Every finding on record at Keystone Ridge Post Acute Nursing and Rehabilitati

Licensure Reference Number 175 NAC 12-006.11 (A)(iv) Based on observation, record reviews and interviews, the facility failed to follow physician ordered diets for 1 (Resident 9) of 5 sample residents. The facility identified a census of 71. Findings are:A. A record review of the facility's Physician Orders policy with a revision date of 11/2022 revealed the following: It is the policy of this facility that drugs and diet orders shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs/diets. B.A record review of Resident 9's Order Summary Report dated 4/16/2026 revealed an order for a regular diet soft and bite sized- level 6 texture, mildly thick- Level 2 consistency. A record review of Resident 9's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 1/27/2026 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 12/15 indicating the resident has moderate cognitive impairment. Resident 9's MDS revealed that the resident has a diagnosis of dysphagia (difficulty swallowing). An observation on 4/16/2026 at 7:30 AM revealed License Practical Nurse (LPN)-D poured Resident 9 a full glass of thin water out of the water pitcher on the medication cart. An observation on 4/16/2026 at 7:38 AM revealed the Administrator (Admin) brought Resident 9 a sandwich and poured Resident 9 thin water from the water pitcher on the medication cart. LPN-D informed the Admin that Resident 9 had just had a glass of water and drank it fast and was coughing. The Admin proceeded to give Resident 9 water. In an interview on 4/16/2026 at 9:45 AM Director of Rehabilitation confirmed that Resident 9 is on a regular diet and nectar thicken water. In an interview on 4/16/2026 at 10:06 AM Administrator (Admin) confirmed that Resident 9 was ordered to be on thicken liquids. The Admin confirmed that the water the admin provided to Resident 9 was not thickened and should have been. In an interview on 4/16/2026 at 11:59 AM License Practical Nurse (LPN)-D confirmed that Resident 9 was ordered to have nectar thicken fluids. LPN-D confirmed that the water that LPN-D provided to Resident 9 was not thickened and should have been.

Licensure Reference Number; 175 NAC 12-006.18Based on observation, record review and interview the facility failed to implement Enhanced Barrier Precautions for 2 (Resident 6 and 7) of 5 residents sampled , and failed perform hand hygiene between gloving for 1 resident (Resident 7) of 4 sampled residents, and failed perform peri care and catheter care in a manor to prevent cross contamination for 1 (Resident 7) of 4 residents sampled. The facility staff identified a census of 71. Findings areA. Observation of an Enhanced Barrier Precautions sign outside room [ROOM NUMBER] on 4/16/26 at 9:58 A.M. stated the following: Stop Enhanced Barrier Precautions (EBP)-Stop; Everyone must clean their hands before entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device Care of use: central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. B. Record review of a facility policy titled IPCP Standard and Transmission-Based Precautions dated 06/2021 with a revision/review date of 7/2022; 10/2022 revealed the following: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. In Long Term Care (LTC), it is appropriate to individualize decisions regarding resident placement (shared or private), balancing infection risk with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. 3. Enhanced Barrier Precautions (EBP): expand the use of Personal Protective Equipment (PPE) and refer to the use of gowns and gloves during high contact resident care activities that provide opportunities for indirect transfer of Multi Drug Resistant Organisms (MDROs, are germs that have become resistant to multiple antibiotics, making infections difficult to treat with standard drugs) to staff hands and clothing then indirectly transferred to residents or from resident-to-resident.(e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). a. PPE: The use of gowns and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, fr nursing home residents with: i. Wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents. c. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: i. Dressing ii. Bating/showering iii. Transferring iv. Providing hygiene v. Changing linens vi. Changing briefs or assisting with toileting vii. Device care or use: central vascular line (including hemodialysis catheters), indwelling urinary catheter, feeding tube, tracheostomy/ventilator. C. Record review of a policy titled Hand Hygiene revealed the following: Policy It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Purpose Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infections. All personnel shall follow the handwashing/hand hygiene procedure to help prevent he spread of infections to other personnel, residents and visitors. Procedure 1. Wash hands with soap and water for the following situations: a. When hands are visibly soiled (e.g., blood, body fluids) b. After caring for a resident with known or suspected Clostridioides © Difficile or Norovirus infection during an outbreak, or if infection rates of C. Difficile Infection (CDI) are high. 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. before direct contact with residents; e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; k. after handling contaminated dressings, contaminated equipment, etc.; l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves D. Record review of a facility policy titled Indwelling Urinary Catheter Care with an original date of 5/2007 and a revision/Review date of 4/2025 revealed the following: Policy It is the policy of this facility that each resident with an indwelling catheter will receive care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. Procedure 7. Perform hand hygiene, using soap and water. 8. [NAME] gloves. 9. Moisten the washcloth and apply soap to the washcloth or using moistened disposable wipes, clean the catheter in a downward motion (front to back) beginning at the urinary meatus (insertion point) and at least 4 inches down (from resident toward the collection bag). Use a clean portion of the washcloth or fresh disposable wipe for one cleansing motion. E. Record Review of Residents 1's Quarterly MDS (MDS, a federally mandated comprehensive assessment tool used to determine a residents functional capabilities and helps nursing home staff identify health problems) dated 3/10/26 revealed Resident 7 was admitted to the facility on [DATE] with diagnoses of obstructive and reflux uropathy (a condition causing urine to back up into the kidneys) requiring an indwelling catheter. Resident 7's cognition was moderately impaired. required substantial/maximal assistance for shower/bathing, and personal hygiene and was dependent on staff for toileting hygiene. Observations of care of Resident 7 on 4/16/26 at 10:00 A.M. revealed Nursing Assistant (N.A.) E gathered the supplies needed, entered the room and did not don personal protective equipment (PPE). N.A. E explained procedure to Resident 7 and applied gloves without performing hand hygiene, took a clean washcloth and put it in a basin of warm water, N.A. E then picked up a bottle of soap and pumped soap onto wet washcloth, N.A. E then took the wash cloth and wiped down the left groin area, wiping back and forth with same side of the washcloth. N.A. E then folded the washcloth and wiped across groin again going back and forth with the same side of washcloth. The soiled washcloth was then placed in a trash bag. N.A. E without changing gloves or preforming hand hygiene, got a new washcloth and put in the water basin to moisten, picked up bottle of soap and pumped soap onto the moist washcloth, wiped down the right groin and up. N.A. E removed catheter tubing from securement device attached to left thigh, folded the washcloth and wiped from tubing connection towards urethra and wiped around the head of the penis and shaft, lifting the penis and wiping around the scrotal area. N.A. E discarded the washcloth into a trash bag. N.A.E. then obtained another washcloth, placed in water basin to moisten used washcloth to rinse down left groin, across the groin, down right side of groin, and from connection of foley towards urethra. N.A. E then replaced foley tubing in the securement device on the left thigh. N.A. E then discarded the soiled washcloth into a trash bag. N.A. E removed gloves and put in trashcan, applied new gloves without preforming hand hygiene, used a dry washcloth to dry resident 7's left groin, across the groin and down the right side of groin, penis and scrotum. N.A. E removed gloves and asked the resident to roll on left side, applied new gloves without preforming hand hygiene got washcloth and moistened in basin of water, picked up the bottle of soap oap to pump soap on washcloth wiped between gluteal folds from front to back, folded washcloth and wiped again front to back, placed the soiled washcloth in the trash bag. N.A. E took a towel, put part of towel in water basin to moisten, wiped between gluteal fold wiping front to back. Folded towel and used dry side of towel to dry between gluteal fold. N.A. E. removed their gloves and discarded them in the trash, applied new gloves without preforming hand hygiene, placed clean brief under resident, removed gloves and discarded then in the trash. In an interview with the N.A.E. on 4/16/26 at10:20 A.M. it was confirmed N.A.E. did not don a gown before performing cares on Resident 7 and should have. In an interview with the N.A. E. on 4/16/26 at10:20 A.M. it was confirmed she did not perform hand hygiene before performing cares on Resident 7 or between gloving and should have. In an interview with the N.A.E. on 4/16/26 at10:20 A.M. it was confirmed the N.A wiped toward the urethra and not away from the urethra and should have. In an interview with the N.A. E. on 4/16/26 at10:20 A.M. it was confirmed the N.A. she did not wipe and fold the washcloth when doing peri care. F. Record review of Resident 6's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-03-2026 revealed the facility staff assessed the following about the resident: -admitted to the facility on [DATE] -had a non-traumatic brain injury. -Brief Interview of Mental Status (BIMS) was scored as a 6. According to the MDS Manual a score of 0 to 7 indicates severe cognitive impairment. -required total assistance with eating, hygiene, dressing, bed mobility, transfers, bathing and wheelchair mobility. -weighed 169 pounds -had a feeding tube -51% or more of Resident 6's total calories came from the tube feeding. Record review of Resident 6's Order Summary (OS) printed on 04-15-2026 revealed Resident 6 had an order for Enhanced Barrier Precautions (EBP) to be utilized for the resident. An observation conducted on 04-15-2026 at 12:15 PM revealed an EBP sign outside Resident 6's room that stated: EBP everyone must: -clean their hands, including before and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High Contact Resident activities: -dressing -bathing -transferring -changing linens -providing hygiene -changing briefs or assisting with toileting -Device care or use: central line, urinary catheter, feeding tube and tracheostomy. -wound care: any skin opening requiring a dressing. An observation conducted on 04-16-2026 at 7:35 AM of Licensed Practical Nurse (LPN) A discontinuing the tube feeding for Resident 6 revealed LPN A entered the room after using Alcohol Based Hand Rub (ABHR) and donned gloves then proceeded to disconnect and flush the feeding tube without donning a gown. An observation conducted on 04-16-2026 at 7:45 AM of Nursing Assistant (NA) B getting Resident 6 out of bed revealed NA B entered the room and donned gloves and proceeded to assist Resident 6 with dressing and changing the brief, then NA C entered the room with a lift machine and donned gloves and assisted NA B transfer Resident 6 with a lift into the wheelchair. NA C then removed gloves and took the lift and left the room. NA B then proceeded to assist Resident 6 with oral care. An interview conducted with LPN A on 04-16-2026 at 10:35 AM confirmed EBP was not utilized when discontinuing Resident 6's tube feeding and should have. An interview conducted with NA B on 04-16-2026 at 10:45 AM revealed NA B did not know a gown was to be worn when working with Resident 6. An interview conducted on 04-16-2026 at 1:30 PM with NA C confirmed a gown was not worn this morning while assisting with Resident 6's transfer and should have.

Licensure Reference Number 175 NAC 12-006.07C Based on record review and interviews; the facility failed to ensure the Quality Assurance Performance Improvement Program [QAPI, a facility process that identifies problems in the facility and works to correct the concerns] identified and addressed concerns related to deficient practice identified on the annual survey 2025 ( F 584, F 791, F 812, F 865 and F880) and to ensure correction for repeat deficient practice from previous surveys (March 2023 and May 2024 for F 584 and May 2024 survey for F 812) was maintained. This had the potential to affect 69 residents that resided in the facility. The facility census was 69. Findings are: Record review of an undated facility policy entitled QAPI Program revealed the following QAPI goals and benefits: QAPI goals: -Develop regulations that help facilities meet new standards -identify areas of need and advancement -expand the level of activities required by existing quality standards -involve all caregivers in problem solving QAPI Benefits -Improve quality of care and life for patients -Prevents or decreases the likelihood of problems in care delivery -addresses gap in health care systems Meeting Times and Scope: The Quality Assurance and performance improvement (QAPI) Committee will meet quarterly at minimum and at each meeting the QAPI Committee will review areas such as: 1. Plan of Correction and Survey results. Including any internal reviews and audits. From this we will review that audits have been completed and are effective to ensure compliance. 2. Infection control data - could include PPE [Personal protective equipemnt] data, clinical data, guidance issued from CDC [Centers for Disease Control] or DIA [unknown] and any other information to ensure infection control program is utilized and data driven with benchmarks tracking and best practices 3. Grievance - including tracking and trending 4. Accidents/incidents - reviewed, tracked, and trended to determine if a PIP [Performance Improvement Project] is necessary 5. Clinical Outcomes tracked, and trended to determine if a PIP is necessary 6. Dietary Performance - tracked, and trended to determine if a PIP is necessary 7. Performance Improvement Plans (PIPs) - discussion based on trends to implement PIP and review monthly current PIPs to determine effectiveness of interventions and how to graduate from the PIP. The QAPI committee will strive to formally meet monthly. The meeting will be extensive and include discussions of data/trends and the appropriateness of PIPS and interventions. During the meeting PIPS will be reviewed and new interventions put in place as needed. Ad Hoc meetings will occur when needed, including when high-risk incidents occur or if current PIPS are not met or interventions are ineffective. (We will not wait for the next meeting if we recognize the need for new interventions) each member of the QAPI committee will be required to prepare their data, create plans to improve outcomes, and report during QAPI meeting. Post-Acute QAPI Goals: The goals of Keystone Ridge Post Acute QAPI Committee for 2025: 1. Implement a QAPI program that involves all staff and focuses on benchmarks to ensure quality for care and quality of life 2. Continued improvement with infection control. 3. Continued improvement of QAPI Program to include data and improvement plans to see overall improvement in all areas of the facility that are identified in QAPI. During the recent survey, with an end date of 05/21/2025, the following citations and repeated citations were identified: - F 584: The facility failed to ensure Resident 5's property was protected from loss and failed to maintain the cleanliness and condition of fixtures, doors, walls, ceilings, baseboards, door jams, curtains, grip strips, lights, beds and odor control in 17 of 41 occupied resident rooms in the facility. - F 791: The facility failed to ensure follow up on dental appointments were provided for Resident 11. - F 812: The facility failed to maintain kitchen appliances and the floor in the facility kitchen in a manner to prevent food borne illness. This had the potential to affect all 69 residents that ate foods prepared in the facility kitchen. - F 865: The facility failed to ensure the Quality Assurance Performance Improvement program [QAPI, a facility process that identifies problems in the facility and works to correct the concerns] identified and addressed concerns related to deficient practice identified on the annual survey 2025 ( F 584, F 791, F 812, F880) and to ensure correction for repeat deficient practice from previous surveys (March 2023 and May 2024 for F 584 and May 2024 survey for F 812) was maintained. This had the potential to affect 69 residents that resided in the facility. -F 880: The facility failed to use a disinfectant wipe to clean a glucometer between resident use for Residents 16 and Resident 44 and failed to ensure Resident 66's catheter bag was not in contact with the trash can or floor. Repeat citations: - F 584 from previous surveys 03/09/2023 and 05/02/2024: environmental concerns -F 812: from previous survey 05/02/2025: kitchen sanitation concerns Interview on 05/21/25 at 11:31 AM with the facility Administrator confirmed that an environmental tag had been written for the past 2 years and was written again this year and no PIP had been brought through the QAPI program related to the environment. The Administrator confirmed that the kitchen tag had been written last year, and a PIP had been started in March but had not been effective in maintaining correction related to kitchen cleanliness. The Administrator confirmed that the QAPI process had identified the kitchen issues but was not effective to avoid a tag this year.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11(E) Nebraska Food Code 2017 4-602.13; 6-201.11 Based on observation, interview and record review; the facility failed to maintain the dual ovens, kitchen stand mixer, and floor in a manner to prevent food borne illness. This had the potential to affect all 69 residents that ate food prepared in the facility kitchen. The facility staff identified a census of 69. Findings are: Observation on 05/17/2025 from 7:17 AM through 7:32 AM during the initial kitchen tour revealed the following: -the presence of black buildup to the bottom of both ovens. -the presence of food debris buildup on the arm and stand of the kitchen mixer. -an absence of grout between two rows of tiles that was eight tiles wide located between the stove top and the dual ovens with a buildup of food debris in the unfilled space. Observation on 05/20/2025 at 10:22 AM with the Certified Dietary Manager (CDM) and the Registered Dietitian (RD) revealed the presence of black buildup to the bottom of both ovens, the presence of food debris buildup on the arm and stand of the kitchen mixer, and the absence of grout with food debris between the tiles between the stove top and dual ovens. An interview on 05/20/2025 at 10:22 AM with the CDM confirmed the presence of black buildup to both ovens, the presence of food debris buildup on the arm and stand of the kitchen mixer, and the absence of grout between the tiles. The CDM revealed that there is a cleaning checklist for the kitchen and confirmed that the ovens should be cleaned weekly, and the kitchen mixer should be cleaned after use. An interview on 05/20/2025 at 10:25 AM with the RD confirmed grout was missing between the tiles and allowed food particles to build up. A record review of facility policy entitled Kitchen Cleaning Policy dated 08/2023 revealed: -the purpose was to maintain a clean, safe, and sanitary kitchen environment that supports the health and well-being of residents, staff, and visitors, and complies with local, state, and federal health regulations. -The CDM oversaw implementation and compliance with the policy. -Kitchen staff were responsible for daily, weekly, and monthly cleaning tasks. A record review of the Nebraska Food Code 2017 revealed the following: -4-602.13: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. -6-201.11: Floors, floor coverings, walls, wall coverings, and ceilings shall be designed constructed and installed so they are smooth and easily cleanable.

Licensure Reference Number 175 NAC 12-006.19(A) Based on observation and interview, the failed to maintain the cleanliness and condition of fixtures, doors, walls, ceilings, baseboards, door jams, curtains, grip strips, lights, beds and odor control in 17 (rooms 511, 514, 516, 518, 520, 525, 528, 5099, 5101, 5102, 5104, 5105, 5106, 5109, 5115, 5119, 5126) of 41 occupied resident rooms. The facility had a total of 50 rooms and the facility census was 69. Findings are: Observation on 05/21/25 between 8:04 AM and 9:10 AM with the Maintenance Director [MD] and the facility Housekeeping Supervisor revealed the following concerns with the facility environment: - The caulking surrounding the base of the toilet was cracked and stained brown in resident bathrooms in rooms 511, 514, 516, 518, 520, 525, 528, 5102, 5104, 5106, and 5109. - There were scrapes present in the drywall on walls in resident rooms and bathrooms in rooms 514, 516, 518, 520, 525, 528, 5099, 5101, 5102, 5104, 5105, 5106, and 5126. - The ceiling tile was cracked and bubbled in resident room [ROOM NUMBER] along the seam of the wall. - The baseboard was pulled away from the wall in the bathroom in resident room [ROOM NUMBER] and 5106 (in the room near the closet). -There were food stains on the ceiling in resident room [ROOM NUMBER] and red and brown water damage stains present in resident room [ROOM NUMBER] and 5104 in the bathroom. - There were scraped areas / holes in the wood of bathroom and room doors in resident rooms 516, 518, 520, 528, 5099, 5101, 5104, 5105, 5106, and 5115. - The nightlight cover in the bathroom was broken / loose in resident room [ROOM NUMBER], 5105, and 5106. - The kick plate was loose from the bathroom door in resident rooms [ROOM NUMBER], - The toilet paper holder is missing / broken in bathrooms in resident rooms 511, 518, 525, 5101, and 5126, - The towel bars were missing or broken in resident bathrooms in rooms 521,5118, 5123, and 5124. - The window curtains / blinds were broken and loose in rooms [ROOM NUMBER] - There was a very strong urine odor in rooms 518, 525 and 5109. - The floors were soiled, wet and sticky in resident rooms 518, 525 and 5109. - There was a missing towel bar in the resident bathroom in room [ROOM NUMBER]. - Fall stop strips were loose and torn which created a surface not able to be cleaned in rooms 520, 5104, 5105, 5115, and 5119. - A overhead light cover was missing from the ceiling in room [ROOM NUMBER]. - Lights were out in resident bathrooms in rooms 518, 5101, 5102, and 5115. - A light was out above the bed in room [ROOM NUMBER]. - The bed was broken and the head of the bed could not be raised in room [ROOM NUMBER] bed 1. - A fall mat had spots of dried tube feeding solution spattered and dried on in room [ROOM NUMBER]. - The finish was peeled in spots on the floor and was coming loose in resident rooms [ROOM NUMBERS]. - The call light cord was missing in the resident bathroom in room [ROOM NUMBER]. Interview on 05/21/25 at 9:00 AM with the MD confirmed that those areas identified needed to be cleaned / repaired. The MD confirmed there were no work orders for the areas identified and that the concerns had not been identified prior to the environmental tour of the facility.

Licensure Reference Number 175NAC 12-006.15 (A) &(B) Based on record reviews and interviews, the facility failed to assist residents in making a dental appointment. This had the potential to affect 2 (Resident 11 and Resident 5) out of 2 residents sampled. The facility staff identified a census of 69. Findings are: A. Record review of Resident 11's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 04/29/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. The MDS manual identified a score of 15 as resident was cognitively intact. An interview was conducted with Resident 11 on 05/18/2025 at 9:55 AM. During the interview Resident 11 reported having a dental appointment that never occurred. A record review of a progress note dated 06/18/2024 revealed Resident 11 had returned from a dental appointment at oral and maxillofacial surgery with a follow up appointment for 06/06/2024. Record review of a the transportation calendar revealed Resident 11 had an appointment scheduled for 08/06/2024 to see oral surgery at the Nebraska Medical Center at 1:30 PM. An interview with the Director of Nursing (DON) on 05/19/2025 at 1:39 PM revealed that Resident 11's appointment was not completed. The DON further confirmed that there was not a rescheduled appointment. B. Record review of Resident 5's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 04/22/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. The MDS manual identified a score of 15 as resident was cognitively intact. An interview was conducted on 05/18/2025 at 12:33 PM with Resident 5. During the interview it was revealed that the facility had lost the Resident's partial during a room move and the facility had not replaced it. Resident 5 reported the missing partial was reported to the Administrator in Training (AIT). An interview was conducted on 05/21/2025 at 09:55 AM with the AIT. During the interview, the AIT reported that resident did report the partial was missing. A Missing Item form dated 03/12/2025 was written regarding the lost partial. A record review of an email dated 03/13/2025 from 360 Care Dental Care revealed Resident 5 would be seen by the dentist on 04/03/2025. An email dated 04/02/2025 from 360 Care Dental Care revealed the appointment was canceled as the doctor could not make it to the facility. Record review of the facility's policy of Dental Services dated 01/01/2018: Policy: It is the policy of this facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. It is likewise the policy of the facility to repair or replace the dentures of a resident except in those situations where the loss or damage directly results from the action of an alert and oriented resident who is responsible for his/her own medical decisions. 2. In the event that a facility resident requires emergency dental services for the repair or replacement of dentures or otherwise, the Facility will: -Promptly and, in any event, no later than 3 business days from the date of loss/damage, refer the resident for dental services. -Assist the resident in making the necessary dental appointments, when necessary or requested -Arrange for transportation to and from the dental services appointment/location, using the lowest cost or no cost option to minimize the financial burden on the resident. 3. If a referral for dental services does not occur within 3 business days from the date of the loss/damage, the Facility will: -document what actions were taken to ensure the resident could eat, drink, and communicate (if applicable) adequately while awaiting dental services -Document the nature of the extenuating circumstances which led to the delay Guidelines for facility compliance: In order to comply with the facility's obligations as set forth in 42 CFR Section 483.55, the facility will: -provide or obtain from an outside resource, routine and emergency dental services for each resident -assist the resident as necessary or requested to make appointments for dental services or arrange for transportation to and from dental services locations. -Promptly, and within 3 days refer a resident with lost or damage partial or full dentures and/or documented extenuating circumstances that led to a delay] -Document what the Facility did to ensure that a resident with missing or damaged partial or full dentures could still eat and drink adequately while awaiting dental services -Not charge a resident for the loss or damage of partial or full dentures determined to by Facility policy to be the Facility's responsibility

LICENSURE REFERENCE NUMBER 12-006.18(B) Based on observation, interview, and record review; the facility failed to store a urinary catheter drainage bag in a manner to prevent cross-contamination for 1 (Resident 66) of 2 sampled residents; and failed to disinfect the glucometer during blood glucose checks. This had the potential to affect 1 (Resident 16) of 2 sampled residents. The facility staff identified a census of 69. Findings are: A. Record review of Resident 66's Admission Record revealed the facility admitted Resident 66 on 02/28/2025 and identified the following diagnoses: hyperosmolality (a condition where the blood is too concentrated) and hypernatremia (too much sodium in blood); severe protein-calorie malnutrition; pressure ulcer of sacral region; anoxic brain damage (a result of the brain not receiving enough oxygen, causing brain cells to die); sepsis (the body's extreme response to an infection); depression; epilepsy; and secondary pulmonary arterial hypertension (high blood pressure in the arteries of the lungs that is caused by another underlying health condition). Record review of Resident 66'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 03/14/2025 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 3. According to the MDS manual, a score of 3 indicated that the resident had severe cognitive impairment. Further review of the MDS identified Resident 66 utilized a urinary catheter for bladder elimination. An observation on 05/20/2025 at 9:45 AM revealed Resident 66 sitting in a wheelchair with the urinary catheter drainage bag hung inside a red trash can. An observation on 05/20/2025 at 11:07 AM revealed Resident 66 in a wheelchair in the resident's room watching television with the urinary catheter drainage bag directly on the floor. An observation on 05/20/2025 at 12:11 PM revealed Resident 66 in a wheelchair in the resident's room watching television with the urinary catheter drainage bag directly on the floor. An observation on 05/20/2025 at 12:43 PM revealed Resident 66 with a noon meal watching television with the urinary catheter drainage bag directly on the floor. An interview on 05/20/2025 at 12:46 PM with Nurse Aide (NA)-C confirmed that Resident 66's catheter bag was on the floor and should not be. NA-C further confirmed that the urinary catheter drainage bag should not be stored inside a trashcan. 52351 B. An observation on 05/19/25 at 7:43 AM of Licensed Practical Nurse (LPN)-A completing a blood glucose check of Resident 16. LPN-A performed hand hygiene and applied gloves, completed the blood glucose check and returned to the treatment cart. LPN-A wiped the glucometer with an alcohol wipe and placed the glucometer on a clean surface. An Interview was conducted on 05/19/25 8:30 AM with the Director of Nursing (DON) and DON confirmed the glucometers should be disinfected with the Sani-Cloth Germicidal Wipes.

