Every finding on record at Good Shepherd Lutheran Community

License Reference Number 175 NAC 12-006.09(I)Based on observation, interview, and record review the facility failed to implement interventions to prevent potential accidents for 3 (Residents 37, 55, and 57) of 3 sample residents. The facility census was 62.Findings are: A. Record Review of the facility's undated policy Safe Resident Handling/transfers revealed the following: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize the risks for injury and provide and promote a safe, secure and comfortable environment for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents required safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. Record review of the facility's undated policy Falls and Fall Risk, Managing revealed the following: Resident-Centered Approaches to Managing Falls and Fall Risk 5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g. Dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Record Review of the facility's undated policy Accidents and Supervision revealed the following: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: Communicating the interventions to all relevant staff Assigning responsibility Providing training as needed Documenting interventions (e.g., plans of action developed through the QAA Committee or care plans for the individual resident) Ensuring that the interventions are put into action Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully Facility-based interventions may include, but are not limited to: Educating staff Repairing the device/equipment Developing or revising policies and procedures Resident-directed approaches may include: Implementing specific interventions as part of the plan of care Supervising staff and residents, etc. Facility records document the implementation of these interventions 1. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: Ensuring that interventions are implemented correctly and consistently Evaluating the effectiveness of interventions Modifying or replacing interventions as needed Evaluating the effectiveness of new interventions 2. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: Defined by type and frequency Based on the individual resident's assessed needs and identified hazards in the resident environment. Record Review of Resident 57's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 3/23/2026 revealed the facility staff assessed the following about the resident: -admitted to the facility on [DATE] -Brief Interview of Mental Status (BIMS) was scored as an 11. According to the MDS Manual a score of 8-12 indicates a person has moderate cognitive impairment. -was dependent on staff for lower body dressing, putting on/taking off footwear, chair to bed/bed to chair transfer, toilet transfer and tub/shower transfers. -had diagnosis of osteo arthritis (deuteriation of joints), pain in left hip, trochanteric bursitis in left and right hip (outer hip pain), age related osteoporosis without current pathological fracture (fragile bones). Record Review of Resident 57's Care Plan revealed the following: -Transfer: required 2 staff assist to move between surfaces and as necessary. -9/20/24- 2 assist with transfers on admission. Date Initiated: 09/24/2024 and revised on 04/11/2025. - 3/4/25-Therapy to eval for transfers and overall weakness. Date Initiated: 03/05/2025. - 4/10/25- Staff education of 2 staff members for all transfers. Date Initiated: 04/11/2025 and revised on 04/11/2025. - Care plan did not reveal the use of a sit to stand lift with transfers for Resident 57. Record Review of the Resident 57's Physical Therapy (PT) Evaluation and Plan of Treatment with a start of care date as 5/1/2026 revealed that the certification period is 5/1/2026-6/29/2026. Further review revealed that Resident 57 was referred to physical therapy due to a decline in functional mobility, strength and activities of daily living performance. Record Review of the facility's Describe the Incident report dated 5/6/2026 revealed the following: -On 5/2/2026 at 9:20 PM Resident 57 was lowered to the floor after attempts were made to transfer Resident 57 to the bed. According to the incident report dated 5/02/2026 Resident 57 was unable to bear weight and was assisted to the floor by a nursing assistant. - Resident 57 complained of ankle pain after doctor's appointment today and was transferred to [NAME] walk in clinic at the hospital. -Received a report from a Nurse Practitioner (NP) at 12:21 that Resident 57 had an acute right ankle pain with a obvious fracture noted. ACE wrap applied to affected extremity. -Received call from the hospital with report that radiologist noted a fracture to the top of Resident 57's foot. Record review of Resident 57's Visual/Bedside Kardex Report dated 5/26/2026 revealed the following: 'Safety' - 4/10/25- Staff education 2 staff members for all transfers. - walker and W/C for mobility. 'Transferring' - Transfers: requires 2 staff assist to move between surfaces and as necessary. -9/20/24- 2 staff assist with transfers on admission. - Resident 57's Kardex Report did not reveal the use of a sit to stand lift with transfers. In an interview on 5/26/2026 at 6:57 AM, Director of Nursing (DON) confirmed Resident 57's transfer status at the time of the fall was 2 assists. DON confirmed that residents' transfer status is always on their Kardex. In an interview on 05/26/2026 at 9:40 AM DON confirmed that causative factor for Resident 57's fall was not completing the 2 assists transfer. In an interview on 05/26/2026 at 4:10 PM, DON confirmed Resident 57 was already on physical therapy at the time of the fall and the intervention after the fall was to have physical therapy evaluate Resident 57. B. A record review of the facility's undated Safe Resident Handling/Transfers revealed all residents require safe handling when transferred to prevent or minimize the risk of injury to the resident or staff. While manual lifting techniques may be utilized, depending on the resident's condition, the use of a mechanical lift is a safer alternative and should be used. The staff would inspect equipment prior to use and alert maintenance if the equipment was not functioning properly. Damaged, broken, or improperly functioning lift equipment would not be used and tagged out according to facility policy. A record review of the facility's Lifting Machine, Using a Mechanical policy dated 2017 revealed the staff should have made sure all necessary equipment (clings, hooks, chains, straps, and supports) were on hand and in good condition. A record review of Resident 37's Clinical Census dated 05/26/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 37's Medical Diagnosis dated 05/26/2026 reveled the resident had diagnoses of Cerebral Infarction (stroke), Alzheimer's Disease, Disorientation, Dementia (confusion), Muscle Weakness, Unspecified Abnormalities Of Gait (pattern of walking or moving) And Mobility, and Unsteadiness On Feet. A record review of Resident 37's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 04/16/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 2 which indicated the resident was severely cognitively impaired (unable to understand). The resident was dependent on staff for all activities of daily living (ADLs) except eating and for mobility and transfers. The resident had bilateral lower extremity (both legs and feet) limited range of motion. A record review of Resident 37's Care Plan Report with an admission date of 12/09/2024 revealed the resident required the assistance of two staff for transferring. The resident was on hospice, and the staff was to adjust the provision (supplying something or a specific measure taken) ADLs to compensate for the resident's changing abilities. An observation on 05/20/2026 at 7:26 AM revealed Nursing Assistant (NA)-L and NA-M entered Resident 37's room to assist the resident in transferring to the resident's wheelchair. NA-L positioned the sit-to-stand mechanical lift that was labeled number 4 in front of the resident, both NAs assisted the resident with dressing, applied the sit-to-stand lift sling around the resident and fastened the sling to the sit-to-stand lift. NA-M went to fasten the leg strap and confirmed the leg strap on the sit-to-stand lift was broke and the buckle was missing, so NA-M attempted to tie the strap. NA-M could not get the sit-to-stand lift leg strap tied, so NA-L and NA-M continued to use the sit-to-stand lift to lift resident off the bed and transfer into the resident's wheelchair. NA-L then placed the sit-to-stand lift in the hallway and NA-M continued to assist the resident with ADLs. An observation on 05/20/2026 at 10:37 AM with the facility's Administrator revealed the leg strap on the number 4 sit-to-stand mechanical lift in the 600 hallway had a missing buckle and could not be fastened. In an interview on 05/20/2026 at 10:05 AM, NA-L confirmed NA-L and NA-M transferred Resident 37 with a sit-to-stand lift and the buckle on the leg strap was broken and they should not have used that lift. NA-L confirmed that when there was a defective piece of equipment, the staff was just to put an order in the facility's work order system (TELS). NA-L confirmed the staff had been using the defective lift for about one month and a workorder had been put in the system. In an interview on 05/20/2026 at 10:37 AM, the facility's Administrator confirmed the sit-to-stand mechanical lift in the 600 hallway's leg strap buckle was broken and could not be fastened. The Administrator confirmed NA-L and NA-M should not have used the defective number 4 sit-to-stand mechanical lift to transfer Resident 37 from the bed to the wheelchair. C. Record review of Resident 55's admission 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 4/29/26 identified the facility admitted the resident on 4/17/26 with a Brief Interview for Mental Status (BIM's, a cognitive screening tool used to determine cognitive function in long term care facilities) of 3/15 indicating severe cognitive impairment. Further review revealed Resident 55 required set up/clean up for eating, partial/moderate assist for oral hygiene, upper body dressing, personal hygiene, and sitting to standing transfers, dependent on staff for toilet hygiene, lower body dressing, and putting on and taking off footwear. Record review of Resident 55's Visual/Bedside Kardex Report revealed a section titled 'safety' with: -5/2/26 Assist resident out of bed between 6:30-7:30 AM -5/4/26 Fall mat placed on left side of bed -fall matt to be placed to left side of bed when resident in bed Observation of Resident 55 on 5/20/26 at 6:35 AM revealed Resident 55 alone in room, sitting up on the left side of the bed with the fall matt folded up against the wall between the dresser and the heating/air conditioner unit. Observation of Resident 55 on 5/21/26 at 7:13 AM revealed the resident sitting on the left side of the bed with the fall matt folded up against the wall between the dresser and the heating/air conditioner unit. In an interview with the Director of Nursing (DON) on 5/20/26 at 6:37 AM confirmed the fall matt was not on the floor next to the bed as is care planned when resident is in bed and should be.

Based on observation, record review and interview, the facility failed to ensure that the posted nurse staffing information contained the required information related to the facility census, the total number of hours worked per discipline per shift and the total number of hours worked for the each shift. This had the potential to affect all residents that resided in the facility. The facility census was 62. Findings are:Record review of an undated facility policy entitled Posting Direct Care Daily Staffing Numbers revealed the following information:Policy Explanation and Implementation:Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. 2. The information recorded on the form shall include the following:The name of the facility.The current date.The resident census at the beginning of the shift for which the information is posted.Twenty - four hour shift schedule operated by the facility.The shift for which the information is posted.Type RN, LPN, LVN or CAN (Registered Nurses, Licensed Practical Nurses, Licensed Vocational Nurses or Certified Nurse Aides) and category (licensed and unlicensed) of nursing staff working during that shift for each category who are paid by the facility (including contract staff).The actual time worked during that shift for each category and type of nursing staff.Total number of licensed and un-licensed nursing staff working for the posted shift. Observation on 05/19/26 at 3:20 PM and 5/20/26 at 3:25 PM revealed the posted nursing staffing information for 05/18/26, 5/19/26 and 5/20/26 did not contain the facility census, a calculation of the number of hours worked per discipline per shift or the total number of hours worked per shift and daily. Record review of 30 days past posted nurse staffing documentation between 4/18/26 and 5/20/26 revealed the daily posted nurse staffing did not contain the facility census, a calculation of the total number of hours worked per discipline per shift and the total number of hours worked for each shift. Interview on 05/21/2026 at 8:34 AM with the facility Director of Nursing [DON] confirmed that the facility census was not included on the past 30 days of the posted nurse staffing information and no calculation of hours worked per discipline and no calculation of the total number of hours worked had been completed or documented on the posted nurse staffing information. The DON confirmed that those items should have been included in the posted nurse staffing information.

Licensure Reference Number 175 NAC 12-006.11 Based on observation, interview, and record review the facility failed to ensure hand hygiene was completed between 2 (Residents 58 and 62) of 2 sampled residents during dining service and failed to perform hand hygiene when indicated during food prep. This had the potential to affect all residents but 1 resident in the facility. The facility census was 62. Findings are: A. RR of the facility's undated Handwashing Guidelines for Dietary Employees policy revealed the following: 6. Frequency of Handwashing: Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and [NAME] use articles and also in the following situations: a. Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet. b. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. c. After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). g. when switching between working with raw food and working with ready to eat food. h. Before donning gloves for working with food. An observation during meal preparation on 5/20/2026 between 8:44 AM and 10:25 AM revealed the Dietary Manager (DM) completed hand hygiene (HH) for 20 seconds (sec), applied gloves, grabbed a box of pork chops, cut open each individual wrapped pork chop and placed them on the baking sheet. The DM removed the soiled gloves and did not complete HH touching clean baking sheets. The DM lined the baking sheets with parchment paper without completing HH and applied gloves. The DM open each individually wrapped pork chop with a knife and place them on the baking sheet. The DM discarded the trash from the porkchops, removed the soiled gloves, and did not complete HH. The DM washed the counter with a sanitizer washcloth towel, took the washcloth to the dish area, did not complete HH, went to walk-in to grab potato salad and brought potato salad back to prep area and opened the containers of potato salad. The DM removed trash, removed the soiled gloves and did not complete HH. In an interview on 5/20/2026 at 9:43 AM DM confirmed that hand hygiene was not completed between glove changes and should have been. B. A record review of the facility's undated Handwashing/Hand Hygiene (sanitizing) policy with a revised date of October 2023 revealed hand hygiene should be completed before touching a resident and after touching a resident. An observation on 05/20/2026 at 8:06 AM revealed Nursing Assistant (NA)-M entered the dining room and assisted Resident 58 with setting up the resident's meal tray and applying a clothing protector while touching the resident's neck and clothing without performing hand hygiene. NA-M then approached Resident 62 and applied a clothing protector while touching the resident's neck and clothing before NA-M sat down beside Resident 62 to assist Resident 62 with eating. No hand hygiene was performed before or after contact with Resident 58, or before resident contact with Resident 62. In an interview on 05/21/2026 at 7:54 AM, the DON confirmed NA-M should have completed hand hygiene before and after resident contact in the dining room.

Based on record review and interview, the facility failed to ensure that the facility assessment included information related to staffing levels needed for specific shifts, a plan to maximize recruitment and retention of direct care staff and a contingency plan for events that do not require the activation of the facility emergency plan but have the potential to impact resident care. This had the potential to affect all residents that resided in the facility. The facility census was 62. Findings are:A record review of the facility's undated Facility Assessment policy revealed The facility would conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations (including nights and weekends) and emergencies. The assessment would address or include the resident population including, but not limited to number of residents and the facility's capacity, staff competencies and skill sets, physical environment, equipment and services, and cultural, ethnic, and religious factors and the facility resources, The care required by the resident and the facility resources. The facility would be used to Inform staffing decisions to ensure sufficient number of staff with appropriate competencies and skill sets, consider specific staffing needs per unit and each shift, develop and maintain plan to maximize recruitment and retention of staff, and a contingency plan for events that do not require activation of the facility's emergency plan.Record review of the Facility assessment dated [DATE] revealed no information related to specific staffing needs per unit and each shift, no total calculation of the hours worked per each shift, no plan for the development or retention of staff and no contingency plan related to events that could happen which don't active the emergency plan but still had the potential to affect residents. Interview on 05/21/2026 at 7:20 AM with the facility Administrator confirmed that the Facility Assessment did not contain specific information related to staffing needs per unit pershift and did not include a list of specific personnel in house to meet the resident needs. The Administrator confirmed that the plan did not cover specific staffing levels withnumbers of staff needed for each shift. The Administrator confirmed that the Facility Assessment did not include information about retention and recruitment of staff and did notinclude a contingency plan for events that did not require the activation of the facility emergency plan but could have the potential to impact resident care.

