Every finding on record at Heritage Estates

Licensure Reference Number 175 NAC 12-006.09Based on interview and record review, the facility failed to follow provider's orders and failed to notify a provider that orders were not initiated for 1 (Resident 4) of 4 sampled residents. The facility identified a census of 99. A record review of Resident 4's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses of displaced fracture of the right humerus (upper arm bone), type 2 diabetes (chronic condition where the body is unable to regulate blood sugars effectively), and acute kidney failure.A record review of progress notes in Resident 4's electronic medical record from 4/28/26 at 10:23 AM revealed the following:Resident 4 had an oxygen saturation of 85% on room air, clear lung sounds with diminished bases.Resident 4 stated they had an upset stomach, they were tired, had a stuffy nose, sore throat, and dry cough. Resident 4 also said it was hard to take a deep breath. Resident 4 had a negative Covid test (taken at 9:03 AM in the prior note).The provider was notified and the nurse obtained a new order for Duonebs (a nebulized medicine that relaxes muscles in the airways and increases airflow to the lungs) four times daily for 10 days, and another new order for oxygen to be administered 2 liters by nasal cannula to keep oxygen saturation more than 90%. The resident and daughter were documented as being updated.A record review of progress notes in Resident 4's electronic medical record (EMR) from 4/28/26 at 5:23 PM revealed Resident 4 had an oxygen saturation of 76% on room air, Duoneb was administered, the nurse encouraged deep breathing, then the oxygen saturation was 92% on room air. A record review of progress notes in Resident 4's EMR from 4/28/26 at 10:00 PM revealed oxygen administration was initiated with the resident.A record review of a facility document titled, Physician Visit/Communication Form, dated 4/28/26 revealed the following: Resident 4 was seen by their health care provider to follow up after starting Duoneb 4 times a day for 10 days. Resident 4 had a non-productive cough, and their oxygen saturation was 85% on room air which increased to 91% after deep breathing. The document revealed three handwritten orders: 1) Mucinex (a medicine used to reduce chest congestion cold, infection, or allergies). 2) Zithromax 500 milligrams (mg) (an antibiotic) first dose, then 250 mg daily for 4 days. 3) Monitor and notify of any decline. An interview with the Director of Nursing (DON) on 8/3/26 at 3:48 PM revealed Resident 4's provider came to the facility at about 5:30 PM on 4/28/26, saw the resident, and wrote the orders for Zithromax, Mucinex, and to monitor for worsening of condition, but did not include indications for the medication orders.Further record review of Resident 4's electronic medical records revealed no evidence of the provider's orders of Mucinex and Zithromax being entered into the EMR or of these orders being implemented. A record review of progress notes in Resident 4's electronic medical record revealed the following for 4/29/26:At 9:34 AM, revealed a skilled note that the resident was receiving continuous oxygen, had diminished lung sounds, and had increased shortness of breath. Resident 4 removed their oxygen tubing and their saturations dropped to 83%. At 11:55 AM, an SBAR (an acronym meaning Situation, Background, Assessment, Recommendation) for suspected respiratory infection and McGeer criteria for infection surveillance checklist completed and placed in the Nurse Practitioner's folder for review.At 5:43 PM, Resident 4 was swabbed for an influenza test, and it was sent to the lab at the hospital.A record review of a facility document dated 4/29/26 and titled, SBAR Communication Tool Template for suspected lower respiratory tract infection, and labeled with Resident 4's name revealed the following: In the Background section, Resident 4 was noted to not have a history of COPD (chronic obstructive pulmonary disease), heart failure, or lower respiratory infection in the last 6 months. The record also revealed Resident 4's oxygen requirement had increased, requiring the use of 2 liters per minute (lpm) of supplemental oxygen.In the Assessment section, Resident 4 was noted to have a new or increased cough, but not purulent sputum production, and no new or worsened delirium, or a respiratory rate greater than 25 breaths per minute.In the Recommendations section, there was an X marking the option which stated the protocol criteria were not met.The SBAR form was signed by the Infection Preventionist nurse on 4/29/26 11:48 AM with the word folder written in the empty space to the left of that section. The Physician Orders/Response section was not filled out. A record review of progress notes in Resident 4's EMR revealed the following for 4/30/26:At 9:05 AM a nurse documented Resident 4 continued to have shortness of breath, low oxygen saturations, and required continuous oxygen at 2 lpm.At 7:49 PM, Resident 4 was in a recliner for a short time that morning then refused to get out of bed. Resident 4 removed their oxygen as soon as the staff left the room, encouragement was not successful.A record review of progress notes in Resident 4's EMR revealed the following for 5/1/26:At 9:00 AM, Resident 4 stated they were still tired and weak, and their lung sounds were diminished, with decreased appetite. The skilled note, also dated at 9:00 AM revealed the resident was on continuous oxygen at 2 lpm, had diminished lung sounds, and a dry cough.At 12:10 PM, Resident 4 required 2 staff for assistance, stand and pivot transfer with a gait belt and a wheelchair due to weakness. Charting prior to this time stated 1 assist with toileting and dressing.At 2:41 PM, Resident 4's provider was in the facility to see the resident and ordered Resident 4 be sent to the ER for evaluation of hypoxia, fatigue, decreased breath sounds, nonproductive cough, oxygen usage higher than their usual which was 90s on room air. Resident 4's POA was notified at that time via phone, and the resident was sent to the emergency room by ambulance at 2:25 PM. At 10:56 PM, Resident 4 was admitted to the hospital with the diagnosis of bilateral pneumonia, and the resident's POA had been notified. A record review of a facility document dated 5/1/26 titled Doctor's orders and progress notes, revealed a handwritten order from Resident 4's provider to send Resident 4 to the emergency room for evaluation. The record also revealed a handwritten progress notes which stated the Mucinex, Zithromax, and monitor for decline physician orders had not been done, and the resident's baseline oxygen saturations were mid 90s on room air until 4/28 and were now mid 90s on 2 lpm. They had a non-productive cough, fatigue, and diminished lungs with rhonchi (low-pitched breath sounds that occur when fluid or mucus obstruct the airways).An interview with DON 8/3/26 at 3:48 PM revealed the following:The usual process for new medication orders is for the facility staff to the orders into the electronic medical record and fax to the pharmacy. For new medication orders that needed to be given right away, there were some medications available at the facility, and any additional medications could be obtained from selected local pharmacies.A process is in place to monitor the prescription of antibiotics in the facility, which includes using the SBAR form. Resident 4's provider did not come to the facility on 4/29 or 4/30 and was not called to be notified that the Zithromax and Mucinex had not been administered. An interview with DON on 8/4/26 at 9:10 AM confirmed there is no policy that includes notification of provider or the time limit for when orders need to be entered into the record.An interview with DON 8/3/26 AT 3:48 PM confirmed the following:No staff member entered the antibiotic order into the EMR for Resident 4's after it was written on 4/28/26. No reason was revealed for why the order was not entered according to the usual practice.The SBAR form was completed by the Infection Preventionist nurse on 4/29/26 at 11:48 AM, put into a folder commonly used to hold information for Resident 4's provider, but was not seen by the provider or communicated to the provider by phone. The SBAR form should not have been left in the folder for the provider to see, and the information should have been communicated some other way.The provider came to the facility on 5/1/26 and sent Resident 4 to the hospital to be evaluated for worsening of their respiratory illness.

Licensure Reference Number 175 NAC 12-006.1(A)(i)Based on observation, record review, and interview the facility failed to ensure that residents were served the approved menu serving sizes. This affected 11 observed residents served food from the facility kitchen (Residents 77, 73, 19, 7, 65, 41, 92, 10, 60, 79, and 85). The facility census was 99.Findings are: A. Record review of the facility Resident Policies dated 12/2020 revealed that the facility will provide the resident with a diet that their physician has ordered. The menu selections are served to meet their orders and have been approved by a qualified dietitian. Record review of the undated Questions & Answers from the undated facility admission packet revealed that the facility serves three meals a day. A dietician oversees dietary needs. Record review of the recipe for Pureed Beef Soft Tacos (pureed is a cooked food item that has been ground with a blender into a smooth pudding-like consistency for residents with difficulty chewing or swallowing) dated 2026 revealed that the portion (serving size) was two #6 scoops (a total of 10.68 ounces). (One #6 scoop equals 5.34 ounces). Record review of the recipe for Spanish [NAME] dated 2026 revealed that the serving size was one #8 scoop (4 ounces). Record review of the recipe for Pureed Spanish [NAME] dated 2026 revealed that the serving size was one #8 scoop (4 ounces). Record review of the recipe for Refried Beans dated 2026 revealed that the serving size was one #8 scoop (4 ounces). Record review of the recipe for Pureed Refried Beans dated 2026 revealed that the serving size was one #8 scoop (4 ounces). Observation on 6/24/26 at 11:08 AM at the 100/200 kitchen revealed 5 blue #16 dishers (scoops for serving food items at a measured amount of ounces) on the steam table. Observation on 6/24/26 at 11:49 AM in the 100/200 kitchen revealed that Dietary Aide-H (DA-H) performed handwashing at the sink. DA-H removed the covers from the pans of food items in the steam table. DA-H placed a blue handled #16 disher (2 ounces) in the steam pan of pureed tacos. DA-H placed a blue handled #16 disher (2 ounces) in the steam pan of regular rice. DA-H placed a blue handled #16 disher (2 ounces) in the steam pan of pureed rice. DA-H placed a blue handled #16 disher (2 ounces) in the steam pan of refried beans. DA-H placed a blue handled #16 disher (2 ounces) in the steam pan of pureed refried beans. DA-H began to plate a meal for Resident 77. DA-H used the blue handled #16 dishers to plate 1 scoop of pureed rice (2 ounces served-only half of the 4 ounces that should be served), 1 scoop of pureed refried beans (2 ounces served-only half of the 4 ounces that should be served), and 1 scoop of pureed taco (2 ounces served- less than 1/5th of the 10.68 ounces that should be served) onto the divided plate. DA-H placed the plate of food onto the service window and staff delivered the meal to the resident. DA-H plated a meal for Resident 73. DA-H used tongs to place a taco onto the plate. DA-H used the blue handled #16 dishers to place 1 scoop of regular rice (2 ounces served-only half of the 4 ounces that should be served) and 1 scoop of refried beans (2 ounces served-only half of the 4 ounces that should be served) onto the plate. DA-H placed the plate of food onto the service counter widow and staff delivered the meal to the resident. DA-H plated a meal for Resident 19. DA-H used the gloved hands to place a soft taco onto the plate. DA-H used the blue handled #16 dishers to place 1 scoop of regular rice (2 ounces served-only half of the 4 ounces that should be served) and 1 scoop of refried beans (2 ounces served-only half of the 4 ounces that should be served) onto the plate. DA-H sat the plate on the service window counter and staff delivered the plate to the resident. DA-H plated a meal for Resident 7. DA-H used tongs to place a taco on the plate. DA-H used the blue handled #16 dishers to place 1 scoop of rice (2 ounces served-only half of the 4 ounces that should be served) and 1 scoop of refried beans (2 ounces served-only half of the 4 ounces that should be served) onto the plate. DA-H sat the plate onto the service window counter and staff delivered the plate to the resident. DA-H used the gloved hands to place a soft taco onto a plate for Resident 65. DA-H used the blue handled #16 dishers to place 1 scoop of rice (2 ounces served-only half of the 4 ounces that should be served) and 1 scoop of refried beans (2 ounces served-only half of the 4 ounces that should be served) onto the plate. DA-H sat the plate onto the service window counter and staff delivered the plate to the resident. DA-H used the gloved hands to place a soft taco onto a plate for Resident 41. DA-H used the blue handled #16 dishers to place 1 scoop of rice (2 ounces served-only half of the 4 ounces that should be served) and 1 scoop of refried beans (2 ounces served-only half of the 4 ounces that should be served) onto the plate. DA-H sat the plate onto the service window counter and staff delivered the plate to the resident. DA-H began to plate a meal for Resident 92. DA-H used the blue handled #16 dishers to place 1 scoop of pureed rice (2 ounces served-only half of the 4 ounces that should be served), 1 scoop of pureed refried beans (2 ounces served-only half of the 4 ounces that should be served), and 1 scoop of pureed taco (2 ounces served-less than 1/5th of the 10.68 ounces that should be served) onto the divided plate. DA-H sat the plate onto the service window counter and staff delivered the plate to the resident. DA-H used tongs to place a taco onto a plate for Resident 10. DA-H used a blue handled #16 disher to place 1 scoop of refried beans (2 ounces served-only half of the 4 ounces that should be served) onto the plate. DA-H sat the plate onto the service window counter and staff delivered the plate to the resident. DA-H used tongs to place a taco onto the plate for Resident 60. DA-H used the blue handled #16 dishers to place 1 scoop of rice (2 ounces served-only half of the 4 ounces that should be served) and 1 scoop of refried beans (2 ounces served-only half of the 4 ounces that should be served) onto the plate. DA-H sat the plate onto the service window counter and staff delivered the plate to the resident. DA-H used the gloved hands to place a soft taco onto a plate for Resident 79. DA-H used a blue handled #16 disher to place 1 scoop of refried beans (2 ounces served-only half of the 4 ounces that should be served) onto the plate. DA-H sat the plate onto the service window counter and staff delivered the plate to the resident. DA-H began to plate a meal for Resident 85. DA-H used the blue handled #16 dishers to place 1 scoop of pureed rice (2 ounces served-only half of the 4 ounces that should be served), 1 scoop of pureed refried beans (2 ounces served-only half of the 4 ounces that should be served), and 1 scoop of pureed taco (2 ounces served- less than 1/5th of the 10.68 ounces that should be served) onto the divided plate. DA-H sat the plate onto the service window counter and staff delivered the plate to the resident. Observation on 6/24/26 at 12:20 PM in the 100/200 kitchen with the Dietary Manager (DM) confirmed that the blue handled dishers were #16, 2 ounces. The DM confirmed that the scoops were the wrong size to provide the amount of the food items as directed by the menu recipe for each item. The DM told DA-H that 2 scoops of pureed taco should be served as 1 scoop was not enough. The DM revealed that there is usually a chart with the disher sizes posted in the kitchen but it was not there. Interview on 6/24/26 at 12:20 PM with the Dietary Manager (DM) confirmed that the amounts of rice and beans served did not meet the required serving size per the menu recipes. The DM confirmed that the amount of pureed tacos did not meet the menu recipe required serving size. B. A record review of recipe lasagna revealed serving size is 3 x 3 inches 1 slice per cooking direction and pan size. A record review of recipe puree lasagna revealed serving size is #6 scoop per cooking direction and pan size. A record review of recipe breadsticks revealed serving size is 1 each portion. A record review of recipe puree breadsticks revealed serving size is #12 scoop per cooking direction. A record review of recipe Cesar salad revealed serving size is 1 cup per assembly and direction. A record review of recipe chopped, soft chilled steamed vegetables revealed serving size is #8 scoop or 4 ounce or 1/2 cup per cooking direction. A record review of puree chilled steamed vegetables revealed serving size is #12 scoop per cooking direction. A record review of recipe fresh fruit cup revealed serving size is 1/2 cup per assembly and direction. A record review of recipe puree soft canned fruit revealed serving size is #10 scoop per assembly and direction. An observation on 6/23/26 at 11:32 AM with Dietary Aide (DA)-K in one of three satellite kitchens revealed the foods being served are: lasagna, salad, fresh fruit, canned vegetables, and breadsticks. DA-K placed all service wear items on top of the food containers prior to serving. An interview on 6/23/26 at 12:00 PM with DA-K revealed they use the scoop that is required for the meal. DA-K continues to reveal (gender) the kitchen staff have a monthly meeting that reveals this information, the scoop size and correlation is listed on a form that is posted on the wall of the satellite kitchen. Record review of an undated form titled, Common Measurements with scoop sizes listed: -#6 Scoop = 2/3 cup (c) = 6 ounces (oz) -#8 Scoop = 1/2 c = 4 - 5 oz -#10 Scoop = 3/8 c = 3 - 4 oz -#12 Scoop = 1/3 c = 2 1/2 - 3 oz -#16 Scoop = 1/4 c = 2 - 2 1/4 oz -#20 Scoop = 3 1/5 tablespoon (tbsp) = 1 ¾ - 2 oz -#30 Scoop = 2 1/5 tbsp = 1 – 1 1/2 oz A record review of recipe crispy beef tacos revealed serving size is 1 taco per modified cooking direction. A record review of recipe beef soft taco revealed serving size is 2 tacos per cooking direction. A record review of recipe puree beef soft taco revealed serving size is 2 #6 scoop. A record review of shredded lettuce and diced tomatoes revealed serving size is 1/2 cup of lettuce and 1/4 cup of tomatoes per portion. A record review of recipe Spanish rice revealed serving size is #8 scoop per cooking direction. A record review of recipe puree Spanish rice revealed serving size is #8 scoop per cooking direction. A record review of recipe refried beans revealed serving size is #8 scoop per cooking direction. A record review of recipe puree refried beans revealed serving size is #8 scoop per cooking direction. A record review of recipe paprika rice revealed serving size is #8 scoop per cooking direction. A record review of recipe seven up cake revealed serving size is 3 x 2 inches 1 slice per cooking direction and pan size. A record review of recipe puree seven up cake revealed serving size is #10 scoop per cooking direction. An observation on 6/24/26 at 11:30 AM with Dietary Aide (DA)-L revealed tacos were proportioned by the cooks. All scoops available for service were all #12 green scoops (1/3 cup scoop size), and 1 #16 blue scoop (1/4 cup scoop size). An interview on 6/24/26 at 12:00 PM with DA-L revealed all green 1/3 cup scoops are for all food items, the blue 1/4 scoop is for all bird eaters. When asked what a bird eater is, DA-L revealed little (genders) who do not eat a lot of food. An interview with the Dietary Manager (DM) on 6/24/26 at 1:00 PM revealed knowing the dietary aides are not certain which scoops to use during service and that some training needs to occur to get everyone on the same process of serving.

