Every finding on record at Good Samaritan Society - St John's

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to ensure that investigation summaries of all state reportable accidents or incidents were submitted within 5 days of the incident occurrence. This affected one (Resident 1) of 3 sampled residents. The facility census was 47.Record review revealed that the 5 day incident investigation report was created on 7/27/2026 was in the file for Resident 1 but there was no proof that it had been sent to the state office for review. In an interview with the Facility Administrator (FA) on 8/10/2026 at 10:45 AM revealed that all of the information concerning this fall and accident was contained in the files of Resident 1 who had to have their falls reported. In an interview with the FA on 8/10/2026 at 11:50 AM revealed that the incidents documents are sent in by a couple of different people. The state reported incidents and accidents the FA sent into the state each had a read receipt. Two did not have the read receipt or proof that the incidents had been sent to the state in the files. FA was going to reach out to the person that should have sent the information to the state to inquire about evidence of submission in the sent file of the email. Interview with the FA on 8/10/2026 at 11:53 AM revealed that the person who filled out the report had not clicked send on the computer to submit the 5 day investigation summary via email on one report. The FA presented the other report. The FA confirmed the 5-day investigation outcome was not sent to the Department of Health and Human Services as required by statute within 5 days and therefore was not sent the information within 5 days after the incident. The information was to be sent to the state now.

Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on record review and interview, the facility failed to identify the causative factors in falls as they related to one of 3 sampled residents (Resident 3). The facility census was 40.Record review of the facility policy dated 6/2/26 Falls Resource Packet - Rehab /Skilled revealed that the facility requires that all locations have a fall reduction program the provides organized and sustained processes that are monitored by designated employees and understood and followed by all employees. A successful fall reduction program is the responsibility of all employees. Employees are required to complete fall prevention and fall management training with a purpose to provide an evidence-based collection of information and tools for an effective fall reduction program that results in well-being for residents and employees. Medical documentation included completion of the SAFE Event Incident report and the Fall Risk Evaluation Report. Definition of a fall was the unintentional change in position coming to rest on the ground or onto the next lower surface or the result of an overwhelming external force (resident pushes another resident for example). The following examples constitute a fall; found on the floor, witnessed fall, slip or trip or resident reports slip trip or fall, eased to the floor assisted or unassisted, rolls or slides off bed or chair onto the floor, and falls off or out of any equipment.Further record review of facility policy's related to falls revealed staff were to use the post fall huddle evaluation to determine the cause of the fall and the appropriate interventions to prevent another fall. A Post Fall Huddle Worksheet was to guide efforts to gather information about possible causes, resident and employee actions and help with trending. The Post Fall Huddle Worksheet is not a part of the medical record, not a comprehensive evaluation, and not an incident report. While the cause will not be the same for each fall, tracking falls, and analyzing the data related to falls will help to identify any common elements and/or trends such as days of the week, certain shifts, certain locations, that may require changes in facility practices. Review of the SAFE Resident Event details for Resident 3 which had a documented date of fall on 5/6/26 revealed the description of the event to be found on floor by (wheelchair) on left side in his room. There was no documented injury but had an immediate intervention put into place to bring the resident to common area after getting up in the morning. Review of the Safe Resident Event details for Resident 3 which had a documented date of fall on 5/28/26 revealed Resident 3 was found with safety alarm on as nurse aide just left room, (Resident 3) was lying in front of wheelchair as pedals were on also. No injury was noted at that time with an immediate intervention put into place to remove the pedals from wheelchair when resident is not being pushed.Record review of the progress notes for Resident 3 revealed The both falls were documented however, there was no causative factors listed for either of the falls in the progress notes.Interview on 6/8/26 at 12:30 PM with Minimum Data Set (MDS) (a standardized, federally mandated clinical assessment tool used in all Medicare and Medicaid-certified nursing homes and skilled nursing facilities used to evaluate the health status, functional capabilities, and care needs of every resident) Coordinator (MDSC) revealed that the staff member that finds the resident who fell on the shift fills out the safety event. There is also a risk event that needs to be completed and they should do the SAFE fall event and vitals and pain assessment. There are several pieces to complete with each fall. Each person filling out the information is expected to put into the reports what happened, the root case if they know what it is and hopefully they can figure that out. Sometimes if it someone that falls all the time they may be non-compliant or unable to learn and so that needs to be included in the cause of the fall. The staff should obtain the vitals. The vitals go into the charting. If there is an unwitnessed fall or they hit their head they will do neuro checks and monitoring for a period of about 3 days. Notes from the interdisciplinary team (IDT) meeting in which facility leaders discuss risk management will be included on the chart if needed. We try to do IDT meetings weekly. Sometimes it is every other week. We discuss every morning the falls in clinical handoffs at shift to shift reports so that all staff are aware of any falls that have taken place and the immediate actions that were taken to avoid more. Finally, the care plan (a personalized document created by healthcare professionals, patients, and caregivers that outlines a specific medical condition, care goals, and the actionable steps needed to achieve them) has to be updated. In a confirmation interview on 6/8/26 at 1:05, the MDSC revealed that on 5/6/26 Resident 3 had a fall. There is no causative factor listed and there is nothing noted in the chart or follow up investigation that reveals the cause of the fall. The chart states that the resident was found on the floor by the wheelchair on left side in the resident's room. This does not tell anyone what caused the fall, it just states that there was a fall. Our staff know why the resident fell, but as an outsider, nobody else would know. I think we become complacent in our charting as nurses and forget to write what needs to be there all the time. On 5/28/26, Resident 3 had another fall and there is nothing that tells us what occurred. The description of the event says the resident was found with safety alarm on as Nurse Aide just left room, (Resident 3) was lying in front of wheelchair as pedals were on also. This does not tell anyone what the cause of the fall was either. There is nothing in the chart note. We don't know if Resident 3 was competent or what Resident 3 was doing. We have a new person that is now doing the quality assurance and performance improvement now to make certain that we are improving on different aspects of the cares we give at the facility. Our new staff member is using spread sheets and fills things out a lot better than has been done in the past. I guess sometimes you don't know what you are missing until you actually have it. I guess there is not really good area that e cause of the falls are charted. We want nursing staff to find the root cause to prevent it from happening again.

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review and interview the facility failed to ensure medication errors with the potential to negatively impact a resident's health or safety did not occur and the potential for negative effects were monitored for 2 (Residents 17 and 54) of 3 sampled residents. The facility census was 46. Findings are:Record review of a facility policy titled Medication Errors and dated 03/02/2026 revealed the definition of a significant medication error is one which causes the resident discomfort or jeopardized their health or safety. A.Record review of an admission Record dated 04/01/2026 revealed that the facility admitted Resident 17 on 04/18/2025 with diagnoses of mixed incontinence (the inability to control both bowel and bladder) and other disorder of the bladder. Record review of a facility document titled SAFE Resident Event and dated 01/19/2026 revealed on that date at 12:00 PM the facility identified a medication error for Resident 17. The resident's provider had written an order for the resident to extend their antibiotic therapy being used to treat their urinary tract infection for an additional 7 days. This order was dated 01/05/2026. The provider's order was received by the facility but was never entered in the resident's orders, therefore the resident's antibiotic therapy was not extended as ordered by the provider. The resident was admitted to the hospital on [DATE] for a urinary tract infection and required intravenous antibiotic therapy for the infection. In an interview completed on 04/02/2026 at 9:50 AM with the facility Director of Nursing (DON), the DON confirmed that the provider's order to extend the resident's antibiotic therapy was not transcribed, resulting in the resident not receiving the full course of antibiotic therapy as prescribed by the provider. The DON confirmed that the antibiotic therapy was being used to treat a urinary tract infection and the resident was subsequently hospitalized to treat the urinary tract infection with intravenous antibiotic therapy. The DON confirmed that the medication error for Resident 17 met the criteria of a significant medication error. B.Record review of an admission Record dated 04/01/2026 revealed the facility admitted Resident 54 on 02/19/2026 with diagnoses of generalized weakness and pain. The resident had a listed medical allergy to the medication Oxycontin (a narcotic pain medication). Record review of a facility document titled SAFE Resident Event and dated 12/21/2025 revealed on that date at 8:45 PM, Resident 54 was administered Oxycontin, which was not prescribed to them. The provider was notified of this error, and instructions were received to monitor the resident for symptoms of an allergic reaction. Record review of Resident 54's Electronic Medical Health Record (EMHR) revealed documentation in the resident's progress notes on 12/22/2025 at 8:22 AM of the incident occurring, the provider and responsible party being notified, and the instructions to monitor the resident for symptoms of an allergic reaction. The progress note documented that the resident's vital signs were within normal limits for the resident and the resident was showing no symptoms of an allergic reaction. There was also documentation of Resident 54's vital signs being obtained on 12/21/2025 at 10:28 PM. Further record review of Resident 54's EMHR revealed no evidence of continued monitoring of the resident for signs or symptoms of an allergic reaction following being administered a medication they were allergic to. There were also no further vital signs documented in the resident's EMHR to demonstrate continued monitoring of the resident for symptoms of an allergic reaction. In an interview completed on 04/02/2026 at 9:50 AM with the facility DON, the DON confirmed that Resident 54 received a medication they were not prescribed and were allergic to and this medication error had the potential to negatively affect the resident's health. The DON confirmed that Resident 54's EMHR did not contain documentation beyond the initial assessment of the resident that the resident had received continued monitoring for symptoms of an allergic reaction and should have.