Licensure Reference Number 175 NAC 12-006.18 Based on observations, record reviews and interviews, the facility failed to ensure staff performed hand hygiene between glove changes and during cares for 4 (Residents 4, 18, 14, and 37) of 5 residents observed, wore gloves during cares on 2 (Residents 37 and 14) of 5 residents observed, ensure staff donned the required Personal Protective Equipment (PPE) before entering 3 (Residents 4, 37 and 14's) 6 EBP rooms observed, ensure respiratory supplies where cleaned and protected on 2 (Residents 4 and 55) of 3 residents observed, and failed to use an applicator during catheter care on 1 (Resident 18) of 1 resident observed, all to prevent cross contamination. The facility census was 62. Finding are: A. Record Review of the facility's undated policy Suctioning, Cleaning and Storage revealed the following: POLICY The facility shall ensure suction equipment and associated supplies are cleaned, disinfected, stored, and maintained according to manufacturer instructions, infection prevention standards, and facility procedures. Suction equipment shall be maintained in a clean and ready-to-use condition and protected from contamination. This policy applies to all suction equipment including: Portable suction machines Suction canisters and lids Tubing Yankauer (medical straw) devices Catheters (a flexible, hollow tube) Collection containers Oral suction supplies Tracheostomy (a surgical hole in the front of the neck directly into the air way) suction equipment PROCEDURE 1. General Infection Prevention Requirements Staff shall perform hand hygiene before and after handling suction equipment. Appropriate personal protective equipment (PPE) shall be worn according to standard precautions and transmission-based precautions. Single-use items shall not be reused unless specifically identified by manufacturer instructions. Suction equipment shall be handled to prevent contamination of clean surfaces and supplies. 4. Tubing and Yankaur Storage Yankaur suction tips shall be stored: Covered Protected from environmental contamination Off floors and contaminated surfaces Tubing shall: Not rest on floors, beds, or visibly contaminated areas Be replaced per manufacturer recommendations, resident condition, and facility procedure Remain free from visible debris or secretions When suction setup remains at bedside: Clean components shall be separated from contaminated components Equipment shall remain organized and protected 5. Storage Requirements Clean suction equipment and supplies shall be stored: In clean, dry locations Protected from dust, moisture, splash, and contamination Away from soiled utility areas Off floors In designated storage areas According to manufacturer instructions 8. Staff Education Staff shall receive education regarding: Cleaning procedures Storage requirements Infection prevention expectations PPE use Manufacturer instructions Equipment operation Record Review of the facility's undated policy Nebulizer Therapy revealed the following: Care of the Equipment Clean after each use. Wash hands before handling equipment. Disassemble parts after every treatment. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. Shake off excess water. Air dry on an absorbent towel. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. Change nebulizer tubing every seventy-two hours or per facility policy. Periodically disinfect unit per manufacturer's recommendations. Record Review of the facility's undated policy Handwashing/Hand Hygiene policy revealed the following: 1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing aseptic task (for example, placing an indwelling device or handling an invasive medical device): c. after contact with blood, body fluids, or contaminated surfaces: d. after touching resident: e. after touching the resident's environment: f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. Record Review of the facility's undated policy Enhance Barrier Precautions revealed the following: Enhanced barrier precautions (EBP's) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP's include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc,); and h. wound care (any skin opening requiring dressing). B. Record review of Resident 4's Order Summary Report dated 5/20/2026 revealed following orders: Enhanced Barrier Precautions (PPE) required for high resident contact care activities. Indications: wounds, indwelling medical device, infection and/or MDRO status. two times a day with a start date of 4/29/2025. Enteral Feed: 325cc (Cubic Centimeter) Jevity (Nutritional formula) 1.5 bolus (single dose) 5 times daily to provide 118G (Grams) protein, 2259 KCAL (calories), 2044cc water per day started on 5/1/2026. OK for suction at bedside for use as needed started on 5/23/2025. Sod (Sodium) Chloride Neb (nebulizer) 0.9% (normal saline, sterile mist) inhale one vial per nebulizer daily (Related Diagnoses: Pneumonia, unspecified organism) (Indications for Use: congestion, secretions) started on 5/8/2026. Sod (Sodium) Chloride Neb (nebulizer) 0.9% (normal saline, sterile mist) inhale one vial per nebulizer three times daily as needed for secretions started on 11/25/2025. An observation on 05/18/2026 at 8:33 AM revealed Resident 4's nebulizer mask was on bedside table. The nebulizer mask was not on a barrier and there was medication in the medication cup. The yankauer was laying on top of the suction machine and there was fluid in the suction canister. An observation on 5/18/2026 at 12:49 PM revealed Resident 4's nebulizer mask was on bedside table. The nebulizer mask was not on a barrier and there was medication residue in the medication cup. The yankauer was laying on top of the suction machine and there was fluid in the suction canister. An observation on 05/19/2026 at 1:16 PM revealed Resident 4's yankauer was lying on the table. There was a clear yellow liquid in the suction canister. The nebulizer mask was lying on bedside table and not on a barrier with residue in the medication cup. An observation on 05/21/2026 at 12:13 PM revealed Resident 4's nebulizer mask was hanging on the suction machine with residue in the medication cup. The yankauer was lying by the suction machine not covered. An observation on 05/26/2026 at 8:00 AM revealed Resident 4's nebulizer mask was hanging on bedside table with residue in medicine cup. The yankauer was hanging off the bedside table, not covered with a clear/yellow substance hanging from the yankauer. In an interview on 05/26/2026 at 8:03 AM Licensed Practical Nurse (LPN)-K confirmed that Resident 4's nebulizer medication cup had residue in it and was not rinsed or on a barrier and should have been. LPN-K confirmed that the yankauer had mucus hanging from it and the yankauer was not rinsed or covered and should have been. C. An observation on 05/19/2026 at 10:39 AM revealed an Enhanced Barrier Precautions sign outside room [ROOM NUMBER] that stated the following: Stop Enhanced Barrier Precautions (EBP)-Stop; Everyone must: Clean their hands including before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device Care of use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. An observation on 05/20/2026 at 6:55 AM revealed Registered Nurse (RN)-J at bedside and was not gowned. RN-J was completing a bolus tube feed for Resident 4. RN-J removed gloves, did not complete hand hygiene, applied a gown and put gloves on. RN-J obtained a suction mouth swab, grabbed the yankauer ( device used to suction secretions) off the bed and suctioned the residents mouth with the yankauer. RN-J removed the yankauer from the suction machine and placed the yankauer on the bedside table without a barrier. RN-J opened a suction swab and attached the swab to the suction machine to clean the residents mouth. RN-J removed the suction swab and applied suction tubing to the suction machine and suctioned the residents mouth. RN-J used a swab and hand swabbed the residents mouth out. RN-J removed the tube from the suction machine and put the yankauer back on. snd RN-J suctioned the residents mouth with the yankauer and then hung the yankauer over the hand rail on the bed. RN-J grabbed a lemon swab to swab Resident 4's mouth, discarded swab and opened a new swab. RN-J removed the soiled gloves to retie gown and did not complete hand hygiene and put new gloves on. RN-J got water and moistened the swab with water to swab the residents mouth. RN-J discarded the swab and used the yankauer to suction the residents mouth. RN-J shut the suction machine off and hung the yankauer over the suction machine. RN-J obtained a clean glove and placed the glove over the open end. In an interview on 05/20/2026 at 7:15 AM RN-J confirmed that hand hygiene was not completed between glove changes and should have been. RN-J confirmed that RN-J did not have a gown on while doing Resident 4's tube feeding and should have. D. Record review of Resident 55's admission 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 4/29/26 identified the facility admitted the resident on 4/17/26 with a Brief Interview for Mental Status (BIM's, a cognitive screening tool used to determine cognitive function in long term care facilities) of 3/15 indicating severe cognitive impairment. Further review revealed Resident 55 required set up/clean-up for eating, partial/moderate assist for oral hygiene, upper body dressing, personal hygiene, and sitting to standing transfers, dependent on staff for toilet hygiene, lower body dressing, and putting on and taking off footwear. Observation of Resident 55 on 5/19/26 at 10:24 AM revealed the oxygen tubing on the oxygen concentrator was dated 5/6/26 and the oxygen tubing on the oxygen concentrator was dated 4/29/26. Observation of Resident 55 on 5/20/26 at 6:35 AM revealed the oxygen tubing on the oxygen concentrator was dated 5/6/26 and the oxygen tubing on the oxygen concentrator was dated 4/29/26. An interview with the Director of Nursing (DON) on 5/20/26 at 6:37 AM confirmed the Oxygen tubing had not been changed weekly and should have been. E. Review of Resident 18's quarterly MDS dated [DATE] revealed an admission date of 10/20/25 with a BIM's of 15/15 indicating intact cognition. Further review revealed Resident 18 required set up for eating, partial to moderate assist for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on and taking off footwear, personal hygiene and sit to stand transfers with diagnosis of obstructive uropathy with a suprapubic catheter, encephalopathy, multiple fractures of pelvis without disruption of pelvic ring, anxiety, depression, and bipolar disorder. Observation of suprapubic care for Resident 18 on 5-20-26 at 11:30 AM revealed RN J entered room and performed hand hygiene, donned gown and gloves. RN J cleansed the area around the supra-pubic with soapy gauze, folded gauze and cleansed down tubing away from abdomen, without changing gloves used a wet gauze to rinse area around catheter and used dry gauze to pat dry. RN J, without changing gloves, used their index finger to remove the medicated cream from medication cup and spread it around the catheter site. RN J then removed the gloves, performed hand hygiene, applied new gloves and placed a dressing around the catheter site. In an Interview with RN J on 5/20/26 at 11:45 A.M. it was confirmed they should have changed gloves before rinsing the site and should have used an applicator to apply the medication around the catheter site. F. A record review of Resident 37's Care Plan Report with an admission date of 12/09/2024 revealed the resident had focus areas that the resident a suprapubic urinary catheter (a tube inserted directly into the bladder to allow urine flow to an external bag), a history of Methicillin-resistant Staphylococcus auris (MRSA)(a difficult to treat infection), an unstageable pressure ulcer (wound) to the left heel, and a wound on the buttock. The resident had a focus area of EBP and an intervention of gown and glove use during high-contact resident care activity (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing brief, or assisting with toileting) and perform hand hygiene before leaving the room. A record review of the undated Enhanced Barrier Precautions signed posted at the entrance to Resident 37's room revealed everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, and for device care or use for a urinary catheter. A record review of the undated Enhanced Barrier Precautions signed posted at the entrance to Resident 14's room revealed everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, and for device care or use for a urinary catheter. An observation on 05/20/2026 at 7:26 AM revealed Nursing Assistant (NA)-L and NA-M entered Resident 37's room to assist the resident in transferring to the resident's wheelchair and with activities of daily living (ADLs). NA-L and NA-M did not perform hand hygiene or apply a gown, but applied gloves before entering the resident's room. NA-L and NA-M transferred the resident from the bed to the wheelchair with a sit-to-stand lift while NA-L handled the urinary catheter bag 3 times and MA-M handled the urinary catheter bag 2 times. During the transfer, both NA-L and NA-M assisted the resident with dressing, and NA-L made the resident's bed. NA-M then removed gloves and applied the resident's footrests to the wheelchair and took Resident 37 to the dining room without performing hand hygiene when exiting the room. NA-L took the sit-to-stand lift to the hallway without performing hand hygiene when exiting the resident's room. NA-L and NA-M then got a Hoyer (full body mechanical lift) lift, applied new gloves and entered Resident 14's room, that had an EBP sign on the door without performing hand hygiene or donning (putting on) a gown. NA-L handled the resident's urinary catheter bag 3 times, both NA-L and NA-M assisted the resident with changing clothes and rolling left and right in bed to put the Hoyer sling under the resident and while NA-M changed the resident's feces soiled brief. After cleaning the resident and removing the resident brief, NA-M removed gloves and donned a new pair without hand hygiene. At 7:51 AM Medication Aide (MA)-N entered the room without applying gloves or a gown and assisted the resident into the wheelchair from the Hoyer. MA-N adjusted the residents shoes onto the wheelchair footrests and then MA-N washed MA-N's hands and. NA-L and NA-M exited the resident's room and went to the hopper room and washed hands. In an interview on 05/20/2026 at 10:05 AM, NA-L confirmed NA-L and NA-M transferred the resident, touched the catheter bag, assisted the resident with dressing, and made the bed without wearing gowns or performing hand hygiene as required. In an interview on 05/20/2026 at 2:03 PM, the Director of Nursing (DON) confirmed the staff should have performed hand hygiene before entering an EBP room, worn a gown and gloves during high-contact cares, had gloves on at all times, and performed hand hygiene before exiting an EBP room and performed hand hygiene between glove changes.

Licensure Reference Number 175 NAC 12-006(F)(i)(5)Based on interview and record review the facility failed to notify the provider of weight change greater than 5 pounds on 1 (Resident 7) of 2 sampled residents. The facility census was 62.Findings are:A. Record Review of the facility's undated policy Following Physician Order revealed the following: PURPOSETo ensure all physician/practitioner orders are accurately received, transcribed, communicated, implemented, monitored, and followed in accordance with professional standards of practice, resident needs, and applicable federal and state regulations.POLICYThe facility shall ensure physician/practitioner orders are implemented as written unless clarified, modified, discontinued, refused by the resident, unavailable, clinically contraindicated, or otherwise unable to be completed. Any inability to follow an order shall be identified, documented, communicated, and addressed timely.Orders include but are not limited to: Medication orders Treatment orders Laboratory and diagnostic orders Therapy orders Dietary orders Activity orders Safety interventions Consultations/referrals Monitoring parameters Isolation/precaution orders Behavioral health interventions Durable medical equipment orders4. Orders Unable to Be CompletedIf an order cannot be implemented as written, staff shall: Assess resident status and immediate risk. Determine cause, including but not limited to: Medication unavailable Equipment unavailable Resident refusal Clinical contraindication Missed dose/treatment Delivery delay Pharmacy issue External appointment delay Notify the physician/practitioner. Obtain additional orders as necessary. Document: Reason order was not completed Notifications made Practitioner response Resident outcome Corrective actions taken Follow alternative interventions ordered by practitioner. B. Record Review of Resident 7's Order Report Summary dated 5/20/2026 revealed the resident has an order to obtain daily weights and notify Resident 7's Primary Care Practitioner (PCP) if weight gain was greater than 5pounds. Record Review of Resident 7's April 2026 and May 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed the following:Weights were not obtained on 4/9/2026, 4/15/2026, 4/16/2026, 4/22/2026, 4/23/2026, 4/25/2026, 4/29/2026, 4/30/2026, 5/1/2026, 5/6/2026 and 5/14/2026. Record Review of Resident 7's Electronic Health Record (EHR) revealed there was no provider notification regarding weight increase on 4/7/2026 with a weight gain of 7 pounds, 4/24/2026 with a weight gain of 7.2 pounds, 4/28/2026 with a weight gain of 5.4 pounds and on 5/10/2026 with a weight gain 8.2 pounds. In an interview on 5/26/2026 at 7:04 AM Infection Preventionist (IP) confirmed that weights were not obtained on 4/9/2026, 4/15/2026, 4/16/2026, 4/22/2026, 4/23/2026, 4/25/2026, 4/29/2026, 4/30/2026, 5/1/2026, 5/6/2026 and 5/14/2026 and should have been. The IP confirmed that there was no notification to the provider seen in the residents EHR regarding the 5 pound or greater weight gain.

License Reference Number 175 NAC 12-0060.02(G)(H)Based on interviews and record reviews the facility failed to complete a thorough fall investigation for 1 (Resident 57's) of 1 sample resident. The facility census was 62.Findings are:A. Record Review of the facility's undated policy Conducting Internal Investigations revealed the following: Policy:The purpose of this policy is to establish procedures for conducting internal compliance investigations.Procedure: The Administrator or designee shall begin and/or oversee investigations on all compliance-related matters following receipt of the report indicating a matter warranting investigation. The Administrator or designee may delegate the investigation responsibilities but will hold ultimate supervision and responsibility for all compliance investigations. The investigation may include, but is not limited to: Reviewing and preserving documents related to the matter; Interviewing appropriate individuals; Reviewing policies and procedures applicable to the matter; Collaborating with an internal facility authority, as needed; Engaging an outside consultant, authority, law enforcement, or regulatory entity to assist in the investigation, as needed. If a significant compliance violation is found, the Administrator or designee shall develop and implement a corrective action plan. All investigation methods and findings pursuant to the investigation must be documented. Copies of supporting documents should be attached to all reports. If the investigation findings do not substantiate the allegation or matter: The investigation will be closed by the Administrator or designee. Documentation regarding the investigation will be filed and maintained by the Administrator or designee for a minimum of seven (7) years after the investigation has closed. If a compliance violation is found: All documentation related to the investigation will be maintained as an open investigation until a corrective action plan has been completed and the matter has been resolved, at which time the investigation will be closed by the Administrator. Once closed, the investigation file will be filed and the applicable Facility Compliance Department for a minimum of seven (7) years after the investigation has been closed. Record Review of the facility's undated policy Accidents and Supervision revealed the following: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: Communicating the interventions to all relevant staff Assigning responsibility Providing training as needed Documenting interventions (e.g., plans of action developed through the QAA Committee or care plans for the individual resident) Ensuring that the interventions are put into action Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully Facility-based interventions may include, but are not limited to: Educating staff Repairing the device/equipment Developing or revising policies and procedures Resident-directed approaches may include: Implementing specific interventions as part of the plan of care Supervising staff and residents, etc. Facility records document the implementation of these interventions 1. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: Ensuring that interventions are implemented correctly and consistently Evaluating the effectiveness of interventions Modifying or replacing interventions as needed Evaluating the effectiveness of new interventions 2. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: Defined by type and frequency Based on the individual resident's assessed needs and identified hazards in the resident environment. B. Record Review of Resident 57's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 3/23/2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE]-Brief Interview of Mental Status (BIMS) was scored as an 11. According to the MDS Manual a score of 8-12 indicates a person has moderate cognitive impairment.-was dependent on staff for lower body dressing, putting on/taking off footwear, chair to bed/bed to chair transfer, toilet transfer and tub/shower transfers.-had diagnosis of osteo arthritis (deuteriation of joints), pain in left hip, trochanteric bursitis in left and right hip (outer hip pain), age related osteoporosis without current pathological fracture (fragile bones). Record Review of Resident 57's Care Plan revealed the following:-Transfer: requires 2 staff assist to move between surfaces and as necessary. 9/20/24- 2 assist with transfers on admission. Date Initiated: 09/24/2024 Revised on: 04/11/2025. - 3/4/25-Therapy to eval for transfers and overall weakness. Date Initiated: 03/05/2025.- 5/2/26 Therapy screen with transfers from recliner to bed Nursing Date Initiated: 05/04/2026. - 4/10/25- Staff education 2 staff members for all transfers. Date Initiated: 04/11/2025 Revision on: 04/11/2025. Record review of Resident 57's Visual/Bedside Kardex Report dated 5/26/2026 revealed the following:'Safety'- 4/10/25- Staff education 2 staff members for all transfers.- walker and W/C for mobility.'Transferring'- 5/2/26 Therapy screen with transfers from recliner to bed- Transfers requires 2 staff assist to move between surfaces and as necessary. -9/20/24- 2 assist with transfers on admission. Record Review of the facility's Describe the Incident report dated 5/6/2026 revealed the following: -On 5/2/2026 at 9:20 PM Resident 57 was lowered to the floor after attempts were made to transfer Resident 57 to the bed. According to the incident report dated 5/02/2026 Resident 57 was unable to bear weight and was assisted to the floor by a nursing assistant. - Resident 57 complained of ankle pain after doctor's appointment today and was transferred to [NAME] walk in clinic at the hospital. -Received a report from a Nurse Practitioner (NP) at 12:21 that Resident 57 had an acute right ankle pain with a obvious fracture noted. ACE wrap applied to affected extremity.-Received call from the hospital with report that radiologist noted a fracture to the top of Resident 57's foot. In an interview on 5/26/2026 at 6:57 AM, the Director of Nursing (DON) and Infection Preventionist (IP) confirmed they were unsure if a gait belt was utilized during the transfer of Resident 57. The DON confirmed that one nursing assistant transferred Resident 57 at the time of the fall. In an interview on 05/26/2026 at 9:40 AM, DON confirmed that causative factor for Resident 57's fall was not completing the 2 assists transfer. In an interview on 05/26/2026 3:49 PM, DON confirmed that the fall investigation completed for Resident 57 was not a thorough investigation.

Licensure Reference Number 175 NAC 12-006.09(E) Based on interview and record review, the facility failed to add oxygen interventions to 1 (Resident 22) of 2 sampled resident's Comprehensive Care Plan (a detailed roadmap outlining a resident's medical, physical, and daily living needs). The facility census was 62. Findings are:A record review of the facility's undated Comprehensive Care Plans policy revealed that the care plan would include the services to be furnished to the resident. A record review of Resident 22's Clinical Census dated 05/26/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 22's Medical Diagnosis dated 05/26/2026 reveled the resident had diagnoses of Cerebral Infarction (stroke) and Morbid (Severe) Obesity. A record review of Resident 22's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 05/15/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 14 which indicated the resident was cognitively aware (able to understand). The resident required setup or clean-up assistance with eating and oral hygiene (cleaning), partial/moderate assistance with upper body dressing and personal hygiene, and required substantial/maximal assistance with lower body dressing, toileting hygiene, bathing, and footwear. The resident required partial/moderate assistance with bed mobility and transfers. The resident was on oxygen. A record review of Resident 22's Clinical Physician Orders dated 05/26/2026 revealed the resident had an order for oxygen at 1-2 liters per minute (l/m) via nasal cannula (a tubing inserted in a resident's nose to deliver oxygen). Notify primary care provider (PCP) if saturations less than 90 percent (%). A record review of Resident 22's Care Plan Report with an admission date of 11/10/2025 did not reveal a focus area or interventions for the resident's oxygen. An observation on 05/18/2026 at 10:12 AM revealed Resident 22 was not in the resident's room, the oxygen concentrator (machine used to purify oxygen) was on, and the nasal cannula was lying on the bed sheet. An observation on 05/20/2026 at 7:01 AM revealed Resident 22 was not in the resident's room, the oxygen concentrator was on, and the nasal cannula was lying on the bed sheet. An observation on 05/20/2026 at 10:45 AM with the Director of Nursing (DON) revealed Resident 22 was not in the resident's room, the oxygen concentrator was on, and the nasal cannula was lying on the bed sheet. In an interview on 05/20/2026 at 7:04 AM, Resident 22 confirmed the resident wore oxygen, but only at night. In an interview on 05/20/2026 at 10:45 AM, the DON confirmed Resident 22 was on oxygen at night. In an interview on 05/26/2026 at 8:52 AM, the DON confirmed Resident 22's oxygen was not on the care plan and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)Based on observation, record review and interview, the facility failed to follow practitioner orders to obtain a urinalysis for 1 (Resident 41) of 3 residents sampled, failed to follow physician orders to notify provider of oxygen saturation less than 90% for 1 of (Resident 22) of 2 residents sampled, and failed to obtain daily weights and notify the provider of a 5 pound or greater weight gain for 1 (Resident 7) of 2 residents sampled. The facility identified a census of 62.Findings are: Findings are: A. Review of an undated facility policy titled 'Following Physician Order' revealed the following: 'PURPOSE To ensure all physician/practitioner orders are accurately received, transcribed, communicated, implemented, monitored, and followed in accordance with professional standards of practice, resident needs, and applicable federal and state regulations. POLICY The facility shall ensure physician/practitioner orders are implemented as written unless clarified, modified, discontinued, refused by the resident, unavailable, clinically contraindicated, or otherwise unable to be completed. Any inability to follow an order shall be identified, documented, communicated, and addressed timely. Orders include but are not limited to: Medication orders Treatment orders Laboratory and diagnostic orders Therapy orders Dietary orders Activity orders Safety interventions Consultations/referrals Monitoring parameters Isolation/precaution orders Behavioral health interventions Durable medical equipment orders Procedure 1. Receiving Orders 2. Order review and verification 3. Implementation of Orders Orders shall be initiated promptly according to: Order timing Resident condition Clinical urgency Staff shall ensure implementation of: Medication administration Treatments Monitoring parameters Laboratory services Referrals/consults Care plan updates Required assessments Equipment acquisition/setup Therapy services Care plans, Kardex, EHR tasks, treatment records, MAR/TAR, and other applicable systems shall be updated as required. 4. Orders Unable to Be Completed If an order cannot be implemented as written, staff shall: Assess resident status and immediate risk. Determine cause, including but not limited to: Medication unavailable Equipment unavailable Resident refusal Clinical contraindication Missed dose/treatment Delivery delay Pharmacy issue External appointment delay Notify the physician/practitioner. Obtain additional orders as necessary. Document: Reason order was not completed Notifications made Practitioner response Resident outcome Corrective actions taken Follow alternative interventions ordered by practitioner. 5. Resident Refusal When residents refuse ordered services/interventions: Staff shall: Educate resident/responsible party regarding risks and benefits Reapproach as appropriate Assess contributing factors Notify practitioner when clinically indicated Documentation shall include: Intervention refused Resident statement/reason Education provided Reapproach attempts Notifications Outcome Ongoing refusals shall be reviewed by the interdisciplinary team. 6. Monitoring and Follow-Up Nursing staff shall monitor implementation and outcomes of orders including: Medication effectiveness Treatment response Laboratory results Adverse reactions Resident condition changes Completion of ordered services Significant findings shall be communicated to the practitioner timely. 7. Documentation Requirements Documentation shall include: Order receipt date/time Implementation date/time Notifications Clarifications obtained Refusals Delays or omissions Practitioner communication Outcomes and follow-up actions Documentation shall be complete, accurate, and entered into the medical record timely. 8. Quality Assurance Monitoring The facility shall monitor compliance through: Medication audits Treatment audits Missed order reviews Pharmacy reports EMR audits QAPI review Incident trending Identified concerns shall be addressed through corrective action and performance improvement processes'. B. Record review Resident 41's Annual 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 4/2/26 revealed the facility admitted the resident on 5/9/25 and readmitted the resident after a hospitalization on 2/24/26. The facility staff assessed Resident 41's Brief Interview for Mental Status (BIM's, a cognitive screening tool used to determine cognitive function in long term care facilities) of 6/15 indicating severe cognitive impairment. In addition, Resident 41 admitted with the with diagnoses of vascular dementia, moderate, without behaviors, metabolic encephalopathy, acute and chronic respiratory failure with hypoxia, neurogenic bladder with suprapubic catheter (a catheter placed directly in the bladder through the abdomen) and hypertension. Further review indicated Resident 41 required set up or clean up assistance for eating, oral hygiene, and upper body dressing, supervision or touching assistance for toileting hygiene, personal hygiene and sit to stand transfers, and partial to moderate assistance for bath/shower self and lower body transfers. Record review of the May 2026 Treatment Administration Record revealed an order dated 5/23/26 at 3 PM for urinalysis screen/culture one time only related to neuromuscular dysfunction of bladder, unspecified. Record review of progress notes revealed the UA was not obtained until 5/25/26 at 12:56 PM Interview with the Director of Nursing (DON) on 5/26/26 at 2:30 PM confirmed the order for obtaining UA/Culture was not followed on 5/23/26 and should have been. C. A record review of the facility's undated Following Physician Order policy revealed that the facility would ensure physician/practitioner orders were implemented as ordered and documentation would include notifications and practitioner communication. A record review of Resident 22's Clinical Census dated 05/26/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 22's Medical Diagnosis dated 05/26/2026 reveled the resident had diagnoses of Cerebral Infarction (stroke) and Morbid (Severe) Obesity. A record review of Resident 22's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 05/15/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 14 which indicated the resident was cognitively aware (able to understand). The resident required setup or clean-up assistance with eating and oral hygiene (cleaning), partial/moderate assistance with upper body dressing and personal hygiene, and required substantial/maximal assistance with lower body dressing, toileting hygiene, bathing, and footwear. The resident required partial/moderate assistance with bed mobility and transfers. The resident was on oxygen (o2). A record review of Resident 22's Care Plan Report with an admission date of 11/10/2025 did not reveal a focus area or interventions for the resident's oxygen. A record review of Resident 22's Clinical Physician Orders dated 05/26/2026 revealed the resident had an order for oxygen at 1-2 liters per minute (l/m) via nasal cannula (a tubing inserted in a resident's nose to deliver oxygen). Notify primary care provider (PCP) if saturations (sats) less than 90 percent (%). A record review of Resident 22's O2 Sats Summary dated 05/26/2026 revealed: - On 05/26/2026 the resident's sats were 84% - On 05/05/2026 the resident's sats were 88% - On 04/21/2026 the resident's sats were 88% - On 04/08/2026 the resident's sats were 88% - On 03/19/2026 the resident's sats were 77% - On 03/12/2026 the resident's sats were 87% - On 03/09/2026 the resident's sats were 89% - On 03/07/2026 the resident's sats were 82% - On 03/05/2026 the resident's sats were 86% - On 02/26/2026 the resident's sats were 84% - On 02/23/2026 the resident's sats were 88% - On 02/11/2026 the resident's sats were 88% - On 02/08/2026 the resident's sats were 84% - On 02/07/2026 the resident's sats were 78% - On 02/06/2026 the resident's sats were 88% - On 02/05/2026 the resident's sats were 88% - On 02/04/2026 the resident's sats were 89% A record review of Resident 22's Progress Notes dated 05/26/2026 did not reveal the resident's PCP had been notified of the above oxygen levels below 90%. A record review of Resident 22's Client Uploaded Files dated 05/26/2026 did not reveal the resident's PCP had been notified of the above oxygen levels below 90%. In an interview on 05/26/2026, the DON confirmed the facility did not have notifications to the PCP and it had not been done and should have been. D. Record Review of the facility's undated policy Following Physician Order revealed the following: PURPOSE To ensure all physician/practitioner orders are accurately received, transcribed, communicated, implemented, monitored, and followed in accordance with professional standards of practice, resident needs, and applicable federal and state regulations. POLICY The facility shall ensure physician/practitioner orders are implemented as written unless clarified, modified, discontinued, refused by the resident, unavailable, clinically contraindicated, or otherwise unable to be completed. Any inability to follow an order shall be identified, documented, communicated, and addressed timely. Orders include but are not limited to: Medication orders Treatment orders Laboratory and diagnostic orders Therapy orders Dietary orders Activity orders Safety interventions Consultations/referrals Monitoring parameters Isolation/precaution orders Behavioral health interventions Durable medical equipment orders 4. Orders Unable to Be Completed If an order cannot be implemented as written, staff shall: Assess resident status and immediate risk. Determine cause, including but not limited to: Medication unavailable Equipment unavailable Resident refusal Clinical contraindication Missed dose/treatment Delivery delay Pharmacy issue External appointment delay Notify the physician/practitioner. Obtain additional orders as necessary. Document: Reason order was not completed Notifications made Practitioner response Resident outcome Corrective actions taken Follow alternative interventions ordered by practitioner. Record Review of Resident 7's Order Report Summary dated 5/20/2026 revealed Resident 7's practitioner had ordered daily weights be obtained and notify Primary Care Practitioner (PCP) if weight gain is greater than 5 pounds. Record Review of Resident 7's April 2026 and May 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed the following: Weights were not obtained on 4/9/2026, 4/15/2026, 4/16/2026, 4/22/2026, 4/23/2026, 4/25/2026, 4/29/2026, 4/30/2026, 5/1/2026, 5/6/2026 and 5/14/2026. Record Review of Resident 7's Electronic Health Record (EHR) revealed there was no provider notification regarding weight increase on 4/7/2026 with a weight gain of 7 pounds, 4/24/2026 with a weight gain of 7.2 pounds, 4/28/2026 with a weight gain of 5.4 pounds and on 5/10/2026 with a weight gain 8.2 pounds. In an interview on 5/26/2026 at 7:04 AM Infection Preventionist (IP) confirmed that weights were not obtained on 4/9/2026, 4/15/2026, 4/16/2026, 4/22/2026, 4/23/2026, 4/25/2026, 4/29/2026, 4/30/2026, 5/1/2026, 5/6/2026 and 5/14/2026 and should have been. The IP confirmed that there was no notification to the provider seen in the residents EHR regarding the 5 pound or greater weight gain.

