Every finding on record at Holmes Lake Rehabilitation & Care Center

The facility failed to ensure food was served in a safe and timely manner to prevent potential food born illnesses. This had the potential to affect all residents who ate from the kitchen. The facility census was 52.Licensure Reference Number 175 NAC 12-006.11 (E) A record review of the kitchen menu revealed the mealtimes were: 8:00 AM for breakfast, noon for lunch and 6:00 PM for supper.An interview on 4/8/26 with the Dietary Manager confirmed that the mealtimes were: 8:00 AM for breakfast, noon for lunch and 6:00 PM for supper.An observation on 4/9/26 at 7:00 AM with the Dietary Manager and the Cook-A who was preparing the lunch meal revealed, Cook-A opened two bags of chicken breast and placed them in two greased pans. Cook-A did not count how many chicken breast had been placed in the two greased pans. The Dietary Manager stated to the Cook-A that (gender) did not believe there was enough chicken breast for the residents. Cook-A stated (gender) believed there was enough chicken. An observation on 4/9/26 at noon with Cook-A serving lunch revealed: -Cook-A took the temperatures before the start of serving: chicken 172.9 degrees (Fahrenheit), rice 167.2 degree and veggies 180.1 degrees-Cook-A then with gloved hands started serving up the plates, where Cook-A would move the food around on the plate with (genders) gloved hands. Cook-A did this without changing (gender) gloves through the whole serving process. Cook-A would move around the kitchen grabbing hot plates, and dish covers with the same gloves on that Cook-A was serving and moving the food around on the plate.-During the serving, it was observed that the main meal of chicken breast was 11 pieces short for the meal.-The Dietary Manager at 12:45 PM started grilling the 11 chicken breasts.-The chicken breast was grilled in the 15 minutes and then coated the chicken breast in the Swiss sauce and put on the plates to serve the remaining residents. An interview on 4/9/26 at 1:30 PM with the Administrator confirmed that Cook-A should not have been touching or moving the food around on the plate with contaminated gloves and that the Dietary Manager should have counted the chicken breast when (gender) did not believe there was enough chicken breast for the meal.

The facility failed to ensure Enhanced Barrier Precautions (EBP, refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were used during G-tube (surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach) feeding and medication administration for 1 sampled resident (Resident 5). The facility census was 52. Licensure Reference Number 175 NAC 12.006.18(B) Findings are: A record review of admission record with the printed date of 4/8/26 revealed Resident 5 was admitted with nutritional problems related to dysphagia (difficulty swallowing) following cerebral infarction (stroke). A. During an observation on 04/08/2026 at 1:00 PM Licensed Practical Nurse (LPN-B) administered gastric tube medications to Resident 5 without wearing appropriate EBP. A record review of the facility's MDRO (multi-drug resistant organisms) PPE-Enhanced Barrier Precaution Policy last revised on 03/20/2024 revealed EBP is to be worn for residents with any of the following indwelling medical devices such as central lines, urinary catheters, feeding tubes, and tracheostomies. During an interview on 4/08/2026 at 2:45 PM Licensed Practical Nurse (LPN-B) confirmed that LPN-B should have worn a gown when administering g-tube medications to Resident 5. During an interview on 04/08/2026 at 2:50 PM with the Director of Nursing (DON) also confirmed that when administering medications via G-tube staff should wear a gown and gloves. B. An observation on 4/8/26 at 9:00 AM on Resident 5 room door was a sign for EBP precautions. An observation on 4/8/26 at 1:00 PM revealed LPN-B laid a barrier down on the tray table (Resident 5) where LPN-B placed the glasses of water, syringe, and medications cups. LPN-B did use hand sanitizer and explained to Resident 5 what (gender) was going to do. LPN-B did not have a gown on. LPN-B did listen for placement of G-tube (surgically placed device used to give direct access the stomach for supplemental feeding, hydration or medicine), with a small amount of air in the syringe. LPN-B then added some water and a cup of medication to the syringe and the water and medication went down the G-Tube. LPN-B then added a small amount of water to the syringe and it (the water) did not go down the G-tube. LPN-B tried some air in the syringe and could not get the water to move down the G-Tube. An observation on 04/08/2026 at 2:43 PM revealed LPN-B and LPN-C attempting to unclog Resident 5's G-Tube and LPN-C ended up cutting the G-Tube were it was clogged. LPN-B and LPN-C did not have gowns on during the procedure. LPN-B continued to administer the tube feeding. LPN-B did apply gloves but did not put on a gown. Record review of the facility's PPE (Personal Protective Equipment)- Enhanced Barrier Precautions policy last revised 3/20/24 stated that EBP are an infection control intervention designed to reduce transmission of resident organisms that employs targeted gown and glove used during high contact resident care activities. EBP may be indicated when contact precautions do not otherwise apply for resident with any of the following wounds or indwelling medical devices, regardless of MDRO colonization status. Indwelling medical devices include central lines, urinary catheters, feeding tubes, tracheostomies, or peripheral intravenous line. An interview on 4/08/2026 at 2:45 PM with LPN-B confirms that (gender) should have worn a gown when administering G-tube medications to Resident 5. An interview on 04/08/2026 at 2:50 PM with the Director of Nursing confirmed that when administering medications via G-tube staff should be wearing gown and gloves.

Licensure Reference Number 175 NAC 12-006.04(E) Based on interviews and record reviews, the facility failed to provide notification to Department of Health and Human Servcies (DHHS) within 5 working days of a change in Director of Nursing (DON) position. This had the potential to affect all the residents that reside in the facility. The facility census was 50. Findings are: Record review of the facilities notification of the change in DON that was sent to State Agency revealed the previous DON service end date was 2/2/2024 and the new DON service start date was 2/3/2024. DHHS received notification of the DON change on 3/31/2025. Interview with DON on 6/10/25 at 3:00 PM confirmed that the 5-day notification of the DON change was not sent into the State Agency within 5 working days as required. Interview with DON on 6/10/25 at 3:05 PM confirmed that the year of service dates should have been dated 2025.

Licensure Reference Number 175 NAC 12-006.09(H) Based on observations, interviews and record reviews, the facility failed to ensure prompt response to call lights to ensure resident needs were being met for 4 (Residents 1, 3, 7, and 8) out of 4 sampled residents. The facility census was 50. Findings are: A. Record review of Resident 1's admission Record dated 6/10/25 revealed admission to the facility was on 2/13/25. Record review of Resident 1's Diagnosis Form dated 6/10/25 revealed diagnoses of Cerebral Infarction (when blood flow to a part of the brain is blocked) due to embolism (a blockage-causing piece of material, inside a blood vessel) of right middle cerebral artery, hemiplegia (weakness or partial paralysis on one side of the body) affecting left nondominant side, Type II diabetes (a disease of inadequate control of blood levels of glucose), moderate persistent asthma (a condition on which a person's airway becomes inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), morbid obesity, anxiety disorder, obstructive sleep apnea (intermittent airflow blockage during sleep), dependence on wheelchair. Record review of Resident 1's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/22/25 revealed: -BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 15 indicating no cognitive impairment. -Dependent with toileting, bathing, rolling side to side in bed, transfers, upper and lower dressing and footwear. Moderate assistance with oral hygiene and personal hygiene. Needs set up assistance for eating. Has a catheter. Incontinent of bowel. Transfers with Hoyer lift. Interview on 6/10/25 at 12:57 PM with Resident 1 revealed that one time this resident had to wait 2 hours for the staff to answer the call light. Resident 1 stated, for the past month, but usually on the evening shift, I have to wait 30 minutes to 1 hour for them (nursing staff) to answer my call light. Record review of Resident 1's call light response time recorded on the Device Activity Report between May 11, 2025 through June 10, 2025 revealed: -The call lights that were answered between 22 to 45 minutes occurred 75 times. -The call lights that were answered between 46 to 100 minutes occurred 39 times. -The call lights that were answered between 101 to 168 minutes occurred 9 times. B. Record review of Resident 3's admission Record dated 6/10/25 revealed admission to the facility was on 4/23/25. Record review of Resident 3's Diagnosis Form dated 6/10/25 revealed diagnoses of unspecified convulsions (type of seizure characterized by sudden, uncontrolled, and often violent shaking of the body due to abnormal electrical activity in the brain), alcohol abuse, generalized anxiety disorder, macular degeneration (an eye disease that affects central vision). Record review of Resident 3's MDS dated [DATE] revealed: -BIMS score was 11 indicating moderate cognitive impairment. -maximum assistance with toilet hygiene, lower body dressing, and footwear. Moderate assistance with oral hygiene, upper body dressing, rolling right to left in bed, transfers and personal hygiene. Bathing not attempted to do medical condition or safety. Set up assistance with eating. Interview on 6/10/25 at 11:15 AM with Resident 3 revealed [gender] has had some issues with call light not being answered timely. Resident 3 stated I have waited a few times for 1 hour, another time 45 minutes and another time it was 1.5 hours and could not identify a specific shift that was worse with call light response times. Record review of Resident 3's call light response time recorded on the Device Activity Report between May 11, 2025 through June 10, 2025 revealed: -The call lights that were answered between 22 to 45 minutes occurred 6 times. C. Record review of Resident 7's admission Record dated 6/10/25 revealed admission to the facility on 8/15/23. Record review of Resident 7's Diagnosis Form dated 6/10/25 revealed diagnoses of acute respiratory failure (occurs when the lungs can't properly exchange gases, causing abnormal levels of carbon dioxide and/or oxygen in the arteries), cerebral infarction (when blood flow to a part of the brain is blocked), urinary incontinence, anxiety, major depressive disorder, post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), history of falling, urge incontinence, dementia (a decline in mental ability severe enough to interfere with daily life), and morbid obesity. Record review of Resident 7's MDS dated [DATE] revealed: -BIMS was 14 indicating no cognitive impairment. -Dependent assistance with toileting hygiene, lower body dressing, footwear, rolling from right to left in bed, and transfers. Maximum assistance with oral hygiene, bathing, upper body dressing and personal hygiene. Always incontinent of bowel and bladder. -Open lesion on foot, moisture associated skin damage. Interview on 6/10/25 at 9:08 AM with Resident 7 revealed that [gender] call light does not get answered for quite a while frequently. This surveyor asked Resident 7 to turn the call light on at 9:10 AM to see about the staff answering the call light. Observation on 6/10/25 at 9:10 AM when Resident 7 turned the call light on, also noting the call system on the wall in the resident's room had a red light indicating the call light was on. -At 9:16 AM Activity Director brought in resident's mail but did not check about the call light. -At 9:22 AM the NA (nurse aide) brought Resident 7's breakfast tray in, sat it on the bedside table and did not check about the call light being on. -Observed at 9:28 AM one NA walked by the room without looking in. -Observed at 9:28 AM the Marquee sign above each hallway entrance and exit displaying the room numbers that have call lights on. Resident 7's room number was scrolling through every 5 seconds on the Marquee. -Observed at 9:32 AM 2 NA's walked by the room and did not look into Resident 7's room. -At 9:33 AM this surveyor walked away and stood within 4 doors away from Resident 7's room and observed one MA walk by resident's room without stopping. -Observed at 9:43 AM the DM (Dietary Manager) went into Resident 7's room and was talking about their food and choices. Another NA went in and stood by the DM, neither staff checked why the light was on. -Observed at 9:47 AM the Administrator walked by when the DM and NA were there and told them to check the call light and they did. Record review of Resident 3's call light response time recorded on the Device Activity Report between May 11, 2025 through June 10, 2025 revealed: -The call lights that were answered between 22 to 45 minutes occurred 62 times. -The call lights that were answered between 46 to 100 minutes occurred 25 times. -The call lights that were answered between 101 to 168 minutes occurred 1 times. D. Record review of Resident 8's admission Record dated 6/10/25 revealed admission to the facility was on 5/24/20. Record review of Resident 8's admission record dated 6/10/25 revealed Diagnosis: Hemiplegia (paralysis or severe weakness on one side of the body) and Hemiparesis (weakness or partial paralysis on one side of the body), cerebrovascular disease (heart condition that include diseased vessels, structural problems, and blood clots) affecting left non-dominant side, atrial fibrillation (irregular often rapid heart rate that commonly causes poor blood flow), diabetes (a disease of inadequate control of blood levels of glucose), anxiety, history of falling, difficulty in walking, shortness of breath, low back pain, and muscle weakness. Record review of Resident 8's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/8/25 revealed: -BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 15 indicating no cognitive impairment. -Impairment of one side of upper and lower extremities, dependent assistance with oral hygiene, toileting hygiene, lower body dressing, footwear and transfer. Maximum assistance with upper body dressing and personal hygiene. Set up assistance with eating, and bathing resident refused. Always incontinent of bowel and bladder. Interview on 6/10/25 at 11:00 AM with Resident 8 revealed that sometimes I have had to wait 1 hour, usually in the evenings 2 hours for the staff to answer my call light. But I would say usually within 30 minutes they come to answer it. Record review of Resident 8's call light response time recorded on the Device Activity Report between May 11th to June 10th, 2025 revealed: -The call lights that were answered between 22 to 45 minutes 115 times. -The call lights that were answered between 46 to 100 minutes 46 times. -The call lights that were answered between 101 to 168 minutes 7 times. Interview on 6/10/25 at 3:00 PM with the DON (Director of Nursing) confirmed the call lights should be answered in less than 20 minutes.

