Every finding on record at Heritage of Emerson

Licensure Reference Number 175 NAC 12-006.18Based on record review and interview; the facility failed to perform hand hygiene and wear gloves at appropriate intervals during care provision for Residents 7, 12, 14, and 26. The sample size was 12 and the facility census was 35. Findings are: Review of the facility policy Hand Hygiene with a revision date of 9/12/17 revealed the following: -The facility exercised proper hand hygiene techniques to prevent the transmission of infectious agents. -Hand hygiene was to occur, before and after patient contact, after removing and disposing of gloves and or other protective equipment, before handling invasive devices for insertion, after contact with bodily fluids, when moving from a contaminated body site to a clean site, after potential exposure to organisms, after using the restroom, after direct resident contact and when hands were visually soiled. Review of the facility policy for Enhanced Barrier Precautions (EBP-targeted use of gown and gloves during high contact care events to prevent the potential spread of MDRO's [multi-drug-resistant pathogens that have developed drug resistance to multiple antimicrobial/antibiotic agents]) dated 4/12/24 revealed the facility implemented EBP to prevent transmission of MDRO's through the use of gown and gloves during high contact resident care. A. Review of Resident 7's Care Plan with a revision date of 8/3/26 revealed the resident had self-care performance deficits related to dementia and the history of a stroke, the resident also was non-weight bearing due to a leg fracture and was on EBP due to a peg tube (feeding tube). The resident was dependent for all hygiene needs. During an observation of the provision of care for Resident 7 on 8/11/26 at 9:20 AM Nurse Aides (NA's) H and I entered the resident room put on gloves and gowns to transfer to resident to bed to check and change an incontinence brief. The resident was transferred using a full body mechanical lift from a wheelchair into bed. The NA's removed the resident's pants and soiled brief and NA-I performed perineal hygiene, removed the soiled gloves. Without performing hand hygiene, NA-I put on clean gloves, applied a clean brief and redressed the resident's lower body. During an interview on 8/13/26 at 9:34 AM the facility Infection Preventionist Registered Nurse confirmed staff should complete hand hygiene between all glove changes. B. Review of Resident 12's Care Plan with a revision date of 5/22/26 revealed the resident had an indwelling suprapubic urinary catheter (a flexible tube place directly into the bladder used for those persons needing a long-term need for bladder drainage/emptying). Further review of the care plan identified the resident was on EBP and staff were to utilize those precautions (gown and glove use) for high contact care activities. During the provision of care for Resident 12 on 8/11/26 at 10:50 AM Nurse Aide (NA) -H entered the resident's room with gown and gloves on to respond to the residents' request for assistance from the toilet. Resident 12 was using a stand-up lift mechanical lifting device. Using the lift, the resident was assisted to stand and NA-H performed perineal hygiene. NA-H removed their gloves, put on clean gloves to pull up the resident's clothing without performing hand hygiene between glove changes. NA-H transferred the resident to a wheelchair, removed the gloves and adjusted the resident's shirt and upper body under clothing after removing the gloves. During an interview on 8/13/26 at 9:34 AM the facility Infection Preventionist Registered Nurse confirmed staff should complete hand hygiene between all glove changes and ensure gloves were being used during high contact care provision such as assistance with dressing for resident's on EBP. C. Review of Resident 14's MDS dated [DATE] revealed the resident was independent with toileting hygiene, transfers, ambulation and bed mobility and was incontinent of bowel and bladder at times. The resident had diagnoses of stroke, congestive heart failure and hypertension. Review of Resident 14's care plan revealed that the resident was occasionally incontinent of urine and wore incontinence products dated revised 8/29/25, and the resident was independent with transfers and toileting hygiene revised 5/22/26. Review of Resident 14's nursing notes documentation on 8/10/26 at 12:00 PM and 8/10/26 at 11:05 PM revealed the resident had increased weakness and confusion. An interview with Medication Aide (MA-D) on 8/11/26 at 10:05 AM revealed Resident 14 required assistance with transfers, ambulation and toileting cares on 8/10/26 and 8/11/26 related to residents increased confusion and weakness. During an observation of provision of care for Resident 14 on 8/11/26 at 10:05 AM, Nurse Aide (NA-C) entered the resident's room, the resident ambulated to the bathroom with a walker, while NA-C provided stand by assistance. NA-C put on gloves, removed a wet incontinent pull up and placed it in the trash, then removed gloves. Without the benefit of hand hygiene, NA-C put on a clean pair of gloves, assisted Resident 14 with putting on a clean incontinent product and stand up from the toilet. NA-C performed perineal cares (washing and caring for the genital and rectal areas of the body) using disposable wipes. NA-C removed gloves and did not wash their hands, assisted Resident 14 with pulling up the incontinent product and pants and walked the resident back to the recliner. An interview on 8/12/26 at 3:00 PM with the Director of Nursing (DON) confirmed that staff were to wash their hands between changing gloves when completing resident cares. D. Review of Resident 26's MDS dated [DATE] revealed the resident was dependent for toileting hygiene, received assistance with transfers and was incontinent of bowel and bladder at times. The resident had diagnoses of Non-Alzheimer dementia, congestive heart failure and adult failure to thrive. Review of Resident 26's care plan revised 8/5/26 revealed the resident transferred with a mechanical lift with 1 staff member and was dependent on staff for toileting hygiene cares. During an observation of provision of care for Resident 26 on 8/11/26 at 10:30 AM, NA-B and NA-C transferred the resident to the bathroom with the use of a mechanical lift. NA-C put on gloves, pulled resident pants down, removed incontinent brief and assisted resident with sitting down on the toilet. NA-C removed their gloves without performing hand hygiene. NA-C put on new gloves and completed perineal care. Resident 26 requested more time to sit on the toilet, NA-C removed gloves and did not wash their hands. NA-C applied a new pair of gloves, completed perineal care and then removed gloves without performing hand hygiene. NA-C applied a new pair of gloves, assisted the resident with standing up from the toilet with use of the mechanical lift, applied a new incontinent product and pulled up the resident's pants. NA-C removed gloves without hand hygiene, assisted resident into the wheelchair, removed the mechanical lift and then washed hands. An interview on 8/12/26 at 3:00 PM with the DON confirmed that staff were to wash their hands between changing gloves when completing resident cares.

Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview; the facility failed to obtain comprehensive informed consents for the use of psychotropic (mind altering) medications for Residents 2, 3, 4, and 12. The sample size was 5 and the facility census was 35. Findings are: A. Review of the facility Psychoactive Medication and Medication Regimen Review Standard dated 6/2026 revealed that each psychoactive medication had an appropriate diagnosis to support the use of the medication. Best practice was to have licensed nursing/social services oversight of facility processes. The facility used appropriate resources to assist in managing psychoactive medications prescribed for residents. Resources include attending physicians, pharmacist, facility team members, regulation and published clinical resources. Identified, documented and clinical rationale for administering medications were based on assessment of the resident's condition and therapeutic goals. The indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological interventions were determined by assessing the resident's condition, signs and symptoms, and preferences for treatment. Consent for the use of psychoactive medication was to be completed prior to initiating and with the increase of any psychoactive medication. Consent was reviewed and updated quarterly in conjunction with the care planning process. Review of Resident 2's Minimum Data Set (MDS-federally mandated comprehensive assessment use to develop resident care plans) dated 6/9/26 revealed the resident had diagnoses of anxiety and depression, and took antianxiety and antidepressant medications. Review of Resident 2's Care Plan dated with a revision date of 8/1/25 revealed the resident used psychoactive medications related to anxiety disorder, depression, insomnia, and pain. The resident was monitored for adverse effects of antianxiety and antidepressant medication. Review of Resident 2's Medication Administration Record dated August 2026 revealed the resident took the following psychotropic medication. -clonazepam (anti-anxiety medication) 1.5 milligrams (mg) daily at bedtime and 0.5 mg as needed daily for anxiety. -sertraline (antidepressant medication) 75 mg daily. Review of Resident 2's Informed Consents for use of Psychotropic Medications revealed the following;-2/2/24 the resident/legal representative consented to the use of clonazepam. There was no dose or frequency listed.