Every finding on record at Indian Hills Manor

Licensure Reference Number 175 NAC 12-006.04(B)(ii) Based on record review and interview, the facility failed to ensure 1 of 5 sampled nurse aides completed 12 hours of in-service educations and 4 hours of dementia training as required.Findings Are: A record review of an untitled facility-provided document revealed a list of current employees of the facility with name, department, job title, and hire dates. The document also revealed Nurse Aide - A (NA-A) was hired on 2/1/2022. Record review of facility staffing documentation revealed that Nurse Aid (NA)-A completed 1.55 training hours between 2/1/2025 and 2/1/2026 which included the following training, completion dates, and hours:-Basics of Tuberculosis Self-Paced, completed 5/15/25, 0.25 hours.-HIPAA documents review, completed 5/15/25, 0.25 hours-HIPAA Do's and don'ts of social media and electronic communication self-paced, completed 5/15/25, 0.25 hours-Infection control: Handwashing, completed 5/15/25, 0 hours-[NAME] compliance and ethics program overview, completed 5/15/25, 0.3 hours-Personal protective equipment-ALL, completed 5/19/25, 0 hours-Safe patient handling training videos, completed 5/15/25, 0.5 hours-Safe patient handling, lifts skills checklist 10/17/19, completed 5/19/25, 0 hours An interview at 12:43 PM on 5/21/26 with the Administrator (ADM) and the [NAME] President of Operations (VPO) confirmed that NA-A did not complete 12 continuing education hours as required and did not complete the 4 hours of required dementia training as required.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record review, the facility failed to ensure outdated food items were not available for use, items were labeled correctly, and failed to perform proper hand hygiene and change gloves while preparing food to prevent the potential for cross contamination and food-borne illness. The facility identified a census of 32. This had the potential to affect all residents who ate out of the kitchen.Findings are: A.Record review of a policy titled Food Safety Requirements, undated, revealed under Policy Explanation and Compliance Guidelines number 1 states Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements include the following: b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. c. Preparation of food, including thawing, cooking, cooling, holding, and reheating. f. Employee hygienic practices. The policy revealed under number 3, c. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers. During initial tour on 5/18/2026 from 9:48 AM until 11:25 AM, the following concerns were identified:-A cart in the prep area was found to have individual jelly and butter packages on the bottom level of the cart. These packets were in trays with no dates located.-The walk-in refrigerator was found to have a gallon bottle of lime juice dated with an expiration date of 3/25/2026. A gallon bottle of [NAME] French dressing was found to have black fuzzy spots scattered on label on the side of bottle. A gallon jar of sweet pickle relish was found with no open date. A clear prep tub with a sealed lid and labeled as marinated chicken was found with contents of raw chicken in a red liquid and was dated for 5/8.-The walk-in freezer was found to have an opened, sealed bag of breaded frozen balls with no label of contents or opened date. A clear bag of breaded strips was opened, not sealed, and had no label of contents or opened date.-In dry storage, a bottle of dark corn syrup was found with the lid crooked, not sealed, and with no open date on the bottle. A clear sealed bag of individual syrup cups was found with no label or expiration date. A box of Cream of Rice that was not opened was labeled best if used by 6/30/2025. A clear sealed bag of shell shaped items was found with no label of what item was or an expiration date written on bag. A bag of classic bowtie noodles was found with no open date. A bag of egg noodles was found with no open date. Interview with the Dietary Manager (DM) on 5/18/2026 at 10:52 AM confirmed undated individual jelly and butter packs, expired lime juice and French dressing, undated sweet pickle relish, marinated chicken in fridge for 10 days, undated and unlabeled breaded items in freezer, undated bag of individual syrups, unlabeled and undated shell-shaped items, undated bag of classic bowtie noodles, undated bag of egg noodles, unsealed and undated dark corn syrup, and expired cream of rice. B.Additional record review of the policy Food Safety Requirements, undated, revealed under number 6, c. Staff shall wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the hands of utensils. Under number 7, a. Staff shall wash hands according to facility procedures. b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tons, deli paper, and spatulas. f. Staff should maintain nails that are clean and neat, and wearing intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection. Record review of a policy titled Handwashing Guidelines for Dietary Employees, undated, revealed under number 6. Frequency of Handwashing b. After hands have touched anything unsanitary e. After handling chemicals and beginning to work with food. f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. h. Before donning gloves for working with food. Under number 7. Handwashing Procedure d. Rub together vigorously for at least 20 seconds. g. Rinse thoroughly under clean, running warm water. During an observation of meal prep on 5/19/2026 from 9:30 AM until 10:27 AM, DM washed their hands with soap and water for 15 seconds, rinsed and then continued holding their hands under running water for an additional 7 seconds. DM measured out 1 quart of rice using a clean measuring scoop and rinsed the rice with water in a strainer in the sink located on the prep counter. DM dumped the rice into a pot, added 2 quarts of rice into the pot, and placed the pot on stove. They grabbed a box of yellow squash and placed the yellow squash into the sink located on the prep counter, scrubbed, washed, and placed yellow squash on a clean cutting board. DM then washed their hands with soap and water for 10 seconds, rinsed and then continued holding their hands under running water for an additional 10 seconds. DM put on gloves and cut the squash. When finished cutting squash, they used a rag out of a red bucket with sanitizer to sanitize the knife and counter and placed the rag back in the bucket. DM placed saran wrap on the bowl of squash and labeled it with the contents and date and placed the bowl in the fridge. DM then washed their hands with soap and water for 5 seconds, rinsed and then continued holding their hands under running water for an additional 20 seconds. They prepared cornbread with a boxed mix, whisked the ingredients together, and scraped the contents into a baking pan with a spatula. DM washed their hands with soap and water for 4 seconds, rinsed and then continued holding their hands under running water for an additional 22 seconds. They grabbed a new cutting board and slid 2 halved onions out of a bag onto the cutting board without touching the onions with their hands. DM washed their hands with soap and water for 22 seconds, rinsed, put on gloves, and proceeded to chop the onions. DM removed the pot of rice from the stove, dumped the rice into a steam table pan, and placed that pan on the steam table. DM used the rag out of the red bucket to wipe the cart where the cutting boards and mixer are located, wiped the hand-washing sink, wiped the front of the stove and front of the oven doors, and wiped the knobs on the front of the oven. DM washed their hands with soap and water for 8 seconds, rinsed and then continued holding their hands under running water for an additional 20 seconds. Additional observation during this meal prep on 5/19/2026 from 9:30 AM until 10:27 AM revealed that Dietary Aide (DA)-B washed their hands with soap under running water for 14 seconds. They loaded dirty dishes into the dishwasher trays. DA-B then washed their hands with soap and water for 7 seconds, rinsed them and then continued holding their hands under running water for an additional 10 seconds. Additional observation of food prep and meal service on 5/19/2026 from 11:15 AM until 1:00 PM revealed DM had gloves on and dumped a bowl of brown and red coated raw shrimp onto a sheet pan and used a spoon to spread them out on the pan. DM removed their gloves and stirred the squash that was on the stove. They poured canned chicken broth onto the vegetables and placed saran wrap on the can of chicken broth. DM washed their hands with soap and water for 6 seconds, rinsed and then continued holding their hands under running water for an additional 10 seconds. DM put on new gloves, sliced a half stick of butter, placed the slices over the shrimp, and poured lemon juice over the shrimp. DM moved 2 hot dogs from the griddle into a steam table pan with a spatula. They cleaned the counter with the rag from the red bucket, placed the rag back into the bucket, and took it out to clean off the knife. DM removed their gloves then applied new gloves. They opened sliced cheese, grabbed 3 slices, and cut them on a new cutting board. DM grabbed ham from a bag and sliced it on the same cutting board. They placed the ham and cheese slices on a plate, covered with saran wrap, and labeled it with the contents and date. DM touched fridge handle with gloved hand to open fridge and walked in to place the plate in the fridge. DM grabbed a bag of lettuce, a bag of tomatoes, and a jar of pickles out of the fridge and placed these items on the counter. They removed their gloves and put hot mitts on. DM dumped the squash into a steam table pan using a spoon. DM removed the hot mitts and used the rag out of the red bucket to clean off the knife then flipped the cutting board over. DM washed their hands with soap and water for 7 seconds, rinsed and then continued holding their hands under running water for an additional 13 seconds. DM put on gloves and proceeded to slice onions. With gloved hands, DM grabbed the bag of tomatoes and took out 4 quartered tomatoes and sliced them. They grabbed 2 clean plates with their gloves on and did not touch the tops of the plates. With the same gloved hands, DM opened the bag of lettuce, grabbed the lettuce with their gloved hands, and placed it onto the plate. With the same gloved hands, they placed the tomatoes and onions onto the plate. With the same gloved hands, they opened the pickle jar, set the lid on the counter, opened a drawer and grabbed tongs out, and grabbed pickles out of the jar with the tongs and placed them on the plate. DM grabbed a clear bag and put 2 halves of onions into the bag using the same gloved hands. DM opened the fridge and placed the bags of onion, tomato, and lettuce and jar of pickles in there with their gloves still on. They proceeded to open sliced cheese and grabs cheese slices with their same gloved hands. With the same gloves on their hands, DM grabbed a bag of bread from dry food storage, opened the fridge, and grabbed a stick of butter. DM placed the stick of butter in a plastic bowl without touching the butter with their hands and placed the bowl in the microwave. DM removed their gloves and washed their hands with soap and water for 11 seconds, rinsed and then continued holding their hands under running water for an additional 15 seconds. DM put on gloves pureed the shrimp in a food processor with chicken broth, scraped the contents into steam table pan, and put that food processor bowl on the dishwasher tray. DM used the rag from red bucket to wipe off the food processor. DM washed their hands with soap and water for 9 seconds, rinsed and then continued holding their hands under running water for an additional 13 seconds. DM put gloves on and used a new food processor bowl to puree the squash with chicken broth. They poured that into a steam table pan and placed the food processor bowl on a dishwasher tray. They removed their gloves and washed their hands with soap and water for 5 seconds, rinsed and then continued holding their hands under running water for an additional 20 seconds. DM grabbed a pie cutter out of a drawer and set it on top of a prepackaged, unopened pie. They opened the lid to another pie and cut the pie with the pie cutter. DM washed their hands with soap and water for 7 seconds, rinsed and then continued holding their hands under running water for an additional 10 seconds. DM put on gloves and began plating food for lunch. With same gloved hands, they obtained 2 potatoes from the dry food storage and scrubbed them clean in the sink located in the prep counter. They pierced the potatoes with a fork and placed them in the microwave. DM removed their gloves and washed their hands with soap and water for 10 seconds, rinsed and then continued holding their hands under running water for an additional 10 seconds. They put on gloves and continued to plate lunch trays. With same gloved hands, DM grabbed 3 buns out of a bag, buttered the top and bottom half, and placed them on the griddle buttered side down. They used tongs to place 3 hamburger patties on the griddle. DM opened the fridge with their same gloved hands, grabbed a tub of sour cream, obtained a scoopful of sour cream, and placed the scoop of sour cream onto the cutting board. With the same gloved hands, DM grabbed a hot potato out of the microwave, placed it on a plate, and brushed it with butter. They added that scoop of sour cream on top of the potato and smashed the potato down with a fork. DM added a bun and hamburger patty to the plate with tongs and spatula. Using the same gloved hands, DM grabbed a slice of cheese from the cutting board and placed it onto the hamburger patty. With same gloved hands, they grabbed 2 slices of bread from a bag, brushed butter on them, and placed them on the griddle. DM added sliced cheese on top of the bread using the same gloved hands. DM opened the fridge with same gloved hands and grabbed the bag of lettuce, bag of onions, bag of tomatoes, and pickle jar and placed them on the counter. With same gloved hands, DM removed lettuce from the bag, removed onion from the bag, removed tomato from the bag, and added them to a plate. DM used a spoon to remove pickles from jar. DM opened the fridge with same gloved hands and returned to the prep counter to add a baked potato to a plate with same gloved hands. An interview with DM on 5/20/2026 at 8:19 AM confirmed that the expectation for washing hands is 20 seconds. DM confirmed hand washing during meal prep did not meet recommended length of time to wash. DM confirmed that gloves should be changed when touching other items or finishing projects. Confirmed that gloves should have been changed more often, especially when DM was making alternative meals.

Licensure Reference Number 175 NAC 12-006.18(A)Based on record review and interview, the facility failed to ensure 3 of 5 sampled residents (Residents 14, 21, 25) had received or declined COVID-19 (coronavirus disease 2019, a highly contagious respiratory illness caused by the SARS-CoV-2 virus) immunizations as required. The facility identified a census of 32 residents. A. Record review of Resident 14's face sheet revealed they were admitted to the facility on [DATE]. Record review of Resident 14's Electric Medical Record (EMR) revealed no evidence of Resident 14 receiving or refusing the COVID-19 immunization, or being medically ineligible to receive it. B. Record review of Resident 21's face sheet revealed they were admitted to the facility on [DATE]. Record review of Resident 21's EMR revealed no evidence of Resident 21 receiving or refusing the COVID-19 immunization, or being medically ineligible to receive it. C. Record review of Resident 25's face sheet revealed they were admitted to the facility on [DATE]. Record review of Resident 25's EMR revealed no evidence of Resident 25 receiving or refusing the COVID-19 immunization, or being medically ineligible to receive it. An interview on 5/21/26 at 9:07 AM with the Director of Nursing revealed the facility documented the immunizations for each resident in the EMR when residents received those immunizations at the facility. The interview revealed the facility did not document the immunizations received outside the facility in the EMR or have COVID-19 immunizations/declinations documented for Residents 14, 21, and 25.

Licensure Reference Number 175 NAC 12-006.18(A)Based on record review and interview, the facility failed to ensure 3 of 5 sampled residents (Residents 14, 21, 25) had received or declined influenza and pneumococcal immunizations as required. The facility identified a census of 32 residents. A. Record review of Resident 14's face sheet revealed they were admitted to the facility on [DATE]. Record review of Resident 14's Electric Medical Record (EMR) revealed no evidence of Resident 14 receiving or refusing the Pneumococcal immunization, or being medically ineligible to receive it. B. Record review of Resident 21's face sheet revealed they were admitted to the facility on [DATE]. Record review of Resident 21's EMR revealed no evidence of Resident 21 receiving or refusing the pneumococcal immunization, or being medically ineligible to receive it. C. Record review of Resident 25's face sheet revealed they were admitted to the facility on [DATE]. Record review of Resident 25's EMR revealed no evidence of Resident 25 receiving or refusing the pneumococcal immunization, or being medically ineligible to receive it. Further record review of Resident 25's EMR also revealed no evidence of influenza immunization, education, or refusal for the most recent influenza season. Interview with [NAME] President of Operations (VPO) on 5/21/2026 at 11:30 AM confirmed that the facility did not have any vaccination records for Resident 25. An interview on 5/21/26 at 9:07 AM with the Director of Nursing revealed the facility documented the immunizations for each resident in the EMR when residents received those immunizations at the facility. The DON revealed they did not document the immunizations received outside the facility in the EMR or have influenza or pneumococcal immunizations/declinations documented for Residents 14, 21, and 25.

Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview, the facility failed to ensure the consultant pharmacist completed a Medication Regimen Review every month as required for 3 of 5 sampled residents (Residents 2, 6, and 25 ). The facility identified a census of 32.Findings Are: Record review of a facility policy dated 11/2022 labeled Medication Regimen Review revealed the following information: - The requirements associated with the Medication Regimen Review (MRR) apply to all residents, whether short or long stay - The pharmacist shall document, either manually or electronically, that each medication regimen review has been completed - Each MRR shall be signed by the pharmacist - The consultant pharmacist shall schedule at least one monthly visit to the facility and shall allow for sufficient time to complete all required activities. A. A record review of Resident 2's admission Record dated 5/20/2026 revealed Resident 2 was admitted to the facility on [DATE] and had the following diagnoses: -Hyperlipidemia (high cholesterol) -Hypertension (high blood pressure) -Type 2 diabetes mellitus (chronic condition characterized by insulin resistance and high blood sugar levels) -Unspecified dementia (condition characterized by a decline in cognitive function, affecting memory, thinking, behavior and the ability to perform everyday activities) -Obstructive and reflux uropathy (blockage in the urinary system that prevents urine from flowing through the ureters) -Paroxysmal atrial fibrillation (episodes of a fast, chaotic heart rhythm) A record review of Resident 2's medication list dated 5/19/2026 revealed the following active medication orders: -Apixaban (a prescription medication used to thin blood to prevent strokes and treat blood clots) -Seroquel (a prescription medication used to treat various mental health conditions) A record review conducted on 5/20/2026 of Resident 2's electronic medical records (EMR) revealed there was no evidence of any medication regimen reviews being completed in 2025 or 2026. B. A record review of Resident 6's admission Record dated 5/20/2026 revealed Resident 6 was admitted to the facility on [DATE] and had the following diagnoses: -Hypertensive heart disease without heart failure (a condition that arises from the chronic effects of high blood pressure) -Hyperlipidemia (high cholesterol) -Hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone) -Gastro-esophageal reflux disease (GERD) (a chronic condition where stomach acid flows back into the esophagus) -Major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities and various emotional and physical problems) -Iron deficiency anemia (when the body lacks sufficient iron which is essential for producing hemoglobin, a protein in red blood cells that carries oxygen) -Type 2 diabetes mellitus (chronic condition characterized by insulin resistance and high blood sugar levels) -Bipolar disorder (a mental health condition characterized by significant mood swings) A record review of Resident 6's medication list dated 5/21/2026 revealed the following active medication orders: -Abilify (a prescription medication used to treat mental health conditions including bipolar disorder) -Insulin lispro (injectable prescription medication used to manage blood sugar levels in individuals with diabetes) -Fluoxetine (prescription medication used to treat various mental health conditions) -Glucagon (prescription medication crucial in regulating blood glucose levels) -Humalog (fast-acting injectable prescription medication used to manage blood sugar levels in individuals with diabetes) -Insulin glargine (long-acting injectable prescription medication used to manage blood sugar levels in individuals with diabetes) -Insulin detemir (long-acting injectable prescription medication used to manage blood sugar levels in individuals with diabetes) -Levothyroxine (prescription medication used to restore normal thyroid hormone levels) -Midodrine (prescription medication used to treat low blood pressure) -Insulin aspart (fast-acting injectable prescription medication used to manage blood sugar levels in individuals with diabetes) -Ozempic (prescription medication used to manage Type 2 Diabetes Mellitus) -Risperdal (prescription medication used to treat mental health conditions including bipolar disorder) -Insulin degludec (long-acting injectable prescription medication used to manage blood sugar levels in individuals with diabetes) -Dulaglutide (prescription medication which helps the pancreas release insulin with blood sugar levels are high) -Wellbutrin (prescription medication used to treat major depressive disorder) A record review conducted on 5/20/2026 of Resident 6's electronic medical records (EMR) revealed a medication regimen review had been completed by the pharmacist on 2/9/2026 and on 3/16/2026. There was no evidence in the EMR of any additional medication regimen reviews being completed in 2026. C. A record review of Resident 25's admission Record dated 5/20/2026 revealed Resident 25 was admitted on [DATE] and had the following diagnoses: -Essential hypertension (high blood pressure) -Benign prostatic hyperplasia (BPH) (enlarged prostate – an accessory gland of the male reproductive system) -Obstructive sleep apnea (common sleep disorder characterized by repeated interruptions in breathing during sleep) -Hyperlipidemia (high cholesterol) -Polymyalgia rheumatica (an inflammatory condition that causes pain and stiffness in the muscles) A record review of Resident 25's medication list dated 5/21/2026 revealed the following active medication orders: -Fentanyl transdermal patch (opioid pain medicine used to treat moderate to severe chronic pain) -Levothyroxine (prescription medication used to restore normal thyroid hormone levels) -Hydrocodone-acetaminophen (an opioid pain reliever used to relieve moderate to severe pain) -Mirtazapine (prescription medication used to treat major depressive disorder) A record review conducted on 5/20/2026 of Resident 25's electronic medical records (EMR) revealed a medication regimen review had been completed by the pharmacist on 3/1/2026 and on 4/27/2026. There was no evidence in the EMR of any additional medication regimen reviews being completed for Resident 25 in 2026.

Based on record review and interview, the facility failed to ensure 1 of 5 sampled residents' (Resident 14) medication regimens were free from unnecessary antibiotics. The facility identified a census of 32 residents. Record review of Resident 14's face sheet revealed they were admitted to the facility on [DATE] and diagnosed with Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), constipation (a problem with passing stool infrequently or because it is hard), moderate intellectual disabilities (limitation in intellectual function, understanding and use of language, and adaptive behavior), chronic kidney disease, and history of urinary tract infections.A record review of Resident 14's physician orders revealed an order for Bactrim (sulfamethoxazole-trimethoprim, an antibiotic) 400-80 milligrams by mouth, once a day, ordered for personal history of urinary tract infections, dated 5/02/2026.A record review of Resident 14's Medication Administration Record (MAR) for May 2026 (printed on May 19, 2026) revealed Resident 14 had received the 5/2/26 Bactrim order daily, beginning on 5/3/26. Resident 14 received Bactrim on 5/1/26 and 5/2/26 to fulfill an order that started 10/2/25 (the same dose size, schedule, and indication).A record review of Resident 14's MAR for April 2026 confirmed the resident received Bactrim daily during April for the same order which was dated 10/2/25.A record review of a facility document titled, Pathology services, subtitled 'Urine culture,' dated 10/11/25 revealed a laboratory report for Resident 14's urine sample which was collected on 10/8/25, with final urine culture results on 10/11/25. Resident 14's urine culture resulted in growth of the bacteria Escherichia coli greater than 100,000 colony forming units per milliliter. The report also included which antibiotics the organism was susceptible and resistant to. The organism was resistant to Bactrim, meaning the bacteria in Resident 14's urine was resistant to being killed in the laboratory test by Bactrim, to the mathematical degree reported.An interview on 5/20/26 at 3:27 PM with the Director of Nursing (DON) confirmed Resident 14 was on long-term antibiotic therapy for a history of urinary tract infections. The DON stated the order was received from Resident 14's urologist along with an order for oral Vitamin C, and the facility was unable to provide any documentation of the provider's rationale for continuing the antibiotic, or that the provider was aware in October that the bacteria in Resident 14's urine was resistant to the antibiotic.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview, record review, the facility failed to ensure oxygen tubing was maintained in a clean and sanitary manner, changed and dated according to physician orders and facility policy to prevent the potential for infection for 1 (Resident 30) of 5 sampled residents. The facility identified a census of 32 residents.Findings Are: Record review of facility policy titled Oxygen Usage Policy with revision date of January 2022 revealed under Care of Equipment section, item number 5 titled oxygen tubing, the policy read to change tubing and mask/cannula at least every two weeks and change tubing if visibly soiled or if cannula/mask becomes contaminated. Record review of Resident 30's physician order dated 7/9/2025 reveals the resident is to be administered oxygen at 2 liters per minute to maintain oxygen saturation above 90%. The resident also had an order to change their oxygen tubing every two weeks and to ensure the tubing was dated. Observations on 5/18/2026 at 10:27 AM, 11:35 AM, 12:41 PM, 1:44 PM and 2:51 PM revealed Resident 30 was not in their room, and their oxygen tubing nasal cannula was observed draped over the resident's bed. No date was noted on the tubing. Observations on 5/19/2026 at 8:22 AM, 9:55 AM, 10:50 AM, 11:48 AM, 12:35 PM, and 1:42 PM revealed Resident 30 was not in their room, and their oxygen tubing nasal cannula was observed lying across the resident's bed with no date noted on the tubing. Observations on 5/20/2026 at 8:01 AM, 9:15 AM, 10:42 AM, 11:50 AM, 12:51 PM and 1:44 PM revealed Resident 30 was not in their room, and their oxygen tubing nasal cannula was observed lying across the resident's bed with no date noted on the tubing. An interview on 5/20/2026 at 1:42 PM, Nurse Aide (NA)-D confirmed the placement of Resident 30's oxygen tubing.

Licensure Reference Number 175 NAC 12-006.09 (J)(iii)Based on observation, record review, and interview, the facility failed to ensure 2 of 2 sampled residents (Residents 14 and 22) received hydration to meet their daily needs. The facility identified a census of 32 residents.Findings are: Record review of a facility policy titled, Resident hydration and dehydration prevention policy, last revised March 2019, revealed the facility would provide adequate hydration, and prevent and treat dehydration, which included providing and encouraging intake of bedside, snack, and mealtime fluids on a daily and routine basis as a part of daily care. A. Record review of Resident 14's face sheet revealed they were admitted to the facility on [DATE] and diagnosed with Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), constipation (a problem with passing stool infrequently or because it is hard), moderate intellectual disabilities (limitation in intellectual function, understanding and use of language, and adaptive behavior), chronic kidney disease, and history of urinary tract infections. A record review of Resident 14's physician orders revealed they had a regular diet for dysphagia (difficulty swallowing) with puree food texture and nectar-consistency thickened liquids, beginning on 2/25/2025. Record review of Resident 14's most recent Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) in section GG (Functional Abilities and Goals) dated 2/6/26 revealed Resident 14 used a wheelchair and was dependent (the helper does all of the effort, the resident does none of the effort, or the assistance of 2 or more helpers is required) for eating and all other activities of daily living. Record review of Resident 14's undated care plan revealed the following directions: Resident 14 required extensive assistance from 1 staff to eat, initiated on 2/28/2025. Encourage good nutrition and hydration to promote healthier skin, initiated on 2/26/2025. Encourage fluids during the day to promote prompted voiding responses, initiated on 1/04/2026. Observations revealed Resident 14 did not have a drinking cup or fluids available to drink in their room at the following times: On 5/18/2026 at 2:05 PM, Resident 14 was in their room, with no drinking water or cup within reach. On 5/19/2026 at 3:02 PM, Resident 14 was in bed awake with their hand behind their head, no water or other fluid or cup nearby. Continuous observation until 3:23 PM revealed no staff entered Resident 14's room. On 5/20/2026 at 10:20 AM, Resident 14 was sitting in a wheelchair in their room, no water, other fluid, or cup present in the room. On 5/20/2026 at 1:40 PM, Resident 14 was sitting in a wheelchair in their room, no water, other fluid, or cup present in the room. On 5/20/2026 at 3:04 PM, Resident 14 was in bed with the room darkened, no cup or fluids available in their room. An interview on 5/20/26 at 3:06 PM with the Director of Nursing (DON) confirmed Resident 14 was served fluids at mealtimes, and that they were able hold a cup but were not able to use a straw. The interview also revealed that Resident 14 was expected to have fluids in their room to meet their daily needs. The interview revealed they were not aware Resident 14 did not have fluids available to drink in their room and confirmed they were not receiving enough fluids. B. Record review of Resident 22's census data revealed the resident was admitted to the facility on [DATE]. A record review of Resident 22's Diagnosis List revealed the following diagnoses: -A diagnosis of Unspecified Dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior) was added on 11/11/2024. -A diagnosis of Down Syndrome (a genetic condition where a person is born with an extra copy of chromosome 21. This can affect how their brain and body develop) was added on 11/11/2024. -A diagnosis of Esophageal Obstruction (narrowing or blockage of the swallowing tube. It frequently leads to progressive difficulty swallowing) was added on 11/11/2024. -A diagnosis of Gastro-Esophageal Reflux Disease without Esophagitis (GERD, a chronic digestive condition where stomach acid frequently flows back into the esophagus [the tube connecting your mouth and stomach] but it doesn't cause any damage to the esophagus) was added on 11/11/2024. Record review of Resident 22's quarterly MDS completed on 4/21/2026 revealed the Staff Assessment for Mental Status determined that Resident 22's ability to make decisions regarding tasks of daily life was severely impaired, and they never/rarely made decisions. Resident 22 was dependent (helper does all the effort) for eating and bringing food and/or liquid to the mouth. Resident 22 requires the use of a wheelchair for mobility with maximal assistance to get around in the wheelchair. Resident 22 had a mechanically altered diet (require changes in texture of food or liquids). A record review of Resident 22's Physician Orders revealed an order for Regular diet, dysphagia puree texture, regular consistency started on 11/11/2024. Record review of Resident 22's care plan dated 5/11/2026 revealed a focus that the resident has bladder incontinence r/t dementia, impaired mobility, inability to communicate needs, initiated and revised on 1/3/26. An intervention for this focus included encourage fluids during the day to promote prompted voiding responses which was initiated on 1/3/26. A focus of Diet/Eating: I require assistance in eating was initiated on 2/10/25. Record review of the task labeled Nutrition – Breakfast - Amount eaten under Question 2 – Amount of fluids consumed in ccs/ml (cubic centimeters/milliliters) for dates 4/22/2026 through 5/21/2026 revealed 3 days of 0 mls consumed, 5 days of 20-100 mls consumed, 16 days of 120-200 mls consumed, and 2 days of 300 mls consumed. The task also revealed there was 1 day marked Resident Not Available, 1 day marked Resident Refused, and 2 days marked Not Applicable. Record review of the task labeled Nutrition – Lunch - Amount eaten under Question 2 – Amount of fluids consumed in ccs/ml for dates 4/22/2026 through 5/20/2026 revealed 4 days of 0 mls consumed, 17 days of 200-300 mls consumed, and 6 days of 370-480 mls consumed. The task revealed there was 1 day marked Not Applicable. Record review of the task labeled Nutrition – Dinner - Amount eaten under Question 2 – Amount of fluids consumed in ccs/ml for dates 4/22/2026 through 5/20/2026 revealed 13 days of 0 mls consumed, 10 days of 25-80 mls consumed, 2 days of 120-140 mls consumed, and 2 days of 320-380 mls consumed. The task revealed there was 1 day marked Resident Refused and 2 days marked Not Applicable. An observation on 5/19/2026 at 1:15 PM revealed Nurse Aide (NA)-A was assisting Resident 22 with eating at the dining room table. NA-A picked up a glass of water and brought glass of water to Resident 22's mouth and tipped it for Resident 22 to take a drink. An observation on 5/20/2026 at 8:42 AM revealed Resident 22 being assisted with eating and being given drinks of liquid from a cup with full assistance. An observation on 5/20/2026 at 10:44 AM in Resident 22's room revealed a full pitcher of water, with no ice, on their bedside table. The beside table was along the wall next to Resident 22's room door. This table was across the room and not within Resident 22's reach while in their recliner or bed. An observation on 5/20/2026 at 11:45 AM revealed Resident 22 sitting at the dining room table. They picked up a can of unopened Pepsi, tilting it side to side, and touched the top of can. Resident 22 was unsuccessful in opening the can or having a drink. An observation on 5/20/2026 at 12:38 PM revealed Resident 22 at the dining table being assisted with eating and getting drinks of liquid from a cup with full assistance. An observation on 5/21/2026 at 9:11 AM revealed a full pitcher of water, with no ice, on bedside table. The beside table was along the wall next to Resident 22's room door. This table was across the room from Resident 22's recliner and bed. The bedside table and pitcher were in same spot as prior observation on 5/20/2026 at 10:44 AM. An observation on 5/21/2026 at 2:02 PM revealed Resident 22 sitting in the recliner in their room. There was a full pitcher of water, with no ice, on bedside table which was along the wall next to Resident 22's room door. This table was across the room from Resident 22's recliner and bed. The bedside table and pitcher in same place as in prior observations on 5/20/202 at 10:44 AM and 5/21/2026 at 9:11 AM. An interview with NA-C on 5/21/2026 at 2:04 PM confirmed that Resident 22 required assistance with drinking fluids at mealtimes. NA-C confirmed that Resident 22 could take drinks if the cup is handed to them. An interview with MA-E on 5/21/2026 at 2:15 PM confirmed that Resident 22 needed assistance with picking up cups from the table. MA-E confirmed that staff must hand Resident 22 the cup and set the cup down. MA-E confirmed that Resident 22 doesn't drink any liquids in their room between meals unless someone is in Resident 22's room and can give Resident 22 assistance with getting a drink.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to ensure oxygen concentrators were turned off when not in use for 2 (Residents 30 and 3) of 5 sampled residents to prevent the potential for accidents. The facility identified a census of 32 residents.Findings are: A record review of the American Lung Association website, https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/oxygen-therapy/using-oxygen-safely, oxygen is a safe gas and is non-flammable, however, it supports combustion. Materials burn more readily in an oxygen-enriched environment. In the Store Oxygen Safely section it stated to turn off the oxygen when not in use, don't set the cannula or mask on a bed or chair if the oxygen is turned on. A:Record review of Resident 30's physician order dated 7/9/2025 revealed the resident was to be administered oxygen at 2 liters per minute to maintain oxygen saturation above 90%. Observation on 5/18/2026 at 10:27 AM, 11:35 AM, 12:41 PM, 1:44 PM and 2:51 PM revealed the oxygen concentrator (a medical device that provides up to 95% pure oxygen for individuals with respiratory conditions and provides continuous flow of oxygen) in Resident 30's room was observed running with oxygen tubing draped over the bed. Resident 30 was observed to be in the common area at these times, therefore oxygen was flowing without being in use by the resident. Observation on 5/19/2026 at 8:22 AM, 9:55 AM, 10:50 AM, 11:48 AM, 12:35 PM and 1:42 PM revealed the oxygen concentrator running in Resident 30's room with oxygen tubing draped over the bed and resident was noted to be in the common area, therefore oxygen was flowing without being in use by the resident. Observation on 5/20/2026 at 8:01 AM, 9:15 AM, 10:42 AM, 11:50 AM, 12:51 PM and 1:44 PM the oxygen concentrator was observed running in Resident 30's room with oxygen tubing draped over the bed while the resident was observed to be in the common area, therefore oxygen was flowing without being in use by the resident. During an interview on 5/20/2026 at 1:42 PM, NA-D confirmed the concentrator was running in Resident 30's room and stated It (the concentrator) runs all the time, and the resident just puts it on whenever they want to wear it in the room. B:Record review of Resident 3's physician order dated 3/20/2026 revealed the resident is to be administered oxygen at 2 liters per minute as needed related to chronic obstructive pulmonary disease (COPD). Observation on 5/18/2026 at 10:27 AM, 11:35 AM, 12:41 PM, 1:44 PM and 2:51 PM revealed the oxygen concentrator in Resident 3's room was observed running with oxygen tubing coiled up and tucked into the handle of the concentrator. Resident 3 was observed to be in the common area at these times, therefore oxygen was flowing without being in use by the resident. Observation on 5/19/2026 at 8:22 AM, 9:55 AM, 10:50 AM, 11:48 AM, 12:35 PM and 1:42 PM the concentrator was observed running in Resident 3's room with the tubing coiled up and tucked into the handle of the concentrator. Resident 3 was noted to be in the common area at these times; therefore, oxygen was flowing without being in use by the resident. Observation on 5/20/2026 at 8:01 AM, 9:15 AM, 10:42 AM, 11:50 AM, 12:51 PM and 1:44 PM Resident 3's oxygen concentrator was observed running in the room with tubing coiled up and tucked into the handle of the concentrator. Resident 3 was noted to be in the common area at these times; therefore, oxygen was flowing without being in use by the resident.

