Every finding on record at Good Samaritan Society - Colonial Villa

Licensure Reference Number 175 NAC 12-006.04Based on observation, record review, and interview the facility failed to have sufficient staff to complete resident assessments and resident observations as required to identify and monitor residents at risk for skin injury. This had the potential to affect all facility residents. The facility census was 33. The facility Administrator was notified on 8/5/26 at 6:25PM of an Immediate Jeopardy (IJ) which began on 3/29/26. The IJ was removed on 8/6/26, as confirmed by surveyor onsite verification.Findings are:Record review of the policy titled, Skin Assessment Pressure Ulcer Prevention and Documentation Requirements dated 3/30/26 revealed that all residents will be identified for their risk of developing pressure ulcers on admission/readmission by a registered nurse using the Braden Scale for Predicting Pressure Sore Risk Evaluation (a widely used tool that helps nurses and health workers predict a patient's risk of getting bedsores or pressure ulcers) User-Defined Assessment (UDA; is a customizable template tool used in electronic health record systems to document clinical findings, routine evaluations, and functional data in nursing facilities). The registered nurse will complete the Braden Scale for Predicting Pressure Sore Risk Evaluation UDA on all residents quarterly or when the resident has a change in condition that could affect his or her risk of developing an ulcer. All residents will have a comprehensive skin inspection done by a licensed nurse on admission/readmission to identify any skin issues present including, but not limited to, pressure ulcers, and the results will be documented in the legal medical record. A systematic skin inspection will be made daily by the nurse aide assigned to those residents at risk for skin breakdown. The nurse aide responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurse. Residents who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves. The positioning schedule should be communicated to the nursing assistants using the Kardex (a quick reference guide that summarizes a patient's daily care needs, and key clinical data).Record review of the admission Record dated 8/5/26 for Resident 2 revealed that Resident 2 admitted into the facility on 8/29/25. Record review of the Braden Scale for Predicting Pressure Score Risk dated 2/18/26 for Resident 2 revealed a score of 15. A score of 15 identified Resident 2 at mild risk for pressure ulcer development. Record review of the Braden Scale for Predicting Pressure Score Risk dated 3/9/26 for Resident 2 revealed a score of 16. A score of 16 identified Resident 2 at mild risk for pressure ulcer development. Record review of the Comprehensive Care Plan (CCP) (a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) for Resident 2 dated 8/5/26 revealed that Resident 2 has potential for pressure ulcer development related to functional deficit. Initiated on 9/11/25. Interview on 8/5/26 at 3:00 PM with the Interim Director of Nursing (IDON) revealed that all residents are to get daily skin checks done by the nursing assistant and a full head to toe skin check is to be done weekly by the licensed nurse.Record review of the Skin Observation dated 2/27/26 for Resident 2 revealed that the skin check revealed redness of Resident 2's groin area. No open skin areas were present. Record review of skin assessments in the assessment tool summary for Resident 2 revealed that no weekly skin checks were documented as being done after 2/27/26 until 3/29/26. (four weeks and 5 days without a skin check by a licensed nurse)Record review of the progress note for Resident 2 dated 3/29/26 at 2:07 PM revealed that Resident 2 has an opened wound to the left buttock. The opened area measured approximately 7 centimeters (cm) long and 2 cm wide. The wound was cared for and covered with a foam dressing. The wound care nurse was notified. A Skin Observation was completed. (Resident 2 now had an open skin wound that was not present on the previous skin check completed on 2/27/26)Record review of the Skin Observation dated 3/29/26 for Resident 2 revealed the open area on the left buttock of Resident 2. The open area measured approximately 7 cm in length and 2 cm in width.Record review of the progress note for Resident 2 dated 3/29/26 at 8:43 PM revealed that the nurse went to check on Resident 2 and the resident was difficult to arouse. Resident 2 did arouse after painful stimuli. The resident's blood pressure was checked which revealed 64/42 (a dangerously low blood pressure). The emergency room was called. An ambulance arrived and took Resident 2 to the hospital.Record review of Resident 2's hospital stay dated 3/29/26 through 3/31/26 revealed that Resident 2 was then transferred to a higher level of care hospital from [DATE] through 4/8/26. The hospital revealed that Resident 2 was admitted to the hospital with a listed principal problem revealing: -Septic shock (a life-threatening medical emergency where an infection causes a severe drop in blood pressure and organ failure) with a source of infection from the decubitus ulcer (the open pressure injury wound on the left buttock of Resident 2). -Acute Kidney Disease (is a sudden loss of kidney function that usually develops within hours or days) secondary to septic shock. -Acute metabolic encephalopathy(a sudden change in brain function) secondary to acute kidney injury and sepsis.Record review of the Facility assessment dated [DATE] revealed that required facility resources included nursing, dietary, office, and support staffing required to provide resident care. The section titled Employee Position Categories revealed that the facility nursing staff required were 11 nurse aides, 5 medication aides, 4 Licensed Practical Nurses, 1 Registered Nurse, 1 MDS Nurse, and 1 Director of Nursing. The facility uses an interdisciplinary approach to meet resident needs across all shifts and considering care planned interventions. Nurse staffing included the Director of Nursing, MDS Coordinator, Registered Nurses, Licensed Practical Nurses, Nurse Aides, Medication Aides, and bath aides. Staffing needs for residents are measured by monitoring call lights, tracking falls, resident council, on-site supervision and evaluation by supervisors. All staff must attend general orientation. Annual education and completing annual competencies with staff is to be provided to ensure that staff knowledge and expertise meets resident care needs. Daily monitoring by Nurse Aides/Medication Aides and daily assessments by appropriate disciplines provide the resources to deliver the care needed by residents and the facility will ensure that the resources are available to meet resident needs. Record review of the facility Nursing Schedule sheets (nursing staff assignment sheets for nursing staff as actually worked) dated from 3/1/26 through 3/31/26 revealed that on 3/25/26 the Director of Nursing (DON) worked 10:00 PM to 6:00 AM (8 total hours) as a nurse aide (2 hours on 3/25/26 10:00 PM -12:00 AM and 8 hours on 3/26/26 12:00 AM-6:00 AM). The Nursing Schedule revealed no Registered Nurse (RN) working as a Registered Nurse on 3/25/26 to perform RN resident assessments. The schedule revealed that on 3/26/26 the DON worked 10:00 PM to 6:00 AM (8 total hours) as a nurse aide (2 hours on 3/26/26 10:00 PM -12:00 AM and 8 hours on 3/27/26 12:00 AM-6:00 AM). The Nursing Schedule revealed no Registered Nurse (RN) working as a Registered Nurse on 3/26/26 to perform RN resident assessments. The schedule revealed that on 3/28/26 the DON worked as a nurse aide from 2:00 PM-10:00 PM. The Nursing Schedule revealed no Registered Nurse (RN) working as a Registered Nurse on 3/28/26 to perform RN resident assessments. The schedule revealed that on 3/31/26 the DON worked as a medication aide from 2:00 PM-10:00 PM. The Nursing Schedule revealed no Registered Nurse (RN) working as a Registered Nurse on 3/31/26 to perform RN resident assessments. Interview on 8/5/26 at 4:38 PM with the IDON confirmed that registered nurses were not available in the facility and were not completing the resident skin assessments as required. The IDON confirmed that there were no staff available for completing required resident skin assessments during the timeframe of development of the pressure injury for Resident 2. Interview on 8/5/26 at 1:07 PM with Bath Aide-H (BA-H) confirmed that BA-H is the main bath aide and works Monday through Friday. BA-H revealed that BA-H starts work at 6 AM and works until baths for the day are done. BA-H confirmed that when there is a nurse aide or medication aide call in that does not come to work, BA-H is at times pulled from baths to work the floor. BA-H revealed that BA-H was pulled off baths on Monday (8/3/26). BA-H revealed that BA-H is now behind on baths for the week. Interview on 8/6/26 at 10:07 AM with Nurse Aide-D (NA-D) revealed that training was provided this morning regarding staff needing to look at resident skin and mark down anything that they see. NA-D confirmed that NA-D was unaware prior to this morning that NA-D was to document skin checks in the electronic Point of Care. NA-D revealed that NA-D is now required to document a resident skin check each shift. Interview on 8/6/26 at 10:09 AM with Nurse Aide-C (NA-C) revealed that there was a packet this morning related to resident skin. NA-C revealed that they were to review and sign the packet but that NA-C didn't really get a chance to review it. NA-C revealed that they would report any skin issue such as red, itchy, discoloration, or open areas on resident skin and report it to the charge nurse. NA-C revealed that NA-C was told this morning that they are to document resident skin checks in the electronic Point of Care that was not available to the nurse aides until today. Interview on 8/6/26 at 10:13 AM with Nurse Aide-E (NA-E) revealed that NA-E received education this morning that the nurse aides are to be charting skin checks. NA-E would call the nurse if any resident skin issue was observed. NA-E revealed that nurse aides are now to document a skin check each shift. NA-E revealed that NA-E did not think the skin check task was there before today. NA-E confirmed that they had not received any education on resident skin checks prior to today. Observation on 8/6/26 at 10:32 AM at the table in the facility tv area across from the Director of Nursing office revealed that the Regional Education Nurse ([NAME]) was providing education to NA-D. The IDON told the [NAME] that the education was supposed to be provided to the staff before the shift.Interview on 8/6/26 at 10:55 AM with the IDON confirmed that nurse aides were required to complete daily skin checks on all residents. The IDON confirmed that all facility residents were at risk of skin breakdown and injury. The IDON confirmed that the nurse aides had not been educated to perform daily resident skin checks prior to today. The abatement plan dated 8/5/26 provided by the facility revealed the facility plan to remove the immediacy of the deficiency. The abatement plan revealed that: Licensed nurses will perform data collection for required skin assessments under Registered Nurse (RN) oversight and will manage resident clinical assessments using the Point Click Care (PCC; the recording and documenting of patient information directly at the bedside or point of care.) Assessment Summary Dashboard. Licensed Practical Nurse (LPN)'s will complete the Skin Check Assessment and Skin Issue User Defined Assessment for all identified pressure-related and non-pressure related and non-pressure related skin issues. LPNs will promptly notify the RN on call and/or provider of any newly identified skin alterations, wounds, pressure injuries, or significant changes in skin condition requiring clinical evaluation or intervention. All assessment findings, notifications, and resulting interventions will be documented in accordance with policy and incorporated into the resident's care plan as indicated.Resident 2 will have a new Braden assessment completed by an RN on 8/5/2026. Based on Braden score, and recommended interventions from Braden will be implemented and care planned. Resident 2's physician and family will be updated by 8/6/2026. Resident 2 was seen by their primary physician on 8/5/2026 and new orders were received.All residents at risk for skin breakdown have the ability to be affected.All residents will have a Braden assessment completed by an RN by 8/5/2026.Systemic change - all nursing staff will be educated on policy and procedure skin assessment pressure ulcer prevention and documentation, or prior to next scheduled shift. New intervention identified based on Braden assessment will be care planned and communicated to staff. Braden assessments will be completed according to policy and procedure.Director of Nursing Services (DNS) and all licensed nurses will be educated on User-Defined Assessment (UDA; in electronic health record platforms like Point Click Care, used by nursing and care staff to document routine resident behaviors, skin conditions, and daily functional activities) reference guide for required assessments, and PCC assessment summary dashboard for assessment completion prior to next scheduled.DNS or designee will audit 25% of resident Braden assessments for completion weekly X 2, then every other week x 2, then monthly x 2 and brought to Quality Assurance Process Improvement (QAPI; a process improvement meeting encompassed with a management team) for further review and recommendation.DNS or designee will audit 100% of residents with pressure ulcers and at risk for pressure ulcers through observation that care plan interventions are in place based on risk weekly X 2, then every other week X 2, then monthly X 2 and brought to QAPI for further review and recommendation.The Administrator or designee will audit 25% of assessments requiring an RN or LPN for completion weekly X 2, then every other week X 2, then monthly X 2 and brought to QAPI for further review and recommendation.At the time of the survey, the violation was determined to be at the immediate jeopardy level L. Based on observation, interview and record review completed during the onsite visit on 8/6/2026, it was determined the facility had not implemented corrective action to remove the IJ violation at the time. The facility implemented an addendum to the previous plan on 8/06/2026 to remove the immediacy.The Abatement Addendum plan dated 8/6/26 provided by the facility revealed that:Education provided to all nursing staff scheduled to work on 8/6/26 dayshift on skin assessment policies and procedures, including the identification of signs and symptoms of skin breakdown and required documentation practices. DNS and all licensed nurses will be educated on UDA reference guide for required assessments, and PCC assessment summary dashboard for assessment completion on 8/6/26 or prior to next scheduled shift.Regional Clinical Services Director RN or Corporate designee will monitor and ensure education and system changes are complete and followed through weekly visits X 4 weeks and will bring findings to QAPI.Education provided to all nursing staff by Regional Clinical Services Director RN on Immediate Jeopardy findings, abatement plan, education identified in abatement plan and system change to ensure understanding and completion of action plans. Education will be completed on 8/6/2026 or prior to next scheduled shift.A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the I level.