Licensure Reference Number 175 NAC 12-006.05(D)&(E) Based on record review and interview the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives prior to administering psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) for 3 of 5 residents reviewed (Residents 17, 2, and 6). The facility census was 46. Findings are:Record review of the facility policy titled Psychotropic Medications dated 12/9/25 revealed that the purpose is to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary psychotropic medications. The family/legal representative will be notified before the administration of non-emergency psychotropic medications. The consent form must be signed for the use of psychotropic medications. The Permission for Use of Psychotropic Medications form will be used to obtain consent and must be signed for the use of psychotropic medications. If a resident is admitted on psychotropic medications or returns from hospitalization on new psychotropic medications, the Permission for Use of Psychotropic Medications form must be completed. A. Record review of the admission Record dated 3/30/26 for Resident 17 revealed that Resident 17 admitted into the facility on 4/18/25. Record review of the Order Recap Report (a listing of all physician orders for a specified period of time that includes order dates and discontinued dates of medications) for Resident 17 dated 4/2/26 revealed all physician orders between 4/1/25 and 4/30/26 including the following psychotropic medications: -An admission order for Bupropion 150 milligrams (mg) daily (a psychotropic medication used to treat major depressive disorder) with an order date of 4/18/25. -A new order for Paroxetine 40 mg daily (a psychotropic medication used to treat major depressive disorder) with an order date of 4/18/25. -An admission order for Venlafaxine 37.5 mg daily (a psychotropic medication used to treat major depressive disorder, anxiety disorder, panic disorder, and social anxiety disorder) with an order date of 3/30/26. Record review of the Care Plan dated 3/30/26 for Resident 17 revealed Resident 17 took antidepressant medications and side effects for these included increased risk for suicidal thoughts, increased drowsiness, changes in mood, and changes in condition. Record review of the medical record for Resident 17 revealed that it contained no consent for use of the psychoactive medications. Interview on 4/2/26 at 9:45 AM with the facility Director of Nursing (DON) confirmed that the facility did not provide education on the psychotropic medications Bupropion, Paroxetine, or Venlafaxine to Resident 17 or their representative. The DON confirmed that the facility did not obtain consent prior to the use of psychotropic medications for Resident 17 as required. B. Record review of a admission Record dated 03/31/2026 revealed the facility admitted Resident 6 on 07/02/2019 with a diagnosis of anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it). Record review of Resident 6's Quarterly 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), dated 03/11/2026 revealed Resident 6 received an antidepressant medication routinely. Record review of Resident 6's Physician Orders on 03/31/2026 revealed Resident 6 had physician orders for Venlafaxine 150 mg (milligrams) to be administered every day for a diagnosis of anxiety and Trazodone (an antidepressant psychotropic medication) 50 mg to be given at bedtime for sleep. Record review of a document titled Permission for Use of Psychotropic Medication and dated 07/2025 revealed Resident 6's name at the top of the document. The document did not list the resident's use of the Venlafaxine or Trazadone medications. The document did not list the risks, benefits, or non-pharmacological alternatives to be used for the resident. The document was signed and dated by the resident on 01/28/2026. An interview completed on 04/02/2026 at 9:45 AM with the facility DON confirmed the document did not list the risks, benefits, non-pharmacological alternatives to uses of these medications for Resident 6 indicating the resident or their responsible party was educated on these things prior to the resident receiving the medications. C. A record review of Resident 2's Facesheet dated 04/02/2026 revealed an admission date of 08/10/2016. A record review of Resident 2's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14, indicating the resident was cognitively intact. The MDS also revealed the resident was taking antipsychotic and antidepressant medications. A record review of Resident 2's Medication Administration Report (MAR) dated 04/02/2026 revealed the resident was taking Rexulti (an antipsychotic used to treat schizophrenia, agitation in Alzheimer's dementia, and as an add-on treatment for major depressive disorder) 0.5 mg for a diagnosis of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a cognitive decline where individuals require assistance with daily tasks (dressing, bathing, toileting) but do not display agitation, hallucinations, or significant mood shifts. A record review of Resident 2's Permission for Use of Psychotropic Medications for the antipsychotic medication Rexulti 0.5 mg revealed no signatures or dates of completion. An interview on 04/02/2026 at 9:45 AM with the facility DON confirmed that the facility did not provide education on the psychotropic medication Rexulti to Resident 2 or their representative. The DON confirmed that the facility did not obtain consent prior to the use of antipsychotic medication for Resident 2 as required.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record reviews and interviews, the facility failed to monitor for adverse drug reactions related to antipsychotic medication use for 1 (Resident 2) of 5 residents sampled. The facility census was 46. Findings are:A record review of facility policy titled, Psychotropic Medications dated 12/09/2025 revealed: The resident will be free from any chemical restraint imposed for the purpose 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 monitoringProcedure:1. Before administration of non-emergency psychotropic medication, the following must be completed:4. The reduction committee will ensure that the family/legal representative and resident are notified of this change in treatment.5. If the physician prescribed an antipsychotic for the resident, a registered nurse must complete the Antipsychotic Medication Assessment and the Abnormal Involuntary Movement Scale in the Electronic Medical Record (EMR).6. A consent form must be signed for the use of psychotropic medications. The Permission for Use of Psychotropic Medications will be used to obtain consent.9. Throughout the administration of the psychotropic medication, the following must be completed:a. Mood and behavior documentation must continue in order to monitor the effect the medication has on the behavior.b. Monitor the side effects of the medication. If a side effect occurs or worsening of a known side effect is noted, the nurse will make a note in the Psychopharmacological Med/Physical Restraint in the EMR and notify the physician and family/legal representative of this change in condition.c. If the resident is on an antipsychotic, a registered nurse must complete the Abnormal Involuntary Movement Scale in EMR every six months. A record review of Resident 2's face sheet dated 04/02/2026 revealed an admission date of 08/10/2016. A record review of Resident 2's 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) dated 02/11/2026 revealed under Section C for cognitive patterns a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14, which indicated the resident was cognitively intact. A record review of Resident 2's Medication Administration Report (MAR) dated 04/02/2026 revealed the resident was taking Rexulti (an antipsychotic medication used to treat schizophrenia, agitation in Alzheimer's dementia, and as an add-on treatment for major depressive disorder) 0.5 milligram (mg) for a diagnosis of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a cognitive decline where individuals require assistance with daily tasks (dressing, bathing, toileting) but do not display agitation, hallucinations, or significant mood shifts. A review of Resident 2's MAR revealed no missed doses during the month of March 2026. The MAR also revealed no orders to monitor for adverse effects related to taking the antipsychotic medication. A record review of Resident 2's 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 03/30/2026 revealed no plan of care related to Resident 2 taking an antipsychotic medication or monitoring for adverse effects related to taking an antipsychotic. A record review of Resident 2's Abnormal Involuntary Movement Scale assessments revealed being completed on 04/15/2025 and then on 01/26/2026. An interview on 04/02/2026 at 9:45 AM with the facility Director of Nursing (DON) confirmed that the facility did not complete monitoring for adverse effects for Resident 2 while taking an antipsychotic as required according to their policy.

Licensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview the facility failed to maintain a comprehensive care plan for 1 of 5 residents reviewed (Resident 11) to provide direction to staff for care required for resident diabetes (a disease characterized by high blood sugar levels when the body does not produce enough insulin to regulate blood sugar levels). The facility census was 46. Findings are:Record review of the facility policy titled Care Plan dated 12/1/25 revealed the Comprehensive Care Plan is a plan of care that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. 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 and review of physician's orders. The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and facility responsibility for providing these services. The resident/family or legal representative will have the opportunity to participate in the planning of his or her care to the extent practicable. 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. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 1/14/26 for Resident 11 revealed that Resident 11 admitted into the facility on [DATE]. The MDS identified that Resident 11 had a diagnosis of diabetes mellitus. The MDS identified that Resident 11 received insulin (a medication use to control the amount of sugar in the blood) all 7 days of the assessment 7-day lookback period. Record review of the Comprehensive Care Plan for Resident 11 dated 3/31/26 revealed that it did not contain a focus area for the care of the resident's diabetes mellitus. The care plan did not identify care required for Resident 11's diabetes, including monitoring for symptoms of high or low blood sugar levels. Interview on 4/2/26 at 9:47 AM with the facility Director of Nursing (DON) confirmed that Resident 11 has a diagnosis of diabetes mellitus. The DON confirmed that the comprehensive care plan for Resident 11 did not identify care for the resident's diabetes mellitus as required.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(5) Based on record review and interview, the facility failed to follow practitioner orders to prevent constipation for 1 (Resident 2) of 1 sampled resident. The facility census was 46. Findings are: A.A record review of Resident 2's Facesheet dated 04/02/2026 revealed an admission date of 08/10/2016. A record review of Resident 2's 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) dated 02/11/2026 revealed under Section C for cognitive patterns a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14, indicating the resident was cognitively intact. The resident was dependent on staff for toilet transfers and for toileting hygiene and was always incontinent of bowels. A record review of Resident 2's undated Care Plan revealed the resident had a diagnosis of constipation. A record review of Resident 2's Medication Administration Report (MAR) for March 2026 revealed the following available medications for constipation ordered as needed:- Dulcolax Rectal Suppository 10 milligram (MG) Insert 1 suppository rectally as needed for constipation give in AM of day 4 without bowel movement (BM), start date 04/22/2025- Milk of Magnesia Suspension 400MG/5milileters (ML) give 30 ml by mouth every 24hours as needed for constipation give daily as needed, start date 05/28/2021- Prune Juice 8 ounces (oz) as needed for constipation give in AM of day 3 without BM x3 days, start date 04/22/2024- Senna Oral Tablet 8.6 MG(Sennosides) give 2 tablet by mouth as needed for in PM if 3 days without BM related to constipation, start date 11/10/2025 Record review of Resident 2's toileting tasks in the EMR revealed the resident went the following date ranges with no bowel movements:-From 03/07/2026 through 03/10/2026, a total of 4 days, and-From 03/14/2026 through 03/20/2026, a total of 7 days. An interview on 04/02/2026 at 9:00 AM with Nurse Aide (NA)-D revealed the staff only document bowel movements on Tasks in the EMR. Record review of the MAR for all days in March 2026 revealed the as needed medications for constipation were not provided on any dates. Record review of Progress Notes for Resident 2 from 03/03/2026 through 04/01/2026 revealed no evidence of the resident being assessed, or as needed medications being provided, for their constipation. An interview on 04/02/2026 at 9:45 AM with the facility Director of Nursing (DON) confirmed that the facility did not offer or provide the as needed medication for constipation as ordered.

Licensure Reference Number 175 NAC 12-006.09(I)Based on observation, record review, and interview the facility failed to ensure that fall prevention interventions were implemented for 1 of 1 resident reviewed (Resident 17). The facility census was 46.Findings are:Record review of the facility policy titled Fall Prevention and Management dated 3/31/26 revealed the purpose was to develop and implement a fall prevention and management program, identify risk factors and implement interventions before a fall occurs, to give prompt treatment after a fall occurs, and to provide guidance for documentation. The facility was to communicate fall risks and interventions to prevent a fall before it occurs, review and update the care plan with any changes/new interventions, and continue to monitor the condition and the effectiveness of the interventions. Record review of the admission Record for Resident 17 dated 3/30/26 revealed that Resident 17 admitted into the facility on 4/18/25 and had a diagnosis of repeated falls. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 1/22/26 for Resident 17 revealed that Resident 17 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 9 which indicated that Resident 17 had moderate cognitive impairment. Resident 17 required verbal cues or intermittent touching/steadying staff contact when standing from a chair, wheelchair, or side of the bed. Record review of the undated facility Survey Report (a listing of resident falls in the facility) revealed that Resident 17 had 13 falls since admission into the facility. Resident 17 had a fall on 5/21/25, 6/25/25, 7/12/25, 9/23/25, 10/5/25, 10/18/25, 10/27/25, 11/13/25, 12/8/25, 12/28/25, 2/14/26, 2/20/26, and 3/24/26. Record review of the Care Plan dated 3/30/26 for Resident 17 revealed a focus area for care for falls and fall prevention. A fall intervention dated 4/18/25 with a revision date of 3/4/26 revealed that Resident 17's wheelchair was to have anti rollback brakes (a safety device mechanism that automatically locks the rear wheels of the wheelchair to prevent the chair from moving backward when a user stands up to prevent falls) to prevent the wheelchair from moving if Resident 17 stood up. Interview on 4/2/26 at 9:28 AM with Nurse Aide-F (NA-F) revealed that Resident 17 transferred from the bed to the wheelchair with minimal assistance for standing and pivoting into the wheelchair. NA-F revealed that Resident 17 did try to self-transfer (moving self between bed, wheelchair, and chair without staff presence or assistance). NA-F revealed they were not aware whether Resident 17's wheelchair was to have anti-rollback brakes. Observation on 4/1/26 at 2:41 PM in the room of Resident 17 revealed that Resident 17's wheelchair had no anti rollback device on it. The wheelchair rolled backwards without resistance when pushed backwards. Interview on 4/1/26 at 2:52 PM with the facility Minimum Data Set Coordinator (MDSC, a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) confirmed that a fall prevention intervention on the care plan for Resident 17 was for an anti rollback brake device on the resident's wheelchair. Observation on 4/1/26 at 2:55 PM in the resident room with the facility MDSC confirmed that the wheelchair of Resident 17 did not have an anti rollback brake installed as care planned. The wheelchair pushed backwards with no resistance. Interview on 4/1/26 at 2:55 PM with the facility MDSC confirmed that the care planned fall intervention for anti rollback brake on the wheelchair of Resident 17 was not in place. The MDSC was not aware if the intervention was ever implemented on the resident wheelchair to prevent falls.