License Reference Number 175 NAC 12-006.18(B)(D)Based on record review and interview, the facility failed to ensure that infection control measures for hand hygiene were followed while assisting residents with eating meals and when donning (putting on) and doffing (taking off) gloves. This affected 8 residents of 8 sampled (Residents 57, 99, 16, 47, 36, 2, 22, and 55.); and the facility failed to ensure that those who had indwelling catheters had catheter bags kept off the floor. This had the potential to affect all residents in the 500 hall (Residents 22, 93, 99, 15, 24, 28, 69, 46, 90, 78, 16, 76, 82, 58, 57, and 5). The facility census was 99. Findings were: Record Review of the Hand Hygiene Competency dated 12/2019 revealed when one is to wash their hands with working within the facility. Hands were to be washed:Before eating or drinkingBefore each resident contactAfter touching a resident or handling their belongingsAfter contact with any body fluidsAfter handling contaminated itemsBefore and after glovingWhenever indicatedHand Hygiene using hand sanitizer was to be completed: 1. Before or after direct contact with a resident 2. After contact with resident's intact skin 3. After removing gloves or between changing gloves 4. After contact with inanimate objects, such as medical equipment in resident's room or vicinity.Record review of the facility policy dated 9/12/2027 Policy for Infection Prevention and Control Surveillance is stated under Standard precautions that all blood and body fluids for ALL Patients shall be considered potentially infectious. Accordingly, appropriate precautions shall be followed when there is a possibility of exposure to body fluids of ANY Resident. Team members must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions. Hand Hygiene shall be done for a minimum of 20 seconds, before and after all patient care. When hands are visibly soiled or contaminated, wash hands with soap and water. An antimicrobial soap is indicated for contract with severely immuno-compromised patients. Alcohol-based hand rubs may be used for decontaminating hands if hands are not visibly soiled, if there is no evidence of certain microbial infections or if running water and soap is not available. Any contact with patient's body fluids should be washed off immediately with soap and water. Hand Hygiene shall be done after removing and disposing of gloves and other protective equipment.Observation of resident care in the dining room of the 500 hallways on 6/22/2026 at between 12:10 PM and 12:50 PM revealed the following: -12:10 PM Resident 57 was seated at the dining table with a catheter cover over the catheter bag but the catheter bag was lying on the floor. -12:20 PM Nurse Aide (NA-B) started serving Resident 16. -12:21 PM Nurse Aide (NA) B and began to assist both Residents 99 and Resident 16 with their meals at the same time. -12:22 PM NA-B donned gloves on both hands then held the hamburger for Resident 16 to take a bite of the hamburger. -12: 23 PM NA-B pulled the wheelchair of Resident 99 closer to self with gloved hands. NA-B then took chips out of the single serving chip bag and fed Resident 16 some of the chips without changing gloves. -12:26 PM NA-B took a napkin for Resident 99 and wiped crumbs from their face. NA-B then started feeding Resident 99 spoons of food with gloved hands. -12:27 PM NA-B cut the Salisbury steak into smaller bites and fed Resident 16 with one hand then served a spoonful of food to Resident 99 with the same hand. - 12:30 PM NA-B continued to assist both Resident 99 and Resident 16 without performing any hand hygiene between residents and without changing gloves. -12:31 PM A staff member brought a covered cup of juice from the kitchen for Resident 99. NA-B removed the paper from the straw with the gloved hands and inserted the straw into the cup and assisted Resident 99 while drinking juice. After Resident 99 took a drink, NA-B continued helping both Resident 99 and Resident 16 with their meals. -12:32 PM NA-B removed both gloves and went to the coffee pot to get a large cup of coffee for Resident 57. NA-B did not use hand hygiene after removal of both gloves. NA-B then returned to the table where they were seated, donned a new set of gloves without performing hand hygiene, and continued to assist Resident 99 and Resident 16 with their meals. -12:35 PM Resident 16 finished eating and NA-B took the paper menu on the table for this resident and asked Resident what they wanted to eat tomorrow. NA-B then gave Resident 99 a drink of water. -12:42 PM NA-B continued assisting both residents and at 12:43 PM used a paper napkin to wipe the face of Resident 99 and then NA-B removed both gloves, took a pencil, and filled out the menu for Resident 16. -12:45 PM Resident 57 put (gender) catheter bag in (gender) lap and continued to sit at the table drinking coffee from a large mug. -12:49 PM NA-B pushed Resident 57 to (gender) room with urinary catheter sitting on top of (gender) lap. NA-B has not used any hand hygiene. -12:50 Resident 22 was pushed to their room in a wheelchair by Licensed Practical Nurse (LPN)-A. After leaving Resident 22's room, LPN-A returned to the dining area, took hold of the wheelchair of Resident 16, and started to go to that resident's room, but NA-B returned to the area and took over. LPN-A didn't use HH and returned to the nursing office. NA-B did not use hygiene. Interview with NA-B on 6/22/2026 at 1:15 PM revealed that both Resident 16 and Resident 99 were assisted with their meals at the time and NA-B did not at anytime use Hand Hygiene by washing hands with soap and water or by using alcohol based hand rubs while feeding the residents. NA-B confirmed they did not use hand hygiene after the use of the gloves. NA-B did know that Resident 57's catheter bag was on the floor but did not hang it on the wheelchair. NA-B did state that Resident 57 wants to do things the way they did it at home prior to entering the facility. NA-B thinks it is care planned because Resident 57 gets upset if things are not done the way (gender) wants with the catheter bag. NA-B did state that when Resident 57 was pushed to their room, that the catheter was in the lap of this resident. NA-B confirmed that they did not know that urinary drainage bags should be kept below the level of the bladder.Interview with Medication Aide (MA) C on 6/22/26 at 1:20 PM revealed knowing that the catheter bag was seated on the floor while Resident 57 was eating and then did see that this resident put the catheter on top of their lap. MA-C confirmed that they did not know that putting the catheter bag on top of ones lap can potentially cause infections. Interview on 6/22/26 at 2:10 PM with LPN-A revealed that the staff get their training as it pertains to the feeding of the elderly during their classes when they become a certified nursing assistant and not certain what training they get through the facility. LPN-A confirmed that they did not know that one could not feed two people at one time without using hand hygiene between each resident. When asked if a urinary catheter bag should be left on the floor, the response of LPN-A was, Absolutely not. LPN-A confirmed that a catheter bag cannot be put onto the lap if the resident as that urine would be above the level of the catheter and cause a backflow of urine into the system. LPN-A stated that Resident 57 wants to do things that way they were done at home and will not keep the catheter bag attached to the chair. LPN-A confirmed that the urinary catheter bag should have been hanging on, or underneath of, the wheelchair as it is an infection control issue as well as a dignity issue. Record review of an untitled document dated 6/24/2026 revealed the following information as it pertained to resident 57: On 5/26/2026 the resident was noted to have his own catheter bag carrier, which was placed on the floor next to them in the dining area during lunch. This nurse attempted to educate the resident about the importance of having the catheter drainage bag attached to the wheelchair to which Resident 57 replied this is how I have always done it, it's ok. That may be how you do it, but I will do it my way. And refused to allow this nurse to assist with attaching the drainage bag to the wheelchair. The document further revealed education that the staff had been given and other findings about the resident and not keeping the catheter drainage bag off the floor as well as the importance of keeping the catheter bag below the level of the catheter to prevent backflow of the urine back into the bladder. On 6/1/2026 it stated that Resident 57 had been educated about receiving a new and clean catheter drainage bag cover and to not store the catheter bag on the floor, but that the resident was unwilling to make changes at that time. Family members as well as Resident 57 had been educated.Interview on 6/24/26 at 1:25 PM with Minimum Data Set (MDS)-O (a standardized, federally mandated clinical assessment tool used in Medicare and Medicaid-certified nursing homes to evaluate every resident's functional, medical, and psychosocial status) who stated, I was asked to write and bring you a letter that describes the issues that we have had with Resident and the care of their catheter bag. We have had issues since Resident 57's arrival at the facility as (gender) wants to do things the way that it was done at and prior to admission. The letter was dated 6/24/26. This describes all that we have done as far as education with the resident, the resident's family, and with our staff. When asked if any of this was documented in the chart or in the electronic medical record prior to the survey team asking for information, MDS-O confirmed there was no documentation in the chart that documented any behaviors for Resident 57. MDS-O further confirmed that it is important to the facility to let the resident have choices, but when those choices affect the safety of other residents within the facility, the staff must work more diligently to make sure Resident 57 is not putting others at risk. B.Observation on 6/23/2026 during the period of 7:57 AM to 8:26 AM in the dining room of the 400 hall. -7:57 AM LPN-E is seated at the table between Resident 47 and Resident 36 assisting each of them with their breakfast. LPN-E did not wear gloves and there was no alcohol-based hand sanitizer (ABHS) on the table during the meal service. LPN-E gave each resident a bite of food while speaking to each of them. -7:58 AM LPN-E moved to sit between Resident 36 and Resident 27. LPN-E did not perform hand hygiene. LPN-E then gave Resident 27 a bite of food. LPN then reached out to assist Resident 36, then turned back to Resident 36. LPN-E continued to speak to all of the residents at the table. - 8:00 AM LPN-E arose from the table and walked to alcohol dispenser on the wall and used AHBS and returned to the chair seated between Resident 36 and Resident 27 and assisted Resident 27 with a bite of food. LPN-E then turned to Resident 36 and gave Resident 27 a bite of food. LPN-E consistently changed which silverware was used. No hand hygiene was performed. A second Nurse Aide (NA) F sat at the table to assist the residents while they ate. -8:04 AM - LPN-E reached out to Resident 36, took a napkin, wiped food off of lap of Resident 36, then reached back to Resident 27 and used a second napkin to wipe food off the clothing protector before serving another bite of food. Neither LPN-E or NA-F used any hand hygiene between residents as they assisted the residents. -8:11 AM MA-D sat at the table between Resident 47 and Resident 36 -8:26 AM MA-D removed their clothing protector after assisting Resident 47, put it in the dirty linens, then went to Resident 36 and removed the clothing protector, and then took Resident 36 to the resident's room. No ABHS was used between the residents while assisting with feeding the meals or after the clothing protectors were removed.In a confirmation interview with LPN-E at 10:05 AM, LPN-E revealed that all nursing staff go through a competency fair each year. There are 10-11 stations on infection control They also do assigned net learning each month where 3-5 learns are assigned. LPN-E confirmed that staff try not to feed more than one person at a time at the dining tables and further confirmed that neither LPN-E nor the other staff helping the Residents at the table used any hand hygiene during the meal process.