Licensure Reference Number 175 NAC 12.006.10(D)The facility failed to prevent significant medication errors for 2 Residents (2 and 6) of 13 Residents sampled. The facility identified a census of 62.Findings are: Findings are: A. Review of a facility policy titled Medication Administration-Medications not available with no date revealed the following Policy Statement The facility shall maintain systems to ensure medications are available for timely administration as ordered. When a medication is unavailable at the time of administration, nursing staff shall immediately initiate actions to obtain the medication, minimize interruption of therapy, ensure resident safety, and appropriately document actions taken. Medications shall not be omitted without assessment, intervention, provider notification when indicated, and appropriate follow-up. Purpose To establish procedures for managing medications that are unavailable at the time of the administration while ensuring resident safety, continuity of care, regulatory compliance, and timely communication. Procedure Identification of medication unavailability When a medication is not available during the scheduled medication administration pass, the nurse shall a. Verify the medication is not available in: -Resident medication cart -Medication stock room -Backup stock/ house stock (if applicable) -Emergency medication supply (E-Box/ eBox) -Alternate storage locations approved by facility policy b. Confirm the medication was not previously delivered or misplaced. c. Verify current physician orders, medication schedule, and administration time. 2. Pharmacy Notification/Retrieval Process If the medication remains unavailable, nursing staff shall immediately contact the pharmacy to: -Determine delivery status -Request urgent delivery, courier, or stat delivery when appropriate -verify availability of replacement medication -obtain guidance regarding expected arrival time -confirm whether emergency dispensing processes are available Documentation shall include: -date and time of delivery -Pharmacy representative spoken with (if available) -expected delivery timeframe -actions taken 3. eBox/Emergency Medication use The nurse shall review and utilize the Emergency Medication Box (eBox/E-Box) when applicable and permitted by facility policy. If the ordered medication or approved equivalent is available within the eBox: -Medication may be obtained following facility procedures -Requires inventory, access, and documentation processes shall be completed -Administration shall be documented in the MAR and applicable logs The nurse shall ensure replacement medication is requested from pharmacy if eBox supply is utilized. 4. Provider Notification If the medication remains unavailable at the scheduled administration time and administration cannot occur as ordered: The attending physician/provider shall be notified. Provider notification shall include: -Medication unavailable -Missed or delayed dose timing -Resident condition /status -Pharmacy actions completed -eBox review/use status -Clinical risk associated with delay The nurse shall obtain and implement new orders as provided. Examples may include: -Hold order -Substitute medication -Schedule adjustment -Clinical monitoring parameters -Alternative route/order -Transfer for urgent evaluation (if indicated) All new orders shall be followed as directed. B. Review of undated facility policy titled Medication Error revealed the following: Policy It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Definitions: Medication error means the observed or identified preparation of administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. 4. The facility will consider factors indicating errors in the medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to, the following: i. Incorrect dose, route of administration, dosage form, time of administration; ii. Medication omission; iii. incorrect medication. C. Record review of Resident 2's Order Summary report revealed an order dated 12/05/25 for Eliquis (an anticoagulant) 5mg take 1 tablet by mouth twice daily for Atrial Fibrillation (an abnormal heart rhythm). Observation of a medication pass on 5/20/2026 at 8:25 AM Registered Nurse (RN) J was asked about Resident 2's Eliquis 5mg tablet, RN J stated she did not have the medication available. RN went back into the Electronic Health Record (HER) and changed documentation to medication not available. In an interview with RN J, on 5/20/26 at 8:27 AM, it was confirmed she had documented the medication was given and then changed it to not available. Record review of Resident 2's MAR revealed the Eliquis 5mg was documented as not available and not given on 5/4/26 at 8 AM, 5/8/26 at 8 AM, 5/9/26 at 8 AM, 5/11/26 at 8 AM and at 8 PM, 5/12/26 at 8 AM and 8 PM, 5/13/26 at 8 AM, 5/14/26 8 AM, 5/18/26 8 AM, 5/20/26 8 AM In an interview was conducted with with the Director of Nursing on 5/20/26 at 2:26 PM. During the interview the DON confirmed medications not available would be considered a medication error. D. Record review of Resident 6's Order Summary Report dated 5/19/2026 revealed the following orders: -Lantus Solos (medication to lower blood sugar) inject 100/ML (milliliter) Inject 15 unit subcutaneously (below the skin) at bedtime related to type 2 diabetes mellitus (your body's inability to break down sugar) without complications started on 10/17/2025. -Levothyroxine (hormone replacement for energy, metabolism and growth) tablet 137MCG (microgram) take 1 tablet by mouth daily on empty stomach *take at least 30 minutes prior to meal related to hypothyroidism (under active thyroid gland) started on 4/28/2026. -Mirtazapine tablet 15MG (milligrams) take one tablet by mouth at bedtime for unspecified mood (affective) disorder started on 4/15/2025. -Olanzapine tablet 5MG take one tablet by mouth at bedtime for unspecified mood (affective) disorder started on 4/15/2025. Record Review of Resident 6's Medication Administration Record (MAR) dated 4/1/2026 - 4/30/2026 and 5/1/2026 - 5/31/2026 revealed the following: -Levothyroxine 125mcg was not administered on 4/17/2026, 4/23/2026, 4/25/2026, and was increased on 4/28/2026 to 137mcg but not administered as scheduled on 5/3/2026, 5/4/2026, 5/9/2026, 5/14/2026. No documentation of administration on 4/12/2026. -Lantus Solos injection was not administered on 4/16/2026, 4/18/2026, 4/22/2026, 4/23/2026, 5/3/2026, 5/13/2026. Refused on 4/21/2026, 4/30/2026 and 5/2/2026. -Mirtazapine tablet 15MG was not administered on 4/16/2026, 4/18/2026, 4/22/2026, 4/23/2026, 5/3/2026, 5/13/2026. -Olanzapine tablet 5MG was not administered on 4/16/2026, 4/18/2026, 4/22/2026, 4/23/2026, 5/3/2026 and 5/13/2026. In an Interview on 5/19/2026 at 1:31 PM, Director of Nursing (DON) confirmed nurses should be attempting to administer the medication three times before charting an omission (not given) and should be documenting that an attempt was made three times in the progress notes. In an Interview on 5/19/2026 at 1:31 PM, Infection Preventionist (IP) confirmed the medications listed were not administered on the dates listed. .

Licensure Reference Number 175 NAC 12-006.05(S)Based on observation and interview; the facility staff failed to ensure privacy during care for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 66. Findings are:A record review of Resident 2's Clinical Resident profile revealed they were admitted to the facility on [DATE].A record review of Resident 2's Minimum Data Set (MDS - a federally mandated standardized assessment tool used in Medicare and Medicaid certified nursing homes to evaluate a resident's functional capabilities, health needs and clinical status) revealed Resident 2 had a Brief Mental Status Interview (BIMS - a mandatory evaluation tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) of 5, indicating they were severely cognitively impaired.A record review of Resident 2's undated Care Plan revealed Resident had the following diagnoses: Lymphedema (a chronic condition causing fluid buildup and swelling in arm and/or legs), venous insufficiency (a long term condition where leg vein valves are damaged or weak preventing blood from flowing efficiently back to the heart), osteoarthritis (chronic degenerative joint disease causing pain in both hips, right hand), rheumatoid arthritis (a chronic systemic disease where the immune system attacks the lining of the joints causing inflammation, stiffness and potential bone deformity), open wound of left buttock, open wound of right buttock, open wound to left lower leg, open wound right lower leg, open wound left thigh, pressure ulcer of right heel, pressure ulcer of left heel, cognitive communication deficit (impaired communication due to cognitive issues relating to memory and attention), severe protein calorie malnutrition (a condition resulting from inadequate intake of protein and calories), and metabolic encephalopathy (a brain dysfunction caused by systemic illness, organ failure or chemical imbalances). A record review of Resident 2's undated Care Plan revealed Resident 2 had actual skin impairment with moisture associated skin damage (MASD) to both buttocks, unstageable pressure ulcer (a severe full-thickness wound where the base is completely hidden by necrotic tissue and the true depth cannot be assessed) to the left heel, Stage 3 pressure injury (a severe, full thickness skin loss appearing as a deep crater like wound) to right lateral foot, right middle lower leg, back left of left lower leg, Stage 1 pressure injury (localized skin injury that does not change color on pressure relief but the skin is intact) right lateral hip, Stage 3 pressure injury right root and a Stage 3 pressure injury to the right hip. A record review of Resident 2's orders summary revealed the following order: Right posterior (further back in position) hip/left posterior hip: Cleanse with saline, apply triad paste (a sterile zinc-oxide paste wound dressing paste) to wound and peri wound (around the edges of the wound), apply silver alginate (a wound dressing made from calcium alginate from seaweed and silver ions), to wound bed, cover with silicone superabsorbent dressing (a bordered foam dressing), change daily and prn (as needed) one time a day.An observation on 3/3/26 at 8:05 AM of wound care performed by Registered Nurse (RN) A for Resident 2 revealed the following. Resident 2's bed was low to the floor with a fall mat placed to the left of the bed. Resident 2 was lying on their left side. A privacy curtain was not present in the residents room. During the provision of Resident 2's wound care, Resident 2's roommate was seated at the side of their bed eating their breakfast. Resident 2 was lying on their left side with their buttocks exposed to the air. Resident 2's roommate commented to Resident 2 nice butt. Resident 2 and RN A laughed and RN A covered Resident 2 with a blanket.An interview on 3/3/26 at 8:20 AM with RN A confirmed Resident 2's room did not have a privacy curtain and that it had been gone for a few weeks. RN A confirmed Resident 2's roommate was able to see all personal and wound care Resident 2 received. RN A confirmed this was a breach of privacy and dignity for Resident 2.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1)Based on observation, interview and record review the facility failed to ensure two of three medical air mattresses for pressure relief (mattresses designed to prevent and treat bedsores by inflating/deflating air cells to redistribute pressure and improve circulation) were inflated in accordance with the residents' weight (Resident 2 and Resident 3). The facility had a census of 66. Findings are:A.A record review of Resident 2's Clinical Resident profile revealed they were admitted to the facility on [DATE].A record review of Resident 2's Minimum Data Set (MDS - a federally mandated standardized assessment tool used in Medicare and Medicaid certified nursing homes to evaluate a resident's functional capabilities, health needs and clinical status) revealed Resident 2 had a Brief Mental Status Interview (BIMS - a mandatory evaluation tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) of 5, indicating they were severely cognitively impaired.A record review of Resident 2's undated Care Plan revealed Resident had the following diagnoses: Lymphedema (a chronic condition causing fluid buildup and swelling in arm and/or legs), venous insufficiency (a long term condition where leg vein valves are damaged or weak preventing blood from flowing efficiently back to the heart), osteoarthritis (chronic degenerative joint disease causing pain in both hips, right hand), rheumatoid arthritis (a chronic systemic disease where the immune system attacks the lining of the joints causing inflammation, stiffness and potential bone deformity), open wound of left buttock, open wound of right buttock, open wound to left lower leg, open wound right lower leg, open wound left thigh, pressure ulcer of right heel, pressure ulcer of left heel, cognitive communication deficit (impaired communication due to cognitive issues relating to memory and attention), severe protein calorie malnutrition (a condition resulting from inadequate intake of protein and calories), and metabolic encephalopathy( a brain dysfunction caused by systemic illness, organ failure or chemical imbalances). A record review of Resident 2's undated Care Plan revealed Resident 2 had actual skin impairment with moisture associated skin damage (MASD) to both buttocks, unstageable pressure ulcer (a severe full-thickness wound where the base is completely hidden by necrotic tissue and the true depth cannot be assessed) to the left heel, Stage 3 pressure injury (a severe, full thickness skin loss appearing as a deep crater like wound) to right lateral foot, right middle lower leg, back left of left lower leg, Stage 1 pressure injury (localized skin injury that does not change color on pressure relief but the skin is intact) right lateral hip, Stage 3 pressure injury right root and a Stage 3 pressure injury to the right hip. A record review of the undated care plan include the following intervention (actions taken to improve a situation): Air mattress: Ensure mattress is inflated and functioning properly.A record review of Resident 2's order summary revealed the following order dated 11/04/2025:Air mattress. Ensure mattress is inflated and functioning properly, two times a day for Monitoring A record review of Resident 2's weight record on 3/3/2026 revealed Resident 2 weighed 154.3lbs An observation on 3/3/2026 at 8:00 AM of Resident 2's bed revealed Resident 2 had an air pressure relieving mattress set at 180lbs.An interview on 3/3/2026 at 8:20 AM with Registered Nurse A (RN) RN A confirmed the pressure on the air mattress was set at 180lbs. RN A confirmed a pressure relieving air mattress should be calibrated in accordance with the individuals weight. RN A confirmed Resident 2 weighed was154.3lbs and the air pressure mattress was set at the incorrect pressure for Resident 2's weight. RN A confirmed an incorrectly set mattress could contribute to skin breakdown for Resident 2.B.A record review of Resident 3's Clinical Resident Profile sheet revealed Resident 3 was admitted to the facility on [DATE].A record review of Resident 3's weights revealed Resident 3's weighed 196.9lbs. A record review of Resident 3's Minimum Data Set, dated [DATE] (MDS - a federally mandated standardized assessment tool used in Medicare and Medicaid certified nursing homes to evaluate a resident's functional capabilities, health needs and clinical status) revealed Resident had a Brief Interview for Mental Status (BIMS - a mandated evaluation tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) of 11 indicating Resident 3 was moderately cognitively impaired (the resident may need assistance with daily activities, experience or memory but is not considered severely impaired). A record review of Resident 3's undated care plan revealed Resident 3 has the following diagnoses: Type 2 diabetes, previous fracture of the shaft of the right tibia, spinal stenosis (a narrowing of the spinal canal), polyneuritis (inflammation and damage of multiple peripheral nerves causing widespread numbness, burning pain and weakness), arthropathy (any disease affecting the joints causing pain, inflammation, swelling and reduced range of motion), osteoarthritis (a chronic degenerative joint disease caused y the breakdown of protective cartilage.A record review of Resident 3's care plan revealed Resident 3 had a Stage 3 Pressure Injury (a severe, full-thickness skin loss causing a deep, crater like wound) to the right buttock.A record review of Resident 3's skin observation notes by the Assistant Director of Nursing (ADON) and dated 01/05/2026, revealed the following: right buttock 3.3cm x 3cm x 0.2cm (measurement) no s/s(signs or symptoms) of infection tx(treatment) in place Type of impairment: pressure injury. A record review of Resident 3's care plan revealed the following intervention: Air Mattress dated 01/28/2025.An observation on 3/3/26 at 10:55 AM revealed Resident 3 had a pressure relieving air mattress which was set at Maximum inflation of 380lbs. An interview on 3/3/26 at 10:55 AM with RN A confirmed Resident 3's pressure relieving air mattress was set at the maximum inflation setting of 380lbs and should have been set according to Resident 3's weight. RN A confirmed the incorrect inflation of the mattress could contribute to skin breakdown for Resident 3.

