Every finding on record at Good Samaritan Society - Bloomfield

Licensure Reference Number 175 NAC 12-006.18(B)&(C) Based on observations, record review, and interview; the facility failed to complete hand hygiene at appropriate intervals during the provision of cares and to provide care and management of Resident 1's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) to prevent the potential for cross contamination and urinary tract infections. The sample size was 3. In addition, the facility failed to prevent the potential spread of COVID-19 related to failure to test staff who displayed signs and symptoms of COVID-19, this had the potential to affect all residents. The facility census was 30. Findings are: A. Review of the facility policy titled Handwashing/hand hygiene revised on 1/30/25 revealed the facility considered hand hygiene the primary means to prevent the spread of infection. The policy indicated staff were to wash hands with an antimicrobial or a non-antimicrobial soap and water when hands were visibly soiled and after contact with a resident with infectious diarrhea. An alcohol-based hand rub containing at least 62% (percent) alcohol or soap and water could be used for the following situations: -before and after direct contact with residents; -before donning gloves; -before and after handling an invasive device; -after contact with bodily fluids; and -after removing soiled gloves. B. Review of the facility policy Catheter Care with a revision date of 4/6/25 revealed the following policies: -indwelling catheters were to be changed only when necessary and were to be connected to closed drainage systems. -all closed collection systems that become contaminated by inappropriate techniques, leaks, or other means are to be immediately replaced. -every effort was to be made to keep the resident's catheter bag covered or out of sight. -catheters are always properly secured, connected, and maintained using a sterile closed drainage system. -catheter tubing should never be allowed to touch the floor. -always make sure the drainage bag and tubing remain below the level of the catheter and bladder and coil tubing to promote drainage. C. Review of Resident 1's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/26/25 indicated the resident was admitted [DATE] with diagnoses of heart failure, previous stroke, paralysis to one side of his body, sepsis (extreme response to infection leading to widespread inflammation, organ damage and potential organ failure), obstructive uropathy (medical condition where the flow of urine is blocked. causing it to back up and potentially damage the kidneys), anxiety, depression, and diabetes. The assessment identified the resident's cognition was intact, the resident required total staff assistance with toileting hygiene, dressing, personal hygiene, bed mobility and transfers, was frequently incontinent of bowel and had an indwelling urinary catheter (thin tube inserted into the bladder to drain urine continuously into a collection bag). During an observation of Resident 1's catheter care and management and toileting/incontinence cares on 11/24/25 from 8:40 AM to 10:00 AM the following was observed: -8:43 AM Nurse Aide (NA)-E entered the resident's room and failed to complete hand hygiene before putting on a disposable gown and a pair of gloves. -8:51 AM NA-D after completing hand hygiene, placed on a gown and gloves, removed the urinary catheter drainage bag from the side of the resident's bedframe, and threaded the drainage bag through the leg opening of the resident's shorts. The drainage bag was then laid directly on the resident's bed linens. The drainage bag was not below the level of the resident's bladder. -8:59 AM NA-D and NA-E positioned the sling for the full lift under the resident and attached the sling to the lift. The staff removed the drainage bag from the bed and attached it to the lift next to the sling strap above the level of the bladder and above the resident's head. Resident 1 was transferred from the bed and was positioned on the bedside commode (a piece of furniture which functions as a toilet with a toilet seat and a hole which can be placed over a toilet or has a bucket beneath the hole for collecting waste). When staff removed the catheter drainage bag and the lift straps from the lift, NA-D hung the drainage bag directly from the seat of the commode. NA-D removed soiled gloves but failed to complete hand hygiene before placing on a clean pair of gloves. The commode chair was pushed into the bathroom and positioned over the toilet. -9:10 AM the resident was involuntary of loose feces which was observed on the disposable incontinence brief and on the resident's mattress. NA-E used pre-moistened cleansing cloths to clean the mattress, removed gloves, and failed to complete hand hygiene before placing on a clean pair of gloves. -9:22 AM the resident indicated completion of toileting and staff pulled the commode chair out of the bathroom and into the center of the resident's room. NA-D used several pre-moistened cleansing cloths to cleanse stool from the resident's buttocks. When care was completed, NA-D removed gloves but failed to complete hand hygiene before putting on a new pair of gloves. -9:28 AM the lift was positioned in front of the resident on the commode chair and the sling was attached to the lift bar above the resident's head. NA-D removed the catheter drainage bag from the seat of the commode chair and attached the bag to the lift by the sling above the level of the resident's head and/or bladder. The resident was transferred back into the bed, the lift was removed, and the urinary catheter drainage bag was placed directly back onto the bed linens. -9:35 AM staff completed incontinence/catheter cares as the resident was lying in bed. Staff continued to remove feces from the resident's buttocks. -when cares were completed, staff removed gloves, completed hand hygiene, and placed on clean gloves. -9:49 AM the resident was again attached to the lift with the catheter bag removed from the bed linens and placed on the lift above the resident's head. The resident was transferred into the recliner and the lift was removed with the urinary catheter drainage bag placed inside of a privacy bag and hung next to the recliner on the drawer of a dresser, below the level of the resident's bladder. An interview with the Registered Nurse (RN)-G on 11/24/25 at 11:00 AM confirmed the staff were to perform hand hygiene whenever removing soiled gloves and before putting on clean gloves. In addition, RN-G confirmed staff should not have placed the resident's urinary catheter drainage bag directly on the resident's bed linens and the drainage bag should not have been positioned above the resident's head and above the level of the resident's bladder when transferring the resident with the lift. D. Review of the Skilled Nursing Facility Covid-19 Work Guidelines with a reviewed date of October 2025 revealed the following; -Symptomatic employees were to be restricted from the workplace until Covid-19 infection was ruled out by testing. E. An observation of the Director of Nursing (DON) on 11/24/25 at 7:30 AM revealed the DON had a blue mask on, voice was hoarse and cough was noted. An interview with the DON on 11/24/25 at 7:45 AM revealed that the DON had not completed a Covid-19 test and was not going to complete one. An interview with Registered Nurse (RN)-B on 11/24/25 at 1:45 PM confirmed that the facility does not test staff or residents when presenting with respiratory symptoms or increased temperature.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04(D)Based on observations, record reviews, and interviews: the facility staff failed to ensure sufficient staff were available to provide timely toileting/incontinence cares for Resident 1 and to respond to call lights within expected timeframes. The total sample size was 3 and the facility census was 30. Findings are: A. Review of Resident 1's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/26/25 indicated the resident was admitted [DATE] with diagnoses of heart failure, previous stroke, paralysis to one side of his body, sepsis (extreme response to infection leading to widespread inflammation, organ damage and potential organ failure), obstructive uropathy (medical condition where the flow of urine is blocked. causing it to back up and potentially damage the kidneys), anxiety, depression, and diabetes. The assessment identified the resident's cognition was intact, the resident required total staff assistance with toileting hygiene, dressing, personal hygiene, bed mobility and transfers, was frequently incontinent of bowel and had an indwelling urinary catheter (thin tube inserted into the bladder to drain urine continuously into a collection bag). Observations of Resident 1 on 11/24/25 from 7:00 AM to 10:00 AM revealed the following: -7:00 AM the resident was lying in the bed with the resident's call light attached to the resident's chest area. The resident was wearing a mask and was receiving a nebulizer breathing treatment (a medical procedure where a machine turns liquid medication into a fine mist that is inhaled directly into the lungs). -7:15 AM the resident's call light was activated. Interview with the resident revealed the nebulizer treatment was completed and the resident was ready to get up and needed to use the commode for a bowel movement. -7:21 AM Medication Aide (MA)-C entered the resident's room, the call light was turned off, and the breathing treatment was removed. MA-C exited the room without providing assistance with toileting needs. -7:43 AM the resident's call light was again activated and the resident indicated a continued need to use the commode. -8:19 AM (35 minutes and 38 seconds later) Housekeeper (HK)-F entered the resident's room, turned on the overhead lights, and turned off the resident's call light. HK-F reported the direct care staff had requested HK-F turn the resident's call light off and to let the resident know they would be in as soon as possible to assist the resident. -8:21 AM the resident's call light was turned back on. -8:39 AM (18 minutes after the call light was last activated and 1 hour and 24 minutes since the resident first indicated a need for assistance) Nurse Aide (NA)-E and NA-D entered the resident's room and turned off the call light to assist the resident with getting out of bed and with use of the bedside commode. During an interview on 11/24/25 at 10:22 AM, NA-D confirmed the following regarding Resident 1: -had requested with the resident's care plan to be assisted out of bed between 7:00 AM and 7:30 AM each morning. -the resident's call light was first turned on that morning at 7:15 AM and the resident reported a need to use the commode for a bowel movement. -the resident required 2 staff assist and the full lift for transfers out of bed and onto the commode. -the facility only had 2 direct care staff working 11/24/25. The resident was left until later as staff were assisting other residents with getting ready for breakfast and Resident 1 took a long time with cares. -staff were trained to answer resident's call lights within 15 minutes of activation. -Resident 1 waited for 1 hour and 24 minutes for staff to assist the resident out of bed and onto the commode. An interview with Resident 1 and the resident's spouse on 11/24/25 at 10:30 AM revealed the following: -the resident had requested that morning to get up at 7:15 AM and was not assisted out of bed until 8:39 AM. The resident needed to use the bedside commode for a bowel movement and had then been involuntary of bowels due to the length of time the resident waited for assistance. -the resident was commonly left until one of the last residents to get out of bed as the facility frequently did not have enough staff. In addition, it was common for the resident to wait greater than 15 minutes for the residents' call light to be answered. An interview on 11/24/25 at 7:30 AM with Registered Nurse (RN)-B confirmed that there were 2 CNA's working 6 AM to 2:30 PM that day and no bath aide, the facility census was 30. Record review of Resident 1's Device Activity Report (DAR, a report of when call lights are turned on and off) revealed the following dates and times the resident's call light response times exceeded 15 minutes: -10/24/25 the call light was on from 10:03 AM to 10:35 AM (a total of 31 minutes) and from 9:49 PM to 10:10 PM (a total of 21 minutes). -10/26/25 the call light was on from 6:17 AM to 6:39 AM (21 minutes), from 8:12 AM to 8:29 AM (17 minutes), from 9:25 AM to 9:44 AM ( 19 minutes) and from 7:44 PM to 8:03 PM (a total of 19 minutes). -10/26/25 the call light was activated from 6:17 AM to 6:39 AM (21 minutes), from 8:12 AM to 8:29 AM (17 minutes), from 9:25 AM to 9:44 AM (19 minutes and from 7:44 PM to 8:03 PM (19 minutes). -10/27/25 the call light was activated from 11:15 AM to 11:37 AM (22 minutes). -10/28/25 the call light was activated from 10:42 AM to 10:58 AM (16 minutes), from 6:49 PM to 7:11 PM (22 Minutes) and from 8:23 PM to 8:47 PM (a total of 24 minutes).