Every finding on record at Highland Park Care Center

Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview, the facility failed to ensure they obtained informed consent prior to the use of psychotropic medications for 1 (Resident 4) of 5 sampled residents. The facility identified a census of 60.Findings Are: A record review of the facility policy Psychoactive Medication and Medication Regimen Review Standard dated 6/2026 revealed the consent for use of psychoactive medication form must be completed prior to initiating and with the increase of any psychoactive medication. A record review of Resident 4's admission Record dated 8/18/2026 revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's Disease (a degenerative brain disease of unknown cause that usually starts in late middle age or in old age, that results in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood). A record review of Resident 4's Order Summary dated 8/18/2026 revealed the following orders:-Olanzapine (an antipsychotic medication) 2.5 milligrams (MG) 1 tablet by mouth every 24 hours as needed for agitation. This order had a start date of 8/7/2026.-Seroquel (an antipsychotic medication) 25 MG one time a day related to dementia. This order had a start date of 7/11/2026. A record review of an undated Informed Consent for use of Psychotropic Medication for Resident 4 revealed the name of the medication was olanzapine 2.5 mg. There were no boxes marked in the Diagnosed condition for which the medication is prescribed, Clinical indication(s) for the use of this medication, or in the Benefits expected from this medication section. The Statement of Consent and Name of individual providing consent sections were both left blank. The document was signed by facility staff and dated 8/7/2026. A record review of Resident 4's Progress Notes dated 8/7/2026 revealed:- (resident representative) called and notified of Olanzapine 2.5 mg daily PRN (as needed) agitation. Went over s/e (side effects) of medication, how it works, and asked if (gender) was okay with order. (resident representative) said that if (gender) was okay with Olanzapine. (resident representative) then said, I'll call you back after a bit and make a decision.- (resident representative) called facility back and said (gender) was okay with order for Olanzapine but if we tried it and it doesn't work, get it D/C (discontinued) right away and get something else.-There were no further progress notes indicating the facility had reviewed the diagnosed condition for which the medication was prescribed, the clinical indications for the medication, or the benefits expected from the medication. A record review of an undated Informed Consent for use of Psychotropic Medication for Resident 4 revealed the name of the medication was Seroquel. There were no boxes marked in the Diagnosed condition for which the medication is prescribed, Clinical indication(s) for the use of this medication, or in the Benefits expected from this medication section. The document was signed by the resident's representative and dated 7/11/2026. A record review of Resident 4's Progress Notes on 7/11/2026 revealed no evidence of the diagnosed condition for which the Seroquel medication was prescribed, the clinical indications for the medication, or the benefits expected from the medication being reviewed with the resident's representative. An interview on 8/18/2026 at 11:00 AM with the Director of Nursing (DON) and Medical Records (MR)-A confirmed there was no evidence that the facility had reviewed the diagnosed condition for which the olanzapine and Seroquel medications were prescribed, the clinical indications for the two medications, or the benefits expected from the two medications with Resident 4's representative.

Licensure Reference Number 175 NAC 12-006.09(D)Based on record review and interviews, the facility failed to accurately code the MDS for pressure ulcers present on admission and wound type for one (Resident 10) of one sampled resident. The facility identified a census of 60. Findings are: Record review of Resident 10's admission Record, dated 8/17/2026, revealed that Resident 10 was admitted to the facility on [DATE]. The resident had the following diagnoses:Unspecified open wound, left lower leg, subsequent encounterPressure ulcer of right ankle, unstageablePeripheral vascular disease, unspecifiedCellulitis of left lower limb Record review of Resident 10's Progress Notes, dated 8/18/2026, revealed a admission assessment note, dated 7/1/2026. The admission note revealed that skin issues #005 was located on the left ankle. The issue type was noted as a pressure ulcer/injury. The note stated that the wound was present on admission and was unknown how long the wound had been present. Further record review of Resident 10's Progress Notes, dated 8/18/2026, revealed a skilled evaluation note on 7/2/2026 that noted skin issues #006 was a pressure ulcer/injury to the left ankle that was present on admission. Further record review of Resident 10's Progress Notes, dated 8/18/2026, revealed a skin check note from 7/3/2026 that noted skin issue #006 as a pressure ulcer/injury on the left ankle that was present on admission. The note revealed a new skin issue for skin issue #010 as a pressure ulcer/injury on the right lateral malleolus (bony prominence on the outer side of the right ankle) that was present on admission. The wound progress was noted to be covered with yellow slough (non-viable tissue) and staged as an unstageable pressure injury presented as a deep tissue injury. Interview with Director of Nursing (DON) on 8/18/2026 at 11:47 AM confirmed the facility used the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) to complete their 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). A. Record review of Resident 10's admission MDS, dated [DATE], revealed under Section M - Skin Conditions, M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each State:F. Unstageable - Slough and/or eschar (dead or devitalized tissue that is hard or soft in texture) (known but not stageable due to coverage of wound bed by slough and/or eschar)1. Number of unstable pressure ulcers due to coverage of wound bed by slough and/or eschar - noted as Resident 10 having 12. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - noted as Resident 10 having 0 Interview with DON and Licensed Practical Nurse(LPN)-C on 8/17/2026 at 9:38 AM confirmed that Resident 10 had both pressure ulcers since the resident was admitted . DON confirmed that Resident 10 had had both pressure ulcers when the resident was admitted for the first time in 2017, as well. Record review of the RAI Manual, October 2025, page M-8 revealed that for each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry. On M-8, the RAI Manual revealed that on admission, the staff would code based on findings from the first skin assessment that was conducted on or after and as close to the admission as possible. Interview with Registered Nurse (RN)-E on 8/17/2026 at 11:09 AM confirmed that there was a pressure ulcer noted on the admission skin assessment note and that the MDS should have been marked as Resident 10 having a pressure ulcer that was present on admission. Interview with MDS-D(MDS Coordinator) on 8/17/2026 at 2:49 PM confirmed the MDS for Resident 10 was inaccurately coded for the pressure ulcer present on admission. B. Record review of Resident 10's admission MDS, dated [DATE], revealed in Section M, M1030 - Number of Venous and Arterial Ulcers, 1 was entered as the total number of venous and arterial ulcers present. Record review of Resident 10's Medical Diagnosis, dated 8/17/2026, revealed no evidence of Resident 10 being diagnosed with a venous or arterial ulcer. Interview with RN-E on 8/17/2026 confirmed that Resident 10 did not have documentation of a venous ulcer. Record review of documentation provided by the facility staff revealed no evidence of the ulcer documented as a venous ulcer. Record review of the RAI Manual, October 2025, on M-30 revealed the steps for assessment of venous and arterial ulcers was to review the medical record and to speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review for determining whether any venous or arterial ulcers were present. Interview with MDS-D on 8/17/2026 at 2:49 PM confirmed there was no evidence in Resident 10's medical record that confirmed the resident had a venous or arterial ulcer.