-2/2/24 the resident/legal representative consented to the use of sertraline. There was no dose or frequency listed. -7/1/25 the resident/legal representative consented to the use of sertraline 75 mg. There was no frequency listed.Further review revealed none of the consents listed included alternative non-pharmacological treatment options. B. Review of Resident 4's MDS dated [DATE] revealed the resident had diagnoses of anxiety, depression, and post-traumatic stress disorder (PTSD). The resident had taken antidepressant and anticonvulsant medication. Review of Resident 4's Care Plan with a revision date of 7/6/26 revealed the resident had mood concerns related to anxiety and delusions. The resident worried about what others were saying or talking about. The resident sometimes felt isolated and/or lonely. The resident was monitored for medication adverse effects. Review of Resident 4's MAR dated August 2026 revealed the resident took the following psychotropic medications: -Effexor XR (extended release, antidepressant) 150 mg daily. -mirtazapine (antidepressant) 15 mg daily at bedtime. -lamotrigine (anticonvulsant- often used to treat mental health conditions) 50 mg twice daily. Review of Resident 4's Informed Consents for use of Psychotropic Medications revealed the following; -1/29/26 the legal representative consented to the use of mirtazapine 15 mg daily at bedtime. -5/20/26 the legal representative consented to the use of lamotrigine 50 mg twice daily. Further review revealed no consent for the Effexor and no evidence any of the consents provided alternative non-pharmacological treatment options. C. Review of Resident 12's MDS dated [DATE] revealed the resident had diagnoses of anxiety and depression and took antidepressant medication. Review of Resident 12's Care Plan with a revision date of 8/5/26 revealed the resident had mild depression and took medications that required monitoring for adverse effects. Review of Resident 12's MAR dated 8/2026 revealed the resident took the antidepressant medication sertraline 100 mg daily. Review of Resident 12's Informed Consents for use of Psychotropic Medications dated 11/8/23 revealed the following; The resident's physician recommended Sertraline 100 mg daily to improve mood and decrease anxiety. Further review revealed none of the consents listed included a non-pharmacological treatment options. D. During an interview on 8/12/26 and 3:00 PM the Director of Nursing (DON) confirmed the facility had not obtained comprehensive informed consent for the use of psychotropic medication, that included the dosages for all of the medications given and/or alternative non-pharmacological treatment options for Residents 2, 4 and 12. E. Review of Resident 3's MDS dated [DATE] revealed the resident was admitted [DATE] with diagnoses of Non-Alzheimer dementia, Parkinson's, anxiety and depression. The following was assessed regarding the resident: -cognitively intact (normal thinking and memory). -staff assessment of the resident's mood revealed the resident felt down or depressed. -received antipsychotic and antidepressant medications. Review of Resident 3's Informed Consent for use of Psychotropic Medication Form dated 8/13/25 revealed the resident had an order for Nuplazid (medication used to reduce hallucinations associated with Parkinson's) for diagnosis of dementia, unspecified severity with psychotic disturbance. Further review revealed no evidence to indicate how often and at what dosage the resident was to receive the medication, or that the facility had provided the representative with education as to the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of Resident 3's Informed Consent for use of Psychotropic Medication dated 8/13/25 revealed the resident had an order for sertraline (antidepressant medication) for anxiety disorder. Further review revealed no evidence to indicate how often or at what dosage the resident was to receive the medication, or that the facility had provided the representative with education as to the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of Resident 3's Informed Consent for use of Psychotropic Medication Form dated 8/13/25 revealed the resident had an order for Rexulti (medication used to treat depressive disorder) for diagnosis of dementia, unspecified severity with psychotic disturbance. Further review revealed no evidence to indicate how often and at what dosage the resident was to receive the medication, or that the facility had provided the representative with education as to the symptoms the resident was displaying, the potential effects or adverse effects and/or nonpharmacological interventions attempted. Review of the Resident 3's Medication Administration Record (MAR) dated 8/2026 revealed the resident continued to receive the following medications: -Nuplazid 34 milligrams (mg) one capsule one time daily for Parkinson's disease with fluctuations and dementia, unspecified severity with psychotic disturbance. -Sertraline 100 mg one tablet one time daily for major depressive disorder. -Rexulti 2 mg one tablet one time daily for psychotic disorder with hallucinations due to known physiological conditions and Dementia, unspecified severity with psychotic disturbance. During an interview with the Director of Nursing (DON) on 8/12/26 at 3:00 PM, the DON confirmed the consents did not include documentation of non-pharmacological interventions attempted prior to initiation of medications and/or treatment alternatives, a list of symptoms the resident was displaying, and the potential effects or adverse effects of the medications. The DON further confirmed the consents did not address the dosage and/or how often the medications were to be administered.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l) Based on record review and interview; the facility failed to implement interventions for falls for 1 (Resident 41) of 7 sampled residents. The facility census was 35. Findings are:Review of the Fall Prevention/Management Standard with a revision date of 6/2026 revealed a Fall Risk Evaluation was to be completed daily for 3 days after admission or re-admission, then weekly for 3 weeks, quarterly and with any significant change in condition. Risk for falls was to be identified and interventions were to be implemented based on individual needs. Interventions should be immediately implemented and were to address the risk factors already identified. If a fall occurred, staff were to investigate to determine the cause of each fall with a root cause analysis to determine what happened, why it happened, and what could be done to prevent it from happening again. Review of Resident 41's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/26/26 revealed diagnoses of non-traumatic brain injury (TBI-an injury to the brain from an external, physical force that can result in diminished cognitive abilities and physical functioning) and Alzheimer's dementia. The MDS further indicated the following:-the resident was cognitively intact.-the resident had verbal behaviors which were directed toward others. -the resident needed substantial/maximal assistance with personal hygiene, bed mobility, and transfers; and the resident was dependent with toileting hygiene, bathing/showering, and dressing.-the resident was frequently incontinent of bowel and bladder. Review of a Fall Scene Investigation Report/Interdisciplinary Review dated 10/24/25 at 7:50 PM revealed the resident had an unwitnessed fall in the resident's room. The resident indicated the fall occurred when the resident was attempting to answer the phone. The staff felt the resident slipped off the side of the bed. An intervention was identified to place the resident's phone within reach as the area was very cluttered. The staff identified impulsivity as the root cause of the fall. The resident was independent and did not like to ask for help. Review by the Interdisciplinary Team (IDT) revealed an intervention to make sure the back of the resident's legs touched the mattress before the resident sat down on the bed. Further review of the resident's medical record revealed no evidence the resident was provided ongoing education to ensure the back of the resident's legs touched the mattress before the resident sat down or that the staff monitored the resident to ensure implementation of the intervention. Review of a Fall Scene Investigation Report/Interdisciplinary Review dated 11/2/25 at 11:00 PM revealed the resident had an unwitnessed fall in the bathroom of the resident's room. The resident was incontinent of bowel and bladder and was confused and uncooperative with the staff. The resident was in a hurry to get to the bathroom, slipped and fell. The report identified the resident was independent with toileting and did not want to have the staff assist as a causal factor. A new intervention was identified to have the staff try to assist the resident with toileting in the evenings. Review of a Fall Scene Investigation Report/Interdisciplinary Review dated 1/13/26 at 7:45 PM revealed the resident was found on the floor of the resident's room by the window and wearing only underwear. Further review of the form revealed the resident had failed to call for assistance with dressing. The room was very cluttered and clothing was all over the floor. Anti-rollback devices (safety accessory that automatically locks the rear wheels when a user begins to stand up. It prevents the chair from rolling backward during transfers) were placed on the back of the resident's wheelchair. The staff were educated to provide 2 assists for all transfers and the resident was re-educated on the need to use the call light for staff assistance with cares. Review of a Fall Scene Investigation Report/Interdisciplinary Review dated 4/6/26 at 8:30 PM revealed the resident had used the controls for the lift recliner to elevate the seat until the chair was in the highest position and the resident slid out onto the floor. The report indicated the call light was in reach but had not been activated. A non-slip pad was placed in the seat of the recliner. Further review of the resident's medical record revealed no evidence the resident had been evaluated to ensure safety with use of the lift recliner despite the resident's fall out of the recliner. Review of Resident 41's current Care Plan with a revision date of 4/2/26 revealed the resident had a history of and/or had a potential for falls related to arthritis, cognitive deficit, left hip pain, incontinence, opioid use, poor balance and poor safety awareness. The care plan identified the resident refused staff assistance with transfers and to participate in therapies. The following interventions were identified:-10/24/25 to be sure the resident's legs were touching the mattress before sitting on the side of the bed.-11/2/25 take the resident to the bathroom later in the evening.-1/13/26 anti-rollback devices placed on the wheelchair. Assist of 2 for all transfers/cares and education on need to call for assistance.-4/16/26 non-slip pad to seat of recliner. During an interview with the Director of Nursing (DON) on 8/13/26 at 9:12 AM the DON confirmed the following regarding the residents' falls: -10/24/25 at 7:50 PM a new intervention was identified to make sure the back of the resident's legs touched the mattress before the resident sat on the bed. The resident was non-compliant with calling for staff assistance with cares and had refused to work with Physical Therapy. The resident was not provided ongoing cues/education or monitoring to ensure implementation and/or the effectiveness of the intervention. -11/2/25 at 11:00 PM the resident fell in the bathroom and was incontinent of bowel and bladder. A new intervention for staff to assist with toileting in the evening was identified. However, the resident remained non-compliant with calling for assistance or allowing staff to assist with cares. -4/16/26 at 8:30 PM the resident slid out of the recliner when the resident used the controls to lift the seat of the chair to the highest position. Resident 41 had never been assessed to determine the resident's safety with use of the electric recliner.

