Every finding on record at Hillcrest Millard LLC

Licensure reference: 175 NAC 12-006.09(H)(iv)(6) Based on record review and interview, the facility failed to ensure an assessment was completed of pressure ulcers on admission and readmission for 1 [Resident 3] of 4 sampled residents. The facility had a total census of 61 residents. Findings are:A.A review of facility policy dated 1/1/26 titled Skin Integrity and Wound/Pressure Injury assessment, Treatment and Documentation Policy revealed the following: - 1. A full body skin assessment should be conducted by a licensed nurse upon admission and then weekly- 2. The assessment may be performed after a change in condition or after any newly identified alterations in skin integrity.- 3. When a skin integrity/wound concern is present upon admission, identified during a weekly skin assessment, or any time during a stay the nurse needs to notify the physician for a treatment plan if one is not already in place. The nurse will complete and document the weekly skin assessment finding.- 4. Assessment and documentation: a. A registered nurse may stage and determine the etiology of a wound. An LPN can stage a wound but an RN/licensed provider is needed to determine the etiology and make a comprehensive assessment of the wound based off of the LPN's data/information gathered. b. If a pressure injury is identified after admission assessment is completed, the nurse may consult with the wound care nurse/designee. c. When a pressure injury is present, daily monitoring may include the following: i. If not dressing is present, evaluation of the ulcer, to include wound bed, undermining and tunneling, exudate and surrounding skin. ii. If dressing is present; evaluation of dressing if it is intact drainage present. iii. The color/condition of surrounding skin iv. Presence of complications, such as, signs of ulceration or soft tissue infection (redness or swelling, warmth) v. Pain or increase in pain vi. Result of current treatment/interventions d. Routine measurements are completed on areas of impaired skin integrity. Hillcrest's best practice is using a clock-face-method. i. Length-head to toe orientation. 12-6 clock face orientation ii. Width-hip to hip orientation. 3-9 clock face orientation iii. Depth-if there is not depth, this equals zero. Deepest part(s).Wound baseUnderminingTunneling.e. Discussion with the interdisciplinary teams on the status of the wounds should occur if the wound is not showing progress toward healing within 2-4 weeks and as needed to determine the need for change of treatment recommendations and interventions. B. A review of Resident 3's admission Record revealed Resident 3 admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record included the following diagnoses for Resident 3: pressure ulcer of sacral region, unstageable, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side [stroke], small cell B-cell Lymphoma [non-[NAME] lymphoma], unspecified site, unspecified severe protein-calorie malnutrition, and Adult Failure to Thrive. A review of Resident 3's admission Minimum Data Set [a comprehensive assessment used for care planning] dated 6/13/26 revealed the following:-A Brief Interview for Mental Status score of 14 which indicated Resident 3 was cognitively intact-Resident 3 had a stage 4 pressure ulcer that was present on admission-Resident 3 had an unstageable pressure ulcer present on admission A review of Resident 3's Care Plan revealed a focus area related to Resident 3 being admitted with a sacral pressure injury and a pressure injury to their (gender) left heel dated 6/13/26 with the following interventions:- Assess/record/monitor wound healing per protocol/order. Measure length, width and depth where possible. Report improvements and declines to the MD [Medical Doctor]. Initiated 6/13/26- If the resident refuses treatment, confer with the resident, IDT [Interdisciplinary Team] and family to determine why and try alternative methods to gain compliance. Document alternative methods. Initiated 6/13/26- Prafo boots per order. Initiated 6/13/26- The resident has an air mattress in place. Initiated 6/13/26- The resident needs assistance to turn/reposition at least every 2 hours. Initiated on 6/13/26- Treat pain as per orders prior to treatments/turning etc. to ensure the resident's comfort. Initiated 6/13/26- Weekly treatment documentation by facility wound nurse. Initiated on 6/13/26- Wound healing supplements as ordered, see MAR/TAR [Medication Administration Record/Treatment Administration Record]. Administer treatments as ordered, see TAR. Monitor for tx [treatment] effectiveness per protocol/order. Initiated on 6/29/26 A review of Resident 3's hospital wound consult notes dated 5/19/26 revealed the following description of Resident 3's wound:-Suspected deep tissue injury located on coccyx measures 5 cm x 3.5 cm x unknown-The wound is considered a deep tissue injury- The wound bed is described as contained contain dark purple/maroon discoloration, slough, and eschar and has no exposed subcutaneous tissue, muscle, tendon, and bone.- The skin around the wound is dry and intact.- There is minimal amount of serosanguinous exudate draining from the wound. A review of Resident 3's admission assessment dated [DATE] revealed the following under the skin section:-Right lower front leg skin tear-Left lower front leg skin tear-Left heel pressure ulcer-Sacrum pressure ulcer-The admission assessment dated [DATE] did not include any measurements or descriptions of any of the wounds. A review of Resident 3's 5/26 MAR [Medication Administration Record] revealed the following treatment ordered for Resident 3's sacrum: - Coccyx 1. Cleanse with wc [wound cleaner] 2. Pat dry 3. Apply [NAME] thick Santyl [an ointment that clears dead tissue from skin ulcers] to wound bed. 4. Top with moisten gauze 5. Cover with ABD [bandage] - Secure with paper or medipore tape only bid [twice per day] and prn [as needed].-Treatment order was dated 5/28/26 and documented as completed A review of Resident 3's Skin Evaluation dated 5/31/26 revealed the following regarding coccyx pressure wound:-Stage: unstageable [depth is hidden by slough or eschar]-Wound bed: slough-Wound exudate: None-Periwound condition: within normal limits-Dressing saturation: none-Wound odor: no-Tissue: painful- Unstageable pressure ulcer noted to coccyx area. Slough tissue noted to center of wound. No noted redness to surrounding wound. No noted drainage/bleeding noted to site.-The Skin Evaluation on 5/31/26 did not include any measurements of the coccyx wound. A review of Resident 3's Progress Note dated 6/3/26 at 6:28 PM as a late entry revealed wound rounds were completed with the following evaluation:- Coccyx described as unstageable PI [Pressure injury] present on admit wound noted to be deteriorating since admit 100% black slough to entire wound bed with heavy purulent drainage and strong foul odor present guest c/o [complains of ] increased pain and discomfort to wound, periwound noted to be macerated pink/white in color. Pain medication and offered to give guest breakfast and wound complete wound measurements and TX [treatment] at a later time when pain had subsided, guest declines and would like TX to be completed at this time approximate measurements 7.0 x 6.0 unable to determine depth d/t [due to] amount of slough in wound bed TX was completed per orders to wash with WC [wound cleaner], pat dry apply nickel thick Santyl to wound top with moist gauze and cover with ABD [wound dressing] and secured with medipore tape. A further review of Resident 3's Progress Note dated 6/3/26 at 6:28 PM as a late entry revealed the following:-The Nurse Practitioner was notified and requested information about outpatient wound care referrals. Wound care was contacted and was unable to get Resident 3 until 6/29/26 and suggested sending Resident 3 to emergency room for evaluation and treatment via non emergent transport. A review of Resident 3's 6/3/26 at 4:38 PM Progress Note revealed Resident 3 left via ambulance for hospital at 4:40 PM. A review of Resident 3's Hospital Wound Consult dated 6/8/26 revealed the following regarding Resident 3's sacrum wound:-Size approximately 8 cm x 7 cm x 3 cm- This wound is considered Full-thickness. The wound bed is described as containing no granular, non-viable tissue and has exposed subcutaneous tissue and bone. The skin around the wound is dry and intact. There is a scant amount of serosanguinous exudate draining from the wound. A review of Resident 3's Nursing admission Screening dated 6/8/26 revealed Resident 3 re-admitted with Stage III Pressure ulcer [a pressure ulcer that extends through the skin's top layers into the fatty subcutaneous tissue] to sacrum with wound vacuum to sacrum running @ 125 mm Hg (wound vac settings). A review of Resident 3's 6/26 MAR revealed the following treatment order for sacrum wound:- Remove old dressing. Cleanse wound with gentle wound cleanser or saline. Pat Dry. Prep peri-wound area with skin prep. Apply drape. Place one piece of white foam over exposed bond and top with black foam. One time per day every Monday, Thu [Thursday]-Treatment was signed off as completed on 6/11/26 and 6/15/26 A review of Resident 3's 6/12/26 Skin Only Evaluation identified that Resident 3 had current skin issues and refused evaluation. A review of Resident 3's 6/17/26 Progress Notes for Wound Rounds revealed the following description of Resident 3's sacrum wound:- Sacrum described as ST 4 PI [Stage 4 Pressure Injury] present on readmit after surgical debridement full thickness loss with new granulation tissue present with exposed subcutaneous tissue and bone present in wound bed measuring 8.0 x 7.03.0 moderate amount of drainage no evidence of s/s of infection surgically debrided and NPWT [Negative Pressure wound Treatment] placed . A review of Resident 3's Progress Notes revealed Wound Rounds were completed on the following dates: 6/25/26, 6/29/26, 7/6/26, and 7/13/26. A review of Resident 3's Progress Notes revealed Resident 3 discharged from the facility on 7/14/26. In an interview on 7/20/26 at 1:18 PM, Clinical Care Coordinator reported seeing Resident 3's sacrum wound on 5/28/26, day of admission. Clinical Care Coordinator confirmed Resident 3 had a deep tissue a injury but did not complete an assessment of the wound to include measurements. Clinical Care Coordinator reported getting an order change to Santyl due to how the wound looked. Clinical Care Coordinator confirmed that the first wound assessment for Resident 3 was completed on 6/3/26 at which time wound needed to be debrided and they were unable to get an appointment at the wound clinic. Clinical Care Coordinator confirmed that Resident 3 as readmitted to the facility on [DATE] after debridement of the wound. Clinical Care Coordinator confirmed that first assessment after readmission on [DATE] was dated 6/17/26 but may have been a late entry for 6/15/26. Clinical Care Coordinator confirmed the only assessment of Resident 3's sacrum wound on admission and readmission were the admission Assessments completed on 5/28/26 and 6/8/26. The Clinical Care Coordinator confirmed that the Clinical Care Coordinator assesseed wound on a weekly basis and wounds are assessed by the charge nurse on admission but the charge nurse is not to take measurements of the wound on admission. Further interview on 7/21/26 at 9:39 AM revealed charge nurses are to notify the Clinical Care Coordinator and Nurse Practitioner of changes in a wound. The Clinical Care Coordinator reported completing wound rounds on Wednesdays. Clinical Care Coordinator reported that an admission skin assessment should include a description of how the wound bed looked, identification of any odor or drainage. In an interview on 7/21/26 at 11:38 AM and 1:41 PM , the Director of Nursing reported that a skin assessment is completed on admission and then weekly thereafter. The Director of Nursing confirmed that the admission assessment should include a description of the wound and some type of measurement or description of the size of the wound. The Director of Nursing confirmed the charge nurses have been trained on measurement of wounds. The Director of Nursing confirmed that Resident 3's wound should have been assessed with the first wound vacuum change after admission on [DATE] and the first wound vacuum change was completed on 6/11/26. In an interview on 7/21/26 at 2:58 PM, the Director of Nursing reported not having any additional information to provide at that time.

Licensure Reference Number 175 NAC 12-006.18(D) Based on record review, observation, and interview, the facility failed to follow infection control standards of practice regarding hand hygiene and glove use during wound care for Resident 2. This affected 1 of 3 residents observed for wound care. The facility census was 61. Findings are:Record review of facility policy titled Hand Hygiene Policy dated 1/1/26 revealed that healthcare personnel should use an alcohol-based hand rub or wash their hands with soap and water for the following clinical indications: -Immediately before touching a patient -Before moving from work on a soiled body site to a clean body site on the same patient -After touching a patient or the patient's immediate environment -After contact with blood, body fluids, or contaminated surfaces -Immediately after glove removalIf the task required gloves; perform hand hygiene prior to donning (putting on) gloves, before touching the patient, or the patient environment. Record review of the admission Assessment dated 07/15/2026 revealed that Resident 2 had a penny size area of redness to the coccyx, charted as pressure. Record review of the skin only assessment dated 07/17/2026 revealed that Resident 2 had an open lesion on their coccyx. An observation of wound care was completed on 07/20/2026 from 11:10AM to 11:20AM by Licensed Practical Nurse- A (LPN-A) on Resident 2. Present in the room was also Certified Nursing Aide- B (CNA-B). The observation went as follows:-LPN-A and CNA-B entered Resident 2's room and donned (put on) gloves. Both LPN-A and CNA-B did not perform hand hygiene prior to, upon entrance, or prior to donning gloves for patient care. -Resident 2 required a brief change prior to Calmoseptine (a moisture barrier that protects surrounding skin from wound drainage and treats partial-thickness wounds) application. -LPN-A used bath wipes to complete peri care, using a new wipe with each pass, and wiped front to back. -LPN-A wiped off the previous Calmoseptine that was on Resident 2's coccyx wound. -LPN-A did not remove Resident 2's brief after completion of peri care and did not doff (remove) their gloves at that time. -LPN-A used their finger with the soiled glove to apply the Calmoseptine after inspection of the coccyx wound. -LPN-A removed the soiled brief from beneath Resident 2 and placed a clean brief at that time. -After repositioning the resident, LPN-A doffed their gloves, no hand hygiene was completed.-LPN-A removed the soiled garbage with ungloved hands. -LPN-A exited Resident 2's room and did not complete hand hygiene. An interview on 7/20/2026 at 11:20 AM with LPN-A confirmed that hand hygiene was not completed prior to donning gloves and after doffing gloves during patient cares in Resident 2's room. LPN-A confirmed that they did not change their gloves or perform hand hygiene when moving from a soiled body surface to a clean body surface. LPN-A then confirmed that they used a soiled glove to apply Calmoseptine to the coccyx wound. LPN-A confirmed that they used non-gloved hands to empty the soiled garbage and exited Resident 2's room without performing hand hygiene for the entirety of the observation. An interview on 7/21/2026 at 8:40 AM with LPN-C revealed that the process to apply Calmoseptine was to complete hand hygiene, then don gloves, and assess the wound. They revealed that they wound then doff their gloves, perform hand hygiene, and don new gloves. After donning new gloves, LPN-C reported they would then apply a thin layer of Calmoseptine, doff their gloves, and perform hand hygiene. An interview on 7/21/2026 at 9:01 AM with the Clinical Care Coordinator (CCC) confirmed that the expectation of the staff when applying ointments or creams to wounds was to perform hand hygiene, don gloves, remove the previous cream or ointment, assess the wound, doff gloves, perform hand hygiene, don gloves, apply thin layer of cream/ointment, doff gloves, and perform hand hygiene.