LICENSURE REFERENCE NUMBER 175 12-006.05(G)Based on record review, interviews, and observations, the facility failed to ensure one (Resident 5) of one sampled resident was free from restraints. The facility identified a census of 55. LICENSURE REFERENCE NUMBER 175-12 006.05(G)Based on record review, interviews, and observations, the facility failed to ensure one (Resident 5) of one sampled resident was free from restraints. The facility identified a census of 55.Findings are:A record review of an admission summary reveals Resident 5 admitted on [DATE] and included a admission diagnosis Cerebral infarction with Hemiplegia and Hemiparesis affecting the Left side of the body (occurs when blood flow to a part of the brain is interrupted, causing brain tissue damage which results in cognitive dysfunction with subsequent paralysis and weakness to affected side of the body). A record review of Resident 5s Physicians Orders revealed Resident 5 was admitted to Hospice on 04/04/2025. A record review of a Quarterly Minimum Data Set (MDS-a federally mandated assessment tool for nursing homes) for Resident 5 revealed in Section C, a Brief Interview for Mental Status (BIMS- an assessment tool used to evaluate the cognitive function of residents in Long Term Care), a BIMS score of 00/15, revealing that Resident 5 had severe cognitive dysfunction. Section GG further revealed that Resident 5 was fully dependent on staff for dressing/undressing, toileting, and transfers. Resident 5 utilized a wheelchair with staff to propel for ambulation. Section P of the MDS indicated the facility was not utilizing the use of restraints for Resident 5.A record review of Resident 5s care plan revealed the facility implemented the use of pillows while Resident 5 was in bed. The pillows were to be placed around Resident 5 to protect from potential injuries related to involuntary arm and leg movements.An observation of Resident 5 in bed on 08/05/2025 at 8:30 AM revealed Resident 5 lying flat and positioned on the left side. Resident 5 appeared to be sleeping at that time with no visible distress or agitation observed. A full-length body pillow was observed to be tucked under the fitted sheet, with Resident 5 was facing the body pillow. The pillow was positioned in a manner consistent in restricting a person from getting out of bed. There were no other pillows observed around Resident 5. An observation on 08/05.2025 at 9:30 AM revealed that Resident 5 could be heard yelling help from the hallway. Resident 5 was observed to be in bed in a flat and laying in a left sided position. Licensed Practical Nurse (LPN) entered the room and asked Resident 5 what did she need Resident 5 who observed waiving right arm in the air purposelessly A Full-length body pillow was observed under the fitted sheet positioned in a manner consistent with restricting a person from getting out of bed. There were no other pillows observed around Resident 5. An observation of Resident 5 in bed on 08/06/2025 9:13 AM revealed Resident 5 lying flat and positioned on left side. A full-length body pillow was observed to be tucked under fitted sheet, with no part of the pillow observed to be touching Resident 5, indicating the pillow was not being used for positioning. The pillow was positioned in a manner consistent with restricting a person from getting out of bed. An interview with Certified Nursing Assistant (CNA-A) on 08/06/2025 at 9:10 AM revealed that CNA-A states the pillow was used to keep Resident 5 from getting out of bed. Confirmed the wedge pillow under the sheet is always there to keep Resident 5 from falling out of bed, report6ing Resident 5 thrashes around and is always moving.An interview with CNA-B on 08/06/2025 at 9:30 Am confirmed the full length body pillow placed on the left side of the bed was used to keep Resident 5 from falling out of bed.An interview with the Director of Nursing (DON) at 3.00 PM on 08/06/2025 confirmed the understanding of how a pillow laced under a fitted sheet and outside the reach of Resident 5 could be considered a restraint. No Notes

License Reference Number 175 NAC 12-006.18 Based on observations, interviews, and record reviews, the facility failed to handle contaminated linens for all residents who were residing within the facility in a way that prevented the potential for cross contamination. The facility census was 53. Findings: A. A record review of facility policy US Centers for Disease Control (CDC) Best Practices for Environmental Cleaning in Global Healthcare Facilities with Limited Resources, Appendix D, Linen and laundry management, dated March 19, 2024, revealed the direction, Never carry soiled linen against the body. Always place it in the designated container. An interview with the Administrator on 8/20/24 at 2:43 PM confirmed that, CDC Best Practices for Environmental Cleaning, Appendix D, what all facility staff, including the Domestic Service (DS) staff, were expected to follow. A record review of CDC Guidelines for Environmental Infection Control in Health Care Facilities (last reviewed July 2019), Section G, subsection 3: Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics, revealed the statement, Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location (where contamination occurs); these bags are then securely tied or otherwise closed to prevent leakage. An observation on 8/20/24 at 12:02 PM revealed DS-D carried contaminated bedding (facility comforter and sheets) against their chest and arms from a resident room on the 100 nursing hall past the nurses' station and towards the laundry room. An observation on 8/20/24 at 12:09 PM revealed DS - Lead (DS-L) carried contaminated bedding (facility comforter and sheets) against their chest and arms from a resident room on the 100 nursing hall past the nurses' station and towards the laundry room. An interview on 8/20/24 at 12:41 PM with DS-L and DS-D confirmed that both staff had taken the contaminated bedding off beds in the residents' rooms, held the bedding against their bodies and carried it from the 100 nursing hall to the laundry room. An interview on 8/21/24 at 2:25 PM with the Director of Nursing (DON) confirmed that facility staff did not bag dirty linen to transport it from each resident's room to the designated location unless it contained body fluids/excretions or was soiled. B. A record review of Strategies for Conserving the Supply of Isolation Gowns, from the CDC and National Institute for Occupational Safety and Health (NIOSH) dated May 9, 2023, revealed the following guidance: Disposable gowns generally should NOT be reused, and reusable gowns should NOT be reused before laundering, because reuse poses risks for transmission among healthcare personnel (HCP) and patients that likely outweigh any potential benefits, and Similar to extended gown use, gown reuse has the potential to facilitate transmission of organisms. An observation on 8/19/24 at 11:45 AM revealed DS-E and DS-F were pushing a white collection bin on wheels from the laundry area through the hallway down to the 100 nursing hall. DS-F was wearing a blue disposable plastic gown and gloves. An observation on 8/19/24 at 11:50 AM revealed DS-E and DS-F pushing the wheeled bin from the 100 nursing hall to the laundry area. DS-F was wearing the same blue disposable plastic gown and gloves. An interview on 8/21/24 at 12:08 PM with DS-L revealed that Domestic Services staff collected linen from the nursing halls each morning. They put on disposable blue plastic gowns and gloves then pushed the collection bin on wheels (with lid) from the dirty laundry area to the areas where they pick up soiled linens and clothing, then return to dirty laundry sorting area while continuing to wear the same gown and gloves. Those gowns are used until they are worn out,. An observation on 8/21/24 at 12:10 PM in the dirty laundry sorting area revealed DS-L was present and there were two blue plastic gowns with stretching, wrinkles, and tears hanging on a hook inside the entrance to the dirty laundry sorting area. An interview with DS-L on 8/21/24 at 12:10 PM confirmed the gowns hanging on the hook in the dirty laundry sorting area had been used while handling soiled linens and were hung in this location so they could be re-used. DS staff also wore the gowns while sorting dirty clothes and linens into the appropriate washers. An interview on 8/21/24 at 2:15 PM with the DON confirmed that staff were required to throw out disposable blue plastic gowns after each use, and they were not supposed to reuse or wear the gowns in resident rooms after they had been used. An interview on 8/21/24 at 2:15 PM with Registered Nurse (RN)-C confirmed that staff were expected to throw away their disposable gowns or wash the re-usable gowns after each use.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to ensure a medication was not given when 1 (Resident 38) of 1 sampled resident's pulse was below the designated parameter in the resident's medication order. The facility census was 53. The Findings Are: A record review of Resident 38's admission record revealed Resident 38 was admitted to the facility on [DATE] and had a diagnosis of essential hypertension (elevated blood pressure). A record review of Resident 38's physician's orders revealed an order for Metoprolol Succinate Extended Release (ER) 24 Hour, 100 Milligrams (MG) one time a day for essential hypertension. The order also stated to hold (not administer) the medication if the resident's pulse was less than 60. A record review of Resident 38's Medication Administration Record (MAR) for May 2024 revealed Resident 38 received their Metoprolol SuccinateER on the following dates despite their pulse being below 60: -On 5/17/24 with a pulse of 50. -On 5/19/24 with a pulse of 59. -On 6/24/24 with a pulse of 55. A record review of Resident 38's MAR for June 2024 revealed Resident 38 received their Metoprolol SuccinateER on the following dates despite their pulse being below 60: -On 6/15/24 with a pulse of 52. -On 6/17/24 with a pulse of 52. -On 6/29/24 with a pulse of 53. A record review of Resident 38's MAR for July 2024 revealed Resident 38 received their Metoprolol SuccinateER on the following dates despite their pulse being below 60: -On 7/12/24 with a pulse of 55. -On 7/20/24 with a pulse of 58. A record review of Resident 38's MAR for August 2024 revealed Resident 38 received their Metoprolol SuccinateER on the following dates despite their pulse being below 60: -On 8/7/24 with a pulse of 51. -On 8/8/24 with a pulse of 51. -On 8/10/24 with a pulse of 53. -On 8/11/24 with a pulse of 51. An interview on 8/21/24 at 10:05 AM with Licensed Practical Nurse (LPN)-I confirmed that if there was a checkmark on the MAR, this indicated that the medication had been administered to the resident. LPN-I also confirmed there were multiple dates when the Metoprolol Succinate ER was administered to Resident 38 despite their pulse being below the designated parameter.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observations, interview, and record review; the facility failed to ensure 1 (Resident 7) of 2 sampled residents received oxygen therapy as ordered. The facility census was 53. The Findings Are: A record review of Resident 7's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 7/18/24 revealed Resident 7 had a diagnosis of Chronic Obstructive Pulmonary Disorder (COPD), a lung disease that limits airflow and causes breathing problems, and required oxygen therapy. A record review of Resident 7's physician's orders revealed an order for oxygen at 2 liters per minute (lpm) at all times to maintain oxygen saturations above 88% for their diagnosis of COPD. An observation on 8/19/24 at 10:37 AM revealed Resident 7 sitting in their wheelchair in the dining room and did not have oxygen on as ordered. An observation on 8/20/24 at 9:07 AM revealed staff pushing Resident 7 to their room in their wheelchair and Resident 7 was not wearing their oxygen as ordered. An observation on 8/20/24 at 12:03 PM revealed Resident 7 sitting in their wheelchair in the dining room with staff sitting next to them. Further observations on 8/20/2024 at 12:03 PM revealed Resident 7 was not wearing their oxygen as ordered. An interview on 8/20/24 at 12:10 PM with NA-H confirmed Resident 7 was not wearing their oxygen and that Resident 7 should have been wearing the oxygen.