Licensure Reference Number 175 NAC 12-006.18 Based on observations, record review, and interviews; the facility failed to follow a policy related to cleaning of Continuous Positive Air Pressure (CPAP) equipment (machine used to keep the airway open using mild air pressure through a mask resident wore while sleeping) for Residents 2 and 30; and failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices)) for Resident 8 during the provision of cares. The sample size was 17. The facility census was 34. Findings are: A. Record review of the facility policy Cleaning your CPAP Equipment with no date revealed staff were to do the following: Daily cleaning of the CPAP equipment: -wash hands, -wipe the portion of the mask that comes in contact with your skin with a damp cloth, -empty the remaining water from the water chamber, -fill the water chamber with soapy water and shake, -rinse the chamber with clean water, -air dry. Weekly Mask and Tubing Cleaning: -remove headgear and chin strap (if used) from mask and handwash the headgear in standard laundry detergent, -air dry the headgear, -wash the mask and tubing in a mixture of warm water and liquid dishwashing detergent, -rinse thoroughly, and -air dry. B. Record review of Resident 2's Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) dated 4/11/25 revealed the resident had a diagnosis of Obstructive Sleep Apnea (the upper airway collapses during sleep) and used a CPAP. Record review of Resident 2's care plan dated 10/10/23 revealed the resident had a diagnosis of Obstructive Sleep Apnea and had a CPAP machine that was used with staff assistance. Record review of Resident 2's Treatment Administration Record (TAR) dated June 2025 revealed that the resident used a CPAP and it was to be placed every night at bedtime related to Obstructive Sleep Apnea. The following observations were made related to Resident 2: -On 6/2/25 at 7:30 PM the CPAP had dried brown specks noted inside the mask and the water chamber was empty, and it was connected to the CPAP machine. -On 6/3/25 at 2:35 PM the CPAP had dried brown specks inside the mask and the water chamber was empty, and it was connected to the CPAP machine. -On 6/4/25 at 9:35 AM the CPAP had dried brown specks inside the mask and the water chamber was empty, and it was connected to the CPAP machine. An interview on 6/4/25 at 9:25 AM with the Director of Nursing (DON) confirmed that there was no documentation on the TAR showing that the CPAP machines were being cleaned per facility policy. C. Record review of Resident 30's MDS dated [DATE] revealed the resident had a diagnosis of Obstructive Sleep Apnea and used a CPAP. Record review of Resident 30's care plan dated 4/7/25 revealed the resident used a CPAP at night related to Obstructive Sleep Apnea. Record review of Resident 30's Medication Administration Record (MAR) and TAR dated 6/25 revealed that there was not any documentation about a CPAP. The following observations were made related to Resident 30: -On 6/2/25 at 6:45 PM CPAP had a heavy layer of dried white coating to the inside of the mask, the water chamber was half full of water and connected to the CPAP machine. -On 6/3/25 at 8:37 AM CPAP had a heavy layer of dried white coating to the inside of the mask, the water chamber was half full of water and connected to the CPAP machine. -On 6/3/25 at 2:30 PM CPAP had a heavy layer of dried white coating to the inside of the mask, the water chamber was half full of water and connected to the CPAP machine. -On 6/4/25 at 7:50 AM CPAP had a heavy layer of dried white coating to the inside of the mask, the water chamber was half full of water and connected to the CPAP machine. An interview on 6/4/25 at 9:25 AM with the DON confirmed that there was no documentation on the MAR or TAR showing documentation that Resident 2 and 30's CPAP headgear and CPAP machines were being cleaned per facility policy. D. Record review of the facility Policy EBP dated 4/12/24 revealed the following: -EBP referred to an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO, germ that is resistant to medications) that required the use of gowns and gloves use during high contact resident cares, -EBP would be initiated on residents with any of the following: chronic wounds and urinary catheters, -infection with a targeted MDRO, -gown and gloves for EBP is only necessary when performing high-contact care activities in the residents room, -high-contact resident care activities included: dressing, transferring, care of catheters and wound care and -MDRO: Methicillin-resistant Staphylococcus aureus (MRSA) E. Record review of Resident 8's MDS dated [DATE] revealed that resident had a diagnosis of MRSA and Peripheral Vascular Disease with 3 venous ulcers. The resident had a catheter. The resident required substantial assistance with transfers. Record review of Resident 8's care plan revealed the resident: -had a suprapubic catheter date initiated 7/20/24, -had Enhanced Barrier Precautions for high contact activities date initiated 7/20/24, -had a hematoma to the right lower leg on 10/22/24 with a culture of pseudomonas aeruginosa on 11/25/24 which developed into a venous stasis ulcer on 1/2/25 and 3/12/25, -had a catheter, -urine analysis on 3/12/25 had a MRSA positive culture and -transferred with a mechanical lift, 1 assist for all transfers with a revised date of 4/24/25. Observation on 6/2/25 at 7:00 PM revealed an EBP sign on the door entering Resident 8's room. Licensed Practical Nurse (LPN)-B confirmed that resident was on EBP due to having a suprapubic catheter and wounds to both lower legs. Observation of care on 6/4/24 at 11:55 AM revealed Medication Aide (MA)-L entered Resident 8's room and did not apply a gown or gloves. The resident was transferred from the wheelchair to the recliner and the catheter bag was moved from the wheelchair to the recliner. All cares were completed with no gown or gloves on. An interview with the DON on 6/4/25 at 12:20 PM confirmed that staff were to wear gown and gloves when transferring resident from wheelchair to the recliner and touching the catheter bag.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, record review and interview; the facility failed to ensure food temperatures were maintained at a level to prevent the potential for food borne illness. This had the potential to affect 1 out of the 34 residents who ate food out of the kitchen. The facility staff identified a census of 34. Findings are: A. Record review of the facility policy Time/Temperature Control for Safety Foods Temperature Guide (undated) revealed maintaining the proper temperature of food reduced the possibility of food borne illness. The following internal temperatures were to be followed to assure food safety: -eggs, fish, meat, and pork to be served at 145 degrees. -ready-to-eat, canned foods and foods from intact packages were to be served at 135 degrees or higher. B. Observations on 6/3/25 from 11:30 AM to 12:15 PM of the noon meal service revealed the following: -At 11:38 AM Dietary [NAME] (DC)-N prepared the food items to be served to residents on a pureed diet. DC-N pureed a single serving each of peas and carrots, cheesy potatoes, and cornflake chicken. Each item was placed in a small bowl, covered with tinfoil, and then placed on the top of the steam table. -At 11:56 AM, DC-N obtained food temperatures of items to be served for the noon meal which had been placed inside of the steam table. DC-N failed to complete a temperature check of the pureed food items which had been stored on the top of the steam table. -At 12:08 PM, DC-N placed the 3 bowls of puree food items on a plate and prepared for service to the resident. No food temperatures were obtained prior to attempting to serve the resident. Upon request, temperatures of the pureed food items revealed the following: -the peas and carrots were 110 degrees. -the cheesy potatoes were 105 degrees. -the cornflake chicken was 122 degrees. Interview with DC-N on 6/3/25 at 1:38 PM confirmed the pureed food items (peas and carrots, chicken, and cheesy potatoes) were placed into small bowls and covered with tin foil and then were positioned on the top of a covered pan on the steam table. No food temperatures were obtained of the puree food items prior to attempting to serve to the resident. All food items should have been temped prior to meal service to ensure the items were safe and palatable. Interview on 6/3/25 at 2:30 PM with the Dietary Manager revealed once pureed food items were prepared, they should be placed inside of the steam table to maintain the temperature of the food. Temperatures of each puree food item should be checked prior to meal service and documented on the temperature log. Food temperatures should be maintained at a minimum of 135 degrees Fahrenheit.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to monitor and to assess bruising, increased swelling, and pain for 1 (Resident 6) of 2 sampled residents. The facility identified a census of 34. Findings are: A. Record review of the facility policy Change in Status, Identifying and Communicating (undated) revealed in a long-term care setting, any change from baseline status must be identified and addressed. The resident should be assessed for changes from baseline status whenever the resident's status changes. Notable changes include a decline in functional status, new or increasing confusion, incontinence, weight gain or loss of more than 5 percent (%) of body weight, temperature elevation, acute onset of pain, shortness of breath, deteriorating mobility, falls, and behavior changes. Unless the resident's condition is life threatening, the resident can be assessed and a treatment plan initiated. At a minimum, the assessment should include: -reviewing the resident's medical record. -asking how the resident feels and what symptoms the resident has. -obtaining vital signs. -observing the resident's overall condition, including function and cognition. -exploring the resident's complaints. Documentation associated with identifying and communicating a change in a resident's status includes: -acute change in status. -oxygen saturation. -nursing interventions and the resident's response to the interventions. -diagnostic testing. -other assessments findings in the appropriate areas in the resident's medical record. B. Record review of Resident 6's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated 2/7/25 revealed the resident was admitted [DATE] with diagnoses of chronic respiratory failure with hypoxia (a condition where tissues and organs are deprived of an adequate amount of oxygen), atrial fibrillation, heart failure, pneumonia, Chronic Obstructive Pulmonary Disease (COPD), and depression. The following was assessed regarding the resident: -The resident was cognitively intact. -The resident was dependent with toileting, dressing, transfers, personal hygiene, and bed mobility. -The resident received an anticoagulant (medication used to help prevent blood clots) and a diuretic (medication which causes the kidneys to make more urine to rid the body of extra fluid) daily. -The resident received oxygen therapy and non-invasive mechanical ventilator (breathing support delivered through a mask or nasal prongs) which were used daily. Record review of Resident 6's Nursing Progress Notes dated 2/19/25 revealed the following: -At 3:29 AM the resident was being transferred with 2 staff assist and a gait belt from the wheelchair to the recliner. The resident could not assist the staff with standing and the resident was lowered