Based on observations, interviews ,and record review; the facility failed to ensure a physician's order for resident dialysis, ensure that pre-dialysis assessment and communication was completed, and failed to assess and monitor resident post dialysis as required for 1 (Resident 7) of 1 sampled resident. The facility census was 46. Findings Are: Record review of the facility policy titled Dialysis Services dated 9/30/25 revealed that facilities caring for residents receiving dialysis services must have an agreement with the provider of the service. Record review of the facility's Outpatient Dialysis Services Agreement dated 9/10/19 revealed that the company will provide outpatient renal dialysis services to the facility. The agreement revealed that renal dialysis services shall include items and services when ordered by the physician. The need for referral of a resident to the dialysis unit shall be determined by the resident's attending physician. Record review of the admission Record dated 3/31/26 for Resident 7 revealed that Resident 7 admitted into the facility on [DATE]. The admission Record revealed that Resident 7 had a diagnosis of chronic kidney disease (a condition where the kidneys are damaged or cannot filter blood properly, causing waste and fluid to build up in the body). Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 1/12/26 for Resident 7 revealed that Resident 7 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) score of 15, which indicated the resident was cognitively intact. Interview on 3/30/26 at 3:58 PM with Resident 7 revealed that Resident 7 went out of the facility for dialysis on Mondays, Wednesdays, and Fridays. A.Observation on 4/1/26 at 11:45 AM at the facility driveway at the front entrance revealed that Patient Transportation Driver (PTD) was unloading Resident 7 from the facility bus. Observation 4/1/26 at 11:48 AM in the facility activity hallway revealed that the facility PTD transported Resident 7 per wheelchair directly from the front entry to the facility dining room. PTD positioned Resident 7 at a table in the dining room. Resident 7 had a dressing on their right forearm. Interview on 4/1/26 at 11:50 AM with Resident 7 confirmed that the dressing on their right forearm was from the dialysis center. Record review of the medical record for Resident 7 revealed that it did not contain a physician's order for dialysis for Resident 7. Record review of the Order Recap Report (a listing of all physician orders for a specified period of time that includes order dates and discontinued dates of medications and treatments) for Resident 7 dated 4/2/26 revealed all physician orders between 11/1/24 and 4/30/26 (all physician orders for Resident 7 from admission on [DATE] to present day). The report revealed no order for dialysis for Resident 7. Interview on 4/2/26 at 9:51 AM with the facility Director of Nursing (DON) confirmed that Resident 7 received dialysis outside of the facility 3 times per week. The DON confirmed that the medical record for Resident 7 did not contain a physician's order for dialysis. The DON confirmed that a physician's order for dialysis was required and that it should include the type of dialysis being received and the frequency. B.Record review of the facility's Outpatient Dialysis Services Agreement dated 9/10/19 revealed that the company will provide outpatient renal dialysis services to residents of the facility. The facility will ensure that all appropriate medical and administrative information accompanies all dialysis residents at the time of referral to the dialysis unit. The facility will be responsible for ensuring that the resident is medically stable to receive treatment at the dialysis center. The section titled Mutual Obligations revealed that both parties (the facility and the dialysis center) will ensure that there is documented evidence of care and communication between the facility and the dialysis center. Interview on 4/1/26 at 4:16 PM with Registered Nurse-A (RN-A) revealed that the nurse was to complete the top portion of the Dialysis Communication/Referral form for Resident 7 on dialysis days. RN-A revealed that the dialysis center normally put information in the bottom section of the form and that the facility received the form back from the dialysis center when the resident returned to the facility after each dialysis treatment. Record review of the medical record for Resident 7 revealed that a dialysis Communication/ Referral (for visits to dialysis) form was initiated for dialysis on 3/18/26. The form was marked No for significant change since last dialysis treatment. The section for Vital Signs which was to contain documentation of the resident's temperature, blood pressure, pulse rate, and respirations were all left blank. The section for Resident Status revealed that Resident 7 was oriented and had edema. The section was signed by an unidentified facility staff. The section of the form titled Dialysis to Complete the Following Section revealed pre-dialysis and post dialysis temperatures, blood pressures, pulse rates, respirations, and weights. The resident was marked as oriented and the section was signed by dialysis staff. Further record review of the medical records for Resident 7 revealed no evidence of Communication/ Referral (for visits to dialysis) forms being completed for Resident 7's dialysis treatment. Record review of the Communication/Referral (for visits to dialysis) forms received following a request by this surveyor for the date range of 12/1/25 through 4/2/26 revealed that the facility provided Communication/ Referral (for visits to dialysis) forms dated 12/4/24, 12/6/24, 12/9/24, 12/11/24, 12/13/24, 12/16/24, 12/18/24, and 12/20/24. The facility provided no forms for the requested date range. Interview on 4/2/26 at 9:10 AM with the facility's Minimum Data Set Coordinator (MDSC, a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) confirmed that the facility could not find any dialysis Communication/Referral forms after December 2024 for Resident 7. The MDSC revealed that they were not sure if the forms were not getting scanned into the resident medical record or if they had some new nurses that were not completing them. Interview on 4/2/26 at 9:51 AM with the facility's Director of Nursing (DON) confirmed that Resident 7 received dialysis outside of the facility 3 times per week. The DON revealed that the expectation was for the nurse on duty to complete the facility's dialysis Communication/Referral form prior to each dialysis appointment. The DON confirmed that the nurse should assess the resident's vital signs, any acute changes, and presence of fistula thrill (a palpable, buzzing vibration felt over a surgical connection between an artery and a vein, usually in the arm, created to make dialysis possible for kidney failure patients). The DON revealed that the dialysis Communication/Referral form was to be sent with the resident to each dialysis appointment. The DON revealed that the form was to be returned to the facility by the dialysis center. The DON confirmed that each dialysis Communication/Referral form was to be scanned into the resident's permanent medical record. The DON confirmed that the forms were either not being completed or scanned into the resident's permanent medical record as required for Resident 7. C.Record review of the facility policy titled Dialysis Services dated 9/30/25 revealed that the Clinical Monitoring Dialysis assessment is available for use in monitoring the resident receiving dialysis. Record review of the facility's Outpatient Dialysis Services Agreement dated 9/10/19 revealed in the section titled Mutual Obligations that both parties (the facility and the dialysis center) will ensure that there is documented evidence of care and communication between the facility and the dialysis center. Interview on 3/30/26 at 3:58 PM with Resident 7 revealed that Resident 7 went out of the facility for dialysis on Mondays, Wednesdays, and Fridays. Resident 7 revealed that the facility staff did not check the dressing on their fistula (a surgical connection between an artery and a vein, usually in the arm, created to make dialysis possible for kidney failure patients) after the resident returned to the facility from their dialysis treatments. Resident 7 revealed that the resident removed the dressing on their own. Interview on 4/1/26 at 11:20 AM with the Patient Transportation Driver (PTD) revealed that Resident 7 was currently out of the facility for dialysis and that PTD was preparing to go pick Resident 7 up from the dialysis center. Observation on 4/1/26 at 11:45 AM at the facility driveway at the front entrance revealed that Patient Transportation Driver (PTD) was unloading Resident 7 from the facility bus. Observation 4/1/26 at 11:48 AM in the facility activity hallway revealed that the facility PTD transported Resident 7 per wheelchair directly from the front entry to the facility dining room and positioned Resident 7 at a table in the dining room. Resident 7 had a dressing on their right forearm. Registered Nurse-A (RN-A) pushed a medication cart into the hall outside of the dining room and did not go into the dining room to assess Resident 7. Interview on 4/1/26 at 11:50 AM with Resident 7 confirmed that the dressing on their right forearm was from the dialysis center. Observation on 4/1/26 at 12:31 PM in the dining room revealed that RN-A entered the dining room and went to the beverage counter. RN-A grabbed a cup and exited the dining room without assessing Resident 7. Record review of the March 2026 calendar revealed that the dates of Mondays, Wednesdays, and Fridays (days of the week Resident 7 receives dialysis) in March were 3/2/26, 3/4/26, 3/6/26, 3/9/26, 3/11/26, 3/13/26, 3/16/26, 3/18/26, 3/20/26, 3/23/26, 3/25/26, 3/27/26, and 3/20/26. There were 13 total dialysis dates. Record review of the Progress Notes for Resident 7 between the dates of 3/1/26 and 3/31/26 revealed 5 progress notes that the resident returned from dialysis. The progress notes contained no evidence of an assessment being conducted for Resident 7 upon their return from dialysis on those dates. Record review of the Progress Note for Resident 7 dated 3/16/26 at 5:45 PM revealed that Resident 7 had returned from dialysis around noon with no new orders. Record review of the Progress Note for Resident 7 dated 3/18/26 at 11:41 AM revealed that Resident 7 had returned from dialysis with no new orders. Record review of the Progress Note for Resident 7 dated 3/23/26 at 12:16 PM revealed that Resident 7 had returned from dialysis without their paperwork. Dialysis was called and they were to fax papers over. Record review of the Progress Note for Resident 7 dated 3/27/26 at 1:06 PM revealed that Resident 7 had dialysis done today and they had no complaints. Resident 7 had gone to the dining room to eat. Record review of the Progress Note for Resident 7 dated 3/30/26 at 12:46 PM revealed that Resident 7 had returned from dialysis with no problems or new orders. Record review of the medical record for Resident 7 revealed that the Clinical Monitoring Dialysis assessment had been completed 4 times in March 2026. Record review of the Clinical Monitoring Dialysis assessment dated [DATE] revealed that it was completed at 2:17 AM. Record review of the Clinical Monitoring Dialysis assessment dated [DATE] revealed that it was completed at 12:38 PM. Record review of the Clinical Monitoring Dialysis assessment dated [DATE] revealed that it was completed at 5:25 AM. Record review of the Clinical Monitoring Dialysis assessment dated [DATE] revealed that it was completed at 6:43 AM. Interview on 4/1/26 at 4:16 PM with RN-A revealed that RN-A did not do any specific assessment of Resident 7 on return to the facility from dialysis treatments. RN-A confirmed that RN-A did not perform any physical assessment of the resident's dressing after dialysis treatments. RN-A revealed that RN-A did try to palpate the fistula for thrill (a palpable, buzzing vibration felt over a surgical connection between an artery and a vein, usually in the arm, created to make dialysis possible for kidney failure patients) each day. RN-A revealed that dialysis wanted the facility to leave the dressing on the fistula overnight after each dialysis treatment. Observation on 4/1/26 at 4:20 PM in the resident room revealed Resident 7 in the recliner. The dressing on the right forearm of Resident 7 was clean and dry. Resident 7 revealed that the facility staff did not remove the dressing following each dialysis treatment, Resident 7 did this on their own. Resident 7 removed the dressing from their forearm, and a small amount of bleeding was observed on the fistula that stopped without intervention. Interview on 4/2/26 at 9:51 AM with the facility Director of Nursing (DON) confirmed that Resident 7 received dialysis outside of the facility 3 times per week. The DON confirmed that the Clinical Monitoring-Dialysis assessment was to be completed each date the resident had dialysis. The DON revealed that the facility discovered sometime in the prior 2 weeks that this assessment was not being completed so the facility had been doing staff education. The DON confirmed that the Clinical Monitoring-Dialysis assessment should be completed on return of the resident from their dialysis treatments. The DON confirmed that the nurse was expected to assess and monitor the dressing on the resident's fistula on return from their dialysis treatments. The DON confirmed that the nurse should be the one removing the dressing and assessing the fistula site rather than the resident. The DON confirmed that the facility had not been assessing Resident 7 after dialysis treatments as required.