Licensure reference: 175 NAC 12-006.04(F)(i)(5). Based on record review and interview, the facility failed to ensure medical provider was notified of blood pressures outside of established parameters for 1 [Resident 6] of 10 sampled residents. The facility had a total census of 67 residents. Findings are: A review of Resident 6's Admission Record revealed Resident 6 was admitted to the facility on [DATE]. Resident 6's Admission Record included the following diagnoses: type 2 diabetes mellitus [a disease that occurs when the body doesn't use insulin properly], chronic obstructive pulmonary disease [lung disease causing restricted air flow and breathing problems], essential hypertension [high blood pressure], and dependence on renal dialysis. A review of Resident 6's 6/2024 MAR [Medication Administration Record] revealed the following orders: -Carvedilol [a medication to treat high blood pressure and heart failure] 25 mg give 1 tablet orally in the evening every Tuesday, Thursday, and Saturday. Hold for SBP [systolic blood pressure] less than 120 and HR [heart rate] less than 50. -Carvedilol 25 mg give 1 tablet orally 2 times a day every Monday, Wednesday, Friday, and Sunday hold for systolic blood pressure less than 120 and heart rate less than 50 -Hydralazine [a medication to treat high blood pressure] 25 mg give 3 tablets orally 3 times per day Monday, Wednesday, Friday, and Sunday -Hydralazine 25 mg give 3 tablets orally 2 times per day every Tuesday, Thursday, and Saturday -Weekly vital signs notify MD of systolic blood pressure greater than 180 or less than 80, Heart rate greater than 120 or less than 50, temperature greater than 100 F, or oxygen saturation less than 88% A review of Resident 6's Progress Notes dated 6/1/24 revealed Resident 6 was admitted to the hospital for hypotensive episode [low blood sugar]. A review of Resident 6's Blood Pressure Summary revealed the following blood pressures: -6/19/24 at 10:47 AM 74/57 -6/21/24 9:48 AM 77/58 A review of Resident 6's Progress Notes did not reveal any documentation of Resident 6's provider being notified of blood pressure of 74/57 on 6/19/24 and 77/58 on 6/21/24. In an interview on 10/24/24 at 12:40 PM, the Director of Nursing confirmed that Resident 6's physician should have been notified for a blood pressure outside of the parameters.

Based on record review and interview, the facility failed to report and submit an investigation of potential neglect for 1 [Resident 1] of 10 sampled residents. The facility had a total census of 67 residents. Findings are: A review of Resident 1's Admission Record revealed Resident 1 admitted to the facility on [DATE] with diagnoses of epilepsy [seizure disorder] and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side [left side paralysis after stroke]. A review of Resident 1's Progress Notes revealed a Progress Note dated 10/13/24 at 10:22 AM revealed Resident 1 reported that Resident 1 had spilled coffee on self in the upstairs dining room yesterday evening. Resident 1 reported pain in groin. Resident 1 was found to have a 10 cm by approximately 2 cm wide area of redness with raised areas through including a fluid filled blister measuring 3 cm x 0.5 cm and a second distal fluid filled blister measuring approximately 0.3 cm x 0.4 cm. A scant amount of blood was noted to redness on inner groin area. The Progress Note stated that Assistant Director of Nursing and Administrator were notified. A review of undated list of facility investigations from 9/23/24 through 10/15/24 did not include an investigation of Resident 1's burn. A review of Performance Improvement Plan initiated 10/13/24 revealed the facility took the following action due to burn from coffee: -10/13/24 Resident 1 was re-evaluated by Occupational Therapy for lidded cup, -10/13/24 A hot liquid evaluation was completed for Resident 1, -10//13/24 Certified Dietary Manager reviewed hot liquid temperature log for 10/12/24 and 10/13/24, -10/14/24 hot liquid policy revised and education provided to staff, -Dietary staff interviewed to verify competency in process from machine to resident, -10/132/4 Staff education provided regarding temperature, coffee handling, and dining. In interviews on 10/21/24 at 1:02 PM and 4:58 PM and 10/24/24 at 2:20 PM, the Administrator reported conducting interviews regarding the burn. The Administrator confirmed that the burn was not reported to Adult Protective Services or a report submitted to the survey agency as the burn was not considered a significant injury. A review of facility policy titled Abuse: Prevention of and Prohibition Against revised 12.2023 revealed the following: -All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. -The investigation will include the following: -An interview with the person(s) reporting the incident; -An interview with the resident(s); -Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; -A review of resident's medical record; -An interview with staff members who may have information regarding the alleged incident; -Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; -An interview with staff members having contact with the accused employee; and -A review of all circumstances surrounding the incident. -Allegations of abuse, neglect, misappropriation or resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable time frames, as per this policy and applicable regulations.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to complete INR monitoring tests to ensure therapeutic dosing of Coumadin for 1 [Resident 1] of 1 sampled resident requiring INR monitoring. The facility Administrator and Director of Nursing was notified on 10/9/24 at 5:00 PM of an Immediate Jeopardy (IJ) which began on 7/10/24. The IJ was removed on 10/9/24, as confirmed by surveyor onsite verification. The Findings are: Record Review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 09-30-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 10. According to the MDS [NAME] a score of 8-12 indicates moderate cognitive impairment. -Had Diagnosis of Atrial Fibrillation (a heart condition that causes the heart to beat irregularly and sometimes very fast), Coronary Artery Disease (a condition that occurs when the coronary arteries narrow or become blocked, preventing the heart muscle from receiving enough blood and oxygen) Cerebrovascular accident (a medical condition that occurs when blood flow to the brain is suddenly interrupted), and seizure disorder. -had a heart valve replacement. -Resident was taking an anticoagulant (medications that prevent blood clots from forming in the bloodstream.). They are given to people who are at high risk of developing blood clots, which can lead to serious conditions like heart attacks and strokes). Record Review of Resident 1's Electronic Health Record (EHR, a digital version of a patient's paper chart) revealed the following for PT/INR (A PT/INR test is most often used to: See how well Coumadin, an anti-coagulant or blood-thinning medicine, is working to prevent blood clots.) testing: -Check PT/INR on 07-10-2024- Resident 1's Treatment Administration Record (TAR) revealed a PT/INR was completed at 6:46 PM and no Coumadin dosing was present on the Medication Administration Record (MAR) for 07-10-2024. -Progress notes dated 07-11-2024 revealed facility followed up with prescriber for Coumadin orders. -Progress notes dated 07-12-2024 revealed the prescriber ordered a PT/INR on 07-15-2024 -Record review of Resident 1's progress notes, MAR, TAR, and Coumadin Flow Sheet (CFS) revealed no PT/INR completed and no Coumadin dosing obtained. Furthermore, no Coumadin dosing was present on the MAR from 07-15-2024 through 07-22-2024. -Record review of Resident 1's progress notes dated 07-18-2024 revealed a PT/INR was obtained per order. -Record review of Resident 1's order listing, MAR, and TAR revealed no order to check PT/INR on 07-18-2024. -Record review of Resident 1's progress notes dated 07-19-2024 revealed Resident 1's responsible partly was updated on a new Coumadin order. -Record review of Resident 1's MAR, TAR and order listing revealed no order for Coumadin on 07-19-2024. -Record review of Resident 1's TAR for August 2024 revealed an order to check a PT/INR and call results to Coumadin clinic. The TAR revealed the PT/INR was completed at 8:37 PM. -Record review of Resident 1's progress notes dated 08-05-2024 revealed the staff were to follow up with the prescriber for Coumadin orders. -Record review of Resident 1's MAR for August revealed an order for Coumadin starting 08-06-2024 and no orders or dosing noted in the MAR for 08-05-2024. -Record review of Resident 1's TAR for August 2024 revealed an order to check a PT/INR on 08-09-2024 and call results to Coumadin clinic by noon. The TAR revealed the PT/INR was checked at 4:33 PM. -Record review of Resident 1's orders revealed an order to check a PT/INR on 08-26-2024 and call and communicate the results for new instructions. -Record review of Resident 1's TAR revealed a PT/INR was completed on 08-26-2024 at 5:20 AM. Results of INR were not called to prescriber until 08-27-2024 and the facility did not receive orders for dosing until 08-28-2024. -Record review of Resident 1's TAR revealed an order to check a PT/INR on 10-07-2024 and call results to the Coumadin clinic by noon. The TAR also revealed the PT/INR was completed on 10-07-2024 at 3:35 PM. -Record review of Resident 1's progress notes dated 10-08-2024 revealed the facility received for Coumadin dosing and an order to recheck PT/INR. An interview on 10-09-2024 at 3:50 PM with the Director of Nursing (DON) confirmed the missed doses of Coumadin were a significant medication error. Record Review of the Facility Policy Medication Errors and Adverse Reactions dated 01-2022 identified a medication error as an administration of medications that was not in accordance with the prescriber's order. Furthermore, Nursing must immediately implement and follow the physician's orders. An interview with the DON on 10-10-2024 at 1:23 PM confirmed the expectation is nursing staff should have called the prescriber with the PT/INR results on the day the PT/INR was taken to avoid a lapse in Coumadin therapy. 04577 The Immediate Jeopardy situation was determined to have begun on 07/10/24. The facility was informed to the Immediate Jeopardy status on 10/9/24. The facility abatement plan was implemented on 10/9/24. The specific requirements that were violated was F760 and 175 NAC 12-006.10 (D) for failure to ensure medications were administered to residents in accordance with physician orders. The facility implemented the following actions on 10/9/24 to remove the immediacy of the situation and to protect the residents: -The DNS [Director of Nursing Services] or designee will identify all other residents on routine narcotics to complete full audit of eMAR [electronic Medication Administration Records] documented administration and verification of medication availability. This audit and verification will be completed by 8:00 PM 10/9/24. -The DNS or designee will educate nurses and CMAs [Certified Medication Aides] currently working and all other licensed staff prior to working their next shift. Electronic education will be completed with all nurses and CMAs by end of day 10/9/24. Education will include expected use and instructions on use of facility emergency medication kit, correct ordering of medication and clear expectation on time and expectation to complete physician ordered PT/INR [prothrombin time/international normalized ration] blood draw, as well as expectation of time deadlines to notify PCP [Primary Care Physician] or coumadin clinic, manually entering telephone orders for next INR and coumadin dose. -The DNS or designated clinical manager will complete all INR draws and notification x 2 weeks, while completing follow up education and verification of understanding with nurses. -The ED [Executive Director] or designee will audit staff education completion of the above areas every shift x 2 days. The DNS or designee will audit e MAR for omissions of missed narcotic prior to end of shift x 7 days or until substantial compliance is determined. The DNS or designee will audit eMAR and progress notes for omissions of INR completion and PCP notification x 4 weeks or until substantial compliance is determined. The above audits will submitted to QAPI [Quality Assurance Performance Improvement] monthly x 3 until substantial compliance is determined. -Resident 1 coumadin is on the building and the INR will be completed by ADON on 10/10/24 in the AM. Results will be called to coumadin clinic on 10/10/24. -Resident 4 is in the hospital but fentanyl patches are available in the EKit and oxycodone is currently available. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review and interview, the facility failed to ensure medications were administered in accordance with physician orders for 2 [Residents 1 and 4] of 4 sampled residents which resulted in significant medication errors. The facility Administrator and Director of Nursing was notified on 10/9/24 at 5:00 PM of an Immediate Jeopardy (IJ) which began on 7/10/24. The IJ was removed on 10/9/24, as confirmed by surveyor onsite verification. The Findings are: A. Record Review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 09-30-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 10. According to the MDS [NAME] a score of 8-12 indicates moderate cognitive impairment. -Had Diagnosis of Atrial Fibrillation (a heart condition that causes the heart to beat irregularly and sometimes very fast), Coronary Artery Disease (a condition that occurs when the coronary arteries narrow or become blocked, preventing the heart muscle from receiving enough blood and oxygen) Cerebrovascular accident (a medical condition that occurs when blood flow to the brain is suddenly interrupted), and seizure disorder -had a heart valve replacement. -Resident was taking an anticoagulant (medications that prevent blood clots from forming in the bloodstream. They are given to people who are at high risk of developing blood clots, which can lead to serious conditions like heart attacks and strokes). Record Review of Resident 1's Record Review of Resident 1's Medication Administration Record (MAR, a report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) and Treatment Administration Record (TAR) for July 2024 revealed the following: -07-10-2024 no orders or coumadin (Coumadin (warfarin) is a blood-thinning medication that requires regular blood tests to monitor how well it's working and prevent blood clots. These tests measure your prothrombin time (PT) and calculate your international normalized ratio (INR) administered.) -07-10-2024 Check PT/INR (a test to evaluate blood clotting) -documented as completed. -07-12-2024 lovenox (an injectable blood thinner) 100 Milligrams (MG or mg) /Milliliter (ML or ml) inject 1 ml twice a day- documented administered. -07-13-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-14-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-15-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-15-2024 no coumadin orders. -07-16-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-16-2024 no coumadin orders. -07-17-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-17-2024 no coumadin orders. -07-18-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-18-2024 no coumadin orders. -07-19-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-19-2024 no coumadin orders. -07-20-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-20-2024 no coumadin orders. -07-21-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-21-2024 no coumadin orders. -07-22-2024 lovenox 100 MG/ML twice a day- documented as administered -07-23-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-24-2024 lovenox 100 MG/ML twice a day- documented as administered. -07-25-2024 lovenox 100 MG/ML twice a day- documented as administered. Record review of Resident 1's orders revealed no orders to hold or skip a day of coumadin on 07-10-2024, or 07-15-2024 through 07-22-2024. Record review of Resident 1's progress note dated 07-11-2024 revealed new orders for coumadin 8 mg now and start lovenox 100 mg injection twice a day and follow up with the coumadin clinic tomorrow per on call prescriber instruction. Record review of Resident 1's progress note dated 07-12-2024 revealed staff followed up with coumadin clinic and received orders for coumadin 8 mg today, 6 mg 07-13-2024 and 07-14-2024. Continue lovenox injection 100 mg twice a day. Obtain a PT/INR on 07-15-2024 and call the coumadin clinic with the results. Record review of Resident 1's progress notes, order listing and MAR revealed no PT/INR testing was completed for 07-15-2024. Record review of Resident 1's progress notes revealed on 07-18-2024 a PT/INR was collected and sent to the lab. Record review of Resident 1's progress notes dated 07-19-2024 Resident 1's responsible party was notified of new coumadin order. Record review of Resident 1's progress notes dated 07-22-2024 revealed staff received an order for Coumadin 8 mg on 07-22-2024, 07-23-2024, and 07-24-2024. Recheck PT/INR on 07-25-2024 and continue lovenox injections daily with subsequent coumadin dosing. Record Review of Resident 1's Record Review of Resident 1's MAR and TAR for August 2024 revealed the following: 08-05-2024- Recheck PT/INR -documented as completed on 10-05-2024. 08-05-2024- no coumadin orders present on MAR for this date. 08-12-2024 no coumadin orders present on MAR for this date. 08-15-2024 coumadin 4 mg documented as not given. 08-22-2024 coumadin 4 mg no documentation that medication was given. 08-26-2024 Recheck PT/INR prior to 12 pm. -documented as completed. 08-27-2024 no coumadin orders present on MAR for this date. Record review of Resident 1's orders dated 08-05-2024 revealed no orders for coumadin or follow up PT/INR testing. Record review of Resident 1's orders dated 08-09-2024 revealed orders for coumadin 6 mg on 08-09-2024 and 08-12-2024. Recheck PT/INR on 08-13-2024. Record review of Resident 1's orders for 08-13-2024 revealed an order for coumadin 6 mg on 08-13-2024 and coumadin 4 mg on 08-14-2024 and 08-15-2024. Recheck PT/INR on 08-16-2024. Record review of Resident 1's orders for 08-19-2024 revealed an order for coumadin 4 mg on 08-19-2024 and 08-20-2024 and 08-22-2024. Record review of Resident 1's orders on 08-23-2024 revealed an order to recheck PT/INR on 08-26-2024 prior to 12 pm. Record review of Resident 1's orders on 08-27-2024 revealed no orders for coumadin or follow up PT/INR testing. An interview on 10-09-2024 at 3:50 PM with the Director of Nursing (DON) confirmed the missed doses of coumadin were a significant medication error. A follow up interview with the DON on 10-09-2024 at 5:00 PM confirmed no records were found for the identified omissions in July, August, September and October except on 08-26-2024 which the facility identified that missing dose as a medication error. Record review of Resident 1's MAR and TAR for September 2024 revealed the following: -09-10-2024 coumadin 6 mg no documentation that medication was given. Record review of Resident 1's orders dated 09-09-2024 revealed an order for coumadin 6 mg give on 09-09-2024, 09-10-2024, 09-12-2024, 09-13-2024, and 09-15-2024 and to give 4 mg on 09-11-2024 and 09-14-2024. Record Review of Resident 1's MAR and TAR for October 2024 revealed the following: -10-07-2024 Check PT/INR and call results into the Coumadin Clinic before noon. -Documented as completed at 3:35 PM. -10-07-2024 No coumadin ordered or given. An interview was conducted on 10-09-2024 with Licensed Practical Nurse (LPN) A at 2:00 PM revealed LPN A had worked on 10-07-2024 but did not know who checked the PT/INR on that day. LPN A confirmed they received orders for coumadin on 10-08-2024. An interview with the DON on 10-10-2024 at 1:23 PM confirmed the expectation is nursing staff should have called the prescriber with the PT/INR results on the day the PT/INR was taken to avoid a lapse in coumadin therapy. Record Review of the Facility Policy Medication Errors and Adverse Reactions dated 01-2022 identified a medication error as an administration of medications that was not in accordance with the prescriber's order. Furthermore, Nursing must immediately implement and follow the physician's orders. 04577 B. A review of Resident 4's Admission Record revealed Resident 4 was admitted to the facility on [DATE] with diagnoses of Pick's disease [a type of frontotemporal dementia], Opioid Dependence [physical and psychological reliance on opioids], and Chronic Pain Syndrome. A review of Resident 4's quarterly Minimum Data Set [a comprehensive assessment used for care planning] dated 7/16/24 revealed the following: -Resident 4 had pain frequently over the last 5 days -Resident 4 occasionally had pain that effected sleep in the last 5 days -Resident 4 occasionally had pain that limited day-to-day activities -Resident 4 rated pain intensity at 5 on a scale of 1-10 over the last 5 days A review of Resident 4's Care Plan revealed a focus area dated 3/31/222 for having chronic pain related to Pick's disease and chronic knee pain with a goal of voicing a level of comfort and the following interventions: -Medications and treatments as ordered initiated 7/25/24. -Monitor and document for side effects of pain medications including constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and falls. Report occurrences to the physician initiated 3/31/22. -Monitor and report to nurse loss of appetite, or refusal to eat and weight loss initiated 3/31/22. -Monitor and report to nurse resident complaints of pain or requests for pain treatment initiated 3/31/22. -Occupational, Physical, speech-Language therapy evaluation and treatment per physician orders initiated 3/31/22. -Pain assessment every shift initiated 3/31/22. -Prefers to have pain controlled by medication initiated 3/31/22. A review of Resident 4's 10/2024 MAR [Medication Administration Record] revealed the following orders: -Fentanyl [synthetic opioid] 25 mcg [microgram]/hour apply to middle of chest topically one time a day every 3 days dated 3/14/2024 -Oxycodone HCl [opioid analgesics] 5 mg [milligrams] tablet, 1 tablet by mouth 3 times per day for pain management dated 8/27/24 A review of Resident 4's Progress Notes revealed the following: -Progress Note dated 10/6/24 7:41 AM stated Fentanyl Patch was not available for administration. Patch was reordered pending delivery. -Progress Note dated 10/3/24 11:59 AM stated Fentanyl Patch was not available for administration -Progress Note dated 9/28/24 at 1:29 PM stated Oxycodone 5 mg tablet was not available for administration waiting on pharmacy -Progress Note dated 9/28/24 at 9:49 AM stated Oxycodone 5 mg tablet waiting on pharmacy for delivery -Progress Note dated 9/27/24 at 5:07 PM stated Oxycodone 5 mg not given waiting for pharmacy -Progress Note dated 9/27/24 at 2:02 PM Oxycodone 5 mg not given waiting on pharmacy A review of Resident 4's 10/2024 MAR revealed Fentanyl Patch 25 mcg/hour apply to middle of chest topically 1 time per day every 3 days was scheduled to be administered on 10/3/24 and 10/6/24 and was not administered on either date. A review of Resident 4's 9/2024 MAR revealed Oxycodone 5 mg 1 tablet 3 times per day was not administered on 9/27/24 or 9/28/24. A review of Resident 4's 9/2024 MAR revealed the following pain levels on a scale of 1-10 with 10 being the most pain for 9/27/24-9/28/24: -9/27/24 6 AM-5; 12 PM 3; 6 PM 6 -9/28/24 6 AM 0; 12 PM 3; 6 PM 3; A review of Resident 4's 10/2024 MAR revealed the following pain levels on a scale of 1-10 with 10 being the most pain for 10/3/24-10/8/24: -10/3/24 6 AM 0; 12 PM 7; 6 PM 5; -10/4/24 6 AM 0; 12 PM 3; 6 PM 3; -10/5/24 6 AM 0; 12 PM 6; 6 PM 0; -10/6/24 6 AM 0; 12 PM 5; 6 PM 4; -10/7/24 6 AM 0; 12 PM 0; 6 PM 5; -10/8/24 6 AM 0; 12 PM 0; 6 PM 5; A review of Resident 4's Progress Notes revealed the following: -10/8/24 at 5:09 PM resident with increased agitation and confusion during the day, scooting self on floor while throwing objects in rooms, knocked trash can over and ripped brief into shreds while on floor. Resident temp [temperature], 02 [oxygen saturation] and pulse within normal limits, resident refuses blood pressure check. Call placed to [Doctor] office with request for UA [urine analysis]. Awaiting return phone call -10/8/24 11:55 PM Res continues series of jacking [jerking] movements uncontrollable series of motion. Sometimes hitting head, lower extremities. Attempts to get VS [vital signs] and make assessment and Resident continue to show signs of stress. New bruises observed coming from the uncontrollable movements. Call made to ON-CALL DON [Director of Nursing] for order. Call placed for [doctor name] with order received to send resident to Hospital to eval [evaluate] and treat. ER [emergency room ] at [hospital] informed and Transfer documents forwarded with arrival of Squad. 11:45 PM Squad arrived for transportation of res to [hospital] -10/9/24 1:18 AM 1:15 AM Revisiting ER for information on admission. Resident would be admitted for dehydration and AKI [acute kidney injury] possibility of a kidney injury would be determined after the result of CT scan. In an interview on 10/9/24 at 2:22 PM, MA [Medication Aide] B confirmed that Resident 4 did not have a Fentanyl patch for administration on Sunday [10/6/24]. MA B stated that MA B had notified the nurse. In an interview on 10/9/24 at 1:43 PM, RN [Registered Nurse] C reported Resident 4 was having fits on the floor. RN C reported calling Resident 4's provider but did not receive a return call by the end of the shift. RN C reported that Resident 4's agitation increased throughout the day and Resident 4 was ripping off brief. RN C indicated that RN C was not aware that Resident 4 was missing medications. In an interview on 10/9/24 at 3:38 PM, LPN D reported Resident 4 was not responding in an understandable manner and was shaking so bad that vital signs could not be taken. LPN D reported Resident 4 had leg bruising from hitting body on the trash can. LPN D reported being unaware that Resident 4 did not have a Fentanyl patch and would have gotten one from the emergency kit. LPN D reported calling Resident 4's doctor and sending Resident 4 to the hospital. A review of email from facility pharmacy dated 10/9/24 at 3:54 PM revealed that Resident 4's Fentanyl patch was reordered thru Point Click Care [medical record and medication administration system] on 10/6/24. The email stated that narcotics cannot be reordered through that interface resulting in the refill request not going through. The email stated that controlled substances reorder requests must be faxed. In an interview on 10/9/24 at 5:01 PM, the DON confirmed that narcotics reorders must be faxed and can not be reordered thru Point Click Care. The DON confirmed that Resident 4's Fentanyl patch and Oxycodone were not refilled for the same reason. The DON confirmed that missing Oxycodone and Fentanyl would both be considered a significant medication error. The DON reported that both Fentanyl patches and Oxycodone were available in the facilities emergency kit. A review of facility policy titled Medication Errors and Adverse Reactions revised 1/2022 revealed the following: -Medication Error' means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: -The prescriber's order; -Manufacturer's specifications (not recommendations) regarding the preparation or administration of the medication or biological; or -Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. A review of facility policy and procedure titled Care and Treatment under section Medications, Provision of Routine, Emergency and OTC [over the counter] revised 2/2022 revealed the following procedure: -1. Medications prescribed on a routine, emergency, or PRN should be administered in a timely manner. -2. When an emergency or stat order is received, the charge nurse: -Determines that the order is a true emergency, i.e., cannot be delayed until the scheduled pharmacy delivery. -Ascertains whether the ordered medication is contained in the emergency kit by referring to the list of contents posted at the nursing station or on the box. -If the medication is not available, calls the pharmacy, using the after-hours emergency number(s), if necessary. -3. The provider pharmacy supplies emergency or stat medications according to the provider pharmacy agreement. -4. Medications are not borrowed from other residents. The required medication is obtained either from the emergency box or from the provider pharmacy. -5. The provider pharmacy is called if an emergency arises requiring immediate pharmacist consultation, using the after-hours emergency number(s), if necessary. In the event that the provider pharmacy is unable to supply essential information regarding the appropriateness of a new drug order, the consultant Pharmacist is contacted. -6. OTC medication could be ordered from a supplier that the facility choses to, an inventory must be kept for the medication ordered and replaced the used ones. The Immediate Jeopardy situation was determined to have begun on 07/10/24. The facility was informed to the Immediate Jeopardy status on 10/9/24. The facility abatement plan was implemented on 10/9/24. The specific requirements that were violated was F760 and 175 NAC 12-006.10 (D) for failure to ensure medications were administered to residents in accordance with physician orders. The facility implemented the following actions on 10/9/24 to remove the immediacy of the situation and to protect the residents: -The DNS [Director of Nursing Services] or designee will identify all other residents n routine narcotics to complete full audit of eMAR [electronic Medication Administration Records] documented administration and verification of medication availability. This audit and verification will be completed by 8:00 PM 10/9/24. -The DNS or designee will educate nurses and CMAs [Certified Medication Aides] currently working and all other licensed staff prior to working their next shift. Electronic education will be completed with all nurses and CMAs by end of day 10/9/24. Education will include expected use and instructions on use of facility emergency medication kit, correct ordering of medication and clear expectation on time and expectation to complete physician ordered PT/INR [prothrombin time/international normalized ration] blood draw, as well as expectation of time deadlines to notify PCP [Primary Care Physician] or coumadin clinic, manually entering telephone orders for next INR and coumadin dose. -The DNS or designated clinical manager will complete all INR draws and notification x 2 weeks, while completing follow up education and verification of understanding with nurses. -The ED [Executive Director] or designee will audit staff education completion of the above areas every shift x 2 days. The DNS or designee will audit e MAR for omissions of missed narcotic prior to end of shift x 7 days or until substantial compliance is determined. The DNS or designee will audit eMAR and progress notes for omissions of INR completion and PCP notification x 4 weeks or until substantial compliance is determined. The above audits will submitted to QAPI [Quality Assurance Performance Improvement] monthly x 3 until substantial compliance is determined. -Resident 1 coumadin is on the building and the INR will be completed by ADON on 10/10/24 in the AM. Results will be called to coumadin clinic on 10/10/24. -Resident 4 is in the hospital but fentanyl patches are available in the EKit and oxycodone is currently available. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