Licensure Reference Number 175 NAC 12-006.18Based on observation and interview, the facility failed to ensure that wound care was being provided to residents in a manner that would prevent cross contamination of the wounds for 3 of 3 residents surveyed (Residents 2, 3 and 4). The facility had a census of 66. Findings are:A. A record review of the facilities Infection Control Guidelines for all Nursing Procedures, revised April 2013, revealed the following: Employees must wash their hands for ten to fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:After handling items potentially contaminated with blood, body fluids or secretions In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, used an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations:Before and after direct contact with residents;A record review of the facility's undated Handwashing policy revealed the following guidelines:After handling used dressings, specimen containers, contaminated linens, etc. After contact with blood, oral secretions, mucous membranes, broken skin, etc.After handling items or work surfaces potentially contaminated with blood, excretions or secretions. B. A record review of Resident 2's Clinical Resident profile revealed they were admitted to the facility on [DATE].A record review of Resident 2's Minimum Data Set (MDS - a federally mandated standardized assessment tool used in Medicare and Medicaid certified nursing homes to evaluate a resident's functional capabilities, health needs and clinical status) revealed Resident 2 had a Brief Mental Status Interview (BIMS - a mandatory evaluation tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) of 5, indicating they were severely cognitively impaired.A record review of Resident 2's undated Care Plan revealed Resident had the following diagnoses: Lymphedema (a chronic condition causing fluid buildup and swelling in arm and/or legs), venous insufficiency (a long term condition where leg vein valves are damaged or weak preventing blood from flowing efficiently back to the heart), osteoarthritis (chronic degenerative joint disease causing pain in both hips, right hand), rheumatoid arthritis (a chronic systemic disease where the immune system attacks the lining of the joints causing inflammation, stiffness and potential bone deformity), open wound of left buttock, open wound of right buttock, open wound to left lower leg, open wound right lower leg, open wound left thigh, pressure ulcer of right heel, pressure ulcer of left heel, cognitive communication deficit (impaired communication due to cognitive issues relating to memory and attention), severe protein calorie malnutrition (a condition resulting from inadequate intake of protein and calories), and metabolic encephalopathy ( a brain dysfunction caused by systemic illness, organ failure or chemical imbalances). A record review of Resident 2's undated Care Plan revealed Resident 2 had actual skin impairment with moisture associated skin damage (MASD) to both buttocks, unstageable pressure ulcer (a severe full-thickness wound where the base is completely hidden by necrotic tissue and the true depth cannot be assessed) to the left heel, Stage 3 pressure injury (a severe, full thickness skin loss appearing as a deep crater like wound) to right lateral (to the side) foot, right middle lower leg, back left of left lower leg, Stage 1 pressure injury (localized skin injury that does not change color on pressure relief but the skin is intact) right lateral hip, Stage 3 pressure injury right root and a Stage 3 pressure injury to the right hip. A record review of Resident 2's orders summary revealed the following order: A record review a physician order dated 2/27/26 revealed the following information: Right posterior (further back in position) hip/left posterior hip: Cleanse with saline, apply triad paste (a sterile zinc-oxide paste wound dressing paste) to wound and peri wound (around the edges of the wound), apply silver alginate (a wound dressing made from calcium alginate from seaweed and silver ions), to wound bed, cover with silicone superabsorbent dressing (a bordered foam dressing), change daily and prn (as needed) one time a day.A record review of a skin/wound note dated 2/27/26 by the Assistant Director of Nursing revealed the following:Location: Right posterior (further back in position) hip. Etiology (cause): Stage 3 PI (Pressure Injury) Measurements: 3.5cm x 2.9cm x 0.2cmWound Status: NewNew treatment orders received for right posterior and lateral (side) hip and right medial (medium) foot. Left posterior hip, right lateral foot, left heel, and right. heel treatments changed this week. Continue current treatments as ordered to all other areas. PCP (primary care provider) and POA (power of attorney) notified of status of areas and new orders.Author: Assistant Director of Nursing [e-SIGNED]An observation on 3/3/26 at 8:05 AM of wound care performed by Registered Nurse (RN) A for Resident 2 revealed RN A reviewed Resident 2's wound care orders and gathered the supplies needed for the treatment. RN A knocked on Resident 2's door and informed (gender) it was time for a dressing change. Resident 2 agreed and RN 2 placed paper towels on Resident 2's bedside table and placed the supplies on the towels. Resident 2's bed was low to the floor with a fall mat placed to the left of the bed. Resident 2 was lying on their left side. RN A used hand sanitizer and donned gloves. RN A pulled Resident 2's brief down on the right hip to expose a dressing. RN A removed the dressing and discarded it in the trash. RN A stated it needed a larger dressing, pulled Resident 2's brief up to cover the undressed and open wound and removed their gloves. RN A returned to the treatment cart and obtained a larger bordered foam dressing and returned to the room. RN A used hand sanitizer, donned clean gloves, and pulled Resident 2's brief down again to uncover the open area. RN A opened the 4x4 gauze packets and poured sterile water over them. RN A pushed the brief back from where it was touching the open wound with their right hand and wiped the wound with the wet gauze held in their right hand without using hand sanitizer or changing gloves. RN A discarded the gauze in the trash and realized they needed a cotton tipped applicator to apply the cream. Resident 2's roommate was seated at the side of their bed eating their breakfast. Resident 2's roommate commented to Resident 2 nice butt. RN A and Resident 2 laughed. RN 2 pulled Resident 2's blanket up to cover residents buttocks. Resident 2's blanket was touching Resident 2's undressed wound. RN 2 exited the room and reentered wearing gloves and carrying a cotton tipped applicator. RN A approached Resident 2's bed, pulled down their blanket, exposed Resident 2's buttocks again and used the cotton tipped applicator to apply the triad cream to the wound without removing their gloves, using hand sanitizer, or cleaning the wound again. RN A discarded their gloves, used hand sanitizer, donned clean gloves, and opened a packet of silver alginate dressing and applied it to the wound and then applied the large, bordered foam dressing. RN A dated and signed the dressing and pulled the resident brief up. RN A discarded their gloves and remaining supplies in the trash, used hand sanitizer, and exited the room.An interview on 3/3/26 at 8:20 AM with RN A confirmed they should not have entered the residents room wearing gloves and provided wound care while wearing those gloves. RN A confirmed they should have cleaned the wound again after Resident 2's blanket touched the uncovered wound. RN A confirmed they should not have touched the residents briefs and then cleaned the wound wearing the same gloves. RN A confirmed they should have used hand sanitizer and changed gloves when moving from a dirty area to a clean area. RN A confirmed Resident 2's brief should not have touched the open and undressed wound and Resident 2's blanket should not have touched the open wound and undressed wound. RN A confirmed these separate actions provided opportunities for cross contamination of the wound. C.A record review of Resident 3's Clinical Resident Profile sheet revealed Resident 3 was admitted to the facility on [DATE].A record review of Resident 3's Minimum Data Set, dated [DATE] (MDS - a federally mandated standardized assessment tool used in Medicare and Medicaid certified nursing homes to evaluate a resident's functional capabilities, health needs and clinical status) revealed Resident had a Brief Interview for Mental Status (BIMS - a mandated evaluation tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility) of 11 indicating Resident 3 was moderately cognitively impaired (the resident may need assistance with daily activities, experience or memory but is not considered severely impaired).A record review of Resident 3's undated care plan revealed Resident 3 has the following diagnoses: Type 2 diabetes, previous fracture of the shaft of the right tibia, spinal stenosis (a narrowing of the spinal canal), polyneuritis (inflammation and damage of multiple peripheral nerves causing widespread numbness, burning pain and weakness), arthropathy (any disease affecting the joints causing pain, inflammation, swelling and reduced range of motion), osteoarthritis (a chronic degenerative joint disease caused by the breakdown of protective cartilage.A record review of Resident 3's care plan revealed Resident 3 had a Stage 3 Pressure Injury (a severe, full-thickness skin loss causing a deep, crater like wound) to the right buttock.A record review of Resident 3's skin observation notes by the Assistant Director of Nursing (ADON) dated 0105/2026 revealed the following: right buttock 3.3cm x 3cm x 0.2cm (measurement) no s/s (signs or symptoms) of infection tx(treatment) in place Type of impairment: pressure injury. A record review of Residents physician orders dated 2/13/2026 revealed the following orders:Right buttock: Cleanse with saline, apply triad paste, cover with silicone supra sorbent dressing, change daily and prn (as needed). One time a day for wound care and as needed for soiling. An observation on 3/3/26 at 10:45 AM of wound care provided to Resident 3 by Registered Nurse (RN) A revealed the following: RN A donned a clean mask and entered Resident 3's room with the required supplies for Resident 3 treatment. RN A placed paper towels on the bedside table and placed the supplies on the paper towels. RN A used hand sanitizer and donned a gown and gloves. RN A assisted Resident 3 to turn onto their left side and untied the residents brief to expose Resident 3's right buttock. RN A removed their gloves, used hand sanitizer, and donned clean gloves and then used their left gloved hand to push and reposition Resident 3' s right buttock to expose the open wound. RN A used their right hand to place the cotton applicator into the triad paste and apply it to the wound. RN A had to remove their left hand from Resident 3's right buttock and use both hands to peel back the adhesive portion of the bordered foam dressing. This allowed the wound and triad paste to come into contact with Resident 3's brief. RN A repositioned Resident 3's buttock with their left hand, placed the dressing on the wound with their right hand and refastened Resident 3's brief. RN A removed their gown and gloves, used hand sanitizer, and exited the room. An interview on 3/3/26 at 10:55 AM with RN A confirmed Resident 3's wound paste and brief touched provided an opportunity for cross contamination of the wound. RN A confirmed they should have used hand sanitizer and changed gloves before opening the foam dressing and applying it to the wound. RN A confirmed touching the clean dressing with their contaminated left glove provided an opportunity for cross contamination of the wound. D.A record review of Resident 4's Clinical Resident Profile revealed Resident 4 was admitted on [DATE]. A record review of Resident 4's Minimum Data Set, dated [DATE] revealed Resident 4 had a BIMS of 6 indicating the resident was severely cognitively impaired.A record review of Resident 4's undated care plan revealed the resident had the following diagnoses: Dementia (a decline in mental ability, including reason, memory and behavior -severe enough to interfere with daily life), age related osteoarthritis (a degenerative joint disease), anxiety disorder (persistent, excessive worry), sarcopenia (age related loss of muscle mass, strength and function) and erythema intertrigo (a chronic skin rash occurring in body folds where skin rubs against skin causing moisture, heat and frictionA record review of Resident 4's skin/wound note dated 2/26/26 by the Assistant Director of Nursing revealed the following:Location: Clarification: left buttock. Etiology: Pressure Injury Stage 3Measurement: 1.5cm x 1.9cm x 1.1cm, undermining (where the tissues under the wound edge detach forming a hidden pocket beneath the skin) from 12 o'clock to 12 o'clock, deepest at 5 o'clock measuring 3cm.Wound Status: Not healed. Treatment changed this week. Primary Care Provider and Power Of Attorney notified of status of area and new orderAuthor: Assistant Director of Nursing .A record review of Resident 4's wound care orders dated 2/26/26 revealed the following information: Left buttock: cleanse with saline, apply triad paste to peri wound, apply Gentelle blue or equivalent to wound bed and undermining, cover with silicone foam dressing, change 3 times weekly and prn (as needed). One time a day for pressure injury and as needed for soiling. An observation on 3/3/26 at 10:25 AM of wound care provided to Resident 4 by Licensed Practical Nurse (LPN) B. LPN B entered the Resident 4's room wearing a face mask and carrying 2 small tubes of saline solution, a cotton tipped applicator, triad paste, Gentelle Blue foam dressing (a foam dressing containing 3 antimicrobial agents) and a bordered foam dressing. LPN B placed a paper towel on Resident B's bed and placed the dressing supplies on the towel. LPN B then used hand sanitizer and donned a gown and gloves. LPN B assisted Resident 4 to roll on their left side and hold the positioning bar. LPN B removed the Resident 4's blankets, unfastened their brief on the right side and uncovered their buttocks. LPN B then place a clean chux pad (a highly absorbent waterproof sheet designed to protect mattresses from incontinence, spills, or bodily fluids) underneath Resident 4's buttocks. LPN B removed their gloves, used hand sanitizer, and donned clean gloves. LPN B used their left hand to lift Resident 4's right buttock and used their right hand to wash the wound with saline solution. Without handwashing and changing the soiled gloves, LPN B patted the area dry with their right hand and a 4inch (in) x4 in gauze pad. LPN B used a cotton tipped applicator to apply triad paste around the wound and then removed their left hand from the resident's buttock, which allowed Resident 4's buttocks to come together and touch the residents brief. LPN B separated Resident 4's buttocks using their left hand and used their right hand to place the Gentelle blue foam into the wound as far as it would go as the wound had undermining. LPN B released Resident 4's buttocks again, allowing them to close over the Gentelle Blue. LPN B used both hands to peel off the adhesive cover on the silicone dressing and apply it to the wound. LPN B refastened Resident 4's brief, gathered and discarded the trash and covered the resident with blankets before they removed their gown and gloves, used hand sanitizer, and exited the room.An interview on 3/3/25 at 10:40 AM with LPN B confirmed allowing Resident 4's buttocks to touch the residents brief and then close over the blue dressing provided two opportunities for cross contamination of Resident 4's wound. LPN B confirmed they should have changed their gloves after they had cleaned the resident wound and before they had applied the paste to the residents wound and confirmed failure to do so provided further opportunity for cross contamination of Resident 4's wound.

Licensure Reference Number 175 NAC 12-006.11 E The facility failed to ensure hand hygiene and gloving were performed in a manner to prevent the potential for food borne illness and failed to maintain the cleanliness and condition of shelving units, serving windows, equipment, floors, ventilation systems, and storage carts in the facility kitchen. This had the potential to affect 66 residents in the facility that ate foods prepared in the facility kitchen. The facility census was 66. Findings are: A. Record review of a facility policy entitled Hand Washing dated 3/19/2020 revealed the following: Hand hygiene will be performed for a minimum of 20 seconds. Procedures: Guidelines on when to perform hand hygiene may include - before preparing or handling food. - - after removing personal protective equipment ( gloves) Perform hand hygiene as follows: a. If using soap and water, turn on faucet, holding fingertips downward to prevent water from running down the arm. Apply soap and work into a lather. b. Rub all surfaces of the hands for at least 20 seconds. c. i. Rinse hands under running water with fingers pointing downward holding hands lower then the wrists and elbows. ii. Dry hands thoroughly using a paper towel, using care not to touch the towel dispenser or sink. Use paper towel to turn off sink. B. Observation on 04/29/25 between 9:20 AM and 10:15 AM in the facility kitchen revealed [NAME] K prepared country style tomatoes. With no hand hygiene performed, [NAME] K donned gloves and poured 3 cans of tomatoes into a large pot. [NAME] K added garlic and sugar and mixed them together. [NAME] K doffed [removed] the soiled gloves and placed the tomatoes into the convection oven to cook. [NAME] K performed a 7 second hand wash, donned [put on] gloves and got out the recipe for the chicken thighs. [NAME] K rinsed out a large, clear container with water at the 3 compartment sink, doffed the soiled gloves and performed 7 second hand wash. [NAME] K donned new gloves and proceeded to wash the chicken thighs with water, then placed them into the clear plastic container until it was half full. [NAME] K took off the soiled gloves, performed a 7 second hand wash, then rinsed another large plastic container with water. [NAME] K doffed the soiled gloves and performed a 10 second hand wash. [NAME] K donned new gloves and continued to wash chicken thighs and place them into the large plastic container. [NAME] K doffed the soiled gloves and performed a 10 second hand wash. [NAME] K left the food preparation area, went to the reach in cooler, touched the door handle with a bare hand and got out buttermilk and mayonnaise. [NAME] K went into storage area and got out ranch dressing mix. [NAME] K returned to the food preparation area and, with no hand hygiene performed, donned new gloves and added those ingredients to the 2 containers of chicken thighs. [NAME] K then mixed the ingredients into the chicken thighs with gloved hands. [NAME] K doffed the soiled gloves and performed a 6 second hand wash. [NAME] K donned new gloves and placed the chicken thighs onto sheet pans. [NAME] K doffed the soiled gloves and put the pan into the oven. With no hand hygiene performed, [NAME] K repeated the same process until 4 pans were full of chicken thighs and were in the oven. After all the pans were in the oven, [NAME] K performed a 7 second hand wash, donned new gloves, threw away the soiled, wet cardboard chicken box, and with the same soiled gloves, touched the door handle of the reach in cooler to put the mayonnaise back into the reach in cooler. [NAME] K doffed the soiled gloves and performed a 10 second hand wash. Interview on 4/29/25 at 10:20 AM with the Dietary Manager [DM] confirmed that hands should be washed for 20 seconds before working with foods, upon return to the food preparation area, after removal of soiled gloves and before new gloves are donned. The DM confirmed that all residents in the facility ate foods prepared in the facility kitchen C. Observation on 04/28/25 between 1:30 PM and 2:30 PM in the facility kitchen revealed the following sanitation concerns: - A wire dish rack next to the steam table had areas of red colored discoloration that resembled rust. - Foam weather stripping had been torn loose from the underside of the serving window. - Food and grease spatters were present on the front and sides of the stove with 2 ovens. - Burned, dried food spatters were present on the backsplash behind the stove top and the exterior of the stove and ovens. - Grease and food particles were present on the shelf above the stove top. - Grease and liquid spatters were present on the side and front of the deep fryer, dripped onto the floor in front of the deep fryer. - Baked on, burned food particles were present inside the working oven. - Grease and a sticky substance were present on the handle and the front of the working oven. - Two of 3 ovens were not operational in the facility kitchen. - Grease spatters and food spatters were present on the front and sides of the convection oven. - Food particles and a dark sticky substance were present in the corners and the floors under the shelves in the reach in cooler. - The floors were sticky in the walk in cooler. - The floors under the food preparation sink surrounding a grease trap were corroded with a dark, sticky substance and food particles and dirt. - Food particles and a build up of dirt and dark colored substance were present on the floors in the dry storage area. - Food particles were present on each shelf of a 3 tier rolling cart that held spices. - Two air conditioner ventilation covers were heavily coated with a gray fuzzy substance. The ventilation covers were directly over the 3 compartment sink and the food preparation area. - Two wire oven racks were heavily coated with grease and a burned on substance. Observations on 04/29/25 between 2:00 PM - 2:25 PM with the DM confirmed the following sanitation concerns: - A wire dish rack next to the steam table had areas of red colored discoloration that resembled rust. - Foam weather stripping had been torn loose from the underside of the serving window. - Food and grease spatters were present on the front and sides of the stove with 2 ovens. - Burned, dried food spatters were present on the backsplash behind the stove top and the exterior of the stove and ovens. - Grease and food particles were present on the shelf above the stove top. - Grease and liquid spatters were present on the side and front of the deep fryer, dripped onto the floor in front of the deep fryer. - Baked on, burned food particles were present inside the working oven. - Grease and a sticky substance were present on the handle and the front of the working oven. - Two of 3 ovens were not operational in the facility kitchen. - Grease spatters and food spatters were present on the front and sides of the convection oven. - Food particles and a dark sticky substance were present in the corners and the floors under the shelves in the reach in cooler. - The floors were sticky in the walk in cooler. - The floors under the food preparation sink surrounding a grease trap were corroded with a dark, sticky substance and food particles and dirt. - Food particles and a build up of dirt and dark colored substance were present on the floors in the dry storage area. - Food particles were present on each shelf of a 3 tier rolling cart that held spices. - Two air conditioner ventilation covers were heavily coated with a gray fuzzy substance. The ventilation covers were directly over the 3 compartment sink and the food preparation area. - Two wire oven racks were heavily coated with grease and a burned on substance. Interview on 04/29/25 at 2:25 PM with the DM confirmed that the observed areas of concern needed to be cleaned. The DM agreed that the issues needed to be corrected and addressed. The DM was unsure of how long 2 of 3 ovens in the facility kitchen had been not operational. The DM confirmed that all residents in the facility ate foods prepared in the facility kitchen Record review of the weekly cleaning schedules in the facility kitchen revealed that the logs for cleaning were filled out weekly or daily as directed. The cleaning schedules did not specifically identify the concerns identified through observation on 04/28/25 or 04/29/25.