to the floor. The resident denied any pain or discomfort. -At 9:00 AM the resident went limp during a transfer with the sit-to-stand mechanical lift (a mobile lift that allows for patient transfers from a seated position to a standing position. This lift is designed to support only the upper body of the resident and requires the resident to have some weight-bearing capability). Staff were able to get the resident into bed safely. The note indicated the staff were now to use the full lift for all transfers. Record review of Resident 6's Nursing Progress Noted dated 2/26/25 at 2:37 PM revealed the resident's left lower leg and ankle had several bruises in various stages. The resident reported the bruising happened on the sit-to-stand lift the previous week when the resident went limp. No injuries were noted at the time of the fall. Staff reported bruising to the resident's left lower leg/ankle on 2/21/25. Nursing discussed with therapy and to limit use of the left leg/ankle. The staff were to continue use of the full lift for all transfers. Record review of Resident 6's electronic medical records from 2/21/25 to 2/26/25 including progress notes, skin monitoring sheets, care plan and practitioner orders revealed there was no indication Resident 6 had bruising to the left lower leg/ankle. Record review of Resident 6's Physician Visit/Communication Form dated 2/27/25 revealed the resident's physician was notified the resident's left lower leg/ankle had several bruises in various stages. There was no documentation of an assessment of the bruises to indicate the sizes or the number of bruises to the resident's leg. Record review of Resident 6's Progress Note dated 2/27/25 at 1:50 PM revealed Physical Therapy (PT) discussed with the Charge Nurse an increase in bruising and swelling to the resident's left lower extremity and the resident confirmed the area was tender when used. Record review of Resident 6's electronic medical record from 2/27/25 to 3/6/25 revealed no evidence an assessment was completed of the resident's left lower leg/ankle regarding bruising, redness, swelling or increased pain/tenderness. Record review of Resident 6's Physician Visit/Communication Form dated 3/6/25 at 10:23 AM revealed the resident's left lower leg continued to be red with increased swelling. Record review of Resident 6's electronic medical record from 3/6/25 to 3/13/25 revealed no evidence an assessment was completed of the resident's left lower leg/ankle regarding complaints of pain. Record review of Resident 6's Nursing Progress Notes dated 3/13/25 at 3:37 PM revealed the resident was seen by the physician with an x-ray due to complaints of left lower leg pain with therapy. Record review of an Imaging Report for Resident 6 dated 3/13/25 revealed 2 views of the tibia (shin bone)/fibula (calf bone) revealed no acute fractures. An abnormality along the lower side of the tibia was noted and the report indicated unsure if it is acute. To have report reviewed by Radiology. Record review of Resident 6's electronic medical record from 3/13/25 to 4/3/25 revealed no evidence staff had assessed and/or monitored the resident's complaints of pain to the resident's ankle. Record review of Resident 6's Nursing Progress Note dated 4/3/25 at 12:57 PM revealed the resident was to have an x-ray of the resident's ankle due to pain and continued need for use of the full lift. Record review of an x-ray report for Resident 6 dated 4/4/25 revealed a nondisplaced fracture to the left ankle and a fracture to the lower left fibula. During an interview on 6/5/25 at 8:13 AM the Director of Nursing confirmed the following: -On 2/19/25 the resident had a fall at 3:29 AM when staff attempted to transfer the resident with 2 assist and a gait belt. The resident had a second fall at 9:00 AM during use of the sit-to-stand mechanical lift. -On 2/26/25 the staff documented the resident had multiple areas of bruising to the left ankle which had first been reported on 2/21/25. No skin assessments were completed to identify the number of bruises or the size of the bruises. -On 2/27/25 the resident had increased swelling and complaints of pain to the ankle. -On 3/6/25 the physician was notified the resident's ankle remained bruised, with swelling/redness and pain. There was no evidence an assessment or ongoing monitoring had been completed of the resident's ankle. -On 3/13/25 the resident had an x-ray due to complaints of left lower leg pain during therapy. The staff failed to complete an assessment or to monitor the resident's pain. An abnormality was noted along the lower side if the tibia and radiology were to review the report. -There was no evidence the facility followed up with radiology regarding the x-ray report. -From 3/13/25 to 4/3/25 the staff failed to document any pain assessments or to have any evidence of monitoring. -On 4/3/25 the resident had a subsequent x-ray due to continued complaints of pain to the resident's ankle and continued use of the full lift. The resident was noted to have a fracture to the left ankle and to the left lower fibula.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report, complete, and submit a thorough investigation of a resident-to-resident altercation involving Residents 19 and 235. The sample size was 2 and the facility census was 34. Findings are: Record review of the facility standard Abuse and Neglect Prevention with a revision date of 1/2023 revealed the following: -The residents had the right to be free from abuse, neglect, misappropriation resident property, and exploitation. -Physical abuse included slapping, hitting, punching, biting, and kicking. -All team members immediately reported acts of witnessed, suspected or reported abuse the facility Administrator or supervisor. -The facility followed the seven components of Abuse and Neglect Prevention Standards including, screening, training, prevention, identification, investigation, protection, and reporting. -Facility team members identified, corrected, and intervened in situations in which abuse, neglect, and/or misappropriation of resident property likely occurred. -Team members had knowledge of assessment, care planning, and monitoring of residents with needs and behaviors that could lead to conflict. -All abuse and/or neglect was investigated and reported in accordance with State and Federal laws. -Residents were separated or moved to a place of safety away from a harmful or abuse situation to prevent reoccurrence and for their own protection. -After conducting an investigation, the facility reported the results to the State Agency within 5 working days. Record review of Resident 235's Minimum Data Set (MDS, federally mandated comprehensive assessment used in care plan development) dated 10/24/24 revealed the resident had cognitive impairment, had displayed verbal behaviors 1-3 days out of the past 7 directed toward others, received assistance with transfers, dressing, and toileting, and had a diagnosis of dementia. Record review of Resident 235's Care Plan with a revision date of 7/23/24 revealed the resident had dementia and also had a history of slapping staff and cursing staff during care provision. Record review of Resident 235's Progress Notes dated 11/26/2024 at 11:38 AM revealed Resident 235 was sitting at the dining room table when staff overheard the resident arguing with another resident. Staff approached the table and witnessed Resident 235 slap the other resident's (Resident 13) hand away. Resident 13 was attempting to cut up Resident 235's chicken and Resident 235 was requesting Resident 13 not to do that. Resident 13 denied any discomfort and reported being fine. A few moments later staff noticed the residents were arguing once again. Resident 13 was attempting to help assist Resident 235 with cutting up food and Resident 235 was yelling. Resident 235 then slapped Resident 13's hand again, and Resident 13 then left the table. The Assistant Director of Nursing, RN-E, and the Administrator were notified. The table was to be rearranged, and Residents 13 and 235 would sit across from each other. During an interview with the facility Administrator on 6/6/25 at 9:55 AM the facility Administrator confirmed the facility investigated the resident to resident altercation on 11/26/24 in which Resident 235 slapped the hand of Resident 13 and determined no abuse occurred with both residents agreeing they were friends and this was a playful interaction, however this was not indicated in the charting of the altercation and the facility did not report the altercation as required prior to the investigation.

Licensure Reference Number 175 NAC 12-006.04B2a Based on record review and interview, the facility failed to ensure 5 [Nurse Aides (NA) B, C, D, E and F] of 9 sampled nurse aides had completed 12 hours of yearly in-service education and failed to complete dementia and abuse in-service training for 1[ NA C] of 9 sampled nurse aides. The facility had a total census of 31 residents. Findings are: A. Record review of a facility Employee List revealed NA B was hired on 5/25/21. Record review of NA B's Inservice education revealed that NA B had completed a total of 4.40 hours of training. B. Record review of a facility Employee List revealed NA C was hired on 5/23/22. Record review of in-service education for NA C revealed that no in-service education had been completed and no abuse or dementia training had been completed. C. Record review of a facility Employee List revealed NA D was hired on 7/9/15. Record review of in-service education for NA D revealed a total of 2.84 hours of training. D. Record review of a facility Employee List revealed NA E was hired on 10/26/20. Record review of in-service education for NA E revealed a total of 9.27 hours of training. E. Record review of a facility Employee List revealed NA F was hired on 11/11/22. Record review of in-service education for NA F revealed a total of 10.32 hours of training. F. Interview on 06/11/24 at 11:18 AM with the Director of Nursing [DON] revealed that that NA's B and C were PRN [as needed] staff that work in the summer. The DON confirmed that NA's D and E were PRN employees and NA F was a part time employee. The DON confirmed that the 12-hour education training requirement had been missed for NA's B, C, D, E, and F. The DON confirmed that the facility did not have a current system to track the number of hours to ensure that the 12 hours of education training were met by all staff including PRN and part time staff. The DON stated they did not have a current system to track abuse and dementia training to ensure completion of the requirement by all staff. G. Record review of the Facility assessment dated [DATE] revealed that training and competencies are provided annually thru monthly team meetings, Net learning (online education requirements), annual competencies, health care conventions, departmental educational sessions / meetings, and Infection control training through the Center for Disease Control online. Medication aides and Nurse aides are required to have 12 hours of training annually. H. Record review of the facility policies entitled Abuse and Neglect Prevention Standard dated January 2023: Section 3 revealed the following: - Training: A. All team members will be trained on the following topics during orientation and at least annually: 1. Facility Abuse and Neglect Prevention standard. 2. Appropriate interventions for Dementia management to prevent and/or manage aggressive and / or catastrophic reactions of residents using the Buddies forever program.