Licensure Reference Number 175 NAC 12-006.09(F)(i) Based on record review and interview the facility failed to complete a baseline care plan (a written plan required to be developed within 24 hours of admission detailing the instructions needed for staff to provide initial effective and person-centered quality care for a resident) for 2 of 3 residents reviewed (Residents 4 and 23) to identify immediate care needs of the resident. The facility census was 46. Findings are:Record review of the facility policy titled Care Plan dated 12/1/25 revealed that the purpose is to provide guidance to the interdisciplinary team in developing the initial care plan and develop a comprehensive care plan using an interdisciplinary team approach. The definition of Baseline care plan revealed that it includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of care. A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and resident representative with a written summary of the baseline care plan. Staff were to use the Progress Note-Care Conference Note to document that the meeting occurred with the resident and resident representative and any significant discussion that occurred. A.Record review of the admission Record dated 3/30/26 for Resident 4 revealed that Resident 4 admitted into the facility on 8/11/25 with diagnoses of Parkinson's Disease, sleep apnea, and dysphagia (difficulty swallowing). Record review of the medical record for Resident 4 revealed no evidence of a baseline care plan being developed for Resident 4. Record review of the Progress Notes for Resident 4 revealed that it contained no care conference note for a baseline care plan for Resident 4. Interview on 4/1/26 at 2:27 PM with the facility Minimum Data Set Coordinator (MDSC, a facility nurse that utilizes a mandatory comprehensive assessment tool for care planning) confirmed that the facility did not complete a baseline care plan for Resident 4 upon admission as required. B.Record review of the admission Record dated 3/30/26 for Resident 23 revealed that Resident 23 admitted into the facility on 2/24/26 with diagnoses of dysphagia, cancer of the esophagus (the hollow, muscular tube that passes food and liquid from your throat to your stomach), and sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues). Record review of the medical record for Resident 23 revealed no evidence of a baseline care plan being developed for Resident 23. Record review of the Progress Notes for Resident 23 revealed that it contained no care conference note for a baseline care plan for Resident 23. Interview on 4/1/26 at 2:27 PM with the facility MDSC confirmed that the facility did not complete a baseline care plan for Resident 23 upon admission as required.

Licensure Reference Number 175 NAC 12-006.09(D) Based on observation, record review, and interview the facility failed to ensure that the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) identified dialysis services (a life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when kidneys have failed) as required for 1 (Resident 7) of 1 sampled resident. The facility census was 46. Findings are:Record review of the facility policy titled Dialysis Services dated 9/30/25 revealed that facilities caring for residents receiving dialysis services must have an agreement with the provider of the service. The facility will be responsible for arranging transportation to and from dialysis services. Care plan dialysis care specific to the resident: for example, unique nutritional needs or fluid restriction, avoid taking blood pressure in the arm with the fistula (a surgical connection between an artery and a vein, usually in the arm, created to make dialysis possible for kidney failure patients), and any other restrictions per the provider. Record review of the facility policy titled Care Plan dated 12/1/25 revealed that the purpose is to provide guidance to the interdisciplinary team in developing the initial care plan and develop a comprehensive care plan using an interdisciplinary team approach. Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment (the MDS). Interview on 4/1/26 at 11:20 AM with the Patient Transportation Driver (PTD) revealed that Resident 7 was out of the facility for dialysis treatment and PTD was preparing to pick Resident 7 up from the dialysis center. Observation on 4/1/26 at 11:45 AM at the facility driveway at the front entrance revealed that Patient Transportation Driver (PTD) was unloading Resident 7 from the facility bus. Observation 4/1/26 at 11:48 AM in the facility activity hallway revealed that the facility PTD transported Resident 7 per wheelchair directly from the front entry to the facility dining room where PTD positioned Resident 7 at a table in the dining room. Resident 7 had a dressing on their right forearm. Interview on 4/1/26 at 11:50 AM with Resident 7 confirmed that the dressing on their right forearm was from the dialysis center. Record review of the MDS assessment for Resident 7 dated 1/12/26 revealed that Resident 17 had a diagnosis of renal insufficiency (the kidneys stop working). The section of the MDS for special treatments revealed Dialysis was not marked as a treatment needed by Resident 7. Interview on 4/2/26 at 9:51 AM with the facility Director of Nursing (DON) confirmed that Resident 7 received dialysis outside of the facility 3 times per week. The DON confirmed that the current MDS assessment did not identify the need for dialysis for Resident 7 and that it should have been identified on the MDS.

Licensure Reference Number 175 NAC 12-006.09(G)(i) Based on record review and interview, the facility failed to complete a discharge summary for 2 (Residents 60 and 62) of 2 sampled residents who had been discharged from the facility. The facility census was 46. Findings are:Record review of a facility policy titled Discharge and Transfer dated 01/15/2026 revealed when a transfer or discharge occurs, the location must ensure that the transfer or discharge is documented in the medical record. A.Record review of an admission Record dated 03/31/2026 revealed the facility admitted Resident 60 on 09/22/2020 and discharged or transferred the resident to the hospital on [DATE]. Record review of Resident 60's Progress Notes revealed on 01/06/2026 at 2:45 AM the resident complained of intolerable abdominal pain and wished to go the emergency department. At 7:06 AM the facility received a telephone call from the emergency department that the resident was being admitted to the hospital. Review of Resident 60's Electronic Medical Health Record (EMR) revealed no evidence of a discharge summary being completed for Resident 60. In an interview completed on 04/01/2026 at 10:25 AM with the Director of Nursing (DON), the DON confirmed that Resident 60 was admitted to the hospital on [DATE] and did not return to the facility. In an interview completed on 04/02/2026 at 9:20 AM with the DON, the DON confirmed that a discharge summary was not completed for Resident 60 and should have been. B.Record review of an admission Record dated 03/31/2026 revealed the facility admitted Resident 62 on 01/06/2026 and discharged the resident to home with home care services on 02/05/2026. Record review of Resident 62's Electronic Medical Health Record (EMR) revealed no evidence of a discharge summary being completed for Resident 60. In an interview completed on 04/02/2026 at 9:20 AM with the DON, the DON confirmed that Resident 62 was discharged from the facility on 02/05/2026 to their home. The DON confirmed that there was no discharge summary completed for Resident 62 and there should have been.

Licensure Reference Number NAC 175 12-006.09(H) Based on record reviews and interviews, the facility failed to follow physician orders, and ensure follow up assessments were completed for 1 (Resident 4) of 3 sampled residents. The facility identified a census of 51. Findings are: Record review of the facility policy titled, Change in Condition Evaluation last reviewed 04/06/2025 revealed the following: Purpose -To improve communication between nurses and a provider when nursing is monitoring a change of condition -To enhance the nursing evaluation of and documentation of a resident who has a change in condition To provide a standard format to collect pertinent clinical data prior to contacting the provider when there is a change in condition To standardize shift to shift communication about a resident change in condition Procedure Nursing judgment should be used when determining the urgency of contacting the provider. In the event the situation requires calling 911, the Change of Condition Evaluation (CICE) would not be used. Before completing CICE: -Review the resident's medical record including diagnosis, medications, recent progress notes from a medical doctor/nurse/practitioner/physician's assistant and consultants, as well as the most recent interdisciplinary notes. -Check with other staff members who have regular contact with the resident to obtain an accurate picture of the change of condition. A record review of progress notes and assessments in Resident 4's Medical Records revealed no CICE completed. A record review of an Order Summary Report dated as of 06/01/2025 revealed the following orders: -Ipratropium-Albuterol Inhalation Solution .5-2.5 (3) milligram(MG)/3milliliter(ML), 3 milliliter inhale orally every 4 hours as needed for wheezing. Order date: 05/16/2025 -Ipratropium-Albuterol Inhalation Solution .5-2.5 (3) milligram(MG)/3milliliter(ML), 3 milliliter inhale orally two times a day for wheezing. Order date: 06/16/2025-06/30/2025 A record review of Progress Notes and Medication Administration Record for June 2025 revealed Resident 4 received medication Ipratropium-Albuterol Inhalation Solution for each as needed (PRN): June 2nd at 4:21 PM for wheezing, results: Effective with decrease congestion by Registered Nurse (RN)-B June 3rd at 8:36 PM for wheezing, results: Effective by Medication Aide (MA)-C June 8th at 7:07 AM and 3:46 PM for wheezing, results for both: Effective no audible wheezing noted documented by RN-B June 14th at 2:37 PM for wheezing, results: Effective by RN-D June 15th at 7:04 AM for cough, results: Effective by RN-D June 23rd at 2:24 PM for wheezing, results: Unknown by MA-E June 24th at 3:06 PM for wheezing, results: Ineffective by MA-F A record review of Resident 4's Progress Notes on a communication to the Physician, 6/25/2025 at 3:55 PM revealed: cough worse this am, has nebulizer twice a day (bid) and every four hours (q4h) as needed (PRN), notified physician cough still and worse, they said to increase the prn treatments to see if helps and if not to get (gender) in for appointment to check aspiration possibly, also will try leave head of bed elevated at night. June 27th at 1:24 PM for wheezing, results: Effective by MA-E June 28th at 10:52 AM for wheezing and coughing, results: Effective by Licensed Practical Nurse (LPN)-A June 28th at 2:41 PM for wheezing, results: Effective by MA-F June 29th at 3:00 AM for wheezing, results: Effective by LPN-G A record review of Resident 4's Progress Notes on administration for medication revealed: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 3 milliliter inhale orally two times a day for wheezing PRN was given right before 6 AM dosage so did not do scheduled dosage at this time June 29th at 6:28 AM for wheezing, results: Ineffective still wheezing by LPN-A at 8:12 AM June 29th at 11:07 AM for wheezing, results: Effective by MA-F A record review of Resident 4's Progress Notes on a communication to the Physician, 6/29/2025 at 3:13 PM revealed: Resident noted to have increased weakness. VS stable. resident continues to have wheezing with a non-productive cough. Nebulizer treatment given every 4 hours while awake this weekend. Skin dry. Appetite poor all weekend. (Spouse-gender) understanding of resident decline and aware of (gender) wheezing could be caused from (gender) Hiatal hernia. Family Member 1 would like resident seen in clinic tomorrow just to be evaluated. June 29th at 3:41 PM for wheezing, results: Effective by MA-F A record review of Resident 4's Progress Notes on a communication between the family and the facility on 6/29/2025 at 7:32 PM revealed: Resident Family Member 2 at facility concerned about change in condition of resident, gender asked for me (nurse) to check temperature, O2 sat, and listen to lungs. Resident was 78% on room air, was placed on oxygen via nasal cannula at 3 liters rose to 83%. Resident audibly wheezing, using accessory muscles for breathing, cannot talk, has temperature of 100.1 degrees Fahrenheit. Resident Family Member 2 called Family Member 1 who decided on sending gender to hospital for evaluation. An interview on 07/02/2025 at 9:25 AM, LPN-A revealed a new order for Ipratropium-Albuterol Inhalation Solution on 06/16/2025 for scheduled administration twice a day due to increased wheezing. Then described RN-B called the clinic on 06/23/2025 about continued wheezing, then RN-D called on 06/25/2025 due to worsening cough and to increase the Ipratropium-Albuterol Inhalation Solution PRN dosage, and to get the Resident in the clinic if no improvement or if the facility felt aspiration was a possibility, but no new orders were given. During an interview on 07/02/2025 at 9:30 AM, the LPN-A stated they did not feel like Resident 4 was in respiratory distress at the time, and do not recall whether or not they assessed Resident 4's lungs. An interview on 07/02/2025 at 10:05 AM with MA-F revealed they monitor efficacy of treatment. An interview on 07/02/2025 at 10:15 AM, the Director of Nursing Services (DNS) revealed the facility did not complete an assessment of treatment for Resident 4. In addition, the DNS further revealed that MA's should not be monitoring whether or not the medication is effective when it comes to the use of medication Ipratropium-Albuterol Inhalation Solution, a licensed nurse should monitor this. When asked about the communication to the physician on 6/25/2025 at 3:55 PM, which revealed: cough worse this am, has nebulizer bid and q4h as needed (PRN), notified physician cough still and worse, they said to increase the PRN treatments to see if helps, why treatments were not increased or change of condition was not appropriate. The DNS reports, they (nurses) could have done more.