Licensure Reference Number Title 175 NAC 12.006.09(H)(iii)(1) & 12.006.09(H)(iii)(2) Based on record reviews, observations, and interviews, the facility failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer development for 1 resident (Resident 2), of 1 resident reviewed. The facility census was 33.The facility Administrator was notified on 8/5/26 at 6:25 PM of an Immediate Jeopardy (IJ) which began on 3/29/26. The IJ was removed on 8/6/26, as confirmed by surveyor onsite verification. Findings are:A record review of a policy titled, Care Plan dated 12/1/25. The policy revealed:Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI, a standardized tool in evaluating each resident's needs to build a personalized plan of care) and review of the physician's orders.The comprehensive plan of care will be finalized during an interdisciplinary care team conference no later than seven days after completion of the comprehensive resident assessment.This plan of care will be modified to reflect the care currently required/provided for the resident.The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident's condition. A record review of a policy titled, Skin Assessment Pressure Ulcer Prevention and Documentation Requirements updated on 3/30/26. The policy reveals:Procedure: All residents will be identified for their risk of developing pressure ulcers on admission/readmission by a registered nurse using the Braden Scale for Predicting Pressure Sore Risk Evaluation User-Defined Assessment (UDA; is a customizable template tool used in electronic health record systems to document clinical findings, routine evaluations, and functional data in nursing facilities).The registered nurse will complete the Braden Scale for Predicting Pressure Sore Risk Evaluation UDA on all residents quarterly or when the resident has a change in condition that could affect (gender) or (gender) risk of developing an ulcer.All residents will have a comprehensive skin inspection done by a licensed nurse on admission/readmission to identify any skin issues present including, but not limited to, pressure ulcers, and the results will be documented in the legal medical record.Residents who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves. The positioning schedule should be communicated to the nursing assistants using the Kardex (a quick reference guide that summarizes a patient's daily care needs, and key clinical data). A.Record review of an admission Record for Resident 2 dated 8/10/26 revealed an admission date of 8/29/25 with the following diagnosis:-Multiple sclerosis (MS; a demyelinating disease marked by patches of hardened tissue in the brain or the spinal cord and associated especially with partial or complete paralysis and jerking muscle tremor)-Chronic obstructive pulmonary disease (COPD; pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation)-Diabetes mellitus type 2 (DM; a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production)-Neuralgia and neuritis (Neuralgia is sharp, shocking, or burning pain that follows the path of a nerve. Neuritis is actual inflammation of a nerve that causes pain plus other physical changes like numbness or weakness)-Insomnia (a common sleep disorder that makes it hard to fall asleep, stay asleep, or causes you to wake up too early and fail to get back to sleep). A record review of a form titled, Braden Scale for Predicting Pressure Score Risk for Resident 2 dated 2/18/26 revealed: an annual assessment score of 15.Activity: resident's ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.Mobility: resident's ability to change and control body position is very limited. Very limited is defined by Braden Scale for Predicting Pressure Sore Risk as: Makes slight changes in body or extremity position but unable to make frequent or significant changes independently.Friction and Shear: Resident requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance.Braden Scale Reference Tool:For use in conjunction with the Braden Scale for Predicting Pressure Sore Risk.Note: Lower score indicates higher risk.Mild Risk =Score of 15-18Moderate Risk = Score of 13-14High Risk = Score of 10-12Very High-Risk = Score of 9 or below. Record review of a Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment), for Resident 2, print dated 8/5/26 revealed:Focus:-The resident has limited physical mobility related to multiple sclerosis (MS; a long-term brain and spinal cord disease) as evidenced by need for assistance with dressing lower extremities and inability to ambulate. Initiation date 12/12/25Intervention:-Mobility; resident uses wheelchair for locomotion, resident is able to propel self in wheelchair. Initiation date of 12/12/25.-Monitor/document/report to health care provider as needed (PRN) sign and symptoms of immobility. Initiation date of 12/12/25.Focus:-The resident has an activities of daily living (ADL; tasks related to personal care, such as dressing, eating, and mobility) self-care performance deficit related to multiple sclerosis as evidenced by weakness. Initiation date of 8/29/25. Revision on 9/9/25Intervention:-Transfer: transfer between surfaces: independently, will call for assistance when needed. Initiation date of 9/9/25. Revision on 12/12/25 -Transfer: Strength: resident is able to stand and pivot independently, will call for assistance when needed. Initiation date of 9/9/25. Revision on 12/12/25Focus:-The resident has potential for pressure ulcer development related to functional deficit. Initiated on 9/11/25Interventions:-Educate resident/family as to causes of skin breakdown including: transfer repositioning requirements; and frequent repositioning. Initiated on 9/11/25-Resident able to reposition self PRN. Initiated on 9/11/25-Encourage resident to turn/reposition at least every 2 hours. Initiated on 12/12/25Record review of an updated Comprehensive working Care Plan (a care plan that is updated as care changes) for Resident 2, print dated 8/5/26 revealed:Focus:-Current functional performance. Initiation date of 5/11/26Interventions:-Resident performance: Locomotion on unit-total assist/one person physical assist. Initiation date of 5/11/26-Resident performance: Transfer-total assist/two person physical assist. Initiation date of 5/11/26Focus:-The resident has an activities of daily living (ADL; tasks related to personal care, such as dressing, eating, and mobility) self-care performance deficit related to multiple sclerosis as evidenced by weakness. Initiation date of 8/29/25. Revision on 9/9/25Interventions:-Mobility: resident uses wheelchair for locomotion, resident needs staff assistance with locomotion. Revision on 5/12/26-Transfer between surfaces: 2 staff assistance Hoyer lift (a specialized mobile patient-transfer device) Initiation date of 9/9/25. Revision on 5/12/26Focus:-The resident has potential for pressure ulcer development related to functional deficit. Initiated on 9/11/25. Revision on 4/8/26. Resolved on 4/8/26Interventions:-Educate resident/family as to causes of skin breakdown including: transfer repositioning requirements; and frequent repositioning. Initiated on 9/11/25. Revision on 4/8/26. Resolved on 4/8/26-Resident able to reposition self PRN. Initiated on 9/11/25. Revision on 4/8/26. Resolved on 4/8/26Focus:-The resident has a pressure ulcer. Initiation on 4/28/26. Revision on 5/11/26.Interventions:-Assist to turn/reposition at least every 2 hours. Initiation on 4/28/26. B.A record review of Progress Notes for Resident 2 dated 2/19/26 revealed resident did have moderate short term memory deficit and mild long term memory deficit. Resident often forgets information told after a few minutes. Resident was resistive to asking staff for assistance. A record review of an assessment titled, Change in Condition Evaluation dated 2/27/26 for Resident 2 revealed:-Shortness of breath, talks less, tired, weak, confused, or drowsy.-Ensure an evaluation of the resident/patient's mental and functional status is completed to reflect current status.-Functional status evaluation reveals: needs more assistance with activities of daily living (ADL; tasks related to personal care, such as dressing, eating, and mobility), generalized weakness, decreased mobility. A record review of hospital notes for Resident 2 dated 2/28/26 revealed the resident was admitted to the hospital for hypoxia (a medical condition where your body tissues do not get enough oxygen to function properly) secondary to Coronavirus disease 2019 (COVID-19; a contagious disease caused by the coronavirus SARS-CoV-2) on 2/28/26 with a discharge on [DATE]. A record review of Progress Notes for Resident 2 dated 3/3/26 revealed Resident 2 tested positive for COVID-19 on 2/27/26. A record review of hospital notes for Resident 2 dated 3/3/26 revealed the resident was readmitted to the hospital for pneumonia (an infection that inflames the air sacs in one or both lungs) secondary to COVID-19 on 3/3/26 with a discharge on [DATE]. A record review of a form titled, Braden Scale for Predicting Pressure Score Risk for Resident 2 dated 3/9/26 revealed: a score of 16.Activity: resident's ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.Mobility: resident's ability to change and control body position is very limited. Very limited is defined by Braden Scale for Predicting Pressure Sore Risk as: Makes slight changes in body or extremity position but unable to make frequent or significant changes independently.Friction and Shear: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. A record review of Progress Notes for Resident 2 dated 3/6/26 revealing Resident 2 continues to refuse to rest in bed. A record review of Progress Notes for Resident 2 dated 3/5/26 through 3/9/26 revealed all services were being rendered in the resident's room, meals, meds, and all cares due to highly infectious status of COVID-19. A record review of Progress Notes for Resident 2 dated 3/19/26 revealed Resident 2's readmission dietician assessment completed after hospitalizations 2/28/26 to 3/2/26 and 3/3/26 to 3/5/26 related to COVID-19 infection with hypoxia, and pneumonia due to COVID-19. Added to nutrition risk monitoring due to weight loss over the last 1 month. Current weight 205.5 lbs. The record review of Care Plan revealed no changes were made to Resident 2's care plan upon readmission to the facility from hospital discharge date s on 3/2/26 and 3/5/26. A record review of a form titled, Braden Scale for Predicting Pressure Sore Risk for Resident 2 dated 3/9/26 revealed: a score of 16 mild risk.Sensory perception: An ability to respond meaningfully to pressure-related discomfort revealing - no impairment, responds to verbal commands. Has no sensory deficit.Moisture: Degree to which skin is exposed to moisture - occasionally moist, skin is occasionally moist, requiring an extra linen change approximately once a day.Activity: Degree of physical activity - chairfast - ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.Mobility: Ability to change and control body position - very limited - makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.Nutrition: Usual food intake pattern - adequate - eats over half of most meals.Friction and shear: Potential problem - moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair restraints or other devices. C.A record review of Resident 2's Skin Assessments in the Assessment tool summary revealed weekly skin checks completed by nurses were not completed weekly. Skin checks were not documented as being done between 2/28/26 and 3/28/26. An interview on 8/5/26 at 3:00 PM with the Interim Director of Nursing (IDON) revealed that all residents were to get daily skin checks done by the nursing assistant and a full head to toe skin check was to be done weekly by the licensed nurse. D.A record review of Resident 2's skin check on 2/27/26 revealed:1. Redness to groin - treatment will be implemented with and order of Nystatin powder (a prescription antifungal medication).2. Generalized bruisingThe form was signed as complete on 7/1/26. A record review of Resident 2's Progress Notes revealed the nurse aides notified the nurse that today on 3/29/26 at 3:47 PM the resident had not been able to stand and a full lift is needed to transfer (gender). The nurse aides revealed the resident had an open wound on the left buttock. The nurse directed the nurse aides to provide the resident a whirlpool bath. After the whirlpool bath, the nurse made the following observations:A record review of Resident 2's skin check on 3/29/26 revealed:1.Sheer to right abdomen2. Reddened right buttock3. Open area approximately 7 centimeters (cm) in length, 2 cm width on left buttock4. Red and irritated, left gluteal fold5. Red and irritated, right gluteal fold6. Bilateral inner thighs have sheer marks7. (Gender) red inflamed and small open area8. Red and yeasty both right and left abdomen folds9. Red under both breasts10. Sheer marks, reddened right thigh front11. Sheer marks, reddened right thigh rear A record review of Resident 2's Progress Notes revealed on 3/29/26 at 8:43 PM, the nurse went to check on Resident 2 and the resident was difficult to arouse. The resident did arouse after painful stimuli. The resident's blood pressure was taken which revealed 64/42. The emergency room was called, an ambulance arrived and took the resident to the hospital. A record review of Resident 2's hospital stay dated 3/29/26 through 3/31/26, then transferred to a higher level of care hospital from [DATE] through 4/8/26.The hospital revealed Resident 2 was admitted to the hospital with a listed principal problem revealing:-Septic shock (a life-threatening medical emergency where an infection causes a severe drop in blood pressure and organ failure) with a source of infection from the decubitus ulcer.-Acute Kidney Disease (is a sudden loss of kidney function that usually develops within hours or days) secondary to septic shock.-Acute metabolic encephalopathy(a sudden change in brain function) secondary to acute kidney injury and sepsis. E.A record review of the facility Order Summary Report dated 8/10/26 for Resident 2 revealed:- Air mattress in alternating mode with 10-minute cycle, maintain weight setting at 230 pounds (lbs). Place the mattress in static mode during transfer, cares or repositioning if additional surface stability is needed. If malfunction noted, unplug and restart. If issue persists, notify maintenance. every day and evening shift -Start date 7/21/26-Check function of air mattress, ensure weight setting is appropriate for resident. If not functioning, attempt to unplug and restart. If this doesn't resolve issue notify maintenance every day and evening shift -Start date- 6/17/26- Resident on bedrest. To be up only for meals, no more than 1 hour at a time. May be up for appointments, bathing. When in bed, turn side to side every 2 hours and PRN. Not to lay on back, ensure heels are floated off bed surface - Start date 6/10/26- Complete and document weekly skin checks under assessments > skin check. Upload photographs from the iPad when appropriate. Notify the provider and DPOA of any new skin concerns. every day shift every Monday - Start date 7/6/26 A record review of a vitals summary for Resident 2's weights revealed:-1/5/26: 208 lbs.-2/6/26: 213 lbs.-3/5/26: 207 lbs.-4/8/26: 208.5 lbs.-5/15/26: 203 lbs.-6/4/26: 196 lbs.-7/3/26: 194 lbs.-7/31/26: 178.5 lbs. An observation of Resident 2 on 8/3/26 at 9:51 AM revealed the resident lying in bed supine (lying flat horizontally on your back with your face, chest, and torso pointing upward) with a gown on, lying on an air mattress. The mattress was covered with a sheet, and a thick pad typically used to soak urine, and an alarm pad, used to alert staff if a resident moves. The bed settings were set at 230lbs, per the directions from the order. An observation of Resident 2 on 8/4/26 at 10:00 AM revealed the resident lying in bed supine, lying on an air mattress, the mattress was covered with a sheet, and a thick pad typically used to soak urine, and an alarm pad, used to alert staff if a resident moves. The bed settings were set at 230 lbs, per the directions from the order. An observation on 8/15/26 at 11:34 AM for Resident 2 during a pressure ulcer treatment revealed Regional Education Nurse ([NAME]), licensed practical nurse (LPN)-A and Infection Prevention Coordinator (IPC) nurse interview the resident related to pain and comfort, the resident reveals the wound is causing pain. Medication was administered prior to wound care treatment per orders.Record review of treatment orders from Order Summary dated 8/10/26 revealed: Treatment to sacral wound: Cleanse with wound cleanser, rinse with saline. Apply Vashe solution wet to dry dressing, apply 1 continuous piece of Vashe moistened gauze into wound base and tract. Apply Calmoseptine (over-the-counter moisture barrier and anti-itch ointment) around wound perimeter, but not in wound bed. Cover with abdominal (ABD; thick, multi-layer sterile medical dressings designed to absorb heavy fluid drainage from surgical incisions, trauma, or large wounds) pad and tape into place.every day and evening shift and as needed, order date 8/4/2026.LPN-A completes alcohol based hand rub, gown and glove. [NAME] and IPC do not complete alcohol based hand rub, however do gown and glove. LPN-A handles Resident 2's foley catheter (a flexible plastic tube passed through the urethra into the bladder to drain urine) with gloved hand, then without changing gloves, removes the resident's soiled dressing. During changing of the dressing, a gloved finger was placed in a cup of medication, the medication was placed on the wound border area of the wound, then the same gloved hand placed back into the medication and reapplied on the wound border edge three times. During dressing application, the dressing was placed in the wound bed at a clockwise position at 3-12-9 placing the moistened strip into the resident's undermining that is present. An interview was observed on 8/5/26 at 11:55 AM between [NAME] and LPN-A reviewing repositioning of Resident 2 and the presence of undermining to the wound, with continued review of when lifting resident up in bed if they should lift or drag. The resident was observed to be drug up in bed for repositioning. [NAME] confirmed the resident should not be drug, rather should be lifted when repositioned. An interview on 8/5/26 at 2:55 PM with LPN-A and IDON revealed that settings on the air mattress are to be based on weight, revealing Resident 2 currently weighs 179 lbs and the mattress was currently at 230 lbs, then revealed the adjusted settings per weight will be signed off on by the provider today. An interview on 8/5/26 at 4:18 PM with the IDON review of policy and wound care observed confirmed that the wound was not cleansed and or treatment correctly related to placing the packing strip in the undermining from counterclockwise 9-3-0. Confirmation that the facility staff did not reposition Resident 2 in a manner to prevent possible further injury to the pressure related skin injury present related to reposition with the bath blanket and dragging the resident up in bed, according to the Braden scale and as appropriate to the resident's current plan of care. F.A record review of an order summary dated 8/10/26 for Resident 2 revealed a change in orders:- Air mattress in alternating mode with 10 minute cycle, maintain weight setting based on current weight. Place the mattress in static mode during transfer, cares or repositioning if additional surface stability is needed. If malfunction noted, unplug and restart. If issue persists, notify maintenance. every day and evening shift. Start date - 8/5/26 G.Record review of Progress Notes on 4/8/26 for Resident 2 revealed resident returns from hospital with antibiotic orders and dressing changes. Record review of Progress Notes on 5/1/26 for Resident 2 revealed skin wound has decreased in size measures 4.3cm, 3.8cm, 0.1cm, wound edges are defined, wound was debrided by hospital wound provider 4/24/26, wound bed is dark brown, moderate amount of drainage. Record review of Progress Notes on 5/22/26 for Resident 2 revealed pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Skin Issues Note: Wound vac dressing changed. Old dressing removed. Foul odor noted. Record review of Progress Notes on 5/25/26 for Resident 2 reveals a strong odor remains from wound. Notified infectious diseases clinic at hospital with increased wound drainage and odor. Record review of Progress Notes on 5/28/26 for Resident 2 revealed skin issue has been evaluated. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Length (cm): 6.57 Width (cm): 8.44 Depth (cm): 4 Area (cm2): 40.25 Undermining: No. Tunneling: No. Record review of Progress Notes on 6/8/26 for Resident 2 revealed pressure ulcer staging: Stage 3 Pressure ulcer and/or injury - full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Wound vac dressing changed. Foul odor noted. Drainage present in wound vac container. Wound assessed and cleaned per protocol. Record review of Progress Notes on 6/9/26 for Resident 2 revealed a new order for an IV (intravenous) antibiotic for a wound infection. Record review of Progress Notes on 6/10/26 for Resident 2 revealed new wound care orders, to be changed every day and evening shift. Record review of Progress Notes on 6/16/26 for Resident 2 revealed pressure ulcer staging: Stage 3 Pressure ulcer and/or injury, full thickness skin loss. Wound acquired in-house. Staged by: Wound care clinic. Skin Issues Note: Wound bed noted with dark black eschar/nonviable tissue present and areas of red tissue visible. Peri wound skin noted to be erythematous with areas of moisture. Heavy serosanguineous drainage noted on dressing. Record review of Progress Notes on 6/18/26 revealed Resident 2's Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Bedfast. Resident is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Nutrition: Probably inadequate. Friction and shear: Problem. Braden Score: 12.0, receives intravenous (IV; giving medicine, fluid, or food directly into a person's vein through a small tube or needle) antibiotic every 6 hours, has grab bars on bed, is unable to ambulate, is 2 staff assist for bed mobility, transfers via Hoyer lift, receives wound treatment for pressure wound on coccyx, no stage 4. Record review of Progress Notes on 6/26/26 for Resident 2's revealed a comprehensive note: wound care nurse coming monthly and Resident 2 goes to wound care every couple of weeks at hospital. Facility changing the dressing daily and PRN If soiled. Skin revealed Coccyx wound-stage 4 per wound care (wound vac on hold). Record review of Progress Notes on 7/9/26 for Resident 2's progress notes from a nurse practitioner an a review of all systems revealed skin: Stage 4 coccyx wound. Record review of Progress Notes on 7/16/26 for Resident 2 revealed at the nutritional meeting documentation states that wound is worse, still on antibiotics, and receiving morphine and Ativan about every 2 hours. Record review of Progress Notes on 7/18/26 for Resident 2 reveal skin issue has been evaluated. Location: Sacrum. Laterality /Orientation: Left. Issue type: Pressure ulcer /injury. Progress: Unknown. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. Staged by: In-house nursing. Record review of Progress Notes on 7/22/26 for Resident 2 revealed wound noted with granulation tissue, yellow tan slough and necrotic tissue present within. Wound cleansed as ordered and applied new dressing. Wound edges irregular. Peri wound skin pink with erythema and slight maceration. Serosanguineous drainage noted on old dressing. Record review of Progress Notes on 8/3/26 for Resident 2 revealed: Pressure ulcer staging: Stage 3. An observation of Resident 2 on 8/3/26 at 9:51 AM revealed the resident lying in bed supine (lying flat horizontally on your back with your face, chest, and torso pointing upward) with a gown on, sitting on an air mattress, the mattress was covered with a sheet, and a thick pad typically used to soak urine, and an alarm pad, used to alert staff if a resident moves. The bed settings were set at 230lbs, per the directions from the order. An interview with Resident 2 on 8/3/26 at 9:51 AM, the resident was crying out help me, when asked what is wrong, the resident states they are hurting. Resident 2 revealed lying in bed supine. An interview on 8/3/26 at 9:51 AM, with staff member Medication Aide (MA)-J revealed the resident has a large wound on (gender) bottom and has a lot of pain associated with it. An observation on 8/3/26 at 10:33 AM with Resident 2 revealed lying in bed supine. An observation of Resident 2 on 8/4/26 at 9:00 AM is up eating breakfast in the dining room, sitting on a sling used to lift someone with a mechanical device. An observation on 8/4/26 at 9:40 AM staff lay Resident 2 down, lying in bed supine. An observation of Resident 2 on 8/4/26 at 11:00 AM in the room watching television sitting in the wheelchair on a sling. MA-J [NAME] medication to the resident prior to appointment. Resident 2 is leaving to go to a wound care appointment located 55 miles away. The resident left the building for the appointment at 11:30 AM. An observation of Resident 2 on 8/4/26 at 3:40 PM, the resident is grimacing, face clenched squeezing fists, tears streaming down cheeks. Staff assisted the resident to lay down. Resident 2 was observed lying in bed supine. The air mattress was set at 230lbs. An observation of Resident 2 on 8/5/26 at 8:03 AM revealed resident lying in bed supine with a pillow tucked partially under the left arm. Resident 2 is smiling waiting for breakfast. An observation of Resident 2 on 8/5/26 at 8:17 AM, the resident is calling out for help. Staff assisted the resident at 8:44 AM stated will assist with adjustment in a bit. A different staff member brought breakfast to Resident 2. An observation of Resident 2 on 8/5/26 at 9:12 AM, the resident reported to the staff member they were at a pain level of 10/10. Staff member returned within minutes with pain medication. Resident 2 is lying in bed supine. An observation of Resident 2 on 8/5/26 at 10:52 AM, the resident reported to the staff member they were at a pain level of 9/10. The resident is calling out help me. The resident is lying in bed with pillows on the resident left side pushed against the resident, the resident is grimacing, and unable to move to get comfortable. An observation of Resident 2 on 8/5/26 at 11:00 AM, licensed practical nurse (LPN)-A stated they will reposition the resident and provide another dose of medication and contact the doctor if the resident reveals ineffectiveness to the changes. An observation of Resident 2 on 8/5/26 at 1:15 PM revealed the resident is lying supine in the bed. During an interview on 8/5/26 at 3:00 PM, the IDON revealed the order: Resident on bedrest, when in bed, turn side to side every 2 hours and PRN. Not to lay on back, ensure heels are floated off bed surface. The IDON further revealed the facility is not always following the order due to staffing concerns, resident compliance and resident comfort. The facility has not gotten an adjustment to the order at this time. H.The facility implemented the following plan on 8/05/2026 to remove the immediacy:Immediate plan of correction 8/05/2026:Resident 2 will have a new Braden assessment completed by a registered nurse (RN) on 8/5/26. Based on Braden score, and recommended interventions from Braden will be implemented are care planned. Resident 2 physician and family will be updated by 8/6/26. Resident 2 seen by primary care physician on 8/5/26, new orders received.All resident at risk of skin breakdown have the ability to be affected.Systemic change: all resident will have a Braden scale assessment and a comprehensive head to toe skin assessment completed by a licensed nurse no later than 6:00 AM on 8/6/26. Any identified skin concerns or risks will be documented, communicated to the interdisciplinary team, provider, and responsible party and addressed through appropriate care plan interventions.System change: all nursing staff, including certified nursing assistants (CNA) and certified medication aides (CMA), will receive education on skin assessment policies and procedures, including the identification of signs and symptoms of skin breakdown and required documentation practices, prior to their next scheduled shift. New interventions identified through skin assessments will be added to the resident's care plan and communicated to all applicable staff, provider, and responsible parties. All skin assessments will be completed in accordance with policy and procedure to ensure timely identification of residents at risk for skin breakdown and implementation of appropriate preventive measures.Director of Nursing Services (DNS) or designee will audit 100% of residents' skin assessments for completion weekly, then every other week X2, then monthly X2 and brought to Quality Assurance Process Improvement (QAPI; a process improvement meeting encompassed with a management team) for further review and recommendation.DNS or designee will audit 100% of residents with pressure ulcers and at risk for pressure ulcers through observation that care plan interventions are in place based on risk weekly X2, then every other week X2, then monthly X2 and brought to QAPI for further review and recommendation.At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit on 8/6/2026, it was determined the facility had not implemented corrective action to remove the IJ violation at the time. The facility implemented an addendum, to the previous plan on 8/06/2026 to remove the immediacy. Abatement Addendum - 8/6/2026Head to toe skin assessment will be complete for all resident's by Director of Nursing Services and Clinical Learning and Development Specialist Registered Nurse (RN) by 8/6/2026. Regional Conical Services Director, RN providing follow up oversight to ensure accuracy of skin assessment and completion. Findings from assessment will be documented in resident medical record and physician/family notified by 8/6/2026.Director of Nursing Services R