-10/29/25 the call light was activated from 6:12 AM to 6:44 AM (31 minutes), from 7:30 AM to 8:00 AM (30 minutes), from 4:30 PM to 4:54 PM (23 minutes), from 6:39 PM to 7:25 PM (46 minutes) and from 8:19 PM to 8:35 PM (16 minutes). -10/30/25 the call light was activated from 10:04 AM to 10:20 AM (16 minutes). -10/31/25 the call light was activated from 1:24 AM to 1:56 AM (32 minutes), 5:44 AM to 6:29 AM (45 minutes), and from 7:58 PM to 8:21 PM (23 minutes). -11/1/25 the call light was activated from 6:37 AM to 7:24 AM (46 minutes), from 8:03 AM to 8:34 AM (31 minutes), from 9:07 AM to 9:47 AM (40 minutes), and from 10:36 AM to 10:55 AM (a total of 18 minutes).-11/2/25 the call light was activated from 7:17 AM to 7:40 AM (22 minutes), from 8:17 AM to 8:48 AM (30 minutes), from 8:53 AM to 9:40 AM (27 minutes) and from 8:03 PM to 8:23 PM (20 minutes).-11/3/25 the call light was activated from 6:00 AM to 6:45 AM (45 minutes) and from 10:34 AM to 10:51 AM (16 minutes).-11/4/25 the call light was activated from 6:18 PM to 7:51 PM (1 hour and 33 minutes). -11/5/25 the call light was activated from 7:20 AM to 7:45 AM (24 minutes), from 8:49 AM to 9:19 AM (30 minutes) and from 8:22 PM to 8:38 PM (16 minutes). B. Review of the facility policy Call Light with a revision date of 7/8/25 revealed when a resident's call light was observed or heard staff were to respond to the call light promptly. C. Review of the facility's call light activity report from 10/22/25 to 11/5/25 revealed the following call light response times that took more than 15 minutes to be answered: -On 10/24/25 there were 9 times that ranged from 17 minutes to 55 minutes. -On 10/25/25 there were 19 times that ranged from 16 minutes to 49 minutes. -On 10/26/25 there were 22 times that ranged from 16 minutes to 48 minutes. -On 10/27/25 there were 21 times that ranged from 16 minutes to 32 minutes. -On 10/28/25 there were 15 times that ranged from 16 minutes to 94 minutes. -On 10/29/25 there were 21 times that ranged from 16 minutes to 127 minutes. -On 10/30/25 there were 15 times that ranged from 16 minutes to 65 minutes. -On 10/31/25 there were 17 times that ranged from 16 minutes to 45 minutes. -On 11/1/25 there were 21 times that ranged from 17 minutes to 51 minutes. -On 11/2/25 there were 23 times that ranged from 16 minutes to 138 minutes. -On 11/3/25 there were 15 times that ranged from 16 minutes to 45 minutes. -On 11/4/25 there were 16 times that ranged from 16 minutes to 105 minutes. -On 11/5/25 there were 14 times that ranged from 16 minutes to 40 minutes. An interview with the Director of Nursing on 11/24/25 at 12:10 PM confirmed that call lights were to be answered in 15 minutes and there were call lights that did not get answered timely in the facility. D. Review of the facility's nursing schedule from 10/22/25 to 11/5/25 revealed the following: -On 10/22/25 there were 3 CNA's from 6 AM to 2:30 PM, -On 10/25/25 (Saturday) there were 2 CNA's from 6 AM to 2:30 PM, -On 10/26/25 (Sunday) there were 2 CNA's from 6 AM to 2:30 PM, -On 10/28/25 from 10 PM to 6:30 AM there was 1 CNA for 8 hours and 1 CNA for 4 hours, -On 10/29/25 there were 3 CNA's from 6 AM to 2:30 PM, and -On 11/2/25 there was 1 CNA from 6 PM to 10 PM and 1 CNA from 10PM to 6:30AM. An interview with the DON on 11/24/25 at 1:15 PM confirmed the following numbers of Certified Nursing Assistants should be scheduled: -Monday through Friday 6 AM to 2:30 PM 4 Certified Nursing Assistants (CNA's), -Saturday and Sunday 6 AM to 2:30 PM 3 CNA's, -from 2:00PM to 10:30 PM there should be 2-3 CNA's, and -from 10:00PM to 6:30 AM 2 CNA's were to be scheduled.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to report to the State Agency, complete an investigation and then to submit the investigation within 5 working days an allegation of staff to resident abuse for 1 (Resident 1) of 3 sampled residents. The facility staff identified a census of 30.Findings are: A. Review of the facility's 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 Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/26/25 indicated the resident was admitted [DATE] with diagnoses of heart failure, previous stroke, paralysis to one side of his body, sepsis (extreme response to infection leading to widespread inflammation, organ damage and potential organ failure), obstructive uropathy (medical condition where the flow of urine is blocked. causing it to back up and potentially damage the kidneys), anxiety, depression, and diabetes. The assessment identified the resident's cognition was intact, the resident required total staff assistance with toileting hygiene, dressing, personal hygiene, bed mobility and transfers, was frequently incontinent of bowel and had an indwelling urinary catheter (thin tube inserted into the bladder to drain urine continuously into a collection bag). During an interview on 11/25/25 at 10:30 AM with Resident 1 and the resident's spouse the following was identified:-11/5/25 the resident had turned their call light on at 7:00 AM.-Nurse Aide (NA)-D had entered the resident's room, turned the call light off and then exited the room.-the resident turned the call light back on and NA-D returned to the room, shut the call light off and then removed the call light from the resident's reach. -it was a common occurrence for staff to remove the resident's call light from reach whether intentional or not as the resident required almost total assistance of x2 staff with cares and cares took a long time to be completed. -the resident and spouse reported the incident to the facility Administrator. The Administrator indicated staff was counseled after the staff member admitted they had done this. Review of facility investigations of potential abuse/neglect from 9/29/25 to 11/24/25 revealed no evidence Resident 1's allegation of potential staff to resident abuse was reported to the State Agency. In addition, there was no evidence that an investigation was completed by the facility and then submitted within 5 working days. An interview with the Director of Nursing (DON) on 11/24/25 at 11:30 AM confirmed the facility did not report the allegation of potential abuse involving Resident 1, complete and then submit an investigation to the State Agency within the required time frame.

Licensure Reference Number 175 NAC 12-006.09(F)(iii)Based on record review and interview; the facility failed to update Resident 1's comprehensive care plan to reflect the resident's preference for getting up in the morning. The sample size was 3 and the facility census was 30. Findings are:Review of Resident 1's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/26/25 indicated the resident was admitted [DATE] with diagnoses of heart failure, previous stroke, paralysis to one side of his body, sepsis (extreme response to infection leading to widespread inflammation, organ damage and potential organ failure), obstructive uropathy (medical condition where the flow of urine is blocked. causing it to back up and potentially damage the kidneys), anxiety, depression, and diabetes. The assessment identified the resident's cognition was intact, the resident required total staff assistance with toileting hygiene, dressing, personal hygiene, bed mobility and transfers, was frequently incontinent of bowel and had an indwelling urinary catheter (thin tube inserted into the bladder to drain urine continuously into a collection bag). Review of a Care Conference Progress Note dated 7/9/25 at 11:18 AM revealed the resident and spouse had attended the resident's care plan conference and had identified a preference for the resident to be up and out of bed at 7:00 AM each morning and to be put to bed at 8:30 PM in the evening. Review of the resident's current Care Plan with a revision date of 11/5/25, revealed the resident had an activity of daily living self-care performance deficit related to a previous stroke with weakness, right side paralysis, and weakness. Interventions included to position the resident up in bed with 2 staff and to use the full sling lift for all transfers. Further review of the resident's care plan revealed no evidence the resident's preferences for what time to get up in the morning or for the time the resident preferred to go to bed at night were identified on the care plan. An interview on 11/24/25 at 1:15 PM with the Director of Nursing confirmed the resident's care plan had not been updated regarding the resident's preferences.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observations, record review, and interview; the facility failed to provide timely toileting assistance/incontinence management for Resident 1 who required assistance with activities of daily living. The total sample size was 3 and the facility census was 30. Findings are: Review of Resident 1's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/26/25 indicated the resident was admitted [DATE] with diagnoses of heart failure, previous stroke, paralysis to one side of his body, sepsis (extreme response to infection leading to widespread inflammation, organ damage and potential organ failure), obstructive uropathy (medical condition where the flow of urine is blocked. causing it to back up and potentially damage the kidneys), anxiety, depression, and diabetes. The assessment identified the resident's cognition was intact, the resident required total staff assistance with toileting hygiene, dressing, personal hygiene, bed mobility and transfers, was frequently incontinent of bowel and had an indwelling urinary catheter (thin tube inserted into the bladder to drain urine continuously into a collection bag). Review of Resident 1's current Care Plan with a revision date of 11/13/25 revealed the resident had an activity of daily living self-care performance deficit related to a previous stroke, right side paralysis, and weakness. The following interventions were identified:-staff to provide assistance with bed mobility, transfers, dressing, toilet use and personal hygiene.-x2 staff to assist with use of the full lift for all transfers. -resident to be transferred onto the commode and then transferred into the bathroom with the commode placed over the toilet for elimination. -resident to be checked and changed every 2 hours when in bed. Observations of Resident 1 on 11/24/25 from 7:00 AM to 10:00 AM revealed the following:-7:00 AM the resident was lying supine in the bed with the resident's call light attached to the resident's chest area. The resident was wearing a mask and was receiving a nebulizer breathing treatment (a medical procedure where a machine turns liquid medication into a fine mist that is inhaled directly into the lungs). -7:15 AM the resident's call light was activated. Interview with the resident revealed the nebulizer treatment was completed and the resident was ready to get up and needed to use the commode for a bowel movement. -7:21 AM Medication Aide (MA)-C entered the resident's room, the call light was turned off, and the breathing treatment was removed. MA-C exited the room without providing assistance with toileting needs. -7:43 AM the resident's call light was again activated and the resident indicated a continued need to use the commode.-8:19 AM (35 minutes and 38 seconds later) Housekeeper (HK)-F entered the resident's room, turned on the overhead lights, and turned off the resident's call light. HK-F reported the direct care staff had requested HK-F turn the resident's call light off and to let the resident know they would be in as soon as possible to assist the resident. -8:21 AM the resident's call light was turned back on. -8:39 AM (18 minutes after the call light was last activated and 1 hour and 24 minutes since the resident first indicated a need for assistance) Nurse Aide (NA)-E and NA-D entered the resident's room and turned off the call light to assist the resident with getting out of bed and with use of the bedside commode. The resident's disposable incontinence brief was soiled with feces. During an interview on 11/24/25 at 10:22 AM, NA-D confirmed the following regarding Resident 1:-the resident's call light was first turned on that morning at 7:15 AM and the resident reported a need to use the commode for a bowel movement.-the resident required 2 staff assist and the full lift for transfers out of bed and onto the commode. -the facility only had x2 direct care staff working 11/24/25. The resident was left until later as staff were assisting other residents with getting ready for breakfast and Resident 1 took a long time with cares. -Resident 1 waited for 1 hour and 24 minutes for staff to assist the resident out of bed and onto the commode.-the resident was involuntarily incontinent of feces by the time assisted the resident with toileting cares.