Licensure Reference Number 175 NAC 12-006.09(F) Based on record review, observation, and interview, the facility failed to ensure 1 (Resident 21) of 2 sampled resident's care plan accurately reflected their physical mobility and psychosocial care, and 1 (Resident 25) of 2 sampled resident's care plan accurately reflected their physical mobility and activities of daily living (ADLs). The facility identified a census of 32 residents. Findings are: Record review of a facility policy titled, Care planning, last revised March 2019, revealed the residents' care plans should be updated between care conferences to reflect current care needs as changes occur. A. A record review of Resident 21's admission record dated 5/21/26 revealed an original admission date of 10/17/2025. The admission record revealed the following relevant diagnoses with onset dates: -Meniere's Disease, unspecified ear (a chronic inner ear disorder caused by an abnormal buildup of fluid, that causes sudden severe vertigo, hearing loss, ringing in the eat and a feeling of aural fullness or pressure) dated 10/17/25, -Pain in right shoulder dated 10/17/25, -Pain in left knee dated 10/17/25, -Dizziness and giddiness dated 10/17/25, -Other chronic pain dated 10/17/25, -Anxiety disorder dated 2/16/26, and -Other reduced mobility dated 10/17/25. Record review of Resident 21's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 4/14/26 revealed Section GG that the resident was dependent on staff for toileting hygiene, and required partial/moderate staff assistance for chair/bed-to-chair and toilet transfers, as well as for going from sitting to standing. An observation made at 8:28AM on 5/19/26 revealed staff assisting Resident 21 with toileting hygiene in bed without offering to bring the resident to the toilet. Nurse Aid (NA)-A and NA-F donned gowns and gloves and then knocked on the resident's door, announcing themselves by saying Nursing before entering the residents' room. NA-A began asking the resident how they were feeling. Both staff members then began removing the blanket from Resident 21. NA-F then grabbed a package of wipes, then both staff members proceeded to remove the resident's brief and perform perineal care. Staff then assisted Resident 21 to roll side to side to remove the soiled brief and pads and replace them with clean ones. After securing a clean brief on the Resident, the staff members turned the resident to their right side and placed a pillow underneath the resident's left hip to relieve pressure. Both staff members then worked to replace the resident's blanket and adjusted the head of the bed to the resident's comfort. An interview at 3:20 PM on 5/18/2026 with Resident 21 confirmed that upon admission to the facility they were able to walk to and from the bathroom with a walker, and they were no longer able to do that. Resident 21 also confirmed they require the use of a Hoyer lift for all transfers. An additional interview at 9:49 AM on 5/20/26 with Resident 21 confirmed that they had only gotten out of bed with the use of a Hoyer lift for baths and a few other times to sit in their recliner since their return from the hospital. Resident 21 confirmed that they would like to get out of bed more often but that it is stressful to get into the Hoyer lift because they have a fear of falling due to history of falling and Meniere's disease that causes dizziness. Resident 21 also confirmed that they had a goal of being able to walk to and from the bathroom as they were able to before. A record review of Resident 21's undated care plan revealed a last review date of 5/19/2026. Resident 21's care plan revealed the following focus points and interventions with date initiated: -Focus: Impaired Physical Mobility. Interventions: Determine level of needed assistance based on Activities of Daily Living (ADL) /Instrumental Activities of Daily Living (IADLs) evaluation dated 10/24/2025. Encourage use of prescribed assistive devices, dated 10/24/2025. -Focus: The resident has an ADL self-care performance deficit related to activity intolerance, fatigue, and impaired balance dated 01/19/2026. Interventions: the resident requires limited assistance x1 staff for toileting dated 01/19/2026, the resident uses a walker with stand-by assistance to maximize independence with transferring dated 01/19/2026. Continued record review of Resident 21's undated care plan revealed no information reflecting their current need for two staff, maximum assistance for toileting hygiene or their need for the Hoyer lift for transfers. Further record review of Resident 21's MDS dated [DATE] revealed the resident was taking antidepressant medication. Record review of Resident 21's Progress Note dated 4/19/26 and labeled 'Psychotropic meds' revealed an order for Buspar 7.5 milligrams (mg) two times a day (B.I.D) related to anxiety. Resident 21 is having increased anxiety, relates fear of falling when we reposition (gender). staff is giving as needed (PRN) meds routinely. Continued record review of Resident 21's care plan revealed no focus listed to psychosocial needs or preferences/interventions related to their fears of falling. The care plan also contained no evidence of information about the resident's antidepressant or antianxiety medication usage, indications, or clinical rationales. An interview at 11:18 AM on 5/20/26 with the Director of Nursing (DON) confirmed that Resident 21's care plan was last reviewed on 5/19/26 and the next review would be on 8/11/26. The DON confirmed that Resident 21's care plan revealed that Resident 21's ADL's and transfers were listed as a 1x assist from staff, and the resident was not care planned for Hoyer lifts and 2 or more staff assists with cares. At 11:44 AM during the same interview, the DON confirmed the resident did not have any information listed in the care plan regarding psychosocial needs, behaviors, or necessity of Anti-Anxiety/Anti-Depressant medications and there was only information regarding monitoring for side effects of these medications. B. Record review of Resident 25's face sheet revealed they were admitted to the facility on [DATE] and diagnosed with urine retention, history of falls, lumbar vertebral compression fracture (fracture of a bone in the lower spine), and polymyalgia rheumatica (an inflammatory condition that causes muscle pain and stiffness, especially in the shoulders, neck, and hips). Record review of an untitled facility document dated 1/8/26 revealed an incident summary for Resident 25 following an unwitnessed fall that took place 1/2/26. The document revealed Resident 25 was transferred to the hospital following the fall then transferred to a hospital in Denver for additional care. The record also revealed Resident 25 was found to have a fractured hip and pelvis. Record review of Resident 25's undated care plan revealed the following about their mobility and activities of daily living: -Transfer: The resident uses walker x1-2 assist to maximize independence with transferring, last revised 1/02/2026. -Toilet use: The resident requires moderate assist x1-2 staff for toilet use. Prefers to use a urinal at bedside at night/when in bed, last revised 1/02/2026. -Dressing: The resident requires moderate assistance x1 staff to dress, last revised 1/02/2026. -Bed mobility: The resident requires moderate assistance x1-2 staff for bedmobility (sitting up/lying down), last revised 1/02/2026. -Ambulation: The resident requires moderate assistance by 1-2 staff to walk inroom and bathroom and as necessary, last revised 1/02/2026. Record review of Resident 25's comprehensive MDS dated [DATE], section GG (Functional Abilities and Goals) revealed the following: -Resident 25 used a wheelchair. -Resident 25 was dependent (helper does all the effort) for toileting hygiene. -Resident 25 required partial to moderate assistance for showering and/or bathing. -Resident 25 required substantial/maximal assistance for upper body dressing, were dependent for lower body dressing and putting on or removing footwear. -Resident 25 was dependent for the following rolling left and right in bed, moving from sitting on the edge of the bed to lying down, and from lying down to sitting up. Section H of the same MDS revealed Resident 25 was frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) and always incontinent of bowel. An interview on 5/20/26 at 3:35 PM with the DON revealed Resident 25 did not wish to be in the wheelchair outside of their room, which included not going to the dining room or attending activities. Record review of Resident 25's care plan did not reveal information regarding the resident's preference to eat in their room for every meal. An interview on 5/21/26 at 9:10 AM with the DON revealed Resident 25 was not able to ambulate since they returned to the facility on 2/20/26 and was no longer weight bearing. The interview confirmed Resident 25 required a Hoyer mechanical lift for all transfers. The interview confirmed the care plan should have been updated to include the resident's current care information and preferences.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report an incident of resident-to-resident abuse to the State Agency within 2 hours, and failed to submit an investigation report to the State Agency within 5 working days of the incident. This affected 2 (Residents 1 and 2) of 2 sampled residents. The facility identified a census of 38. A record review of Resident 1's face sheet revealed Resident 1 was admitted on [DATE] with unspecified dementia (a decline in cognitive function affecting memory, thinking, and behavior), weight loss, unsteadiness on feet, and type 2 diabetes mellitus (a metabolic disorder where the body does not regulate blood sugar effectively).A record review of Resident 2's face sheet revealed Resident 2 was admitted on [DATE] with chronic obstructive pulmonary disease (a progressive lung disease that restricts breathing, often caused by smoking), pneumonia (an infection that inflames the air sacs in the lungs), bladder dysfunction, and heart failure.A record review of an untitled facility document revealed the following:An incident of resident-to-resident abuse between Resident 1 and Resident 2 occurred on 2/28/26 at 12:45 PM. Details of the incident were also recorded on the document.The Administrator was notified the 2/28/26 at 1:15 PM.The State agency was notified 3/2/26 at 1:00 PM.The results of the investigation were submitted to the State agency on 3/6/26.A record review of a facility policy titled, Abuse prevention plan, dated February 2023, revealed that the Administrator (ADM), DNS (Director of Nursing Services), or the nursing supervisor, will ensure that a report is filed, an investigation begins immediately, and the reporting takes place. The policy also revealed that an alleged violation of abuse or neglect is reported to the ADM and the State agency immediately.An interview on 3/11/26 at 2:07 PM with the Director of Nursing (DON) revealed they were notified on 2/28/26 by telephone that an incident of abuse had occurred in the facility between Resident 1 and Resident 2. The DON confirmed they notified the ADM by telephone.An interview on 3/11/26 at 2:17 PM with the ADM revealed they were notified on 2/28/26 by telephone that an incident of abuse had occurred between Resident 1 and Resident 2. The interview also revealed that the incident was reviewed on the next working day 3/2/26, and the incident was then reported to the State agency. The interview confirmed this was beyond the 24 hours required by regulation and by the facility policy and should have been reported the day it occurred. The interview also confirmed that the investigative report was submitted on 3/6/26, which was more than the 5 days required.

Licensure Reference 12-006.18 Licensure Reference 12-006.09 (D)2 Based on observations, record review, and interview, the facility failed to implement a water management program as required to monitor and prevent the potential for legionella and other waterborne pathogens. This had the potential to affect all residents that resided within the facility. The facility also failed to perform hand hygiene as required during wound care for 1 (Resident 2) of 1 sampled resident. The facility identified a census of 27. Findings are: A. A record review of a facility policy titled, Water system management program prevention plan for legionella, and dated 2022, revealed in the policy explanation and compliance guidelines section: 2. The maintenance director maintains documentation that describes the facility's water system. 6. Control measures will be applied to address potential hazards at each control point. The measures shall be specified in the water management program action plan. The Sample Water System Surveillance QAA Action Plan section revealed the following: Control point/program area Unoccupied unit, The control measure/action needed was to perform twice weekly flushing of sinks and fixtures with hot and cold water. Control point/program area eyewash station, the control measure/action needed was to run water for 5 minutes weekly. Record review of a facility document titled, Water System Infection Control Risk Assessment, dated 6/6/24, revealed several risk factors/threats of manual faucets, showerheads and hoses, and 4 eyewash stations. Record review of a facility document titled, Water testing and flushing, dated 12/31/24 revealed the chlorine level in 4 tested eyewash stations and selected resident rooms was 0. Each of these rooms was documented as flushed. Record review of a facility document titled, Water testing and flushing, dated 1/7/25 revealed the chlorine level in 4 tested eyewash stations and selected resident rooms was 0. Each of these rooms was documented as flushed. Record review of a facility document titled, Water testing and flushing, dated 2/19/25 revealed the chlorine level in 4 tested eyewash stations and selected resident rooms was 0. Each of these rooms was documented as flushed. An interview with the Nursing Home Administrator (NHA) on 3/4/25 at 9:53 AM confirmed the facility did not have a description of the facility's water systems, and that the facility chlorine levels were tested on [DATE], 1/7/25, and 2/19/25, and found to be zero. The NHA also confirmed the same eyewash stations and randomly selected resident rooms' sinks and toilets were flushed on the three listed dates. There were no additional dates those tasks were performed during the time period. B. Record review of Resident 2's admission record revealed they were admitted on [DATE]. Record review of Resident 2's physician orders revealed an order dated 1/8/25 to perform wound care on Resident 2's right gluteal fold daily. An observation on 3/3/25 at 10:47 AM revealed Licensed Practical Nurse -K (LPN-K) removed the soiled dressing from Resident 2's right buttock area, then removed their gloves. LPN-K put clean gloves on, then put a new dressing onto Resident 2's right buttock. Record review of a facility policy titled, Dressing Clean/Aseptic, last revised in March 2019, revealed that after gloves are removed following the removal of a soiled wound dressing, hand hygiene is necessary (with soap and water or alcohol-based hand sanitizer) prior to putting on new gloves. An Interview on 3/3/25 at 11:08AM with LPN-K confirmed they did not perform hand hygiene after removing a dirty dressing and before applying clean gloves and putting on new dressing.

Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to ensure that 4 of 5 sampled employees had completed at least 12 hours of ongoing training for the year as required. This had the potential to affect all residents who reside within the facility. The facility identified a census of 27. Findings are: A record review the facility's Facility Assessment Tool with a date of 2/26/2025 revealed all training will be completed at least upon orientation, annually, and as needed of at least 12 hours per year. Topics of training included dementia, abuse/neglect, effective communication, resident's rights, infection control, culture changes, and orthopedic special care. A record review of an undated staff list provided by the facility revealed the following: - Medication Aide (MA) - D was hired on 8/19/2010. - Nurse Aide (NA) - A was hired on 7/1/2022. - MA-G was hired on 4/21/2013. - MA-F was hired on 5/3/2022. A record review of MA-D's Training Hours from 8/19/2023-8/19/2024 revealed MA-D had a total of 0.5 hours of ongoing training. MA-D had 0 hours of ongoing training on dementia or abuse/neglect. A record review of NA-A's Training Hours from 7/1/2023-7/1/2024 revealed a total of 4.95 hours of ongoing training. Additional record review revealed NA-G had completed duplicate courses of Teepa Snow(Dementia training): Dementia 101 for 0.25 hours. Therefore, NA-G had completed a total of 4.7 hours of ongoing training. A record review of MA-G's Training Hours from 4/21/2023-4/21/2024 revealed MA-G had a total of 9 hours of ongoing training. A record review of MA-F's Training Hours from 5/3/2023-5/3/2024 revealed MA-F revealed a total of 15.7 hours of ongoing training. Additional record review revealed MA-F had completed duplicate courses of Dementia Care, Hazardous Chemicals, Preventing/Managing Accidents, Safe Patient Handling, and Tuberculosis Basics for a total of 4 duplicate hours. Therefore, MA-F had completed a total of 11.7 hours of ongoing training. An interview on 3/3/2025 at 1:45 PM with the Administrator confirmed NA-A and MA-F had completed duplicate courses and MA-D had not completed training for the year on dementia or abuse/neglect for the year. The Administrator also confirmed MA-D, NA-A, MA-G, and MA-F had not completed at least 12 hours of ongoing training for the year as required.