Licensure Reference Number 175 NAC 12.006.17 Based on record review, interviews, and observation, the facility failed to provide catheter care in a manner to prevent cross contamination and the potential for infections for1 (Resident 6) of 2 residents reviewed. The facility census was 31. Findings are: Record review of Resident 6's census revealed an admitted into the facility of 11/1/23. Record review of Resident 6's Minimum Data Set (MDS, a federally mandated assessment tool used for care-planning) dated 5/14/24, revealed Resident 6 had a Brief Interview of Mental Status (BIMS, an interview used to determine cognition) with a score of 15. A score of 15 indicated Resident 6's cognition was intact. The MDS identified Resident 6 as having a suprapubic catheter (a suprapubic catheter is a surgically placed catheter through the abdomen into the bladder to drain urine) and was occasionally incontinent of bowel. The assessment revealed Resident 6 required dependent level of assistance with toileting and required suprapubic catheter care. Record review of Resident 6's diagnosis sheet dated dated 11/1/23 revealed a diagnosis of retention of urine. Record review of Resident 6's Physician Orders dated 11/6/23 revealed an order to change the suprapubic dressing twice daily with a split dressing and to cleanse area with soap/water and pat dry. Report any signs of infection to the Primary Care Provider (PCP). Observation on 6/10/24 at 8:10 AM on the outside of Resident 6's room was a sign for Enhanced Barrier Precautions (EBP).EBP is an infection control strategy that uses personal protective equipment (PPE) to reduce the spread of multidrug-resistant organisms (MDRSs) in skilled nursing facilities (SNFs). MDROs are microorganisms, like bacteria, fungi, and viruses, that are resistant to many antibiotics and antifungals, making them difficult to treat. The spread of MDROs can lead to increased healthcare costs, as well as higher rates of illness and death among residents of a SNF. Residents with wounds or indwelling medical devices (suprapubic catheter) are at a particularly high risk. Observation on 6/12/24 at 8:20 AM revealed suprapubic catheter cares were performed by Nurse Aide (NA)-A. Resident 6 was lying in a supine position in their bed. NA-A was wearing a gown and gloves. Supplies to be used for suprapubic catheter cares were lying on the bedside table with a barrier underneath the supplies. Resident had towels over the abdomen and the peri-area for privacy as well as the privacy curtain pulled. NA-A moved the towels just enough to perform the procedure with minimal exposure of the resident. NA-A removed the dirty dressing from around the suprapubic catheter and without benefit of Hand Hygiene (HH) or changing gloves used 3 disposable cleansing wipes to clean around the suprapubic catheter. Used a new disposable cleansing wipe each time and each time went from the resident moving away from the resident with one wipe. The suprapubic catheter insertion site skin was intact, pink, and clean. NA-A picked up the barrier cream without benefit of HH or a glove change, squeezed the tube with the dirty glove onto her other dirty gloved hand and applied barrier cream around the suprapubic catheter site. NA-A picked up the split sponge (dressing) without benefit of HH or changing gloves, opened the package and applied the clean dressing with dirty gloves over the resident's suprapubic catheter site. NA-A removed gloves and covered resident up with the towels with no HH. Interview on 6/12/24 at 8:40 AM with NA-A revealed after [gender] removed the suprapubic catheter dressing, HH and a glove change should have been completed. NA-A confirmed HH and glove change should also have been done before placing hands on the barrier cream tube. NA-A confirmed new gloves and HH should have been done before touching the clean split sponge for application to the suprapubic catheter site. Interview on 6/12/24 at 8:45 AM with the Director of Nursing (DON) confirmed HH and glove change should have been done after the removal of the dirty split sponge. The DON confirmed HH and glove change should have been done before touching the barrier cream tube. The DON confirmed HH and glove change should have been done before touching the clean split sponge for application to the suprapubic catheter site. Record review of facility policy and procedure for suprapubic catheter care of an established catheter dated 2024 revealed the following checklist steps: If required, verify the practitioner's order. Gather and prepare the necessary equipment and supplies. Perform hand hygiene. Confirm the patient's identify using at least two patient identifiers. Provide privacy. Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs. Raise the bed to waist level before providing care. Perform hand hygiene. Put on gloves. Place the patient in the supine position. Stabilize the catheter with your nondominant hand. With your dominant hand, clean the skin around the catheter insertion site using a washcloth that contains mild soap and water, moving outward in concentric circles. Gently dry the area around the catheter insertion site with a towel or gauze pad. Assess the stoma for irritation, erosion, urine leakage; assess the surrounding skin for redness, swelling, warmth, and tenderness. Notify the practitioner if these signs are present. Using a catheter securement device, secure the urine drainage system tubing below the level of the bladder. Rotate the application site for the catheter securement device, as needed. Return the bed to the lowest position. Discard used supplies in appropriate receptacles. Remove and discard your gloves. Perform HH Monitor the patient's intake and output. Observe the urine for appearance, odor, color, and any unusual characteristics. Monitor for signs of infection, such as increasing suprapubic pain or tenderness, fever, and tachycardia. Perform HH. Document the procedure.

Based on record review and interview, the facility failed to ensure COVID-19 testing was completed in accordance with the facility mitigation plan (a plan to reduce the severity or seriousness of COVID-19) for 2 unvaccinated staff (Nursing Assistant) NA-A and (Dietary Aid) DA-B of 5 staff members reviewed. This had the potential to affect all residents residing in the facility. The facility identified a census of 30. The findings are: Record Review of the COVID response plan dated 6/18/2020 revealed the following: -When community transmission levels are not high (blue, yellow or orange) and the facility is not in an outbreak, team members may choose not to wear source control. -Routine testing is not generally recommended. At a minimum, unvaccinated team members who have medical or religious exemptions will be required to test weekly. This requirement is subject to change as needed. Interview with the Administrator on 4/17/23 at 2:00 PM revealed testing was occurring weekly for staff members with exemptions. A. Record Review of the facility COVID-19 Staff Vaccination Status for contracted employees revealed NA-A is an agency staff member that was unvaccinated and had a religious exemption. Review of the April 2023 schedule revealed NA-A worked a scheduled 6 0'clock shift on Wednesday 4/5/23. Review of the testing logs for the week of 4/1- 4/7/2023 revealed no testing for NA-A. An interview with the Interim DON (Director of Nursing) on 4/19/23 at 9:18AM confirmed that NA-A was an agency staff that had an exemption from the COVID-19 vaccine and that NA-A had worked on 4/5/23. Review of the testing log with the DON confirmed that NA-A had not been tested the week of 4/1-4/7/23. B. Record review of the COVID-19 Staff Vaccination Status for Providers revealed DA-B was unvaccinated and had a religious exemption for the COVID-19 vaccination. Review of the dietary schedule for April 2023 for DA-B revealed that DA-B worked on 4/2, 4/4, and 4/7/23. Review of the testing logs for 4/1-4/7/23 revealed no testing for DA-B. Interview with the DON on 4/19/23 at 1:52 PM confirmed DA-B had worked 4/2, 4/4, and 4/7/23 and was not tested the week of 4/1-4/7/23.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review, the facility failed to evaluate the residents level of pain and the effectiveness of routine Opioid [a broad group of pain relieving drugs used for pain control] medications used to control pain and failed to re-evaluate the pain management program for 2 (Residents 18 and 26) of 2 residents reviewed for pain management. The facility census was 30. Findings are: A. Record review of a facility policy entitled Pain Management Standard dated [DATE] revealed the following: - Residents will be pain free, or their pain will be managed to a level that is acceptable to the resident. - The definition of Persistent / Chronic pain: Pain that lasts for a prolonged period of time and is associated with chronic disease or injury (e.g., osteoarthritis). Persistent pain is often associated with functional loss, mood disruptions, out of character responses or reduced quality of life. - Pain Recognition: Every resident should be regularly and systematically evaluated for pain. The best indicator of the pain experience is the residents own report which must include a review of pain intensity and the effect of pain on activities of daily living. At least daily for residents with a known painful condition. Continual assessment for pain is accomplished through daily interaction with residents by team members. - Managing pain in older adults with common chronic conditions: - If reassessment findings indicate pain is not adequately controlled, revise the pain management regimen and care plan as indicated. - Physician and responsible party (when applicable) should be notified if pain is not controlled. - If pain has resolved and there is no longer indication for pain medication, the IDT should work to discontinue or taper analgesics. B. Record review of Resident 18's Admission Face Sheet revealed that Resident 18 was admitted to the facility on [DATE] with diagnoses that included Arthritis in the left shoulder and Parkinson's Disease. A record review of Resident 18's annual Minimum Data Set [MDS, a comprehensive assessment used to develop a resident's care plan) dated 3/2/23 identified that Resident 18 had a Brief Interview of Mental Status [BIMS] score of 15 ( 13-15 indicates cognitively intact), was independent with activities of daily living and received Opioid medication daily. Section J of the MDS indicated that resident had almost constant pain that made it hard to sleep and limited the residents day to day activities. The resident reporting a pain rating of 5 on a 0-10 level scale (0 being no pain and 10 being excruciating pain). A record review of Physician Orders dated 2/28/23 related to pain management revealed an order for Hydrocodone - Acetaminophen [an Opioid medication] 7.5 - 325 milligrams [mg] 1 tablet by mouth three times a day for pain and an order dated 10/14/21 for Muscle Rub Cream [a pain relieving gel] 10-15 percent [%] (Menthol - Methyl Salicylate) apply to affected areas topically three times per day for pain. Resident 18 also had an order for Tylenol [a pain medication] Tablet 325 MG (Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Pain. An interview on 04/19/23 at 10:53 AM with Resident 18 revealed that [gender] had pain most of the time in the neck and shoulder. The resident stated that the staff had not asked the level of pain when they gave the routine pain medication or put on the muscle rub. The resident stated the staff had not asked to see if the pain had been relieved with the use of the medications. The resident stated that, at the time of the interview, they were not having any pain and they could tell the staff if they had pain and could ask for pain medication. A record review of a pain assessment document titled Pain Interview V-2 dated 3/2/23 revealed Resident 18 reported having pain almost constantly with a pain rating of 5. The resident reported that the pain had made it hard to sleep and Resident 18 had limited their day to day activities due to the pain. A record review of a pain assessment document titled Pain Interview V-2 dated 11/30/22 revealed Resident 18 reported having pain almost constantly with a pain rating of 8. Resident 18 indicated that it did not cause trouble sleeping or the daily living activities to be limited. A record review of Resident 18's MAR (Medication Administration Record) dated April and May 2023 revealed that pain ratings were not documented with each administration of the routine Hydrocodone or the routine Muscle Rub medication and that the level of effectiveness of the routine pain medications had not been identified or documented. C. Record review of Resident 26's Admission Face Sheet revealed that Resident 26 was admitted to the facility on [DATE] with diagnoses that included Stroke affecting the right side, Osteoarthritis and Low back pain. A record review of Resident 26's annual MDS dated [DATE] identified that Resident 26 had a BIMS score of 15, required limited to extensive assistance with activities of daily living and took Opioid medication daily. Section J of the MDS indicated that resident had frequent pain that made it hard to sleep and limited the residents' day to day activities. The resident reporting a pain rating of 6 on a 0-10 level scale. A record review of Resident 26's Physician Orders dated 12/20/22 related to pain management revealed an order for Hydrocodone - Acetaminophen 5 - 325 mg 1 tablet by mouth two times a day for pain and Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain. Further review of the physician orders revealed that the as needed Hydrocodone pain medication had been discontinued on 2/16/23 due to the fact that the residents pain was managed thru the use of routine Hydrocodone. An interview on 04/19/23 at 9:50 AM with Resident 26 revealed that [gender] took a routine medication daily for pain and had pain mostly in the legs. The resident stated that the staff had not asked the level of pain when they gave the routine pain medication. The resident stated the staff hadn't asked to see if the pain had been relieved with the use of the medication. The resident stated that, at the time of the interview, they were not having any pain and they could tell the staff if they had pain. A record review of a pain assessment document titled Pain Interview V-2 dated 3/9/23 revealed Resident 26 reported having pain frequently with a pain rating of 6. The resident reported that the pain had made it hard to sleep and Resident 26 had limited their day to day activities due to the pain. A record review of a pain assessment document titled Pain Interview V-2 dated 12/6/22 revealed Resident 26 reported having pain frequently with a pain rating of 6 and that the pain made it hard for Resident 26 to sleep. A record review of Resident 26's MAR's dated April and May 2023 revealed that pain ratings were not documented with each administration of the routine Hydrocodone and that the level of effectiveness of the routine pain medication had not been identified. An interview with Registered Nurse (RN) C on 4/19/23 at 11:49 AM revealed that the electronic health system for medication administration did not prompt the nurses to ask the resident their pain level or prompt them to check the effectiveness of the routine pain medication after it was given. An interview on 4/19/23 at 1:05 PM with the facility Director of Nursing (DON) confirmed that it was the expectation that residents' pain levels were to be assessed with each pain medication given and the effectiveness of the medication was to be evaluated and documented. The DON confirmed that this was not done for Resident 18 or Resident 26. The DON confirmed there was no assessment of the pain level or follow up of the effectiveness of the medication. The interview also confirmed that the overall pain management program, including routine medications, for Resident 18 and 26 should have been reviewed for potential necessary changes.