Licensure Reference Number 175 NAC 12.006.18(B) Based on record review observation, and interview, the facility staff failed to implement measures to prevent the potential contamination of resident supplies that affect all residents in the facility, the facility staff failed to change oxygen tubing per practitioner's order for Resident 26, and the facility failed to follow enhanced barrier precautions for Resident 50. The facility identified a census of 66. Findings are: A. A record review of a facility provided policy titled Storage Areas, Maintenance, dated December 2009 revealed, all storage areas must be kept free from accumulation of trash, rubbish, oily rags, paper, etc., at all times. Record review of a receipt of payment to dated 5/8/2024 to a roofing company for the amount of $4000.00 related to work that applied a patch to the roof. A record review on 4/30/2025 revealed a facility provided email dated May 10, 2024, indicating the management company was aware of the functional damage the campus sustained. An observation on 4/30/2025 8:13 AM with (Maintenance Supervisor) MS-G revealed the second floor is unoccupied and is not used by any residents, and: -A room located in the southwest corner of the second floor had 65 boxes of incontinent products of varying sizes. -There were jugs of a disinfectant cleaner with the label identifying Cleanslate among the boxes of briefs. -There were also black spots on the ceiling where the ceiling tiles were missing. -The room located next to the above stated room revealed boxes of PPE, Covid tests, Lancets, medication cups, multiple types of dressings, drinking straws, drinking cups, Insulin syringes, mouthwash, piston syringes and irrigation solution. An observation on 4/30/25 8:45 AM with the Administrator (ADM) revealed the office in the therapy gym had discolored ceiling tiles that are brown with black in the center, and the therapy gym above a TV that has portions of plaster substance missing with brick exposed behind the plaster substance. In addition the area in the therapy office on the 1st floor had a plaster substance missing with brick exposed. An observation on 4/30/2025 12:00 PM with Physical Therapy Assistant (PTA) revealed black spots on the ceiling tiles above the desks. The PTA reported the black spots were mold. The east window of the office has plaster substance missing from the wall and is exposing the brick. The PTA reported their belief was that it was from the leaking ceiling. An interview with the ADM on 4/30/2025 at 8:30 AM revealed the second floor and the therapy gym on the main floor had water damage. The ADM confirmed the management company has been advised and has advised the owner of the water damage. The ADM confirmed no repairs have been completed since May 2024. An interview with ADM on 4/30/24 11:06 AM revealed the roof has been leaking since the email to the management company in 2024. The ADM confirmed there is no current plan to fix the leaking roof or the mold like spots that were on the ceiling tiles in the gym and in the supply room on the second floor. B. Record review of Resident 26's Treatment Administration Record (TAR) dated 4/30/2025 revealed the following orders: -Change 02 tubing weekly. - [NAME] residents' initials, date, staff initials on tubing. Wipe down concentrator with warm wash cloth. One time a day every Sunday. An observation on 4/28/2025 at 8:46 AM Resident 26 was out of the room. The oxygen concentrator (A machine that delivers oxygen) was running. The Nasal cannula tubing was attached to the concentrator with tape around the nasal cannula dated 4/20/2025 at 10:00 PM. An observation on 4/28/2025 8:48 AM of Resident 26's oxygen concentrator was on in the resident's room. The tape around the tubing attached to the concentrator is dated 4/22/2025 at 10:00 PM and initialed by a nurse. Resident 26 was not in the room. An observation on 4/28/2025 8:52 AM The oxygen concentrator remained on in the resident's room and the tape around the tubing attached to the concentrator is dated 4/22/2025 at 10:00 PM, initialed by a nurse. An observation 4/28/2025 1:28 PM of Resident 26's oxygen tubing has the tubing dated 4/20/2025 @ 10:00 PM. An observation 4/28/2025 2:00 PM Resident 26 asleep in the recliner with the oxygen turned on and the nasal cannula was in the resident's nostrils. The tubing continued to be dated 4/20/2025. 05/01/2025 9:14 AM Interview with the Director of Nursing (DON) confirmed the oxygen tubing was dated 4/20/2025 and had not been changed. DON confirmed the documentation the charting is invalid. Record review of the facility provided Medication Administration -Oxygen Policy Interpretation and Implementation, dated 6.22.14 revealed, 13. Infection control measures include: a. Change oxygen tubing and mask/cannula weekly and as needed. 52351 C. Record review of Resident 50' so Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) dated 2/15/2025 scored a 3. According to the Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) [NAME] a score of 0 to 7 indicates a person has severe cognitive impairment. Record review of Resident 50's order summary dated April 2025 revealed Resident 50 was in Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices)) for an indwelling medical device. Resident 50's order summary dated April 2025 revealed an order for contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) (a serious bacterial infection that is resistant to many common antibiotics) of a sebaceous cyst. An observation on 4/30/25 at 7:22 AM revealed NA-Z and RN-A-A transferred Resident 50 from the recliner in the common area to the wheelchair. Neither staff member was wearing Personal Protective Equipment (PPE, includes clothing, gloves, face shields, goggles, facemask's, respirators, and other equipment to protect front-line workers from injury, infection, or illness). NA-Z hooked the Foley catheter bag to the scrub pant leg pocket. Staff then transferred resident to the wheelchair then transported to resident's room. Staff transferred resident from the wheelchair to bed with no PPE. Once resident in bed, both staff applied hand sanitizer and donned PPE. An interview was conducted on 5/01/25 at 7:22 AM with IPC-BB (Infection Preventionist/LPN) regarding how nurse aides know which residents are in EHB. IPB-BB stated, there is a sign on the door. IPB-BB reported staff should are expected to don (put on) gown and gloves for transfers and aware that staff were not using appropriate PPE when transferring Resident 50 from the recliner to wheelchair when Resident is in the common area. An interview was conducted on 5/01/25 at 12:31 PM with NA-CC regarding how staff is made aware of which residents are on EBP. NA-CC stated there are pocket care plans to determine which residents are on EBP and there are signs on the door for EBP. The pocket care plan has information whether they have a Foley/supra pubic catheter/wounds to determine EBP. A record review of Enhanced Barrier Precautions dated August 2022 stated Policy Interpretation and Implementation 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing b. bathing/showering c. transferring d. providing hygiene e. changing linens f. changing briefs or assisting with toileting g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) and h. wound care (any skin opening requiring a dressing 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 9. staff are trained prior to caring for residents on EBPs

Licensure Reference Number 175 NAC 12-006.19A Based on record review, observation and interview, the facility failed to repair leaks in the facility's roof. This had the potential to affect all residents that resided in the facility. The Facility identified a census of 66. Findings are: A record review of a facility policy titled Storage Areas, Maintenance, dated December 2009 revealed, all storage areas must be kept free from accumulation of trash, rubbish, oily rags, paper, etc., at all times. A record review on 4/30/2025 of an email dated May 10, 2024 revealed the management company was aware of the functional damage the campus sustained. Record review of a receipt of payment to dated 5/8/2024 to a roofing company for the amount of $4000.00 related to work that applied a patch to the roof. An observation on 4/30/25 8:45 AM with the Administrator (ADM) revealed the office in the therapy gym had discolored water like stained ceiling tiles that are brown with black in the center, and the therapy gym above a TV that has portions of plaster substance missing with brick exposed behind the plaster substance. In addition the area in the therapy office on the 1st floor had a plaster substance missing with brick exposed. An observation on 4/30/2025 12:00 PM with Physical Therapy Assistant (PTA) revealed black spots on the ceiling tiles above the desks. The PTA reported the black spots were mold. The east window of the office has plaster substance missing from the wall and is exposing the brick. The PTA reported their belief was that it was from the leaking ceiling. An interview with the ADM on 4/30/2025 at 8:30 AM revealed the second floor and the therapy gym on the main floor had water damage. The ADM confirmed the management company has been advised and has advised the owner of the water damage. The ADM confirmed no repairs have been completed since May 2024. An interview with ADM on 4/30/24 11:06 AM revealed the roof has been leaking since the email to the management company in 2024. The ADM confirmed there is no current plan to fix the leaking roof or the mold like spots that were on the ceiling tiles in the gym and in the supply room on the second floor.

Licensure Reference Number 175 NAC 12-007.04 D Based on observation, record review and interview; the facility failed to ensure a working ventilation system in 20 (302, 303, 304, 305, 306, 307, 308, 310, 311, 400, 401, 402, 404, 405, 406, 407, 408, 409, 410, 411) of 28 occupied resident rooms on the 300 and 400 halls in the facility. The total number of occupied resident rooms in the facility was 52. The facility census was 66. Findings are: Observations of the facility environment on 05/01/25 between 8:30 AM and 9:15 AM with the facility Maintenance Director [MD] revealed that the ventilation system in resident bathrooms in rooms 302, 303, 304, 305, 306, 307, 308, 310, 311, 400, 401, 402, 404, 405, 406, 407, 408, 409, 410, 411 did not draw a 1 ply square of tissue to the surface of the ventilation covers in resident bathrooms. The fact that the tissue square was not drawn to the cover indicated that the system was non-operational at the time of the observation. Interview on 05/01/25 at 09:15 AM with the MD confirmed the ventilation system did not draw in bathrooms on the 300 and 400 halls. The MD was unsure if documentation had been completed of the last time the ventilation systems had been checked for operation. Interview on 05/01/25 at 09:20 AM with the Environmental Services Account Manager confirmed there was no documentation of the last time the ventilation systems in resident bathrooms were checked for draw and operation.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record reviews and interviews; the facility failed to notify the medical practitioner and family of 1 (Resident 52) of 5 residents sampled for refusal to take medications. The facility census was 66. Findings are: Record review of Resident 52'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 03/28/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 99. The MDS manual identified a score of 99 as resident was unable to complete the interview. Record review of Resident 52's Order Summary dated 4/29/2025 revealed the following medications were prescribed by the practitioner: -Acetamin tab 325 milligrams (mg) twice daily for pain -Aspirin 81 mg for heart health -Atorvastatin 80 mg for hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides in your blood) -Carvedilol 10 mg extended release (ER) for essential primary hypertension (high blood pressure) -Fluoxetine Solution 20 mg/5 milliliters (ML) for depression -Omeprazole cap 40 mg for GERD (a digestive disorder where stomach acid frequently flows back up into the esophagus, the tube connecting the mouth to the stomach) -Prevagen 10 mg capsule for memory support -Risperidone solution 1 mg/ML twice daily for dementia -Senna tablet 8.6 mg for constipation Record review of Resident 52's Medication Administration record (MAR) (a Medication Administration Record documents every medication a patient receives, including the name, dose, route, and time) dated April 2025 revealed Resident 52 had refused the following medications: - Aspirin, Carvedilol, Omeprazole, Prevagen, and Senna on 4/1/2025, 4/2/2025, 4/4/2025, 4/5/2025, 4/6/2025, 4/7/2025, 4/11/2025, 4/14/2025, 4/15/2025, 4/18/2025, 4/19/2025, 4/20/2025, 4/23/2025, 4/24/2025, 4/25/2025, 4/27/2025, and 4/28/2025. -Acetamin was refused on 4/1/2025 AM, 4/2/2025 AM, 4/3/2025 PM, 4/4/2025, 4/5/2025, 4/6/2025 both AM/PM, 4/7/2025 AM, 4/11/2025 AM/PM, 4/14/2025 AM, 4/15/2025 AM/PM, 4/16/2025, 4/17/2025 PM, 4/18/2025 AM/PM, 4/19/2025 AM/PM, 4/20/2025 AM, 4/21/2025, 4/22/2025 PM, 4/23/2025 AM, 4/24/2025 AM, 4/25/2025 AM/PM, 4/26/2025 PM, 4/27/2025 AM, 4/28/2025 AM/PM -Fluoxetine and Senna were refused on 4/2/2025, 4/4/2025, 4/5/2025, 4/6/2025, 4/7/2025, 4/11/2025, 4/14/2025, 4/15/2025, 4/18/2025, 4/19/2025, 4/20/2025, 4/23/2025, 4/24/2025, 4/25/2025, 4/27/2025, and 4/28/2025. Record review of Resident 52's progress notes did not indicate the primary medical provider was notified of Resident 52's refusals to take medications on 4/1/2025, 4/2/2025, 4/4/2025, 4/5/2025, 4/6/2025, 4/7/2025, 4/11/2025, 4/14/2025, 4/15/2025, 4/18/2025, 4/19/2025, 4/20/2025, 4/23/2025, 4/24/2025, 4/25/2025, 4/27/2025, and 4/28/2025. An interview on 5/1/2025 at 8:06 AM was conducted with the Director of Nursing (DON). During the interview the DON confirmed Resident 52's practitioner was not notified Resident 52 was refusing medications and should have been. A Record review of facility Policy Requesting, Refusing and/or Discontinuing Care or Treatment revised February 2021 stated the following: Policy Interpretation and Implementation 7. Documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following: a. date and time the care or treatment was attempted b. the type of care or treatment c. the resident's response and stated reason(s) for request, discontinuation or refusal d. the name of the person who attempted to administer the care or treatment e. that the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the medication and/or treatment f. the resident's condition and any adverse effects due to the request g. the date and time the practitioner was notified h. all other pertinent observations i. the signature and title of the person recording the data 8. The healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request. For example, a resident's refusal to take a diuretic while experiencing acute congestive heart failure should be reported immediately, while a refusal to take a blood pressure medication while the blood pressure is well controlled can be reported within 24 hours.

Licensure Reference Number 175 NAC 12-006.05(G) Based on record reviews and interview; the facility failed to ensure a rationale was documented for the continued use of PRN (as needed) antianxiety medication for 1 (Resident 42) of 5 sampled residents. The facility staff identified a census of 66. The findings are: A record review of a facility policy entitled Documentation and Communication of Consultant Pharmacist Recommendations dated revised August 2024 revealed: -D. Psychotropic PRN (as-needed) medication order (excluding antipsychotics): Order for PRN psychotropic medication will be time limited (i.e., 14 days) and only for specific clearly documented circumstances. -a. Order may be extended beyond 14 days if the attending physician or prescribing practitioner: -b. Believes it is appropriate to extend the order -and -c. Documents clinical rationale for the extension -and -d. Provides a specific duration of use. -e. Rationale should include effectiveness, ongoing specific diagnosed conditions, indication, and duration. A record review of Resident 42's Admission Record identified the facility admitted the resident on 01/18/2024 and identified diagnoses of delirium due to known physiological condition, major depressive disorder, psychosis, unspecified mood disorder, senile degeneration of brain, and Alzheimer's disease with late onset. A record review of Resident 42's Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 03/31/2025 identified the resident's Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score was 5/10. According to the MDS Manual, a score of 0-7 indicated the resident had severe cognitive impairment. The MDS further identified the resident did not display behaviors and received antipsychotic and antidepressant medications. A record review of Resident 42's Order Summary Report printed 04/30/2025 revealed an order for lorazepam (antianxiety medication) 2 milligram (mg)/milliliter (mL) give 1mg by mouth every 1 hour as needed for anxiety/restlessness. A record review of a Pharmacist's Recommendation to Prescriber dated 03/31/2025 revealed that Resident 42 was prescribed lorazepam and states CMS requires a 14 day stop on all PRN psychotropic medications unless the prescriber documents clinical rationale for continued use and provides a new duration for use on the continued order. Further review revealed that the pharmacist's recommendation was to continue the PRN lorazepam for 6 months. The document was signed by the provider and the agree check box was marked. The provider did not document a rationale for the continued use of the PRN lorazepam. An interview on 05/01/2025 at 9:42 AM with the Director of Nursing (DON) confirmed that there was no rationale documented for the continued use of the PRN lorazepam.

Licensure Reference Number 175 NAC 12.006.02(8) Based on record review and interview; the facility failed to report an allegation of resident-to-resident abuse within the required timeframe to Adult Protective Services (APS) for 1 (Resident 119) of 4 facility self-report investigations reviewed. The facility census was 66. Findings are: Record review of an undated facility policy entitled Abuse and Neglect Reporting revealed the following information: All staff members, residents, visitors are required to immediately report any incidents or suspected incidents of resident mistreatment, abuse, or neglect, exploitation, including injuries of unknown source and misappropriation of properties. Procedure: 1. Any alleged violations involving abuse or negligence neglect including injuries of an unknown source and misappropriation of resident property must be reported. 3. Staff members aware of an incident or suspected incident of abuse or neglect must immediately report knowledge of such incidents to the charge nurse, department head or administration. 5. The staff person receiving the initial allegation of abuse or neglect must immediately contact the facility manager and administrator 6. When an alleged or suspected case of mistreatment, exploitation, misappropriation of resident property, abuse or neglect is reported, the facility administrator or designee will notify the following persons of such incident: Within 24 hours: a. Adult Protective Services (APS) 24 hour hotline: 1. Report allegations of abuse, neglect, exploitation results not later than 24 hours if a suspicion of abuse, neglect or exploitation does not result in bodily harm. Record review of Resident 119'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 1/29/25 revealed an admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease, coronary artery disease and heart failure. The MDS identified that Resident 119 had a BIMS (Brief interview Mental Status, a brief screener that aids in detecting cognitive impairment) score of 6. The MDS manual identified that a score of 0-7 indicated severe cognitive impairment. The MDS identified that Resident 119 used a wheelchair and was dependent on staff for all activities of daily living needs such as toileting, dressing and personal hygiene. Record review of a facility investigation dated 1/9/25, related to an allegation of resident to resident abuse that involved Resident 119 as the victim, revealed an investigation was initiated on 1/6/25 at 9:10 AM by the facility administrator. Record review of a description of the incident revealed that the incident between Resident 119 and another resident had occurred on 1/4/25 at 3:30 PM. The facility investigation revealed no injury had resulted to Resident 119. The facility investigation revealed that the administration was not notified of the incident until 1/9/25 at 9:10 AM. Adult Protective Services was not notified until 1/9/25 at 9:40 AM which was not within the required 24 hour timeframe for an allegation of abuse with no injury. Interview on 04/30/25 at 6:53 AM with the Director of Nursing (DON) confirmed staff did not immediately notify administration of the incident on 1/4/25 at the time of the incident and they should have. The DON confirmed that staff had been educated in the past to notify the administration as soon as an incident occurred so the investigation and reporting could be done. The DON confirmed that the allegation of abuse had not been reported to APS within the required 24 hour timeframe.