Licensure Reference 175 NAC 12-006.04(B)(i) Based on record reviews and interview, the facility failed to ensure 5 of 5 sampled employees had completed initial orientation training within 2 weeks after beginning employment that included resident rights and emergency procedures as required. This had the potential to affect all residents who resident within the facility. The facility identified a census of 27. Findings are: A record review the facility's Facility Assessment Tool with a date of 2/26/2025 revealed training will be completed at orientation, annually, and as needed. Trainings will include effective communication, resident right's abuse/neglect, infection control, and culture change. A record review of an undated staff list provided by the facility revealed the following: - Cook-H was hired on 11/7/2024. - Dietary Aide (DA) - I was hired on 1/7/2025. - The Director of Nursing (DON) was hired on 2/16/2025. - Nurse Aide (NA) - B was hired on 1/6/2025. - NA-C was hired on 12/2/2024. A record review of Cook-H's personnel file documents provided by the facility revealed no evidence initial orientation training had been completed. A record review of DA-I's personnel file documents provided by the facility revealed no evidence initial orientation training had been completed. A record review of the DON's Training Hours dated 3/3/2025 revealed no evidence initial orientation training regarding resident rights and emergency procedures had been completed. A record review of NA-B's Training Hours dated 3/3/2025 revealed no evidence initial orientation training regarding resident rights and emergency procedures had been completed. A record review of NA-C's Training Hours dated 3/3/2025 revealed no evidence initial orientation training regarding resident rights and emergency procedures had been completed. An interview on 3/3/2025 at 4:20 PM with the Administrator confirmed no initial orientation had been completed by Cook-H or DA-I and no initial orientation on resident rights or emergency procedures had been completed by the DON, NA-B, or NA-C within two weeks of hire as required.

Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to ensure that 4 of 5 sampled employees had completed at least 12 hours of ongoing training in the year which included dementia management training and resident abuse prevention training. This had the potential to affect all residents who reside within the facility. The facility identified a census of 27. Findings are: A record review the facility's Facility Assessment Tool with a date of 2/26/2025 revealed all training will be completed at least upon orientation, annually, and as needed of at least 12 hours per year. Topics of training included dementia, abuse/neglect, effective communication, resident's rights, infection control, culture changes, and orthopedic special care. A record review of an undated staff list provided by the facility revealed the following: - Medication Aide (MA) - D was hired on 8/19/2010. - Nurse Aide (NA) - A was hired on 7/1/2022. - MA-G was hired on 4/21/2013. - MA-F was hired on 5/3/2022. A record review of MA-D's Training Hours from 8/19/2023-8/19/2024 revealed MA-D had a total of 0.5 hours of ongoing training. MA-D had 0 hours of ongoing training on dementia or abuse/neglect. A record review of NA-A's Training Hours from 7/1/2023-7/1/2024 revealed a total of 4.95 hours of ongoing training. Additional record review revealed NA-G had completed duplicate courses of Teepa Snow(Dementia training): Dementia 101 for 0.25 hours. Therefore, NA-G had completed a total of 4.7 hours of ongoing training. A record review of MA-G's Training Hours from 4/21/2023-4/21/2024 revealed MA-G had a total of 9 hours of ongoing training. A record review of MA-F's Training Hours from 5/3/2023-5/3/2024 revealed MA-F revealed a total of 15.7 hours of ongoing training. Additional record review revealed MA-F had completed duplicate courses of Dementia Care, Hazardous Chemicals, Preventing/Managing Accidents, Safe Patient Handling, and Tuberculosis Basics for a total of 4 duplicate hours. Therefore, MA-F had completed a total of 11.7 hours of ongoing training. An interview on 3/3/2025 at 1:45 PM with the Administrator confirmed NA-A and MA-F had completed duplicate courses and MA-D had not completed training for the year on dementia or abuse/neglect for the year. The Administrator also confirmed MA-D, NA-A, MA-G, and MA-F had not completed at least 12 hours of ongoing training for the year as required.

Licensure Reference Number 175 NAC 12-006.09(F)(i) Based on interview and record review the facility failed to develop and implement a baseline care plan within 48 hours of admission for 3 (Resident 35, 27, and 23) of 4 sampled residents. The facility identified a census of 27. The findings are: A record review of a Baseline Care Plan Policy dated 4/23/2019 revealed the baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including but not limited to: i. Initial goals based on admission orders ii. Physician orders iii. Dietary orders iv. Therapy services v. Social Services vi. PASARR recommendations, if applicable. A. A record review of an admission face sheet for Resident 35 revealed an admitted [DATE]. Resident 35 was admitted to the facility for Palliative Care (care that is focused on symptom control, pain relief, and quality of life). A record review of an admission facesheet for Resident 35 revealed the following pertinent diagnoses: 1. Atrial Fibrillation- a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly. 2. Osteomyelitis- an infection of the bone that causes inflammation and destruction of bone tissue. 3. Neuralgia and Neuritis- severe, sharp, or burning pain that follows the path of a specific nerve and inflammation of the nerve. A record review of a Care Plan for Resident 35 revealed a focus area of Resident 35 being admitted to facility for comfort cares with an initiation date of 1/30/25. An advanced directives focus area was initiated on 1/30/25. An emergency and evacuation preference focus area was initiated on 1/30/25. Focus areas including mobility, diet/nutrition, pain, catheter, skin, and mood were noted to have an initiation date of 2/2/25. An interview with the Social Services Director (SSD) on 3/3/25 at 3:45 PM revealed the process for developing the care plan involves all departments inputting the data pertaining to their own department. This process begins on the day of admission. The SSD stated the facility does not incorporate the use of a separate baseline care plan while developing the comprehensive care plan. The SSD confirmed that a baseline care plan was being developed as part of the comprehensive care plan and had not been developed to include mobility, diet/nutrition, pain, catheter, or skin focus areas as required in the regulatory time frame. An interview with the Director of Nursing (DON) on 3/3/25 at 4:00 PM revealed that the nursing portion is electronically pulled to the care plan based off of the admission assessments that are performed by floor nurses the day of admission. If those assessments are late or are not locked, they do not pull over in time. The DON confirmed that the facility does not utilize a baseline care plan separately from the comprehensive care plan. The DON confirmed that the Nursing Departments' portion of the care plan was not initiated until 2/2/25. 51122 B. Record review of Resident 23's medical record revealed that Resident 23 was admitted on [DATE] with a primary diagnosis of diabetes type 2. A record review of Resident 23's care plan (including revision history in the electronic medical record) revealed the earliest entry was made on 2/11/25. An interview on 3/3/25 at 1:45 PM with the Registered Nurse Clinical Coordinator (RN-CC) revealed that the facility used Point Click Care (healthcare technology platform) for the care plans from the day of admission, and that there was not any other paper or electronic care plan used during a resident's first 48 hours in the facility. An interview on 3/4/25 at 11:59 AM with Director of Nursing (DON) confirmed there was not a baseline care plan for Resident 23 and there should have been. C. A record review of Resident 27's medical record revealed that Resident 27 was admitted on [DATE] with diagnoses of dementia (group of symptoms affecting memory, thinking and social abilities) and a femur (thigh bone) fracture. A record review of Resident 27's care plan revealed the earliest entry was made on 10/1/24. An interview on 3/4/25 at 11:59 AM with the DON confirmed there was not a baseline care plan for Resident 27 and there should have been.

Licensure Reference 175 NAC 12-006.09(H)(vi)(3)(g) Based on interview and record review the facility failed to ensure that monitoring during the course of their acute illness was documented for 3 (Resident 3, 8, and 18) of 3 sampled residents . The facility identified a census of 27. The findings are: A record review of a Change of Condition Policy dated 3/2019 revealed on page 4 (B.)- The Nurse will record information relative to changes in the residents condition or status in the resident's medical record. The residents' condition is assessed and reported in a timely manner either verbally or written if the resident experiences signs and symptoms of infection. A. A record review of Resident 18's admission face sheet revealed an admitted [DATE]. A record review of Resident 18's pertinent diagnoses include: 1. Unspecified dementia (a condition where cognitive decline and memory loss occur, but the specific underlying cause cannot be determined). 2. Ventricular Tachycardia (a fast, abnormal heart rhythm). 3. Cardiomyopathy (disorder that affects the heart muscles ability to pump effectively). A record review of a quarterly Minimum Data Set (MDS-a standardized assessment of the health of residents in nursing homes) dated 1/3/25 revealed in Section C, a Brief Interview for Mental Status (BIMS- a screening tool that assesses a person's cognitive impairment on a score of 0/15) score of 9/15, indicating that Resident 18 had moderate cognitive impairment. Section GG indicated that Resident 18 used a walker for ambulation and received stand-by or touching assistance from staff for dressing, undressing, hygiene, and toileting. A record review of Resident 18's current physician orders revealed an order for Doxycycline (an antibiotic) 100 milligrams (mg) by mouth twice a day for seven days related to a recent diagnosis of pneumonia (an infection of the lungs that causes inflammation of the air sacs). A record review of an Admission Note dated 2/24/25 revealed Resident 18 had returned to the facility after a hospital admission. The nursing note revealed Resident 18 was transported to the hospital via Resident 18's daughter over the weekend due to Resident 18 having a recent diagnosis of influenza A (a type of respiratory virus) and not recovering well. Resident 18 was diagnosed with pneumonia and was admitted to the hospital for treatment. A record review of nursing notes prior to 2/24/25 revealed no documented evidence of Resident 18's transfer to the hospital. There was no documented evidence of a nursing assessment or decision to send Resident 18 for emergent evaluation and treatment. An interview on 2/26/25 at 2:30 PM with the DON revealed that the expectation of the nurse when a change in condition occurs is to do a full assessment of the resident including vital signs and a neurological assessment. That information is to be charted as a nurses note. The nurse is then to call the provider and family with the results of the assessment. The nurse should receive and document any new orders. The DON confirmed there was no documentation regarding Resident 18's transfer to the hospital or their condition or assessment prior to transferrring to the hospital. The DON confirmed that there should have been documentation of Resident 18's condition, results of Resident 18's assessment, and subsequent transfer to the hospital. 49766 B. A record review of an Admission Record indicated the facility admitted Resident 3 on 1/11/2022 with a diagnosis of Dementia and Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs that can cause airflow obstruction and breathing difficulties.) A record review of Resident 3's Care Plan revealed that on 2/19/2025 a care focus area for Resident 3 having Influenza A was initiated. Interventions listed were to encourage fluid intake and monitor and document for signs of dehydration, such as poor skin turgor, dry mucous membranes, slowed capillary refill, increased heart rate, cool dry skin, sunken eyeballs, decreased urinary output, difficulty breathing, or low blood pressure. A record review of Resident 3's Progress Notes from 2/10/2025-2/28/2025 revealed the following: - On 2/10/2025 at 7:06 AM, it was noted that Resident 3 had been up most of the night, hollering out they did not feel good, but was unable to give a description. Resident 3 was noted to have a non-productive cough and congestion without fever. Resident 3 was test for Influenza A at 4:30 AM and tested positive. Resident 3's physician was notified by fax of these results. - There was no evidence of further documentation or assessment between 2/10/2025 and 2/14/2025. - On 2/14/2025 at 9:42 PM, it was noted that Resident 3 continued to have a non-productive cough and congestion, in addition to a sore throat and fatigue. It was also noted that Resident 3 was lethargic (a decrease in consciousness,) pallor (pale skin,) and expiratory wheezing. Oxygen saturation was noted to be 92% without oxygen supplementation, no fever, and normal respirations. The head of bed was raised and fluids were encouraged. There was no evidence that the physician had been notified of Resident 3's condition. - There was no evidence of further documentation or assessment between 2/14/2025 and 2/18/2025. - On 2/18/2025 at 3:52 PM, Resident 3's physician was there to do a monthly medication review and found resident to continue to have wheezing. The physician prescribed a nebulizer treatment. - There was no evidence of further documentation or assessment after 2/18/2025. A record review of Resident 3's Vitals Summary from 2/10/2025-2/28/2025 revealed the following: - Resident 3's temperature was checked on 2/13/2025, 2/15/2025, 2/16/2025, 2/17/2025, 2/18/2025, and 2/23/2025. Resident 3 had a fever on 2/14/2025 and all other temperatures were within normal limits. - Resident 3's respirations were measured on 2/16/2025 and 2/23/2025. Both were within normal range. - Resident 3's oxygen saturation was measured on 2/13/2025, 2/14/2025, 2/15/2025, 2/16/2025, 2/17/2025, 2/18/2025 at 9:45 AM, 2/18/2025 at 9:32 PM, and 2/23/2025. All oxygen saturations were within normal limits, except on 2/14/2025 with a low oxygen saturation of 89% without oxygen supplementation. - Resident 3's blood pressure was measured on 2/16/2025 and 2/23/2025. Both were within normal ranges. An interview on 3/3/2025 at 12:30 PM with the Director of Nursing (DON) revealed during acute illnesses like Influenza A, residents should be monitored through a full assessment with vital signs at least once a shift. The DON confirmed Resident 3 had not been monitored every shift during their acute illness and should have been. C. A record review of an Admission Record indicated the facility admitted Resident 8 on 12/19/2028 with Congestive Heart Failure (a chronic condition where the heart muscle is weakened and cannot pump blood efficiently,) diabetes, and vascular dementia. A record review of Resident 8's Progress Notes from 2/10/2025-2/28/2025 revealed the following: - On 2/10/2025 at 6:21 AM, it was noted that Resident 8 had complaints of a headache and sinus pressure. Resident 8 also had a non-productive cough and no fever. A test for Infleunza A was performed at 4:50 AM and was positive. Resident 9's physician was notified by fax of these results. - There was no evidence of further documentation or assessment between 2/10/2025 and 2/16/2025. - On 2/16/2025 at 1:59 AM, it was noted that Resident 8 continued to have a non-productive cough, in addition to a sore throat and fatigue. Resident 8 had no fever and oxygen saturation was within normal ranges. Resident 8 reported feeling better. - There was no evidence of further documentation or assessment between 2/16/2025 and 2/18/2025. - On 2/18/2025 at 4:06 PM, Resident 8 was seen by their physician for a monthly medication review. Resident 8 continued to have non-productive cough and was prescribed guaifenesin (a medication used to help clear mucus from the chest.) - There was no evidence of further documentation or assessment after 2/18/2025. A record review of Resident 8's Vitals Summary from 2/10/2025-2/28/2025 revealed the following: - Resident 8's temperature was monitored on 2/13/2025, 2/14/2025, 2/15/2025, 2/16/2025, 2/17/2025, 2/18/2025, and 2/23/2025 and all were within normal range. - Resident 8's respirations were monitored on 2/16/2025 and 2/23/2025 and were found to be 20 breaths per minute. - Resident 8's pulse was monitored on 2/16/2025 and 2/23/2025 and were within normal range. - Resident 8's oxygen saturation was monitored on 2/13/2025, 2/14/2025, 2/15/2025, 2/16/2025, 2/17/2025, 2/18/2025, and 2/23/2025 and all were within normal range. An interview on 3/3/2025 at 12:35 PM with the DON revealed during acute illnesses like Influenza A, residents should be monitored through a full assessment with vital signs at least once a shift. The DON confirmed Resident 8 had not been monitored every shift during their acute illness and should have been.

Licensure Reference 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to protect the private health information of 3 (Residents 9, 23, and 32) of 4 sampled residents. The facility identified a census of 27. Findings are: A continuous observation on 2/27/25 from 7:26 AM to 8:00 AM revealed Registered Nurse (RN-J) administering medications in the dining room using a laptop computer mounted on a mobile medication cart. The observation revealed RN-J preparing medications for Resident 32. RN-J took the prepared medications to Resident 32's table, leaving the computer screen open with Resident 32's private health information visible while they walked to the resident and administered the medications. RN-J then returned to the medication cart, marked the medications as administered in the computer and proceeded to the next resident. The observation revealed RN-J preparing medications for Resident 9. RN-J took the prepared medications to Resident 9's table, leaving the computer screen open with Resident 9's private health information visible while they walked to the resident and administered the medications. RN-J then returned to the medication cart, marked the medications as administered in the computer and proceeded to the next resident. The observation revealed RN-J preparing medications for Resident 23. RN-J took the prepared medications to Resident 23's table, leaving the computer screen open with Resident 23's private health information visible while they walked to the resident and administered the medications. RN-J then returned to the medication cart and documented the medications. A record review of a facility document titled, HIPAA health insurance portability and accountability act; privacy policies and procedures, dated 8/1/18, revealed the following statement, It is the policy of Facility to protect the privacy of individual health information and to ensure that such information is used and disclosed appropriately and in accordance with all applicable laws and regulations. A record review of a facility document titled, Resident rights policy, last revised November 2019, revealed the following statement, The resident has a right to personal privacy and confidentiality of his or her personal and medical records. The policy also revealed the resident has a right to secure and confidential personal and medical records. An interview on 2/27/25 at 8:00 AM with RN-J confirmed they did leave the computer screen open with the private health information of Residents 9, 23, and 32 visible to anyone in the vicinity of the cart while they were performing medication administration in the dining room and this shouldn't have happened. RN-J also confirmed this was their usual routine.