Licensure Reference Number 175 NAC 12-006.09(I) Based on record reviews and interviews, the facility failed to implement a plan of care to prevent potential injuries for 1 (Resident 9) of 3 sampled residents. The facility identified a census of 51. Findings are: Record review of the facility policy titled, Fall Prevention and Management last reviewed 04/08/2025 revealed the following: Purpose -To promote resident well-being by developing and implementing a fall prevention and management program. -To identify risk factors and implement intervention before a fall occurs Proactive approach before a fall occurs (e.g., New Admit) Procedure -On admission or readmission, review the applicable documents (i.e., discharge summary from transferring agency, transfer record, history and physical, lab values, nursing admit/readmit data collection) and any additional admit information documentation for fall risk factors. -Complete the Falls Tool UDA (User Defined Assessment) for fall screening and identifying fall risk factors. -Care Plan the appropriate interventions, including personalizing all areas. -Communicate fall risks and intervention to prevent a fall before it occurs per the 24-hour report, care plan and Kardex (a documentation system used by nurses to organize and quickly reference key patient information). -Communicate any identified environmental changes or needs (e.g., dietary, therapy). Record review of Resident 9's admission Record revealed the resident was admitted to the facility on [DATE] with the following diagnosis: -Stable burst fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing -Unspecified dementia (loss of memory, language, problem-solving and other thinking abilities) without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety -Unspecified fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing -Generalized anxiety disorder (an abnormal and overwhelming sense of apprehension and fear) -Depression (a mental health condition characterized by persistent sadness, loss of interest in activities, and changes in mood, behavior, and physical well-being) A record review of Resident 9's Falls Tool UDA in assessments on 07/02/2025 revealed none were completed. Record review of Resident 9's Progress Notes dated 06/27/2025 through 07/02/2025 revealed on 06/27/2025 at 3:06 PM Resident 9 admitted to facility. Alert to self only. Advanced dementia. Mumbles to self. Unable to answer questions. gender is present at bedside to answer questions. Put alarms on per gender request due to multiple falls in the last 2 weeks. Record review of Resident 9's Progress Notes dated 06/27/2025 at 3:54 PM revealed for Resident 9 safety facility asked gender to move resident closer to Nurses station, gender verbally agreed. Record review of Resident 9's Progress Notes dated 06/28/2025 at 12:00 PM revealed: What is being monitored daily: -Nursing to monitor vital signs, pain, surgical site to mid-lumbar, mood and behavior, ADL and transfer needs, lung sounds, participation in skilled therapies and any other abnormalities noted. Nursing interventions provided/required by nursing to address the resident's medical condition: -Resident with dementia and does not verbalize with staff. Resident with minimal eye contact. Resident requires 1 assist to dress. Resident bears weight but does not pick up feet or follow directions to pivot to toilet. Resident restless and tries to get up in which staff toilet resident and does void. How effective are the interventions/what progress is the resident making: -Resident remains on room air. No shortness of breath noted. Lungs clear. Will monitor for abnormalities. Resident with order for skilled therapies due to recent fall with lumbar fracture and surgical repair. Resident also has a left rib fracture. Record review of Resident 9's Progress Notes dated 07/01/2025 at 07:40 PM revealed: -Resident's alarm sounding. Resident found on the floor beside gender wheelchair. Lying face down. Unwitnessed. Resident unable to explain what happened due to cognitive deficits. Abrasion to right eyebrow. Physician, family and Director of Nursing Services (DNS) notified. Vitals and Neurological checks started per policy. During an interview with Licensed Practical Nurse-A (LPN-A) on 07/02/2025 at 09:15 AM revealed Resident 9 was sitting in the wheelchair in the living area alone when the resident fell. LPN-A was asked where the Baseline Care Plans (BCP, a plan of care for the resident that includes the minimum information needed to provide effective, person-centered care immediately upon admission) were located to view the interventions to prevent accidents. LPN-A handed this surveyor a binder labeled Care Plans. Record review of Resident BCP for Resident 9 revealed no BCP in the binder. During an interview on 07/02/2025 at 9:30 AM with the Health Information Manager (HIM) reported they were not certain why the BCP was not completed at the time of admission, pulled a blank form from the binder and stated they will look for it. On 07/02/2025 at 10:05 AM HIM revealed the BCP was found in their office, the BCP was dated 06/30/2025 which revealed: -The resident is provided therapy services for all disciplines. The BCP reveals Resident 9 is confused, forgetful, non-verbal and uses an alarm. Additional information reveals Resident 9 is high risk for falls demonstrated by confusion. During an interview on 07/02/2025 at 11:05 AM the DNS revealed that it is their expectation that staff complete the BCP within 12-24 hours of admission. The DNS further agreed that BCP interventions were not implemented timely to prevent accidents for Resident 9.

License Reference Number 175 NAC 12-006.04(A)(iii) Based on record review and interview the facility failed to ensure that employee healthcare questionnaires were completed, reviewed, and maintained prior to the hire dates for 5 of 5 sampled employees. This had the potential to affect all residents in the facility. The facility census was 44. Findings are: An interview on 01/06/2025 at 1:30 PM with the Facility Administrator (FA) revealed that all new hires were given paperwork which was to be filled out prior to being hired. The FA provided a copy of the facility's General Orientation Packet, which contained the paperwork the new hires were to complete. A record review of an undated copy of the facility's General Orientation Packet (GOP) revealed all paperwork in the packet must be completed by the new hire and returned to the Director of Nursing Services prior to starting work. The following documents were included in this section; -Medical History Questionnaire (a 5-page document), -Employee/Candidate Tuberculosis Screening Questionnaire (a 3-page document), -Hepatitis B Consent and Immunization Form (1 page document), and -Hepatitis B Vaccination Declination (1 page document). A. A record review of the Minimum Data Set (MDS) Nurse's employment file revealed MDS was hired by the facility on 9/17/2024. The file contained a single paged paper entitled Communicable Disease Screening (a 1-page document) which was dated and signed by MDS on 09/27/2024. There were no other documents from the GOP in the file and the Communicable Disease Screening sheet contained no evidence that it had been reviewed by facility staff. An interview on 01/06/2025 at 5:00 PM with FA confirmed this was all of the healthcare information in the personnel file for MDS. B. A record review of Facility Driver (DR)-F's employment file revealed DR-F was hired by the facility on 9/17/2024. The file contained the Employee/Candidate Tuberculosis Screening Questionnaire (a 3 page document) which was dated and signed by DR-F on 09/17/2024. This document revealed that the Infection Control Preventionist (IP) had reviewed the information. An interview on 01/06/2025 at 5:00 PM with FA confirmed this was all of the healthcare information in the personnel file for DR-F. C. A record review of Cook-K's employment file revealed Cook-K was hired on 4/29/2024. The file contained the Medical History Questionnaire, the Hepatitis B Consent and Immunization Form, and the Hepatitis B Vaccination Declination. The Hepatitis B Vaccination Declination form was signed and dated 04/29/2024 and the Hepatitis consent and immunization form was blank (because the hepatitis vaccination was declined). The first 4 pages of the Medical History Questionnaire was completed by the new hire. Page 5 of the Medical History Questionnaire was blank. This page was to be completed by the Human Resources Representative or designee, indicate that the information has been reviewed, and then signed and dated by the person reviewing. An interview on 01/06/2025 at 5:00 PM with FA confirmed this was all of the healthcare information in the personnel file for Cook-K. D. A record review of Nurse Aide (NA)-L's employment file revealed NA-L was hired by the facility on 3/4/2024. The file contained the Medical History Questionnaire signed and dated by NA-L on 03/04/2024, the Hepatitis B Consent and Immunization Form with NA-L's name on it but no other section was completed, and a blank Hepatitis B Vaccination Declination form. There was no Employee/Candidate Tuberculosis Screening Questionnaire. The first 4 pages of the Medical History Questionnaire was completed by the new hire. Page 5 of the Medical History Questionnaire was blank. This page was to be completed by the Human Resources Representative or designee, indicate that the information has been reviewed, and then signed and dated by the person reviewing. An interview on 01/06/2025 at 5:00 PM with FA confirmed this was all of the healthcare information in the personnel file for NA-L. E. A record review of Maintenance Technician (MAINT)-G's employment file revealed MAINT-G was hired on 10/9/2024. The file contained a one page Communicable Disease Screening document dated 10/09/2024. There was an untitled document that stated Completed by Location - RN Required in some states at the top and contained sections to indicate the Communicable Disease Review had been completed and Immunizations reviewed and then signed by a facility staff member, this document had not been filled out. An interview on 01/06/2025 at 5:00 PM with FA confirmed this was all of the healthcare information in the personnel file for MAINT-G.