Licensure Reference Number 175 NAC 12-006.02(H) Based on interviews and record reviews, the facility failed to complete and send a 5-day written investigation of an alleged abuse to the Department of Health and Human Services (DHHS) as required for 1 (Resident 8) of 3 sampled residents. The facility census was 50. Findings are: Record review of the facility's undated investigation form Abuse, Neglect, or Misappropriation revealed: The complete form must be faxed to Health Facility investigations [PHONE NUMBER] within 5 working days from the date of the allegation/incident. Record review of Resident 8's admission Record dated 6/10/25 revealed admission to the facility was on 5/24/20. Resident 8 had diagnoses of Hemiplegia (paralysis or severe weakness on one side of the body) and Hemiparesis (weakness or partial paralysis on one side of the body), cerebrovascular disease (heart condition that include diseased vessels, structural problems, and blood clots) affecting left non-dominant side, atrial fibrillation (irregular often rapid heart rate that commonly causes poor blood flow), diabetes (a disease of inadequate control of blood levels of glucose), anxiety, history of falling, difficulty in walking, shortness of breath, low back pain, and muscle weakness. Record review of Resident 8's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/8/25 revealed: -The resident had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score was 15 indicating no cognitive impairment. Record review of Resident 8's investigation report, regarding an allegation of abuse from 3/18/25 revealed the 5-day investigation report was not sent to the State Agency (DHHS) as required within 5 days. The investigation report was submitted to DHHS on day 7. Interview on 6/10/25 at 3:16 PM with the Director of Nursing (DON) confirmed that the 5-day investigation report for Resident 8 should have been sent in within 5 working day to DHHS and that it was sent in late.

Licensure Reference Number 175 NAC 12-006.04C3a(5) Based on interview and record review the facility failed to have a nursing services representative present during the care plan conferences for 4 (Residents 1, 4 and 6) of 4 sampled residents. The facility identified a census of 52. Findings are: A record review of the facility policy dated 9/2019 and titled Care Plan Process revealed that that Care Plan Conferences should include the resident, Family/Legal Representative (if the resident is not able to attend or gives approval for participations, Clinical Reimbursement Manager/ MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) Coordinator, Director of Nursing Services or Registered Nurse (RN) designee and that the signature of the DON or designee indicated knowledge of the care plan and that is appropriate for the residents's needs. A record review of the Care Plan Conference note dated 9/17/24 for Resident 6 revealed no one from nursing services attended the Care Plan Conference. A record review of the Care Plan Conference note dated 1/2/25 for Resident 4 revealed no one from nursing services attended the Care Plan Conference. A record review of the Care Plan Conference note dated 9/17/24 and 12/31/24 for Resident 1 revealed no documentation that nursing services attended these Care Plan Conferences. An interview on 1/9/25 at 12:29 PM with the facility Administrator revealed that the DON (Director of Nursing) was expected to attend Care Plan Conferences for nursing services representation. ADM confirmed that the DON did not attend Residents 1, 4, 6 Care Plan Conference.

Licensure Reference Number 175 NAC 12.00610(D) Based on observation, record review and interview, the facility failed to ensure1 resident (Resident 3) of 5 sampled residents were free from significant medication errors. The facility census is 52. Findings are: Record review of the facility's undated policy, titled Using the Flexpen Insulin Competency revealed instructions to dial a test dose of 2 units, hold the pen upright and tap to bring any bubbles to the top. Prime the pen and dial the ordered dose before injecting dose. Record review of Diabetes Journal article titled Insulin Pen Priming dated [DATE] revealed priming an insulin pen is recommended to remove air bubbles from needle to ensure the full dose of insulin. If you do not prime the pen before each injection, you may get too much or too little insulin. An observation on 1/8/25 at 9:09 AM Registered Nurse (RN) - A completed an accucheck on Resident 3. The resident was lying in bed and stated (gender) had not eaten breakfast yet. RN - A applied gloves and prepped the area, then injected the insulin pen into the resident's left arm then dialed the pen and injected the insulin. The nurse did not prime the pen. In an interview on 1/8/25 at 9:10 AM RN - A confirmed that (gender) did not dial the prescribed dose of insulin or prime the pen before injecting Resident 3 with insulin but should have. Record review of Resident 3's entry Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 12/31/24 revealed that the resident was admitted to the facility on [DATE] with an active diagnosis of Type 2 Diabetes Mellitus. Review of Resident 3's physician orders dated 12/31/24 revealed order for Insulin Glargine (long acting) inject 20 units subcutaneously twice daily. Review Resident 3's Treatment Administration Record (TAR) for January 2025 revealed an order dated 1/6/25 to increase Insulin Glargine to 20 units in the morning and 22 units in the evening. In an interview on 1/13/24 at 8:06 AM the Administer (Adm) confirmed that the insulin pen should have been primed and dialed to dose before injecting the insulin into resident 3 to ensure an accurate dose. In an interview on 1/13/25 at 12:34 PM the Regional Nurse Consultant (RNC) confirmed there were 13 residents in the facility that required injectable insulin.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview and record review the facility failed to ensure infection control procedures were followed and maintained during peri cares (the process of washing the genitals and anal area) for one (Resident 11) of two residents sampled. The facility identified a census of 52. Findings are: A record review of the document titled Admission Record, printed on 1/9/25, revealed Resident 11 admitted to the facility on [DATE] with a primary diagnosis of cerebral infarct (occurs when blood flow is blocked causing brain tissue to die). An observation on 1/9/25 at 12:02 PM, accompanied by the facility's Regional Nurse Consultant, revealed Nurse Aide (NA)-F preparing to toileting Resident 11. During the observation NA-F ambulated Resident 11 to the bathroom, assisted [gender] onto the toilet, pulled down Resident 11's pants and soiled brief without gloves on. NA-F then performed hand hygiene and applied gloves. Next NA-F removed Resident 11's shoes, pants and soiled brief, applied a clean brief and then had Resident 11 stand and proceeded to wipe the peri/rectal area without performing hand hygiene or changing gloves. An interview on 1/9/25 at 12:12 PM with the facility Regional Nurse Consultant confirmed that NA-F did not change gloves after removing shoes, clothing and soiled brief and prior to providing perineal cares and should have. An interview on 1/9/25 at 12:12 PM with NA-F confirmed that [gender] did not change gloves after removing shoes, clothing and soiled brief and prior to providing perineal cares and should have.

Licensure Reference Number 175 NAC 12-006.17 Based on observations, interviews, and record reviews, the facility failed to ensure staff was wearing N-95 mask for Resident 1, wear the N-95 mask appropriately, not placing the Covid sample on clean surface, and washing hands between gloves changes to prevent potential for cross contamination. The facility census is 46. Findings are: A. On 10/21/24 at 9:05 AM observed Nurse Aide-A wearing N95 without one of the strings over the top of head as it is designed to wear. On 10/21/24 at 9:07 AM interview with NA-A confirmed that [gender] should have both mask strings over the head. Observation on 10/21/24 at 9:09 AM of SSD (Social Service Director) and Maintenance worker in dining room wearing their N95 mask without one of the strings over the top of their head. Interview with SSD on 10/21/24 at 9:10 AM revealed [gender] should have both mask strings over their head. Interview with Maintenance worker on 10/21/24 at 9:11 AM revealed [gender] should have both mask strings over their head. B. On 10/21/24 Observation of Garden Walk hallway. Red dots by room [ROOM NUMBER],44,45,46,47,49 and 56 indicating COVID positive. They also had EBP (Enhanced Barrier Precaution) equipment outside their door and/or sharing the container with the room across. The trash is inside the rooms where they place their used gowns. On 10/21/24 Observation on Wilderness Way hallway revealed COVID positive rooms are 21,22,24,25,29,30,31,33 and 35. They have EBP outside their room or is being shared with room across the hall. The trash is inside the rooms where they place their used gowns. On 10/21/24 at 9:17 AM observation of Registered Nurse (RN) going into Resident 1's room with PPE (personal protective equipment) on except RN is wearing a surgical mask instead of N95 mask. Resident 1 is in [gender] room which is a Covid + room. RN doffed (took off) the gown in the room then placed the COVID sample directly on the treatment cart with no barrier. RN removed gloves and donned (put on) new gloves without washing hands and picked up the Covid sample well and took it to the director of nurse's office and set it on the counter. RN read the Covid testing instructions to see what the pink and blue line meant and the results was positive. RN then threw the sample well away and removed gloves but did not wash hands or clean the medication cart. RN kept surgical mask on and sat down and start typing on the computer. Interview with RN on 10/21/24 at 9:23 AM revealed that the RN should have worn a N-95 mask, placed the Covid sample well on a clean barrier, and wash hands when removing gloves each time. On 10/21/24 at 11:07 AM an interview with Director of Nursing (DON) revealed that staff are to wear the N95 mask with both straps up over head as the masks are designed to wear. On 10/21/24 at 11:45 AM an interview with DON revealed that RN should have been wearing a N95 mask, washed hands in between changing gloves and should have placed the Covid sample well on a clean barrier. Record Review of Infection prevention and control program policy revised 1/2024 revealed: Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections. Hand Hygiene Protocol: a. All staff shall wash their hands when coming on duty, between resident s contact, after handling contaminated objects, after PPE removal, before/after eating, before/after toileting, and before going off duty. b. Staff shall wash their hands before and after performing resident care procedures. c. Hands shall be washed in accordance with our facility's established handwashing procedure. Record review of Handwashing Policy revised 3/20/24 revealed: This facility considers hand hygiene the primary means to prevent the spread of infections. -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and C. difficile. -Use an alcohol-based hand rub, containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents, after removing gloves, before and after entering isolation precaution settings. - Hand hygiene is the final step after removing and disposing of personal protective equipment. Record review of Carestart COVID-19 Antigen Home Test quick reference instructions revealed: -Remove the test cassette and place on on a flat, clean surface.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview and record review; the facility failed to maintain the cleanliness of the kitchen to prevent the potential for food-borne illness and failed to ensure fluids were provided that were maintained within the required temperature range. This had the potential to affect all 47 residents that ate food prepared in the facility kitchen. The facility census was 47. Findings are: A. Record review of the Nebraska Food Code dated 2017. Section 4-602.13 revealed that nonfood- contact surfaces of equipment shall be cleaned at a frequency necessary to prevent the accumulation of soil residues. An observation of the facility kitchen on 10/02/2024 between 7:35 AM and 8:10 AM revealed the following environmental concerns: -A ceiling exhaust fan, located directly above the walkway between the facility stove and food prep table, was coated with a fuzzy dark gray/black substance. Food was being prepared in this area and the exhaust fan was turned on. -Ceiling light panels near the facility stove and food preparation area were coated with multiple specks of a dark gray/black substance. -Exhaust fans located in the dry storage room were coated with a dark gray/black substance. -Food debris was observed on the bottom shelf of the freezer in the dry storage room. -Two white bins (resembling large trash cans) on a mobile base in the dry storage room contained food debris inside the bins and the mobile base was coated with a dark gray, thick and shiny substance. -A 6-shelved storage rack located in the kitchen near the dry storage room door had multiple staff personal items on the top shelf that included a box of Kleenex, 3 drink Koozies, a small metal tin labeled herbal healing salve, toothpicks, and an open can of Sprite. The shelves on this storage rack had visible food debris on all shelves and were coated with a sticky/greasy substance. -A wheeled cart with 3 shelves that had an attached can opener on the top shelf was coated with visible food debris and was coated with a brown, thick and shiny substance. -The floor in the dishwashing area (clean side) was coated with a dark gray substance around the base tiles and in the corners. An interview with DM on 10-2-2024 at 10:35 AM confirmed all items identified above were not clean and had the potential to cause food borne illness if any of the food debris or dark gray/black substance were to drop down into the food. DM confirmed that they were unsure when the last time the ceiling exhaust fan near the stove was cleaned. DM confirmed that all 47 residents that resided in the facility ate food that was prepared in the facility kitchen. B. Record review of facility policy Food Safety requirements dated/revised: May 2022 and January 2024 revealed It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. This policy identified a definition of Danger Zone meant temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. An observation on 10-3-2024 at 12:27 PM revealed lunch was being served to the facility residents by the Cook. The lunch meal consisted of Swiss steak with gravy, mashed potatoes, cascade blend vegetables, toffee bar blondie (dessert bar), milk, tomato juice, iced tea, and coffee. During the observation a test tray was requested to be prepared and provided with room trays for residents who ate in their rooms. An observation on 10-3-2024 at 12:45 PM revealed the Dietary Manager (DM) obtained a facility thermometer and followed the room trays out the kitchen. Once the final resident room tray was delivered, the test tray was removed from the cart at 1:04 PM and DM obtained the temperature of the fluids and reported their findings with the following results: -White milk temperature was 60 degrees. DM reported that the temperature of the milk was concerning and refused to taste test. -Tomato Juice temperature was 62 degrees. DM reported that the temperature of the tomato juice was concerning and refused to taste test. -Iced tea temperature was 61 degrees. DM reported that ice should still be in the tea and that tea should be cold instead of room temperature. Interview with DM on 10-3-2024 at 1:15 PM confirmed that the temperatures of the milk and tomato juice were not cold enough and should not have been served to the residents.