Licensure Reference 175 NAC 12-006.09(D) Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) accurately reflected active diagnoses for 1 (Resident 3) of 12 sampled residents. The facility identified a census of 27. Findings are: A record review of a facility policy, MDS Policy with a revision date of March 2019 revealed a the purpose of the policy was to ensure the timeliness and accuracy of all MDS' by ensuring the facility staff followed the guidelines laid out in the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities.) A record review of the RAI Manual with an effective date of 10/1/2023 revealed the following in regarding to Section I: Active Diagnoses under steps for assessment: - Identify which diagnoses are active, noting that active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. - Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses. A record review of an Admission Record indicated the facility admitted Resident 3 on 1/11/2022 with a diagnosis of Dementia (a progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior.) A record review of Resident 3's Medical Diagnosis List as of 2/27/2025 revealed the following: - A diagnosis of a trochanteric fracture (break) of the femur (thigh bone) with a date of 3/6/2023 and without a resolved date. - A diagnosis of the sixth cervical (neck) vertebra fracture with a of 1/11/2022 and without a resolved date. - A diagnosis of the seventh cervical vertebra fracture with a date of 1/11/2022 and without a resolved date. A record review of Resident 3's quarterly MDS with an an Assessment Reference Date (ARD) of 7/22/2024 revealed Hip fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and fractures of the trochanter and femoral neck) and Other Fracture listed under the Active Diagnoses section. A record review of Resident 3's quarterly MDS with an ARD of 10/22/2024 revealed Hip fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and fractures of the trochanter and femoral neck) and Other Fracture listed under the Active Diagnoses section. A record review of Resident 3's annual MDS with an ARD of 1/20/2025 revealed Hip fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and fractures of the trochanter and femoral neck) and Other Fracture listed under the Active Diagnoses section. A record review of Resident 3's medical chart from 7/1/2024 through 2/27/2025 revealed no evidence of current fractures that had a direct effect on Resident 3's current health status, ongoing treatments, or ongoing monitoring. An interview on 3/3/2025 at 12:30 PM with the Assistant Director of Nursing (ADON) confirmed Resident 3's fractures had resolved well over a year ago. An interview on 3/3/2025 at 3:00 PM with the MDS Nurse confirmed Resident 3's MDS' from 7/22/2024, 10/22/2024, and 1/20/2025 were coded incorrectly as active hip fracture and should have been coded as having a history of these fractures.

Licensure Reference 175 NAC 12-006.09(H)(i)(3) Based on record reviews and interviews, the facility failed to provide bathing services during isolation precautions for 1 (Resident 3) of 1 sampled resident. The facility identified a census of 27. Findings are: A record review of a facility policy, ADL Assistance Provided Per Care Plan with a revised date of 9/2022 revealed bathing and showering would be provided as needed based upon the resident's desires, assessment, care plan, and ADL (Activities of Daily Living) assistance deemed necessary. A record review of an Admission Record indicated the facility admitted Resident 3 on 1/11/2022 with a diagnosis of Dementia (a progressive condition marked by the development of multiple cognitive deficits such as memory impairment, aphasia, and the inability to plan and initiate complex behavior.) A record review of Resident 3's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date of 1/20/2025 revealed Resident 3 had severe cognitive impairment. The MDS also revealed Resident 3 was dependent for bathing. A record review of Resident 3's Care Plan revealed on 1/11/2022 a focus area revealing Resident 3 needed assistance with bathing was initiated. A revised intervention on 2/26/2023 revealed Resident 3 needed extensive assistance with bathing. A record review of Resident 3's Progress Note from 2/10/2025 revealed Resident 3 had tested positive for Influenza A and was placed into isolation precautions. A record review of Resident 3's POC Response History (a document that provides a history of documentation from the past 30 days) with a date of 2/27/2025 revealed Resident 3 had a documented bath on 1/29/2025, 2/19/2025, and 2/23/2025. A record review of a Weekly Bath Sheet for the week of 2/2/2025-2/8/2025 revealed on 2/2/2025 and 2/5/2025 that Resident 3 received a bath. A record review of a Weekly Bath Sheet for the week of 2/9/2025-2/15/2025 revealed on 2/9/2025 and 2/12/2025 Resident 3 was marked as in isolation and no bath was given. A record review of a Weekly Bath Sheet for the week of 2/16/2025-2/22/2025 revealed on 2/16/2025 that Resident 3 was marked as in isolation and no bath was given. An interview on 2/27/2025 at 10:35 AM with Nurse Aide (NA) - B revealed the baths are documented on the weekly bath sheets and then later charted in the Electronic Health Record (EHR.) An interview on 3/3/2025 at 10:25 AM with NA-A revealed staff had been instructed not to give residents who were in isolations baths to limit the spread of influenza. NA-A also revealed staff could offer bed baths to residents in isolation which would have been documented on the Weekly Bath Sheets then in the EHR if it had been completed. An interview on 3/3/2025 at 12:30 PM with the Assistant Director of Nursing (ADON) confirmed Resident 3 had not received a bath from 2/5/2025 until 2/19/2025 or for two weeks while they were in isolation. But should have been given a bath after the residents who were not in isolation or offered a bed bath.

Licensure Reference Number 175 NAC 12-006.09D8b Based on observations, record review and interview; the facility failed to implement, evaluate and/or revise nutritional interventions to address ongoing and significant weight loss for 3 (Residents 3, 4 and 27) of 4 sampled residents. The facility census was 34. Findings are: A. Review of a Weight Assessment policy with a revision date of 3/19 revealed it was the policy of the facility to prevent, monitor, and intervene to prevent undesirable weight loss for the residents. The following procedure was identified regarding weight assessment: -staff were to measure the resident's weight on admission, the next day and then weekly thereafter, -the weights were to be recorded in each resident's individual medical record, -any weight change of 5 percent (%) or more since the previous weight would be retaken the next day. If the weight was confirmed, the Registered Dietician (RD) was to be notified in writing, -the RD was to review the weight record by the 15th of the month and evaluate for significant weight changes, and -the threshold for significant unplanned and undesired weight loss would be based on the following criteria: 5% weight loss in 1 month would be considered significant and greater than 5% severe, 7.5% loss in 3 months was significant and greater than 7.5% severe, and 10% in 6 months was significant and weight loss greater than 10% would be considered severe. Interventions to address undesirable weight loss were to be based on the following: -resident choice and preferences, -nutrition and hydration need, -functional factors that may inhibit independence with eating, -environmental factors that could inhibit appetite, -chewing and swallowing abnormalities, -medications, -use of supplements, and -end of life decisions. B. Review of Resident 4's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 2/16/24 revealed diagnoses of chronic pain, anemia, chronic obstructive pulmonary disease (COPD), anxiety, depression and dementia and the resident had a weight of 92 pounds (lbs.). In addition, the assessment indicated the resident had an order for a mechanically altered diet (a type of texture-modified diet for people who have difficulty chewing and swallowing) and required supervision and/or touching assistance with eating and drinking. Resident 4 did not have a condition or a chronic disease that could result in a life expectancy of less than 6 months. Review of Resident 4's current, undated Care Plan revealed the resident had a potential for nutritional problems related to dementia and poor appetite. The following interventions were identified: -provide and serve nutritional supplements (Ensure to be provided twice a day) as ordered, -Registered Dietican (RD) to evaluate and make changes as needed, -monitor intake and record with each meal, -provide total staff assistance as needed with eating/drinking, -provide sippy cups with lids and straws, -resident prefers to have snacks between meals, -provide diet as ordered (no added salt, mechanical soft with thin liquids), and -weight weekly. Review of Resident 4's Weights and Vitals Summary Sheet (form used to document a resident's weight, blood pressure, respiration, temperature, and pulse) revealed the following regarding the resident's weight: -9/27/23 weight was 92 lbs. -10/8/23 weight was 88 lbs. -12/21/23 weight was 85 lbs. (7.6% loss in 3 months) -1/19/24 weight was 82 lbs. -2/5/24 weight was 83 lbs. (9.8% loss in 5 months) Further review of the resident's Weights and Vitals Summary Sheet revealed from 2/6/24 through 4/5/24, there was no further documentation in the electronic medical records of the resident's weights. Review of a Nutritional Risk Screen dated 2/19/24 at 2:17 PM confirmed the Resident 4's most recent, documented weight was 83 lbs. The screen completed by the RD did not identify the residents significant weight loss and no dietary changes were recommended despite the residents ongoing weight loss. Review of handwritten documents titled Weekly Bath Sheet from 2/18/24 to 4/5/24 revealed the following: -received a bath on 2/23/24 with a weight of 84 lbs. -received a bath on 3/1/24 with a weight of 82 lbs. -received a bath on 3/6/24 with a weight of 82 lbs. -received a bath on 3/15/24 with a weight of 84 lbs. -received a bath on 3/29/24 with a weight of 84 lbs. -received a bath on 4/5/24 with a weight of 82 lbs. Review of the resident's meal intakes for the breakfast meal from 3/11/24 through 4/6/24 revealed the following regarding the resident's intakes: -consumed 0-25% on 3/16 and on 4/3/24, -consumed 26-50% on 3/26 and on 3/21/24, and -no documentation of the resident's meal intakes on 3/13, 3/14, 3/17, 3/18, 3/19, 3/23, 3/24, 3/27, and on 3/28/24 (9 out of 25 meals provided). Review of meal intakes for the noon meal from 3/11/24 through 4/6/24 revealed the following regarding meal intakes: -consumed 0-25% on 3/26, 3/29, 3/30, 3/31, 3/16, 3/20, 3/21, 3/22, and 4/4/24 (9 out of 21 meals provided), -consumed 26-50% on 3/12, 3/15, 3/25, 4/1, 4/2, and 4/3/24 (6 out of 21 meals), and -no documentation of the resident's meal intakes on 3/13, 3/14, 3/17, 3/18, 3/19, 3/23, 3/24, 3/27, and 3/28/24 (9 out of 21 days). Review of Resident 4's evening meal intakes from 3/11/24 to 4/4/24 revealed the following: -consumed 0-25% on 3/16, 3/20, 3/21, 3/22, and 4/2/24 (5 out of 21 days), -consumed 26-50% on 3/11, 3/25, 3/30, and 4/1/24 (4 out of 21 meals served), -no documentation of the resident's meal intakes on 3/14, 3/15, 3/18, 3/19, 3/23, 3/24, 3/27, 3/28, 3/31 and 4/4/24 (10 out of the 21 days the meal was offered). Observations of Resident 4 on 4/7/24 at the noon meal revealed the following: -12:15 PM the resident was seated in a tilt-n-space wheelchair (chair with ability to tilt the resident up to 30-60 degrees, while maintaining hip and knee angles at 90 degrees) next to the assisted, dining room table. The resident's chair was tilted approximately 30 degrees and bilateral foot pedals were elevated. A sippy cup with water and a container of Ensure Nutritional Supplement were positioned on the table in front of the resident. The wheelchair had been pushed away from the table, and the resident was unable to access and/or reach the drinks, Resident 4 attempted multiple times to reach out and to grasp the table to pull the wheelchair closer but was unable. -12:30 PM the resident's meal of mashed potatoes with gravy, and ground meat with gravy was served. Resident 4 remained unable to reach the table. -12:35 PM Nurse Aide (NA)-C offered the resident a bite of the mashed potatoes. NA-C then walked away from the resident and proceeded to help with meal intakes for Residents 5, 7 and 15 who were positioned at the same table as Resident 4. NA-C continued to rotate between the residents offering each 1-2 bites of food before continuing to assist the next resident. -12:58 PM the resident was assisted out of the dining room. The resident had consumed only bites of the noon meal but did consume 100% of the Ensure Supplement. During an interview on 4/8/24 at 4:30 PM with the Director of Nursing (DON) confirmed the following: -the resident should have been provided increased and timely assistance with eating/drinking the resident's noon meal on 4/7/24. -the nursing staff were responsible for documenting the resident's meal intakes after each meal. -the facility did not have a qualified Dietary Manager (DM) and the RD was to come to the facility every other week. -the RD was responsible for reviewing the resident's weights and was to notify the nursing staff if a weight loss was identified. -the resident's weights were to be obtained weekly with the resident's bath and then documented in the electronic medical record. -the DON was unaware the resident's weights were not being documented in the electronic medical record and was not aware of the resident's significant weight loss. -the RD would not have had access to the handwritten bathing schedules with the resident's weights and did not identify the resident had no documented weight since 2/5/24 or had a significant weight loss. -there was no documented evidence the RD had provided further assessment and monitoring of the resident's nutritional status and weight loss since the Nutritional Risk Screen completed 2/19/24 at 2:17 PM. -no additional interventions were developed to address the resident's ongoing and significant weight loss. 49263 C. A record review of Resident 27's Admission Record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of Cerebral Infarction due to Thrombosis of Right Middle Cerebral Artery. A record review of Resident 27's MDS, dated [DATE], revealed in Section K that the resident had not had a weight loss and that they were on a therapeutic diet. Section GG revealed that the resident required partial/moderate assistance with eating. A record review of Resident 27's Physician's Orders revealed the resident was on a Consistent Carbohydrate diet and that the resident was not receiving any dietary supplements. The resident also had an order, with a start date of 11/30/2022 that stated to obtain the resident's weight monthly. A record review of Resident 27's undated Care Plan revealed the resident had a goal to have no significant weight loss of 5% in 30 days or 10% in 180 days and interventions to meet this goal included for staff to monitor the resident's intake and to record every meal. On 3/7/2023, a focus was added of I am independent in eating with interventions including I eat in the dining room and I want staff to monitor for changes in my ability to eat independently or safely. There was also an intervention, initiated on 12/14/2022, that stated to weight the resident weekly. A record review of Resident 27's most recent Nutritional Screen Assessment, completed on 3/18/24 by the RD revealed documentation that the resident had not had any weight loss and that the resident's average food intake over the prior 7 days had been 75-100%. A record review conducted on 4/9/24 of Resident 27's Task: Nutrition- Breakfast revealed there was no documentation for 10 of the previous 30 days. The resident consumed less than 50% of their meal on 8 days and there was no alternate food offered according to the documentation. A record review conducted on 4/9/24 of Resident 27's Task: Nutrition- Lunch revealed there was no documentation for 10 of the previous 30 days. The resident consumed less than 50% of their meal on 7 days with the resident being offered an alternate food only one of those days. The resident did consume over 75% of the alternate food that day. A record review conducted on 4/9/24 of Resident 27's Task: Nutrition- Dinner revealed there was no documentation for 11 of the previous 30 days. The resident consumed less than 50% of their meal on 8 days with the resident being offered an alternate food 6 of those days. The resident consumed 25% or less of the alternates offered. A record review conducted on 4/9/24 of Resident 27's Task: Nutrition- HS (hour of sleep) Snacks revealed there was no documentation for 9 of the previous 30 days. The resident consumed an HS snack one time according to the documentation. A record review of a document provided by the facility administrator on 4/9/24 revealed Resident 27 had not had a weight documented in their electronic health record since 3/4/24. A record review of a document provided by [NAME] President of Operations(VPO)-H titled Weekly Bath Sheet and dated March 3rd-9th revealed Resident 27 had a bath on 3/4/24 with a weight documented of 144 pounds. The resident also had a bath on 3/9/24 with a weight documented of 142.5 pounds. There were no other baths or weights documented that week. A record review of a document provided by VPO-H titled Weekly Bath Sheet and dated March 10th-16th revealed Resident 27 had a bath on 3/16/24 with a weight documented of 137.5 pounds. There were no other baths or weights documented that week. A record review of a document provided by VPO-H titled Weekly Bath Sheet and dated March 17th-23rd revealed Resident 27 did not received any baths that week and had no weights documented. A record review of a document provided by VPO-H titled Weekly Bath Sheet and dated March 24th-30th revealed Resident 27 had a bath on 3/25/24 with a weight documented of 135.5 pounds. There were no other baths or weights documented that week. A record review of a document provided by VPO-H titled Weekly Bath Sheet and dated March 31st- April 6th revealed Resident 27 had a bath on 4/6/24 but there was no weight documented. There were no other baths or weights documented that week. A record review conducted on 4/10/24 of a document provided by VPO-H titled Weekly Bath Sheet and dated April 7th-13th revealed Resident 27 had not had a bath yet that week and had no weights documented. Based on the record review of Resident 27's weights of 144 pounds on 3/4/24 and 135.5 pounds on 3/25/24, the resident had a 5.9% weight loss in less than one month. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual revealed a weight change of 5% in 1 month was a significant amount of weight loss and should prompt a thorough assessment of the resident's nutritional status. An observation on 4/7/24 beginning at 12:14 PM revealed Resident 27 sitting at a table in the dining room with their eyes closed. NA-C put a plate of food on the table in front of the resident and cut up the chicken that was on the plate. NA-C attempted to wake the resident by saying their name and gently shaking the resident's shoulder, then walked away from the resident's table. The resident did not respond or open their eyes. A continued observation on 4/7/24 at 12:26 PM revealed Resident 27 continued to have their eyes closed with their food still sitting in front of them, uneaten. No staff had reapproached the resident during this time. A continued observation on 4/7/24 at 12:31 PM revealed Resident 27 opening their eyes, looking around, then closing their eyes again. The food was still sitting in front of the resident, uneaten, and no staff had reapproached the resident. A continued observation on 4/7/24 at 12:48 PM revealed Resident 27 with their eyes still closed, the same uneaten food in front of them, and no staff had reapproached the resident. A continued observation on 4/7/24 at 12:51 PM revealed NA-C approached the resident at that time and woke the resident. NA-C asked the resident if they wanted something else to eat, walked over to the kitchen, then went to the table next to Resident 27's table and began assisting another resident without reapproaching Resident 27. A continued observation on 4/7/24 at 12:53 PM revealed Resident 27 had closed their eyes again and had no begun eating their food. A continued observation on 4/7/24 at 12:56 PM revealed NA-C moved Resident 27's plate away from the resident, placed a bowl of soup in front of the resident, and then walked away. Resident 27 looked at the soup and then closed their eyes again. A continued observation on 4/7/24 at 01:01 PM revealed Resident 27 with their eyes still closed and no staff had reapproached them. A continued observation on 4/7/24 at 1:20 PM revealed Resident 27 with their eyes still closed with the same bowl of soup in front of them, untouched. No staff had reapproached the resident during this time. A continued observation on 4/7/24 at 1:23 PM revealed NA-C woke Resident 27, spoke briefly to them, and then took the resident from the table and back to their room. The resident's soup remained uneaten and the drinks that had been on the table throughout the mealtime were not drank. An observation on 4/8/24 beginning at 8:17 AM revealed Resident 27 sitting at a dining room table with their eyes open. The resident then closed their eyes and bowed their head at 8:18 AM. A continued observation on 4/8/24 at 8:27 AM revealed Resident 27 still sitting at the table with their eyes open and with no food having been served to them yet. The resident did have two cups with straws in front of them that were full. A continued observation on 4/8/24 at 8:33 AM revealed Resident 27 still sitting at the table but had their head bowed and eyes closed. A white mashed substance in a bowl that was sitting on top of a plate and a biscuit, syrup, and butter had been placed in front of the resident but there was no staff at the table assisting the resident. A continued observation on 4/8/24 at 8:40 AM revealed MA-A waking Resident 27 and then MA-A poured the syrup into the bowl and mixed it with the food in the bowl. MA-A cued the resident to pick up their spoon and take a bite. Resident 27 then stirred the food with the spoon and then started taking bites independently. An observation on 4/8/24 at 12:50 PM revealed Resident 27 sitting in their wheelchair in their room. The resident's head was bowed, and their eyes were closed. There was an overbed table in front of the resident with a pitcher of water on it but no other food or fluids. An observation on 4/8/24 at 12:59 PM revealed Resident 27 still sitting in their wheelchair in their room with their eyes closed. A plate of food and a small cup of red liquid were sitting on the overbed table in front of the resident. There was no staff present in the resident's room and the plate of food was untouched. An observation on 4/8/24 at 1:55 PM revealed Resident 27 still sitting in the same position as an hour prior with the same food sitting untouched in front of them and no staff in the room. The resident did have their eyes open at that time and was looking around their room. An observation on 4/8/24 at 2:10 PM revealed Resident 27 still sitting in the same position with the same food sitting untouched in front of them and no staff in the room. The resident was watching the television in their room. An observation on 4/8/24 at 2:48 PM revealed Resident 27 sitting in their recliner with their legs elevated and their eyes closed. The plate of food was no longer in resident's room. An interview on 4/8/24 at 2:50 PM with MA-A revealed Resident 27 had eaten a couple of bites of the potato salad that had been on the plate in their room, but the resident had not wanted to eat anything else. An observation on 4/9/24 at 8:55 AM revealed Resident 27 sitting in their recliner with their eyes open and looking toward the television, which was not turned on. There was water in a pitcher on the resident's overbed table that was positioned near the resident. An observation on 4/9/24 at 9:34 AM revealed Resident 27 sitting in their recliner with their eyes closed. There was a plate with cut up sausage and a bowl with hot cereal sitting on the overbed table in front of the resident. An observation on 4/9/24 at 10:31 AM revealed Resident 27 still sitting in their recliner, their feet had been elevated, and their eyes were closed. The plate and bowl were sitting on a counter near the resident's door with all of the food still remaining. An interview on 4/9/24 at 3:30 PM with the DON revealed Resident 27 had had a stomach bug since the previous Friday and had not been eating as well as they normally did, and that the resident's fluid intake had been hit and miss. The DON revealed that when residents who normally eat independently were not eating well, the DON's expectation would be for staff to assist the resident. An interview on 4/10/2024 at 9:08 AM with NA-K revealed Resident 27 occasionally ate in their room but their level of assistance needed varied by day depending on the resident's alertness and that the staff would check on the resident to see their progress with eating and if the resident had not eaten, the staff would provide feeding assistance. An interview on 4/10/24 at 9:50 AM with the DON confirmed that the bath aides were supposed to transfer weights that were written on the bath sheets into each resident's electronic health record in Point Click Care (PCC). The DON confirmed there was no one verifying that the weights were being entered in PCC. The DON confirmed they were not aware of Resident 27's recent weight loss prior to the interview. 49766 D. A record review of an Admission Record indicated the facility admitted Resident 14 on 1/17/2020 with diagnoses of Dementia, Parkinson's disease, delusional disorder, Major Depressive Disorder, anxiety, heart failure, and Chronic Obstructive Pulmonary Disease. A record review of Resident 14's weights revealed the following: - 10/21/2023: 169.5 lb - 11/23/2023: 159.5 lb - 12/27/2023: 153 lb - 1/30/2024: 146.5 lb - 2/28/2024: 143.5 lb - 3/27/2024: 141 lb (-16.81% loss over 6 months) A record review of a Nutritional Evaluation with a date of 1/9/2024 confirmed a significant weight loss of 56 pounds over past year and referred to Care Plan for nutritional plan. A record review of Resident 14's Activities of Daily Living Care Plan revealed Resident 14 had an ADL self-care performance deficit related to loose fitting dentures, tremors in hands, and limited mobility. The interventions included Resident 14 required assistance by 1 staff to eat with a date initiated of 9/3/2023. An interview on 4/7/2024 at 3:02 PM with Resident 14's family member revealed Resident 14 needs cued to open mouth during feeding as Resident 14 does not open mouth very well and tremors have made it difficult to eat independently. An observation on 4/8/2024 at 12:39 PM revealed NA-A had stopped feeding assistance to go outside. An observation on 4/8/2024 at 12:47 PM revealed NA-A had stopped feeding assistance to go outside. An observation on 4/8/2024 at 12:56 PM revealed NA-A had stopped feeding assistance to resident while being on personal cellphone. An observation on 4/8/2024 at 1:01 PM revealed Resident 14 had ate less than 25% of the meal. An interview on 4/9/2024 at 9:48 with NA-A revealed Resident 14 needs assistance with feeding since the last six to twelve months due to an increase in tremors and inability to feed self. An interview on 4/9/2024 at 5:00 PM with DON revealed expectation would be for aides to assist with feeding uninterrupted according to Care Plan for interventions. A record review of Resident 14's Nutritional Care Plan, initiated on 7/10/2023, revealed Resident 14 had a potential nutritional problem for weight loss related to confusion with an intervention to monitor intake and record each meal. A record review of meal intakes revealed there were no meal intakes charted for breakfast or lunch on 4/6/2024, 4/7/2024, or 4/8/2024.