License Reference Number 175 NAC 12-007.01(B)(ii) Based on observations and interviews, the facility failed to provide a sanitary environment in the laundry area (three specific areas which are ante room, storage room, and dirty laundry) for staff. This had the potential to affect all laundry staff and all residents. The current facility census was 44. Findings are: During the initial observation tour of the facility laundry department on 01/02/2025 at 8:43 AM, revealed the following: -The ante room to the clean laundry area. There were 3 shelves to the left which contained blankets and other various items folded. Under the shelf on the left side there was one metal mouse trap, a step stool, and cardboard boxes filled with items. The floor in that area was dusty, had dirt debris, brownish gray fuzzy matter, and paper trash on the floor. On the right side of the ante room, were hooks which held staff winter wear. At the floor level was a long wooden shelving approximately 5 feet long that lifted things off the floor approximately one inch. On that shelving piece were cardboard boxes and plastic totes stacked upon each other, one metal mouse trap, and a small trashcan. This area was also had fuzzy debris and dirt, and had not been swept. One could not see underneath the shelving piece that lifted these items directly off the floor. -In the storage room in the laundry area. There was a large framed print covered in grey fuzzy substance between the wall and one of the small tables. There was grey fuzy substance, debris, pieces of paper, a pen, a straw, and fuzz as well as two more large cardboard boxes overflowing with clothing on the floor -The dirty laundry area was inspected. Soiled clothing had been sorted into different containers and ready to be washed. There were two cardboard boxes on the floor that had at one point been wet and then dried sitting on the floor. The stainless-steel sink was covered in what looked to be soap scum and mineral deposits and was not clean. The linen scale was covered in grey fuzzy substance and debris. The vent was covered in gray fuzzy substance. A second observation tour occurred on 01/02/25 at 2:51 PM with Facility Administrator (FA) and Infection Control Preventionist (IP) in the laundry area. The Housekeeping/Laundry Supervisor (EVS) was in the storage room sorting, discarding, and organizing. Interview on 01/02/2025 at 3:00 PM with IP who revealed the laundry area was rarely inspected or observed by the IP. All of the items on the floor, including the boxes in the dirty area that had water damage, and generalized lack of cleanliness in the laundry department was discussed. IP agreed that this area had been overlooked as an area of concern for cleanliness as well as infection control. Interview on 01/02/2025 at 3:00 PM with FA revealed that EVS had been told many times to clean up that area and didn't do it and had started on it today. Staff are going to sort items and discarding what they able to eliminate and keep only what is needed.