Based on interview and record review, the facility failed to ensure a qualified person was the director of food and nutrition services. This has the potential to affect all 55 residents of the facility. Findings are: A review of certificate dated 11/22/10 submitted on 2/26/26 revealed the Dietary Director had completed an Associate degree in Applied Science General Education. The certificate did not provide any evidence that the Dietary Director had completed the course work for the Dietary Manager certification. In an interview on 2/24/26 at 2:01 PM, the Administrator reported the Dietary Director had completed course work for the Certified Dietary Manager program. According to the Administrator, the Dietary Director could not locate the documentation at the time but the certificate would be submitted to the survey agency.The facility was unable to provide evidence the Dietary Director qualification prior exit on 2224-2026. In a follow up interview on 3-3-2026 at 9:52 AM with Administrator. the Administrator confirmed no additional documentation of the Dietary Director qualifications were available.

Licensure reference: 175 NAC 12-006.11(E) Based on observation and interview, the facility failed to ensure foods were stored in a manner to protect from potential cross contamination, failed to ensure kitchen equipment was maintained in a clean manner, and failed to ensure dietary staff member wore beard restraint. The has the potential to affect all 64 residents of the facility. Findings are: A.Observations on 2/18/26 between 7:21-7:54 AM revealed raw chicken and a precooked chicken patty product being thawed in the same pan on the lower rack in the walk-in refrigerator. In an interview on 2/18/26 at 8:17 AM, the Dietary Director confirmed that raw chicken should not be thawed together with a precooked chicken product. A review of 2022 United States Food and Drug Food Code revealed the following:-Food shall be protected from cross contamination by separating raw animal foods during storage, preparation, holding and display from cooked ready-to-eat food. B.Observations on 2/23/26 at 10:33 AM revealed unwrapped hot dogs lying in the bottom of an unclean food preparation sink in the kitchen. In an interview on 2/23/26 at 10:33 AM, [NAME] A reported that [NAME] A planned to take the hot dogs out of the sink, put them in a zip lock bag and put them in the freezer for use later. In an interview on 2/23/26 at 10:33 AM, Dietary Director confirmed that the sink was not clean and the hot dogs could not be used. Dietary Director discarded the hot dogs. A review of 2022 United States Food and Drug Food Code revealed the following:- During preparation, unpackaged food shall be protected from environmental sources of contamination. C.Observations on 2/18/26 between 7:21-754 AM revealed [NAME] A was preparing and serving breakfast and was not wearing a beard restraint over [NAME] A's beard. Observations on 2/23/26 at 10:36 AM revealed [NAME] A cutting meatloaf for service at lunch and was not wearing a beard restraint over [NAME] A's beard. In an interview on 2/18/26 at 8:17 AM, Dietary Director confirmed that [NAME] A should be wearing a beard restraint. A review of 2022 United States Food and Drug Food Code revealed the following:-Food employees shall wear hair restraints such as beard restraints that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens and unwrapped single service and single-use articles. D.Observations on 2/18/26 between 7:21-7:54 AM revealed the sides and doors of the oven and range, sides of the grill, and drawers under the fryer were heavily soiled with dried on food spills. Observations on 2/23/26 between 10:36-11:05 AM revealed outsides of equipment including range, oven, fryer, and grill continued to be soiled with dried on food spills In an interview on 2/24/26 at 1:28 PM, Dietary Director confirmed the outsides of the cooking equipment was soiled. Dietary Director reported that there was not currently a cleaning schedule and that Dietary Director was doing the cleaning. A review of 2022 United States Food and Drug Food Code revealed the following:- Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. A review of facility policy dated 12/5/17 and titled Culinary Cleaning Policy revealed the following:- Each piece of equipment will have a cleaning procedure and a weekly schedule for cleaning posted in the kitchen.

Licensure reference: 175 NAC 12-006.19 Based on observation and interview, the facility failed to ensure common areas, dining room, and 8 [103, 117, 118, 119, 130, 162, 168, and 176] of 64 occupied rooms were maintained in a clean and sanitary manner. The facility had a total census of 64 residents. Findings are:A. Observation of Resident room [ROOM NUMBER] on 02/18/2026 at 2:32 PM revealed the floor appeared shiny directly under the bed and appeared as though a liquid was spilled and dried. B. Observation of resident room [ROOM NUMBER] on 02/18/2026 at 3:18 PM revealed dried bowel movement on the toilet riser. C. Observation of Resident room [ROOM NUMBER] on 02/18/2026 12:28 PM revealed the toilet is soiled with brown splatters and trash is full with a brief. D. Observation of Resident room [ROOM NUMBER] on 02/18/2026 at 2:22 PM revealed the toilet has a riser that has a brown substance on the seat, toilet paper on the seat, toilet paper on the floor and brown substance on the floor in front of the toilet. There is paper towels on the floor next to the bed. There is a meal tray on the floor in the entry way of room. E. Observations of room [ROOM NUMBER] on 2/18/26 at 10:29 AM revealed a white powdery substance scattered on the floor under the head of the bed. Observations of room [ROOM NUMBER] on 2/19/26 at 7:21 AM revealed white powdery substance scattered on the floor under the head of the bed was still present. Observations of room [ROOM NUMBER] on 2/19/26 at 11:05 AM revealed some of the white powdery substance on floor under head of bed had been cleaned up with smears of white powdery substance remaining. Observations of room [ROOM NUMBER] on 2/23/26 at 7:40 AM revealed smears of white powdery substance on floor under head of bed remained. F. Observations of room [ROOM NUMBER] on 2/18/26 at 1:33 PM revealed floor was soiled with debris. G. Observations of room [ROOM NUMBER] on 2/18/26 at 1:59 PM revealed floor in room and bathroom was soiled throughout with debris. Toilet was soiled with a dried brown substance. Observations of room [ROOM NUMBER] on 2/19/26 at 7:18 AM revealed the floor was soiled with debris and had spots of dried liquid. H. Observations on 2/23/26 at 5:27 AM revealed a large dark stain on carpet near [NAME] seats by common area and a red stain under dining room table near entrance to the kitchen. I. Observations on 2/24/26 between 9:07-9:43 AM revealed the following environmental concerns: -In the dining room, there was a red stain on the floor underneath the dining room table near the entrance to the kitchen and the dining room floor was soiled with debris throughout. -In room [ROOM NUMBER], the floor was soiled throughout with debris and small pieces of paper and crumbs under the bed. The toilet riser was soiled with brown spots. -In room [ROOM NUMBER], there was a soiled spot under the bed and wheel tracks could be seen on the floor. The toilet was soiled. -In room [ROOM NUMBER], the floor was soiled with debris and popcorn. There was a large, dried liquid spot on the floor at the foot of the bed. There was a white creamy substance on the bedside table. -In room [ROOM NUMBER], the floor was soiled with small pieces of paper and debris throughout the room and bathroom. The toilet riser and toilet were soiled with a white creamy substance and brown stains. -In room [ROOM NUMBER], the floor with a dried brown stain never the door to the room and debris under the bed and behind the toilet. The toilet riser and the toilet were soiled with brown spots. -In room [ROOM NUMBER], the floor throughout the room was soiled with debris and small pieces of paper. A white powdery substance was spilled on the floor by the over bed table. -In room [ROOM NUMBER], the floor was soiled with debris, small pieces of paper, and a tissue. There was a dried liquid stain on the over bed table. -In room [ROOM NUMBER], the floor was soiled throughout with dried streaks, debris, and M&M candies. -In the Railroad common area, the drain area in the cabinet under the ice machine was soiled with a green stain. J. During a tour of the facility on 2/24/26 between 10:31-10:50 AM, the Administrator confirmed the soiled floor in the dining room, the stain on the carpet near the bleachers in the common area, the stain and soiled area in the cabinet under the ice machine in the Railroad common area, and the soiled floors and toilets identified in rooms 103, 109, 115, 117, 118, 119, 130, 162, 169, and 175. K. In an interview on 2/24/26 at 10:03 AM, the Administrator reported that facility was having difficulty hiring for a housekeeper position and the new Environmental Service Director had started the previous day. The Administrator reported that high contact surfaces in resident rooms were to be cleaned daily and a deep cleaning is to be done weekly and at discharge. Moping of resident room floors would be done based on the condition of the floor. The Administrator reported that any documentation for room cleaning would be incomplete.

Licensure Reference Number 175 NAC 12-006.02(H)Based on interviews and record review the facility failed to report to the State Agency an allegation of potential physical abuse for 1 (Resident 4) of 2 sampled resident. The facility census was 64. Findings are:A record review of the facility's Reporting Allegation of Abuse/Neglect/Exploitation dated 2/9/2018 revealed the following:The Licensed Nurse or Designee will: a. Remove the accused team member, guest, visitor from the area immediately. b. Notify the director of clinical services, Administrator & Director of Transitions. c. Notify the attending physician, guest family/legal representative, and medical director. d. Monitor and Document the guest's condition, including response to medical treatment or nursing interventions. e. Document actions taken in the electronic health record. A record review of Resident 4's Comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing homes identify health problems) dated 1/16/2026 revealed Resident 4 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 15-15 indicated the resident had intact cognition. In an interview on 02/18/2026 at 12:53 PM, Resident 4 reported Resident 4 felt manhandled. Resident 4 reported having told someone about the incident. In a follow up interview on 02/19/2026 at 1:34 PM, Resident 4 reported Resident 4 told the Director of Recreation (DOR) about the incident. In an interview on 02/19/2026 at 1:57 PM, DOR confirmed Resident 4 did tell the DOR of the incident. The DOR confirmed the DOR did not tell the Administrator or the Director of Nursing about what Resident 4 told the DOR. In an interview on 02/19/2026 2:05 PM, the facility Administrator confirmed the DOR should have reported any concern of roughness or mistreating behavior against residents to the Administrator or the Director of Nursing. The Administrator confirmed that there have been no reports concerning resident mistreatment.

Based on record review and interview, the facility failed to notify the resident or resident representative in writing at the time of transfer the reason for hospital transfer for 1 (Resident 89) of 2 sampled residents. The facility staff identified a census of 64.Findings are:Record review of Resident 89's admission Record (AR) showed the facility admitted the resident on 11/19/2025. Further review of the AR revealed Resident 89 had diagnoses that included displaced fracture of right tibia, fracture with routine healing, and hypertension.Record review of Resident 89's Progress Notes revealed the resident was transferred to the hospital for low blood pressure.Record review of Resident 89's Electronic Health Record (EHR) including progress notes, scanned documents, and assessments revealed no evidence that the resident or resident representative was notified in writing in a manner understood by the resident or resident representative at the time of hospital transfer.During an interview on 02/23/2026 at 12:15 PM, the Director of Nursing confirmed there was no evidence the reason for hospital transfer was provided to the resident or resident representative in writing at the time of transfer.

Licensure Reference Number 175 NAC 12-006.09(J)(i)(1)Based on record review, observation, and interview, the facility failed to implement interventions to prevent weight loss for 1 (Resident 99) of 4 sampled residents. The facility staff identified a census of 64.Findings are:Record review of facility policy entitled Weight Monitoring Policy dated 01/01/2023 revealed resident weights should be obtained daily for three days on admission, then weekly for four weeks, then at least monthly or as ordered by the provider, and per the direction of the Culinary Coordinator or Dietician. Further review of the policy revealed a re-weigh would be obtained if a significant weight change was noted and the Culinary Director or Dietician should be consulted to assist with interventions with the interventions recorded in the medical recorded.Record review of Resident 99's admission Record (AR) revealed the facility admitted the resident on 02/09/2026. Further review of the AR showed the resident had diagnoses that included fracture of right femur, chronic diastolic congestive heart failure, and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 99'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 02/16/2026 revealed Resident 99 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. Further review of the MDS revealed Resident 99 ate independently without assistance from staff.Record review of Resident 99's Weights & Vitals revealed the facility recorded the following weights: -02/10/2026 - 111.0 pounds (lbs.) -02/12/2026 - 111.2 lbs. -02/18/2026 - 97.6 lbs.According to the weights within the medical record, the resident had a 12.07 percent (%) weight loss in six days.Record review of Resident 99's Meal Intakes revealed the following: -02/19/2026 at 8:55 AM the resident consumed 0-25 percent (%). -02/19/2026 at 1:10 PM was documented as not applicable. -02/19/2026 at 8:43 PM the resident consumed 51-75%. -02/20/2026 at 12:27 PM the resident consumed 51-75%. -02/20/2026 at 1:22 PM the resident consumed 51-75%. -02/20/2026 at 9:55 PM the resident consumed 51-75%. -02/21/2026 at 9:43 AM the resident consumed 51-75%. -02/22/2026 at 5:31 PM the resident consumed 0-25%. -02/23/2026 at 9:00 AM the resident consumed 76-100%. -02/23/2026 at 1:00 PM the resident consumed 51-75%.Further review of Resident 99's Electronic Health Record (EHR) including progress notes did not identify any additional weight information or any additional meal intake information, nor did it reveal any refusal of weight by the resident.Record review of a Nurse Tech Assignment Sheet (NTAS) dated 02/21/2026 revealed a re-weigh was required for the resident in room [ROOM NUMBER]. There was no weight listed.Record review of a NTAS dated 02/22/2026 revealed no request for a re-weight for Resident 99.Interview on 02/23/2026 at 11:25 AM with the Registered Dietician (RD) revealed the RD identified the weight change for Resident 99. The RD requested a re-weigh for Resident 99. The RD reported reweighs are communicated with nursing staff either by e-mail, or in writing on the nurse tech assignment sheet.Interview on 02/23/2026 at 11:37 AM with Clinical Care Coordinator (CCC)-B confirmed Resident 99 occupied room [ROOM NUMBER] on 02/21/2026. CCC-B reported that when a resident needed a re-weigh, it was placed on the NTAS. If the weight was not obtained on the day it was requested, that information should be given to the night nurse to place on the following days NTAS. CCC-B confirmed Resident 99 was listed for a re-weigh and no weight was listed. CCC-B further confirmed there was no documented refusal of weight for Resident 99 on 02/21/2026 and Resident 99 was not listed on the NTAS for 02/22/2026.During a follow-up interview on 02/23/2026 at 12:48 PM, the RD confirmed meal intakes were ordered three times daily. The RD reported they would expect a response three times a day, even if the resident refused. The RD confirmed there were not three meal intakes listed daily for 02/21/2026, 02/22/2026, and 02/23/2026.