Licensure Reference Number 175 NAC 006.09(H) Based on record review and interview, the facility failed to evaluate 1 (Resident 4) of 3 sampled residents following identification of an injury from unknown sources. The facility had a total census of 67 residents. Findings are: A. A record review of Resident 4's Admission Record revealed Resident 4 was admitted to the facility on [DATE] with diagnoses of Pick's disease (a type of frontotemporal dementia), Opioid Dependence (physical and psychological reliance on opioids), and Chronic Pain Syndrome. A record review of Resident 4's Care Plan revealed a focus area of being at risk for falls dated 3/31/24 with an identified preference of Resident 4's to sit on the floor. The Care Plan identified that the Team will not count my preference of sitting on the floor as a fall unless Resident 4 has visible injury. The following interventions were identified in the Care Plan: -Offer resident extra pillow to help define perimeter of bed and decrease change of rolling off, initiated on 1/7/23. -Fall mat placed next to bed to prevent injury, initiated 5/22/24. -Avoid rearranging furniture, dated 3/31/22. -Be sure the call light is within reach and encourage to use it to call for assistance as needed, initiated 3/31/22. -Ensure resident is wearing appropriate footwear when ambulating or wheeling in wheelchair, initiated 3/31/22. -Maintain a clear pathway, free of obstacles, initiated 3/31/22. -Occupational, Physical, Speech-Language Therapy evaluation and treatment per physician orders, initiated 3/31/24. -Place sign in room for a reminder to use call light for assistance, initiated 3/9/23. -Resident self-transfers from floor to recliner per therapy. Resident is aware to call for assistance but refuses to at times because resident wants to get in dresser and get out clothes and look through items, initiated 10/17/22. -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes if possible. Educate resident/family/caregivers/interdisciplinary team as to causes, initiated 3/31/22. -Staff will ensure resident's bed is in the lowest position while the resident is in bed, initiated 3/4/23. A record review of a Weekly Skin Evaluation dated 10/8/24 at 12:19 AM revealed Resident 4 had some swelling on their left eye but Resident 4 said it was an itching spot. A record review of Resident 4's Progress Notes revealed the following: -10/8/24 at 5:09 PM resident with increased agitation and confusion during the day, scooting self on floor while throwing objects in rooms, knocked trash can over and ripped brief into shreds while on floor. Resident's temperature, 02 (oxygen saturation) and pulse within normal limits, resident refuses blood pressure check. Call placed to (Doctor) office with request for UA (urine analysis). Awaiting return phone call. -10/8/24 at 11:55 PM Resident continues series of jacking [jerking] movements, uncontrollable series of motion. Sometimes hitting head, lower extremities. Attempts to get vital signs and make assessment and Resident continues to show signs of stress. New bruises observed coming from the uncontrollable movements. Call made to On-Call DON (Director of Nursing) for order. Call placed to [doctor name] with order received to send resident to hospital to eval [evaluate] and treat. ER (emergency room ) at (hospital) informed and Transfer documents forwarded with arrival of Squad. At 11:45 PM, Squad arrived for transportation of resident to (hospital). -10/9/24 at 1:18 AM At 1:15 AM, re-visiting ER for information on admission. Resident would be admitted for dehydration and AKI [acute kidney injury], possibility of a kidney injury would be determined after the result of CT scan. Further record review of Resident 4's Progress Notes did not reveal any documentation of an evaluation of Resident 4's left eye. In an interview on 10/9/24 at 12:06 PM, Medication Aide (MA)-E revealed that the left side of Resident 4's face was swollen and Resident 4 had dried blood on their mouth. MA-E also revealed that they had noted purple and red bruising on Resident 4's legs. MA-E also revealed that injuries were reported to the nurse. In an interview on 10/9/24 at 1:27 PM, MA-F reported Resident 4 had a black eye and their mouth had dried blood in it. MA-F stated that the Resident 4 had reported hitting their head on the floor. MA-F reported Resident 4 had bruises on their legs from rolling on the floor. MA-F reported the injuries to the Assistant Director of Nursing (ADON) In an interview on 10/9/24 at 1:43 PM, Registered Nurse (RN)-C reported that Resident 4 had a black eye when RN-C came on shift. RN-C stated they had reported their concerns to Assistant Director of Nursing (ADON). In an interview on 10/9/24 at 3:38 PM, Licensed Practical Nurse (LPN)-D confirmed that Resident 4 had a black eye which was not unusual for Resident 4. LPN-D confirmed that the black eye had started small and had gotten much bigger. In interviews on 10/9/24 at 3:26 PM and 10/10/24 at 1:21 PM, the Director of Nursing (DON) reveaeled Resident 4's black eye had not been reported to them. The DON confirmed that neuro (neurological) checks should have been started and an incident report should have been completed. The DON reported that an order should have been placed in the Treatment Administration Record for a change of condition and shiftly follow up completed for 72 hours, then weekly until resolution. A record review of facility policy titled Quality of Care, in the subject section Incidents and Accidents revised 11/2023 revealed the following procedure: 1. Assisting Incident/Accident Victim: Any staff witnessing an accident/incident, or find it necessary to aid an accident victim (resident, staff), should: A. Render immediate assistance. Do not move the victim until he/she has been examined for possible injuries; B. If possible, move the injured to the treatment room, or if it is a resident in his/her room, move the resident to his or her bed; and C. If assistance is needed, summon help. If you cannot leave the victim ask someone to report to the nurses' station that help is needed, or if possible, use the call system located in the resident's room to summon help. 2. Licensed nurse will assess the resident (or visitor or staff), including vital signs, neuro checks if needed, complaints of pain and location, and determine if treatment or additional care is needed, including accessing the EMS [Emergency Medical System] system. 3. Licensed nurse will notify medical provider for residents, and obtain orders for further treatment or diagnosis as deemed necessary by the provider.

Licensure Reference Number 175 NAC 12-006.09D(l) Based on record review, interviews, and observations, the facility failed to implement assessed interventions to prevent potential injuries for 3 of 3 residents (Residents 1, 4, and 5). The facility identified a census of 65. Findings are: A. Record review of Resident 1 Census Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 6/11/24 revealed the resident had a Brief Interview for Mental Status (BIMS, is a brief screener that aids in detecting cognitive impairment) with a score of 10. According to the MDS [NAME] a BIMS score of 10 identified the resident is moderately cognitively impaired. Resident 1 required set up or clean up assist with eating. The resident required substantial/maximum assist with toileting, bed mobility and transfers. Resident 1 is frequently incontinent of urine and occasionally incontinent of bowel. Record review of Resident 1's Fall assessment dated [DATE] revealed the resident had a score of 13. A score of 13 on the fall assessment dated [DATE] revealed the resident to be at high risk for falls. Record review of Resident 1's Care Plan dated 2/17/22 revealed the resident is at risk for falls related to deconditioning, gait/balance problems, unaware of safety needs, preference to be independent and forgetfulness. The following intervention with dates had been put into place for fall preventions: -03/17/24 Frequent checks by staff. Date Initiated: 03/18/2024 -03/17/24 Offer activities outside of room. Date Initiated: 03/18/2024 -6/3/24 Offer assistance to bed and/or toileting after evening smoke time. Date Initiated: 06/03/2024 -Be sure the call light is within reach and encourage to use it to call for assistance as needed. Date Initiated: 02/17/2022 -Ensure resident is wearing appropriate footwear when transferring, ambulating or wheeling in wheelchair. Date Initiated: 11/20/2022 -Low bed Date Initiated: 02/17/2022 -Occupational, Physical, Speech-Language Therapy evaluation and treatment per physician orders Date Initiated: 03/10/2022 -Resident prefers to get up and ready for the day before breakfast. Staff will offer assistance with rising and activities of daily living and ensure resident gets to dining room for breakfast by 8 am as is her preference. (3/26/24) Date Initiated: 03/26/2024 -Staff to offer toileting assistance after meals (3/4/2022) Date Initiated: 03/04/2022 -Wheelchair next to bed. Date Initiated: 02/17/2022 Record review of the facility Adult Protective Services (APS) report dated 6/4/24 revealed on 6/3/24 at 7:30 PM Resident 1 was observed lying on their back on the floor of Resident 1's room next to the bed. When inquired about what happened, Resident 1 reported I was trying to get from my chair to my bed and just fell down. Resident 1 reported hit their head but had no loss of consciousness. Resident 1 was alert and oriented to person, place, time, and situation. Resident 1 complained of head pain, sharp neck and sharp, radiating back pain and was rated a 10/10. A call was made to the on-call physician and an order was received to send the resident to the emergency room (ER) for evaluation. Director of Nursing (DON) and Executive Director (ED) were notified of fall and transport of Resident 1 to the ER. Observation on 7/2/24 at 6:45 AM revealed Resident 1 was laying in bed with their eyes closed. The right side of Resident 1's bed was pushed up against the wall and the call light was hanging down the side with the call light button on the floor and out of reach of Resident 1. A interview on 7/2/24 at 6:57 AM was conducted with the Assistant Director of Nursing (ADON). During the interview the ADON confirmed Resident 1's call light was out of the resident's reach. B. Record review of Resident 4's Census Sheet revealed the resident was admitted to the facility on [DATE]. Record review of Resident 4's MDS dated [DATE] revealed the resident had a BIMS score of 15. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact. According to Resident 4's MDS dated [DATE] Resident 4 was dependent for assistance with toileting, bed mobility, and transfer and was frequently incontinent of bowel and bladder. Record review of Resident 4's Fall assessment dated [DATE] revealed a score of 12. A score of 12 on the Fall Assessment revealed the resident to be at high risk for falls. Record review of Resident 4's Care Plan dated 5/26/15 revealed Resident 4 was at risk for fall related to activities of daily living and mobility deficits, seizure disorder, psychoactive drug use, use of narcotic medication, incontinence of bowel and bladder, and weakness. Resident 4 had a history of behaviors as evidenced by sliding out of wheelchair for attention and pretending (gender) was having a seizure. The goal of the care plan was to prevent serious injury. To meet the goal interventions with dates were identified as follows on Resident 4's Care Plan: -08/22/23 Add non-skid mat to seat of wheelchair to prevent sliding down. Date Initiated: 08/23/2023 -5/8/24- placed on 1:1 until transferred to hospital related to psychosis and intentionally sliding out of wheelchair. Date Initiated: 05/08/2024 -5/8/24- When up in wheelchair provide 1:1 with staff during moments of psychosis, yelling, paranoia, accusatory remarks until resident can be transferred into low bed. Date Initiated: 05/08/2024 -Anticipate and meet needs as able. Date Initiated: 05/26/2015 -Be sure the call light is within reach and encourage to use it to call for assistance as needed. Date Initiated: 05/26/2015 -Bed will placed in lowest position while in it. (12/17/2023); lock bed control to prevent resident from raising height. (5/3/24) Date Initiated: 12/17/2023 -Ensure proper positioning in wheelchair as needed. Date Initiated: 05/26/2015 -Fall risk assessment quarterly, and as needed. Date Initiated: 05/26/2015 -Foam placed on foot rests to prevent injury when sliding out of chair. (2/5/24) Date Initiated: 02/05/2024 -Grab bars to both sides of bed to assist with repositioning. Date Initiated: 05/26/2015 -Keep needed items, water, etc, in reach. Date Initiated: 05/26/2015 - Observe for seizure activity and notify MD as needed if noted. Date Initiated: 05/26/2015 -Patient to be placed on 1:1 activities ongoing 1-2 times weekly per patient preference. (5/2/24) Date Initiated: 05/03/2024 -Resident will have side pillow to assist with positioning while in wheelchair. Date Initiated 11/21/2023 -Wheelchair lap belt to wheelchair. Resident 4 is able to release it. Date Initiated: 02/05/2024 Record review of the facility APS report dated 5/14/24 revealed the following information: -Resident 4 was found on the floor in the dining room sitting on the footrest of wheelchair with legs extended out straight and arms crossed over chest. -Resident was last seen shortly before when (gender) had asked to go sit in the dining room with a safety belt was in place at that time. -When questioned about what happened and how (gender) slid out of wheelchair, Resident 4 replied (gender) did it intentionally because (gender) likes to cause trouble. -When staff approached Resident 4 to reposition the resident off the foot pedals to prevent injury, Resident 4 became physically combative, cursing at staff, and stated (gender) wanted to kill (gender). -Resident 4 was placed in a low bed to prevent injury should (gender) continue behaviors or throw (gender) out of bed. -Nurse Practitioner for Resident 4 was called and Resident 4 was placed on 15-minute checks for safety. -Resident 4 continued to have aggressive behavior with Resident 4 being sent to the ER for evaluation of mental/behavioral status. -Resident 4 returned to the facility at 5:45 P.M. via a ambulance with no new orders. -Resident 4 continued to be combative with staff, refusing assessment, vital signs, and neuro checks the remainder of the evening. -Immediate steps taken to protect the resident were staff to remain with Resident 4 on a 1:1 until Resident 4 could be relocated in bed with the bed placed in low position and locked to prevent injury as a consequence of ongoing behaviors, - Resident 4 was placed on 15-minute checks and all potentially harmful objects removed from the Resident's room following harm statement. A observation on 7/2/24 at 6:53 AM revealed Resident 4 in bed with the bed in the high position. A interview with the ADON on 7/2/24 at 6:57 AM confirmed Resident 4's bed was in the high position and should be in low position. ADON demonstrated during the interview that Resident 4's bed control cannot be locked as indicated on Resident 4's Care Plan. Interview with Nursing Assistant-A (NA-A) on 7/2/24 at 9:37 AM, NA-A confirmed (gender) was not aware of how to find the Care Plan interventions for the resident under (gender) care. C. Record review of Resident 5's Census Sheet revealed Resident 5 was admitted to the facility on [DATE]. Record review of Resident 5's MDS dated [DATE] revealed Resident 5 had a BIMS score of 14. The MDS also revealed Resident 5 required set-up/clean-up assist with eating, substantial/maximum assist with transfers and toileting. Resident 5 required partial/moderate assist with bed mobility and was frequently incontinent of urine and always continent of bowel. Record review of Resident 5's Fall assessment dated [DATE] revealed a score of 10. A score of 10 was considered medium risk for falls. Record review of report dated 6/03/24 to APS revealed the following: -Resident was found sitting on the side of low bed when staff entered the room and noticed swelling a developing bruise of (gender) nose and left orbital (eye) area. -Resident 5 reported Resident 5 had been lying in bed and reached for something and rolled out onto the floor and hit (gender) nose. -Area examined by the nurse, no blood present, vision unaffected, but resident complains of pain. Resident 5's Nurse Practitioner was contacted and gave telephone order for nasal X-ray, OK for mobile X-ray per resident preference. -The X-ray was completed at approximately with the results diagnosed as a nasal fracture received at 1:59 PM. Record review of Resident 5's Care Plan dated 3/31/22 revealed Resident 5 was at risk for falls related to disease process, antidepressant use, decreased vision, and cognitive deficits. The goal for Resident 5's was not to sustain serious injury. To meet this goal the following interventions with dates were on Resident 5's Care Plan: -1/07/2023: Offer resident extra pillow to help define perimeter of bed and decrease chance of rolling off. Date Initiated: 01/07/2023 -5/22/24: Fall mat placed next to bed to prevent injury. Date Initiated: 05/22/2024 -Avoid rearranging furniture. Date Initiated: 03/31/2022 -Be sure the call light is within reach and encourage to use it to call for assistance as needed. Date Initiated: 03/31/2022 -Ensure resident is wearing appropriate footwear when ambulating or wheeling in wheelchair. Date Initiated: 03/31/2022 -Maintain a clear pathway, free of obstacles. Date Initiated: 03/31/2022 -Occupational, Physical, Speech-Language Therapy evaluation and treatment per physician orders Date Initiated: 03/31/2022 -Place sign in room for a remind to use call light for assistance. (3/9/23) Date Initiated: 03/09/2023 -Reminder to use call light for assistance Date Initiated: 03/09/2023 -Resident self-transfers from floor to recliner per therapy. Resident is aware to call for assistance but refuses to at times because resident wants to get in dresser and get out clothes and look through her items. Date Initiated: 10/17/2022 -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/Interdisciplinary Team as to causes. Date Initiated: 03/31/2022 -Staff will ensure residents bed is in lowest position while in bed (3/4/23) Date Initiated: 03/04/2023 Observation on 7/2/24 at 6:38 AM of Resident 5 revealed no floor mat on the floor beside the bed. Interview with Resident 5 on 7/2/24 at 6:39 AM revealed Resident 5 reported a staff member took the floor mat about a week ago for another resident. Interview with the ADON on 7/2/24 at 6:47 AM, ADON confirmed a floor mat should be on the floor next to Resident 5's bed. Record review of the Policy/Procedure for Fall Management System dated 6/2022 revealed the following: -Standards This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. -Policy: It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Procedures: 1 On admission, the Fall Risk evaluation will be completed to determine his/her risk for sustaining a fall. 2 Residents with high risk factors identified on the Fall Risk evaluation will have an individualized care plan developed that includes measurable objectives and time frames. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. 3 When a resident sustains a fall, an assessment will be completed by a licensed nurse, with results documented in the medical record. Unwitnessed falls and witnessed falls with impact to head will also include the initiation of neurological assessment. The Attending physician and Resident rep shall be notified of the fall and the resident status. Follow-up documentation will be completed for a minimum of 72 hours following the incident. A Fall Risk Evaluation will be completed post fall incident. 4 Review of the fall incident will include investigation to determine probable causal factors. 5 The investigation will be reviewed by the Interdisciplinary Team. A Summary of the investigation and recommendations will be documented in the Risk Management system. 6 Resident's care plan will be updated. 7 The Quality Assurance committee will analyze trends related to falls and will determine if further intervention is needed.

