Every finding on record at Heritage of Webster County

Licensure Reference Number 175 NAC 12-006.04(A)(iii)(2)(b)(c) Based on observation, record review, and interview; the facility failed to ensure Adult Protective Service (APS)/Child Abuse Neglect (CAN) checks were completed prior to hire as required for 4 of 5 sampled staff. This had the potential for residents to be cared for by staff with adverse findings related to abuse or neglect. The facility census was 28. Findings are:A.Record review of the facility policy titled Abuse, Neglect and Exploitation dated 07/2024 revealed that it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. 1. Screening: Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees. The facility will maintain documentation of proof that the screening occurred. Observation on 08/11/2025 at 10:36 AM outside of the room of Resident 3 revealed that Nurse Aide (NA)-E exited the resident's room. Record review of the undated and untitled list of facility employees revealed that NA-E had a hire date of 04/14/2025. Record review of the employee file (a file containing required employee registry and criminal background checks and other facility employee records) for NA-E revealed an Adult Protective Service (APS)/Child Abuse Neglect (CAN) check was labeled as incomplete for NA-E. An interview on 08/12/2025 at 3:18 PM with Human Resources (HR) confirmed that pre-employment background and registry checks for potential employees means the expectation is for the checks to be completed before they start working in the facility. The HR confirmed that this included APS/CAN checks. Interview on 08/12/2025 at 3:15 PM with HR confirmed that APS/CAN checks were run but not reviewed or printed for NA-E. B.Observation on 08/13/2025 at 12:40 PM revealed Dietary Aide (DA) entering and exiting the room for Resident 28 delivering a meal. Record review of the undated and untitled list of facility employees revealed that DA had a hire date of 11/01/2024. Record review of the employee file for DA revealed an APS/CAN check labeled as incomplete. Interview on 08/12/2025 at 3:15 PM with HR confirmed that APS/CAN checks were run but not reviewed or printed for DA. C.Observation on 08/13/2025 at 10:15 AM revealed Housekeeping (HSK) entering and exiting the room for Resident 13 while cleaning. Record review of the employee file for HSK revealed an APS/CAN check labeled as incomplete for HSK. Interview on 08/12/2025 at 3:15 PM with HR confirmed that APS/CAN checks were run but not reviewed or printed for HSK. D.Record review of the undated and untitled list of facility employees revealed that Medication Aide (MA)-G had a hire date of 5/13/2025A review of a nursing schedule (as worked) dated August 2025 revealed that MA-G worked on dates in August 4th,5th,6th, 9th,10th, 12th, and 14th, of 2025.Record review of the employee file for MA-G revealed that APS/CAN checks for MA-F were printed by previous employers prior to being hired on 05/13/2025. APS/CAN checks were not available and/or printed for the date of hire of 5/13/2025. An Interview on 08/12/2025 at 3:15 PM with HR confirmed that APS/CAN checks were run but not printed for MA-G.

Licensure Reference 175 NAC 12-006.04(A)(iii)(2)(a)Based on observation, record review, and interview; the facility failed to ensure that Nurse Aide Registry Checks (a state required record of a successful completion of training and competency to be a nurse aide and any findings of abuse, neglect, or misappropriation of property) were completed prior to hire as required for 3 of 5 sampled staff. This had the potential for residents to be cared for by staff with adverse findings related to abuse or neglect. The facility census was 28. Findings are:A.Record review of the facility policy titled Abuse, Neglect and Exploitation dated 07/2024 revealed that it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. 1. Screening: Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees. The facility will maintain documentation of proof that the screening occurred. Observation on 08/11/2025 at 10:36 AM outside of the room of Resident 3 revealed that Nurse Aide (NA)-E exited the resident's room. Record review of the undated and untitled list of facility employees revealed that NA-E had a hire date of 04/14/2025. Record review of the employee file (a file containing required employee registry and criminal background checks and other facility employee records) for NA-E revealed that it contained a Nurse Aide Registry Check for NA-E dated 8/12/2025 (this was almost 4 months after NA-E started working in the facility). An interview on 08/12/2025 at 3:18 PM with Human Resources (HR) confirmed that pre-employment background and registry checks for potential employees means the expectation is for the checks to be completed before they start working in the facility. The HR confirmed that this included Nurse Aide Registry checks. Interview on 08/12/2025 at 3:15 PM with HR confirmed that the nurse aide registry check for NA-E was not completed prior to their hire date as required. B.Observation on 08/13/2025 at 12:40 PM revealed Dietary Aide (DA) entering and exiting the room for Resident 28 delivering a meal. Record review of the undated and untitled list of facility employees revealed that DA had a hire date of 11/01/2024. Record review of the employee file for DA revealed that it did not contain a Nurse Aide Registry Check for DA. Interview on 08/12/2025 at 3:15 PM with HR confirmed that the nurse aide registry check for DA was not complete. C.Observation on 08/13/2025 at 10:15 AM revealed Housekeeping (HSK) entering and exiting the room for Resident 13 while cleaning. Record review of the employee file for HSK revealed that it did not contain a Nurse Aide Registry Check for HSK. Interview on 08/12/2025 at 3:15 PM with HR confirmed that the nurse aide registry check for HSK was not complete.

Licensure Reference Number 175NAC 12-005.06(D)Licensure Reference Number 175NAC 12-006.19(C)Based on observation, record review, and interview, the facility failed to utilize proper hand hygiene during meal preparation and service and failed to transport clean and soiled linens in a manner to prevent cross contamination. This had the potential to affect all residents receiving food and linen supplies in the facility. The facility census was 28. Findings are:B. A review of a facility policy titled Hand Hygiene dated 8/1/2024 revealed all staff will perform proper hand hygiene to prevent the spread of infection. This applies to all staff working in all locations within the facility. Hand hygiene technique when using soap and water instructed to rub hands together vigorously for at least 20 seconds and to use a clean towel to turn off the faucet. The use of gloves does not replace hand hygiene. If your task requires gloves perform hand hygiene prior to donning gloves and immediately after removing gloves. In an observation completed on 8/13/2025 at 9:47 AM the [NAME] picked up a clear plastic tube like package containing raw ground beef with a gloved hand. The [NAME] placed the meat into a clear plastic container sitting on a scale. The [NAME] then removed the glove from their hand that was holding the package of meat then with both hands removed the clear plastic container from the scale and placed it on the counter. The cook did not complete hand hygiene after removing the glove and continuing the with meal prep task. In an observation completed on 8/13/2025 at 10:02 AM the [NAME] completed hand hygiene using soap and water for 12 seconds. The cook did not vigorously rub hands for a minimum of 20 seconds. In an observation completed on 8/13/2025 at 10:05 AM the Dietary Aide (DA) entered the kitchen area. The DA completed 15 second hand hygiene and turned off the sink with the paper towels they used to dry their hands. The DA did not wash hands vigorously for a minimum of 20 seconds and did not use a clean paper towel to turn off the sink. In an observation completed on 8/13/2025 at 10:14 AM the [NAME] used gloved hands to combine/stir a mixture of lettuce, shredded cheese, tomatoes, and onions in a large metal bowl. When completed the [NAME] removed the gloves from both of their hands and walked over to the stove and using a plastic utensil stirred the meat that was cooking in a pot on the stove. The cook then walked back to the table where the bowl containing the lettuce mixture sat and obtained a piece of aluminum foil from a box. The cook placed the aluminum foil over the bowl using a sharpie to label and date the aluminum foil then took the bowl over to the refrigerator and placed the bowl in the refrigerator. The cook then returned to the stove and stirred the meat mixture again. The [NAME] did not complete hand hygiene after removing their gloves. In an observation completed on 8/13/2025 at 10:24 AM the DA performed hand hygiene with soap and water for 16 seconds. The DA then used the paper towels that they dried their hands with to turn off the water. The DA did not rub their hands vigorously for a minim of 20 seconds and use a clean paper towel to shut off the sink. In an observation completed on 8/13/2025 at 10:26 AM the [NAME] completed hand hygiene using soap and water for 10 seconds. The cook did not vigorously rub hands for a minimum of 20 seconds. In an interview completed on 8/13/2025 at 12:41 PM the [NAME] confirmed that hand hygiene should be completed after removing gloves and hands should be vigorously for a minimum of 20 seconds. In an interview completed on 8/13/2025 at 12:41 PM the DA confirmed that the water should be shut off with a clean paper towel and not the paper towels they used to dry their hands with. In an interview completed on 8/13/2025 with the Infection Control Coordinator (ICC) the ICC confirmed that hand hygiene should be completed after removing gloves, that hand hygiene with soap and water should be done for a minimum of 20 seconds and that the water should be shut off with a clean paper towel not the paper towel used to dry their hands. B. Observation on 8/11/2025 at 06:10 AM of Medication Aide (MA) D carrying dirty bedding to the laundry area through the hallway in both arms without putting the linens in a bag or in a closed container. The soiled linens were against MA D's clothing which could contribute to cross contamination. Observation on 08/11/2025 at 7:10 AM MA-C who took dirty clothing from a resident's room to the spa room and placed in a dirty linen hamper. Although MA C did not carry the soiled clothes against [gender] clothing, they were not carried in a plastic bag or covered soiled linen container. Interview 08/11/2025 1:30 PM with MA C who confirmed the process is to place all dirty linen in a bag and then take to the dirty /soiled clothing /linens. MA C confirmed the clothes were not placed in a plastic bag prior to carrying them down the hallway to the soiled utility container in the Spa area. Confirmation interview on 08/13/2025 at 11:43 AM with Infection Control Coordinator (ICC) who confirmed that the soiled linens were not in a plastic bag when carried down the hallway by MA C and MA D as is expected by all of the staff carrying soiled items. This is an infection control issue.

