Every finding on record at Legacy Square

Licensure Reference Number 175 NAC Chapter 1-005.06(H)Based on interviews and record reviews, the facility failed to designate a dedicated staff member as the infection preventionist who is responsible for the facility's infection prevention and control program that works at least part-time. This had the potential to affect 33 residents that resided in the facility at the time of the survey. The facility census was 33.Findings are: A record review of the Laboratory Supervisor/Infection Preventionist Job Description (JD) dated 8.21.2025 revealed responsibilities to include the identification, investigation, reporting, prevention and control of infections, and communicable diseases within the organization. The JD was signed by the Infection Control Coordinator (ICC) and reports to the Chief Nursing Officer (CNO) and Quality Assurance Coordinator (QAC). During an interview on 1.14.2026 at 9:00AM with the Infection Control Coordinator (ICC) confirmed: Takes recommendations and follows the guidelines from the Centers for Disease Control and Prevention (CDC) Other duties included Lab Supervisor, ICC, and Safety Committee for the hospital, including long term care Tried to devote at least five hours per week to the IPP (Infection preventionist) role but does not get over to long term care often due to other duties Denied having access to resident records to audit or monitor documentation for signs or symptoms of infection Unaware if the ICC hours were coded or dedicated to long term care in the payroll system. A record review of the Timecard dated 10.1.2025 through 1.15.2026 for the ICC revealed all hours coded to [NAME] Health Care Services, Inc. The Human Resource Director (HRD) confirmed on 1.14.2026 that all ICC hours were allocated to the Hospital and not long-term care. A record review of the undated note signed by the HRD confirmed the Hospital payroll system is not currently set to differentiate out the ICC hours and reflects only the primary position of Lab Manager. During an interview on 1.14.2026 at 10:50AM with the QAC confirmed supervising the ICC role and there was no allocation of ICC hours to long term care as required. The QAC further confirmed the ICC receives infection control communication from the Assistant Administrator (AA), Director of Nursing (DON), and the Administrator (ADM) for updates or new infections.

Licensure Reference Number 175 NAC 12-006.18(B)Based on observations, interviews, and record reviews, the facility failed to prevent cross-contamination of COVID-19 (an infectious disease that is highly contagious) between 10 residents (Resident 2, 3, 8, 12,14, 15, 18, 22, 24, and Resident 30) out of 22 sampled residents. The facility census was 33 at the time of the survey. Findings are: A record review of the Facility Assessment with a Quality Assessment Committee review date of June 2025, under part two revealed: Offers care based on the resident's needs Offers infection prevention and control by identifying, containing, and preventing infections Offers management of medical conditions by assessment and early identification of medical symptoms, including infections A record review of the facility's undated COVID Tracking for Residents log revealed: Resident 15 tested positive for COVID on 12.21.2025 Resident 22 tested positive for COVID on 12.22.2025 Resident 14 tested positive for COVID on 12.22.2025 Resident 30 tested positive for COVID on 12.24.2025 Resident 2 tested positive for COVID on 12.24.2025 Resident 18 tested positive for COVID on 12.24.2025 Resident 24 tested positive for COVID on 12.29.2025 Resident 3 tested positive for COVID on 1.2.2026 Resident 12 tested positive for COVID on 1.5.2026 Resident 8 tested positive for COVID on 1.14.2026 A record review of the CDC's Recommendations for COVID-19 in Nursing Homes (2026) guidance revealed emphasis on universal masking (wearing a mask at all times), surgical or procedural masks can be worn as source control (to protect others) or as personal protective equipment (to protect the wearer), active surveillance, and testing to prevent the spread of infection. These guidelines aim to contain outbreaks through a multi-layered approach focusing on universal masking as a key tool. A record review of the Facility Infection Control Meeting minutes dated 12.29.2025 under New Business revealed to increase Flu (influenza), Norovirus (a highly contagious virus), and COVID monitoring, especially in long term care since long term care had a current outbreak (a sudden or violent start of something) of COVID. No other