License Reference Number 175 NAC 12-006.09(J) Based on observation, record review and interview, the facility failed to ensure that food was prepared according to the recipe in order to retain nutritional value. This had the potential to affect all residents that ate foods prepared in the facility kitchen. The facility had a census of 60. Findings are: An observation on 09/11/2024 at 10:45 AM of Chef A preparing Salisbury steak patties for lunch on 09/12/24. revealed Chef A washed their hands and donned gloves. Chef A put unmeasured amounts of beef base, tomato ketchup, Worcestershire sauce, garlic, liquid eggs, mustard, breadcrumbs, onion powder, chopped onions, bell peppers and ground beef into a large pan. Chef A mixed the ingredients together while wearing gloves and then patted out unmeasured amounts of beef into patties. Chef A did not weigh the patties to ensure they met the required ounces identified in the recipe. An interview on 09/11/2024 at 10:55 AM with Chef A confirmed they did not measure ingredients or follow the recipe as it was written. A record review of the facility Recipe for Salisbury steak revealed the following information: Ingredients: -Ground beef 20lbs -eggs, liquid pasteurized 3 cups 2 Tbsp -breadcrumbs, plain 1 qt -Onion, Yellow Fresh, diced 1 qt ,-Worcestershire sauce 2/3 cup - Parsley flakes, dried 2/3 cups - Seasoning Italian 2/3 cups - pepper, black ground 1 tbsp - 2 tsp. Salt, iodized. An interview on 9/12/2024 at 11:32 AM with the Culinary Director (CD) confirmed that preparing food with unmeasured items not in the recipe could alter the nutritional value of the food.

Licensure Reference Number 175 NAC 12.006.04 Based on observation, interview and record review the facility failed to ensure that call lights were answered in a timely manner for 10 of 28 (Resident 103, 33, 58,56, 61, 44, 70, 156, 13 and 253) sampled residents. The facility census was 60. The Findings are: A. Record review of Resident 61's Electronic Health Record (EHR, is a digital version of a patient's paper chart) revealed a nursing admission screening/history document dated 09-03-2024 which indicated Resident 61 had diagnosis of Diabetes Mellitus and anemia, required staff assistance with bed mobility and was dependent on staff for transfers. Record review of a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) dated 09-05-2024 for Resident 61 revealed a score of 14 indicating cognitively intact. An interview with Resident 61 on 09-09-2024 at 12:38 PM revealed Resident 61 had to wait 4 hours to be transferred out of his wheelchair. Record review of Hillcrest Millard's Device Activity Log (HMDAL) for Resident 61 from 09-03-24 to 09-10-2024 revealed call light response times as follows: -09-04-2024 at 4:17 PM Call Light Response Time (CLRT) was 20 minutes. -09-04-2024 at 5:20 PM CLRT was 33 minutes. -09-05-2024 at 6:26 AM CLRT was 24 minutes. -09-05-2024 at 6:50 AM CLRT was 30 minutes. -09-05-2024 at 7:37 AM CLRT was 21 minutes. -09-05-2024 at 8:22 AM CLRT was 24 minutes. -09-06-2024 at 6:32 AM CLRT was 20 minutes. -09-06-2024 at 7:54 AM CLRT was 56 minutes. -09-06-2024 at 9:13 AM CLRT was 45 minutes. -09-08-2024 at 8:52 AM CLRT was 47 minutes. -09-10-2024 at 11:20 AM CLRT was 20 minutes. -09-10-2024 at 1:01 PM CLRT was 24 minutes. B. Record review of Resident 56's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) revealed an admitted [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Right Below the Knee Amputation (BKA) and anxiety. The MDS indicated Resident 56 was cognitively intact with a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 13 which indicated intact cognition and required supervision with transfers, upper body dressing and hygiene and required moderate assistance with bathing and lower body dressing. An interview with Resident 56 on 09-09-2024 at 2:27 PM revealed Resident 56 had at times waited a long time to get assistance from staff. Record review of the HMDAL for Resident 56 from 09-01-2024 to 09-09-2024 revealed call light response times as follows: -09-04-2024 at 4:26 AM CLRT was 90 minutes. -09-04-2024 at 11:22 AM CLRT was 26 minutes. -09-04-2024 at 12:29 PM CLRT was 36 minutes. -09-06-2024 at 6:34 AM CLRT was 68 minutes. -09-06-2024 at 7:11 AM CLRT was 31 minutes. -09-06-2024 at 9:24 AM CLRT was 42 minutes. -09-06-2024 at 1:37 PM CLRT was 27 minutes. -09-06-2024 at 6:12 PM CLRT was 20 minutes. C. Record Review of Resident 44's admission MDS dated [DATE] revealed the facility staff assessed the following about the resident: -Resident 44 admitted to the facility on [DATE] with a diagnosis of Osteoarthritis and Resident 44 had a left total knee replacement prior to admission. -Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 15 indicating intact cognition. -required moderate staff assistance for transfers and bed mobility. -required total assistance bathing and lower body dressing. An interview with Resident 44 on 09-09-2024 at 11:01 AM revealed call lights are not answered quickly and Resident 44 gives the staff a little time to respond and then takes (gender) to the bathroom. Record review of Resident 44's HMDAL from 09-01-2024 to 09-10-2024 revealed call light response times as follows: -09-02-2024 2:12 PM CLRT was 25 minutes. -09-02-2024 8:13 PM CLRT was 22 minutes. -09-04-2024 9:00 AM CLRT was 37 minutes. -09-07-2024 8:45 AM CLRT was 34 minutes. -09-08-2024 7:59 PM CLRT was 25 minutes. -09-08-2024 10:19 PM CLRT was 20 minutes. D. Record Review of Resident 70's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -Resident 70 had Arthritis, Fibromyalgia, and COPD -required moderate assistance with upper body dressing and bed mobility. -required maximal assistance with transfers. -required total assistance with toileting, bathing and lower body dressing. -was frequently incontinent of urine. - Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) dated 09-06-2024 revealed a score of 15 indicating Resident 70 was cognitively intact. An interview with Resident 70 on 09-10-2024 at 7:57 AM revealed to go to the bathroom it was an hour wait for assistance. Record review of Resident 70's HMDAL from 09-01-2024 to 09-10-2024 revealed the following call light response times: -09-06-2024 at 8:09 PM CLRT was 21 minutes. -09-06-2024 at 9:44 PM CLRT was 21 minutes. -09-07-2024 at 5:09 PM CLRT was 27 minutes. -09-09-2024 at 6:37 AM CLRT was 25 minutes. E. Record Review of Resident 13's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -Resident 70 was morbidly obese and had COPD -BIMS score of 15 indicated intact cognition. -required maximal assistance with toileting hygiene, bathing, and lower body dressing. -was occasionally incontinent of urine and frequently incontinent of bowel. An interview with Resident 13 on 09-09-2024 at 1:20 PM revealed Resident 13 had waited a half an hour to get assistance off of the toilet. Record Review of Resident 13's HMDAL from 09-01-2024 to 09-10-2024 revealed the following call light response times: -09-01-2024 at 7:54 AM CLRT was 23 minutes. -09-01-2024 at 8:05 PM CLRT was 32 minutes. -09-01-2024 at 11:37 PM CLRT was 29 minutes. -09-04-2024 at 6:06 AM CLRT was 28 minutes. -09-05-2024 at 7:49 AM CLRT was 30 minutes. -09-06-2024 at 7:37 AM CLRT was 30 minutes. -09-06-2024 at 11:01 PM CLRT was 23 minutes. -09-07-2024 at 2:18 PM CLRT was 27 minutes. -09-07-2024 at 7:19 PM CLRT was 42 minutes. -09-08-2024 at 9:02 PM CLRT was 31 minutes. -09-09-2024 at 9:14 PM CLRT was 26 minutes. F. Record Review of Resident 156's MDS dated [DATE] revealed the following about the resident: -Resident 156 admitted to the facility on [DATE] with diagnosis of Heart Failure, Respiratory Failure and COPD. -Resident 156 had a BIMS score of 15 which indicated intact cognition. -required moderate assistance with bathing and bed mobility -required maximal assistance with lower body dressing. -required total assistance for transfers. Record Review of Resident 156's EHR revealed a discharge date of [DATE]. Record review of the facility's grievance log revealed Resident 156's family representative had voiced concerns about call light response times on 08-14-2024 and again on 08-22-2024. Record review of Resident 156's HMDAL from 08-11-2024 to 08-21-2024 revealed the following call light response times: -08-11-2024 at 7:32 PM CLRT was 31 minutes. -08-11-2024 at 8:17 PM CLRT was 48 minutes. -08-12-2024 at 3:29 PM CLRT was 33 minutes. -08-13-2024 at 6:10 PM CLRT was 36 minutes. -08-14-2024 at 9:32 AM CLRT was 27 minutes. -08-14-2024 at 5:22 PM CLRT was 26 minutes. -08-14-2024 at 6:50 PM CLRT was 41 minutes. -08-14-2024 at 7:42 PM CLRT was 79 minutes. -08-15-2024 at 5:24 PM CLRT was 49 minutes. -08-16-2024 at 5:55 PM CLRT was 25 minutes. -08-17-2024 at 11:38 AM CLRT was 43 minutes. -08-17-2024 at 6:46 PM CLRT was 44 minutes. -08-17-2024 at 8:25 PM CLRT was 27 minutes. An observation on 09-12-2024 at 9:20 AM at the nurse's station on the Railroad Crossing Hallway revealed 2 cell phone pagers for the call light system at the nurse's station. Also during this observation the computer screen for the call light system revealed room [ROOM NUMBER]'s call light was on since 8:59 AM. An observation on 09-12-2024 at 9:22 AM revealed Nurse Aid (NA) J walking up to the nurse's station to look at the computer screen for call lights. An interview was conducted during this observation with NA J that revealed NA J was not carrying the cell phone pager for call lights. NA J explained (gender) had been busy and forgot to pick one up. NA J confirmed that since 6:00 AM (gender) was not carrying a cell phone pager. An interview on 09-12-2024 at 9:45 AM with NA I revealed (gender) was not carrying a cell phone pager at that time because the battery was dead and had placed the cell phone pager on the charger at the nurse's station. An interview with the Director of Nursing (DON) on 09-12-2024 at 12:15 PM revealed the expectation was for call light response times of 15 minutes or less. The DON also confirmed that a performance improvement plan (PIP) had been on-going in the facility and agreed the PIP was ineffective. 45614 G. A record review of the call light log times for August 2024 for Resident 253 revealed the following- -8/11/2024-Call light at 1:50 PM for 46 minutes and at 2:59 PM the call light was on for 50 minutes. -8/12-2024-Call light at 9:33 PM for 37 minutes. -8/13-2024- Call light at 11:03 AM for 26 minutes. -8/14-2024-Call light at 12:36 PM for 31 minutes. -8/17/2024-Call light at 2:41 PM for 33 minutes. An interview on 9/11/24 at 2:00 PM with Licensed Practical Nurse (LPN) D revealed LPN D had not been trained on the phone pager and did not carry one. An interview on 9/11/24 at 2:25 PM with LPN E confirmed LPN E did not carry a phone pager and had not been trained to use a phone pager. An interview on 9/12/2024 at 11:15 AM with Medication Aide (MA) F confirmed they do not carry a phone pager. 17285 H. Observation on 09/9/24 at 10:30 AM on the Lumberyard side of the facility revealed the call light system rings through to a computer at the desk outside the nursing station and the record of the room and what time the call light was activated can be visually seen on the computer screen. I. Record review of Resident 33's admission Face Sheet revealed an admitted [DATE] with diagnoses that included Pneumonia, acute respiratory failure with Hypoxia, Chronic Obstructive Pulmonary Disease, muscle weakness and need for assistance with personal care. Record review of Resident 33's Minimum Data Set (MDS - a comprehensive assessment tool used to develop a resident's plan of care) dated 8/16/24 revealed that the MDS was in progress and had not been completed. Interview on 09/09/24 at 11:24 AM revealed that Resident 33 was alert and oriented and had a complaint of the call light not being answered in a timely manner. Record review or Resident 33's call light Device Activity Records for September 2024 revealed the following long call lights: -9/1/24-Call light at 11:39 AM for 16 minutes. -9/1/24-Call light at 11:06 AM for 27 minutes. -9/2/24-Call light at 7:30 PM for 19 minutes. -9/2/24-Call light at 5:02 PM for 26 minutes. -9/3/24-Call light at 7:39 PM for 26 minutes. -9/4/24 Call light at 3:58 PM for 31 minutes. -9/5/24-Call light at 5:59 AM for 62 minutes. -9/5/24-Call light at 7:07 AM for 19 minutes. -9/6/24-Call light at 4:47 PM for 22 minutes. -9/6/24-Call light at 10:16 AM for 17 minutes. -9/7/24-Call light at 11:56 AM for 21 minutes. J. Record review of Resident 58's admission Face Sheet revealed an admitted [DATE] with diagnoses that included Acute infarction of spinal cord and Paraplegia. Record review of Resident 58's 5-day MDS date 09/12/24 revealed that the MDS was in progress and not completed. Interview on 09/09/24 at 11:59 AM revealed that Resident 58 was alert and oriented and had a complaint of call lights not being answered in a timely manner. Record review of Resident 58's September 2024 Device Activity Report revealed the following long call light response times: -9/5/24-Call light on at 6:06 PM for 28 minutes. -9/6/24-Call light on at 9:24 PM for 29 minutes. -9/10/24-Call light on at 8:34 AM for 18 minutes. K. Record review of Resident 103's admission Face Sheet revealed an admitted [DATE] with diagnoses that included Malignant Neoplasm of Liver, Pulmonary Embolism, Heat Failure, Atrial Fibrillation, unsteadiness on feet and muscle weakness. Record review of Resident 103's (closed record) MDS dated [DATE] revealed a BIMS score of 14 which indicated Resident 103 was cognitively intact and the resident was independent with activities of daily living at the time of admission. Record review of a Concern Form for Resident 103 dated 2/3/24 revealed a grievance from the family related to long call light response time. Attached to the grievance was the following call light times on a Device Activity Report: -2/3/24 at 2:08 PM for 43 minutes. -2/3/24 at 2:54 PM for 26 minutes. -2/4/24 at 1:53 AM for 22 minutes. -2/4/24 at 5:15 AM for 24 minutes. -2/4/24 at 9:05 AM for 37 minutes. L. Interview on 09/10/24 at 07:58 AM with NA G on the Lumberyard side of the facility revealed that the call lights ring to a cell phone and the NA's all carry the cell phone pagers. Interview on 09/11/24 at 8:05 AM with LPN D revealed the nurses and the medication technicians did not carry cell phone pagers and the NA's were responsible for answering the call lights. M. Observations (continuous) on 9/12/24 from 06:41 AM to 8:10 AM of call light response times were as follows: -room [ROOM NUMBER]: Call light on at 6:59 AM. Call light was on for 61 minutes and continued to be on at 8:10 AM. -room [ROOM NUMBER]: Call light on at 7:09 AM. Call light was on for 51 minutes and continued to be on at 8:10 AM -room [ROOM NUMBER]: Call light on at 7:24 AM. Call light on for 36 minutes and continued to be on at 8:10 AM. -room [ROOM NUMBER]: Call light on at 7:51 AM. Call light on for 19 minutes and continued to be on at 8:10 AM. -room [ROOM NUMBER]: Call light on at 7:53 AM. Call light on for 17 minutes and continued to be on at 8:10 AM. Interview on 09/12/24 at 10:28 AM with Registered Nurse [RN] H confirmed that the nurses do not carry the cell phone pagers, only the nurse aides carry the pagers. N. Interview on 09/12/24 at 12:11 PM with the DON confirmed that the expectation is that call lights should be answered in under 15 minutes. The DON confirmed the long call light times for Residents 33, 58 and 103. The DON confirmed that the nurses and the medication technicians are expected to assist with answering the call systems and that the medication technicians should carry a cell phone pager. The DON stated that the nurses don't have to wear a cell phone pager but they should assist with answering the call lights. The DON confirmed that the facility had identified this as a problem and had implemented a performance improvement project [PIP] in June 2024 to try to improve call light response times. The DON agreed that the PIP for call lights had not been effective and long call light response times continued to be an issue at the facility.