Licensure Reference Number: 175 NAC 12-006.09D7b Based upon record review and interviews, and observations the facility failed to identify causal factors following a resident fall. This affected 3 of 4 residents reviewed (Resident 2, 3, and 4). The facility census was identified as 72. FINDINGS ARE: A. Record review of Resident 2's Admission Record, dated 06/01/2017, revealed Resident 2 was admitted with some of the following medical Diagnoses: [REDACTED]. A record review of Resident 2's nursing progress notes dated 4/28/2017 revealed Resident 2 was sitting in (gender) wheel chair near the med cart by nurses' station and was observed moving a straight back chair about. LPN A (Licensed Practical Nurse A) noted this and moved the chair from in front of the resident back to where the chair was originally placed and informed Resident 2 that staff would be along shortly to assist resident into bed. LPN A then went to give another resident medication. After LPN A returned to the med cart and began setting up meds for another resident when LPN A heard a thud. LPN A turned to observe Resident 2 lying on the floor in a prone position with glasses on and a laceration to the left side of Resident 2's forehead. A record review of Resident 2's MDS (Minimum Data Set): a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility) dated 03/10/2017 revealed a BIMS Score (Brief Interview for Mental Status-a screening tool that aids in detecting cognitive impairment) score of 3, (score of three indicates the resident has severe cognitive impairment). A record review of Resident 2's Quarterly Morse Fall Scale (MFS: a rapid and simple method of assessing a patient's likelihood of falling) dated 03/04/2017 revealed a score of 75 (A score of 45 and higher indicates high risk). A record review of Resident 2's MFS dated 04/28/2017 revealed a post fall score of 55. It further revealed that the resident was one to Overestimates or forgets limits. A record review of Physician communication form dated 4/28/2017 revealed the following: FYI: Resident had a unwitnessed fall out of W/chair (wheelchair) onto floor (carpeted) landing in a prone position with laceration to the left forehead. Resident transported by ambulance to ER (emergency room ) for evaluation. resident sustained [REDACTED]. Patient returned with order for triple antibiotic ointment, we applied Steri-strips, Telfa and Kerlex. A record review of Resident 2's Care Plan dated 03/18/2014 revealed Resident 2 was at risk for falls related to poor safety awareness, weakness and unsteady gait. Interventions included that Resident 2 used a chair and bed electronic alarm. The facility was to ensure the device was in place as needed. A record review of Resident 2's Care Plan dated 04/29/2017 for Resident 2 revealed the following: I fell out of my chair while trying to stand up. I have a skin tear to my left elbow. The care plan had the following interventions: Continue interventions on the at-risk plan. Nursing to apply treatment as directed by MD. An interview with the DON (Director of Nursing) revealed that the resident did not have any causal factors identified on the fall facility incident report. The DON also confirmed there were no interventions to prevent this type of fall from occurring again. A record review of Resident 2's Fall Scene Investigation Report dated 05/02/2017 revealed under the root cause area Chair in wrong position and medication review? There was no documentation under the sections of describe initial interventions to prevent future falls. An interview with the Assistant Director of Nursing (ADON) on 06/01/2017 at 1:45 PM revealed that the resident was in a Tilt-N-Space wheel chair. There was no documentation to identify interventions to prevent the same situation from occurring again. B. Record review of Resident 3's Admission Record dated 06/01/2017 revealed Resident 3 was admitted with some of the following medical Diagnoses: [REDACTED]. A record review of Resident 3's nursing progress notes dated 5/12/2017 revealed a staff member alerted nursing that they heard a loud crash in Resident 3's room. Resident 3 was observed sitting on buttocks and leaning toward left side. ROM (Range of Motion) was WNL (Within Normal Limits) to all extremities. Voices c/o (complaint of) pain in left elbow/wrist but able to move them on (gender) own. Assisted into standing position with assist of two staff and gait belt without incident and placed into wheel chair. A record review of Resident 3's MDS dated [DATE] revealed a BIMS Score of 11(a score of 11 indicates moderate cognitive impairment). Observations on 06/01/2017 from 07:57 AM - 08:22 AM revealed Resident 3 was in the bathroom alone. Upon exiting the bathroom Resident 3 said that Resident 3 was closing the door to walk back to bed with Resident 3's walker. Resident 3 was wearing slippers. An interview with Resident 3 on 06/01/2017 at 08:25 AM revealed that Resident 3 blacked out and had fallen both at the facility and at home. The resident stated that (gender) was hard of hearing. Resident 3 stated that (gender) does use and push the call light button, but staff are not fast enough. Interview with Medication Aide B (MA B) at 08:30 AM revelaed that the staff checked on Resident 3 every 2 hours or so. Staff were to keep Resident 3's slippers near and remind Resident 3 to use (gender's) walker. The staff also makes sure Resident 3's floor and room were free from clutter. MA B stated that Resident 3 can be up and ambulatory independently. If staff does assist, they do use a gait belt. A record review of Resident 3's Quarterly MFS dated 03/28/2017 revealed a score of 90. It further revealed that Resident 3 had Impaired gait and was one to Overestimates or forgets limits. A record review of the Un-Witnessed Fall Incident Report dated 05/12/2017 revealed Resident 3's statement was I was walking to the bathroom by myself like I always do and lost my balance. It further revealed under the section Predisposing Physiological Factors: Gait imbalance and Weakness/Fainted. Under the section Predisposing Situation Factors: Improper foot wear, ambulating without Assist and during Transfer. In the section other info: wears loose slippers, refuses to wear tennis shoes. A record review of a Physician communication form dated 5/12/2017 revealed the following: patient was ambulating to bathroom without walker and lost (gender) balance. Observed sitting on buttocks leaning to left side. Noted a 3 x 2 purple bruise to lost posterior hand and 2 x 2.5cm bruise to left elbow (small scattered busies around left elbow as well.) ROM is WNL. Denies hitting head. Refusing to see doctor or allow ice pack to site. FYI. A record review of a Confirmation of Physician Visit dated 05/12/2017 revealed under the Reason for Visit was that the resident fell this AM and had increased edema (swelling) and pain. Under the physician progress notes [REDACTED]. A record review of Resident 3's Care Plan dated 5/16/2017 revealed the resident had a fall in the resident's room on 5/12/2017. Under interventions: I have poor safety awareness. Please check on me frequently during your shifts to encourage assistance so I don't try to toilet independently. The DON confirmed that the resident did not have any causal factors identified on the fall facility incident report. A record review of Resident 2's Fall Scene Investigation Report dated 05/16/2017 revealed that the Root Cause section was blank. C. Record review of Resident 4's Admission Record dated 06/01/2017 revealed Resident 4 was admitted with some of the following medical Diagnoses: [REDACTED]. The first symptoms of this disorder include varying degrees of weakness or tingling sensations in the legs). A record review of Resident 4's nursing progress notes dated 5/22/2017 revealed a staff member was assisting the resident to the bathroom. The resident stated their legs were giving out so the resident was lowered to the floor. During this time, the resident's head grazed against the door. A record review of Resident 4's MDS dated [DATE] revealed a BIMS Score of 13. A score of 13 indicates the resident is cognitively intact. Interview with LPN C at 09:10 AM revealed the fall of Resident 4 was a freak occurrence so the staff have been keeping a good eye on (gender) with no other interventions. Observation and interview with Resident 4 at 09:22 AM revealed Resident 4 stated that (gender) had one fall some time back, but did not remember any of the particulars including. A record review of Resident 4's Quarterly MFS dated 03/05/2017 revealed a score of 90. It further revealed that Resident 4 had Impaired gait and was one to Overestimates or forgets limits. A record review of the Witnessed Fall Incident Report dated 05/22/2017 revealed the following: Lowered to the floor by MA D and Resident 4's statement was stated hit head on door. A record review of Resident 4's Care Plan dated 6/16/2016 revealed: the focus: I am weak and have multiple falls at home. Intervention: I will let you know if my legs are giving out on me. A record review of Resident 4's Fall Scene Investigation Report, dated 05/31/2017, revealed under the Root Cause section: Weakness. Under the section: Describe initial interventions to prevent future falls: resident communicating with staff when his legs can no longer hold him. Under summary of meeting: Just discharged from therapy services. Under the sections conclusion and additional care plan/nurse aide assignment updates, there was no documentation noted. An interview with the ADON on 06/01/2017 at 1:45 PM stated that weakness was a new issue for Resident 4 and the facility had not identified the cause of the weakness.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8B Based on observation, record review and interview, the facility failed to identify, evaluate and implement interventions to prevent significant weight loss for Resident 73, one of three residents sampled. The facility Census was 72. Findings are: Record review of Resident 73's Admission Record dated 5/25/16 revealed that Resident 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Facility Weight Loss Policy/Procedure, (undated) revealed: - Residents will be weighed at least monthly and the weights noted in the weight book at the nurses station. - Monthly they will be turned into the Director of Nursing (DON), and the DON will give a copy to the Dietary Manager. -The Dietary Manager will then notify the registered dietician should a significant weight loss occur (>5%). -The Registered Dietician will notify the resident's physician for any dietary recommendations regarding the weight loss. A copy of these recommendations will be given to the DON. -Any signed physician recommendations regarding a significant weight loss will then be noted and passed on to dietary. Record review of Resident 73's comprehensive care plan (CCP) dated 11/26/14 and revised on 3/01/17 revealed that Resident 73 was at risk for nutritional problems related to the [DIAGNOSES REDACTED]. Observation on 4/19/17 from 8:39 AM to 9:24 AM revealed Resident 73 sitting at a large table seated between two residents. A breakfast of puree foods was on a divided plate, oatmeal was present off to the resident's left, and there were 3 beverages present in adaptive cups. Resident 73 had a built up handled spoon and was observed to have the spoon sitting in the same position on the plate for long lengths of time. At 9:20 AM, Resident 73 completed the food on the divided plate. Other residents had left the dining area and the dishes were being removed and the tables wiped down. Resident 73 continued to sit. No staff was observed to provide Resident 73 cues to eat or assist in eating. The oatmeal was observed to not be prepared with milk or sugar and was removed from the table. Resident was then cued to stand and walk with Nurse Aide (NA) C and NA D, who assisted resident down the hall by cues. Observation on 4/20/17 from 08:00 to 08:45 revealed Resident 73 sitting at a large table in the dining room between two residents who were being assisted by staff. Observation did not reveal Resident 73 being cued or assisted with breakfast during this time. Interview on 4/19/17 at 9:24 AM with NA D revealed that Resident 73 had a decline and was unable to feed self , required assistance such as cue to pick up the spoon, and, at times, staff may need to lift the arm to get the motion started to get the cup to the lips. Interview on 4/19/17 at 9:24 AM with NA C confirmed that Resident 73 had a decline, and that Resident 73 snacked in the room all the time. But when the decline started and foods became puree'd, the family removed all the snacks from the room. NA C confirmed that resident did not like to go to the activities and was in the resident's room during the activities, including those that snacks were offered. Resident 73 was able to stand and ambulate and would leave the activity. Record review of the facility Mini Nutritional assessment dated [DATE] revealed no weight loss. Record review of the facility Mini Nutritional assessment dated [DATE] revealed no weight loss. Record review of the facility Mini Nutritional assessment dated [DATE] revealed no weight loss. Record review revealed Nutritional Dietary note by the Registered Dietitian (RD) dated 4/17/17 revealed that Resident was 66 and 167 lbs (pounds) and was at 128% IBW (Ideal body weight). Weight was down 5% in 30 days, 11% decline in 90 days, and 13% in 180 days. Diet was regular with pureed texture and the resident ate 50-100% with encouragement. Resident 73 had snacks in room, but presently seemed more confused and did not seem able to initiate self-eating. Resident 73 was encouraged to attend more activities where snacks were offered in a group event. At this time, the RD recommended offering a magic cup 2times (X) a day (supplement), and continue to follow. Interview with Dietary Manager on 4/20/17 at 1:05 PM confirmed that Resident 73 was provided many snacks by the family prior to the latest decline. The Dietary Manager revealed that Resident 73's weight from March to April had a decline of 10 lbs, or 5.6%. Dietary Manager confirmed that the Dietitian was notified of the significant weight loss and that a recommendation of magic cup 2 x day and fortified foods. Dietary Manager confirmed that the system did not pick up and alert the facility to the significant decline from 10/20/16 of 194 lbs. The Dietary Manager confirmed the weights as listed. The Dietary manager confirmed that Resident 73 had a 5.65% weight loss in 1 month, 11.2% weight loss in 90 days, and 13.9% weight loss in 180 days. Record review of Resident 73's monthly weights revealed the following: 4/14/17: 167 lbs., 3/16/17: 177 lbs., 2/05/17: 182 lbs., 1/10/17: 188 lbs., 12/14/16: 189 lbs., 11/16/16: 193 lbs., and 10/20/16: 194lbs. Interview with Dietary Manager and the Assistant Director of Nursing on 4/20/17 at 1:31 PM confirmed that Resident 76 did have a significant weight loss, and that the facility had not notified the physician or placed new interventions in place to prevent the significant weight loss.

Licensure Reference Number 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility failed to transfer a resident in a safe manner to prevent the resident from falling for one of three residents sampled (Resident 1). This fall resulted in an injury to the resident. The facility census was 80. Findings are: Observation of Resident 1 on 12/19/16 at 9:50 AM revealed Resident 1 was lying in bed on their back with their right hand tightly around a cell phone. Resident 1 had the left leg straight in bed with an immobilizer on. The resident had showed facial grimacing with movement. Interview with Resident 1 on 12/19/16 at 9:50 AM revealed that someone had dropped the resident when transferring the resident. Resident 1 rated the their leg pain at 6 on a 10 point scale with 10 being the worst pain the resident had ever felt. Interview with Resident 1 on 12/19/16 at 10:53 AM revealed the resident was in terrible pain and had requested pain medication. Observation of the transfer of Resident 1 on 12/19/16 at 11:20 AM from the bed to the wheelchair by NA C and NA D revealed that Resident 1 had received pain medication of Hydrocodone 5/325 (Norco) at 10:55 AM. Resident 1 was placed in a Hoyer lift by the 2 staff members. One staff member then held resident's leg as the resident was moved to be placed into the wheel chair with the left leg extender on. Resident 1 moaned and cried out in pain during the transfer. Observation of the undated posting of care requirements for Resident 1 located on a hook behind the resident ' s door revealed the transfer requirements were 2 assist, sit/stand as needed (prn) and for toileting 2 assist required. Interview with the Physical Therapist on 12/19/16 at 11:12 AM confirmed that Resident 1 was a 2 person transfer prior to the resident ' s fall. Resident 1 was unable to stand, therefore, was not a one person assist Interview with NA D on 12/19/16 at 1:45 PM revealed that NA D had taken care of Resident 1 before the fall and that transfers and toileting did require assist of two staff because the resident was not able to stand. Record review of the Facility policy of Transfers with one person revealed that residents who require 1 assist will be transferred with a gait belt to prevent resident and employee injuries. Residents that require one assist to transfer will be weight-bearing and need only guidance by the staff. Record review of Resident 1's (Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility) dated 10/13/16 revealed that Resident 1 required extensive assistance of two persons physical assist for transfer and toilet use. Record review of the facility investigation revealed that on 12/1/16 at 11:50 AM Nursing Assistant (NA) A was transferring Resident 1 from the toilet to the wheelchair when Resident 1 was unable to stand and was lowered to the floor. NA A was not using a gait belt with transfer and did not have a second staff member assisting with transfer. Record review of Physician Nursing Home Rounds dated 12-2-16 revealed that the resident was lowered to the floor on 12-1-16. The resident had complaints of left hip pain and was to have their hip and knee x-rayed. Record review of the Confirmation of Physician Visit dated 12/2/16 revealed that the resident was crying and voicing complaints of pain to their left lower extremity related to a fall on 12/1/16. The resident was sent to the hospital for x ray with the results of a non-displaced femur fracture. The resident was sent from x-ray to see an Orthopedic Surgeon. Resident 1 was placed in a knee immobilizer to the left leg and ordered strict non weight bearing of left leg for 6 weeks. The resident was to follow up with the Orthopedic Surgeon in one week. The resident was to have an extended wheel chair leg for the left leg. Record review of the Confirmation of Physician Visit dated 12/9/16 revealed an x-ray of the displaced distal left femur fracture and additional orders were for Computed Axial tomography scan (CT) Scan that was to be performed on 12/12/16 The resident was to have a history and physical and a cardiology consult for surgery on 12/16/16 for a repair of the Left femur fracture. Interview with the Director of Nursing (DON) on 12/19/16 at 11:45 AM confirmed that Resident 1 was being transferred one staff person with no gait belt when the fall occurred. The DON confirmed that Resident 1 had required assist of two for transfer as recorded on the MDS dated [DATE].

Based on observation, clinical record review and staff interview, the facility failed to ensure residents were free from a potential injury of a scald from hot liquids. This finding constituted an Immediate Jeopardy situation. This had the potential to affect Residents 61, 63, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79 and 80. The facility census was 77. Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. An interview of Registered Nurse 30 (RN 30) was conducted on 8/27/15 at 5:40 AM and a temperature test of the hot liquids was verified by RN 30. A test of the temperature of the liquid dispensed on 8/27/15 at 5:40 AM from the automatic hot drink dispenser revealed the cappuccino and hot chocolate liquid dispensed was 161 degrees Fahrenheit. The hot coffee was tested for a temperature of 163 degrees Fahrenheit. RN 30 was advised of the serious and immediate concerns by the survey team. RN 30 verified the drink dispenser and the coffee maker were located in an area accessible to residents on the dementia unit and the area was unsupervised. RN 30 unplugged the hot beverage dispensers and left the unit. Interview of Licensed Practical Nurse 40 (LPN 40), who was working the secure care unit on 8/27/15 at 6:00 AM, identified the following residents as confused residents who wander on the secure unit: R61, R63, R70, R71, R72 and R73 and was advised of the serious concerns for potential injury to residents by the liquids dispensed from the hot beverage machines in an unsupervised area. Observation of two facility staff Certified Nursing Assistants (CNAs) on 8/27/15 at 6:05 AM revealed they plugged the units back in to an electrical outlet and turned the hot beverage machines on and made coffee. The two CNAs then walked out of the dining area, leaving the two drink dispensers unsupervised and back in operation. The facility failed to provide supervision in the area of the hot beverage dispensers. The facility administrator and the Director of Nursing were notified of the serious concerns by the survey team on 8/27/15 at 9:30 AM. The facility Administrator was notified of the recommendation of Immediate Jeopardy in the area of accident hazards on 8/27/15 at 9:50 AM. The Immediate Jeopardy was removed on 8/27/15 at 11:00 PM and continued at a lower severity level when the facility completed the following corrective actions: · 8/27/15 at 10:00 AM, all hot fluid machines were disconnected and moved to the main kitchen away from resident accessibility · 8/27/15 at 10:20 AM, six dietary staff were educated. A new procedure was put in place regarding hot liquids. All hot fluids were to be placed in carafes and taken to the dining rooms. The dietary staff would measure the temperature of the liquids and make certain the fluid temperature would not scald a resident if contact was made with skin. Dietary staff would document the temperatures of liquids sent to the resident dining area on a flow sheet in order to ensure temperatures of hot liquids remained at a level below 120 degrees Fahrenheit · The Quality Assurance Committee representative would review all documentation related to fluid temperature monitors to ensure safety daily for seven days, weekly for four weeks and monthly for six months. All documentation would be reviewed quarterly through the next annual survey · On 08/27/15 at 2:00 PM, 6:00 PM and 10:00 PM, all staff would attend a mandatory meeting and would be educated on the awareness of hot fluids and safety of the residents. Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. Staff interview of Certified Nurse Assistant 81 (CNA 81) on 8/27/15 at 6:10 AM revealed the hot beverage dispensers were for the use of residents and visitors. CNA 81 stated residents were able to get a beverage if they wished. Further observation of the hot beverage dispensers was continued to determine if residents used the dispensers without staff supervision. Observation of R63 on 8/27/15 at 7:08 AM revealed the resident walked into the dining area and obtained a cup of coffee with cappuccino mixed. The cup was filled to the top. The resident spilled a portion of the hot beverage on her hand as she attempted to carry the drink to a table. The resident stated ouch, ouch, ouch and wiped her hand with a paper towel. Review of the clinical record for R63 revealed the resident had a [DIAGNOSES REDACTED]. The assessment documented the resident wandered daily. The assessment documented the resident required supervision for eating. Interview of Medication Aide 90 (MA 90) on 8/27/15 at 8:12 AM verified the hot beverage center was available for use by residents on the 200, 300 and 400 units. Observation of the beverage center off the main dining room on 8/27/15 at 8:12 AM revealed a hot beverage dispenser for coffee and hot chocolate. A test of the temperature of the liquids dispensed revealed the coffee was 158 degrees Fahrenheit and the hot chocolate was 160 degrees Fahrenheit. Residents identified by Registered Nurse 100 (RN 100) on the facility units 200, 300 and 400 at risk for injury by the hot liquids dispensed from the beverage center located in the main dining room with a [DIAGNOSES REDACTED]. Observation of the kitchenette area on 8/27/15 at 10:00 AM and the beverage center off the main dining room verified all hot liquid beverage machines had been removed from unsupervised areas accessible to residents who were confused and mobile. On 8/27/15 at 2:00 PM, the facility Administrator provided the first in-service of staff, which was also attended by the state surveyor, who was observing the survey. The education presented to staff included the risk of burn with hot fluids and the process regarding how to reduce the risk of scald. The Administrator explained how the facility was going to ensure the coffee was not served too hot to protect the residents from burns. The dietary staff were to ensure the coffee had cooled to 120 degrees Fahrenheit and were to ask the residents if the coffee temperature was acceptable. The facility planned to complete hot liquid assessments on all residents to assess their risk. The facility planned to complete a care plan for the residents at risk of hot liquid spills. The staff were instructed to use coffee cups with lids. There were 70 staff members at the first in-service on 8/27/15 at 2:00 PM. The Administrator planned to hold additional in-services on 8/27/15 at 6:00 PM and at 10:00 PM. The in-service was mandatory education for all staff. Interview of the facility staff on 8/27/15 between 2:30 and 3:00 PM following the in-service held at 2:00 PM included seven Certified Nurse Assistants (CNA), the Activity Director and five Registered Nurses. All staff evidenced knowledge of the procedure put in place on 8/27/15 to ensure residents' safety in relation to hot liquids. During the staff interviews, facility staff voiced a concern regarding the hot beverage machine on the Secure Care Unit previous to the identification by the surveyor team, but revealed no action had been taken by the facility. This included interviews with two nurses and three CNAs who wished to remain anonymous.