mention of COVID related measures implemented to prevent the spread. A record review of the undated facility Floor Plan revealed COVID positive residents were located throughout the facility. During an interview on 1.14.2026 at 9:00 AM with the Infection Control Coordinator (ICC) confirmed: Positive COVID cases in the facility beginning December 2025 with the latest resident testing positive on 1.14.2026 Denied knowledge of the actual number of COVID cases Could not provide tracking or trending of resident COVID cases Encouraged staff to wear masks after the first COVID case in December (2025) Reviews recommendations and follows the guidelines from the Centers for Disease Control and Prevention (CDC) regarding infections, including COVID Other duties included Lab Supervisor, ICC, and Safety Committee for the hospital, including long term care Tried to devote at least five hours per week to the IPP role but does not come to long term care often due to other duties Could not provide a timeline during the COVID outbreak Did not have access to resident records to audit or monitor documentation for signs or symptoms of infection During an interview on 1.15.2026 at 9:40 AM with the Housekeeper (HSK) confirmed staff were not required to wear a mask while the COVID outbreak occurred and masking was a choice. During an interview on 1.15.2026 at 9:45AM with the Nurse Aide (NA-A) confirmed masking was optional during the COVID outbreak per the Assistant Administrator (AA), and Director of Nursing (DON). During an interview on 1.15.2026 at 9:50 AM with the Activity Coordinator (AC) confirmed if there were three or more COVID cases, masking was recommended, some staff did but some did not wear a mask. During an interview on 1.15.2026 at 10:00 AM with the AA confirmed: Currently there are 10 cases of residents with COVID Responsible for keeping a log of the COVID cases but did not indicate room number or location Initiated COVID testing two times per week following three positive COVID cases First COVID case was 12.21.2025 COVID positive cases spread to 10 residents currently, then stated which is concerning Agreed that masks should be utilized to prevent the spread of COVID, and the staff should be wearing the masks Observations throughout the facility survey on 1.13.2026 through 1.15.2026 revealed staff not wearing masks in the public hallways, dining areas, kitchen, and resident rooms [except for the positive COVID resident rooms {Resident 8 and Resident 12}]. During an interview on 1.15.2026 at 2:30 PM with the Administrator (ADM) confirmed the facility could and should have done more to prevent the spread of COVID infection in the facility.

Licensure Reference Number 175 NAC 12-006.11EBased on observations, record reviews and interviews, the facility failed to ensure hand hygiene was completed and hair was restrained during meal service. This failure had the potential to affect all 32 residents receiving meals from the kitchen. The facility census was 33 at the time of survey. Findings are:Record review of 2022 Food Code revealed the following:-2-301.12 FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under S 5-202.12 and Subpart 6-301. P-2-301.14 FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES -(E) After handling soiled EQUIPMENT -(F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P -(G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD;- (H) Before donning gloves to initiate a task that involves working with FOOD; and -(I) After engaging in other activities that contaminate the hands.-2-402.11 FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.-3-301.11 Preventing Contamination from Hands. FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12.-Multiuse gloves, especially when used repeatedly and soiled, can become breeding grounds for pathogens that could be transferred to food. Soiled gloves can directly contaminate food if stored with ready-to-eat food or may indirectly contaminate food if stored with articles that will be used in contact with food. Multiuse gloves must be washed, rinsed, and sanitized between activities that contaminate the gloves. Hands must be washed before donning gloves. Gloves must be discarded when soiled or other contaminants enter the inside of the glove.Record review of the undated facility policy titled Hand Hygiene, revealed proper and frequent hand washing is the healthcare worker's first line of defense against becoming infected or spreading infection to someone else, and that all staff shall use the hand-hygiene guidelines per the CDC guidelines with the indication for using an alcohol based hand rub, antimicrobial soap or soap and water revealed use after removing gloves.Review of CDC Guidelines revealed the CDC emphasize washing hands thoroughly before putting on gloves, between glove changes (especially when switching tasks or touching contaminants), and after removing them, as germs can transfer and to change gloves immediately if dirty.Review of CDC Glove use guidelines revealed: Think of gloves as an extension of your hands, not a replacement for washing.Review of Key CDC Guidelines for Handwashing & Gloves in LTC Kitchens:-Before Gloves: Wash hands with soap and water or use alcohol-based sanitizer before donning gloves.