified the resident wanted a house supplement (nutritional drink with added calories and nutrients) daily due to poor appetite related to pain and that the resident had been refusing MiraLAX (laxative) and Colace (stool softener) every morning. -10/1/24 at 10:52 AM the facility received a physician's order to change the MiraLAX and the Colace to as needed (PRN) and to start a house supplement daily. Further review of the resident's medical record revealed no evidence as to the amount of supplement the resident was to receive. Review of the resident's Weight and Vitals Summary sheet revealed on 10/5/24 the resident's weight was 151lbs. (down 7 lbs. in 10 days). Review of a Nursing Progress Note dated 10/16/24 at 12:18 PM revealed the resident was seen by the pain physician with new orders to start Percocet (medication for pain) every 4 hours PRN pain. Review of a Nutritional Progress Note dated 10/21/24 at 9:54 AM by the Registered Dietician (RD) revealed the resident's weight was down 3% in less than 2 weeks and the resident's average meal intakes were 54%. No new nutritional interventions were identified. Review of a Nursing Progress Note dated 10/22/24 at 11:37 AM revealed the resident received an injection for pain. Review of the resident's Weight and Vitals Summary sheet revealed on 10/23/24 the resident's weight was 143 lbs. (down 15 lbs. in 1 month). Review of the resident's Nursing Progress Notes revealed the following: -10/25/24 at 6:30 PM the facility received an order for an Enema (introducing fluid into the rectum to stimulate bowel movement) daily PRN. -10/30/24 at 2:34 PM the physician was notified the resident's admission weight was 158 lbs. and on 9/24/24 the resident had a weight of 143 lbs. (a 15 lb. weight loss since admission). The resident continued to receive the house supplement daily and had been eating 50% or less of meals. -10/31/24 at 11:02 AM new orders were received to increase the house supplement to 3 times daily, and the resident's physician indicated considering the use of Remeron (antidepressant with a side effect of stimulating the resident's appetite) if no improvement. Review of the October 2024 Medication Administration Record (MAR) revealed no documentation from 10/1/24 to 10/8/24 to indicate the amount of house supplement consumed when offered to the resident. Review of the resident's Weight and Vitals Summary sheet revealed the following: -11/3/24 weight was 140 lbs. -11/9/24 weight was 138 lbs. Review of Nursing Progress Notes revealed the following: -11/12/24 at 12:18 PM new orders were received for Buspar (antianxiety medication) 5 milligrams (mg) daily for depression and Speech Therapy was to evaluate and treat the resident due to difficulty with swallowing. -11/12/24 Speech Therapy evaluation was completed with no change in diet recommended. -11/14/24 at 11:57 PM a new order was received for Zofran (antinausea medication) 4 milligrams (mg) every 6 hours PRN nausea. Review of the resident's Weight and Vitals Summary sheet revealed on 11/17/24 the resident's weight was 141 lbs. Review of Nursing Progress Notes revealed the following: -11/20/24 at 10:07 AM a new order was received for a consult with a gastroenterologist (physician who specializes in the digestive system, diagnosing and treating disorders that affect it). -11/26/24 at 1:37 PM the resident and family refused to see the gastroenterologist. The resident was started on Omeprazole (medication which reduces acid in the stomach) 40 mg daily. Review of a Nutritional Progress Note dated 11/26/24 at 2:20 PM confirmed the residents weight loss and indicated the resident had a weight loss of 11% in less than 90 days. Further review revealed no changes were made regarding weight loss interventions. Review of the resident's Weight and Vitals Summary sheet revealed on 11/30/24 the resident's weight was 140 lbs. Review of the November 2024 MAR revealed the facility staff failed to document the resident's intakes of the house supplement from 11/1/24 to 11/21/24. Review of a Nursing Progress Note dated 12/3/24 at 10:48 am revealed the resident was seen by the physician. New orders were received to discontinue the Omeprazole, and the resident was referred to a surgeon for dysphagia (difficulty with swallowing) and abdominal pain. A recommendation was received for an EGD (medical procedure that involves inserting a tube with a camera down the esophagus and into the stomach to look at the organs for abnormalities). Review of the resident's Weight and Vitals Summary sheet revealed the following: -12/7/24 the resident's weight was 139 lbs. -12/15/24 the resident's weight was 140lbs. Further review of the resident's medical record revealed no evidence a weight was obtained and documented for the resident from 12/15/24 until 12/29/24. Review of Nursing Progress Notes revealed the following: -12/16/24 at 12:44 AM an order was received for Tums (antacid) 1-2 chewable tablets 2 times daily PRN upset stomach. -12/16/24 at 10:45 AM the EGD was completed and revealed a large hiatal hernia (a condition in which part of the stomach pushed up through the chest cavity), there were no change in orders. -12/18/24 at 2:36 PM the resident refused to travel out of town to see a physician for the hiatal hernia. Review of a Nutritional Progress Note dated 12/23/24 revealed the resident's current weight was 140 lbs. which was a severe weight loss of 11.4% in 90 days. There was no evidence the RD revised current nutritional interventions or developed additional interventions despite the resident's ongoing weight loss. Review of the resident's Weight and Vitals Summary sheet revealed the following: -12/29/24 weight was 135 lbs. -1/4/25 weight was 135lbs. (this weight was found on a bathing sheet the morning of 1/14/25). An interview on 1/13/25 at 12:45 PM with the Dietary Manager (DM) verified that resident was on the weight loss list and was being reviewed in the risk meetings. The resident continued to receive the house supplement 3 times per day. The DM verified that the amount of house supplement the resident drank should be documented each time administered. The resident's weight on 1/14/25 at 8:59 AM was 136 lbs. and was completed by Registered Nurse (RN)-G. An interview with the Director of Nursing (DON) on 1/14/25 at 1:30 PM verified the resident was not being weighed weekly. An interview with the DON, RN-J, and the DM on 1/14/25 at 2:55 PM verified there was not a specific amount of house supplement to administer on the house supplement order. The DM verified that the kitchen was sending 120 cubic centimeters (cc) of the house supplement with the resident meals. The DON verified that the Remeron suggested on 10/31/24 was never addressed despite the resident's weight loss. During an interview with the DON and DM on 1/14/25 at 3:15 PM verified the following: -the resident eats meals in their room and requests small portions for meals, -the resident had concerns with constipation, and medication changes had been made on 10/1/24 and 10/25/24, -the resident had complaints of pain, and medication changes had been made on 10/6/24 and resident received an injection for pain on 10/22/24, -house supplement was started on 10/1/24 1 time daily and the order did not state how much to administer, the house supplement was increased on 10/31/24 to 3 times daily and the order continued to not have an amount to administer, -the resident was started on an antidepressant on 11/12/24, -Speech Therapy evaluation was completed on 11/12/24 with no change in diet order, -the resident received an order for an antinausea medication as needed on 11/14/24, -the resident had an order to see a gastroenterologist and refused to go see the gastroenterologist, -the resident had an EGD on 12/16/24 but refused further treatment due to not wanting to go out of town, -the resident's weight and dietary intake was reviewed by the Dietician and the DM, and the only dietary interventions in place for the resident are house supplement 3 times per day.