Licensure Reference Number 175 NAC 12.006.04(F)(i)(5) Based on interview and record review the facility failed to notify the physician and obtain treatment orders for a pressure ulcer for 1 (Resident 61) of 1 resident sampled. The facility census was 60. The findings are: Record review of Resident 61's Electronic Health Record (EHR, is a digital version of a patient's paper chart) revealed a nursing admission screening/history document dated 09-03-2024 revealed an admitted [DATE] and Resident 61 had diagnosis of Diabetes Mellitus and anemia, required staff assistance with bed mobility and was dependent on staff for transfers. The document also revealed Resident 61 had a history of pressure ulcers. Record review of a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) dated 09-05-2024 revealed a score of 14 indicating cognitively intact. An interview with Resident 61 on 09-09-2024 at 9:38 AM revealed Resident 61 reported having a pressure ulcer to the buttocks. Record review of Resident 61's Treatment Administration Record (TAR) printed 09-10-2024 revealed a skin only assessment was scheduled for 09-03-2024 that was not signed as completed. The TAR did not have a treatment identified for the pressure ulcer to buttocks. An observation on 09-11-2024 at 7:39 AM of Nurse Tech (NT)B repositioning Resident 61 revealed a dressing dated 09-09-2024 on Resident 61's buttocks. An interview with Licensed Practical Nurse (LPN) C on 09-11-2024 revealed Resident 61 had a pressure ulcer to the coccyx (The coccyx, or tailbone, is a small triangle-shaped bone derived from the fusion of the four rudimentary coccygeal vertebrae at the bottom of the vertebral column) and was calling the doctor for treatment orders. An observation of Resident 61 on 09-11-2024 at 8:55 AM with LPN C performing wound care revealed Resident 61 had a pressure ulcer to the coccyx. An interview conducted on 09-11-2024 at 12:46 PM with the facility's Regional Nurse Consultant (RNC) confirmed the physician was not notified and treatment orders were not obtained until 09-11-2024 for Resident 61. Record review of the facility's undated policy titled Hillcrest [NAME] Skin Integrity, Skin Injury Prevention Policy revealed the following: -Policy: to provide direction to the Clinical Team for obtaining correct orders for treatment in skin integrity and wound care concerns. All team members are responsible for preventing, caring for, and providing treatment to any patient/guest/elder/client that has altered skin integrity. -Purpose: 1. To identify at risk/guests/patients/elders for potential altered skin integrity. 2. To prevent breakdown of skin tissue or ulcerations 3. To provide treatment that promotes prevention of altered skin integrity and to resolve existing areas of altered skin integrity. 4. To appropriately identify and utilize prevention techniques and pressure redistribution surfaces on guests/patients/elders at risk for altered skin integrity. -Procedure: 1. Licensed staff will perform a head-to-toe assessment upon admission/readmission and continue to do so routinely and as needed. The findings of each assessment will be documented per facility protocol on the admissions assessment form and/or skin assessment form. 2. Licensed staff members will complete a Braden Scale Assessment once the head-to-toe assessment is completed for all admissions/readmissions. 3. Any skin integrity issues identified will be documented and communicated to the physician. Areas identified will be communicated to the physician on Wound Letter communication forms.

Licensure Reference Number 175 NAC 12-006.19 and 12.006.19(B) Based on observation and interviews, the facility failed to maintain cleanliness of floors, toilets, equipment, and upkeep of the floors and walls in 4 resident rooms ( 157, 153, 104, and 142). The facility identified a census of 60. Findings are: Observations in room [ROOM NUMBER] on 9/9/24 at 11:28 AM and 9/10/24 at 1:40 PM revealed scratches where paint and dry wall had worn away on the bathroom door frame. Observations in room [ROOM NUMBER] on 9/9/24 at 11:28 AM and 9/10/24 at 1:25 PM revealed a carpet stain right inside the resident's room. Observations in room [ROOM NUMBER] on 9/9/24 at 1:45 PM and 9/10/24 at 1:30 PM revealed a toilet riser over the toilet with the foot pegs of the toilet riser sunken in the floor with the cement around the foot pegs worn away. The floor around the toilet was also stained. Observations in room [ROOM NUMBER] on 9/9/24 at 12:13 PM and 9/10/24 at 12:03 PM revealed a urinary catheter bag stained with blood in the bathroom sitting on a shower chair. Interview on 9/10/24 at 1:55 PM with the Maintenance Director (MD-A) confirmed room [ROOM NUMBER] had scratches where the paint and dry wall were worn away on the bathroom door frame. MD-A confirmed the carpet was stained in room [ROOM NUMBER]. MD-A confirmed the floor in room [ROOM NUMBER] needed cleaning and repaired. Interview on 9/10/24 at 1:47 PM with Regional Nurse Consultant (RNC) confirmed the urinary catheter bag stained with blood should have been removed from the room. Interview on 09/10/24 03:04 PM with the Facility Administrator (ADM) confirmed there had not been any housekeeping schedules. MD-A had accepted the position 9/10/24 after 3 months with no MD. The ADM reported that the ADM had overseen maintenance, laundry, and housekeeping for the past 3 months.

Licensure Reference Number 175 NAC 12.006.09(H)(iii)(1) Based on observation, interview and record review the facility failed to identify, evaluate and provide treatment for a pressure ulcer for 2 (Resident 61 and 155) of 3 sampled residents. The facility census was 60. Findings are: A. Record review of Resident 155's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 06-07-2024 revealed the facility staff assessed the following about the resident: - Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 15 indicating cognitively intact. -Required moderate assistance with bed mobility, transfers and lower body dressing. -Required maximal assistance with bathing. -Currently had a pressure ulcer. Record review of Resident 155's Electronic Health Record ((EHR, is a digital version of a patient's paper chart)) revealed a nursing admission screening/history dated 05-31-2024 revealed Resident 155 had blanchable redness (a skin condition where redness disappears when pressure is applied to the area, and then returns when pressure is released) to the buttocks region. The EHR also revealed Resident 155 was discharged to the hospital on 06-10-2024. Record review of Resident 155's base line care plan dated 05-31-2024 revealed no skin issues. Record review of a Skin Only Evaluation Sheet dated 06-04-2024 revealed Resident 155 had unmeasured excoriation (a place where your skin is scraped or abraded) to buttocks, and an unmeasured open wound to the sacrum. Record review of Resident 155's Treatment Administration Record (TAR) revealed no treatment for excoriation to the buttocks or treatment for an open area to the sacrum until 06-10-2024. Record review of the facility's policy titled Hillcrest [NAME] Skin Integrity, Skin Injury Prevention Policy revealed the following: Policy: to provide direction to the Clinical Team for obtaining correct orders for treatment in skin integrity and wound care concerns. All team members are responsible for preventing, caring for, and providing treatment to any patient/guest/elder/client that has altered skin integrity. Purpose: -To identify at risk/guests/patients/elders for potential altered skin integrity. -To prevent breakdown of skin tissue or ulcerations -To provide treatment that promotes prevention of altered skin integrity and to resolve existing areas of altered skin integrity. -To appropriately identify and utilize prevention techniques and pressure redistribution surfaces on guests/patients/elders at risk for altered skin integrity. Procedure: -Licensed staff will perform a head-to-toe assessment upon admission/readmission and continue to do so routinely and as needed. The findings of each assessment will be documented per facility protocol on the admissions assessment form and/or skin assessment form. -Licensed staff members will complete a Braden Scale Assessment once the head-to-toe assessment is completed for all admissions/readmissions. -Any skin integrity issues identified will be documented and communicated to the physician. Areas identified will be communicated to the physician on Wound Letter communication forms. -Nurse techs will complete visual body audits daily with every basic ADL (Activities of Daily Living) care and bathing occurrence. If there are concerns, the tech will notify the nurse immediately through verbal communication. -Notification to the Registered Dietician will occur with any significant skin integrity change or new admission with impaired skin integrity. -A skin integrity plan of care will be initiated for prevention and risk for development and/or reduction of impaired skin integrity. An interview with the Regional Nurse Consultant (RNC) on 09-11-2024 at 12:46 PM confirmed interventions to promote healing and treatment of Resident 155's wounds to sacrum and buttocks were not obtained until 06-10-2024. B. Record review of Resident 61's Nursing Admission Screening/History document dated 09-03-2024 revealed Resident 61 had diagnosis of Diabetes Mellitus and Anemia, required staff assistance with bed mobility and was dependent on staff assistance for transfers. The document also revealed Resident 61 had a history of pressure ulcers. Record review of a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) dated 09-05-2024 revealed a score of 14 indicating cognitively intact. An interview with Resident 61 on 09-09-2024 at 9:38 AM revealed Resident 61 had a pressure ulcer to the buttocks. Record review of a Braden Scale (The Braden Scale is a tool used to assess a patient's risk of developing pressure ulcers or injuries. The scale's total score ranges from 6-23, with lower scores indicating a higher risk of developing pressure ulcers. The risk categories are: 19-23: No risk, 15-18: Mild risk, 13-14: Moderate risk, 10-12: High risk, 9 and less: Very high risk) conducted for Resident 61 on 09-03-2024 revealed a score of 13 which indicated a moderate risk for pressure sore development. This review also revealed the absence of a skin assessment on 09-03-2024. Record review of Resident 61's Treatment Administration Record (TAR) printed 09-10-2024 revealed a skin only assessment was scheduled for 09-03-2024 that was not signed as completed. The TAR did not have a treatment listed for the pressure ulcer to the buttocks. An observation on 09-11-2024 at 7:39 AM of Nurse Tech (NT)B repositioning Resident 61 revealed a dressing dated 09-09-2024 on Resident 61's buttocks. An interview with Licensed Practical Nurse (LPN) C on 09-11-2024 at 8:03 AM revealed Resident 61 had an open area to the coccyx (The coccyx, or tailbone, is a small triangle-shaped bone derived from the fusion of the four rudimentary coccygeal vertebrae at the bottom of the vertebral column) and was calling the doctor for treatment orders. An observation of Resident 61 on 09-11-2024 at 9:15 AM with LPN C performing wound care revealed an open area to Resident 61's coccyx that was approximately 1 centimeter in length by 0.3 centimeters in width and approximately 0.1 centimeters in depth. The skin around the wound was red in color, the wound edges were pale pink in color and the wound bed was dark pink color. An interview with Resident 61 during the dressing change on 09-11-2024 at 9:15 AM revealed Resident 61 told the facility staff on the date of admission that (gender) had a pressure ulcer and requested an air mattress. A follow up observation during wound care for Resident 61 on 09-11-2024 at 9:20 AM revealed a non air mattress in use on Resident 61's bed. Record review of a progress note from Resident 61's healthcare practitioner dated 09-11-2024 revealed Resident 61 was seen for a stage 2 ( stage 2, partial-thickness loss of skin with exposed dermis, presenting as a shallow) open ulcer pressure ulcer to the coccyx. An interview conducted on 09-11-2024 at 12:46 PM with the facility's Regional Nurse Consultant (RNC) confirmed a skin assessment was not conducted on admission, interventions to promote healing was not put into place and treatment orders were not obtained until 09-11-2024 for Resident 61.

