Every finding on record at Hillcrest Health & Rehab

Licensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure all food stored in the facility's kitchen was labeled, dated, and/or sealed, ensure kitchen was maintained in a clean and sanitary manner, ensure food holding temperatures (temps) were completed prior to food service all to prevent foodborne illness. The facility failed to ensure food temperature probes were sanitized between product usage, ensure staff washed hands between glove changes, and failed to ensure tongs were stored in a manner to prevent cross contamination. This had the potential to affect 118 residents that consumed food prepared in the facility kitchen. The total facility census was 120. Findings are:A.A record review of the facility's Proper Food Storage policy dated 05/23/2017 revealed all food handlers must follow proper guidelines for food storage to ensure all products were safe and sanitary for their residents. Staff were to only use proper food storage containers, all food products must be covered, label all foods removed from their original container, and clearly label all food with: product or item name, preparation date, use by date, expiration or sell by date, and prepared by. An observation on 06/01/2026 at 7:06 AM - 8:12 AM with the Dietary Manager (DM) revealed:Superior 2 door reach-in refrigerator (fridge) contained: - 1 opened bag of yellow shredded cheese not dated. - 1 opened pack of white cheese slices wrapped with plastic wrap not dated. - 1 open bag of white meat chucks not sealed, labeled, or dated.Walk-in fridge contained: - 1 bag white shredded cheese partially wrapped in plastic wrap, not dated. - 1 block of butter that was open and exposed, not sealed or dated. - 1 clear plastic container with a green lid that was not fastened on the container and contained red chunks was not labeled, dated or sealed.Walk-in freezer contained: - 1 opened but tied shut bag of green beans not dated. - 1 opened bag of French fries wrapped in plastic wrap not dated. - 1 large steam pan full of an unknown substance covered with aluminum foil, not labeled or dated. - 1 open bag Grilled Chicken Breast Filets, not sealed or dated. - 1 open bag Country Fried Beef Fritters not sealed or dated. - 1 open box of hamburger patties not sealed or dated. In an interview on 06/01/2026 at 7:06 AM - 8:12 AM, the DM confirmed throughout the observation they saw the above items and confirmed the items were not labeled, dated and/or sealed and should have been. B.A record review of the facility's Culinary Cleaning Policy dated 12/05/2017 revealed the equipment, surfaces, and floors in the kitchen would be thoroughly cleaned and sanitized throughout the day and at closing. An observation on 06/01/2026 at 7:06 AM - 8:12 AM with the DM revealed: - [NAME] and brown food splatters and debris on the [NAME] Mixer. - [NAME] and brown food splatters on the walk-in freezer wall behind the [NAME] mixer. - Food debris and splatters throughout the kitchen floors. - Food splatters and debris throughout the exterior front of the Superior reach-in fridge. - [NAME] food splatters on the exterior front of the ice machine. - The Southbend range front exterior contained food splatters and debris, and the handles were sticky to the touch. - The bottom shelf of the preparation table to the right of the Southbend range contained food debris. - There was food debris and splatters on the shelf below the steam table. - There was pipe insulation and food debris on the floor below the clean side of the dish machine table. - The walk-in fridge floor contained food debris and splatters throughout. An observation on 06/03/2026 at 7:51 AM revealed: - [NAME] and brown food splatters and debris on the [NAME] Mixer. - [NAME] and brown food splatters on the walk-in freezer wall behind the [NAME] mixer. - Food debris and splatters throughout the kitchen floors. - Food splatters and debris throughout the exterior front of the Superior reach-in fridge. - The Southbend range front exterior contained food splatters and debris, and the handles were sticky to the touch. - The bottom shelf of the preparation table to the right of the Southbend range contained food debris. - There was food debris and splatters on the shelf below the steam table. An observation on 06/03/2026 at 12:01 PM revealed food splatters on the front of the Magnolia Circle kitchen oven and cabinets below the steam table. In an interview on 06/01/2026 at 7:06 AM - 8:12 AM, the DM confirmed throughout the observation they saw the above items and confirmed the items were not clean and should have been. In an interview on 06/03/2026 at 12:35 PM, the DM confirmed the Magnolia Circle oven and cabinets below the steam table were not clean and should have been. C.A record review of the Food Temperatures policy dated 01/01/2026 revealed food temps would be taken and recorded daily before service of meals. Foods would be held at temps of 41 degrees Fahrenheit (F) or below for cold foods and above 140 degrees F for hot foods. A record review of the Week At A Glance menu for lunch on 06/03/2026 was spaghetti and meatballs, Italian blended vegetables, garlic bread, fruit crisp, and a beverage. A record review of the Culinary Temp Logs Main Kitchen sheets dated 05/01/2026 revealed 82 of 93 meals did not have cold food holding temps and the lowest hot food temp was 163 degrees F. The sheets only contained 1 column for cold foods for each meal, 1 column for breakfast hot foods, 1 column for lunch protein and 1 column for lunch starch, 1 column for dinner protein and 1 column for dinner starch. The sheets only contained food holding temps columns, there were no columns to document final cooking temps or temps of mechanically prepared foods (foods placed in a blender to make the consistency easier to swallow). A record review of the Magnolia Temp Logs Terrace sheets dated May 2026 revealed 41 of 93 meals did not have cold food holding temps. 15 meals did not have temps recorded. The sheets only contained 1 column for cold foods for each meal, 1 column for breakfast hot foods, 1 column for lunch protein and 1 column for lunch starch, 1 column for dinner protein and 1 column for dinner starch. A record review of the Magnolia Temp Logs Circle sheets dated May 2026 revealed 58 of 93 meals did not have cold food holding temps. 16 meals did not have temps recorded. The sheets only contained 1 column for cold foods for each meal, 1 column for breakfast hot foods, 1 column for lunch protein and 1 column for lunch starch, 1 column for dinner protein and 1 column for dinner starch. An observation on 06/03/2026 at 9:42 AM - 11:27 AM revealed the DM recorded final cooking temperature on the Food Holding Temps column of the Culinary Temp Logs Main Kitchen sheet dated 05/01/2026. An observation on 06/03/2026 at 9:42 AM - 11:27 AM did not reveal holding temps of any of the foods on the steam table were checked prior to plating the food. An observation on 06/03/2026 at 12:10 PM of the Magnolia Terrace kitchen did not reveal Culinary Server (CS)-Q checked the temps of all protein and starch steam pans before serving the food. An observation on 06/03/2026 at 12:20 PM of the Magnolia Circle kitchen did not reveal CS-R checked the temps of all protein and starch steam pans before serving the food, just the sauce and blended vegetables. In an interview on 06/03/2026 at 12:20 PM, CS-R confirmed CS-R did not check the temp of all steam pans of protein and starch foods because they were out of spots on the log sheets. In an interview on 06/03/2026 at 1:44 PM, the DM confirmed that staff should have checked the holding temps of the food prior to serving the food. D.A record review of the United States Food and Drug Administration's 2022 Food Code dated 01/18/2023 revealed equipment food-contact surfaces and utensils shall be cleaned before using or storing a food temperature measuring device and at any time during the operation when contamination may have occurred. A record review of the facility's Infection Prevention And Control Program dated 01/01/2026 revealed staff should perform hand hygiene (cleaning) before donning (putting on) and after removing gloves. An observation on 06/03/2026 at 12:10 PM of Magnolia Terrace kitchen revealed CS-Q placed a food thermometer (temp probe) in the pasta without cleaning the probe, grabbed another temp probe out of the drawer and did not clean it, just placed it in meatballs, it didn't work, so CS-Q took the temp probe from the pasta, wiped it with a dry napkin and put it in the meatballs. CS-Q wiped the condensation off the top of the steam pan cover that had other steam pans on top of it with the napkin that was used to wipe off the temp probe after removing it from the pasta. CS-Q used that same contaminated wet napkin used to wipe the condensation of the steam pan lid to wipe the temp probe and placed it in the apple crisp. An observation on 06/03/2026 at 12:20 PM of the Magnolia Circle kitchen revealed CS-R placed a temp probe in the apple crisp to check the holding temp. CS-R removed the temp probe from the apple crisp, ran the probe under water and wiped the probe with a wash cloth that was laying in the sink, and put it in the spaghetti sauce. CS-R then removed gloves and re-gloved without handwashing, then removed the temp probe from the spaghetti sauce, rinsed the temp probe with water and used same contaminated washcloth from the sink to temp the blended vegetables. CS-R removed the temp probe from the blended vegetables, rinsed it with water and wiped probe with same contaminated washcloth, put the protector on it, and placed it in the drawer. CS-R then removed gloves and applied new gloves without handwashing prior to plating food. In an interview on 06/03/2026 at 12:35 PM, the DM confirmed that staff should have sanitized the temp probe before placing it in the food product and between placing it in different foods to prevent cross contamination. The staff should have washed their hands between glove changes. E.A record review of the United States Food and Drug Administration's 2022 Food Code dated 01/18/2023 revealed equipment food-contact surfaces and utensils shall be cleaned at any time during the operation when contamination may have occurred. An observation on 06/03/2026 at 10:11 AM - 11:27 AM revealed Cook-S placed 2 sets of tongs (hinged utensil used to handle and serve food) on the sticky, contaminated, range handle in preparation for lunch service. At 11:21 AM Cook-S put on gloves, got 2 pieces of bread and put cheese between them and placed in a small frying pan on the stovetop, Cook-S removed the gloves, picked up tongs from the range handle flipped the grilled cheese sandwich, and placed the tongs back on the range handle, allowing the food contact areas of the tongs to touch the contaminated range exterior and range handle. Then Cook-S removed the tongs from the range handle, again allowing the food contact surface to contact the range exterior and handle, and took the grilled cheese from frying pan and placed it on a plate. Cook-S then returned the tongs to the range handle. In an interview on 06/03/2026 at 12:35 PM, the DM confirmed that staff should not have hung the tongs on the range handle or allowed the food contact surfaces to get contaminated by the range exterior or handle before handling the food product with the tongs.