Licensure Reference Number 175 NAC 12-006.10 Based on record review and interview, the facility failed to ensure 1 (Resident 7) of 15 sampled residents did not receive medication in doses exceeding the parameters set by the prescriber. The facility census was 53. The Findings Are: A record review of Resident 7's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 7/18/24 revealed Resident 7 had a diagnosis of pain and was receiving pain medication routinely. A record review of Resident 7's physician's orders revealed an order for Tylenol 8-Hour Arthritis Pain Tablet Extended Release 650 Milligrams (MG), give 2 tablets by mouth three times a day for pain. The order also stated not to exceed 3 grams (GM) of Tylenol per day and had a start date of 6/27/22. A record review of website www.unitconverters.net revealed 3 GM is equivalent to 3,000 MG. An interview on 8/21/24 at 11:15 AM with the Director of Nursing (DON) confirmed Resident 7's routine Tylenol order stated not to exceed 3 GM per day and that the total daily dose being administered, per the order instructions, was 3.9 GM. The DON also confirmed that the Tylenol order had been in place and had been being administered to Resident 7 since 6/27/22.

Licensure Reference 175 NAC 12-006.09(H)(vi) Based on record review and interview;the facility staff failed to ensure the clinical rational for the continued use of an as needed (PRN) psychotropic and failed to complete a does reduction for 2 (Resident 40 and 46) of 5 sampled residents. The facility census was 53. Findings are: A record review of a facility policy Psychoactive Medication and Medication Regimen Review Management Standard with a date of 6/2024 indicated periodic re-evaluation is necessary to determine whether prolonged use of a medication is indicated with a clinical rationale for continued use. A. A record review of an Admission Record indicated the facility admitted Resident 40 on 1/4/2024 with diagnoses of depression and restless leg syndrome. A record review of Resident 40's quarterly Minimum Data Set (MDS,) a standardized assessment tool that measures health status in nursing home residents, with an Assessment Reference Date (ARD) of 7/11/2024 indicated Resident 40 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated Resident 40 had moderate cognitive impairment. The MDS also indicated a Resident Mood Interview had been completed and Resident 40 did not attest to feeling down, depressed, or hopeless or little interest or pleasure in doing things during the past two weeks. The MDS also indicated Resident 40 was being administered an antianxiety medication and antidepressant. A record review of Resident 40's Order Summary with a date of 8/21/2024 revealed an order for bupropion (a medication for depression) with a start date of 1/4/2024. A record review of a Medication Regimen Review with a date of 5/21/2024 indicated the pharmacist had recommended a trial gradual dose reduction of Resident 40's bupropion. Resident 40's physician had declined with a clinical rationale of depression and a risk/benefit statement of continue. An interview on 8/21/2024 at 11:50 AM with Licensed Practical Nurse (LPN) - G confirmed depression was a diagnosis and not a valid clinical rationale to not perform a gradual dose reduction as recommended by the pharmacist on the Medication Regimen Review. B. A record review of an Admission Record indicated the facility admitted Resident 46 on 4/5/2024 with diagnoses of history of a stroke and anxiety. A record review of Resident 46's quarterly MDS with an ARD of 7/11/2024 revealed Resident 46 had a BIMS of 2/15, which indicated Resident 46 had severe cognitive impairment. The MDS also indicated Resident 46 experience delusions and had behaviors of disruptive sounds daily. The MDS also indicated a Resident Mood Interview had been completed and Resident 46 did not attest to feeling down, depressed, or hopeless or little interest or pleasure in doing things during the past two weeks. The MDS also indicated Resident 46 was being administered an antianxiety medication. A record review of Resident 46's Care Plan indicated on 6/14/2024 family was offered Hospice services but declined. A record review of Resident 46's Order Summary with a date of 8/20/2024 revealed an order for PRN Ativan (a medication for agitation.) A record Review of Medication Regimen Review with a date of 7/16/2024 indicated the pharmacist had recommended a clinical rationale for continued use of the PRN medication past the 14 days. The physician had responded with a rationale of hospice. An interview on 8/20/2024 at 11:50 AM with LPN-G confirmed Resident 46 was never on Hospice and confirmed the physician had not provided an accurate clinical rationale for the continuance of Resident 46's PRN Ativan for the Medication Regimen Review.