Licensure Reference Number 175 NAC 12-006.04 Based on record review and interviews; the facility failed to have staff adequate to meet the needs of Residents 1, 2, 4, and 5. This had the potential to affect all facility residents. The sample size was 5 and the facility census was 35. Findings are: A. Record review of the Facility Assessment (comprehensive data driven evaluation of a facilities physical condition and it's ability including the resources (including staff) needed to provide adequate care and services) with a review date of 8/15/25 revealed the facility provided assistance with Activities of Daily Living (ADLs, tasks related to personal care, such as dressing, eating, and mobility) and utilized evidence based, data driven methods to have appropriate staffing to meet the needs of the residents. This included nights and weekends. As the needs of the population changed staffing patterns were adjusted to meet those needs. The facility confirmed resident needs were met through frequent communication with residents, their families/representatives at regular care conferences, rounding, quality assurance audits, resident group meetings, availability of suggestions/concern forms and email surveys. Record review of the facility's Suggestion or Concerns dated 7/7/25 through 9/23/25 revealed the following concerns put in writing by residents and/or their representatives: -7/7/25: Concern about 1 bath in a 2 weeks time frame, and treatment being properly administered. -8/11/25: Concern about lack of staff on 8/9/25 and 8/10/25 (weekend). -9/3/25: Concern regarding staffing issues on 8/31/25 and 9/1/25, and call light attentiveness on 8/22/25. -9/8/25: Concern about call light response time and medications being administered timely. -9/23/25: Concern including untimely meals and long call light response times. Record review of a facility letter dated 9/9/25 in response to a grievance/concern revealed the facility had a personal standard of 10 minutes or less response time to call lights. B. Record review of Resident 5's Care Plan dated 4/15/25 revealed the resident had a history of dizziness, had self-care deficits, and limited physical mobility related to weakness and arthritis. The resident needed assistance with ADL's. This included the assistance of one staff member to ambulate and assistance of one staff member to bathe. The resident wanted to bathe 2 times weekly during the summer season. In addition, the resident needed the assistance of one staff member for toileting hygiene, transferring from one surface to another, and adjusting clothing up and down to accommodate toileting. Record review of Resident 5's Bathing Record from August 1, 2025, through September 29, 2025, revealed that the resident was bathed on the following dates: 8/1, 8/15 (14 days later), 8/19, 8/26, 9/6 (10 days later), 9/9, and 9/16 : As of 9/29/25 the resident had not been bathed for 13 days. Record review of Resident 5's Call light Response times for September 1, 2025 through September 29, 2025 revealed the following call light response times greater than 10 minutes: -9/2/25 at 9:59:55 PM, a response time of 20 minutes and 46 seconds. -9/6/24 at 7:34:32 PM, a response time of 12 minutes and 24 seconds. -9/9/25 at 4:14:12 PM, a response time of 13 minutes and 20 seconds. -9/9/25 at 7:07:21 PM, a response time was 12 minutes and 31 seconds. -9/10/25 at 10:08:44 PM, a response time was 20 minutes and 32 seconds. -9/12/25 at 2:32:23 PM response time of 13 minutes and 34 seconds -9/15/25 at 8:52:42 PM, a response time of 10 minutes and 55 seconds -9/17/25 at 4:26:18 PM, a response time of 12 minutes and 25 seconds -9/18/25 at 3:30:50 PM, a response time of 12 minutes and 42 seconds -9/19/25 at 8:04:56 PM, a response time of 53 minutes and 3 seconds. -9/20/25 at 7:16:02 PM, a response time of 11 minutes and 16 seconds C. Record review of Resident 2's Care Plan with a revision date of 9/2/25 revealed the resident had impaired cognitive function and self-care deficits due to dementia. The resident was unable to bear weight or ambulate and required the assistance 1-2 staff for bathing, moving in bed, transfers, hygiene, toileting and eating. In addition, the resident was incontinent of bowel and bladder and used incontinence brief and was checked and changed by the staff. Record review of Resident 2's of call light response times from 9/1/25 through 9/29/25 revealed the following call light response times over 10 minutes: -9/1/25 at 1:01:33 PM the call light ran for 15 minutes and 10 seconds. -9/1/25 at 5:16:39 PM the call light ran for 13 minutes and 13 seconds. -9/2/25 at 8:48:00 PM the call light ran for 10 minutes and 6 seconds. -9/3/25 at 8:08:17 PM the call light ran for 27 minutes and 13 seconds. -9/4/25 at 3:13:29 PM the call light ran for 26 minutes and 35 seconds. -9/8/25 at 7:34:42 PM the call light ran for 40 minutes and 2 seconds. -9/9/25 at 5:08:44 PM the call light ran for 11 minutes and 58 seconds. -9/9/25 at 8:32:02 PM the call light ran for 26 minutes and 58 seconds. -9/10/25 at 5:33:42 PM the call light ran for 49 minutes and 42 seconds. -9/10/25 at 8:33:22 PM the call light ran for 17 minutes and 38 seconds -9/11/25 at 8:18:15 PM the call light ran for 13 minutes and 31 seconds. -9/12/25 at 8:31:32 PM the call light ran for 16 minutes and 36 seconds. -9/19/25 at 8:44:06 PM the call light ran for 42 minutes and 18 seconds. -9/20/25 at 5:21: 22 PM the call light ran for 19 minutes and 16 seconds. -9/20/25 at 9:27:57 PM the call light ran for 20 minutes and 39 seconds. D. Record review of Resident 3's care plan revealed that the resident had an Activity of Daily Living deficit related to diagnosis of Alzheimer Dementia. The resident was unable to find own clothes and personal care items without staff assistance. Resident required 1 assist with putting on pants and set up assist and cues required for brushing teeth. Record review of the facility Call Light Response times from 9/1/25 to 9/29/25 for Resident 3 revealed the following:-On 9/4/25 the call light was on from 5:40 PM to 6:30 PM (50 Minutes).-On 9/12/25 the call light was on from 2:23 AM to 2:36 AM (12 min 42 seconds).-On 9/16/25 the call light was on from 8:36 AM to 9:03 AM (26 min 38 seconds).-On 9/20/25 the call light was on from 2:44 PM to 3:04 PM (19 minutes 54 seconds). E. Record review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 8/25/25 revealed the resident was admitted on [DATE], had severe cognitive impairment, had limited range of motion of 1 side for both upper and lower extremities, was dependent on staff for assistance with toileting, and required substantial assistance with dressing and hygiene; and had diagnoses of Non-Alzheimer's Dementia, Anxiety, and Depression. Record review of the facility Call Light Response Times dated 9/1/25 through 9/29/25 revealed the following call light times for Resident 1: -on 9/11/25 from 7:04 PM-7:19 PM (14 minutes, 33 seconds), -on 9/11/25 from 7:40 PM-7:52 PM (12 minutes, 25 seconds), -on 9/12/25 from 6:47 PM-7:00 PM (13 minutes, 14 seconds), -on 9/13/25 from 4:00 PM-4:21 PM (20 minutes, 57 seconds), -on 9/14/25 from 2:24 PM-2:36 PM (11 minutes, 28 seconds), -on 9/14/25 from 6:36 PM-7:25 PM (49 minutes, 23 seconds), -on 9/15/25 from 6:46 PM- 7:28 PM (42 minutes, 4 seconds), -on 9/20/25 from 8:59 AM-9:13 AM (14 minutes, 56 seconds), and -on 9/20/25 from 4:35 PM-5:10 PM (34 minutes, 19 seconds). F. Record review of the facility's Daily Staffing Posting from 8/15/25 through 9/29/25 revealed the following total Nurse Aide (NA) hours worked over each 24-hour period that did not meet predetermined Nurse Aides staffing needs: -8/15/25 with a census of 26, a total of 16 NA hours -8/16/25 with a census of 27, a total of 36 NA hours -8/17/25 with a census of 27, a total of 44 NA hours -8/18/25 with a census of 27, a total of 34.5 NA hours -8/19/25 with a census of 27, a total of 44.5 NA hours -8/20/25 with a census of 27 a total of 40 NA hours -8/21/25 with a census of 27 a total of 42 NA hours -8/22/25 with a census of 27, a total of 39 NA hours -8/23/25 with a census of 28, a total of 44.5 NA hours -8/24/25 with a census of 28, a total of 43 NA hours -8/25/25 with a census of 28, a total of 41.5 NA hours -8/26/25 with a census of 29, a total of 48.5 NA hours -8/27/25 with a census of 29, a total of 47.5 NA hours -8/28/25 with a census of 29, a total of 44.5 NA hours -8/29/25 with a census of 28, a total of 23.5 NA hours -8/30/25 with a census of 29, a total of 44.0 NA hours -8/31/25 with a census of 30, a total of 30 NA hours -9/1/25 with a census of 30, a total of 37 NA hours -9/2/25 with a census of 30, a total of 44.5 NA hours -9/3/25 with a census of 31, a total of 52.5 NA hours -9/4/25 with a census of 32, a total of 40.5 NA hours -9/5/25 with a census of 32, a total of 35.5 NA hours -9/6/25 with a census of 34, a total of 49.0 NA hours -9/7/25 with a census of 34, a total of 52.5 NA hours -9/8/25 with a census of 35, a total of 41.5 NA hours -9/9/25 with a census of 36, a total of 41 NA hours -9/10/25 with a census of 36, a total of 57 NA hours -9/11/25 with a census of 36, a total of 51.5 NA hours -9/12/25 with a census of 36, a total of 43.5 NA hours -9/13/25 with a census of 34, a total of 32 NA hours -9/14/25 with a census of 34, a total of 44 NA hours -9/15/25 with a census of 34, a total of 37.5 NA hours -9/16/25 with a census of 34, a total of 44 NA hours -9/17/25 with a census of 34, a total of 39.5 NA hours -9/18/25 with a census of 34, a total of 54.5 NA hours -9/19/25 with a census of 34, a total of 28 NA hours -9/20/25 with a census of 34, a total of 49 NA hours -9/21/25 with a census of 34, a total of 37 NA hours -9/22/25 with a census of 34, a total of 68 NA hours -9/23/25 with a census of 35, a total of 58.5 NA hours -9/24/25 with a census of 35, a total of 43 NA hours -9/25/25 with a census of 35, a total of 46.5 NA hours -9/26/25 with a census of 35, a total of 30.5 NA hours -9/27/25 with a census of 35, a total of 32.5 NA hours -9/28/25 with a census of 35, a total of 28 NA hours -9/29/25 with a census of 35, a total of 31 NA hours. G. During an interview on 9/29/25 at 1:55 PM Nurse Aide (NA)-F confirmed working as a nurse aide most days despite being the full-time housekeeping staff, however even when working as a NA the facility often had only 2 NA's working on the floor during the day with one bath aid some days. It's not uncommon to help get 16 or 17 residents ready for the day and often times it was difficult to get residents out for breakfast timely. NA-F confirmed with the current census the facility needed 3 nurse aides on the day shift and they had that today because NA-F was pulled from housekeeping duties. H. During an interview on 9/29/25 at 2:30 PM with the Director of Nursing (DON) revealed on all days of the week with the current census of 35, Nurse Aide hours include 3 Nurse Aides (NA's) during day shift (plus an additional NA to provide bathing up to 5 days a week up to 8 hours a day), 2.5 Nurse Aides on the evening shift, and 2 Nurse Aides on the night shift. This would be a total of 60 (+8 hour Bath Aide) hours of NA coverage over 24 hours for the current census of 35. In comparison, a census of 27 residents would include 2 nurse aides on the day shift (plus an additional NA to provide bathing up to 5 days a week up to 8 hours a day), 2 Nurse Aides on the evening shift and 2 Nurse Aides on the night shift. This would be a total of 46 nurse aid + 8 hours NA up to 5 days a week per 24 hours for a census of 27. In review of the facility staff posting from August 15th through [DATE]th, 2025, the DON confirmed the facility had not met needed NA staffing levels from August 15 through September 29th. I. Review of the undated facility Daily Cleaning of a Residents Room revealed all resident rooms would have the following cleaning provided: - The floor would be dust mopped, and the trash would be emptied. -Staff would wipe off the following areas of the room: -light switches, -door knobs, -remote controls, -bed rails, -call lights, -dressers and stands and -telephones. -In the resident's bathroom area, the following would be completed: -The mirror would be cleaned, and the sink and handles would be wiped down. -The light switches, handrails, call lights and door frame would be wiped down and -The inside and outside of the toilet would be cleaned. J. An interview on 9/29/25 at 1:45 PM with Environmental Services Supervisor (ESS-F), confirmed that the residents' rooms were to be cleaned daily. ESS-F confirmed that the resident rooms were not being cleaned daily, there was only one house keeping staff member and this member worked in the facility as a nursing assistant (NA). ESS-F confirmed that from 9/21/25 to 9/27/25, housekeeping staff only worked on 9/22/25. K. An interview on 9/29/25 at 2:00 PM with the Administrator confirmed that there was not a housekeeping schedule and that when ESS-F was working as an NA the maintenance and laundry staff cleaned some resident rooms and halls. The administrator was unsure what rooms were cleaned by maintenance and laundry staff. L. An interview on 9/29/25 at 2:15 PM with maintenance staff (G) confirmed that the facility was unsure of what rooms were cleaned from 9/21/25 to 9/27/25 by maintenance and housekeeping staff. M. Interview with the Administrator on 9/29/25 at 3:09 PM confirmed the facility census had increased from 27 to 35 and they had identified increasing call light response times since the increase in census. The facility was reviewing all admissions on an individual basis to determine if they could meet the needs of the residents. The Administrator was aware the facility was having concerns with call light response times and had started a Performance Improvement Plan to address those concerns. In addition, the facility is trying to hire additional staff but was using agency and pool nursing but had not filled all available shifts.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review, and interviews the facility failed to provide needed Activities of Daily Living (ADL, tasks related to personal care, such as dressing, eating, and mobility) assistance to Resident 5 in a timely manner. The sample size was 5 and the facility census was 35. Findings are: A. Record review of the facility policy Activities of Daily Living dated 12/23/24 revealed the facility provided residents with appropriate treatment and services to maintain or improve abilities in activities of daily living for the well-being of mind, body, and soul. Any resident unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal hygiene. ADL's included the following: Hygiene, Bathing, Dressing, Mobility, Toileting, Eating, and Communication. Record review of the facility policy for Call Lights dated 7/8/25 revealed the facility ensured residents had a method of calling for assistance and promptly answered resident call lights. The facility responded to requests for assistance as soon as possible. Record review a facility letter dated 9/9/25 in response to a resident/family grievance revealed the facility had a personal standard of 10 minutes or less response time to call lights. B. Record review of Resident 5's Care Plan dated 4/15/25 revealed the resident had a history of dizziness, had self-care deficits, and limited physical mobility related to weakness and arthritis. The resident needed assistance with ADL's. This included the assistance of one staff member to ambulate and assistance of one staff member to bathe. The resident wanted to bathe 2 times weekly during the summer season. In addition, the resident needed the assistance of one staff member for toileting hygiene, transferring from one surface to another, and adjusting clothing up and down to accommodate toileting. Record review of Resident 5's Bathing Record from August 1, 2025 through September 29, 2025, revealed that the resident was bathed on the following dates. 8/1, 8/15 (14 days later), 8/19, 8/26, 9/6 (10 days later), 9/9, and 9/16: As of 9/29/25 the resident had not been bathed for 13 days. Record review of Resident 5's Call light Response times for September 1, 2025- September 29, 2025 revealed the following call light response times greater than 10 minutes: -9/2/25 at 9:59:55 PM, a response time of 20 minutes and 46 seconds. -9/6/24 at 7:34:32 PM, a response time of 12 minutes and 24 seconds. -9/9/25 at 4:14:12 PM, a response time of 13 minutes and 20 seconds. -9/9/25 at 7:07:21 PM, a response time was 12 minutes and 31 seconds. -9/10/25 at 10:08:44 PM, a response time was 20 minutes and 32 seconds. -9/12/25 at 2:32:23 PM, a response time of 13 minutes and 34 seconds-9/15/25 at 8:52:42 PM, a response time of 10 minutes and 55 seconds-9/17/25 at 4:26:18 PM, a response time of 12 minutes and 25 seconds-9/18/25 at 3:30:50 PM, a response time of 12 minutes and 42 seconds-9/19/25 at 8:04:56 PM, a response time of 53 minutes and 3 seconds. -9/20/25 at 7:16:02 PM, a response time of 11 minutes and 16 seconds D. During an interview with Resident 5's child on 9/29/25 at 11:20 AM revealed the child consistently felt the facility did not have enough staff to prevent residents from not getting bathed regularly and not having their call lights answered in a reasonable amount of time. This had been a concern with the facility off and on over the past 3 to 4 months and the child felt that despite being reassured their concerns were addressed, nothing had changed significantly. They had been told the resident would be bathed twice weekly and that lasted about 2 weeks and now the resident had not had a bath for 2 weeks. During an interview on 9/29/25 at 1:10 PM, Resident 5 confirmed having had complained to administrative staff multiple times about being short staffed especially when there are only 2 Nurse Aides (NA's) in the building. This often happened during the day and evening time, and more so on the weekends. Resident 5 reported sometimes having to wait 20 or 30 minutes for help after having activated the call light and was unhappy about the response time to calls for assistance. This forced decisions to get up unassisted in which the resident felt unsafe, however didn't want to be incontinent. In addition, the resident desired 2 baths weekly, however rarely got 2 baths and sometimes went 2 weeks between baths. The resident felt they were not receiving the services paid for. In addition, the resident reported the NA's work very hard and are always kind and caring but having to cover 4 halls with 2 persons is just not enough help and when the resident complained to administration, the administration insisted they did have enough help. Resident 5 felt that had been going on since being admitted to the facility last spring. During an interview on 9/29/25 at 2:30 PM with the Director of Nursing (DON) revealed on all days of the week with the current census of 35, Nurse Aide hours include 3 Nurse Aides (NA's) during day shift (plus an additional NA to provide bathing up to 5 days a week up to 8 hours a day), 2.5 Nurse Aides on the evening shift, and 2 Nurse Aides on the night shift. This would be a total of 60 (+8 hour Bath Aide) hours of NA coverage over 24 hours for the current census of 35. In comparison, a census of 27 residents would include 2 nurse aides on the day shift (plus an additional NA to provide bathing up to 5 days a week up to 8 hours a day), 2 on the evening shift and 2 at night. This would be a total of 46 nurse aid hours + 8 hours NA up to 5 days a week per 24 hours for a census of 27. In review of the facility staff posting, the DON confirmed the facility was not meeting needed NA staffing levels.