Licensure Reference Number 175 NAC 12-006.10DBased on record review, observations, and interviews, the facility failed to have medication error rate less than 5%. There were 5 errors and 27 opportunities with was an actual rate of of 18.5% error rate. The facility census was 28. Findings are:Record review of the manufacturer's directions for the Novo Nordisk Novolog insulin flex pen dated 3/2023 states that when using the pen and after attaching a new needle to the flex pen:1. Turn the dose selector to select 2 units2. Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat, but no more than 6 times. If you still do not see a drop of insulin, change the needle and repeat steps3. Clean your injection site with an alcohol swab. Let your skin dry. Do not touch this area again before injecting. 4. Insert the needle into your skin. Press and hold down the dose button until the dose counter shows 0. Continue to keep the dose button pressed and keep the needle in your skin and slowly count to 6. If the needle is removed before you count to 6, you may see a stream of insulin coming from the needle tip. If you see a stream of insulin coming from the needle tip you will not get your full dose. If this happens you should check your blood sugar levels more often because you may need more insulin.Record review of the manufacturer's directions for Novo Nordisk's Fiasp flexpen dated 07/2023 revealed Fiasp insulin comes in a disposable insulin pen and contains a rapid-acting insulin used to manage blood sugar levels in people with diabetes. It's designed for injection at the start of a meal or within 20 minutes after starting to eat.1. Turn the dose selector to select 2 units2. Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat, but no more than 6 times. If you still do not see a drop of insulin, change the needle and repeat steps3. Clean your injection site with an alcohol swab. Let your skin dry. Do not touch this area again before injecting. 4. Insert the needle into your skin. Press and hold down the dose button until the dose counter shows 0. Continue to keep the dose button pressed and keep the needle in your skin and slowly count to 6. If the needle is removed before you count to 6, you may see a stream of insulin coming from the needle tip. If you see a stream of insulin coming from the needle tip you will not get your full dose. If this happens you should check your blood sugar levels more often because you may need more insulin.Record review of the manufacturer's instructions for the [NAME] Lilly Humalog Kwikpen insulin dated 07/2023 revealed this is a short acting insulin that is given by an injectable pen. The directions for use stated:1. Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. If you do not see insulin, repeat priming steps 6 to 8, no more than 8 times. If you still do not see insulin, change the Needle and repeat priming steps2. Turn the Dose Knob to select the number of units you need to inject. The Dose Indicator should line up with your dose.3. Insert the Needle into your skin. Push the Dose Knob all the way in. Continue to hold the Dose Knob in and slowly count to 5 before removing the Needle.Record review of the [NAME]'s Drug Guide for Nurses revealed that Novolog insulin is a rapid-acting insulin with more rapid onset and shorter duration than human regular insulin; Administer insulin aspart (Novolog) subcutaneously in the abdominal wall, thigh, or upper arm within 5-10 min before a meal. April Hazard Vallerand, PhD, RN, FAAN, [NAME] A. Sanoski, BS, PharmD, FCCP, BCPS, eds. 2025. [NAME]'s Drug Guide for Nurses - 19th Ed. Philadelphia, PA. F. A. [NAME] CompanyRecord review of the undated policy Medication Administration revealed the policy is so medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. This policy explanation and compliance guidelines stated; 10. Ensure that the six rights of medication administration are followed: A. Right resident B. Right drug C. Right dosage D. Right route E. Right time F. Right documentationA.Record review of the Medication Administration Record for Resident 27 revealed an order for Fiasp 14 units insulin pen to be given subcutaneously within 2 minutes prior to the meal or within 20 minutes of the start of the meal. Observation on 8/11/2025 at 7:35 AM of Registered Nurse (RN) A who administered Fiasp 14 units by insulin pen in the room of Resident 27. RN A did not hold the insulin injection pen in place for a total of 6 seconds. Interview on 8/11/2025 at 7:55 AM with RN A who confirmed the insulin was administered without priming the needle and that RN A did not leave the needle and pen in place for a total of 6 seconds.B.Record review of the physician orders printed on 8/11/2025 for Resident 20 revealed an order for HumaLOG KwikPen subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject 9 unit subcutaneously in the morning.Observation on 8/13/2025 at 8:20AM of Registered Nurse (RN) A who did not prime the insulin pen needle and who did not count to 5 seconds when the insulin was administered.Interview on 8/11/2025 at 7:55 AM with RN A who confirmed the insulin was administered without priming the needle and that RN A did not leave the needle and pen in place for a total of 5 seconds.C.Record review of Medication Administration Record dated 8/12/2025 for Resident 2 revealed an order for NovoLOG Injection Solution 100 UNIT/ML Inject as per sliding scale: if 0 - 150 = 0; 151 - 200 = 5; 201 - 250 = 10; 251 - 300 = 15; 301 - 350 = 20; 351+ = 25, subcutaneously as needed for In place of routine insulin when when skipping meal or not eating well at 0800 1200 1700.Observation on 8/12/2025 at 11:37 AM of RN F who administered Novolog Insulin 58 units to Resident 2 at 11:37 AM. At that time no nutritious snack was given to the resident.Observation on 8/12/2025 at 12:20 PM when Resident 2 was served the noon meal in the dining room.Interview on 08/12/2025 at 12:30 PM with RN F; RN F thought that insulins could be given up to one hour prior to a meal. Encouraged to review the inserts for the insulin pens to learn more. RN F did not know about the need for a snack of nutritive value within 10-15 minutes if the meal is not served within that time period.D.Record review of the Medication Administration Record dated 8/12/2025 for Resident 24 which revealed an order for NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 8 unit subcutaneously two times a day. Give before lunch and dinner. Hold if blood sugar is less than 120.Observation of RN F who gave insulin to Resident 24 but did not prime the insulin needle and held the needle in place for only one second.Interview on 08/12/2025 at 11:45 AM with RN F who confirmed RN F did not hold the needle in place for 6 seconds or prime the pen.E.Record review of the Medication Administration Record dated 8/12/2025 for Resident 27 which revealed an order for Fiasp 14 units insulin pen to be given subcutaneously within 2 minutes prior to the meal or within 20 minutes of the start of the meal. Observation on 8/12/2025 at 11:21 AM of RN F who held the insulin pen, primed the pen, and held the pen in place for a total 1.5 seconds instead of 6 seconds or more during administration of the Fiasp in the room of Resident 27. Did not offer the resident a nutritious snack prior to leaving the room.Interview on 08/12/2025 at 11:45 AM with RN F who confirmed RN F did not hold the needle in place for 6 seconds when administering the medication to Resident 27.Observation on 08/12/2025 at 11:50 AM of Resident 27 seated in the dining room and had not been served the meal. Only a glass of water and a glass of tea were in front of Resident 27 while seated at the dining table. Observation on 08/12/2025 at 12:04 PM of Resident 27's yawning at the dining table. Resident 27 still had not been served a meal and had only water and tea in front of Resident 27. Observation at 08/12/2025 on 12:11 PM Resident 27 was served the noon meal. Interview on 08/12/2025 at 12:30 PM with RN F; RN F thought that insulins could be given up to one hour prior to a meal. Encouraged to review the inserts for the insulin pens to learn more. RN F did not know about the need for a snack of nutritive value within 10-15 minutes if the meal is not served within that time period.F.Interview on 8/12/2025 at 10:50 AM with the Infection Control Coordinator (ICC) revealed that they are not aware of any insulin training that has been completed or any competencies that have been completed with staff about the use of insulin pens and how long the pens must be held in place prior to removing the insulin needle. The ICC also stated that insulin could be given up to 30 minutes prior to any meal. The ICC admitted to not knowing the FIASP had to be administered within 2 minutes of the start of any meal per the physician orders and per the manufacturer's directions. Interview on 8/12/2025 at 10:50 AM with the Director of Nursing (DON) revealed that insulin could be given up to 15 minutes prior to a meal. The DON was not 100% certain how long the insulin pen needles needed to stay in place when administering the insulin. Confirmed that giving insulin without priming the needles is not an accurate method of giving insulin when using insulin pens. The DON also confirmed that there should have been a snack given prior to the meal if the meal wasn't going to be served immediately. The DON admitted to not knowing the FIASP had to be administered within 2 minutes of the start of any meal per the physician orders and per the manufacturer's directions.