License Reference Number 175 NAC 12-006.10 Based on record reviews, observations and interviews, the facility failed to ensure labeled medications and medication orders listed on the Medication Administration Records were the same for 1 (Resident #34) of seven residents sampled.) The facility census was 53. Finds are: Record review of the Physician's Order Summary for Resident #34 during the month of August 2024 revealed an order for Ferrous Sulfate Oral Solution 300 mg (milligrams)/5 ml (milliliter). Staff were to administer 13.5 ml once a daily (13.5 ml is equivalent to a dose of 810 mg of medication). Record review of the Pharmacy Label on the bottle of Ferrous Sulfate liquid revealed Resident #34 was to receive Ferrous Sulfate liquid 18.5 ml daily (18.5 ml of this solution is equivalent to a dose of 814 mg of medication). The Ferrous Sulfate liquid was supplied with a concentrated liquid of 220 mg/5 ml. Record review of the Medication Administration Record (MAR) for the month of August 2024 revealed an order for Ferrous Sulfate 13.5 ml of a 300 mg/5 ml solution was administered daily at noon. Observation on 8/20/2024 at 12:05 of Licensed Practical Nurse-A (LPN-A) administered Ferrous Sulfate liquid 13.5 milliliters to Resident 34. The ferrous sulfate bottle had a solution strength of 220 mg/ml. a 13.5 ml of this solution would result in a dose of 594 mg of medication or 216 mg less than the ordered dose of the medication. Interview 8/20/2024 at 12:40 PM with LPN A confirmed that the medication label and the order on the MAR were different. Interview 8/20/2024 at 1:00 PM with the Director of nursing( DON). During the interview the DON confirmed the medication label and order on the MAR were different.

Licensure Reference Number 175 NAC 12-006.11E Based on observation and interview the facility failed to label and date opened food items and failed to maintain cleanliness of ceiling vents to prevent the potential for food borne illness. This had the potential to affect all residents in the facility. The facility census was 54. Findings are: A. Kitchen observation upon entry on 07/10/2023 at 8:30 AM revealed 1 open bag of pepperoni and 1 open bag of hashbrowns in the upright freezer were not labeled with an open date. One jar of sweet relish, 2 gallons of whole milk, 1 bottle of Thousand Island dressing in the upright refrigerator were not labeled with an open date. An open box of instant mashed potatoes and bag of marshmallows were not labeled and dated. Observation on 07/11/2023 at 9:45 AM revealed One bag of shredded lettuce in the walk-in refrigerator, 1 open bag of pepperoni and 1 open bag of hashbrowns in the upright freezer were not labeled with an open date. One jar of sweet relish, 2 gallons of whole milk, 1 bottle of Thousand Island dressing in the upright refrigerator were not labeled with an open date. Observation on 07/12/2023 at 12:34 PM revealed One bag of open shredded lettuce in the walk-in refrigerator, 1 open bag of pepperoni and 1 open bag of hashbrowns in the upright freezer were not labeled with an open date. In addition, One jar of sweet relish, 2 gallons of whole milk, 1 bottle of Thousand Island dressing in the upright refrigerator were not labeled with an open date. An open box of instant mashed potatoes and bag of marshmallows were not labeled and dated. An interview with the Dietary Manager on 07/12/2023 at 12:34 PM confirmed that the open food items were not labeled with an open date. An interview with the administrator on 07/13/2023 at 10:30 AM verified that any food items that were open should have been labeled with an open dated. Review of the 07/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for the food service sanitation practices, revealed the following: 3-2011.11(C) Package Food shall be labeled as specified by law, including 21 CFR 101 Food labeling, 9 CFR 317 Labeling, Marking Devices, and Containers and 9 CFR 381 Subpart Labeling and Containers, and as specified under 3-202.17 and 3-202.18. B. Observation on 07/10/2023 at 8:30 AM revealed 3 exhaust fans over food preparation areas in the kitchen had buildup of dirt and lint/dust debris located on and around the fan. Observation on 07/11/2023 at 9:30 AM revealed 3 exhaust fans over food preparation areas in the kitchen had buildup of dirt and lint/dust debris located on and around the fan. Observation on 07/12/2023 at 12:30 PM revealed 3 exhaust fans over food preparation areas in the kitchen had buildup of dirt and lint/dust debris located on and around the fan. An interview with the Dietary Manager on 07/13/2023 at 12:34 PM confirmed 3 exhaust fans over food preparation areas in the kitchen had buildup of dirt and lint/dust debris located on and around the fan. Review of the 07/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for the food service sanitation practices, revealed the following: 6-5-1.14(A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interview; the facility failed to disinfect reusable resident care equipment in accordance with manufacturer recommendations and facility policies to prevent the potential spread of infection. The sample size was 17 and the facility census was 56. Findings are: A. Review of the undated facility Cleaning and Disinfecting Guidelines for the facility Blood Glucose Test Meter used to test facility resident's blood glucose levels, revealed cleaning and disinfection were to be completed using a commercially available Environmental Protection Agency (EPA)-disinfectant detergent or germicidal wipe. B. Review of the undated facility Lift Competency revealed the facility procedure for the use of the lifts including wiping down all lift surfaces that came in direct contact with the resident's skin with an approved disinfectant between each resident use whether the lift was visibly soiled or not. C. During an observation of care on 7/11/23 at 11:35 AM Nurse Assistant (NA) B and NA C assisted a dependent resident to the toilet from bed using a mechanical stand-up lift (lift in which the resident stands on a platform and grasps the handles allowing the resident to be lifted and transfer between surfaces). After completing cares with the dependent resident, NA-B draped a soiled shirt and washcloth over the lift before placing the soiled items in a plastic bag, then exited the room returning the lift to a storage area without cleaning or sanitizing the lift where the soiled clothing had been placed or where the resident's hands contacted the lift. Further observation revealed within 3 minutes another staff member retrieved the lift from a storage area and entered another resident room with the un-sanitized lift. D. During an observation of care on 7/11/23 at 12:30 PM, NA's B and NA C assisted a dependent resident to the toilet from bed using a full body mechanical lift (lift which lifts a dependent non-wt. bearing resident in a sling from one surface to another). The resident was then transferred using the lift to bed, and then to a recliner chair. During the course of care provision, the resident touched the sling contact hooks on 2 occasions. After providing care the lift was removed from the resident's room and placed in a storage area without being sanitized. E. During an observation on 7/12/23 at 11:45 AM Licensed Practical Nurse (LPN)-G performed a blood glucose monitoring test on Resident 30, exited the room with the blood glucose monitoring device (used on multiple residents requiring blood glucose monitoring) and cleaned the meter with an alcohol swab (not an approved disinfectant) and placed it into the cart used to store it. F. During an interview on 7/12/23 at 2:00 PM the Director of Nursing (DON) confirmed the blood glucose meter used by the facility was used on multiple residents, was to be cleaned with approved disinfectant wipes, and an alcohol swab was insufficient disinfection for a blood glucose meter being used on multiple residents. Additional interview confirmed all mechanical lifts are to be cleaned with disinfectant wipes after each use anywhere the resident's skin, or potentially soiled items came in contact with the mechanical lifts.

Licensure Reference Number 175 NAC 12-006.09D Based on interviews and record review, the facility failed to ensure residents were free from unnecessary medications related to Resident 39's as needed psychoactive (affecting the mind) medication not being given beyond 14 days without a face to face provider reassessment. The sample size was 1 and the facility census was 56. Findings are: A. Review of the facility policy Documentation for Psychoactive Medications dated May 2019 revealed the following: -Consent for use of psychoactive medications should be completed. -Document the physician's order and responsible party notification/consent in the medical record under progress notes. -All as needed psychoactive medications must have a stop date. -As needed Antipsychotic medications (used to treat psychotic disorders) may not be ordered for more than 14 days and a practitioner must see the resident to renew or extend the order for another 14 days. B. Review of Resident 39's undated care plan revealed the following: -the resident was cognitively impaired and required extensive assistance with transfers, dressing, toileting and personal hygiene; -diagnoses of depression, anxiety disorder, and dementia; and -the resident used psychoactive medications related to anxiety disorder, dementia with agitation and behavioral disturbances. Review of Resident 39's Medication Administration Records dated 6/1/23 - 6/30/23 and 7/1/23 -7/31/23 revealed the resident had an order for Haldol (a psychoactive medication) 5 milligrams (mg) 1 tablet every 6 hours as needed dated 6/1/23. There was no stop date and Haldol was administered to the resident on the following dates: 6/9/23, 6/17/23, 6/21/23, 6/23/23, 7/1/23 and 7/7/23. During an interview with Licensed Practical Nurse (LPN)-M on 7/12/23 @ 1:30 PM, LPN-M confirmed there was no documentation of evidence the physician evaluated Resident 39 every 14 days for the prescribed as needed antipsychotic medication (Haldol 5 mg) and the resident was administered the Haldol beyond the 14 day provider reassessment time frames. LPN-M also confirmed the as needed Haldol order did not have a stop date and should not exceed 14 days in duration.