Licensure Reference Number 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to ensure the residents and /or the resident's representatives were notified in writing of the reason for transfer to the hospital for 1 resident ( Resident 2) of 1 residents reviewed for hospitalization . The facility census was 30. Findings are: A. Record review of Resident 2's Clinical Census Record revealed that Resident 2 was sent to the Hospital on 1/16/23 and returned to the facility on [DATE]. Review of Resident 2's Electronic Medical Record revealed an absence of documentation related to a written notice of the reason for transfer to the hospital. No reason for transfer had been provided to the resident and / or resident's representative for the hospitalization on [DATE]. An interview on 4/19/23 at 8:49 AM with the facility Social Services Supervisor [SSS] confirmed that no written notice of transfer to the hospital on 1/16/23 had been provided to Resident 2 or the resident's representative. The SSS confirmed that the family was notified by phone of Resident 2's transfer to the hospital.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1c Based on observations, record review and interviews; the facility failed to provide toileting assistance for Resident 17, who required assistance with activities of daily living. The sample size was 15 and the facility census was 28. Findings are: Review of Resident 17's Minimum Data Set (MDS - a federally mandated comprehensive assessment tool used for care planning) dated 10/13/21 indicated the resident was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident's cognition was severely impaired, the resident required extensive assist for transfers and toileting and was frequently incontinent of bowel and bladder. Review of Resident 17's current undated care plan revealed the resident required assistance with transfers and toileting and was incontinent of bowel and bladder. The care plan identified the resident was at risk for skin breakdown with an intervention to check on or toilet the resident before and after meals. Review of Resident 17's Bladder Elimination record from 12/4/21 to 12/6/21 indicated the resident was incontinent of urine at the following times: -12/4/21 at 03:23 AM, 09:48 AM, 7:51 PM, and 9:52 PM; -12/5/21 at 03:43 AM, 10:48 AM, and 8:49 PM; and -12/6/21 at 12:57 AM, 05:38 AM, and 10:30 AM. An observation of Resident 17 on 12/5/21 at 10:02 AM revealed the resident was seated in a recliner and a strong urine odor was noted. Observations of Resident 17 on 12/6/21 from 07:30 AM to 11:35 AM revealed the following: -At 7:30 AM the resident was seated in the wheelchair and a strong urine odor was noted; -9:15 AM the resident was seated in the recliner and a strong urine odor was noted; -10:00 AM the resident was seated in the recliner and a strong urine odor was noted; -11:20 AM to 11:35 AM, NA-E and NA-F assisted the resident to the bathroom and the resident's brief was saturated with urine and feces. During an Interview with NA-E on 12/6/21 at 11:20 AM, NA-E confirmed Resident 17 had not been assisted with toileting or checked for incontinence since the resident got out of bed before 7:30 AM. An interview with the Director of Nurses (DON) on 12/6/21 from 1:20 PM to 1:30 PM, revealed staff were expected to assist Resident 17 with toileting and/or checking the resident for incontinence before and after meals in addition to the scheduled times of 9:00 AM, 1:00 PM and 5:30 PM to prevent potential skin breakdown.

LICENSURE REFERENCE NUMBER NAC 175 12-006.10A(1)(2) Based on observations, record review and interview; the facility failed to provide safe storage and administration of medications that were left unsupervised with 2 residents (Residents 22 and 26) who were not assessed as safe to administer their own medications. The total sample size was 15 and the facility census was 28. Findings are: A. Review of the facility's Oral Drug Administration Skills Checklist dated 7/10/2020 revealed staff should stay with residents during medication administration until the resident has swallowed the medication. B. Review of the facility's policy titled Self-Administration of Medications dated 2/2018 revealed the purpose of the policy was to assure residents were assessed as safe to self-administer medications before the resident could exercise that right and a physician's order must be obtained that states the specific medications the resident may self-administer. C. Review of Resident 22's medical records revealed no evidence the resident was assessed as safe to take oral medications without supervision and there was no physician's order for self-administration of medications. An observation of Resident 22 on 12/5/21 at 08:55 AM revealed medications were left with the resident on the bedside table in a clear cup and no staff were in the room. Review of Resident 22's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] ½ of a 20mg tablet. D. Review of Resident 26's Medication Self-Administration record dated 10/13/21 revealed the resident was assessed as safe to administer 2 specific medications; Refresh eye drops and [MEDICATION(S)] mouth wash. No other medications were included on the self-administration record or in the physician's orders. An observation of RN-F on 12/6/21 from 08:12 AM to 08:25 AM revealed RN-F left medications in a cup on the dining room table for Resident 26 and did not observe the resident swallow the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -Tylenol 325 mg 2 tablets; -Aspirin 81mg 1 tablet; -Citrical+D 1 tablet; -HCTZ 12.5mg (1/2 tablet); -Losartin 50mg 1 tablet; -[MEDICATION(S)] 25mg 1 tablet; and a -Multivitamin 1 tablet. Review of Resident 26's Emar dated 12/2021 revealed RN-F administered the following medications on 12/6/21 at 08:00 AM: -Tylenol 325 mg 2 tablets; -Aspirin 81mg 1 tablet; -Citrical+D 1 tablet; -HCTZ 12.5mg (1/2 tablet); -Losartin 50mg 1 tablet; -[MEDICATION(S)] 25mg 1 tablet; and a -Multivitamin 1 tablet. An interview with RN-F on 12/6/21 at 9:00 AM confirmed RN-F left medications with Resident 26 this a.m. and did not observe the resident swallow the medications. RN-F indicated the resident preferred to take medications without anyone watching closely. E. During an interview with the DON on 12/6/21 from 1:20 PM to 1:30 PM, the DON confirmed the following: -Nurses administering medications were expected to observe the residents swallow all oral medications and should not leave medications with residents; -Resident 26 had been assessed to self-administer specific medications, however the medications that were left with the resident on 12/6/21 at 08:12 AM were not included in the list of authorized medications the resident may self-administer; -Resident 22 had not been assessed as safe to self-administer medications and should not have had medications left in the room.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and interview; the facility failed to implement and monitor nutritional interventions to address ongoing weight loss for 1 (Residents 23) of 1 sampled residents. The facility identified a census of 28. Findings are: A. Review of the facility policy titled Interventions for Unintended Weight Loss (undated) revealed the following examples of interventions to improve food/fluid intakes: -fortification of food (additional protein, fat and/or carbohydrate added to foods) to help increase calories to promote weight gain which included adding butter or margarine to hot cereals and vegetables and sour cream or half-and-half to cereals, soups, gravies or sauces; and -nutritional supplements to be ordered by the physician. The individual acceptance of supplements was to be documented and monitored with adjustment as needed. B. Review of Resident 23's Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated 11/24/21 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment identified the following: -cognition was severely impaired; -supervision provided by staff with dietary intakes; and -weight of 97 pounds (lbs.) with a loss of 5 percent (%) in the last month or a loss of 10% or more in the last 6 months. Resident was not on a physician prescribed weight loss regimen. Review of a Nutrition/Dietary Note dated 6/23/21 at 8:25 AM revealed the resident's weight was 108 lbs. The resident was receiving Carnation Instant Breakfast (CIB-nutritional supplement with added calories) drink twice a day, Magic Cup (nutritional supplement with added protein and calories) daily and Boost Breeze (nutritional drink with added calories and protein) 120 cubic centimeters (cc) three times a day. The note indicated the resident was consuming 100% of these supplements. No new recommendations were identified. Review of Resident 23's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature and pulse) revealed the following regarding the resident's weight: -7/22/21 weight was 106 lbs. -8/27/21 weight was 99 lbs. (down 7 lbs. or a 7% loss in 1 month). Review of a Nutrition/Dietary Note dated 9/22/21 at 10:24 AM revealed the resident's current body weight was 97 lbs. (down 2 lbs. in 1 month). The Registered Dietician (RD) identified a goal for no further weight loss. No additional nutritional interventions were identified. Review of a Weights and Vitals Summary Sheet revealed the resident's weight on 11/15/21 was 95 lbs. Review of documentation of the resident's intakes of the CIB supplement dated 11/7/21 through 12/4/21 revealed the staff failed to document the resident's acceptance of the 120 cc of CIB the resident was to receive three times a day to address the resident's ongoing weight loss on 11/7, 11/10, 11/21 11/24, 11/26 and 11/30 at the evening meal and on 11/18 at the noon meal. The resident refused or consumed less than half of the supplement on 11/19 at the breakfast meal; 11/7, 11/9, 11/15, 11/19, 11/22, 11/23, 11/24, 11/25, 11/27, 11/29 and 12/4 at the noon meal; and 11/11, 11/27 and 12/3 at the evening meal. During an observation of Resident 23 on 12/5/21 at 12:12 PM the resident was served the noon meal which consisted of turkey which had been cut into bite sized pieces and covered with gravy, stuffing with gravy, corn and a dinner roll. In addition, the resident received a 4 ounce glass of Orange Juice and an 8 ounce glass with water. Further observations of the noon meal revealed the resident did not receive the 120 cc of CIB. During an observation on 12/6/21 at 8:36 AM the resident was served the breakfast meal which consisted of a bowl with Rice Krispies, a slice of toast with jelly, a 4 ounce glass with Orange Juice and an 8 ounce glass of ice water. Further observation revealed the resident did not receive the 120 cc of CIB the resident was to receive for weight loss. During an interview on 12/6/21 at 12:01 PM, the Dietary Manager confirmed the following regarding Resident 23: -resident has ongoing weight loss; -the resident is to receive CIB 120 cc every meal. Dietary are to provide the supplement and then to chart the resident's acceptance; and -staff failed to assure the supplement was received at each meal and the acceptance was then documented to assure an effective intervention.