Licensure Reference Number 175 NAC 12-006.19(A)Based on observation, record review, and interview the facility failed to ensure that handrails were maintained to prevent the potential for injury. This had the potential to affect all facility residents. The facility census was 33.Findings are:Record review of the facility admission Packet dated 10/2025 revealed that the facility agrees to furnish the resident with room/bed, maintenance and housekeeping services. Record review of the undated Resident Handbook revealed that the facility is responsible for the maintenance and service of the building and all equipment owned by the facility. Record review of the facility Resident's Rights for Skilled Nursing Facilities dated 2022 revealed that the facility must care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The facility must protect and promote the rights of the resident. Observation on 8/4/26 at 10:10 AM on the facility 100 hallway revealed that the end of the brown handrail was missing at the entry to the laundry room. The exposed metal was sharp to the touch. The end of the brown handrail in the cove leading to the Family Room on the facility 100 hall was missing. The exposed metal was sharp to the touch. Observation on 8/4/26 at 10:12 AM on the facility 300 hallway revealed that the end piece of the handrail was missing outside the doorway of room [ROOM NUMBER]. The exposed metal was sharp to the touch. The end piece of the handrail was missing outside of the doorway of room [ROOM NUMBER]. The exposed metal was sharp to the touch.Interview on 8/6/26 at 11:13 AM during a facility walk-through with the facility Maintenance Supervisor (MS) confirmed that the handrails have some missing pieces. MS confirmed that a piece of handrail was missing entering the 100 hallway near the laundry entrance and at the entrance to the facility family room. MS confirmed that a piece of handrail was missing on the handrail outside of room [ROOM NUMBER] and room [ROOM NUMBER].Interview on 8/6/26 at 4:01 PM with the Facility Administrator (ADM) confirmed that the handrails are to be maintained to prevent the potential for resident injury. The ADM confirmed that the facility would address the issue.

Licensure Reference Number 175 NAC 12-006.11 Based on record review, observation, and interview; the facility failed to ensure hand hygiene was completed as required during meal service. This had the potential to affect all residents receiving food from the kitchen. The facility census was 33. Findings are: Record review of a document titled 2022 Food Code from the US Food and Drug Administration revealed food employees shall clean their hands after handling soiled equipment or utensils and after engaging in activities that have the potential to contaminate the hands. During an observation completed on 08/05/2026 of meal service being completed by [NAME] B from 12:21 PM to 1:16 PM the following was observed:-Cook B, using their bare hands, opened the door to the walk-in refrigerator and obtained a plastic 4-wheeled cart with covered trays on it. The cook wheeled the cart to the meal service area and removed the plastic from the top of all of the trays and threw the plastic away. The cook then obtained serving utensils from the counter and placed them into the food items sitting in the steam table. The cook then began to serve the meal using the utensils to scoop food stuff items from the containers on the steam table and onto a plate, then handing the plate to an alternate staff member who then took the plate to a resident. The cook did not complete hand hygiene after touching the walk-in door, obtaining the cart, and removing the plastic covering from the items, all potentially contaminated surfaces.-Cook B, with their bare hands, opened the cupboard above and to the right of the meal service area and obtained a plate from the cupboard. The cook then used tongs to place a roll onto the plate and then handed the plate to an alternate staff member that served the plate with the roll on it to a resident. The cook did not complete hand hygiene after touching the cupboard door a potentially contaminated surface. In an interview completed on 08/05/2026 at 1:16 PM with [NAME] B, [NAME] B confirmed that they were to complete hand hygiene after touching any potentially contaminated items and prior to serving meals to the residents. The cook confirmed that they did not wash their hands after obtaining the cart from the walk-in refrigerator, uncovering the items and serving the residents. The cook confirmed that they also should have washed their hands after obtaining the plate from the cabinet and did not. In an interview completed on 08/05/2026 at 1:16 PM with the Dietary Manager (DM), the DM confirmed that the cook should have completed hand hygiene after touching potentially contaminated items and prior to serving the residents their meals and did not.

Licensure Reference Number 175 NAC 1-005.06(C) Based on interviews and record reviews, the facility failed to have an effective antibiotic stewardship program. This had the potential to affect all facility residents. The facility census was 33. Findings are:A.A record review of a facility policy titled, Antibiotic Stewardship dated 12/22/25 revealed its purpose is to promote appropriate antibiotic use, optimize treatment of infections, and reduce adverse events associated with antibiotic use.The policy revealed facilities must develop and implement an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of antibiotic oversight; the program should incorporate antibiotic use protocols to address antibiotic prescribing practices such as reviewing antibiotics for documentation of an indication, dose and duration.The seven core elements of an antibiotic stewardship program include:-Leadership commitment-Accountability-Drug expertise-Action-Tracking-Reporting-EducationEach location will develop and implement an antibiotic stewardship plan. The antibiotic stewardship plan should be reviewed annually, and as needed, by the Infection Preventionist (IP).The IP will report antibiotic use data to the interdisciplinary team and implement improvement plans as needed.The policy also revealed that Loeb Criteria are a minimum set of signs and symptoms which, when met, indicate that the resident likely has an infection and that an antibiotic might be indicated, even if the infection has not been confirmed by diagnostic testing.Loeb criteria are prospective, relying on the clinical presentation, and provide a standardized definition to guide decision making when caring for an individual who may have an infection. B.Record review of a facility policy titled Catheter Care, and Specimen dated 03/02/2026 revealed when a specimen is needed and if the catheter has been in place more than two weeks (14 days) or has sediment, it must be replaced before any specimen for analysis is obtained. Record review of a document titled Urine Culture Stewardship and dated 04/14/2024 from https://www.cdc.gov/uti/hcp/clinical-guidance revealed prior to collection of a urine specimen from an indwelling urinary catheter, if catheter has been in place greater than 14 days replace the catheter prior to specimen collection and never collect a urine culture from the collection bag. Record review of Resident 4's Orders Report revealed the resident had an order to change the resident's indwelling suprapubic catheter once every 2 months on the 26th day of the month and as needed. Record review of Resident 4's Treatment Administration Record for the Month of May 2026 revealed documentation that the resident's catheter was changed on the 26th day of the month as ordered. There was no documentation indicating the resident's catheter was changed on an as needed basis prior to the 26th of the month. Record review of a document titled Fax communication to physician for urinary symptoms and dated 06/10/2026 for Resident 4 revealed the provider wrote orders for a urinary analysis to be completed and to utilize a catharized specimen with their next catheter change. Record review of Resident 4's Treatment Administration Record for the Month of June 2026 revealed no documentation of Resident 7's indwelling catheter being changed either routinely or on an as needed basis. Record review of Resident 4's Progress Notes for the Month of June 2026 revealed no evidence that Resident 4's indwelling catheter was changed routinely or on an as needed basis that month. Record review of a Laboratory Report document dated 06/10/2026 revealed the laboratory report was for a urine specimen obtained via catheter for Resident 4. On the report, the provider wrote an order for Augmentin (an antibiotic medication) 875 milligrams (mg) twice daily for 14 doses per last urinary culture obtained. The specimen was obtained from an indwelling catheter that had been in place more than 14 days. Record review of Resident 4's Treatment Administration Record for the month of July 2026 revealed documentation that the resident's catheter was changed on the 26th day of the month as ordered. There was no documentation indicating the resident's catheter was changed on an as needed basis prior to the 26th of the month. Record review of a Laboratory Report document dated 07/10/2026 revealed the laboratory report was for a urine specimen obtained via voided urine for Resident 4 (the resident continued to have an indwelling catheter and did not void urine). On the report, the provider wrote an order for Augmentin (an antibiotic medication) 875 mg twice daily for 14 doses per last urinary culture obtained. Further record review of Resident 4's Electronic Medical Health Record (EMHR) revealed that the resident's catheter was last changed on 06/26/2026, indicating that the specimen obtained and dated 07/10/2026 was obtained from a catheter that had been in place more than 14 days. Record review of a Laboratory Report document dated 07/31/2026 revealed the laboratory report for a specimen obtained via voided urine for Resident 4 (the resident continued to have an indwelling catheter and did not void urine). This report did not contain a urine culture. Record review of a document titled Orders and Progress Notes and dated 07/31/2026 for Resident 4 revealed that the provider wrote an order for Macrobid (an antibiotic medication) 100 mg to be administered twice daily for 7 days. In an interview completed on 08/05/2026 at 11:30 AM with the facility Interim Director of Nursing (IDON), the IDON confirmed that the facility had not received Resident 4's Microbiology Specimen report back from the laboratory for the urine specimen obtained on 07/31/2026 and would request it. The IDON confirmed that Resident 4 had an indwelling catheter when the urine specimen was obtained and the Laboratory Report should not have stated that the urine specimen was obtained via void and that this was an error. In a follow up interview completed on 08/06/2026 at 10:35 AM with the IDON, the IDON stated that Resident 4's provider was in the facility the afternoon of 08/05/2026 and reviewed the Microbiology Specimen report for Resident 7's urine specimen that was obtained on 07/31/2026 and wrote new orders to discontinue the Macrobid that was ordered on 07/31/2026 and per this report to change the resident's antibiotic to Augmentin 875 mg twice daily for 14 days. In an interview completed on 08/06/2026 at 1:20 PM with Licensed Practical Nurse A (LPN-A), LPN-A confirmed that when collecting the urine specimens for Resident 4 in the Month of June 2026 and July 2026, they did not ensure that the catheter had not been in place greater than 14 days prior to obtaining the specimen from the catheter. The LPN stated that the obtained-on specimen by clamping the resident's catheter tubbing and putting the urine into a specimen cup and changing the resident's urinary specimen bag allowing urine to drain into the new specimen bag and then emptying the urine into a specimen cup. The LPN confirmed that this was not the correct technique for collecting urinary specimen from a resident with an indwelling urinary catheter. In an interview completed on 08/06/2026 at 1:20 PM with the facility IDON, the IDON confirmed that Resident 4's urinary specimens were not obtained in the correct manner and should have been. C.In an interview completed on 08/06/2026 at 3:53 PM with the Facility IPC, the IPC confirmed that Resident 4's specimens were not collected in a manner to prevent the potential for contamination and standards of practice. The IPC confirmed that information regarding whether the resident's signs and symptoms met the criteria for an infection were completed with each instance and communicated to the resident's provider. The IPC confirmed that antibiotic time outs were being completed and were a review of the antibiotic, how the resident was tolerating the antibiotic, and whether symptoms were improving. The IPC stated that the culture reports were not utilized to ensure the pathogens present in the sample was susceptible to the prescribed antibiotic medication and therefore this information could not be communicated to the provider in a timely manner so treatment changes could be made if needed. The IPC confirmed a lack of knowledge and training to be able to proficiently complete all of the aspects of an antibiotic stewardship program as required.