Licensure Reference Number 12.006.09(1) Based on observation, interview and record review the facility failed to investigate and identify causal factors for injuries for 1 (Resident 56) of 5 sampled residents. The facility census was 60. Findings are: Record review of Resident 56's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) revealed an admitted [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Right Below the Knee Amputation (BKA) and anxiety. The MDS indicated Resident 56 required supervision with transfers, upper body dressing and hygiene and required moderate assistance with bathing and lower body dressing. An observation on 09-09-2024 at 9:23 AM revealed a foam island dressing to Resident 56's right elbow with the date 09-09-2024 written on the dressing. An interview on 09-09-2024 at 9:30 AM with Resident 56 revealed (gender) had bumped the right elbow on the handrail next to the toilet sometime last week. Record review of a progress note dated 09-03-2024 revealed Resident 56 had a new skin tear to the right elbow. Record review of a Hillcrest [NAME] communication sheet dated 09-08-2024 which revealed the staff communicated to the nurse practitioner that Resident 56 had 2 skin tears to the right upper extremity and requested treatment orders. The nurse practitioner responded with an order to cover the skin tears with a mepilex dressing, and change it every other day. Record review of a progress note for Resident 56 dated 09-09-2024 that indicated the facility staff received new orders from the Nurse Practitioner for wound care to right elbow. Cleanse with soap and water, pat dry, apply xeroform gauze to the skin tear and cover with mepilex every Monday, Wednesday, and Friday. An observation on 09-11-2024 at 10:15 AM of Licensed Practical Nurse (LPN) C performing wound care to Resident 56's right elbow, revealed 2 dressings were in place to the right elbow, dated 09-10-2024. LPN C removed the old dressings to reveal 5 skin tears. The skin tears were approximately 1 to 1.5 centimeters in length in various stages of healing. Record review of Resident 56's medical record revealed no measurements for the skin tears and no event report or investigation into the causal factors of the skin tears. An interview with the Director of Nursing (DON) on 09-12-2024 at 8:41 AM confirmed that an event report or an investigation into the causal factors of the skin tears to the right elbow was not conducted. Record review of an undated policy titled Hillcrest [NAME] Skin Integrity, Wound, Ulcer Assessment Prevention Treatment Documentation policy revealed the following: -Policy- to provide direction to the Clinical Team for obtaining correct orders for treatment in skin integrity and wound care concerns. -Purpose- -To identify at risk guests for potential altered skin integrity - to prevent breakdown of skin tissue or ulcerations, -to provide treatment that promotes prevention of altered skin integrity and to resolve existing areas of altered skin integrity, -to appropriately identify and utilize prevention techniques and pressure redistribution surfaces on guests at risk for altered skin integrity. -Assessment and Documentation -a licensed nurse/physician/therapist may stage a wound and determine etiology. -measurement of the wound must be completed upon identification. -if a bruise, contusion, abrasion, skin tear or laceration is observed on a guest, an event report should be completed with causal factors.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to identify and monitor specific target behaviors for the use of an antidepressant [a class of medications used to treat depression] medication for 2 (Residents 58 and 73) of 5 residents reviewed for psychotropic [a group of medications used to treat mental health disorders] medication use. The facility census was 60. Findings are: A. Record review of a facility policy entitled Psychotropic Medication dated 1/1/23 identified the following: - A psychotropic drug is any drug that affects the brains activities associated with mental processes or behavior. Psychotropic drugs include Antidepressants. - Use of psychotropic medications in specific circumstances: b. Enduring conditions ( non-acute, chronic, prolonged): The patients symptoms and therapeutic goals shall be specifically identified and documented. B. Record review of Resident 58's admission Face Sheet revealed that Resident 58 was admitted to the facility on [DATE] and included a diagnosis of Major Depressive Disorder and Anxiety disorder. Record review of Resident 58's 5 day MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's plan of care) dated 9/12/24 was in progress and not completed. Record review of Resident 58's admission Physician Orders dated 9/5/24 revealed a physician order for Mirtazapine [an antidepressant medication] 15 milligrams [mg] give 1 tablet by mouth at bedtime for Depression. The Physician orders dated 9/5/24 also included antidepressant behavior monitoring for sign / symptoms of target behaviors. No specific target behaviors were identified in the physician orders. Record review of Resident 58's Medication Administration Record [MAR] for September 2024 revealed that Resident 58 received Mirtazapine 15 mg 1 tablet by mouth at bedtime for Depression. The medication was ordered and started on 9/5/24. There was documentation of generalized monitoring of behaviors on the MAR but no specific individualized target behaviors were identified for Resident 58. Record review of Resident 58's Comprehensive Care Plan (CCP, a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) dated 9/5/24 did not identify resident specific target behaviors to be monitored for the use of an antidepressant medication. Record review of Resident 58's Electronic Medical Record [EMR] revealed that no specific target behaviors had been identified and no monitoring for specific target behaviors had been completed. C. Record review of Resident 73's admission Face Sheet revealed that Resident 73 was admitted to the facility on [DATE] and included a diagnosis of Major Depressive Disorder, recurrent moderate and Anxiety Disorder. Record review of Resident 73's admission MDS dated [DATE] revealed that Resident 73 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 13 which indicated that Resident 73 was cognitively intact, exhibited no behavioral symptoms, had a psychiatric diagnosis of Major Depressive Disorder and Anxiety, and used an anti-depressant medication daily. Record review of Resident 73's admission Physician Orders dated 8/29/24 revealed a physician order for Escitalopram Oxalate [an antidepressant medication] 20 mg 1 tablet by mouth in the morning for depression. Physician orders dated 8/29/24 also included antidepressant behavior monitoring for signs / symptoms of target behaviors. No specific target behaviors were identified in the physician orders. Record review of Resident 73's MAR for August and September 2024 revealed Resident 73 received Escitalopram Oxalate 20 mg 1 tablet by mouth in the morning for depression. The medication was ordered and started on 8/29/24. There was documentation of generalized monitoring of behaviors on the MAR but no specific individualized target behaviors were identified for Resident 73. Record review of Resident 73's CCP dated 8/29/24 did not identify resident specific target behaviors to be monitored for the use of an antidepressant medication. Record review of Resident 73' EMR revealed that no specific target behaviors had been identified and no monitoring for specific target behaviors had been completed. D. Interview on 9/11/24 at 12:52 PM with the Regional Nurse Consultant [RNC] confirmed that Resident 58 and 73 did take antidepressant medications regularly and that there were no resident specific target behaviors identified. The RNC confirmed no specific monitoring for individualized target behaviors had been completed for the continued use of the antidepressant medications.

Licensure Reference Number 175 NAC 12-006.09(F)(i) Based on record review and interview, the facility failed to ensure that the baseline care plan (BCP, a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) included significant medical information needed to provide care was completed for 2 (Residents 58 and 73) of 15 sampled residents reviewed for baseline care plans. The facility census was 60. Findings are: A. Record review of Resident 58's admission Face Sheet revealed an admitted [DATE]. Diagnoses included: Diabetes Mellitus Type 2 (DM insulin dependent) and Hypertension (HTN, high blood pressure), Atrial Fibrillation and Major Depressive Disorder Record review of Resident 58's admission Physician Orders dated 9/5/24 revealed the following orders for monitoring: - Antidepressant behavior monitoring for signs / symptoms of target behaviors. Notify physician of increased behaviors or ineffective antidepressant medication. - Blood Glucose Monitoring four times a day for diabetes. Notify Medical Doctor [MD] of BS <70 or >400. - Hypoglycemic Episode - Conscious as needed for diabetes If patient is conscious and blood glucose level is less than 70, give 15-20 grams of carbs [carbohydrates] (IE: 4 ounces of apple juice) May give glucose gel, recheck in 15 minutes. Do not give hypoglycemic medications such as Metformin, etc. Notify MD/nurse on call. - Hypoglycemic Episode - Unconscious as needed for Hypoglycemic Episode If Patient is unconscious and blood glucose less than 70, administer injection of Glucagon. Notify physician/nurse on call and/or call 9-1-1 for further medical intervention. - Observe closely for side effects of Diuretic medication including decreased PO intake, acute confusion, agitation, delusions, aggression, lethargy, decreased sweating, tachycardia, hypotension, orthostasis, generalized weakness, sunken eyes one time a day for monitoring 'Y' if observed and select chart code Other/ See Nurses Notes' and write progress note of findings. 'N' if none were observed. - Observe closely for significant side effects of Antidepressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior one time a day for monitoring 'Y' if observed and select chart code 'Other/ See Nurses Notes' and write progress note of findings. 'N' if none were observed. - Pain Monitoring - Assess for pain every shift for monitoring Monitor for non-verbal S/S or C/O pain. Utilize [NAME] Scale for patients who are non-verbal. Utilize numeric scale for verbalization. Record review of Resident 58's Baseline Care Plan dated 9/5/24 revealed 2 problems identified on the BCP, transition needs / plans and nutritional risk. The BCP did not contain any information related to the increased need for blood pressure monitoring for HTN, blood sugar and basic monitoring for DM, use of antidepressants and monitoring for depression, bleeding risk associated with anticoagulant use [Eliquis medication], monitoring for use of diuretic medication [Torsemide] or pain monitoring for Resident 58. Interview on 9/11/24 at 12:42 PM with the Regional Nurse Consultant [RNC] confirmed that Resident 58's BCP did not contain significant medical information related to monitoring for Hypertension, monitoring for Diabetes Mellitus, increased bleeding risk, monitoring for diuretic use, pain monitoring and behavior monitoring for antidepressant use. B. Record review of Resident 73's admission Face Sheet revealed an admitted [DATE]. Diagnoses included: Diabetes Mellitus Type 2, Hypertension (HTN, high blood pressure) and Major Depressive Disorder. Record review of Resident 73's admission Physician Orders dated 8/29/24 revealed the following orders for monitoring: - Antidepressant behavior monitoring for signs / symptoms of target behaviors. Notify physician of increased behaviors or ineffective antidepressant medication. - Blood Glucose monitoring prn [as needed]. Call if <70 or >400 as needed for signs or symptoms of hypo or hyperglycemia [low or high blood sugar respectively]. - Observe closely for significant side effects of Antidepressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other unusual changes in mood or behavior one time a day for monitoring 'Y' if observed and select chart code 'Other/ See Nurses Notes' and write progress note of findings. 'N' if none were observed. - Pain Monitoring - Assess for pain every shift for monitoring Monitor for non-verbal signs/ symptoms or complaints of pain. Utilize [NAME] Scale for patients who are non-verbal. Utilize numeric scale for verbalization. Record review of Resident 73's Physicians Orders dated 8/29/24 revealed the following medications ordered for Resident 73: - Escitalopram Oxalate Tablet 20 MG Give 1 tablet by mouth in the morning for Depression. - Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for neuropathy [Nerve damage with pain symptoms]. - Glipizide Oral Tablet 5 MG (Glipizide) Give 1 tablet by mouth in the morning for DIABETES. - Ibuprofen Oral Tablet 200 MG (Ibuprofen) Give 3 tablets by mouth every 8 hours for back pain Record review of Resident 73's Baseline Care Plan dated 8/29/24 revealed 1 problem identified on the BCP, fall risk. The BCP did not contain any information related to blood sugar and basic monitoring for DM, monitoring for depression or pain monitoring for Resident 73. Interview on 9/11/24 at 12:45 PM with the Regional Nurse Consultant [RNC] confirmed that Resident 73's BCP did not contain significant medical information related to monitoring of blood sugars for Diabetes Mellitus, pain monitoring or behavior monitoring for antidepressant use.