Licensure Reference Number: 175 NAC 12-006.11E Based on observations and interviews, the facility failed to ensure that staff 1) performed hand hygiene for at least 20 seconds when indicated during meal service in the MSU (Memory Support Unit), 2) did not handle drinking glasses by the rims and the top of drinking straws in the MSU, 3) did not touch the inside of the silicone covers while placing them on the top of water and juice glasses in the MSU, 4) did not place a used food thermometer inside the pureed meat container without cleaning it in the MSU and 5) cleaned the kitchen floor to reduce the risk of cross contamination. The facility census was 50 with the potential to affect all of the residents. Findings are: A. Observations of the meal service on 5/2/22 between 11:45 AM and 12:30 PM in the MSU revealed DA (Dietary Aide) - A washed hands for approximately five seconds two times when hands became soiled. B. Observations of the meal service on 5/2/22 at 11:45 AM in the MSU revealed DA - A poured apple juice and water into glasses touching the rims of the glasses. Further observations revealed DA - A touched the inside of the silicone covers while placing them on the water and juice glasses for several residents. C. Observations of the meal service on 5/2/22 at 11:55 AM revealed DA - A removed a food thermometer from the container of gravy in the steam table and placed it in the pureed meat container to obtain the temperature. DA - A did not clean the thermometer before placing it in the pureed meat. Interview with the Dietary Manager on 5/4/22 at 2:00 PM confirmed that the dietary staff were to wash their hands for at least 20 seconds when indicated during the meal service, were not to handle drinking glasses by the rims or the top of drinking straws, and were to clean food thermometers before they were placed in a different food containers to reduce the risk of cross contamination. Further interview confirmed that 14 residents resided in the MSU and one resident was on a pureed diet. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -Cleaning Procedure (A) food employees shall clean their hands and exposed portions of their arms for at least 20 seconds. -Preventing Contamination by Employees, except when washing fruits and vegetables, food employees shall minimize bare hand and arm contact with exposed food. -Food shall only contact surfaces of equipment and utensils that are cleaned. D. On 05/02/22 at 10:54 AM an observation revealed that the kitchen floor had dirt, debris (chunks of food), and grease build up. On 05/02/22 at 11:00 an interview with the dietary manager confirmed that the kitchen floor had dirt, debris, and grease build up. On 05/03/22 at 11:25 AM an observation revealed that the kitchen floor had dirt, debris, and grease build up. On 05/04/22 at 10:48 AM an observation revealed that the kitchen floor continued to have dirt, the same debris that was seen in the last two observations, and grease build up. On 05/04/22 at 11:10 AM an interview with the Dietary Manager varified that the kitchen floor had dirt, debris, and grease build up. Review of the 7/21/16 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authorittive reference for the food service sanitation practices revealed the following: Equipment, Food-Contact Surfaces, NonFood-Contact Surfaces, and Utensils. (C) NONFOOD-CONTACT SURFACES of equipment shall be kept free of an accumulation of dust, dirt, residue and other debris.

Licensure Reference Number 175 NAC 12-006.05 Based on observation, record review, and interview; the facility failed to ensure residents were allowed to choose their medical care as agreed upon in the admission agreement for 1 resident (Resident #37.) The facility census was 50 residents. Findings are: A review of the Admission Record for Resident #37 revealed the resident was admitted to the facility on [DATE]. An observation on 5/4/2022 at 08:45 AM revealed LPN-E (Licensed Practical Nurse) preparing medication for Resident #21. LPN-E pulled medication cards for Resident #21 from the medication cart and began preparing them for administration. The medications were packed in unit dose medication cards prepared by the local pharmacy. An observation on 5/4/2022 at 09:19 AM revealed LPN-F preparing medication for Resident #36. LPN-F pulled medication cards for Resident #36 from the medication cart and began preparing them for administration. The medications were packed in unit dose medication cards prepared by 2 separate pharmacies. An observation on 5/4/2022 at 09:30 AM revealed medication cards for Resident #37 were packaged in unit dose medication cards prepared by the facility chosen pharmacy. On 5/3/2022 a telephone interview with the POA (Power of Attorney) for Resident #37 confirmed that medications for Resident #37 had been transferred to a different pharmacy against the wishes of Resident #37 and the POA for Resident #37. The POA revealed the facility had given notice that a pharmacy change was going to happen March 9, 2022. The POA revealed that during a phonce call with the facility administrator, it was relayed that neither the resident nor the POA had a choice in regards to switching pharmacies. The interview revealed the POA for Resident #37 and Resident #37 strongly preferred to have kept the local pharmacy as the provider for the medication for Resident #37 and were against switching pharmacies. The interview revealed the POA was told by the Administrator that the resident and/or POA did not have the right to choose their pharmacy and that the pharmacy change was a must. On 5/5/2022 a review of the facility correspondence with residents and resident responsible parties revealed a letter addressed January 11, 2022, announcing a preferred provider of pharmacy services for the facility residents beginning March 9, 2022. A review of the Admission Agreement signed by Resident #37 on 11/9/2020 revealed the following clause: F. Pharmacy. Our Facility utilizes the unit dose system of dispensing medication. As long as the Facility is using a unit dose system, you agree to accept the pharmaceutical arrangement we have made, or if you elect, you may select another pharmacy using a drug distribution system compatible with the system used by our Facility. A review of the revised Admission Agreement revealed the following revision: F. Pharmacy. Our facility contracts exclusively with (pharmacy name) as it's Pharmacy provider of choice. (Pharmacy name) utilizes the unit dose system of dispensing medication and is contracted with all CMS approved Medicare Part D plans. You agree to accept the pharmaceutical arrangement we have made, or if you elect, you may select another pharmacy that also contracts with all CMS approved Medicare Part D pland, uses the exact drug formulary, ordering, distribution/transportation system, dose methodology, and back up distribution as the Facilities existing contracted pharmacy. On 05/04/22 at 10:21 AM an interview with the Administrator confirmed letters were sent out to residents, family members, and responsible parties regarding the facility's change in pharmaceutical providers. The Administrator verified that the letter was sent out as information only, not to offer a choice. The Administrator further confirmed the expectation was the residents must change to the facility preferred pharmacy. The Administrator confirmed that the facility changed some residents pharmacy against the resident and/or resident responsible parties wishes or consent. The Administrator verified the letter of notification from the facility to the residents was mailed without allowing for consent or agreement in regards to the residents' choices pertaining to individual care as agreed to upon signature of the Admission Agreement.

Licensure Reference Number: 175 NAC 12-006.05 (21) Based on observations, record review and interview; the facility failed to ensure that a cover or drape was used during personal cares to promote privacy for one current sampled resident (Resident 12). The facility census was 50 with 19 current sampled residents. Findings are: Observations on 5/4/22 at 10:30 AM revealed Resident 12 on the bed for catheter care. Further observations revealed NA (Nursing Assistant) - B and NA - C removed the top linens from the resident and placed them at the foot of the bed, exposing the resident from the waist down. NA - B continued with catheter care with no attempt to cover or drape the resident. Review of the facility procedure Catheter Care, dated 2016, revealed the following including: Critical Steps . 10. Cover resident with bath blanket and fanfold top linens to the bottom of the bed. Interview with the Director of Nursing on 5/5/22 at 8:45 AM confirmed that staff were to drape or cover the resident during personal cares to minimize exposure of the resident for privacy and to promote comfort.

Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to document bruising on the hands and wrist for one current sampled resident (Resident 10). The facility census was 50 with 19 current sampled residents. Findings are: Observations of Resident 10 on 5/3/22 at 11:08 AM revealed round purple bruises on hands and right wrist. Review of the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes, dated 4/1/22 through 5/3/22, revealed no documentation of the bruises. Interview with Registered Nurse - D, Charge Nurse, on 5/4/22 at 2:33 PM revealed that there was no documentation of the resident's bruising in the notebook which contained Non-Pressure Skin Condition Record forms. Interview with the Director of Nursing on 5/4/22 at 2:50 PM confirmed that the nurses were to document skin injuries on the Non-Pressure Skin Condition Record and follow up weekly to ensure healing without complications.

Licensure Reference Number: 175 NAC 12-006.17B Based on observations and interview, the facility failed to ensure that used disposable wipes were placed in the trash after use during personal cares for one current sampled resident (Resident 12) to reduce the risk of cross contamination. The facility census was 50 with 19 current sampled residents. Findings are: Observations on 5/4/22 at 10:30 AM revealed NA (Nursing Assistant) - B provided catheter care for Resident 12. Further observations revealed that NA - B cleaned the resident's skin and catheter with disposable wipes and placed the used wipes directly on the bottom bed sheet. Interview with the Director of Nursing on 5/5/22 at 8:45 AM confirmed that the staff were to place used disposable wipes in the trash to reduce the risk of cross contamination.

Licensure Reference Number: 175 NAC 12-006.05(21) Based on observations and interviews, the facility failed to ensure urinary catheter drainage bags were covered for one current sampled resident (Resident #2) to promote dignity. The facility census was 48 with 13 sampled residents. Findings are: Observation on 01/13/21 at 03:04 revealed Resident 2 seated in a recliner in the room with the Door open and catheter drainage bag was uncovered and visible for anyone passing by to see. Observation on 01/19/21 at 10:26 AM revealed Resident 2 laying on the bed and the catheter drainage bag hanging on the side of the bed uncovered and visible for everyone to see when the room door is open. Resident interview on 01/19/21 at 10:28 AM Resident 2 confirmed the catheter drainage bag was uncovered and had remained this way for days. Staff interview on 01/19/21 at 11:29 AM Director of Nursing and Administrator confirmed staff were to ensure that the urinary catheter drainage bag was placed in a cover to promote dignity for the resident.

Licensure Reference Number 175 NAC 12.006.09D Based on record review and interviews, the facility failed to ensure that the use of a prn (pro re nata or as needed) [MEDICAL CONDITION] (capable of affecting the mind, emotions, and behavior Medical Definition of [MEDICAL CONDITION] drug https://www.medicinenet.com) medication was reviewed by a physician within 14 days to provide a reason for continued use as a prn medication for one sampled resident (Resident 45). Facility census was 48. Sample size was 13 current residents. Finding are: Review of Resident 45's MAR (Medication Administration Record) for January of 2021 revealed an order for [REDACTED]. Review of Resident 45's current Order Summary Report verified that this medication was ordered on [DATE] with no stop date. Review of a Physician Visit/Communication Form dated 4/30/2020 showed the Order Summary Report that was seen by the physician on that date did not include the order for prn [MEDICATION NAME], and the physician signed the page with No new orders. Review of a Physician Visit/Communication Form signed on the last page with a date of 6/23/2020 did show the order for [MEDICATION NAME] was reviewed based on a note x 9 seen next to the order. This was over 2 months after the original order and did not include a reason for continued use or a stop date for this prn medication. On 1/20/21 at 2:03 PM, an interview with the facility's DON (Director of Nursing) and LPN (Licensed Practical Nurse)-A who worked in medical records and who the DON identified as assisting in reviewing medications verified that both nurses were aware of the need to review prn [MEDICAL CONDITION] medications within 14 days and to have a stop date in place if continuing therapy. They explained that the medication was ordered by Hospice and that the resident remained on Hospice care. They also explained they believed since the medication was ordered by Hospice for Resident 45 the need to review the order did not apply. Review of Hospice Progress notes with the DON did not show any evidence that Hospice had reviewed the prn use of this [MEDICAL CONDITION] medication with a physician within 14 days. On 1/20/21 at 2:37 PM, a follow up interview with LPN-A verified the [MEDICATION NAME] order was not reviewed by a physician on 4/30/2020 as the Order Summary Report was printed ahead of time on 4/7/2020 before [MEDICATION NAME] was ordered. LPN-A explained that the order was reviewed in June and acknowledged that this review was not completed within 2 weeks for prn use of a [MEDICAL CONDITION] medication and there was no stop date listed.

Licensure reference Number: 175 NAC 12-006.04D2a Based on record reviews and interview, the facility failed to ensure the Dietary Manager had the credentialing to meet the regulatory requirements for the position. This had the potential to affect all residents. Facility Census was 60. Findings are: Record review of the Dietary Manager's employee record verified the Dietary Manager didn't have the regulatory required training to meet the required credentials. Staff interview on 06/27/17 at 09:06 a.m. Dietary Manager verified not having the required credentials for the Dietary Manager Position. The Dietary Manager reported being enrolled in a food service management course that would be completed within a year. Staff interview on 07/01/19 at 11:00 a.m. Administrator verified the Dietary Manager did not have the required credentials for the Dietary Manager Position.