Based on observations, clinical record review, review of the facility's policy and procedure for the Continuous Quality Improvement (QCI) Committee and staff interview, the facility failed to ensure residents were free from a potential injury of a scald from hot liquids. This finding constituted an Immediate Jeopardy situation. This affected 13 of 77 residents with a [DIAGNOSES REDACTED]. (R61, R63, R70, R71, R72, R73, R74, R75, R76, R77, R78, R79 and R80). Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. An interview of Registered Nurse 30 (RN 30) was conducted on 8/27/15 at 5:40 AM and a temperature test of the hot liquids was verified by RN 30. A test of the temperature of the liquid dispensed on 8/27/15 at 5:40 AM from the automatic hot drink dispenser revealed the cappuccino and hot chocolate liquid dispensed was 161 degrees Fahrenheit. The hot coffee was tested for a temperature of 163 degrees Fahrenheit. RN 30 was advised of the serious and immediate concerns by the survey team. RN 30 verified the drink dispenser and the coffee maker were located in an area accessible to residents on the dementia unit and the area was unsupervised. RN 30 unplugged the hot beverage dispensers and left the unit. Interview of Licensed Practical Nurse 40 (LPN 40), who was working the secure care unit on 8/27/15 at 6:00 AM, identified the following residents as confused residents who wander on the secure unit: R61, R63, R70, R71, R72 and R73 and was advised of the serious concerns for potential injury to residents by the liquids dispensed from the hot beverage machines in an unsupervised area. Observation of two facility staff Certified Nursing Assistants (CNAs) on 8/27/15 at 6:05 AM revealed they plugged the units back in to an electrical outlet and turned the hot beverage machines on and made coffee. The two CNAs then walked out of the dining area, leaving the two drink dispensers unsupervised and back in operation. The facility failed to provide supervision in the area of the hot beverage dispensers. Interview with the Director of Nursing on 8/27/15 at 8:45 AM revealed the CQI (Continuous Quality Improvement) committee met monthly with the facility staff and quarterly with the facility staff, Medical Director, and the Pharmacist. She also revealed the committee had identified problems in the Secured Care Unit for falls and skin and had developed plan to correct the problems. The CQI committee failed to identify the issue with the hot beverage dispensers in the facility located in areas accessible to confused residents with no supervision and the potential for injury to these residents. The facility Administrator and the Director of Nursing were notified of the serious concerns by the survey team on 8/27/15 at 9:30 AM. The facility Administrator was notified of the recommendation of Immediate Jeopardy in the area of accident hazards on 8/27/15 at 9:50 AM. The Immediate Jeopardy was removed on 8/27/15 at 11:00 PM and continued at a lower severity level when the facility completed the following corrective actions: · 8/27/15 at 10:00 AM, all hot fluid machines were disconnected and moved to the main kitchen away from resident accessibility · 8/27/15 at 10:20 AM, six dietary staff were educated. A new procedure was put in place regarding hot liquids. All hot fluids were to be placed in carafes and taken to the dining rooms. The dietary staff would measure the temperature of the liquids and make certain the fluid temperature would not scald a resident if contact was made with skin. Dietary staff would document the temperatures of liquids sent to the resident dining area on a flow sheet in order to ensure temperatures of hot liquids remained at a level below 120 degrees Fahrenheit · The Quality Assurance Committee representative would review all documentation related to fluid temperature monitors to ensure safety daily for seven days, weekly for four weeks and monthly for six months. All documentation would be reviewed quarterly through the next annual survey · On 08/27/15 at 2:00 PM, 6:00 PM and 10:00 PM, all staff would attend a mandatory meeting and would be educated on the awareness of hot fluids and safety of the residents. Findings include: Observation of the secure care unit on 8/27/15 at 5:30 AM revealed an open kitchenette area located in the dining/lounge area of the unit where residents with a [DIAGNOSES REDACTED]. The area was not visible from the nurse's station. Staff interview of Certified Nurse Assistant 81 (CNA 81) on 8/27/15 at 6:10 AM revealed the hot beverage dispensers were for the use of residents and visitors. CNA 81 stated residents were able to get a beverage if they wished. Further observation of the hot beverage dispensers was continued to determine if residents used the dispensers without staff supervision. Observation of R63 on 8/27/15 at 7:08 AM revealed the resident walked into the dining area and obtained a cup of coffee with cappuccino mixed. The cup was filled to the top. The resident spilled a portion of the hot beverage on her hand as she attempted to carry the drink to a table. The resident stated ouch, ouch, ouch and wiped her hand with a paper towel. Review of the clinical record for R63 revealed the resident had a [DIAGNOSES REDACTED]. The assessment documented the resident wandered daily. The assessment documented the resident required supervision for eating. Interview of Medication Aide 90 (MA 90) on 8/27/15 at 8:12 AM verified the hot beverage center was available for use by residents on the 200, 300 and 400 units. Observation of the beverage center off the main dining room on 8/27/15 at 8:12 AM revealed a hot beverage dispenser for coffee and hot chocolate. A test of the temperature of the liquids dispensed revealed the coffee was 158 degrees Fahrenheit and the hot chocolate was 160 degrees Fahrenheit. Residents identified by Registered Nurse 100 (RN 100) on the facility units 200, 300 and 400 at risk for injury by the hot liquids dispensed from the beverage center located in the main dining room with a [DIAGNOSES REDACTED]. Observation of the kitchenette area on 8/27/15 at 10:00 AM and the beverage center off the main dining room verified all hot liquid beverage machines had been removed from unsupervised areas accessible to residents who were confused and mobile. On 8/27/15 at 2:00 PM, the facility Administrator provided the first in-service of staff, which was also attended by the state surveyor, who was observing the survey. The education presented to staff included the risk of burn with hot fluids and the process regarding how to reduce the risk of scald. The Administrator explained how the facility was going to ensure the coffee was not served too hot to protect the residents from burns. The dietary staff were to ensure the coffee had cooled to 120 degrees Fahrenheit and were to ask the residents if the coffee temperature was acceptable. The facility planned to complete hot liquid assessments on all residents to assess their risk. The facility planned to complete a care plan for the residents at risk of hot liquid spills. The staff were instructed to use coffee cups with lids. There were 70 staff members at the first in-service on 8/27/15 at 2:00 PM. The Administrator planned to hold additional in-services on 8/27/15 at 6:00 PM and at 10:00 PM. The in-service was mandatory education for all staff. Interview of the facility staff on 8/27/15 between 2:30 and 3:00 PM following the in-service held at 2:00 PM included seven Certified Nurse Assistants (CNA), the Activity Director and five Registered Nurses. All staff evidenced knowledge of the procedure put in place on 8/27/15 to ensure residents' safety in relation to hot liquids. During the staff interviews, facility staff voiced a concern regarding the hot beverage machine on the Secure Care Unit previous to the identification by the surveyor team, but revealed no action had been taken by the facility. This included interviews with two nurses and three CNAs who wished to remain anonymous. Review of the facility policy for CQI, dated 6/15/14, revealed the facility will establish and maintain CQI to perform quality assessment activities and oversee the identification in handling of quality issues. There was no evidence the QCI committee identified the dangerous safety hazards related to the hot beverage dispensers on the Secured Care Unit and in the Beverage Center located in the main dining. The dispensers were assessable to all 13 residents identified with a [DIAGNOSES REDACTED].

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to evaluate casual factors, monitor and re-evaluate interventions to promote healing and prevent further pressure ulcer development for 2 (Resident 41 and 44). The facility staff identified a census of 79. Findings are: A. Record review of an Admission and Discharge Summary sheet dated 2-21-2014 revealed Resident 41 was admitted to the facility with the [DIAGNOSES REDACTED]. Record review of Resident 41's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated as completed on 3-06-2014 revealed the facility staff assessed the following about the resident: -Resident 41 had short and long term memory problems. -Usually understands and was understood. -Required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. -Required extensive assistance with toilet use. -Occasionally was incontinent of bowel and had an indwelling catheter (tube placed into bladder to drain urine). -Resident 41 was at risk for developing pressure ulcers and currently had 1, stage 2 ( partial thickness skin loss involving epidermis, dermis,or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater). Record review of a Braden Scale sheet (tool used to predict pressure ulcer risk) dated 2-21-2014 revealed Resident 41 had scored a 12. According to the information on the Braden Scale sheet, a score of 12 or less "Represents high Risk". Record review of Resident 41's Comprehensive Care Plan (CCP) dated 3-13-2014 revealed Resident 41 was identified as having a skin impairment to the groin folds. The goal identified on Resident 41's CCP was Resident 41 would maintain or develop clean and intact skin. Interventions identified on the CCP included assess, monitor and record skin issue per facility policy. Identify and document potential causative factors and eliminate/resolve where possible. Treat area per physician's orders. Monitor healing and report to PCP (Primary Care Provider) if area was not healing. Observation on 5-06-2014 at 3:21 PM revealed Resident 41 was in bed and moving the left leg back and forth on the mattress, rubbing the left heel on the mattress. Resident 41 did not have heel protection on. Record review of a Resident-Data Collection, Status Upon Admission form dated 2-21-2014 revealed Resident 41 was admitted to the facility with 1, stage 2 pressure ulcer to the coccyx area. No measurements of the pressure ulcer were recorded on the form. Record review of Resident 41's Physician admission orders [REDACTED]. Record review of a Skin Assessment sheet dated 2-22-2014 revealed the facility staff assessed Resident 41 with the following: - "old scabbed area" to the left heel that measured 0.6 cm (centimeters) by 0.3 cm's. -"Red area to butt/sacral area, open area 0.5 cm slit on coccyx, excoriated peri area". -"Open area R (right) anterior, 2 cm by 0.8 cm. Location of the wound was not indicated on the Skin Assessment form. Record review of a Fax sheet dated 3-04-2014 revealed the facility Registered Dietitian (RD) had requested and received orders for a protein supplement for the stage 2 ulcer. Record review of Resident 41's Daily Skilled Nurse's Notes (DSNN) dated 2-21-2014 revealed Resident 41 had a stage 2 pressure ulcer. The DSNN did not indicate the location of the pressure ulcer. Record review of Resident 41's DSNN dated 2-22-2014 revealed Resident 41 had a pressure ulcer to the buttocks, an open lesion to the coccyx and a "scab (to) left heel". Record review of Resident 41's DSNN dated 2-23-2014 revealed Resident 41 "left heel scab" was open to air and cream was applied to Resident 41's "excoriated buttocks and coccyx slit". Record review of Resident 41's DSNN dated 2-24-2014 revealed Resident 41 had an open lesion to the left foot. Observation on 5-07-2014 at 9:53 AM with Registered Nurse (RN) D of Resident 41's buttocks and left heel revealed Resident 41's left and right buttock including the coccyx area was deep red that measured approximately 8 cm's roundish in shape. Resident 41's right buttocks had 2 open areas that measured approximately 0.5 cm round and the left buttocks had 3 open areas that measured approximately 0.25 cm to 0.5 cm per RN D. RN D applied a No Sting Barrier spray to the buttocks. Observation of Resident 41's left heel revealed a calloused like area that measured 0.3 cm per RN D. Record review of Resident 41's medical record, Treatment Administration Records (TARS) and CCP did not contain any information of the monitoring of the pressure ulcers, the evaluation of the casual factors for developing new pressure ulcers and what the change in treatment had been. An interview on 5-07-2014 at 11:44 AM was conducted with RN D. During the interview, RN D confirmed that Resident 41's pressure ulcers had not been monitored and "there should be skin sheets for all the areas". When asked if the new areas were pressure ulcers. RN D stated " I'm not sure what the cause is, (gender) stays up to long". When asked if the treatment had been changed, RN D stated "no" and when asked if the areas were worse, RN D stated "yes". An interview on 5-07-2014 at 12:10 PM was conducted with the Director of Nursing (DON). During the interview, review of Resident 41's pressure ulcers condition was reviewed with the DON. The DON confirmed the areas to Resident 41's buttocks had not been evaluated for the casual factors for the pressure ulcer development. The DON confirmed the skin monitoring had not been completed for Resident 41. Record review of the facility Policy and Procedure for Pressure Sores revealed the following information: -Procedure: -2. If pressure sore is present, document plan to address condition on CCP. -4. Pressure sore assessments will be documented on the photographic wound documentation sheet. Photographs for comparative documentation will be taken monthly unless frequent documentation is necessary. A handwritten entry identified that the Charge Nurses on each unit are in charge of pictures and measurements weekly on skin conditions. -5. Width and depth of areas will be measured weekly for stage 2. -7. Routine preventative care measures provided to prevent pressure sores will include turning, proper positioning, application of pressure reduction devices. -14. Any resident with a pressure sore will receive the necessary treatment and services to promote healing, prevent infection and prevention new sores from developing. B. Face sheet for Resident 44 revealed the resident was admitted to the facility on [DATE]. Review of Resident 44's skin assessment tool dated 2-25-14 revealed the resident had a pressure ulcer stage 2 to coccyx. No measurements or description of the ulcer were documented. Review of Resident 44's Daily skilled Nursing note dated 3-27-14 revealed a pressure ulcer to coccyx, decreased blanchability, skin very poor, pale condition, decreased appetite. Review of the nurse aide care plan for Resident 44 revealed the resident needed 2+ physical assist for bed mobility and transfer. The resident was non ambulatory, incontinent of bladder and bowel, alert and oriented, and had skin ulcers. Review of Resident 44's record revealed no weekly monitoring or wound assessment of the pressure ulcer. Resident 44's care plan for skin impairment revealed an abrasion to coccyx and the stated intervention were: document location/size and treatment, and report abnormalities to physician. Interview with the Director of Nursing on 5-8-14 at 9 am confirmed that pressure ulcers should be measured, assessed and documented weekly.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interviews, the facility failed to have an effective Quality Assurance program as identified by repeated citations (F314, F323, F329, and F371) and additional citations (F164, F241, F312, F332, F356, F412, F43). The facility census was 79. Findings are: Review of the findings for the last annual survey conducted on 1-31-13 revealed deficiencies at: F314 (treatment of [REDACTED]. The annual survey conducted on 5-8-14 also cited deficiencies in these areas. Interview with Nurse Aide E on 5-8-14 at 12 pm revealed being unaware when the QA committee met and what they were working on. Interview with the social worker on 5-8-14 at 11am revealed that the Quality Assurance (QA) committee meets monthly and things were brought forth to be QA'd by the old administrator so not sure how things were really chosen to make a QA plan. Interview with the Assistant Administrator, on 5-8-14 at 11:45am revealed they could not find any QA meeting notes or minutes and (gender) did not know how things were chosen to be action planned because the old administrator did that. Review of facility policy dated March 2013 stated: The QAA committee meets quarterly to identify issues with respect to which quality assessment and assurances activities are Separate identified sub-committees will turn in an updated action plan for review by the QAA committee quarterly. Reporting: 1. Residents, family and staff may report to any member of the QAA committee of a concern or idea for quality review, a concern may also be submitted to a supervisor who will forward the issue for review of the committee. 2. Monthly res council meeting minutes will be reviewed by the committee for any quality deficiencies reported at the meeting. 3. General observation of staff that shows evidence to determine practices and processes reflect negative outcomes will be submitted for review by the QAA committee. 4. If the QAA team identifies a concern that reflects actual or probably noncompliance, the committee will determine that an action plan is needed.

Licensure Reference: 175 NAC 12-006.09D2a and 12-006.09D2b Based on observation, interview, and record review, the facility failed to assess skin breakdown and follow facility skin policy for 1 (Resident 6) and evaluate causal factors and implement additional interventions to prevent pressure sores from developing for 1 (Resident 1) of 16 sampled and 10 non-sampled residents. The facility had a total census of 80. Findings are: A. Resident 6 was admitted to the facility on [DATE] according to admission and discharge summary. The admission and discharge summary listed the following [DIAGNOSES REDACTED]. A review of Resident 6's quarterly MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 6/7/10 listed Resident 6 as requiring extensive assistance of one for bed mobility and limited assist of one for transfer, toilet use, walk in room, and personal hygiene. Resident 6 was listed as having an OK short and long term memory and being independent with cognitive skills for daily decision making. A review of Resident 6's Care Plan revealed a problem dated 3/8/10 of potential for altered skin integrity with the following interventions: - " [MEDICATION NAME] paste/moisture barrier cream to peri/rectal areas prn (as needed) redness " - " Res (Resident) sleeps on pressure relief mattress " - " Encourage Res to use commode, may use bed pan for no longer than 5 minutes " - " Encourage Res to roll over and transfer weight " A review of Skin Charting Notes dated 2/16/10 revealed Resident 6's open area to left buttock was healed. On a 4/30/10 Braden Scale (a tool used to predict pressure sore risk), Resident 6 scored 22. A Braden Scale score of 9 or below was considered severe risk, 10-12 high risk, 13-14 moderate risk, and 15-18 mild risk for development of pressure sores. In interviews between 2:20-2:50 PM and at 4:50 PM on 6/8/10, Resident 6 reported Resident 6 had a " bed sore " on Resident 6's bottom. Resident 6 estimated Resident 6 had the pressure sore for 2 weeks and had been putting creme on it that was provided by a facility staff member. Resident 6 had creme that Resident 6 was using on pressure sore in Resident 6's drawer in room. A review of Resident 6's medical record on 6/8/10 did not reveal any documentation regarding a pressure sore on Resident 6's bottom. Observations at 3:20 PM on 6/8/10 revealed an open area with surrounding red tissue on Resident 6 ' s left buttock. Nurse's Notes dated 6/9/10 at 10:30 AM stated " .5 cm (centimeter) round superficial open area noted while bath was being given " . Wound assessment and Care Tool with Braden Scale for Resident 6 dated 6/9/10 stated Resident 6 had a .5 cm x .5 cm x .2 cm, Stage II pressure sore on left buttock. Pressure sore was being treated with moisture barrier cream. Observations on 6/8/10 at 7:45 AM, 8:30 AM, 10:05 AM, 11:30 AM and 5:16 PM and on 6/9/10 at 8:30 AM, 9:46 AM, and 11:55 AM, revealed Resident 6 resting in bed on back with head of bed elevated. In an interview on 6/8/10 at 4:20 PM, the DON (Director of Nursing) reported Resident 6 had a standard pressure relieving mattress on bed. A review of physician's orders [REDACTED]. In an interview on 6/9/10 at 2:35 PM, the DON reported the physician order [REDACTED]. In an interview on 6/9/10 at 10:17 AM, Nurse Aide B reported assisting Resident 6 to clean up the previous week. Nurse Aide B reported Resident 6's bottom was red and Nurse Aide B notified the charge nurse who provided Resident 6 with creme to put on bottom. In an interview on 6/10/10 between 10:33-10:45, Wound Nurse LPN (Licensed Practical Nurse) C reported Wound Nurse LPN C had not become aware of Resident 6's pressure sore until 6/9/10 nor was Wound Nurse LPN C aware Resident 6 was putting creme on it. Wound Nurse LPN C reported Wound Nurse LPN C was to be notified of all pressure sores including stage I pressure sores. A review of facility treatment checklist updated 9/09 for Stage II pressure sores revealed the following steps are to be taken in addition to others: -Measure and record in skin notes, -Relieve pressure. -Review standing orders-Wash with Wound Cleanser, Pat dry, Apply Skin Prep to peri-wound skin allow to dry 1 min., Apply Exuderm to area change every 3 days and PRN (as needed) until healed -Request RD (Registered Dietitian) consult -Initiate repositioning every 2 hours, if not being done-maximum up 2 hours if coccyx or Ischial area -Complete Unusual Occurrence Report and Investigation; Notify MD (Physician), DON, Skin nurse, family, therapies B. Record review of an Admission and Discharge Summary sheet dated 11/16/2009 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's significant change in condition dated and signed as completed on 4/01/2010 revealed the staff assessed the following about the resident: -Short and long term memory problems. -Modified independence in daily decision making. -At ease doing planned or structured activities. -Extensive assistance with toilet use. -total dependence with bed mobility, transfers, locomotion, eating and personal hygiene. -Decline in function. -Frequently incontinent of bowel and bladder. -Weight loss. -1 Stage II pressure ulcer ( the ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). Review of Resident 1's Nurses Notes (skin) dated 2/23/2010 revealed Resident 1 was assessed to have an open area to the coccyx area that measure 3cm x's 2.5cm x's 0.1cm. Record review of a Wound Care Doctor Fax dated 2/23/2010 revealed the area to the coccyx was assessed as a Stage II pressure area. Record review of Resident 1's record did not contain an assessment of casual factors in an attempt to determine the reason why Resident 1 had developed a pressure ulcer after being assessed at low risk for pressure ulcers. According to a Wound Assessment and Care Tool with Braden Scale sheet dated 3/26/2010, the area to Resident 1's coccyx had healed. Record review of a Skin Nurse's notes dated 4/19/2010 revealed that Resident 1 had developed a "split at the coccyx area". Record review of Resident 1's record did not contain an assessment of causal factor or if the "split" was caused from pressure. The record did not contain Wound Assessment sheets for monitoring of the "split" to the coccyx. Record review of Resident 1's Nurse's Notes dated 6/05/2010 revealed the resident had developed an open area to the right buttock. The resident's record did not contain evidence of causal factors for the development of the area and to rule out pressure as a cause of the open area. Record review of a Fax communication /Facility Request sheet dated 6/09/2010 revealed the resident physician had been notified of the area 4 days after the facility had identified the open area. Observation on 6/08/2010 at 7:40 AM revealed Resident 1 was seated in a dinning room chair with out any pressure reliving/reducing cushion in the chair. Observation on 6/09/2010 at 8:00 AM revealed that Resident 1 was in the dinning room for breakfast. Resident 1 was seated in a dinning room chair and did not have a pressure reducing/reliving cushion in the chair. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 4/05/2010 did not identify that Resident 1 had a history of [REDACTED]. An interview with LPN C was conducted on 6/09/2010 at 8:59 AM. During the interview LPN C confirmed that (gender) was the wound treatment nurse. When asked if the causal factors had been assessed in an attempt to determine why Resident 1 developed a pressure ulcer, LPN C state"no, (gender) had a decline, but I'm not sure". An interview with the DON was conducted on 6/09/2010 at 3:50 PM. During the interview, the DON was asked if Resident 1 needed to have a cushion in the dinning room chair, the DON stated "yes". Record review of an undated Policy and Procedure for Pressure Sore provided by LPN C revealed the following: -#7, Routine preventive care measures provided to prevent pressure sores will include; turning and proper positioning, application of pressure reduction or relief devices.... -#13, If a resident does develop a pressure sore, documentation in the record will support based on the condition of the resident, the pressure sore was clinically difficult to prevent. -#14, Any resident with a pressure sore will receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The following measures will be implemented and documented on the comprehensive care plan and medical record, relieving pressure...