Licensure Reference Number 175 NAC 12-006.07(C) Based on record review and staff interviews; the facility Quality Assessment Performance Improvement Plan (QAPI) failed to identify issues relevant to F 553, F 578, F 580, F 628, F 641, F 656, F 684, F689, F692, F 695, F 698, F 757, F 812, F 842, F 880 and implement plans of action to identify and correct the deficient practice. This deficient practice had the potential to affect all residents who reside in the facility. The facility sample size was 51. The facility staff identified a census of 120. Findings are:Record review of the facility QAPI program policies dated 01/01/2026 revealed the following information: Policy: The purpose of the Quality Assurance and Performance Improvement (QAPI)program is to ensure person-centered care. The QAPI program will evaluate,maintain, and improve the quality of services provided to guests at HillcrestHealth and Rehab. The QAPI program is intended to: 1) monitor critical aspectsof service line operations, 2) provide data on feedback on performancecompared to threshold, 3) continually improve quality of care and quality of life tocomply with regulatory requirements and customer satisfaction, 4) use resourcesmore efficiently, 5) support the integration of services within Hillcrest HealthSystems, 6) meet Five Star criteria, and 7) provide additional areas of educationfor team members.Procedure:1. Hillcrest Health and Rehab (HCF) will maintain a QAPI Committee for the purpose ofidentifying and addressing quality of care and quality of life issues. The service line mustmaintain a QAPI Committee (F Tag 520) consisting of 1) Administrator, 2) Director ofClinical Services 3) Director-Quality & Education, 4) a physician designated by theservice line, and 5) at least three (3) other service line team members.2. QAPI Committee roles and responsibilities will include implement data collection(dashboard), analyze findings, identify areas of opportunity, and implement systemicsolutions.3. The HCF QAPI Committee will: 1) meet quarterly between the 16th and end of month inJanuary, April, July, and October, and as needed, to identify issues with respect to whichQAPI activities are necessary, and 2) develop and implement appropriate plans of actionto correct identified quality concerns. The Administrator is responsible to plan the specificQAPI Committee calendar and provide to the Director-Quality & Education by November30th for the next calendar year. Study periods are January-March reported in April; April-May reported in June; June-September reported in October; and October-Decemberreported in January.4. The QAPI Committee will maintain a) agendas to indicate date of meeting, general topicsto be covered, discuss last quarter's results of plans of action, and b) minutes that showgeneral topics covered, areas of opportunity identified, plans of action, and teammembers who attended.5. The QAPI committee will identify quality concerns and develop and implement plans ofaction to correct these quality concerns, including monitoring the effect of implementedchanges and making needed revisions to the action plans.6. The QAPI Committee will identify important processes and functions that affect healthcare outcomes, efficient use of company resources, and customer perception of care.The focus will be on high risk, high volume, and/or problem-prone activities.7. Hillcrest Health and Rehab team members will be expected to demonstrate proficiency in the use of root cause analysis. Systemic actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement.8. Data collection will be used to design and assess new processes, performance, measure the level of performance and stability of existing processes, and identify areas of improvement in existing processes and if the results of changes improve processes.9. Each QAPI committee member is responsible to report on their data collection findings. Data collection will be maintained by the administrator or designee.10. Areas identified on the dashboard as red require a written plan of action to the [NAME] President -Facility-based Operations and Director-Quality & Education within 10 working days.11. The administrator or designee will record results quarterly and as necessary. In addition, the administrator or designee will provide quarterly: minutes, dashboard, and plans of action to Director-Quality and Education. Results will be reported quarterly to the executive team by the Director-Quality and Education. This dashboard report will include:-Identifying problems-Recommending appropriate action-Implementing recommendations-Results12. Hillcrest Health and Rehab will work toward the goal of increased desirable outcomes, and ensure compliance with the requirements of all federal, state, and accrediting agencies, as outlined in the QAPI master program. Interview on 06/04/2026 at 12:01 PM with the facility Administrator confirmed that the following citations had not been identified by the QAPI process and no plans of actions were implemented to identify and correct the deficient practices for the following Federal deficiencies identified during the annual survey: F 578, F 580, F 605, F 628, F 641, F 656, F 684, F689, F 690, F692, F 695, F 698, F 757, F 812, F 842, F 880: - F 553: Failed to ensure residents / representatives were invited to care plan meetings. - F578: Failed to ensure right to formulate advanced directive.- F 580: Failed to notify the practitioner of changes in condition. - F 628: Failed to complete recapitulation of stay.- F 641: Failed to ensure accuracy of Minimum Data Set.- F 656: Failed to develop a Comprehensive Care Plan related to specific resident identified issues.- F 684: Failed to follow fluid restriction orders. - F 689: Failed to evaluate equipment for safety.- F 695: failed to have valid orders for respiratory services.- F 698: Failed to coordinate services for Dialysis.- F 757: Failed to ensure medications were provided within parameters.- F 812: Failed to ensure foods were labeled, holding temperatures of food were maintained, equipment was maintained and stored in a sanitary manner and the kitchen was maintained in a clean and sanitary manner.- F 842: Failed to ensure documentation was accurate.- F 880: Failed to ensure gloves were applied prior to giving injectable medications, equipment was not in contact with the floor and hand hygiene and gloving were performed between residents during medication administration.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on interview and record review the facility failed to notify the provider of blood sugars outside of parameters for 1 resident (Resident 151), medications provided outside of parameters for 3 residents (Resident 2, 146 and 151), failed to notify provider of a change in an Abnormal Involuntary Movement Scale (AIMS, a clinical tool used to detect and measure involuntary muscle movements, primarily Tardive Dyskinesia in patients taking neuroleptic or antipsychotic medications) score for 1 (Resident 30) and no Continuous Positive Airway Pressure (CPAP, a device primarily used to treat obstructive sleep apnea) available for 1 resident (Resident 32) of 6 sampled residents. The facility identified a census of 120. Findings are: A. Record Review of the facility's Medication Administration Policy dated 1/1/2023 revealed the following: Policy: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 1. The attending Physician is notified promptly of any significant error or adverse consequence. The physicians' orders are implemented as ordered for monitoring. 2. The following information is documented in the medication error report and in the resident's clinical record: a. Factual description of the error or adverse consequence. b. Name of physician and time notified. c. Physician's subsequent orders. d. Resident's condition for 24 to 72 hours or as directed. Record Review of the facility's Unnecessary Medication Policy with a revision date of 11/18/2025 revealed the following: Policy: Residents are not prescribed medications unless they are necessary to treat a specific condition, as diagnosed and documented in the medical record, and the medication is beneficial to the resident, as evidenced by monitoring and documentation of the resident's response to the medication(s). Policy and Guidelines: 1. Each resident's medication regimen must be free from unnecessary medications. Criteria may include: excessive dose, excessive duration, inadequate monitoring, inadequate indication for use, adverse consequences, duplicate therapy. 2. The indications for initiating, withdrawing or withholding medication(s), as well as the use of nonpharmacological approaches, shall be determined by the provider along with the interdisciplinary team, and resident/family. 5. Resident who use psychotropic medications will be monitored for both the effectiveness of the medication's as well as any possible adverse consequences from medications. 7. Resident who are prescribed antipsychotic medication should have an Abnormal Involuntary Movement Scale (AIMS) or similar test performed on admission, annually and with significant change in condition, medication change or as deemed necessary. 9. The resident response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. Record Review of the facility's undated Change in Condition or Status of Resident revealed the following: Policy: The facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Responsibility of: Nurse, Clinical Care Coordinator, Interdisciplinary Team' Procedure: 1. The Nurse will notify the guest's Attending Physician or On-Call Physician when there has been: An Accident or incident involving the resident; A discovery of injuries of an unknown source; A reaction to medication; A significant change in the resident's physical/emotional/mental condition; A need to alter the resident's medical treatment significantly; A need to transfer the resident to a hospital/treatment center; A discharge without proper medical authority; and/or Instructions to notify the Physician of changes in the resident's condition 7. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. B. Record Review of Resident 151's Order Summary Report dated 06/02/2026 revealed an order for the following: Blood Glucose Monitoring three times a day, notify MD (Medical Director) of BS (Blood Sugars) less than 70 or greater than 400. Record Review of Resident 151's Medication Administration Record (MAR) dated 11/2025 revealed that the following blood sugars were obtained: -11/21/2025 blood sugar at night was 452 -11/23/2025 blood sugar at noon was 405 -11/23/2025 blood sugar at night was 481 -11/25/2025 blood sugar at noon was 426 -11/25/2025 blood sugar at night was 483 -11/28/2025 blood sugar at dinner was 528 -11/28/2025 blood sugar at night was 491 Record review of Resident 151's medical records revealed no evidence of their provider being notified of their blood sugars that were greater than 400. In an interview on 06/03/2026 at 1:06 PM, Director of Nursing (DON) confirmed the listed blood sugars. The DON also confirmed that there was no evidence that the provider was notified of the blood sugars. C. Record Review of Resident 151's Order Summary Report dated 6/2/2026 revealed the following order: Carvedilol Tablet 3.125 MG, give 1 tablet by mouth two times a day for hypertension. Hold for systolic blood pressure less than 90 and pulse less than 60. Take with Meals. Record Review of Resident 151's Medication Administration Record (MAR) dated 11/2025 and 12/2025 revealed the Carvedilol medication was administered on the following dates despite the corresponding pulses: -11/24/2025 pulse of 59 -11/28/2025 pulse of 56 -11/30/2025 pulse of 57 -12/07/2025 pulse of 53 -12/19/2025 pulse of 55 In an interview on 06/03/2026 at 1:06 PM, the DON confirmed that Resident 151's Carvedilol was administered on the listed dates with the listed pulses and should not have been. In an interview on 06/04/2026 at 6:37 AM, DON confirmed that administering medication outside of parameters would be considered a medication error. DON confirmed that the provider should have been notified of the medication administered outside of parameters for Resident 151 and there was no evidence that provider was notified. D. Record Review of Resident 2's Order Summary Report dated 06/04/2026 revealed the following order: Metoprolol Succinate ER (extended release) tablet, Extended Release 24 Hour, 25 milligram (MG). Give 0.5 tablet by mouth one time a day for hypertension. Hold for systolic blood pressure less than 90 or pulse less than 60. Record review of Resident 2's MAR dated 5/2026 revealed that the medication was administered on the following dates despite the corresponding blood pressure/pulse: -05/18/2026 blood pressure was 104/60 -05/19/2026 blood pressure was 102/60 -05/22/2026 pulse was 57 -05/25/2025 blood pressure was 100/58 -05/28/2026 blood pressure was 102/62 In an interview on 06/04/2026 at 7:57 AM, DON confirmed that Resident 2's medication was administered on the listed dates with the listed blood pressures and pulse and should not have been. DON further confirmed that the provider should have been notified of the medication being administered outside of parameters for Resident 2 and there was no evidence that the provider was notified. E. Record Review of Resident 146's Order Summary Report dated 6/2/2026 revealed the following order: Hydrochlorothiazide tablet 25 MG, give 12.5 mg by mouth one time a day for hypertension. Hold if systolic blood pressure is less than 110. Record Review of Resident 146's Medication Administration Record (MAR) dated 02/2026 and 03/2026 revealed the hydrochlorothiazide was administered on the following dates despite the corresponding blood pressure: -02/03/2026 blood pressure was 109/70 -02/04/2026 blood pressure was 105/72 -02/12/2026 blood pressure was 108/69 -02/17/2026 blood pressure was 104/70 -03/02/2026 blood pressure was 106/70 In an interview on 06/03/2026 at 1:20 PM, DON confirmed that Resident 146's medication was provided outside of parameters on the listed dates and should not have been. DON further confirmed that the provider should have been notified that the medication was provided outside of parameters for Resident 146 and there was no evidence that the provider was notified. F. Record Review of Resident 30's AIMS Evaluation dated 05/28/2025 revealed a score of 6. Record Review of Resident 30's AIMS Evaluation dated 05/20/2026 revealed a score of 9. Scoring: 1. TOTAL SCORE - Sum of items 1-7. The higher the score (0-28), the greater the impact of observed movements on resident. Record Review of Resident 30's Progress Notes did not reveal that the provider was notified of an AIMS score increase. Record Review of Resident 30's 60 Day LTC (long term care) Visit note date 02/18/2026 did not reveal any information regarding the increased AIMS score. In an interview on 06/04/2026 at 9:52 AM, DON confirmed that provider was not notified of an increased AIMS score for Resident 30. DON confirmed that the provider reviews every 60 days and there is no mention of an increase in AIMS scoring in the provider visit note. In an interview on 06/04/2026 at 12:05 PM Clinical Care Coordinator (CCC)-G confirmed that CCC-G completed the AIMS assessment on Resident 30. CCC-G confirmed that there was no documentation in Resident 30's electronic health record regarding provider notification. E. Record review of Resident 32's admission Record (AR) revealed the facility admitted the resident on 05/07/2026. Further review of the AR identified Resident 32 had a diagnosis of obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep because the throat muscles relax, causing the airway to collapse and block airflow). Record review of Resident 32's Medication Review Report which showed active orders as of 05/07/2026 identified an order for a continuous positive airway pressure device (CPAP, a small bedside device that pumps a steady stream of gentle, pressurized air through a mask which keeps the throat open preventing blockages) with settings from home dated 05/07/2026. Record Review of Resident 32's Comprehensive Care Plan (CCP, 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) revealed an intervention to encourage the resident's use of CPAP dated 05/20/2026. Record review of Resident 32's Treatment Administration Record (TAR) dated May 2026 revealed the CPAP was documented as not administered on 05/09/2026, 05/13/2026, and 05/20/2026. Further review of the TAR identified the CPAP order was discontinued on 05/22/2026. Record review of Resident 32's Progress Notes (PN) dated 05/07/2026 through 05/22/2026 identified there was no CPAP equipment available for use on the following dates: 05/09/2026, 05/13/2026, and 05/21/2026. Record review of Resident 32's Electronic Health Record (EHR) which included progress notes and scanned documents showed a lack of evidence the provider was notified that the Resident did not have CPAP equipment or actions taken to obtain the CPAP equipment. During an interview on 06/04/2026 at 7:04 AM with Clinical Care Coordinator (CCC)-B present, CCC-H confirmed Resident 32 never had a CPAP machine available. CCC-H further confirmed there was no evidence Resident 32's representative or provider were notified of the unavailability of the CPAP machine and reported the representative and provider should have been notified.

Licensure Reference Number 175 NAC 12-006.05(E)Licensure Reference Number 175 NAC 12-006.09(F) Based on interview and record review, the facility failed to ensure comprehensive care plan (documents that outlined a resident's medical, emotional, and daily living needs) meetings and invitations to the residents and families were completed quarterly for 3 (Residents 14, 9, and 130) of 6 sampled residents. The facility census was 120. Findings are:A record review of the facility's Care Planning policy dated 01/2026 revealed the Interdisciplinary Team (a group of professionals from different fields to achieve a common goal) was responsible for the review and updating the care plan at least quarterly. The resident had the right to participate in the planning process and identify individuals to be included. A record review of the Medicare.gov's undated What's a nursing home care plan? revealed that a health assessment must be completed at least every 90 days, or more often if a resident's needs change, and changes made to the care plan as needed. The resident, the resident's family, or someone acting on behalf of the resident had the right to take part in planning the care with the nursing home staff. https://www.medicare.gov/providers-services/original-medicare/nursing-homes/care-plan A.A record review of Resident 14's Clinical Census dated 06/04/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 14's Medical Diagnosis dated 06/04/2026 reveled the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus (uncontrolled blood sugars), Chronic Diastolic (Congestive) Heart Failure, and Post-Traumatic Stress Disorder (PTSD). A record review of Resident 14's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 03/13/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to understand). A record review of Resident 14's Progress Notes dated of 06/02/2026 revealed the last care plan meeting the resident had was on 04/24/2025. The progress notes did not reveal a meeting, resident, or family invitations since that date. A record review of Resident 14's Clinical - Assessment list dated 06/02/2026 did not reveal that the facility had a care plan meeting for the resident or that the resident or family was invited to a care plan meeting. A record review of Resident 14's Client Uploaded Files list dated 06/02/2026 did not reveal that the facility had a care plan meeting for the resident or that the resident or family was invited to a care plan meeting. In an interview on 06/01/2026 at 9:17 AM, Resident 14 confirmed the resident had not been invited to a care plan meeting and was not sure if the resident's family had been. In an interview on 06/02/2026 at 2:17 PM, the facility's Administrator confirmed the facility was supposed to be doing care plan meetings every quarter (3 months) and if the resident had a significant change in condition, and those meeting would be documented in progress notes. The facility was supposed to send invitations verbally to the residents and by phone or email to the resident's family and that would be documented in the resident's progress notes. The administrator confirmed that the facility had not conducted a care plan meeting with, or invited Resident 14 to a care plan meeting since 04/24/2025. B.A record review of Resident 130's Clinical Census dated 06/04/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 130's Medical Diagnosis dated 06/04/2026 reveled the resident had diagnoses of Spinal Stenosis (narrowing of spaces within the spine), Essential Hypertension (high blood pressure), Depression, and Anxiety. A record review of Resident 130's MDS dated [DATE] revealed the resident had a BIMS of 12 which indicated the resident was moderately cognitively impaired (confused). A record review of Resident 130's Progress Notes dated of 06/02/2026 revealed the last care plan meeting the resident had was on 06/25/2025. The progress notes did not reveal a meeting, resident, or family invitations since that date. A record review of Resident 130's Clinical - Assessment list dated 06/02/2026 did not reveal that the facility had a care plan meeting for the resident or that the resident or family was invited to a care plan meeting. A record review of Resident 130's Client Uploaded Files list dated 06/02/2026 did not reveal that the facility had a care plan meeting for the resident or that the resident or family was invited to a care plan meeting. In an interview on 06/01/2026 at 12:23 PM, Resident 130 confirmed the resident had never been invited to a care plan meeting. In an interview on 06/02/2026 at 2:17 PM, the facility's Administrator confirmed the facility was supposed to be doing care plan meetings every quarter and if the resident had a significant change in condition, and those meeting would be documented in progress notes. The facility was supposed to send invitations verbally to the residents and by phone or email to the resident's family and that would be documented in the resident's progress notes. The administrator confirmed that the facility had not conducted a care plan meeting with, or invited Resident 130 to a care plan meeting since 06/25/2025. C.A record review of Resident 9's Clinical Census dated 06/04/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 9's Medical Diagnosis dated 06/04/2026 reveled the resident had diagnoses of Chronic Kidney Disease, Type 2 Diabetes Mellitus (uncontrolled blood sugars), Chronic Diastolic (Congestive) Heart Failure, and Need For Personal Care. A record review of Resident 9's MDS dated [DATE] revealed the resident had a BIMS score of 8 which indicated the resident was moderately cognitively impaired (confused). A record review of Resident 9's Progress Notes dated of 06/02/2026 revealed the last care plan meeting the resident had was on 05/28/2025. The progress notes did not reveal a meeting, resident, or family invitations since that date. A record review of Resident 9's Clinical - Assessment list dated 06/02/2026 did not reveal that the facility had a care plan meeting for the resident or that the resident or family was invited to a care plan meeting. A record review of Resident 9's Client Uploaded Files list dated 06/02/2026 did not reveal that the facility had a care plan meeting for the resident or that the resident or family was invited to a care plan meeting. In an interview on 06/01/2026 at 1:50 PM, Resident 9 confirmed the resident had not been invited to a care plan meeting. In an interview on 06/02/2026 at 2:17 PM, the facility's Administrator confirmed the facility was supposed to be doing care plan meetings every quarter and if the resident had a significant change in condition, and those meeting would be documented in progress notes. The facility was supposed to send invitations verbally to the residents and by phone or email to the resident's family and that would be documented in the resident's progress notes. The administrator confirmed that the facility had not conducted a care plan meeting with, or invited Resident 9 to a care plan meeting since 05/28/2025.

Based on interview and record review the facility staff failed to obtain a signed code status prior to changing the code status in the electronic health record for 1 (Resident 16) of 32 sampled residents. The facility identified a census of 120. Findings are:A.Record Review of the facility's undated policy titled Cardiopulmonary Resuscitation Directive revealed the following: Policy:Patients admitted to Hillcrest Care & Rehabilitation Center shall indicate in writing their preference regarding resuscitation. The facility will follow the pre-admission advance directive of the resident. The explanation of cardiopulmonary resuscitation is:Responsibility of: Nurse manager, medical recordsSupplies Needed: CPR/No CPR formProcedure: As part of the admission process, the admitting personnel will explain the facility's CPR/no CPR procedure. Once the patient/responsible party understands this process, they will be offered an opportunity to sign CPR/No CPR form. Any discussion with patient/responsible party, in regard to the patient's advance directive will be documented as needed. The admitting personnel will then copy the signed directive; sending one copy to the patient's physician for signature. Admitting personnel will also obtain a copy of any other advanced directive the patient has executed (i.e. living will, etc.) to be kept in the EHR as available. After the physician has signed and returned the form to the facility, the updated copy will be placed in the resident's EHR. If patient denies CPR: Choosing No CPR does not mean, Do Not Treat. The nursing team will notify the attending provider of ongoing illnesses, and the residents will receive treatment as prescribed. B.Record Review of Resident 16's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated [DATE] revealed the facility staff assessed the following about the resident:- admitted on [DATE]- Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 15 indicates a person is cognitively intact. Record Review of Resident 16's signed CPR/NO CPR dated [DATE] revealed the most recent documentation acknowledged by Resident 16 was for cardiopulmonary resuscitation (CPR). Record Review of Resident 16's Order Summary dated [DATE] revealed that Resident 16 had an order for DNR (Do Not Resuscitate). Record Review of Resident 16's Electronic Health Record (EHR) dated [DATE] revealed that Resident 16 was a do not resuscitate (DNR). In an interview on [DATE] at 9:25 AM, Resident 16 confirmed that Resident 16 was a full code. In an interview on [DATE] at 9:45 AM, Clinical Care Coordinator (CCC)-B confirmed that CCC-B changed Resident 16's code status to DNR. CCC-B confirmed that Resident 16 is a full code (wants the use of CPR).