Licensure Reference Number 175 NAC 12-006.09Based on record review, observations, and interviews, the facility failed to ensure that glucometer testing supplies were dated and discarded when expired according to the manufacturer's instructions; and the facility failed to ensure nurses had been trained adequately in the use of the continuous blood glucose monitoring systems. This affected all residents with diabetes, a total of 7 residents (Residents 1, 2, 14, 20, 24, 27, and 28), and the facility failed to ensure insulin (abnormal blood glucose) medication was administered or withheld in accordance with the prescribers' orders for 1 (Resident 1) of 1 sampled resident. The facility census was 28. Findings are: A. Record review of the undated facility policy “Blood Glucose Monitoring” revealed it is the policy of the facility to perform blood glucose monitoring to diabetic residents as per physicians’ orders. The policy explanation and compliance guidelines further stated; 1- The facility will perform blood glucose monitoring as per physician’s orders. 2- The nurse will perform the blood glucose test utilizing the facility’s glucometer as per manufacturer’s instructions. 3- If possible, glucometers should not be shared between residents, but if this is not possible, the nurse is responsible for cleaning and disinfection of the machine between residents following the manufacturer’s instructions and in accordance with the facility’s glucometer disinfection policy. 4- Calibration checks on glucometers must be performed ____(Specify frequency/shift) as per manufacturer’s instructions. 8- For residents who have continuous glucose monitoring systems, blood glucose via glucometer for verification of results will be done as per physician order. (See Continuous Glucose Monitors Policy.) Record review of the undated facility policy “Continuous Glucose Monitors” revealed the continuous glucose monitor (CGM) systems are used to increase glycemic time in range and decrease hypo and hyperglycemic episodes (episodes of low or high blood sugars). CGMs may be considered for residents with inconsistent or confounding glycemic control, particularly when insulin is prescribed. It is the policy of this facility to allow diabetic residents access and use of a CGM system when ordered by their physician. Care planning of the CGM use is necessary to meet the needs of each resident and to prevent adverse effects on a resident’s condition. The policy definition of the continuous glucose monitoring system defined the system as the use of a small sensor inserted subcutaneously (sensory needle in the skin) to continuously measure glucose levels in interstitial fluid (the body fluid between blood vessels and cells). Results from the sensor are transmitted to a receiver device, insulin pump, and/or smart phone which displays real time glucose levels and glycemic trends. The policy explanation and compliance guidelines stated 1- Staff and resident training will be provided per facility policy. Consider contacting the device manufacturer’s local representative as well as viewing online training videos from the manufacturer. 2- Continuous glucose monitor values will be recorded as part of daily vital signs. 4- The facility will document in the resident’s chart the site, date and time the CGM sensor and or transmitter was applied with a note of when the device will expire. 16- An adequate supply of CGM sensors/transmitters will be kept on hand for a resident with physician orders. CGM sensors/transmitters will be reordered and stored according to facility policy. Record review of the (brand name) glucometer calibration testing solutions on page 23 dated 03/14 from (company name) manufacturing instructions revealed that once glucometer testing solutions are opened, under part B; Storage and Handling, use the control solution within 90 days (3 months) of first opening or discard. It is recommended that the date of opening on the control solution is written as a reminder to dispose of the opened solution after 90 days. Under the testing procedure for the testing solution, the manufacture stated: Step 3 – Mix solution by gently inverting control solution bottles several times. Remove the cap from the control solution bottle. Place cap on flat surface. Squeeze the bottle and discard the first drop. Apply the second drop to the top of the clean cap. Furthermore, on page 21, the manufacturer stated- when you first open the bottle, write the date on the bottle label. Use the test strips within 3 months of first opening the bottle. Step 4 – Bring meter and strip to drop. Test strip will draw up the solution. The meter will show the result. Record review of the (brand name) CGM system user guide revised and published 07/2025 stated on page 37 of the manual that there are only two times that is important to check the CGM with the glucometer You can use your (brand name CGM) to treat. However, there are two situations when you should use your BG meter instead: There is no number and/or no arrow on the monitor where there should be a numerical reading and/or when the resident symptoms don't match sensor readings. Record review of the Midnight Census Report dated [DATE] received from the Director of Nursing who had denoted who was using a continuous blood sugar monitoring device, received insulin, and who received blood glucose monitoring only included the following residents; Resident 1; had a CGM and received insulin injections (medication to control blood sugars) Resident 2; had a CGM and received insulin injections Resident 14; had a CGM and received insulin injections Resident 20; had a CGM and received insulin injections Resident 24; used only glucose monitoring without a CGM and received insulin Resident 27; had a CGM and received insulin injections Resident 28; had only glucose monitoring and no CGM and no insulin injections Record review of the Glucometer Monitoring Record for Resident 11 revealed 1 documented glucometer reading dagted [DATE] using glucometer calibration testing solution Level 1 with the lot number 022224A with a manufacturer expiration date of [DATE] which was not dated with the date opened and a testing solution Level 2 with lot number 0222824A with an expiration date of [DATE] which was not dated when opened. Record review of the Glucometer Monitoring Record for Resident 20 revealed 2 documented glucometer readings dated [DATE] and a second reading of [DATE] was entered after the calibration process with Registered Nurse (RN) A was completed. using glucometer calibration testing solution Level 1 with the lot number 022224A with a manufacturer expiration date of [DATE] which was not dated with the date opened and a testing solution Level 2 with lot number 0222824A with an expiration date of [DATE] which was not dated when opened. Record review of the Glucometer Monitoring Record for Resident 2 revealed 1 documented glucometer reading dated [DATE] using glucometer calibration testing solution Level 1 with the lot number 022224A with a manufacturer expiration date of [DATE] which was not dated with the date opened and a testing solution Level 2 with lot number 0222824A with an expiration date of [DATE] which was not dated when opened. Record review of the Glucometer Monitoring Record for Resident 1 revealed 2 documented glucometer readings dated [DATE] and [DATE] using glucometer calibration testing solution Level 1 with the lot number 022224A with a manufacturer expiration date of [DATE] which was not dated with the date opened and a testing solution Level 2 with lot number 0222824A with an expiration date of [DATE] which was not dated when opened. Record review of the Glucometer Monitoring Record for Resident 24 revealed 2 documented glucometer readings dated [DATE] and [DATE] using glucometer calibration testing solution Level 1 with the lot number 022224A with a manufacturer expiration date of [DATE] which was not dated with the date opened and a testing solution Level 2 with lot number 0222824A with an expiration date of [DATE] which was not dated when opened. Record review of the Glucometer Monitoring Record for Resident 28 revealed no glucometer calibration records were found. Resident 28 had orders for glucometer checks to be completed every Monday. Record review of the Glucometer Monitoring Record for Resident 27 revealed the last glucometer calibration record test found was performed on [DATE] using a different testing solution. Observation on [DATE] at 7:20 AM as RN A checks the CGM system. Reading is 322. RN A then does a glucometer check with a fingerstick glucometer reading of 297. RN A then calibrated the CGM monitoring device to the glucometer reading obtained. Observation on [DATE] at 7:40 AM of the personal blood testing boxes for each diabetic resident in the facility revealed the Test strips for Resident 20 were opened but not dated, the test strips for Resident 27 were opened but not dated, the test strips for Resident 14 were opened but not dated, the test strips for Resident 1 were opened but not dated, and the test strips for Resident 28 were opened but not dated. Observation on [DATE] at 7:45 AM of RN A who calibrated the blood glucometer (blood sugar testing device). RN A did not gently shake either of the testing solutions prior to use. The cap of each solution was removed and wiped with a Kleenex. RN A placed two drops of the testing solution on the top of each lid from the testing solutions. RN A then placed a glucose testing strip from the testing supply box of Resident 20 into the glucometer, touched the drop of solution which had been placed on the testing solution cap, and tested the Level 1 calibration solution. This was repeated testing the Level 2 calibration solution in the same way. The blood glucose testing strips had not been dated when opened. The glucometer testing Level 1 solution had an open date of [DATE]. The manufacturer’s expiration date was [DATE]. Lot number 022224A. The glucometer testing Level 2 solution had an open date of [DATE]. The manufacturer’s expiration date was [DATE]. Lot number 0222824A. RN A cleansed the testing space and the top of the testing solutions with a Kleenex and not with a disposable cleansing wipe or any other cleansing solution. When RN A realized the Testing strips were not dated with an open date, RN A wrote [DATE] on the testing strips bottle because “Resident 20 just returned from the hospital and so I think they are new strips.” Interview on [DATE] at 7:40 AM with RN A who revealed all staff use the glucose control solutions until the manufacturer’s date of expiration. The staff do write the date the solutions were opened on the box, but not on the bottles of testing solution. RN A did not know that the testing solution had to be disposed 90 days after opening. RN A did not know the recommended manufacturer’s recommendations stated the solutions had to be discarded 90 days after opening. RN A did know that the testing glucometer strips had to be dated when opened, but did not know that the bottle had to be discarded 90 days after opening. RN A was not able to find any of the calibration and blood glucometer monitoring logs that included the calibration dates, testing solutions and lot numbers with expiration numbers except what RN A found on the clipboard. RN A stated the controls are conducted every ten days for those who wear a CGM, when the new glucose testing strips are opened, and at times when any staff member feels the glucose test needs to be conducted to compare to the CGM results. RN A doesn’t like the CGM very well and does check the glucometer with the CGM readings frequently. RN A does not know how often the other nursing staff do a calibration. Interview on [DATE] at 8:10 AM with the Director of Nursing (DON) who revealed no other documented records could be found for the CGM and blood sugar monitor calibration readings. Interview on [DATE] at 9:00 AM with the DON who confirmed there were no more documents of the glucometer calibrations found other than the ones that had been on the clip board so it looked as if the calibrations were not being completed, confirmed that the staff did not change the glucometer calibration solutions after 90 days, and confirmed that testing strips were not being dated after opening. the DON Confirmed that the calibration testing solution had been open longer than 90 days. DON also confirmed no records of trainings for nursing staff related to insulin injections, the use of insulin pens, the use of CGM systems, or glucometers and calibrations have been found. The DON had only been in the position for the past month and was working with the ICC to do the needed trainings. Interview on [DATE] at 10:40 AM with RN A who stated no formal education was given to staff about using the CGM device. The only training we received was when the last Director of Nursing sat them down and showed them how to use it. That was the only education we received and that training lasted about 10 minutes. The last director of nursing did not review the manufacturer instructions or guidelines. RN A did not remember signing anything confirming education or competency for the use of the CGM. When asked about calibrating education received to know when the glucometer and the CGM had to be calibrated together, RN A stated it seemed to be just common sense – “If you get two different numbers, you calibrate the machine.” RN A stated there were no parameters to follow, but felt that any CGM readings over 200 were too high and anything less than 120 was too low and at that point felt there was a need to recalibrate the CGM with a glucometer reading. This is in addition to the recalibration that is completed every 10 days when the new CGM is placed on a resident using the device. RN A did not feel the current system the facility used was very accurate and frequently performed finger stick glucometer checks to check that readings with the CGM. The last DON wanted to use them and RN A simply didn’t trust them. Interview on [DATE] at 2:15 PM with the Infection Control Coordinator (ICC) nurse who stated if we are using the CGM then there is no need to be sticking these residents to do a fingerstick blood sugar check with the glucometer. ICC stated [gender] was unable to find any training or competencies related to insulin injections, insulin pens, or the use of the CGM. B. Record review of a facility policy titled, “Timely Administration of Insulin” undated revealed; It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident’s condition. Explanation and Compliance Guidelines: 1. All insulins will be administered in accordance with physician’s orders. Record review of an admission record for Resident 1 revealed an admission date of [DATE]. Additional reviews revealed Resident 1 relevant diagnosis listed as Type 2 Diabetes Mellitus with Diabetic Neuropathy (diabetes (chronic disease of insufficiency to produce insulin) with nerve damage) Record review of an admission record for Resident 1 revealed an admission date of [DATE]. Additional reviews revealed Resident 1 relevant diagnosis listed as Type 2 Diabetes Mellitus with Diabetic Neuropathy (diabetes (chronic disease of insufficiency to produce insulin) with nerve damage) Record review Resident 1’s physician orders related to insulin, Continuous glucose monitor (CGM) and blood glucose monitoring revealed: -Change CGM every 10 days and as needed (PRN) missing/malfunctioning. every day shift every 10 day(s) -Insulin Lispro Injection Solution 100 UNIT/ milliliter (ML) , Inject 10 unit subcutaneously 0800; 1200; 1700 ***Please hold insulin if blood glucose is less than 110*** -Check blood sugar prior to meals and bedtime four times a day. -May check blood sugar per finger stick glucometer checks PRN if CGM is not available Record review of Resident 1’s blood sugars that are taken four times a day on 0800 (8:00 AM); 1200 (12:00 PM); 1700 (5:00 PM); and 2000 (8:00 PM) from [DATE], [DATE] and [DATE]-12, 2025 revealed several times Resident 1’s blood glucose was listed less than 110 milligrams per deciliter (mg/dL) and insulin was or should have been withheld: 6/3 at 12:00 PM =100mg/dL - Medication date and time on the MAR states HL=(Medication was held). 6/7 at 12:00 PM =101mg/dL - Medication date and time on the MAR states HL. 6/20 at 12:00 PM =97mg/dL - Medication date and time on the MAR states HL. 6/26 at 5:00 PM =96mg/dL - Medication marked as given, Progress Notes for dates [DATE] revealed no notation or explanation. 6/29 at 5:00 PM =107mg/dL - Medication date and time on the MAR states DR=(Drug Refused) notation in Progress Notes on [DATE] Resident 1 refused the medication. 7/3 at 12:00 PM =105mg/dL - Medication marked as given, Progress Notes for dates [DATE] revealed no notation or explanation. 7/3 at 5:00 PM =101mg/dL - Medication date and time on the MAR states OT= (Other Notes); notation in Progress Notes on [DATE] for 1700 revealed the medication was withheld per physician orders. 7/8 at12:00 PM =108mg/dL - Medication marked as given, Progress Notes for dates [DATE] revealed no notation or explanation. 7/28 at 5:00 PM =109mg/dL - Medication date and time on the MAR states HL. An interview on [DATE] at 1:59 PM with the Director of Nursing (DON) agreed that nursing staff should be following physician orders for insulin administration, notifying the physician and documenting a rationale if the medication was given when outside of physician parameters.