Licensure Reference Number 175 NAC 12-006.19(C)(i) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, interview, and record review, the facility failed to ensure staff handled contaminated and clean laundry and linens to prevent cross contamination, failed to ensure Enhanced Barrier Precautions (EBP) signage was posted and Personal Protective Equipment (PPE) was available for staff use in 3 (Residents 23, 31, and 40) of 4 sampled resident's rooms, failed to ensure 1 (Resident 5) of 2 sampled resident's Positive Airway Pressure (PAP, a machine use to treat sleep apnea) device contained a filter, and failed to clean and store PAP supplies for 1 (Resident 2) of 2 sampled residents. The facility census was 47. Findings are: A. A record review of the facility's Standard Precautions policy with a last revised date of 01/2024 revealed soiled linens are handled in a manner that prevents contamination of clothing and avoids transfer of microorganisms (small germs) to other residents in the facility. Clean linen requires staff handle, store, process, and transport all linens and laundry in accordance with accepted national standards in order to produce hygienically (clean and free from bacteria) clean laundry and prevent the spread of infection to the extent possible. Linen should be covered when transporting and/or bagged so as not to come in contact with the staff's uniform. A record review of the facility's Laundry policy with a last revised date of 01/2024 revealed all used laundry was handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. Contaminated laundry is placed in a bag or container at the location where it was used. Contaminated laundry bags/containers are not held close to body or squeezed during transport. An observation on 10/07/2024 at 8:36 AM revealed Nursing Assistant (NA)-A walked from the utility room and down the Garden Walk resident hallway with linens between NA-A's left arm and chest with the linens touching NA-A's clothing and entered a resident room. An observation on 10/07/2024 at 8:43 AM revealed Housekeeping Aide (HSK)-B obtained linens from the Serenity Lane linen closet and delivered the linens to room [ROOM NUMBER] and then to room [ROOM NUMBER] while carrying the linens between HSK-B's left arm and chest with the linens touching HSK-B's clothing. An observation on 10/07/2024 at 8:51 AM revealed HSK-B exit a resident room on Serenity Lane and walk to the laundry room with soiled linens held between HSK-B's arm and chest, touching HSK-B's clothing. The soiled linens were not bagged. HSK-B then obtained 2 leak chux pads (pads used to protect bedding and furniture from accidents or spills) and delivered then to resident room [ROOM NUMBER], allowing the chux pads to touch HSK-B's clothing during the transport. An observation on 10/07/2024 at 9:32 AM revealed the Environmental Services Director (ESD) delivered hanging laundry to resident room [ROOM NUMBER] while allowing the clothing to drag on and touch the floor and the ESD's clothing. The ESD then returned to the clean laundry cart and delivered hanging clothes to resident room [ROOM NUMBER] allowing the clothing to drag on the floor and touch ESD's clothing. The ESD returned to the clean laundry cart and held a blanket between their left arm and chest, against the ESD's clothing, and delivered to resident room [ROOM NUMBER]. The ESD then returned to the cart and delivered hanging clothes to resident rooms [ROOM NUMBERS] while allowing the clean clothing to touch the ESD's clothing. The ESD then delivered clean laundry to resident rooms [ROOM NUMBERS] and allowed the residents' clothing to come in contact with the ESD's clothing. The ESD then continued delivering clothing in that same manner to the rest of the residents' rooms. An observation on 10/07/2024 at 9:35 AM revealed NA-C left the residents' bath house with clean linens pressed between NA-C's arm and clothing and delivered the linens to resident room [ROOM NUMBER]. An observation on 10/07/2024 at 9:50 AM with the Director of Nursing revealed the facility's ESD delivered clean clothing to residents room [ROOM NUMBER] while allowing the clean clothing to come into contact with ESD's clothing. In an interview on 10/07/2024 at 9:50 AM, the DON confirmed the staff should not allow clean or contaminated laundry or linens to come into contact with the staff's clothing. B. A record review of the facility's Infection Prevention and Control Program policy with a revised date of 01/2024 revealed laundry and direct care staff shall handle, store, process, and transport linens so as to prevent the spread of infection. Clean linen shall be delivered to resident care units on covered linen carts with the covers down. An observation on 10/07/2024 at 9:32 AM revealed the ESD exited the laundry room and delivered the laundry cart down the Garden Walk resident hallway with the cart's side cover draped over the cart and laundry on top of the cart. An observation on 10/07/2024 at 9:50 AM with the Director of Nursing (DON) revealed the ESD delivered the laundry cart down the Garden Walk hallway with the side cover draped over top of the cart. In an interview on 10/07/2024 at 9:50 AM, the DON confirmed the staff laundry carts should have all covers down when transported in resident care areas. C. A record review of the facility's Multi Drug Resistant Organism (MDRO) PPE-Enhanced Barrier policy with a last revised date of 01/2024 revealed EBP's are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities. EBP may be indicated for residents with wounds or indwelling medical devices (devices inserted into the body), regardless of MDRO colonization (a group of MDRO germs living in or on the body) status. Indwelling medical device examples included urinary catheters. The facility should post clear signage on the door or wall outside the resident's room indicating the type of precautions and the required PPE. For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Gown and gloves should be available outside each resident room. A record review of the facility's un-titled, un-dated resident matrix (a list of problem areas a resident had) revealed Residents 23, 31, and 40 had indwelling catheters but did not reveal the residents were in transmission-based precautions (isolation). A record review of Resident 23's Clinical Physician Orders dated 10/07/2024 revealed the resident had orders to change their indwelling urinary catheter every month and for catheter cares to be done every 12 hours. A record review of Resident 23's Care Plan with an admitted [DATE] revealed the resident had a Suprapubic (SP) catheter (drain tube inserted in the urinary bladder). A record review of Resident 23's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to develop a resident's care plan) dated 07/23/2024 revealed the resident had an indwelling catheter. A record review of Resident 31's Clinical Physician Orders dated 10/07/2024 revealed the resident had orders to measure catheter output every shift and to provide catheter cares every shift. A record review of Resident 31's Care Plan with an admitted [DATE] revealed the resident had a foley catheter (drain tube inserted in the urinary bladder). A record review of Resident 40's Clinical Physician Orders dated 10/07/2024 revealed the resident had orders to measure catheter output every shift and to provide catheter cares every shift. A record review of Resident 40's Care Plan with an admitted [DATE] revealed the resident had a foley catheter. A record review of Resident 40's MDS dated [DATE] revealed the resident had an indwelling catheter. An observation on 10/07/2024 at 9:58 AM with Licensed Practical Nurse (LPN)-E revealed Resident 23 had a visible catheter bag. An observation on 10/07/2024 at 2:16 PM revealed Residents 23, 31, and 40 all had visible catheter bags but did not reveal EBP signage or PPE carts outside their rooms. An observation on 10/07/24 at 2:19 PM with the DON revealed Residents 23, 31, and 40 all had visible catheter bags but did not reveal EBP signage or PPE carts outside their rooms. In an interview on 10/07/2024 at 9:58 AM, LPN-E confirmed Resident 23 had an indwelling urinary catheter but did not have an EBP sign or PPE cart outside their rooms and should have. In an interview on 10/07/24 at 2:19 PM the DON confirmed Residents 23, 31, and 40 all had indwelling catheters but did not have EBP signage or PPE available outside their rooms and should have. D. A record review of the facility's Cleaning Respiratory Equipment policy dated 05/01/2017 revealed the facility was committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. The staff was to change filters used with a PAP circuit per manufacturer's recommendations. A record review of the undated ResMed AirSense 10 Users Guide revealed the air filter should be replaced at least every 6 months and more often if needed. https://document.resmed.com/documents/products/machine/airsense-series/user-guide/airsense-10-device-with-humidifier_user-guide_amer_eng.pdf A record review of Resident 5's Treatment Administration Record (TAR) dated September 2024 and October 2024 revealed the resident's PAP filter was last changed/replaced on 09/25/2024. An observation on 10/02/2024 at 11:57 AM revealed Resident 5 had a ResMed AirSense 10 Autoset Continuous Positive Airway Pressure (CPAP), but the unit did not have a filter. An observation on 10/03/2024 at 11:35 AM revealed Resident 5 had a ResMed AirSense 10 Autoset CPAP, but the unit did not have a filter. An observation on 10/07/2024 at 8:21 AM revealed Resident 5 had a ResMed AirSense 10 Autoset CPAP, but the unit did not have a filter. An observation on 10/07/2024 at 8:40 AM with LPN-F revealed Resident 5 had a ResMed AirSense 10 Autoset CPAP, but the unit did not have a filter. In an interview on 10/07/2024 at 8:40 AM, LPN-F confirmed Resident 5's CPAP did not have a filter and should have had one. 42861 E. A record review of the facility policy titled Cleaning Respiratory Equipment, dated 5/1/2017 read as follows; Procedure 1.Supplies: - Replace masks and/or cannula used by an individual resident within seven days. - When not in use, store masks and cannulas in plastic bags labeled with the resident's name and date. A record review of the document titled Admission Record revealed Resident 2 had been admitted to the facility on [DATE] with a primary diagnosis of dementia (general term that represents a group of diseases and illnesses that affect your thinking, memory, reasoning, personality, mood and behavior) with behavioral disturbances. A record review of the Minimum Data Set (MDS, a federally mandated comprehensive assessment of each resident's physical and mental functional capabilities) dated 8/2/24 revealed that Resident 2 had a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function, while scores of 00 or 99 indicate total confusion) score of 9, which indicated the resident had moderately impaired cognition. An observation on 10/02/24 at 8:05 AM revealed Resident 2's Continuous Positive Airway Pressure (CPAP, a treatment that uses mild air pressure to keep your breathing airways open) mask to be attached to undated tubing that was attached to the CPAP machine and the mask was lying uncovered on the floor next to the head of the resident's bed. An observation on 10/03/24 at 10:03 AM revealed Resident 2's CPAP mask to be attached to undated tubing that was attached to the CPAP machine while draped over the 3-drawer cart next to the resident's nightstand with the face side of the mask touching the cart. An interview on 10/03/24 at 10:10 AM with LPN-E, after observing Resident 2's CPAP mask attached to the tubing and machine and draped over the 3-drawer cart, confirmed that the CPAP masks were to be stored in a bag and confirmed that Resident 2's CPAP mask was not being cleaned and stored to prevent the potential for cross contamination.

Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview; the facility failed to ensure current staff were completing the required 12 hours of continuing education annually. This had the potential to affect all residents in the facility. The facility identified a census of 47. Findings are: A record review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides, dated 11-17; 1-2024 revealed the following guidelines; It is the policy of this facility too comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing educate of its nurse aides. 5. The facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. a. Documentation of in-services will be forwarded to the HR Director and maintained in the employee's personnel file. An interview on 10/07/24 at 2:40 PM with the facility's Corporate Nurse Consultant confirmed that NA-O hired on 3/4/22, NA-G hired on 6/30/22, MA-P hired on 6/22/09 and MA-Q hired on 2/16/18 had not completed 12 hours of continuing education annually as required. The facility Corporate Nurse Consultant also confirmed that the only education that these 4 staff members had completed in the last one year was an Abuse and Neglect training.