Licensure Reference Number 175 NAC 12-006.05 (E)Licensure Reference Number 175 NAC 12-006.09 (E)(i)Licensure Reference Number 175 NAC 12-006.09 (F)(ii) Based on record review and interview the facility failed to ensure that residents , as well as their resident representatives, were invited to the care plan meetings on a quarterly basis for 1 of 4 residents reviewed (Resident 22); and failed to revise the care plan to meet the needs of the resident when an antipsychotic was initiated for 1 resident (Resident 51) of 5 residents sampled. The facility census was 99. Findings are:Record review of the policy Comprehensive Care Plans dated 11/28/2026 revealed that the facility will develop and implement a comprehensive care plan (a detailed, step-by-step guide used in long-term care (LTC). It lists a resident's exact medical, physical, and emotional needs. The goal is to help the resident stay as healthy and happy as possible) for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy explanation and compliance guidelines stated that person centered care means to focus on the resident as the center of control and support and the resident in making their own choices and having control over the daily lives. The care plan would include an assessment of the resident's strengths and needs and would incorporate the resident's personal and cultural preferences in developing goals of care. The comprehensive care plan would be developed within 7 days after completing the comprehensive Minimum Data Set (MDS) (a standard, required health form used by nursing homes. The Centers for Medicare and Medicaid Services (CMS) requires staff to use it to evaluate a resident's physical, mental, and emotional health) assessment. The comprehensive care plan would be prepared by an interdisciplinary team that includes but it not limited to: - the attending physician, -a registered nurse, -a nurse aide, -a member of dietary, -the resident and the resident's representative when practicable, -other staff as needed or requested. The comprehensive care plan would include measurable goals and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The goals would be utilized to monitor the resident's progress. Record review of the Quarterly Care Plan Conference Summary for Resident 22 dated 10/14/2025 revealed that Resident 22 was not invited to the care plan conference and did not attend the care plan conference. A family member, the resident's responsible party, did attend. The summary revealed that during the meeting, nursing concerns, dietary intake, life enrichment participation and social service concerns were reviewed. It was also determined that Resident 22 would start meetings with a telehealth physician or nurse, and that the resident had started participating in more life enrichment opportunities. Record review of the Care Plan Acknowledgement Form dated 10/14/2026 revealed that the care plan had been conducted over the phone with the Power of Attorney (POA) - a trusted person who cares for financial and legal affairs) and Healthcare Power of Attorney (HPOA) - a trusted person who makes medical decisions for you. This person only steps in to make choices if you become too sick or hurt to speak for yourself. It ensures your doctors follow your exact wishes of Resident 22. There was no signature for Resident 22 and no indication that Resident 22 had attended nor was there evidence that Resident 22 was invited to the conference. The signature line of the Representative of Resident 22 was marked with an X and stated phone call with (POA) and then form was signed by the facility Director of Nursing (DON). Record review of the Care Plan Acknowledgement Form dated 11/4/2025 revealed that the family had declined the care conference and the Interdisciplinary Team (IDT) held a meeting (a collaborative meeting where professionals from different healthcare or service disciplines come together to plan, coordinate, and review a patient's care) to discuss the resident cares and Resident 22 was not in attendance nor was there evidence that Resident 22 was invited to the conference. Record review of the Care Plan Acknowledgement Form dated 1/6/2026 revealed that the family had declined the care conference and the IDT held a meeting to discuss the resident cares and Resident 22 was not in attendance nor was there evidence that Resident 22 was invited to the conference. Record review of the Care Plan Conference Summary dated 3/3/2026 revealed that Resident 22 had not been invited to the Care Plan conference. Record review of the Comprehensive Care Plan schedule list from 7/8/2025 revealed that the family had been notified of the care plan but no indication an invitation had been sent to Resident 22. Family member was coming to town in July and wanted to set up a conference on July 18th if possible. Record review of the Comprehensive Care Plan schedule list from 8/12/2025 revealed that there was a Care Plan meeting at 10:45 AM with the family only. There was no indication that the resident had attended the Care Plan conference. Record review of the Comprehensive Care Plan schedule list from 10/7/2025 revealed that there was a Care Plan meeting scheduled with Resident 22's family/POA on 10/14/2026 at 10:00 AM. There was no indication that the resident had attended the Care Plan conference. Record review of the Comprehensive Care Plan schedule list from 10/14/2025 revealed that there was a Care Plan meeting at 10:00 AM with the family only over the phone. Record review of the Comprehensive Care Plan schedule list from 11/4/2025 revealed the POA did not want to schedule a Comprehensive Care Plan conference as the POA of Resident 22 had been in close contact with the Nursing staff while this resident had been ill. There was no indication as to whether Resident 22 had been invited or attended the care plan meeting. Record review of the Comprehensive Care Plan schedule list from 6/2/2026 revealed a message had been left with the POA. It was unknown what the date of the care plan meeting was to be and no indication that Resident 22 had been invited to the care plan meeting to discuss preferences or concerns about cares. Record review of the Progress Notes about Resident 22 revealed that throughout the past year: 10/3/2025 at 12:44 PM revealed Social Services review note that started Resident 22 had started having some pain that was interfering with their ability to function. Resident 22 also had osteoporosis and osteoarthritis. Continues to be able to express themselves sufficiently. 10/14/2025 at 10:09 revealed a care plan conference in which the family was invited by telephone and the resident did not attend the conference with the IDT present for the call. The resident started participating in more activities at the facility. 1/6/2026 at 8:34 PM Social Services review for a quarterly Social services review revealed Resident 22 had no advanced directive in place to tell the staff what to do in the event if Resident 22's heart stopped beating or Resident 22 stopped breathing. Information was obtained from Resident 22 who revealed they only wanted selective treatment with artificial nutrition and nothing further. Cognitively, Resident 22 was able to express themselves sufficiently and able to make wants and needs known to staff as well as make all daily choices. Resident 22 was involved in activities, currently showed no signs of depression or anxiety, was able to talk to staff and other residents, and liked to watch television and talk to family on the phone weekly. Family was invited to the care plan. 3/2/2026 at 11:52 AM a note as entered by social services revealed Resident 22 had no advanced directive in place to tell the staff what to do in the event if Resident 22's heart stopped beating or Resident 22 stopped breathing. Information was obtained from Resident 22 who revealed they only wanted selective treatment with artificial nutrition and nothing further. Cognitively, Resident 22 was able to express themselves sufficiently and able to make wants and needs known to staff as well as make all daily choices. Resident 22 was involved in activities, currently showed no signs of depression or anxiety, was able to talk to staff and other residents, and liked to watch television and talk to family on the phone. 3/3/2026 10:46 that a care plan meeting was held by the IDT including the POA/Resident Representative for Resident 22 by phone care. Resident 22 did not attend the meeting. It was noted that Resident had a new medication which they refused to take due to making them feel nauseated. Interview on 06/22/2026 at 1:35 PM with Resident 22 revealed that when asking about care and treatment within the facility, Resident 22 was knowledgeable about hospitalizations, cares, staff, meals, some medications but not all, activities in the facility and those Resident 22 preferred to attend, some specific past medical history pertaining to infections, knowledge of other diagnoses, but had no knowledge of care plans or what care plan meetings were. When an explanation of what care plan meetings were and who is allowed to attend care plan meetings, Resident 22 stated they still had no knowledge of care plan meetings nor did Resident 22 recall having attended any in the past. Interview on 06/23/2026 at 2:57 PM with the Medical Records and Social Services Nurse (MR) who stated that Resident 22's Power of Attorney (POA) that used to live in town passed away last year (March 2025). After that, the new POA appointed was another family member who resides out of state. The POA was enacted. Because the POA was enacted, we (the facility staff) usually have a care conference over the telephone and just leave it at that. So even though Resident 22 could be invited to come to the care conference, we don't always have the residents who have a POA come to those conferences or have any input since we have a phone call with the POA. When asked at what point residents give up their resident rights to attend care plan conferences to discuss their plans of care, MR stated that residents do not give up their rights to attend care conferences. When asked if the staff speak to the residents about their cares, MR stated that staff do talk to them but most input is from the Resident Representative or POA. We usually invite residents to the Care Plan meetings based on their BIMS score, MR stated that anyone with a BIMS score over 3 should be invited to the care plan meetings. When asked to confirm this, the MR again stated that anyone with a BIMS score over 3 should be invited to the care plan meetings so that they had some input into the plans of care for that individual. There are individuals whose BIMS scores change because they were sick one month and now, they are back to their normal baseline. Even though we usually just check in with the family, there is really no reason we couldn't have the residents come to the care plan meetings to visit or listen to the plans especially if they are able to speak to us. If there is something that we discuss that may upset them such as they are no longer able to go home and this is going to be their permanent home or other serious matters, we could take the residents back to their rooms and then finish the meetings with the POA. Yes, I do think that going forward we probably should bring the residents to the meetings if they are able to attend, or they want to attend, so they can talk to all of us. An interview on 6/24/26 at 9:00 AM with the Social Services Director (SSD) revealed Resident do not give their rights to participate in care plan meetings, it has more to do with their ability to understand what the care plan meeting is about. Interview on 6/24/26 at 9:08 AM with Medical Records and Social Services nurse (MR) revealed residents never give up their rights to be able to attend a care plan meeting. So I guess, all of them need to be invited to the care plan whether the family wants them there or not. If we get to a point in a meeting when it may be upsetting to the resident and the family would like to discuss part of the care plan without the resident in attendance, we could probably remove the resident from the situation at the time. Interview on 6/24/26 at 11:00 AM with the Facility Administrator (FA), it was revealed after record review of the undated and untitled note about the information pertaining to Resident Rights sent to Resident 22's POA also had a copy of the Resident Rights presented to surveyors with the admission packet. The FA further stated that residents who have a lower BIMS score are not invited to the care plan meetings either because family has asked that they not be there or because they have a lower BIMS score and would not understand. For those who have a BIMS score that changes due to health status, if the BIMS score is 6 and changes to an 11, we would not invite them if the score was 6 but if it changes and it is now an11, they would be invited. Invitations to the care plan meetings are dependent upon the BIMS score. We do send the resident representative a copy of the Resident rights in the mail each year. Surveyors were given a copy of the resident rights. When asked if the resident rights says that residents have the right to participate in their care plans depending upon their BIMS score, the FA agreed that it states Residents have a right to participate in their care plan. Residents have a Resident Council and Resident 22 attends the Resident Council meetings frequently. In the council meetings they discuss the resident rights at that time, so all of the residents should know they have a right to go to their care plan meetings. When asked if the Residents ever give up the right to attend care plan meetings, the FA again stated that residents are invited to the care plan meetings if their BIMS score is high enough which would indicate whether they would understand what they are discussing in the meeting. In a confirmation interview with the Director of Nursing (DON) on 6/24/26 at 11:00 AM, the DON confirmed that all residents had a right to be invited to the care plan meetings, that residents do not give up this right, and that residents are not being given an opportunity to attend the care plan conferences by the facility. We are inviting the Resident representatives or [NAME] of Attorney, but we are not inviting the Facility Residents themselves to the care plan meetings. Some may get invited just in passing as we visit them, but there is no written invitation and it is not documented in the chart. There was no documentation in the resident records that confirm the resident had been invited and that the resident had chosen either not to attend or did not want to attend. C. Record review of the facility policy titled Psychoactive Medication and Medication Regimen Review Standard dated 6/26 revealed that if a resident is on psychoactive medication, there should be a separate care plan in place (separate problem/need, goal, and interventions). Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) for Resident 51 dated 5/6/26 revealed that Resident 51 had a diagnosis of depression and non-Alzheimer's dementia (a diverse group of brain disorders causing cognitive and functional decline). The MDS revealed that Resident 51 received an antipsychotic (a psychotropic medication) 7 days of the 7-day MDS lookback period. Record review of the current care plan for Resident 51 dated 6/7/24 revealed that Resident 51 used medications with black box warnings (alerts to healthcare providers and patients to serious, life-threatening, or permanently disabling adverse effects). Additional review of Resident 51's care plan reveals no reference to an antipsychotic medication, the residents goals or interventions. Record review of the Order Summary (a listing of all physician orders for a resident) for Resident 51 dated 6/24/26 revealed that Resident 51 had an order for Abilify (an antipsychotic medication) 2 milligrams (mg) daily for depression. The order date was 5/4/26. An interview on 6/24/26 at 1:45 PM with MDS-P revealed that when an antipsychotic is initiated and the medication falls within the MDS lookback period, this will be added to the care plan. MDS-P agreed that the care plan for Resident 51 was missing the antipsychotic problem/need, goal, and interventions needed to care for the resident.