Based on record reviews and interviews, the facility failed to ensure frequency, timeliness, and required physician visits were made by a physician personally. This affected 3 of 5 sampled residents (Resident 5, Resident 6, and Resident 24). The facility census was 28. Findings are:A. Record review of Resident 5's admission Record dated 08/12/2025 revealed an admission date of 02/27/2025. The admission record has a documented attending physician listed as an Advance Practice Registered Nurse (APRN). Record review of a hospital record prior to admission for Resident 5 revealed resident was seen by an APRN, a review of the resident and care coordination was provided including the admission to the Nursing Facility by the APRN. Record review of a Physician Visit/Communication Form dated 3/3/2025 revealed this visit was provided by the APRN. Record review of a Physician Visit/ Communication Form dated 3/31/2025 revealed this visit was provided by the APRN. Record review of a Physician Visit/ Communication Form dated 5/5/2025 revealed this visit was provided by the APRN. Record review of a Physician Visit/ Communication Form dated 6/3/2025 revealed this visit was provided by the APRN. Record review of a Physician Visit/ Communication Form dated 6/16/2025 revealed this visit was provided by the APRN. Record review of a Physician Visit/ Communication Form dated 8/4/2025 revealed this visit was provided by the APRN. B. Record review of Resident 6's admission Record dated 08/12/2025 revealed an admission date of 07/13/2022. The admission record has a documented attending physician listed as an Advance Practice Registered Nurse (APRN). Record review of Resident 6's Physician Visit/Communication Form and office clinic note dated 7/1/2024 revealed a 60day visit/recertification was listed and signed as the Primary Care Physician an APRN. Record review of Resident 6's Physician Visit/Communication Form and office clinic note dated 10/7/2024 revealed a 60day visit/recertification was listed and signed as the Primary Care Physician an APRN. Record review of Resident 6's Physician Visit/Communication Form and office clinic note dated 12/09/2024 revealed a 60day visit/recertification was listed and signed as the Primary Care Physician an APRN. Record review of Resident 6's Physician Visit/Communication Form and office clinic note dated 2/10/2025 revealed a 60day visit/recertification was listed and signed as the Primary Care Physician an APRN. Record review of Resident 6's Physician Visit/Communication Form and office clinic note dated 4/14/2025 revealed a 60day visit/recertification was listed and signed as the Primary Care Physician an APRN. Record review of Resident 6's Physician Visit/Communication Form and office clinic note dated 6/15/2025 revealed a 60day visit/recertification was listed and signed as the Primary Care Physician an APRN. An interview with the Director of Nursing (DON) on 08/14/2025 at 10:00 AM revealed that Resident 5 and Resident 6 are not under the care of a physician. The APRN listed oversees and conducts care, orders, visits and recertifications for Resident 5 and Resident 6 as the Primary Care Physician even though the APRN is not a licensed Physician. C. Record review of the Resident Clinical Census report revealed that Resident 24 was admitted to the facility on [DATE]. The admitting and the primary physician is listed as an Advanced Practice Registered Nurse (APRN). Record review of the admission History and Physical dated 03/08/2025 was written and signed by the admitting and attending physician who is actually and APRN. There was no admission note from a physician as required. Record review of the Electronic Medical Records (EMR) for Resident 24 did not reveal a 30 day visitation by either a physician or an advanced practice provider. Record review of the Physician Visit Consultation note dated 05/13/2025 for Resident 24's 60 day visit after admission revealed that this resident was seen by an APRN. Record review of the EMR for Resident 24 did not reveal a 90 day visit after admission by either a physician or an advanced practice provider. Record review of the Physician History and Physical dated 07/15/2025 was completed by an APRN. Interview on 08/14/2025 at 10:00 AM with the Infection Control Coordinator (ICC) who confirmed that physicians do not see the residents. All 60 day visits are completed by the APRN, who is not a physician, who oversees this resident for all physician visits and orders, as well as other residents. Confirmation that Resident 24 is under the sole care of an APRN.

Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on Record reviews and interviews, the facility failed to ensure that Medication Record Reviews (MRRs) were completed by a pharmacist each month for those residents living in the facility. This affected 2 residents (Residents 13, and 24) of 5 residents reviewed. The facility census was 28. Findings are:Record review of the undated policy Medication Regimen Reviews policy statement said the consultant pharmacist reviews the medication regimen of each resident at least monthly. The Policy Interpretation and Implementation revealed- 1. The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication.- 2. MRRs are done upon admission or as close to admission as possible and at least monthly thereafter, or more frequently if indicated.- 4. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication.- 5. The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors, and other irregularities, for example; Medications ordered in excessive doses or without clinical indication Medication regimens that appear inconsistent with the resident's stated preferences Duplicative therapies or omissions of ordered medications Inadequate monitoring for adverse consequences Potentially significant drug-drug or drug food interactions Potentially significant medication related adverse consequences or actual signs and symptoms that could represent adverse consequences Incorrect medication, administration times, or dosage forms, Other medication errors including those related to documentation- 8. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physician for each resident identified as having a non-life threatening medication irregularity. The report contains; The resident name The name of the medication The identified irregularity The pharmacist's recommendation- 14. The consultant pharmacist provides the Director of Nursing (DON) services and medical director with a written, signed and dated copy of all medication regimen reports.- 15. Copies of the medication regimen review reports, including physician responses, are maintained as a part of the permanent medical record.A.Record review of the Annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 07/02/2025 revealed Resident 13 was admitted to the facility on [DATE] and was unable to be scored on the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) which indicated the resident had severe cognitive impairment. Resident 13 received routine antipsychotic, anti-anxiety, antidepressant, diuretic, antihypertensive, and anticonvulsant medications. Record review of the Medication Administration Record printed and reviewed 08/13/2025 for Resident 13 revealed this resident had been actively taking medications since the admission date of 06/24/2024 and continued to have new medications orders added over time. Resident 13 had orders for the following active medications ( as well as others not listed) and their corresponding order and start date:- Acetaminophen - 07/01/2024-Gabapentin - 06/24/2024-Hydrochlorothiazide - 06/24/2024-Lisinopril - 06/24/2025-Olanzapine - 09/04/2024-Senna S - 10/02/2024Record review of the Electronic Medical Record (EMR) for Resident 13 did not reveal monthly MRR data in this resident's permanent EMR.Record review of the Record of Medication Regimen and Chart Review from the consulting pharmacist revealed there were no records for the months of August 2024 and September 2024 from the consulting pharmacist.Record review of the Record of Medication Regimen and Chart Review from the consulting pharmacist revealed that Resident 13's chart had not been reviewed during the month of October 2024.Record review of the Record of Medication Regimen and Chart Review from the consulting pharmacist revealed that Resident 13's chart had not been reviewed during the month of January 2025.Record review of the Record of Medication Regimen and Chart Review from the consulting pharmacist revealed that Resident 13's chart had not been reviewed during the month of February 2025.Record review of the Record of Medication Regimen and Chart Review from the consulting pharmacist revealed that Resident 13's chart had not been reviewed during the month of March 2025.Record review of the Record of Medication Regimen and Chart Review from the consulting pharmacist revealed that Resident 13's chart had not been reviewed during the month of April 2025.In an interview completed on 8/13/2025 at 3:00 PM with the facility Infection Control Coordinator (ICC) confirmed that the consulting pharmacist should conduct a review of the resident's medication regimen monthly and communicate irregularities and make recommendations to the provider for dosage reductions. The ICC stated that the pharmacist did not do this monthly for Resident 13 and should have.In an interview completed on 8/13/2025 at 3:20 PM with the facility DON, the DON confirmed that the pharmacist did not conduct monthly medication regimen reviews on Resident 13 and should have.B.Record review of the Resident Clinical Census report for Resident 24 revealed this resident was admitted on [DATE] and discharged from the facility on 11/22/2024. Resident 24 was then again admitted on [DATE]. Record review of the Record of Medication Regimen and Chart Review from the consulting pharmacist revealed that Resident 24's chart had an MRR during the month of 11/2024, 12/2024, and 01/2024. Resident 24 did not reside in the facility during the months 12/2024 or 01/2025. In an interview completed on 8/13/2025 at 3:00 PM with the facility Infection Control Coordinator (ICC) confirmed that the consulting pharmacist should conduct a review of the resident's medication regimen monthly and communicate irregularities and make recommendations to the provider for dosage reductions. The ICC stated that the pharmacist did not do this monthly for Resident 24 and should have.In an interview completed on 8/13/2025 at 3:20 PM with the facility DON, the DON confirmed that the pharmacist did not conduct monthly medication regimen reviews on Resident 24 and should have.Interview on 08/14/2025 at 4:05 PM with the Infection Control Coordinator revealed all of the MRRs that the facility had available from the consulting pharmacist had been presented for review. All MRR's given to the facility over the past year had been asked and received from the consulting pharmacist and had been presented for review. The ICC had no knowledge as to why Resident 24 had been listed as a resident who had been reviewed by the consulting pharmacist during the months of 12/2024 and 01/2025.

Licensure Reference Number 175NAC 12-00.02(H)Based on record review and interview, the facility failed to submit a written investigation of a possible instance of abuse or neglect to the state agency within 5 working days for 1 (Resident 29) of 1 sampled residents. The facility census was 28.Findings are:A review of a facility policy titled Abuse, Neglect and Exploitation dated 07/2024 revealed the facility will report all alleged violations of abuse or neglect no later then 24 hours after the event if the event does not result in serious bodily injury. The facility will report the results of an investigation of allegations within 5 working days of the incident, as required by the state agency. A review of an admission Record revealed the facility admitted Resident 29 on 3/21/2024 with diagnosis of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior).The Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 6/18/2025 revealed Resident 29 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 2 indicating the resident had severe cognitive impairment. did not have impairment to the function of their upper or lower extremities, and required staff set up or clean up assistance with eating.A record review of a facility document titled Hot Liquids Risk Assessment revealed the resident exhibited risk factors of impaired cognition, confusion, and dementia placing them at risk for hot liquid accidents.A record review of Resident 29's Progress Notes revealed on 7/30/2025 documentation stating that the resident spilled coffee on themselves while sitting at the dinning room table. The resident was taken to their room and was observed to have a light pink area to their skin on the left side of their abdomen.A record review of an Incident Investigation dated 7/30/2025 revealed an order was placed to monitor Resident 29's burn to their abdomen.In an interview completed on 8/12/2025 at 3:30 PM with the facility Director of Nursing (DON), the DON confirmed that they did not submit the investigation into Resident 29's burn received due to a hot coffee spill to the state agency and should have.