Licensure Reference Number 175 NAC 12-006.18(B)&(D) Based on record review, observation, and interview the facility failed to change gloves at the designated interval when completing supra pubic catheter cares for Resident 4 and failed to complete hand hygiene between glove changes while providing peri cares for Resident 1. The sample size was 2 and the facility census was 33.Findings Are: A.Record review of a facility policy titled Catheter Care, and Specimen and dated 03/02/2026 revealed for care of an indwelling catheter to wash hands before entering the room and apply gloves, to adjust the position of the resident's bed to a working height, then remove gloves and complete hand hygiene and don new gloves, to use a clean wash cloth to clean the insertion site, surrounding skin, and exposed catheter cleansing away from insertion site, using a circular motion, and a clean section of the washcloth for each stroke. In an observation completed on 08/04/2026 at 9:25 AM of care being provided to Resident 4's Supra Pubic indwelling Foley catheter (a hollow tube that is placed directly into the bladder through a small cut into the lower abdomen for urine to drain into) by Medication Aide F (MA-F), the following was observed:-MA-F with gloved hands assisted the resident, who was in a sitting position in their bed, to change their shirt. The resident then utilized their remote and lowered the head of their bed. Without first performing hand hygiene (HH) or changing their gloves, the MA took a gray basin into the resident's bathroom and used the sink to add soap and water to the basin; then returned to the resident's room and placed the basin on a covered bedside table. The MA then unfastened the resident's disposable incontinence product and removed a piece of gray cloth from the resident's right and left abdominal folds. The MA then placed a washcloth into the basin of soap and water, wrung out the washcloth, and then used the washcloth to cleanse the resident's skin surrounding the insertion site of their suprapubic catheter starting approximately 3 inches outside the insertion site and moving towards the insertion site. The MA used the washcloth spread all the way out for the first stroke, then folded the washcloth in half for the next stroke, and then in fourths for the next stroke. The MA then unfolded the washcloth and repeated the wipes, all while continuing to wear the same pair of soiled gloves. The MA then obtained a clean, wet washcloth and folded it into fourths. The MA used this cloth to repeat the cleansing stroke, ensuring that a new section of the cloth was used for each stroke by folding down a corner of the washcloth and exposing a clean section for each stroke. Without first performing HH or donning new gloves, the MA then obtained a dry hand towel and used the towel to pat the area they had cleansed dry. The MA then picked up the 2 pieces for gray cloth off of the resident's bed and placed one on into the resident's right abdominal fold and the other into the resident's left abdominal fold. The MA then re-fastened the resident's disposable incontinence brief. The MA then took the gray basin with soap and water in it into the bathroom and emptied the continents into the sink. The MA then removed the gloves they had worn throughout the entire process, completed HH and donned a new pair of gloves. In an interview completed on 08/04/2026 at 10:31 AM with MA-F, MA- F confirmed that they did not change their gloves or complete HH when going from working with potentially soiled items or tasks and then to clean items or tasks while completing suprapubic catheter cares for Resident 4. In an interview completed at 08/04/2026 10:40 AM with Regional Educational Nurse ([NAME]), the [NAME] confirmed that MA-F did not change gloves or complete HH at the required intervals during suprapubic catheter cares for Resident 4 in a manner to prevent the possibility of contamination of the catheter and insertion site. B.Record review of a facility policy titled Perineal Care (cleansing of private parts and the anal area) and dated 07/30/2025 revealed that after providing perineal care staff were to remove their gloves and complete hand hygiene. In an observation completed on 08/04/2026 at 9:14 AM of perineal care being provided to Resident 1 by Nurse Aide D (NA-D) the following was observed:-NA-D applied gloves to both of their hands. NA-D then utilized the controller of the mechanical sit to stand lift to assist Resident 1 from a sitting position on the toilet to a standing position in front of the toilet. NA-D then obtained disposable perineal wipes from a plastic container and utilized the disposable wipe to wipe between the resident's legs going from front to back. The NA folded the disposable wipe with each wipe exposing a new area of the wipe with each wipe three times. With the same gloved hands, the NA then pulled up the resident's incontinence brief and pants and then removed the gloves from both of their hands and threw them into the trash can. Without first performing HH, NA-D navigated the lift with the resident in a standing position over to the resident's wheelchair and then utilized the controller to lower the resident into a seated position in their wheelchair. The NA removed the lift jacket from the sit to stand lift and from around the resident and then placed the resident's foot pedals onto their wheelchair. The resident requested a wet washcloth for their hands. The NA went into the resident's bathroom and obtained a wet washcloth for the resident and handed it to the resident. The NA then returned to the resident's bathroom and completed HH using soap and water for 16 seconds. In an interview completed on 08/04/2026 at 10:10 AM with NA-D, NA-D confirmed that they should have completed HH after providing peri care to Resident 1 and removing their gloves and did not. In an interview completed on 08/04/2026 at 10:40 AM with the [NAME], the [NAME] confirmed that staff are trained and competency to complete HH after removing their gloves. The [NAME] confirmed that NA-D should have completed HH and did not.

Licensure Reference Number 175 NAC 12-006.09 Based on observation, record review, and interview; the facility failed to manage, evaluate and reevaluate pain control for effectiveness for 1 (Resident 2) of 1 sampled resident. The facility identified a census of 33. A record review of a facility policy titled, Pain Management dated 1/29/26 revealed:Purpose: To provide residents' assistance in pain managementTo promote well-being by ensuring that residents are as comfortable as possible.To consistently collect data related to pain.To determine what pain relief intervention specific to the resident can be used to aid in maintaining a comfortable level of function and quality of life.Policy: All residents will receive interdisciplinary consultations on assistance in managing pain. Individualized approaches will be developed to address the resident's pain management needs in a holistic manner.The licensed nurse will assess current pain levels and develop with the physician and interdisciplinary team (IDT, to address the complex needs of individuals to ensure that all aspects of a participant's health and well-being are considered) interventions that may be non-pharmacological, as well as pharmacological.The nurses working directly with resident must continually monitor and observe the resident for success of the pain management plan and report to the nurse manager and prescriber as necessary to keep the resident comfortable.1.Determine if the resident is currently experiencing pain and complete the Pain Evaluation User Defined Assessment (UDA; is a customizable template tool used in electronic health record systems to document clinical findings, routine evaluations, and functional data in nursing facilities) Matrix.2. Develop a care plan including pain focus, goal and interventions. Once these interventions are care planned, a pain management plan should be person centered. Update care plan as needed to reflect current effective interventions.4. Pain documentation by the Certified Nursing Assistant (CNA) is ideally entered using the interventions from the care plan. This is the most efficient and resident-specific way to allow documentation of pain and response to interventions. Any time a resident is in pain, the nursing assistant should make the resident as comfortable as possible and verbally communicate with the nurse on duty. Record review of a Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment), dated 8/10/26 for Resident 2 revealed:Focus: Acute pain/chronic pain date initiated: 5/11/2026Interventions: Evaluate effectiveness of pain-relieving interventions (non-medication and medication). Evaluate pain.Focus: The resident is on pain medication therapy related to neuropathy and pressure wound. Date initiated 9/11/25; revision on 5/12/26Interventions: Review pain medication efficacy: Assess whether pain intensity is acceptable to resident. Resident identified level of pain tolerated 3 out of 10. Resident pain is aggravated by movement. Observe/record/report to Nurse any signs and symptoms (s/s) of non-verbal pain. Resident's pain is rated using a numerical scale (00-10) A record review of current Treatment Order Summary for Resident 2 dated 8/10/26 revealed the following orders:- Air mattress in alternating mode with 10 minute cycle, maintain weight setting at 230 pounds(lbs). Place the mattress in static mode during transfer, cares or repositioning if additional surface stability is needed. If malfunction noted, unplug and restart. If issue persists, notify maintenance. every day and evening shift -Start Date- 07/21/2026 1600- Resident on bedrest. To be up only for meals, no more than 1 hour at a time. May be up for appointments, bathing. When in bed, turn side to side every 2 hours and PRN. Not to lay on back, ensure heels are floated off bed surface. An observation of Resident 2 on 8/3/26 at 9:51 AM revealed the resident lying in bed supine (lying flat horizontally on your back with your face, chest, and torso pointing upward) with a gown on, sitting on an air mattress, the mattress was covered with a sheet, and a thick pad typically used to soak urine, and an alarm pad, used to alert staff if a resident moves. The bed settings were set at 230 lbs, per the directions from the order. An interview with Resident 2 on 8/3/26 at 9:51 AM, the resident was crying out help me, when asked what was wrong, the resident stated they were hurting. An interview on 8/3/26 with staff member Medication Aide (MA)-J revealed the resident had a large wound on (gender) bottom and had a lot of pain associated with it. An observation on 8/3/26 at 10:33 AM of Resident 2 revealed relieved from pain and resting. An observation of Resident 2 on 8/4/26 at 9:00 AM revealed the resident was up eating breakfast in the dining room, sitting on a sling used to lift someone with a mechanical device. An observation of Resident 2 on 8/4/26 at 11:00 AM revealed the resident sitting in their room watching television sitting in the wheelchair on a sling. MA-J [NAME] medication to the resident prior to their appointment. Resident 2 was leaving to go to a wound care appointment located 55 miles away. The resident left the building for the appointment at 11:30 AM. An observation of Resident 2 on 8/4/26 at 3:40 PM, the resident was grimacing, face clenched and squeezing fists, tears streaming down cheeks. Staff assisted the resident to lay down. Resident 2 was observed lying on their back in their bed which had an air mattress that was set at 230 lbs. An observation of Resident 2 on 8/5/26 at 8:03 AM revealed the resident sitting up in bed with a pillow tucked partially under their left arm. Resident 2 ws smiling waiting for breakfast. An observation of Resident 2 on 8/5/26 at 8:17 AM revealed the resident was calling out for help. Staff assisted the resident at 8:44 AM and stated will assist with adjustment in a bit. A different staff member then brought breakfast to Resident 2. An observation of Resident 2 on 8/5/26 at 9:12 AM, the resident reported to the staff member they were at a pain level of 10/10. Staff member returned within minutes with pain medication. An observation of Resident 2 on 8/5/26 at 10:52 AM, the resident reported to the staff member they were at a pain level of 9/10. The resident was calling out help me. A record review of current Medication Order Summary for Resident 2, dated 8/10/26 reveal the following orders:- Acetaminophen (an over the counter pain medication) tablet 325 milligram (MG) Give 650 MG by mouth every 4 hours as needed (PRN) for pain, not to exceed 3,000 mg per day. Order date: 8/30/25- Gabapentin (an anticonvulsant medication often used for nerve pain) oral capsule 300 MG Give 600 mg by mouth two times a day for neuropathy. Order date: 7/10/26- Morphine Sulfate (a narcotic pain medication) oral solution 20 MG/5 milliliter (ML) Give 0.5 ml by mouth every 1 hour as needed for breakthrough pain. Order date 8/6/26- Morphine Sulfate oral solution 20 MG/5ML Give 0.5 ml by mouth every 2 hours for breakthrough pain. Order date 8/6/26- Tramadol oral tablet 50 MG give 1 tablet by mouth every 8 hours PRN for use for pre medication for wound care appointments only. Order date 4/24/26 A record review of a Medication Administration Review form for Resident 2 revealed on 8/5/26 at 10:52 AM, the resident had already received Morphine Sulphate that was due at 11:00 AM. An interview on 8/5/26 at 11:00 AM with the Medication Aide (MA)-G revealed they gave Resident 2 medication already. When asked for clarification, MA-G opened the narcotic medication book that annotates administration of dates and times per resident. The narcotic administration book revealed the 11:00 AM dose on 8/5/26 for Resident 2 was given at 10:11 AM and they are able to receive another dose shortly. When asked if they did a follow up pain scale, MA-G stated yes and revealed the resident was reporting a 9/10. When questioned if this was acceptable, the licensed practical nurse (LPN)-A was standing at the cart and both LPN-A and MA-G stated no this was not acceptable. When asked what their process was, LPN-A stated they would reposition the resident and provide another dose of medication and contact the doctor if the resident revealed ineffectiveness to the changes. A record review of Medication Order Summary Recap for Resident 2, dated 8/10/26 reveal the following recapitulation of orders for pain medications:- Tramadol oral tablet 50 MG, give 1 tablet by mouth every 8 hours PRN for moderate to severe pain. Order date 9/26/25; End date 1/2/26.- Tramadol oral tablet 50 MG, give 1 tablet by mouth every 6 hours PRN for moderate to severe pain. Order date 1/2/26; End date 1/15/26.- Tramadol oral tablet 50 MG, give 1 tablet by mouth every 8 hours PRN for use for pre medication for wound care appointment for 1 day. Order date 4/22/26; End date 4/24/26.- Tramadol oral tablet 50 MG, give 1 tablet by mouth every 8 hours PRN for use for pre medication for wound care appointment for 1 day. Order date 4/24/26, Start Date 5/13/26; End date 5/14/26.-Tramadol oral tablet 50 MG, give 1 tablet by mouth every 8 hours PRN for use for pre medication for wound care appointments only. Order date 4/24/26; Start date 5/13/26.- Morphine Sulfate Oral Solution 20 MG/ML, give 0.25 ml by mouth every 3 hours as needed for pain. Order date 7/1/26; End date 7/10/26.- Morphine Sulfate Oral Solution 20 MG/5ML, give 0.25 ml by mouth every 2 hours as needed for pain. Order date 7/10/26; End date 8/5/26.- Morphine Sulfate Oral Solution 20 MG/5ML , give 0.25 ml by mouth four times a day for pain management related to pressure ulcer of contiguous site of back, buttock and hip. Order date 7/15/26; End date 7/29/26.- Morphine Sulfate Oral Solution 20 MG/ML, give 0.5 ml by mouth every 4 hours for pain. Order date 7/29/26; End date 8/6/26.- Morphine Sulfate Oral Solution 20 MG/5ML, give 0.5 ml by mouth every 2 hours as needed for pain. Order date 8/5/26; End date 8/6/26. A record review of a summary of pain levels for Resident 2 revealed the resident experienced levels of pain higher than recorded preference according to the CCP tolerance levels of 3 out of 10 on dates of:- 7/9/26: 8:13 AM - 10/10, follow up at 10:42 AM - 10/10, follow up at 11:57 AM- 4/10.- 7/11/26: 9:39 AM - 9/10, follow up at 9:44AM - 9/10, follow up at 11:04 AM - 10/10, follow up at 11:05 AM - 10/10, follow up at 12:13 PM - 8/10, follow up at 2:08 PM - 10/10, follow up at 2:14 PM - 10/10, follow up at 5:14 PM - 10/10, follow up at 7:10 PM-2/10.- 7/12/26: 7:40 AM - 9/10 (Using a Pain indicator scale to obtain visual identifiers of pain levels revealed): Occasional labored breathing, short period of hyperventilation, repeated troubled calling out, loud moaning or groaning, crying. Facial grimacing, tense distressed pacing. Rigid fists clenched, knees pulled up, pulling or pushing away, striking out, unable to console, distract or reassure.- 7/12/26: 7:48 AM - 7/10, follow up at 12:06 PM - 8/10, follow up at 2:13 PM - 7/10 (Using a Pain indicator scale to obtain visual identifiers of pain levels revealed): Occasional labored breathing, repeated troubled calling out, loud moaning or groaning, crying. Facial grimacing, tense distressed pacing. Consolability; distracted or reassured by voice or touch. Follow up at 6:14 PM 0/10.- 7/16/26: 3:12 PM - 10/10 - Follow up at 6:13 PM 0/10.- 7/17/26: 12:21 PM - 10/10 Follow up at 6:15 PM 0/10.- 7/18/26: 12:00 AM - 9/10, follow up at 10:52 AM - 9/10, follow up at 11:10 AM - 8/10.- 7/20/26: 2:21 PM - 9/10, follow up at 2:22 PM - 9/10 Follow up at 5:38 PM 4/10.- 7/22/26: 6:48 AM - 9/10, follow up at 9:19 AM - 9/10, follow up at 10:55 AM - 7/10, follow up at 12:20 PM - 8/10, follow up at 4:48 PM - 9/10.- 7/28/26: 6:28 AM - 10/10, follow up at 8:39 AM - 10/10 Follow up at 10:23 AM 5/10, follow up at 10:47 AM - 10/10 Follow up at 11:35 AM 1/10.- 8/3/26: 9:17 AM - 9/10 Follow up at 10:33 AM 9/10 Follow up at 12:00 PM 3/10.- 8/3/26: 12:20 PM - 9/10 Follow up at 4:06 PM 10/10 Follow up at 4:16 PM 8/10.- 8/4/26: 3:15 PM - 10/10 Follow up at 5:08 PM 7/10 Follow up at 5:44 PM 4/10.- 8/5/26: 9:13 AM - 10/10 Follow up at 9:13 AM 0/10.- 8/5/26: 11:13 AM - 10/10 Follow up at 1:52 PM 0/10.- 8/5/26: 4:55 PM - 8/10 Follow up on 8/6/26 at 1:27 AM 9/10, follow up at 9:02 AM 9/10, follow up at 11:13 AM 8/10, follow up at 11:14 AM 9/10, follow up at 1:16 PM 9/10, follow up at 1:30 PM 9/10, follow up at 2:23 PM 10/10, follow up at 4:22 PM 9/10, follow up at 5:39 PM 1/10. A record review of a Communication with Physician for Resident 2 revealed communication on 8/5/26 requesting an increase to pain medication. Physician increased pain medication as reflected in order summary with a start date of 8/6/26.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview the facility failed to ensure that residents were free of significant medication errors related to insulin (a natural hormone that manages your blood sugar level) administration for 1 (Resident 3) of 4 sampled residents. The facility census was 33. Findings are:Record review of the admission Record dated 8/10/26 for Resident 3 revealed that Resident 3 admitted into the facility on 3/20/26. Resident 3 had a diagnosis of diabetes (a chronic health condition where blood sugar levels are too high. This happens because the body either does not make enough insulin or cannot use insulin the right way, causing too much sugar to stay in the blood instead of turning into energy). Record review of the facility policy titled Medication Administration dated 3/30/26 revealed that the purpose of the policy is to administer medications correctly and in a timely manner. Record review of the Humalog (Lispro) insulin manufacturer Instructions for Use dated July 2023 revealed that Humalog (Lispro) insulin may cause serious side effects that can lead to death, including low blood sugar (hypoglycemia). Humalog (Lispro) insulin starts acting fast and should be injected within 15 minutes before or right after eating a meal. Observation on 8/5/26 at 12:12 PM at the nurse's station revealed that Licensed Practical Nurse-A (LPN- A) performed hand sanitization and picked up a small plastic basket of supplies. LPN-A went to the room of Resident 3. Resident 3 sat in the wheelchair in the middle of the room, there was an overbed tray was at the side of the bed and not within reach of Resident 3. LPN-A requested to see the resident's blood sugar sensor. Resident 3 removed the sensor from the resident's right shirt pocket. LPN-A pressed the button on the sensor and a blood sugar of 295 was displayed. LPN-A reviewed the sliding scale order for Resident 3 which read to administer 6 units of Lispro insulin for a blood sugar between 251-300. LPN-A drew 6 units of insulin lispro into the syringe. LPN-A asked Resident 3 what site to use for injection and the resident agreed to the abdomen. LPN-A wiped an area on the resident's right upper abdomen with an alcohol prep pad and then injected the 6 units of insulin subcutaneously (under the skin into the layer of fat between the skin and muscle) into the right upper abdomen. The time was 12:17 PM. LPN-A asked Resident 3 if they were ready for dinner and Resident 3 responded yes. LPN-A told Resident 3 that LPN-A would return to take the resident to the dining room. LPN-A exited the room of Resident 3 and returned to the treatment cart next to the nurse's station. Resident 3 remained in the wheelchair with nothing to drink or eat within their reach. Nurse Aide-E (NA-E) entered the room of Resident 3 at 12:21 PM. NA-E transported Resident 3 from the resident's room to a table in the dining room. A glass of tea and a glass of water sat on the table for Resident 3. Resident 3 did not drink any tea or water and there was no food present. Resident 3 remained seated at the table in the dining room with the glasses of tea and glass of water, which remained full. Resident 3 had their eyes closed and chin down towards their chest. An unidentified dietary staff delivered a meal to Resident 3 at 12:50 PM (33 minutes after the insulin lispro was administered). Resident 3 picked up the dinner roll and tore it in half. Resident 3 buttered the roll and took a bite at 12:51 PM (this was 34 minutes after the insulin was administered). Record review of the Treatment Administration Record (TAR, a legal record of the administration of scheduled treatments or performance of other scheduled medical tasks for a resident by a health care professional such as a licensed nurse) for Resident 3 dated 8/5/26 revealed that LPN-A documented the administration of 6 units of insulin Lispro for the blood sugar of 295 on 8/5/26. Interview on 8/5/26 at 12:56 PM with LPN-A confirmed that the insulin lispro administered to Resident 3 was a fast acting insulin. LPN-A confirmed that the resident is to be provided some nourishment within 15 minutes after administration of the insulin to prevent low blood sugar. LPN-A revealed that LPN-A assures the resident gets nourishment by just giving the insulin before lunch. LPN-A confirmed that LPN-A should have given Resident 3 some juice or ensured that some nutrition was provided within 15 minutes of administering the insulin. LPN-A confirmed that LPN-A did not ensure that Resident 3 received nourishment within 15 minutes of administering the insulin as required. Interview on 8/5/26 at 3:20 PM with the facility Interim Director of Nursing (IDON) confirmed that staff were required to ensure that residents receive nutrition within 15 minutes of administration of Lispro insulin.