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record review and interviews; the facility failed to develop new interventions and/or revise current interventions to prevent ongoing falls for Residents 182 and 26. The sample size was 4 and the facility census was 31. Findings are: A. Review of the Fall Prevention and Management Policy with a revision date of 7/29/24 revealed the purpose of the policy was to promote the resident's well-being by developing and implementing an individualized fall prevention and management program. Staff were to identify risk factors and implement interventions before a fall occurred. The following procedure was identified: -observe the fall scene. -determine if there may be a suspected injury. -if the fall was not witnessed then staff are to complete neurological checks per policy. -review the resident's current interventions to determine if a revision is needed or new interventions developed. -if any teaching is done as an intervention, then to document in the resident's medical record. -review and update the care plan with any changes/new interventions. B. Review of Resident 182's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/21/24 revealed the resident was admitted [DATE] with diagnoses of colon cancer, anemia (a blood disorder that occurs when the body doesn't produce enough healthy red blood cells), and high blood pressure. The following was assessed regarding the resident: -cognition was moderately impaired. -required substantial to maximal assist with oral, personal and toileting hygiene, transfers, dressing, and showering/bathing. -occasionally incontinent of urine. -has a condition or a chronic disease that may result in a life expectancy of less than 6 months. -2 or more falls without injury since previous assessment. -bed and chair alarm used daily. Review of Nursing Progress Note dated 5/7/24 at 11:52 PM revealed the resident was found on the floor in front of the resident's recliner. The resident identified standing and then sliding down the front of the recliner as the resident was not wearing shoes. A new intervention was identified for a non-slip pad to be placed in the seat of the recliner and to ensure the resident was wearing gripper socks or shoes. Review of a Nursing Progress Note dated 6/9/24 at 2:10 AM revealed the resident's call light was on and the resident was found on the floor. The resident was incontinent and indicated a need to use the bathroom. No new interventions were identified, and current fall interventions were not revised. Review of a Nursing Progress Note dated 6/11/24 at 11:38 AM revealed at 7:00 AM the resident was heard calling out for help. The resident was found on the bathroom floor with the walker and the resident's oxygen tubing was wrapped around the wheel of the walker. Staff placed a urinal next to the resident's bed to try and prevent the resident from getting up without assistance. A new toileting plan for the resident was identified with the resident to be toileted before and after meals and every 2 hours at night. Review of a Nursing Progress Note dated 6/28/24 at 5:50 PM revealed the staff lowered the resident to the floor when attempting to ambulate the resident. Further review revealed no evidence a new intervention was developed or that current fall interventions were revised. Review of a Nursing Progress Note dated 8/7/24 at 7:05 AM revealed the resident was found on the floor. The resident's call light was on, and the bed alarm was in place and was connected but had not sounded. A new intervention was put into place to change the fall alarm to a push button alarm to prevent the resident from turning the alarm off. Review of a Nursing Progress Note dated 8/23/24 at 6:54 PM revealed the resident was founding sitting on the floor of the resident's room. The resident's call light was on, and the fall alarm was sounding. Further review revealed no evidence of new interventions or that current interventions were revised to prevent further falls for Resident 182. During an interview on 1/14/25 at 9:22 AM, the Director of Nursing ( DON) confirmed the staff were to assess residents after a fall and were to determine causal factors and either revise current interventions or develop new interventions at the time of the fall. Otherwise, falls would be reviewed with the next risk meeting and interventions reviewed and/or revised at that time. During an interview on 1/14/25 at 10:51 AM, Registered Nurse (RN)-B indicated the Charge Nurses were responsible for assessing a resident after a fall and were then to complete an incident report. Staff were to document causal factors and then document any revised fall interventions or new interventions. The Charge Nurse was then responsible for updating the care plan. RN-B verified the following: regarding Resident 182: -admitted on hospice and was at the facility for end-of-life cares. -multiple falls while at the facility. -the facility failed to revise interventions or to develop new interventions to prevent further falls on 6/9/24 at 2:10 AM, 6/28/24 at 5:50 PM and on 8/23/24 at 6:05 PM. 51391 C. Review of resident 26's MDS dated [DATE] revealed the resident had a diagnosis of Stroke (a medical emergecny that occurs when blood flow to the brain is interrupted), Aphasia (loss or impairment of the power to use or comprehend words usually resulting from brain damage.), Dementia (a usually progressive condition marked by the development of multiple cognitive deficits ((such as memory impairment, aphasia, and the inability to plan and initiate complex behavior)), Depression(a mental health condition that involved a prolonged low mood and loss of interest in activities)and Schizophrenia (a mental illness that is characterized by disturbances in thought, perception, and behavior, by a loss of emotional responsiveness and extreme apathy, and by noticeable deterioration in the level of functioning in everyday life.) . The following was assessed regarding the resident: -received substantial assistance with toileting cares, bathing, dressing and personal hygiene and partial assistance with transfers, -is frequently incontinent of bowel, -occasionally incontinent of urine, -ambulates with a walker, 1 assistance, -bed and chair alarm used daily, -1 fall since previous assessment with minor injury, -received antipsychotic medications and antidepressants, -had short- and long-term memory issues, and -cognition was severely impaired. Review of Nursing Progress Note dated 9/18/24 at 5:50 AM revealed that at 4:24 AM Resident 26 was found on the floor laying in-between the bed and the bathroom door on their back. Review of the Internal Risk note dated 9/18/24 at 4:24 AM revealed that the pressure pad alarm was not sounding. Review of the resident care plan revealed that a new intervention was identified for a fall mat to be placed in front of the bed. The fall mat was then removed due to being a fall risk (unsure when it was removed). Review of Nursing Progress Notes dated 9/28/24 at 6:10 PM revealed the resident was in the wheelchair with staff pushing the wheelchair, the resident stood up out of the wheelchair, and ambulated through the dining room into the chapel. The resident walked up to the alter and tried to step up, grabbed the alter, and pulled it over. The resident rolled onto their left side then to the ground. Review of the resident's care plan and Internal Risk Note revealed that no new fall interventions were put into place. Review of Nursing Progress Notes dated 10/7/24 at 5:50 AM revealed the resident was found on the floor next to the bed, face down, and tangled in blankets. A small amount of red drainage was noted to the left nare. The resident's vital signs were difficult to obtain. The resident was sent to the emergency room at 6:39 AM and returned to facility at 10:11 AM with no new orders. Review of the resident's care plan and Internal Risk Note revealed that no new fall interventions were put into place. Review of Nursing Progress Notes dated 10/31/24 at 4:52 PM revealed the resident had a witnessed fall at 8:31 AM. Resident had feet tangled in the bed sheets, the alarm had sounded, and staff responded to the the alarm right away. Review of the resident's care plan revealed that no new fall interventions were put into place. Review of Nursing Progress Notes dated 11/18/24 at 6:57 AM revealed that the resident was found on the floor in resident's room at 3:55 AM. The resident had received Trazadone (antidepressant) as needed at 10:30 PM. Review of the resident's care plan revealed that a fall intervention was put into place to avoid giving the resident medications that would affect their ability to ambulate safely. Review of Nursing Progress Notes dated 11/18/24 at 7:08 AM revealed that the resident was on the