Licensure Reference Number 175 NAC 12-006.09D7b (3 and 4) Based on record reviews and interview, the facility failed to ensure that interventions were in place to prevent recurrent falls with injuries including a cervical fracture with ongoing pain and multiple abrasions with pain for one current sampled resident (Resident 54). The facility census was 53 with 22 current sampled residents. Findings are: Review of Resident 54's care plan, goal date 8/20/18, revealed that the resident had a history and potential for falls related to a history of self transfers and self ambulation, confusion, impaired gait and balance, incontinence, antidepressant and diuretic medications, was unaware of safety needs, weakness, difficulty in walking, refusal of cares and physical and verbal aggression and agitation at times. Further review revealed a focus area, dated 8/20/18, which stated that the resident sustained [REDACTED]. Other focus areas included that the resident had cognitive impairment related to both short term and long term memory troubles and the resident required assistance with activities of daily living including transfers and toileting. Interventions listed on 7/4/18 revealed that the resident often self transfers, attempts to self ambulate and will often transfer self to the bathroom unassisted. Review of the Progress Notes revealed the following including: - 7/24/18 at 7:20 PM The staff found the resident on the floor at the foot of the bed. The resident stated was going to the bathroom. The resident complained of neck and shoulder pain and refused to go to the hospital for evaluation. The resident was educated on the use of the call light; - 7/25/18 at 1:35 PM The resident was sent to the to physician for evaluation of severe neck and shoulder pain almost unbearable; - 8/2/18 at 11:00 AM The resident was readmitted from the hospital with a [DIAGNOSES REDACTED].; - 8/4/18 at 1:08 PM The resident transferred self back to bed after breakfast and staff gave frequent reminders to call for assistance, the resident required extensive assistance of two staff for all transfers; 6:47 PM The resident attempted to self transfer multiple times this shift; - 8/10/18 at 1:23 PM The provider changed pain medications from routine to as needed; - 8/14/18 at 11:10 AM The resident was unable to use legs to stand up correctly in sit to stand lift, full body lift used at this time; - 8/17/18 at 1:27 PM The nurse witnessed the resident slip to the floor from the bed, the resident frequently attempts self transfers, no injuries noted; - 8/19/18 at 2:58 PM The resident was observed on the floor at 1:15 PM, the resident stated tried to get into bed, did not use the call light for assistance. The resident was transported to the emergency room via ambulance for evaluation. The resident returned to the facility at 6:45 PM and was treated for [REDACTED]. - 8/20/18 at 3:00 PM The resident is very confused and has been attempting to self transfer since 2:00 PM, 9:48 PM The resident had been attempting multiple times to self transfer this shift and is very confused and does not call for help; - 8/21/18 at 3:50 AM The resident was confused and was observed attempting to get up from bed, legs hanging out over the side of the bed. Review of the MAR (Medication Administration Record), dated (MONTH) (YEAR), revealed that the resident received [MEDICATION NAME] as needed for pain related to the cervical fracture 17 times from 8/11/1- 8/20/18 for pain rated 4-7 on the 0-10 pain scale with 0 indicating no pain and 10 the worst possible pain. The resident rated pain at 4 three times, 5 seven times, 6 three times and 7 four times. Review of the facility Fall Scene Investigation Reports revealed the following including: - 7/24/18 Initial Cause (s) of the fall? The resident did not call for assistance to go to the bathroom, knocked the wheelchair over, still did not call for help and then attempted to self transfer to the bathroom. Interventions to prevent future falls and verify implementation were encourage the use of the call light, educate on the use of the call light every time staff enters room and possible placement of a fall alarm. IDT (Interdisciplinary Team) interventions added to the care plan related to the event and observe to verify implementation: 1. Place anti -tip device on the wheelchair. 2. Have therapy evaluate transfer and determine if a trapeze would be appropriate for repositioning. 3. Offer to move the bed against the wall to open up room if the residents wants to self transfer. - 8/17/18 Initial cause(s) of the fall? Bed positioning and frequent attempts to self transfer. Interventions to prevent future falls and verify implementation: Care plan update, will not position the bed with both the head and foot elevated at the same time. IDT interventions added to the care plan related to the event and observe to verify implementation: 1. Staff to monitor bed position with each encounter and reposition bed if both foot and head elevated. 2. Remove turn sheet when not in use. - 8/19/18 Initial cause(s) of fall? Attempted to self transfer. Interventions put into place to prevent future falls and verify implementation: Provider ordered transport to the hospital emergency room per ambulance for assessment. IDT interventions added to the care plan related to the event and observe to verify implementation: 1. Schedule pain medications. 2. Document pain levels two times a day and report to provider if not adequate. Review of the Non -Pressure Skin Condition Records, dated 8/23/18, revealed the following skin injuries related to the fall on 8/19/18: - Digits to the left foot have multiple abrasions in various stages of healing and pain; - Digits to the right foot have abrasions to all digits except the fifth digit. Abrasions in various stated of healing and pain; - Entire left knee is reddened, several abrasions in various shapes and sizes inside the reddened area and pain; - Entire right knee is reddened with several abrasions in various sizes and shapes throughout the reddened area and pain. Interview with the Director of Nursing on 8/23/18 at 10:35 AM confirmed that the resident had a history of [REDACTED]. Further interview confirmed that fall interventions in place were not effective to prevent self transfers and subsequent falls with injuries.

Based on observations, record reviews, and interviews; the facility failed to: Activate alarm interventions as specified in the resident's fall prevention care plan for 1 sampled closed record (Resident 17). Sample size was 16 current residents and 3 closed records. Facility census was 53. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7 Review of Resident 17's "Face Sheet" dated 11/4/11 revealed the resident was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]." Review of Resident 17's "Fall Risk Assessment" forms revealed on 1/28/12 Resident 17 was assessed to have a fall risk score of "21" with a "Total Score 10 or more= High Risk (of falling)". Review of an OT (Occupational Therapy) "Plan of Treatment" signed by the OT on 2/29/12 revealed a note related to Resident 17's "Safety- the patient demonstrates severely impaired (less than or equal to 25% intact) safety awareness and requires 85% verbal, tactile, and visual instruction/cues during functional transfers". Review of Resident 17's closed record revealed a "History and Physical" form dated 2/20/12 documenting Resident 17 was admitted to the hospital for "confusion and hypoxia" related to an assessed [DIAGNOSES REDACTED]. Further review revealed hospital "History and Physical" dated 2/29/12 which documented the resident "fell earlier today" with "complaint of right hip pain and inability to bear weight, so was taken to the emergency room ." The document recorded the resident "was found to have a right intertrochanteric femur fracture." A "Radiology Department Imaging Report" for Resident 17 dated 2/29/12 included findings of an x-ray of the right hip with an impression of the findings documented: "Acute intertrochanteric fracture of the right hip. Severe osteopenia limiting assessment of the remainder of the pelvis". Review of Resident 17's "Interdisciplinary Progress Notes" revealed an entry on 2/29/12 at 7:50 a.m. which read: "Resident transported to (hospital name) ER (emergency room ) p (after) observed on floor @ (at) 0610 (6:10 a.m.) this a.m. (morning). c/o (complains of) RLE (right lower extremity) pain, unable to assess for internal, external rotation or shortening due to increased c/o pain..." Review of Resident 17's Care Planning documents revealed a problem for "history of falling" was initiated on 10/23/11 with updated problems of: 1/25/12 "dx (diagnosis) of osteopenia; and 2/23/12 "weakness r/t (related to) hospital stay." Interventions were recorded on the care plan including: "Use of a Tab alarm while in the chair" and "Use a Tab alarm while in bed". These interventions were changed on 12/1/11 with instructions to use chair and bed sensor alarm pad" and discontinuation of the Tab alarms. Review of the facility "Accident Report" for Resident 17 revealed the following documentation: "(Resident 17)" was admitted on [DATE]" for "muscle weakness, dementia without behavioral disturbance, osteopenia, difficulty in walking and congestive heart failure. (Resident 17) was recently hospitalized on [DATE] post pneumonia with generalized weakness. Upon return, (Resident 17) was evaluated and being treated by physical therapy and occupational therapy. (Resident 17) is an assist of one with ambulation and could ambulate with staff with gait belt and hands on assist with walker. At times, resident does use his/her call light and at times (Resident 17) does independently ambulate and self transfer. The report further documented: "On February 29, 2012 (Resident 17) was attended to at 3:15 am and 5:15 am during rounds with no complaints. (Resident 17) was observed on the floor on his/her right side at 610 am. The aides called the nurse to the room. When staff asked what happened, (Resident 17) stated he/she fell out of bed. (Resident 17) was complaining of pain in his/her right hip... (Resident 17) was observed with his/her pajama bottoms being wet and the outside of his/her brief wet. The brief was dry on the inside. It was noted that the brief was almost pulled all the way up and his/her pajama bottoms were just above his/her knees. When staff went to get another brief from the bathroom, urine was noted on the bathroom floor... In conclusion, (Resident 17) did not call for assistance and tried to independently ambulate to the bathroom. Bed was in lowest position and call light was in reach. Resident was cared for less than one hour before being observed on the floor..." The report conclusion did not include any documentation pertaining to the resident's use or non-use of alarming devices or whether or not the devices were in place or working at the time of the incident. Interview with the DON (Director of Nursing) and LPN (Licensed Practical Nurse)-A, the Resident Services Coordinator on 5/21/12 at 3:20 p.m. revealed that the DON described the facility investigation into Resident 17's fall on 2/29/12. The DON stated two nurse aides attended to Resident 17 at around 5:15 a.m. and that the staff members assisted the resident to the toilet and returned the resident to bed. During the transfer, the staff disarmed the alarming devices and following the cares forgot to turn the alarm on. LPN-A and the DON verified that Resident 17's fall prevention program prior to the fall included the use of alarms. LPN-A and the DON agreed that the investigation of the fall determined the resident had independently transferred self from the bed to the bathroom and was returning to bed when the incident occurred.