Based on record review and interview, the facility failed to complete a recapitulation of stay (the clinical story of a person's time in a care facility) for 1 (Resident 148) of 2 sampled residents. The facility staff identified a census of 120.Findings are:Record review of Resident 148's admission Record (AR) revealed the facility admitted the resident on 03/20/2026. Further review of the admission record identified Resident 148 had diagnoses of displace trimalleolar fracture of the right lower leg (a fracture of the ankle joint in three different places where the broken bones had shifted out of normal position), and foot drop of the left foot (inability to lift the front part of the foot due to weakness or paralysis).Record review of Resident 148's Clinical Census identified the facility discharged Resident 148 on 04/16/2026.Record review of Resident 148's Electronic Health Record (EHR) which included progress notes, assessments, and scanned documents revealed a lack of evidence to show a recapitulation of the resident's stay was completed.During an interview on 06/04/2026 at 12:25 PM, the Director of Nursing reported a recapitulation of stay was not completed for Resident 148 because the social services department had not initiated the document in the charting system. The DON further confirmed a recapitulation of stay should have been completed.

Licensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview, the facility failed to accurately code the 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) for 2 (Resident 32 and Resident 70) of 46 sampled residents. The facility staff identified a census of 120.Findings are:A. Record review of Resident 32's admission Record (AR) revealed the facility admitted the resident on 05/07/2026. Further review of the AR identified Resident 32 had a diagnosis of obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep because the throat muscles relax, causing the airway to collapse and block airflow). Record review of Resident 32's Treatment Administration Record (TAR) for 05/07/2026 through 05/21/2026 revealed the resident had an order for a Continuous Positive Airway Pressure (CPAP, a device primarily used to treat obstructive sleep apnea) and the following was documented: -The CPAP was documented as not administered on 05/09/2026, 05/13/2026, and 05/20/2026. -The CPAP was documented as administered on all remaining days from 05/07/2026 through 05/21/2026. Record review of Resident 32's Progress Notes (PN) dated 05/07/2026 through 05/22/2026 identified there was no CPAP equipment available for use on the following dates: 05/09/2026, 05/13/2026, and 05/21/2026. Record review of Resident 32's admission MDS dated [DATE] revealed the facility identified the resident received a non-invasive mechanical ventilator during the assessment review period. During an interview on 06/04/2026 at 7:04 AM with Clinical Care Coordinator (CCC)-B present, CCC-H confirmed Resident 32 never had a CPAP machine available. CCC-H further confirmed the entries on the TAR on dates the CPAP was marked as administered was not accurate. During an interview on 06/04/2026 at 7:21 AM, MDS Coordinator (MDSC)-P reported the facility had retained services from an MDS consultant and the MDS consultant had completed Resident 32's MDS remotely. MDSC-P confirmed Resident 32's MDS included a non-invasive mechanical ventilator. MDSC-P further confirmed the MDS was coded incorrectly as the resident did not ever have a CPAP machine available for use in the assessment review period. During an interview on 06/04/2026 at 11:32 AM, the Director of Clinical Services (DCS)-E reported the facility did not have a policy regarding MDS accuracy, they followed the RAI manual. B. Record review of Resident 70's AR revealed the facility admitted the resident on 04/20/2026. Further review of the AR identified the resident had diagnoses of dysphagia (difficulty swallowing) following cerebral infarction (stroke). Record review of Resident 70's Order Summary Report revealed an order for 240 milliliters (mL) Osmolite 1.5 (type of tube feeding formula) through the feeding tube four times daily, with a start date of 04/20/2026. Record review of Resident 70's oral intakes beginning on their date of admission, revealed no oral intakes recorded until 05/11/2026. Record review of Resident 70's admission MDS dated [DATE] revealed the facility evaluated that Resident 70 received 25 percent (%) or less of total calories through parenteral (nutrition delivered directly to the bloodstream) or tube feeding while a resident. Further review of the MDS identified Resident 70 received 501 mL per day or less of daily average fluid intake by intravenous (IV) administration or tube feeding. During an interview on 06/04/2026 at 11:32 AM, the Director of Clinical Services (DCS)-E reported the facility did not have a policy regarding MDS accuracy, they followed the RAI manual. During an interview on 06/04/2026 at 12:58 PM, the Director of Nursing (DON) confirmed Resident 70 received no oral intake until 04/29/2026. The DON further confirmed the resident received all nutrition and hydration through tube feeding during the MDS assessment review period. The DON confirmed the admission MDS was coded inaccurately.

Licensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to develop a Comprehensive Care Plan (CCP, 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) for 2 ( Resident 12, related to seizures, and did not develop a CCP for identified care areas for Resident 11) of 51 sampled residents reviewed for CCP's. The facility census was 120. Findings are: A. Record review of a facility policy entitled Care Planning effective 01/2026 revealed the following information: Policy: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents' medical, nursing, mental and psychological needs is developed for each resident. 4. The comprehensive person-centered care plan will: a. Include measurable objectives and time frames. b. Describe services that are to be provided to attain or maintain the residents highest practicable physical, mental and psychosocial wellbeing. g. Incorporate risk factors associated with identified problems. Risk factors are determined by the resident assessment. j. Recognize currently accepted standards of practice for problem areas and conditions. 5. Areas of concern that are identified during the residents assessment are evaluated using specific assessment tools before interventions are added to the care plan. 6. Care plan interventions are developed that are clinically relevant and are meaningful to the resident. 8. Assessments of residents is ongoing and care plans are revised as information about the resident and the resident condition change. B. Record review of Resident 12's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 04/06/2026 revealed an admission date of 6/16/25 and a diagnosis of seizures. The MDS identified that Resident 12 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 6. The MDS identified that a score of 0-7 indicated severe cognitive impairment. The MDS identified that Resident 12 used an anticonvulsant drug daily with indication for use present. Record review of Resident 12's Physician Orders revealed an order dated 04/03/2026 for levetiracetam [an anti-seizure medicine] tablet 500 milligrams [mg], 1 tablet by mouth twice per day for seizures. Record review of Resident 12's Medication Administration Record dated May 2026 and June 2026 revealed that Resident 12 did receive levetiracetam [an anti-seizure medicine] tablet 500 mg, 1 tablet by mouth twice per day for seizures. Record review of Resident 12's Progress Notes dated 03/31/2026 revealed that Resident 12 had a seizure that lasted 5 minutes with tremors, twitching and shewing motions noted. The primary care provider responded with the following recommendation; send to ER [emergency room] by 911. Record review of Resident 12's undated CCP did not identify any specific information related to seizure activity or history and no specific care related to the treatment for seizures for Resident 12. Interview on 06/04/2026 at 10:10 AM with the Director of Nursing [DON] reviewed the CCP for Resident 12 and confirmed there was no care plan developed related to Resident 12's seizure activity and there should have been. The DON confirmed Resident 12 did have a history of seizures and took medications for the treatment of the seizures. C. Record review of Resident 11's admission MDS dated [DATE] revealed facility staff assessed the following about the resident: -Resident 11 required supervision for eating and personal hygiene; supervision for oral hygiene and upper body dressing; substantial assistance for toileting hygiene, bathing, lower body dressing, and putting on or taking off footwear. -Resident 11 had an indwelling urinary catheter and was frequently incontinent of bowel. -Resident 11 had a fall in the last month prior to admission and had a fracture related to a fall in the six months prior to admission. -Resident 11 was at risk for pressure ulcer development. -Resident 11 received antipsychotic and antianxiety medication during the assessment review period. -Resident 11 had frequently experienced pain in the last 5 days that frequently effected the resident's ability to sleep and limited the resident's day-to-day activities. Further review of Resident 11's MDS identified the facility staff would develop a comprehensive care plan with interventions for the following areas: functional abilities, urinary incontinence; falls; nutritional status; dehydration/fluid maintenance; pressure ulcer/injury; psychotropic drug use, and pain. Record review of Resident 11's undated CCP revealed there were no identified interventions for the following areas: functional abilities, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, psychotropic drug use, and pain. During an interview on 06/04/2026 at 10:21 AM, the MDS Coordinator (MDSC)-P confirmed the comprehensive care plan was not developed for Resident 11 and should have been.

Licensure Reference Number 175 NAC 12-006.09(I)Based on record reviews, observations, and interviews, the facility failed to complete a recliner chair safety evaluation for 2 (Resident 79 and Resident 70) of 8 sampled residents; and the facility failed to turn off an oxygen concentrator when not in use for 1 (Resident 20) of 2 sampled residents. The facility staff identified a census of 120.Findings are: A. Record review of facility policy entitled Fall Risk Management Policy dated 01/01/2023 revealed: -After completion of additional assessments, the admitting nurse or therapist determines what factors could contribute to fall risk. Record review of Resident 79's admission Record (AR) revealed the facility admitted the resident on 05/01/2026 with diagnoses of lack of coordination, generalized muscle weakness, unsteadiness on feet, and unspecified dementia. Record review of Resident 79's Fall Risk Evaluation dated 05/01/2026 identified Resident 79 was at-risk of falls. Record review of an Un-witnessed Fall document dated 05/15/2026 revealed Resident 79 attempted to lower the footrest of their electric recliner and the recliner tipped forward causing Resident 79 to slide to the floor. Resident 79 did not sustain an injury. Record review of Resident 79's Electronic Health Record (EHR) including scanned documents, progress notes, and assessments showed no recliner safety evaluation was completed for Resident 79. During an interview on 06/04/2026 at 7:04 AM with Clinical Care Coordinator (CCC)-B present, CCC-H confirmed a recliner chair safety evaluation was not completed for Resident 79 and further confirmed an evaluation should have been completed. B. A record review of Resident 70's admission Record revealed that the resident was admitted to the facility on [DATE] with diagnoses of hemiplegia (a medical condition that causes severe weakness or paralysis on one entire side of the body) and hemiparesis (a medical condition that refers to muscular weakness or partial loss of movement) following a cerebral infarction (a medical condition when blood flow to an area of the brain is blocked or significantly reduced). A record review of Resident 70's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 4/22/2026, revealed the following: -The Brief Interview for Mental Status (BIMS, 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) revealed a score of 12. According to the MDS manual, a score of 12 indicated the resident was cognitively moderately impaired. -The resident has functional limitation on one side of the body both upper and lower extremities and the resident's mobility is dependent on staff. -The hemiplegia affected the resident's left side which is the residents non-dominant side. -The resident was on occupational and physical therapy case loads. A record review of Resident 70's Fall Risk Evaluation effective date 5/5/2026, revealed a score of 11 which identified the resident was at risk for falls. A record review of Resident 70's Un-witnessed Fall report dated 4/26/2026 revealed the resident was found lying in front of the recliner with the Hoyer sling underneath the resident and the recliner was in the upright position. Resident 70 told staff Resident 70 could not figure out the recliner remote and slid out. The record review further revealed immediate actions taken were to educate Resident 70 on use of the recliner remote with return demonstration and educated staff not to leave Hoyer sling under the resident in the chair. A record review of Residents 70's Electric Lift Chair Assessment revealed that the assessment was not completed. A record review of Resident 70's Care Plan Report last updated 5/11/2026, revealed Resident 70 was working with physical and occupational therapies. An interview with Resident 70 on 06/04/2026 at 12:15 PM confirmed that Resident 70 does not sit in the recliner because the fabric is too slick and kept sliding out. An interview with Clinical Care Coordinator (CCC)-B and CCC-H on 06/04/2026 at 12:38 PM confirmed an Electric Lift Chair Assessment should have been complete on Resident 70 after sliding out of the electric recliner. CCC-B stated if a resident falls or slides out of a recliner the case managers would put in a referral to physical therapy and have them complete an Electric Lift Chair Assessment. CCC-B further confirmed an Electric Lift Chair Assessment was not completed on Resident 70. C. Record Review of the facility's undated policy titled Oxygen Therapy and Storage revealed the following: 9. Oxygen concentrators are to be turned off when not in use. If they are not connected to the guest, any team member can turn off the machine. An observation on 06/03/2026 at 8:20 AM revealed that Resident 20's oxygen concentrator was on, and the nasal cannula was laying on the floor. In an interview on 6/3/2026 at 08:41 AM, Medication Tech (MT)-A confirmed that the oxygen concentrator should have been shut off prior to MT-A exiting the room and was not.