Based on record review and interview the facility failed to maintain staff documentation of offering the COVID 19 vaccine, education on COVID 19 vaccine, and the current Covid 19 vaccination status of 1 of 1 staff record audited. This has the potential to affect all the current residents in the facility. The facility reported a census of 73. Findings are: Record review of CNA-A personnel record revealed no record of the facility offering the COVID 19 vaccine, education on the COVID 19 vaccine, or record of current COVID vaccination status. Record review of policy entitled: Immunization Staff. Policy-The facility has established a process for staff immunizations based on: The CDC ACIP State or local health department The intent is to help reduce the risk of staff contracting and spreading influenza or SAR-COVID to reduce the chance of staff contracting Hepatitis B from exposure to blood or other contaminated sources, and as part of wound management. The facility will educate staff on the risks and benefits for the specific vaccines, offer to administer vaccine(s) and report vaccination data to the CDC National Healthcare Safety Network and/or state/local agencies as required. Interview on 4/30/24 at 3:40 PM with the Director of Nursing (DON) revealed staff are offered the Hepatitis B vaccine series, influenza vaccine, and the COVID 19 vaccine. Interview on 05/02/24 at 10:39 AM with the DON confirmed no education, screening, or records of COVID vaccine for the staff could be found.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interviews, and facility documentation review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in accordance with professional standards for food service safety, in that foods were kept past their expiration date, and foods were not labels or dated when they were opened. The facility failed to ensure the food equipment and food preparation areas are clean and sanitized. This failure could place residents who received food prepared in the facility kitchen at increased risk of exposure to food-borne illnesses. Total census was 73 and potentially affected all 73 residents. Findings are: A. During the initial tour of the kitchen 4/29/2024 from 1:05 PM to 1:55 PM revealed the following; -There was a buildup of grease on the floor in the dish room with dirt and food crumbs, a cup on the floor under a storage rack and cups lying in a tin all stacked together. -The floor behind and beside the oven area had grease build up with food debris and visible dirt stuck to it. -There were small bowls and small plates stacked face up on a tray on the shelf by the wash sink. While staff washing their hands in the wash sink, it was observed that water splash from the wash sink, splattered water onto these small bowls and small plates. -There were three (3) trays with dark, dry substances on this shelf with other plates and bowls. Two (2) plates and one (1) bowl with dried food debris on them. -Dishes and cooking equipment stored on a wired rack cart that had dust and rust on it. A wired rack, near the food prep counter, had three (3) loaves of bread, one (1) canister of opened oatmeal, a personal lunch box, a personal cell phone, and menus with clean pots and pans. -The meat slicer stored on the lower shelf was visibly dirty with large amount of dried old food particles. -Another wired rack, next to the other rack, had a large box of bananas and 14 bottles of syrup on a blue tray. -Several small steam tray pans turned upside down directly on the food rack which had visible food debris. These small steam tray pans were later used to serve food in. -On a blue tray there were observed a three (3) hole puncher, along with a bottle of Vanilla and an outdated bottle of green food coloring dated 2/22/2020. -Two (2) woks were dirty with old food crumbs. On the top shelf of this rack were one (1) lamp with 2 extension cords. The Certified Dietary Manager (CDM) reported that the lamp and extension cords are used when they have to look into the walk- in freezer as the light did not work. -The floor by the oven revealed a drain that had grease, dirt and other unidentified substances all around it. -The flour bin had an open paper bag of undated flour in it along with 2 Styrofoam cups and dish towels lined the bottom of the bin. Dust and a spilled dark, dry, substances were observed on the large prep table along with a square storage container of what looked like grape jelly but had no label, and a roll of toilet paper. -The shelf below the large prep table observed with cutting board stacked on it had a dried purple substance along with food crumbs and dust on it. -The floor the large prep table below with corrosion and a metal box covered with rust. A utensil rack hanging above a prep table revealed an Emerald lanyard with a key hanging on in direct contact with a food strainer. A large floor mixer had four (4) walkie-talkies laying on the shelf it was sitting on. -A prep cart with wheels revealed dried, sticky substance on the bottom shelf with a butter knife lying on it. Two (2) large cooking pots had dust on them. -The prep table with the microwave on it with food debris, food crumbs and dust on the bottom shelf. A large shop vac was sitting on the floor beside the stove and directly across from a food prep area. - The three (3) compartment sink was dirty with splattered food and water stains. The counter attached to the three-compartment sink had dried food debris on it along with four (4) bags of what appeared to be frozen chili. An observation at 1:35 PM on 4/29/2024 revealed a dietary staff member taking the trash out on a cart and returned to the kitchen without cleaning the cart, the dietary staff member took the cart into the dry storage room and loaded boxes of food for meal prep. The back up chest freezer located near the dry storage room had 9 boxes of bread on it. The Dry Storage Room revealed several bottles of bleach on the shelves below other food items. A different shelf had a large bottle of Lime Away, a cleaning caddy with an open bottle of Windex, a can of rust blaster, and 2 bottles of [NAME] protein hair conditioner. One (1) bottle of spray hand sanitizer, 1 can of Comet, 1 can of wasp spray, 1 large jug of multi quat solution on the cart beside food. Wrappers and dirt observed on the floor under the shelves. A personal black jacket hanging on a cart that smelled of smoke. A thick red substance noted on the wall above the food in the dry storage room. Inside the upright refrigerator there were 2 cups of poke cake not covered and not dated. The cart beside the refrigerator showed a coffee maker that had buildup on the floor below of dirt and grime. The walk-in freezer revealed a large amount of ice buildup inside and outside of the freezer door. The freezer door did not close completely; a large vacant space noted below the freezer door which allowed room air to come in, which resulted in a thick layer of ice on the inside of the freezer door and ice on the bottom of the outside of the freezer door. The freezer door jam had a black wire on it, which the CDM reported the light switch and wire caught on fire a while back and it doesn't work. There were pancakes in the freezer with ice on them. Record Review of the Daily Cleaning Duties in the kitchen for April 2024 revealed the following were cleaned 2 days out of the month of April: -Oven Face, Sides, and Top Scrubbed Clean -Flour/Sugar Bins Cleaned -Can Opener Cleaned -Hand Sink Cleaned/Soap and Paper Towels Full -Grill trap emptied/Fryer Cleaned, and Grease Fresh (It is to note that facility does not have a fryer). An observation in the kitchen on 4/29/2024 at 3:05 PM revealed a chest freezer located near the dry storage room with excessive frost on all sides and on the rim of the freezer. One thermometer inside the chest freezer read negative 10 degrees and another thermometer inside the chest freezer read negative 20 degrees. The following items were in the freezer: -1 bag of what looked like chicken patties with freezer burn and had no label or date. -1/4 bag of chicken wings that had a buildup of ice on them with no date and label. -1 bag of Canadian bacon dated 07/02 with no year had a large amount of freezer ice all over it. - 2 Sysco sliced corned beef with pack dated 10/05/2022, freeze by date of 12/19/2022 had large amount of freezer ice all over the package. - 1 bag of frozen hot dogs dated 02/22/2023 that were discolored and with ice buildup on them. An observation on 4/29/2024 at 1:20 PM with the CDM revealed all the above listed items were not clean, sealed, labeled, and/or dated. An interview on 5/01/2024 at 12:15 PM with Cook -E about cleaning schedule in the kitchen revealed that there is a cleaning log for the kitchen and copies were obtained. Cook-E reported that it is difficult to deep clean the kitchen floor without functioning drains on the floor. An interview with Maintenance Director (MD) on 5/02/2024 at 10:24 AM confirmed that the floor drains in the kitchen had not been working and approximately 2 weeks ago a plumber was called in and snaked all the kitchen floor drains and added an additional cover over the floor drain next to the oven. Maintenance Director confirmed that all drains have been working now for 2 weeks. Maintenance Director (MD) verified that the metal box located under the food prep table that was covered with rust, grease and food debris was a junction box. An interview with the CDM on 4/29/2024 at 1:20 PM confirmed that the facility had ordered a new freezer door before COVID and it didn't get installed due to COVID because the company who had ordered the door gave it to another facility.The CDM confirmed that It's been years since requesting a new freezer door. The CDM confirmed the CDM observed and confirmed the above listed items were not clean, sealed, labeled, and/or dated and should have been. B. An observation of meal service on 5/2/24 at 8:04 AM in the Garden Cafe dining room revealed CDM arrived with food cart for the Garden Cafe. The CDM placed 3 medium size pans in the steamer,2 small pans on top of steam tray and 1 large pan on top of the cart.The CDM proceeded to make coffee and Dietary Aide (DA)-G without a hair net on, entered the dining room and performed hand hygiene for 6 seconds. DA-G was observed touching resident plates with bare hands. After [NAME] goves, DA-G put a steam tray lid on top of the bread and cups. While scooping food, DA-G leaned over the cart with their sweatshirt and fanny pack touching the clean plates. DA-G did not refer to any meal tickets while serving the residents in the dining room and instead hollered across the dining room to ask the residents what they wanted to eat, touched the coffee cake with soiled gloves. Four meal plates were dished, and DA-G delivered them to the residents at their table. DA-G stopped to wrap silverware in napkins then continued to serve meals with same soiled gloves on. DA-G without removing the soiled gloves and completing hand hygiene touch the coffee cake that was being served to the residents. Sugar packets for a resident was obtained by DA-G obtained sugar packets and with the same soiled gloves poured the sugar onto a resident's cereal. DA-G continued to touch plates in center of plate and then served food on those plates with the same soiled gloves. DA-G placed soiled gloved fingers in bowls, used the soiled gloved fingers to put eggs, sausage and coffee cake into a bowl from a plate and used the same soiled gloved fingers to tear up the sausage.The DA -G continued to serve plates to residents with the same soiled gloves. DA-G removed gloves and opened sugar packets to put in cereal bowl for a resident without completing hand hygiene. DA-G applied new gloves without performing hand hygiene, sorted through the meal tickets with gloves on to see if everyone in the dining room had been served.The DA-G placed the meal tickets on the trays on the room tray cart and removed gloves and their sweatshirt. DA-G hand hygiene was performed for 7 seconds and new gloves applied. DA -G started to plate room trays at 8:35 AM and while filling plates DA-G obtained toast with soiled gloves on that was being served to residents. DA-G prepared drinks for the cart for the residents in their rooms, removed the soiled gloves gloves,wiped sweat from forehead with a paper towel and performed hand hygiene for 7 seconds. DA-G finished pouring drinks and then stopped to wrap silverware for resident use. A interview was conducted with Resident #20 on 5/02/2024 at 9:33 AM. During the interview Resident #20 reported the ground sausage was ice cold and they would not eat the eggs because they are never good. An interview with CDM on 5/02/2024 at 11:45 AM confirmed the concerns with hand hygiene and gloving and cross contamination in the Garden Cafe Dining Room. C. Record review of the facility undated policy titled Infection Control Prevention and Control Program- Hand Hygiene under the Policy revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy also stated that Use an alcohol-based hand rub containing at least 62% alcohol: or alternatively, soap (antimicrobial or non-antimicrobial) and water . which included Before and after eating or handling food. According to the Centers for Disease Control (CDC) Hand Hygiene in Health-Care Settings (2022) at https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf revealed the following: -When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Review of the Nebraska Food Code, Section 3-501.19 revealed: (1) The FOOD shall have an initial temperature of 5 C (41 F) or less when removed from cold holding temperature control, or 57 C (135 F) or greater when removed from hot holding temperature control; P.

Licensure Reference Number 175 NAC 12-006.11D Based on observation, interviews, and facility documentation review, the facility failed to prepare and serve food that is palatable, attractive and at a safe and appetizing temperature. This failure could place all residents who received food prepared in the facility kitchen at increased risk of exposure to food-borne illnesses. Total census was 73 and potentially affected all 73 residents. Observation on 5/01/2024 at 9:10 AM revealed Cook -E was preparing lunch meal for the facility residents. Cook -E had previously placed ham in 4 different pans and was observed adding brown sugar and pineapple on top of each ham. Cook -E placed foil over the top of the pans with ham and placed the ham into the oven. Cook -E performed hand hygiene for 12 seconds and applied gloves. Cook-E opened four (4) boxes of diced potatoes and took the bags of diced potatoes out of the box and placed them on the prep table. Cook-E opened a bag of diced potatoes and dumped them in a large bowl and then sprinkled them with garlic seasoning, pepper, parsley flakes, onion powder, liquid butter and salt. No measurements of any spices or butter was completed. Cook-E placed the paper liner on a baking sheet and pushed the paper liner down on the baking sheet with a soiled glove. Cook -E sprayed [NAME] (a cooking spray) on the baking sheet and poured the potatoes onto the pan and covered them with foil with Cook-E repeated this same process for the remaining 3 bags of potatoes. Cook-E removed their gloves, put spices away after wiping the spice containers and the counter with a sanitizer wipe. Cook-E obtained five (5) cans of corn and opened them with a attached can opened, obtained other spices and applied gloves without the benefit of hand hygiene. Cook-E obtained four (4) cooking pans and placed one can of corn into each pan. Cook-E added the 5th can of corn and added 8 cups of corn into two (2) of the pans. Cook-E put approximately 1/2 tablespoon of salt in each pan and squeezed an unmeasured amount of liquid butter into each pan. Cook-E filled the liquid butter bottle, removed gloves, and placed foil on top of the pans, put masking tape on top of pan to label. Cook -E placed the potatoes that were on baking sheets on a wheeled rack cart and placed in the refrigerator. Cook -E placed the corn into the over and performed hand hygiene for 10 seconds. At 10:00 AM Cook-E took the ham out of the oven, washed hands for 5 seconds and then put gloves on. Cook-E obtained the temperature of the ham which was at 162 degrees for 15 seconds, re-covered the ham with foil and placed back into the oven. Cook -E lowered the oven temperature to 180 degrees to keep the ham warm. An interview on 5/01/2024 at 9:40 AM with Cook-E revealed that the corn recipe was for 133 residents. Cook-E confirmed there were 73 residents in the facility and that they were all receiving the lunch meal out of this kitchen. There were no other options different serving sizes. Cook-E reported that is hard to determine how much ingredients and spices to put in when you have to make the corn in four different pans. B. On 5/01/2024 Cook-F left the kitchen at 11:47 AM and returned at kitchen at 12:04 PM. Cook-F spoke to residents who were present in the dining room to get their meal choices and then lined up meal tickets. Cook -F performed hand hygiene for 12 seconds, applied gloves, prepared a plate, wiped off a dirty cart with a rag and changed gloves without performing hand hygiene. Cook -F dished 5 more plates and at 12:08 PM with the same soiled gloves on took the cart to the dining room and served those residents who were at different tables. In the main dining room, the Certified Dietary Manager (CDM) loudly cued Cook -F to serve all residents at one table then move on and asked why the cook had gloves on. The CDM reminded Cook -F to wash hands with glove changes. Cook -F returned to the kitchen, applied gloves without completing hand hygiene and plated 6 more plates of food and took them to the dining room at 12:21 PM. Cook-F returned to kitchen and removed gloves and performed hand hygiene for 18 seconds and put on new gloves. Cook -F continued to touch clean and dirty surfaces with gloves on including touching a serving counter (dirty surface) and then touch serving ladles and then touching the inside of serving bowls with soiled gloves. C. An observation of the meal being served on 5/01/2024 from 11:40 AM to 12:42 PM revealed Cook -F was preparing room trays out of the main kitchen. Room trays were dished first and placed into a wheeled multi-rack kitchen tray serving cart. A Test tray that had been requested was plated and put into serving cart at 11:45 AM. Test tray delivered to the conference room on 5/01/2024 at 11:47 AM with the CDM using the facility thermometer revealed the food temperatures were as followed: -Ham 102 degrees. -Ground Ham 104.1 degrees. -Diced potatoes 98.4 degrees. -Corn 106 degrees. On 5/01/2024 at 11:47 AM an interview was completed with the CDM. During the interview the CDM confirmed the food did not reach 135 degrees and confirmed the ham and potato's were cold. An interview on 5/02/2024 at 7:55 AM with the CDM confirmed the facility uses RD Dining Menu and it is for 133 servings. CDM also confirmed that the cook should have mixed the potatoes in a large tote and followed the recipe. Review of the Nebraska Food Code, Section 3-501.19 revealed: (1) The FOOD shall have an initial temperature of 5 C (41 F) or less when removed from cold holding temperature control, or 57 C (135 F) or greater when removed from hot holding temperature control; P

License Reference Number 175 NAC 12.006.04C2 Based on record review and interview the facility failed to ensure a Registered Nurse (RN) was present in the facility for at least 8 consecutive hours on 03-31-2024 and 4-28-2024, which had the potential to affect all residents that reside in the facility. The facility census was 73. Findings are: Record review of the facility's Daily Nursing Daily Deployment sheets revealed there was not a RN present in the facility for 8 consecutive hours on 03-31-2024 and 04-28-2024. Record review of the facility's Nurse Staffing Hours posting revealed there was not a RN present in the facility for 8 consecutive hours on 03-31-2024 and 04-28-2024. An interview conducted with the Administrator (ADM) on 05-02-2024 at 1:06 PM who confirmed there was not a RN working for 8 consecutive hours on 03-31-2024 and 04-28-2024.

Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to maintain the cleanliness and condition of walls, floors, curtains, fixtures, ceiling tiles, ventilation covers, baseboards, doors and nightlight's in 23 (Rooms 511, 512, 513, 514, 516, 520, 521, 525, 526, 528, 5101, 5104, 5106, 5109, 5110, 5116, 5118, 5119, 5121, 5123, 5124, 5126 and 5128 ) of 43 total occupied resident rooms, the bath house on both levels of the facility, the activity room on the garden level of the facility, the walls across from the elevator and across the nurses station on the garden level and hand rails on both levels of the facility. The facility failed to ensure that rooms were homelike as evidenced by no closet doors present in 19 (Rooms: 510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522, 524, 525, 526, 527, 528, 529) of 19 occupied resident rooms on the garden level of the facility. The facility census was 73. Findings are: Observation on 05/02/24 between 8:00 AM and 9:15 AM with Maintenance Director [MD] revealed the following concerns with the facility environment: - The caulking surrounding the base of the toilet was cracked and broken in resident bathrooms in rooms [ROOM NUMBERS] and the garden level bathhouse. - There were scrapes present in the drywall on walls in resident rooms 511, 513, 516, 521, 526, 5101, 5104, 5106, 5109, 5116, 5118, 5119, 5123, and 5126 and along the length of the wall by the nurses' station and the elevator on the garden level of the facility. - There were stained, brown areas present around the base of the toilet in resident bathrooms in rooms 514, 5118 and 5106 and the garden level bathhouse. - The ceiling tile was cracked/missing and bubbled in resident room [ROOM NUMBER] above the window, in room [ROOM NUMBER]'s bathroom, in the garden level bathhouse and in the activity area on the garden level of the facility. - The baseboard was pulled away from the wall in the bathroom in resident rooms 512, 516, 525, and 521 (in the room near the closet), -There were patched areas of the ceiling that were not painted in resident bathrooms in rooms [ROOM NUMBER]. - There were scraped areas in the wood of bathroom and room doors in resident rooms 512, 514, 516, 520, 5285101, 5104, 5106, 5110, and 5121. - The ventilation system covers in resident bathrooms were coated with a gray fuzzy substance that resembled dust in resident rooms 511, 525, 526, 5101, 5109, 5116, 5118, 5119, 5121, 5123, 5124, 5126 and 5128. - There were round holes in the wall behind the door from where the doorknob came into contact with the wall in resident rooms [ROOM NUMBERS]. - The nightlight in the bathroom was broken in resident room [ROOM NUMBER]. - A wall plate was not securely attached to the wall in resident bathroom in room [ROOM NUMBER]. - The toilet paper holder is missing / broken in bathrooms in resident rooms 521, 5101, 51165118, 5119, and 5126. - The towel bars were missing or broken in resident bathrooms in rooms 521,5118, 5123, and 5124. - The window curtains were broken and loose in rooms 5101, 5104 and 5106. - A plastic glove holder was broken and jagged plastic present along the broken edge in resident bathroom in room [ROOM NUMBER]. - There was a very strong urine odor in room [ROOM NUMBER]. - The floors were soiled, wet and sticky in resident rooms [ROOM NUMBERS]. - The bathroom door in room [ROOM NUMBER] would not close unless lifted up and pushed in. - A toilet support bar in resident bathroom in room [ROOM NUMBER] was loose and missing one side of the support. It was laying on the floor and the other support bar was very loose and pushed outward away from the toilet. A toilet support bar (left side) was missing on the toilet in the bathhouse on the med center level of the facility. - There were several areas that had scrapes on the wooden handrails on both levels of the facility. - There were no closet doors present in resident rooms 510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522, 524, 525, 526, 527, 528, and 529. Interview on 05/02/24 at 9:15 AM with the MD confirmed that those areas identified needed to be cleaned / repaired. The DM confirmed that there were no work orders for the areas identified and that the concerns had not been identified prior to the environmental tour of the facility. The DM confirmed that having no closet doors on closets was not homelike.

Licensure Reference Number 175 12-007.04D Based on observation and interview, the facility failed to ensure that ventilation systems were operational in resident bathrooms in 6 (rooms 5116, 5119, 5121, 5124, 5126, and 5128) of 43 occupied rooms in the facility. The facility census was 73. Findings are: Observation on 5/2/24 between 08:00 AM to 9:15 AM with the facility Maintenance Director revealed that the ventilation system was not functional and would not draw a 1 ply square of toilet paper to the surface of the ventilation cover in resident bathrooms in resident rooms 5116, 5119, 5121, 5124, 5126, and 5128. Interview on 05/2/24 at 09:15 AM with the Maintenance Director confirmed that the ventilation system did not draw a 1 square ply of toilet paper in resident bathrooms 5116, 5119, 5121, 5124, 5126, and 5128. The Maintenance Director confirmed that the ventilation system had not been for draw and that there was no documentation of when the last time the system had been checked to ensure it was operational.