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review, the facility failed to ensure coordination of medication administration with dialysis schedule for 2 [Residents 2 and 4] of 2 sampled residents requiring dialysis. The facility had a total census of 72 residents. Findings are: A. A review of a Admission Record revealed Resident 2 was admitted to the facility on [DATE] with a readmitted [DATE]. The Admission Record for Resident 2 listed a primary diagnosis of pneumonia [an infection in the lungs] and diagnoses of type 2 diabetes mellitus [a disorder in which the body has trouble controlling blood sugar] without complications and end stage renal disease [a condition in which the kidneys lose the ability to remove waste and balance fluids]. A review of Resident 2's 4/2024 MAR [Medication Administration Record] revealed Resident 2 had an appointment for dialysis at 6:15 AM every Tuesday, Thursday, and Saturday with Resident 2 to arrive at the dialysis facility at 5:45 AM. In an interview on 4/18/24 at 9:14 AM, LPN A reported that Resident 2 was to have a blood sugar check and insulin but Resident 2 had already left for dialysis. In an interview on 4/18/24 at 9:20 AM, Medication Aide D confirmed Medication Aide D had not provided medications to Resident 2 before Resident 2 left for dialysis. In an interview on 4/18/24 at 9:22 AM, LPN Unit Manager C reported Resident 2 leaves for dialysis at 4:30 AM. Observations on 12/18/24 at 12:15 PM revealed Resident 2 had returned from dialysis. A check of Resident 2's blood sugar by LPN A revealed a blood sugar of 249. LPN A administered 5 units of Aspart insulin [Rapid acting insulin] to back of Resident 2's right arm. In an interview on 4/18/24 at 12:15 PM, Resident 2 reported returning from dialysis at 10:30 AM and that Resident 2 had eaten lunch. Resident 2 reported that Resident 2 received 2 medications before going to dialysis. A review of Progress Notes revealed Resident 2 was admitted to the hospital on 4/9/24 and was readmitted on [DATE]. A review of Resident 2's 4/2024 MAR revealed the following medications were documented as not being given due to Resident 2 being out of facility or at dialysis: -Amlodipine Besylate 10 Milligrams (mg) [medication for hypertension] scheduled for AM; not administered on 4/2/24, 4/6/24, and 4/18/24 -Aspirin 81 mg scheduled for AM; not administered on 4/2/24, 4/6/24 and 4/18/24 -Calcitrate Plus D 315 mg 5 mcg [Calcium and Vitamin D] oral tablet scheduled for AM; not administered on 4/2/24, 4/6/24 and 4/18/24 -Cholecalciferol [a vitamin D supplement] 1000 units; not administered on 4/2/24, 4/6/24 and 4/18/24 -Glargine insulin [long acting insulin] 10 units scheduled for AM; not administered on 4/2/24, 4/6/24 and 4/18/24 -Potassium Chloride ER 10 MEQ scheduled for AM; not administered on 4/2/24, 4/6/24 and 4/18/24 -Toresemide [diuretic] 100 mg scheduled for AM; not administered on 4/2/24, 4/6/24 and 4/18/24 -Valsartan [medication for high blood pressure] 20 mg scheduled for AM; not administered on 4/2/24 and 4/18/24 -Acidophilus [probiotic] 1 capsule schedule for AM; not administered on 4/2/24, 4/6/24 and 4/18/24 -Amoxicillin-Pot Clavulanate [antibiotic] 875-125 mg scheduled for AM and hour of sleep; not administered on 4/18/24 AM -Carvedilol [a medication for high blood pressure] scheduled for AM and PM; not administered in AM on 4/2/24, 4/6/24 and 4/18/24 -Entresto [a medication for heart failure] oral tablet 24-26 mg .5 tablet scheduled for AM and hour of sleep; not administered in AM on 4/6/24 -Insulin Aspart [rapid acting insulin] 3 units scheduled for AM, Noon, and PM; not administered in AM on 4/2/24, 4/6/24, and 4/18/24 -Insulin Aspart sliding scale insulin scheduled for AM, Noon and PM; not administered in AM on 4/2, 4/6/24, and 4/18/24 A review of Resident 2's 4/2024 MAR and care plan did not reveal any directions on how to provide medications when Resident 2 was going out to dialysis. In an interview on 4/18/24 at 3:06 PM, LPN B reported that residents that leave between 4-5 AM for dialysis are not back to the facility until noon. LPN B reported morning medications are not given to the residents and that noon medications, blood sugar checks and noon insulin are administered to residents when they get back to the facility according to LPN B. In an interview on 4/18/24 at 3:15 PM, LPN A reported if a resident is gone from the facility at the time medications are to be provided, out of the facility is documented, and medications are resumed when the resident returns to the facility. In an interview on 4/18/24 at 3:17 PM, LPN Unit Manager C reported administration of medications for residents going to dialysis varies based on provider direction and could be provided after return from dialysis or scheduled around dialysis. In an interview on 4/18/24 at 4:34 PM, the Director of Nursing (DON) reported had started to work with providers on adjustment of times of medications for residents going to dialysis. According to the DON, physicians are to be notified of medications not provided to residents. B. A review of Admission Record revealed Resident 4 was admitted to the facility on [DATE] with a readmitted [DATE] with a primary diagnoses of end stage renal disease, dependence on renal dialysis, and a type 2 diabetes mellitus without complications. A review of Resident 4's 4/2024 MAR revealed Resident 4 had an appointment for dialysis at 5:30 AM on Tuesdays, Thursdays, and Saturdays. In an interview on 4/18/24 at 9:14 AM, LPN A reported that Resident 4 is to have a blood sugar check and insulin but Resident 4 leaves for dialysis prior to the start of the shift. In an interview on 4/18/24 at 9:20 AM, Medication Aide D confirmed Medication Aide D had not provided medications to Resident 4 before Resident 4 left for dialysis. In an interview on 4/18/24 at 9:22 AM, LPN Unit Manager C reported Resident 4 leaves for dialysis at 5:45 AM. Observations on 4/18/24 at 12:44 PM revealed Resident 4 eating lunch. A check of Resident 4 of Resident 4's blood sugar revealed a blood sugar of 108. LPN A administered 7 units of Aspart insulin in the back of Resident 4's right arm. In an interview on 4/18/24 at 12:44 PM, Resident 4 reported taking 1 medication before going to dialysis and stated that Resident 4 doesn't want anything to eat before dialysis. A review of Resident 4's 4/2024 MAR revealed the following medications were documented as not being given due to Resident 4 being out of facility or at dialysis: -CertaVite Senior Oral Tablet [vitamin with minerals] 1 tablet scheduled to be administered in AM; was not administered on 4/4/24, 4/9/24, 4/11/24, and 4/13/24 due to Resident 4 being out of facility; medication was documented as held on 4/2/24 and 4/6/24 with note that medication is held due to Resident 4 was at dialysis -Sertraline [medication for depression] 50 mg scheduled to be administered in AM; was not administered on 4/4/24, 4/9/24, 4/11/24, and 4/13/24 due to Resident 4 being out of the facility; medication was documented as held on 4/2/24 and 4/6/24 with note that medication is held due to Resident 4 being at dialysis -Tracrolimus [antirejection medication] .5 mg scheduled to be administered in AM and PM; AM dose was not administered on 4/4/24, 4/9/24, 4/11/24, and 4/13/24 due to Resident 4 being out of the facility; medication was documented as held on 4/2/24 and 4/6/24 with note that medication is held due to Resident 4 being at dialysis -Calcium Citrate plus D oral table 315 mg, 6.25 mcg 2 tablets scheduled for AM and PM; AM dose was not administered on 4/4/24, 4/9/24, 4/11/24, and 4/13/24 due to Resident 4 being out of the facility; medication was documented as held 4/6/24 with note that medication is held due to Resident 4 being at dialysis -Cholestyramine [medication to lower cholesterol] oral packet 4 gram scheduled for AM and PM; AM dose was not administered on 4/4/24, 4/11/24 due to Resident 4 being out of the facility and was documented as held on 4/6/24 and 4/13/24 -Medroxyprogesterone [medication used to stop uterine bleeding] 10 mg scheduled to be administered in AM; AM dose was not administered on 4/4/24 due to Resident 4 being out of the facility and held on 4/2/24 and 4/6/24 due to dialysis -Mycophenolate sodium oral tablet delayed release [anti-rejection medication] scheduled to be administered AM and PM; AM dose was not given on 4/4/24, 4/9/24, 4/11/24, 4/13/24 due Resident 4 being out of the facility and held on 4/2/24 and 4/6/24 due to Resident 4 being at dialysis -Nystatin Powder [treats fungal or yeast infections] scheduled to be administered AM and PM; AM dose was not given on 4/4/24, 4/9/24, 4/11/24, 4/13/24, 4/18/24 due to Resident 4 being out of the facility and was held on 4/6/24 due to Resident 4 being at dialysis -Aspart insulin 7 units to administered AM, noon, and PM; AM dose was not given on 4/4/24, 4/6/24, 4/9/24, 4/11/24 and 4/16/24; insulin was held on 4/2/24 and 4/13/24 -Sildenafil Citrate 20 mg [medication for pulmonary hypertension] scheduled to be administered AM and PM; AM dose was not given to Resident 4 being out of the facility on 4/4/24, 4/9/24, 4/11/24, 4/13/24, and was held on 4/2/24 and 4/6/24 A review of Resident 4's 4/2024 MAR and care plan did not reveal any directions for administration of medication on dialysis days. In an interview on 4/18/24 at 3:06 PM, LPN B reported that residents that leave between 4-5 AM for dialysis are not back to the facility until noon. LPN B reported morning medications are not given to residents on dialysis. LPN B reported noon medications, blood sugar checks and noon insulin are administered to residents when they get back to the facility from dialysis. In an interview on 4/18/24 at 3:15 PM, LPN A reported if a resident is gone from the facility at the time medications are to be provided, out of the facility is documented, and medications are resumed when the resident returns to the facility. In an interview on 4/18/24 at 3:17 PM, LPN Unit Manager C reported administration of medications for residents going to dialysis varies based on provider direction and could be provided after return from dialysis or scheduled around dialysis. In an interview on 4/18/24 at 4:34 PM, the DON reported had started to work with providers on adjustment of times of medications for residents going to dialysis. The DON reported the physicians are to be notified of medications not provided to residents. C. A review of facility policy dated 1/1/2023 titled Dialysis Monitoring Policy revealed the following: -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.

Licensure reference: 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to ensure the medical provider was notified of blood sugar levels outside of parameters for 1 [Resident 4] of 4 sampled residents. The facility had a total census of 72 residents. Findings are: A review of Admission Record revealed Resident 4 was admitted to the facility on [DATE] with a readmitted [DATE] with a primary diagnoses of end stage renal disease, dependence on renal dialysis, and a type 2 diabetes mellitus without complications. A review of Resident 4's 4/2024 MAR [Medication Administration Record] revealed an order for blood glucose monitoring 4 times per day with the physician to be notified of blood sugars of less than 70 or greater than 400. A review of Resident 4 Progress Notes dated 4/8/24 at 4:39 PM revealed Resident 4's Aspart insulin [rapid acting insulin] was held due a blood sugar of 67 with a snack given. Progress note did not reveal that Resident 4's medical provider was notified of blood sugar outside of parameters. A review of Resident 4's Progress Note dated 4/4/24 at 7:49 PM revealed Resident 4's blood sugar was 59 in PM. The Progress Note stated that a snack was given as well as dinner. According to Resident 4's Progress Note dated 4/4/24 at 7:49 PM Resident 4's Blood sugar was 124 now. Resident 4's Progress Note did not reveal Resident 4's medical provider was notified of blood sugar outside of parameters. In an interview on 4/18/24 at 4:02 PM, the Director of Nursing confirmed there was no evidence of Resident 4's medical provider being notified of blood sugars being outside of parameters and that medical provider should have been notified. A review of facility policy with effective date of 2/1/23 titled Blood Glucose Testing Procedure revealed the following: -Notify the provider,, if needed, of abnormal findings.

Licensure reference: 175 NAC 12-006.12E1 Based on observations, interview, and record review, the facility failed to ensure insulin pens were labeled with date opened for 3 [Residents 2, 3, and 4] of 4 sampled residents with orders for insulin. The facility had a total census of 72 residents. Findings are: A. Observations on 4/18/24 at 12:15 PM revealed Resident 2's Aspart [rapid acting insulin] and Glargine [long-acting insulin] insulin pens were not dated with date opened. LPN A obtained a new Aspart insulin pen from the facility emergency medication stock for administration of insulin to Resident 2. In an interview on 4/18/24 at 12:15 PM, LPN A indicated both insulin pens would be disposed of due to not being dated when opened. A review of Resident 2's 4/2024 MAR [Medication Administration Record] revealed insulin pen is to be discarded 28 days after initial use. B. Observations on 4/18/24 at 7:19 AM revealed Resident 3's Glargine insulin pen was not labeled with date opened. LPN A obtained a new Glargine insulin pen from the facility emergency medication stock for administration of insulin to Resident 3. In an interview on 4/18/24 at 7:19 AM, LPN A confirmed Glargine insulin pen was not dated and would be discarded. A review of Resident 3's 4/2024 MAR revealed insulin pen is to be discarded 28 days after initial use. C. Observations on 4/18/24 at 12:44 PM revealed Aspart pen had no label with Resident 3's name on it or dated with date opened. LPN A disposed of pen and obtained a new insulin pen from medication refrigerator for Resident 3. A review of Resident 4's 4/2024 MAR [Medication Administration Record] revealed insulin pen is to be discarded 28 days after initial use. D. In an interview on 4/18/24 at 4:02 PM, RN [Registered Nurse] Consultants E and F confirmed insulin pens are to be dated when first used.