Licensure Reference Number 175 NAC 12-006.09(J) Based on record reviews, observations, and interviews, the facility staff failed to follow ordered fluid restrictions for 1 (Resident 32) of 1 sampled resident. The facility identified a census of 120. Findings are:Record review of facility policy entitled Fluid Restriction dated revised 11/20/2017 revealed guests on fluid restrictions should not have a water pitcher at bedside and nursing staff would be responsible for documenting fluid intakes in the clinical record. Record review of Resident 32's admission Record (AR) revealed the facility admitted the resident on 05/07/2026. Further review of the AR identified Resident 32 had diagnoses of chronic diastolic (congestive) heart failure (lower heart chambers don't relax as they should). Record review of Resident 32's Order Summary Report revealed an order dated 05/08/2026 for 2,000 milliliter (mL) fluid restriction with 400 mL served at each breakfast, lunch, and dinner, and 800 mL left over for nursing med pass. Record review of Resident 32's May 2026 Medication Administration Record (MAR) revealed the following: -On 05/09/2026, the total daily fluid restriction amount was exceeded by 1,900 mL. -On 05/10/2026, the total daily fluid restriction amount was exceeded by 300 mL. -05/14/2026 the total daily fluid restriction amount was exceeded by 1,300 mL. -05/17/2026 the total daily fluid restriction amount was exceeded by 250 mL. -05/25/2026 the total daily fluid restriction amount was exceeded by 1,000 mL. Observation on 06/03/2026 at 10:29 AM revealed Resident 32 was in bed with a clear water pitcher within Resident 32's reach. The water pitcher was clear with markings to indicate mL in the cup. Water was up to approximately the 300 mL mark. Observation on 06/03/2026 at 12:21 PM revealed Resident 32 sitting in their room with a water pitcher in reach. The water was filled to the 450 mL mark. Observation on 06/04/2026 at 8:13 AM revealed Resident 32 was in the commons area with water pitcher and breakfast. During an interview on 06/03/2026 at 11:03 AM, Nurse Tech (NT)-T reported direct care staff were responsible for tracking fluids the resident received through meal trays and the water pitcher. NT-T reported they would document the amount of the fluids the resident received on their shift on the MAR and would report to the licensed nurse. NT-T confirmed the direct care staff did not document the fluid anywhere except for the total recording at the end of their shift. NT-T reported staff should probably record this information somewhere. During an interview on 06/04/2026 at 9:43 AM, Licensed Practical Nurse (LPN)-I confirmed Resident 32 received water pitchers in the room. LPN-I reported direct care staff verbally communicated the amounts of fluids the resident was given but did not record it anywhere. LPN-I further reported they were unaware of the resident ever going over the fluid restriction. During an interview on 06/04/2026 at 10:05 AM, the Director of Nursing (DON) confirmed residents with ordered fluid restriction should not have a water pitcher in the room. The DON further confirmed the fluid restriction was exceeded on 05/09/2026, 05/10/2026, 05/14/2026, 05/17/2026, and 05/25/2026. The DON reported facility staff should have a paper on the back of the resident's room door or another mechanism for tracking fluids as they were given.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to have valid Positive Airway Pressure (PAP)(a machine used to treat sleep apnea) device orders for 2 (Residents 7 and 14) of 2 sampled residents, and failed to have and follow valid oxygen orders for 3 (Residents 14, 13, and 9) of 3 sampled residents. The facility census was 120. Findings are: A record review of the National Library of Medicine's undated Nursing Skills, Chapter 11 Oxygen Therapy revealed that a prescription was required for a PAP device. www.ncbi.nlm.nih.gov/books/NBK593208/ A record review of the facility's undated Oxygen Therapy and Storage policy revealed oxygen would be administered to guests per physician's order and the staff would adjust flow rate per physician's order. A record review of the National Library of Medicine's undated Nursing Skills, Chapter 11 Oxygen Therapy revealed that oxygen was considered a medication and required a prescription. www.ncbi.nlm.nih.gov/books/NBK593208/ A record review of the National Library of Medicine's undated Nursing Skills, Basic Concepts of Administering Medications revealed that according to the Centers for Medicare & Medicaid Services, all orders for the administration of drugs and biologicals must contain the following information: Drug name Dose, frequency, and route Name/Signature of the prescriber Specific instructions for use, when applicable https://www.ncbi.nlm.nih.gov/books/NBK593215/#:~:text=Components%20of%20a%20Medication%20Order,instructions%20for%20use%2C%20when%20applicable A. A record review of Resident 14's Clinical Physician Orders dated 06/02/2026 revealed the resident had orders for Continuous Positive Airway Pressure (CPAP) set up in the morning and CPAP settings: on at hours of sleep (HS) off in the morning (AM) settings from home or when delivered from medical supply. The order did not include the settings for the machine. A record review of Resident 14's Care Plan Report with an admission date of 06/29/2021 revealed the resident had a focus area of the resident had Chronic Obstructive Pulmonary Disease (COPD) and interventions of CPAP as ordered and oxygen as ordered. It did not contain CPAP settings. A record review of Resident 14's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated June 2026 revealed the resident wore the PAP every night. A record review of Resident 14's MAR & TAR dated May 2026 revealed the resident wore the PAP every night. An observation on 06/01/2026 at 9:34 AM revealed Resident 14 had a PAP machine on the bedside table. An observation on 06/02/2026 at 8:41 AM revealed Resident 14 had a PAP machine on the bedside table. In an interview on 06/01/2026 at 9:34 AM, Resident 14 confirmed the resident used the PAP device located on the bedside table every night. In an interview on 06/04/2026 at 6:42 AM, Registered Nurse (RN)-C confirmed Resident 14 wore the PAP faithfully every night and there were not settings listed on the resident's PAP order. In an interview on 06/04/2026 at 11:10 AM, the DON confirmed the facility did not have any other orders for Resident 14 other than what was in the resident's Clinical Physician Orders and the PAP should have the setting listed on the order. B. A record review of Resident 14's Clinical Physician Orders dated 06/02/2026 revealed the resident had an order for oxygen 1 liter per minute (l/m) with CPAP at bedtime. A record review of Resident 14's Care Plan Report with an admission date of 06/29/2021 revealed the resident had a focus area of the resident had Chronic Obstructive Pulmonary Disease (COPD) and interventions of CPAP as ordered and oxygen as ordered. It did not contain oxygen settings. A record review of Resident 14's MAR & TAR dated June 2026 revealed the resident wore the oxygen every night. A record review of Resident 14's MAR & TAR dated May 2026 revealed the resident wore the oxygen every night. An observation on 06/01/2026 at 9:34 AM revealed Resident 14 had an oxygen concentrator (a machine used to purify oxygen) in the room, and it was set at 2 l/m. An observation on 06/02/2026 at 8:41 AM revealed Resident 14 had an oxygen concentrator in the room, and it was set at 2 l/m. An observation on 06/02/2026 at 6:37 AM with RN-C revealed Resident 14 had an oxygen concentrator in the room, and it was set at 2 l/m. In an interview on 06/01/2026 at 9:33 AM, Resident 14 confirmed the resident used the oxygen concentrator every night. In an interview on 06/04/2026 at 6:42 AM, RN-C confirmed Resident 14's oxygen order was for the oxygen to be set at 1 l/m, but but their concentrator was set at 2 l/m and should not have been. In an interview on 06/04/2026 at 11:10 AM, the DON confirmed the facility did not have any other orders for Resident 14 other than what was in the resident's Clinical Physician Orders and the oxygen should have been set at the setting listed there. C. A record review of Resident 9's Clinical Physician Orders dated 06/04/2026 revealed the resident had an order for oxygen at 3 l/m as needed for shortness of breath at night. A record review of Resident 9's Care Plan Report with an admission date of 10/11/2023 revealed the resident had a focus area of the resident had oxygen therapy related to ineffective gas exchange and interventions of oxygen settings: oxygen at 3 l/m as needed for shortness of breath and night. An observation on 06/01/2026 at 1:07 PM revealed Resident 9 was wearing an oxygen nasal cannula (a tubing the goes in the nose to delivery oxygen) and the oxygen concentrator was set at 2 l/m. An observation on 06/04/2026 at 6:38 AM with RN-C confirmed Resident 9 was wearing an oxygen nasal cannula and the oxygen concentrator was set at 2 l/m. In an interview on 06/01/2026 at 1:07 PM, Resident 9 confirmed the resident used oxygen most of the time. In an interview on 06/04/2026 at 6:46 AM, RN-C confirmed Resident 9's oxygen order was for the oxygen to be set at 3 l/m, but it was set at 2 l/m and should not have been. In an interview on 06/04/2026 at 11:10 AM, the DON confirmed the facility did not have any other orders for Resident 9 other than what was in the resident's Clinical Physician Orders and the oxygen should have been set at the setting listed on the order. D. A record review of Resident 13's Clinical Physician Orders dated 06/04/2026 revealed the resident had an order for oxygen for comfort. The order did not reveal settings for the oxygen. A record review of Resident 13's Care Plan Report with an admission date of 08/01/2022 did not reveal a focus area or interventions for oxygen. A record review of Resident 13's MAR & TAR dated June 2026 revealed the resident wore the oxygen for comfort every day. A record review of Resident 13's MAR & TAR dated May 2026 revealed the resident wore the oxygen every day. An observation on 06/01/2026 at 1:03 PM revealed Resident 13 was wearing an oxygen nasal cannula, and the oxygen concentrator was in the restroom, and it was set at 1.5 l/m. An observation on 06/04/2026 at 6:44 AM with RN-C revealed Resident 13 was wearing an oxygen nasal cannula, and the oxygen concentrator was in the restroom, and it was set at 2 l/m. In an interview on 06/04/2026 at 11:10 AM, the DON confirmed the facility did not have any other orders for Resident 13 other than what was in the resident's Clinical Physician Orders and the oxygen order should contain a setting but did not. E. Record review of Resident 7's admission Record revealed that Resident 7 was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation.) Record review of Resident 7'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 5/17/2026 revealed that Resident 7 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. Record review of Resident 7's orders revealed no orders for a CPAP machine. An observation on 6/2/2026 at 7:30 AM of Resident 7's room revealed a continuous positive airway pressure (CPAP, a medical device that is used to treat pulmonary disease) medical device was noted on the resident's bedside nightstand. The mask was attached to Resident 7's bed rail with Velcro. An interview with Resident 7 on 6/3/2026 at 2:14 PM confirmed that Resident 7 used the CPAP machine and mentioned that the hospital set the machine up to automatically turn on when the mask was placed on the resident's face. Resident 7 further confirmed that the only thing staff did to assist with the CPAP was by adding distilled water into the holding tank on the machine. An interview with Registered Nurse (RN)-N on 6/4/2026 at 9:43 AM confirmed there was no CPAP settings order or cleaning schedule orders for Resident 7.

Based on observation, interview, and record review the facility failed to coordinate meals and transportation for dialysis for 1 (Resident 7) of 1 sampled resident. The facility identified a census of 120. Findings are:Record review of facility policy, Dialysis Monitoring Policy effective date 1/1/2023, revealed:-Policy Explanation and Compliance Guidelines 1. Transportation to dialysis will be coordinated by the facility and communicated with the resident. 2. The facility will co-ordinate care with the dialysis provider in developing an appropriate plan of care to include, but not limited to:b. Any recommended medication schedule change to accommodate dialysis schedule.c. Meal or snack to be sent with resident as needed. Record review of Resident 7's admission Record revealed that facility admitted Resident 7 on 5/14/2026 with diagnoses of chronic kidney disease, stage 4 (severe kidney damage) with dependance on renal dialysis (a life- sustaining treatment for severe kidney disease that filters the blood and removing waste products, toxins and excess fluids from the blood stream) muscle weakness with abnormal gait and mobility, and right lower extremity, non-pressure related, wound. Record review of Resident 7'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 5/17/2026 revealed that Resident 7 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. Record review of Resident 7's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment), with an initiated date of 5/15/2026 revealed the following:-The resident needs dialysis related to renal failure.-The resident has potential/actual impairment to skin integrity related to . on dialysis. One of the interventions listed included encouraging good nutrition and hydration in order to promote healthier skin. Record review of Resident 7's Order Summary Report revealed the following:-Dialysis transportation was ordered for 5:30 AM pick up and to arrive at the dialysis clinic at 6:15 AM on Monday, Wednesday, and Friday each week. -Diet is liberalized with regular texture and regular/thin liquids consistency. A.An interview with Resident 7 on 6/2/2026 at 7:30 AM revealed that the resident had concerns with the social work department in regard to transportation to and from the dialysis center. An observation on 6/3/2026 at 6:17 AM revealed that Resident 7 was loading in a contracted transport van. An interview with License Practical Nurse (LPN)-A on 6/3/2026 at 11:57 AM revealed transportation needs for residents were arranged by Clinical Support Assistant (CSA)-A. An interview with Resident 7 on 6/3/2026 at 2:14 PM revealed the following:-The resident spoke to the dialysis center social worker about the transportation being late to pick the resident up from the nursing facility on several occasions. The resident expressed this was unacceptable because it made the resident arrive after the scheduled dialysis clinic arrival time of 6:15 AM. The resident further revealed that it was the same driver that was late and confirmed the care coordinator and social work offices were made aware. An interview with CSA-M on 06/04/2026 at 10:45 AM revealed the following:-Transportation scheduling process: the admission team would send an email to CSA-M, CSA-M then confirmed dialysis times with the dialysis facility and then arranged transportation. CSA-M notifies the admissions team to continue with the admission.-CSA-M stated that no complaints had been reported by any facility staff about timeliness of the transportation companies. -CSA-M further revealed that the dialysis clinic Resident 7 is assigned to was just down the way a couple of minutes so they could leave at 6:00 AM and be on time. An interview with Resident 7 on 6/4/2026 at 12:30 PM confirmed dialysis transportation on 6/1/2026 and 6/4/2026 were late for pickup from the nursing facility and was the same driver both times. B.An interview with Resident 7 on 6/3/2026 at 2:14 PM revealed the following:-The resident voiced concern about the breakfast meal not being available or provided prior to the resident on dialysis treatment days. The resident further revealed that the facility staff have discussed the new system used to place residents' meal orders with the residents. The resident stated that once back from dialysis the nurse aides will reheat the breakfast tray, but the resident chooses to wait for the lunch meal. - No snacks are offered or provided to the resident on dialysis treatment days.-The resident eats the supper meal, is not offered a bedtime snack, and then waits until almost 1:00 PM to eat the lunch meal on dialysis treatment days. An interview with Nurse Assistant (NA)-L on 06/04/2026 at 9:54 AM confirmed the resident did not get their breakfast in the mornings before being transported to dialysis, but NA-L did order a breakfast tray for Resident 7 and would let it sit on the bedside table until the resident got back from dialysis around 11:00 AM. NA-L confirmed the resident didn't want breakfast warmed up and the resident would wait to eat until lunch. NA-L further confirmed resident wasn't available for breakfast was charted 6/2/2026 and 6/4/2026 for Resident 7.

Licensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review the facility failed to ensure residents were not provided medications outside of ordered parameters for 3 (Residents 2, 146 and 151) of 8 sample residents. The facility identified a census of 120. Findings are:A.Record Review of the facility's Unnecessary Medication Policy with a revision date of 11/18/2025 revealed the following:Policy:Residents are not prescribed medications unless they are necessary to treat a specific condition, as diagnosed and documented in the medical record, and the medication is beneficial to the resident, as evidenced by monitoring and documentation of the resident's response to the medication(s).Policy and Guidelines:1. Each resident's medication regimen must be free from unnecessary medications. Criteria may include: excessive dose, excessive duration, inadequate monitoring, inadequate indication for use, adverse consequences, duplicate therapy.2. The indications for initiating, withdrawing or withholding medication(s), as well as the use of nonpharmacological approaches, shall be determined by the provider along with the interdisciplinary team, and resident/family.5. Resident who use psychotropic medications will be monitored for both the effectiveness of the medication's as well as any possible adverse consequences from medications.7. Resident who are prescribed antipsychotic medication should have an Abnormal Involuntary Movement Scale (AIMS) or similar test performed on admission, annually and with significant change in condition, medication change or as deemed necessary.9. The resident response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. B.Record Review of Resident 151's Order Summary Report dated 6/2/2026 revealed the following order: Carvedilol Tablet 3.125 MG Give 1 tablet by mouth two times a day for hypertension. Hold for systolic blood pressure less than 90 and pulse less than 60. Take with Meals. Record Review of Resident 151's Medication Administration Record (MAR) dated 11/2025 and 12/2025 revealed Medication was administered on the following dates: 11/24/2025 pulse of 59 11/28/2025 pulse of 56 11/30/2025 pulse of 57 12/07/2025 pulse of 53 12/19/2025 pulse of 55 In an interview on 06/03/2026 at 1:06 PM, Director of Nursing (DON) confirmed that Resident 151's medication was administered on the listed dates with the listed pulses and should not have been. C.Record Review of Resident 2's Order Summary Report dated 06/04/2026 revealed the following order: Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 milligram (MG). Give 0.5 tablet by mouth one time a day for hypertension. Hold for systolic blood pressure less than 90 or pulse less than 60. Record review of Resident 2's Medication Administration Record (MAR) dated 5/2026 revealed that the medication was administered on the following dates: 05/22/2026 pulse was 57 In an interview on 06/04/2026 at 7:57 AM, DON confirmed that Resident 2's medication was administered on the listed date with pulse below 60 and should not have been. D.Record Review of Resident 146's Order Summary Report dated 6/2/2026 revealed the following order: Hydrochlorothiazide Tablet 25 MG Give 12.5 mg by mouth one time a day for hypertension. Hold if systolic blood pressure is less than 110. Record Review of Resident 146's Medication Administration Record (MAR) dated 02/2026 and 03/2026 revealed the following: 02/03/2026 blood pressure was 109/70 02/04/2026 blood pressure was 105/72 02/12/2026 blood pressure was 108/69 02/17/2026 blood pressure was 104/70 03/02/2026 blood pressure was 106/70 In an interview on 06/03/2026 at 1:20 PM, DON confirmed that Resident 146's medication was provided outside of parameters on the listed dates and should not have been.