Licensure Reference Number 175 NAC 12-006.09D2a 175 NAC 12-006.09D2b Based on observations, record review, and staff interviews; the facility failed to provide interventions to prevent the development of pressure sores for a resident identified at risk for the development of pressure sores, failed to provide care including treatments as ordered by the physician, and failed to provide pressure relief to promote healing of a pressure sore for 1 sampled resident (Resident 67). The facility census was 45 and the Stage 2 survey sample size was 27 residents. Findings are: Review of the "Face Sheet" revealed that Resident 67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Admission Nursing Evaluation", dated 1/13/11, revealed that the resident had no pressure ulcers, was lethargic, was confused at times, did not resist cares, and required assistance with 2 people for bed mobility, transfers, toileting, personal hygiene, and bathing. Review of the "Braden Scale - For Predicting Pressure Sore Risk", dated 1/13/11 revealed a score of "18" and on 1/20/11 a score of "14". According to the form, a score of "15-18" was mild risk and a score of "13-14" was moderate risk. Review of the "Interdisciplinary Progress Notes", dated 1/16/11, revealed that 2 areas were noted on the right buttock that were reddened area with superficial skin impairment. The right was circular with a diameter of 4 cm. (centimeters) and no bleeding. Left area measured 4.75 cm. x 4 cm. with loose skin covering the area which was reddened and irregular and with evidence of deep red areas underneath the loose impaired skin. "[MEDICATION NAME]" was applied. Review of the treatment record for January 2011 revealed an order, dated 1/16/11, to monitor pressure ulcer on left and right buttocks and apply "[MEDICATION NAME]" until resolved. Review of the "Pressure Ulcer Record", dated 1/17/11, revealed that the bath aide reported fluid filled blisters on the resident's right heel and left heel and heel floating boots were applied to the feet. Further review revealed no assessment of the blisters, including causal factors or further treatment interventions. The dietary department and the physician were notified of the blisters on 1/20/11. An assessment was completed on 1/21/11 for the left heel as follows: Stage - DTI (Deep Tissue Injury, suspected deep tissue injury, which presents as purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shoes, and the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). Size was 5 cm. X 5 cm., and depth unknown. There was no undermining or no exudate. Surrounding skin color was pink with no pain. Review of the assessment, dated 1/21/11, for the right heel revealed Stage - DTI, that was size 9 cm. X 12 cm. Depth was unknown. There was no undermining or exudate. Surrounding skin color was pink, and there was no pain. Review of the "Admission Nursing Evaluation", dated 2/2/11, revealed that the resident was readmitted to the facility after hospitalization for Pneumonia. Review of the skin condition section revealed that the resident had skin tears at the right arm, and dressings were dry and intact at both heels. Further review revealed no assessment of the heels. Review of the "Interdisciplinary Progress Notes", dated 2/2/11, revealed that the RN (Registered Nurse) would assess the heels and a small pressure area at the right buttocks. Review of the "Weekly Pressure Ulcer Record", dated 2/3/11, revealed the following for the left heel: unstageable, 3 cm. X 4 cm., no exudate, no odor, surrounding skin intact, surrounding tissue/wound edges, pink/smooth, and no pain. Review of the "Weekly Pressure Ulcer Record", dated 2/3/11, revealed the following for the right heel: unstageable, 7 cm. x 10.5 cm, depth - superficial, scant serosanguinous drainage, and no odor. Review of the current "Care Plan", goal date 5/19/11, revealed a problem pressure ulcers on both heels and history of a healed pressure ulcer on right buttock. Approaches included measure wounds weekly and document the status of the pressure areas, administer treatments as ordered by the physician, provide diet and supplements as ordered, pressure reducing devices to bed and chair. On 3/4/11, surgical consult for right heel debridement was added. Further review revealed that the use of pressure relieving boots and the therapeutic setting for the air mattress were not on the care plan to ensure the optimal therapeutic benefits of pressure relief. Review of the "Interdisciplinary Progress Notes", dated 3/4/11, by the wound consultant nurse revealed that the resident had an unstageable pressure ulcer at the right heel which encompassed the entirety of the heel. It was covered with eschar and loosened nonviable tissue. Pink granulation tissue showed through with necrotic tissue in the same area. There was a moderate amount of red and yellow serosanquinous drainage on the dressing which was changed yesterday. Further review revealed that the wound nurse suggested that the wound be surgically debrided, use dressing of "[MEDICATION NAME]" to minimize the chance of infection, and change the dressing daily to control drainage. Review of the "Treatment" sheet, dated April 2011, revealed an order dated 2/3/11 to clean eschar heels with warm water or normal saline, pat dry, apply "[MEDICATION NAME]" to areas then "Vasoline". Staff was to cover the right heel with foam dressing and change every day and as needed. The left heel was left open to air, and off loading boots were to be on at all times. Review of the "Report of Consultation", dated 3/23/11, revealed that the podiatrist debrided the right heel pressure ulcer. Observation on 4/6/11 at 3:00 PM revealed the resident seated in the wheelchair with foot rests in place, seat cushion in place, and protective boots on bilaterally. Interview with PTA (Physical Therapy Assistant) - G revealed that the left foot was healed and the nurses continued to treat the right heel. Further observation revealed that the resident had an air mattress set at "5 1/2" at normal pressure. The dial showed a rate of "1 - 10". Observation on 4/7/11 at 7:20 AM revealed the resident seated in the wheelchair in room with the right foot directly on a vinyl covered pad on the floor used as a calf support on the wheelchair. Further observation revealed that the resident moved the right foot up and rested it on a sock covered left foot. Reddish, brown malodorous drainage was noted on the sock and on the cushion. The DON (Director of Nursing) lifted the resident's right leg up for the treatment. RN (Registered Nurse) - B, set up supplies for the wound care, washed hands applied gloves, placed a towel on the floor over the vinyl cushion. RN - B proceeded to clean the wound with saline solution, patted the wound with a gauze pad, noted reddish brown colored drainage, and removed gloves. RN - B washed hands applied gloves, applied a skin prep to the surrounding skin, applied a "PolyMem" dressing, and secured the dressing with "[MEDICATION NAME]" tape. RN - B removed gloves and washed hands, returned to the resident and applied the protective boot to the right foot, removed the sock from the left foot, and noted a dry scaly area on the left heel. The DON stated that the nurses continued to use the protective boots for both feet to provide pressure relief for the heels. Interview on 4/7/11 at 1:40 PM with RN - B confirmed that the daily wound care consisted of cleaning the right heel wound with saline, applying skin prep to help the tape stay on the resident's skin, and the "PolyMem" dressing. RN - B did not mention the use of "[MEDICATION NAME]" or "Vaseline" as directed on the treatment orders. Interview on 4/7/11 at 2:00 PM with the DON confirmed that the nurses were to follow the dressing change procedure as ordered by the physician. Further interview confirmed that the resident's foot should have been positioned in a manner to provide pressure relief and comfort and to protect the pressure ulcer from direct contact with the vinyl cushion on the floor or the sock on the left foot to reduce the risk of infection.