Licensure Reference Number 175NAC 12-00.09 (I)Based on observation, record review, and interview the facility failed to protect residents from accidents and or incidents for 2 residents (Resident 6 and Resident 29) of 2 sampled residents. The facility census was 28.Findings are:A.A review of an admission Record revealed that the facility admitted Resident 6 on 7/13/2020 with a diagnosis of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior).The Comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 6/17/2025 revealed Resident 6 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 1 indicating the resident had severe cognitive impairment, the resident required substantial or maximal assistance with bed mobility, transfers, and toilet use, and the resident had 3 falls since the prior assessment (in the last 90 days).Review of Resident 6's Care Plan (a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) on 8/12/2025 revealed a focus of the resident had a history and the potential for falls with date initiated of 7/14/2020. Interventions were listed that the resident was to have a pressure alarm while in wheelchair and bed dated 6/19/2023 and to ensure the fall alarm was out of the residents reach but still audible dated 11/5/2023.In an observation completed on 8/13/2025 at 2:05 PM Resident 6 was self-propelling their wheelchair down the 200 hallway. The resident stopped in front of the couch located at the end of the hall. The resident transferred independently from their wheelchair onto the couch. No alarm was heard to be sounding. There was a white box with a cord coming out of it attached to the back of the resident's wheelchair. The Director of Nursing (DON) came down the hall witnessed the resident sitting on the couch and assisted the resident back into their wheelchair. The DON then reached for the bottom of the white box and turned on the resident's alarm.In an interview completed on 8/13/2025 at 2:08 PM with the facility DON, the DON confirmed that Resident 6's alarm was not turned on allowing the resident to self-transfer from their wheelchair to the couch without staff assistance. The DON confirmed that Resident 6's alarm is to always be on when in their wheelchair.In an interview completed on 8/13/2025 at 2:14 PM with Medication Aide C (MA-C), MA-C confirmed that Resident 6 had a history of falls and was to have their alarm on at all times to alert staff to when the resident was attempting to self-transfer so staff could intervene and assist the resident to prevent the resident from falling.In an interview completed on 8/13/2025 at 2:15 PM with Medication Aide D (MA-D), MA-D confirmed that Resident 6 had a history of falls and was to have their alarm on at all times to alert staff to when the resident was attempting to self-transfer so staff could intervene and assist the resident to prevent the resident from falling.In an observation completed on 8/14/2025 at 8:43 AM Resident 6 was observed to be sitting at the table in the dining area in their wheelchair. The residents' white alarm box or alarm cord was not visible, indicating the residents' alarm was attached or on while the resident was sitting in their wheelchair.In an observation completed on 8/14/2025 at 9:17 AM Medication Aide G (MA-G) was observed to be assisting Resident 6 to their room via their wheelchair. When in the residents' room MA-G removed the white alarm box from the residents' bedside table and connected it to the resident and placed it on the back of the resident's wheelchair.In an interview completed on 8/14/2025 at 9:17 AM with MA-G, MA-G confirmed that Resident 6 is to always have their alarm on to alert staff to when the resident was attempting to self-transfer for staff to intervene and prevent the resident from falling. The MA confirmed they had just placed the alarm to the resident and the alarm should have been on while the resident was in their wheelchair and was not.In an interview completed on 8/14/2025 at 9:18 AM with the DON, the DON confirmed that Resident 6 was to always have the alarm on.B.A review of an admission Record revealed the facility admitted Resident 29 on 3/21/2024 with diagnosis of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior).The Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 6/18/2025 revealed Resident 29 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 2 indicating the resident had severe cognitive impairment. did not have impairment to the function of their upper or lower extremities, and required staff set up or clean up assistance with eating.A record review of a facility document titled Hot Liquids Risk Assessment and dated 3/24/2025 revealed the resident exhibited risk factors of impaired cognition, confusion, and dementia placing them at risk for hot liquid accidents. The document stated the resident was to be evaluated by therapy and staff were to provide supervision with meals until evaluation was completed.A record review of Resident 29's Progress Notes revealed on 7/30/2025 documentation stating that the resident spilled coffee on themselves while sitting at the dining room table. The resident was taken to their room and was observed to have a light pink area to their skin on the left side of their abdomen.A record review of an Incident Investigation dated 7/30/2025 revealed on order was placed to monitor Resident 29's burn to their abdomen.In an interview completed on 8/12/2025 at 3:30 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 29 was not evaluated by therapy and supervised during meals until evaluated by therapy as directed on the 3/24/2025 Hot Liquid Risk Assessment. The DON confirmed that Resident 29 did have a burn due to a hot liquid spill on 7/30/2025

Licensure Reference Number 175 NAC 12-006.04(E)Based on interviews and observations, the facility failed to notify the department of a change in Director of Nursing within 5 working days as required. This had the potential to affect all facility residents. The facility census was 28. Findings are: An observation on 08/11/2025 at 10:00 AM revealed the Director of Nursing (DON). An interview with the DON on 08/11/2025 revealed they began their position about 1 month ago however had worked on the floor as a floor nurse for about 1 year prior. An interview with the Administrator (ADMIN) on 08/11/2025 at 11:15 AM revealed they come to the facility for a few hours a day to oversee operations. An interview on 8/12/2025 at 2:15 PM with the ADMIN revealed that the previous DON left about 1 month ago and a new DON was since hired who is active at this time. When asked about when the Department was notified about the change in DON, the ADMIN stated this had not been done yet and guessed it needed to be done as soon as possible.

Licensure Reference Number 175 NAC 12-006.05(G) Based on record reviews and interviews, the facility failed to provide a rationale for not conducting a Gradual Dose Reduction (GDR, Stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) for 1 (Resident 23) of 5 residents sampled. The facility census was 28. Findings are:Record review of a policy titled, Use of Psychotropic Medication(s) undated revealed:7. The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication, specifically an antipsychotic medication, to another category of psychotropic medication.16. Psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: a. PRN orders for psychotropic medication, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. b. PRN orders for antipsychotic medications only, shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.Record review of Resident 23's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 7/16/2025 revealed Resident 23 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 1/15. The MDS manual identified a score of 1 as a severe impairment. Record review of Resident 23's medication order summary revealed Quetiapine Fumarate Oral Tablet 25 milligram (mg) was ordered and the amount to be administered was 25 mg to be taken 1 time per day for vascular dementia, unspecified severity, with other behavioral disturbance. A pharmacy review of the medication was conducted by a pharmacist on 07/02/2025 with a recommendation to gradually reduce the amount to be administered. The primary physician disagreed with the recommendation for a dose reduction and did not provide a rationale for disagreement. An interview with the Director of Nursing (DON) on 08/14/25 at 9:16 AM confirmed there was no rationale provided by the doctor regarding not conducting the GDR of Quetiapine for Resident 23.

Based on interview and record review the facility failed to employee a Infection Preventionist (IP) (a facility member that looks for patterns, observes, and educate staff on infection control and compiles infection data for the facility) at least part-time, that is not the Director of Nursing (DON). This had the potential to affect all 26 residents in the facility. The facility census was 26. Findings are: A record review of Licensed Personnel and Consultants sheet provided by the facility during survey revealed the Director of Nursing (DON) was listed as the DON and the Infection Control Coordinator. A record review of the Quality Assurance Performance Improvements (QAPI) Committee Members sheet provided during the survey revealed the DON was listed as the DON and the Infection Control Nurse. An interview on 6/26/24 at 1:30 PM with the DON confirmed they had not taken the course for the Infection Preventionist and was the full time DON at the facility. The DON further reported they were also doing the Infection Preventionist role full time in the facility. The DON reported a Licensed Practical Nurse (LPN) from the hospital has the training for Infection Control, however, has not overseen the infection control program at the facility.