Licensure Reference Number 175 NAC 12-006.09(I) Based on record review and interview; the facility failed to review, revise and/or implement care plan interventions to prevent falls for Resident 1. The sample size was 3 and the facility census was 35. Findings are:Record review of the facility policy Fall Prevention and Management last reviewed 4/8/25 revealed the following:-staff were to use a proactive approach before a fall occurred which included screening to identify risk factors, care planning appropriate interventions, and communicating fall risks and interventions. Fall Procedure:-after a fall a nurse was to observe the resident and perform a full-body exam to determine if there may be a suspected injury,-if no serious injury, staff were to use a total body lift to transfer the resident off the floor,-when the resident was stable, staff were to investigate the causal factors of the fall,-initial documentation would be in the SAFE Event Report form and if any additional documentation was needed it would be in the Progress Notes, -if any teaching was completed it would be documented in the Progress Notes, -staff would communicate that a fall occurred during the shift change and daily meetings, and -the residents care plan would be reviewed and revised with any changes and/or new interventions. Record review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 8/25/25 revealed the resident was admitted on [DATE], had severe cognitive impairment, had limited range of motion of 1 side for both upper and lower extremities, was dependent on staff for assistance with toileting, and required substantial assistance with dressing and hygiene; and had diagnoses of non-Alzheimer's 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)), anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), and depression. Record review of Resident 1's Care Plan with a revision date of 9/15/25 revealed the resident required the assistance of 1 staff member for ambulation, bed mobility, transfers and toileting; had falls on 8/28/25, 8/29/25, 9/8/25, and 2 falls on 9/13/25; and fall interventions that staff were to encourage the resident to participate in activities that promote exercise, ensure the resident has appropriate footwear, and monitor for significant changes in gait, mobility, positioning device, standing/sitting balance, and lower extremity joint function. Record review of the facility forms SAFE Resident Event revealed the following regarding Resident 1 revealed the following:-a fall on 8/28/25 at 8:00 PM revealed no documentation that an intervention to prevent falls had been put into place, -a fall on 8/29/25 at 7:45 PM revealed no documentation that an intervention to prevent falls had been put into place,-a fall on 9/8/25 at 10:45 PM revealed no documentation that an intervention to prevent falls had been put into place, -a fall on 9/13/25 at 8:00 PM revealed no documentation that an intervention to prevent falls had been put into place, -a fall on 9/22/25 at 8:45 PM revealed no documentation that an intervention to prevent falls had been put into place, and-a fall on 9/27/25 at 7:30 PM revealed no documentation that an intervention to prevent falls had been put into place. An interview with the Director of Nursing on 9/29/25 at 3:30 PM confirmed interventions to prevent future falls were not implemented for falls on 8/28/25, 8/29/25, 9/8/25, 9/13/25, 9/22/25, and 9/27/25 and the care plan should have been updated.

Based on record review and interview; the facility failed to have documented clinical rationale for not completing Gradual Dose Reductions (GDR)'s for Residents 13 and 18 Psychotropic (drugs that affect the mind, emotions, and behavior) medications. The sample size was 5 and the facility census was 29. Findings are: A. Review of the facility policy Psychotropic Medications with a revision date of 5/12/25 revealed the following: -The facility evaluated behavior interventions before using psychotropic medications and eliminated unnecessary psychotropic medications. The residents would be free from chemical restraints imposed for purposes of discipline or convenience or not required to treat the residents' medical symptoms. -Resident were not given psychotropic drugs unless the medication was necessary. -Residents who used psychotropic medications received gradual dose reductions unless clinically contraindicated, in an effort to discontinue the medications. -A consent form must be signed for the use of psychotropic medications. -The use of as needed psychotropic medications was not encouraged, and the facility ensured clear parameters, and a clear duration for use beyond 14 days. -Mood and behavior documentation was completed to monitor the effects of the psychotropic medication. -Gradual dose reductions were completed in accordance with federal regulations. -The facility psychotropic medication reduction committee reviewed the need for psychotropic medications at least every 3 months and documented the rationale for continuing the medication. -The purpose of tapering medication was to find an optimal dose or to determine if continued use of the medication was a benefit to the residents. -Within the first years a resident admitted taking psychotropic medication or after the location had initiated the medication a gradual dose reduction was attempted unless clinically contraindicated. Dose reductions were attempted or must be clinically contraindicated annually. Review of the undated facility policy Medication Regimen Review revealed the following: -The Medication Regimen Review (MRR) was a thorough process of review and assessment conducted by a consultant pharmacist of the medications ordered for each resident with a goal of promoting positive outcomes and minimizing adverse consequences associated with medications. -The process occurred at least monthly for each resident. -Findings and recommendations were reported to the facility Administrator, Director of Nursing (DON), the Attending Physician and or Medical Director as it applied. -The Consultant Pharmacist utilized federally mandated standards of care, in addition to other applicable standards. -Concerns and irregularities identified were forwarded to the Administrator, DON and Attending Physician. -The facility notified and obtained responses from the Attending Physicians in a timely manner. B. Review of Resident 13's Care Plan with a revision date of 5/27/25 revealed the resident had impaired cognition, dementia, and impaired thought processes. In addition, the resident had anxiety, depression and behavioral symptoms related to psychosis such as pinching, hitting and biting the staff. The resident was taking the antipsychotic medication Seroquel. Review of Resident 13's Medication Administration Record (MAR) dated June 2025 revealed the resident took the antipsychotic medication Seroquel 12.5mg one time daily for abuse behaviors related to psychosis and the antidepressant medication Paroxetine 20mg daily. Review of Resident 13's Note to Attending Physician/Prescriber dated 5/8/25 revealed the Consultant Pharmacist requested a review for dosage reduction, and the provider on 6/23/25 responded by indicating No however did not document a clinical rationale as to why a reduction was contraindicated. During an interview on 6/26/25 at 12:29 PM Register Nurse (RN)-A confirmed the facility had not addressed pharmacist requests for gradual dose reductions of Resident 13's Seroquel and Paxil that was dated 5/8/25 until 6/23/25 (45 days) and when the provider addressed the request for review, no clinical contraindication to reduce the doses were documented. C. Review of Resident 18's Care Plan with a revision date of 1/21/25 revealed the resident had sleep disturbance related to sleep apnea and insomnia and took the medications Melatonin (naturally occurring hormone supplement that affects sleep and wake cycles) and Trazadone (antidepressant medication) to help with nighttime sleeping. Review of Resident 18's MAR dated June 2025 revealed the resident took the antidepressant medication Trazadone 100mg daily at bedtime and the supplement Melatonin 10mg daily at bedtime. Review of Resident 18's Note to Attending Physician/Prescriber dated 6/7/25 generated by the consultant pharmacist indicating the resident's Trazadone was due to be reviewed for a dosage reduction. On 6/23/25 the Provider indicated No to the dosage reduction but did not document a clinical rationale for not attempting to reduce the dose. During an interview on 6/26/25 at 12:29 PM RN-A confirmed the pharmacist recommendation for review of Resident 18's Trazadone that was dated 6/7/25 and signed by the provider on 6/23/25, addressed the request for review, however, no clinical rationale to not reduce the dose was documented.