Licensure Reference: 175 NAC 12-006.09D5 Based on interviews, observations, and record review, the facility failed to evaluate psychosocial needs and implement interventions to promote social interaction for 1 (Resident 6) of 16 sampled and 10 non-sampled residents. The facility had a total census of 80 residents. Findings are: A. Resident 6 was admitted to the facility on [DATE] according to admission and discharge summary. The admission and discharge summary listed the following [DIAGNOSES REDACTED]. A review of Resident 6's quarterly MDS (Minimum Data Set; a comprehensive assessment used for care planning) dated 6/7/10 revealed Resident 6 exhibited an OK short and long term memory and was independent with cognitive skills for daily decision making. A review of Resident 6's Care Plan revealed a problem dated 5/12/10 of "resident displays a sad/anxious mood that is easily altered" and "resident exhibits persistent anger with self or others." Resident 6's Care Plan listed the following interventions: - " Provide 1:1 visits prn (as needed) " - " Attempt to identify and situational cause for sadness/anxiety; help to correct if possible " - " Encourage resident to ventilate feelings. Give realistic, positive feedback " - " Medicate as ordered with [MEDICATION NAME] " - " Discuss possible need for psychological consult with health care team prn " - " Encourage participation in activities of facility " - " Attempt to identify and resolve basis for voiced/demonstrated anger " - " Encourage family/friends to communicate frequently with resident via visits/phone calls " Observations on 6/8/10 at 7:45 AM, 8:30 AM, 10:05 AM, 11:30 AM and 5:16 PM and on 6/9/10 at 8:30 AM, 9:46 AM, and 11:55 AM, revealed Resident 6 resting in bed on back with head of bed elevated. Resident 6 was not observed to change out of Resident 6 ' s pajamas. Observations on 6/8/09 and 6/9/09 revealed Resident 6 did not attend any facility activities and ate breakfast and lunch in room. Nurse's Notes dated 6/9/10 at 10:30 AM stated " .5 cm (centimeter) round superficial open area noted while bath was being given " . Wound assessment and Care Tool with Braden Scale for Resident 6 dated 6/9/10 stated Resident 6 had a .5 cm x .5 cm x .2 cm, stage II pressure sore on left buttock. A review of Vital Sign and Weight Flow sheet revealed Resident 6 experienced an 11 lb (7.7%) weight loss between admission on 11/24/09 and 5/1/10. Geriatric Depression Scale for Resident 6 revealed a score of 7 on 12/8/09 and a score of 6 on 4/20/10. According to Geriatric Depression Scale, a score greater than 5 indicated probable depression. Activities Progress Note dated 3/17/10 stated "Spends time in bed little act (activities)." Dietary Progress note dated 3/17/10 stated resident refused to come out to dining room for meals. Fax Communication to the physician regarding Resident 6 dated 2/2/10 stated " Res (Resident) currently on [MEDICATION NAME] 60 mg (milligram) q d (every day) with occ (occasional) episodes of tearfulness. Can we increase or give additional antidepressant. " Physician orders [REDACTED]. Resident 6 was seen by the Nurse Practitioner for mental health on 2/25/10 with orders to continue current medications and a follow up appointment scheduled in 4 weeks. In an interview on 6/9/10 at 2:35 PM, the DON (Director of Nursing) reported Resident 6 refused to go to the follow up appointment with the mental health Nurse Practitioner. The DON reported the primary care physician was not notified of Resident 6's refusal. Social Services Progress Note for Resident 6 dated 2/11/10 reported Resident 6's POA (Power of Attorney) stated the following: " (POA) stated that (Resident 6) has been in 7 indep. (independent) living/AL (assisted living) in the last 7 yrs. (years). This is (Resident 6) first NH (Nursing Home) placement (with) hx (history) of depression. (Resident 6) really shuts (Resident 6) self in. (Resident 6) does not read or watch tv. SSD (Social Service Director) stated that (gender) would notify activities so they do more 1-on-1 (with) Res. Also, Res would enjoy more visits from facility pastor. . . " In an interview on 6/9/10 at 2:45 PM, the Activity Director reported 1-1 visits were made to Resident 6 to ask Resident 6 to go to activities. The Activity Director reported the staff member who did 1-1 visits was currently on leave. In an interview on 6/9/10 between 2:50-3 PM, the Social Service Director reported there was no formalized plan for Resident 6 to receive 1-1 visits. The Social Service Director reported the volunteer Ombudsman did a weekly visit to Resident 6 but there were no other interventions planned.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility staff failed to evaluate the effectiveness nutritional interventions and food preference for 3 (Resident 10, 6 and 3) of 16 sampled and 10 non-sampled residents. The facility staff identified a census of 80. Findings are: Record review of an Admission and Discharge Summary sheet dated 2/12/2010 revealed Resident 10 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 10's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 2/11/2010 revealed the facility staff assessed the following about the resident: -Ok short and long term memory. -Independent with decision making. -Able to make self understood and understands. -Independent with ADL's (Activities of Daily living). -Significant weight loss in the last 180 days. Record review of a Vital Sign and Weight Flow Sheet revealed the following recorded weights: -7/7/2009: weight 165 lbs (pounds). -8/7/2009: weight 160 lbs. -9/01/2009: no weight recorded. -10/01/2009: weight 155 lbs. -11/2009: weight 149 lbs. -12/01/2009: no weight recorded. -1/11/2010: weight 144 lbs. -2/11/2010: weight 141 lbs. -3/07/2010: weight 139 lbs. -4/27/2010: weight 137 lbs. -5/04/2010: weight 136 lbs. Record review of Resident 10's Dietary Progress Notes dated 12/18/2009 revealed the Registered Dietician (RD) identified that Resident 10 "continues to trigger out as a significant weight loss of 11.4% in the last 180 days. [MEDICATION NAME] (diuretic medication) was changed to increase [MEDICAL CONDITION] at that time, which contributed to weight loss". No recommendations were made at this time for Resident 10. Record review of Resident 10's Dietary Progress Notes dated 1/15/2010 revealed the RD identified Resident 10 with a " significant weight loss (of) 12.7% in 180 days. CBW ( current body weight) 144# (lbs). The RD recommended laboratory work and to start a health shake, 4oz (ounce)BID (2 times a day). Record review of Resident 10's Dietary Progress Notes dated 1/15/2010 revealed the Dietary Manager (DM) had visited with Resident 10 due to Resident 10 had declined taking the health shakes. No further recommendations were identified as being offered to the resident to address the weight loss. Record review of Resident 10's Dietary Progress Notes dated 2/15/2010 revealed the DM identified that Resident 10 "continues to trigger a significant wt (weight) loss of 11.9% in 180 days." No recommendations or interventions were initiated to prevent further weight loss. Record review of Resident 10 Dietary Progress Notes dated 3/1/2010 revealed the RD identified that Resident 10's "CBW was 141#. Wt is (down) 11.9%, significant loss in the last 180 days." Recommendation was to try resource juice BID"...Will have CDM ( Certified Dietary Manager) visit with resident re (regarding); wt loss". Record review of Resident 10's Dietary Progress Notes dated 4/15/2010 revealed the RD identified that Resident 10 "continues to trigger out as a significant weight loss 11.6% in the last 180 days. CBW 137#....Will discuss trying to add calories/menu items". Record review of Resident 10's Dietary Progress Notes dated 5/10/2010 revealed the DM " visited with (Resident 10) about the weight which has stabilized this month. CBW 136#". Observation on 6/08/2010 at 7:55 AM revealed that Resident 10 was in the dinning room for breakfast. Resident 10 had cold cereal, milk,water, eggs. Resident 10 did not eat the eggs. Observation on 6/08/2010 at 12:15 PM revealed Resident 10 was in the dinning room for lunch. Resident 10 was served a hot roast beef with gravy. Resident 10 removed all the bread and ate the roast. On 6/08/2010 at 11:20 AM, an interview was conducted with Resident 10. During the interview, the weight loss was discussed with Resident 10. Resident 10 stated at this time that (gender) did not like the taste of the food at the facility and hated getting soggy toast and bread. Resident 10 further stated that the eggs did not taste good and would not eat them. When asked if any one had discussed (gender) food preference, Resident 10 stated "no". Record review of Resident 10's Comprehensive Care Plan (CCP) dated 6/11/2009 did not identify that Resident 10 had a significant weight loss, what the resident's goal was for weight management or what intervention were in place to manage the weight loss. An interview on 6/10/2010 at 8:00 AM was conducted with the DM. During the interview the DM confirmed Resident 10 had a significant weight loss. When asked if Resident 10's food preference were discussed with the resident, the DM stated not until 2/15/2010. The DM stated "it should have been done sooner". When asked what other interventions were attempted other than the health shake and juice, the DM stated "I'm not sure, just offering foods (gender) liked". Review of Resident 10's CCP was conducted with the DM. The DM confirmed the residents CCP did not address the weight loss, the residents' goal or intervention to prevent further weight loss. Review of the RD recommendation dated 3/01/2010 that the DM speak with the resident about the weight loss was conducted with the DM. The DM confirmed during the interview that this did not occur until 5/10/2010. When asked what was the DM expectation that the recommendation be followed up with, the DM stated with in 48 to 72 hours. B. Resident 6 was admitted to the facility on [DATE] according to admission and discharge summary. The admission and discharge summary listed the following [DIAGNOSES REDACTED]. A review of Resident 6's quarterly MDS dated [DATE] revealed Resident 6 exhibited an OK short and long term memory and being independent with cognitive skills for daily decision making. A review of Resident 6's Care Plan revealed a problem dated 12/30/09 of potential for choking related to missing teeth and need for mechanical soft diet with a goal of resident being adequately nourished with diet ordered. Interventions included the following: - "Serve diet as ordered, mechanical soft, NAS (no added salt). Res. (Resident) request meats to be chopped". - "Chart intakes". - "Res eats all meals in (resident) room. Feeds self after set up". - "Offer snacks (between) meals TID (three times per day)". - "Monitor wt (weight) monthly". - "Review labs as available. Notify MD (Physician) of any abnormal". - "Boost shakes BID (twice a day)". - "2-cal (supplement) 4 oz BID". A review of Vital Sign and Weight Flow sheet revealed Resident 6 experienced an 11 lb (7.7%) weight loss between admission on 11/24/09 and 5/1/10. Resident 6 ' s weights are as follows: -11/24/09: 142.5 lbs. -1/2/10: 138 lbs. -2/1/10: 134 lbs. -3/7/10: 133 lbs. -4/4/10: 134 lbs. -5/1/10: 131 lbs. Nurse's Notes dated 6/9/10 at 10:30 AM stated " .5 cm (centimeter) round superficial open area noted while bath was being given". Wound assessment and Care Tool with Braden Scale for Resident 6 dated 6/9/10 stated Resident 6 had a .5 cm x .5 cm x .2 cm, Stage II pressure sore on left buttock. Observations at 1 PM on 6/8/10 revealed Resident 6 ate only bites of hot roast beef sandwich with mashed potatoes, none of the cottage cheese, 1 prune, all of the apple crisp and all of the asparagus. Observations at 1:05 PM on 6/8/10 revealed Resident 6 ate ? of the chicken, none of the potato, none of the green beans, one bite of pineapple, all of the prunes and cookie. Resident 6 reported Resident 6 could not chew the pineapple. Observations at 9 AM on 6/10/10 revealed Resident 6 refused the breakfast tray. In interviews on 6/8/10 at 1 PM and between 2:20-2:50 PM, Resident 6 reported Resident 6 had lost weight. Resident 6 reported Resident 6 did not eat breakfast. A review of supplement list revealed Resident 6 was to receive 4 ounces of regular shakes/supplement with dinner and supper. A review of Resident 6's 6/10 MAR (Medication Administration Record) revealed Resident 6 was to receive Boost Drink (supplement) 1 can at 8 AM and 6 PM and 4 ounces 2-cal (supplement) at 8 AM and 6 PM. According to meal schedule, meals were served as follows: 8 AM breakfast, 12 PM lunch/dinner, and 6 PM supper. In an interview on 6/9/10 at 9:15 AM, LPN (Licensed Practical Nurse) D Charge Nurse, reported Resident 6 refused Boost at night and refused the 2 cal supplement almost every time. A review of the 6/10 MAR indicated [REDACTED]. Dietary Progress Notes dated 3/17/10 stated Resident 6 refused to come out to dining room for meals. Dietary Note dated 3/17/10 stated Resident 6 intake averages 30-41%. In an interview between 10:06-10:25 AM on 6/10/10, the Dietary Manager reported the Dietary Manager was not aware Resident 6 was getting Boost and 2-cal supplement at meals as both were provided by nursing. The Dietary Manager reported dietary provided strawberry shakes with meals. The Dietary Manager reported Resident 6 was due for a quarterly review and all supplements needed to be looked at. C. According to the Admitting Face Sheet, Resident 3 had been admitted [DATE]. Review of the Physician's History & Physical dated5/19/10 contained the [DIAGNOSES REDACTED]. Record review of Resident 3's MDS assessment dated [DATE] revealed the staff had assessed the following: - Mental status varies with behaviors of repeating questions, self Deprecation, believes bad things will happen, health complaints and expressions of sadness and pain. - Resident 3's Activities of Daily Living (ADL'S) had declined in function and the resident needed increased physical support to perform the ADL's. - A significant weight loss had been identified. The MDS assessment completed 12/29/09 contained a weight of 138 pounds (lbs) with no indication of weight loss. Resident 3's weight was 120 lbs on the MDS completed 4/5/10. On 6/7/10 at 9:50 A.M. observation revealed Resident 3 had consumed the following for breakfast: one scramble egg leaving 2 bites, a bowl of cheerios with milk (leaving a small amount of milk in the bowl), 1 bite of the Strawberry jelly coated bagel, 1 cup coffee and 1 small glass of water. On 6/7/10 at 12:25 P.M. observation of the noon meal revealed food items of beef with gravy, mashed potatoes with gravy, asparagus, fruit cocktail, and an apple dessert placed on Resident 3's table position. The liquids consisted a strawberry shake-4 ounces (oz), cranberry juice 4 oz, water -4 oz, and coffee -8oz. The resident requested a second cup of coffee. Observation revealed LPN-T gave Resident 3 the 2.0 Cal Med Pass -120 cc (centimeters) with medications at the time of the noon meal -12:25 P.M. on 6/710. The remainder of the 2.0 Cal Med Pass had been given to Resident 3 with instructions to drink all of it with the meal. Interview and observation of Resident 3 at the meal time (12:25 P.M. on 6/7/10) revealed the resident commenting that " I have to drink all that (Med Pass) then I'm full " . When encouraged to eat food items, Resident 3 replied, "No, I'm full - I can't - I was told to drink all that (Med Pass) with my meal". The dietary intake had been recorded for the meal at 12:25 PM on 6/7/10 as 25 % consumed. On 6/7/10 following the meal served at 12:25 P.M., interview with LPN-T related to serving supplements prior to and at meal time replied that the 2.0 Cal Med Pass was given with the med (medication) pass and the med pass was done at meal times. On 6/7/10 following the meal served at 12:25 P.M., interview with the DON revealed there was no policy and procedure related to administration times of the 2.0 CAL Med Pass supplement. The 2.0 Call had just always been given with medications at med pass time and that was usually with meals. Review of Dietary notes reveal the identification of a significant weight loss 4/15/10. Resident 3 had a very sore mouth with Physician visits 4/1 and 4/10/10. Supplements provided with Skakes BID (2 times daily) and 2.0Cal 60cc QID (4 times per day). Review of the Dietary note on 5/14/10 revealed a significant weight loss of 14 % continued in 180 days. The weight had been stable at 117 lbs in last 30 days. Recommended the 2.0 Cal to be increased to 120 cc QID.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on staff interview and record review; the facility's Quality Assurance/Quality Improvement committee failed to identify ongoing issue relevant to F176, F248, F252, F274, F280, F281, F283, F314, F319, F323, F325, F332, F363, F371, F428, F441, F 467 and F465. and failed to implement effective plans of action to correct the deficient practice. F314, F319 and F325 were identified at a harm level and isolate scope. The survey sample consisted of 16 sampled and 9 non-sampled residents. The facility staff identified a census of 80. Findings are: Record review of the facility's Quality Assurance/Quality Improvement policy and procedure dated 7/2006 revealed the following: -Purpose: The purpose of the Quality Assurance/Quality Indicator (QA/QI) program is to insure and/or review the processes and procedures in place to meet the needs and provide optimum quality of care for those that we serve and also for those employed at good Shepherd Lutheran Community. -Objective: The object of the Quality Assurance/Quality Indicator program is to identify and select concerns for investigation based on information received within the facility from various resources. -Procedure: The committee determines areas of potential concern based on information received from various resources, committee reports, complaints, grievances, etc. An interview on 6/10/2010 at 9:50 AM was conducted with the facility Administrator. When asked what type of issues the facility QA/QI committee was working on, the Administrator stated " Marketing and the QIS (Quality Indicator Survey)". When asked if the committee was working on anything relating to weight loss or pressure ulcers, the Administrator stated "no". "We have routine meetings for pressure and weight, those areas are ok". An interview on 6/10/2010 at 10:00 AM was conducted with the Director of Nursing (DON). During the interview the DON stated the committee had completed work on the "use of catheters and staff skills in the maintance and cleansing of the catheters". When asked if the QA/QI committee was working on pressure ulcers or weight loss, the DON stated "no, those are fine, we have routine meetings for them, there no problems". On 6/10/2010 at 10:20 AM an interview was conducted with the Activity Director (AD). AD was asked what type of issues the QA/QI committee was working on and the AD stated " I'm not sure, I don't always go, I don't have time." When asked if the committee had identified any issues with the activity program in the facility, the AD stated "no". When asked if the AD was a member of the QA/QI committee, the AD stated "yes". An interview was conducted on 6/10/2010 at 10:30 AM with the Care Plan/ MDS (Minimum Data Set a federally mandated comprehensive assessment tool used for care planning) Coordinator. During the interview the MDS Coordinator stated " I'm not sure " when asked what type of issue were QA/QI committee was working on. When asked when does the committee meet, the MDS Coordinator state " I really not sure how all that works". When asked if the MDS Coordinator was a member of the QA/QI committee, the MDS Coordnitor stated "Yes". An interview on 6/10/2010 at 10:33 AM was conducted with the facility Staff Education/In-service Coordinator (SEIC). During the interview the SEIC was asked if the QA/QI committee was working on any pressure or weight loss issue, the SEIC stated "no, just routine monitoring". When asked how the QA/QI committee functions, the SEIC stated " I'm not sure how that works". When asked if (gender) was a member of the QA/QI committee. SEIC stated "yes". On 6/10/2010 at 10:50 AM an interview was conducted with the Dietary Service Manager (DSM). When asked if the DSM was member of the QA/QI committee, the DSM stated "no". When asked if the QA/QI Committee was working on weight loss or pressure ulcers issue, the DSM stated " no, I would know if they were working on those because it would involve my department".

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and observation; the facility Quality Assurance/ Quality Improvement committee failed to correct ongoing issues relevant to F176, F281, 332 and 441 and failed to implement effective plans of actions to correct the deficient practice and maintain correction. The survey consisted of 11 sampled and 6 non-sampled residents. A. Record review of the facility's Quality Assurance/Quality Improvement policy and procedure dated 7/2006 revealed the following: -Purpose: The purpose of the Quality Assurance/Quality Indicator (QA/QI) program is to insure and/or review the processes and procedures in place to meet the needs and provide optimum quality of care for those that we serve and also for those employed at good Shepherd Lutheran Community. -Objective: The object of the Quality Assurance/Quality Indicator program is to identify and select concerns for investigation based on information received within the facility from various resources. -Procedure: The committee determines areas of potential concern based on information received from various resources, committee reports, complaints, grievances, etc. The facility had an annual survey completed on 6/10/2010. The facility had areas of deficiencies that required a plan of correction. A re-visit to the facility was completed on 8/19/2010 in regards to their plan of correction for those deficiencies cited on the 6/10/2010 inspection. The facility did not maintain correction for the regulation that are identified in this report and repeated deficiencies were written.