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review the facility failed to provide bathing services as required for four (Residents 2, 31, 35 and 38) of eight sampled residents. The facility identified a census of 47. Findings are: A record review of the facility policy titled Activities of Daily Living (ADLs) dated 1/2024, revealed that ADL's included the resident's ability to bathe, dress and groom but did not indicate a frequency related bathing. A. A record review of the document titled Admission Record revealed Resident 2 had been admitted to the facility on [DATE] with a primary diagnosis of Dementia (general term that represents a group of diseases and illnesses that affect your thinking, memory, reasoning, personality, mood and behavior) with behavioral disturbances. A record review of the Minimum Data Set (MDS, a federally mandated comprehensive assessment of each resident's physical and mental functional capabilities) dated 8/2/24 revealed that Resident 2 had a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function, while scores of 00 or 99 indicate total confusion) score of 9, which indicated the resident had moderately impaired cognition. A record review conducted on 10/08/24 at 8:03 AM of the bathing logs titled Documentation Survey Report V2, Intervention/Task, ADL-bathing for Resident 2 over the prior 90 days revealed that no bath had been given or no refusal had been documented from 8/22/24 to 9/1/24 for a total of 10 days and also 9/19/24 to 10/3/24 for a total of 15 days. A record review of the undated, active Care Plan for Resident 2 revealed no evidence of bathing preference related to bathing frequency for Resident 2. An interview on 10/7/24 at 3:16 PM with Nurse Aide (NA)-J confirmed that the facility had no specific bath aide and that all NAs gave resident baths daily according to a list posted at the nurses' station. B. A record review of the document titled Admission Record revealed Resident 35 had been admitted to the facility on [DATE] with a primary diagnosis of protein calorie malnutrition, severe. A record review of the MDS dated [DATE] revealed that Resident 35 had a BIMS score of 00/15, which indicated the resident had severe cognitive impairment. A record review completed on 10/08/24 at 8:03 AM of the bathing logs titled Documentation Survey Report V2, Intervention/Task, ADL-bathing for Resident 35, for the prior 90 days, revealed that no bath had been given or refused from 8/12/24 through 8/25/24 for a total of 13 days, no bath had been documented as given or refused from 8/26/24 through 9/22/24 for a total of 27 days, and on 9/22/24 ADL-Bathing had been documented as NA meaning not applicable and no other documentation related to bathing had been done until a refusal was documented on 9/29/24. An interview on 10/7/24 at 3:16 PM with NA-J confirmed that the facility had no specific bath aide and that all NAs gave resident baths daily according to a list posted at the nurses' station. A record review of the undated, active care plan for Resident 35 revealed no bathing preference related to frequency of bathing. C. A record review of the document titled Admission Record revealed Resident 38 had been admitted to the facility on [DATE] with a primary diagnosis of multiple right rib fractures and acute pain due to trauma. A record review of the MDS dated [DATE] revealed that Resident 38 had a BIMS score of 8/15, which indicated the resident had moderately impaired cognition. A record review conducted on 10/08/24 at 8:03 AM of the bathing logs titled Documentation Survey Report V2, Intervention/Task, ADL-bathing for Resident 38 over the prior 90 days revealed that no bath had been given or refused from 8/23/24 to 9/1/24 for a total of 9 days and from 9/23/24 to 10/3/24 for a total of 11 days. An interview on 10/3/24 at 12:51 PM with the DON, after review of the bathing logs for Resident 38, confirmed that bathing is slim. The DON voiced awareness of the lack of bathing and voiced that a PIP had been initiated 3 days prior however no audits had been completed yet to show any kind of improvement in the bathing or frequency of. During the interview, the DON confirmed that the facility expectation was that all residents received a minimum of one bath weekly. A record review of the undated, active care plan for Resident 38 revealed no bathing preference related to frequency of bathing. An interview on 10/7/24 at 3:16 PM with NA-J confirmed that the facility had no specific bath aide and that all NA's gave resident baths daily according to a list posted at the nurses' station. An interview on 10/3/24 at 12:51 PM with the Director of Nursing (DON), after review of the bathing logs for Residents 2, 35, and 38, confirmed that bathing is slim. The DON voiced awareness of the lack of bathing and voiced that a PIP (Process Improvement Plan) had been initiated 3 days prior however no audits had been completed to show any kind of improvement in the bathing or frequency of bathing. During the interview, the DON confirmed that the facility expectation was that all residents received a minimum of one bath weekly. 50683 D. An interview on 10/07/2024 at 1:31 PM with Resident 31 revealed that Resident 31's bath days were on Mondays and Thursdays, but they had only received 1 (one) shower in the prior 4 (four) weeks and they got shaved in the shower. An observation on 10/07/2024 at 1:45 PM revealed Resident 31 had facial hair growth on cheeks, chin and above and below lips. Resident 31 stated I like to be clean shaven, at least once a week. A record review of facility provided documentation revealed that Resident 31's last shower was on 08/29/2024, which indicated that the resident hadn't had a shower in 39 days. A record review of Resident 31's care plan, reviewed on 10/08/2024 revealed no bathing preferences. A record review of a bathing list that was posted at the nurse's station revealed Resident 31 was on the schedule to receive a shower on Mondays and Thursdays, in the morning. An interview with the Director of Nursing (DON) on 10/07/2024 at 3:40 PM confirmed that it was the facility's expectation that all residents were provided with personal hygiene including bathing services, and that baths were to be given at least weekly. E. Based on observation, record review and interview, the facility failed to change Resident 31's indwelling catheter monthly per the resident's physician's order. The sample size was 1 and the facility census was 47. Findings are: Record review of Resident 31's Clinical Census dated 10/02/2024, revealed the resident was admitted to the facility on [DATE]. Record review of the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated August 12, 2024 revealed the following related to Resident 31: -The resident had a Brief Interview for Mental Status (BIMS, a brief assessment used to determine cognitive ability) score of 12 out of 15 which indicated the resident had moderately impaired cognition. -The resident required substantial/maximal assistance with toileting hygiene. -The resident had an indwelling urinary catheter (a small tube that is inserted into the bladder to drain urine that drains into a urinary collection bag) often referred to as a Foley catheter. -The resident had a diagnosis of Neurogenic Bladder (a condition where the nerves along the pathway between the bladder and the brain do not work properly resulting urine being retained in the bladder). An observation on 10/2/2024 at 1:50 PM of Resident 31 revealed that the resident had an indwelling catheter that was connected to a leg bag (a small urinary collection bag that is secured to the leg). An interview with Resident 31 on 10/02/2024 at 1:50 PM confirmed that they had an indwelling catheter and that the facility was supposed to change the catheter every 4 weeks but the catheter had not been changed in months. A record review of Resident 31's Physician Orders revealed an order dated 07/31/2024 that stated to change the resident's catheter every month using a latex-free catheter. A record review of Resident 31's Progress Note on 07/20/2024 at 6:16 AM revealed Unable to irrigate Foley, has leaked around cath with almost no output per foley, replaced foley with 16FR foley per sterile technique, instilled 25 cc water into balloon, resident is upset that foley was clogged and (gender) sleep was interrupted, (gender) did allow CNAs to change (gender) brief. A record review of Resident 31's Progress Note on 08/31/2024 at 6:27 AM revealed that the Foley catheter did not get changed because Latex free catheter unavailable. A record review of Resident 31's Progress Note on 09/30/2024 at 12:37 AM revealed Latex free catheter unavailable. Note left to have them ordered. An interview on 10/08/2024 at 10:15 AM with the Director of Nursing confirmed that Resident 31's last indwelling Foley catheter change was on 07/20/24 and that their catheter should have been changed every month and had not been. NE004 Licensure Reference Number 175 NAC 12-006.09(H)(iv) Based on observation, record review and interview, the facility failed to change Resident 31's indwelling catheter monthly per the resident's physician's order. The sample size was 1 and the facility census was 47. Findings are: Record review of Resident 31's Clinical Census dated 10/02/2024, revealed the resident was admitted to the facility on [DATE]. Record review of the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) dated August 12, 2024 revealed the following related to Resident 31: -The resident had a Brief Interview for Mental Status (BIMS, a brief assessment used to determine cognitive ability) score of 12 out of 15 which indicated the resident had moderately impaired cognition. -The resident required substantial/maximal assistance with toileting hygiene. -The resident had an indwelling urinary catheter (a small tube that is inserted into the bladder to drain urine that drains into a urinary collection bag) often referred to as a Foley catheter. -The resident had a diagnosis of Neurogenic Bladder (a condition where the nerves along the pathway between the bladder and the brain do not work properly resulting urine being retained in the bladder). An observation on 10/2/2024 at 1:50 PM of Resident 31 revealed that the resident had an indwelling catheter that was connected to a leg bag (a small urinary collection bag that is secured to the leg). An interview with Resident 31 on 10/02/2024 at 1:50 PM confirmed that they had an indwelling catheter and that the facility was supposed to change the catheter every 4 weeks but the catheter had not been changed in months. A record review of Resident 31's Physician Orders revealed an order dated 07/31/2024 that stated to change the resident's catheter every month using a latex-free catheter. A record review of Resident 31's Progress Note on 07/20/2024 at 6:16 AM revealed Unable to irrigate Foley, has leaked around cath with almost no output per foley, replaced foley with 16FR foley per sterile technique, instilled 25 cc water into balloon, resident is upset that foley was clogged and (gender) sleep was interrupted, (gender) did allow CNAs to change (gender) brief. A record review of Resident 31's Progress Note on 08/31/2024 at 6:27 AM revealed that the Foley catheter did not get changed because Latex free catheter unavailable. A record review of Resident 31's Progress Note on 09/30/2024 at 12:37 AM revealed Latex free catheter unavailable. Note left to have them ordered. An interview on 10/08/2024 at 10:15 AM with the Director of Nursing confirmed that Resident 31's last indwelling Foley catheter change was on 07/20/24 and that their catheter should have been changed every month and had not been.

Licensure Reference Number 175 NAC 12.006.04(F)(i)(5) Based on interview and record review, the facility failed to ensure 2 (Residents 23 and 38) of 4 sampled resident's representative was notified following all falls. The facility census was 47. Findings are: A record review of the facility's Fall Management policy with a last date revised of 01/2024 revealed after a resident's fall, the facility would contact the physician and family and document in the medical record, including time and person spoken with. A. A record review of Resident 23's Clinical Census dated 10/07/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 23's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to develop a resident's care plan) dated 07/23/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) of 3 out of 15 that indicated the resident was severely cognitively impaired. The MDS revealed the resident had fallen in the last 2-6 months. A record review of the facility's Incident By Incident Type log dated 10/02/2024 revealed Resident 23 had fallen on 01/04/2024, 04/22/2024, 08/27/2024, 09/24/2024, and 10/02/2024. A record review of Resident 23's Progress Notes dated 10/07/2024 revealed the resident fell from the recliner on 10/02/2024 and the progress note did not reveal evidence that the family/Power of Attorney (POA, person assigned to make decisions for another person) was notified. A record review of Resident 23's Fall (Un-witnessed) document dated 10/02/2024 revealed the resident fell from a power lift recliner and the person listed as being notified was the Nurse Practioner. It did not reveal evidence that the family had been notified of the fall. In an interview on 10/08/2024 at 9:51 AM, Resident 23's family member/POA confirmed the POA was upset and concerned because the facility did not notify the family of the resident's fall on 10/02/2024. The family member/POA confirmed they found out by accident a couple of days later when the family was at the facility. In an interview on 10/08/2024 at 2:15 PM the facility's Clinical Nurse Consultant (CN) confirmed the resident's representative was not notified following the 10/02/2024 fall and should have been. 42861 B. A record review of the document titled Admission Record revealed Resident 38 had been admitted to the facility on [DATE] with a primary diagnosis of multiple right rib fractures with acute pain due to trauma. A record review of the Minimum Data Set (MDS, a federally mandated comprehensive assessment of each resident's physical and mental functional capabilities) dated 6/25/24 revealed that Resident 38 had a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function, while scores of 00 or 99 indicate total confusion) score of 8, which indicated the resident's cognition was moderately impaired. A record review conducted on 10/02/24 at 10:07 AM of the Facility Incident Log dated 10/2/23 through 10/2/24 revealed Resident 38 had had 2 recent falls on 9/18/24 and 9/24/24. An interview on 10/02/24 at 10:33 AM revealed that Resident 38's representative had not been notified of the resident's falls on 9/18/24 and 9/24/24. A record review of Resident 38's Progress Notes dated 6/1/24 through 10/8/24 revealed Resident 38 did have a fall on 9/18/24 and the Progress Notes read as follows; -9/18/2024 at 5:43 PM Resident observed lying on side in hallway, several staff nearby rushed to assist. Neuro checks negative for head injury. See risk management report for full synapsis. VSS (vital signs stable) NP (Nurse Practitioner) notified via fax. Resident is own responsible party, so family was not called. Resident denies pain or injury. Confused. Oriented to self only. Skin appears to be without injury. Resident advised to use call light for assistance when ambulating until we receive direction from MD (Medical Doctor) or NP. Resident indicates understanding but remains confused. The record review of the Progress Notes dated 6/1/24 through 10/8/24 for Resident 38 related to the fall revealed no documentation of family or representative notification nor any follow up documentation post fall. An interview with the facility Administrator on 10/08/24 at 1:55 PM confirmed that the expectation was that family/resident representative be notified along with the physician on any and all falls. An interview on 10/08/24 at 2:48 PM with RN-I revealed that the facility process related to falls was to notify the resident's physician and their family, ASAP (as soon as possible) if needed. If there was no injury, RN-I stated (gender) would not notify the family until the next day if it was late at night or during the night. An interview on 10/08/24 at 2:49 PM with CN (Corporate Nurse) confirmed that Resident 38's representative had not been notified of falls that had occurred on 9/18/24 and 9/24/24 and should have been.