Licensure Reference number 175 NAC 12-006.17(A)(v)Licensure Reference Number 175 NAC 1-008(xii)Based on record review and interview, the facility staff failed to accurately document the use of a continuous positive airway pressure device (CPAP, a small bedside device that pumps a steady stream of gentle, pressurized air through a mask which keeps the throat open to prevent blockage) for 1 (Resident 32) of 3 sampled residents and failed to document restorative (services provided to maintain range of motion ability] services provided for 1 (Resident 67) of 1 reviewed. The facility staff identified a census of 120.Findings are: A. Record review of Resident 32's admission Record (AR) revealed the facility admitted the resident on 05/07/2026. Further review of the AR identified Resident 32 had a diagnosis of obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep because the throat muscles relax, causing the airway to collapse and block airflow). Record review of Resident 32's Medication Review Report which showed active orders as of 05/07/2026 identified an order for a continuous positive airway pressure device (CPAP, a small bedside device that pumps a steady stream of gentle, pressurized air through a mask which keeps the throat open preventing blockages) with settings from home dated 05/07/2026. Record review of Resident 32's Treatment Administration Record (TAR) for 05/07/2026 through 05/21/2026 revealed the following: -The CPAP was documented as not administered on 05/09/2026, 05/13/2026, and 05/20/2026. -The CPAP was documented as administered on all remaining days from 05/07/2026 through 05/21/2026. Record review of Resident 32's Progress Notes (PN) dated 05/07/2026 through 05/22/2026 identified there was no CPAP equipment available for use on the following dates: 05/09/2026, 05/13/2026, and 05/21/2026. During an interview on 06/04/2026 at 7:04 AM with Clinical Care Coordinator (CCC)-B present, CCC-H confirmed Resident 32 never had a CPAP machine available. CCC-H further confirmed the entries on the TAR on dates the CPAP was marked as administered was not accurate. B. Record review of an undated facility policy entitled Restorative Program Policy revealed the following information: Policy: to identify residents appropriate for restorative nursing services and provide structured interventions to help them maintain or improve functional abilities and support quality of life. Documentation should include type of program, frequency and duration, resident participation, level of assistance provided, tolerance / response, refusals / barriers, progress toward goals, monthly or periodic summaries. C. Record review of Resident 67's annual MDS dated [DATE] revealed an admission date of 04/12/2024 with a diagnosis of Cerebral Vascular Accident [CVA,stroke] with Hemiplegia [paralysis that affects one side of the body] affecting the left side. The MDS (Minimum Data Set-a federally mandated clinical assessment tool that helps generate a plan of care) identified that resident 67 had a BIMS score of 6 which indicated severe cognitive impairment. The MDS identified that Resident 67 had range of motion impairment on one side of the body affecting the upper and lower extremity. The MDS identified that Resident 67 was dependent on staff for assistance with activities of daily living such as dressing, bathing, toilet use, personal hygiene and transfers. The MDS identified that Resident 67 received no therapy services and no range of motion, active or passive, during the look back period and did not use a splint or brace. Observation on 06/02/2026 at 8:16 AM revealed that Resident 67 was seated in a wheelchair at the breakfast table on the secured unit of the facility. The residents had a contracture [a shortening of muscle fibers resulting in the loss of joint mobility] of the left hand and was not able to open the hand or extend the fingers. Observation on 06/02/2026 at 8:30 AM revealed that Restorative Nurse Aide [RNA]-D asked Resident 67 if the resident wanted to go to have a restorative [a type of treatment aimed at helping individuals regain physical function] therapy session. Resident 67 agreed to the request and proceeded to go to the therapy area and received a restorative therapy session with range of motion to the left hand provided. Record review of Resident 67's Electronic Medical Record [EMR] did not include documentation the type of restorative program, duration, resident participation, level of assistance provided, tolerance / response, refusals / barriers, progress toward goals, or monthly or periodic summaries related to the contracture of the left hand. Interview on 06/03/2026 at 1:22 PM with the Director of Nursing [DON] confirmed that the Resident 67 did get restorative exercises but confirmed there was no documentation of what restorative services had been provided to Resident 67. Interview on 06/04/2026 at 9:53 AM with RNA-D revealed that Resident 67 received range of motion to the left hand 1-2 times per week. RNA-D confirmed that there wasn't anywhere to document the services provided and hasn't been for a long time.

Licensure Reference Number 175 NAC 12-006.18 Based on observations, record reviews and interviews, the facility staff failed to apply gloves prior to administering an injectable medication, discard the nasal cannula (oxygen tubing) that was lying on the floor for 1 (Resident 20) of 1 sampled residents and failed to perform hand hygiene between taking off and putting on new gloves during medication administration for 1 (Resident 14) of 6 sampled residents. The facility identified a census of 120. Findings are:A. Record Review of the facility's undated Insulin Administration Competency revealed the following: 5. Check the MAR for injection site to be used. 6. Apply gloves. 7. Clean the site with an alcohol wipe and allow to air dry. 8. Grasp the skin at the injection site between the index finger and thumb, with the other hand, insert the needle at a 45-degree angle. B. An observation on 06/03/2026 at 8:20 AM, Medication Tech (MT)-A obtained a blood pressure cuff and entered Resident 20's room. MT-A obtained the blood pressure on Resident 20's right arm. MT-A provided a medication cup to Resident 20. MT did not complete hand hygiene or apply gloves, swabbed the back of Resident 20's right arm, removed the plastic cap over the needle and injected the medication into the back of Resident 20's right arm. Further observation revealed Resident 20's oxygen tubing/nasal cannula (a lightweight plastic tubing that is used to deliver oxygen) lying on the floor by Resident 20's bed and oxygen tubing was connected to running oxygen concentrator (a medical device that extracts and purifies oxygen from the surrounding air). In an interview on 06/03/2026 at 8:41 AM, MT-A confirmed that MT-A should have had gloves on prior to administering the injectable medication. MT-A confirmed that MT-A should have discarded Resident 20's nasal cannula prior to exiting the room. C. A record review of the facility's Infection Prevention And Control Program dated 01/01/2026 revealed staff should perform hand hygiene (cleaning) before donning (putting on) and after removing gloves An observation on 06/02/2026 at 8:41 AM revealed Registered Nurse (RN)-C performed hand hygiene, gloved, entered Resident 14's room and administered the resident's insulin. After the insulin administration, RN-C removed RN-C's gloves and applied new gloves without performing hand hygiene before administering the resident's eye drops. In an interview on 06/02/2026 at 11:12 AM, RN-C confirmed RN-C did not perform hand hygiene between glove changes before administering Resident 14's eye drops and should have.

Licensure Reference Number NAC 175 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to implement interventions for the prevention of pressure ulcers for 2 (Resident 2 and 4) of 4 residents sampled and failed to provide practitioner ordered wound care to promote healing of pressure ulcers for 1 (Resident 4) of 4 residents sampled. The facility census was 121. The findings are:Record review of the facility policy dated 07-25-2025 revealed all team members are responsible for preventing, caring for and providing treatment for any patient with altered skin integrity. Record review of the facility's undated policy titled Braden Scale revealed the facility uses the Braden Scale as a tool to assess the resident's level of risk for development of pressure ulcers. The evaluation is based on six indicators: sensory perception, moisture, activity, mobility, nutrition, and friction or shear. A lower Braden Scale Score indicates a lower level of functioning, therefor a higher level of risk for pressure ulcer development. Team members will update the plan of care with identified interventions for the resident to decrease the risk of skin breakdown. A. Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 11-11-2025 revealed the facility staff assessed the following about the resident: -admission date was 06-20-2024. -Brief Interview of Mental Status (BIMS) was scored as a 1. According to the MDS Manual a score of 0 to 7 indicates severe cognitive impairment. -Required limited assistance with bed mobility and upper body dressing. -Required extensive assistance with hygiene, toileting, bathing, lower body dressing and transfers. -was frequently incontinent of bowel and bladder. -was at risk of developing a pressure ulcer. -was receiving hospice care. Record review of Resident 2's Comprehensive Care Plan (CCP) printed on 12-29-2025 revealed under the focus section Resident 2 had a potential for pressure ulcer development related to incontinence and limited mobility dated 07-03-2024. The goal was Resident 2 will have a reduced risk for alteration in skin through the review date, dated 07-03-2024 revised 12-12-2025. Interventions listed were administer treatments as ordered and monitor effectiveness, follow facility policies and protocols for the prevention and treatment of skin breakdown, and monitor nutritional status. Serve diet as ordered, monitor intake and record. The CCP also revealed a focus that Resident 2 was at risk for alteration in skin related to altered independence with activities of daily living (ADL) and mobility, incontinence, cognitive deficits, altered gait, compulsive transfers and intermittent refusal of cares dated 07-02-2024. The goal dated 07-02-2024 and revised 12-12-2025 was Resident 2's skin injury Maceration Associated Skin Damage (MASD: according to the MDS Manual, MASD is superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration) of the bilateral buttocks will attain and maintain intactness by the review date and dated 10-17-2025 Resident 2 would have reduced risk of skin breakdown through the review date. Interventions were to encourage frequent toileting and assist with cleaning after incontinent episodes dated 07-02-2024, encourage Resident 2 to reposition often dated 07-02-2024, skin treatment per order dated 07-02-2024 and air mattress ordered per hospice dated 12-23-2025 Record review of Resident 2's Braden Scale (BS: According to the MDS Manual a Braden Scale is an assessment tool for predicting pressure sore risk) score dated 11-04-2025 was scored at a 16 indicating Resident 2 was at risk of developing a pressure ulcer. Record review of Resident 2's BS dated 11-11-2025 was scored at a 13 indicating moderate risk of developing a pressure ulcer. Record review of Resident 2's CCP printed on 12-29-2025 revealed no new interventions were implemented on 11-11-2025. Record review of Resident 2's BS dated 12-09-2025 revealed a score of 13 indicating Resident 2 was at moderate risk of developing a pressure sore. Record review of Resident 2's Skin Only Evaluation ([NAME]) dated 12-09-2025 revealed Resident 2 had MASD to bilateral buttocks. Record review of Resident 2's Hospice Nursing Clinical Note (HNCN) dated 12-10-2025 revealed Resident 2's skin was pale, skin was dry and no wounds were identified, and no pressure relief devices were in use. Record review of Resident 2's BS dated 12-16-2025 revealed a score of 12 indicating Resident 2 was at high risk of developing a pressure sore. Record review of Resident 2's Progress Note (PN) dated 12-16-2025 revealed the facility staff updated the hospice nurse that Resident 2's buttocks wounds were getting worse and the hospice nurse was ordering an air mattress. Record review of Resident 2's [NAME] dated 12-16-2025 revealed Resident 2 had MASD to the left buttock and coccyx (tailbone) and a fading bruise to the right hip. Record review of Resident 2's [NAME] dated 12-17-2025 revealed Resident 2 had MASD to the left buttock and a stage 2 pressure ulcer to the sacrum measuring 1 centimeter (cm) length by 1 cm width by 0.1 cm in depth, the skin surrounding the wound was fragile. The [NAME] also revealed hospice was ordering a Roho Cushion (According to the manufacturer, a Roho cushion is an air-filled cushion that uses interconnected air cells that adapt to the body's shape, providing superior pressure relief, circulation and stability to prevent skin breakdown and pressure ulcers) for Resident 2. Record review of an email communication dated 12-17-2025 revealed a new order for a foam dressing to be applied to sacrum change every 3 days and as needed and a Roho cushion has been ordered. Record review of Resident 2's Hospice Nursing Clinical Note (HNCN) dated 12-22-2025 revealed Resident 2's skin was pale, skin was dry and no wounds were identified, and no pressure relief devices were in use. Record review of Resident 2's CCP printed on 12-29-2025 revealed a focus dated 12-17-2025 revised on 12-23-2025 Resident 2 had a stage 2 pressure ulcer to the sacrum related to immobility and general decline and Resident 2 had a pressure ulcer to the right heel. The goal was Resident 2's pressure ulcer will show signs of healing and remain free from infection by the review date. Interventions listed dated 12-17-2025 were to administer medications as ordered, administer treatments as ordered and monitor for effectiveness, assess, record, monitor wound healing, measure length, width and depth, assess and document status of the wound perimeter, wound bed and healing progress. Report improvements and declines to the physician, educate resident, family and care givers as to causes of skin breakdown including transfer and positioning requirements, importance of taking care during transfers, good nutrition, and frequent repositioning, hospice ordered a Roho cushion, and a pressure reducing mattress in place for prevention and treatment. The CCP also revealed an additional intervention for heel protectors on feet while in bed dated 12-23-2025. Record review of Resident 2's BS dated 12-23-2025 was scored at an 11, indicating Resident 2 was at high risk of developing a pressure ulcer. Record review of Resident 2's [NAME] dated 12-23-2025 revealed Resident 2 had MASD to the left buttock, a stage 2 pressure ulcer to the sacrum measuring 0.9 cm length by 0.9 cm width by 0.1 depth, and an unstageable pressure ulcer to the right heel measuring 1.5 cm length by 1.3 cm in width, the wound bed was necrotic, and the skin around the wound was reddened. The [NAME] also revealed the hospice nurse was updated and provided heel protectors for Resident 2. An observation conducted on 12-29-2025 at 11:18 AM revealed Resident 2 was sitting in a wheelchair in [gender] room without a Roho cushion and a scoop mattress was in place on the bed. An observation conducted on 12-29-2025 at 12:37 PM revealed Resident 2 was sitting in wheelchair without a Roho cushion and the facility staff entered the room to assist Resident 2 into bed and there was no air mattress on the bed. An observation conducted on 12-29-2025 at 2:35 PM revealed Resident 2 was in bed with the Head of Bed (HOB) elevated, there was no Roho cushion in the wheelchair or the recliner and there was no air mattress on Resident 2's bed. An observation conducted on 12-30-25 at 6:20 AM revealed Resident 2 was in bed with HOB elevated, no air mattress on the bed and no Roho cushion in the recliner or wheelchair. An observation conducted on 12-30-2025 at 7:40 AM revealed Resident 2 was in bed with HOB elevated, no air mattress on the bed and no Roho cushion in wheelchair or recliner. An interview conducted on 12-30-2025 at 11:20 AM with Nurse Tech (NT) H confirmed Resident 2 did not have a Roho cushion or an air mattress in place. An interview conducted with the facility's Wound Nurse, Registered Nurse (RN) F on 12-30-2025 at 12:00 PM revealed RN F would need to look at the facility policy when asked what interventions were put into place when the BS Score worsened, furthermore RN F revealed hospice has ordered a Roho Cushion for Resident 2. An interview with RN F on 12-30-2025 at 2:00 PM revealed the Roho cushion was ordered on 12-17-2025 by hospice and confirmed the Roho cushion had not been delivered and 13 days was too long of a wait. Furthermore, RN F revealed the air mattress for Resident 2 was not implemented and heel protectors were implemented on 12-23-2025 after the wound to the right heel had developed. B. A record review of Resident 4's Clinical Census dated 12-02-2025 revealed the resident was readmitted to the facility on [DATE]. A record review of Resident 4's Medical Diagnosis dated 12-04-2025 revealed the resident had diagnoses of Hypertensive Chronic Kidney Disease (high blood pressures that damage the kidney blood vessels), Spinal Stenosis (narrowing of spaces in the spine), Morbid Obesity (very overweight), Presence of Right Artificial Knee Joint, and Presence of Left Artificial Knee Joint. A record review of Resident 4's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 11-04-2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to think and comprehend). The resident was independent with oral hygiene (cleaning), required setup or clean-up assistance with eating, required partial/moderate assistance with toileting, upper body dressing, and personal hygiene, required substantial/maximal assistance with bathing and footwear, and was dependent on staff for lower body dressing, and footwear. The resident required Partial/moderate assistance with sit to lying positioning and lying to sitting on the side of the bed. The resident needed substantial/maximal assistance with sit-to-stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The resident did have 1 unstageable pressure ulcer (severe wound). The MDS did not reveal that the resident used a mechanical lift. A record review of the facility's New Pressure Ulcer incident report dated 09/25/2025 revealed that Resident 4 had an open ulcer on the left medial metatarsal (bone on the inside midfoot) that was assessed and treated. The resident foot was deformed and there was a prominent bunion (bump that forms on the side of the foot at the base of the big toe) that the ulcer formed over. The resident had been pivot transferring with the left foot with socks on related to (r/t) right knee restrictions. Education was provided to the resident regarding using a shoe for the left foot with all transfers. A record review of Resident 4's Care Plan with an admission date of 09/19/2025 revealed a focus area of The resident acquired (got) an unstageable pressure injury to left medial metatarsal r/t not wearing appropriate footwear with pivot transfers and recent surgery which affects (gender) weight transfer to left foot during position changes. The Care Plan had intervention of administer medications as ordered, administer treatments as ordered, assess/record/monitor wound healing and report changes to the provider, and educate the resident as to the causes of skin breakdown including transfer/positioning requirements. The Care Plan did not reveal interventions related to the cause of the pressure ulcer such as appropriate footwear with all transfers or transfer needs. A record review of Resident 4's Shoe Color Change Assessment dated 09/20/2025 revealed the resident was to be transferred with 2 caregivers and a sit-to-stand lift (a mechanical lift) but did not reveal any special instructions. A record review of Resident 4's Client Uploaded Files dated 12/29/2025 revealed the resident had special instructions of assist of 2 with sit-to-stand lift, slide board assist of 2 bed to wheelchair to recliner, sit-to-stand to toilet. It did not reveal the resident needed to wear a left shoe with all transfers. An observation on 12/30/2025 at 8:58 AM revealed Nurse Tech (NT)-C and NT-D transferred Resident 4 to the restroom using a sit-to-stand lift. The observation did not reveal the resident was wearing any shoes during the transfer. An observation on 12/30/2025 at 8:58 AM revealed Nurse Tech (NT)-C and NT-D transferred Resident 4 to the restroom using a sit-to-stand lift with the resident's feet in socks, flat on the sit-to-stand lift. The observation did not reveal the resident was wearing any shoes during the transfer. An observation on 12/30/2025 at 9:18 AM revealed Nurse Tech (NT)-C and NT-E transferred Resident 4 from the restroom to the resident's wheelchair using a sit-to-stand lift with the resident's feet in socks, flat on the sit-to-stand lift. The observation did not reveal the resident was wearing any shoes during the transfer. In an interview on 12/30/2025 at 9:10 AM, NT-C confirmed the only things NT-C was aware of to prevent pressure on Resident 4's left foot was gripper socks and compression hose. NT-C confirmed Resident 4 did not wear shoes during the transfer. In an interview on 12/30/2025 at 9:28 AM Resident 4 confirmed the resident did not use shoes when transferring, only to therapy. The resident confirmed the staff did not tell the resident anything different to do after the pressure ulcer was found. In an interview on 12/30/2025 at 2:25 PM, Registered Nurse (RN)-F, the wound nurse, confirmed that when the wound occurred, RN-F added to wear shoes with transfers to the Care Plan under the Focus Area for the left medial pressure ulcer. C. A record review of Resident 4's Clinical Physician Orders dated 12/30/2025 revealed the resident had an order for wound treatments to the left medial metatarsal Monday, Wednesday, Friday and as needed (PRN) with a start date of 09/25/2025 and an end date of 12/10/2025. The order was changed to every day shift and as needed on 12/10/2025. A record review of Resident 4's Medication Administration Record and Treatment Administration Record dated September through December 2025 revealed the left medial metatarsal wound care orders were not completed: - 09/26/2025 - 09/29/2025 - 10/06/2025 - 10/17/2025 - 10/31/2025 - 11/17/2025 - 11/19/2025 - 12/05/2025 - 12/12/2025 - 12/19/2025 - 12/22/2025 A record review of Resident 4's Progress Notes dated 06/05/2025 - 12/28/2025 revealed RN-F completed a skin evaluation on 11/19/2025 and the wound treatment was completed. In an interview on 12/30/2025 at 9:55 AM, RN-F confirmed if RN-F completed the wound care during a skin evaluation, then RN-F would mark it off as being completed, but failed to mark it off on 11/19/2025. In an interview on 12/30/2025 at 2:25 AM, RN-F confirmed Resident 4's left medial metatarsal wound care orders were not completed on 9/26/2024, 9/29/2025, 10/6/2025, 10/17/2025, 10/31/2025, 11/17/2025, 12/5/2025, 12/12/2025, 12/19/2025, or 12/22/2025 and should have been.