Licensure Reference Number 175 NAC 12-006.05(21) Based on observation and interviews, the facility failed to treat 2 of 2 sampled residents (Residents #36 and #8) with dignity, respect, and care that promotes maintenance and enhancement of the resident's quality of life while recognizing the individuality of each resident. The facility identified a census of 73. Finding are: On 5/01/2024 during observation of meal service in the main dining room between 12:10 PM and 12:46 PM revealed Cook-F dishing food and serving in the dining room in random order and not according to where residents sat resulting in residents eating food in front of their tablemates for up to 30 minutes before other table mates being served. At 12:19 PM, Resident # 36 was sitting at a table by themselves but became visibly upset when surrounding tables of residents were served their meal between 12:10 PM and 12:20 PM. At 12:27 PM Resident #36 stood and reached for their walker to leave the dining room when their meal was served and sat back down at the table to eat lunch meal. Three residents seated together at a table in the main dining room were served at different times (12:10 PM, 12:16 PM, and 12:30 PM). An interview on 5/1/2024 at 12:19 PM with Resident # 36 revealed that the resident was upset that tables all around were being served lunch and then stated, This is bullshit and points to the other residents were being served. Observation at 5/01/2024 at 12:32 PM noted the Certified Dietary Manager (CDM) asking in a loud raised voice to Cook-F What is this for? The CDM was holding a plate resembling a Peanut Butter and Jelly sandwich. Cook -F replied back in a loud, raised voice It is for 'resident's first name'. An observation on 5/2/2024 at 8:04 AM revealed Dietary Assistant (DA)-G was preparing to serve breakfast to residents in the Garden Cafe. DA-G did not refer to the individual meal tickets but instead spoke in a loud, raised voice to the residents when they entered the dining room What do you want for breakfast? The residents were over approximately 40 feet away. An observation in the Garden Cafe dining room on 5/02/2024 at 8:10 AM revealed Resident #52 saying out loud, This is how they always talk to us, always yelling at us. An observation on 5/02/2024 at 8:20 AM in the Garden Cafe Dining Room, revealed Resident #8 pouring coffee from their coffee cup into a Pepsi Bottle and the resident accidentally spilled the coffee on the table and the floor. The CDM was overheard speaking to Resident #8, in a loud voice, asking the resident if they were pouring their coffee and spilling it. The CDM went on to say, You can't do that! You will get burned! Other residents in the dining room stopped talking and eating to look at the resident who was being talked to. Resident #8 appeared embarrassed and tried to explain that (gender) wanted to save the coffee for later. An observation on 5/02/2024 at 8:21 AM in the Garden Cafe' Dining Room revealed Resident #52 stating loudly, See, this happens all the time, you should be here every day. On 05/02/2024 at 11:50 AM an interview with Resident #8 revealed when asked if it bothered them how the CDM talked to them that morning. The resident replied, I don't let things like that bother me. Review of CMS document Your Rights and Protections as a Nursing Home Resident referenced at https://downloads.cms.gov/medicare/Your_Resident_Rights_and_Protections_section.pdf revealed You have the right to be treated with dignity and respect.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review and interview; the facility staff failed to ensure 1 (Resident 600) of 3 sampled residents was free of a significant medication errors. The facility staff identified a census of 44. Findings are: A. Record review of Resident 600's Comprehensive care Plan (CCP) dated 9-07-2015 revealed Resident 600 had short and long term memory impairments with moderately impaired decision making abilities. Further review of Resident 600's CCP dated 9-07-2015 revealed intervention identified to assist Resident 600 in decision making were to elicit family input with decision making and for staff to provide assistance with decision making. Record review of Resident 600's Medication Review Report (MRR) sheet printed on 7-08-2019 revealed Resident 600's practitioner ordered medications that included [MEDICATION(S)] Mix 75/25 suspension insulin, 55 units to be given 3 times a day. Further review of Resident 600 MRR revealed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 600's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 600's medical record revealed there was not evidence the facility staff had follow up with Resident 600's practitioner on Resident 600's not receiving the ordered insulin each time. On 7-09-2019 at 1:14 PM an interview was conducted with Pharmacist Consultant (PC) A. During the interview review of Resident 600's refusing insulin was discussed. When asked if Resident 600 refusing insulin was a significant medication error, PC A stated if there was not follow up with the physician then that would be a significant medication error. On 7-09-2019 at 1:45 PM an interview was conducted with Resident 600's Advanced Registered Nurse Practitioner (ARNP) B, During the interview review of Resident 600's MAR for June 2019 was conducted. During the interview ARNP B reported being aware that Resident 600 was refusing blood sugar checks, however, was not aware Resident 600 had been refusing much of the ordered insulin. ARNP B confirmed Resident 600 had been admitted to the hospital due to high blood sugar levels with a change in condition. Record review of Resident 600's Progress Note dated 6-20-2019 revealed Resident 600 had a change in condition and was sent to the hospital. Review of Resident 600's MRR sheet printed on 7-08-2019 revealed Resident 600 was sent to the hospital due to high blood sugar levels.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility Quality Assurance Improvement Program (QAIP) failed to identify ongoing issues relevant to F578, F582, F584, F602, F609, F656, F658, F732, F741, F761, F880 and F923 and implement effective plans of action to identify and correct the deficient practice. The QAIP failed to ensure repeated deficiencies at F677, F679, F689, F690, F759, F760, F812 and F835 were corrected and the correction maintained. The facility staff identified a census of 60. Findings are: Record review of the facility QAPI Program sheet dated 1-17-2019 revealed the following information: -#3. The outcome of the QAIP is the quality of care and quality of life of the residents. -#4. QAIP includes all employees, all departments and all services provided. -#5. QAIP focuses on systems and process's. The emphasis is on identifying system gaps. -#6. Decisions are based on data, which includes the input and experience of caregivers, residents, healthcare providers and families. -Program Purpose: -The major purpose of the QAPI committee is to improve the residents' total environment and all aspects of their lives-physical, social, physiological, spiritual and intellectual; and to improve the effectiveness, efficiency and quality of healthcare services delivered to the residents. On 4-11-2019 at 7:35 AM an interview was conducted with Licensed Practical Nurse (LPN) I. When asked if LPN J was aware of what the QAPI committee was working on, LPN I reported not aware of what the issues were. On 4-11-2019 at 7:40 AM an interview was conducted with nursing Assistant (NA) C. During the interview, NA C reported now being aware of what the QAIP committee was working on. On 4-11-2019 at 7:42 AM an interview was conducted with NA J. During the interview NA J reported not being aware of what the QAIP committee was working on. On 4-11-2019 at 7:50 AM an interview was conducted with NA K. During the interview NA K was not able to identify any issue the QAIP committee was working on. On 4-11-2019 at 8:00 AM an interview was conducted with LPN [MI] During the interview, LPN L was able to identify the facility had a QAIP proram, however, LPN L was not able to identify any issues the QAIP was working on prior to the start of the annual survey.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review and interviews the facility staff failed to utilize facility resources to ensure provision of care and services were provided to the facility residents. This had the potential to effect all residents who reside in the facility. The facility staff identified a census of 60. The findings are: Review of the current survey revealed the following deficiencies: A. F578. The facility staff failed to ensure the desired code status was documented consistently and correctly throughout the medical record. B. F582. The facility staff failed to inform one resident of Medicare Coverage change by not issuing the required forms. C. F584. The facility staff failed to ensure sufficient linen and adult briefs were available for use. D. F602. The facility staff failed to complete inventory sheets for residents. E. F609. The facility staff failed to report allegations of abuse within 2 hours and failed to report a significant injury within 2 hours to the state agency. F. F656. The facility staff failed to individualize the care plan for smoking. G. F677. The facility staff failed to provide oral care to a dependent resident. H. F679. The facility failed to implement specific activities. I. F689. The facility staff failed to ensure a resident was supervised during smoking, failed to ensure the laundry room, maintenance room and employee restroom was secured, and failed to maintain bathing temperatures to prevent potential scalds. J. F690. The facility staff failed to implement a toileting program. K. F732. The facilty failed to ensure posted nurse staffing was completely documented. L. F741. The facility failed to ensure sufficient staffing for restorative program, failed to ensure a full time wound nurse, and failed to ensure minimum staffing was completed on the facility assessment. M. F658. The facility failed to ensure insulin and [MEDICATION NAME] were administered as ordered. N. F759. The facility failed to ensure a medication error rate of less than 5%, observations of 25 medications revealed 3 errors resulting in a medication error rate of 12% O. F760. The facility staff failed to administer medication as ordered by the physician. P. F761. The facility failed to ensure medication carts were secured. Q. F812. The facility failed to date food items stored in the refrigerator. R. F835. The facility failed to utilize facility resources to ensure provision of care and services were provided to facility residents. S. F865. The facility failed to have an effective quality assurance program. T. F880. The facility failed to identify organisms that cause illness in the infection control program. U. F921. The facility failed to ensure cleanliness of stairwell, laundry room and handrails. V. F923. The facility failed to ensure that ventilation system was functioning.

Based on record reviews and interviews; the facility staff failed to ensure the desired code status was documented consistently and correctly throughout the record for 7 (Resident 53, 31, 21, 51, 1, 34, and 309) residents of 30 sampled residents. The findings are: Review of the Policy and Procedure for Code Status Listing dated ,[DATE] revealed a complete list of residents with code status will be kept in a covered paper binder at each nurse's station. A.Record review of Resident 53's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 53's desire to be a DNR (Do Not Resuscitate). Record review of Resident 53's electronic medical record revealed no information regarding Resident 53's code status. Interview conducted with LPN A on [DATE] at 02:15 PM confirmed the code status was not on the electronic medical record. B.Record review of Resident 31's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 31's desire to be a Full Code/CPR. Record review of Resident 31's electronic medical record revealed no information regarding Resident 31's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. C.Record review of Resident 21's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 21's desire to be a Full Code/CPR. Record review of Resident 21's electronic medical record revealed no information regarding Resident 21's code status. Interview conducted with LPN A on [DATE] at 02:17 PM confirmed the code status was not on the electronic medical record. D.Record review of Resident 51's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 51's desire to be a DNR. Record review of Resident 51's electronic medical record revealed a Full Code CPR status. Interview conducted on [DATE] at 02:35 PM with RN B confirmed that the Advance Directive documenting Resident 51's code status did not match Resident 51's electronic medical record. E.Record review of Resident 1's medical record revealed an Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 1's desire to be a DNR. Record review of Resident 1's electronic medical record revealed no information regarding Resident 1's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. F.Record Review of Resident 34's medical record revealed and Advanced Directives/Medical Treatment Decisions form dated [DATE] documenting Resident 34's desire to be a Full Code/CPR. Record review of Resident 34's electronic medical record revealed no information regarding Resident 34's code status. Interview conducted with LPN A on [DATE] at 02:16 PM confirmed the code status was not on the electronic medical record. Interview conducted on [DATE] at 02:10 pm with LPN A and CMA C (Certified Medication Aide) revealed the way the staff knows the code status of residents was there are blue stars on the doors that mean the resident is to have CPR and red stars are DNR. LPN A revealed the code status for each resident is in the electronic record. Observation conducted with CMA C of residents' doors revealed there were red stars on residents name plates and no blue stars were present. Interview conducted on [DATE] at 02:35 PM with Clinical Resource Nurse confirmed that facility staff were correcting DNR status of residents in the electronic record as the staff made the list of Code Status requested by surveyors. Review of Code status list provided by the facility staff revealed Resident 51 was listed as full code status. Interview conducted with DON (Director of Nursing) on [DATE] at 02:20 PM revealed that an in-service was conducted with the staff on [DATE] on Code status which instructed the staff that blue stars on the residents doors meant do CPR and the stars were on order and had not been placed on the residents doors. Abatement Statement: Based on the information provided on [DATE] to correct the immediacy of the situation, the facility staff provided the following information to protect residents: 1. A full audit of residents' signed code status reviewed and cross checked with the electronic record Point Click Care to ensure correctness. 2. Binders with each residents' signed Advanced Directives on each unit reviewed for correctness. 3. Blue stars to residents' doors implemented. 4. Managers will review all new admits and orders every day and discharges will be reviewed. 5. Full audit once a week x 4 weeks then bring to Quality Assurance for review and revision as warranted. 6. All staff re-educated on code status and Point Click Care Status. 7. Agency staff orientation checklist updated to reflect identifying code status. 8. All staff notified that they cannot work until education is complete. The Policy and Procedure for Code Status Listing updated [DATE] revealed the following: -Upon admission, residents identified as electing Full Code Status will have a blue star placed by the name card outside their room. -A complete list of residents with code status will be kept in a covered binder at each nurse's station. -Medical Records or designee will be responsible to keep code status list current and updated whenever a change occurs. The immediacy had been removed, however, the deficient practice was not totally corrected. Therefore, the severity was lowered to an F level. G: On [DATE], Record review of Resident 309 the Electronic Health Record (EHR) revealed that the Advance Directive was signed and indicated DNR. On [DATE] ,Record review of the Care Plan and the Medication Administration Record( MAR) did not reveal the code status of Resident 309. On [DATE] 1:25 PM an interview with CNA, U, was conducted , during the interview when asked how to tell the code status of the residents, CNA,U reported if there is a Red heart on the residents door it means , do not resuscitate (DNR). On [DATE] 1:35 PM an interview with CNA, V was conducted, during the interview when asked how to tell the code status of the residents CNA, V reported it was in point click care ( Electronic Health Record). On [DATE] 1:40 PM an interview with CNA, C was conducted , during the interview when asked how to tell the code status of the residents, CNA, C stated I do not know. On [DATE] 1:45 PM an interview CNA,N was conducted,during the interview when asked how to tell the code status of the residents , CNA,N reported , if there is a blue star on the door the resident is a Code ( Do Resuscitate) On [DATE] 1 :50 PM an interview with RN M was conducted, during the interview when asked how to tell the code status,he reported it is on the Demo graphic Sheet and report sheet On [DATE] at 1:55 PM observation of the Med. Center floor there were no blue stars on residents rooms. ,

LICENSE REFERENCE NUMBER 175 NAC 12-006 09D7 Based on observation, interview and record review the facility failed to ensure Resident 14 was supervised during smoking. This had the potential to affect one resident (Resident 14). The facility census was 60. Findings are: A. On 04/9/19 at 9:30 AM an observation of Resident 14 in wheel chair (w/c) outside, on the northeast side of the facility. One staff person had walked out with Resident 14 and walked around the building after lighting Resident 14's cigarette. Resident 14 sat in w/c on porch area for a while and then wheeled self, in a motorized w/c, down the driveway past the building, out of eyesight of the staff member and returned up driveway a short time later. Resident 14 did not have on a smoking apron. Resident 14 keeps cigarette in mouth the entire time of smoking as Resident 14 is unable to use hands to hold cigarette. When Resident 14 was finished with the cigarette, staff remove the cigarette. On 4/9/19 at 2:15 PM an observation of Resident 14, who was outside, on the northeast side of the facility with a different staff person, staff lit Resident 14's cigarette. Resident 14 in w/c, went down the driveway out of eyesight of staff, and returned. Resident 14 did not have a smoking apron on at this time. On 4/10/19 at 8:40 PM an observation of Resident 14 outside, on the northeast side of the facility, in w/c with a lit cigarette in mouth and no staff were around. Resident 14 said there was no staff member outside at this time. There was not a smoking apron on Resident 14. On 4/10/19 at 10:30 am a record review of the facility's smoking policy revealed residents admitted before [DATE] (YEAR) will be attempted to accommodate the practices of those residents, on an interim basis. The facility will permit supervised smoking in one designated area at designated times. In addition the facility will offer smoking alternatives, cessation programs and education. The facility expects to complete its campus wide conversion to tobacco free by (MONTH) 1, (YEAR). On and after this date, smoking will not be permitted at any time or in any location on the property. 1) The policy continues that Keystone does not allow smoking of any kind within the Facility. A designated smoking area is located along the concrete walkway at the northwesterly point of the Facility ground, and is at least 20 feet away from the building. 2) The designated smoking area shall be under the periodic observation of facility personnel or responsible adults. 3) Residents wishing to smoke must be physically able to smoke without the assistance of staff, as assessed on admission and thereafter. Residents who cannot physically smoke may call on volunteers to provide smoking assistance during the scheduled smoking times. Residents wishing to smoke must have a smoking assessment to determine safety. Such assessment will be kept in the resident's chart. 4) Cigarettes will be lit by staff. 5) The Facility reserves the right to immediately confiscate smoking materials and rescind individual smoking privileges in the interests of of resident or staff safety. If a resident is non-compliant with the smoking policy, he/she will be given a thirty (30) day notice of discharge in accordance with applicable State and Federal regulations on the grounds that his/her presence creates a threat to the safety of other individuals in the facility. On 4/10/19 at 10:40 am a record review of Resident 14 Smoking evaluation dated, 3/4/19, revealed resident is unable to hold a cigarette on own, is unable to light cigarette. Holds cigarette in mouth until the cigarette is done and then requires assist to put it out. On 04/10/19 at 11:25 AM an interview with the ADM revealed that supervised smoking was when a staff person had the resident within eyesight at all times. The ADM confirmed that the smoking area was on the northwest side of the building and Resident 14 was smoking on the northeast side of the building. The ADM also confirmed Resident 14 was an unsafe smoker as resident is unable to hold the cigarette with hands or put the cigarette out when finished. On 4/10/19 at 6:30 pm an interview with the ADM confirmed the smoking policy had stated no one was to smoke on grounds after (MONTH) 1, (YEAR) and that Resident 14 was smoking on facility grounds.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D3 Based on observation, record review and interview; the facility staff failed to implement interventions or a toileting program to prevent urine incontinence for 1 (Resident 1) of 5 sampled residents. The facility staff identified a census of 50. Findings are: Record review of Resident 1's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 9-20-2018 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was 11. According to the MDS Manuel, a score of 8 to 12 indicates moderately impaired cognition. -Was very important to choose between a tub bath, shower, bed bath or sponge bath. -Required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. -Direct care and resident believed Resident 1 was capable of increased independence in at least some Activities of Daily Living (ADL). -Occasionally incontinent of bowel and bladder with no trial of a toileting program. Observation on 10-17-2018 at 1:50 PM revealed a urinal was hanging on a bar attached to the bed used for assisting with bed mobility. Observation on 10-17-2018 at 3:30 PM revealed Resident 1 was in bed and a urinal was hanging on the bar attached to the bed used for assisting with bed mobility. Observation on 10-18-2018 at 7:05 AM revealed Nursing Assistant (NA) F, NA G and NA H preparing Resident 1 for personal cares. NA G pulled back Resident 1's cover and unfastened an adult brief and pushed it between Resident 1's legs. NA H, using a wash cloth, cleansed the peri area of Resident 1. NA F and NA G assisted Resident 1 into a left laying position. Licensed Practical Nurse (LPN) C entered Resident 1's room to complete a wound dressing to Resident 1's buttock. Resident 1 reported to LPN C being wet and the staff on the night shift had taken the urinal away at 1:00 AM. Resident 1 further reported to LPN C the staff instructed Resident 1 to go and they would come in and clean Resident 1 up. Further observation revealed a bath blanket that had been placed under Resident 1 was wet as well as the fitted sheet on Resident 1's bed and a urinal was not in place for Resident 1 to use. On 10-18-2018 at 7:05 AM an interview was conducted with NA H. During an interview NA H reported the adult brief Resident 1 had been wearing was soaked through. On 10-18-2018 during personal cares for Resident 1 at 7:05 AM , NA G reported Resident 1 was all the way wet that included the bath blanket and fitted sheet on Resident 1's bed. On 10-18-2018 at 9:14 AM an interview was conducted with Resident 1. During the interview Resident 1 stated they took my urinal away and said I didn't need it anymore. Resident 1 reported being very wet soaked. When asked how it made Resident 1 feel, Resident 1 stated embarrassed. Resident 1 was observed to become tearful during the interview related to the urinal being taken away and being incontinent. On 10-17-2018 at 1:25 PM an interview was conducted with the Assistant Director of Nursing (ADON). During the interview the ADON reported there were not any evaluations of the facility residents for a toileting program. Record review of Resident 1's medical record revealed there was no evidence the facility staff had evaluated a toileting program for Resident 1 or ensure Resident 1 had a urinal within reach.

Licensure Reference Number: 175 NAC 12-006.07C Based on record review and interview, the facility failed to have an effective Quality Assurance and Performance Improvement Plan to address facility identified concerns related to coffee temperatures. The facility had a total census of 57 residents. Findings are: A review of facility policy and procedure titled Performance Improvement revised 9/2017 identified the purpose of the plan is to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individual's highest practicable physical, mental, and social well-being. A review of Performance Improvement Plan initialed 6/8/18 identified potential out of range water temperatures on facility coffee machine in dietary. Interventions included checking the temperature in of the coffee in each cup before serving to each resident. If the coffee is too hot, staff are to cool down in a carafe or a coffee thermos without the lid. In an interview on 6/11/18 at 10:14 AM, the Director of Nursing reported an investigation had been completed the following week due to a burn on a Resident 1's foot. From that investigation, it was discovered the coffee was very hot and the coffee pot was to be replaced. Staff were provided education regarding the hot coffee. A review of In-Service Training Report dated 6/8/18 revealed training was provided to 7 staff members that coffee had to be cooled down and hot liquids need to be temped at 140 degrees F or lower before giving to resident. In an interview on 6/13/18 at 11:12 AM, Administrator and Director reported second degree burn had been discover on Resident 4 that morning and Director of Nursing had been notified. The Administrator reported coffee temperature was to be checked and cooled before giving to resident. The investigation was being completed at that time and the coffee machine had been locked to prevent its use. In an interview on 6/13/18 at 12:32 PM, Dietary Aide A reported attending the in-service last week and adding ice cubes to the coffee if it is too hot. Dietary Aide A reported that Dietary Aide A did not check the temperature of the coffee but could tell if the coffee was hot by feeling the bottom of the cup. In an interviews on 6/13/18 at 12:35 PM, the Administrator reported coffee temperature was found to be 168 to 170 degrees F when coming out of the coffee machine. The Administrator had expected staff to record the temperatures of the coffee after being cooled and before service to resident but that was not being done. According to the Administrator, the current coffee machine was going to be removed and replaced with the coffee machine that the facility had previously used.