Licensure Reference Number 175 NAC 12-006.09(I) Based on interview and record review, the facility failed to ensure interventions were implemented to prevent falls for 1 (Resident 23) of 5 sampled residents. The facility census was 47. Findings are: A record review of the facility's Fall Management policy with a last date revised of 01/2024 revealed that after a resident falls, the facility would assess and review resident risk factors and implement appropriate interventions to reduce the risk of falls. The facility would adjust/add interventions on the plan of care and educate the staff, resident, and family. A. A record review of Resident 23's Clinical Census dated 10/07/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 23's Medical Diagnosis dated 09/04/2024 revealed the resident had diagnoses of Muscle Weakness, History Of Falling, Alzheimer's Disease, Difficulty Walking, Acute On Chronic Diastolic (Congestive) Heart Failure, Acute Respiratory Failure, and Other Pulmonary Embolism (clot in the lungs). A record review of Resident 23's MDS dated [DATE] revealed the resident had a BIMS score of 3 out of 15 which indicated the resident was severely cognitively impaired. The resident required partial/moderate assistance with personal and oral hygiene (cleaning), and was dependent on staff for dressing, bathing, and toileting. The resident required substantial/maximal assistance with sit to stand positioning, chair to bed transfer, and toilet transfer and was dependent on staff for tub/shower transfers. The MDS revealed the resident had fallen in the last 2-6 months. A record review of the facility's Incident By Incident Type log dated 10/02/2024 revealed Resident 23 had falls on 01/04/2024, 04/22/2024, 08/27/2024, 09/24/2024, and 10/02/2024. A record review of Resident 23's Progress Notes reviewed on 10/07/2024 revealed: - 9/24/2024 - the resident was playing with the power recliner remote and lifted the chair all the way up and slid out onto the floor. - 10/02/2024 - the power recliner was raised to the standing position and the staff found the resident on the floor in front of the power recliner. A record review of the facility's Fall report dated 09/24/2024 revealed Resident 23 was playing with the power recliner remote and lifted the chair all the way up and slid out onto the floor. The resident was alert and oriented to person only per baseline. The resident had no injuries. Predisposing environmental factors was furniture. Predisposing physiological factors included confused and weakness. Under Other Information it revealed the resident playing with recliner remote. A record review of the facility's Fall (un-witnessed) report dated 10/02/2024 revealed the power recliner was raised to the standing position and the staff found Resident 23 on the floor in front of the power recliner. The resident was alert and oriented to person, place, and situation. The resident had no injuries. Predisposing environmental factors was none. Predisposing physiological factors included impaired memory. A record review of Resident 23's Care Plan with an admitted [DATE] revealed the resident needed 2 staff and a Hoyer lift (full body lift) for transfers. The resident was experiencing cognitive function/dementia. The resident has had an actual fall and was at high risk for falls related to unsteady gait. The Care Plan did not reveal new interventions for the 09/24/2024 and 10/02/2024 falls. A record review of the facility's Clinical document dated 09/01/2024 through 09/27/2024 revealed Resident 23's 09/24/2024 fall was on the list and an intervention was: Make sure feet elevated when resident is.The question for Risk Management Completed? was marked in progress and the question for Care Plan Updated? was blank. A record review of the facility's Clinical document dated 08/12/2024 through 10/09/2024 revealed Resident 23's 10/02/2024 fall was on the list and an intervention was: remote to side of recliner. The question for Risk Management Completed? was marked in progress and the question for Care Plan Updated? was blank. A record review of the facility's Clinical - Assessment list dated 10/07/2024 for Resident 23 revealed a Nursing Bedside Recliner Chair Assessment had been completed on 03/30/2024 and on 06/29/2024 but did not reveal a Nursing Bedside Recliner Chair Assessment had been completed for September 2024 or following the falls from a power recliner on 08/27/2024, 09/24/2024, or 10/02/2024. An observation on 10/02/2024 at 7:50 AM revealed Resident 23 was sleeping in the power recliner with the legs up and leaning to the right. The power recliner remote was not in reach and was laying on the floor. An observation on 10/02/2024 at 2:24 PM revealed Resident 23 was sleeping in the power recliner with the legs up, but the resident was sliding down with the feet off the end to mid-calf. The power recliner remote was not in reach and was laying on the floor. An observation on 10/07/2024 at 1:31 PM revealed Resident 23 was sleeping in the power recliner with the feet elevated and the power recliner remote was on the arm of the chair and the cord was tied to the upper right-hand side of the chair. An observation on 10/07/2024 at 3:50 PM revealed Resident 23 was awake and reclined in the power recliner with the feet elevated and the power recliner remote was in the pouch on the bottom of the right-hand side of the chair and the cord was tied to the upper right-hand side of the chair. In an interview on 10/08/2024 at 2:37 PM, NA-G confirmed NA-G was not working at the time of any of Resident 23's falls. NA-G confirmed the resident played with the power recliner remote and had previously slid out of the recliner. NA-G was not aware of any Care Plan interventions to prevent it from happening but did confirm to prevent it from happening, NA-G puts the controller in the pocket on the side of the recliner. In an interview on 10/08/2024 at 2:37 PM, NA-H confirmed NA-H was not working at the time of any of Resident 23's falls. NA-H confirmed the resident played with the power recliner remote and had previously slid out of the recliner. NA-G was not aware of any Care Plan interventions to prevent this from happening again. In an interview on 10/08/2024 at 9:51 AM, Resident 23's family member/Power of Attorney (POA) confirmed the POA was concerned that the resident was lifting the recliner all the way up and was being found on the floor. The family member/POA confirmed the resident needed the recliner for keeping the legs elevated and because the resident had sleep apnea and refused treatment. The family member/POA confirmed staff had not educated the family on the risk versus benefits of the power recliner and was upset due to the facility did not notify the family of the resident's fall on 10/02/2024, they were only notified of the fall in the bath house and 1 of the falls from the power recliner. In an interview on 10/08/2024 at 2:15 PM the facility's Clinical Nurse Consultant (CN) confirmed that the facility should have completed new Recliner Chair Assessments following each of Resident 23's falls from the power recliner to evaluate safety, but they were not completed. The CN confirmed that interventions should have been added to the Care Plan following the 09/24/2024 and 10/02/2024 falls from the recliner, but they had not been. 42861

Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review, the facility failed to ensure rationale was provided and the provider's order was followed for 1 (Resident 26) of 5 sampled resident's as needed (PRN) Lorazepam (an antianxiety medication used to treat anxiety). The facility census was 47. Findings are: A record review of the facility's Medication Regimen Review (MRR) policy with a reviewed date 01/2024 revealed the pharmacist must report any irregularities to the attending physician, the facility's medical director, and the director of nursing (DON) and the reports must be acted on. Upon completion of the MRR, the facility designee and/or physician will respond to the recommendations in a timely manner. PRN orders for psychotropic drugs (substance that affect how the brain works) are limited to 14 days unless the attending physician believes that it is appropriate for the PRN order to be extended beyond 14 days, then they should document their rationale in the resident's medical record and indicate the duration for the PRN order. A record review of Resident 26's Clinical Census dated 10/03/2024 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 26's Medical Diagnosis dated 09/04/2024 revealed the resident had diagnoses of Restlessness and Agitation, Depression, and Psychotic Disorder (severe mental illness that causes a person to lose touch with reality). A record review of Resident 26's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to develop a resident's care plan) dated 07/16/2024 revealed the resident had a Brief Interview for Mental Status (BIMS, a score of a residents cognitive abilities) score of 15 out of of 15 which indicated the resident was cognitively aware. The MDS did not reveal the resident had behaviors during the assessment period. Anxiety was not listed in the MDS for the resident's mood disorders but the resident was on an antianxiety medication. A record review of Resident 26's Care Plan with an admitted [DATE] revealed the resident had a potential psychosocial (interrelation of social factors and thought and behavior) well-being problem related to the need for admission and possible need for long term care, but no specific interventions for the use of an antianxiety medication. A record review of the facility's pharmacy Admission Medication Regimen Review dated 07/15/2024 for Resident 26 revealed the pharmacist marked that the resident had a PRN psychotropic medication which will discontinue (DC) in 14 days, if physician does not want to DC in 14 days, please provide both rational and duration for the continued use of Lorazepam. The Nurse Practitioner ordered: indication anxiety times (x) 30 day then re-evaluate use. A record review of the facility's pharmacy Pharmacist Recommendation to Prescriber dated 08/27/2024 for Resident 26 revealed a recommendation to DC the Lorazepam or if denied, the physician was to provide a clinical rationale for need and a date for reassessment was needed. There was no evidence of the physician having addressed the recommendation. A record review of Resident 26's Order Summary Report dated 10/03/2024 revealed the resident had an order for Lorazepam tablet 0.5 milligrams (MG) by mouth twice daily as needed for anxiety. The indications for use were anxiety/agitation. The order start date was 07/10/2024 and no stop date was listed. In an interview on 10/03/2024 at 12:46 AM, the facility's Clinical Nurse Consultant (CN) confirmed when the Nurse Practitioner ordered: indication anxiety times (x) 30 day the re-evaluate use on the Admission Medication Regimen Review dated 07/15/2024, the indication of anxiety was not a valid rationale to continue the Lorazepam for 30 days. In an interview on 10/03/2024 at 2:53 PM, the CN confirmed the rationale to continue the PRN Lorazepam for Resident 26 was not provided by the Nurse Practitioner, that the diagnosis was not a rationale, and the PRN Lorazepam was not stopped or re-evaluated in 30 days as ordered. The CN also confirmed that the Lorazepam was still ordered as PRN and should not have been.

Licensure Reference Number 175 NAC 12-006.09D7b Based on record review and interview; the facility staff failed to implement and re-evaluate interventions to prevent ongoing falls for 1 (Resident 1) of 3 sampled residents. The facility staff identifed a census of 50. Findings are: A record review of the facility policy tilted Fall Prevention Program dated October 2021 revealed the following: -All residents identified at risk for falls will have deficits and interventions care planned -Reassess risk factors following a fall in order to evaluate and identify the root cause of fall and care plan interventions -Updates of fall prevention interventions will be communicated to staff Record review of Resident 1's Admission Record dated 3/13/2024, revealed the resident was admitted into the facility on [DATE] with diagnoses of: - Wernick's Encephalopathy (a condition that is similar to dementia and is caused by drinking too much alcohol). - acquired absence of the right toes (amputation). - depression. - alcohol abuse. - generalized Anxiety Disorder. - hypertension. - repeated falls. - encephalopathy (brain disease the alters brain function). - hypotension. - muscle weakness. - history of falling. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 7/03/2023 revealed Resident 1's Brief Interview of Mental Status (BIMS a brief cognitive screening measure that focuses on orientation and short-term word recall) score was 13 which indiciated Resident 1 was cognitivley intact. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 5/04/2023 revealed Resident 1 had fallen on 3/06/2024 with an injury which resulted in Resident 1 being sent to the emergency room . Resident 1's CCP identified Resident 1 sustained a fractured nose, multiple bruises and a laceration to their face. Further review of Resident 1's CCP revealed there were no indications a new intervention had been implemented to prevent ongoing falls related to the fall on 3/06/2024. A record review of Resident 1's Morse Fall Scale ( tool used assess a residents likelihood of falling) assessments done on 8/12/22, 11/10/22, 2/9/2023, 6/18/2023, 9/18/2023 and 12/17/2023 revealed that Resident 1 was a high risk for falling. Record review of the Fall Investigation Report for Resident 1 was completed on the following dates of 1/1/2024, 1/7/24, 1/10/24 1/15/25, 1/19/24, 1/23/24, 1/27/24, 1/31/24 revealed the root cause of the falls were Resident 1 was self transferring. The initial interventions to prevent falls dated 1/7/2024 was to continue the current safety measures. No new interventions were put into place to prevent ongoing falls. A record review of the Fall investigation Reports completed on 2/1/24, 2/2/24, 2/5/24, 2/5/24, 2/8/24, 2/13/24, 2/14/24, 2/16/24, 2/17/24, 2/18/24, 2/25/24, 2/26/24, 2/27/24, revealed the root cause of the fall was Resident 1 was self transferring. The initial interventions to prevent falls was to continue current safely measures and frequently monitoring. There were no new interventions put in place to prevent future falls for Resident 1. Record review of Resident 1's Progress Notes (PN) revealed: - 3/6/2024 Resident 1 had fallen with no documentation of root cause, intervention, or a fall investigation report. - 3/7/2024 at 10:45 AM Resident 1 had fallen with no documentation of root cause, intervention, or a fall investigation report. - 3/7/2024 at 7:10 PM Resident 1 had fallen with no documentation of root cause, intervention, or a fall investigation report. - 3/8/2024 at 9:39 PM Resident 1 had fallen with no documentation of root cause, intervention, or a fall investigation report. - 3/11/2024 at 10:23 PM Resident 1 had fallen with no documentation of root cause, intervention, or a fall investigation report. A record review of Resident 1's Safety Monitoring sheet indiciated the facility staff were to complete hourly safety checks on Resident 1 related to their frequent falls. The facility staff were to initial when the checks were completed. The Safety Monitoring Sheet revealed the below where initials were not completed. -1/5/2024, 1/6/2024, 1/7/2024, and 1/8/2024 in a 24 hour period revealed that there was 16 blank blanks where staff did not initial -1/9/2024 in a 24 hour period revealed that there was no staff initials -1/10/2024 in a 24 hour period revealed that there was 10 blanks with no staff initials -1/11/2024 in a 24 hour period revealed that there was 13 blanks with no staff initials -1/12/2024 in a 24 hour period revealed that there was 9 blanks with no staff initials -1/13/2024 in a 24 hour period revealed that there was 15 blanks with no staff initials -1/14/2024 in a 24 hour period revealed that there was 15 blanks with no staff initials -1/15/2024 in a 24 hour period revealed that there was 15 blanks with no staff initials -1/16/2024 in a 24 hour period revealed that there was 7 blanks with no staff initials -1/17/2024 in a 24 hour period revealed that there was 15 blanks with no staff initials -1/18/2024 in a 24 hour period revealed that there was 10 blanks with no staff initials -1/19/2024 in a 24 hour period revealed that there was 15 blanks with no staff initials -1/20/2024 in a 24 hour period revealed that there was 7 blanks with no staff initials -1/21/2024 in a 24 hour period revealed that there was 8 blanks with no staff initials -1/22/2024 in a 24 hour period revealed that there was 8 blanks with no staff initials -1/23/2024 in a 24 hour period revealed that there was 10 blanks with no staff initials -1/24/2024 in a 24 hour period revealed that there was 15 blanks with no staff initials -1/25/2024 in a 24 hour period revealed that there was 16 blanks with no staff initials -1/26/2024 in a 24 hour period revealed that there was 17 blanks with no staff initials -1/27/2024 in a 24 hour period revealed that there was 8 blanks with no staff initials -1/28/2024 in a 24 hour period revealed that there was 6 blanks with no staff initials -1/29/2024 in a 24 hour period revealed that there was 23 blanks with no staff initials -1/30/2024 in a 24 hour period revealed that there was 16 blanks with no staff initials -1/31/2024 in a 24 hour period revealed that there was 16 blanks with no staff initials -2/1/2024 in a 24 hour period revealed that there was 9 blanks with no staff initials -2/2/2024 in a 24 hour period revealed that there was 16 blanks with no staff initials -2/5/2024 in a 24 hour period revealed that there was 16 blanks with no staff initials -2/6/2024 in a 24 hour period revealed that there was 9 blanks with no staff initials -2/7/2024 in a 24 hour period revealed that there was 13 blanks with no staff initials -2/8/2024 in a 24 hour period revealed that there was 7 blanks with no staff initials -2/9/2024 in a 24 hour period revealed that there was 16 blanks with no staff initials -2/10/2024 in a 24 hour period revealed that there was 10 blanks with no staff initials -2/11/2024 in a 24 hour period revealed that there was 15 blanks with no staff initials -2/12/2024 in a 24 hour period revealed that there was 16 blanks with no staff initials -2/13/2024 in a 24 hour period revealed that there was 8 blanks with no staff initials -2/14/2024 in a 24 hour period revealed that there was 9 blanks with no staff initials -2/15/2024 in a 24 hour period revealed that there was 17 blanks with no staff initials -2/23/2024 in a 24 hour period revealed that there was 8 blanks with no staff initials -2/24/2024 in a 24 hour period revealed that there was 9 blanks with no staff initials -2/25/2024 in a 24 hour period revealed that there was 16 blanks with no staff initials -2/26/2024 in a 24 hour period revealed that there was 8 blanks with no staff initials -2/27/2024 in a 24 hour period revealed that there was 8 blanks with no staff initials -2/28/2024 in a 24 hour period revealed that there was 1 blanks with no staff initials -2/29/2024 in a 24 hour period revealed that there was 8 blanks with no staff initials An interview on 3/12/2024 at 10:00 AM with Certified Medication Assistant (CMA)-A confirmed that Resident 1 was a high risk for falls. CMA-A reported there was a sheet of paper taped to the door that said hourly safety checks and monitoring and the other side of the paper was the dates, times and initial of staff that had checked on Resident 1. CMA-A confirmed the staff who is checking on Resident 1 is to sign off on the sheet when they lay eyes on Resident 1. An interview on 3/12/2024 at 10:15 AM with Nursing Assistant (NA)-B confirmed Resident 1 had fallen several times. NA-B reported the Safety Monitoring sheets to be completed hourly had been in place for Resident 1 for several months. According to NA-B, the staff are to initial when they have checked on Resident 1 every hour. An interview on 3/13/2024 at 10:00 AM was completed with the DON. During the interview the DON revealed the nursing staff (Registered Nurse, Licensed Practical Nurse, NA's and CMA's) are responsible for the hourly safely checks. The DON reported the staff are to be initialing the Safety Monitoring sheets when they have laid eyes on Resident 1. The DON confirmed the Safety Monitoring sheets for the months of January and February were not being done every hour and that the Safely monitoring is the intervention that had been put in place months ago. The DON reported there were no new interventions put in place with each fall to prevent future falls for Resident 1. The DON reported new interventions should of been put in place with each fall to prevent future falls for Resident 1.