Licensure Reference Number 175 NAC 12-006.09D2a Based on interviews and record review, the facility failed to initiate care and treatment to prevent the development of pressure ulcers for on sampled resident (Resident 1). Facility census was 34. Sample size was 1 former resident and 2 current residents. Findings are: On 3/4/2020 at 8:08 AM and interview with Resident 1's POA (Power of Attorney) who was also a family member revealed that family members had observed pressure areas on the resident's heels during a visit to the facility on [DATE]. The POA reported that the facility was aware that the resident had fragile skin and was at risk for pressure ulcers during the admission process. The POA also reported that padded boots were seen in the resident's room but were not in use to protect the resident's feet. Review of the Weekly Skin Assessement for Resident 1 dated 1/22/2020 showed numerous areas of bruising, scabs, and skin discoloration but no pressure ulcers. Review of the Weekly Skin Assessment for Resident 1 completed on 2/12/2020 showed no areas of concern on the resident's heels. The Weekly Skin Assessment completed on 2/19/2020 showed a 4 cm (centimeter) blood blister on the left heel and a 3x1 cm scab on the same heel as well as a 3x1.5 cm Stage II Pressure Ulcer (Pressure ulcers are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis; woundsource.com) on the right heel. The Progress Notes which were written by the same nurse on that date noted existing unstageable pressure wound to back of right heel; scab still intact and noted stage II pressure wound on back of left heel along with notes regarding other skin issues which were seen at that time. Review of the resident's Care Plan showed a concern related to skin was initiated on 2/20/2020 with no mention of preventative measures being put in place before that date. Review of the facility's response to a grievance filed by the POA showed a note on 2/7/2020 that indicated the resident would not leave boots on. On 2/22/2020, when the POA reported that his boots were not on but were behind the tv, the aide caring for the resident was interviewed and reported the boots were on all morning but they forgot to put them back when the resident was laid down after lunch. Only two Progress Notes reflected the use of padded boots and those were dated 2/25 and 26/2020. The response to the grievance also indicated that an air mattress was placed on the bed on 2/25/2020. On 3/4/2020 at 10:40 AM, an interview with the DON (Director of Nursing) verified that the Care Plan showed a start date of 2/20/2020 for interventions which was after the injuries to the resident's heels had occurred. The DON clarified that the use of padded boots was in place before that date but was not being documented and therefore could not be verified.

Licensure Reference Number 175 NAC 12-006.09D2a 175 NAC 12-006.09D2b Based on record reviews and staff interview, the facility failed to 1) identify increased risk for pressure ulcers, 2) provide care to prevent the development of multiple pressure ulcers, and 3) assess an ongoing basis to ensure the pressure ulcers to ensure treatments and interventions were effective to promote healing for one sampled resident (Resident 2). The facility census was 43. Findings are: Review of Resident 2's "Admission Evaluation and Interim Care Plan", dated 8/1/14, revealed that the resident had medical issues including Arthritis, Numbness/tingling at toes, Weak legs, Sleep Apnea, and [MEDICAL CONDITION] (slow heart rate). Further review revealed that the resident was alert, had no problems with cognition, behaviors, nutrition, or skin. The resident was dependent on staff for transfers and required supervision with personal hygiene and toileting. Review of the "Progress Notes" revealed the following related to pressure ulcers: - 10/5/14 at 11:00 PM - noted a 5.3 cm. (centimeter) x 2 cm. opened pressure area on the right gluteus, dressing applied and the resident agreed to be turned every two hours; - 10/6/14 at 5:00 PM - dressing intact; - 10/9/14 at 6:57 PM - assessment of the resident's left great toe reveals necrotic, foul smelling tissue on the entire tip of the toe, area was debrided down to the best tissue, wound bed still has slough (dead issue separated from living tissue or ulceration) present but there is some bleeding, area measures 3 cm. x 2 cm. x 0.4 cm, area was cleaned and a dressing was applied, the physician was called and ordered an antibiotic for seven days; - 10/10/14 at 7:02 PM - dressing is clean, dry, and intact, no drainage noted; - 10/11/14 at 7:58 PM - resident remains on antibiotic treatment for [REDACTED]. circular; - 10/12/14 at 3:12 AM - dressing to left great toe is clean, dry, and intact; - 10/13/14 at 3:03 PM - dressing to left great toe is clean, dry, and intact; - 10/13/14 at 3:42 PM - returned from a doctor's appointment and orders were received to continue current treatment to the left great toe; - 10/16/14 at 11:30 AM - left great toe has a dressing, signs of healing noted, right coccyx, Stage 2 (a partial thickness loss of skin layers that presents as an abrasion, blister, or shallow crater) skin breakdown, resident refuses to lie down in bed, sits in wheelchair; - 10/16/14 at 6:43 PM - dressing to the coccyx changed today, wound is much improved, unable to measure due to the resident not tolerating standing, silver padded sacral dressing applied, dressing is easily dislodged by urine; dressing to the left great toe was changed on 10/15/14, this area is much improved as well, smaller in size; - 10/17/14 at 5:10 PM - dressing off of the wound, applied a new dressing; - 10/21/14 at 5:15 PM - foley catheter was inserted due to two Stage 2 pressure ulcers on resident's bilateral lower sacral areas that are not healing; - 10/22/14 at 3:56 PM - dressing change to coccyx area - Stage 2 skin breakdown; - 10/23/14 at 1:43 PM - performed wound care to bilateral buttock wounds and note that right buttock wound has 90 percent slough in wound bed, left buttock wound has a 100 percent red and moist wound bed, faxed MD for treatment order for the slough wound, - 10/24/14 at 5:23 PM - orders received for dressing changes to coccyx every three days, sacrum wound bed is to be cleansed with wound wash; - 10/24/14 at 5:44 PM - dressing covering the left and right buttock and dressing intact to the left great toe; - 10/25/14 at 2:21 AM - right buttock crease wound is open to air, cleaned with wound wash and applied a dressing to the coccyx; - 10/25/14 at 5:22 PM - dressing saturated and changed per order; - 10/27/14 at 5:35 PM - dressing changed to both buttocks due to covered in feces, Stage 2 to the right buttock is now tunneling, was unable to measure at this time but it is approximately 1 cm. deep with slough still present; - 10/28/14 at 5:46 PM - dressing in place; - 10/30/14 at 10:48 PM - dressing changed to the left great toe; - 10/31/14 at 1:54 AM - new orders were received from the wound nurse, resident has a Stage 3 (full thickness of skin is lost, exposing the subcutaneous tissue, presents as a deep crater with or without undermining adjacent tissue) ulcer to the left great toe and a Stage 3 pressure ulcer to the left and right ischium (the lower portion of of the hip bone); - 11/1/14 at 5:04 PM - there was no dressing in place today, so a dressing was placed according to orders on the left ischium ulcer, depth of wound is now 2.2 cm. and wound is foul smelling; Stage 3 pressure ulcer at the right ischium, dressing was replaced as it was saturated with blood, wound is foul smelling; - 11/2/14 at 3:34 PM - dressing changed left great toe and left ischium; - 11/4/14 at 9:54 PM - dressing changed to left great toe, ulcer measures 1.5 cm. x 1.5 cm. with 0.5 cm. depth, dressing changed to the left ischium ulcer which measures 1.5 cm. x 2 cm. with 0.5 cm. depth, and the dressing was changed to the right ischium ulcer which measures 2.5 cm. x 2.5 cm. with 2.5 cm. depth; - 11/6/14 at 2:19 AM - dressing changed as ordered to the left ischium, right ischium, and the left great toe; - 11/8/14 at 5:41 AM - dressing changed, saturated in blood, applied silver because couldn't find calcium alginate; - 11/8/14 at 5:44 PM - dressings changed to the right ischium ulcer, right ischium ulcer has a blackish gray wound base and has depth to it, the left ischium wound is shallow with clear serosanguinous (bloody) drainage; - 11/9/14 at 2:44 PM - left and right ischium wound care done as ordered, noted serosanguinous drainage from the left ischium wound and slight serous tan drainage from the right ischium wound with a blackish gray base; - 11/14/14 at 2:25 PM - dressings changed; - 11/16/14 at 11:40 PM - dressing was changed to the gluteus, area measured 5.6 cm. x 5.2 cm. x 3.0 cm. depth and greenish/black slough with a very foul smell, dressing was changed on the left gluteus which measured 3.1 cm. x 3.0 cm. x 0.2 cm. depth with a small amount of slough; - 11/17/14 at 11:28 AM - condition of the wound to the left ischium has declined, noted foul odor, increased drainage and the wound bed is now yellow/dark green in color, the physician was notified and orders were received for a wound culture and a referral to another doctor; - 11/17/14 at 3:54 PM - the resident transferred to the hospital. Review of the "Wound Care - Skin integrity- Evaluation" form, dated 10/29/14, revealed the following: "Wound 1 - left great toe, date of onset - 10/5/14, moderate exudate, full thickness Stage 3, length 1.2 cm x width 1.7 cm. x depth less than 0.2 cm., serosanguinous drainage, facility acquired. "Wound 2 - left ischium, date of onset - 10/5/14, moderate exudate, full thickness Stage 3 pressure ulcer, size length 3.00 cm. x 1.70 cm., depth less than 0.2 cm., serosanguinous drainage, facility acquired. "Wound 3 - right ischium, date of onset 10/5/14, moderate exudate, full thickness, Stage 3 pressure ulcer, size length 3.5 cm. x width 1.50 cm. x depth 1.3 cm., serosanguinous drainage, facility acquired. Further review revealed treatment recommendations which were approved by the physician on 10/31/14. Review of the "FAX Cover Sheet", dated 10/17/14, revealed that the physician was notified of the resident's "Stage II area to the right buttocks and area to left great toe" and request for "Juven" supplement two times a day to promote tissue healing. Further review revealed that the physician approved of the supplement. Review of the "FAX Cover Sheet", dated 10/23/14, revealed that the physician was notified that the right "buttock wound has slough in 90% of the wound" and requested an order for [REDACTED]. Review of the "Treatment Administration Record", dated November 2014, revealed no documentation that the treatment and dressing changes ordered daily at the right ischium Stage 3 pressure ulcer, the left great toe Stage 3 pressure ulcer, and the left ischium Stage 3 pressure ulcer were done as ordered on [DATE], and 11/10/14. Interview on 12/9/14 at 11:45 AM with the DON (Director of Nursing) revealed that the resident was identified at "high" risk for pressure ulcers on 8/15/14. Further interview revealed that the next risk assessment was completed on 10/10/14 and the resident was at "moderate" risk for the development of pressure ulcers. The DON confirmed that further pressure ulcer risk assessments were not completed for the resident. The DON stated that the resident developed significant pain, Shingles, and decreased sensation in lower extremities and back, and severe incontinence which increased the risk for skin breakdown. Interview on 12/9/14 at 11:45 AM with the DON (Director of Nursing) confirmed that the documentation in the "Progress Notes" and the wound assessments, dated 10/29/14, as stated above were the only documentation of the residents pressure ulcers found in the resident's closed medical record. Further interview confirmed that the nurses did not assess the resident's increased risk for pressure ulcers as the resident's physical condition declined. The DON verified that changes in nursing interventions were not identified, implemented, or evaluated to reduce the risk of pressure ulcers, to promote healing of the ulcers after they developed, or as they became infected and increased in size. Further interview confirmed that the resident's skin condition, the development of the pressure ulcers, and the decline in the pressure ulcers described above, were not accurately or consistently assessed or documented.