Licensure Reference Number 175 NAC 12.006.18(B) Based on observation, interview, and record review, the facility failed to ensure staff donned (put on) masks during a COVID-19 outbreak, ensure Enhanced Barrier Precautions (EBP) were followed for Resident 2, and maintain vinyl coverings on six recliners to reduce the potential for cross contamination in the Magnolia Trail commons area. The facility census was 121. Findings are:Licensure Reference Number 175 NAC 12.006.18(B) Based on observation, interview, and record review, the facility failed to ensure staff donned (put on) masks during a COVID-19 outbreak, ensure Enhanced Barrier Precautions (EBP) were followed for Resident 2, and maintain vinyl coverings on six recliners to reduce the potential for cross contamination in the Magnolia Trail commons area. The facility census was 121. Findings are: A. A record review of the facility's Coronavirus Disease 2019 (COVID-19) SNF Policy with an effective date 05/15/2023 revealed source control (wearing of a surgical mask or N-95 respirator) would be required for all staff when the facility is in outbreak status for a minimum of 14 days after the last confirmed positive case. A record review of Resident 6's (in room [ROOM NUMBER]) Hospital Medicine – Initial Visit dated 12/24/2025 revealed the resident had Influenza A. A record review of the facility's Daily Census dated 12/28/2025 revealed the residents in rooms 10.2, 83, 85, 94, and 102 had tested positive for COVID-19. An observation on 12/30/2025 at 6:09 AM revealed Nurse Tech (NT)-J was in the Ivy Court hallway without a mask on and Licensed Practical Nurse (LPN)-K was in the Ivy Lane hallway and entered Resident 7's room without a mask on. An observation on 12/30/2025 at 6:14 AM revealed Environmental Services Tech (EST)-L was in the main hallway entering and exiting the offices without a mask on. An observation on 12/30/2025 at 6:15 AM revealed NT-M exited Resident 6's room, room [ROOM NUMBER], into the Ivy Court hallway without a mask on. NT-M walked to the hopper room by room [ROOM NUMBER] on Ivy Lane with a bag of laundry, then entered room [ROOM NUMBER] without a mask on. Resident 6's door revealed a sign that the resident was in droplet precautions and staff were to wear a N-95 mask, gown, and gloves. In an interview on 12/30/2025 at 9:10 AM, NT-C confirmed the staff had all been told they need to wear an N-95 mask when in areas that have a COVID-19 positive resident and a surgical mask in all other areas of the building. In an interview on 12/30/2025 at 9:26 AM, NT-E confirmed that the staff had been given guidance to wear a surgical mask throughout the facility and if that unit had a COVID-19 positive resident, they needed to wear an N-95. In an interview on 12/30/2025 at 8:33 AM, the facility's Administrator confirmed the facility was in a COVID-19 outbreak status and the facility Medical Director said all staff should wear source control. B. A record review of the facility's Enhanced Barrier Precautions (EBP) for Prevention of Multidrug-Resistant Organism Transmission with an effective date of 1/1/2024 revealed EBP would be implemented for residents with a chronic wound. The staff must wear required personal protective Equipment (PPE) during high-contact care of gloves and gown. Signage should be posted outside the resident's room. A record review of Resident 4's Clinical Census dated 12/02/2025 revealed the resident was readmitted to the facility on [DATE]. A record review of Resident 4's Medical Diagnosis dated 12/04/2025 revealed the resident had diagnoses of Hypertensive Chronic Kidney Disease (high blood pressures that damage the kidney blood vessels), Spinal Stenosis (narrowing of spaces in the spine), Morbid Obesity (very overweight), Presence of Right Artificial Knee Joint, and Presence of Left Artificial Knee Joint. A record review of Resident 4's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 11/04/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to think and comprehend). The resident was independent with oral hygiene (cleaning), required setup or clean-up assistance with eating, required partial/moderate assistance with toileting, upper body dressing, and personal hygiene, required substantial/maximal assistance with bathing and footwear, and was dependent on staff for lower body dressing, and footwear. The resident required Partial/moderate assistance with sit to lying positioning and lying to sitting on the side of the bed. The resident needed substantial/maximal assistance with sit-to-stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The resident did have 1 unstageable pressure ulcer (severe wound). The MDS did not reveal that the resident used a mechanical lift. A record review of the facility's New Pressure Ulcer incident report dated 09/25/2025 revealed that Resident 4 had an open ulcer on the left medial metatarsal (bone on the inside midfoot) that was assessed and treated. The resident foot was deformed and there was a prominent bunion (bump that forms on the side of the foot at the base of the big toe) that the ulcer formed over. The resident had been pivot transferring with the left foot with socks on related to (r/t) right knee restrictions. Education was provided to the resident regarding using a shoe for the left foot with all transfers. A record review of Resident 4's Care Plan with an admission date of 09/19/2025 revealed a focus area of The resident acquired (got) an unstageable pressure injury to left medial metatarsal r/t not wearing appropriate footwear with pivot transfers and recent surgery which affects (gender) weight transfer to left foot during position changes. The Care Plan had intervention of administer medications as ordered, administer treatments as ordered, assess/record/monitor wound healing and report changes to the provider, and educate the resident as to the causes of skin breakdown including transfer/positioning requirements. The Care Plan did not reveal interventions related to the cause of the pressure ulcer such as appropriate footwear with all transfers or transfer needs. A record review of Resident 4's Client Uploaded Files dated 12/29/2025 revealed the resident had special instructions of assist of: Enhanced Barrier Precautions (EBP) – chronic wounds An observation on 12/29/2025 at 2:24 PM revealed Resident 4's room did not have an EBP sign posted, and no gowns were available. RN-N entered the resident's room and completed wound care orders on the resident's left medial metatarsal pressure ulcer. RN-N did not donn (put on) a gown prior to completing wound care. During the wound care, RN-N removed the right-hand glove and held the dressing against the wound with the ungloved right hand while taping the dressing. RN-N then walked down the Ivy Court hallway to the nurse's station. An observation on 12/29/2025 at 2:58 AM revealed Resident 4's room did not have an EBP sign posted, and no gowns were available. RN-F, the wound nurse, completed wound care orders on the resident right knee surgical incision without donning a gown. RN-F kneeled on the floor with RN-F's clothing directly touching Resident 4's carpeting. RN-F then exited the resident's room, walked down the Ivy Court hallway to the laundry room on Ivy Lane, then continued down the main hall to the Registered Dietician's office (shared with RN-F) and then down the [NAME] Way hallway. In an interview on 12/29/2025 at 2:57 PM, RN-F, the wound nurse confirmed that RN-F was unsure why Resident 4 was not in EBP. In an interview on 12/29/2025 at 3:05 PM, the Assistant Director of Nursing (ADON), Infection Preventionist, confirmed that Resident 4 should have been in EBP and was not. The ADON confirmed staff should have worn a gown and gloves during wound care. B. Observation on 12/29/2025 at 2:44 PM revealed six recliners in the commons area centered around a television with vinyl that had peeled away from the arm rests and the seats, which prevented the surface from being able to be fully cleaned. An interview on 12/30/2025 at 7:47 AM with the Environmental Services Director (EVSD) confirmed the chairs were missing vinyl and were unable to be cleaned.

Licensure Reference Number 175 NAC 12-006.09 and 12-006.09(H)(iv)(5).Based on observation, interview, and record review, the facility failed to implement neurological checks for an unwitnessed fall for 2 (Residents 1 and 2) of 3 sampled residents, and failed to monitor bowel movements and provider ordered interventions to prevent the potential for constipation for 1 (Resident 2) of 1 sampled resident. The facility staff identified a census of 121.The findings are:A. Record review of a facility policy entitled Neuro Checks dated revised 3/31/2021 revealed: -A neuro check is a simple and standardized assessment to detect changes in level of consciousness. These may be performed on an individual with a post-fall head injury, or unwitnessed fall. **Consciousness is the most sensitive indicator of neurological status. -1. Neuro checks will be completed per physician order or initiated by the nurse, at their discretion, based on physical assessment of the resident, guest, or elder. -2. Neuro checks will be completed on the resident, guest, or elder with an unwitnessed fall or fall with head injury. -3. The nurse should review the previous assessment for comparison and report any significant/abnormal variances to the physician for further instruction. -4. If a resident, guest, or elder is transferred for further evaluation and is medically cleared for return to the facility, the neuro checks may be discontinued unless otherwise directed by their provider. Record review of Resident 1's admission Record revealed the facility admitted the resident on 9/11/2025. Further review of the admission record identified the resident had diagnoses that included infection and inflammatory reaction due to internal left knee prosthesis, bacteremia (a blood stream infection of bacteria in the blood), myasthenia gravis (a chronic autoimmune disease causing fluctuating weakness in voluntary muscles such as the eyes, face, throat, and limbs due to nerve-muscle communication breakdown, where antibodies block signals, worsening with activity and improving with rest), essential tremors, abnormalities of gait, and unsteadiness on feet. Record review of Resident 1's admission 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 9/17/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS Manual, a score of 15 indicated the resident was cognitively intact. The MDS identified Resident 1 had no behaviors including rejection of care. Further review of the MDS identified Resident 1 had a range of motion impairment on one side with both upper and lower extremities and was dependent upon staff for assistance with transfers. Record review of Resident 1's fall investigations revealed Resident 1 sustained a fall on 9/26/2025 at 6:55 PM. Record review of Resident 1's Neuro Checks sheet revealed the resident was to have neurological checks completed every 15 minutes for four assessments, every 30 minutes for four assessments, every one hour for four assessments, every four hours for four assessments, and every eight hours for four assessments. Further review of the neuro check sheet revealed neurological checks were not completed on 9/27/2025 at 6:50 AM, 10:50 AM, and 2:50 PM; 9/28/2025 at 9:15 PM; and 9/29/2025 at 5:15 AM. Interview on 12/30/2025 at 11:31 AM with Nurse Tech (NT)-A revealed Resident 1's fall on 9/26/2025 was an unwitnessed fall. Interview on 12/30/2025 at 1:27 PM with the Director of Compliance (DOC) revealed the facility did not have any additional documentation of Resident 1's neurological checks. The DOC confirmed the neurological checks were not completed as expected. B. Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 11-11-2025 revealed the facility staff assessed the following about the resident: -admission date was 06-20-2024 -Brief Interview of Mental Status (BIMS) was scored as a 1. According to the MDS Manual a score of 0 to 7 indicates severe cognitive impairment. -Required limited assistance with bed mobility and upper body dressing. -Required extensive assistance with hygiene, toileting, bathing, lower body dressing and transfers. -was frequently incontinent of bowel and bladder. -had 2 or more falls in the last 90 days. -was receiving hospice care. Record review of Resident 2's fall investigations revealed Resident 2 had an unwitnessed fall on 07-31-2025 and 08-01-2025. Record review of Resident 2's progress notes, evaluations, and miscellaneous documents did not reveal neurological checks were conducted after both unwitnessed falls. An interview with the Director of Compliance on 12-30-2025 at 1:25 PM confirmed neurological checks were not conducted after the unwitnessed falls on 07-31-2025 and 08-01-2025 and should have been. C. Record review of the facility policy titled Bowel Management dated 01-01-2023 revealed all residents should be monitored, and staff should intervene when necessary to prevent constipation. The nurse or designee should review bowel movement records to determine which residents have gone 3 or more days without having a Bowel Movement (BM) and report to the oncoming nurse. The nurse should contact the provider if there are no as needed (PRN) bowel medication orders and obtain, as necessary. The nurse should administer a laxative or stool softener as ordered to the resident who have not had a BM. If there have been no results from the PRN bowel medication by the following day, the nurse should administer further PRN medications as ordered. The provider should be called if no results from the above interventions. Record review of Resident 2's bowel records revealed Resident 2 did not have BM from 12-10-2025 to 12-17-2025 and no BM from 12-26-2025 to 12-30-2025. Record review of Resident 2's Medication Administration Record (MAR) for December 2025 revealed no PRN bowel medications were administered between 12-10-2025 and 12-17-2025 or 12-26-2025 and 12-30-2025. An interview conducted with Licensed Practical Nurse (LPN) I on 12-30-2025 at 6:35 AM revealed the night shift nurse runs a report from the Electronic Health Record and a list of residents that have not had a BM for 3 days are placed on the list. The list is communicated through shift change report and each resident on the list are given the PRN bowel medication. An interview conducted with Nurse Tech (NT) H on 12-30-2025 at 7:40 AM revealed when Resident 2 had a BM, the staff document the BM in the Electronic Health Record. An interview conducted with the Clinical Care Coordinator (CCC) G on 12-30-2025 at 2:30 PM confirmed Resident 2 was not provided with PRN bowel medications between 12-10-2025 and 12-17-2025 or 12-26-2025 and 12-30-2025 and should have been.