Licensure Reference Number 175 NAC 12.006.05(D&E)Based on record reviews and interviews, the facility failed to fully inform the resident and/or the resident representative on the risks versus benefits, alternatives to treatment and a consent to treat prior to dispensing a psychotropic medication for 1 resident (Resident 31) of 5 residents reviewed. The facility census was 33. Findings are:A record review of a facility form titled, Permission for Use of Psychotropic Medications dated 2/18/26 revealed an admission date for Resident 31 of 2/18/26. The form further revealed the resident was prescribed the following medications:-Risperidone (an antipsychotic medication), without a dose, without a frequency, with indications for use.-Zolpidem (sedative medication used for the short-term treatment of insomnia) 5 milligram (MG), without a frequency, with indication for use.Both medications have listed risks versus benefits and alternatives to treatment. There is a consent and signature dated the same day. A record review of a facility form titled, Permission for Use of Psychotropic Medications dated 2/20/26 for Resident 31. The form further revealed the resident was prescribed the following medication:-Trazadone (a medication used to treat major depressive disorder) 25 MG every 8 hours as needed (PRN), with indications for use.The medication listed risks versus benefits and alternatives to treatment. There is a consent and signature dated the same day. A record review of a facility form titled, Permission for Use of Psychotropic Medications dated 7/24/26 for Resident 31. The form further revealed the resident was prescribed the following medication:-Ativan (a benzodiazepine used to treat anxiety disorders) 0.5 MG, without a frequency, with indications for use.The medication has listed risks versus benefits and alternatives to treatment. There is a consent and signature dated the same day. A record review of a facility form titled, Permission for Use of Psychotropic Medications dated 7/26/26 for Resident 31. The form further revealed the resident was prescribed the following medication:-Lorazepam (a benzodiazepine used to treat anxiety disorders), without a dose, without a frequency, with indications for use.The medication has listed risks versus benefits and alternatives to treatment. There is a consent and signature dated the same day. A record review of a facility form titled, Order Recap Report (a report that lists a patient's past and active medication orders, dosages, and administration records) for Resident 31, dated 8/10/26 revealed the following medications:-Ativan (Lorazepam) 0.5 MG give every 8 hours PRN for increase anxiety; order date 2/20/26, end date 3/6/26-Lorazepam 0.5 MG give every 8 hours PRN for anxiety; order date 3/11/26, end date 4/16/26-Lorazepam 0.5 MG give every 8 hours PRN for anxiety; order date 4/16/26, end date 4/16/27-Risperidone 1 MG give 1 one time a day for agitation; order date 2/18/26, end date 6/1/26-Risperidone 0.75MG give 1 one time a day for agitation; order date 6/1/26, end date 6/28/26-Risperidone 1 MG give 1 one time a day for agitation; order date 6/28/26, end date 6/28/26-Risperidone 1 MG give 1 one time a day for agitation; order date 6/28/26, no end date-Zolpidem 5 MG give one time a date for insomnia; order date 2/18/26, no end date The Interim Director of Nursing (IDON) was interviewed on 8/10/26 at 1:21 PM and confirmed that all psychotropic medications need a permission for use from either the resident or the resident representative prior to dispensing the medication. The IDON agreed that the permission for use of a psychotropic medication for Resident 31 was not completed timely.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interviews the facility failed to obtain urine specimens in a manner to prevent the potential for cross contamination for 1 (Resident 4) of 1 sampled resident. The facility census was 33. Findings are:Record review of a facility policy titled Catheter Care, and Specimen dated 03/02/2026 revealed when a specimen is needed and if the catheter has been in place more than two weeks (14 days) or has sediment, it must be replaced before any specimen for analysis is obtained. Record review of a document titled Urine Culture Stewardship and dated 04/14/2024 from https://www.cdc.gov/uti/hcp/clinical-guidance revealed prior to collection of a urine specimen from an indwelling urinary catheter, if catheter has been in place greater than 14 days replace the catheter prior to specimen collection and never collect a urine culture from the collection bag. Record review of Resident 4's Orders Report revealed the resident had an order to change the resident's indwelling suprapubic catheter once every 2 months on the 26th day of the month and as needed. Record review of Resident 4's Treatment Administration Record for the Month of May 2026 revealed documentation that the resident's catheter was changed on the 26th day of the month as ordered. There was no documentation indicating the resident's catheter was changed on an as needed basis prior to the 26th of the month. Record review of a document titled Fax communication to physician for urinary symptoms and dated 06/10/2026 for Resident 4 revealed the provider wrote orders for a urinary analysis to be completed and to utilize a catharized specimen with their next catheter change. Record review of Resident 4's Treatment Administration Record for the Month of June 2026 revealed no documentation of Resident 7's indwelling catheter being changed either routinely or on an as needed basis. Record review of Resident 4's Progress Notes for the Month of June 2026 revealed no evidence that Resident 4's indwelling catheter was changed routinely or on an as needed basis that month. Record review of a Laboratory Report document dated 06/10/2026 revealed the laboratory report was for a urine specimen obtained via catheter for Resident 4. On the report, the provider wrote an order for Augmentin (an antibiotic medication) 875 milligrams (mg) twice daily for 14 doses per last urinary culture obtained. The specimen was obtained from an indwelling catheter that had been in place more than 14 days. Record review of Resident 4's Treatment Administration Record for the month of July 2026 revealed documentation that the resident's catheter was changed on the 26th day of the month as ordered. There was no documentation indicating the resident's catheter was changed on an as needed basis prior to the 26th of the month. Record review of a Laboratory Report document dated 07/10/2026 revealed the laboratory report was for a urine specimen obtained via voided urine for Resident 4 (the resident continued to have an indwelling catheter and did not void urine). On the report, the provider wrote an order for Augmentin (an antibiotic medication) 875 mg twice daily for 14 doses per last urinary culture obtained. Further record review of Resident 4's Electronic Medical Health Record (EMHR) revealed that the resident's catheter was last changed on 06/26/2026, indicating that the specimen obtained and dated 07/10/2026 was obtained from a catheter that had been in place more than 14 days. Record review of a Laboratory Report document dated 07/31/2026 revealed the laboratory report for a specimen obtained via voided urine for Resident 4 (the resident continued to have an indwelling catheter and did not void urine). This report did not contain a urine culture. Record review of a document titled Orders and Progress Notes and dated 07/31/2026 for Resident 4 revealed that the provider wrote an order for Macrobid (an antibiotic medication) 100 mg to be administered twice daily for 7 days. In an interview completed on 08/05/2026 at 11:30 AM with the facility Interim Director of Nursing (IDON), the IDON confirmed that the facility had not received Resident 4's Microbiology Specimen report back from the laboratory for the urine specimen obtained on 07/31/2026 and would request it. The IDON confirmed that Resident 4 had an indwelling catheter when the urine specimen was obtained and the Laboratory Report should not have stated that the urine specimen was obtained via void and that this was an error. In a follow up interview completed on 08/06/2026 at 10:35 AM with the IDON, the IDON stated that Resident 4's provider was in the facility the afternoon of 08/05/2026 and reviewed the Microbiology Specimen report for Resident 7's urine specimen that was obtained on 07/31/2026 and wrote new orders to discontinue the Macrobid that was ordered on 07/31/2026 and per this report to change the resident's antibiotic to Augmentin 875 mg twice daily for 14 days. In an interview completed on 08/06/2026 at 1:20 PM with Licensed Practical Nurse A (LPN-A), LPN-A confirmed that when collecting the urine specimens for Resident 4 in the Month of June 2026 and July 2026, they did not ensure that the catheter had not been in place greater than 14 days prior to obtaining the specimen from the catheter. The LPN stated that the obtained-on specimen by clamping the resident's catheter tubbing and putting the urine into a specimen cup and changing the resident's urinary specimen bag allowing urine to drain into the new specimen bag and then emptying the urine into a specimen cup. The LPN confirmed that this was not the correct technique for collecting urinary specimen from a resident with an indwelling urinary catheter. In an interview completed on 08/06/2026 at 1:20 PM with the facility IDON, the IDON confirmed that Resident 4's urinary specimens were not obtained in the correct manner and should have been.