Licensure Reference Number: 175 NAC 12-006.18E3 Based on observation, interview, and record review, the facility failed to protect 1 (Resident 4) of 4 sampled residents from a hot liquid burn and the facility failed to ensure that water temperatures did not present a potential scald hazard This practice had the potential to affect 37 residents who consume hot liquids, 55 residents who take baths in the facility and 32 residents of the facility who utilized the bathroom sinks in resident rooms. The facility had a total census of 57 residents. Findings are: A. Resident 4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observations on 6/13/18 at 11:45 AM revealed multiple fluid filled blisters to Resident 4's lower left arm. A review of a Skin Ulcer Non-Pressure assessment dated [DATE] revealed the following: -Chin burn, two areas in close proximity, measuring 3 cm (centimeter) in length x 2 cm in width. -Chest/left breast burn, multiple areas measured as one 22 cm in length x 16.5 cm in width. -Left arm burn, multiple areas, measured as one 16.6 cm in length x 6.2 cm in width. A review of a 6/13/18 at 6:30 AM Progress Note revealed a staff member was called to the resident's room and multiple areas were found. A review of Resident 4's Hot Liquid Safety assessment dated [DATE] revealed Resident 4 required staff set up for drinking hot liquids. Recommendations were cool beverages prior to handling/drinking. Educate resident/caregivers of hot liquids as a causative factor to prevent skin injury. Resident 4 requires a 2 handle cup and lid for hot liquids. In an interview on 6/11/18 at 10:14 AM, the Director of Nursing reported an investigation had been completed the following week due to a burn on Resident 1's foot. From that investigation, it was discovered the coffee was very hot and the coffee pot was to be replaced. Staff were provided education regarding the hot coffee. A review of the In-Service Training Report dated 6/8/18 revealed training was provided to 7 staff members that coffee had to be cooled down and hot liquids needed to be temped at 140 degrees F or lower before giving to resident. In an interview on 6/13/18 at 11:12 AM, Administrator and Director reported second [MEDICAL CONDITION] been discovered on Resident 4 that morning and the Director of Nursing had been notified at 9 AM. The Administrator reported coffee temperatures were to be checked and cooled before giving to resident. The investigation was being completed at that time and the coffee machine had been locked to prevent its use. In an interview on 6/13/18 at 12:32 PM, Dietary Aide A reported attending the in-service last week and adding ice cubes to the coffee it is too hot. Dietary Aide A reported that Dietary Aide A did not check the temperature of the coffee but could tell if the coffee was hot by feeling the bottom of the cup. In an interviews on 6/13/18 at 12:35 PM, the Administrator reported coffee was found to be 168 to 170 degrees F when coming out of the coffee machine. The Administrator had expected staff to record the temperatures of the coffee after being cooled and before service to resident but that was not being done. According to the Administrator, the current coffee machine was going to be removed and replaced with the coffee machine that the facility had previously used. B. Observations on 6/11/18 at 10:38 AM revealed a hot water temperature of 145 degrees F (Fahrenheit) in the shower on the Medical Center floor of the facility. Observations on 6/11/18 at 10:44 AM revealed a hot water temperature of 122 degrees F in the whirlpool on the Medical Center floor of the facility. Observation on 6/11/18 at 10:50 AM revealed a hot water temperature of 116 degrees F in the whirlpool and 116.6 F in the shower on the Garden level. Observations on 6/11/18 at 1:32 PM revealed a hot water temperature of 133 degrees F in the whirlpool on the Medical Center floor of the facility. In an interview on 6/11/18 at 1:32 PM, the Maintenance Director reported the water heater had been adjusted down and the water line just needed to be emptied. Observations on 6/11/18 at 1:58 PM revealed a hot water temperature of 130.2 degrees F in the bathroom sink for room [ROOM NUMBER]. Observations on 6/11/18 between 3:52 and 4:16 PM revealed the following hot water temperatures: -bathroom sink in room [ROOM NUMBER]-121.4 degrees F -bathroom sink in room [ROOM NUMBER]-125.7 degrees F -bathroom sink in room [ROOM NUMBER]-122.5 degrees F -Medical Center shower-120.2 degrees F A review of water temperature log from 6/5/17 to 6/8/18 revealed checks of hot water temperature had been checked on garden tub, medical center tub on 6/8/18, 8/25/17, and 7/27/18 In an interview on 6/11/18 at 10:52 AM, the Maintenance Director reported water temperatures are not to exceed 120 F in bathing fixture and facility water temperatures usually are between 108-110 degrees F in the facility. In an interview on 6/11/18 at 11 AM, the Director of Nursing reported all baths in the facility had been stopped. In an interview on 6/11/18 at 4:17 PM, the Administrator reported the facility was getting bids for repair of the water mixing valve. In a telephone interview on 6/11/18 at 4:34 PM, the facility Outside Contracted Plumber reported one mixing valve had been determined to be in need of repair. The hot water had been rerouted to go through the other mixing valve. The Outside Contracted Plumber reported the water temperature had been set between 115-117 F and the water temperature in the sinks and bathing areas would decrease once the water in the pipes was used. A review of 30 minute water temperature checks completed between 5:30 PM on 6/11/18 and 9 AM on 6/12/18 revealed 90 of 144 water temperatures were greater than 121 degrees F in bathing fixtures and resident bathroom sinks. In an interview on 6/12/18 at 10:19 AM, the Administrator reported signs stating not to use sink were being put on sinks with high water temperatures. In an interview on 6/12/18 at 11 AM, the Regional Director reported the hot water in the building had been shut off until one of the mixing valves could be repaired. A review of Center for Medicare and Medicaid Services guidelines effective 11/28/17 for temperatures revealed for the following: -Temperatures of 120 degrees F can cause a third degree burn within 5 minutes -Temperature of 133 degrees F can cause a third degree burn within 15 seconds -Temperature of 140 degrees F can cause a third degree burn within 5 seconds -Temperature of 148 degrees F can cause a third degree burn within 2 seconds

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observation, record review, and interview; the facility failed to ensure the administrative team utilized resources in a manner to ensure provision of care and services for residents. Facility census was 66. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance with an extended survey required related to substandard quality of care. Please refer to the Tag citations for specific detailed findings. -F 550; The facility failed to ensure water temperature for bathing was at a comfortable level for resident 56 one of one resident, the facility census was 66. -F580; The facility failed to notify Resident 39's representative of fall for one of three residents. Facility census was 66 -F609; The facility failed to submit an investigation to the state agency as required, within 5 working days. Resident 48, 3, 15. -F 655; The facility failed to include information related to antipsychotic medication in initial plan of care for use for Resident 52, 160. -F 656; The facility failed to develop activity care plans for Residents 49, 36. -F 657; The facility failed to revise plan of care for assisting resident with nutritional intake for Resident 36. -F675; The facility failed to implement a bowel care regimen to prevent impaction for Resident 36. -F 676; The facility failed to ensure dentures were available for use and failed to ensure Resident 51 was assisted with dressing. -F677; The facility failed to provide assistance with morning cares and meals for Resident 39 and provide standard of care for transfer with use of gait belt for Residents 12, 21. -F 679; The facility failed to provide activities to meet resident interest for Resident 36 and 49. -F680; The facility failed to have a activity director that meets the required qualifications. This has the potential to affect all residents in the facility. The facility Census was 66. -F684; The facility failed to ensure the coordination of care for Hospice Resident Resident 36. -F686; The facility failed to identify pressure ulcers, and failed to implement interventions to prevent development/redevelopment of pressure ulcers for Residents 160, 36, 51, and 3. -F688; The facility failed to implement a specific restorative program for Resident 3. - F689; The facility failed to implement interventions to prevent falls for Resident 38, failed to provide supervision during smoking for Resident 3, and failed to utilize gait belt in a manner to prevent potential accidents for Resident 12, 21. -F690; The facility failed to ensure that residents were free of indwelling catheters for Resident 23 and 49. -F692; The facility failed to assist Resident 36 with nutritional intake. -F712; The facility failed to ensure Residents receive primary physician visits in a routine manner for Residents 47,18,39,2,12,21. -F725; The facility failed to provide sufficient staffing levels to provide Activity of Daily Living services, nutritional intake prevention of pressure ulcer development, bowel elimination and accident prevention, with the potential to affect all residents residing in the facility. The facility census was 66. -F726; The facility failed to provide training for gait belt use and specialized equipment to maintain Range of Motion. -F758; The facility failed to monitor behaviors for use of [MEDICAL CONDITION] medication use for Resident 52 and 160 -F759; The facility failed to maintain a medication error rate less than 5 % the medication error rate was 7.69. -F760; The facility failed to ensure Resident number 23 was free of a significant medication error. -F801; The facility failed to have a qualified dietary manager, this had the potential to affect all resident. -F804; The facility failed to ensure food were provided in a manner that was maintained at a temperature that was appealing to residents. This had the potential to affect all residents the Facility census was 66 -F812; The facility failed to ensure hair restraints covered all hair during food service, and failed to utilize hand washing and gloving techniques to prevent food contamination during food service. -E0015; The facility failed to ensure sufficient supply of nutritional provisions food supplies were maintained for residents, and staff in case of emergency. -F835; The facility failed to ensure administer utilize resources in a manner to ensure provision of care, provision of services for residents. -F867; The facility failed to ensure an effective quality improvement plan as evidenced by new and repeat deficient practice Interview on 1/2/18 at 9:00 AM with the Administrator revealed the management was in the process of building its team to improve quality care to the residents of the facility. The administrator and the facility consultant confirmed that the facility did need to improve areas of deficient practice and competencies of staff.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on observations, record reviews and interviews conducted during the standard annual and extended survey process related to substandard equability of care. The facility failed to ensure an effective quality improvement plan as evidenced by new and repeat deficient practice. Facility census was 66. Findings are: Interview on 12/27/17 at 2:03 PM with the facility Director of Nursing (DON) and Nurse Consultant N revealed that the Quality Improvement Committee oversees the quality of Resident care. Nurse Consultant N confirmed the facility had not identified the current deficient practices and there were no PIP/QUAPI programs in place at this time for the following Tag citations The facility was found to be deficient in multiple areas of regulatory compliance requiring an extended survey process for substandard quality of care. Please refer to the Tag citations for specific detailed findings: -F 550; The facility failed to ensure water temperature for bathing was at a comfortable level for resident 56 one of one resident, the facility census was 66. -F580; The facility failed to notify Resident 39's representative of fall for one of three residents. Facility census was 66 -F609; The facility failed to submit an investigation to the state agency as required, within 5 working days. Resident 48, 3, 15. -F 655; The facility failed to include information related to antipsychotic medication in initial plan of care for use for Resident 52, 160. -F 656; The facility failed to develop activity care plans for Residents 49, 36. -F 657; The facility failed to revise plan of care for assisting resident with nutritional intake for Resident 36. -F675; The facility failed to implement a bowel care regimen to prevent impaction for Resident 36. -F 676; The facility failed to ensure dentures were available for use and failed to ensure Resident 51 was assisted with dressing. -F677; The facility failed to provide assistance with morning cares and meals for Resident 39 and provide standard of care for transfer with use of gait belt for Residents 12, 21. -F 679; The facility failed to provide activities to meet resident interest for Resident 36 and 49. -F680; The facility failed to have a activity director that meets the required qualifications. This has the potential to affect all residents in the facility. The facility Census was 66. -F684; The facility failed to ensure the coordination of care for Hospice Resident Resident 36. -F686; The facility failed to identify pressure ulcers, and failed to implement interventions to prevent development/redevelopment of pressure ulcers for Residents 160, 36, 51, and 3. -F688; The facility failed to implement a specific restorative program for Resident 3. - F689; The facility failed to implement interventions to prevent falls for Resident 38, failed to provide supervision during smoking for Resident 3, and failed to utilize gait belt in a manner to prevent potential accidents for Resident 12, 21. -F690; The facility failed to ensure that residents were free of indwelling catheters for Resident 23 and 49. -F692; The facility failed to assist Resident 36 with nutritional intake. -F712; The facility failed to ensure Residents receive primary physician visits in a routine manner for Residents 47,18,39,2,12,21. -F725; The facility failed to provide sufficient staffing levels to provide Activity of Daily Living services, nutritional intake prevention of pressure ulcer development, bowel elimination and accident prevention, with the potential to affect all residents residing in the facility. The facility census was 66. -F726; The facility failed to provide training for gait belt use and specialized equipment to maintain Range of Motion. -F758; The facility failed to monitor behaviors for use of [MEDICAL CONDITION] medication use for Resident 52 and 160 -F759; The facility failed to maintain a medication error rate less than 5 % the medication error rate was 7.69. -F760; The facility failed to ensure Resident number 23 was free of a significant medication error. -F801; The facility failed to have a qualified dietary manager, this had the potential to affect all resident. -F804; The facility failed to ensure food were provided in a manner that was maintained at a temperature that was appealing to residents. This had the potential to affect all residents the Facility census was 66 -F812; The facility failed to ensure hair restraints covered all hair during food service, and failed to utilize hand washing and gloving techniques to prevent food contamination during food service. -E0015; The facility failed to ensure sufficient supply of nutritional provisions food supplies were maintained for residents, and staff in case of emergency. -F835; The facility failed to ensure administer utilize resources in a manner to ensure provision of care, provision of services for residents. -F867; The facility failed to ensure an effective quality improvement plan as evidenced by new and repeat deficient practice Interview on 1/27/17 at 1:00 PM with NA(Nursing Assistant) J, revealed that NA J , worked mostly day shift, and was not able to identify any of the members of the Q A &A committee, or what current projects the committee were working on. Interview on 1/27/17 at 2: 00 PM with NA S revealed that NA S, worked mostly the afternoon shift, and was not able to identify any of the members of the Q A &A committee, or what current projects the committee were working on. Repeat tags included: (Tag numbers have changes, new and old listed) F157 on 09/06 16 survey andF580 for current survey. F225 on 9/6/16, 9/2015 and F 609 for current survey. F248 on 9/6/16 and F679 for current survey. F248 on 9/6/16 and F676 for current survey. F325 on 9/6/16 and F 692 for current survey. F332 on 9/6/16 and F759 for current survey. F371 on 9/6/16 and F812 for current survey. F520 on 9/6/16 and F867 for current survey.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed to identify pressure ulcers and failed to implement assessed interventions to prevent development of pressure ulcers for 4(Resident 3, 36, 51 and 160) of 4 sampled residents. The facility staff identified a census of 66. Findings are: A. Record review of Resident 51's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 12-06-2017 revealed the facility staff assessed the following about Resident 51: -Brief Interview for Mental Status (BIMS) was a 14. According to the MDS Manuel a score of 13 to 15 indicates a person is cognitively intact. -Required supervision with eating. -Required extensive assistance with 2 or more persons assisting with bed mobility, transfers, dressing, toilet use and personal hygiene. -Always incontinent of bowel and bladder. -Identified Resident 51 at risk for the development of pressure ulcers. Record review of Resident 51's Braden Scale (tool used for predicting pressure sore risk) dated 12-06-2017 revealed Resident 51 scored a High Risk rating. Record review of Resident 51's Comprehensive Care Plan (CCP) dated 11-24-2017 revealed Resident 51 had the [DIAGNOSES REDACTED]. Further review of Resident 51's CCP updated on 12-06-2017 revealed Resident 51 had returned from the hospital with an open wound to the sacrum and prevalon boots (type of pressure relieving foot wear) in place to both feet. According to Resident 51's CCP, the prevalon boots were worn at all times. Observation on 12-20-2017 at 2:49 PM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 at 11:00 AM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 11:22 AM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Observation on 12-21-2017 at 1:10 PM revealed Resident 51 was in bed, in a back laying position and did not have the prevalon boots on. Further observation on 12-21-2017 at 1:10 PM revealed Resident 51's Family member was in the room with Resident 51. Resident 51's Family member stated see (gender) doesn't have (gender) boots on and with a pointing movement indicated the prevalon boots were placed in a chair in Resident 51's room. Resident 51's family member confirmed the prevalon boots were to be on Resident 51. Observation on 12-21-2017 2:00 PM with Licensed Practical Nurse (LPN) B of Resident 51's heels revealed Resident 51 had an approximately 5 centimeters (cm) roundish fluid looking blister to the left heel. On 12-21-2017 at 2:00 PM an interview was conducted with LPN B. During the interview, LPN B confirmed Resident 51 did not have the prevalon boots on (gender) feet. LPN B further reported not being aware Resident 51 had a wound to the left heel. Record review of Resident 51's record revealed there was no evidence Resident 51 had a pressure area to the left heel. Further review of Resident 51's medical record revealed there was no evidence the facility had completed daily monitoring of Resident 51's feet. Record review of a Skin Pressure Ulcer Weekly (SPUW) sheet dated 12-21-2017 with a time of 2:50 PM revealed the area to Resident 51's left heel was measured as 2.9 cm by 2.5 cm and staged as a Suspected Deep Tissue Injury ( SDTI). The description of the left heel SDTI was identified as black/brown, eschar (dead tissue). According to Woundeducators.com, a SDTI is A deep tissue injury is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. B. Record review of Resident 3's MDS dated as completed on 10-03-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 15. -Total dependence for bed mobility, transfers, dressing, eating, toilet use and personal hygiene with 2 plus people assisting with bed mobility, transfers, dressing and personal hygiene. -No pressure ulcers were identified for Resident 3. Record review of a Skin Evaluation sheet dated 12-17-2017 revealed there were not any pressure ulcers identified for Resident 3. Record review of a Braden Scale evaluation sheet dated 9-21-2017 revealed Resident 3 was evaluated as low risk for the development of pressure ulcers. Record review of Resident 3's CCP dated 10-13-2017 revealed Resident 3 was to have Prafo (type of pressure relieving boots) while in bed. Further review of Resident 3's CCP dated 12-17-2017 revealed Resident 3 had the potential for impaired skin integrity and pressure. The goal for Resident 3 was to remain free of sign and symptoms of new skin breakdown. Interventions identified were to assist with repositioning, Prafo boots while in bed, pressure reducing mattress and wheelchair cushion. On 12-21-2017 at 4:12 PM an interview was conducted with Resident 3. During the interview Resident 3 reported having a pressure ulcer to the right heel. Review of Resident 3's medical record revealed there was no evidence the facility staff had identified a pressure ulcer on the resident's right heel. On 12-26-2017 at 5:04 AM an interview was conducted with Resident 3. Resident 3 reported (gender) had a pressure ulcer to the right heel. On 12-26-2017 at 5:20 AM observation of Resident 3's right heel with Registered Nurse (RN) D revealed a had a dark purple looking area to the right heel. Record review of a SPUW sheet dated 12-27-2017 revealed Resident 3 was identified with an unstageable pressure ulcer to the right heel that measured 1.5 cm by 4.0 cm. The wound bed was identified as black/brown eschar. On 12-27-2017 at 7:26 AM an interview was conducted with Registered Nurse (RN) E. During the interview RN E reported there was no monitoring of the right heel ulcer for Resident 3. C. Record review of Resident 160's MDS dated as completed on 12-20-2017 revealed the facility staff assessed the following about the resident: -BIMS was a 6. According to the MDS Manuel, a score of 0 to 7 indicates severe cognitive impairment. -Required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. -Resident 160 was identified at risk for developing pressure ulcers. -No pressure ulcers were identified for this resident. Record review of a Braden Scale form dated 12-07-2017 revealed the facility assessed Resident 160 as a low risk for the development of pressure ulcers. Observation on 12-27-2017 at 6:30 AM revealed Resident 160 was in bed, in a back laying position. Observation on 12-27-2017 at 7:45 AM revealed Resident 160 was in bed, in a back laying position. Observation on 12-27-2017 at 8:25 AM revealed Resident 160 was in a back laying position. Observation on 12-27-2017 at 1:35 PM with RN E revealed Resident 160 had several red areas with defined edges. Record review of a SPUW sheet dated 12-27-2017 timed at 7:47 PM revealed the facility staff assessed Resident 160 with 3, stage 1 (Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness) caused from pressure) pressure ulcer. The 3 pressure ulcers were identified as the following: -Site 1, left buttocks, stage, with measurements of 2.0 cm by 0.6 cm. -Site 2, lower left buttocks, stage 1 with measurements of 2.0 cm by 0.6 cm. -Site 3, right buttocks, stage 1 with measurements of 2.0 by 1.0 cm. C. Review of Resident 36's Comprehensive Care Plan (CCP) revealed a problem statement of: Alteration in skin integrity. Resident 36 requires assistance with repositioning. The CCP revealed on12/13/17 Resident 36 was identified as having a pressure ulcer on the coccyx (tailbone). Review of Resident 36's Comprehensive Care Plan for Bed Mobility revealed Resident 36 required extensive assistance of 1 staff to reposition and turn in bed and staff to assist Resident 36 every 2 hours and as needed. 12/27/2017 observations of Resident 36 revealed the resident was in the following positions: -6:30 AM; On back. -7:00 AM; On back -7:50 AM; On back, -8:35 AM; On back, -9:15 AM; On back, -9:40 AM; On back. Observation on 12/27/2017 at 9:40 AM of Resident 36 revealed an area on Resident 36's coccyx bony prominence was open. Interview on 12/27/2017 at 9:40 AM with the Assistant Director of Nursing (ADON) revealed Resident 36 should have been turned at least every 2 hours. Review of a facility form dated 12/18/2017 revealed Resident 36 had a pressure ulcer on the resident's coccyx identified on 10/30/2017 as unstageable which was assessed as healed on 12/18/2017. Review of wound documentation dated 12/23/2017 revealed Resident 36 had no alteration of skin integrity. Review of the facility document dated 9/2017 titled Wound Management revealed the purpose of the policy was to ensure the resident did not develop pressure ulcers unless clinically unavoidable and the facility provided care and services to prevent the development of additional pressure ulcers. Interview on 12/27/2017 at 2:00 PM with LPN-C revealed Resident 36 did have an area on the coccyx that had previously healed and did reopen and is a stage 2 area with a small unstageable area in the center.

License Reference Number: 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility failed to assist 1 of 1 residents (Resident 36) with nutritional intake to avoid a continued significant weight loss. The facility census was 66. Findings are: Review of a Physician order [REDACTED]. Observation on 12/21/2017 at 9:50 AM revealed Resident 36 in a nightgown in bed. Resident 36 was attempting to eat independently. Resident 36 stated to staff entering the room that the resident's neck was sore and staff lowered the head of the resident's bed and removed Resident 36's breakfast tray. Resident 36 had attempted to eat the cooked cereal that was served but no other food had been touched. The sausage on the plate was not cut. Resident 36 received no assistance or encouragement for eating. Observation on 12/26/2017at 9:30 AM revealed Resident 36 received a room tray for breakfast. At 9:55 AM Resident 36 was in a semi seated position with the tray table in front of Resident 36. No one was in the room assisting Resident 36 at this time. Approximately 50% of the meal was eaten. Observation on 12/27/2017 at 9:40 AM revealed Resident 36 had not received a breakfast tray. Interview on 12/27/2017 at 9:40 AM with the Assistant Director of Nursing (ADON) revealed it did not appear Resident 36 had received a tray. Review of dietary notes dated 10/3/2017 revealed Resident 36's weight was 92-93 pounds which was equal to a 5.1% loss in 30 days and the resident had developed a new pressure ulcer. No new interventions were initiated until the resident was placed on hospice care and had a further decline to 89 pounds. Interview on 12/27/2017 at 10:30 AM with the Director of Nursing (DON) revealed that if the resident had an order to assist the resident with meals, a staff member should have been in the room with the resident during meals at assist the resident in eating their meal.