Licensure Reference Number : 175 NAC 12-006.09 Based on record review and interview, the facility staff failed to ensure neurological assessments were completed after a fall to evaluate for potential changes in condition for 2 [Residents 5 and 3] of 4 sampled residents with falls. The facility had a total census of 59 residents. Findings are: A. A review of facility policy titled Neuro Checks dated 3/31/2021 revealed the following policy: 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 change. Procedure is as follows: 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 instructions. 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. B. A review of Resident 5's admission record revealed an admitted [DATE] with a primary diagnosis of Ventral Hernia (hernia that occurs through your front abdominal muscles) without obstruction or gangrene. A review of a Incident Report/Incident Report log dated 2/17/24 at 7:38 AM and Progress Note (PN) dated 2/17/24 for Resident 5 revealed a nurse heard a bump while walking to Resident 5's door. According to the PN dated 2/17/2024 when the door was opened, Resident 5 was starting to go down to the floor. Resident 5 was seen falling and hit their head on a plastic trash can in Resident 5's room. Resident 5 reported losing (gender) balance and sliding. Resident 5 was able to stand with 2 persons assistance and a gait belt. A review of Resident 5's Progress Notes revealed the following follow up charting regarding the fall: -2/17/24 10:55 AM, Resident 5 did fall this AM around 7:30 AM while attempting to change their gown. Resident 5 is alert and oriented and able to voice Resident 5 needs to staff and peers. -2/17/24 4:10 PM Resident 5 is currently on fall charting and denies any issues. -2/18/24 4:33 AM Resident 5 continues on fall charting related to a witnessed fall on 2/18/24. Resident 5 had no complaints of pain or discomfort. -2/18/24 3:43 PM Resident 5 continues on follow up fall charting from 2/17. No injuries noted or reported at this time. -2/19/24 Resident 5 continues on fall charting related to a witnessed fall on 2/18/24 when Resident 5 hit their head on the trash can in room. Resident 5 has no complaints of pain or discomfort. A review of electronic medical record did not reveal any documentation of neuroloical assessments being completed on Resident 5 after their fall on 2/17/24. A review of Incident Report/Incident Report log dated 2/20/24 at 10:23 AM and PN dated 2/20/24 at 10:40 AM revealed Resident 5 was ambulating from the bathroom and Resident 5 fell to the floor. Resident 5 was laying with their head by their bed and recliner with legs stretched out. Resident 5 denied hitting their head and denied pain. Neurolocial assessments were initiated for Resident 5 and Resident 5's Range of Motion was within normal limits. A review of Incident Report/Incident Report log dated 2/20/24 at 11:46 AM and PN dated 2/20/24 at 4:31 PM for Resident 5 revealed Resident 5 transferred off the toilet, lost their footing/balance and fell backwards hitting their head on the toilet. Resident 5 had a 5 centimeter (cm) x 5 cm bump on the back of their head. Resident 5 reported having neck pain. The PN dated 2/20/24 revealed the facility started over with vital signs and crani checks which were all within normal limits. The PN revealed Resident 5's pupils were equal and reactive and the resident reported 5 out of 10 pain. A review of Resident 5's Progress Notes revealed the following charting regarding the fall: -2/20/24 at 4:51 PM Resident 5 has fallen 2 times this shift. Neurological assessments were started due to an unwitnessed fall. Resident 5 also stated that Resident 5 hit their head on toilet during second fall. A review of Resident 5's Neurological Checks form in the electronic medical record revealed the form was initiated on 2/20/24 at 10:30 AM. Each neurological check had documented dates and times for the vitals. A review of of the Neurological checks revealed the following the time frames for conducting the Neurological Checks with results: -Check 1, initial Neurological Assessment-Vitals were documented as taken on 2/20/24 at 9 AM with remainder of neuro check completed -Check 2, 15 minute evaluation # 1-Vitals were documented as taken on 2/20/24 at 12 AM with remainder of neuro checks completed -Check 3,15 minute evaluation #2 was not completed -Check 4,15 minute evaluation #3 was not completed -Check 5,15 minute evaluation #4 -Vital signs were documented as taken on 2/20/24 at 9:45 AM with remainder of neuro checks completed -Check 6,30 minute evaluation #1-was not completed -Check 7,30 minute evaluation #2-Vital signs were documented as taken on 2/20/24 at 9:45 AM with remainder of neuro checks completed -Check 8,30 minute evaluation #3-was not completed -Check 9,30 minute evaluation #4-Vital signs were documented as taken on 2/20/24 at 10:15 AM with remainder of neuro checks completed -Check 10, hour evaluation #1-Vials were documented as taken on 2/20/24 at 11:15 AM with remainder of neuro checks completed. -Check 11, hour evaluation #2 was not completed -Check 12, hour evaluation #3 was not completed -Check 13, hour evaluation #4-Vital signs were documented as taken on 2/20/24 at 11:45 AM with remainder of neuro checks completed -Check 14, hour evaluation #1 was not completed -Check 15, hour evaluation #2-Vital signs were documented as taken on 2/20/24 at 7:45 PM with remainder of neuro checks completed -Check 16, hour evaluation #3-Vital signs were documented as taken on 2/20//24 at 11:30 PM with remainder of neuro checks completed -Check 17, hour evaluation #4-Vital signs documented as taken on 2/21/24 at 3:45 AM with remainder of neuro checks completed -Check 18, hour evaluation #1 was not completed -Check 19, hour evaluation #2 was not completed -Check 20, hour evaluation #3 was not completed. A review of Health Care Provider visit note dated 2/21/24 revealed Resident 5 was seen per nursing request due to multiple falls. Further review of the Health Care Provider visit note dated 2/21/2024 revealed the following information: -Neuro checks have been stable per nursing. -Vitals stable. -Orders for Complete Blood Count and Basic Metabolic Panel in AM due to 2 falls. -Resident 5 continues to have nausea and vomiting which Resident 5 has had since the hospital. A review of Progress Notes for Resident 5 revealed the following: -2/22/24 at 12:20 PM a Nurse from Resident 5's surgeon's office reported Resident 5 was being sent to emergency room from the doctor's office. -2/22/24 at 3:50 PM Resident 5 was being admitted to the hospital for a subdermal hematoma. A review of General Surgery Consult Note for Resident 5 with encounter date of 2/22/24 revealed Resident 5 complained of posterior head pain, fogginess, lack of clear vision, pain in lower back and tailbone region. A Cat Scan [imaging test] showed small right posterior para-falcine subdural hemorrhage [bleeding in your brain] without significant mass effect or midline shift. In interviews on 2/29/24 at 11:19 and 11:59 AM, the facility Director of Nursing reported there were not additional neurological assessments to be provided. The Director of Nursing confirmed that neurological assessments should have been completed after fall on 2/17 and both falls on 2/20/24 with neurological assessments starting over after the second fall on 2/20/24. C. A review of Resident 3's admission record revealed they were admitted to the facility on [DATE] with a diagnosis of Orthostatic Hypotension [a sudden drop in blood pressure when one stands up]. A review of Resident 3's Incident Report/Incident Report log dated 2/20/24 at 9:14 AM and Progress Note dated 2/20/24 at 8:15 AM revealed Resident 3 was found sitting on the floor by the side of their bed. Resident 3 denied hitting their head and denied they had nausea/vomiting or dizziness. Neurological assessments were initiated. A review of Resident 3's Neurological Checks form in the electronic medical record revealed the form was initiated of 2/20/24 at 9:14 AM. Each neurological check had documented dates and times for the vitals. A review of of the Neurological checks revealed the following the time frames for conducting the Neurological Checks with results: -Check 1 initial Neurological Assessment-Vital signs from 2/20/24 at 7:17 AM with remainder of neuro checks completed -Check 2,15 minute evaluation #1-Vital signs documented as taken on 2/20/24 at 8:15 AM with remainder of neuro checks completed -Check 3,15 minute evaluation #2-Vital signs documented as taken on 2/20/24 at 8:30 AM with remainder of neuro checks completed -Check 4,15 minute evaluation #3-Vital signs documented as taken on 2/20/24 at 8:45 AM with remainder of neuro checks completed -Check 5,15 minute evaluation #4-vital signs documented as taken on 2/20/24 at 9 AM with remainder of neuro checks completed -Check 6,30 minute evaluation #1-Vital signs documented as taken on 2/20/24 at 9:30 AM with remainder of neuro checks completed -Check 7,30 minute evaluation #2-Vital signs documented as taken on 9/20/24 at 10 AM Vital signs refused with remainder of neuro checks completed -Check 8,30 minute evaluation #3-Vital signs documented as taken on 2/20/24 at 10:30 AM with remainder of neuro checks completed -Check 9,30 minute evaluation #4 was not completed due to Resident 3 sleeping -Check 10,1 hour evaluation #1 was not completed due to Resident 3 sleeping -Check 11,1 hour evaluation #2 -Vital signs documented as taken on 2/20/24 at 1 PM with remainder of neuro checks completed -Check 12,1 hour evaluation #3-Vital signs documented as taken on 2/20/24 at 2 PM with remainder of neuro checks completed -Check 13,1 hour evaluation #4-vitals documented as taken on 2/20/24 at 3 PM with remainder of neuro checks completed -Check 14,4 hour evaluation #1 was not completed -Check 15,4 hour evaluation #2 was not completed -Check 16,hour evaluation #3 was not completed -Check 17,4 hour evaluation #4 was not completed -Check 18,8 hour evaluation #1 was not completed -Check 19,8 hour evaluation #2 was not completed -Check 18,8 hour evaluation #3 was not completed A review of Resident 3's Progress Note dated 2/25/24 at 7:45 PM revealed Resident 3 was sitting on their fallmat in their room on their left side of the bed after rolling out of the bed. Resident 3 is alert and oriented x 3 with intermittent confusion. Resident 3 denied head impact. Resident 3's neurolocial assessment and vital signs within normal limits. A review of electronic medical record did not reveal any documented neurological assessments for Resident 3 after the fall on 2/25/24. In an interview on 2/29/24 at 12:29 PM, the Director of Nursing confirmed that neurological assessments should have been completed for Resident 3 after falls on 2/20/24 and 2/25/24 as the falls were unwitnessed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview; the facility staff failed to complete a nutritional assessment and failed to evaluate weight loss for 1 (Resident 2) of 1 sampled resident. The facility staff identifed a census of 71. The findings are: Review of Resident 2's medical record revealed an admitted [DATE] with an admission weight documented of 147 pounds. Review of Resident 2's admission assessment dated [DATE] revealed a documented weight of 147 pounds. Review of Resident 2's Treatment Administration Record (TAR) revealed a weight of 136.3 pounds on 09/24/22 which is a loss of 7.28% from documented weight on 09/23/22. Further review of Resident 2's medical record revealed no indication the facility staff had evaluated or implemented interventions to manage Resident 2's significant weight loss. Review of Resident 2's electronic record revealed a documented weight on 09/29/22 of 127 pounds which resulted in a weight loss of 20 pounds or 13.61% since 09/23/22. Review of Resident 2's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 09/30/22 revealed a weight of 127 pounds. Further review of the MDS revealed eating was coded as a 7 which indicates activity occurred only once or twice over a 7 day period. Record review of Resident 2's medical record that included Physician orders, Registered dietician notes and progress notes revealed there was not a nutritional assessment completed or an evaluation of Resident 2's weight loss. Review of the facility weight monitoring policy dated 05/23/17 revealed the following: -A significant change in weight is defined as : a. 5% change in weight in 1 month b.7.5% change in 3 months c. 10% change in 6 months -The physician should be encouraged to document the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -The Dietician should be consulted to assist with interventions; interventions are to be recorded in the medical record. On 10/17/22 at 02:42 PM an interview was conducted with the Interim Director of Nursing which confirmed that Resident 2 had not had a nutritional assessment completed and the significant weight loss had not been evaluated.