floor in the resident's room leaning against the bed on their left side. The resident was incontinent of bowel. Review of the Internal Risk Note revealed that the pressure alarm was not sounding. Review of Nursing Progress Notes dated 11/18/24 at 11:55 AM revealed that the Trazadone had been decreased to 25 mg at bedtime as needed. Review of Nursing Progress Notes dated 1/4/25 at 11:05 PM revealed that the resident was laying on the floor on the right side in the hallway. The resident did not respond to staff initially. Review of the resident's care plan and Internal Risk Note revealed that no new interventions were put into place. During an interview on 1/13/25 at 9:00 AM, the DON verified that no new fall interventions were put into place for the falls on 1/4/25, 10/31/24, 10/7/24 and 9/28/24. During an interview on 1/13/25 at 9:15 AM, RN-B verified that the Charge Nurses were responsible for assessing the resident after a fall, completing the fall incident report, and updating the care plan with new fall interventions. During an interview on 1/14/25 at 9:22 AM, the DON confirmed the staff were to assess residents after a fall, were to determine causal factors, and revise the current interventions or develop new interventions at the time of the fall. Falls were reviewed with the next risk meeting and interventions were reviewed/revised if needed at that time.

Licensure Reference Number 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility failed to identify and implement measures to prevent a significant weight loss and notify the provider for 1 (Resident 29) of 3 residents sampled. The facility census was 33. Findings are: Review of the facility policy Nutrition Risk Committee- Food and Nutrition Services last revised 3/24/23 revealed the following: -the purpose was to provide a process for monitoring and evaluating resident who had impaired nutrition or were at risk for nutrition-related problems, -the nutrition risk committee used documentation of weights, food and fluid intakes, meal observation and other pertinent data to identify residents at risk, -the Director of Food and Nutrition (DFN), dietician or designee were to provide the list of residents to be discussed during the committee meeting, -the nutrition risk committee was to meet as often as necessary, but at least monthly, -the nutrition risk committee consisted of interdisciplinary team members: DFN, the dietician, nursing representative, and any other appropriate employee, -the nurse representative, dietician or designated staff were to contact the physician regarding any significant change in nutritional status and recommended interventions, -the care plan was to be updated as needed, -nutrition risk committee member was to document discussion and recommendations in the progress notes or where deemed appropriate, and -document interventions offered and refused by the resident and family. Review of Resident 29's MDS dated [DATE] revealed the following: -the resident was admitted [DATE], -diagnosis of pneumonitis due to inhalation of food and vomit, -was cognitively impaired, -required supervision with eating and oral hygiene, required partial assistance with personally hygiene, and required maximal assistance with toileting and upper/lower body dressing; and -weighed 133 pounds (lbs). Review of the resident's Care Plan last revised 11/10/23 revealed the following: -the resident had a nutritional problem related to aspiration of food. The resident had a texture modified diet- minced and moist and an order for a nutritional supplement, -the resident was to be weighed weekly, and -the resident required assistance with bed mobility, dressing, eating, oral care, personal hygiene, toilet use, and transfers. Review of the facility form titled Weights and Vitals Summary (a form used to measure the resident's temperature, pulse, respirations, blood pressure, body mass index, height, and weights) revealed the following weights for the resident: -1/10/24: 114 pounds (lbs), -12/20/23: 123 lbs, -10/25/23: 126 lbs, -10/19/23: 133 lbs, -9/13/23: 125 lbs, -9/1/23: 127 lbs, -8/23/23: 128.5 lbs, -8/17/23: 132 lbs, -8/9/23: 130.5, -8/2/23: 135 lbs, -7/26/23: 138 lbs, -7/19/23: 126.5 lbs, -7/14/23: 146.5 lbs -6/12/23: 146.5 lbs Review of the resident's Progress Notes revealed an entry on 10/26/23 at 11:26 AM by the Registered Dietician (RD) that noted the resident weighed 126 lbs which was a severe weight loss of 5.3% in 1 week and 8.7% in 90 days. The resident received a supplement of choice and consumed 10 out of 14 servings. Further review of the Progress Notes from 10/3/23-1/10/24 revealed no documentation that the physician or the resident's family were notified of the weight loss. Review of the facility form Mini-Nutritional Assessment for the resident dated 10/13/23 revealed the following: -had no decrease in food intake, -had weight loss between 2.2 and 6.6lbs, -had severe dementia or depression, -had a total score of 10 which indicated the resident was at risk of malnutrition. The following observations were made: -on 1/3/24 the resident was in bed with eyes closed at 8:20 AM (during the breakfast meal), -on 1/3/24 at 11:55 AM the resident was in bed with eyes closed (during the lunch meal), -on 1/3/24 at 12:30 PM the resident was in bed with eyes closed, -1/3/24 at 12:55 PM the resident was in bed with eye open, -1/4/24 at 6:40 AM the resident was in bed with eyes closed, -1/4/24 at 10:10 AM the resident was in bed with eyes closed, -1/4/24 at 11:25 AM the resident was up and dressed sitting in the wheelchair with family present, -1/10/24 at 9:15 AM the resident was in bed with eyes closed, -1/10/24 at 10:05 AM the resident was sitting on the side of the bed eating toast and drinking coffee. Review of the resident's Medication Administration record for January 2024 revealed the resident consumed 4 oz 12 out of 19 doses; less than 4 oz 3 times and refused 4 times. Review of the resident's meal intakes for 30 days, out of the meals charted (total number of 74 out of 90 meal opportunities) the resident refused 2 meals, consumed 0-25% of 42 meals, 26-50% of 6 meals, 51-75% of 2 meals, and 76-100% of 22 meals. Interview with the resident's POA on 1/4/24 at 11:40 AM revealed that they were not aware of any weight loss the resident had. Interview on 1/10/24 at 10:05 AM with Nursing Assistant (NA)-D revealed the resident does a natural awakening to help with behaviors. The resident will eat when they wake up and the resident takes supplements well and snacks in between meals. NA-D was unaware if the resident had any weight loss and was unsure how often the resident was weighed. Interview on 1/10/24 at 2:15 PM with the Certified Dietary Manager (CDM) revealed they were unaware if the resident had a significant weight change. Further interview confirmed the resident was not getting fortified meals. The CDM revealed that the CDM usually checks weights and will notify the RD and nursing, but nursing is to update the physician and the family. Interview on 1/10/24 at 2:20 PM with the Director of Nursing confirmed the resident had a significant weight change of 22.18%, weekly weights were not in the Medical Record, and that the physician and the resident's POA had not been informed of the significant weight change. Further interview confirmed the facility was not conducting a weight risk management meeting.