Based on observation and interview, the facility failed to ensure daily nurse staffing was posted. This had the potential to affect all 50 residents in the facility. Findings are: An observation on 11/30/2023 at 10:40 AM revealed, the daily posted nurse staffing reports for the facility were placed in a clear plastic folder taped to the window of the Administrator's office with dates of 03/04/2023, 03/06/2023, 03/07/2023, 03/08/2023, and 03/09/2023. In an interview on 11/30/2023 at 11:32 AM with the Accounting Director (AD) revealed, the daily posted nurse staffing reports were going to be the AD's responsibility and they have not been completed since 03/09/2023. In an interview on 11/30/2023 at 10:40 AM with the Human Resources Director revealed, the daily posted nurse staffing reports have not been completed since 03/09/2023 and should have been completed and posted every day. In an interview on 11/30/2023 at 11:32 AM with the Director of Nursing revealed, the posted nurse staffing had not been completed since 3/9/23 when the previous HR director was employed and they should have been completed and posted every day.

Licensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.006.17D Based on record reviews, observations, and interviews, the facility failed to 1) ensure they had a water management plan which had the potential to affect all 50 residents 2) ensure hand hygiene, glove changes, and a barrier were placed to prevent cross contamination during wound care for 2 (Resident 4 and 14) of 4 sampled residents. The facility census was 50. Findings are: A. Record review of the facility's Emergency Preparedness book revealed the Water Management Program Policy dated July 2017, stated the facility was to establish a water management plan for reducing the risk of Legionnaires and other opportunistic pathogens. Record review of the facility's Emergency Preparedness book did not reveal the facility had a water management plan. An interview on 11/28/23 at 8:56 AM with the facility Maintenance Director-E revealed, the facility did not have a water management program to identify Legionnaires or other opportunistic pathogens. 45641 B. A record review of the Policy Hand Hygiene Effective date 4/30/2018 Guideline revealed, hand hygiene will be completed and is indicated after touching blood, body fluids, secretions, excretions, and contaminated items whether gloves or not are worn. Wash hands immediately after gloves are removed. It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross contamination to different body sites. Alcohol based sanitizer if soap and water are no readily available use hand sanitizer that contains at least 60% alcohol. A waterless antiseptic may be used to supplement routine hand washing. Regular hand washing must be performed on a routine basis. A record review of Resident 14's Medical Diagnosis dated 11/29/2023 revealed, the resident had diagnoses of: Non-Pressure Chronic Ulcer of Skin of Other Sites with Unspecified Severity (sores not related to pressure), and Unspecified Open Wound Left Lower Leg Subsequent Encounter. A record review of Resident 14's Care Plan with an admitted [DATE] revealed, the resident had a focus area of actual impairment to skin integrity and had interventions to monitor/document location, size, and treatment of skin injury and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, exudate (drainage), and any other notable changes or observations. A record review of the Resident 14's Order Summary Report dated 11/29/2023 revealed, orders for: Wound care to left lower leg (LLL) open area. Cleanse with soap and water, apply wound veil (a dry dressing), moistened Therabond to area and cover with abdominal (ABD) pad (a dry dressing to absorb drainage). daily dressing changes. Wound Care: Wash right lower leg (RLL) with soap and water, apply wound veil and Therabond, cover with dry dressing daily (use same Therabond for 14 days) for skin integrity. An observation on 11/27/2023 at 7:23 AM revealed, Licensed Practical Nurse (LPN)-A gloved, adjusted Resident 14's recliner, removed the resident's left shoe and pulled down compression stocking. LPN-A removed the dressing on the left lower leg and cleaned wound with a 4x4 dressing with soap and water on it. LPN-A then allowed wound on the left lower leg to rest directly back on the recliner footrest with no barrier. LPN-A then cleaned the Therabond dressing with water and put dressing on the resident's wound, applied a 4/4 dressing over the Therabond and reapplied the compression stocking and shoe. LPN-A then took the resident's right shoe, pulled down stocking, removed Therabond dressing, cleansed the Therabond with water, cleansed wound with soap and water, re-applied Therabond dressing, applied a 4x4 over the Therabond, pulled compression stocking up, and put right shoe back on. LNP-A then completed handwashing with soap and water for 10 seconds. No hand hygiene (cleaning) or glove changes were completed when going from the contaminated site to the clean site on either leg, or when going from left to right leg. In an interview on 11/29/2023 at 1:25 PM with LPN-A revealed, LPN-A did not perform hand hygiene when going from a contaminated body site to a clean body site and should have. LPN-A also revealed [gender] did not do hand hygiene when going from 1 body part to another body part and should have. LPN-A further revealed, [gender] did not put a barrier between the wound and a contaminated surface and allowed the clean wound to rest on a contaminated surface. LPN-A revealed, that [gender] should have used a barrier between the wound and the contaminated surface of the recliner footrest. 48703 C. A record review of Resident 4's Admission Record undated revealed, Resident 4 admitted to facility on 11/30/22 and has diagnoses of pressure ulcer of sacral region, unspecified stage, pressure ulcer of unspecified site stage 4, pressure ulcer of other site unstageable. A record review of Resident 4 's Novemeber 2023 Medication Administration Record revealed, an order for the buttock wound to apply xeroform dressing topically and cover with dry gauze and dressing to be change three times a week on Monday, Wednesday, and Friday. A record review of Resident 4's Minimum Data Set (MDS is a standardized assessment tool that measures health status in nursing home residents) dated 10/9/23 revealed, Resident 4 had a Brief Interview for Mental Status (BIMS is used to get a quick snapshot of how well you are functioning cognitively now) score of 15 which indiciated resident was cognitively intact. The MDS revealed Resident 4 had open skin lesions. An interview on 11/30/23 at 12:02 PM with the Wound Clinic revealed, Resident 4 has a stage 3 pressure injury on the left buttock. An observation on 11/29/23 at 11:50 AM was conducted of LPN-A performing wound care to Resident 4. LPN-A gathered supplies at the medication cart. Locked cart with bare hands and entered Resident 4's room. No hand hygiene was performed upon entering the room. LPN-A then gathered supplies in the Resident 4's room out of their top dresser drawer including a scissors and placed supplies on the top of the dresser with bare hands. LPN-A then put on gloves and did not perform hand hygiene prior. With gloved hands LPN-A opened the bathroom door in resident's room using the door handle knob and turned on the bathroom sink. LPN-A then opened gauze sterile pad and placed under the running water in the sink. Next LPN-A placed the wet gauze directly on top of the dresser at the besides without a barrier between the wet gauze and dresser. LPN-A then received a phone call which [gender] reached in [gender] pocket and grabbed the phone and answered phone with the same gloves. LPN-A then placed the phone back in [gender] pocket after the phone call. LPN-A did not perform hand hygiene or change gloves after re-placing the phone in [gender] pocket. LPN-A then prepared a new colostomy bag with the same gloves. Next LPN-A turned around to the dresser and opened xeroform package for Resident 4's wound and cut to size and then placed the scissors on Resident 4's dresser with no barrier. LPN-A then cleaned Resident 4's stoma site with the same gloves and applied a new colostomy bag. LPN-A took the gloves off and performed hand hygiene with soap and water and placed on new gloves. Then, LPN-A assisted with rolling the resident to their left side touching Resident 4's upper back and their right hip with gloves on. Next with the same gloves LPN-A took the dressing off Resident 4's left buttock. The wound had 10% dry black scabbed edges, and 90% red tissue to the rest of the wound. There was with no redness to the surrounding tissue or drainage from the wound. LPN-A without changing gloves cleaned the wound with wet gauze that was directly on top of the dresser. LPN-A then with same gloves placed xeroform on the wound and covered with a dry dressing. After wound care was completed LPN-A took off the gloves and performed hand hygiene. An interview on 11/29/23 at 11:59 AM with LPN-A revealed, that Resident 4 had a pressure injury for 3 years and [gender] was a slow healer. Resident 4 was seen at a wound clinic for their wounds every 2-3 weeks depending on when the doctor wants to see the wound. LPN-A also revealed that [gender] works during the week and does all of Resident 4's wound care. LPN-A stated that it is not normal practice to answer the phone during cares but was waiting on this phone call. LPN-A also stated [gender] should have used a barrier for clean supplies and it was not normal practice to not use a paper towel as a barrier. An interview on 11/30/23 at 9:18 AM with LPN-A revealed, that the facility does not provide any training on wound care. An interview on 11/30/23 at 10:08 AM with the Director of Nursing (DON) revealed, that there are no wound care procedures policies, nurse competency or education completed on wound care management.