Licensure Reference Number 175 NAC 12-006.04C3a (6) Based on record review and staff interview, the facility failed to notify the physician of the development of pressure ulcers, symptoms of infection, and increased size of pressure pressure ulcers for one sampled resident (Resident 2) closed record. The facility census was 43. Findings are: Review of Resident 2's "Progress Notes" revealed the following: - 10/5/14 at 11:00 PM - resident developed a 5.3 cm. (centimeter) x 2 cm. opened pressure area of the right gluteus; - 10/11/14 at 7:58 PM - pressure ulcer at the resident's left great toe increased in size; - 10/27/14 at 5:35 PM - pressure ulcer at the right buttock was tunneling; - 11/1/14 at 5:04 PM - ulcers at the left and right ischium were foul smelling; - 11/16/14 at 11:40 PM - increased size and depth of pressure ulcers, very foul smelling; - 11/17/14 at 11:28 AM - physician was notified of the decline in the pressure ulcers, increased drainage, and foul odor. The physician ordered a wound culture and referral to another doctor; - 11/17/14 at 3:54 PM - the resident was transferred to the hospital. Interview on 12/9/14 at 11:45 AM with the DON (Director of Nursing) confirmed that there was no documentation that the physician was notified as indicated when the pressure ulcers were identified, increased in size, and had symptoms of infection. Further interview confirmed that the physician should have been notified of these changes so that further evaluation and treatment interventions could be considered to promote healing and comfort for the resident.

LICENSURE REFERENCE: 175 NAC 12-006.09D7, 12-006.09D7a Based on observation, record review and interview; the facility failed to assess residents with history of falls for causal factors and implement care interventions to protect residents from falls with injury. The facility had a census of 46 and a complaint survey sample of 3. This affected Resident 39 and Resident 45.Findings are: A. According to the 4/23/12 FACE SHEET, Resident 39 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. Review of the Care Plan (print date 9/30/12) for Resident 39 revealed that the resident was identified as a risk potential for falls and had actual falls on 9/4/12, 9/14/12 and 10/18/12. The goal for the fall risk was that Resident 39 would maintain freedom from injuries related to falls over the next 90 days. The following were the interventions: -Complete fall risk assessment on admission, quarterly, annually and as needed. -Determine the reason for the fall and implement a new intervention each time a resident falls. - Contact MD (physician) and family for any fall. - Answer calls quickly and anticipate needs. - Provide an environment that is: clutter free, bed in low position, floors even and free from spills, items within reach, adequate lighting. - 1/27/11 Instruct resident on proper foot wear. - 8/3/11 Encourage resident to call for SBA (stand by assistance) when transferring. - 9/14/12 Staff educated on importance of gait belt use with transfers and the facility policy. - If using the walker staff will be SBA and use a gait belt. - 9/4/12 (Resident 39) to use slipper socks or shoes when transferring .- Handwritten - 10/18/12 Resident will be 1 assist with transfers and ambulation.- Handwritten - 10/18/12 Resident will be moved to a room closer to the nurse's station. Observation on 10/30/12 at 10:09 AM confirmed the resident had the following interventions in the resident's room: a hi/lo bed, pressure sensor pad by the bed and the resident was now 4 rooms closer to the nurse's station. Review of the FALL RISK EVALUATION for Resident 39 completed on 7/18/12 revealed that the resident was evaluated at a score of 18. The EVALUATION documented that a score of 10 or more put the resident at "higher" risk for falls and interventions should be "promptly" put in place. Interview on 10/30/12 at 10:15 AM with the ADM (Administrator) confirmed that the FALL RISK EVALUATION should be completed on every resident on admission, quarterly, annually and as needed. The ADM clarified that "as needed" meant it should be done after every fall so that new interventions could be promptly implemented. Review of a RESIDENT INCIDENT REPORT dated 9/4/12 revealed that Resident 39 was found on the floor in the resident's room. The resident's back was partially against recliner and range of motion to the lower extremities was within normal limits. The resident complained of "extreme" right sided pain in back. Also written on the form was: Back pain has been an issue all weekend. The treatment provided and action taken - call was placed to "BHC" to make appointment for an evaluation. Interview on 10/30/12 at 10:15 AM with the ADM confirmed that the facility determined that Resident 39 did not have proper foot wear on at the time of the fall on 9/4/12. The facility failed to identify why the resident was not wearing the proper foot wear as identified on the CARE PLAN on 1/27/11. The facility failed to complete a FALL RISK EVALUATION for Resident 39 until 9/10/12 and the new score had increased to 23. The increased areas on the EVALUATION were that Resident 39 had falls in the previous 90 days, had a cognitive status change and was displaying behaviors such as altered awareness or perception of surroundings. The only CARE PLAN intervention added was that Resident 39 should use slipper socks or shoes when transferring. Review of CLINICAL NOTES confirmed that Resident 39 was hosptalized on [DATE] and found to have a vertebral compression fracture. Review of a RESIDENT INCIDENT REPORT dated 9/13/12 revealed that Resident 39 was found on the floor in the resident's room. The resident sustained [REDACTED]. The resident complained of pain to the right knee and right hip. The treatment provided and action taken - the resident was assisted to wheelchair and the resident was given education. Interview on 10/30/12 at 10:15 AM with the ADM confirmed that the facility determined that Resident 39 did not have proper foot wear on at the time of the fall on 9/13/12. The facility failed to identify why the resident was not wearing the proper foot wear as identified on the CARE PLAN on 1/27/11 and 9/4/12. The facility failed to complete a FALL RISK EVALUATION for Resident 39 after the fall and failed to put new CARE PLAN interventions in place. Review of a RESIDENT INCIDENT REPORT dated 9/14/12 revealed that Resident 39 was being transferred from toilet to wheelchair and the resident's legs gave out causing the aide to lower Resident 39 to the floor. Interview on 10/30/12 at 10:15 AM with the ADM confirmed that the facility determined that the nurse aide was not using a gait belt as per facility policy during this transfer. The treatment provided and action taken - "Patient education" on facility policy regarding gait belt use. The facility completed a FALL RISK EVALUATION for Resident 39 on 9/14/12 and the new score had increased to 26. The increased areas on the EVALUATION were that Resident 39 had 2 falls in the previous 90 days and the resident's ability to see was moderately impaired. The CARE PLAN interventions added were that staff would be educated on the facility policy and importance of gait belt use with transfers and when Resident 39 used the walker, staff would provide SBA and use a gait belt. Review of a RESIDENT INCIDENT REPORT dated 10/18/12 revealed that Resident 39 was sitting on the resident's walker seat in front of the sink in the bathroom. Staff heard a crash and responded to find the resident lying on the floor on the left side with the head under the sink and feet in doorway. The treatment provided and action taken - the resident had immediate complaints of pain in left hip and call placed to 9-1-1. The resident was transported to the hospital via ambulance. The facility conducted an investigation of the INCIDENT. Review of a WITNESS STATEMENT dated 10/21/12 at 2:12 PM confirmed that the staff member in charge of the care of Resident 39 when the fall happened documented assisting the resident to sit in the walker seat. The staff member reported placing the resident in front of the sink in the bathroom and leaving the resident unattended while the resident was using the walker. The staff member went 2 rooms down the hall to assist another resident. The facility failed to provide stand by assistance and a gait belt while the resident was using the walker as per the CARE PLAN. Review of CLINICAL NOTES confirmed that Resident 39 was hosptalized on [DATE] with a fractured left hip and pelvis. Review of CLINICAL NOTES confirmed that Resident 39 returned to the facility on [DATE]. B. Review of a FACE SHEET dated 10/10/12 revealed Resident 45 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].Review of a MONTHLY SUMMARY dated 7/20/12 revealed Resident 45 was independent with bed mobility, transfers between surfaces, toileting, and uses a wheelchair for mobility.Review of a SOCIAL SERVICE REVIEW dated 9/24/12 revealed Resident 45 "Res. (resident) has poor ability to remember. BIMS (brief interview for mental status) score was 7 on 9/19/12". (A score of 0-7 out of 15 indicates severe cognitive impairment, while a score of 8-12 indicates a resident's cognitive ability is moderately impaired.) "Res is alert (with) confusion". Interview with Resident 45 on 10/30/12 at 1153 AM CST revealed the resident had a fall "a few days ago", then explained "it's hard to stand up when your legs are weak" . Review of NURSES NOTES revealed the following:- 9/6/12 on 1900 "fell in bathroom, no injury, turned call light on after fall."- 9/7/12 at 6:00 PM "found on floor beside bed. Gender stated gender was going to the wheelchair when one of the wheels wasn't locked." - 10/8/12 at 1115 AM - "resident on floor with no injury. MD (Physician) notified of increased confusion and falls."-10/9/12 at 5:39 PM - "Resident located on floor of room between the WC (wheelchair) and the bed. Placed call light on (before or after fall) stated was reaching for genders glasses."Review of RESIDENT INCIDENT REPORT completed for Resident 45 revealed:- 9/5/12 at 5:00 PM, resident was transferring self from toilet to the wheelchair - one wheelchair brake not on;- 9/7/12 at 6:00 PM, resident in wheelchair, leaned over to pick slippers off floor when the resident fell out of the wheelchair, onto the floor;- 9/7/12 at 10:15 PM, resident was transferring self from bed to wheelchair - wheelchair brakes not locked - resident fell ;- 10/8/12 at 7:45 AM, found on floor - resident stated was reaching for something and slid out of wheelchair; - 10/9/12 at 5:20 PM, found on floor - resident stated was reaching for glasses. - The Resident Incident Reports did not identify causal factors that contributed to Resident 45's falls and did not have new interventions established to prevent further falls. Review of Resident 45's CARE PLAN dated 9/27/12 revealed: Problem as "At risk for falls R/T (related to) history of falls, confusion", Atrial fibrillation, Hypertension, depression, [DIAGNOSES REDACTED], pain, and Diabetes mellitus:= Goal date 12/31/12 "(Resident 45) first will maintain current level of mobility with no increase in the incidence of falls/injuries"-- Interventions included:-- "Resident to ask staff for help to pick things up off the floor" and -- 6/21/11 "bath mat at bedside to reduce feet sliding". -- The care plan did not include interventions to prevent falls due to Resident 45 reaching for items or to ensure the wheelchair brakes were locked before Resident 45 transferred self. Observation on 10/30/12 @ 12:42 PM revealed Resident 45 lying in bed. The wheelchair sat next to bed with the right arm rest next to resident. The left brake was locked and right brake was off (next to bed) The wheelchair would have to be moved for Resident 45 to be able to transfer into the chair as the seat of the wheelchair faced the wall where the head of the bed was located. An interview with the Administrator on 10/30/12 at 1:30 PM, revealed a causal factor with Resident 45's falls was the wheelchair brakes not on (locked). The Administrator stated Maintenance would be asked about the anti-locking device in which the wheelchair automatically locks when there is no pressure in the wheelchair. The Administrator revealed wheelchair brakes were not addressed on the care plan, except to encourage Resident 45 to lock the brakes, but the resident intermittently had cognitive problems. The Administrator revealed Resident 45 tended to be on the move and hadn't looked at the resident's activities at certain times of day to establish interventions. The Administrator revealed the times Resident 45 had fallen had not been reviewed for trends. The Administrator reveled the implementation of an intervention had been to move the wheelchair out of Resident 45's reach, because if the resident couldn't t reach the wheelchair, Resident 45 would call for help. The Administrator stated "I don't see that the intervention made it to the Care Plan.