Licensure Reference Number 175 NAC 12-006.09(E)(iii) Based on record reviews,observation and interviews, the facility failed to develop a Care Plan (CP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) to address Resident #7 regarding ambulation, Resident #18 regarding falls, and Resident # 25 regarding falls of13 sampled residents. The facility census was 26. Findings are: A.) A record review of the Admission Record dated 6/25/24 revealed Resident # 7 was admitted on [DATE] with the diagnosis of muscle weakness(decreased strength in muscles), difficulty in walking(walking off balance or impaired gait), Urinary tract infection(an infection in any part of the urinary system), Chronic obstructive Pulmonary disease(a group of lung conditions that make it hard to breathe and restricts airflow), Heart Failure(the heart doesn't pump blood as well as it should), Diabetes(to much sugar in the blood), Chronic Kidney Disease( progressive loss of kidney function), Depression (loss of pleasure or interest in activities) and Gout(severe pain, swelling,redness,and tenderness in joints). A. Record review of Resident #7's CP revealed the following focus area: -Restorative Program revised on 08/24/2023 revealed a goal to prevent decline. The intervention to meet this goal was staff were to ambulation Resident #7 in the hallways. An observation on 6/25/24 at 7:45 AM of Resident # 7 revealed during a transfer from the recliner to the wheelchair, Resident # 7 was able to stand and pivot with 2 staff assisting the resident. An observation on 6/26/24 at 1:30 PM of Resident #7 revealed during the transfer from the wheelchair to the recliner Resident # 7 required 2 staff to assist with stand and pivoting. An interview on 6/26/24 at 10:30 AM with Medication Assistant (MA)-A confirmed Resident # 7 stands and pivots with transfers and does not ambulate. MA-A reported Resident # 7 has not ambulated for over 6 months. An interview on 6/26/24 at 11:00 AM with the DON confirmed Resident #7's care plan had not been updated to reflecting Resident # 7 does not ambulate and Resident #7's care plan should of been updated. B. A record review of the Admission Record sheet dated June 26, 24 revealed Resident # 18 was admitted on [DATE] with diagnosis of Dementia(impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Depression(mood or loss of pleasure or interest in activities), Muscle weakness(decrease strength in the muscles), Hypertension(blood vessels have persistently raised pressure), and other symptoms and signs involving cognitive functions(perception, memory, learning, attention, decision making, and language abilities and awareness). A record review of Resident #18's Progress Notes (PN) dated 5/1/2024 revealed Resident # 18 had fallen in (genders) room with no injuries and Resident #18's walker was out of reach of the resident. A record review of the MDS(Minimum Data Set, A comprehensive assessment of each resident's functional capabilities) dated June 18, 2024 revealed a BIMS (Brief Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) of 4 indicating Resident #18 was severely cognitively impaired. A record review of Resident #18's CP revealed no new focus, goal or interventions for the fall on 5/1/24 was addressed on the CP. An interview on 6/26/24 at 11:00 AM with the DON confirmed Resident #18's CP did not have any new interventions from the fall on 5/1/24. The DON reported there should have been a new intervention place onto Resident #18's CP. C. A record review of the Admission Record sheet dated June 26th 2024 revealed Resident # 25 was admitted on [DATE] with diagnoses of Rheumatoid Arthritis(inflammatory that affects joints causing painful swelling., Parkinson's Disease(Affects the nervous system and the pars of the body it controls), atherosclerotic Heart Disease(damage or disease in the hearts major blood vessels usually plaque buildup). A record review of the MDS ( Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 4/23/2024 revealed a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 14, indicating Resident 14 was cognitively intact. A record review Resident #25's Progress Notes (PN) dated 4/20/24 revealed Resident # 25 had a fall in (genders) room having slide out of a recliner. A record review of Resident #25's CP dated 4/17/24 revealed there was no focus, goals, or interventions for the fall on 4/20/24. An interview on 6/26/24 at 11:00 AM with the DON confirmed Resident # 25 fallen. The DON further confirmed new interventions should have been placed onto Resident #25's CP.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observations, record review and interviews, the facility failed to involve Resident #26 in the development of the Comprehensive Care Plan (CCP), failed to include Resident #26 was a high risk for elopement , failed to revise the care plan for Residents #11 and #17 regarding impaired skin integrity and failed to identify Resident #18 was on hospice, out of 13 sampled residents. The facility census was 26. Findings are: A). A record review of the Admission Record dated 6/25/24 revealed Resident # 26 was admitted to the facility on [DATE] with diagnoses of Schizoaffective disorder (characterized by abnormal thought processes and an unstable mood), Covid-19( characterized mainly by fever and cough and is capable of progressing to severe symptoms), Generalized Anxiety(A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Chronic Obstructive Pulmonary Disease(a chronic lung disease that causes breathing problems and restricted airflow), and Chronic Kidney Disease( a gradual loss of kidney function over time). A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated June 3rd 2024 revealed a BIMS ( Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15 indicating cognitively intact. An interview on 6/24/24 at 1:25 PM with Resident #26 confirmed that (gender) was not aware of what a care plan was and had not been invited to care plan meeting. A record review of a letter dated May 21, 2024 revealed a letter was sent out to Resident # 26 POA notifying the POA of a care plan meeting scheduled for Thursday May 23, 2024 at 9:45 AM. A record review of the Progress Notes (PN) dated May 21, 2024 through May 25th 2024 revealed there was no progress notes related to the care plan meeting taking place for Resident #26. A record review of a undated Care Plan acknowledgement form revealed that after the care plan meeting takes place, resident and representative and facility staff sign the form that Resident/family attended or did not attend the care plan meeting. There was no Care Plan acknowledgement form signed for Resident #26. An interview on 6/26/24 at 11:00 AM with the Director of Nursing (DON). The DON confirmed that Resident #26 had not been invited to the care plan meeting. B. An observation on 6-24-2024 at 1:25 PM of Resident #26 revealed Resident #26 had a wanderguard bracelet ( device to alert staff when a residents attempts to leave the facility. Commonly use with residents who are a elopement risk) on right wrist. A record review of Elopement/ wandering review assessment dated [DATE] revealed Resident #26 was a high risk for elopement. A record review of Resident #26's CCP dated 5/23/24 reveals that there is no focus, goals or interventions in place regarding the wanderguard or high risk for elopement. An interview on 6/26/24 at 11:00 AM with the DON confirmed that Resident #26 does have a wander guard bracelet on Resident #26 right wrist and that Resident #26 assessment for elopement indicated Resident #26 was a high risk for elopement. The DON confirmed that Resident #26 CCP does not have any focus, goals, or interventions for the wanderguard or elopement risk and there should of been focus, goals and interventions for the elopement risk and wanderguard. C. A record review of the Admission Record dated 6/26/24 revealed that Resident #18 was admitted to the facility on [DATE] with diagnoses of Dementia without behavioral disturbance, psychotic disturbance, mood disturbance (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) , Anxiety(A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Depression(mood disorder that can affect how a person feels, thinks, and functions in their daily life), Muscle weakness( when the body can't contract muscles properly, resulting in reduced strength), and symptoms and signs involving cognitive functions and awareness(including learning, thinking, reasoning, remembering, problem solving, decision making, and attention). A record review of the MDS dated [DATE] revealed a BIMS score of 4 indicating Resident #18 was severely cognitively impaired. A record review of Resident #18's Progress Notes dated 6/19/24 revealed Resident # 18 was admitted to Ascera Care Hospice services. A record review of Resident #18's CCP dated 6/12/2024 revealed the CCP did not address Resident #18 being admitted to Hospice. An interview on 6/26/24 at 11:00 AM with the DON confirmed that residents care plan has not been updated to reflect Resident # 18 being admitted to hospice services. D. A record review of the Admission Record dated 6/27/24 revealed Resident # 11 was admitted to the facility on [DATE] with diagnoses of Age-related Cognitive decline (a gradual loss of thinking abilities, such as learning, remembering, paying attention, and reasoning),Muscle Weakness (when the body can't contract muscles properly, resulting in reduced strength), Bacterial Pneumonia (an infection of the lung), Squamous Cell Carcinoma of skin of the other parts of face,(type of skin cancer that can develop on the face and other areas of the body, including the ears, neck, lips, arms, and hands). A record review of the MDS dated [DATE]th 2024 revealed a BIMS score of 3 indicating Resident #11 was severely cognitively impaired. A record review of a skin assessment for Resident #11 dated 6/22/24 revealed a skin assessment for a bruise on the right hand middle digit. A record review of Resident #11's CCP update on 3/22/24 did not address the bruising to Resident # 11 right hand middle digit from middle of finger. An interview on 6/26/24 at 11:00 AM with the DON confirmed Resident #11's care plan did not address the bruising to Resident #11 right hand middle digit. 45484 E. A review of Resident 17's Admission Record dated 06/25/2024 revealed the resident was admitted [DATE] and had diagnoses of chronic kidney disease, a kidney transplant, high blood pressure, and type 1 diabetes mellitus (a disease in which the body does not produce insulin, resulting in high blood sugars). A review of Resident 17's Modification of Quarterly MDS dated [DATE] revealed a BIMS of 15 indicating Resident 17 was cognitively intact. An interview with Resident 17 on 06/24/2024 at 1:09 PM revealed the resident had an open area on their right buttock. The resident revealed that the open area started as a blister and opened up. A review of a Non-Pressure Skin Condition Record dated 05/29/2024 for Resident 17 revealed a Date First Observed of 05/29/2024. A review of a form provided on 06/25/2024 by the Director of Nursing (DON) titled From our RISK report 6/20/2024 + [Resident 11] (6/22/24) revealed Resident 17 had one wound to the right buttock, noted 05/29/2024 with assessment date of 06/04/2024. This was described as Moisture damage, and had measurements of 2 centimeters (cm) by 2 cm several areas. A review of Resident 17's CCP printed 06/25/2024 revealed no mention of the open area on Resident 17's right buttock. A review of the facility's Skin and Wound Management Standard Rev 4/2019 revealed for Non-Pressure Skin Conditions: 1. Monitoring/Documentation. Non-pressure skin conditions will be assessed and measured every 7 days or more frequently if indicated, until resolved. and 2. Care plan. All actions/interventions will be included in the care plan at the time of identification. An interview with the DON on 06/27/2024 at 12:55 PM confirmed that Resident 17's CCP had not been updated to include the open area on the resident's right buttock