Licensure Reference Number 175 NAC 12-006.09D Based on interview and record review; the facility failed to ensure practitioner's orders were followed for 1 (Resident 25) of 1 sampled resident. The facility identified a census of 29. Findings are: Review of the facility policy Medication Administration with a revision date of 4/8/25 revealed if a medication was not available for 24 hours, the practitioner was to be notified the medication was not available and the staff were to be given directions for how to proceed. If the resident chose not to take the medication, this should be reported to the charge nurse and documented on the Medication Administration Record (MAR). The practitioner should also be notified if the resident continues to choose not to take the medication for more than 3 doses so that the prescriber can consider an alternative. Review of Resident 25's Medication Administration Record (MAR) dated 5/2025 revealed an order dated 4/25/25 for Yupelri (a medication which is used in the treatment of respiratory disease by relaxing the muscles around the airways in the lungs to make it easier to breath) Inhalation Solution 175 micrograms (mcg)/3 milliliters (ml) once daily for treatment of shortness of breath. Further review of the MAR revealed the medication was not available and had not been administered from 5/14/25 to 5/31/25 (18 out of the 31 days the medication was to have been received). Review of the resident's electronic medical record revealed no evidence the resident's practitioner was aware the Yupelri Inhalation Solution had not been available and had not been administered to the resident from 5/14/25 to 5/31/25. In addition, there was no documentation to indicate an alternate treatment/medication was provided for the resident. Further review of the resident's MAR dated 5/2025 revealed the resident had an order dated 4/23/25 for Novolog (rapid-acting insulin used to manage blood sugar levels in residents with diabetes) to inject 5 units before meals and at bedtime. From 5/3/25 to 5/12/25 the resident refused the scheduled Novolog insulin on 5/3 at 4:00 PM, 5/4 at 4:00 PM, 5/5 at 7:00 AM, at 11:00 AM, at 4:00 PM and at 9:00 PM, 5/6 at 7:00 AM, 11:00 AM and at 9:00 PM, on 5/7 at 7:00 AM, 11:00 AM. 4:00 PM, and 9:00 PM, 5/8 at 7:00 AM, 11:00 AM, 4:00 PM and 9:00 PM, 5/9 at 7:00 AM, 4:00 PM and 9:00 PM, on 5/11 at 9:00 PM and on 5/12 at 7:00 AM, 11:00 AM, 4:00 PM and at 9:00 PM (a total of 25 doses). Review of the resident's electronic medical record from 5/3/25 to 5/11/25 revealed no evidence the practitioner was aware of the resident's multiple refusals of the Novolog insulin. In addition, there was no documentation to indicate an alternate treatment was provided for the resident. Review of the Resident's MAR dated 6/2025 revealed the resident had an order dated 4/23/25 for Oxycodone (opioid analgesic used for treatment of moderate to severe pain) 5 milligram (mg) once in the AM and once in the PM. Further review of the MAR revealed the resident had refused the AM oxycodone dose from 6/1 to 6/6, from 6/9 to 6/15, from 6/18 to 6/20, on 6/23 and 6/24 and from 6/26 to 6/28 (a total of 21 out of 30 doses). Review of the resident's electronic medical record from 6/1/25 to 6/30/25 revealed no evidence the practitioner was aware of the resident's multiple refusals of the Oxycodone and that an alternate treatment/medication was ordered. During interviews on 7/1/25 at 7:11 AM and at 8:35 AM with the resident and the resident's spouse the following was identified. -the resident's Yupelri Inhalation Solution had not been available from the pharmacy and the resident was never offered any alternate treatment option. -the resident had been at home prior to the resident's admission to the facility on 4/23/35. While at home the resident only took the Novolog insulin with sliding scale (diabetes management method where the amount of insulin administered changes based on a person's current blood sugar level) to keep the resident's blood sugar from getting too low. -the resident had been refusing the AM dose of the Oxycodone as it made the resident too sleepy to participate in therapy or to visit with spouse. The resident was not offered any alternative pain medication. An interview with the Director of Nursing on 7/1/25 at 8:38 AM confirmed the resident had not received the Yupelri Inhalation therapy, the scheduled dose of Novolog insulin and the scheduled doses of Oxycodone as ordered by the resident's physician.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on record review and interviews; the facility failed to evaluate pressure ulcers (localized injury to the skin and underlying tissue, typically caused by prolonged pressure on the skin), to monitor interventions to ensure healing and to prevent the development of further pressure ulcers for 1 (Resident 21) of 3 sampled residents. The facility staff identified a census of 29. Findings are: Review of the facility policy Skin Assessment, Pressure Ulcer Prevention and Documentation with a revision date of 4/6/25 revealed the purpose of the policy was to systematically assess residents regarding potential risk of skin breakdown, to accurately document observations and assessments of residents, and to appropriately use prevention techniques and pressure re-distribution surfaces on those residents at risk for pressure ulcers. The following procedures were identified: -all residents were to be assessed/identified for their risk of developing pressure ulcers on admission/readmission by a Registered Nurse (RN) using the Braden Scale for Predicting Pressure Sore Risk form. -the assessment was to be completed quarterly or with a change in condition that could affect their risk for developing an ulcer. -all residents were to have a comprehensive skin assessment/inspection to identify any skin issues present including but not limited to pressure ulcers on admission/readmission and the results were to be documented in the medical record. -a comprehensive assessment was to be completed by the licensed nurse evaluating risk factors, the resident's skin condition and the nature of the pressure to which the resident may be subjected. The assessment was to identify which risk factors could be removed or modified. -when a pressure ulcer was present, staff were to complete the Wound Data Collection form daily. Documentation should include an evaluation of the ulcer if no dressing was present, the status of the dressing if present, the status of the area surrounding the ulcer and the presence of complications such as signs of infection, and an increase in area of ulceration. -the Primary Care Provider (PCP) was to be notified of the wound to obtain orders for treatment. -the dietary department was to be notified of the wound. -if the pressure ulcer was not determined to be clinically unavoidable, the ulcer should show signs of improvement. -the ulcer should be assessed weekly and documented on the Wound RN Assessment form. Observations of the wound's characteristics were to be documented by a licensed nurse and should include measurements: length, width and depth, characteristics of the ulcer including the wound bed, undermining, and tunneling exudate (fluid that leaks out of blood vessels into nearby tissues) surrounding skin, the presence of pain and the current treatment. Review of the resident's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 3/22/25 revealed the following regarding Resident 21: -cognitively intact. -was dependent on staff for assistance with toileting hygiene, showering/bathing, dressing, personal hygiene, bed mobility and transfers. -occasionally incontinent of bowel and bladder. -diagnoses of hip fracture, atrial fibrillation, diabetes, arthritis, and end stage renal disease. -at risk for pressure ulcer development, but no current pressure ulcers. Review of a Nursing Progress Note dated 4/15/25 at 6:21 PM revealed the resident's family was notified the resident had a wound to the resident's right heel. Review of Wound Data Collection forms revealed the following: -4/15/25 at 6:35 PM the resident had a stage 2 (the staging system is a method of summarizing characteristics of pressure ulcers, including the extent of tissue damage, a stage 2 pressure ulcer is a partial thickness skin loss that presents as an abrasion, blister or shallow crater) pressure ulcer which measured 1.9 centimeter (cm) by 1.8 cm with a depth of .1 cm. A new treatment was identified for the use of padded dressings and heel protectors (devices such as padded boots which are designed to reduce pressure to the heels). -4/20/25 at 7:10 AM the borders to the wound were reddened and the resident reported pain to the wound site. Bilateral heel protectors were in place and heels were offloaded (raise heels from surfaces to relieve pressure to the heels) as the resident allowed. -4/24/25 at 9:40 PM a minimal amount of serosanguineous (containing both blood and a thin watery fluid) drainage was observed to the right heel. No measurements were completed and there was no further assessment of the wound characteristics. -4/30/25 at 7:10 PM the pressure ulcer remained at a stage 2. There were no measurements and/or assessments of the wound to identify potential healing or a decline in the wound. -5/2/25 (2 weeks and 3 days after the ulcer was first identified) at 5:58 AM the resident's pressure ulcer measured 1.5 cm by 1.8 cm. The assessment indicated that the resident now had a pressure ulcer to the left heel which measured 1 cm by 0.8 cm. -5/11/25 at 5:59 PM the resident voiced complaints of pain to the pressure ulcers to both heels and there was a moderate amount of drainage. Further review revealed no measurement or further assessments of the ulcers. -5/20/25 at 7:26 PM the right heel pressure ulcer had now been assessed as a stage 3 (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss). The right heel pressure ulcer had an increasing area of ulceration, there was increased redness and swelling around the wound with increased drainage. The pressure ulcer was larger in diameter and was musty, foul, and odorous. There were no measurements included with this assessment. -5/23/25 at 3:20 PM the pressure ulcer to the right heel had brown/green exudate to the wound bed and measured 6.5 cm x 6 cm with a depth of 0.1 cm. The wound bed had a foul odor with heavy serosanguineous drainage. The resident's left heel pressure ulcer measured 1 cm by 1.4 cm with a depth of 0.2 cm. Review of a Nursing Progress Note dated 5/23/25 at 3:41 PM revealed the resident was seen by the Wound Nurse. New orders were received to cleanse the pressure ulcers with soap and water, apply a zinc-based cream to the wound edges, then place a Dankin's (antimicrobial wound cleanser) soaked gauze pad to the wound bed and cover with a padded dressing. The resident was started on Amoxicillin (antibiotic) 875-125 milligrams twice a day for 10 days due to the infection of the resident's right heel. Review of Wound Data Collection forms revealed the following: -5/24/25 at 10:42 AM the pressure ulcer to the right heel was noted to have a brown wound bed, moderate drainage to the dressing when removed, foul odor, and macerated (broken down due to prolonged exposure to moisture) wound edges. The skin to the wound edges of the left heel pressure ulcer was also macerated and the wound bed was covered with brown exudate. -5/25/25 at 1:10 AM the resident's right heel pressure ulcer had a brown/blackish wound bed, a moderate amount of purulent drainage with a foul odor and macerated wound edges. -5/26/25 at 2:24 PM the right heel was a full thickness pressure ulcer. The tissue surrounding the dressing was reddened with purulent (consisting of pus, a thick, yellowish-white fluid typically associated with infection)/serosanguinous drainage. The left heel was also identified as a full thickness pressure ulcer. Review of Dietary Progress Note dated 5/27/25 at 3:13 PM revealed a recommendation by the Registered Dietitian for Arginaid (nutritional supplement with added protein to aid in wound healing) to be provided at all meals. Review of the resident's electronic medical record revealed no evidence the Arginaid was implemented for the resident. A review of a Physician Visit form dated 5/29/25 revealed the resident was seen at the Wound Clinic. New orders were received for Enluxtra (dressing which provides moist healing of chronic to acute wounds with heavy drainage) dressing to both heels. The dressings were to remain in place until the next Wound Clinic appointment and the resident was to wear Prevalon boots (heel protectors). The resident was to have legs elevated above the level of the heart as much as possible and to avoid sitting with legs down. Cultures (process of growing microorganisms to determine the type of bacteria in a wound) were completed of the wounds to both heels. Review of a Nursing Progress Note dated 6/2/25 at 2:31 PM revealed a new order was received for Doxycycline (antibiotic) 100 mg twice a day for 20 administrations for wound healing. Review of a Nursing Progress Note dated 6/3/25 at 12:19 PM revealed the facility had received a phone call from the wound clinic advising the facility the resident needed to be transferred to the hospital for further evaluation of vascularization (the process where new blood vessels develop, either naturally or as a result of a medical condition, within a tissue or organ) to lower extremities. The wound nurse indicated that due to the resident's poor vascular status, the wounds would have gotten worse no matter what interventions were put into place. Review of a Progress Note dated 6/5/25 at 8:10 AM revealed the resident left the facility at 7:15 AM for admission to the hospital. During an interview on 6/30/25 at 8:34 AM, the Director of Nursing (DON) identified the following regarding Resident 21's pressure ulcers: -the resident was admitted [DATE] after a fall at home with subsequent left shoulder and left hip fracture. No pressure ulcers were assessed with the resident's admission assessment. -the resident had ongoing pain management issues related to the resident's back and recent fractures. The resident was not always compliant with getting up and out of bed and with repositioning due to pain. -a Wound Data Collection form was completed 4/15/25 at 6:35 PM and indicated the resident had a stage 2 pressure ulcer to the right heel. The wound was measured and assessed with a treatment initiated. Staff were to float the resident's heels and heel protectors were placed on the resident when in bed. -the right heel ulcer was not measured again until 5/2/25 (2 weeks and 2 days later) and the wound was 1.5 cm x 1.8 cm. Also at this time, a new pressure ulcer was identified to the left heel which measured 1 cm x 0.8 cm. -treatment was not initiated to the left heel pressure ulcer until 5/5/25. -5/20/25 the pressure ulcer to the resident's right heel was now assessed as stage 3. The wound was larger in size, with increased drainage and had a foul odor. No measurements of the wound were completed. -the right heel pressure ulcer was not measured again until 5/23/25 (3 weeks later) and the ulcer now measured 6.5 cm x 6 cm with a depth of 0.1 cm. The wound continued to have a foul odor with heavy drainage and brown/green exudate to the wound bed. The wound nurse evaluated, and new treatment orders were implemented. An antibiotic was started for signs of infection. -5/23/25 (3 weeks since previous measurement) the left heel was measured at 1 cm x 1.4 c x 0.2 cm. No further measurements were completed of the resident's heel pressure ulcers. -5/27/25 at 3:13 PM a recommendation was received by the RD for a nutritional supplement with added protein for wound healing to be given with each meal. There was no documentation in the medical record that this supplement was given and/or accepted by the resident. -5/29/25 the resident was seen at the wound clinic and new orders implemented for the pressure ulcers. Cultures were completed on both residents' pressure ulcers. -6/2/25 at 2:31 PM the resident was started on an additional antibiotic based on results of the wound cultures. -6/3/25 the resident was sent to a follow up appointment at the wound clinic with a recommendation for hospitalization. -6/5/25 at 7:15 Am the resident was sent to the hospital. -staff failed to ensure a weekly assessment was completed to include documentation of the pressure ulcers measurements and characteristics of the wound to ensure healing of the pressure ulcers and to determine a need for a change in treatment of the ulcers.