Based on record review and interview, the facility failed to submit accurate Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities) for the medication regimen for 1 (Resident 5) of 5 sampled residents. The facility identified a census of 99 residents. Findings are:Record review of a facility document titled, admission record, revealed Resident 5 was admitted on [DATE] with diagnoses of Type 2 diabetes mellitus (a chronic disease in which the body does not use insulin effectively, leading to irregular blood sugar levels and medical complications), acute respiratory failure, lymphedema (tissue swelling caused by extra fluid that is usually drained by the body's lymphatic system), and chronic lymphocytic leukemia (CLL, a type of cancer that affects the blood and bone marrow).Record review of Resident 5's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities) dated 1/14/26, Section N revealed Resident 5 had received 2 insulin injections in the 7 days prior to the assessment. Record review of Resident 5's quarterly MDS dated [DATE], Section N revealed Resident 5 had received 1 insulin injection in the 7 days prior to the assessment.A record review of Resident 5's medication orders in Point Click Care (PCC, an electronic medical record system), revealed an order for an injection of semaglutide (Ozempic) 1 milligram at bedtime weekly for weight loss related to Type 2 diabetes. The orders also revealed no order for insulin.A record review of Resident 5's electronic Medication Administration Record (MAR) for January 2026 revealed they did not receive any insulin products. A record review of Resident 5's MAR for February 2026 revealed they did not receive any insulin products. A record review of Resident 5's MAR for March 2026 revealed they did not receive any insulin products. A record review of Resident 5's MAR for April 2026 revealed they did not receive any insulin products. A record review of the prescribing information for Ozempic last revised May 2026, revealed semaglutide reduces blood sugar by stimulating insulin secretion (Section 7 Drug interactions and Section 12 Clinical pharmacology). The prescribing information also revealed Ozempic did not contain insulin, can be administered while also taking insulin, and the ingredients did not list insulin.An interview on 6/24/26 at 11:08 AM with the MDS Coordinator (MDS-O) confirmed the facility reported the resident as receiving insulin injections for the January and April MDS assessments, and that Resident 5 did not receive insulin, they received Ozempic. MDS-O revealed the facility's corporate home office had previously advised them to report that way, but on 6/5/26 MDS-O was notified in writing that the facility should begin reporting Ozempic as insulin. The interview also revealed no corrections or modifications had been submitted for Resident 5's January or April 2026 MDS assessments.

Licensure Reference Number 175 NAC 12-006.05(E)(F)Based on record review and interview, the facility failed to ensure that Resident Rights, which are presented to the residents and resident representatives at the time of admission, are honored and followed as written. This affected one resident of one sampled, Resident 22. The facility census was 99. Record review of the Resident Rights (federally protected rights that ensure a safe, dignified, and respectful life which guarantee freedom from abuse, the ability to make personal choices, and the right to proper medical care. Facilities must fully inform residents of these rights upon admission.) received from the Facility Administrator (FA) had a copyright date of 2017 and revealed the document is to inform you of your rights as a resident of this facility. Federal law requires that we provide these rights in writing, in a language and format you understand, upon admission and throughout your stay. Carefully review these rights by yourself and / or with your responsible party. During your stay, if any of these change, you will be given a revised copy. In addition, these rights are posted in the facility. Understanding your rights is important, and it helps us provide you with the highest level of care. Included were the following rights:Your Right: To be information of all your rights upon admission and during your stay in the facility (F572)Your Right: To review and make changes to your own plan of care (F553)Your Right: To make choices about aspects of your life in the facility that are significant to you, the resident.Your Right: To be informed of your health status medical condition. TO be given information about the type of care that will be provided during your stay. To participate in planning you own care. Record review of the Quarterly Care Plan Conference Summary for Resident 22 dated 10/14/2025 revealed that Resident 22 was not invited to the care plan conference and did not attend the care plan conference. A family member or the resident's responsible party did attend. The summary revealed that during the meeting, nursing concerns, dietary intake, life enrichment participation and social service concerns were reviewed. It was also determined that Resident 22 would start meetings with a telehealth physician or nurse, and that the resident had started participating in more life enrichment opportunities. Record review of the Care Plan Acknowledgement Form dated 10/14/2026 revealed that the care plan had been conducted over the phone with the Power of Attorney (POA) - a trusted person who cares for financial and legal affairs) and Healthcare Power of Attorney (HPOA) - a trusted person who makes medical decisions for you. This person only steps in to make choices if you become too sick or hurt to speak for yourself. It ensures your doctors follow your exact wishes of Resident 22. There was no signature for Resident 22 and no indication that Resident 22 had attended nor was there evidence that Resident 22 was invited to the conference. The signature line of the Representative of Resident 22 was marked with an X and stated phone call with (POA) and then form was signed by the facility Director of Nursing (DON)Record review of the Care Plan Acknowledgement Form dated 11/4/2025 revealed that the family had declined the care conference and the Interdisciplinary Team (IDT) held a meeting (a collaborative meeting where professionals from different healthcare or service disciplines come together to plan, coordinate, and review a patient's care) to discuss the resident cares and Resident 22 was not in attendance nor was there evidence that Resident 22 was invited to the conference. Record review of the Care Plan Acknowledgement Form dated 1/6/2026 revealed that the family had declined the care conference and the IDT held a meeting to discuss the resident cares and Resident 22 was not in attendance nor was there evidence that Resident 22 was invited to the conference. Record review of the Care Plan Conference Summary dated 3/3/2026 revealed that Resident 22 had not been invited to the Care Plan conference.Record review of an undated and untitled note from the facility Administrator presented to the surveyors for review stated the following: Annually Resident Rights are sent out via mail to first Emergency Contact/POA or handed out to resident who are cognitively intact. Resident Rights Letters in our facility are sent out every January; Brief Interviews for Mental Status scores (BIMS Score - a quick, 15-point cognitive screening test used primarily in nursing homes and post-acute care settings to evaluate a patient's memory, ability to learn, and orientation. 13 to 15 Points (Cognitively Intact): Normal thinking and memory; the patient can generally function independently with minimal tailored cognitive support. 8 to 12 Points (Moderate Cognitive Impairment): Noticeable memory and thinking issues. The patient may require extra assistance with certain daily tasks and tracking cognitive decline. 0 to 7 Points (Severe Cognitive Impairment): Significant difficulties in orientation and memory.) are reviewed and sent out at that time. January 2026 Resident Rights Letter for Resident 22 was sent via mail to their Resident Representative. At that time, Resident 22 had a recent health decline and had increased confusion. BIMS Score on 12/30/2025 was 6/15. Residents Rights reviewed with POA during care conference on 3/3/2026. Resident Rights are reviewed monthly at Resident Council Meetings. Resident rights letter and Resident Right Packet were signed and provided to Resident 22 in 2025.A blank form letter accompanied this undated and untitled note from the FA which revealed the following: Enclosed you will find a copy of the Residents' Rights according to law. It is important that you are aware of these rights, and it is out obligation to provide them to you on an annual basis.Interview on 06/22/2026 at 1:35 PM with Resident 22 revealed that when asking about care and treatment within the facility, Resident 22 was knowledgeable about hospitalizations, cares, staff, meals, some medications but not all, activities in the facility and those Resident 22 preferred to attend, some specific past medical history pertaining to infections, knowledge of other diagnoses, but had no knowledge of care plans or what care plan meetings were. When an explanation of what care plan meetings were and who is allowed to attend care plan meetings, Resident 22 stated they still had no knowledge of care plan meetings or having attended any in the past.Interview on 06/23/2026 at 2:57 PM with the Medical Records and Social Services Nurse (MR) who stated that Resident 22's Power of Attorney (POA) that used to live in town passed away last year (March 2025). After that, the new POA appointed was another family member who resides out of state. The POA was enacted. Because the POA was enacted, we (the facility staff) usually have a care conference over the telephone and just leave it at that. So even though Resident 22 could be invited to come to the care conference, we don't always have the residents who have a POA enacted come to those conferences or have any input since we have a phone call. When asked at what point residents give up their resident rights to attend care plan conferences to discuss their plans of care, MR stated that residents do not give up their rights to attend care conferences. When asked if the staff speak to the residents about their cares, MR stated that staff do talk to them but most input is from the Resident Representative or POA. We usually invite residents to the Care Plan meetings based on their BIMS score, MR stated that anyone with a BIMS score over 3 should be invited to the care plan meetings. When asked to confirm this, the MR again stated that anyone with a BIMS score over 3 should be invited to the care plan meetings so that they had some input into the plans of care for that individual. There are individuals whose BIMS scores change because they were sick one month and now, they are back to their normal baseline. Even though we usually just check in with the family, there is really no reason we couldn't have the residents come to the care plan meetings to visit or listen to the plans especially if they are able to speak to us. If there is something that we discuss that may upset them such as they are no longer able to go home and this is going to be their permanent home or other serious matters, we could take the residents back to their rooms and then finish the meetings with the POA. Yes, I do think that going forward we probably should bring the residents to the meetings if they are able to attend, or they want to attend, so they can talk to all of us.Interview on 6/24/26 at 9:00 AM with the Social Services Director (SSD) revealed At no point do residents give their rights away to participate in care plan meetings, it has more to do with their ability to understand what the care plan meeting is about. Interview on 6/24/26 at 9:08 AM with Medical Records and Social Services nurse (MR) revealed residents never give up their rights to be able to attend a care plan meeting. So I guess, all of them need to be invited to the care plan whether the family wants them there or not. If we get to a point in a meeting when it may be upsetting to the resident and the family would like to discuss part of the care plan without the resident in attendance, we could probably remove the resident from the situation at the time. Interview on 6/24/26 at 11:00 AM with the FA, it was revealed after record review of the undated and untitled note about the information pertaining to Resident Rights sent to Resident 22's POA also had a copy of the Resident Rights presented to surveyors with the admission packet. The FA further stated that residents who have a lower BIMS score are not invited to the care plan meetings either because family has asked that they not be there or because they have a lower BIMS score and would not understand. For those who have a BIMS score that changes due to health status, if the BIMS score is 6 and changes to an 11, we would not invite them if the score was 6 but if it changes and it is now an11, they would be invited. Invitations to the care plan meetings are dependent upon the BIMS score. We do send the resident representative a copy of the Resident Rights in the mail each year. Surveyors were given a copy of the resident rights. When asked if the resident rights says that residents have the right to participate in their care plans depending upon their BIMS score, the FA agreed that it states Residents have a right to participate in their care plan. Residents have a Resident Council and Resident 22 attends the Resident Council meetings frequently. In the council meetings they discuss the resident rights at that time, so all of the residents should know they have a right to go to their care plan meetings. When asked if the Residents ever give up the right to attend care plan meetings, the FA again stated that residents are invited to the care plan meetings if their BIMS score is high enough which would indicate whether they would understand what they are discussing in the meeting.In a confirmation interview with the Director of Nursing (DON) on 6/24/26 at 11:00 AM, the DON confirmed that all residents had a right to be invited to the care plan meetings, that residents do not give up this right, and this is not being done by the facility. There was also no documentation in the resident records that confirm the resident had been invited and that the resident had chosen either not to attend or did not want to attend.

Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview the facility failed to obtain complete consents for psychoactive medications for 2 of 5 residents (Residents 28 and 46), and failed to ensure that the resident power of attorney (POA; a legal document that allows a person to designate someone else to make decisions or act on their behalf regarding financial, legal, or medical matters) provided informed consent for use of psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) as required for 1 of 5 residents reviewed (Resident 51). The facility census was 99. Findings are:Record review of a facility document titled, Psychoactive medication and medication regimen review standard, dated 6/2026, revealed a policy for managing residents' medication regimens, as well as guidelines for psychoactive medications. The policy also revealed a consent for the use of psychoactive medications must be completed prior to initiating any psychoactive medication. A. Record review of a facility document titled, admission record, revealed Resident 46 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a progressive lung disease which causes restricted breathing), anxiety, major depressive disorder (mood disorder that can cause persistent feelings of sadness, hopelessness, and loss of interest in activities, bipolar disorder, and cervical spondylosis with radiculopathy (the degeneration of bones and disks in the neck which results in nerve pain). A record review of Resident 46's medication orders in Point Click Care (PCC, an electronic medical record system), revealed that Resident 46 had orders for the following psychoactive medications: - Alprazolam (an antianxiety medication) 0.5 milligrams (mg) by mouth 2 times daily for anxiety with an order date of 11/6/25. -Divalproex (Depakote, a medication for bipolar, epilepsy - a seizure disorder, and migraine headaches) 125 mg twice daily, for major depressive disorder, with an order date of 6/12/26. -Paroxetine (an antidepressant) 10 mg tablet at bedtime every other day for major depressive disorder, with an order date of 3/28/26. -Quetiapine (Seroquel, an antipsychotic, used to treat schizophrenia, bipolar disorder, and major depressive disorder) 25 mg at bedtime every other day for major depressive disorder, with an order date of 3/16/26. A record review of the Resident 46's electronic medical record (EMR) revealed the following facility documents each titled, Informed consent for use of psychotropic medications: -A consent for Resident 46's paroxetine 10 mg at bedtime signed on 11/6/25 without a checkmark to select the antidepressant section or any side effects, and in the section, Statement of consent, neither box was checked to select if the medication had been consented to or not. -A consent for Resident 46's Seroquel 25 mg every other day signed on 11/6/25 without a checkmark to select the antipsychotic section or any side effects, and in the section, Statement of consent, neither box was checked to select if the medication had been consented to or not. -A consent for Resident 46's alprazolam 0.5 mg twice a day signed on 11/6/25 without a checkmark to select the antianxiety section side effects. -A consent for Resident 46's divalproex signed on 6/12/26 revealed no diagnosis for which the medication was prescribed, and in the section, Statement of consent, neither box was marked to indicate whether the medication had been consented to or not. A record review of Resident 46's progress notes included a note dated 6/11/26, which revealed Resident 48 had been prescribed Depakote for 30 days, ending on 5/25/26. Resident 46's medical provider had noted during a visit on 6/10/26 the medication was no longer on the resident's medication list and wanted to restart it. A record review of the EMR revealed no evidence Resident 46 or their representative had consented to the administration of Depakote for the 30 days ending 5/25/26. The facility did not provide evidence that consent had been obtained. B. Record review of a facility document titled, admission record, revealed Resident 28 was admitted on [DATE] with diagnoses of Type 2 diabetes mellitus (a chronic disease in which the body does not use insulin correctly, which can lead to high blood sugar levels and severe complications), chronic respiratory failure, and major depressive disorder. A record review of Resident 28's medication orders in PCC revealed an order to administer mirtazapine (an antidepressant) 7.5 mg tablet at bedtime for major depressive disorder, with an order date of 6/17/26. A record review of the Resident 28's EMR revealed a facility document titled, Informed consent for use of psychotropic medications, signed on 6/1/26 revealed a consent for Resident 28's mirtazapine 7.5 mg. No diagnosed condition was selected on the form to indicate why the medication was prescribed and, in the section, Statement of consent, no option was marked to indicate whether the medication had been consented to or not. An interview on 6/25/2026 at 8:45 AM with the Director of Nursing confirmed the psychoactive medication consents for Residents 46 and 28 were not filled out completely and should have been. An interview on 6/25/26 at 8:34 AM with the Facility Administrator confirmed the psychoactive medication consents for Residents 46 and 28 were not filled out completely and should have been. C. Record review of the facility policy titled Psychoactive Medication and Medication Regimen Review Standard dated 6/26 revealed that consent for use of psychoactive medication form must be completed prior to initiating and with the increase of any psychoactive medication. It must be reviewed/updated quarterly in conjunction with the care planning process and as needed (PRN). Completion of this form is required for every resident that receives routine or prn psychoactive medication. Record review of the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) for Resident 51 dated 5/6/26 revealed that Resident 51 had a diagnosis of depression and non-Alzheimer's dementia (a diverse group of brain disorders causing cognitive and functional decline). The MDS revealed that Resident 51 received an antipsychotic (a psychotropic medication) 7 days of the 7-day MDS lookback period. Record review of the current care plan for Resident 51 dated 6/7/24 revealed that Resident 51 used medications with black box warnings (alerts to healthcare providers and patients to serious, life-threatening, or permanently disabling adverse effects). Additional review of Resident 51's care plan reveals resident's (family member gender) is resident's POA and HPOA (healthcare power of attorney). Record review of the Order Summary (a listing of all physician orders for a resident) for Resident 51 dated 6/24/26 revealed that Resident 51 had an order for Abilify (an antipsychotic medication) 2 milligrams (mg) daily for depression. The order date was 5/4/26. Record review of the medical record for Resident 51 revealed no evidence of a consent for use of psychotropic medications with acknowledgement of the POA. Interview on 6/24/26 at 11:18 AM with the nurse manager licensed practical nurse (LPN)-N for Resident 51 confirmed that the facility is required to receive a psychotropic consent form for the resident or the POA as required. Interview on 6/24/26 at 12:58 PM with the facility Staff Development Nurse (SDN) revealed that the nurse manager is responsible for receiving a psychotropic medication consent form when a medication is ordered from the physician, signed either by the resident or the resident's POA.

Based on observation, interview, and review of the 2022 Food Code, the facility failed to ensure: 1) there was a trash can near the handwashing sink; 2) pots and pans were stored inverted; 3) expired food items were discarded; and 4) staff washed their hands when they entered the kitchen before they began to prepare food. These deficient practices affected all residents who received food from the kitchen. Findings included: 1. Section ,d+[DATE] Storing of the 2022 Food Code published by the United States Food and Drug Administration, indicated (B) Clean equipment and utensils shall be stored as specified under [symbol] (A) of this section and shell be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. Section ,d+[DATE].20 Disposable Towels, Waste Receptables. A handwashing sink or group of adjacent handwashing sinks that is provided with disposable towels shall be provided with a waste receptable as specified under [symbol] ,d+[DATE].16(C). During a concurrent observation and interview on [DATE] at 9:00 AM, the surveyor noted there was not a trash can by the handwashing sink. The surveyor also noted there were six to 10 quart size pots stored that were not inverted and five ladles exposed to debris. The Culinary & Dining Coordinator (CDC) stated the pots and pans were always stored inverted. During an interview on [DATE] at 10:33 AM, the CDC stated there should be a trash container that opened with food control at every handwashing sink. During an interview on [DATE] at 11:18 AM, the Administrator stated pots and pans should be hung or stored inverted to avoid contamination. 2. During a concurrent observation of the facility's refrigerator and interview on [DATE] 9:15 PM, the surveyor noted there was a three-pound bag of mini cauliflower that had black spots in various areas and one rancid tomato with black and white spots. The CDC stated the cauliflower had black mold and the black and white spots on the tomato was mold. The CDC discarded the tomato. During a concurrent observation of the facility's freezer and interview on [DATE] 9:20 PM, there was a package of hot dogs that had a manufacturer date of [DATE]. The CDC stated the hot dogs were expired and discarded them. During an interview on [DATE] at 10:33 AM, the CDC stated Culinary Lead (CL) I entered the facility's refrigerator on [DATE] and noticed the rancid tomato, was going to return to the refrigerator to discard the tomato but got called to do something else and forgot to return to the refrigerator to discard the tomato. 3. During a concurrent observation and interview on [DATE] at 11:08 AM, Culinary Assistant (CA) C entered the kitchen and did not wash their hands before they began to prepare food. CA C stated they were trained and were supposed to wash their hands when they entered the kitchen. CA C stated they normally washed their hands, but spaced out and forgot. CA C stated it was important for staff to wash their hands because of germs. During an observation on [DATE] at 11:18 AM, CL D entered the kitchen without washing their hands and began to prepare a hamburger. During an interview on [DATE] at 11:18 AM, the Administrator stated the first thing staff should do when they enter the kitchen was wash their hands to ensure their hands were clean before they handled food items to avoid contamination. During an interview on [DATE] at 1:13 PM, CL D stated they were supposed to wash their hands when they entered the kitchen. During an interview on [DATE] at 3:37 PM, the Director of Nursing (DON) stated staff should wash their hands all the time. Per the DON, there was supposed to be a trash can by the handwashing sink. The DON stated she did not know how pots and pans should be stored.

Based on observation, interview, and record review, the facility failed to store respiratory equipment when not in use to prevent contamination for 1 (Resident #9) of 3 sampled residents reviewed for respiratory care. Findings included: An Admission Record revealed the facility admitted Resident #9 on 11/13/2018. According to the Admission Record, the resident had a medical history to include a diagnosis of Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2025, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident was severe cognitive impairment. The MDS indicated that the resident required oxygen therapy. Resident #9's Care Plan Report included a focus area initiated 06/26/2024, that indicated the resident was at risk for altered respiratory function related to oxygen therapy. Interventions directed staff to check oxygen saturation as required and monitor for shortness of breath as needed. Resident #9's physician's order dated 11/15/2024, indicated oxygen at 2 liters per minute (L/min) via nasal cannula (NC) to be titrated to maintain oxygen saturation greater than 90%. During an observation on 04/14/2025 at 10:02 AM, Resident #9 was resting in bed receiving oxygen therapy at 2 L/min. The oxygen tubing was attached to Resident # 9's oxygen concentrator, which was dated 04/13/2025. Resident #9 had a portable oxygen tank attached to the side of their wheelchair and the oxygen tubing with the cannula was not in a bag but was tucked into the pocket on the back of the resident's wheelchair. During an observation on 04/15/2025 at 9:45 AM, Resident #9 was in the common area and had oxygen on and the oxygen was set at 2 L/min. During a concurrent observation and interview on 04/15/2025 at 9:54 AM, Resident # 9 was in the community area resting with portable oxygen at 2 L/min via NC. The tubing was dated 04/13/2025. Medication Aide (MA) E stated Resident #9 came out of their room for activities and would sit in the community area to watch television. MA E stated residents would use portable oxygen canisters when they were out of their room or out of the facility and oxygen concentrators were used in resident rooms. MA E stated Resident #9 received continuous oxygen at 2 L/min and Nursing Assistant (NA) F put the resident's oxygen on that morning. MA E stated oxygen tubing and cannulas should be stored in black bags when not in use or they could get soiled which could lead to the resident breathing in dirt. MA E verified Resident #9 did not have the black bag for oxygen tubing storage. During an interview on 04/15/2025 at 10:08 AM, NA F revealed they was trained to store oxygen tubing in the black bags when not in use. NA F stated they cared for Resident #9 and helped the resident out of bed that on 04/15/2025. NA F stated they noticed the resident's oxygen tubing was not stored in the black back and meant to change out the tubing but forgot to do so. NA F stated if the oxygen tubing was not stored properly, the tubing would become contaminated. During an interview on 04/16/2025 at 10:05 AM, Licensed Practical Nurse (LPN) G stated oxygen concentrators should have a black bag attached to oxygen concentrator or portable canister for storage. LPN G stated oxygen tubing should be rolled up and placed in the bag while not in use. LPN G stated this was important for infection control. LPN G stated they were familiar with Resident #9 and that the resident received oxygen at 2 L/min. During an interview on 04/16/2025 at 3:20 PM, the Director of Nursing (DON) stated oxygen tubing and cannulas should be stored in black bags while not in use. The DON stated all nursing staff were responsible for ensuring and monitoring for oxygen tubing being stored properly. The DON stated Resident #9 was on continuous oxygen at 2 L/min. The DON stated the expectation would be that the concentrator and the portable oxygen would both have storage bags. The DON stated if any oxygen tubing were left unbagged while not in use, the expectation would be to change the tubing to a new one. During a follow-up interview on 04/16/2025 at 1:58 PM, the DON stated the facility did not have a policy related to storage of oxygen tubing and cannulas.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer treatment interventions were implemented in an effort to prevent new or worsening pressure ulcers for 1 (Resident #10) of 2 sampled residents reviewed for pressure ulcer/injury. Findings included: An Admission Record revealed the facility admitted Resident #10 on 09/22/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of pressure-induced deep tissue damage of the sacral region. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with lower body dressing and was dependent on staff for putting on/taking off footwear. According to the MDS, the resident was at risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. Resident #10's Care Plan Report included a focus area initiated 10/02/2023 and reviewed 04/03/2023, that indicated the resident had a potential for skin breakdown. Interventions directed staff to provide pressure-relieving devices to the resident's chair and bed at all times (initiated 10/02/2023), a pressure relieving cushion to the resident's wheelchair and recliner when being used (initiated 04/22/2024), and for the resident to wear off-loading boots to bilateral feet while in bed or recliner (initiated 10/28/2023). Resident #10's Braden Scale for Predicting Pressure Sore Risk dated 03/29/2025 indicated the resident was at risk for the development of pressure ulcers. Resident #10's Pressure Ulcer Record indicated on 04/01/2025, the resident's unstageable pressure ulcer measured 0.2 centimeter (cm) by (x) 0.2 cm x 1.3 cm and on 04/08/2025, the resident's pressure ulcer measured 0.2 cm x 0.2 cm x 1.4 cm. Per the Pressure Ulcer Record, the resident continued with a chronic wound to their coccyx. Resident #10's Order Recap Report for the timeframe 01/01/2025 - 04/30/2025, revealed an order dated 09/24/2024, that directed the staff to ensure the resident always wore off-loading boots to both feet except when ambulating or transferring every shift for skin integrity. During an observation on 04/15/2025 at 8:00 AM and 8:14 AM, Resident #10 was noted at a table for breakfast. The resident did not have a pressure-relieving device in their chair. During an observation on 04/15/2025 at 10:57 AM, Resident #10 was noted in a chair in the activity room and the resident did not have a pressure-relieving device. During an observation on 04/15/2025 at 10:58 AM, Nursing Assistant (NA) H assisted Resident #10 in walking back to their room. NA H placed the resident in their recliner, but did not place off-loading boots on the resident's bilateral feet. During an interview on 04/15/2025 at 11:07 AM, NA H stated that when they took Resident #10 back to their room, they elevated the resident's legs and placed their boots on. NA H acknowledged the resident was not wearing their off-loading boots at the present time and they did not ask the resident if they wanted the off-loading boots on. During a concurrent observation and interview on 04/15/2025 at 11:48 AM, NA A stated every time Resident #10 was in their recliner or bed, the resident was supposed to have their off-loading boots on and a cushion should be placed in their chair. Per NA A, Resident #10 had the off-loading boots and cushion because they had a sore on their bottom. NA A observed the resident in their room and stated the resident did not have their off-loading boots on. NA A looked in the resident's room for the off-loading boots and found them in the resident's closet. On 04/15/2025 at 1:43 PM, the surveyor observed Registered Nurse (RN) B provide wound care for Resident #10. RN B measured the resident's coccyx pressure ulcer and stated the wound measured 0.2 cm x 0.2 cm x 0.2 cm. During an interview on 04/15/2025 2:08 PM, RN B stated Resident #10 should have the pressure-relieving cushion in place. During an observation on 04/15/2025 at 2:56 PM, Resident #10 was in activities and there was no pressure-relieving device in their chair. During a follow-up telephone interview on 04/15/2025 at 3:23 PM, NA A stated when they came to work at 6:00 AM on 04/15/2025 Resident #10 was in their recliner and had off-loading boots on. NA A stated they removed the resident's off-loading boots when they took the resident to breakfast at 7:30 AM. According to NA A, an unknown person removed the resident from activities and took them to their room and did not place the resident's off-loading boots on when they placed the resident in their recliner that did not have a pressure-relieving cushion. During an interview on 04/15/2025 at 3:27 PM, the RN - Staff Development (RN SD) stated they was the facility's wound care nurse. The RN SD stated Resident #10's pressure ulcer was facility-acquired and the wound was much better now as the facility had made a significant amount of progress in healing the resident's pressure ulcer. The RN SD stated Resident #10 should have their off-loading boots all the time except when they were ambulating. During an interview on 04/16/2025 at 10:33 AM, the Director of Nursing (DON) stated Resident #10 was to have off-loading boots on when in bed. The DON stated Resident #10 had a pressure relieving cushion which should be used in their recliner. During an interview on 04/16/2025 at 11:53 AM, the Administrator stated they deferred questions to the clinical team.

Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent the development of pressure ulcers for 1 (Resident #10) of 2 sampled residents reviewed for pressure ulcer/injury. Findings included: An Admission Record revealed the facility admitted Resident #10 on 09/22/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of pressure-induced deep tissue damage of the sacral region. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with lower body dressing and was dependent on staff for putting on/taking off footwear. According to the MDS, the resident was at risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. Resident #10's Care Plan Report included a focus area initiated 10/02/2023 and reviewed 04/03/2023, that indicated the resident had a potential for skin breakdown. Interventions directed staff to provide pressure-relieving devices to the resident's chair and bed at all times (initiated 10/02/2023), a pressure relieving cushion to the resident's wheelchair and recliner when being used (initiated 04/22/2024), and for the resident to wear off-loading boots to bilateral feet while in bed or recliner (initiated 10/28/2023). Resident #10's Order Recap Report for the timeframe 01/01/2025 - 04/30/2025, revealed an order dated 09/24/2024, that directed the staff to ensure the resident always wore off-loading boots to both feet except when ambulating or transferring every shift for skin integrity. During an observation on 04/15/2025 at 8:00 AM and 8:14 AM, Resident #10 was noted at a table for breakfast. The resident did not have a pressure-relieving device in their chair. During an observation on 04/15/2025 at 10:57 AM, Resident #10 was noted in a chair in the activity room and the resident did not have a pressure-relieving device. During an observation on 04/15/2025 at 10:58 AM, Nursing Assistant (NA) H assisted Resident #10 in walking back to their room. NA H placed the resident in their recliner, but did not place off-loading boots on the resident's bilateral feet. During an interview on 04/15/2025 at 11:07 AM, NA H stated that when they took Resident #10 back to their room, they elevated the resident's legs and placed their boots on. NA H acknowledged the resident was not wearing their off-loading boots at the present time and they did not ask the resident if they wanted the off-loading boots on. During a concurrent observation and interview on 04/15/2025 at 11:48 AM, NA A stated every time Resident #10 was in their recliner or bed, the resident was supposed to have their off-loading boots on and a cushion should be placed in their chair. Per NA A, Resident #10 had the off-loading boots and cushion because they had a sore on their bottom. NA A observed the resident in their room and stated the resident did not have their off-loading boots on. NA A looked in the resident's room for the off-loading boots and found them in the resident's closet. During an interview on 04/15/2025 2:08 PM, Registered Nurse (RN) B stated everyone was responsible for implementing a resident's care plan interventions. RN B stated Resident #10 should have the pressure-relieving cushion in place. During an observation on 04/15/2025 at 2:56 PM, Resident #10 was in activities and there was no pressure-relieving device in their chair. During a follow-up telephone interview on 04/15/2025 at 3:23 PM, NA A stated when they came to work at 6:00 AM on 04/15/2025 Resident #10 was in their recliner and had off-loading boots on. NA A stated they removed the resident's off-loading boots when they took the resident to breakfast at 7:30 AM. According to NA A, an unknown person removed the resident from activities and took them to their room and did not place the resident's off-loading boots on when they placed the resident in their recliner that did not have a pressure-relieving cushion During an interview on 04/16/2025 at 10:33 AM, the Director of Nursing (DON) stated Resident #10 was to have off-loading boots on when in bed. The DON stated Resident #10 had a pressure relieving cushion which should be used in their recliner. The DON stated a resident's care plan was used by the staff to direct them as to the care provided to the resident and it should be implemented by the staff. During an interview on 04/16/2025 at 11:53 AM, the Administrator stated they deferred questions to the clinical team. During a follow-up interview on 04/16/2025 at 12:04 PM, the DON stated the facility did not have a policy for care plans but followed professional standards of care.

Licensure Reference 175 NAC 12-06.09(J)(i)(1) Based on record reviews and interviews, the facility staff failed to implement interventions to manage weight loss for 2 (Resident 1 and 2) of 3 sampled residents. The facility staff identified a census of 97. Findings are: A record review of an undated facility policy Significant Weight Loss indicated the following: - Significant weight loss in 1 week is 1-2%; more than 1-2% is considered severe weight loss. - Significant weight loss over 1 month is 5%; more than 5% is considered severe weight loss. - Significant weight loss over 3 months is 7.5%; more than 7.5% is considered severe weight loss. - Significant weight loss over 6 months is 10%; more than 10% is considered severe weight loss - The policy defined avoidable weight loss as an individual that did not maintain acceptable parameters of nutritional status and that the facility did not do one or more of the following: evaluate the individual's clinical condition, define and implement interventions, monitor and evaluate the impact of the interventions, and revise the interventions as appropriate. A. A record review of an Admission Record indicated the facility admitted Resident 1 on 6/7/2023 with diagnoses of Dementia, duodenitis (inflammation in the first part of your small intestine,) depression, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone,) and difficulty swallowing. A record review of Resident 1's quarterly (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 11/7/2024 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) of 12/15, indicating Resident 1 had moderate cognitive impairment. The MDS also indicated Resident 1 required supervision with eating. It also indicated Resident 1 was noted to have a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months and was not on a physician-prescribed weight-loss regimen. A record review of Resident 1's Care Plan revealed a focus area that indicated Resident 1 was at risk for potential impaired nutrition status related to pain, duodenitis, poor food intake, and depression with a last revised date of 11/12/2024. A record review of Resident 1's Weight Summary as of 1/22/2025 revealed the following information: -7-22-2024, weight (wt) was 116. lbs. -10-21-2024, wt was 97. lbs, a loss of 18 lbs or 15.51 %. The facility implemented the intervention of carnation breakfast with cereal at breakfast, ensure (supplement) twice a day and a milkshake at bed time. -11-21-2024, wt was 93. Lbs A record review of Resident 1's Order Summary Report as of 1/22/2025 revealed an order for a house supplement of 2-cal with directions to give 8 ounces four times a day as a weight loss supplement with a start date of 11/19/2024. A record review of Resident 1's Treatment Administration Record for the month of November 2024 revealed Resident 1's House Supplement was not given with a reason of Other/See Progress Note for the following dated: 11/24 8:00 PM dose, 11/25 8:00 PM dose, 11/26 4:00 PM dose, 11/26 8:00 PM, 11/28 4:00 PM dose, and 11/28 8:00 PM. A record review of Resident 1's Treatment Administration Record for the month of December 2024 revealed Resident 1's House Supplement was not given with a reason of Other/See Progress Note for the 12/7 8:00 PM dose, 12/12 8:00 PM dose, and 12/13 8:00 PM. A record review of Resident 1's Treatment Administration Record for the month of January 2025 revealed Resident 1's House Supplement was not given with a reason of Other/See Progress Note for the 1/9 8:00 PM dose, 1/21 5:00 PM dose, and 1/21 8:00 PM dose. A record review of Resident 1's Progress Notes from 11/24/2024 to 1/21/2024 revealed the following entries: - 11/24/2024 7:27 PM: House Supplement not given with a text entry reason of None available. Nurse notified. - 11/25/2024 8:34 PM: House Supplement not given with a text entry reason of Only 2 ounces available in fridge. - 11/26/2024 5:04 PM: House Supplement not given with a text entry reason of Waiting on kitchen. - 11/26/2024 7:09 PM: House Supplement not given with a text entry reason of Waiting on kitchen. - 11/28/2024 3:11 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 11/28/2024 7:19 PM: House Supplement not given with a text entry reason of Pending kitchen. - 12/7/2024 8:17 PM: House Supplement not given with a text entry reason of No 2-cal available. Nurse notified. - 12/12/2024 7:34 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 12/13/2024 7:02 PM: House Supplement not given with a text entry reason of None available, notified Charge Nurse. - 1/9/2025 7:24 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 1/21/2025 3:49 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 1/21/2025 7:39 PM: House Supplement not given with a text entry reason of Pending kitchen supply. An interview on 1/22/2025 at 4:22 PM with the Health Information Manager (HIM) and Clinical Coordinator RN-A confirmed Resident 1's supplements on the following dates were documented as not given: 11/24 8:00 PM dose, 11/25 8:00 PM dose, 11/26 4:00 PM dose, 11/26 8:00 PM, 11/28 4:00 PM dose, 11/28 8:00 PM dose, 12/7 8:00 PM dose, 12/12 8:00 PM dose, and 12/13 8:00 PM dose, 1/9 8:00 PM dose, 1/21 5:00 PM dose, and 1/21 8:00 PM dose. B. A record review of an Admission Record indicated the facility admitted Resident 2 on 8/2/2022 with diagnoses of Dementia, anemia (low red blood cells,) depression, and difficulty swallowing. A record review of Resident 2's quarterly MDS with an ARD of 1/1/2025 indicated that Resident 2 had a BIMS score of 3/15, which indicated Resident 2 had severe cognitive impairment. The MDS also indicated Resident 2 required supervision with eating and was on a mechanically altered diet. A record review of Resident 2's Care Plan reveal a focus area that indicated Resident 2 was at risk for potential impaired nutritional status related to poor food intake, weight loss, Dementia, anemia, difficulty swallowing, and depression with a last revised of 1/2/2025. A record review of Resident 2's Weight Summary as of 1/22/2025 revealed the following information: -7-20-2024, wt was 129.5 lbs. -10-19-2024, wt was 126.5 lbs. -12-21-2024, wt was 125.0 lbs. -1-21-2024, weight was 121.0 A record review of Resident 2's Order Summary Report as of 1/22/2025 revealed an order for a house supplement of 2-cal with directions to give 4 ounces four times a day as a nutritional supplement with a start date of 10/10/2024. A record review of Resident 2's Treatment Administration Record for the month of November 2024 revealed Resident 2's House Supplement was not given with a reason of Held/See Progress Note for the 11/5 8:00 AM dose and Other/See Progress Note on 11/6 8:00 PM dose, 11/25 8:00 PM dose, 11/26 8:00 PM dose, 11/28 5:00 PM dose, and 11/28 8:00 PM dose. A record review of Resident 2's Treatment Administration Record for the month of December 2024 revealed Resident 2's House Supplement was not given with a reason of Other/See Progress Note for the 12/12 5:00 PM dose, 12/12 8:00 PM dose, and 12/13 8:00 PM dose. A record review of Resident 2's Progress Notes from 11/5/2024 to 12/13/2024 revealed the following entries: - 11/5/2024 9:47 AM: House Supplement not given with a text entry reason of Pending kitchen. - 11/6/2024 7:51 PM: House Supplement not given with a text entry reason of Awaiting pharmacy. - 11/25/2024 7:23 PM: House Supplement not given with a text entry reason of Not enough available in fridges. - 11/26/2024 7:35 PM: House Supplement not given with a text entry reason of Waiting on kitchen. - 11/28/2024 5:02 PM: House Supplement not given with a text entry reason of Pending kitchen. - 11/28/2024 7:48 PM: House Supplement not given with a text entry reason of Missing. - 12/12/2024 5:17 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 12/12/2024 8:03 PM: House Supplement not given with a text entry reason of Pending kitchen supply. - 12/13/2024 7:10 PM: House Supplement not given with a text entry reason of None available, notified Charge Nurse. An interview on 1/22/2025 at 4:22 PM with the Health Information Manager (HIM) and Clinical Coordinator RN-A confirmed Resident 2's supplements were documented as not given on the following dates: 11/6 8:00 PM dose, 11/25 8:00 PM dose, 11/26 8:00 PM dose, 11/28 5:00 PM dose, 11/28 8:00 PM dose, 12/12 5:00 PM dose, 12/12 8:00 PM dose, and 12/13 8:00 PM dose. An interview on 1/22/2025 at 4:20 PM with the Certified Dietary Manager (CDM) revealed the dietary department makes the house supplements every morning and calculate enough for all residents' supplements for the day. The CDM also revealed that nursing was responsible for letting the dietary department know if they were running low before close, as nursing does not have access to additional supplement after the kitchen closes around 7:30 PM. An interview on 1/23/2025 at 9:50 AM with Medication Aide (MA) - D revealed that MA-D charts pending kitchen supply when the house supplement is not available and not available to be given. MA-D revealed frequent difficulties with having the house supplement available and has met challenges with calling the dietary department and being told it is not available as they do not have any and/or not being brought to nursing. An interview on 1/23/2025 at 10:00 AM with MA-E confirmed nursing is responsible for calling the dietary department if they are in need of additional house supplement. MA-E also confirmed that a note of pending kitchen supply means the house supplement was not given due to being unavailable. MA-E also confirmed that they frequently run out of house supplement for the 8:00 PM administration and the kitchen has already closed, so there is no access to obtaining additional supplement to be able to administer it.