Licensure Reference Number 175 NAC 12-006.18(B); 12-006.18(D) Based on observation, record review, and interviews, the facility failed to ensure hand hygiene and glove changes were performed according to standards to prevent the potential for cross-contamination during wound cares for 2 residents (Resident 3 and Resident 17) of 5 residents sampled for wounds, and the facility failed to implement enhanced barrier precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes. EBP involves wearing a gown and gloves during high-contact resident care activities, such as wound care, for residents known to be colonized or infected with a MDRO as well as residents at increased risk of MDRO acquisition [for example, residents with wounds or indwelling medical devices]) for 3 residents (Resident 3, Resident 15, and Resident 17) of 5 sampled for wounds. The facility census was 26. Findings are: A. A review of the facility's Hand Hygiene Competency dated 2/2017 revealed the following: -Under the Procedure Step Hand Hygiene Using Antimicrobial Soap and Water: 4. Lather and Rub hands together for full 20 seconds. -Under the procedure Step Hand Hygiene Using Hand Sanitizer: Examples: After removing gloves or between changing gloves. B. A review of Resident 3's Admission Record dated 06/25/2024 revealed the resident was admitted [DATE] and had diagnoses of respiratory failure, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), heart failure, and peripheral vascular disease (PVD-reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). A review of Resident 3's Significant Change Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 06/11/2024 revealed a Brief Interview for Mental Status (BIMS-a screening tool used to assess cognition [relating to the mental process involved in knowing, learning, and understanding things]. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points indicates severe cognitive impairment; 8 to 12 points indicates moderate cognitive impairment; and 13 to 15 points indicates that cognition is intact) score of 99, indicating the resident was unable to complete the interview. The Staff Assessment for Mental Status question C1000 Cognitive Skills for Daily Decision Making was answered as Moderately Impaired, meaning the resident's decisions were poor and they required cues/supervision. A review of a form provided on 06/25/2024 by the Director of Nursing (DON) titled From our RISK report 6/20/2024 + [Resident 11] (6/22/24) revealed Resident 3 had a Stage 3 pressure ulcer to the left heel. An observation on 06/24/2024 at 3:25 PM revealed Resident 3 resting in bed. There were no gowns noted inside or outside of the resident's room, and no signs indicating the need for EBP. An observation on 06/26/2024 at 9:30 AM of Licensed Practical Nurse (LPN) C performing wound care on Resident 3's right heel wound. The LPN gathered supplies and positioned the resident with their foot up. LPN C washed their hands with soap and water for eight seconds, then rinsed the soap off. LPN C then put on gloves, but no gown. The LPN then removed the old dressing, cleaned the wound with wound spray and gauze, reached back into the package of clean gauze with the soiled glove and got gauze to pat area dry, and applied a new dressing with the same gloves on. The LPN repositioned the resident's legs, and adjusted the bed, then removed their gloves and washed hands with soap and water for 20 seconds. There were no gowns noted inside or outside of the resident's room, and no signs indicating the need for EBP. An interview on 06/26/2024 at 9:35 AM with LPN C confirmed the LPN did not change their gloves and perform hand hygiene between removing the old dressing, cleaning the wound, and applying a new dressing, and should have. LPN C further confirmed they did reach into the package of clean gauze with a soiled glove and should not have, and that hand washing was supposed to be done for 20 seconds. C. A review of Resident 15's Admission Record dated 06/25/2024 revealed the resident was admitted [DATE] and had diagnoses of end stage renal disease, COPD, type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and heart failure. A review of Resident 15's Modification of Admission MDS dated [DATE] revealed a BIMS score of 13, indicating the resident was cognitively intact. A review of a form provided on 06/25/2024 by the DON titled From our RISK report 6/20/2024 + [Resident 11] (6/22/24) revealed Resident 15 had two open areas to the right medial (inner) lower leg, one to the left medial lower leg, and one to the left lateral (outer) lower leg. An observation on 06/24/2024 at 2:47 PM revealed no gowns inside or outside of the resident's room, and no signs indicating the need for EBP. An observation on 06/25/2024 at 8:23 AM revealed no gowns inside or outside of the resident's room, and no signs indicating the need for EBP. An observation on 06/27/2024 at 8:42 AM of LPN C performing wound care on Resident 15's leg wounds revealed LPN C did not wear a gown during wound care. D. A review of Resident 17's Admission Record dated 06/25/2024 revealed the resident was admitted [DATE] and had diagnoses of chronic kidney disease, a kidney transplant, high blood pressure, and type 1 diabetes mellitus (a disease in which the body does not produce insulin, resulting in high blood sugars). A review of Resident 17's Modification of Quarterly MDS dated [DATE] revealed a BIMS of 15. A review of a form provided on 06/25/2024 by the DON titled From our RISK report 6/20/2024 + [Resident 11] (6/22/24) revealed Resident 17 had an open area to the right buttock. An interview with Resident 17 on 06/24/2024 at 2:42 PM revealed the resident had open area to the right buttock. Resident 17 revealed that staff were wearing gloves, but not gowns during wound care. An observation on 06/24/2024 at 2:42 PM revealed no gowns noted inside or outside of the resident's room, and no signs indicating the need for EBP. An observation on 06/25/2024 at 3:51 PM revealed no gowns noted inside or outside of the resident's room, and no signs indicating the need for EBP. An observation on 06/26/2024 at 8:55 AM of LPN C performing wound care on Resident 17's right buttock open area. LPN C gathered supplies, washed their hands with soap and water for six seconds then rinsed the soap off. The LPN closed the door, put on gloves but no gown, and assisted the resident onto their right side. LPN C then touched the window curtain and the light switch light, pulled down Resident 17's pants and incontinence wear and placed an absorbent pad under the buttocks. LPN C changed their gloves without performing hand hygiene, and removed the old dressing. The LPN changed gloves and cleaned the wound with wound spray and gauze, reached back into the package of clean gauze with the soiled glove, cleaned the left buttock, and reached into package of clean gauze with the soiled glove again to get more gauze and patted the areas dry. LPN C removed the gloves, went into hall to the treatment cart by the door to get more supplies, then put on new gloves without performing hand hygiene. Resident 17 complained of nausea, so the LPN provided a towel. LPN C applied ointment to the open area on the right buttock using a cotton swab, and put on a new dressing, then pulled up the resident's incontinence wear and pants. Resident 17 did vomit, and without changing gloves the LPN picked up the towel and wiped the resident's face and arm with it, then adjusted the resident's position, and covered them with a light blanket. LPN C took their gloves off, moved the soiled towel using their bare hands, and washed their hands with soap and water for six seconds, then rinsed the soap off. An interview on 06/26/2024 at 9:10 AM with LPN C confirmed the LPN did not perform hand hygiene when changing gloves and should have, and that they should have changed gloves and performed hand hygiene between completing the dressing change and touching Resident 17's face. LPN C further confirmed they did reach into the package of clean gauze with a soiled glove and should not have, and that hand washing was supposed to be done for 20 seconds. E. An interview on 06/26/2024 at 1:49 PM with Medication Aide (MA) A revealed that MA A was unfamiliar with what EBP was. An interview on 06/26/2024 at 2:24 PM with Nurse Aide (NA) B revealed that NA B had not heard of EBP. An interview on 06/26/2024 at 3:52 PM with LPN C revealed that LPN C was unfamiliar with what EBP was. An interview on 06/27/2024 at 8:54 AM with the DON revealed the facility did not have a policy for EBP, and had not been implementing EBP for Resident 3, Resident 15, or Resident 17. The DON further confirmed that EBP should be in place for those residents due to them having open wounds. An interview on 06/27/2024 at 12:55 PM with the DON confirmed that hand washing should be done with soap and water for at least 20 seconds, and that sanitizer should be used between changing gloves.

Licensure Reference Number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN-a notice given to Medicare beneficiaries to inform them that Medicare will most likely deny the care that they are about to receive. It must be delivered in advance to give the beneficiary time to consider the options and make an informed choice) to Resident 9 and Resident 21 or their representatives to notify them of charges for non-covered care items and services prior to a change in Medicare A coverage. This affected 2 of 2 residents sampled for Advance Beneficiary Notification. The facility census was 26. Findings are: A. A review of the Beneficiary Notice-Residents discharged Within the Last Six Months provided to the facility during the Entrance Conference revealed that Resident 9 was discharged from Medicare A services with days remaining on 04/22/2024 and remained in the facility. A review of the SNF Beneficiary Protection Notification Review form for Resident 9 revealed a Medicare A Skilled Services Episode Start Date of 01/25/2024 and a Last covered day of Part A Service of 04/22/2024. Further review of the form revealed the facility initiated the discharge when there were benefit days remaining. Question 1 Was an SNF ABN, Form CMS-10055 provided to the resident? was marked in the box for no. The facility was unable to provide a copy of a SNF ABN for Resident 9. During an interview on 06/26/2024 at 8:23 AM, the Director of Nursing (DON) confirmed that Resident 9 had not been provided with a SNF ABN upon discharge from Medicare A services, and that Resident 9 had remained in the facility after discharge from Medicare A services. 2. A review of the Beneficiary Notice-Residents discharged Within the Last Six Months provided to the facility during the Entrance Conference revealed that Resident 21 was discharged from Medicare A services with days remaining on 06/20/2024 and remained in the facility. A review of the SNF Beneficiary Protection Notification Review form for Resident 9 revealed a Medicare A Skilled Services Episode Start Date of 06/11/2024 and a Last covered day of Part A Service of 06/20/2024. Further review of the form revealed the facility initiated the discharge when there were benefit days remaining. Question 1 Was an SNF ABN, Form CMS-10055 provided to the resident? was marked in the box for no. The facility was unable to provide a copy of a SNF ABN for Resident 21. During an interview on 06/26/2024 at 8:23 AM, the DON confirmed that Resident 21 had not been provided with a SNF ABN upon discharge from Medicare A services, and that Resident 21 had remained in the facility after discharge from Medicare A services.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3) Based on observation, record review, and interviews, the facility failed to complete and document weekly non-pressure wound assessments for Resident 15 and Resident 17. This affected 2 of 4 residents sampled for impaired skin integrity. The facility census was 26. Findings are: A. A review of the facility's Skin and Wound Management Standard Rev 4/2019 revealed for Non-Pressure Skin Conditions: 1. Monitoring/Documentation. Non-pressure skin conditions will be assessed and measured every 7 days or more frequently if indicated, until resolved. and 2. Care plan. All actions/interventions will be included in the care plan at the time of identification. B. A review of Resident 15's Admission Record dated 06/25/2024 revealed the resident was admitted [DATE] and had diagnoses of end stage renal disease, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and heart failure. A review of Resident 15's Modification of Admission Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 04/15/2024 revealed a Brief Interview for Mental Status (BIMS-a screening tool used to assess cognition [relating to the mental process involved in knowing, learning, and understanding things]. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points indicates severe cognitive impairment; 8 to 12 points indicates moderate cognitive impairment; and 13 to 15 points indicates that cognition is intact) score of 13, indicating the resident was cognitively intact. An observation on 06/25/2024 at 07:56 AM revealed dressings to both lower legs. An interview with Resident 15 on 06/25/2024 at 7:56 AM revealed that the resident went to wound clinic once a week. The resident revealed there were open areas on the medial (inner) and lateral (outer) aspects of the left lower leg, and only on the medial aspect of the right lower leg. A review of a form provided on 06/25/2024 by the Director of Nursing (DON) titled From our RISK report 6/20/2024 + [Resident 11] (6/22/24) revealed Resident 15 had 4 wounds: -One to the left lateral lower leg, noted 04/08/2024, with assessment date 06/08/2024. No measurements listed. -One to the left medial lower leg, noted 05/07/2024, with assessment date 06/08/2024. No measurements listed. -One to the right medial lower leg, superior (upper) wound, noted 04/21/2024, with assessment date 06/08/2024. No measurements listed. -One to the right medial lower leg, inferior (lower) wound, noted 05/07/2024, with assessment date 06/08/2024. No measurements listed. C. A review of Resident 17's Admission Record dated 06/25/2024 revealed the resident was admitted [DATE] and had diagnoses of chronic kidney disease, a kidney transplant, high blood pressure, and type 1 diabetes mellitus (a disease in which the body does not produce insulin, resulting in high blood sugars). A review of Resident 17's Modification of Quarterly MDS dated [DATE] revealed a BIMS of 15, indicating the resident was cognitively intact. An interview with Resident 17 on 06/24/2024 at 1:09 PM revealed the resident had an open area on their right buttock. The resident revealed that the open area started as a blister and opened up. A review of a form provided on 06/25/2024 by the Director of Nursing (DON) titled From our RISK report 6/20/2024 + [Resident 11] (6/22/24) revealed Resident 17 had one wound to the right buttock, noted 05/29/2024 with assessment date of 06/04/2024. This was described as Moisture damage, and had measurements of 2 centimeters (cm) by 2 cm several areas. D. An interview with the DON on 06/25/2024 at 10:00 AM revealed that the DON had been monitoring wounds. The DON further revealed that wound documentation was not up to date. An interview with the DON on 06/27/2024 at 12:55 PM confirmed that non-pressure skin issues should be assessed and documented weekly and that was not being done.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(2) Based on record review and interviews, the facility failed to complete weekly pressure ulcer assessments for 1( Resident 3) of 1 sampled resident. The facility census was 26. Findings are: A review of Resident 3's Admission Record dated 06/25/2024 revealed the resident was admitted [DATE] and had diagnoses of respiratory failure, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), heart failure, and peripheral vascular disease (PVD-reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel). A review of Resident 3's Significant Change Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 06/11/2024 revealed a Brief Interview for Mental Status (BIMS-a screening tool used to assess cognition [relating to the mental process involved in knowing, learning, and understanding things]. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points indicates severe cognitive impairment; 8 to 12 points indicates moderate cognitive impairment; and 13 to 15 points indicates that cognition is intact) score of 99, indicating the resident was unable to complete the interview. The Staff Assessment for Mental Status question C1000 Cognitive Skills for Daily Decision Making was answered as Moderately Impaired, meaning the resident's decisions were poor and they required cues/supervision. A review of a form provided on 06/25/2024 by the Director of Nursing (DON) titled From our RISK report 6/20/2024 + [Resident 11] (6/22/24) revealed Resident 3 had a wound to the left heel, noted 03/12/2024 with assessment date of 06/03/2024. This was described as a Stage 3 pressure area, and had measurements of 1.5 centimeters (cm) by 0.8 cm by 0.3 cm. A review of a Pressure Ulcer Record dated 06/11/2024 for Resident 3 revealed documentation of an open area 1.5 cm X 0.8 cm with approximately 0.3 depth. We will consider this a Stage 3 pressure wound at present. A review of Resident 3's Progress Notes from 06/29/2023 to 06/25/2024 revealed no documentation of wound assessment after 06/11/2024. A review of the facility's Skin and Wound Management Standard Rev 4/2019 revealed for Pressure Ulcer/ Injury Skin Conditions: 1. Monitoring/Documentation Pressure ulcers/injuries will be formally assessed, staged, and measured every 7 days or more frequently if indicated (measure length, width, depth, odor, drainage, pain, wound bed and peri wound appearance). Tunneling and undermining - use the face of a clock and include depth (i.e., 2 cm undermining from 12:00 to 3:00 o'clock). and 2. All actions/interventions will be included in the care plan in PCC [PointClickCare-the Electronic Health Record (EHR) used by the facility]. An interview with the DON on 06/25/2024 at 10:00 AM revealed that the DON had been monitoring wounds. The DON revealed that they were not documenting wounds in the medical record, but were using the Risk reports as a tracking tool for wound assessments and measurements. The DON further revealed that wound documentation was not up to date.