Licensure Reference Number 175 NAC12-006.09D3 (5) Based on observation, record review and interview; the facility failed to implement a bowel care regimen to prevent a fecal impaction (a mass of dry, hard stool that will not pass out of the rectum) for 1 of 1 residents reviewed (Resident 36). The facility census was 66. Findings are: Observation on 12/27/2017 at 9:40 AM of the Assistant Director of Nursing (ADON) providing incontinent care to Resident 36 revealed Resident 36 to have hard stool in rectal opening. ADON attempted to assist Resident 36 to expel stool, however was unsuccessful. Observation of Resident 36 on 12/27/2017 at 9:40 AM revealed the resident was hollering Ouch when nurse attempted to assist Resident 36 to expel the fecal matter. Resident 36 was unable to expel fecal matter from rectum independently. Interview on 12/27/2017 at 9:45 AM with the ADON revealed the ADON would need to check for orders for bowel management for Resident 36. The ADON revealed the fecal matter was hard and was causing Resident 36 pain. Review of Resident 36's Bowel Movement (BM) Tracking form for the previous 30 days revealed the resident had a Medium or Large Bowel Movement each day or every other day until 12/22/2017. Review of Resident 36's bowel movement tracking revealed Resident 36 last had a medium BM on 12/22/2017 with a small on 12/23/2017 and 12/24/2017. Review of Resident 36's Medication Administration Record [REDACTED]. Interview on 12/28/2017 at 8:20 AM with Registered Nurse (RN)-A revealed the facility had a bowel management protocol. RN-A reported the protocol was to give the resident a laxative or prune juice if the resident had gone 3 days without a Bowel Movement. If the resident did not have any results a suppository would be given followed by an enema until the resident has results. Based on the bowel record for Resident 36 RN-A revealed that Resident 36 should have received some bowel care on 12/24/2017 based on only having a small Bowel Movement in three days. Interview on 12/27/2017 at 11:05 AM with the ADON revealed Resident 36 was given an enema with large hard Bowel Movement results and Resident 36 was worn out. Review of Resident 36's progress notes dated 12/27/2017 revealed neither the doctor nor hospice nurse were notified for orders for a change in bowel management. Interview on 1/2/2017 at 12:40 PM with the ADON revealed once the enema was given and the plug was removed the resident had an extra-large Bowel Movement result.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to develop and implement a pain management program that relieved the pain for 1 resident (Resident 89). The facility staff identified a census of 60. Findings are: Record review of Resident 89's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 8-23-2016 revealed the facility staff assessed the following about the resident: -admission date of [DATE] and re-admission 8-03-2016. -Brief Interview for Mental Status (BIMS) was a 13. According to the MDS Manuel. a score of 13 to 15 indicated cognitively intact. -Required Limited assistance with dressing. -Required extensive assistance with bed mobility, and personal hygiene. -Activity of transfer and toilet use occur once or twice. -Had an indwelling catheter ( tube placed into the bladder to drain urine). -Always incontinent of bowel. -Active [DIAGNOSES REDACTED]. -Pain was identified as a 4 on a scale of 0 to 10 with O being no pain and 10 being the worst pain a person can imagine. Record review of a LN (Licensed Nurse) Pain Risk Evaluation (LN-PRE) sheet signed on 8-07-2016 revealed Resident 89 was evaluated as having a pain level of 4. According to the information on the LN-PRE sheet dated 8-07-2016, Resident 89 category was high risk. The LN-PRE sheet did not contain information what Resident 89's pain was with movement. Record review of Resident 89's discharge orders from the Hospital to the Nursing Facility revealed Resident 89 had wounds to the abdomen, buttocks, right hip, right shoulder slit,skin tears under the left breast, skin tears to abdomen folds, and a skin tear to the lower back. Record review of Resident 89's Treatment Administration Record (TAR) for August 2016 revealed Resident 89 had a wound to the back of the upper left leg, wounds to the lower right and left legs and outer ankle. Record review of Resident 89's Comprehensive Care Plan (CCP) dated 6-24-2016 revealed Resident 89 had acute and chronic pain related to the wounds. The goal for Resident 89 was to verbalize adequate pain control or the ability to cope with incompletely relieved pain. Intervention listed on the CCP were as follows: -Assess pain characteristics, location, duration, aggravating factors and relieving factors. -Administer medications as ordered. Evaluate the effectiveness of pain interventions. -Follow pain scale to medicate as ordered. -Notify the physician if interventions are unsuccessful. -Pain is aggravated by wound care, offer pain management interventions before, during and after wound care. -Pain screen every shift. -reposition for comfort or offer non-pharmaceutical interventions for pain relief as needed. -Report to the nurse of the residents complaints of pain or request for pain treatment. Observation with the Director of Nursing (DON) on 8-31-2016 at 10:28 AM of personal care and a wound treatment revealed Nursing Assistant (NA) A and NA B washed hands and donned gloves. NA A and NA B positioned Resident 89 into the left laying position. Resident 89 moaned and groaned with facial furrowing. Resident 89 was observed to be incontinent of bowel. NA A using a cleansing wipe, began to cleans Resident 89. Observation during the cleansing revealed Resident 89 moaned, groaned during the procedure. NA A rolled up a soiled pad and pushed it under Resident 89 causing Resident 89 to moan loudly. Further observation revealed a dressing on the right hip covering a wound area had been soiled and needed to be changes. Registered Nurse (RN) D entered Resident 89's room with a new dressing to be applied to the wound on the right hip. During the treatment, Resident 89 moaned and groined with deep facial furrowing. NA A and NA B rolled Resident 89 into a back laying position and completed cleansed of the peri area. Resident 89 continued to moan, groan and had a deeply furrowed brow. NA A and NA B rolled Resident 89 on to a right laying position. Resident 89 yelled out, moaned loudly and had a deeply furrowed brow. NA A and NA B stated to Resident 89 sorry several times as Resident 89 began to cry. NA B using a wiping cloth, began to clean the left side of Resident 89 when the abdominal dressing fell off. The DON left the room to inform the nurse of the need for a new dressing. RN C entered Resident 89's room, and after washing hands,donning a pair of gloves, applied a new dressing to the abdominal area. Resident 89 was observed to moan, groined and started to cry. RN C reported at this time Resident 89 had pain medication at 7:30 AM and had not been pre-medicated prior to the personal cares and treatment. The DON intervened and had staff reposition the resident into a back laying position to allow Resident 89 to rest. Resident 89 was observed to use the night gown (gender) had on to wipe the tears away. On 8-31-16 at 10:28 AM an interview was conducted with NA A. When asked if Resident 89 was always painful, NA A reported Resident 89 is always painful with cares. On 8-31-2016 at 11:10 AM an interview was conducted with the DON. During the interview, the DON confirmed Resident 89 had been very painful with the personal cares and treatments. When asked what the staff should have done, the DON reported staff should have stopped personal care and seen if Resident 89 could have anything for pain. On 8-31-2016 at 3:47 PM an interview was conducted with Resident 89. During the interview, Resident 89 reported (gender) current pain level was a 2 on a scale of 0 to 10, and that (gender) does get very painful though. On 8-31-2016 at 3:55 PM an interview was conducted with Advanced Registered Nurse Practitioner (ARNP) H. During the interview ARNP H reported that Resident 89 was very painful and there are pain medications that can be used. When asked if Resident 89 should be premedicated for pain before personal cares and treatments, ARNP H stated at least 1/2 hour before. An interview was conducted on 8-31-2016 at 4:05 PM with NA I. When asked if Resident 89 was painful, NA I reported Resident 89 was .always painful. On 8-31-2016 at 4:09 PM an interview was conducted with RN J. During the interview, RN J reported Resident 89 had indicators of pain such as facial grimacing and groaning. RN J confirmed Resident 89 was painful with cares and treatments.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on observation, record review and interview; the facility staff failed evaluate weekly skin condition, implement treatment, evaluated factors and implement additional interventions to improve pressure ulcer healing and prevent additional pressure ulcers for 2 residents (Resident 4 and 5) The facility staff identified a census of 60. Findings are: A. Record review of the facility Policy and Procedure for skin assessment dated ,[DATE] revealed the following information: -Policy: -A full skin assessment will be preformed weekly. -Purpose: -To identify resident at risk for skin breakdown and institute appropriate preventative measures. B. Record review of Resident 4's Comprehensive Care Plan (CCP) dated 6-08-2015 revealed Resident 4 was admitted to the facility on [DATE]. According to the CCP, Resident 4 was at risk for pressure ulcer development. The goal identified on the CCP dated 6-08-2015 was Resident 4 would be free of pressure ulcer development. Interventions identified on the CCP included: pressure reducing devices, Air overlay and Roho (pressure reducing chair cushion) cushion, Prevalon (Pressure reducing boots to relieve pressure on the heels) boots in bed and while up in wheelchair, and weekly head to toe skin at risk assessments. Record review of Resident 4's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 11-19-2015 revealed the facility staff assessed the following about the resident: -Scored a 15 on the Brief Interview for Mental Status. According to the MDS Manuel, a score of 13 to 15 indicated cognitively intact. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Record review of Resident 4's Braden Scale ( a tool use to predicting pressure sore risk) dated 9-02-2015 revealed Resident 4 scored a 15. According to the information on the Braden Scale form, a score of 15 indicated low risk for the development of a pressure ulcer. Record review of a LN (Licensed Nurse) Skin Assessment /Evaluation PRN (as needed) and Weekly (LNSAE) sheet dated 11-28-2015 revealed Resident 4 was not identified as having a pressure ulcer. Review of Resident 4's record revealed there was not any evidence the facility staff had evaluated Resident 4 skin for breakdown weekly from 11-28-2015 to 12-16-2015 ( a 2 week time frame). Record review of Resident 4's LNSAE sheet dated 12-16-2015 revealed Resident 4 was not identified as having a pressure ulcer. Review of Resident 4's record revealed there was not any evidence the facility staff had evaluated Resident 4 skin for breakdown weekly from 12-16-2015 to 02-01-2016 ( a 6 week time frame). Record review of a LNSAE dated 2-01-2016 revealed Resident 4 was identified as having a open area to the left gluteal fold that measured 3 centimeters (cm) by 4 cm, with a depth of 1 cm. According to the information on the LNSAE dated 2-01-2016, the wound was evaluated as having beefy red wound bed, wound edges were light pink with a yellow stringy substance that was also observed in the wound. Record review of Resident 4's LNSAE dated 2-02-2016 revealed the area to the left gluteal fold was identified as a stage 3 (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). Record review of a information sheet dated 2-02-2016 revealed the facility had informed Resident 4's practitioner of the open area and on 2-03-2016, Resident practitioners gave orders to use the facility protocol for the treatment of [REDACTED]. Review of Resident 4's medical record revealed there was not a comprehensive evaluation of why Resident 4 had developed a pressure ulcer. Observation on 2-08-2016 at 6:43 PM of the pressure ulcer treatment, with the facility Director of Nursing (DON) revealed Registered Nurse (RN) A obtained the treatment supplies for Resident 4. RN A cleansed the pressure ulcer to the left gluteal fold area. RN A, using a measuring device, evaluated Resident 4's wound. RN A reported the pressure ulcer measured 5 cm by 6 cm with a depth of 2 cm. RN A identified wound tunneling at position of 12:00 that measured 1.5 cm. At 9:00, tunneling was evaluated as 2.0 cm. At the 6:00 position, tunneling was measured at 2.0 cm. Observation of the wound revealed black tissue with string like tissue hanging out of the pressure ulcer. RN A completed the treatment for [REDACTED]. Record review of an in information sheet revealed the facility staff had notified Resident 4's practitioner of the open area and would start the facility protocol for the wound ulcer. According to an undated Wound Care Protocol sheet revealed a Stage 3 pressure ulcer was to be treated daily and as needed until healed. Record review of Resident 4's Treatment Administration Record (TAR) for 2-01-2016 through 2-29-2016 revealed the entry on the TAR indicated the order date was 2-08-2016 and there were no entries of the pressure ulcer treatment being completed. Record review of Resident 4's progress notes dated 2-06-2016 revealed the treatment to Resident 4's pressure ulcer. Further review of Resident 4's progress notes from 2-2-2016 through 2-07-2016 revealed there was no evidence the pressure ulcer treatment had been completed for Resident 4. An interview on 2-08-2016 at 7:10 PM was conducted with the DON. During the interview, when asked what the stage of the pressure ulcer was for Resident 4, the DON reported the pressure ulcer was a stage 4 ( Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). An interview was conducted on 2-08-2016 at 5:05 PM with the facility Nurse Consultant (NC). The NC confirmed, during the interview, the weekly skin evaluations had not been completed for Resident 4. According to the NC, it was the facility policy to have the weekly skin evaluation completed. An interview was conducted on 2-09-2016 at 10:01 AM with the DON and the facility NC. During the interview, the NC confirmed there were no skin evaluations from 12-16-2015 through 2-01-2016. The facility NC confirmed there was not a comprehensive evaluation of the casual factors for the development of the pressure ulcer for Resident 4. The NC confirmed there was not evidence the pressure ulcer treatment had been completed daily. C. Record review of Resident 5's CCP dated 7-20-2015 revealed Resident 5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further review of Resident 5's CCP revealed Resident 5 had developed a pressure ulcer to the left buttock. The goal identified for Resident 5 was to be free from further pressure ulcer development and the pressure ulcer to the left buttock would progress towards healing. Interventions listed on the CCP included weekly head to to skin at risk assessments. Record review of Resident 5's Braden scale dated 9-22-2015 revealed a score of 14. According to the information on the Braden's scale form, a score of 14 placed Resident 5 at moderate risk of developing a pressure ulcer. Record review of a Resident 5's LNSAE sheet dated 11-11-2015 revealed Resident 5 had a pressure ulcer that measured 0.8 cm by 0.4 cm to the right buttocks. The area was identified a Stage 2 (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcers and had a Stage 2 pressure ulcer to the left buttocks that measured 1.6 cm by 1.4 cm with an onset dated of 7-06-2015. Record review of Resident 5's record revealed the LNSAE had not been completed from 11-25-2015 through 12-09-2015 ( a 2 week time frame). Further review of Resident 5's record revealed from 12-16-2015 through 1-07-2016 the weekly LNSAE had not been completed for Resident 5. In addition, there was no evaluation of Resident pressure ulcers from 1-14-2015 to the start of the survey on 2-8-2016. Observation on 2-08-2016 at 11:57 AM revealed Licensed Practical Nurse (LPN) B obtained the required supplies for the pressure ulcer treatment. Observations of Resident 5 during the treatment revealed the left and right buttock were fire red that measured approximately 7 cm and were roundish. Inside the red area were several dark colored areas. LPN 5 applied the treatment as order. An interview was conducted on 2-09-2016 at 9:25 AM with the DON and facility NC. During the interview, the facility NC confirmed the weekly skin evaluation had not been completed for Resident 5.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation,record review and interview; the facility staff failed to evaluate and implement interventions to control pain and failed to evaluate and monitor an impaired skin condition for 1 resident (Resident 186). The facility staff identified a census of 79. Findings are: A. Record review of a MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated as completed on 9-18-2013 revealed Resident 186 was admitted to the facility on [DATE]. Further review of the MDS revealed the facility staff assessed the following about the resident: -Resident 186 scored an 8 on the BIMs (Brief Interview of Mental Status. A score of 8-12 indicates moderately impaired cognition). -No behaviors were identified. -Required extensive assistance with bed mobility, transfers, dressing, eating and toilet use. -Active [DIAGNOSES REDACTED]. -Occasionally had pain with the intensity of 4 on a scale of 0 to 10. -No current pressure ulcer and was at risk for developing pressure ulcers. Record review of Resident 186's MDS dated as completed on 10-01-2013 revealed the facility staff assessed the following about the resident: -BIMs of 9. -No behaviors. -Required extensive assistance with bed mobility,transfers,dressing,toilet use and personal hygiene. -Vocal complaints of pain. -2 unstageable pressure ulcers. Record review of Resident 186's Comprehensive Care Plan (CCP) dated 9-19-2013 revealed Resident 186 was at risk for pain. The goal for Resident 186 was to verbalize or demonstrate minimal pain/discomfort through next review. The interventions to meet the goal included the following:. -Assess non-verbal signs of discomfort (grimacing, withdrawal). -Assess verbal signs of discomfort, asking resident to be specific regarding location severity and type of pain once every shift. -Administer PRN (as needed) medications as ordered noting effectiveness following administration. -Offer non-pharmaceutical means of pain relief (positioning, elevation of extremities on pillows, relaxation)prn. -Notify MD of increase in pain or if [MEDICATION NAME] is ineffective for pain control. Record review of Resident 186's Skilled Daily Nurses Notes (SDNN) dated 10-04-2013 revealed Resident 186 complained of pain all over, with a pain rating of 10 on a scale of 0 to 10. Record review of Resident 186's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of Resident 186's SDNN dated 10-05-2013 revealed Resident 186 had pain all over with a rating of 10 on the day shift. (Facility shifts are 6 AM to 6 PM and 6 PM to 6 AM). Record review of Resident 186's MAR for 10-2013 revealed [MEDICATION NAME] 325 mg (milligrams), 2 tabs were given at 10:05 PM on 10-5-13. There was no indication of the evaluation of the effectiveness of the medication. Record review of Resident 186's SDNN dated 10-6-2013 for the day shift revealed Resident had pain all over and rated a 10. Record review of Resident 186's MAR for 10-2013 did not contain evidence pain medication was given on the day shift for 10-6-2013. Record review of Resident 186's SDNN dated 10-13-2013 and 10-14-2013 revealed Resident 186 had pain at a intensity of 10. Record review of Resident 186's 10-2013 MARs and medical record did not contain evidence of interventions to control the pain. Observation on 10-28-13 at 1:44 PM revealed Nursing Assistant (NA) D was providing personal care for Resident 186. Observations revealed as NA D repositioned Resident 186 yelled out " oh My God, that hurts". NA D continued with personal cares and did not attempt to identify why the resident had pain. NA D completed the personal care and started to apply an adult brief when Resident 186 stated "it hurts, it hurts". Observation of the treament to Resident 186's heels,leg and elbow was conducted on 10-29-2013 at 11:57 AM with RN (Registered Nurse) B and the Assistant Director of Nursing (ADON) . During the observation of the treatment to Resident 186's right heel revealed RN B removed the soiled dressing and cleansed the right heel area Resident 186 yelled out "Oh that hurts, that hurts". Observation revealed Resident 186's face had a grimacing appearance during the treatment. RN began to wrap the foot when Resident 186 yelled " Oh that hurts, hurry hurry, that hurts ow". RN B began a treatment to a wound on the resident's right calf area. RN began to remove the soiled dressing that had stuck to the wounds, Resident 186 yelled out, "ouch, that hurts" and had facial grimacing. RN B was heard to say " I know it hurts". RN B completed the treatment to the right calf and began the treatment to an elbow skin tear. RN B removed the soiled dressing and began to cleanse the elbow skin tear. Resident 186 yelled out "oh that hurts". During the observation of the treament, interventions were not implemented to control Resident 186's pain. Record review of Resident 186's record contained no evidence that Resident 186 was premeditated for pain prior to the treatment. Further review of Resident 186's record did not contain any evidence of an evaluation of pain or the re-evaluation of pain management interventions. An Interview was conducted with the ADON on 10-29-13 at 1:17 PM. During the interview the ADON confirmed Resident 186's pain had not been monitored and also confirmed an evaluation of Resident 186's pain had not been completed. Record review of an undated policy and procedure for Pain Assessment revealed the following information: -Policy: -Every shift, every resident of the facility will be assessed by the licensed nurse regarding (the) presences of complaints of pain and/or lack of pain. Should a resident voice pain, the resident shall be medicated accordingly as per order and assessed for efficacy of the medication. -Procedure: -#2. If (a)resident verbalizes pain, pain symptoms are evaluated and the resident medicated with currently ordered [MEDICATION NAME] medication. -#3. The licensed nurse will later inquire of residents efficacy of pain medication. Efficacy shall be documented. -#4. Should the pain medication as administered be ineffective, the physician shall be notified in an effort to maintain the resident pain free as possible. Should, following admission, the resident exhibit pain which is not sufficiently controlled by current pain medications ordered, a pain assessment shall be completed and any necessary interventions implemented accordingly. -#6. The care plan for the individual resident shall be reviewed to ensure pain management is addressed. B. Observations on 10-28-2013 at 1:44 PM of personal care revealed Resident 186 had an area approximately 9 cm (centimeter) roundish dark red to purple color with several excoriated looking areas to the left buttocks. NA D reported the area had been there for "awhile". Observation on 10-29-2013 at 10:02 AM was conducted with the ADON. During the observation, the ADON felt around the area revealing a hard mass that was approximately the size of a golf ball. The ADON reported the area was noticed on 10-24-13 or 10-25-13 and thought it was a boil like area. The ADON confirmed Resident 186's medical record did not contain monitoring of the boil like area and should have been. The ADON further confirmed interventions had not been implemented to treat the boil like area.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to provide treatment and interventions to promote pressure ulcer healing and prevention of additional pressure ulcers for 1 (Resident 68). The facility staff identified a census of 81. Findings are: A. Record review of a Face Sheet dated 8-23-2013 revealed Resident 68 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 68's Comprehensive Care Plan (CCP) dated 7-15-2013 revealed Resident 68 had a pressure ulcer to the left ischium and to the coccyx area's. Interventions listed on the CCP were for Resident 68 to have a cushion in the wheelchair and an alternating air mattress. According to the information on the CCP, Prevalon boots to Resident 68's feet were discontinued on 7-7-2013. Record review of a Follow Up Visit: Wound Progress/Procedure Note (WPPN) dated 8-21-2013 by a wound physician revealed, under the section titled Pressure Relief/Offloading, the physician had instructed that Resident 68 heels be offloaded with Prevalon boots. According to the note, the plan of care was discussed with the facility staff. Record review of a WPPN dated 8-28-2013 revealed the Wound Physician had instructed the Prevalon boots be used to offload Resident 68's heels. Record review of a WPPN dated 9-04-2013 revealed the wound Physician had instructed staff to offload Resident 68's heels with pillows/Prevalon boots. Observation on 9-05-2013 at 7:31 AM revealed Resident 68 was in bed. Resident 68 did not have prevalon boots on and no pillow was being used to offload Resident 68's heels. An interview on 9-05-2013 at 10:01 AM was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON confirmed, during the interview, that the wound physician instructed that Prevalon boots/pillows be used to offload Resident 68's heels. B. Record review of a Physician's Telephone Orders sheet revealed, on 7-10-2013 an order was received to cleanse Resident 68's ischium and coccyx pressure ulcers with normal saline; apply skin prep around the edges of the wounds, apply [MEDICATION NAME] AG (brand of wound dressing) to the coccyx wound, and to change the dressing every other day and as needed. The left ischium was to be packed with [MEDICATION NAME] AG and cover with a gauze border and to change this dressing daily. Observation on 9-4-2013 at 1:29 PM revealed the wound Physician and Licensed Practical Nurse (LPN) F were preparing to evaluate and completed the treatment. The dressing to Resident 68's pressure ulcers were removed and the Wound Physician evaluated Resident 68's pressure ulcers. The wound Physician completed the evaluation, discussed the wound with LPN F and left the room. LPN F had obtained the supplies for the dressing change prior to the physician evaluation. Observation of the wound treatment revealed LPN F cleansed the wounds, applied [MEDICATION NAME] AG to the top of coccyx and ischium and covered with a dressing. When asked if the left ischium was to be packed, LPN F stated "no, just covered". An interview on 9-05-2013 at 10:01 AM was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). During the interview the ADON confirmed the pressure ulcer to the left ishium was to be packed with [MEDICATION NAME] AG.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a, 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to prevent, monitor, and evaluate casual factors for the development of a pressure ulcer for 1 (Resident 186) and failed to implement interventions for treament and prevention of pressure ulcers for 3 (Residents 186, 96 and 5). The facility staff identified a census of 79. Findings are: A. Record review of a MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated as completed on 9-18-2013 revealed Resident 186 was admitted to the facility on [DATE]. Further review of the MDS revealed the facility staff assessed the following about the resident: -Resident 186 scored an 8 on the BIMs (Brief Interview of Mental Status. A score of 8-12 indicates moderately impaired cognition). -No behaviors were identified. -Required extensive assistance with bed mobility, transfers, dressing, eating and toilet use. -Active [DIAGNOSES REDACTED]. -Occasionally had pain with the intensity of 4 on a scale of 0 to 10. -No current pressure ulcer and was at risk for developing pressure ulcers. Record review of Resident 186's MDS dated as completed on 10-01-2013 revealed the facility staff assessed the following about the resident: -BIMs of 9. -No behaviors. -Required extensive assistance with bed mobility,transfers,dressing,toilet use and personal hygiene. -Vocal complaints of pain. -2 unstageable pressure ulcers. Record Review of Resident 186's Admission Nursing assessment dated [DATE] revealed the facility staff had identified Resident 186 had "...Reddened area's on coccyx/buttocks". Record review of Resident 186's Admission Care Plan dated 9-05-2013 did not contain interventions to prevent pressure ulcer development. Record review of a Braden Scale (tool used for predicting pressure ulcer risk) dated 9-05-2013 revealed Resident 186 scored a 14. A score of 14 placed Resident 186 at moderate risk for the development of pressure ulcers. Record review of Resident 186's Skilled Daily Nurses Note (SDNN) dated 9-09-2013 revealed Resident 186 had complained of pain to both feet. The rating of pain was a 4 on a scale of 0 to 10 and "very tender to touch, soft heels bilat ( both sides) heel protectors while in bed". Record review of Resident 186's medical record did not contain an evaluation of casual factors for the soft heels, the implementation of heel protectors or any monitoring of the heels for complications. Record review of Resident 186's SDNN from 9-10-2013 through 9-16-2013 did not identify any skin impairment for Resident 186. Record review of Resident 186's SDNN dated 9-17-2013 revealed Resident 186 was identified as having fluid filled blisters to both heels. According to the documentation, the right heel blister measured "5 cm (centimeters) by 4 cm" and the left heel blister measured "3 cm by 2.5 cm". with a pain level of 5. Record review of a fax sheet dated 9-17-2013 revealed Resident 186's physician was notified of the blisters to Resident 186's heels. Resident 186's physician gave orders that Resident 186 was to wear heel protectors at all times. Record review of Resident 186's Comprehensive Care Plan (CCP) dated 9-20-2013 revealed Resident 186 had "unstageable pressure areas to each heel". The goal was the " unstageable pressure areas to (the) heels will progress towards heeling". Interventions included heel protectors when in bed. Observation on 10-28-13 at 1:44 PM revealed Resident 186 was in bed and did not have heel protectors on. Observation on 10-28-2013 at 2:55 PM revealed Resident 186 was in bed, positioned on the left side and did not have heel protectors on. Observation on 10-28-2013 at 3:43 PM revealed Resident 186 was in bed and did not have heel protectors on. An interview with Licensed Practical Nurse (LPN) A was conducted on 10-28-2013 at 3:43 PM. During the interview when asked if Resident 186 was to wear heel protectors, LPN A stated 'I'm not sure I'll check". LPN A confirmed Resident 186 was to have heel protectors on at all times. LPN A confirmed Resident 186 was not wearing heel protectors. Observation on 10-29-2013 at 11:57 AM of the treatment to Resident 186's heels by Registered Nurse (RN) B revealed Resident 186's right heel had a brown area. RN B began to cleanse the ulcer area when the brown patch was removed revealing the skin was no longer open. The right heel skin was pink, and the heel remained soft. The dressing to the left heel was removed revealing an area that was approximately 4 cm round with black necrotic tissue that measured approximately 1 cm roundish with slough tissue through out the remaining wound area. RN B completed the dressing change. An interview was conducted with the facility Assistant Director of Nursing (ADON) on 10-29-2013 at 2:45 PM. During the interview review of Resident 186's record completed review with the ADON. When asked if an evaluation of casual factors had been completed for the development of the pressure ulcers to Resident 186's heels, the ADON stated "no". The ADON stated during the interview "there should have been an evaluation at that time to determine what the skin issue was and the heels should have been monitored and were not". B. Record review of a face sheet dated 8-22-2013 revealed Resident 96 was admitted to the facility on [DATE]. Record review of Resident 96's CCP dated 7-08-2013 revealed Resident 96 had developed a blister to the left heel on 5-14-2013. The goal for Resident 96 was the ulcer would show healing through the next review. Intervention listed on the CCP included Gel cushion to the wheelchair, elevate heels off the bed and to were a Prafo boot to the left foot. Further review of Resident 96's CCP revealed the ulcer area to the left heel had "healed". The new goal was for Resident 96 to" remain free of skin breakdown through next review". The Prafo boot to left foot remained as an intervention. Record review of Resident 96's Pressure Ulcer Skin Report sheet dated 9-26-2013 revealed the area to the left heel had "healed". Observation on 10-28-2013 at 1:41 PM revealed Resident 96 was was seated in a wheelchair and did not have a Prafo boot on to the resident's left foot. Observation on 10-28-2013 at 2:47 PM revealed Resident 96 was seated in a wheelchair in (gender) room. Resident 96 was asked at this time if (gender) wore a heel boot. Resident 96 reported that (gender) was to wear a boot,"but staff don't put it on". Resident 96 further stated " I would like it on". Observation on 10-28-2013 at 3:50 PM with the ADON was conducted of Resident 96. During the observation, Resident 96 was not wearing the heel boots. The ADON asked Resident 96 if (gender) wanted the heel boot on. Resident 96 reported that (gender) wanted the boot on. The ADON confirmed Resident 96 did not have the boot on during the observation. Observation on 10-29-2013 at 3:12 PM with the ADON was conducted of Resident 96's heels. During the observation, Resident 96's left heel had a brown scab like area that measured approximately 0.5 cm. The ADON confirmed during the observation the area to the left heel. The ADON confirmed monitoring had not been completed and needed to be started. C. Record review of a Face Sheet dated 8-22-2013 revealed Resident 5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 5's CCP dated 7-18-2013 revealed Resident 5 was at risk for the development of pressure ulcers. The goal was Resident 5 would be free from pressure ulcers. Further review of Resident 5's CCP revealed a hand written entry that identified Resident 5 as having a pressure ulcer to the coccyx, The new goal was that Resident 5 would not develop further pressure ulcers by the next review date. The interventions identified on the CCP to meet the goal included Resident 5 was to have " blue gel boots on while in bed". Observation on 10-28-2013 at 1:36 PM revealed Resident 5 was in bed and did not have any heel boots on their feet. Observation on 10-28-2013 at 2:51 PM revealed Resident 5 was in bed and did not have any boots on their feet. Observation on 10-28-2013 at 3:36 PM revealed Resident 5 was in bed and did not have any heel boots on their feet. An interview was conducted on 10-28-2013 at 3:48 PM with the Medication Assistant (MA) C. During the interview MA C checked to see if Resident 5 had heel boots. MA C confirmed Resident 5 did not have any heel boots on. Record review of an undated policy and procedure for Pressure Ulcer Prevention revealed the following: -Policy: -Personel will recognize those residents most likely to experience skin breakdown, and take precautions necessary to prevent breakdown. Equipment: Elbow protectors, Heel protectors, Pressure relieving mattress and cushions. -Procedure: -#4. Reposition residents approximately every two hours as possible and position residents with pillows or supportive devices protecting bony prominence. -10. Provide appropriate pressure re-distributing support surfaces.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview, the facility staff failed to implement assessed interventions to prevent additional pressure ulcers for 1 (Resident 4). The facility staff identified a census of 87. Findings are: A. Record review of a face sheet dated 6-24-2013 revealed Resident 4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 4's MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated 6-11-2013 revealed the facility staff assessed the following about the resident; -Resident 4 was understood and usually understands. -Required supervision with eating. -Required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. -Currently had a pressure ulcer. Record review of Resident 4's Comprehensive Care Plan (CCP) dated 7-15-2013 revealed Resident 4 did have current pressure ulcer. The goal identified on Resident 4's CCP was Resident 4"...will have no further skin breakdown r/t (related to) pressure". Intervention to reach the goal included Cushion to the wheelchair, specialty mattress on bed and that Resident 4 was to have prevalon boots to heels at all times. Observations on Observation on 7-16-2013 at 3:50 PM revealed Resident 4 was in bed. Resident 4 did not have prevalon boots or any other type of heel protection on (gender) feet. Observation on 7-16-2013 at 4:30 PM revealed staff were assisting Resident 4 to the bathroom. Resident 4 did not have the prevalon boots on. Observation on 7-17-2013 at 5:14 AM revealed Resident 4 was in bed. Resident 4's prevalon boots had been placed in Resident 4's wheelchair. Resident 4 did not have any heel boots on to (gender) feet. Nursing Assistant (NA) A entered Resident 4's room at this time. When asked if Resident 4 had heel boots on, NA A stated "no". On 7-17-2013 at 5:25 AM an interview was conducted with Licensed Practical Nurse (LPN) B. During the interview LPN B stated " I don't think (gender, Resident 4) wears any boots. Review of Resident 4's CCP was conducted with LPN B. LPN B confirmed Resident 4 was to have prevalon boots on at all times. B. Record review of a face sheet dated 6-21-2013 revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Admission Nursing assessment dated [DATE] revealed Resident 1 did not admit to the facility with any pressure ulcers. Resident 1 was evaluated as oriented and able to communicate needs. Record review of a bed Mobility Screen for determining Need for Grab Bars sheet dated 6-20-2013 revealed the Occupational Therapist (OT) had evaluated Resident 1 for the use of grab bars for assistance with positioning. according to the information, Resident 1 wanted the grab bars to assist in positioning. Record review of Resident 1's Braden Scale Assessment Tool (tool used to identify pressure ulcer risk) dated 6-19-2013 revealed Resident 1 scored a 18. According to the information on the Braden scale, a score of 18 placed Resident 1 at mild risk for the development of a pressure ulcer.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07 Based on observation and record review; the facility Quality Assessment and Assurance Committee (QAAC) failed to implement effective plans of action to ensure repeated deficiencies at F314, 441 and F520, were corrected and the correction maintained and failed to identify ongoing issues relevant to F157, F309 and F315 and implement effective plans of action to identify and correct the deficient practice. The facility staff identified a census of 79. Findings are: Record review of the facility QAAC process revealed the following information: -Purpose: -The QAAC will identify quality deficiencies and develop and implement plans of action to correct these quality deficiencies, including monitoring the effect of implemented changes and make needed revisions to the action plans. An interview with the facility Administrator was conducted on 10-29-2013 at 2:25 PM. During the interview the deficiencies were reviewed with the Administrator. The Administrator stated during the interview that (gender) "...thought they were in compliance". The facility action plans were reviewed and discussed and the Administrator confirmed the facility needed new action plans to correct the deficient practices. On 10-29-2013 at 8:40 AM the facility Administrator provided a Revised Corrective Action Plan that revised the monioring for pressure reducing devices, infection control practices and perineal care. The action plan did not include the QAAC and how the QAAC would use the information.