Licensure Reference Number 175 NAC ,d+[DATE].04C3a(6) Based on record review and interview; the facility failed to notify Resident 22's physician, Resident 29's responsible party and physician, and Resident 2's responsible party of a change in condition. The sample size was 3 residents. The facility census was 33. Findings are: A. Review of the facility policy Change in Condition Evaluation (CICE), last revised/reviewed [DATE] revealed the following: -the purpose of the CICE was to improve communication between nurses and a provider when nursing is monitoring a change in condition, enhance the nursing evaluation and documentation of a resident who had a change in condition, and provide a standard format to collect pertinent clinical data prior to contacting the provider, -nursing judgement was to be used when determining the urgency of contacting the provider, -nursing staff checked with other staff members who had regular contact with the resident to obtain an accurate picture of the change in condition, -nursing staff completed a Change in Condition Evaluation Assessment, -nursing judgement determined at what point to call the provider, and -a change in condition alert was be created to communicate or remind nurses to keep a closer eye on a resident when something seemed different. B. Review of Resident 22's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated [DATE] revealed the resident had the following: -diagnoses of: Cancer, Hypertension, Alzheimer's Disease, Seizures or Epilepsy; and Depression, -was cognitively intact, -was independent with eating and personal hygiene -received substantial/maximal assistance with toileting and upper and lower body dressing, and -the resident was frequently incontinent of urine, and always continent of bowels. Review of Resident 22's Progress Notes revealed on [DATE] at 11:15 AM the resident's Power of Attorney (POA) was in the facility to see the resident and asked how the resident was doing. Registered Nurse (RN)-H explained Resident 22 had declined since the previous week and RN-H was concerned with a gurgle and a cough that was heard but was not there the previous day. RN-H informed the POA the provider was going to be at the facility at 2:45 PM and would assess the resident. RN-H discussed the code status with the POA and the POA stated they needed to have a discussion with the family, and the POA wanted to talk to the provider when they came to assess the resident. Review of Resident 22's Progress Notes revealed an entry dated [DATE] at 1:04 PM that stated the resident was resting well and the resident did not swallow their medications with the morning medication pass. Review of Resident 22's Progress Notes documented by RN-H dated [DATE] at 5:32 PM revealed the following: -at 6:45 AM the resident was sleeping comfortably, -at 7:37 AM the resident was awake and comfortable, -the resident was assisted with breakfast and consumed 50%, -at 10:21 AM RN-H went back into the resident room to administer medications, the resident opened their mouth, took medications and a drink of water and started coughing and RN-H could hear a gurgle in the resident's throat, -Physical Therapy (PT) was entering the resident room as RN-H was exiting and stated they heard the gurgle when they were in the resident room prior and they discussed the resident needing a swallow evaluation. RN-H told PT that the provider was coming at 2:45 (almost 4 and a half hours later) and RN-H would discuss the findings with the provider when they arrived, -at 10:45 RN-H noted the resident's lungs were diminished. The resident's Blood Pressure was ,d+[DATE] and the pulse was 119, -RN-H discussed the resident's vital signs and the gurgle with another nurse and they concluded they would discuss these findings with the provider when they arrived later that afternoon (in 4 hours from this time), -The resident's POA arrived and was updated on the resident's condition and discussed the resident's code status, -The resident was asleep when lunch meal room trays were passed and the resident did not eat, -at 1:00 PM the resident was still asleep for the afternoon medication pass. RN-H did not want to wake the resident and did not feel it was safe to administer the afternoon medications since the resident had a gurgle and had a cough with the morning medication pass, -at 1:25 PM PT entered the resident room and reported to RN-H that the resident did not look good and that PT heard a gurgle too. RN-H did not go into the resident's room at 1:25 PM because after what PT reported, the resident was unchanged, -at 1:30 PM another nurse and 2 nursing assistants went into the resident room and the resident was not breathing. Cardiopulmonary Resuscitation (CPR) was not performed due to the resident had obvious signs of death with blue toned skin, dependent lividity (a discoloration of the skin resulting from the pooling of blood after death has occurred) and was without a pulse and wasn't breathing. There were no signs of life at 1:30 PM, and -at 1:48 PM the POA was notified, at 1:50 PM the provider was notified, and at 1:56 PM the County Attorney was notified of the death. Review of the Resident 22's Care Plan last revised [DATE] revealed the following: -The resident had an altered cardiovascular status due to diagnosis of hypertension. Staff were to monitor/document/report to the health care provider as needed any signs/symptoms and obtain blood pressure and pulse on the 7th of every month, -the resident was independent to limited assist with bed mobility, the resident was independent with dressing and toilet use, and was independent to extensive assist with personal hygiene, and the resident was able to transfer independently to a limited assist. Interview with the Director of Nursing (DON) on [DATE] at 9:15 AM revealed the provider was notified of the resident's increased blood pressure on [DATE], the provider was to see the resident on [DATE] but was not able to due to a snowstorm, so the provider was to see the resident on rounds on [DATE]. Further interview confirmed the provider was not notified of the increased blood pressure on [DATE]. Interview on [DATE] at 11:35 AM with RN-H confirmed they would normally do a change in condition assessment but since the physician was coming to the facility that afternoon, they did not do one. RN-H confirmed the physician was not notified of the change in condition because the provider was to be coming to the facility at 2:45 PM (4 hours after the change in condition). Further interview confirmed the resident's gurgle was new and that they did not do a change in condition assessment. Interview on [DATE] at 12:07 PM with the DON confirmed the physician was not notified of the resident's change in condition on [DATE]. Further interview confirmed they were waiting for the physician to come to the building to do rounds at 2:45 PM 4 hours after the change in condition was identified. C. Review of Resident 29's MDS dated [DATE] revealed the following: -the resident was admitted [DATE], -diagnosis of pneumonitis due to inhalation of food and vomit, -was cognitively impaired, -required supervision with eating and oral hygiene, required partial assistance with personally hygiene, and required maximal assistance with toileting and upper/lower body dressing; and -weighed 133 pounds (lbs). Review of Resident 29's Care Plan last revised [DATE] revealed the following: -the resident had a nutritional problem related to aspiration of food. The resident had a texture modified diet- minced and moist and an order for a nutritional supplement, -the resident was to be weighed weekly, and -the resident required assistance with bed mobility, dressing, eating, oral care, personal hygiene, toilet use, and transfers. Review of the facility form titled Weights and Vitals Summary for Resident 29 revealed the following weights: -[DATE]: 114 pounds (lbs), -[DATE]: 123 lbs, -[DATE]: 126 lbs, -[DATE]: 133 lbs, -[DATE]: 125 lbs, -[DATE]: 127 lbs, -[DATE]: 128.5 lbs, -[DATE]: 132 lbs, -[DATE]: 130.5, -[DATE]: 135 lbs, -[DATE]: 138 lbs, -[DATE]: 126.5 lbs, -[DATE]: 146.5 lbs -[DATE]: 146.5 lbs Review of Resident 29's Progress Notes revealed an entry on [DATE] at 11:26 AM by the Registered Dietician (RD) that noted the resident weighed 126 lbs which was a severe weight loss of 5.3% in 1 week and 8.7% in 90 days. The resident received a supplement of choice and consumed 10 out of 14 servings. Further review of Resident 29's Progress Notes from [DATE]-[DATE] revealed no documentation that the physician or the resident's family were notified of the weight loss. The following observations were made: -on [DATE] the resident was in bed with eyes closed at 8:20 AM (during the breakfast meal), -on [DATE] at 11:55 AM the resident was in bed with eyes closed (during the lunch meal), -on [DATE] at 12:30 PM the resident was in bed with eyes closed, -[DATE] at 12:55 PM the resident was in bed with eye open, -[DATE] at 6:40 AM the resident was in bed with eyes closed, -[DATE] at 10:10 AM the resident was in bed with eyes closed, -[DATE] at 11:25 AM the resident was up and dressed sitting in the wheelchair with family present, -[DATE] at 9:15 AM the resident was in bed with eyes closed, -[DATE] at 10:05 AM the resident was sitting on the side of the bed eating toast and drinking coffee. Interview with Resident 29's POA on [DATE] at 11:40 AM revealed that they were not aware of any weight loss the resident had. Interview on [DATE] at 10:05 AM with NA-D revealed the resident does a natural awakening to help with behaviors. The resident will eat when they wake up and the resident takes supplements well and snacks in between meals. NA-D was unaware if the resident had any weight loss and was unsure how often the resident was weighed. Interview on [DATE] at 2:15 PM with the Certified Dietary Manager (CDM) revealed they were unaware if the resident had a significant weight change. Further interview confirmed the resident was not getting fortified meals. The CDM revealed that the CDM usually checks weights and will notify the RD and nursing, but nursing is to update the physician and the family. Interview on [DATE] at 2:20 PM with the DON confirmed the resident had a significant weight change, weekly weights were not in the Medical Record, and that the physician and the resident's POA had not been informed of the significant weight change. 