Licensure Reference Number: 175 NAC 12-006.09D Based on record review and interviews, the facility failed to: 1) Monitor the degree and nature of ongoing elevated temperatures; 2) assess and monitor the causal factors for persistent nausea, vomiting, and diarrhea; and 3) Assess and monitor the degree of ongoing pain; for 1 sampled resident (Resident 2). The resident's symptoms resulted in a hospitalization [MEDICAL CONDITION] and [MEDICAL CONDITION]. Sample size was 2 current residents and 2 closed records. Facility census was 46. Findings are: A. Review of Resident 2's "Clinical Notes Report" revealed an entry dated 5/22/12 at 9:25 p.m. read: "(Resident 2's) vitals were 100.4 (temperature)... PRN (as needed) tylenol as given by day shift for elevated temp and was effective..." A second entry dated 5/23/12 at 5:39 a.m. which read: "... (resident) has been running a slight temp throughout the night PRN tylenol given and was effective..." A late entry for 5/22/12 from Resident 2's notes dated 5/24/12 at 5:44 p.m. read: "... Temp (resident temperature) was elevated at 1700 (5 p.m.) " The nurse's notes revealed the resident was running a temperature throughout the day and night on 5/22/12 and 5/23/12. There were no recordings related to the time of day or readings determining the degree of the resident's fever or effectiveness of the tylenol. There were no assessments of the resident's fever indicating what was being done to determine causal factors or interventions other than tylenol to attempt to relieve the resident's symptoms. B. Review of Resident 2's "Clinical Notes Report" revealed an entry on 5/23/12 at 5:39 a.m.in which the resident was sent to the hospital for a blood pressure reading of 74/56. This note documented: "during the day yesterday 5-22-12 res (resident) was experiencing episodes of vomiting, through out the night res was experiencing diarrhea the vomiting had stopped." Prior to this note, there was no documentation regarding the residents episodes of vomiting or diarrhea through out the night. A late entry dated 5/23/12 at 6:00 p.m. revealed documentation for events occurring to Resident 2 on 5/22/12. this entry stated the resident had fallen at 1:15 p.m. The note further read: "At approx. (approximately) 1500 (3 p.m.), called back to res room. res lying in bed, CNA (Nurse Aide) reports that res had another emesis. Noted in trash bag a moderate amount of digested food. Approx. 30 mins (minutes) later, reported to this nurse that res had another emesis... Review of Resident 2's closed record revealed no further entries or documentation on 5/22/12 and 5/23/12 indicating the nursing staff monitored the nausea, vomiting, and diarrhea which had continued from early afternoon on 5/22/12 until hospitalization on [DATE] at 5:30 a.m. There was no documentation to support the Licensed Practical Nurses, working as charge nurses, provided interventions to alleviate the symptoms. C. Closed record review of Resident 2's "Clinical Notes Report" revealed the following entries: - an entry on 5/21/12 at 6:42 a.m. which documented the resident was found on the floor behind a television stand. The documentation in the entry revealed the resident had skin tears to the right elbow and left forearm which were cleansed and steristripped. -A note on 5/21/12 at 2:19 p.m. revealed documentation: "...(Resident 2's) dressings have been changed today- cont (continues) to have significant amounts of serosanguinous drainage..." -A note on 5/22/12 at 9:25 p.m. revealed documentation: "... skin tears bilaterally to both arms, res (Resident 2) is c/o (complaining of) generalized pain and discomfort. Vitals were 100.4 (Fahrenheit body temperature)... prn tylenol as given by day shift for elevated temp and was effective..." -A note on 5/23/12 at 1:17 a.m. revealed a pain medication ([MEDICATION NAME]) was administered for pain and discomfort related to the skin tears. The right arm dressing was re-dressed at this time. -Additional notes on 5/23/12 revealed that at 4:15 a.m., the dressing to Resident 2's left arm was changed at fifteen minutes after midnight and at 1:20 a.m., the nurse was called to again change the dressing which was saturated. -At 3:00 a.m. and 4:00 a.m. on 5/23/12, Resident 2's dressing was dry and intact and the resident "is experiencing unilateral [MEDICAL CONDITION] to lt. (left arm". -At 4:20 a.m. on 5/23/12, the nurse was called back because the resident wound was "seeping, new dressing applied to this lt arm including abd (a thick bandage) and arm sleeve." -An entry at 5:39 a.m. on 5/23/12 revealed: The resident was sent to the hospital due to a blood pressure of 74/56. This note documented there was increased drainage to the left arm saturating 2 abd pads within a 2-3 hour window. The wound description included: "has a odor" and the resident was described as "running a slight temp throughout the night prn tylenol given and was effective during the day yesterday, 5-22-12". "Res was experiencing episodes of vomiting, through out the night". "Res was experiencing diarrhea the vomiting had stopped, res had voiced multiple time that (Resident 2) was experiencing pain, prn [MEDICATION NAME] was given for this pain but was not effective..." A late entry for events occurring on 5/22/12 for Resident 2 included documentation on 5/23/12 at 6:00 p.m.: The resident experienced a fall at 1:15 p.m. The dressing to the left lower arm was "saturated with red/orange fluid. Dressing changed at this time. At approx. (approximately) 1500 (3 p.m.) called back to res room., res lying in bed... had an emesis. Noted in trash bag a moderate amount of digested food. Approx 30 mins (minutes) later reported to this nurse that res had another emesis. Noted small amount of clear liquid. Temp was elevated at 1700 (5 p.m.) Tylenol administered. Res was also c/oing (complaining) pain to left arm. Noted this dressing to be again full of the red/orange fluid. Redressed but did wrap with a Kling wrap at this time. Several times following this wrapping res did attempt to remove it , but was redirected each time with success,. Will notify of following shift of residents condition." A review of Resident 2's Medication Administration History record between 5/1/12 and 5/24/12 revealed on between 5/21/12 at 5:17 p.m and 4:12 a.m. on 5/23/12 Resident 2 received four doses of [MEDICATION NAME] for pain and additional Tylenol doses were also administered during this time frame. There was no additional documentation from the clinical record to indicate the Licensed Practical Nurses, acting as charge nurses assessed the resident for the degree or pain rating, monitored the times and complaints of the ongoing pain, determined causal factors for pain There was no additional documentation from the clinical record to determine the degree and color of the drainage or when the odor developed. Interview with the Administrator and Director of Nursing on 7/3/12 at 5:00 p.m. verified Resident 2 experienced symptoms of ongoing pain, elevated body temperatures, saturation of wound drainage, and nausea/vomiting and diarrhea beginning on the day shift on 5/22/12 and continuing through the evening and night until hosptalized on [DATE]. The Administrator verified the documentation had not recorded the symptoms of diarrhea/nausea, and vomiting until hospitalized and then in a late entry. The Administrator verified the timeline of events and what the Licensed Practical Nurses had done regarding these symptoms was not recorded.

Licensure Reference Number: 175 NAC ,[DATE].04C3a (6) Based on record review and interviews, the facility failed to notify the physician of ongoing symptoms of pain, saturated dressings, elevated body temperature, nausea, diarrhea and vomiting for one sampled resident (Resident 2). The resident's symptoms resulted in a hospitalization [MEDICAL CONDITION] and [MEDICAL CONDITION]. Sample size was 2 current residents and 2 closed records. Facility census was 46. Findings are: Closed record review of Resident 2's "Clinical Notes Report" revealed the following entries: - an entry on [DATE] at 6:42 a.m. which documented the resident was found on the floor behind a television stand. The documentation in the entry revealed the resident had skin tears to the right elbow and left forearm which were cleansed and steristripped. -A note on [DATE] at 2:19 p.m. revealed documentation: "...(Resident 2's) dressings have been changed today- cont (continues) to have significant amounts of serosanguinous drainage..." -A note on [DATE] at 9:25 p.m. revealed documentation: "... skin tears bilaterally to both arms, res (Resident 2) is c/o (complaining of) generalized pain and discomfort. Vitals were 100.4 (Fahrenheit body temperature)... prn tylenol as given by day shift for elevated temp and was effective..." -A note on [DATE] at 1:17 a.m. revealed a pain medication ([MEDICATION NAME]) was administered for pain and discomfort related to the skin tears. The right arm dressing was re-dressed at this time. -Additional notes on [DATE] revealed that at 4:15 a.m., the dressing to Resident 2's left arm was changed at fifteen minutes after midnight and at 1:20 a.m. the nurse was called to again change the dressing which was saturated. At 3:00 a.m. and 4:00 a.m., Resident 2's dressing was dry and intact and the resident "is experiencing unilateral [MEDICAL CONDITION] to lt. (left arm". -At 4:20 a.m. on [DATE], the nurse was called back because the resident wound was "seeping, new dressing applied to this lt arm including abd (a thick bandage) and arm sleeve." -An entry at 5:39 a.m. on [DATE] revealed: The resident was sent to the hospital due to a blood pressure of ,[DATE]. This note documented there was increased drainage to the left arm saturating 2 abd pads within a ,[DATE] hour window. The wound description included: "has a odor" and the resident was described as "running a slight temp throughout the night". Prn tylenol given and was effective during the day, yesterday, [DATE]. "Res was experiencing episodes of vomiting". "Through out the night res was experiencing diarrhea the vomiting had stopped". "Res had voiced multiple time that (Resident 2) was experiencing pain, prn [MEDICATION NAME] was given for this pain but was not effective..." - A late entry for events occurring on [DATE] for Resident 2 included documentation on [DATE] at 6:00 p.m.: The resident experienced a fall at 1:15 p.m. The dressing to the left lower arm was "saturated with red/orange fluid. Dressing changed at this time. At approx. (approximately) 1500 (3 p.m.) called back to res room., res lying in bed... had an emesis. Noted in trash bag a moderate amount of digested food. Approx 30 mins (minutes) later reported to this nurse that res had another emesis. Noted small amount of clear liquid. Temp was elevated at 1700 (5 p.m.) Tylenol administered. Res was also c/oing (complaining) pain to left arm. Noted this dressing to be again full of the red/orange fluid. Redressed but did wrap with a Kling wrap at this time. Several times following this wrapping res did attempt to remove it , but was redirected each time with success,. Will notify of following shift of residents condition." A review of Resident 2's Medication Administration History record between [DATE] and [DATE] revealed that between [DATE] at 5:17 p.m and 4:12 a.m. on [DATE], Resident 2 received four doses of [MEDICATION NAME] for pain and additional Tylenol doses were also administered during this time frame. There was no documentation from the clinical record to indicate the resident's physician was notified of the ongoing symptoms of elevated temperature, nausea and vomiting, diarrhea, saturated dressings, and ongoing pain with little relief. Record review of Resident 2's "Certificate of Death" dated [DATE] signed by the physician revealed the resident expired on [DATE]. The "Immediate Cause (of death)" included the conditions of "[MEDICAL CONDITION] left arm" with an approximate interval of 14 days prior to the death and "Sepsis" with an approximate interval of 10 days prior to the death. Interview with the Administrator and Director of Nursing on [DATE] at 5:00 p.m. verified there was no evidence that Resident 2's physician had been notified of ongoing symptoms of wound drainage and saturation, elevated temperatures, ongoing pain, nausea and vomiting, and diarrhea, beginning on [DATE] and continuing throughout the day on [DATE] and night on [DATE].

Licensure Reference Number: 175 NAC 12-006.05 (9) Based on record reviews and interviews, the facility failed to prevent neglect by delaying transfer or evaluation by emergency services for one sampled resident (Resident 1) exhibiting ongoing medical symptoms of pain and leg deformity following a fall. Facility census was 53. Sample size was 5. Findings are: Review of Resident 1's "Face Sheet" revealed the resident was admitted to the faciltiy on 8/26/09 with [DIAGNOSES REDACTED]. Review of "Interdisciplinary Progress Notes" for Resident 1 on 8/16/11 revealed the following: - LPN (Licensed Practical Nurse)-A documented hearing a resident yelling for help at 4:00 a.m. LPN-A observed the bed at an angle away from the wall and discovered Resident 1 half way under the bed next to the wall. No visible injuries were observed while resident was on the floor. After receiving help from NA (Nurse Aide)-E, Resident 1 was assessed on the floor for range of motion where LPN-A documented the resident complained of "pain with q (every) thing". - LPN-A documented at 4:45 a.m. after repositioning noted "L (left leg) rotated to left. Asked resident if (resident) was hurting said yes my left leg. Moved both legs equal c/o (complains of) no increased pain with movement. Assessment done with the nurse present advised to send (Resident 1) to hospital. Resident nurse (LPN-B) stated will monitor and have day shift assess condition of leg." - LPN-B documented at 4:17 that a medication aide notified LPN-B of resident's condition and staff needing assistance to clean the resident. LPN-B documented "(LPN-A) gave me report on res. (resident) condition..." - LPN-B documented at 4:46 a.m. Resident 1 was positioned on back in bed and "Res. c/o increased leg pain & L leg c (with) external rotation one [MEDICATION NAME] po (oral administration) given for pain". - LPN-B documented at 5:46 a.m. the day shift nurses were updated on Resident 1's condition. - LPN-B documented at 7:08 the resident was transferred by ambulance to the hospital. - LPN-C documented the family was notified of resident condition at 6:20 a.m. and the ambulance called for transport to the hospital at 6:30 a.m. LPN-C documented the physician was notified of the fall by fax and message left on the on-call number at 6:40 a.m. LPN-C documented the Administrator was notified of the fall at 6:45 a.m. and the DON (Director of Nurses) at 6:50 a.m. - LPN-D documented at 9:15 a.m. the hospital reported the resident was being transferred to another faciltiy due to a "Fx (fractured) Lt (left) hip". Review of Resident 1's "Medication/Treatments Delivered" form with documentation between 8/1/-8/17/11 revealed LPN-B had administered a "[MEDICATION NAME]" tablet to Resident 1 at 4:48 a.m. for "c/o generalized pain". No follow up documentation regarding the effectiveness of this medication was documented on the form. Documentation on Resident 1's 'Neurological Assessment Flowsheet" revealed an entry documented by LPN-B on 8/16/11 at 4:50 a.m. which read "c/o pain L hip". Review of the faciltiy investigation of the incident occurring on 8/16/11 related to Resident 1's [MEDICAL CONDITION] revealed the following documentation: A. The documentation recorded the incident occurred at 4:00 a.m. on 8/16/11 resulting in a resident [MEDICAL CONDITION]. The report indicated the type of medical attention required as "hospitalization and surgery to repair [MEDICAL CONDITION]". B. Statement by LPN-A: Written statement signed by LPN-A dated 8/16/11 recorded LPN-A had assessed Resident 1 after falling and "Noted an obvious rotation of L leg. Suggested to send (Resident 1) to hospital. (LPN-B) said I'm not sure if it is broken its almost time for day shift to arrive. We will have them assess (the resident) since there (sic) more familiar with (the resident). I suggested that we should have CNA (Nurse Aide named) look @ (at) leg to see if this is (resident's) normal. LPN-B disagreed and did not trust CNA judgement of (the resident's) normal leg positioning. LPN-B continued to monitor (resident)". LPN-A asked the nurse aide to look at the leg confirming this "wasn't (the resident's) normal position of leg. We then approach LPN-A... confirmed the L leg abnormal. I also told LPN-B we need to send (the resident) to hospital. LPN-B told me that days should be arriving soon and they can look @ (the resident) and they think (the resident) needs to be sent, they can send (the resident)". C. Statement by LPN-B: E-mail statement from LPN-B dated 8/16/11 at 8:42 p.m. recorded LPN-B received a report at 4:20 a.m. to come to Resident 1's room due to the resident being found on the floor. LPN-B indicated the resident complained of pain from the catheter. LPN-A reported what had happened and the resident was given pain medication at 4:46 a.m. About 5:00 a.m. LPN-B stated the resident "was now complaining of left upper leg hurting. Between 5 and 5:30 a.m. LPN-B stated the "resident more consistently complained of left leg pain when asked and (the resident's) left leg was showing more external rotation... During this time frame I discussed with LPN-A that I felt the (the resident) needed to go by ambulance to the hospital. We were all answering call lights and alarms as well as attending to this resident... This resident was not showing any distress while laying still... (the resident) stated 'not too bad' when asked about pain at rest at about 5:30 a.m. I talked to LPN-A about waiting until the day shift arrived before I called the ambulance. This was about 5:20 am. I expected the day shift at 5:45 am. I felt it was a prudent decision because of the relatively high demand on the staff in the building at this time and the need to care for other residents". LPN-B's statement recorded giving report to LPN-C and the day shift nurse aides and narcotic counting with the next shift before filling out a transfer report while LPN-C called the ambulance which arrived just before 7 am. D. Statement from the Administrator: Signed and dated on 8/16/11 documented the Administrator received a phone call from LPN-C at approximately 6:45 a.m to report Resident 1 had fallen at 4:00 a.m. with a probable fractured left hip resulting. LPN-C reported to the administrator that LPN-B reported "the resident was having increased pain in the left hip after the fall. Doctor and family had not been notified until Day Nurse arrival". The Administrator documented that upon arrival at 7 a.m. the resident was being loaded into the ambulance. The Administrator was approached by LPN-C and told LPN-A was "very upset over what happened with this resident. LPN-C also expressed concern over the delay in resident going to the ER (emergency room ). Review of the faciltiy "Policy & Procedure" for "Abuse" defines "Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness". Interview with the Administrator on 10/12/11 at 11:45 a.m. verified that Resident 1 fell at 4:00 a.m. on 8/16/11 resulting in a [MEDICAL CONDITION] requiring surgery and hospitalization . The Administrator verified LPN-B had failed to notify the physician and family, at the time of the incident, that a fall had occurred resulting in leg deformity and pain. The Administrator verified that staff on duty including LPN-A and nursing assistants felt the resident's condition and symptoms warranted transporting the resident to the ER but were over-ridden by LPN-B, the licensed nurse assigned to the care of Resident 1. The Administrator verified none of the staff contacted the Administrator or Director of Nursing with these concerns. The Administrator verified that failing to act, resulted in Resident 1 not receiving emergency medical attention until transport at 7:00 a.m. The Administrator verified the night shift nursing staff had failed to contact or seek medical attention for the resident after observing continued pain and abnormal deformity of the resident's leg. The Administrator agreed the delay in seeking medical attention of Resident 1's symptoms met the definition of neglect as defined in the facility policy.