Licensure Reference Number 175 NAC 12-006.11E Based on observations and record review; the facility failed to assure food was served in a manner to prevent the potential for food borne illness related to dietary cook handling food with bare hands and did not wash hands consistently between handling food items. The total sample size was 19 and the facility census was 35. Findings are: An observation of the kitchen and dining room on 12/11/19 from 12:28 PM to 12:30 PM revealed: -Dietary Cook D, reached inside the pan of grilled cheese sandwiches with bare hands touching the sandwich with her left hand and cut the sandwich holding a spatula in her right hand. -Dietary Cook D, picked up grilled cheese sandwich with bare hand and placed it on the plate. -Dietary Cook D, reached inside an open package of saltine crackers with bare hands, picking up several crackers and placed them on the plate. -Dietary Cook D, repeated serving 2 additional grilled cheese sandwiches and crackers touching them with bare hands and placing them on plates without washing hands in between. On 12/12/19 at 7:45 AM Dietary Cook D removed 2 pieces of toast from the toaster with bare hands. Dietary Cook D, washed hands with soap and water after. On 12/12/19 at 2:00 PM Dietary Cook D prepared a cheese sandwich directly on the counter with bare hands and then placed it inside a baggie. Review of the undated facility policy on Bare Hand Contact with Food and Use of Plastic Gloves confirmed plastic gloves were to be worn whenever handling the food directly with hands. Review of the undated facility policy on Hand Washing confirmed hands were to be washed during food preparations, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks, and before donning gloves for working with food.

Licensure Reference Number 175 NAC 12-006.04D2a Based on interview and record review, the facility failed to ensure the Dietary Manager (DM) had the required qualifications. The total sample size was 19 and the facility census was 35. Findings are: Interview with the DM on 12/17/19 at 8:45 AM revealed the DM had not completed the required course work to be a Certified DM. Interviews with the Administrator on 12/17/19 at 9:00 AM and 9:08 AM confirmed the DM had not completed the required course work and the Registered Dietitian only came to the facility on ce a month. Review of the DM's file revealed the DM was currently enrolled (but had not completed) the Nutrition and Foodservices Professional Training Program.

Licensure Reference Number: 175 NAC 12-006.12B Based on observation, record review, and interview; the facility failed to ensure an accounting of medications to prevent the potential for misappropriation. This had the potential to affect all facility residents. The total sample size was 19 and the facility census was 35. Findings Are: [NAME] Review of the facility Policy and Procedure titled Medication Destruction/Disposal with revision date 5/2019 revealed if medications were to be returned to the pharmacy for credit, the medications were to be listed in the medical record as returned to the pharmacy. The method of identifying and communicating the proper method for recording returned medications was to be identified by the Director of Nursing (DON). B. Observation on 12/11/19 at 10:00 AM of the medication room revealed a brown paper sack labeled Heritage was positioned on a counter top. Further observation revealed the paper sack was empty. A form labeled Pharmacy Return was next to the paper sack. The following was documented on the form: -11/26/19 [MEDICATION NAME] (medication used to treat dizziness) 75 milligrams (mg) 10 tablets; -11/26/19 [MEDICATION NAME] (medication for treatment of [REDACTED]. -12/4/19 [MEDICATION NAME] (medication for treatment of [REDACTED]. -12/5/19 [MEDICATION NAME] (medication used to treat high blood pressure) 5 mg 14 tablets; -12/11/19 [MEDICATION NAME] (medication for treatment of [REDACTED]. -12/11/19 Calcium with Vitamin D 134 tablets; -12/11/19 [MEDICATION NAME] (medication used to treat depression) 20 mg 22 tablets; and -12/11/19 Acidophilus (medication to treat yeast infections) 90 tablets. In addition, there was an area at the bottom of the form for documentation of the pick-up date, the time and the staff's name. Further review revealed the areas at the bottom of the form were left blank. During an interview on 12/17/19 at 7:56 AM, the DON verified the following: -the brown paper sack located on the counter top of the medication room was to be used for the storage of medications which were to be sent back to the pharmacy for credit; -if a medication was placed in the brown paper sack; the date, the name and dosage of the medication was to be documented followed by the staff's name on the Pharmacy Return form; -a representative from the pharmacy was to pick up these medications for return; -when a pharmacy representative picked up the medications, staff were to document the pick-up date and time and then sign their name as well as having the representative sign; and -there was no documentation on 12/11/19 to indicate the pharmacy representative had collected the medications or that the medications were accounted for to prevent the potential for misappropriation.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7b Based on record review and interview; the facility failed to implement fall prevention interventions, to identify causal factors, and to revise and/or develop new interventions to prevent ongoing falls for Resident 29. The sample size was 2 and the facility census was 35. Findings are: Review of Resident 29's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/23/19 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS further revealed the following regarding Resident 29: -severe cognitive impairment; -required extensive assistance with bed mobility, transfers and toileting; -frequent bowel and occasional urine incontinence; -scheduled toileting, prompted voiding (urination) or bladder training; and -history of falls with a fracture related to a fall in the last 6 months. Review of a Fall Scene Investigation report dated 2/3/19 revealed the resident had a witnessed fall at 9:50 PM. Further review of the report revealed there was no evidence to indicate the facility had identified causal factors related to the resident's fall. An intervention was identified for staff education. Review of a Fall Scene Investigation report dated 3/1/19 at 9:30 AM revealed the resident was assisted with a transfer, the resident crossed feet, lost balance and was assisted to the floor. An intervention was identified for staff education. Review of a Fall Scene Investigation report dated 4/11/19 at 11:10 AM revealed the resident had an unwitnessed fall in the resident's room. The report indicated the resident was attempting to self-transfer from the bed to the recliner. The assessment identified the resident's recliner required repair as a potential causal factor for the fall. The following interventions were identified: -notify the resident's family regarding need for repair of the recliner; -encourage the resident to sit in the recliner after breakfast if not attending an activity; and -staff to check with the resident at the 10:00 AM snack pass to assist with toileting if needed. Review of a Fall Scene Investigation report dated 4/21/19 at 4:00 PM revealed the resident had a fall in the living room area after the completion of an activity. The report further revealed an intervention for the resident to be one of the first residents assisted out of the area when the activity was finished. Review of a Fall Scene Investigation report dated 4/27/19 at 4:15 PM revealed the resident had been seated in the dining room area for a music activity. The resident fell when attempting to independently leave the activity. Staff were provided education regarding the need to assist the resident as soon as the activity was completed. Review of a Fall Scene Investigation report dated 5/10/19 at 3:40 PM revealed the resident had an unwitnessed fall in the resident's room. The resident was found with a gait belt wrapped around the resident's feet. An intervention was developed for staff to place the resident's gait belt in a bag on the resident's walker. Review of a Fall Scene Investigation report dated 6/21/19 at 5:30 PM revealed the resident had an unwitnessed fall in the resident's room. The resident identified the need to use the bathroom. An intervention was developed to assist the resident to the bathroom before the evening meal. Review of a Fall Scene Investigation report dated 7/1/19 at 4:00 PM revealed the resident had an unwitnessed fall in the resident's room. Review of the form revealed no causal factors were identified, fall interventions were not revised and no additional interventions were developed. Review of a Fall Scene Investigation report dated 8/21/19 at 4:25 PM revealed the resident had an unwitnessed fall in the resident's room. The assessment identified the resident had been agitated prior to the resident's fall. Staff were provided education on provision of purposeful activity for the resident and the resident's family was to be contacted about moving the resident closer to the Nurse's Station. Review of a Fall Scene Investigation report dated 10/16/19 revealed the resident had an unwitnessed fall in the resident's room at 12:30 AM. The resident identified a need to use the bathroom. The report indicated the resident had last been toileted at 8:30 PM (4 hours earlier) and the resident had been incontinent of urine. An intervention was identified to assist the resident with toileting between 10:00 PM and 11:00 PM. Review of a Progress Note dated 10/16/19 at 10:28 AM revealed the resident was seen by the physician and was with diagnosed with [REDACTED]. Review of a Nursing Progress Note dated 11/4/19 at 12:28 PM revealed the resident's family had agreed to move the resident to a room closer to the Nurse's Station. The note indicated the facility was planning on moving the resident in a day or two. Review of a Fall Scene Investigation report dated 11/4/19 at 10:22 PM revealed the resident had a fall in the resident's room when attempting to self-transfer to the bathroom. The resident sustained [REDACTED]. During an interview on 12/16/19 at 11:40 AM the Director of Nursing (DON) confirmed the following: -when a resident had a fall, staff were to conduct an assessment of the resident to determine injuries and then were to complete a Fall Scene Investigation report. All areas of the report were to be completed in an attempt to identify potential causal factors. Current fall prevent interventions were to be reviewed for potential revision or a new intervention was to be developed based on causal factors for the fall; -several areas of the Fall Scene Investigation report dated 2/3/19 at 9:50 PM had been left blank and no causal factors were identified. An intervention for staff education was identified. There was no evidence as to what education staff had been provided to prevent further falls for Resident 29; -staff inattention was identified as the causal factor of Resident 29's fall on 3/1/19 at 9:30 AM. An intervention for staff education was identified. There was no evidence as to what education staff had been provided; -the resident had a fall on 4/21/19 at 4:00 PM related to an attempt to self-transfer out of an activity. An intervention was developed to assist the resident out of an activity as soon it was completed. The resident had another fall on 4/27/19 at 4:15 PM while trying to self-transfer after an activity as the staff had failed to assist the resident out of the activity after its completion; -no causal factors were identified related to the resident's fall on 7/1/19 at 4:00 PM, interventions were not revised and no additional fall prevention interventions were developed; -family was contacted after fall on 8/21/19 at 4:25 PM about moving the resident to a room closer to the Nurse's Station but the family declined; -resident fell while self-transferring to the bathroom on 10/16/19 at 12:30 AM. The resident last been toileted at 8:30 PM (4 hours previous) and sustained fractures to left wrist and arm with fall: -resident's family agreed to move the resident to a room closer to the Nurse's Station on 11/4/19 at 12:28 PM; and -before the resident was moved to a different room, the resident had a fall on 11/4/19 at 10:22 PM and sustained a laceration to the resident's scalp and a fracture to the left femur.