29638 D. Review of the facility policy Notification of Change with a revision date of [DATE] revealed the purpose of the policy was to identify when regulations required notifications to occur. The policy indicated the facility must immediately inform the resident's physician and the resident's representative when there was: -an accident involving the resident which resulted in an injury and had the potential for physician intervention. -a significant change in the resident's physical, mental, or psychosocial status. -a need to alter treatment significantly, a need to discontinue or change an existing form of treatment or to commence a new form of treatment. E. Review of Resident 2's MDS dated [DATE] revealed diagnoses of: non-traumatic brain dysfunction, schizoaffective disorder, atrial fibrillation, osteoporosis, anxiety, depression insomnia and hallucinations. Review of Resident 2's Nursing Progress Notes revealed the following: -[DATE] at 4:08 PM the resident's physician ordered a urinalysis and an abdominal x-ray due to the resident's complaint of back pain. -[DATE] at 12:09 PM the resident's physician confirmed negative results for x-ray and the urinalysis. -[DATE] at 11:40 AM the resident had expiratory wheezes with complaints of feeling worn out. -[DATE] at 2:08 PM the resident received a new order for DuoNeb's (combination of medications provided by inhalation and used to treat wheezing and shortness of breath) to be administered twice a day for 7 days. During an interview on [DATE] at 2:32 PM, Resident 2's family member indicated the facility had not been notifying the family of changes. The family had received a bill for urinalysis testing, x-rays, and new medications, but family had not been notified of these changes. During an interview on [DATE] at 12:00 PM, the DON confirmed family members are to be notified within 24 hours of new orders or any changes in the resident's condition. The DON verified there was no evidence Resident 2's family had been notified of new orders for urinalysis and x-rays related to complaints of back pain, the results of the testing and new orders to treat wheezing and increased shortness of breath.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and staff interviews; the facility failed to revise and implement nutritional interventions to address weight loss and poor appetite for Resident 50. Facility census was 45. Findings are: Review of Resident 50's MDS dated [DATE] indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 50 had an unstageable pressure ulcer (The staging system is a method of summarizing certain characteristics of pressure sores, including the extent of tissue damage. Unstageable refers to a full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough eschar or slough is removed to expose the base of the wound, the true depth, and therefore the stage cannot be determined) and identified use of nutritional and hydration interventions for pressure ulcer care. The MDS identified a weight of 104 lbs. (pounds) and use of a therapeutic diet. Review of Resident 50's Progress Notes revealed the following: -10/7/13 at 4:00 PM, The resident was readmitted from the hospital following a fall with subsequent left [MEDICAL CONDITION]. The resident's readmission orders [REDACTED]. -10/8/14 at 4:07 PM, Resident's weight identified as 124 lbs (pounds). Food and fluid intakes are poor and resident does not accept assist from staff with eating. -10/8/13 at 4:46 PM, "Resident noted to have pressure ulcers to left and right buttocks. Protective dressing applied and physician notified." -10/9/13 at 9:55 AM, Resident took 25% of breakfast meal. -10/11/13 at 4:57 PM, Resident refused nutritional supplement drink. -10/20/13 at 7:07 PM, Resident refused nutritional supplement drink. -10/22/13 at 9:27 AM, "Resident noted to have increase size with open area to buttock. Area to buttocks noted to be fairly superficial and clean and area covered to protect." -10/28/13 at 9:28 AM, "Resident reported to have incontinent BM (bowel movement) over weekend with enlargement to area on buttocks as well as a blister to left buttock. Area noted to have increased depth as well." Progress Note indicated the resident's physician was notified. -10/28/13 at 4:00 PM, Nutritional supplement drink held as resident not awake enough to drink. -10/31/13 at 7:54 AM, "...resident takes AM meal the best and has been refusing noon and evening meals with only bites taken ..." -11/4/13 at 1:48 PM, "Left buttock stage 2 pressure ulcer 1 x .6 cm, red area to buttock with .4 cm open area and right buttock with suspected deep tissue wound (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) dark discoloration of buttock measures 1.3 x 3 cm..." -11/10/13 at 2:30 PM ... "Resident ate AM meal well and drank 580 cc liquids but at noon does not eat or drink much. " -11/11/13 at 5:00 PM, Resident would not open mouth to drink nutritional supplement drink. -11/11/13 at 5:41 PM, Wound Specialist assessed resident's coccyx and initiated a new treatment of [REDACTED]. (Wound Specialist did not evaluate Resident until 31 days after the pressure ulcer was identified.) -11/12/13 at 11:10 AM, "...spoke with physician regarding the resident's intakes. Resident is assisted with meals but very difficult to get resident to drink ..." -11/12/13 at 4:02 PM, "For the week ending 11/4/13 the resident's weekly average meal intake was 36%. Resident often refuses to eat or drink. Resident offered 4 ounces of house supplement TID (three times a day) but often takes only 60-90 cc (cubic centimeters). " -11/18/13 at 3:23 PM, Resident is reviewed by the RD (41 days after the identification of pressure ulcer and continued poor intakes and weight loss) and recommendation received for Juven (nutritional supplement with additional protein for wound healing) 8 oz BID (twice a day) and for [MEDICATION NAME] (medication used to stimulate appetite) to help increase appetite. "...significant weight loss noted over 30 and 180 days. Current weight 105 lbs (pounds) weight is down 12.1% (percent) in 30 days, 6.2 % in 90 days and 16% in 180 days. Resident has a stage 3 sacrum wound noted ..." -11/19/13 at 2:53 PM ... "Resident's weight on 11/19/13 was 105 lbs. and is showing a 9.9% weight loss in the last 30 days. Resident is seated at an assisted table and receives set-up assist and cueing. Resident often is difficulty to encourage." -Review of Progress Notes from 11/22/13 to 12/17/14 revealed Resident 50 refused nutritional supplement drink and/or Juven drink 20 out of 25 days. -12/17/13 at 4:24 PM ...call received from clinic and [MEDICATION NAME] (29 days after recommended by RD) has been approved for 1 year ..." -12/18/13 at 2:24 PM, Resident evaluated by RD with meal intakes reviewed, intakes 25-75%. RD also noted resident had an order for [REDACTED]. No new interventions were recommended. -12/22/13 at 11:09 AM ... "incontinent of BM and irritation to coccyx wound increased since yesterday..." -12/22/13 at 7:05 PM, Nutritional supplement drink held due to resident ' s condition. -12/23/13 at 10:32 AM, Resident refused to drink nutritional supplement drink. -12/24/13 at 10:37 AM, Resident received the first dose of [MEDICATION NAME] which had been recommended by RD 36 days ago. -12/24/13 at 10:42 AM, Physician notified of increased tunneling to the resident's coccyx wound. Wound measured 1.2 cm x .4 cm with depth of 3.2 cm. -12/28/13 at 7:53 PM, Resident