Licensure Reference Number 175 NAC 12-006.09(F)(ii)&(iii) Based on record reviews and interviews, the facility failed to review and revise the Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) after a change of condition and change in services provided for 2 (Residents 2 and 4) of 2 residents reviewed. The facility census was 33. Findings are: A record review of a policy titled, Skin Assessment Pressure Ulcer Prevention and Documentation Requirements dated 3/30/26 revealed: Procedure: All residents will be identified for their risk of developing pressure ulcers on admission/readmission by a registered nurse using the Braden Scale for Predicting Pressure Sore Risk Evaluation User-Defined Assessment (UDA; is a customizable template tool used in electronic health record systems to document clinical findings, routine evaluations, and functional data in nursing facilities). The registered nurse will complete the Braden Scale for Predicting Pressure Sore Risk Evaluation UDA on all residents quarterly or when the resident has a change in condition that could affect his or her risk of developing an ulcer. All residents will have a comprehensive skin inspection done by a licensed nurse on admission/readmission to identify any skin issues present including, but not limited to, pressure ulcers, and the results will be documented in the legal medical record. Residents who are unable to reposition themselves independently, should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves. The positioning schedule should be communicated to the nursing assistants using the Kardex (a quick reference guide that summarizes a patient's daily care needs, and key clinical data). A record review of a policy titled, Care Plan dated 12/1/25 revealed each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI, a standardized tool in evaluating each resident's needs to build a personalized plan of care) and review of the physician's orders. -The comprehensive plan of care will be finalized during an interdisciplinary care team conference no later than seven days after completion of the comprehensive resident assessment. -This plan of care will be modified to reflect the care currently required/provided for the resident. -The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated, and updated when there is a significant change in the resident's condition. A. A record review of a facility form titled, Braden Scale for Predicting Pressure Sore Risk (A scale that identifies patients at risk for pressure ulcers) for Resident 2 dated 2/18/26 revealed: Mobility: resident's ability to change and control body position is very limited. Very limited is defined by Braden Scale for Predicting Pressure Sore Risk as: Makes slight changes in body or extremity position but unable to make frequent or significant changes independently. Activity: resident's ability to walk is severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Friction and Shear: resident requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Record review of a Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment), for Resident 2, print dated 8/5/26 revealed: Focus: -The resident has limited physical mobility related to multiple sclerosis (MS; a long-term brain and spinal cord disease) as evidenced by need for assistance with dressing lower extremities and inability to ambulate. Initiation date 12/12/25. Intervention: -Mobility; resident uses wheelchair for locomotion, resident is able to propel self in wheelchair. Initiation date of 12/12/25. -Monitor/document/report to health care provider as needed (PRN) sign and symptoms of immobility. Initiation date of 12/12/25. Focus: -The resident has an activities of daily living (ADL; tasks related to personal care, such as dressing, eating, and mobility) self-care performance deficit related to multiple sclerosis as evidenced by weakness. Initiation date of 8/29/25. Revision on 9/9/25. Intervention: -Transfer: transfer between surfaces: independently, will call for assistance when needed. Initiation date of 9/9/25. Revision on 12/12/25. -Transfer: Strength: resident is able to stand and pivot independently, will call for assistance when needed. Initiation date of 9/9/25. Revision on 12/12/25. Focus: -The resident has potential for pressure ulcer development related to functional deficit. Initiated on 9/11/25. Interventions: -Educate resident/family as to causes of skin breakdown including: transfer repositioning requirements; and frequent repositioning. Initiated on 9/11/25. -Resident able to reposition self PRN. Initiated on 9/11/25. -Encourage resident to turn/reposition at least every 2 hours. Initiated on 12/12/25. Record review of an updated Comprehensive working Care Plan for Resident 2, print dated 8/5/26 revealed: Focus: -Current functional performance. Initiation date of 5/11/26. Interventions: -Resident performance: Locomotion on unit-total assist/one person physical assist. Initiation date of 5/11/26. -Resident performance: Transfer-total assist/two person physical assist. Initiation date of 5/11/26. Focus: -The resident has an activities of daily living (ADL; tasks related to personal care, such as dressing, eating, and mobility) self-care performance deficit related to multiple sclerosis as evidenced by weakness. Initiation date of 8/29/25. Revision on 9/9/25 Interventions: -Mobility: resident uses wheelchair for locomotion, resident needs staff assistance with locomotion. Revision on 5/12/26 -Transfer-transfer between surfaces: 2 staff assistance Hoyer lift (a specialized mobile patient-transfer device) Initiation date of 9/9/25. Revision on 5/12/26 Focus: -The resident has potential for pressure ulcer development related to functional deficit. Initiated on 9/11/25. Revision on 4/8/26. Resolved on 4/8/26 Interventions: -Educate resident/family as to causes of skin breakdown including: transfer repositioning requirements; and frequent repositioning. Initiated on 9/11/25. Revision on 4/8/26. Resolved on 4/8/26 -Resident able to reposition self PRN. Initiated on 9/11/25. Revision on 4/8/26. Resolved on 4/8/26 Focus: -The resident has a pressure ulcer. Initiation on 4/28/26. Revision on 5/11/26. Interventions: -Assist to turn/reposition at least every 2 hours. Initiation on 4/28/26. An interview with Minimum Data Set Coordinator (MDSC; a licensed nurse who manages patient health assessments in long-term care and skilled nursing facilities) on 8/6/26 at 8:00 AM revealed the MDSC could not recall Resident 2's needs at the time of the required assessments or when the resident's change of condition occurred. The MDSC stated they were not the only person responsible for completing the assessments or care plans updates. An interview with the Interim Director or Nursing (IDON) on 8/5/26 at 3:45 PM stated any function status changes should be updated in each resident's plan of care. The IDON confirmed the plan of care was not updated to reflect Resident 2's mobility and transfer status after being identified in their assessment on 2/18/26 or after being readmitted from a hospital stay on 3/2/26, 3/5/26, and 4/8/26. B. Record review of Resident 4's Care Plan on 08/04/2026 revealed a focus of the resident having a respiratory infection related to being Covid-19 positive, dated 02/27/2026. Goals of the resident would be free from signs and symptoms of infection and would be symptom free of respiratory distress by the review date were dated 02/27/2026. Interventions were listed as the resident was on droplet and contact precautions dated 02/27/2026. In an observation completed on 08/04/2026 at 9:25 AM there was a visible orange sign hanging on the resident's door indicating Enhanced Barrier Precautions everyone must complete hand hygiene before and when leaving the residents room and that gloves and gowns should be work for high contact resident care activities. There was no signage indicating that the resident was on droplet and or contact isolation precautions. In an observation completed on 08/04/2026 at 9:25 AM of cares being provided to Resident 4 by Medication Aide F (MA-F) and Nurse Aide I (NA-I) it was observed that both staff members wore personal protective equipment of gowns and gloves. The staff did not have masks or eye protection on while providing direct resident care to the resident. In an interview completed on 08/04/2026 at 9:50 AM with MA-F, MA-F stated that Resident 4 required Enhanced Barrier Precautions when providing direct resident care and was not on contact or droplet precautions that staff had been notified of. In an interview completed on 08/04/2026 at 9:50 AM with NA-I, NA-I stated that Resident 4 required Enhanced Barrier Precautions when providing direct resident care and was not on contact or droplet precautions that staff had been notified of. In an interview completed on 08/04/2026 at 10:05 AM with Resident 4, Resident 4 stated that they were going outside of the facility to have their hair done. In an observation completed on 08/04/2026 at 10:15 AM Resident 4 was observed to utilize their electric wheelchair to leave their room enter the hallway, go down the hall passing other residents, exit the building and be assisted into a van and leave the facility property. The resident did not have any personal protective equipment on. In an interview completed on 08/04/2026 at 11:55 with Resident 4, Resident 4 stated they had just returned to the facility from getting their hair done at the local beauty parlor. The resident denied knowledge of being in contact or droplet isolation precautions. The resident stated that they had covid during the late winter early spring and was on in room isolation at that time only. In an interview completed on 08/10/2026 at 1:05 PM with the facility Infection Prevention Coordinator (IPC), the IPC confirmed that Resident 4 was currently on Enhanced Barrier Precautions and their Covid-19 status from February had resolved without issue. In an interview completed on 08/10/2026 at 1:05 PM with the facility Interim Director of Nursing (IDON), the IDON confirmed that Resident 4's care plan was not up to date and did not accurately reflect the care and services that were being provided to the resident.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report to the required regulatory agencies an allegation of misappropriation and submit a written report within 5 working days to the required regulatory agency of the allegation of misappropriation for 1 (Resident 1) of 1 sampled resident. The facility census was 33. Findings are:Record review of a facility policy titled Abuse and Neglect and dated 04/07/2025 revealed an allegation of misappropriation would carry the potential of an allegation of abuse and neglect. Listed under notification procedures, alleged or suspected violations would be reported immediately to the administrator and the designated agencies will be notified in accordance with state law including State Survey and Certification Agency and if applicable Adult Protective Services. Record review of a facility supplied, untitled document on 08/04/2026 revealed on 04/11/2026 Resident 1 had reported an allegation of misappropriation and the responsible individual created a event report. In an interview completed on 08/04/2026 at 12:50 PM with the facility Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) Coordinator (MDSC), the MDSC confirmed that an investigation was conducted into the allegation of misappropriation received by the facility on 04/11/2026. The MDSC stated that the did not report the event or allegation to Adult Protective Services and submit a written report to the State Agency due to the investigation resulting in the allegation being unfounded. In an interview completed on 08/04/2026 at 12:50 PM with the Facility Administrator (FA), the FA confirmed that it was the policy of the facility to report all allegations of abuse or neglect to Adult Protective Services and submit a written report as required to the State Agency and this was not done for Resident 1's allegation of misappropriation on 04/11/2026 and should have been.

Licensure Reference Number 12-006.05(S)Based on interviews and observation, the facility failed to ensure a resident's appearance was maintained in a well-kept manner for 1 resident (Resident 3) of 5 sampled residents. The facility census was 33.Findings are:In an interview completed on 08/03/2026 at 2:23 PM with Resident 3's spouse, the spouse stated that the resident's facial hair is often unshaved, and their fingernails are long and have soiling underneath them when they visit the resident in the facility.In an observation completed on 08/03/2026 at 3:00 PM Resident 3 is observed to be sitting in their room in their wheelchair. The resident's facial hair is long (approximately 2-3 centimeters length from the resident's face). The residents' fingernails on both hands are observed to be long (approximately 3-4 centimeters of free edge extending from the nail plate). Some of the nails are waved and or disformed in shape and there is visible brown, black substance beneath the nails.In an interview completed on 08/03/2026 at 3:00 PM with Resident 3, Resident 3 stated that they do not know when their face was shaved last. The resident took their hand and rubbed at the stubble present on their cheek and chin. The resident then stated, Yes I guess it is getting long; I don't know where a razor is or how to get shaved. When asked, the resident agrees that their fingernails are longer than they usually keep them. The resident shrugs their shoulders when asked if there is soiling under their nails.Record review of Resident 3's Diagnosis on 08/03/2026 revealed that the resident had a diagnosis of Diabetes Mellitus (DM- Type 2, a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia (high blood sugars resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production).In an observation completed on 08/04/2026 at 2:10 PM Resident 3 was observed to be resting in their recliner in their room. The resident continues to have long facial hair and long fingernails with black, brown underneath the free edge of the nail.In an interview completed on 08/04/2026 at 3:30 PM with the Infection Prevention Coordinator (IPC), who also acts as a charge nurse, the IPC stated residents should be shaved and receive nail care with bathing by the bath aide. The IPC stated that residents who are diabetic, the bath aide will notify the nurse on duty to come and complete the residents' nail care.In an interview completed on 08/05/2026 at 9:46 AM with Bath Aide H (BA-H), BA-H states that they shave residents' facial hair using an electric razor after the resident is bathed. The bath aide stated that sometimes this does not get completed due to time and the razor not working. The bath aide stated that they do not use a straight razor to shave residents only the electric razor so if they are in a hurry or the razor is not working the resident does not get shaved. BA-H stated that if a resident is a diabetic that they notify the nurse on duty to complete nail care. The bath aide stated if the resident refused these cares, they would notify the nurse. The BA-H confirmed that Resident 3 was scheduled to have a bath on this day and planned to complete the residents bathing prior to the noon meal.In an observation completed on 08/05/2026 at 9:59 AM Resident 3 was observed to be sitting in their wheelchair in their room. The resident continued to have long facial hair and long fingernails with black, brown underneath the free edge of the nails. In an interview completed on 08/05/2026 at 9:59 AM with Resident 3, Resident 3 confirmed that they had not been shaved and had long facial hair needing to be shaved. The resident confirmed that their nails were long and had not been trimmed and was told that they would receive a bath before lunch this day.In an observation completed on 08/05/2026 at 1:45 PM Resident 3 was observed to be resting in their recliner in their room. The resident continued to have long facial hair and long fingernails. There was no longer black, brown underneath the free edge of the nails.In an interview completed on 08/05/2026 at 2:10 PM with BA-H, BA-H confirmed that they cleaned underneath Resident 3's nails during their bath. The bath aide confirmed that they did not shave the resident after their bath and stated that they did not notify the nurse that the resident needed their nails cut.In an interview completed on 08/11/2026 at 1:04 PM with the IPC, the IPC stated that they had trimmed Resident 3's nails on 08/09/2026 after being notified by the resident's spouse that their nails were long and needing trimmed. In an interview completed on 08/11/2026 at 1:04 PM with the Interim Director of Nursing (IDON), the IDON confirmed that residents should be shaved with bathing or during normal routine morning cares and that diabetic residents were to have their nails cut after bathing to prevent the possibility of injury and or bleeding during nail care for these residents. The IDON confirmed that these cares were not provided to Resident 3 until their spouse indicated the need for the care to be provided on 08/09/2026 and should have been.