3 LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation,record review and interview; the facility staff failed to evaluate and implement interventions to control pain and failed to evaluate and monitor an impaired skin condition for 1 resident (Resident 186). The facility staff identified a census of 79. Findings are: A. Record review of a MDS (Minimum Data Set: a federally mandated comprehensive assessment tool used for care planning) dated as completed on 9-18-2013 revealed Resident 186 was admitted to the facility on [DATE]. Further review of the MDS revealed the facility staff assessed the following about the resident: -Resident 186 scored an 8 on the BIMs (Brief Interview of Mental Status. A score of 8-12 indicates moderately impaired cognition). -No behaviors were identified. -Required extensive assistance with bed mobility, transfers, dressing, eating and toilet use. -Active [DIAGNOSES REDACTED]. -Occasionally had pain with the intensity of 4 on a scale of 0 to 10. -No current pressure ulcer and was at risk for developing pressure ulcers. Record review of Resident 186's MDS dated as completed on 10-01-2013 revealed the facility staff assessed the following about the resident: -BIMs of 9. -No behaviors. -Required extensive assistance with bed mobility,transfers,dressing,toilet use and personal hygiene. -Vocal complaints of pain. -2 unstageable pressure ulcers. Record review of Resident 186's Comprehensive Care Plan (CCP) dated 9-19-2013 revealed Resident 186 was at risk for pain. The goal for Resident 186 was to verbalize or demonstrate minimal pain/discomfort through next review. The interventions to meet the goal included the following:. -Assess non-verbal signs of discomfort (grimacing, withdrawal). -Assess verbal signs of discomfort, asking resident to be specific regarding location severity and type of pain once every shift. -Administer PRN (as needed) medications as ordered noting effectiveness following administration. -Offer non-pharmaceutical means of pain relief (positioning, elevation of extremities on pillows, relaxation)prn. -Notify MD of increase in pain or if [MEDICATION NAME] is ineffective for pain control. Record review of Resident 186's Skilled Daily Nurses Notes (SDNN) dated 10-04-2013 revealed Resident 186 complained of pain all over, with a pain rating of 10 on a scale of 0 to 10. Record review of Resident 186's Medication Administration Record [REDACTED]. Record review of Resident 186's SDNN dated 10-05-2013 revealed Resident 186 had pain all over with a rating of 10 on the day shift. (Facility shifts are 6 AM to 6 PM and 6 PM to 6 AM). Record review of Resident 186's MAR for 10-2013 revealed [MEDICATION NAME] 325 mg (milligrams), 2 tabs were given at 10:05 PM on 10-5-13. There was no indication of the evaluation of the effectiveness of the medication. Record review of Resident 186's SDNN dated 10-6-2013 for the day shift revealed Resident had pain all over and rated a 10. Record review of Resident 186's MAR for 10-2013 did not contain evidence pain medication was given on the day shift for 10-6-2013. Record review of Resident 186's SDNN dated 10-13-2013 and 10-14-2013 revealed Resident 186 had pain at a intensity of 10. Record review of Resident 186's 10-2013 MARs and medical record did not contain evidence of interventions to control the pain. Observation on 10-28-13 at 1:44 PM revealed Nursing Assistant (NA) D was providing personal care for Resident 186. Observations revealed as NA D repositioned Resident 186 yelled out oh My God, that hurts. NA D continued with personal cares and did not attempt to identify why the resident had pain. NA D completed the personal care and started to apply an adult brief when Resident 186 stated it hurts, it hurts. Observation of the treament to Resident 186's heels,leg and elbow was conducted on 10-29-2013 at 11:57 AM with RN (Registered Nurse) B and the Assistant Director of Nursing (ADON) . During the observation of the treatment to Resident 186's right heel revealed RN B removed the soiled dressing and cleansed the right heel area Resident 186 yelled out Oh that hurts, that hurts. Observation revealed Resident 186's face had a grimacing appearance during the treatment. RN began to wrap the foot when Resident 186 yelled Oh that hurts, hurry hurry, that hurts ow. RN B began a treatment to a wound on the resident's right calf area. RN began to remove the soiled dressing that had stuck to the wounds, Resident 186 yelled out, ouch, that hurts and had facial grimacing. RN B was heard to say I know it hurts. RN B completed the treatment to the right calf and began the treatment to an elbow skin tear. RN B removed the soiled dressing and began to cleanse the elbow skin tear. Resident 186 yelled out oh that hurts. During the observation of the treament, interventions were not implemented to control Resident 186's pain. Record review of Resident 186's record contained no evidence that Resident 186 was premeditated for pain prior to the treatment. Further review of Resident 186's record did not contain any evidence of an evaluation of pain or the re-evaluation of pain management interventions. An Interview was conducted with the ADON on 10-29-13 at 1:17 PM. During the interview the ADON confirmed Resident 186's pain had not been monitored and also confirmed an evaluation of Resident 186's pain had not been completed. Record review of an undated policy and procedure for Pain Assessment revealed the following information: -Policy: -Every shift, every resident of the facility will be assessed by the licensed nurse regarding (the) presences of complaints of pain and/or lack of pain. Should a resident voice pain, the resident shall be medicated accordingly as per order and assessed for efficacy of the medication. -Procedure: -#2. If (a)resident verbalizes pain, pain symptoms are evaluated and the resident medicated with currently ordered [MEDICATION NAME] medication. -#3. The licensed nurse will later inquire of residents efficacy of pain medication. Efficacy shall be documented. -#4. Should the pain medication as administered be ineffective, the physician shall be notified in an effort to maintain the resident pain free as possible. Should, following admission, the resident exhibit pain which is not sufficiently controlled by current pain medications ordered, a pain assessment shall be completed and any necessary interventions implemented accordingly. -#6. The care plan for the individual resident shall be reviewed to ensure pain management is addressed. B. Observations on 10-28-2013 at 1:44 PM of personal care revealed Resident 186 had an area approximately 9 cm (centimeter) roundish dark red to purple color with several excoriated looking areas to the left buttocks. NA D reported the area had been there for awhile. Observation on 10-29-2013 at 10:02 AM was conducted with the ADON. During the observation, the ADON felt around the area revealing a hard mass that was approximately the size of a golf ball. The ADON reported the area was noticed on 10-24-13 or 10-25-13 and thought it was a boil like area. The ADON confirmed Resident 186's medical record did not contain monitoring of the boil like area and should have been. The ADON further confirmed interventions had not been implemented to treat the boil like area.

2 LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to provide treatment and interventions to promote pressure ulcer healing and prevention of additional pressure ulcers for 1 (Resident 68). The facility staff identified a census of 81. Findings are: A. Record review of a Face Sheet dated 8-23-2013 revealed Resident 68 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 68's Comprehensive Care Plan (CCP) dated 7-15-2013 revealed Resident 68 had a pressure ulcer to the left ischium and to the coccyx area's. Interventions listed on the CCP were for Resident 68 to have a cushion in the wheelchair and an alternating air mattress. According to the information on the CCP, Prevalon boots to Resident 68's feet were discontinued on 7-7-2013. Record review of a Follow Up Visit: Wound Progress/Procedure Note (WPPN) dated 8-21-2013 by a wound physician revealed, under the section titled Pressure Relief/Offloading, the physician had instructed that Resident 68 heels be offloaded with Prevalon boots. According to the note, the plan of care was discussed with the facility staff. Record review of a WPPN dated 8-28-2013 revealed the Wound Physician had instructed the Prevalon boots be used to offload Resident 68's heels. Record review of a WPPN dated 9-04-2013 revealed the wound Physician had instructed staff to offload Resident 68's heels with pillows/Prevalon boots. Observation on 9-05-2013 at 7:31 AM revealed Resident 68 was in bed. Resident 68 did not have prevalon boots on and no pillow was being used to offload Resident 68's heels. An interview on 9-05-2013 at 10:01 AM was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON confirmed, during the interview, that the wound physician instructed that Prevalon boots/pillows be used to offload Resident 68's heels. B. Record review of a Physician's Telephone Orders sheet revealed, on 7-10-2013 an order was received to cleanse Resident 68's ischium and coccyx pressure ulcers with normal saline; apply skin prep around the edges of the wounds, apply [MEDICATION NAME] AG (brand of wound dressing) to the coccyx wound, and to change the dressing every other day and as needed. The left ischium was to be packed with [MEDICATION NAME] AG and cover with a gauze border and to change this dressing daily. Observation on 9-4-2013 at 1:29 PM revealed the wound Physician and Licensed Practical Nurse (LPN) F were preparing to evaluate and completed the treatment. The dressing to Resident 68's pressure ulcers were removed and the Wound Physician evaluated Resident 68's pressure ulcers. The wound Physician completed the evaluation, discussed the wound with LPN F and left the room. LPN F had obtained the supplies for the dressing change prior to the physician evaluation. Observation of the wound treatment revealed LPN F cleansed the wounds, applied [MEDICATION NAME] AG to the top of coccyx and ischium and covered with a dressing. When asked if the left ischium was to be packed, LPN F stated no, just covered. An interview on 9-05-2013 at 10:01 AM was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). During the interview the ADON confirmed the pressure ulcer to the left ishium was to be packed with [MEDICATION NAME] AG.

LICENSURE REVERENCE NUMBER 175 NAC 12-006.09D8b Based on record review and interview, the facility staff failed evaluate accuracy of weights related to significant weight loss and failed to implement interventions to prevent additional weight loss for 2 (Resident 60 and 27). The facility staff identified a census of 89. Findings are: A. Record review of a Face Sheet dated 9-26-2012 revealed Resident 60 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Weight Details Report (WDR) sheet revealed Resident 60's weight was 141.7 pounds on 10-5-2012 and dropped to 100.0 pounds on 1-16-2013. Record review of a Routine Vital Weight Record (RVWR) sheet revealed Resident 60 weight was 143.9 pounds on 9-24-2013 and dropped to 100.0 pounds on 1-16-2013. Further review of the RVWR sheet revealed instructions at the bottom of the page that directed staff to obtain a re-weight with in 24 hours if there is a 5 # (pound) variance from the last weight. There were no re-weight for the 10-21-2012 weight on the RVWR sheet. Record review of the Resident 60's Dietary Notes dated 10-01-2012 revealed the facility Registered Dietician (RD) documented Resident 60's weight as 143.9 pounds and that Resident 60 was receiving both a tube feeding and was able to eat food. No recommendations was made by the RD for Resident 60. Record review of Resident 60's Dietary Notes dated 10-24-12 revealed the facility RD had identified Resident 60's weights were fluctuating and requested a re-weight. Record review of Resident 60's Dietary Notes revealed the facility RD identified continued weight fluctuation and requested a reweigh on: - 11-01-2012; - 11-29-2012 with a weight of 104.5 pounds, - 12-06-2012, and - 12-13-2012 with a weight of 105.9 pounds. Record review of Resident 60 Dietary Notes dated 12-24-2012 revealed the facility RD had requested staff re-weigh Resident 60 ' to verify current weight". According to the RD documentation, Resident 60's weight was "107.7 pounds with clothing". The Facility RD identified the weight loss as significant with a loss of 26.1%. The facility RD documented the responsible party was notified by the RD and discussions of interventions. An interview with the facility RD K was conducted on 6-6-2013 at 10:07 AM. Review of Resident 60's Dietary notes was conducted. During the interview, RD K identified having difficulty in having accurate weights for Resident 60. RD K confirmed weights were not obtained as requested for accurate weights to make recommendations for interventions. Review of the WDR for Resident 60 was conducted with RD K. RD K confirmed during the interview Resident 60 had a significant weight loss on 11-21-2012. An interview with Registered Nurse (RN) F was conducted on 6-06-2013 at 8:15 AM. Review of the RVWR was conducted with RN F. RN F confirmed Resident 60 had a significant weight loss on 11-21-12. RN F confirmed the re-weight were not obtained on 10-21-2012 and 12-7-2012 as instructed on the RVWR sheet. A follow up interview was conducted with RN F on 6-06-2013 at 9:19 AM. During the interview RN F confirmed the scale had not been evaluated for the accuracy of weights for Resident 60. Record review of a physician order [REDACTED]. - 9-28-2012; the tube feeding for Resident 60 was discontinued and to continue with the flushing of the tube with 120 ccs of water every 4 hours; - 10-17-2012 [MEDICATION NAME] 1.2 thickened formula was ordered two times a day; - 10-19-2012 the [MEDICATION NAME] 1.2 formula was discontinued. - Record review of a Appointment form dated 1-7-2013 revealed the tube used for feedings was removed from Resident 60. B. Record review of Resident 60's medical record did not contain evidence that Resident 60's physician or family were informed of the significant weight loss. A record review of the RD notes for Resident 27 dated 5-19-13 revealed Resident 27's weight was down suddenly to 159.5 lbs and meal intakes were stable at 75%, recommended reweighing the resident. Review of Resident 27's weight record revealed the next weight was not done until 6-5-13 and was 160 lbs. This is a weight loss of 5%. An interview with the DON (Director Of Nursing) on 6-6-13 at 9 am confirmed there were no weights taken between 5-19-13 and 6-5-13. An interview with the RD on 6-6-13 at 10:10 am revealed the RD notified the DON on 5-18-13 requesting a reweigh be done. The RD reported requesting a reweigh again on 5-30-13 at a resident review meeting. The RD revealed the reweigh was never completed until 6-5-13 and should have been done sooner. Since the reweigh was not completed, the physician was not notified and new interventions were not started.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.07 Based on record review and interview; the facility Quality Assurance Plan (QAP) failed to identify ongoing issues relevant to F157, F 223, F 225, F 241, F 253, F 280, F 325, F 364, F 371, F 431, F 441 and F 514 and implement effective plans of action to identify and correct the deficient practice. The QAP failed to ensure the repeated deficiencies at F 371 and F 441 were corrected and the correction maintained. The facility census was 89. Findings are: Record review of the Quality Assessment and Assurance committee process (no date) revealed that the purpose of the committee was to identify quality deficiencies and develop and implement plans of actions to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plans. Interview on 6/5/13 at 3:08 PM with the Director Of Nursing (DON) revealed that ongoing QA audits were completed related to infection control practices which included catheter care. The DON confirmed that those were ongoing audits and any concerns would be brought to the QA meeting. The DON stated that during the infection control audits, no trends or concerns had been identified related to catheter care. The DON confirmed that no linen handling audits had been completed. The DON confirmed that the QAP had not effectively identified concerns with infection control. Interview on 6/5/13 at 3:18 PM with the Dietary Manager (DM) revealed that the DM conducted monthly audits of the kitchen related to kitchen cleanliness, food temperatures and food service and that no trends or concerns had been identified through these audits. B. On 6-06-2013 at 9:55 AM an interview was conducted with the Dietary Manager relating to the to the Quality Assurance (QA) process for the kitchen. When asked if room tray food temperatures and cleanliness of the kitchen were identified as potential area the committee wanted to work on, the Dietary Manager stated "no".

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07 Based on record review and interview, the facility failed to implement an effective Quality Assurance program as evidenced by the re-citation of F241 (dignity), F364 (Food Preperation) and F441 (Infection Control) and failed to identify ongoing issues related to additional cited deficiencies, F312 (Activities of Daily Living assistance), F314 (Pressure Ulcer treatment/Prevention), F328 (Equipment for Special needs), and F425 (Provision of Medications). The facility census was 81 Findings are: Review of the survey revealed the reciting of the following tags: F364, and F441 from the previous annual survey conducted on 6-6-13. An interview conducted with the administrator on 9-5-13 at 11am revealed that the staff developed an immediate plan to correct the issues that were brought up with pericare and pressure ulcers today and this was developed today. Record review of the Quality Assessment and ASsurance committee process(no date) revealed that the purpose of the committee was to identify quality deficiencies and develop and implement plans of actions to correct these quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the actions plans.