refused to drink nutritional supplement drink. -12/29/13 at 6:30PM ... "resident is lethargic and has been refusing to eat much for the last few days..." -12/29/13 at 10:49 PM, Resident was admitted to the hospital for evaluation of septic shock. -1/3/14 at 1:23 PM, Resident was readmitted to facility on Hospice services. -1/4/14 at 10:30 AM, Hospice brought an air mattress for the resident's bed and a new wheelchair with pressure reduction cushion to seat. -1/13/14 at 4:51 PM, coccyx wound noted to have yellow/green drainage and foul odor. -1/3/14 at 11:30PM ... "resident consumed 10-25% of food offering..." -1/4/14 at 10:35 PM ... "resident out for supper and ate 25%..." -1/6/14 at 1:03 PM, Resident refused nutritional supplement drink. -1/9/14 at 11:08 AM, Resident refused nutritional supplement drink. -1/9/14 at 4:08 PM, Resident's weight down from 107.5 lbs on 12/22/13 to 104.5 Lbs on 1/9/14. Notes indicate the resident's physician was notified of weight loss but not the RD. -1/12/14 at 12:05 PM, Resident refused nutritional supplement drink. -1/14/14 at 12:53 PM, Resident refused nutritional supplement drink. -1/16/14 at 9:34 AM, Resident refused Juven drink. -1/20/14 at 1:29 PM, Evaluated by RD and identified continued significant weight loss. Resident had 6.6% weight loss at 30 days and 8.6% weight loss in 180 days. RD noted intake had decreased to 0-50%. RD recommended multivitamin with minerals for wound healing but made no further recommendation to address the resident's continued weight loss and poor intake of meals and supplements. -1/31/14 at 7:20 PM, Resident refused to drink nutritional supplement drink. -2/3/14 at 1:15 PM, Wound Specialist evaluated wound to coccyx and packed the wound with normal saline and gauze. Recommendation made for staff to continue to treat wound this way as..."if wound is not packed this way, wound will become infected from the drainage." -2/6/14 at 11:15 AM, RD evaluated and identified continued slow weight loss despite nutritional interventions. No new recommendations were made. Review of Resident 50's Care Plan with revision date of 1/29/14 revealed the resident nutritional problem related to loss of weight, Alzheimer ' s disease, coccyx ulcer and poor meal intake. Interventions for weight loss included the following: -Monitor and record intake at each meal. -Seat resident at an assisted table and provide with cueing and assist as needed. -Resident to have drinks served in blue handles cups and to wear a clothing protector. -Weigh with weekly bath. -Offer snack daily at 3 PM, 4 ounces of nutritional drink (house supplement) TID and offer Juven package BID for skin healing. During an interview on 2/26/14 from 4:30 PM to 5:00 PM, the Dietary Manager (DM) confirmed the RD did not evaluate the nutritional status of Resident 50 until 11/18/13 (41 days after the pressure ulcer to Resident 50's coccyx was identified). DM indicated the dietary department was unaware of Resident 50's pressure ulcer until 11/18/13 so interventions were not initiated in a timely manner. In addition, DM confirmed the RD failed to assess and initiate new interventions as needed for Resident 50 despite continued weight loss, poor intakes of food, fluids and nutritional supplements and continued worsening of the resident's pressure ulcer.

Licensure Reference Numbers: 175 NAC 12-006.09D2b Based on observations, record review and staff interviews; the facility failed to implement interventions and to revise interventions as needed to promote healing of pressure ulcers for 2 residents (Residents 6 and 50). Facility census was 45. Findings are: A. Review of facility policy titled "Skin Assessment and Pressure Ulcer Prevention" (revised 1/14) revealed the following procedures: -Residents who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is recommended based on observation of the resident's skin over a period of time. -A systematic skin inspection will be made daily by the Nursing Assistant assigned to those residents at risk for skin breakdown. The Nursing Assistant responsible for this will report any abnormal findings or signs of skin impairment to the Licensed Nurse. -Dietary will automatically be notified when the Wound Data Collection is signed and locked in the computer. B. Review of Resident 6's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/13/14 indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 6 had an unstageable pressure ulcer (The staging system is a method of summarizing certain characteristics of pressure sores, including the extent of tissue damage. Unstageable refers to a full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough eschar or slough is removed to expose the base of the wound, the true depth, and therefore the stage cannot be determined). The MDS identified use of pressure reducing devices to chair and bed, a turning and repositioning program, nutritional and hydration interventions and pressure ulcer care. Review of Resident 6's Braden Scale completed 10/9/13 indicated the resident was at risk for pressure ulcer development. Review of Resident 6's Progress Notes revealed the following: -10/22/13 at 10:52 AM ... "Right sock was taken off and skin from right heel removed with sock and began to have red drainage from the heel. Resident noted to have discoloration to right heel as well. Area is purple in color with some fluid noted under with touch. Area at center of heel is noted to be normal skin color. Resident was noted after AM meal while in wheelchair to have R (right) foot resting in front pedal with pressure of pedal to back of heel. " Progress notes indicated the physician was notified of the pressure ulcer and new order for Vaseline gauze to heel with a foam pad dressing was received. Notes also indicated facility staff was to "place a pad to keep heels off bed and wheelchair pedals". -11/10/13 at 1:36 PM, "Resident has dry necrotic (dead tissue due to disease, injury or lack of blood supply) area to right heel with slight odor noted. Area dry for the most part and no spongy areas noted to heel." -11/15/13 at 2:44 PM, "Continues to have pressure ulcer to (R) heel and remains necrotic/firm and painful for resident with cleansing and dressing changes" -11/18/13 at 3:01 PM, reviewed by Registered Dietician (RD) ... "Right heel pressure ulcer with necrotic tissue noted. Recommend 8 oz (ounces) of Juven (high protein nutritional supplement) BID (twice a day) to help with wound healing." (RD did not evaluate the resident until 27 days after pressure ulcer to right heel was identified). -11/19/13 at 3:04 PM, "Resident has unstagable pressure ulcer to right heel. Dietician reviewed on 11/18/13. Tried heel protectors when in the wheelchair and in bed but due to safety concerns it was determined they are not appropriate. Heel riser in place at foot of bed is ordered." -11/22/13 at 8:13 PM, Resident received first dose of Juven supplement which had been recommended by RD for wound healing (4 days after RD made recommendation). -12/30/13 at 10:31 AM, "Resident received initial dose of antibiotic of Bactrim DS for redness and warmth to right foot." -2/3/14 at 5:24 PM, Wound Specialist in facility, evaluated pressure ulcer to right heel and made recommendation for Vaseline Gauze with foam padding for dressing. (Wound Specialist did not evaluate the resident's unstagable pressure ulcer until 104 days after pressure ulcer to right heel was first identified) -2/4/14 at 3:09 PM, Care Plan intervention initiated to transfer the resident to bed after all meals. The resident was to be the last one up in the morning and the first one down after meals and to be positioned from side to side. Review of Resident 6's Care Plan with revision date of 2/16/14 revealed the resident had the potential for skin issues and pressure ulcers with pressure ulcer development to right heel on 10/22/13 and identified the following interventions: -Transfer the resident to bed after meals, resident to be one of the last up before meals and one of the first down after meals. -Position the resident from side to side and assist to reposition frequently. -Notify charge nurse immediately of any new areas of skin breakdown, redness, blisters, bruises or discoloration noted with bath and with daily cares. -Heels to be kept off bed and wheelchair pedals at all times. During observations, Resident 6 was observed seated in a wheelchair with no