Based on record review and interview, the facility failed to submit an investigation to the State Agency within 5 working days after 1 resident (Resident 50) had a fall with injury requiring medical treatment. The sample size was 4 and the facility census was 31. Findings are: A. Review of the facility policy titled Abuse and Neglect Prevention Standard (revision date 3/2017) included the following: -Any accident that resulted in serious resident injury should be reviewed for potential abuse/neglect and also must be reported to the proper agency; and -After conducting an internal investigation, a report of all investigation results must be reported to the state within five working days. B. Review of Progress Notes dated 11/11/18 at 7:20 AM revealed Resident 50 was observed sitting on the floor in front of the room door and bathroom. The resident sustained [REDACTED]. Documentation further indicated the laceration was 6 centimeters in length and required staples. The resident was to remain overnight at the hospital for observation. Review of facility investigations of potential abuse/neglect for 11/2018 revealed an investigation was not submitted to the State Agency regarding Resident 50's fall with injury on 11/11/18. Interview with the Administrator on 12/3/18 at 11:35 AM confirmed an investigation regarding Resident 50's fall with injury was not submitted to the State Agency as required.

Licensure Reference Number NAC 12-006.09D2a Based on observation, record review and interview, the facility failed to prevent an avoidable pressure ulcer for Resident 8, and failed to assess the pressure ulcer to reflect accurate staging of a pressure ulcer for Resident 13. Facility census was 30 . Findings are: A. Record review of Resident 8's Face Sheet revealed the admission date of [DATE], with [DIAGNOSES REDACTED]. Supra-pubic (above the pelvis) Catheter for urine drainage. Record review of Resident 8's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 5/17/17 revealed that Resident 8 required extensive assistance of one person for bed mobility, transfer, to walk, to dress, and to use the toilet. Observation of Resident 8 on 8/29/17 and 8/30/17 from 9:30 AM to 4: 00 PM revealed Resident 8 was assisted from the dining room after breakfast and placed into the recliner in room. Recliner had two separate cushions to relief pressure, one on top of the other. Resident 8 did not go for lunch on 8/29 or 8/30/17. The resident remained in room seated in the recliner. Interview on 8/30/17 at 4:46 PM with NA (Nursing Assistant ) G revealed that the NA was not aware that Resident 8 had a wound. NA G revealed that, if NA G had been aware of Resident 8 having a pressure area, NA G would have repositioned the resident every two hours to relieve pressure and encouraged Resident 8 to lay down during the day. NA G confirmed that Resident 8 was not repositioned every 2 hours when in the recliner. Interview on 8/31/17 at 8:13 AM with RN (Registered Nurse) B confirmed that, once the NA's get Resident 8 up in the morning, the resident stayed up in the chair all day and did not lay down. RN B confirmed that Resident 8 did have a pressure relief cushion in the chair but was not positioned off the coccyx (tail bone) or asked to lay down in the bed. Observation on 8/31/17 at 9:56 Registered Nurse B observed to perform wound care to Resident 8's coccyx to reveal an open area. Record review of Braden Scale for Predicting Pressure Ulcers, dated 8/16/17 and 8/30/17, revealed Resident 8 was at risk for Pressure sores with the score of 17 (The Braden Scale indicates this is mild risk). Record review of Pressure Ulcer Record for Resident 8, dated 8/31/17, revealed that Resident 8 had a facility acquired Pressure Ulcer. The Pressure Ulcer Record, revealed that date of onset for the coccyx wound was 8/30/17 and it measured 1.5 cm x 0.6 cm (wounds are measured in centimeters (cm) with length x width x depth and any tunneling) that was un-stageable with depth not determined due to slough present in wound. Specialty Interventions needed were wheel chair cushion. Progress note summary revealed that the wound bed had over 50% yellow slough (dead tissue that is separating from the wound bed), and that surrounding tissue was normal for skin tone. The area was covered with [MEDICATION NAME] (a foam dressing with self-adhesive) after cleansing. There were no signs and symptoms of infection at the time. Record of facility plan of care revealed that on 12/3/14 Resident 8 was identified as a Potential for skin breakdown related to decreased mobility. The goal set for Resident 8 was to maintain intact skin integrity. The approaches last updated on 3/8/17 revealed: *weekly and as needed (prn) skin monitoring by professional nurse * Braden Scale quarterly and as needed * offer fluids * Dietician to evaluate resident nutritional status as need * Provide peri care after each incontinent episode * Encourage repositioning. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 8/31/17 at 10:31 AM confirmed that Resident 8 was at risk for pressure ulcers, per the Braden assessment. DON and ADON confirmed that, according to the facility policy of avoidable vs unavoidable, that Resident 8 acquired un-stageable wound would have been avoidable. The DON and ADON confirmed that Resident 8 did not leave the room for lunch and was positioned in the room in the recliner after breakfast until evening meal. B. Record review of the Face Sheet for Resident 36 revealed an admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident 36's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated May 16, 2017 revealed that Resident 36 required: * Extensive assist of two for bed mobility. * Total dependent on assist of two for Transfers. * Unable to walk in room or in corridor * Total dependent on assist of one for locomotion on or off the unit * Extensive assist of two for dressing * Extensive assist of one for personal hygiene. * Resident always occasionally incontinent of urine. * Resident always continent of bowel. * Resident has 1 Un-stageable wound with l sough and or eschar (dark hard, scab like tissue covering the wound), measuring 2.5 cm length x 1 cm width and 1 cm depth. Record review of Resident 36's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated June 06, 2017 revealed that Resident 36 have changes and required: * Transfer changed to Extensive assist of two * Locomotion on and off unit with supervision one person to assist. * Personal hygiene with limited assist of two persons. * Resident had 1 stage 2 pressure ulcer * No un-stageable pressure ulcers with no measurements. Record review of Pressure Ulcer Record dated 5/8/17 revealed that Resident 36 had a unstageable pressure ulcer to the coccyx/tailbone area that measured 2.5 x 1 x 1 cm with small yellow wound surrounding skin dark red purple. Pain was present related to the wound. Resident was admitted to the facility with pressure ulcer. Record review of Pressure Ulcer record dated 5/28 revealed that Resident 36 had a unstageable pressure measuring 2 cm x 1 cm x 2 cm with undermining and serous (clear liquid) exudate. A small amount of the wound was red/yellow with surrounding skin pink. Pain was present . Record review of Physician visit dated 6/12/17 revealed that Resident 36's had a pressure sore to coccyx with length and width decreasing but had tunneling. Measurements taken were 1.4 cm x 1 cm x 1.2 cm with tunneling measuring 2 cm. Record review of Pressure Ulcer Record date of 7/10/17 revealed Unstageable wound 1.2 x 1 x 2.1 with tunneling, serous and purulent (infected) exudate with odor. The wound bed was red with white gray pallor and surrounding skin macerated. Record review of Consulted Wound Care, dated 8/4/17, revealed that Resident 36 had a pressure ulcer that was a stage III and required culture. Also, Resident 36 was to start on antibiotics. Record review of Consulted Wound Care, dated 8/15/17, revealed that Resident 36's pressure ulcer was a stage IV and measured 1/5 x 1 x 2 cm with tunneling of 3 cm at 11 o'clock. Record review of Consulted Wound Care, dated 8/25/17, revealed Resident 36 had a Stage IV Pressure Ulcer with measurements of 2 cm x 1.5 cm x 2 cm with tunneling of 3 cm at 11 o'clock. Record review of Physician order, dated 6/26/17, revealed an order for [REDACTED]. Record review of Resident 36's Plan of Care, dated 5/8/17 revealed Resident had stage II pressure ulcer to coccyx or potential for ulcer development, with target date of 9/25/17. Interview with DON on 08/29/17 at 3:14 PM revealed that Resident 36 had a Stage II Pressure Ulcer. The DON revealed that, was not aware that it was un-stageable upon admission. The DON confirmed that Resident 36 was going out to receive recommendations from Wound Care Nurse. The DON confirmed that the facility sent a Physician Visit Communication Form with residents for appointments. The DON confirmed that the facility did receive back the form with orders. The DON confirmed that the facility had not requested the Wound Care Center's documentation of the visit with wound measurements or staging. Interview with the DON and ADON, on 8/31/17 at 10:31 AM, that staff (including the DON and ADON) have had no formal training to assess pressure ulcer wounds and that Resident 36's Pressure ulcer did not reflect an accurate assessment of staging of Resident 36's pressure ulcer stages.