B. Record review of Resident 1's admission Record revealed the facility admitted the resident on 9/11/2025. Further review of the admission record identified the resident had diagnoses that included infection and inflammatory reaction due to internal left knee prosthesis, bacteremia (a blood stream infection of bacteria in the blood), myasthenia gravis (a chronic autoimmune disease causing fluctuating weakness in voluntary muscles such as the eyes, face, throat, and limbs due to nerve-muscle communication breakdown, where antibodies block signals, worsening with activity and improving with rest), essential tremors, abnormalities of gait, and unsteadiness on feet. Record review of Resident 1's admission 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 9/17/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS Manual, a score of 15 indicated the resident was cognitively intact. The MDS identified Resident 1 had no behaviors including rejection of care. Further review of the MDS identified Resident 1 had a range of motion impairment on one side with both upper and lower extremities and was dependent upon staff for assistance with transfers. Record review of a Witnessed Fall Risk Management document dated 9/26/2025 pertaining to Resident 1 revealed nurse technicians notified the nurse assigned to care for Resident 1 that Resident 1 tried to take a step to reach his bed and he fell into the bed with his feet on the floor. Further review of the document showed Resident 1 reported that [gender] tried to reach the bed, but [gender] felt the socks caught on the carpet and caused him to fall forward onto the bed. The risk management document showed the resident as transferred off the floor and into the bed with a full body mechanical lift, there was no injury noted after the fall, and predisposing physiological factors included gait imbalance. The risk management also included a statement from Staff dated 9/27/2025 that read Resident 1 was assisted back to bed without difficulty and denied any pain. No injury noted. There were no other statements or investigative documents provided for review. A record review of Resident 1's progress notes dated 9/11/2025 through 10/16/2025 revealed no information regarding the fall. A telephone interview on 12/30/2025 at 9:39 AM with Registered Nurse (RN)-B revealed it was reported to her by Nurse Tech (NT)-A that staff were entering Resident 1's room and Resident 1 was trying to get up. Resident 1 took a step towards the bed and went down on one knee with the torso in the bed. RN-B staff were present at the time Resident 1 went down on the knee. RN-B reported that they did not obtain a written statement of details from the staff members who observed the resident on the knees on the floor and that neurological checks were begun out of habit. In an interview on 12/30/2025 at 11:06 AM, the Assistant Director of Nursing (ADON) revealed the facility reviewed and further investigated falls during the morning clinical start up and IDT meeting. The ADON revealed the facility did not have documentation of the review of Resident 1's fall during the meeting as the facility was not completing the Daily Clinical Review form. A telephone interview on 12/30/2025 at 11:31 AM with NT-A revealed NT-A was in Resident 1's room prior to Resident 1 being observed on his knee at bedside. NT-A reported [gender] had entered Resident 1's room and Resident 1 wanted to transfer from the recliner to bed. NT-A further reported [gender] told Resident 1 that additional help was needed to complete the transfer and to remain in the recliner. When NT-A returned to the room with help, Resident 1 was at the side of his bed, down on one knee with the torso in the bed. NT-A reported that [gender] did not observe the resident go down on the knee, nor did NT-A recall being asked to write a statement of events or being asked additional questions regarding the events surrounding the fall. A follow up interview on 12/30/2025 at 2:22 PM with the ADON revealed the facility had no additional investigative notes or other files to determine whether Resident 1's fall was fully investigated. Record review of facility policy entitled Fall Risk Management Policy dated 01/01/2023 revealed post fall follow up will include an effort to determine root cause. Some examples of this may include observation of the environment, interviews of resident and team members if applicable, an observation of resident condition at the time of the fall. A. Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 11-11-2025 revealed the facility staff assessed the following about the resident: -admission date was 06-20-2024 -Brief Interview of Mental Status (BIMS) was scored as a 1. According to the MDS Manual a score of 0 to 7 indicates severe cognitive impairment. -Required limited assistance with bed mobility and upper body dressing. -Required extensive assistance with hygiene, toileting, bathing, lower body dressing and transfers. -was frequently incontinent of bowel and bladder. -had 2 or more falls in the last 90 days. -was receiving hospice care. Record review of Resident 2's Comprehensive Care Plan (CCP) revealed Resident 2 was at risk for falls related to being unaware of safety needs. The goal for Resident 2 would have a reduced risk for serious injury. Interventions the staff were to implement were: -Call Don't Fall sign placed in room dated 10-21-2024. -hospice ordered and provided a scoop mattress dated 12-05-2025. -Be sure call light is within reach and encourage resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Dated 07-03-2024/ -a bell was provided to resident and a sign on the bedside table reminding resident to use call light or bell for assistance. -pillows removed from wheelchair and a cushion ordered by hospice. Dated 09-08-2025. -if Resident 2 is restless during the day or night, staff were to bring resident out of room and set up a western movie to be watched in the day room dated 09-09-2025 -keep room clear of any obstacles dated 11-29-2024. -rounds to be increased when resident in the room to prevent resident from getting up without assistance dated 11-10-2025/ -Dycem and cushion placed to the seat of the recliner to prevent sliding out of the chair dated 11-05-2025. -staff to offer toileting frequently during each shift. An observation conducted on 12-29-2025 at 11:18 AM revealed Resident 2 was sitting in wheelchair in room and Resident 2's bell was sitting on dresser next to the television. An observation conducted on 12-29-2025 at 2:35 PM revealed Resident 2 was in bed, call light in reach and bell was still on the dresser next to the television out of Resident 2's reach. An observation conducted on 12-30-2025 at 6:20 AM revealed Resident 2 was lying in bed and unable to observe the location of the call light and the bell was on the dresser next to the television out of Resident 2's reach. An observation conducted on 12-30-2025 at 7:40 AM revealed Resident 2 was in bed and Nurse Tech (NT) H entered the room to provide assistance. NT H confirmed Resident 2 did not have a call light in reach or the bell and took the bell off of the dresser next to the television and placed it on Resident 2's bedside table. An interview conducted with NT H on 12-30-2025 at 11:20 AM revealed Resident 2's call light was broken and a work order had been placed for it to be repaired. An interview conducted with the Environmental Service Director (EVSD) on 12-30-2025 at 12:30 PM revealed a work order had not been placed for the repair of Resident 2's call light. An interview conducted with the Assistant Director of Nursing (ADON) on 12-30-2025 at 12:35 PM confirmed that Resident 2 was without a call light and bell for over an hour and should a call light and hand bell in reach.

Based on record review and interview, the facility failed to evaluate change of condition for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 119. Findings are:A. A review of Resident 3's admission Record revealed Resident 3 was admitted to the facility on [DATE] with a diagnosis of infection and inflammatory reaction due to internal right hip prosthesis, chronic systolic heart failure [a condition in which the heart muscle is weakened and cannot pump blood effectively], and presence of prosthetic heart valve. A review of Resident 3's Progress Note dated 8/22/25 revealed Brief Interview for Mental Status [an evaluation of cognitive status] score of 11. A review of MDS [Minimin Data Set; a comprehensive assessment used for care planning] Manual revealed a score of 8-12 indicates moderately impaired cognitive impairment. A review of Resident 3's oxygen saturation levels [a percentage of oxygen carried by red blood cells in the blood stream] documented in the vitals section of the electronic medical record revealed Resident 3's oxygen saturation level was between 92-98% on room air between 8/21/25-8/29/25. A review of undated facility document titled Vital Sign Alert Parameters identified a low threshold of less than 90% for oxygen saturation. A review of Resident 3's oxygen saturation level documented in the vitals section of the electronic medical record revealed an oxygen saturation level of 86% on room air at 9:59 PM on 8/29/25. A review of Resident 3's Progress Note dated 8/30/25 at 4:03 AM revealed Resident 3's oxygen saturation was low in one hand and above 90% in the other hand on 1.5 liters of oxygen. A review of Resident 3's order recap report for orders between 8/21/25-9/30/25 did not reveal an order for oxygen. A review of Resident 3's oxygen saturation level documented in the vitals section of the electronic medical record revealed the following oxygen saturation levels:-8/30/25 at 7:17 AM 90% on room air-8/30/25 at 6:25 PM 86% on room air A review of Resident 3's Progress Note on 8/30/25 at 8:30 PM revealed Resident 3's oxygen saturation level was rechecked and found to be 91% on room air. Resident 3 was noted to refuse oxygen. A review of Resident 3's oxygen saturation level documented in the vitals section of the electronic medical record revealed an oxygen saturation level of 54% on 8/31/25 at 6:58 AM. In an interview on 9/3/25 at 12:55 PM, Nurse Aide A reported that Nurse Aide A checked Resident 3's oxygen saturation level on 8/31/25. Nurse Aide A first checked oxygen saturation on Resident 3's pinkie finger and it was 42-47%. Nurse Aide A then checked oxygen saturation level on Resident 3's ring finger and it started going up to 57-59%. Nurse Aide A reported Resident 3's other vital signs were normal and Nurse Aide A got busy and forgot to notify the nurse of the oxygen saturation level. In an interview on 9/3/25 at 1:17 PM, Medication Aide B reported Resident 3's oxygen saturation level was low and Medication Aide B replaced Resident 3's oxygen when checked on 8/31/25. Medication Aide B reported that Resident 3 was not having trouble breathing. In an interview on 9/3/25 at 11:59 AM, Registered Nurse C reported that Registered Nurse C was not alerted by staff that Resident 3's oxygen level was low. Registered Nurse C reported being alerted by dietary staff around 9:30 AM on 8/31/25 that Registered Nurse C needed to check on Resident 3. Registered Nurse C entered the room and discovered that Resident 3 was gone. A review of Resident 3's Progress Note dated 8/31/25 at 3:49 PM revealed that Registered Nurse C was notified at 9:30 AM that Resident 3 was not responding. Resident 3 was checked on and no signs of life were noted including no heartbeat or respirations. In interviews on 9/3/25 at 4:07 PM, 4:48 PM, and 5:23 PM, the Director of Nursing reported the expectations:-Resident 3's doctor/provider would have been notified when oxygen was applied to Resident 3-When Resident 3's oxygen saturation was low the physician orders would have been checked for any orders for oxygen or as needed medication orders-Resident 3 would have been checked to ensure Resident 3 was breathing through the nose as oxygen was coming through nasal cannula-Resident 3's oxygen saturation level would be rechecked and if oxygen saturation level did not improve doctor would have been called A review of undated facility policy titled Change In Condition or Status of Guest revealed the following:- 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (Interact Version 4.0) Communication Form. B. In interviews on 9/3/25 at 7:47 AM, 10:12 AM, and 10:30 AM, the Administrator reported that an investigation was started on 8/31/25 after Administrator was notified of Resident 3's death with involved staff members being suspended. The Administrator reported that education was of all nursing staff members with all nursing staff members required to complete the education before the next scheduled shift. An audit of all residents with oxygen was completed to ensure oxygen orders were in place. Vital sign parameters were posted in facility clinics. A review of facility education began on 8/31/25 revealed staff members were educated about the following:-Clinical alert monitoring-Change in Condition or Status policy A review of facility competency checks revealed competency evaluations began on 8/31/25 on notification of nurses of changes of condition.