pressure relieving device to heels and right heel resting directly on the surface of an unpadded foot pedal at the following times: -On 2/25/14 from 11:45 AM to 1:54 PM. -On 2/26/14 from 7:35 AM to 9:15 AM and from 11:30 AM to 2:15 PM. -On 2/27/14 from 8:00 AM to 1:30 PM. During an interview on 2/27/14 from 10:30 AM to 10:50 AM, the Director of Nursing (DON) confirmed a pressure relieving device should have been used when the resident was in the wheelchair to keep pressure off of right heel. DON indicated heel protectors had been tried and increased the resident's risk for injury due to attempts to self-transfer. DON confirmed resident no longer attempted to self- transfer out of wheelchair and the facility had failed to reassess the resident for alternate pressure relieving devices to keep pressure off the resident's heels. In addition, the DON confirmed Resident 6 should have been transferred to bed as soon as the resident had completed meals and resident was not transferred to bed after breakfast meal on 2/27/14 as the resident's bed was not made until after 11:00 AM. C. Review of Resident 50's MDS dated [DATE] indicated [DIAGNOSES REDACTED]. The MDS further indicated Resident 50 had an unstageable pressure ulcer and identified use of pressure reducing devices to chair and bed, a turning and repositioning program, nutritional and hydration interventions and pressure ulcer care. Review of Resident 50's Braden Scale completed 8/20/13 indicated the resident was at risk for pressure ulcer development. Review of Resident 50's Progress Notes revealed the following: -10/7/13 at 4:00 PM, The resident was readmitted from the hospital following a fall with subsequent left [MEDICAL CONDITION]. The resident's readmission orders [REDACTED]. -10/8/13 at 4:46 PM, "Resident noted to have pressure ulcers to left and right buttocks. Protective dressing applied and physician notified." --10/22/13 at 9:27 AM, "Resident noted to have increase size with open area to buttock. Area to buttocks noted to be fairly superficial and clean and area covered to protect." -10/27/13 at 10:00 AM, "... open area to coccyx measures 1.5 x 1 cm (centimeter)..." -10/28/13 at 9:28 AM, "Resident reported to have incontinent BM (bowel movement) over weekend with enlargement to area on buttocks as well as a blister to left buttock. Area noted to have increased depth as well." Progress Note indicated the resident's physician was notified. -10/31/13 at 7:54 AM, "...resident takes AM meal the best and has been refusing noon and evening meals with only bites taken ..." -11/4/13 at 1:48 PM, "Left buttock stage 2 pressure ulcer 1 x .6 cm, red area to buttock with .4 cm open area and right buttock with suspected deep tissue wound (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) dark discoloration of buttock measures 1.3 x3 cm..." -11/11/13 at 5:41 PM, Wound Specialist assessed resident's coccyx and initiated a new treatment of [REDACTED]. (Wound Specialist did not evaluate Resident until 31 days after the pressure ulcer was identified.) -11/12/13 at 11:10 AM, "...spoke with physician regarding the resident's intakes. Resident is assisted with meals but very difficult to get resident to drink ..." -11/12/13 at 4:02 PM, "For the week ending 11/4/13 the resident's weekly average meal intake was 36%. Resident often refuses to eat or drink. Resident offered 4 ounces of house supplement TID (three times a day) but often takes only 60-90cc (cubic centimeters). " -11/18/13 at 3:23 PM, Resident is reviewed by the RD (41 days after the identification of pressure ulcer) and recommendation received for Juven 8 oz BID (twice a day) and for [MEDICATION NAME] (medication used to stimulate appetite) to help increase appetite. "...significant weight loss noted over 30 and 180 days. Current weight 105 lbs (pounds) weight is down 12.1% (percent) in 30 days, 6.2 % in 90 days and 16% in 180 days. Resident has a stage 3 sacrum wound noted ..." -12/16/13 at 9:02 AM, ... "pressure ulcer measures 1.2 cm x .5 cm and now depth noted to be 2.8 cm with tunneling. Resident with tenderness present especially with cleansing and measuring depth ..." -12/17/13 at 4:24 PM ...call received from clinic and [MEDICATION NAME] (29 days after recommended by RD) has been approved for 1 year ..." -12/18/13 at 2:24 PM, Resident evaluated by RD with meal intakes reviewed, intakes 25-75%. RD also noted resident had an order for [REDACTED]. No new interventions were recommended. -12/22/13 at 11:09 AM ... "incontinent of BM and irritation to coccyx wound increased since yesterday..." -12/24/13 at 10:37 AM, Resident received the first dose of [MEDICATION NAME] which had been recommended by RD 36 days ago. -12/24/13 at 10:42 AM, Physician notified of increased tunneling to the resident's coccyx wound. Wound measured 1.2 cm x .4 cm with depth of 3.2 cm. -12/29/13 at 6:30PM ... "resident is lethargic and has been refusing to eat much for the last few days..." -12/29/13 at 10:49 PM, Resident was admitted to the hospital for evaluation of septic shock. -1/3/14 at 1:23 PM, Resident was readmitted to facility on Hospice services. -1/4/14 at 10:30 AM, Hospice brought an air mattress for the resident's bed and a new wheelchair with pressure reduction cushion to seat. -1/13/14 at 4:51 PM, coccyx wound noted to have yellow/green drainage and foul odor. -1/20/14 at 1:29 PM, Evaluated by RD and identified continued significant weight loss. Resident had 6.6% weight loss at 30 days and 8.6% weight loss in 180 days. RD noted intake had decreased to 0-50%. RD recommended multivitamin with minerals for wound healing but made no further recommendation to address the resident's continued weight loss and poor intake of meals and supplements. -2/3/14 at 1:15 PM, Wound Specialist evaluated wound to coccyx and packed the wound with normal saline and gauze. Recommendation made for staff to continue to treat wound this way as..."if wound is not packed this way, wound will become infected from the drainage." -2/6/14 at 11:15 AM, RD evaluated and identified continued slow weight loss despite nutritional interventions. No new recommendations were made. Review of Resident 50's Care Plan with revision date of 1/29/14 revealed the resident had the potential for skin issues and pressure ulcers with pressure ulcer development to buttocks on 10/7/13 and identified the following interventions: -Transfer the resident to bed to rest after meals, resident to be the last up and the first down. -Position the resident from side to side in bed and assist to reposition at least every 2 hours and as needed. -Notify charge nurse immediately of any new areas of skin breakdown, redness, blisters, bruises or discoloration noted with bath and with daily cares. - Provide pressure relieving device to bed and wheelchair. Keep resident off back with direct pressure to buttocks. During observations, Resident 50 was observed seated in a wheelchair at the following times: -On 2/25/14 from 7:30 AM to 10:30 AM and from 11:45 AM to 3:00 PM -On 2/26/14 from 7:30 AM to 9:30 AM and from 11:30 AM to 2:10 PM -On 2/27/14 from 7:25 AM to 10:05 AM and From 11:45AM to 1:30 PM D. During an interview on 2/26/14 from 4:30 PM to 5:00 PM, the Dietary Manager (DM) confirmed the RD did not evaluate the nutritional status of Resident 6 (27 days after pressure ulcer to right heel identified) and Resident 50 (41 days after the pressure ulcer to Resident 50's coccyx was identified) until 11/18/13. DM indicated the dietary department was unaware of Resident 6's and Resident 50's pressure ulcers until 11/18/13 so interventions were not initiated in a timely manner. In addition, the RD failed to assess and initiate new interventions as needed for Resident 50 despite continued weight loss, poor intakes and continued worsening of the resident's pressure ulcer. E. During an interview on 2/27/14 from 9:30 AM to 9:50 AM, the DON confirmed the facility failed to initiate new interventions as needed for Resident 50 to prevent continued worsening of pressure ulcer to the resident's coccyx. In addition, staff should have transferred the resident into bed as soon as the resident completed meals in accordance with the resident's Care Plan to relieve pressure to the resident's coccyx.