Licensure Reference Number 175 NAC 12-006.09(I) Based on record review and interviews; the facility failed to implement and monitor Care Plan fall prevention interventions for Resident 20. The sample size was 1 and the facility census was 29. Findings are: Review of the facility policy Fall Prevention and Management dated 4/8/25 revealed the following: -The facility promoted resident well-being by developing and implementing a fall prevention and management program to identify risk and implement measures before falls occurred. -Communicated that a fall had occurred and updated the Care Plan with any changes or new interventions, and -monitored the condition and effectiveness of interventions. Review of Resident 20's Falls Tools (tool used to evaluate fall risk) revealed the following: -on 5/19/25 at 1:58 PM the fall tool revealed the resident was at high risk for falling, -on 6/16/25 at 8:30 PM the fall tool revealed the resident was at high risk for falling. Review of the Resident 20's Event Abstract dated 5/18/25 at 1:30 PM revealed Resident 20 was trying to hurry to the toilet and sat on the bathroom floor. The intervention was telling the resident to call for help when needed. Review of the Resident 20's Event Abstract dated 6/15/25 at 8:30 PM revealed Resident 20 fell trying to get into the w/c to use the bathroom when the w/c moved and caused the resident to slide off the side of the bed. The resident was observed sitting on the floor next to the bed and the w/c, and the left w/c brake was unlocked. The intervention was for routine toileting in the morning, before and after meals, at bedtime and as needed. Review of Resident 20's Care Plan with a revision date of 6/16/25 revealed the resident was at risk for falling, had weakness, and difficulty walking. The following interventions were added to the Care Plan following falls: -On 6/2/25 an anti-roll back device was added to the resident's wheelchair on 5/18/25, and staff were to keep the wheelchair (w/c) locked at bedside, for the resident to use when transferring and ambulating in the room. -On 6/16/25 the facility was to review the resident's bowel and bladder continence status and establish and/or review the toileting plan based on resident's needs and provide routine toileting before and after meals, at bedtime and as needed through the night. During an interview on 6/26/25 at 9:13 AM Registered Nurse (RN)-A reported that when the RN asked nursing staff about cares and a toileting schedule the Nurse Aides on duty reported that the resident was independent. During an interview on 6/26/25 at 11:50 AM with Nurse Aide (NA)-C revealed we help the resident get ready in the morning, but then the resident took self to the bathroom throughout the day. The NA was not aware of any routine toileting plan for Resident 20. During an interview on 6/30/25 at 8:40 AM NA-F revealed the resident was normally independent. Staff set up the clothing in the morning and provided reminders about mealtimes, activities or other things. The resident toileted independently during the day, was normally continent, and the staff did check for incontinence products in the trash throughout the day. NA-F was not aware of any routine toileting plan for Resident 20. During an interview on 7/1/25 at 10:24 AM the Director of Nursing (DON) confirmed the following: after falling on 6/15/25 the facility reviewed the Resident 20's fall and implemented a measure for toileting with morning and bedtime cares and before and after meals. The DON was not aware staff were not completing this approach to fall prevention and confirmed staff should have been doing so. Further interview confirmed the fall intervention was not effectively communicated or being monitored.

Based on record review and interview; the facility failed to ensure Resident 6, was offered the COVID-19 vaccine, or was provided with education on the benefits and risks of the vaccine in order to make an informed decision on staying up to date on the COVID-19 vaccination status. The sample size was 5 and the facility census was 29. Findings are: Review of the facility policy Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19, and Other with a revision dated of 11/20/24 revealed the following: -The facility provided residents with the opportunity to receive immunizations as they fit into their healthcare goals and to provide guidance for the facilities program including recommended vaccines. -The facility reviewed each resident's immunizations upon admission, and on an ongoing basis. -The facility provided vaccine information statements for influenza, pneumococcal, and COVID-19 vaccines. -The facility provided documented education on the benefits and potential side effects of the vaccinations for which residents were eligible, obtained written consent if required, and -administered the vaccine or referred the resident to a provider, pharmacy, or 3rd party administering the vaccines. Review of Resident 6's Care Plan with a revision date of 5/27/25 revealed the resident was admitted to the facility on [DATE], had heart failure and heart disease as well as mild cognitive impairment. The resident had received treatment with an antibiotic for an upper respiratory infection starting 5/19/25. Review of Resident 6's Vaccine Consent dated 6/19/25 revealed the resident did not consent to or decline the COVID-19 vaccine. Review of Resident 6's Immunization Report dated July 1, 2025, revealed the resident's most recent COVID-19 Booster Vaccine was received on 11/21/23. During an interview on 6/30/25 at 2:06 PM the facility Infection Preventionist Register Nurse confirmed Resident 6 was admitted to the facility on [DATE] and was not offered a COVID 19 vaccine booster at the time of admission or since, thus the resident was not current on the COVID vaccine.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, interview, and record review; the facility failed to identify causal factors and to revise and/or develop fall interventions to prevent ongoing falls for Residents 79, 25, and 6 and to implement fall interventions for Resident 6. The sample size was 4 and the facility census was 24. Findings are: A. Review of the facility policy Fall Prevention and Management last reviewed on 4/2/24 revealed the following: -the facility would care plan the appropriate interventions, -communicate fall risks and interventions to prevent a fall before it occurred, care plan it, add to the daily standup meetings and/or fall committee meetings, -communicate any identified environmental changes and/or referral needs, -if any teaching was done, it would be documented in the medical record, -fall occurrences would be communicated during shift change and daily stand-up meetings, -care plans would be updated with any changes and new interventions, and -the effectiveness of interventions would be monitored. B. Review of Resident 6's Minimum Data Set (MDS), a federally mandated assessment tool used in care planning, dated 5/31/24 revealed the following: - the resident admitted on [DATE], - the resident had diagnoses of: depression, arthritis, and epilepsy (seizure disorder), - the resident was severely cognitive impaired, - the resident was dependent with toileting, and required substantial assistance with dressing, hygiene, and transfers, and - the resident had 1 fall with no injury. Review of Resident 6's Care Plan last revised 6/9/24 revealed the following: -the resident had impaired cognitive function related to a genetic disability, -the resident required assistance with transfers, dressing, toilet use and personal hygiene, and -fall interventions included: education to family, ensure resident was wearing appropriate footwear, avoid clothing that was a fall risk such as loose, slippery, and too long, review bowel and bladder continence, and establish a toileting plan. Review of Resident 6's nursing order administration record for July 2024 revealed the resident had an order implemented on 6/14/24 for a pull tab alarm on their recliner/wheelchair and staff were to check the function every shift. The alarm was documented as on and functioning normally July 1, 2024 through July 8, 2024. Review of the facility form Incident Reports for Resident 6 regarding falls revealed the following: -5/27/24 at 4:15 AM the resident had a fall while attempting a self-transfer with no long-term intervention implemented, -6/8/24 at 3:45 PM the resident had a fall where the resident was found on the floor in their room with no long-term intervention implemented, -6/14/24 at 4:20 PM the resident slid out of the recliner and was found on the floor in the resident room with no intervention implemented (this report was not fully completed or signed), -6/16/24 at 6:00 PM the resident was found on the floor in the resident's room, the pull tab alarm was not hooked up and an intervention to toilet at 4 PM had been implemented, -6/23/24 at 10:30 AM the resident was found in the dining room on the floor after reaching for an item, the report did not indicate whether the alarm was on and functioning, and no long-term intervention had been implemented, and -7/6/24 at 4:05 PM the resident had a fall while attempting a self-transfer, the resident's pull alarm had been removed and no long-term intervention had been implemented. Observation on 7/3/24 at 11:30 AM with Nursing Assistant (NA)-E revealed Resident 6's pull tab alarm was on the recliner and not hooked up to the resident. NA-E assisted the resident to the bathroom, and when finished NA-E did not secure the alarm to the resident. The resident self-propelled the wheelchair independently out of the resident's room. Observation on 7/3/24 at 11:40 AM revealed Resident 6 was self-propelling their wheelchair to the dining room. There was no alarm in place. Observation on 7/3/24 at 2:40 PM revealed Resident 6's pull tab alarm remained on the resident's recliner in the resident's room. The resident was in the commons area and no alarm was in place. Interview on 7/3/24 at 2:42 PM with Registered Nurse (RN)-D confirmed Resident 6 was to have an alarm in place when in the recliner and in the wheelchair. Further interview confirmed the resident did not have an alarm on. Observation on 7/8/24 at 10:35 AM revealed Resident 6's pull tab alarm was in the resident's room on the resident's recliner. The resident was in their wheelchair in the dining room working on a puzzle with no alarm in place. Interview on 7/8/24 at 10:35 AM with Licensed Practical Nurse (LPN)-H confirmed the resident had an order for a pull tab alarm in the recliner and in the wheelchair. Further interview confirmed the resident did not have the alarm in place. Interview on 7/8/24 at 10:40 AM with the Director of Nursing (DON) confirmed the resident should always have the pull tab alarm on when in the recliner and in the wheelchair. Further interview at 12:33 PM confirmed interventions had not been implemented to prevent future falls. C. Review of Resident 25's MDS dated [DATE] revealed the following: - the resident admitted on [DATE], - the resident had diagnoses of: dementia, high blood pressure, atrial fibrillation (irregular heartbeat), and kidney disease, - the resident had severe cognitive impairment, - the resident was dependent with toileting, dressing, transfers, and hygiene needs, and - the resident had 2 or more falls with no injuries. Review of Resident 25's Care Plan last revised 5/31/24 revealed the following: - the resident had impaired cognitive function related to dementia, - the resident required assistance with transfers, toileting, and dressing, - the resident had a personal alarm to alert staff of ambulation attempts, and - the resident's fall interventions included: ensure the resident was wearing appropriate footwear, avoid clothing that is too loose, personal alarm in bed, wheelchair, and recliner. Review of the facility form Incident Reports regarding Resident 25's falls revealed the following: -5/31/24 at 8:35 PM the resident had a fall while attempting to self-transfer out of the recliner with no long-term intervention implemented, -6/10/24 at 9:45 PM the resident had a fall while attempting to self-transfer to the toilet with no long-term intervention implemented, -6/12/24 at 10:20 AM the resident had a fall while attempting to self-transfer with no long-term intervention implemented, and -6/16/24 at 8:50 PM while attempting to self-transfer the resident slid out of the wheelchair with no long-term intervention implemented. Interview with the DON on 7/8/24 at 12:33 PM confirmed interventions were not implemented for Resident 25 to prevent future falls. 29638 D. Review of Resident 79's MDS dated [DATE] revealed the following: - the resident had diagnoses of a hip fracture, arthritis, and anxiety, - the resident required substantial assistance with toileting, bed mobility and transfers, and - the resident had moderate cognitive impairment. Review of Resident 79's current Care Plan dated 11/1/23 revealed the resident was at risk for falls related to a previous fall at home and a subsequent hip fracture. The following fall interventions were identified: -educate/instruct the resident on safe use of assistive devices, -remind the resident not to bend over to pick items up from the floor, -ensure use of appropriate footwear, and -avoid clothing which increases risk of falls. Review of facility Incident Reports for Resident 79 regarding falls revealed the following: -11/7/23 at 11:25 PM the resident was found on the floor of the resident's room. The resident had attempted to self-transfer and fell . A new intervention for a pull tab alarm to be always on the resident. -11/13/23 at 11:20 AM the resident was found on the floor in the corridor outside of the resident's room. Further review of the report revealed no causal factors were identified, there was no documentation to indicate if the pull tab alarm was in place and/or functioning and current fall interventions were not revised or new interventions developed. -11/25/23 at 2:15 PM the resident was found on the floor of the resident's room. Staff were to monitor the resident for the remainder of the shift for any changes. No causal factors were indicated, there was no evidence the pull tab alarm was in place or if the alarm was functional. No long-term interventions were developed to prevent further falls. -12/6/23 at 11:50 AM the resident was found on the floor of the resident's room. The assessment made no mention as to whether the resident's pull tab alarm was in use. A new intervention for a silent fall alarm was established. -12/8/23 at 9:15 PM the resident was found on the floor in the doorway of the bathroom. No causal factors were indicated, and the staff failed to document if the pull tab alarm and/or the silent alarm were in use at the time of the fall. No additional interventions were identified. -12/14/23 at 1:11 PM the resident was found on the floor of the resident's room. The resident had slid off the footrest of the recliner. The fall alarms were in place and were sounding. The resident was wearing a regular pair of socks and staff indicated a new intervention for gripper socks. -12/27/23 at 6:20 PM the resident was found on the floor of the corridor. The resident was in the wheelchair and leaned forward, falling out of the chair, and triggering the fall alarms. Staff identified an intervention to place the resident in the recliner or in the bed if the resident was having increased restlessness and to not leave the resident in the wheelchair. -1/6/24 at 6:15 PM the resident was found on the floor of the resident's room. The resident had slipped out of the recliner. No causal factors were indicated, and the staff failed to document if the pull tab alarm and/or the silent alarm were in use at the time of the fall. A new intervention was indicated for the staff to place the resident in a recliner in the commons/television room for increased supervision. -1/9/24 at 5:20 AM the resident had been found on the floor of the commons/television area. The report identified the resident's alarms were in place, however, did not alarm. Further review revealed no evidence an investigation was completed to determine why the alarms did not sound and no new interventions were developed. An interview with the DON on 7/8/24 at 10:01 AM, confirmed the following for Resident 79: -11/7/23 a pull tab alarm was placed on the resident for fall prevention. -the resident had falls on 11/13/23 at 11:20 AM, on 11/25/23 at 2:15 PM, and on 12/8/23 at 9:15 PM. No causal factors were identified. there was no evidence the pull tab alarm was in place and there were no additional interventions identified to prevent ongoing falls. -the resident had a fall on 1/6/24 at 6:15 PM. No causal factors were identified, and staff failed to document if fall alarms were in place and functional at the time of the fall. -the resident had a fall on 1/9/24 at 5:20 AM. The pull tab and silent alarms were in place at the time of the fall, but they did not alarm. There was no investigation to determine why the alarms had malfunctioned and no new fall interventions were developed.