Licensure Reference Number ,d+[DATE].09 Based on record reviews and interviews, the facility failed to identify a change of condition for Resident 1. The facility census was 57. Review of Resident 1's admission progress note revealed Resident 1 was admitted to the facility on [DATE] with a goal of returning home. Resident 1 was assessed as being alert and oriented. Review of Resident 1's Admission Evaluation revealed the resident had a cognitive score of ,d+[DATE], indicating mild cognitive impairment. Resident 1 did use a [CONDITION(S)] (Continuous Positive Air Pressure) at night and had oxygen during the daytime hours and Resident 1 was receiving [CONDITION(S)] treatments. Review of Resident 1's progress note dated [DATE] revealed Resident 1 was alert and oriented and able to make needs known. The facility was working with Resident 1 and family on potential discharge in one week. Review of Resident 1's progress note dated [DATE] at 10:43 AM revealed Resident 1 was alert and oriented, denied shortness of breath, pain or discomfort. Review of an SBAR (a communication tool to alert of a change of condition) written on [DATE] at 11:47 AM by Therapist B revealed Resident 1 could not remain awake long enough to move in bed and oxygen was turned up to 4Liters per minute and Resident 1's oxygen Level only maintained ,d+[DATE]%. Therapist B notified Resident 1's nurse. Nurse follow-up revealed Resident 1 was at baseline and very tired from [CONDITION(S)]. Review of Resident 1's progress notes revealed Resident 1's baseline to be alert and oriented and able to make needs known. Review of Resident 1's treatment administration record revealed Resident 1's oxygen levels in the 90% range on 2 Liters per minute of oxygen. Interview with LPN A (Licensed Practical Nurse) on [DATE] at 11:10 AM revealed family came to visit and Resident 1 was sitting up in bed wiggling to get comfortable sitting up in bed. LPN A asked Resident 1 if Resident 1 was in pain or hungry and Resident 1 indicated no. LPN A left the room and returned with RN C (Registered Nurse). LPN A revealed that a full assessment was completed but no vital signs (temperature, pulse, respiration and blood pressure) were completed because it was completed earlier in the morning and were within normal limits. Interview on [DATE] at 11:30 AM with the Director of Nursing revealed a full assessment would include vital signs to determine a change of condition. Review of Resident 1's progress notes revealed on [DATE] at 4:09 PM, LPN A received a call from the nurse at the [CONDITION(S)] clinic and Resident 1 had been sent to the emergency room with 102 degree temperature and oxygen levels of 60%. Interview with DON revealed resident was admitted to ICU and expired.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview; the facility staff failed to notify the practitioner and responsible party of a deterioration of a skin wound for 1 (Resident 21) of 3 sampled residents. The facility staff identified a census of 70. Findings are: Record review of Resident 21's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 21's Clinical Notes (CN) dated 11-9-2019 revealed Licensed Practical Nurse (LPN) A removed a dressing to the left elbow revealing an abrasion that measured 4.0 centimeters (CM) by 2.5 cm's. According to the CN dated 11-9-2019, LPN A cleansed the wound, applied a dressing and notified the practitioner and family. Record review of a Wound Assessment (WA) sheet dated 11-9-19 revealed the wound size to the left elbow was 4.0 cm by 2.50 cm. The wound was identified as having 50% intact skin and 50 % of bright red, beefy skin with a small amount of drainage. According to the WA sheet dated 11-9-2019, the abrasion was of unknown etiology. Record review of Resident 21's WA dated 11-16-19 revealed the wound to the left elbow measured 25% intact skin, 50 % pale pink skin and 25 % of bright red skin. Further review of the WA dated 11-16-19 revealed the size of the wound to the left elbow measured 4.90 cm by 3.80 cm with a small amount of drainage, a deterioration in the condition of the wound. Record review of Resident 21's medical record revealed no evidence the facility staff had completed any treatments or followed up with Resident 21's practitioner and reported the deterioration of the wound to the left elbow, in addition, there was not evidence the facility staff had notified Resident 21's responsible party. Record review of Resident 21's WA dated 11-23-19 revealed the wound to the left elbow measured 7.20 cm by 4.50 cm had a non blanchable area that measured 10%, pale pink area that measured 10% and 80 % of a firm hard area. There was not any drainage and the surrounding skin was evaluated as abnormal. According to the WA dated 11-23-19 the left elbow wound progressed to an unstageable pressure ulcer (Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar (dead tissue). On 12-04-2019 at 3:30 an interview was conducted with the Director of Nursing (DON). During the interview, the DON confirmed the was not evidence the facility staff had obtained orders for a treatment to the left elbow on 11-9-19. The DON further reported nursing staff should have obtained an order to treat the left elbow area for Resident 21. The DON confirmed the WA sheet dated 11-16-19 of the wound to Resident 21's elbow had deteriorated and Resident 21's practitioner and responsible party had not been notified and should have been.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2 Based on record review and interview; the facility staff failed to identify skin breakdown for 1 (Resident 20) of 4 sampled residents. The facility staff identified a census of 75. Findings are: Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 20's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10-15-2019 at 11:25 AM by Licensed Practical Nurse (LPN) F revealed LPN F completed wound care on Resident 20 legs. During the observation Resident 20 was observed to have an open area to the right heel. LPN F measured the area to be 1.1 centimeters (CM) by 0.5 cm. During the observation of the left heel, Resident 20 reported having told staff a few days ago. On 10-15-2019 at 11:35 PM an interview was conducted with LPN F. During the interview LPN F confirmed Resident 20 had an open area to the left heel. On 10-16-2019 at 8:15 AN during a random interview with Resident 20, Resident 20 reported the left heel had hurt about 2 days ago.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interviews; the facility staff failed to implement a pain management program for 1 (Resident 21) of 4 sampled residents. The facility staff identified a census of 75. Findings are: Record review of Resident 21's Progress Note dated 10-01-2019 revealed the facility staff had identified Resident 21 had .persistent left hip pain. Record review of Resident 21's Progress Note dated 10-03-2019 revealed the facility staff had identified Resident 21 had .persistent left hip pain. Record review of Resident 21's PN dated 10-05-2019 revealed the facility staff had documented Resident 21 had chronic L (left) hip pain. Record review of Resident 21's PN dated 10-09-2019 revealed the facility staff had identified Resident 21 would yell out through out the shift with cares and to get staff attention. There was not evidence the facility staff had evaluated Resident 21 for pain indicators. Record review of Resident 21's PN dated 10-11-2019 revealed Resident 21 .Guest had very little complaints with the exception of persistent left hip pain. Record review of Resident 21 PN dated 10-13-2019 revealed Resident 21 occasionally complained of left hip pain. Record review of Resident 21's PN dated 10-15-2019 revealed Resident 21 Continues to complain of left hip pain. Hollers out with cares. On 10-15-2019 at 3:05 PM an interview was conducted with Resident 21's Responsible Party (RP). During the interview Resident 21's RP reported Resident 21 had pain to the left hip and left arm. Resident 21's RP reported Resident 21's pain had increased and did not know what the facility staff were doing about it. Record review of Resident 21's Initial Care Plan (ICP) dated 9-26-2019 revealed Resident 21 goal was to have pain managed to a level acceptable to their tolerance. Interventions identified on the ICP was that staff were to provide pain relief such as medications, heat and massage. Observation on 10-16-2019 at 6:50 AM through 7:32 AM revealed Nursing Assistant (NA) A was assisting Resident 21 with personal cares. NA A was using a washcloth wiping the left side of the groin area when Resident 21 was observed to yell out my hip, my hip. NA A without stopping and reporting to the nurse continued to provide personal care. NA A had unfastened an adult brief and began to push the brief between resident 21's legs when Resident 21 yelled out watch that Hip, Oh that hurts, Resident 21 then yelled out stop that hurts, that hurts. NA A did not stop and report to Resident 21 nurse of the continued pain. NA A cued Resident 21 to turn to the left to removed the brief. NA A attempted to assist Resident 21 with turning to the left when Resident 21 yelled out watch the hip, watch the hip, oh wait it hurts, it hurts, let me do it. NA A did not stop the care and report to Resident 21's nurse of Resident 21's pain. NA A removed the soiled brief, cleansed Resident 21's buttocks. NA A obtained a clean adult brief and as NA A began to apply the brief, Resident 21 yelled out Watch the hip, watch the hip, oh that's enough, I want a pain pill, get me a pain pill. NA A without stopping and reporting to Resident 21's nurse of request for pain medication continued to apply the adult brief. NA A then assisted Resident 21 into a back laying position. NA A obtained a pair of black looking sweat pants. NA A began to apply the sweat pants when Resident 21 stated it hurts my leg, come on, my leg hurts, that enough, it hurts. NA A asked Resident 21 if Resident 21 hurt with Resident 21 reporting it hurts real bad. NA A then obtained the assistance of NA C for transferring Resident 21 from bed to a recliner. NA A and NA C prepared Resident 21 for a transfer using a mechanical lift. NA C obtained a sweatshirt and assisted Resident 21 with putting the sweat shirt on. NA A and NA C obtained a sling and as NA A and NA C began to position the sling under Resident 21, Resident 21 yell out watch the hip, watch the hip, go slow, go slow. Resident 21 reported to NA A and NA C, that was torture. On 10-16-2019 at 7:42 AM during an interview reported pain of an 8 on a scale of 0 to 10 with 10 being the worst pain. On 10-16-2019 at 8:00 AM an interview was conducted with Licensed Practical Nurse (LPN) B. During the interview when asked if Resident 21 pain had been reported to LPN B, LPN B stated no. When asked if Resident 21's pain should have been reported to LPN B, LPN B reported Resident 21's pain should have been reported to the nurse. On 10-16-2019 at 8:35 AM an interview was conducted with NA C. During the interview NA C reported having worked with Resident 21 on a regular bases. When asked if Resident 21 was always painful in the left hip, NA C stated yes, in the mornings (gender) is always painful in the mornings and other times. Review of Resident 21's medical record revealed there was not evidence of a comprehensive pain management program for Resident 21 that would included identifying causes of pain, specific interventions to be implemented when Resident 21 was having pain, how staff were to rate Resident 21's pain, how the facility staff were to evaluate the pain management interventions and implement additional interventions to manage Resident 21's pain. On 10-16-2019 at 10:25 AM an interview was conducted with Registered Nurse Consultant (RNC) D. During the interview RNC reported staff should have stop providing cares and reported to Resident 21's nurse of Resident 21's pain. RNC reported the facility had not completed a comprehensive management program for Resident 21 and should have. Record review of the Facility Pain Management Policy dated 5-23-2017 revealed the following information: -Policy: -It is the policy to provide appropriate mechanisms to support and foster the right of all guest to comfort and dignity through the effective management of pain. Pain intensity and relief will be assessed and reassessed on a routine basis to provide effective pain management. -Procedure: -1. A pain assessment will be completed upon admission, quarterly and as needed. -4. The nurse for each shift will be responsible for effectively monitoring and managing pain through the use of the facility assessment tools.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on interviews and record reviews; the facility staff failed to develop and implement a plan to correct and maintain compliance regarding Federal and State deficiencies related to F692, F725 and F684 and failed to ensure addition deficiencies were identified at F609, F698 and F760 during a revisit survey. The facility practice had the potential to affect all residents in the facility. The facility staff identified a census of 70. Findings are: Record review of the facility Policy for Quality Assessment and Process Improvement (QAPI) dated 1-12-2018 revealed the following information: -Policy: -The QAPI Committee will identify negative trends or area for improvement based on : -Data Collection through QAPI activities. -Team/guest/family feedback. -Perception of risk. -Negative trends or areas for improvement are targeted and monitored for improvement based on risk/high volume criteria. On 12-05-2019 at 5:50 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview when asked what the facility QAPI committee was working on, LPN D stated I'm not sure what they are working on. On 12-05-2019 at 5:55 AM an interview was conducted with Registered Nurse (RN) E. During the interview RN E reported not being aware of what the QAPI committee was working on. On 12-05-2019 at 5:58 AM an interview was conducted with Nursing Assistant (NA) F. During the interview NA F reported not being aware of what the QAPI committee was working on. On 12-05-2019 at 5:58 AM an interview was conducted with NA G. During the interview when asked what the QAPI committee was working on, NA G stated I'm not sure. On 12-05-2019 at 6:00 AM an interview was conducted with RN H. During the interview RN H reported not being aware of what the QAPI committee was working on. On 12-05-2019 at 6:02 AM an interview was conducted with LPN I. During the interview LPN I reported not being aware of QAPI. On 12-05-2019 at 6:07 AM an interview was conducted with NA J. During the interview NA J reported not being sure about QAPI.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility failed to evaluate causal factors and re-evaluate interventions to prevent pressure ulcer development for 2 (Resident 2 and 10) of 3 sampled residents. The facility staff identified a census of 53. The findings are: Record review of the Policy and Procedure for Assessment Prevention Treatment Documentation for Skin Integrity dated 8/9/2018 revealed that licensed clinical members will perform a head to toe assessment upon admission/readmission and continue to do so weekly and as needed. A. Review of Resident 10's Medical Record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Admission Evaluation sheet dated 01/02/2019 for Resident 10 revealed the facility staff assessed Resident 10's skin as intact. Record review of Weekly Skin assessment dated [DATE] revealed the facility staff assessed Resident 10's skin as not intact with further documentation of an abrasion to the Right 4th toe, but did not identify any pressure areas. Record review of Re-admission Evaluation sheet for Resident 10 dated 01/16/2019 revealed Resident 10's skin was not intact with further documentation of Bruise/ Diabetic Ulcer. Further review of the 01/16/2019 Re-admission Evaluation sheet revealed the location of the Bruise/Diabetic Ulcer was not identified. Record review of Weekly Skin Assessment for dated 01/24/2019 revealed Resident 10's skin was assessed as being intact. Review of Resident 10's medical record revealed there was no evidence of further weekly skin assessments until 02/07/2019 which revealed Resident 10's skin was not intact with further documentation of a facility acquired Stage II Partial Thickness Pressure Ulcer (the top layer of the skin is broken creating an open sore) to Left Buttocks. Record review of Resident 10's medical record revealed there was no evidence of further weekly skin assessments until 03/14/2019 which revealed that Resident 10's skin was not intact with further documentation of Stage II Partial Thickness Pressure Ulcer to Left Buttocks. Review of the current Comprehensive Care Plan dated 2/5/2019 revealed that Resident 10 was at risk for skin issues due to decreased mobility and [DIAGNOSES REDACTED]. The goals included Resident 10 would have reduced risk for skin breakdown and Resident 10 will have no skin breakdown. The interventions were as follows: 1. Float heels while in bed or recline recliner as needed. 2. Keep head of bed elevated. 3. Encourage footwear when up for protection. 4. Encourage ambulation as tolerated for pressure relief. 5. Pressure reduction mattress. 6. Wheelchair cushion. Observation of wound care 3/21/2019 at 09:38 AM revealed that Resident 10 had an open area to the left buttocks. Record review of the Policy and Procedure for Assessment Prevention Treatment Documentation for Skin Integrity dated 8/9/2018 revealed that licensed clinical members will perform a head to toe assessment upon admission/readmission and continue to do so weekly and as needed. Interview conducted with Director of Clinical Service on 3/21/2019 at 02:39 PM confirmed that Resident 10 did not have skin assessments completed weekly, there was no evaluation of causal factors for why Resident 10 developed a pressure ulcer, and Resident 10 developed a facility acquired pressure ulcer. B. Review of Resident 2's Medical Record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Weekly Skin Evaluation form dated 12/30/2018 for Resident 2 revealed an open wound to right heel present on admission. Record review of Resident 2's Medical Record revealed there was no evidence of weekly skin assessments being completed until 01/21/2019 which revealed that Resident 2's skin was not intact and the rest of the assessment was incomplete. Record review of Resident 2's Medical Record revealed there was no evidence of weekly skin assessments completed from 1/21/2019 until 02/28/2019 when the facility staff assessed Resident 10 with a deep tissue injury (a pressure-related injury to skin tissues under intact skin) to the right heel and left heel. Review of Resident 2's Comprehensive Care Plan dated 2/8/2019 revealed that Resident 2 was at risk for skin integrity due to immobility, history of skin breakdown. The goal for Resident 2 was to have no further skin breakdown. The interventions were as follows: 1. Treatment per MD order. 2. Air mattress. 3. Assist with repositioning. 4. Dietary interventions. 5. Wheelchair cushion. The Comprehensive Care Plan for Resident 2 further identified a Right Heel Pressure Ulcer with a goal of Ulcer will heal. Interventions were as follows: 1. Check for incontinence. 2. Adjust diet/supplements as indicated. 3. Refer to treatment record for current order. 4. Use pillows, pads, wedges to reduce pressure on heels and pressure points. Turn and reposition. 5. Air mattress and pressure-reducing pads when sitting. Interview conducted with Director of Clinical Service on 03/21/2019 at 02:39 PM confirmed that skin assessments for Resident 2 were not completed weekly and Resident 2 developed a facility acquired pressure ulcer.