Licensure Reference Number 175 NAC 12-006.05 (G) Based on observations, record review, and interviews, the facility failed to evaluate the need for physical restraints for 1 (Resident 2) of 1 residents. The facility census was 26. Findings are: A review of Resident 2's Admission Record dated 06/25/2024 revealed the resident was admitted on [DATE] and had diagnoses of hemiplegia (paralysis) and hemiparesis (weakness) on the left side of the body related to a past cerebral infarction (disruption of blood flow to part of the brain), unspecified kyphosis (excessive forward rounding of the back), and generalized muscle weakness. A review of Resident 2's Quarterly Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 03/26/2024 revealed the resident had a Brief Interview for Mental Status (BIMS-a screening tool used to assess cognition [relating to the mental process involved in knowing, learning, and understanding things]. The BIMS assessment uses a points system that ranges from 0 to 15 points: 0 to 7 points indicates severe cognitive impairment; 8 to 12 points indicates moderate cognitive impairment; and 13 to 15 points indicates that cognition is intact) score of 14, indicating the resident was cognitively intact. An observation on 06/24/2024 at 10:46 AM revealed Resident 2 was sitting up in a wheelchair with a strap that went under the left arm and over the left shoulder, and fastened to the top of the wheelchair back. An interview with Resident 2 on 06/24/2024 at 10:46 AM revealed that the resident was unable to unfasten the strap without assistance. An observation on 06/26/2024 at 9:35 AM revealed Resident 2 was sitting up in a wheelchair with a strap that went under the left arm and over the left shoulder, and fastened to the top of the wheelchair back. An interview with Resident 2 on 06/25/2024 at 3:25 PM revealed the strap over the resident's left arm is to help them sit up straight. Resident 2 revealed they would still be unable to get out of their wheelchair if the strap was not there. Resident 2 confirmed they were unable to unfasten or remove the strap without assistance. An interview with Medication Aide (MA) A on 06/26/2024 at 9:40 AM revealed that Resident 2 requested the straps on the wheelchair, and that Resident 2 was unable to sit up without the strap in place. MA A further confirmed that the resident was unable to unfasten or remove the wheelchair strap without assistance. A review of Resident 2's Electronic Health Record (EHR) revealed no documentation of the wheelchair straps being evaluated for use prior to application of the device, or of risks and benefits being discussed with the resident and/or their representative prior to use. A review of the facility's Restrictive Device Determination Guidelines dated 1/2017 revealed: All devices which may impede the movement of residents will be evaluated prior to application, on a quarterly basis, and with any significant change in condition. These devices may involve but are not limited to: Assist bars, scoop mattresses, reclining wheelchairs, recliners, wedge cushions, lap buddy, alarms, bed against the wall, low bed, etc. 1. Prior to the initiation of any potentially restraining device being implemented, a designated member of the nursing team, with Interdisciplinary Team involvement, will complete the Pre-Restraining Evaluation and request therapy screen and/or evaluation. Alternatives to these devices will be considered and the appropriate referrals will be made. If the resident can remove, release, or freely move about, the device is not restrictive and not determined to be a restraint. 2. If the device is considered to be a restraint, the nurse will initially obtain and review the Informed Consent for Use of Restraints with the resident/responsible party, discussing the benefits and potential risks. An interview with the Director of Nursing (DON) on 06/27/2024 at 8:54 AM confirmed that if Resident 2 was unable to remove the shoulder strap on their own, it was a restraint. The DON further confirmed the facility had not done any evaluations for restraint use, and did not have a consent form for the shoulder strap.

Licensure Reference Number 175 NAC 12-006.08 Based on observation, interview and record review, the facility failed to notify the physician of weight loss for 1 (Resident 26) out of 6 residents sampled for weight loss. The facility identified a census of 30 at the time of survey. Findings are: A. Interview on 6/26/23 at 11:23 AM with Resident 26 revealed that they had lost weight since coming to this facility. Record review of Resident 26's weight record revealed admission weight on 5/25/23 was 118.0 pounds. On 06/22/2023, the resident weighed 109 pounds which is a -7.63 % loss. Record review of Resident 26's Comprehensive Careplan (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed the date of Admission was 5/24/23. Record review of Resident 26's CCP revealed a Potential for impaired nutritional status was initiated on 5/31/23 with an intervention to notify the physician with a significant weight loss. Interview on 6/28/23 at 7:05 AM with the Administrator revealed the physician had not been notified regarding the significant weight loss of Resident 26 and should have been. Interview on 6/28/23 at 11:53 AM with DM -E confirmed faciltiy staff discuss weight loss at risk meetings weekly and nursing leadership is made aware of which residents are losing weight. Record review of weekly risk meeting notes regarding weight loss for Resident 26 revealed Resident 26 was addressed at each meeting beginning on 6/7/23. Record review of the undated facility policy titled Recommended points of documentation, revealed facility staff were to notify the MD of a weight change status. Interview on 6/29/23 at 11:11 AM with RD - E confirmed that when the weight loss was identified on Resident 26 nursing was informed but the provider was not notified.

LICENSURE REFERENCE 175 NAC 12-006.09D7 Based on observation, record review, and staff and resident interview; the facility failed to prevent accidents with injuries from occurring for 1 (Resident 1) resident reviewed. The facility census was 31 at the time of the survey and the survey sample size was 27. Findings are: A. Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] according to the FACE SHEET on the medical record. The following [DIAGNOSES REDACTED]. B. Observation on 3/13/2012 at 2:05 PM revealed that Resident 1 was seated in the wheelchair with a leg brace on the right knee. Review of Resident 1's Nurse's Notes dated 2/11/2012 at 8:00 AM revealed that the resident complained of pain in lower right leg during assistance to the toilet. The physician was notified and Resident 1 was taken for x-rays and treatment. Review of the facility Investigations file revealed that Resident 1 had experienced an injury during a transfer on 2/11/2012. Documentation of the incident revealed that the staff heard a "pop" when transferring Resident 1 from the wheelchair to the toilet. Resident 1 complained of right leg pain. Review of the Investigation File dated 2/15/2012 revealed documentation that Resident 1 had a nondisplaced tibial fracture per the MRI (magnetic resonance imaging) report. Review of Resident 1's comprehensive care plan revealed a problem of resident "requires extensive assistance for all ADLs (Activities of Daily Living) related to disease process" with a target date of 4/11/2012 for "All ADLs will be met by staff...". Under Approaches, documentation revealed that Resident 1 was to be transferred with EZ stand lift with assistance of 2. Review of Resident 1's Lift and Transfer Evaluation dated 3/2/2010 revealed that Resident 1 was to be transferred with a sit to stand (EZ stand) mechanical lift. C. Interview on 3/12/2012 at 9:20 AM with Resident 1 revealed that, during a transfer, the leg "popped" which resulted in a fracture. Interview on 3/13/2012 at 2:11 PM with the DON (Director of Nursing) confirmed that Resident 1 was to have been transferred with the EZ lift. The DON stated that Resident 1 did have to bear some weight with the use of the EZ stand lift but using the lift did not pivot Resident 1 with weight on legs. The DON stated that the facility's 2 lifts were being used by other residents at the time of the incident on 2/11/2012 and that Resident 1 was yelling that (gender) had to use the bathroom. The DON stated that nursing staff had pivot transferred Resident 1 in the past and the staff thought they still could. The DON stated that the nursing staff pivot transferred Resident 1 with 2 assist and gait belt and during the transfer, they heard a pop. Resident 1 complained immediately of pain and the physician was notified. Interview on 3/13/2012 at 2:11 PM with the DON confirmed that some nursing staff admitted to pivot transferring Resident 1 and were not following the comprehensive care plan's intervention of using the EZ stand lift for all transfers as instructed. Interview on 3/14/2012 at 9:48 AM with LPN (Licensed Practical Nurse) S revealed that (gender) was involved in the transfer on 2/11/2012 of Resident 1 when (gender) leg "popped". LPN S stated that Resident 1 was upset and demanding to go to bathroom. Both EZ stand lifts were in use at the time and a pivot transfer was performed to move Resident 1 from the wheelchair to the toilet. During the transfer, Nursing staff heard the "pop" and an assessment of the resident was performed. LPN S stated that Resident 1 complained of alot of pain. LPN S confirmed that Resident 1's comprehensive care plan for transfers was to use the EZ stand with 2 assist. LPN S stated that nursing staff did not follow the comprehensive care plan for correct transfer of Resident 1. Interview on 3/14/2012 at 9:56 AM with MT (Med Tech) J revealed that (gender) was also involved in the transfer of Resident 1 when (gender) leg "popped" on 2/11/2012. MT J stated that Resident 1 had already been to the dining room for breakfast. Resident 1 had to use the bathroom and both EZ stand lifts were occupied. Resident 1 insisted that (gender) had to go now and agreed that (gender) would do a pivot transfer from the wheelchair to the toilet, using the bar. While proceeding, nursing staff heard a "pop" and Resident 1 said that leg hurt. MT J stated that nursing staff should have used the EZ stand lift but when Resident 1 was so insistent and stated that (gender) couldn't wait, Resident 1 was transferred without using the lift. MT J stated that Resident 1's comprehensive care plan's approach was to use EZ stand lift for all transfers.