Licensure Reference Number 175NAC 1-005.06(D)Licensure Reference Number 175NAC 12-006.18(B) Based on observation, record review, and interview the facility failed to ensure that hand hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) occurred between residents while administering medications to prevent the potential for cross-contamination. This affected 3 of 4 residents sampled (Residents 19, 2, and 8); the facility failed to ensure that staff performed hand hygiene as required before and after glove use during the provision of resident cares and failed to ensure that staff performed hand washing for the required length of time during resident cares. This affected 1 of 1 sampled residents (Resident 21). The facility census was 32. Findings are:A. Record Review of the Medication Administration policy dated 4/8/2025 revealed one purpose to be to provide direction regarding medication aides. Furthermore, it revealed that medications are administered to the residents according to the Six Rights. All employees passing medications are familiar with action and adverse reactions of medications. Page 5 of the 8-page policy revealed that medication administration is a nursing task. The procedure stated: -Wash your hands prior to beginning med pass and following the administration of medication for each resident. If hands are visibly soiled, wash hands with soap and water. If hands are not visibly soiled, the use of an alcohol-based hand sanitizer (ABHS) is acceptable. -Review the Medication Administration Record for medications due. -Check for allergies prior to administering any medications -Follow the Six Rights: right medication, right dose, right resident, right route, right time, and right documentation. -Administer medications on each side of ordered time, except for STAT (immediate need) medications which must be given immediately or other time sensitive medications. Page 8 of the Medication Administration policy was the medication aide clinical skill checklist. The first sentence of the clinical checklist stated: Wash your hands prior to beginning the medication pass and following the administration of medication for each resident. Record review of the Hand Hygiene Policy dated 3/29/2022 revealed hand hygiene is the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings. Hand hygiene was either to be by handwashing (washing hands with soap and water) or applying hand sanitizer. The policy further revealed that Health Care workers would use waterless alcohol-based hand sanitizer (ABHS) or soap and water to clean their hands before preparing or administering medications. Record review of the Facility Education Report of Medication Aide A Revealed that MA-A had received the following education on the these dates: -Hand Hygiene and Infection Prevention on 01/02/2024, -Infection Control; Enhanced Barriers on 05/27/2024, -Infection Prevention and Medication Administration on 06/06/2024, -Medication Administration overall process on 09/09/2024, -Infection Prevention 1 and 2 on 10/02/2024. Observation of Medication Aide (MA) A on 09/15/2025 between 8:33 AM to 8:55 AM revealed that MA-A did not use hand sanitization prior preparing the medications. MA-A took the medications to Resident 19 and took the empty medication cup and water glass to the trash. At 8:47 AM, MA-A completed the documentation of the medications for Resident 19. MA-A then prepared medications for administration for Resident 8. MA-A did not use ABHS prior to preparing medications for administration. MA-A administered Resident 8's medications, then took the used glass to the trash and did not use ABHS afterwards. MA-A did not use ABHS. At 8:55 AM, MA-A then started preparing the medications for Resident 2. The medications were prepared and administered with a glass of supplement to Resident 2. When Resident 2 finished, MA-A took the used glass and disposed of this in the trash. MA-A did not use ABHS and then began to prepare medications for another resident. At no time did MA-A use any type of handwashing or ABHS to do hand sanitization while medications were prepared and administered to Residents 19, 2, and 8. Interview on 09/15/2025 at 9:05 AM with MA-A revealed that staff were to use ABHS or wash hands with soap and water between Residents while administering medications. MA-A did reveal the ABHS carried in MA-A's in pocket and did state that there was ABHS at the doors of the residents' rooms. MA-A confirmed hand hygiene had not been performed between the Residents 19, 2, and 8 while medications were prepared and administered. B. Record review of the facility policy titled Hand Hygiene dated 3/29/22 revealed that hand hygiene is the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings. Hand hygiene is a general term that applies to either handwashing or applying hand sanitizer. All employees will adhere to the 4 moments of hand hygiene and 2 zones of hand hygiene. The 4 moments of hand hygiene are: 1. Entering room. 2. Before Clean Task. 3. After Bodily Fluid/Glove Removal. 4. Exiting room. The 2 zones of hand hygiene are: Patient zone and Health-care zone. Gloves are a protective barrier for the healthcare worker. Hand Hygiene should be performed after glove removal. If gloves are used to perform a clean/aseptic procedure hand hygiene must be completed before putting on gloves. Hand hygiene must be done after removing gloves regardless of the task completed. Hand hygiene will be done when moving from a contaminated body site to a clean body site during patient care. The procedure for washing hands with soap and water revealed that staff must wet the hands and apply soap to the hands. Rub hands together briskly for at least 15-20 seconds covering all surfaces of the hands, fingers, and wrists. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 7/9/25 for Resident 21 revealed that Resident 21 admitted into the facility on 7/3/25. Resident 21 was dependent on staff for toileting hygiene and dependent on staff for transfers and repositioning (roll to left and right, chair to bed transfers, and toilet transfers). The MDS revealed that Resident 21 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 3 (BIMS scoring: 13–15: Cognitively intact; 8–12: Moderately impaired; 0–7: Severely impaired) indicating that Resident 21 had severely impaired cognition. Record review of the current care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 21 dated 9/10/25 revealed that Resident 21 has limited physical mobility and requires 2 staff to assist with bed mobility and transfers. The care plan revealed that Resident 21 has an activities of daily living (basic everyday tasks including bathing, eating, dressing, getting in and out of bed, and toileting) performance deficit and requires staff assistance with personal hygiene. Observation on 09/11/25 at 1:25 PM at the resident commons tv area revealed that Nurse Aide-K (NA-K) transported Resident 21 per wheelchair from the commons area into the resident room. Medication Aide-J (MA-J) brought the mechanical total body lift (a mechanical assistive device used to transfer a resident with difficulty standing up on their own) into the resident's room. NA-K and MA-J did not perform hand hygiene on entering the resident's room as required. NA-K removed the lap blanket from Resident 21 with the bare hands. NA-K and MA-J both put on gloves. NA-K and MA-J did not perform hand hygiene prior to putting on the gloves as required. MA-J revealed that Resident 21 has sores on the heels and gets daily dressing changes. MA-J and NA-K adjusted the loops on the lift sling (a fabric device with straps that is placed underneath a resident when a mechanical assistive device is used to transfer a resident with difficulty or the inability to stand up on their own from a seated or lying position) from underneath Resident 21. NA-K and MA-J connected the loops of the lift sling to the hooks of the mechanical total body lift using the gloved hands. NA-K operated the lift and lifted Resident 21 from the wheelchair and positioned Resident 21 over the bed. NA-K lowered Resident 21 onto the bed. MA-J reached over Resident 21 with the bare forearm of MA-J touching the bare right thigh of the resident to disconnect the sling loops from the lift. MA-J placed a gloved hand between the resident's legs to steady themself with the gloved hand touching the left heel boot (a cloth padded device to protect areas from pressure) as MA-J reached across the resident to unhook the far sling loop from the lift hook. NA-K and MA-J adjusted the position of Resident 21 on the bed with the bare forearms and gloved hands of NA-K touching the bare calves of Resident 21. The bare forearms and gloved hands of NA-K touched the bare left thigh of Resident 21 as NA-K and MA-J repositioned Resident 21 onto their right side. NA-K and MA-J used the gloved hands to reposition Resident 21 onto their left side. NA-K and MA-J used the gloved hands to remove the lift sling from underneath Resident 21. NA-K removed and discarded the gloves. NA-K did not perform hand hygiene as required. NA-K exited the room to get a package of wipes. NA-K did not perform hand hygiene on exiting the resident room as required. MA-J removed and discarded their gloves and went into the resident bathroom. MA-J performed hand washing with soap and water and scrubbed the hands for 10 seconds and rinsed and dried the hands (MA-J did not scrub the hands for 15-20 seconds as required). MA-J put on new gloves. NA-K returned to the room with a package of wipes. NA-K did not perform hand hygiene upon entering the room. NA-K put on a pair of gloves. NA-K did not perform hand hygiene prior to putting on the gloves as required. MA-J positioned themself on the left side of the resident's bed. NA-K positioned themself on right side of the resident's bed. NA-K and MA-J unhooked the brief of Resident 21 using the gloved hands. NA-K used wipes to wipe the front private area (a contaminated body site) of Resident 21. NA-K and MA-J rolled Resident 21 onto their left side using the gloved hands. NA-K used wipes to wipe the anal area (a contaminated body site) of Resident 21 with the gloved right hand. NA-K removed and discarded the gloves. NA-K went into the resident's bathroom and performed hand washing for a total of 5 seconds (scrubbing, rinsing, and drying the hands). NA-K put on new gloves. NA-K and MA-J positioned a new brief underneath Resident 21 with their gloved hands. NA-K and MA-J repositioned Resident 21 with their bare forearms and gloved hands touching the bare thighs of Resident 21. NA-K and MA-J removed and discarded the gloves. NA-K and MA-J did not perform hand hygiene after removing the gloves as required. NA-K used the bare hand to operate the bed control. NA-K lowered the resident bed to the low position. NA-K removed the trash bag from the trash can and exited the resident room. NA-K performed hand hygiene with alcohol based hand rub (ABHR) on exit from the room. MA-J positioned the over bed table next to Resident 21's bed using the bare hands. MA-J put on gloves. MA-J did not perform hand hygiene prior to putting on the gloves as required. MA-J removed the mechanical total body lift from the room of Resident 21 and began to disinfect the lift with disinfecting wipes. Interview on 9/15/25 at 12:48 PM with the facility Infection Preventionist (IP) confirmed that facility staff are expected to follow the facility Hand Hygiene policy. The IP confirmed that staff are expected to follow the hand hygiene policy during resident care and revealed that the IP does monthly audits of hand hygiene for all facility staff. Interview on 9/16/25 at 12:07 PM Interview with Medication Aide-J (MA-J) confirmed that hand hygiene is to be performed prior to putting on gloves and again after removing gloves. MA-J confirmed that staff are expected to scrub the hands for 20 seconds during handwashing. MA-J confirmed that hand hygiene and hand washing were not completed as required during the care of Resident 21.

Licensure Reference Number 175NAC 12-00 6.09(7)Based on record review and interview the facility failed to ensure that a recapitulation (A concise summary of the resident's stay and course of treatment in the facility) was completed as required for 1 of 1 sampled residents (Resident 36); and the facility failed to notify the state ombudsman (a state appointed advocate for residents of nursing homes) of resident discharge for 1 of 1 sampled residents (Resident 36). The facility census was 32. Findings are: A.Record review of the facility policy titled Discharge and Transfer dated 3/28/25 revealed that when a transfer or discharge occurs the location (facility) must ensure that the transfer or discharge is documented in the medical record. With a transfer or discharge the location must send a copy of the facility or other state required form to a representative of the Office of the State Long-Term Care Ombudsman. The section titled Home revealed that the charge nurse or other designated individual will complete the progress note Discharge Home, obtain an order from the physician for discharge to home with medications, complete the Discharge or Therapeutic Leave Medication List assessment, complete the Miscellaneous section of the admission Record, complete and review any relevant portions of the progress note Teaching Resident/Family, and complete the Discharge Summary.Record review of the admission Record dated 9/15/25 for Resident 36 revealed that Resident 36 admitted into the facility on 5/8/25 and discharged to home from the facility on 6/23/25.Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 6/23/25 for Resident 36 revealed that the assessment was for discharge reporting. Active diagnoses included diabetes, malnutrition, and anxiety. Record review of the Discharge summary dated [DATE] for Resident 36 revealed that the section titled admission Diagnoses was left blank. The sections titled Hearing/Speech/Vision; Cognitive Patterns; Mood and Behavior; Preferences for Customary Routines and Activities; Functional Status; Bladder and Bowel; Active Disease Diagnoses; Health Conditions; Swallowing/Nutritional Status; Oral/Dental Status; Skin Conditions; Medications; Special Treatments and Procedures; Restraints; and Strengths and Goals were all left blank with no information documented. Record review of the Discharge admission Record dated 6/26/25 for Resident 36 revealed that the section titled Miscellaneous was not completed and contained no documented information.Record review of the progress note dated 6/23/25 at 6:49 PM for Resident 36 revealed that Resident 36 went home with all of their personal belongings. A friend came and picked up the resident. PICC Line was pulled prior to Resident 36 leaving. Record review of the progress notes for Resident 36 revealed no recapitulation of stay.Record review of the medical record for Resident 36 revealed no recapitulation of stay.Interview on 9/16/25 at 10:16 AM with the facility Director of Nursing (DON) confirmed that the discharge summary for Resident 36 did not contain all of the required information and much of the summary was left blank by the nurse. The DON confirmed that the facility did not have a recapitulation of stay for Resident 36.B.Record review of the facility policy titled Discharge and Transfer dated 3/28/25 revealed that when a transfer or discharge occurs the location (facility) must ensure that the transfer or discharge is documented in the medical record. With a transfer or discharge the location must send a copy of the facility or other state required form to a representative of the Office of the State Long-Term Care Ombudsman.Record review of the admission Record dated 9/15/25 for Resident 36 revealed that Resident 36 admitted into the facility on 5/8/25 and discharged to home from the facility on 6/23/25.Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 6/23/25 for Resident 36 revealed that the assessment was for discharge reporting. Active diagnoses included diabetes, malnutrition, and anxiety. Interview on 9/15/25 at 2:15 PM with the facility Social Services Director (SSD) revealed that the SSD sends the Emergency Transfers from Facility form to the state ombudsman monthly by email to notify the ombudsman of resident transfers. This surveyor requested the ombudsman notification for June 2025.Record review of the Emergency Transfers from Facility form for the month of June 2025 provided by the SSD revealed that it did not contain the discharge of Resident 36. Interview on 9/16/25 at 9:28 AM with the facility SSD confirmed that Ombudsman notification of the discharge of Resident 36 did not occur.

Licensure Reference Number 175NAC 12-006.09(H)(iv)(5) Based on record review and interviews; the facility failed to follow physician orders on bowel protocols for 1 (Resident 31) of 1 sampled residents. Facility census was 32. Findings are: A record review of the Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 04/05/2024 revealed: -The resident has impaired cognitive function/dementia or impaired though process related to cognitive decline evidenced by a diagnosis of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities.). -The resident has an activity of daily living (ADLs) (basic everyday tasks including bathing, eating, dressing, getting in and out of bed, and toileting) self-care performance deficit related to confusion evidenced by a diagnosis of dementia. A record review of the assessment Functional abilities dated 07/08/24 revealed the following: -Resident 31 is independent/supervision/touch assistance for all mobility activities. -Resident 31 is a setup or clean up assistance for- toilet hygiene, upper and lower body dressing, and personal hygiene, Further record review of the undated Standing Orders list revealed the following medications for bowel regimen: -Dulcolax suppository 10 milligrams (mg) rectally as needed for constipation, give daily as needed. Contact provider if there are three days without a significant bowel movement (BM), -Fleet Enema 7-19 gram (gm)/118milliliter (mL)-insert rectally as needed for constipation one time daily as needed Contact provider if there are three days without a significant BM, -Milk of Magnesia Suspension 400 MG/5ML give 30ml by mouth as needed for constipation give daily as needed. Contact provider/practitioner if there are 3 days without a significant BM, contraindicated for residents with renal impairment, -Senna-S Tablet 8.6-50MG give 2 tablets by mouth as needed for constipation give up to twice daily as needed, hold for loose stool. Contact provider if there are three days without a significant BM. Record review of Resident 31's EMR revealed a signed physician order for the standing orders. Record review of Point of Care charting (the recording and documenting of patient information directly at the bedside or point of care) on a 30 day look back period from 06/24/2024-07/23/2024 for questions on toileting revealed the resident did not have a bowel movement for 3 or more days from 06/24/2024 through 06/29/2024, 07/11/2024 through 07/15/2024. Review of Resident 31's Medication Administration Record (MAR) summary for the month of June 2024 and July of 2024 revealed no medication being administered from the standing order list for bowel regimen. Review of Resident 31's Progress Notes for the month of June 2024 and July of 2024 revealed no communication from the facility to the physician regarding three or more days without a significant BM. Record review of Resident 31's EMR did not reveal a fax communication contacting the provider regarding three or more days without a significant BM. An interview on 07/23/2024 at 1:09 PM with Medication Aide-A (MA-A) revealed that the Nursing Assistant (NA) will chart in the electronic medical record (EMR, digital collection of medical information about a person that is stored on a computer) when a resident has a bowel movement. If a resident is independent, the NA will need to ask the resident about their bowel movement to chart accurately. The resident is asked several times a day for charting purposes. If the charting reveals the resident does not have a bowel movement for 2 days and/or more days consecutively, the nurse will get an alert in the EMR and the resident is offered a medication from the physician standing orders list named Standing Orders that is physician approved. An interview on 07/23/2024 at 1:30 PM the Director of Nursing confirmed that no medication was given to Resident 31 for having three or more days without a significant BM and that the physician was not notified.

Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on interviews and record reviews, the facility failed to ensure that the monthly medication drug reviews were received and reviewed by facility staff to identify priority irregularities which needed addressed. This affected 1 resident (Resident 6) of 3 sampled residents. The facility census was 32. Findings are: A record review of the facility policy titled Medication Drug Regimen Review (MRR) dated 2/28/2024 stated the review is done to prevent medication errors that could cause harm to a resident, result in resident hospitalization , and to identify potential adverse events. The Pharmacist will complete a written report noting any drug irregularities or issues of concern for each resident reviewed, complete the MRR Summary, and give a copy to the Director of Nursing (DON) upon completion of the monthly MRR. These reports must be shared with the Medical director and the attending physician and the reports must be acted upon. If the consulting pharmacist detects a potential or actual problem that requires urgent action to protect the resident, the pharmacist will promptly alert the direct care nurse for immediate action. A record review of the Pharmacy Consultation report dated 6/30/2024 for Resident 6 revealed the report was time sensitive and had a prescriber response and facility action requirement of July 1, 2024 by 11:59 PM per the Federal Impact Act. This was a warning for potentially duplicate orders for the ropinirole (a medication that is used for restless leg syndrome) that Resident 6 was prescribed as there were three different orders in the medication administration record. A record review of the Monthly MRR's for Resident 6 revealed that the reviews were done monthly, however the results for June 2024 were missing. An interview on 7/22/2024 at 4:30 PM with the Director of Nurses (DON) revealed that the June 2024 MRR had been done by a consulting pharmacist. The DON revealed that the facility didn't get a copy of any of the consultation reports for June 2024. The DON assured the surveyors the reports would be available the following day. An interview on 7/23/2024 at 9:20 AM with the DON. Consulting Pharmacist June 2024 MRR paperwork was made available for review. The DON stated the Medical Director would be in the facility the following day and be able to review all of the reports and address them at that time. None of the paperwork from the June reports had been seen by the physician and the physician wouldn't see them until the following day. An interview on 7/23/2024 at 2:45 PM with the Consulting Pharmacist (CP). The CP always fills out the consultation reports from the monthly MRR's and sends them to the DON and the Facility Adminstrator (FA) either the same day or the day after the MRR has been completed. However, during the month of June the CP was not at the facility and another pharmacist had done the MRR. An interview on 7/23/2024 at 3:40 PM with Registered Pharmacist (RP-C) who had completed the MRR on June 30, 2024. RP-C stated that once the MRR had been completed, the MRR reports were sent to the facility on the same date. The email was sent to the DON and cc'd to the Administrator. At this point, the RP-C checked the sent box of email and stated it was indeed sent from RP-C's to the facility DON. RP-C had called the facility to notify a nurse (could not recall the name of the nurse) to let that nurse know that there was an order that needed to be addressed as soon as possible. An interview on 7/23/2024 at 4:00 PM with DON. The DON confirms that the consultation reports were not reviewed for the month of June 2024 as the DON had not received them. Today was the first time that (the DON) saw them. The physician won't see them until tomorrow. Tomorrow is a routine for the physician to be here (in the facility).