Licensure Reference Number 175 NAC 1-009.01(B) Licensure Reference Number 175 NAC 12-006.19(A) Based on observation, interview, and record review; the facility failed to ensure that resident equipment was cleaned and maintained for 5 residents (Residents 15, 17, 29, 7, and 18) of 8 residents sampled. This affected the residents' right to a dignified existence. The facility census was 44. Findings are: A. A record review of the facility's Resident Handbook dated 06/2021 revealed in the section titled Maintenance Services that the facility is responsible for the maintenance and service of the building and all equipment owned by the center. The section titled Resident Mobilization Information revealed the facility strives to sustain and improve each resident's health with frequent mobilization. The resident's weight-bearing support needs will be determined and the appropriate equipment will be provided for bed mobility, transfers, and ambulation. Residents who are determined to need weight bearing assistance or hands on assistance by staff will receive mobility assistance specific to their needs. A record review of the facility document Resident's Rights for Skilled Nursing Facilities dated 01/2022, revealed that the resident has the right to a dignified existence. The facility must protect and promote the rights of each resident. The facility must treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life. The facility must protect and promote the rights of the resident. A record review of the facility's Admission Agreement dated 07/2020, revealed in the section titled Services and Charges that the facility agrees to furnish the resident with the following services included in the daily rate: nursing services, food and nutrition services, an activities program as defined by regulations, room/bed maintenance and housekeeping services, basic laundry services, medically related social services and other services required by law. A record review of the Admission Record dated 12/31/2024 for Resident 15 revealed that Resident 15 was admitted into the facility on [DATE]. A record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 10/24/2024 for Resident 15 revealed that Resident 15 used a manual wheelchair for mobility. An observation on 12/31/2024 at 7:22 AM in the room of Resident 15 revealed that Resident 15 was seated in a wheelchair next to the bed watching the tv. The floor in front of the resident was soiled with yellowish crumbs or food debris. The right wheelchair wheel was soiled with a large amount of tan crusty debris and grayish debris that was visible from the doorway. The wheelchair was soiled with visible tan and grayish crusty debris on the right wheelchair wheel and build up on the right brake. The edge of the wheelchair seat was soiled with a tan residue. [NAME] residue soiling was also visible on the wheelchair pedals. An observation on 12/31/2024 at 11:19 AM in the room of Resident 15 revealed that Resident 15 was seated in the recliner facing towards the tv. The resident's wheelchair was also in their room and the right wheelchair wheel was visibly soiled with a large amount of tan crusty debris and grayish debris. [NAME] crusty debris build up was piled on the right brake of the wheelchair. The seat and edge of the seat along the seat frame was soiled with tan residue. [NAME] residue soiling was also visible on the wheelchair pedals. An observation on 1/2/2025 at 8:27 AM in the facility dining room revealed that Resident 15 sat in the wheelchair at a table. The right wheelchair wheel was soiled with a large amount of tan crusty debris and grayish debris. [NAME] crusty debris build up was piled on the right brake of the wheelchair. The seat and edge of the seat along the seat frame was soiled with tan residue. The left wheelchair wheel was soiled with a brown substance on the left wheel. [NAME] residue soiling was visible on the wheelchair pedals. An observation on 01/06/2025 at 7:47 AM in the front tv room near the activity room revealed that Resident 15 sat in the wheelchair. The right wheelchair wheel remained soiled with a large amount of tan crusty debris and grayish debris. [NAME] crusty debris build up remained piled on the right brake of the wheelchair. The seat and edge of the seat along the seat frame remained soiled with tan and light yellow debris build up and chunks of food debris along the left and right edges of the wheelchair cushion. [NAME] residue soiling was also visible on the wheelchair pedals. An interview on 01/06/2025 at 11:20 AM with Nurse Aide (NA)-D revealed that resident wheelchairs were rarely cleaned and they were not on a regular cleaning schedule. An interview on 01/06/2025 at 11:56 AM with NA-E revealed that the night shift was supposed to clean wheelchairs weekly or biweekly and document the cleaning. An observation on 01/06/2025 at 12:01 PM in the facility dining room with the Facility Administrator (FA) revealed that Resident 15 sat in the wheelchair at a table. The wheelchair remained soiled with the dried white/tan, yellow, and gray debris on the wheelchair wheels, frame along the wheelchair seat cushion, and had a large crusty grayish-tan buildup on the top of the right brake. An interview on 01/06/2025 at 12:01 PM with the FA confirmed that the wheelchair of Resident 15 was soiled with dried white, yellow, and gray debris on the wheelchair wheels, frame along the wheelchair seat cushion, and had a large crusty grayish buildup on the top of the right brake. The FA confirmed that the wheelchair needed to be cleaned. A record review of the Wheelchair/Walker Cleaning Schedules for 06/23/2024-08/31/2024 revealed no cleaning of resident wheelchairs and walkers was documented. A record review of the Wheelchair Cleaning Schedule dated 10/07/2024-10/12/2024 revealed no documented cleaning of wheelchairs for Resident 15. A record review of the Wheelchair Cleaning Schedule dated 10/20/2024 revealed documentation that the wheelchair of Resident 15 was cleaned on 10/20/2024. No Wheelchair cleaning schedules were completed for 10/27/2024-01/06/2025. An interview on 01/06/2025 at 12:08 PM with the FA confirmed that the night shift was to clean wheelchairs weekly. The FA confirmed that no cleaning of wheelchairs had been documented since October 2024. The FA confirmed that the wheelchair of Resident 15 had not been cleaned since October 2024. B. A record review of the Admission Record dated 12/31/2024 revealed that Resident 17 was admitted to the facility on [DATE]. A record review of the Care Plan for Resident 17 dated 12/30/2024 revealed that Resident 17 used a manual wheelchair for independent mobility. An observation on 12/31/2024 at 10:58 AM in the room of Resident 17 revealed that Resident 17 sat in the wheelchair in the middle of the room. Scattered tan debris soiling and debris were visible on the wheelchair wheels, hand propel wheels, rims, and frame. An observation on 01/02/2025 at 8:27 AM in the facility dining room revealed that Resident 17 sat in the wheelchair at a dining room table. Debris of various colors was stuck on the wheelchair on both rubber wheels, the hand propel bars, and rims. An approximately 2 centimeter x 1 centimeter whitish food chunk was visible on the right brake lever connection. An observation on 01/06/2025 at 7:47 AM outside the room door of Resident 17 revealed that Resident 17 sat in the wheelchair. Scattered tan and dark brown debris soiling remained on the wheels and frame of the wheelchair. An observation on 01/06/2025 at 12:04 PM in the facility dining room with the Facility Administrator (FA) revealed that Resident 17 sat in the wheelchair at a table. The wheelchair remained soiled with the dried white, yellow, and gray debris and residue on the wheelchair wheels, frame, along the wheelchair seat cushion, and had food debris on the top of the right brake lever connection. An interview on 01/06/2025 at 12:01 PM with the FA confirmed that the wheelchair of Resident 17 was soiled with dried white, yellow, and gray debris on the wheelchair wheels, frame, along the wheelchair seat cushion, and had food debris on the top of the right brake connection. The FA confirmed that the wheelchair needed to be cleaned. A record review of the Wheelchair/Walker Cleaning Schedules for 6/23/2024-8/31/2024 revealed no cleaning of resident wheelchairs and walkers was documented. A record review of the Wheelchair Cleaning Schedule dated 10/07/2024-10/12/2024 revealed no documented cleaning of wheelchairs for Resident 17. A record review of the Wheelchair Cleaning Schedule dated 10/20/2024 revealed documentation that the wheelchair of Resident 17 was cleaned on 10/20/2024. No Wheelchair cleaning schedules were completed for 10/27/2024-01/06/2025. An interview on 01/06/25 at 12:08 PM with the FA confirmed that the night shift was to clean wheelchairs weekly. The FA confirmed that no cleaning of wheelchairs had been documented since October 2024. The FA confirmed that the wheelchair of Resident 17 had not been cleaned since October 2024. C. A record review of the Admission Record dated 12/31/2024 for Resident 29 revealed that Resident 29 was admitted into the facility on [DATE]. A record review of the Minimum Data Set (MDS) dated [DATE] for Resident 29 revealed that Resident 29 used a manual wheelchair for mobility. An observation on 12/31/2024 at 7:59 AM in the room of Resident 29 revealed that the wheelchair sat next to the resident's bed. Brown, tan, and gray debris was visible on both wheels, the wheel frames, and foot pedal peg platforms. An observation on 01/02/2025 at 10:20 AM in the room of Resident 29 revealed that Resident 29 sat in the wheelchair at the card table in the corner of the room at the foot of the bed. Food and trash debris was visible on the floor in front of the recliner and under the resident bed. The wheelchair of Resident 29 was soiled with brown, tan, and gray debris on both wheels, the foot pedal pegs, and wheelchair frame. An observation on 01/06/2025 at 9:43 AM at the room of Resident 29 revealed that Resident 29 propelled themselves out of the room in the wheelchair. [NAME] and other various colored dried debris remained visible on both wheels, foot pedal peg platforms, and frame of the wheelchair. An observation on 01/06/2024 at 11:56 AM in the room of Resident 29 with the FA confirmed that the wheelchair of Resident 29 was soiled with gray debris on the wheel spokes, brownish debris on the wheelchair frame, and other brown, tan, and gray debris on the wheelchair foot pedal platforms and the frame. A record review of the Wheelchair Cleaning Schedule dated 10/07/2024-10/12/2024 revealed no documented cleaning of wheelchairs for Resident 29. A record review of the Wheelchair Cleaning Schedule dated 10/20/2024 revealed no documentation that the wheelchair of Resident 29 was cleaned. No Wheelchair cleaning schedules were completed for 10/27/2024-01/06/2025. An interview on 01/06/2025 at 12:08 PM with the FA confirmed that the night shift was to clean wheelchairs weekly. The FA confirmed that no cleaning of any wheelchairs had been documented since October 2024. The FA confirmed that the wheelchair of Resident 29 had not been cleaned since sometime before October 2024. D. An observation on 12/30/2024 at 12:07 PM in the bathroom of Resident 7 revealed that the bathroom exhaust vent was soiled with a buildup of fluffy grayish debris. The base of the toilet had missing caulking and the base of the toilet was soiled with brown and yellow debris. An observation on 01/06/2025 at 11:58 AM with the Facility Administrator (FA) in the bathroom of Resident 7 revealed that the exhaust vent was soiled with fluffy grayish debris. The base of the toilet had missing caulking and was soiled with brown to yellow debris buildup. An interview on 01/06/2025 at 11:58 AM with the FA confirmed that the exhaust vent in the bathroom of Resident 7 was soiled and needed to be cleaned. The FA confirmed that the toilet in the bathroom of Resident 7 was soiled with brown to yellow debris buildup and needed to be cleaned. E. An observation on 12/30/2024 at 11:59 AM in the bathroom of Resident 29 revealed that the bathroom exhaust vent was soiled with a buildup of fluffy gray debris. An observation on 01/06/2025 at 11:56 AM with the FA in the bathroom of Resident 29 revealed that the exhaust vent was soiled with a buildup of fluffy gray debris. An interview on 01/06/2025 at 11:56 AM with the FA confirmed that the exhaust vent in the bathroom of Resident 29 was soiled and needed to be cleaned. F. An observation on 12/30/2024 at 11:56 AM in the bathroom of Resident 18 revealed that the hot water temperature was 110.3 degrees Fahrenheit per a thermometer with the hot water running. The water continued to rise up in the sink as the water ran. This surveyor shut the water off before it ran over the sink. The water drained slowly. An observation on 01/06/2025 at 11:58 AM in the bathroom of Resident 18 with the FA revealed that the water built up in the sink as the water was on. The water continued to rise in the sink until this surveyor shut the water off. An interview on 1/6/2025 at 11:58 AM with the FA confirmed that the drain in the bathroom sink of Resident 18 was not draining properly and needed to be fixed. G. An observation on 12/30/2024 at 12:03 PM in the bathroom of Resident 15 revealed that the hot water temperature was 110.3 degrees Fahrenheit per a thermometer with the hot water running. The water continued to rise up in the sink as the water ran. This surveyor shut the water off before it ran over the sink. The water drained slowly. An observation on 01/06/2025 at 12:04 PM in the bathroom of Resident 15 with the FA revealed that the water built up in the sink as the water was on. The water continued to rise in the sink until this surveyor shut the water off. An interview on 01/06/2025 at 12:04 PM with the FA confirmed that the drain in the bathroom sink of Resident 15 was not draining properly and needed to be fixed.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on record review, interviews, and observations, the facility failed to ensure bathing was offered and completed for residents who needed assistance. This affected 4 (Residents 1, 20, 203, and 252) of 5 sampled residents. The facility census was 44. Findings are: A record review of the facility Policy and Procedure for Bathing reviewed and revised on 09/03/2024, stated that the purpose of the policy is; - To promote cleanliness and general hygiene, - Stimulate circulation of the skin, - Promote comfort, relaxation, and well-being, - Observe resident's condition, - Assist resident with personal cares, and - To promote safety for the resident in the bath. Procedures outlined in the policy included tub or shower bathing and bed baths. A. A record review of the Minimum Data Set (MDS, a mandated assessment tool used to evaluate the health and functional status of residents in nursing homes used for care planning) dated 12/10/2024 for Resident 1 indicated this resident was admitted to the facility on [DATE]. Resident 1 had a Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 15/15 indicating the resident is cognitively intact. The MDS also revealed Resident 1 needed partial to moderate assistance with bathing. A record review of Resident 1's Care Plan (a detailed document outlining a person's health needs, current medical conditions, treatment plan, and specific goals for their care) printed and reviewed on 12/30/2024 revealed Resident 1 had a self-care deficit related to the fractured pelvis and needed assistance with bathing. An interview on 12/30/2024 at 3:38 PM with Resident 1 revealed that the resident wanted to take a bath or have a whirlpool bath. However, because of a pressure ulcer Resident 1 had obtained prior to admission to the facility and daily dressing changes to the sacral area, Resident 1 was not allowed to have a regular bath. When asked how long it had been since Resident 1 had been allowed to take a bath, the resident stated let's just say it's been awhile. A record review of Resident 1's 30-day look back period of their bathing record printed on 12/31/2024 revealed that the last recorded bath was on 12/03/2024 with no other baths recorded for the month. An interview on 1/02/25 at 10:40 AM with Resident 1 revealed Resident 1's family member had gotten very upset because Resident 1 was not getting any baths. Resident 1 stated their family member had gone to the staff and requested Resident 1 have a bath immediately. Resident 1 revealed they were then given a whirlpool bath on 1/1/2025. B. A record review the MDS, dated [DATE], for Resident 20 revealed the resident was admitted to the facility on [DATE]. Resident 20 had a BIMS score of 15/15 and was alert to person, place and time. The MDS data also revealed the resident was able to shower and bathe per self without assistance. A record review of the care plan for Resident 20 revealed Resident 20 had a self-care deficit related to chronic kidney disease and weakness and required the assistance of one person for bathing and personal hygiene. Resident 20 was at risk for skin breakdown due to morbid obesity and the care plan stated that skin was to be kept clean and dry. A record review of Resident 20's 30-day look back period on the bathing record printed on 12/30/2024 revealed Resident 20 had received a bath on 12/04/2024 and 12/26/2024. An observation on 12/30/24 at 3:35 PM of Resident 20 revealed the resident was seated in a personal recliner in their room and that the resident had a foul smelling body odor. An interview on 12/31/24 at 12:00 PM Resident 20 revealed they had been given a shower that day. An interview on 1/02/2025 at 7:45 AM with Resident 20 revealed the resident had an in-room shower the resident could use if there was someone who could assist with the shower. Resident 20 stated I am scared to shower by myself because the floor floods in my bathroom when I am in the shower and i have to use a shower chair. I just need to have someone in the room with me when I shower. An interview on 01/02/25 at 10:41 AM with Nursing Assistant (NA)-B confirmed NA-B had received no training on the use of the whirlpool bath but did assist residents with their showers once or twice a month. C. A record review of the MDS dated [DATE] for Resident 252 revealed this resident had an admitted [DATE] and was admitted to the facility as a Hospice care resident. Resident 252 had a BIMS score of 14/15 and was alert and oriented to person, place, and things. A record review of Resident 252's Care Plan, with a reviewed date of 12/30/2024 revealed the resident needed assistance with activities of daily living but did not specify what type of assistance was needed. A record review of Resident 252's Care Plan after it was updated on 1/2/2025, revealed Resident 252 required set-up assistance and oxygen management assistance while bathing. A record review of Resident 252's 30-day look back period for bathing on their Bathing Tasks printed on 1/2/2025 revealed there had been no baths recorded for the prior 30 days. An observation on 12/20/2024 at 11:23 AM of Resident 252 in their room revealed Resident 252's lower right leg had yellow, crusted exudate on it. The resident's lower left leg had a bandage wrapped around the resident's calf. An interview on 01/01/2025 at 9:55 AM with Resident 252 revealed the resident used shower wipes rather than bathe because the nursing staff completed dressing changes to both of the resident's legs so early in the day and did not want to wash the medication off while bathing. Resident 252 also revealed that Resident 252 needed assistance with showers because of their oxygen tubing and due to the resident getting tired while showering. An interview on 12/31/2024 at 1:30 PM with the Facility Administrator (FA) revealed that bathing was an issue in the facility as the bath aide had been terminatied at the beginning of December 2024. FA confirmed the residents, including Residents 1, 20, and 252 were not being assisted with bathing as required. 50105 D. A record review of an Admission Record indicated the facility admitted Resident 203 on 12/03/2015. A record review of Resident 203's Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) updated on 12/30/2024 revealed that Resident 203 had an activity of daily living (ADL, basic everyday tasks including bathing, eating, dressing, getting in and out of bed, and toileting) self-care performance deficit. Interventions preferences for baths was 1 whirlpool bath per week. Other interventions for ADL care includes 1 assist for bathing/showering and dressing, while transferring and toilet use requires full lift assistance with 2 staff assisting. A record review of Resident 203's 30-day look back task record for bathing revealed documentation that the resident must have a shower, no tub bath related to suprapubic catheter (SPC, a tube that drains urine from the bladder by inserting through the abdominal wall and into the bladder). The look back period revealed no data found for any charting that a shower was offered or completed for the 30-days prior to 1/02/2025 for Resident 203. An observation of Resident 203 on 12/30/2024 at 11:20 AM revealed the resident lying in bed with their face unshaven. The resident had pink matter at both corners of their mouth and teeth. The resident was wearing a hospital gown with brown soiling on the shoulder and chest area of the gown. An interview on 12/30/24 at 11:20 AM with Resident 203 revealed that the brown matter was from a chocolate shake that was part of their breakfast. Resident 203 also stated they had received a shower but could not recall when it was. An interview on 12/31/2024 at 1:45 PM with the Facility Administrator (FA) revealed that the lack of charting for bathing residents was accurate, and there was no other charting to disclose bathing tasks being completed for facility residents, including Resident 203. The FA further revealed that bathing had not occurred because of staffing concerns.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interview, the facility failed to ensure that the resident/resident representative were provided the opportunity to participate in quarterly care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) review as required for 1 resident (Resident 29) of 5 residents reviewed. The facility census was 44. Findings are: A. A record review of the facility policy titled Care Plan and dated 12/2/2024, revealed that 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. The resident/family or legal representative will have the opportunity to participate in the planning of his or her care to the extent possible. The interdisciplinary team will review care plans at least quarterly. A record review of the facility policy titled Comprehensive Care Plan and Care Conferences and dated 12/4/2023, revealed that the purpose is to provide an ongoing method of evaluating and updating the resident's care plan to help maintain the resident's highest practicable level of function. The section titled Coordinating the Care Conference revealed that the social worker or designee will establish the time and place to hold the care conference and invite residents and their representative at least two weeks in advance of the care conference. Invitations may be sent to the resident representative using the Care Plan Invitation Letter. If the resident and/or resident representative is not invited to the care conference, an explanation must be included in the medical record. Inform residents and representatives of the right to request meetings, request revisions to the care plan and to be informed in advance of changes to the care plan. A record review of the Admission Record dated 12/31/2024 for Resident 29 revealed that Resident 29 was admitted into the facility on [DATE]. Resident 29 had a Power of Attorney (POA) for healthcare. The POA was a child of Resident 29. An interview on 12/30/2024 at 1:02 PM with the POA for Resident 29 revealed that they were concerned that they had not been invited to a care plan for Resident 29 since last spring or summer. A record review of the Progress Note for Resident 29 dated 8/6/2024 at 11:14 AM revealed that social services called the POA and notified them that they had a care plan conference on 8/08/2024 at 10:00 AM. A record review of the Progress Note for Resident 29 dated 8/06/2024 at 11:19 AM revealed that family stated that they would prefer to have the care plan meeting on 8/09/2024 at 9:30 AM to accommodate family schedule. A record review of the Care Plan Review note dated 8/07/2024 at 4:10 PM revealed that social services documented that Resident 29 had met goals and would continue the same course at that time. The note contained no documentation of resident or family presence or absence at the review. A record review of the Progress Notes in the medical record for Resident 29 dated from 8/08/2024 through 12/31/2024 revealed that it contained no documentation of the resident or family being invited to a care plan meeting or attending a care plan meeting. The medical record contained no documentation or explanation for the resident or family not being invited to a care plan meeting. A record review of the Care Plan Review note dated 12/19/2024 revealed it was a nursing note that the care plan was reviewed and reflected Resident 29's current Minimum Data Set assessment (a mandatory comprehensive assessment tool used for care planning). The note contained no documentation of resident or family participation in the review. An interview on 1/06/2025 at 2:25 PM with the facility Social Services Director (SSD) confirmed that a care plan meeting with each resident/family was to occur quarterly to review and discuss their care plan. SSD revealed that the facility had no documentation of Resident 29 or Resident 29's family participation or declination to participate in quarterly care plan meetings in the past year. The SSD confirmed that the SSD was unable to find any documentation that Resident 29 and Resident 29's family participated in quarterly care plan meetings in 2024 as required.