Licensure Reference Number 172 NAC 12-006.05(21) Based on observations, interviews, record reviews, and facility policy review, the facility failed to maintain the dignity of 3 (Residents #43, #87, and #60) of 3 residents who were observed during dining. The facility failed to serve all residents who were sitting at the same table their meal at the same time before proceeding to the next table, leaving the residents to watch their tablemate's eat. The facility census was 99. Findings are: An undated excerpt from the employee handbook titled [Name of facility ownership] Values revealed, We will create a living environment that radiates love, peace, spiritual contentment, dignity and safety, while encouraging personal independence. A. A review of an Admission Record revealed the facility admitted Resident #43 on 04/02/2017. According to the Admission Record, the resident had a medical history that included diagnoses of hypertension and dementia. A review of Resident #43's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/2024 revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required supervision or touching assistance from staff with eating. A review of Resident #43's care plan revealed a Focus area revised on 04/04/2024 that indicated the resident required assistance with activities of daily living (ADLs). Interventions indicated the resident could eat independently after the meal was set up. B. A review of an Admission Record revealed the facility admitted Resident #87 on 10/02/2023 with diagnoses of unspecified dementia with behavioral disturbances and unspecified anxiety disorder. A review of Resident #87's quarterly MDS, with an ARD of 03/27/2024, revealed Resident #87 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required setup or clean-up assistance from staff with eating. A review of Resident #87's care plan revealed a Focus area initiated on 10/15/2023 that indicated the resident required assistance with ADLs. Interventions indicated the resident could eat independently after the meal was set up. An observation was made of the breakfast service in the 300 unit dining room on 04/17/2024 beginning at 8:15 AM. There were six tables in the dining room, with two to three residents seated at each table, for a total of 13 residents having breakfast in the dining room. Resident #43 was seated at a table with two other residents. At 8:30 AM, a tablemate of Resident #43 was served their breakfast. This was the first resident to receive their breakfast, and immediately, staff started to assist the resident with eating. Resident #43 and the other tablemate were sitting and looking at the resident who was eating. Resident #43's other tablemate was served at 8:40 AM. Resident #43 was the last resident in the dining room to receive their breakfast tray at 8:50 AM. During this same observation, Resident #87 was observed seated at a table with one other resident. Resident #87's tablemate was served breakfast at 8:35 AM. Resident #87 stated loudly, Where is my breakfast? Everyone is eating but me. Staff tried to assure the resident that their meal would be served shortly. Two other residents received their breakfast tray, at which time Resident #87 again stated, Where is my food? Resident #87 received their tray at 8:40 AM. During an interview on 04/17/2024 at 8:52 AM, Medication Aide (MA) A stated they had been trained to serve all residents at one table before starting meal service at other tables. MA A stated they would feel bad if they had to sit and wait 20 minutes to receive their meal tray and watch their tablemate's eat, as had happened between Resident #43 and their tablemate's. MA A stated they had no reason why they had not followed the meal service process as they had been trained. During an interview on 04/17/2024 at 9:00 AM, Registered Nurse (RN) B, who had been in the dining area assisting residents during the meal service, stated staff had been trained to serve all residents at one table before beginning meal service at another table. RN B stated it was important to serve all residents at one table at the same time so no resident would feel left out. RN B stated the expectation was for one table to be completely serviced before proceeding to the next table. RN B acknowledged that Resident #43 should not have waited to receive the breakfast tray for 20 minutes after the first resident at their table had been served. RN B acknowledged they had heard Resident #87 yelling out for their breakfast tray and stated everyone else was eating but Resident #87. During an interview on 04/18/2024 at 8:59 AM, RN C stated staff were taught to serve all residents at one table before moving to another table. RN C stated that when a resident was not served at the same time as their tablemate's, it was considered a dignity issue. During an interview on 04/18/2024 at 9:47 AM, the Social Services Director (SSD) stated staff were encouraged to serve everyone at a table before proceeding to the next table and added this was important so all residents could eat their meals together. The SSD stated that dining in the facility was like dining in a restaurant and that it was a dignity issue to make tablemate's wait for their meals. During an interview on 04/18/2024 at 12:18 PM, the Social Services Assistant (SSA) stated that during the past few months, residents had mentioned an issue regarding not all residents at one table being served at the same time. The SSA stated they understood how not being served at the same time as tablemate's would bother some residents, but added the facility had open-concept dining, which meant residents came to the dining room as they wished. The SSA stated that when Resident #87 asked where their food was during the observation, the staff should have served Resident #87 next and not passed other trays. During an interview on 04/18/2024 at 1:10 PM, the Director of Nursing (DON) stated the facility was trying to get away from a strict dining schedule and give the residents more choices. The DON stated if all residents were sitting at a table ready to be served, they expected all residents at the table to be served before moving to another table. During an interview 04/18/2024 at 12:38 PM, the Administrator stated they did not see residents at one table not being served at the same time as a dignity issue since the facility had an open concept dining plan. The Administrator stated they did not want anyone to feel bad about not having their meal served and the facility tried to serve everyone as quickly as possible. 29673 C. A review of an Admission Record revealed the facility admitted Resident #60 on 08/22/2020. The Admission Record revealed the resident had a diagnosis of need for assistance with personal care. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/07/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. According to the MDS, the resident required setup or clean-up assistance with eating. During an interview on 04/15/2024 at 11:52 AM, Resident #60 stated their only complaint was that the facility did not serve meals to those seated at the table in the dining room at the same time. The resident said they sat at a table with three other residents and that it could take up to 20 minutes for everyone at the table to receive their meal. Resident #60 stated they did not like watching others eat while he/she was hungry and did not like to eat while others did not have their food. An observation was made of the noon meal being served in the 500 Unit dining room on 04/18/2024 at 12:03 PM. Resident #60 was seated at a table with three other residents with the first resident at the table was served at 12:04 PM, and the second resident was served at 12:05 PM. After serving the second resident seated at Resident #60's table, staff served residents at two separate tables before returning to Resident #60's table. Resident #60 received their tray at 12:10 PM. During an interview on 04/18/2024 at 8:59 AM, Registered Nurse (RN) C stated staff were taught to serve all residents at one table before moving to another table. RN C stated that when a resident was not served at the same time as their tablemate's it was considered a dignity issue. During an interview on 04/18/2024 at 9:47 AM, the Social Services Director (SSD) stated staff were encouraged to serve everyone at a table before proceeding to the next table and added that it was important so all residents could eat their meal together. The SSD stated it was considered a dignity issue to make tablemate's wait for their meals. During an interview on 04/18/2024 at 1:10 PM, DON stated if all residents seated at the same table were ready to be served, staff were expected to serve all residents at the table before serving another table.

Licensure Reference Number 175 NAC 12-006.14 Based on observation, interviews, record review, and facility policy review, the facility failed to provide routine dental services for 1 (Resident #71) of 1 sampled resident reviewed for dental services. The facility census was 99. Findings are: A review of the facility policy titled Dental Policy dated August 2017, revealed the Facility must arrange for transportation to and from the dental services locations; and must assist residents who are eligible to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan such as Medicaid. A review of an Admission Record indicated the facility admitted Resident #71 on 04/13/2021 with diagnoses of unspecified dementia and convulsions. The Admission Record identified Dental Provider D as Resident #71 dental provider and indicated the resident was a Medicaid recipient. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2024, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #71 required supervision or touching assistance from staff for the completion of oral hygiene. The MDS further indicated Resident #71 had no dental/oral issues and no significant weight loss. A review of Resident #71's care plan revealed a Focus area revised on 03/22/2024 that indicated the resident had an activities of daily living (ADL) self-care performance deficit and identified the resident's teeth as being in poor condition and the resident was missing a majority of their teeth. The care plan further indicated the resident had upper partials. Further review of the care plan revealed a Focus area revised on 03/22/2024 that indicated dental exams would be tracked to meet the overall resident's dental needs. Interventions directed staff to set up appointments and allow the provider to be chosen as indicated. The care plan revealed that Resident #71 had last seen the dentist on 06/29/2021. A review of Resident #71's quarterly Nutritional Risk assessment dated [DATE] indicated Resident #71 had no significant weight changes. The assessment failed to address the resident's dental status. A review of Resident #71's Order Summary Report, with active orders as of 04/18/2024, revealed an order to remove the resident's partial dentures at bedtime and clean and soak the dentures in a denture cup. The Order Summary Report for Resident #71 did not contain orders for dental appointments. An observation was made on 04/15/2024 at 10:01 AM. Resident #71 was missing teeth. The resident was unable to relay if the missing teeth were causing a problem. Registered Nurse (RN) C was interviewed on 04/17/2024 at 3:53 PM. RN C stated dental appointments for residents were arranged by the Social Services Director (SSD) and the Administrator. RN C added the facility utilized a contract dental company that visited the facility every six months, while other residents had their own established dental providers. RN C stated a resident's payer source determined which provider they were seen by. RN C stated local dental providers rarely accepted Medicaid as a payment source. RN C stated that upon admission, the resident and/or the family signed a contract for dental service. RN C stated all residents were offered the option of seeing a dentist at least yearly but had the right to refuse dental services. The Social Services Director (SSD) was interviewed on 04/18/2024 at 9:12 AM. The SSD stated residents were seen by the dentist quarterly. The SSD stated dental services were provided by two companies, which included Dental Provider D and Dental Provider E. The SSD stated Dental Provider E started last fall, and all residents were asked to enroll. The SSD reviewed the list of residents who had signed up for Dental Provider E and stated Resident #71 was not on the list because the family chose not to accept the offer. The SSD stated there was no documentation that a conversation about dental services had been held with Resident #71's family or that the family had declined dental services. The SSD confirmed Resident #71 had not been seen by a dentist for routine dental care, cleaning, or assessment of their remaining teeth since 2021. A telephone interview was held with Resident #71's Power of Attorney (POA) on 04/18/2024 at 10:50 AM. Resident #71's POA acknowledged the facility had asked if they would like for Resident #71 to be seen by Dental Provider E, and stated they told the facility the preference was for Resident #71 to be seen by Dental Provider D, where the resident was already comfortable. Resident #71's POA stated that a co-pay for Dental Provider E was not discussed, but the preference was still for Resident #71 not to change dentists, and they wanted Resident #71 to be seen by a dentist as needed. The Director of Nursing (DON) was interviewed on 04/18/2024 at 1:10 PM. The DON defined routine dental services as being as the public would see a dentist, such as yearly or every six months. The DON stated they were unaware Resident #71 had not seen a dentist in three years. The DON added they were sure contact had been made with the family regarding dental services, but it probably had not been documented. The DON stated they would have expected arrangements to be made for Resident #71 to be seen by dental services within the past three years. The Administrator was interviewed on 04/18/2024 at 12:38 PM. The Administrator stated if any resident chose not to sign up with Dental Provider E, that resident would continue to be seen by Dental Provider D. The Administrator stated the problem with Dental Provider D was the company did not accept appointments, and residents had to show up and wait in line. The Administrator stated they were surprised Resident #71 had not been seen by a dentist in three years and stated they would have expected staff to present the option of a dental visit to the resident and family within the past three years.