Licensure Reference Number 175 NAC 12-006.12(D) Based on observation, interview and record review, the facility failed to ensure 4 residents' (Residents 6, 8, 17, and 83) medications had a record of accounting to prevent loss or theft of medications while awaiting disposition. The sample size was 4 and the facility census was 24. Findings are: A. Review of the undated facility policy Medication: Disposition with a revised dated of 8/1/23 revealed the purpose of the policy was to ensure accurate disposal of medications and provided instruction for the disposition of medications. The following procedures were identified: -physician orders to discontinue medications were to be recorded and the medication immediately removed from the resident's supply, -discontinued medications were to be kept in a secure place in the medication room until returned to the pharmacy or destroyed, -disposal of any medication was to be carried out in accordance with local, state, and federal guidelines, and -documentation of medications to be returned to the pharmacy or destroyed was to include the resident's name, medication name, prescription number, quantity, date of disposition and the involved staff member or applicable individuals. B. An observation of the medication storage room on 07/08/24 at 10:09 AM revealed a locked cabinet drawer which was unlabeled, and which contained 5 medications stored inside. Interview on 07/09/24 at 10:15 AM with Licensed Practical Nurse (LPN)-H revealed the medications were awaiting destruction. Further observation on 07/08/24 at 10:20 AM of the medication room revealed no evidence of record keeping/accounting for each medication stored in the drawer and awaiting destruction. Interview with Registered Nurse (RN) Consultant-P on 07/08/24 at 10:30 AM confirmed there was no documentation related to medications which had been discontinued and were to be destroyed for the following residents and medications: -Resident 6 (Erythromycin ophthalmic ointment (medication used to treat infections of the eye) and Moxifloxacin (medication used to treat a bacterial infection) solution 0.5 percent), -Resident 8 (Naphcon A (medication used to treat allergies) ophthalmic drops). In addition, the RN Consultant-P confirmed the residents' medications were at risk of potential loss or theft without the required documentation and should have included the residents' name, date, medication name, dosage, and quantity of each medication, -Resident 17 Ativan (medication used to treat anxiety) 2 milligrams per milliliter, and -Resident 83 Lorazepam (medication used to treat anxiety) 2 milligrams per milliliter. In addition, the RN Consultant-P confirmed the residents' medications were at risk of potential loss or theft without the required documentation and should have included the residents' name, date, medication name, dosage and quantity of each medication.

Licensure Reference Number 175 NAC 12-006.06 Based on record review and interviews; the facility failed to address repeat grievances, and to ensure sustainable resolutions of concerns related to the provision of cares and activities for Resident 21. The sample size was 1 and the facility census was 24. Findings are: Review of the facility's Grievances, Suggestions and Concerns Policy with a revision date of 11/14/23 revealed the purpose of the policy was to document concerns, investigative findings, and plans of correction and to develop a systematic approach in resolving grievances as a tool to ensure continuous quality of care. The following procedure was identified: -a grievance was to be documented and then submitted to the grievance official Social Service Director (SSD), -the grievance official was to route the grievance to the appropriate department manager as soon as reasonably possible, -an investigation was to be completed for all grievances. The investigation could be informal, but it was to be thorough, -the grievance official was to issue a written grievance decision to the individuals filing the concern and to the Administrator. The decision needed to include the date the grievance was received, a summary statement of the grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions, a statement whether the grievance was confirmed or not, any corrective action because of the grievance and the date the written decision was issued, and -if the individual was not satisfied with the response and/or resolution to the grievance, the Administrator was to be notified. Review of a Suggestion/Concern/Grievance form dated 8/22/23 revealed Resident 21's family had the following concerns: -oral cares were not completed, -towels/wash cloths were rarely use in the resident's bathroom, -the resident's fall alarm had been left unplugged from 8/19/23 to 8/23/23, and -the resident was not being toileted before the breakfast meal. Further review of the form revealed a resolution dated 8/31/23 for training and education to be provided to the direct care staff regarding these concerns. In addition, documentation dated 9/5/23 revealed the family had no further concerns. Review of a Suggestion/Concern/Grievance form dated 8/28/23 revealed Resident 21's family did not feel the resident was receiving the needed assistance with the resident's meals. A resolution dated 9/5/23 revealed the Director of Nursing (DON) was to ensure the resident received adequate assistance at mealtimes. A resolution dated 9/5/23 revealed no further concerns. Review of a Suggestion/Concern/Grievance form dated 11/1/23 revealed family did not feel Resident 21 was receiving 1:1 activity on a weekly basis as documented in the resident's Care Plan. A resolution dated 11/1/23 revealed the resident's 1:1 activity would be increased to 2-3 times a week. Staff documented on 11/8/23 the family was happy with this resolution. Review of a Suggestion/Concern/Grievance form dated 11/11/23 revealed Resident 21's family came to the facility to assist the resident with eating the breakfast meal. The family found a room tray from the previous evening left uncovered on a bedside table in the resident's room. Family was upset as the resident had been losing weight and it did not seem as if staff were providing assistance to the resident with eating/drinking. 11/14/23 a documented resolution revealed staff had received re-education regarding the need to assist residents with intakes especially when having weight loss. 11/30/23 the Administrator and the SSD followed up with the family and they indicated they were happy with resolution. Review of a facility document labeled Education/Counseling dated 11/30/23 revealed 3 staff, Nurse Aides (NAs)-C, E and Q received education regarding accurate documentation of a nutritional supplement, checking/changing and toileting residents every 2 hours and making sure all residents were toileted when they were provided morning cares, and before/after each meal. Review of a Documentation Survey Report (form used to document the resident's participation in activities) from 11/1/23 to 11/30/23 revealed Resident 21 received no 1:1 activity during this time frame. Review of a Documentation Survey Report from 12/1/23 to 12/31/23 revealed the resident received a 1:1 activity on only 1 day, 12/23/23. Review of a Suggestion/Concern/Grievance form dated 1/31/24 revealed Resident 21's family were concerned the resident's fall alarm was not being plugged in; the resident was not being toileted every 2 hours; and the resident's nutritional supplement was not documented correctly. 2/7/24 the nursing staff were educated regarding proper use of the fall alarms, documentation of nutritional supplements and toileting schedules. 2/15/24 the family indicated no further concerns. Review of a Documentation Survey Report from 1/1/24 to 1/31/24 revealed Resident 21 received no 1:1 activity during this time frame. Review of a Documentation Survey Report from 5/1/24 to 5/31/24 revealed Resident 21 received a 1:1 activity on only 1 day, 5/9/24. Review of a Documentation Survey Report from 6/1/24 to 6/30/24 revealed Resident 21 received no documented 1:1 activity during this time frame. During interviews on 7/2/24 at 2:20 PM and on 7/3/24 at 1:44 PM, Resident 21's family reported continued concerns related to 1:1 activity provision, assistance with food/fluids at meals, toileting assistance, oral cares, and repositioning. Interview with the DON and the Administrator on 7/8/24 at 2:57 PM verified no further documentation other than the counseling provided to staff on 11/30/23 that direct care staff had received re-education regarding the provision of cares for Resident 21 to address the family's ongoing concerns. Interview with the SSD on 7/9/24 at 10:03 AM confirmed there was no evidence additional 1:1 activity was provided for Resident 21 despite the family's continued concerns.

Licensure Reference Number: 175 NAC 12-006.04(F)(i)5 Based on record review and interviews; the facility failed to notify Resident 21's family/responsible party of changes in the resident's condition related to weight loss and the initiation of nutritional interventions to address weight loss. The sample size was 1 and the facility census was 24. Findings are: A. Review of the facility policy Notification of Change with revision date of 12/4/23 revealed the facility was to monitor residents for changes in their condition, to respond appropriately to these changes and to notify the physician and the responsible party/family members of the changes. B. Review of Resident 21's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 4/10/24 revealed diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, and depression. The resident required substantial to moderate assistance with dressing, personal hygiene, bed mobility and transfers and was dependent with oral and toileting hygiene; was incontinent of bowel and bladder; and cognition was severely impaired. Review of Resident 21's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature, and pulse) revealed the following regarding the resident's weights: -9/7/23 weight was 132 pounds (lbs.). -11/13/23 weight was 118 lbs. (down 14 lbs. or an 11% weight loss in 2 months). Review of Resident 21's Nursing Progress Note dated 11/15/23 at 3:42 PM revealed the resident's Primary Care Physician (PCP) was notified of the resident's substantial weight loss and that Magic Cup (nutritional supplement which was like ice cream when frozen and was like pudding when refrigerated) was started to prevent further weight loss. Review of Resident 21's medical record revealed no evidence the resident's responsible party/family had been notified of the resident's weight loss or of the initiation of the Magic Cup nutritional supplement. Review of Resident 21's Nursing Progress Note dated 11/28/23 at 6:37 PM revealed a new order to change the resident's diet to soft, bite sized food. Review of Resident 21's medical record revealed no evidence the family/responsible party was notified of the resident's diet change. Review of Resident 21's Nutritional Progress Note by the Registered Dietician dated 12/22/23 at 9:04 AM revealed the resident had an open area to the resident's coccyx and made a recommendation to start Arginaid (nutritional supplement with added protein for wound healing) 240 cubic centimeters (cc) daily. Review of Resident 21's Progress Note dated 2/3/24 at 1:26 PM revealed a new order to discontinue use of the Magic Cup nutritional supplement as it was no longer available from the supplier. Review of Resident 21's Medication Administration Record (MAR) dated 6/2024 revealed the resident was re-started on the Magic Cup 6/18/24 to maintain the resident's weight. Review of Resident 21's medical record from 12/22/23 to 6/20/24 revealed no evidence the family/responsible party was notified of: -initiation of the Arginaid on 12/23/23, -discontinuation of the Magic Cup on 2/3/24, and -re-starting of the Magic Cup on 6/18/24 to maintain the resident's weight. During an interview on 7/3/24 at 1:44 PM, Resident 21's family member reported a concern regarding lack of notification related to the resident's weights and weight loss interventions to maintain the resident's weight. Interview with the Director of Nursing (DON) on 7/8/24 at 9:58 AM confirmed staff should have notified Resident 21's responsible party/family of the resident's significant weight loss on 11/13/23, initiation of the Magic Cup on 11/15/23, change in diet order on 11/28/23, starting the Arginaid on 12/22/23 for wound healing, discontinuation of the Magic Cup on 2/3/24 and the re-starting of the Magic Cup on 6/18/24.