Licensure Reference Number 175 NAC 12.006.04B2a Based on interview and record review, the facility failed to complete 12 hours of on ongoing education for nursing assistants. This had the potential to affect all 50 residents in the facility. The total facility census was 50. Findings are: A record review of the Facility's Employee Files revealed, ongoing continuing education had not been completed since the end of March 2023 for 5 of 5 sampled staff files for Nursing Assistant (NA)-D, NA-E, NA-F, NA-G, and NA-H. A record review of the Facility's Training Logbook revealed, that the only training completed in the past 12 months was Abuse and Neglect training dated 01/26/2023 and Fire/Tornado Training on 04/28/2023. In an interview on 11/30/2023 at 10:40 AM with the Human Resources Director (HR) revealed, the nursing assistant training only included Abuse and Neglect training dated 01/26/2023 and Fire/Tornado Training on 04/28/2023. HR also revealed, none of the NA's employed by the facility had received the required 12 hours of ongoing training.

Licensure Reference Number 175 NAC 12-006.17A(2) and 12-006.17A(4) Based on observations, interviews and record reviews; the facility failed to prevent and contain COVID-19 by A) failure to implement and follow zoning guidelines for COVID-19. B) failure to isolate and relocate COVID-19 positive residents to a dedicated red zone away from resident who tested negative, C). failure to ensure resident doors and the clean linen closet doors were closed on the red/yellow unit. This affected 3 residents (Resident 5, 7 and 9) who shared rooms with a resident who was COVID -19 positive and subsequently each of these residents (Resident 5, 7 and 9) contracted COVID 19. This had the potential to affect 29 resident residing on the yellow/red zone. The facility census was 44. Findings are: A. An observation on 9/30/20 at 4:00 PM of the facility revealed the facility had 14 non-occupied rooms on the green and gray units. The gray unit was divided between 2 halls (the front of the halls were green with the back of the halls gray). Six rooms on the Wilderness hallway had 1 room occupied the other 5 gray rooms were not occupied, and 5 Gray rooms on Serenity hallway 3 were occupied a and 2 not occupied. The yellow zone was cohorting positive, negative and recovered residents. Record review of Facility Daily Census from the BOM (Business Office Manager) dated 9/30/20 revealed the yellow zone hallway had 9 recovered residents, 13 negative residents (Residents 2, 11, 14, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26), and 2 positive residents (Residents 1 and 3). The residents (Resident 7, Resident 5 and Resident 29) on the dedicated Red zone were recovered and one resident who refused to test (Resident 30). room [ROOM NUMBER] had a COVID positive resident (Resident 1) cohorting with a COVID negative resident (Resident 2). Record review NETEC (a National Emerging Special Pathogen Training and Education Center-an organization that is mobilized to increase the capability of the public health and health care systems to safely and effectively manage individuals with suspected and confirmed special pathogens) Recommendations for zoning dated 9/11/20 revealed; 1. Dark Red Zone: This is an isolation area for all residents who have tested positive for COVID-19. o Individuals testing positive can share a room so long as there are no co-infections and other criteria per the facility are met i.e. gender rules. o It is recommended that all room doors are kept closed, but/ if doors cannot be kept closed for safety reasons, the hallway must be considered a red zone. 2. Light Red Zone: This is an isolation zone for all residents who are symptomatic and are suspected to have COVID-19 but have not yet tested positive. This could be a resident who has had known exposure to someone who has tested positive for COVID-19 and is displaying one or more symptoms of the illness. o Residents in the light red zone cannot share a room. o All doors must remain closed to prevent potential cross contamination into rooms where residents rule out for having COVID-19. 3. Yellow Zone: This is a 14-day quarantine zone for residents who may have been exposed to COVID-19 but are asymptomatic. This could be someone who shared a room with someone who tested positive for COVID-19, but they themselves have no symptoms. o Doors in the yellow zone must remain closed since disease status is unknown/and it is possible for asymptomatic shedding of COVID-19. 4. Green Zone: This is for residents who have had no potential exposure and do not have any symptoms of COVID-19. This is not quarantine nor isolation, but these residents must be protected from becoming exposed. Staff must wear source control protection and practice good infection prevention. It is not necessary to keep doors closed in this zone, but it is good practice. Residents may share rooms if they meet the facility criteria for doing so. 5. Gray Zone: This is a quarantine zone for residents who have no symptoms but have had a potential for exposure by leaving the facility for outside appointments such as for [MEDICAL TREATMENT] or doctor appointments. Doors to these rooms must be kept closed as exposure history is unknown. Interview on 9/30/20 at 2:03 PM with the DON confirmed the residents past the fire doors (dedicated red zone) were past the 10 days and would be considered recovered from COVID19. The DON reported residents were testing positive, but there were no rooms to move resident into the red zone. The DON confirmed the residents in rooms past the fire doors on the yellow hall were past the 10 days and would be considered recovered. The DON revealed at this point in time residents were testing positive, but no rooms were available to move into so the red zone was changed to yellow. The DON confirmed the residents who tested positive had not been relocated to the red zone An interview on 10/1/20 at 1:15 PM with the DON confirmed initially the back of the Peach unit Garden Walk, the back 4 rooms would be the Isolation zone, they do have fire doors to that area. The green unit (Serenity) had 4 rooms that were designated for the admission unit. The DON confirmed the facility ; had a gray zone on 2 different wings and the facility had tried to move residents however, the residents did not want to move. The DON acknowledged the 1135 waiver for the emergent need for moving residents. The DON reported staff do go between the gray unit and the green unit. The DON confirmed the 2 gray areas are not efficient as staff has to work on both green and gray zones in one hall. B. Record review of cohorting residents and roommates COVID positive residents with COVID negative residents revealed; 1. Roommates Residents 4 and 5 Record review of Resident 4 COVID test dated 8/26/20 revealed Resident 4 was positive for COVID-19. Record review of Clinical Census for Resident 4 revealed Resident 4 was in room [ROOM NUMBER] bed 1 from 12-14-20 through 9-1-20. Resident 4 was relocated away from roommate according to census on 9/2/20 to room [ROOM NUMBER]-1. Record review of Resident 4's temperature on September 4th and 5th revealed Resident 4 had a temperature of 99.1 and oxygen saturations was 91% on August 30, 2020. Record review of Resident 5's COVID test dated 8/26/20 revealed Negative test on 8/26/20. Record review of Resident 5's COVID test dated 9/2/20 revealed Resident 5 was positive for COVID-19. Record review of Clinical Census revealed Resident 5 resided in room [ROOM NUMBER]-bed 2 from 7-29-20 to 9-10-20 2. Roommates Residents 6 and 7 Record review of Resident 6's progress notes dated 8/23/20 revealed at 8:10 PM Temperature was 99.3, LS (Lung Sounds) auscultate with expiratory rubs bilateral, no cough or other s/s (Signs and symptoms) of COVID-19 noted, resident was lethargic & at times unsteady as (gender) ambulated, urine is cloudy yellow with mucous per Foley catheter, has no c/o(Complaints of) discomfort, per communication with DON staff will continue to check on resident & roommate for s/s of COVID, resident rests in recliner watching TV, ate 2 sandwich halves for HS (night time) snack, at 11:00 PM Temperature was 98.4 and resident was asleep. Record review of Resident 6 COVID test dated 8/26/20 revealed Resident 6 was positive for COVID 19. Record review of Clinical Census for Resident 6 revealed Resident 6 was in room [ROOM NUMBER] bed 2 from 6/29/20 to 9/2/20. Resident 6 was relocated away from roommate according to census on 9/2/20 to room [ROOM NUMBER]-2. Record review of Resident 7's COVID test dated 8/26/20 revealed Resident 7 was negative for COVID-19. Record review of Resident 7's COVID test dated 9/2/20 revealed Resident 7 was positive for COVID-19. Record review of Clinical Census revealed Resident 7 resided in room [ROOM NUMBER]-bed 1 from 7-16-20 until 9/9/20 was moved to 59-2. 3. Roommates Resident 8 and 11 Record review of Resident 8 COVID test dated 8/26/20 revealed Resident 8 was negative for COVID 19. Record review of Resident 8 COVID test dated 9/2/20 revealed Resident 8 was negative for COVID 19 Record review of Resident 8 COVID test dated 9/10/20 revealed Resident 8 was positive for COVID 19. Record review of Clinical Census for Resident 8 revealed; Resident 8 was in room [ROOM NUMBER] bed 2 from 2/14/20 to present. Record review of Resident 8's Progress note dated 9/14/20 revealed had elevated Temperature, 100.7, respirations regular & unlabored, no other indications of COVID-19. Record review of Resident 11's COVID test dated 8/26/20 revealed Resident 11 was negative for COVID 19. Record review of Resident 11's COVID test dated 9/2/20 revealed Resident 11 was negative for COVID 19. Record review of Resident 11's COVID test dated 9/10/20 revealed Resident 11 was negative for COVID 19. Record review of Resident 11 COVID test dated 9/16/20 revealed Resident 11 was negative for COVID 19. Record review of Resident 11 COVID test dated 9/23/20 revealed; Resident 11 was negative for COVID 19. Record review of Clinical Census for Resident 11 revealed Resident 11 was in room [ROOM NUMBER] bed 1 from 1/1/20 to present. 4. Roommates Resident 12 and 3 Record review of Resident 12's COVID test dated 8/26/20 revealed Resident 12 was negative for COVID 19. Record review of Resident 12's COVID test dated 9/2/20 revealed Resident 12 was negative for COVID 19. Record review of Resident 12's COVID test dated 9/10/20 revealed Resident 12 was positive for COVID 19. Record review of Clinical Census for Resident 12 revealed Resident 12 was in room [ROOM NUMBER] bed 2 12/23/20 to 9/1/20 moved to room [ROOM NUMBER] bed 1. Record review of Resident 3's COVID test dated 8/26/20 revealed Resident 3 was negative for COVID 19. Record review of Resident 3's COVID test dated 9/2/20 revealed Resident 3 was negative for COVID 19. Record review of Resident 3's COVID test dated 9/10/20 revealed Resident 3 was negative for COVID 19. Record review of Resident 3's COVID test dated 9/16/20 revealed Resident 3 was positive for COVID 19. 5. Roommates 13 and 14 Record review of Resident 13's COVID test dated 8/26/20 revealed Resident 13 was negative for COVID 19. Record review of Resident 13's COVID test dated 9/2/20 revealed Resident 13 was negative for COVID 19. Record review of Resident 13's COVID test dated 9/10/20 revealed Resident 13 was positive for COVID 19. Record review of Clinical Census for Resident 13 revealed Resident 13 was in room [ROOM NUMBER] bed 1 from 08/20/20 to 9/24/20 moved to room [ROOM NUMBER]-1 then on 9/26/20 transferred to hospital. Record review of Resident 14's COVID test dated 8/26/20 revealed Resident 14 was negative for COVID 19. Record review of Resident 14's COVID test dated 9/10/20 revealed Resident 14 was negative for COVID 19. Record review of Resident 14's COVID test dated 9/16/20 revealed Resident 14 was negative for COVID 19. Record review of Resident 14's COVID test dated 9/23/20 revealed Resident 14 was negative for COVID 19. Record review of Clinical Census for Resident 14 revealed Resident 14 was in room [ROOM NUMBER] bed 2 form 06/01/20 to present. 6. Roommates Resident 1 and 2 Record review of Resident 1's COVID test dated 8/26/20 revealed Resident 1 was negative for COVID 19. Record review of Resident 1's COVID test dated 9/2/20 revealed Resident 1 was negative for COVID 19. Record review of Resident 1's COVID test dated 9/10/20 revealed Resident 1 was negative for COVID 19. Record review of Resident 1's COVID test dated 9/16/20 revealed Resident 1 was negative for COVID 19. Record review of Resident 1's COVID test dated 9/23/20 revealed Resident 1 was positive for COVID 19. Record review of Clinical Census for Resident 1 revealed Resident 1 had resided in room [ROOM NUMBER]-2 since 7/31/2020 Record review of Resident 2's COVID test dated 8/26/20 revealed Resident 2 was negative for COVID 19. Record review of Resident 2's COVID test dated 9/2/20 revealed Resident 2 was negative for COVID 19. Record review of Resident 2's COVID test dated 9/10/20 revealed Resident 2 was negative for COVID 19. Record review of Resident 2's COVID test dated 9/16/20 revealed Resident 2 was negative for COVID 19. Record review of Resident 2's COVID test dated 9/23/20 revealed Resident 2 was negative for COVID 19. Record review of Clinical Census for Resident 2 revealed Resident 2 had resided in room [ROOM NUMBER]-1 since 7/1/2020. An observation on 9/30/20 at 9:40 AM of Resident 1 and Resident 2 cohorting as roommates. An observation on 9/30/20 at 4:00 PM of the facility revealed the facility had 14 non-occupied single occupancy rooms on the green and gray units. The gray units were divided between 2 halls with 6 rooms on the Wilderness hallway with 1 room occupied the others were not occupied, and 5 Gray rooms on Serenity hallway had 3 occupied rooms with 2 not occupied. An observation on 10/1/20 at 10:44 AM of 2 residents as roommates revealed Resident 1 who had positive COVID test results cohorting with Resident 2 who had negative test results. Record review of the Yellow/Red hallway Census document the facility provided which indicated: COVID Positive Residents, COVID Negative Residents, and Recovered from COVID Residents revealed; 2 Residents were Positive for COVID resided in rooms, 1 Resident in room [ROOM NUMBER] and 1 Resident in room [ROOM NUMBER] (with negative roommate). There were 13 Residents on the yellow hall that tested negative for COVID-19 2 Residents in room [ROOM NUMBER](Resident 17 and 18), 1 Resident in room [ROOM NUMBER] (Resident 14), 1 Resident in room [ROOM NUMBER] (Resident 19), 1 Resident in room [ROOM NUMBER] (Resident 20), 2 Residents in room [ROOM NUMBER] (Resident 21 and 22), 1 Resident in room [ROOM NUMBER] (Resident 11), 2 Residents in room [ROOM NUMBER] (Resident 23 and 24) 2 Residents in room [ROOM NUMBER] (Resident 25 and 26), and 1 Resident in room [ROOM NUMBER] (Resident 2). There were 9 Residents considered to be recovered that resided in rooms: 1 Resident in room [ROOM NUMBER] (Resident 27), 1 Resident in room [ROOM NUMBER] (Resident 17), 2 Residents in room [ROOM NUMBER] (Resident 10 and 9), 1 Resident in room [ROOM NUMBER] (Resident 6), 1 Resident in room [ROOM NUMBER] (Resident 8), 1 Resident in room [ROOM NUMBER] (Resident 28), and 2 Residents in room [ROOM NUMBER] (Resident 5 and 29)1 Resident in room [ROOM NUMBER] (resident 7). Record Review of the facility Policy for Guidelines for Transition Care Area Gray Zone and Quarantine Area Yellow and or Red zone dated 5/21/20 revealed if a positive or suspected positive COVID-19 patient is diagnosed with [REDACTED]. Record review of the facility Protocol for Management of Patients with Suspected or Confirmed COVID-19 dated 4/2/20 revealed ;for Residents with suspected COVID will be transferred to the red zone, test will be done?. An interview on 9/30/20 at 2:03 PM with the IP (Infection Preventionist) revealed ICAP (Infection Control Assessment and Promotion Program- a program designed to prevent health care-associated infections) recommendations were to separate COVID-19 positive residents from the residents who were testing negative. The IP revealed; results are received 5 days after testing completed. The facility had not moved the negative resident who was the roommate with the positive resident because they were already exposed so there was no point moving the negative room-mate. The IP confirmed the facility had identified a designated red zone. The IP revealed positive residents who remain asymptomatic for 10 days would be considered recovered. An interview on 9/30/20 at 2:03 PM with the DON confirmed the residents in rooms past the fire doors on the yellow hall were past the 10 days and would be considered COVID19 recovered. The DON revealed at this point in time residents were testing positive, but no rooms were available to move into so the red zone was changed to yellow. C. An observation on 10/1/20 at 10:30 AM of the yellow/red unit revealed; the following room doors were open: The following rooms considered yellow rooms where doors were open were room [ROOM NUMBER], 45, 46, 48, 49, 50, 51, 52, 53, 54, 55, 57, 58, 59 and a clean linen door was open. The rooms considered red zone with open doors were 44 and 56. An observation on 10/1/20 at 10:57 AM of Fire doors separating the designated Red zone were open. An observation on 10/1/20 at 10:58 AM there was no poly wall separating the activity room from the designated red zone. An interview on 9/30/20 at 2:03 PM with the IP (Infection Preventionist) confirmed the facility no longer had red zone, the fire doors were not closed related to residents behind the doors were recovered and had no need to be quarantined. Record review NETEC recommendations dated 9/11/20 reveal; Doors to resident rooms are not being kept closed in the yellow or red zones. COVID-19 testing results are a 'moment in time' and it is uncertain how many residents or staff become positive after the tests were obtained. For that reason, source control should include that all doors are kept closed to reduce air flow out of the rooms and potential contamination to the hallways and other resident rooms. Dark Red Zone: It is recommended that all room doors are kept closed, but/ if doors cannot be kept closed for safety reasons, the hallway must be considered a red zone. Yellow Zone: This is a 14-day quarantine zone for residents who may have been exposed to COVID-19 but are asymptomatic. This could be someone who shared a room with someone who tested positive for COVID-19, but they themselves have no symptoms. Doors in the yellow zone must remain closed since disease status is unknown/ and it is possible for asymptomatic shedding of COVID-19. An interview on 09/30/20 at 12:58 PM with the DON confirmed the doors to resident rooms on the RED/YELLOW zone hallway were open due to the residents were considered high fall risk. Abatement: An abatement completed on 10/1/20 at 6:30 PM revealed; the facility made the yellow unit a red unit and will close the Fire Doors at the end making rooms [ROOM NUMBER] a Red zone. The facility will continue to explore ways to separate from the yellow zone. The Red zone will be clearly marked with red circles. Staff will be trained for caring for COVID positive residents/wearing Personal Protective equipment, with proper linen and garbage disposal in the Red zone. The facility will move the 2 COVID-19 Positive Residents to the Red zone. The resident who refused testing would remain in the red zone. The facility would review and implement the COVID cohorting policy supplied to us by NETEC. The facility would evaluate the CMS Blanket Wavier regulations and utilize them in our future planning. The facility would complete audits to insure Resident Room doors and linen closet doors are closed to lessen the germ spread. If a Resident was a Fall Risk precautions will be taken. The facility would only cohort positive Residents with positive Residents. Negative Residents will be placed with negative Residents. The facility would isolate COVID positive Residents from negative Residents. If possible positive Residents will occupy a room by themselves. In case of an outbreak move recovered Resident Serenity and/or Wilderness LANE to create more Red Zone rooms if necessary. Record review of a document received by the facility revealed; the facility had a plan to move residents testing positive to the designated Red zone and move residents who were considered recovered from the Red zone. An observation on 10/1/20 at 7:00 PM of the Wilderness hall way had been changed from yellow unit to a Red unit. On 10/1/2020 the facility abatement was received, the immediacy removed and the Immediate Jeopardy abated to a scope and severity of H