Licensure Reference Number 175NAC 12-006.09(H) Based on record review and interviews, the facility failed to implement AIMS monitoring for 1 (Resident 21) of 5 sampled residents, to identify potential adverse effects of antipsychotic medications. Facility census was 32. Findings are: A review of a facility policy dated 12/06/2023 titled Psychotropic Medications revealed: -The resident will be free from any chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. -Each resident's drug regimen must be free from unnecessary drugs. An Unnecessary drug is any drug when used without adequate monitoring and without adequate indications for use. -Before administration of non-emergency psychotropic medications, the following must be completed: If the physician prescribes an antipsychotic for the resident, a registered nurse must complete the Initial Antipsychotic Medication Assessment and the Abnormal Involuntary Movement Scale in the electronic medical record (EMR) (digital collection of medical information about a person that is stored on a computer). -Throughout the administration of the psychotropic medications, the following must be completed: If the resident is on an antipsychotic, a registered nurse must complete the Abnormal Involuntary Movement Scale (AIMS) in the EMR every 6 months. If there is a change in the results of the AIMS in EMR (electronic medical record), the physician and family/legal representative must be notified, and this notification must be documented in the medical record. A record review of Resident 21's most recent Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated April 27, 2024, revealed resident is taking an antipsychotic on a routine basis. A record review of Resident 21's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 11/14/2022 with a revision date of 4/16/2024 reveals: -The resident is on an antipsychotic medication related to dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities) with behavioral symptoms. -The resident has a behavior symptom related to dementia with behaviors being argumentative, striking out at staff, exit seeking, raising her voice, being disruptive, demanding large sums of money. -The resident uses psychopharmacological medications related to dementia with behaviors. A record review of Resident 21's Medication Administration Record (MAR, a legal record of the medications administered to a patient at a facility by a health care professional) revealed, an order for Geodon (antipsychotic medication) 40 milligram (mg), 1 capsule by mouth 2 times a day with date initated 11/01/2022. A record review of Resident 21's assessments revealed no Abnormal Involuntary Movement Scale (AIMS) monitoring (an assessment used to assess for abnormal irregular, involuntary movements most commonly in areas of the face, around the eyes, and of the mouth, including the jaw, tongue, and lips) for the antipsychotic medication. On 7/22/2024 at 3:14 PM an interview with the Minimum Data Set Coordinator (MDSC, a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) revealed that the AIMS assessment should be triggered to be completed for all residents receiving an antipsychotic medication. The MDSC confirmed that for Resident 21, it had not been initiated or completed during the duration of the prescribed antipsychotic.

Licensure Reference Number 175 NAC 12-006.12D(vi) Based on observation, record review, and interviews; the facility failed to ensure that resident medications had labels that matched the physician's order for 2 (Residents 20 and 15) of 5 residents observed. This had the potential for risk to resident safety related to medication administration. The facility census was 32. Findings are: A. A record review of the facility policy titled Medication: Administration Including Scheduling and Medication Aides dated 3/29/23 revealed the purpose of the policy was to administer medications correctly and in a timely manner. The section titled Procedure revealed the instruction to review the Medication Administration Record (MAR, a legal record of the medications administered to a patient at a facility by a health care professional) for medications due. Follow the Six Rights: Right medication, right dose, right resident, right route, right time, and right documentation. Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup, and just before administering the medication. An observation on 7/18/24 at 8:39 AM at the medication cart just outside the facility dining room revealed that Medication Aide-A (MA-A) began medication set up for Resident 20. MA-A reviewed the MAR for Resident 20. The MAR for Resident 20 revealed that Venlafaxine HCl ER (a medication used to treat depression and anxiety) Oral Tablet Extended Release 24 Hour 150 milligrams (mg) (Venlafaxine HCl) Give 150 mg by mouth two times a day was due to be administered. MA-A removed the medication container of Venlafaxine from within the medication cart and looked briefly at the label on the medication container for the Venlafaxine. This surveyor reviewed the label on the medication container. The label read Venlafaxine 75mg and instructed to give 75mg orally daily; take with 150mg dose for total of 225mg every day. The label did not match the current physician order for Resident 20 to receive 150mg twice a day (a total of 300mg daily). Further observation on 7/18/24 at 8:39 AM at the medication cart just outside the facility dining room revealed that MA-A reviewed the MAR for Resident 20. The MAR for Resident 20 revealed that Fluticasone Propionate Suspension (a medication sprayed into the nose for relief of allergy symptoms) 50 micrograms (mcg) 1 spray in both nostrils 1 time a day was due to be administered. MA-A removed the clear plastic bag containing the Fluticasone bottle from within the medication cart. MA-A looked at the pharmacy label on the clear plastic bag. This surveyor reviewed the pharmacy label on the plastic bag for the bottle of Fluticasone spray. The label read Fluticasone Propionate 120 metered sprays 50mcg 2 sprays intranasally (into the nostril) daily. The label did not match the physician's order to administer 1 spray into each nostril. A record review of the Order Summary dated 7/18/24 for Resident 20 revealed the current physician order for Venlafaxine HCL ER 150mg. Give 150mg by mouth two times a day for anxiety due to depression. Monitor for adverse effects peripheral edema (swelling in the legs, ankles, or feet from excess fluid), headache, constipation, nausea, vomiting, and back pain. The order start date was 4/15/24. A record review of the Order Summary dated 7/18/24 for Resident 20 revealed the current physician order for Fluticasone Propionate Suspension 50mcg 1 spray in both nostrils one time a day for allergy. The order start date was 9/11/22. An interview on 7/18/24 at 10:23 AM with the facility Director of Nursing (DON) confirmed that the label for Resident 20's Venlafaxine 75mg instructed to give 75mg orally daily; take with 150mg dose for total of 225mg every day. The DON confirmed that the label did not match the current physician's order for Venlafaxine 150 mg by mouth two times a day for a total of 300mg. The DON revealed that they would notify the pharmacy of the label discrepancy. The DON confirmed that the label for Resident 20's Fluticasone Propionate Suspension 50 mcg instructed to give 2 sprays intranasally daily. The DON confirmed that the label did not match the current physician's order for Fluticasone Propionate Suspension 50 MCG 1 spray in each nostril 1 time a day. The DON revealed that the DON would notify the pharmacy of the label discrepancy. The DON confirmed that the expectation is that the pharmacy labels for medications match the physician's order for the medication so that staff administer the medications as ordered. B. An observation on 7/18/24 at 8:55 AM at the medication cart just outside the facility dining room revealed that Medication Aide-B (MA-B) began medication set up for Resident 15. MA-B reviewed the MAR for Resident 15. The MAR for Resident 15 revealed that Albuterol Sulfate 108mcg (a medication inhaled into the lungs to treat breathing difficulty) 2 puffs inhale orally two times a day was due to be administered. MA-B opened the medication cart drawer and removed the Albuterol Sulfate inhaler for Resident 15. The inhaler was not in a labeled plastic bag or any other container. This surveyor reviewed the inhaler. The inhaler had a label applied to it containing the name of the resident and the name of the medication Albuterol Sulfate. The label had no instructions containing the physician's order instructions for administration. This surveyor asked MA-B where the label for the Albuterol inhaler was located. MA-B revealed that the label is normally located on a plastic bag that the inhaler is stored in. MA-B revealed that the plastic bag for the Albuterol inhaler for Resident 15 was missing. MA-B had no label containing the physician's administration order for the Albuterol inhaler to compare with the MAR as required. A record review of the Order Summary dated 7/18/24 for Resident 15 revealed the current physician order for Albuterol Sulfate Inhalation Aerosol 108mcg 2 puffs inhale orally two times a day. An interview on 7/18/24 at 11:29 AM with the facility DON confirmed that the facility did not have a pharmacy label with instructions for Resident 15's Albuterol inhaler. The DON confirmed that the expectation was for the Albuterol inhaler to have a pharmacy label with instructions for use matching the physician's order so that staff administered the medication as ordered.

Licensure Reference 175 NAC 12-006.17D Based on observation, interview, and record review; the facility failed to ensure hand hygiene was completed per expectation during a dressing change which affected 1 of 2 sampled residents, Resident 34, before starting medication administration which affected 1 of 3 residents observed, Resident 25; and during the distribution of water which affected 8 of 9 residents, Resident 15, 14, 27, 23, 21, 18, 1, and 8. The facility identified a census of 35 at the time of survey. Findings are: A. Observation of unit 3 on 6/14/23 from 9:47 AM to 9:53 AM revealed MA-A (Medication Aide) pushed a 3 tiered cart that had pitchers of ice water on the top shelf from the kitchen down the hall. MA-A had disposable gloves on. MA-A took a clean pitcher off the cart and took it into Resident 13's room. MA-A sat the new pitcher of ice water down and picked up the pitcher that was sitting on the stand and picked it up by the handle and brought it out and put it on the 2nd shelf of the cart. MA-A picked up a new pitcher off the top shelf by the handle with the same gloved hands and took a pitcher in to Resident 15's room, sat it down on the table, then picked up the pitcher that was already sitting on the table by the handle and took it out of the room and placed it onto the 2nd shelf of the cart. Using the same gloved hands, MA-A repeated the process for Resident 14, Resident 27, Resident 23, Resident 21, Resident 18, Resident 1, and Resident 8. MA-A wore the same pair of gloves to handle the clean pitchers and the dirty pitchers. MA-A then pushed the cart back to the kitchen after MA-A passed the clean pitchers and picked up the dirty ones. Interview with the IP (Infection Preventionist) on 6/21/23 at 1:49 PM revealed the facility staff were expected to wash hands for 2 minutes before each med pass and in between residents. Interview with the DON (Director of Nursing) on 6/21/23 at 1:50 PM revealed the staff were to sing the ABC song to themselves twice during the hand washing process to ensure they were washing their hands long enough. Staff were also expected to gel in gel out (apply hand sanitizer when they enter a room and when they exit a resident room) and scrub with the hand sanitizer until their hands were dry. If they had dirty gloves on they were expected to remove them and do hand hygiene before they put new gloves on. The DON confirmed the pitchers on the top of the cart were the clean ones and the staff were expected to do hand hygiene in between the clean and dirty pitchers and not wear the same pair of gloves during the process. If the staff performed a dirty task, they were expected make sure they were washing hands or gel in gel out. Review of the facility policy Hand Hygiene dated 3/29/2022 revealed the following: All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. All employees in patient care areas will adhere to the 4 moments of Hand Hygiene and 2 Zones of Hand Hygiene: 1. Entering room [ROOM NUMBER]. Before Clean Task 3. After Bodily Fluid/Glove Removal 4. Exiting room [ROOM NUMBER]. Zones: patient zone and health-care zones. Gloves are a protective barrier for the HCW (Health Care Worker) according to standard precautions. 1. Gloves are never to be reused or sanitized. 2. Hand hygiene should be performed after glove removal. Procedure: HCW will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: when entering patient room; before preparing or administering medications, if gloves are used to perform a clean/aseptic procedure, hand hygiene must be completed before donning gloves; after removing gloves regardless of task completed; after contact with a patient's non-intact skin, wound dressings, secretions, excretions, mucous membranes, as long as hands are not visibly soiled; when moving from contaminated body site to a clean body site during patient care; when entering healthcare zone; when exiting patient room. Using alcohol-based hand sanitizer: apply adequate amount of product to palm of one hand and rub hands together covering all surfaces of hand and fingers until hands are dry which should take 15-20 seconds. Washing with soap and water/liquid antiseptic and water: wet hands first with tepid water, apply amount of soap to hands as recommended by the manufacturer. Rub hands together briskly for at least 15-20 seconds covering all surfaces of the hands, fingers and wrists. Rinse hands with water and dry thoroughly with a disposable towel or warm-air hand dryer if disposable towel not available. Use towel to turn off the faucet. Change gloves when moving from a dirty to a clean or sterile activity performing hand hygiene in between changing gloves. Gloves are single use and should not be washed or sanitized for reuse. Hand hygiene must be performed after removal regardless of task. 46438 B. Observation on June 21,2023 at 11:37 AM revealed RN (Registered Nurse)-B was changing and cleaning a pressure ulcer dressing for Resident 34. After preparing the materials needed for changing and cleaning the wound and dressing the RN washed hands for 10 seconds total with soap and water. The RN proceeded with the wound cleaning and dressing change and then washed with soap and water for a total of 15 seconds. C. Observation of medication pass on 6/21/2023 at 9:00 AM with RN-B revealed that the RN washed hands with soap and water in the sink for a total of 15 seconds before the medications pass then administered medications to Resident 25 by handling the medication containers and medication cup.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.14 Based on observation, record review and staff interview; the facility failed to provide dental services to meet the needs of the 1 resident (Resident 53), which contributed to the resident's loss of weight. The facility was census was 39 at the time of the survey and the survey sample size was 39. Findings are: Review of a FACE SHEET dated 8/16/12 revealed Resident 53 was admitted to the facility on [DATE]. Review of a CUMULATIVE [DIAGNOSES REDACTED]. CARE PLAN dated 8/29/12 revealed dental status and services were not addressed. During an interview on 10/03/12 at 3:27 PM, Resident 53's child revealed the resident had problems chewing and/or eating due to mouth pain, because Resident 53 had a canker sore on the bottom gum. Resident 53's child stated the resident had been swishing salt water in Resident 53's mouth. Resident 53's child revealed the sore could have been caused by the lower denture not fitting correctly. NUTRITION ASSESSMENT completed for Resident 53 and dated 8/16/12 revealed "Diet order adequate to meet nutritional needs, & if cont (continue) to consume 75%, will meet nutritional needs. Will cont (with) diet as ordered & monitor accordingly". The document was signed by the Registered Dietician. Review of INTERDISCIPLINARY PROGRESS NOTES revealed: - 9/16/12 at 9:15 PM - "c/o (complaints of) mouth pain et (and) some sores are noted under dentures"; - 9/17/12 at 1:10 PM - "approx (approximately) 2 x (by) 1 cm (centimeter) white area (under) tongue. c/o it being sore. Removed denture b/t (between) meals & do salt water rinses"' - 9/20/12 at 4:20 PM - "Nutrition: Added to NRP (Nutrition Risk Program) to monitor due to poor intakes". "Offered more than adequate nutrition, but not consuming adequately," "(2) will encourage staff to provide res (resident) (with) toast & honey on hallways as this is one of (the resident's) favorite snacks". Review of Resident 53's MEAL INTAKE RECORDS revealed daily meal intake had decreased between the 8/15/12 through 9/15/12 time period and the 9/16/12 and 10/9/12 time period after the mouth sore had been documented as evidenced by: - consumption of 16.67% - 24% of meals, increased from 6.25% to 12.5%; - consumption of 25% - 49% of meals, increased from 34.4% to 45.8%; - consumption of 50% - 74% of meals, decreased from 43.75% to 37.5%; and - consumption of 75% or more of meals, decreased from 15.6% to 4.2%. Review of Resident 53's WEIGHT REPORT revealed the following: - 9/17/12 = 122.0 pounds; - 9/25/12 = 121.0 pounds; - 10/2/12 = 119.5 pounds; and - 10/9/12 = 118 pounds. This was a 4 pound weight loss within 3 weeks since the sore in the resident's mouth was documented. An interview with Resident 53 on 10/10/12 at 9:23 AM, revealed the resident still had the sore in (gender) mouth. Resident 53 pointed under the tongue and observation revealed the presence of a white area. Resident 53 revealed (gender) removed the crust from toast before the resident ate it, because Resident 53 didn't want to irritate the sore. During an interview on 10/10/12 at 9:42 AM, Medication Aide (MA) -L revealed (gender) heard during report that Resident 53 had a sore in the resident's mouth about 2 weeks ago. MA-L stated it was believed that Resident 53 possibly had gotten something stuck under the bottom denture. MA-L revealed (gender) wasn't sure whether or not any follow-up had been done, and wasn't sure if Resident 53 still had the sore in the resident's mouth. During an interview on 10/10/12 at 9:58 AM, the Dietary Manager (DM) revealed the DM first heard of the sore in Resident 53's mouth on Monday, 10/8/12 and thought a dental appointment had been made for the resident. The DM revealed Resident 53 had been added to the Nutrition Risk Program because the resident had lost weight. The DM revealed the "canker sore" in Resident 53's mouth may have contributed to the resident's weight loss. An interview with Hall Manager, Licensed Practical Nurse (LPN) -R on 10/10/12 at 12:10 PM revealed a MA reported the sore in Resident 53's mouth "probably at least a week ago" and LPN-R thought maybe Resident 53 wasn't eating very well because of it. LPN-R revealed Resident 53 had done salt water rinsing, and was reported to LPN-R that it wasn't helping, "so I told the charge nurse an appointment with the DDS needed to be made, so the sore could be looked at". LPN-R stated, "since I only work 2 days a week, I would have expected the charge nurses to have monitored and documented the condition of the sore more often".