Licensure Reference Number 175 NAC 12-006.09D7 Based on record review and interview; the facility failed to review falls for causal factors and implement measures to prevent ongoing falls for Resident's 15, 17, 20, and 75. The sample size was 4 and the facility census was 21. Findings are: A. Record review of the facility policy Fall Prevention and Management with a revision date of 3/29/23 revealed the following; -The facility promoted resident well-being by developing and implementing a fall prevention and management program. -identified risk factors and implemented interventions before falls occurred, -gave prompt treatment after a fall occurred, -utilized proactive approaches before falls occurred, -care planned appropriate and personalized interventions, and -communicated fall risks and interventions to prevent falls. -following a fall staff would update the plan of care with any changes or new interventions, and -monitor the resident's condition and the effectiveness of interventions. B. Record review of Resident 20's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident Care Plans) dated 3/23/23 revealed the resident was admitted to the facility on [DATE], had diagnoses of Parkinson's disease, Hypertension, and Depression, received assistance with bed mobility, dressing, and toileting, and had fallen prior to and since admission. Review of Resident 20's Incident Reports revealed the following; -On 3/19/23 at 3:55 PM the resident had a fall in the bathroom with family present. The family member had assisted the resident into a recliner after the fall. The resident sustained a small cut to the arm. The facility educated the family and resident about call light use, and asking that the staff assist the resident rather than family doing it. -On 4/12/23 at 6:20 PM staff responded to a door slam and found the resident on the floor beside the closet. There was no evidence the facility reviewed the fall for a potential cause or implemented any additional measures to prevent ongoing falls. -On 4/26/23 at 10:30 AM the resident fell while in therapy. There was no evidence the facility reviewed the fall for a potential cause or implemented any additional measures to prevent ongoing falls. -On 4/28/23 at 10:45 AM the resident reported falling in the bathroom and crawling to a recliner in the room. The resident was moved to a room closer to the nurse's station for closer observation. -On 4/30/23 at 12:35 PM the resident was found lying on the floor in the hallway after losing balance and falling with staff attempting to intervene. The resident was re-educated on the importance of using the call light to request assistance. -On 5/11/23 at 9:00 AM the resident fell in the dining room after losing balance. Staff were present and assisted but were unable to prevent the fall. There was no evidence the facility reviewed the fall for a potential cause or implemented any additional measures to prevent ongoing falls. -On 5/16/23 at 9:30 AM the resident was found lying on the floor in the dining area near the resident's table. There was no evidence the facility reviewed the fall for a potential cause or implemented any additional measures to prevent ongoing falls. -On 5/23/23 at 8:35 AM the resident stood up from a wheelchair in the dining and the wheelchair rolled back and the resident fell to the floor. The intervention was to take the resident back to the resident room following meals and assist to bed or recliner. -On 5/27/23 at 5:45 PM the resident was found on floor at bedside just after having been assisted to bed. There was no evidence the facility reviewed the fall for a potential cause or implemented any additional measures to prevent ongoing falls. -On 5/30/23 at 7:52 PM the resident fell while trying to get up from a wheelchair, tripped over the wheelchair pedals, and fell into the wall. Record review of Resident 20's Care Plan with a revision date of 5/31/23 revealed the resident had limited physical mobility, weakness, self-care deficits, poor balance, and was at risk for falling. Additional review revealed no evidence the fall prevention interventions were reviewed or updated following falls on 4/12/23, 4/26/23, 4/30/23, 5/11/23, 5/16/23, 5/23/23, and 5/27/23. C. Record review of Resident 17's MDS dated [DATE] revealed the following; the resident had a diagnosis of Dementia, had severe cognitive impairment, required assistance with bed mobility, transfers, dressing, and toileting, and had 2 or more falls since the previous assessment. Record review of Resident 17's Incident Reports revealed the following; -On 12/30/22 at 5:40 PM the resident was found sitting on the floor of the resident's room. The resident reportedly lost balance. There was no evidence the facility reviewed the fall for a potential cause or implemented any additional measures to prevent ongoing falls. -On 1/12/23 at 5:45 PM the resident was found lying on the floor in the dining room. Immediate action to be taken was to increase supervision with ambulation. -On 2/23/23 at 4:30 PM the resident was found sitting on the floor in a resident room. The resident was not using a walker as needed and was reminded to use a walker. There was no evidence the facility implemented any new or additional measures to prevent ongoing falls. -On 3/31/23 at 12:55 PM the resident was found sitting on the floor in the resident's room. A fall alarm for the resident's bed and chair were initiated. -On 4/10/23 at 1:15 PM the resident was found on the floor outside of a restroom. There was no evidence the facility implemented any new or additional measures to prevent ongoing falls. -On 4/17/23 at 9:40 AM the resident was founding lying on the floor in the resident's room. An intervention to have the resident sit in the TV sitting area during awake hours was initiated. Record review of Resident 17's Care Plan with a revision date of 5/10/23 revealed the resident had Dementia with impaired cognitive function, limited physical mobility, weakness, a history of falling, and was at risk for falling. Additional review revealed no evidence the fall prevention interventions were reviewed or updated following falls on 12/30/22 or 2/23/23. D. Record review of Resident 15's MDS dated [DATE] revealed the resident had diagnoses of dementia, anxiety, and depression. In addition, the resident was severely impaired cognitively, displayed inattention and disorganized thinking, wandered daily, and received assistance with bed mobility, transfers, dressing, toileting and eating; was incontinent of bowel and bladder, and had fallen since the previous assessment. Record review of Resident 15's Incident Reports revealed the following; -On 3/28/23 the resident was found on the floor outside of the facility laundry room. There was no evidence the facility reviewed the fall for a potential cause or implemented any additional measures to prevent ongoing falls. -On 4/25/23 the resident was found on the floor of the resident's room. Initially the family member was at the bedside for the afternoon, however there was no evidence the facility reviewed the fall for a potential cause or implemented any additional measures to prevent ongoing falls. Record review of Resident 15's Care Plan with a revision date of 5/31/23 revealed the resident had impaired cognitive function, difficulty following directions, self-care deficits, and was at risk for falling. Additional review revealed no evidence the fall prevention interventions were reviewed or updated following falls on 3/28/23 or 4/25/23. E. Interview on 6/7/23 at 1:15 PM with the Director of Nursing (DON) revealed the facility did not evaluate all falls for causal factors and develop new interventions based on causal factors to prevent ongoing falls for Resident's 15, 17, and 20. F. Rcord review of Resident 75's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of stroke, traumatic brain injury, anxiety, depression and repeated falls. The following was assessed regarding Resident 75: -cognition was severely impaired; -required extensive staff assistance with toilet use, bed mobility, transfers, dressing and personal hygiene; and -frequently incontinent of urine. Record review of an Incident Report dated 3/24/23 at 4:10 PM revealed the staff went to check on the resident who had been left alone in the bathroom and found the resident lying on the floor. The resident stated, I slipped off the toilet. Further review of the report revealed the following fall prevention interventions were developed: -resident not to be left alone in the bathroom; -due to left arm amputation, the resident was moved to another room so that the grab bar in the bathroom was available on the right side; -video monitor was placed in the room; -TABs alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident) to the wheelchair; -sensor alarm (an electronic pressure sensitive sensor pad designed for use in chairs or beds which will alarm if a resident tries to get up without assistance) to the resident's bed and recliner; -bed to be placed in the lowest position; and -fall mat/mattress to the floor next to the resident's bed. Rcord review of an Incident Report dated 3/28/23 at 4:15 PM revealed the resident was found lying on the floor next to the resident's bed. Further review of the report revealed no evidence current interventions were revised or that additional interventions were developed. Record review of an Incident Report dated 4/15/23 at 11:40 AM revealed the resident was found seated on the floor in front of the resident's recliner. The resident identified self-transferring as the resident needed to use the bathroom. No additional interventions were implemented to prevent ongoing falls. Record review of an Incident Report dated 4/29/23 at 3:45 AM revealed the resident's call light had been activated and when the staff responded, the resident was found on the floor. No causal factors or additional interventions were identified. Record review of an Incident Report dated 5/7/23 at 2:00 PM revealed the resident was found on the floor in front of the recliner in the resident's room. Further review revealed no evidence the facility reviewed the incident for causal factors or that additional measures were implemented to prevent further falls. Record review of an Incident Report dated 5/23/23 at 7:30 AM revealed the resident's call light was going off. The staff entered the resident's room and found the resident lying on the floor next to the resident's bed. Further review of the report revealed the staff had failed to direct the video monitor to the resident's placement in bed. The monitor was pointed at the resident's recliner instead. Staff were educated to check the monitor to assure it was directed at wherever the resident was positioned while in the room. Interview on 6/6/23 at 8:54 AM, the DON revealed Resident 75 was admitted to the facility due to repeated falls when living at home and remained at high risk for falls. The DON verified the facility staff failed to evaluate Resident 75's falls to determine causal factors and to implement new fall interventions on 4/29/23 at 3:45 PM and on 5/7/23 at 2:00 PM. Furthermore, the DON revealed the facility failed to revise current interventions or to develop new interventions for fall prevention after the resident's falls on 3/28/23 at 4:15 PM and on 4/15/23 at 11:40 AM. The DON indicated there was no documentation to identify the staff were provided re-education after the resident's fall on 5/23/23 at 7:30 AM regarding the proper use of the video monitor.

Licensure Reference Number 175 NAC 12-006.09A Based on record review and interview; the facility failed to ensure a Preadmission Screening Resident Review (PASARR- a federally mandated screening program to ensure Nursing Home resident with mental illness and/or developmental disabilities receive the care and services they need in the most appropriate settings) screen was completed accurately and/or a new PASARR was initiated to determine if a Level II PASARR evaluation was warranted for Resident 16. The sample size was 1 and the facility census was 21. Findings are: Review of the facility policy Pre-Admission Screening and Resident Review (PASARR) revised 12/21/22 revealed the following; -the purpose was to ensure individuals with serious mental illness receive the care and services in the appropriate setting, -the purpose of a Level I was to identify individuals who have or may have mental disorders or intellectual disability who would then require a Level II evaluation, -serious mental illness was considered if the individual met requirements on diagnosis- such as a mood, paranoid, panic or other severe anxiety disorders, level of impairment and duration of illness such as interpersonal function- the person has difficulty interacting appropriately and has a possible history of avoidance of interpersonal relationships and social isolation, -the social worker would ensure the PASARR Level I screening had been completed prior to admission and obtain a copy, and -the Level I screening would be reviewed to determine whether a Level II evaluation was required. Review of Resident 16's PASARR dated 11/24/21 revealed Resident 16 was assessed at a Level I determination with no mental health illness. Review of Resident 16's Minimum Data Set (MDS-a mandatory assessment tool used for care planning) dated 4/12/23 revealed the resident was admitted [DATE] with a diagnosis of bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function), anxiety and depression. The MDS also had documentation Resident 16 received an antipsychotic (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood, and emotion) on a routine basis. Review of Resident 16's Care Plan with a revision date of 4/21/23 revealed Resident 16 used psychotropic medications related to bipolar disorder with severe depression and anxiety. Further review of resident 16's care plan revealed the resident had a preference and history of reduced social interactions, preferred to spend time alone, was quiet and withdrawn, had limited interest in scheduled groups, and a history of solitary activity such as not wanting to leave the resident's room. Review of Resident 16's Medication Administration Record (MAR) for June 2023 revealed the resident had an order for Quetiapine Fumarate (antipsychotic medication) 50 milligrams two times a day for diagnoses of dementia and bipolar disorder and 25 milligrams in the evening for bipolar disorder. Interview with Resident 16 on 6/5/23 at 10:30 AM revealed the resident had a diagnosis of bipolar disorder, was antisocial and did not like big gatherings of people. Interview with the Director of Nursing (DON) on 6/8/23 at 10:40 AM confirmed the resident had a mental illness diagnosis of bipolar disorder, a new PASARR was not completed upon admit, and no Level II PASARR had not been completed.

Licensure Reference Number: 175 NAC 12-006.09D8a Based on observation, record review and interview; the facility failed to provide Resident 7 with a Level 5 Minced and Moist diet (foods that are ground, soft, moist and easy to chew) as recommended by the Speech Therapist and ordered by the practitioner. The sample size was 1 and the facility census was 21. Findings are: Record review of Resident 7's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 5/17/23 revealed the resident was admitted [DATE] with diagnoses of heart failure, end stage renal disease, Alzheimer's disease, dementia and malnutrition. Resident 7's cognition was assessed as severely impaired with behaviors which included rejection of cares. The resident had a weight of 160 pounds and was identified as having a weight loss of 5 percent (%) or more in the last month or a loss of 10% or more in the last 6 months with no physician prescribed weight-loss regimen indicated. Record review of a Speech Therapy Plan of Care dated 3/17/23 revealed Resident 7 was evaluated to determine the most appropriate diet as the resident was edentulous (lacking teeth) with dysphagia (difficulty swallowing). A recommendation was made for a Level 5 Minced and Moist diet to assure the resident was able to safely swallow without aspiration and to maintain nutrition and hydration status. Record review of a practitioner order dated 3/30/23 revealed an order for a Level 5 Minced and Moist diet and for fortified (additional calories and nutrients) foods. Record review of a facility information sheet (undated) provided by the Dietary Manager (DM) revealed the following directions regarding preparation of a Level 5 Moist and Minced diet: -food was to be soft and moist with no liquid dripping from the food; -minimal chewing required; -lumps of 4 millimeters (mm) in size which can be mashed with the tongue; -food should be easily mashed with just a little pressure from a fork; and -meat to be served finely minced or chopped to a 4 mm lump size and served in a thick, smooth non-pouring sauce or gravy Observations on 6/06/23 from 12:02 PM to 12:33 PM, during the noon meal service, revealed the following regarding Resident 7: -served mashed potatoes with a brown gravy, mashed green beans, mandarin orange slices and beef stroganoff (whole beef cubes which measured 1 centimeter (cm) by 1 cm with a brown gravy served over noodles); -resident took a bite of beef stroganoff with a beef cube. Resident chewed the meat repeatedly until finally spitting the meat into a paper napkin; and -the resident exited the dining room leaving several of the beef cubes uneaten on the resident's plate. Interview on 6/7/23 at 8:00 AM with the Registered Dietician (RD) revealed Resident 7 was to receive a Level 5 Moist and Minced diet. The RD confirmed the resident should have received ground beef at the noon meal on 6/06/23 and should not have received the whole beef cubes with the beef stroganoff.