Licensure Reference Number 175 NAC 12-006.12E1 Based on observations, record reviews, and interview; the facility failed to ensure open dates were recorded on medication multi-dose vials and bottles kept in storage to ensure medications weren't outdated. This failure could potentially affect the effectiveness of these medications for residents (Resident #71, #79, #30, #39, #34, #75, #26 and #33) receiving medications from these vials and bottles. Facility census was 91. A. Observations on 01/26/2022 beginning at 02:27 PM revealed the following: - The 200 unit medication cart contained 2 bottles of Artificial Drop Tears and 1 bottle of [MEDICATION(S)] Spr 0.01% nasal spray for Resident #71; one bottle of [MEDICATION(S)] Nasal Spray for Resident #30; and a tube of Ayr Saline Nasal Gel with an incomplete/torn label, missing a name. These multi dose bottles were missing opened dates. - The 600 unit medication cart contained 1 bottle of [MEDICATION(S)] Powder for Resident #33. This multi-dose bottle was missing an opened date. An interview with the Director of Nursing on 1/26/2022 at 3:25PM confirmed the multi dose containers stored on the 200 unit medication cart and the 600 unit medication cart were open, being used for the residents, and were not marked with opened dates. B. On 01/26/22 at 01:45 PM an observation of the medication cart on the 200 Unit revealed that two open medication containers for Resident #39 (Refresh Tears and [MEDICATION(S)] eye drops) were not marked with the date of opening. Observation also revealed that one open medication container for Resident #30 ([MEDICATION(S)] nasal spray), Resident #26 ([MEDICATION(S)] Ultra Solution) and Resident #79 ([MEDICATION(S)] Nasal Spray) were not marked with the date of opening. On 01/26/22 at 02:00 PM an interview with MA-C (Medication Aide) and RN-D (Registered Nurse) confirmed there were four bottles of medications stored in the medication cart that were open, being utilized, and not marked with the date they were opened. C. On 01/26/22 at 02:26 PM an observation of the medication cart on the 600 Unit revealed that two open medication containers for Resident #34 ([MEDICATION(S)] [NAME] 0 and Artificial DRO Tears) also one medication container for Resident #75 ([MEDICATION(S)] MAL Solution) were not marked with the date of opening. On 01/26/22 at 02:40 PM an interview with LPN-E (License Practical Nurse) and LPN-F confirmed there were three bottles of medications stored in the medication cart that were open, being utilized, and not marked with the date they were opened.

Licensure Reference Number: 175 NAC 12-006.17B Based on observations and interview, the facility failed to ensure that a urinary catheter drainage bag was covered and not placed on the floor for one current sampled resident (Resident 40) to reduce the risk of cross contamination. The facility census was 91 with 19 current sampled residents. Findings are: Observations on 1/24.22 at 11:00 AM and on 1/25/22 8:30 AM and 1:30 PM revealed Resident 40 seated in the recliner with a urinary drainage bag uncovered and on the floor nest to the recliner. Interview with RN (Registered Nurse) - B, Unit Coordinator, on 1/25/22 at 1:30 PM confirmed that the urinary catheter drainage bag was to be placed in a privacy bag and not on the floor to reduce the risk of cross contamination.

Licensure Reference Number: 175 NAC 12-006.04G Based on observations and interviews, the facility failed to ensure the call light was accessible to alert staff when needed for one current sampled resident (Resident 52). The facility census was 85 with 21 current sampled residents. Findings are: Observations on 8/11/20 at 9:30 AM revealed Resident 52 seated in a recliner in room. Further observation revealed no call light within reach of the resident. The call light was found under the bed linens. Interview on 8/11/20 at 9:30 AM with the resident confirmed was not able to find the call light. Interview on 8/12/20 at 10:00 AM with LPN (Licensed Practical Nurse) - A, Charge Nurse, confirmed that the resident used the call light to access staff when needed. Further interview confirmed that the staff were to ensure that the call light was placed within reach so that the resident could use it to access staff when needed.

Licensure Reference Number: 175 NAC 12-006.09C1b Based on observations, record reviews, and interviews, the facility failed to develop care plans to active problems related to: 1) one sampled resident's (Resident 8) skin condition; and 2) one sampled resident's (Resident 3) use of a seat belt device in the wheelchair. The sample size included 21 current residents. Facility census was 85 Findings are: A. Observation on 08/11/20 at 3:37 p.m. Resident 8 was sitting down in the recliner watching television. Resident was groomed nicely as hair was combed and resident was wearing a short sleeved shirt and slacks. Resident 3's left and right arms were covered in bruises. Resident interview on 08/11/20 at 3:37 p.m. Resident 8 verified having bruises on both left and right arm. Resident 3 confirmed bruising easily due to diabetes and being on [MEDICAL TREATMENT] three times a week. Resident 3 was not sure how all the bruises were obtained, but had stated having bumped into things. Record review - Diagnosis - I69.351 [MEDICAL CONDITION] AND [MEDICAL CONDITION] FOLLOWING CEREBRAL INFARCTION AFFECTING RIGHT DOMINANT SIDE SLP Acute Neurologic 5/10/2017 Primary 5/10/2017 cschmunk view I69.320 [MEDICAL CONDITION] FOLLOWING CEREBRAL INFARCTION SLP Acute Neurologic 5/10/2017 [DIAGNOSES REDACTED]. view I48.91 UNSPECIFIED [MEDICAL CONDITION] FIBRILLATION Cardiovascular and Coagulations 5/10/2017 [DIAGNOSES REDACTED]. view R56.9 UNSPECIFIED CONVULSIONS Medical Management 8/9/2018 [DIAGNOSES REDACTED]. view F03.91 UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE Medical Management 6/1/2018 [DIAGNOSES REDACTED]. view G14 POSTPOLIO SYNDROME Acute Neurologic 5/10/2017 [DIAGNOSES REDACTED]. view N31.9 NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED Medical Management 5/10/2017 [DIAGNOSES REDACTED]. view K59.2 [MEDICAL CONDITION] BOWEL, NOT ELSEWHERE CLASSIFIED Medical Management 5/10/2017 [DIAGNOSES REDACTED]. view R60.9 [MEDICAL CONDITION], UNSPECIFIED N/A, not an acceptable Primary Diagnosis 5/10/2017 [DIAGNOSES REDACTED]. view R13.12 DYSPHAGIA, OROPHARYNGEAL PHASE N/A, not an acceptable Primary Diagnosis 1/23/2019 [DIAGNOSES REDACTED]. view I10 ESSENTIAL (PRIMARY) HYPERTENSION N/A, not an acceptable Primary Diagnosis 5/10/2017 [DIAGNOSES REDACTED]. view M19.90 UNSPECIFIED [MEDICAL CONDITION], UNSPECIFIED SITE N/A, not an acceptable Primary Diagnosis 5/10/2017 [DIAGNOSES REDACTED]. Record review of Resident 8's care plan verified there were no programs identifying Resident 3's bruises on both left and right arms. Record review of Resident 8's assessments confirmed there were no assessments completed identifying Resident 8's bruising to both arms. Staff interview on 08/13/20 at 9:55 a.m. with NA-(Nursing Assistant) - E confirmed that Resident 8 had bruising to both arms and some of this bruising occurred when Resident 8 was at [MEDICAL TREATMENT], however NA-E was not sure of this and NA-E was not clear on how the nurse on duty documented this. Staff interview on 08/13/20 at 10:00 a.m. with LPN (Licensed Practical Nurse) - B verified that they did not chart on Resident 8's bruised arms as this is chronic due to [MEDICAL TREATMENT]. LPN-B Confirmed there is no care plan to address Resident 8's bruised arms. Staff interviews on 08/13/20 at 10:51 a.m. RN (Registered Nurse) - C and LPN (Licensed Practical Nurse) - D both confirmed that Resident 8 did not have any care planning developed to address Resident 8's bruising to both arms. Staff interview on 08/13/20 at 11:27 a.m. The Director of Nursing verified that Resident 8 did not have any care planning developed to address the bruising that had occurred on Resident 8's left and right arm. B. Resident observation on 08/11/20 at 10:15 a.m. Resident 3 was sitting in electric wheelchair at a table in own room while working on a puzzle. Resident 3 was wearing a seat belt/lap belt while sitting in electric wheelchair. Resident observation on 08/12/20 at 8:00 a.m. Resident 3 was sitting in electric wheelchair at a table in own room eating breakfast and Resident 3 was wearing a seatbelt/lap belt that went around the waist and was in a locked position. Resident interview on 08/12/20 at 8:00 a.m. Resident 3 confirmed being able to unlatch the seatbelt on the wheelchair and demonstrated this. Resident 3 only able to use left hand to undo seatbelt as Resident 3's right hand and arm had no functional ability. Record review of Resident 3's Diagnosis - I69.351 [MEDICAL CONDITION] AND [MEDICAL CONDITION] FOLLOWING CEREBRAL INFARCTION AFFECTING RIGHT DOMINANT SIDE SLP Acute Neurologic 5/10/2017 Primary 5/10/2017 cschmunk view I69.320 [MEDICAL CONDITION] FOLLOWING CEREBRAL INFARCTION SLP Acute Neurologic 5/10/2017 [DIAGNOSES REDACTED]. view I48.91 UNSPECIFIED [MEDICAL CONDITION] FIBRILLATION Cardiovascular and Coagulations 5/10/2017 [DIAGNOSES REDACTED]. view R56.9 UNSPECIFIED CONVULSIONS Medical Management 8/9/2018 [DIAGNOSES REDACTED]. view F03.91 UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE Medical Management 6/1/2018 [DIAGNOSES REDACTED]. view G14 POSTPOLIO SYNDROME Acute Neurologic 5/10/2017 [DIAGNOSES REDACTED]. view N31.9 NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED Medical Management 5/10/2017 [DIAGNOSES REDACTED]. view K59.2 [MEDICAL CONDITION] BOWEL, NOT ELSEWHERE CLASSIFIED Medical Management 5/10/2017 [DIAGNOSES REDACTED]. view R60.9 [MEDICAL CONDITION], UNSPECIFIED N/A, not an acceptable Primary Diagnosis 5/10/2017 [DIAGNOSES REDACTED]. view R13.12 DYSPHAGIA, OROPHARYNGEAL PHASE N/A, not an acceptable Primary Diagnosis 1/23/2019 [DIAGNOSES REDACTED]. view I10 ESSENTIAL (PRIMARY) HYPERTENSION N/A, not an acceptable Primary Diagnosis 5/10/2017 [DIAGNOSES REDACTED]. view M19.90 UNSPECIFIED [MEDICAL CONDITION], UNSPECIFIED SITE N/A, not an acceptable Primary Diagnosis 5/10/2017 [DIAGNOSES REDACTED]. Record Review of Resident 3's care plan verified there had been no care plan developed to address the use of a seatbelt/lap belt for Resident 3, while Resident 3 was seated in the electic wheelchair. Staff interview on 08/12/20 at 10:30 a.m. NA (Nursing Assistant) - F and NA (Nursing Assistant) -A both confirmed that Resident 3 uses a seatbelt/lap belt when using the electric wheelchair. Staff interview on 08/12/20 at 10:35 a.m. LPN (Licensed Practical Nurse) -G and LPN ( Licensed Practical Nurse) -D were both present and verified Resident 3 did not have any care planning developed to address the seatbelt/lap belt being utilized by Resident 3. Staff interview on 08/12/20 at 10:40 a.m. Director of Nursing confirmed Resident 3 had no care planning developed to address the seatbelt/lapbelt that was being used by Resident and stated this should have been care planned.

Licensure Reference Number: 175 NAC 12-006.09D6(7) Based on observations, record review and interview; the facility failed to ensure that oxygen was administered as ordered by the practitioner for one current sampled resident (Resident 60). The facility census was 85 with 21 current sampled residents. Findings are: Observations on 8/11/20 at 10:48 AM and 2:00 PM revealed Resident 60 seated in a wheelchair in the lounge area with oxygen on per tank at 2 liters per minute. Observations on 8/12/20 at 8:15 AM revealed the resident seated in a wheelchair in the room with oxygen on per concentrator at 2 liters per minute. Review of the TAR (Treatment Administration Record), dated August 2020, revealed an order for [REDACTED]. Oxygen was administered on the evening shift at 4 liters per minute at 8/1, 8/5, 8/8; 3 liters per minute at 8/2, 8/3, 8/7, 8/9, 8/10 and 8/11 and 2 liters per minute on 8/4 and 8/6. Oxygen was administered on the night shift at 4 liters per minute on 8/8; 3 liters per minute on 8/1, 8/2, 8/7, 8/9, 8/10 and 8/11 and at 2 liters per minute on 8/3, 8/4, 8/5 and at 8/6. Interview on 8/12/20 at 10:00 AM with LPN (Licensed Practical Nurse) - A, Charge Nurse, confirmed that oxygen was not administered as ordered by the practitioner.

Licensure Reference Number: 175 NAC 12-006.09D Based on record reviews and interview, the facility failed to ensure that behavior logs were completed to monitor symptoms of depression and anxiety for one current sampled resident (Resident 41) taking routine antidepressant and antianxiety medications. The facility census was 85 with 21 current sampled residents. Findings are: Review of Resident 41's MAR (Medication Administration Record), dated August 2020, revealed that the resident routine received Alprazolan (antianxiety) and [MEDICATION NAME] (antidepressant). Review of the Behavior/lntervention Monthly Flow Record, dated July 2020, revealed that the staff monitored the resident for restlessness and potential adverse symptoms including [MEDICAL CONDITION], dizziness and tiredness. Further review revealed no documentation after 7/16/20. Review of the Behavior/lntervention Monthly Flow Record, dated July 2020, revealed that the staff monitored the resident for withdrawal and potential adverse symptoms including dizziness, drowsiness and weight gain. Further review revealed no documentation after 7/17/20. Interview on 8/12/20 at 10:00 AM with LPN (Licensed Practical Nurse) - A, Charge Nurse, confirmed that there was no documentation that the resident's symptoms of anxiety and depression were monitored and documented to ensure that the resident received the therapeutic benefits of the medications.