Licensure Reference Number 175 NAC 12-006.09(H)(iv)(5) Based on record reviews and interviews, the facility failed to follow physician orders on bowel protocols for 1 resident (Resident 38) of 1 sampled resident. Facility census was 44. Findings are: A record review of a facility policy titled, Bowel Regimen and Standing Facility Orders dated 01/19/2024 revealed the following guidance for treating residents' bowel needs: -On Days 1 & 2 without bowel movement-do nothing. -On Day 3 without a bowel movement begin the following protocol: -On Day 3 in the AM: Administer 30 milliliters (ml) of Milk of Magnesia by mouth (PO) one time for constipation. Give 8 ounces of prune juice daily for 3 days. -If the resident does not have a bowel movement proceed to the next steps. -On Day 3 in the PM: Administer two Senna 8.6 tablets PO one time for constipation. Administer polyethylene glycol 17 grams/240 ml PO one time. -If the resident does not have a bowel movement proceed to the next steps. -On Day 4 in the AM: Administer 1 Dulcolax suppository 10 milligrams (mg) rectally for constipation. Administer polyethylene glycol 17 grams/240ml, PO one time. -On Day 5: If the resident has had no bowel movement, contact their primary physician for further clinical guidance. A record review of an Admission Record revealed the facility admitted Resident 38 on 09/18/2023 with diagnoses of constipation, communication deficit. A record review of Resident 38's annual Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning), with an assessment reference date (ARD) of 12/11/2024, revealed Resident 38 had a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairments) score of 00/15 which indicated the resident had severe cognitive impairment. The MDS also revealed that Resident 38 was wheelchair bound, unable to propel and required substantial and/or maximum assistance for activities of daily living (ADLs, basic everyday tasks including bathing, eating, dressing, getting in and out of bed and toileting). A record review of Resident 38's Physician Orders for the month of 12/2024 revealed the following orders related to bowel management: -An order dated 05/25/2024 for Senna (a stimulant laxative) 8.6 milligrams (MG), 2 tablets by mouth as needed for constipation, give in PM of day 3 without bowel movement (BM). -An order dated 05/25/2024 for Dulcolax (a stimulant laxative) 10 MG, 1 suppository rectally every 24 hours as needed for constipation. -An order dated 05/26/2024 for Prune Juice 8 ounces (oz) as needed for constipation, give in AM of day 3 without BM for 3 days. A record review of Resident 38's 30-day look back task record for toileting and charting BM's revealed that the resident had no BM from 12/13/2024-12/15/2024 (three days) and from 12/27/2024-12/31/2024 (5 days). A record review of Resident 38's Medication Administration Record for the month of December 2024 revealed the medications Senna, Dulcolax, and Prune juice had not been provided to Resident 38 at any time that month. A record review of Progress Notes and medical records for the month of December 2024 for Resident 38 revealed no communication to the physician for clinical guidance regarding the management or treatment for bowel protocols extending to day 5 of no bowel movement. During an interview on 12/31/2024 at 3:15 PM the Quality Assurance Coordinator (QAC) revealed that bowel protocols had not been initiated as ordered for Resident 38 during the month of December 2024.

STATE LICENSURE REFERENCE 175 NAC 12-006.09D7 Based on record review, staff interviews and resident family member interview; the facility failed to protect residents from injuries and ensure that the environment was safe to prevent accidents with significant injuries from occurring for 2 (Closed Record-Resident 101 and Resident 40) of 5 residents reviewed. The facility census was 66 at the time of the investigation and sample size was 5. Findings are: A. Closed Record (Resident 101) was admitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. Review of Closed Record (Resident 101) revealed that a transfer record, dated 5/1/2012 contained documentation that the resident had been transferred to the hospital on that date with a distended and painful abdomen, low blood pressure and numb on the left side. Interview on 5/17/2012 at 11:20 AM with a family member of Closed Record (Resident 101) revealed that, when the resident arrived at the emergency room , Closed Record (Resident 101) was diagnosed with [REDACTED]. Interview on 5/16/2012 at 1:44 PM with NA (Nursing Assistant) J revealed that Closed Record (Resident 101) was transferred from the bed to the wheelchair on 5/1/2012. NA J stated that during the transfer, Closed Record (Resident 101) allowed (gender) arms to relax while in the sit to stand lift and the resident was lowered immediately back onto the bed. NA J stated that Closed Record (Resident 101) slid down in the sling a couple of inches. NA J stated that the lift belt was not on the resident tight but it was secure. NA J stated that the resident did not complain of any pain or discomfort at the time but thought that Closed Record (Resident 101) was very groggy that day. Interview on 5/16/2012 at 3:23 PM with NA A revealed that Closed Record (Resident 101) was transferred on 5/1/2012 with the sit to stand lift. When Closed Record (Resident 101) complained of being dizzy and faint and sick to stomach while using the lift, the resident was lowered to the bed and then transferred using the full sling lift. NA A stated that Closed Record (Resident 101) went limp and kept arms up when using the sit to stand lift. NA A stated that Closed Record (Resident 101) did not go limp enough and was not up high enough that the resident could have gotten hurt. NA A stated that the resident had been at a partial standing position but was still over the bed when started complaining of being dizzy, faint and sick to stomach. Interview on 5/17/2012 at 11:30 AM with the attending physician of Closed Record (Resident 101) revealed that the resident had been admitted to the hospital on [DATE] with a bleed into the pectoralis muscle and 2 fractured ribs on the left side. The fractures of left 9th and 10th ribs were non-displaced. The physician stated that some kind of trauma caused the rib fracture and subsequent prolonged hospitalization . The physician also stated that the fracture did not happen prior to a fall that occurred on 4/24/2012 as a scan of the chest on 4/26/2012 was clear of fractures. That fall occurred prior to Closed Record (Resident 101)'s admission to the facility. The physician stated that if facility staff had pulled on the lift belt when the resident became dizzy, faint and sick to stomach, it could have caused the trauma to Closed Record (Resident 101) as the resident had renal problems that could lead to osteoporosis. B. Review of COMPREHENSIVE CARE PLAN dated 3/1/12 revealed Resident 40 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of facility Incident Reports revealed: - 3/22/12 at 11:00 AM, Resident 40 had not waited for staff assistance and fell . The resident had a raised area on the head. There was no new intervention documented. - 3/22/12 at 3:40 PM, the resident had slipped and fallen. Resident 40 had no injury. Intervention documented was for staff to walk with resident anytime Resident 40 ambulated. - 4/10/12 at 5:15 AM, Resident 40 was found on the floor. No injury documented with intervention to "re -education to putting shoes on correctly or calling for assistance". - 4/20/12 at 6:45 PM, Resident 40's knees buckled and resident went to the floor. No injuries were documented. Blood sugar testing was done and glucerna given for a low blood sugar reading. - 4/28/12 at 5:30 AM, Resident 40 was found on the floor. No injury documented with intervention "remind resident to ask for help with ADL's"(activities of daily living). - 5/1/12 at 8:15 PM, Resident 40 had fallen and received a bruise to the left side of the head. Intervention documented was "re education of laundry not on floor". Review of Resident 40's COMPREHENSIVE CARE PLAN dated 3/1/12 revealed: - PROBLEMS/NEEDS/CONCERNS: "RISK FOR FALLS R/T (related to) POOR SAFETY AWARENESS, COG (cognitive) DECLINE, PHYSICAL DECLINE, RECENT FALLS; -- PLANS AND APPROACHES: --- "FALL MATT IN PLACE WHEN IN BED"; --- "ENC (encourage) TO USE CALL LIGHT IF NEEDED"; --- "PLACES CLOTHES & ITEMS ON WALKER. REMOVE TO PREVENT IT FROM TIPPING OVER"' --- "MONITOR FOR APPROPRIATE FOOTWEAR"; --- "Sensor alarms to bed for night use" (was a handwritten addition and was not dated). During an interview on 5/17/12 at 1:39 PM, the Assistant Director of Nursing (ADON) revealed interventions to prevent falls for Resident 40 had not been written on the permanent care plan due to being 24 hour interventions, but would have been in the report book and verbalized to staff. The ADON revealed Resident 40 got up early in the morning and didn't always call for assistance and was not sure if night shift staff checked on Resident 40 between 5:00 AM and 5:30 AM, instead of waiting for the resident to call. The ADON revealed Resident 40 had a persistent problem with fluctuations in the resident's blood sugar and was the ADON's first thought when Resident 40 had falls, that the cause could be a decline in the blood sugar. The ADON revealed checking Resident 40's blood sugar level was an intervention, but was not documented on the care plan. The ADON revealed when Resident 40 had fallen on 4/28/12, the sensor pad was not on the bed as specified by the care plan. The ADON stated the intervention after that fall was to be sure interventions were in place and to educate the staff. The ADON stated Resident 40 didn't always get ready for bed right after supper and staff were to watch for when the resident wanted to get ready for bed to give assistance. During an interview on 5/17/12 at 4:55 PM, the Social Worker revealed residents or family members were not asked about the residents routines or preferences for getting up in the morning or times they went to bed.