Licensure Reference Number 175 NAC 12-006.09D7b Based on record reviews and interviews; the facility failed to ensure an assessment was completed and interventions were implemented for the use of an electric recliner to prevent a fall with fracture for 1 resident (Resident 1) of 3 sampled residents. The facility census was 61. Findings are: Record review of Nurses note dated 2/3/19 at 01:55 AM revealed; Resident 1 was on the floor on the right side. Resident 1 reported they were trying to walk. The recliner was in the highest position the call light was attached to the residents clothing. A Hoyer lift was used to transfer to the recliner. 0300 AM Resident had large abrasion to the top of head and forehead. Resident complained of right knee pain, abrasion to the right eyebrow and forehead. A second fall on 2/3/19 at 3:45 AM, resident was on floor again, in similar position, to fall at 1:55 AM recliner was in the upright position. At 4:30 AM Resident 1 had increased pain to the right knee, and right knee bruising was present. Record review of a Fall Scene Investigation Report dated 2/3/19 revealed Resident 1's falls that occurred at 01:55 AM and 03:45 AM were documented on the same Fall Scene Investigation Report. There was one new intervention recorded for both falls: frequent safety checks. The root cause analysis of the both falls was: 1) the resident raised the recliner to the highest point 2 times and 2) poor safety awareness. Record review of Resident 1's X-ray report date 2/3/19 revealed; an acute right knee fracture. Record review revealed; the facility was requested to provide a resident recliner assessment form and was unable to provide a recliner assessment for Resident 1. Record review revealed; the facility was unable to provide documentation of Risk/Benefit for Resident 1's recliner use and family education. Record review of Holmes Lake Rehabilitation and Care Center Investigation Report dated 2/7/19 revealed; Interventions of Neurological and safety checks, the care to skin tears, ice to the right knee, as needed pain medication, consult with provider regarding bed/recliner use upon return to the facility, conversation with DHHS (Department of Health and Human Services regarding request of family to place resident in recliner, education of family regarding benefits of utilizing bed verses chair, and education to family on hospice benefits. Record review of the facilities Guideline for Accidents Involving Falls/Skin Tears/Abrasions and Bruises dated, 2/4/15 revealed; 1) A follow up Assessment to be done every shift for the first 72 hours, Vitals as needed, Pain rate, Range of Motion, and Neurological checks will be done per guidelines. 2) Licensed Nurse will observe 1 transfer in the first 24 hours for potential changes from prior status. 3) After 72 hours is done a Daily Assessment on the shift that the fall occurred for another 4 days. Record review of Care Plan dated 3/28/17 for fall risk revealed; interventions of transfer with sit/stand was discontinued on 2/3/19. Interventions in place were 1) Blood Pressure and Pulse, 2) Fall Risk Assessment Quarterly, 3) anticipate needs 4) low bed with mat next to bed dated 2/4/19, 5) observe for adverse effects of medications, 6) medications as ordered, 7) educate family and resident on potential risk/benefits of medication use, 8) monitor for effectiveness of [MEDICAL CONDITION] medications, 10) Pharmacy review of medications, 11) notify Cheney Psychiatric of any changes in behavior, 12) transfer with a Hoyer Lift dated 2/3/19 and 13)Hinged knee brace Right lower Extremity dated 2/4/19. An interview on 2/26/19 at 09:55 AM with LPN (Licensed Practical Nurse) B revealed; the procedure to follow for the nurse post resident fall was to assess for injury, ask if the resident if they were hurt, assist the resident back to bed, record vital signs, initiate neurological checks, notify the physician and family, fill out the incident report, fall investigation report, physician communication or a telephone order if the resident needed to be sent out, correct the environment if it caused the fall, safety concerns (Gripper socks or shoes). Interview on 2/26/19 at 10:26 AM with the DON (Director of Nurses) confirmed; both of Resident 1's falls were recorded on the same Fall Scene Investigation report. The DON confirmed the interventions on the care plan should correlate with the root cause analysis. The DON confirmed there was not a recliner assessment. Interview on 2/26/19 at 11:49 AM with the Administrator confirmed the facility did not have documentation of interventions on the care plan. Administrator reported the facility did not have documentation of the education to the family in regard to the Risk/Benefits of recliner use after the fall. The Administrator reported the family was adamant about Resident 1 being placed in the recliner. The Administrator reported the nurse on duty had a conversation with the family about the recliner and safety.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D5a Based on observation, interview and record review; the facility failed to provide medically related social services to one resident (Resident 65) with ongoing symptoms of depression that resulted in weight loss, isolation and increased need for assistance with activities of daily living. The facility census was 54. Findings are: Review of the Nurses Notes dated 1/7/16 revealed that Resident 65 was informed of a family member's death the night before. Further review of the Nurses Notes indicated that by 1/17/16 Resident 65 had started refusing to go to the dining room for meals. Nurses Notes on 1/19/16 indicated that the resident refused to go to the dining room, refused to eat breakfast and refused to bathe. Resident 65 reported being sad and depressed but did not give specifics. Resident's change of condition was reported to the mental health provider at that time. Resident 65's Nurses Notes dated 1/21/16 further revealed that the mental health provider increased the resident's antidepressant. The resident continued to have withdrawn behavior and declined to discuss feelings. These notes indicated the resident reported being sad and having no appetite. A Nurses' Note on 1/22/16 revealed that Resident 65's weight on 1/12/16 was 147.5 pounds and on 1/22/16 the resident's weight was 132 pounds. This was a loss of 15.5 pounds. The resident's care plan, dated 1/22/16, revealed that a supplement was added as well as an afternoon snack. On 1/26/16, Nurses' Notes stated that the resident's physician faxed an order that Resident 65 be sent to the emergency room for evaluation of condition but the resident refused. According to the notes on 1/29/16 in the PM revealed the resident refused all medications and food that evening and again on 1/30/16. Resident 65 also declined medications on 1/31/16 at bedtime. Review of Resident 65's meal intake record, for the month of January, 2016, revealed the resident had been eating 100% of all three meals each day until 1/17/16. After this day and through 1/31/16 the resident started refusing most meals or took only 25%. On 1/27/16 at 8:20 AM Resident 65 was observed in bed with covers pulled over head. When asked about this, the resident stated was not wanting to get up or eat. At 8:23 AM on 1/27/16 Medication Aide (MA) F said MA-F was going to try to get resident up but doubted Resident 65 would go to the dining room. The MA said this resident had been very depressed since a family member's recent passing. At 10:15 AM on 1/27/16 Resident 65 was observed seated in a recliner in room with an untouched breakfast tray in front of Resident 65. The resident stated not wanting to eat breakfast and then pulled shirt up over their head. On 2/1/16 at 10:15 AM an interview was conducted with the MDS (Minimum Data Set: A federally mandated assessment tool used to develop care plans) Registered Nurse (RN) regarding Resident 65's condition. The RN said this resident had a significant change in condition related to not wanting to eat, take medications, come out of room or participate in activities of daily living (ADLs). The RN said this resident had also expressed wanting to die. The facility Social Worker (SW) was interviewed on 2/1/16 at 10:06 AM about Resident 65's condition. The SW confirmed this resident had a decline in mood and behavior. The SW further revealed there was no ongoing monitoring of the interventions already attempted by other departments and there were no other planned interventions or ongoing monitoring for Resident 65's continued change in condition related to declining mood. The SW could provide no evidence that there was any Social Service assessment or interventions since the resident had experienced the loss of the family member and had begun to deteriorate.