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2 Based on observations, record review, review of policies and procedures, family and staff interviews; the facility failed to provide treatment and services to prevent development of pressure ulcers and promote healing of existing ulcers for 2 of 12 sampled residents (Residents 14 and 28). Sample size was 12. Facility census was 47. Findings are: A. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Minimum Data Set (MDS - a federally mandated comprehensive assessment tool used for care planning) dated 3/17/10 revealed [DIAGNOSES REDACTED]. The same MDS further identified the resident had fallen and had a fracture. The Resident Assessment Protocol dated 3/11/10 identified Resident 14 was admitted with a splint on the fractured right ulna. Review of the Comprehensive Care Plan dated 3/17/10 revealed no documentation that the fractured ulna was in a splint and no interventions for care of the splint were identified. Review of the Braden scale (a measurement that identifies risk of skin breakdown) dated 3/19/10 revealed the resident was at risk to develop pressure ulcers. Review of the 2/10 and 3/10 Treatment Records revealed no orders/instructions for nursing staff to check Resident 14's splint to the fractured ulna. Review of the Clinic Referral form dated 4/16/10 (48 days after admission to the facility) revealed the physician documented, "Fractured R (right) elbow. Open sore to R elbow when splint removed. Foul odor noted". At this visit the physician ordered the splint to be removed every other day, change dressing to right elbow and to wash and moisturize the skin. Review of the Interdisciplinary Progress Notes (IPN) dated 4/16/10 at 3:00 PM revealed the following documentation after the facility received a phone call from the Physician's Assistant (PA) at the Doctor's office: The PA asked, "If the facility staff had been removing the splint et (and) this writer stated we hadn't had orders to remove the splint at all. PA informed this writer that this type of splint was made to be removed et (and) skin checked. This writer again stated we had no specific instructions to remove this splint". The IPN further documented that no open area was found by the facility and that the area would be re-assessed on 4/18/10. Review of IPN dated 4/18/10 at 9:00 AM revealed the resident had a 1.5 cm (centimeter) reddened area with approx. (approximately) 1 cm abrased-like area to center at point of elbow". There was no further documentation of the stage (The staging system is a method of characterizing pressure ulcers, including the extent of tissue damage.) or size of the wound until 5/2/10 (14 days later). On 5/2/10 at 11:30 AM the IPN documented, "Resident has open area on Rt (right) elbow measure 1.5 cm diameter". The PA was notified and the treatment changed. Review of the Wound Flow Sheet revealed no documentation of the pressure ulcer until 5/2/10. At that time the ulcer measured 1.5 cm by .2cm. On 5/27/10 this same sheet documented the pressure ulcer was healed. Interview with the Director of Nurses (DON) on 7/20/10 from 11:40 until 11:45 AM verified the splint to the elbow should have been removed with an assessment of the skin daily; and the physician should have been contacted on admission for splint care orders. B. Review of the Pressure Ulcer Practice Guidelines revised 3/08 indicated the following: - "The RN (Registered Nurse) should assess and evaluate the wound status at least weekly for progress towards healing. If progress is not noted in a two week time frame, there may be a need to change interventions that modify/eliminate the risk factors or a change to the treatment. At a minimum documenting the evaluation of the healing process and lack of progress should be documented along with the decisions made to continue or change the interventions." C. Review of Resident 28's MDS dated [DATE] indicated [DIAGNOSES REDACTED]. Review of the Braden Scale for Predicting Pressure Sore Risk dated 4/9/10 indicated Resident 28 was at high risk for the development of pressure ulcers. Review of the Comprehensive Care Plan dated 4/20/10 indicated Resident 28 had problems with pressure ulcers and nursing interventions included notification of the physician as needed, repositioning every 1 to 2 hours while in bed, and weekly monitoring and documentation on the "skin flow sheet" . Review of the Wound Flow Sheet dated 5/28/10 revealed Resident 28 developed a Stage 2 (A Stage 2 pressure ulcer involves partial thickness skin loss and presents clinically as an abrasion, blister, or shallow crater.) pressure ulcer on the "left center coccyx" (tailbone) measuring 0.4 cm in diameter. Review of the Treatment Administration Record dated 6/10 revealed the pressure ulcer on Resident 28's coccyx was treated with an Alginate [MEDICATION NAME] dressing (a gel-like adhesive dressing used to treat pressure ulcers) changed every 3 days and as needed from 6/15/10 to 6/30/10. Review of the Wound Flow Sheet dated 6/30/10 indicated the pressure ulcer measured 0.2 cm by 0.3 cm. Review of the Treatment Administration Record dated 7/10 revealed the pressure ulcer on Resident 28's coccyx continued to be treated with an Alginate [MEDICATION NAME] dressing changed every 3 days and as needed from 7/1/10 to 7/8/10. Review of the Wound Flow Sheet dated 7/8/10 indicated the pressure ulcer measured 1 cm. This indicated an increase in the size of the pressure sore. Review of the Treatment Administration Record dated 7/10 revealed the pressure ulcer on Resident 28's coccyx continued to be treated with an Alginate [MEDICATION NAME] dressing changed every 3 days and as needed from 7/9/10 to 7/16/10. Review of the Wound Flow Sheet dated 7/15/10 indicated the pressure ulcer continued to measure 1 cm. This indicated the resident's pressure ulcer showed a lack of progress toward healing since 6/30/10 (2 weeks and 1 day prior). There was no documentation in the resident's medical record to indicate the lack of progress in wound healing had been assessed by the RN (Registered Nurse), or that interventions and/or treatment had been modified in an attempt to promote healing. During observation on 7/19/10 Resident 28 was seated in wheelchair in room at 8:45 AM, 9:50 AM, 10:30 AM, 11:20 AM and 11:45 AM. On the same day, Resident 28 was observed seated in a wheelchair in dining room for noon meal from 12:20 PM to 12:30 PM. During observation of nursing care on 7/19/10 from 1:50 PM to 2:10 PM, Nursing Assistant (NA)-D and NA-H pivot transferred Resident 28 from the wheelchair to the bed and provided incontinent care. A Jay cushion (a cushion used to reduce pressure for residents at risk for the development of pressure ulcers) was observed in the seat of the resident's wheelchair. Resident 28's incontinent brief was wet and the resident's rectal and buttock areas were heavily smeared with feces. The resident's coccyx and buttocks were red. Resident 28 was observed to have a pressure ulcer directly on the coccyx and a second pressure ulcer directly above the rectum. RN-M verified Resident 28 had 2 pressure ulcers and placed an Alginate [MEDICATION NAME] dressing over the entire area, covering both pressure ulcers. Review of the resident's medical record indicated there was no documentation to indicate the presence of a second pressure ulcer located directly above the rectum. During interview on 7/20/10 from 7:30 AM to 7:40 AM, the DON verified there was no documentation related to the pressure ulcer observed directly above the resident's rectum. The DON verified documentation of the pressure ulcer should have been initiated at the time it was first observed. Review of a Resident/Visitor Incident Report dated 7/20/10 at 9:30 AM (1 day after first observed) and completed by RN-M revealed a pressure ulcer measuring 0.4 cm by 0.1 cm was observed "above (Resident 28's) rectal area" during perineal hygiene on 7/19/10 at 2:00 PM. Review of a Wound Flow Sheet completed on 7/20/10 described the pressure ulcer as Stage 2. The same form indicated the wound treatment was changed from "[MEDICATION NAME]" (a type of [MEDICATION NAME] dressing) to an Opsite dressing (a transparent adhesive dressing used to treat pressure ulcers) to be changed weekly and as needed. During interview on 7/21/10 from 10:00 AM to 10:15 AM, the resident's family member verified Resident 28 was supposed to be out of the wheelchair as much as possible due to the presence of a pressure sore. However, the family member verified Resident 28 sometimes "sits longer than should" .