Licensure reference: 175 NAC 12-006.09(I)(i)(1) Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were implemented for 2 [Residents 4 and 7] of 4 sampled residents with falls. The facility had a total census of 142 residents. Findings are: A. A review of Resident 4's Admission Record revealed Resident 4 was admitted to the facility on [DATE] with a diagnosis of displaced fracture of lateral end of right clavicle and acute respiratory failure with hypoxia. Admission Record indicated Resident 4 was discharged to an acute care hospital on 2/27/25. A review of Resident 4's MDS [Minimum Data Set; a comprehensive assessment used for care planning] dated 2/10/25 revealed Resident 4 required partial/moderate assistance with transfer and supervision or touching assistance with walking 10 feet. Resident 4 was identified has having falls in the last month prior to admission and fall with fracture in the last 6 months prior to admission. Resident 4's Brief Interview for Mental status score was 5 indicating severe cognitive impairment. A review of Resident 4's Fall Risk Evaluation dated 2/5/25 identified Resident 4 as being at a high risk for falls. A review of Resident 4's Care Plan revealed a focus area dated 2/14/25 for actual fall with no injury. The following interventions were listed for Resident 4: -Bed alarm placed dated 2/14/25 -Physical Therapy consult for strength and mobility dated 2/14/25 -Resident to be offered as one of the first to get up in the mornings dated 2/27/25 -Scoop mattress to bed dated 2/27/25 A review of Incident Report dated 2/14/25 at 5:00 AM revealed Resident 4 was found next to bed with brief around knees and puddle of urine under Resident 4. In the notes section of the Incident Report was identified that bed alarm was placed for Resident 4 on 2/14/25. A review of Incident Report dated 2/27/25 at 8:30 AM revealed Resident 4 was found on the floor next to bed. Under the notes section of the Incident Report was identified that Resident 4 was sent to the emergency room for evaluation of treatment of left hip fracture. A review of Resident 4's Treatment Administration Record for 2/2025 revealed the alarm function need to be checked to ensure proper placement and functioning every shift. The section for the night shift on 2/26/25 had not been completed to indicate that Resident 4's alarm was in placed and functioning. The section for the day shift on 2/27/25 was initialed to indicate that Resident 4's alarm was on and functional. In an interview on 3/11/25 at 11:48 AM, Medication Aide A confirmed that when Resident 4 fell out of bed on 2/27/25 Resident 4's alarm did not go off. In an interview on 3/11/25 at 11 AM, the Director of Nursing reported that staff had signed off indicating the alarm was in place when Resident 4 fell but the alarm was not in place. Staff had been educated on ensure fall interventions were in place. In interviews on 3/11/25 at 12:18 PM and 3:15 PM, Clinical Care Coordinator B confirmed that Resident 4's alarm was not on when Resident 4 fell . Clinical Care Coordinator B reported obtaining a new alarm and placing it on Resident 4 after Resident 4 fell . Clinical Care Coordinator B reported staff had been educated on checking alarms to ensure alarms were in place and functional. Clinical Care Coordinator B reported doing monitoring of residents with alarms since Resident 4's fall to ensure that alarms were in place and functional. B. A review of Resident 7's Admission Record revealed Resident 7 was admitted to the facility on [DATE] with a diagnosis of infection and inflammatory reaction due to internal right knee prosthesis. A review of Resident 7's MDS dated [DATE] identified Resident 7 was dependent for transfer and was not able to walk 10 feet. Resident 7's Brief Interview for Mental Status identified a score of 3 which indicates severe cognitive impairment. A review of Resident 7's Care Plan revealed a focus area of Resident 7 had an actual fall with no injury dated 2/19/25 with the following interventions identified: -Alarm to wheelchair and bed to alert staff when guest is getting up dated 2/24/25 -Continues to be on skilled therapy for strength and mobility. Consulted with Occupational Therapy for wheelchair cushion suggestions dated 2/19/25 -Dycem applied to wheelchair and talked with therapy who provided a different cushion type with the hope to reduce the chance of Resident 7 sliding out dated 2/19/25 -Resident 7 should have alarm on wheelchair and bed at all times. Staff working with Resident 7 to be educated to keep alarms on and to monitor that Resident 7 has it under Resident 7. Observations on 3/11/25 at 11:42 AM revealed Resident 7 in wheelchair in common area with alarm in place and functioning. Another alarm was observed in place on Resident 7's bed. A review of Incident Report for Resident 7 dated 2/16/25 revealed Resident 7 was found on the floor during routine rounding. Resident 7 was found on floor in front of wheelchair with both legs pulled up trying to get self back in wheelchair. Resident 7 was not found to have any apparent injuries. In the notes section of the Incident Report was identified that Dycem was applied to Resident 7's wheelchair and therapy had provided a different cushion type. A review of Incident Report for Resident 7 dated 2/20/25 revealed Resident 7 sliding out of wheelchair to the floor. Resident 7 was not found to have any apparent injuries. In the notes section of the Incident Report was identified that Resident 7 was placed on increased rounds and alarm was placed in wheelchair and bed. A review of Incident Report for Resident 7 dated 2/28/25 without a time revealed Resident 7 was found sitting on the floor by Resident 7's bed. Resident 7 reported Resident 7 was trying to get in bed. Resident 7 was not found to have any apparent injuries. In the notes section of the Incident Report was identified that Resident 7 should have an alarm on wheelchair and bed at all times. Staff members working with resident to be educated on keeping alarms on and to monitor that alarm is under Resident 7. A review of Resident 7's Treatment Administration Record for 2/2025 revealed the alarm function need to be checked to ensure proper placement and functioning every shift. The section for day and evening shift on 2/28/25 had been initialed to indicate that Resident 7's alarm was placed and functioning. The section for the night shift on 2/28/25 was not initialed to indicate that Resident 7 was in place and functional. In an interview on 3/11/25 at 3:20 PM, Clinical Care Coordinator B confirmed Resident 7's alarm was not in place when Resident 7 fell on [DATE]. Clinical Care Coordinator B report that Resident 7 did not have a functional alarm in chair on 3/3/25. Clinical Care Coordinator B reported providing education to staff on ensure that alarms were in place and functional on 3/4/25. C. A review of facility education documentation dated 2/28/25 revealed staff members were educated on ensuring that alarms are on and functioning before initializing treatment administration record that alarm is in place. D. A review of facility education documentation dated 3/4/25 revealed staff members were education on ensuring all fall interventions are in place. E. In interviews on 3/11/25 at 1:45 and 2:45 PM, the Administrator reported a review of falls was began on 2/26/25 as the initial step in establishing a process improvement program regarding falls.

Licensure Reference Number 175 NAC 12-006.09D3 Based on interviews and record reviews, the facility failed to evaluate urinary incontinence on admission and with a decline in continence for 2 residents (Residents 34 and 138) of 2 residents sampled and the facility failed to evaluate the use of an indwelling Foley catheter for 1 resident (Resident 62) of 3 residents sampled. The facility staff identified the resident census at 110 . The findings are: A. A review of Resident 34's Face Sheet dated 8-1-17 revealed the resident was admitted to the facility on [DATE]. A review of Resident 34's comprehensive admission Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 3-7-17 revealed that the resident was not on a toileting plan, had frequent bladder incontinence, and was continent of bowel. The resident required extensive assistance with the help of 2 staff to transfer and use the toilet. A review of Resident 34's ADL (Activities of Daily Living) Verification Worksheet dated 2-28-17 to 3-7-17 revealed the resident was incontinent of 11 out of 16 times bladder elimination was documented. A review of Resident 34's MDS dated [DATE] revealed that the resident was not on a toileting plan, was always incontinent of bladder, and frequently incontinent of bowel. The resident required extensive assist of 1 staff to transfer and use the toilet. A review of Resident 34's ADL Verification Worksheet dated 5-31-17 to 6-6-17 revealed that the resident was incontinent 17 out of 17 times bladder elimination was documented. A review of Resident 34's medical record revealed no documentation of an evaluation of the resident's continence since the resident admitted to the facility. B. A review of Resident 138's Face Sheet revealed the resident was admitted to the facility on [DATE]. A review of Resident 138's comprehensive admission MDS dated [DATE] revealed the resident was not on a toileting plan and was occasionally incontinent of bladder. The resident required extensive assist for transfers and toileting. A review of Resident 138's ADL Verification Worksheet dated 3-14-17 to 3-20-17 revealed the resident was incontinent of urine 1 out of the 22 times bladder elimination was documented. A review of Resident 138's MDS dated [DATE] revealed the resident was not on a toileting plan and was frequently incontinent of bladder. The resident required extensive assist for transfers and toileting. A review of Resident 138's ADL Verification Worksheet dated 6-8-17 to 6-15-17 revealed the resident was incontinent of urine 30 out of the 38 times bladder elimination was documented. A review of Resident 138's Care Plan dated 6-8-17 revealed a goal to have increased continence and an intervention to complete incontinence assessments as indicated. A review of Resident 138's medical record revealed no documentation of an evaluation of the resident's continence since the resident admitted to the facility. C. An interview conducted on 8-1-17 at 10:52 AM with the Education Specialist revealed there had been no incontinence evaluations completed for Resident 138. An interview conducted on 8-1-17 at 11:09 AM with MDS Coordinator E revealed that the process for a decline in continence was to do an evaluation, talk to the physician if needed, and update the care plan. An interview conducted on 8-1-17 at 11:38 AM with the Director of Nursing (DON) revealed their expectation was that a bowel and bladder evaluation was to be done on admission. The DON reported that if a resident had a decline in continence the staff should check for an infection. If there was no infection present, the staff should complete a bowel and bladder log, determine why the resident had a decline and put interventions into place. An interview conducted on 8-1-17 at 12:40 PM with the DON revealed that the DON had done a random check of residents' medical records and found that incontinence evaluations were not being completed on admission. A review of the facility's Bladder Incontinence Management Program dated 4/2016 revealed Procedure: 1. Bladder assessments will be completed on admission, with a quarterly assessment, and PRN (as needed). C. During Stage 1 staff interviews, on 07/26/2017 at 10:08 AM, interview revealed that Resident 62 had an indwelling Foley catheter (a device that is placed in the bladder to facilitate the drainage of urine) was in use. Record review of Resident 62's admission records dated 06/28/2017 revealed that there were no orders for use of nor any indications for a Foley catheter. Record review of the hospital Continuum of Care Transfer Report for Resident 62 dated 06/27/2017, make no mention of the Foley catheter other than to state it was placed on 06/22/2017. Record review of Resident 62's care plan dated 06/28/2017, under the section interventions, it has the following two interventions: Incontinence assessment as indicated and [DIAGNOSES REDACTED]. Record review of Resident 62's assessments revealed that there was no urinary assessment or incontinence assessment found. An interview with Nurse Tech C (NT C) on 07/31/2017 at 03:50 PM revealed that the resident does not have any reddened or broken skin. An interview with Registered Nurse D (RN D), on 07/31/2017 at 10:20 AM, revealed that the Resident 62 had removed (gender) Foley on Saturday evening (07/29/2017) and that Resident 62 currently did not have another Foley in place. A follow-up interview with RN D on 07/31/2017 at 3:25 PM revealed that RN D just received an order to discontinue the Foley for this resident. RN D could not say if any staff had attempted to replace the Foley, but the process would be to either replace as soon as practically possible or get an order to discontinue the Foley. Interview with the DON on 08/01/2017 at 09:00 AM, revealed that the DON's expectations for Foley usage was that, if a resident was admitted with one, that the use of the Foley should be reevaluated for continued use and, if the Foley usage would not be indicated, that it should be removed within two weeks of admission. The DON stated that hospice wanted the Foley to remain, but confirmed that here was no assessment found to continue the use of the Foley.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 2 residents (Resident 6 and Resident 9), and failed to identify and implement additional interventions for 1 resident (Resident 9). The facility staff identified a census of 109. Findings are: A. Record review of an Admission Assessment sheet printed on 4-25-2016 revealed Resident 6 was admitted to the facility on [DATE]. Record review of Resident 6's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 3-29-2016 revealed the facility staff assessed the following about Resident 6: -Short and long term memory problems. -Required supervision for personal hygiene,dressing, eating and locomotion off the unit. -Required extensive assistance with bed mobility, transfers, locomotion on the unit and toilet use. -Balance during transitions and walking was assessed as not steady, only able to stabilize with staff assistance. -[DIAGNOSES REDACTED]. -1 fall since admission to the facility. Record review of a Fall Risk Assessment sheet dated 3-17-2016 revealed Resident 6 scored a 12. According to the Fall Risk Assessment sheet dated 3-17-2016, a score of 10 or above identified that a resident should be considered high risk for potential falls. Record review of Resident 6's Care Plan (CP) printed on 4-25-2016 revealed an effective date of 3-17-2016 to present. Further review of Resident 6's CP identified Resident 6 had falls. The goal was that Resident 6 would not have any falls with injury. The intervention listed on the CP included Falling Leaf as indicated, encourage to use call light, Physical and Occupational therapy as ordered. Further review of Resident 6's CP revealed an additional problem area that Resident 6 was at risk for falls and Resident 6 will have reduced risk for falling. The goal was Resident 6 would demonstrate the ability to ambulate/transfer without fall related injuries over the next 90 days. Interventions listed on the CP included keeping the area free of obstructions, place call bell/light within easy reach, respond promptly to calls for assistance to the toilet, use alarm to monitor attempts to rise and foot wear to fit properly and have non-skid soles. Record review of a Nursing Tech Care Plan ( NTCP, sheet of paper that identified basic information and care needs of Resident 6) dated 3-17-2016 revealed Resident 6 was to have alarms that were pressure (activated) to the bed and Tab alarm. Record review of the NTCP dated 3-18-2016 revealed the pressure or tabs alarms were no longer identified as an intervention to prevent potential falls. Record review of the NTCP dated 3-23-2016 revealed the pressure or tabs alarms were no longer identified as an intervention to prevent potential falls. Record review of a Clinical Notes Report (CNR) sheet dated 3-25-2016 revealed Resident 6 was found sitting on the floor. The alarm was sounding but very softly. According to the CNR dated 3-25-2016 the tab alarm had been placed on Resident 6 when in bed or a chair. Record review of a Causal Factors sheet signed by Registered Nurse (RN) C on 3-25-2016 revealed interventions were to place Resident 6 onto a falling star program, placed a chair alarm, relocated alarm box out of resident sight and blue pads at bed side. An interview on 4-26-2016 at 10:23 AM was conducted with RN C. During the interview review of the NTCP dated 3-18-16 and 3-23-16 for Resident 6 was completed. During the interview, RN C confirmed the interventions for the pressure alarm and Tabs alarm was not identified on the NTCP. RN C stated they should have been. When asked if the pressure alarm had been in place when Resident 6 was found on the floor, RN C reported the pressure alarm was not in place. When asked what interventions were implemented after Resident 6 was found on the floor, RN C reported the pressure alarm and blue pad. Record review of a CNR sheet dated 3-26-2016 revealed Resident 6 was on the floor and the alarm had not sounded. Record review of a CNR dated 3-27-2016 revealed Resident 6's practitioner was informed that Resident 6 was having pain and the right leg was externally rotated. The practitioner ordered an x-ray of the right hip. Record review of a Radiology Report dated 3-27-2016 revealed the results of the x-ray was that Resident 6 had a right femur fracture. On 4-26-16 at 10:51 AM an interview was conducted with RN D. During the interview, review of the facility investigation was completed with RN D. When asked if the pressure alarm and blue pad was in place, RN D stated I'm not sure. Record review of information sheet titled Accidents dated 3-28-2016 revealed the date of the incident was 3-26-2016. The Accident sheet identified bed and chair alarms were to be used and the interventions to prevent the accident/incident from reoccurring was identified as a bed and tab alarm were on the resident and functioning with frequent checks by team member. Further review of the Accident sheet dated 3-28-2016 revealed there was not any indication the mat at bed side was in place or why the pressure alarm did not sound. On 4-27-2016 at 2:21 PM a phone interview was conducted with Licensed Practical Nurse (LPN) F. During the interview, review of Resident 6 being found on the floor on 3-26-2016 was conducted with LPN F. LPN F confirmed during the interview that (gender) was the nurse for Resident 6 on 3-26-2016. When asked if the sensor alarm and blue pad was next to Resident 6's bed, LPN F stated no, they weren't. LPN F further reported that the reason (gender) remembered was the Nurse Tech was going to place one under the resident. B. Record review of Resident 9's Face Sheet dated 04/26/2016 revealed that Resident 9 was admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident 9's Minimum (MDS) data set [DATE] revealed that Resident 9 had a Brief Interview for Mental Status (BIMS) Score of 4; (BIMS scores between 0 and 7 indicate severe cognitive impairment). Record review of Resident 9's care plan for falls dated 04/26/2016 revealed a goal of will have no fall with injury and the following interventions to prevent falls: - Alarms in place all the time/TAB, - Frequent rounding, - Engage patient in activities with rec therapy, - Offer snacks and redirection in the afternoon, - Fall risk assessment completed, - Encourage to use call light. Record review of a Fall Risk assessment dated [DATE] revealed it was started but not completed. This was confirmed by Registered Nurse (RN H) on 04/26/2016. A second fall risk assessment was completed on 04/18/2016 and revealed that Resident 9 had a fall risk score of 16. The assessment states high risk is a score of 10 or above. Record review of Nursing Progress notes, dated 04/10/2016, revealed Resident 9's bed alarm was sounding and Resident was found sitting on the floor. No injuries noted Record review of Nursing Progress notes, dated 04/23/2016, revealed Resident 9 was found on the floor in front of Resident 9's wheel chair. Tab alarm was attached but did not disconnect from the alarm box and sound. No injury noted. Interview with RN H, on 04/26/2016 at 11:18 AM revealed there were no new interventions identified and put in place following two of Resident 9's falls-04/10/2016 fall and the 04/23/2016 afternoon fall.