-After Gloves: Wash hands with soap and water immediately after removing gloves.-Change Gloves Often: Change gloves between tasks (e.g., raw food to cooked food) and after touching contaminated items or surfaces.Record review of the undated facility policy titled Hair Restraints, revealed if food is on the service line or being served, hair restraints must be worn at all times in the kitchenette.During an observation on 01/13/2026 at 8:31 AM in the Slate kitchenette revealed Dietary Aide (DA) - B applied gloves with no hand hygiene performed, cracked and fried an egg in a skillet on the stove, put it (the fried egg) on a plate, removed gloves with no hand hygiene performed and then served the tray in the dining room.During an observation on 01/13/2026 at 8:47 AM DA-B returned to the kitchenette and applied gloves with no hand hygiene. DA - B then reached for a waffle with gloved hands and put the waffle in the microwave, grabbed a sausage patty with gloved hand and put it on a plate and cut it into bite sized pieces using a knife and gloved hand. DA-B covered the plate with a metal plate cover and removed gloves with no hand hygiene performed.During an observation on 01/13/2026 at 8:52 AM DA- B put on gloves with no hand hygiene performed, scooped and picked up scrambled eggs out of the steamer table with gloved hands and put the eggs on a plate, reached for a waffle out of the steamer table and put the waffle in the microwave, then took the waffle out of microwave and put it on plate. DA-B with gloved hand then cut the waffle using a knife.During an interview on 01/13/25 at 8:56 AM DA - B confirmed that (gender) is supposed to wash their hands and sing the ABC's every time they remove gloves and before putting on new gloves.During an observation on 01/14/25 at 8:08 AM in the Sun kitchenette DA - B applied gloves, cracked and fried an egg in a skillet on the stove, reached in a bag of prunes and grabbed a few prunes, grabbed strawberries from the cold side of the serving table, gathered a piece of French toast out the steamer table and put it on a plate and cut the French toast using a gloved hand and a knife, and then obtained a handful of grapes, peeled and cut a banana and put everything on a plate and covered it with a metal lid. DA-B reached for cup of ice tea and put the cup on the tray. DA - B went back to the stove and covered the egg with a lid, then grabbed bread out of bread bag, put the bread in the toaster, and grabbed a cup of prune juice. DA- B then put (gender) hands on the counter and touched the computer tablet screen. DA - B grabbed the handle of frying pan and put the fried egg on the plate with a spatula, grabbed toast out of the toaster and buttered the toast with a knife. DA-B performed these tasks without changing gloves or performing hand hygiene.During an observation on 01/14/25 at 8:15 AM DA - B removed (gender) gloves, did not perform hand hygiene and took the tray out to the dining room.During an interview on 01/14/25 at 8:18 AM DA - B revealed (gender) normally grabs and touches the food with (gender) gloved hands but confirms (gender) should use the utensils or the tongs.Observation on 01/14/2026 at 8:31 AM in the Slate Kitchen revealed DA - C with hair restraint not covering all of (gender) hair and food was in the steam table and on the counter in the kitchenette.During an interview on 01/14/26 at 8:32 AM DA - C confirmed that (gender) hair restraint should cover all of (gender) hair. During an interview on 01/14/2026 at 10:32 AM the Director of Nutrition (DN) confirmed that kitchen staff should not grab food with gloved hands and should use tongs and hair restraints should cover hair. DN revealed that the kitchen staff shouldn't need to wash their hands after removing gloves if they are not going to touch food.During an interview on 01/14/2026 at 11:23 AM the DN confirmed that (gender) monitors and supervises both kitchenettes in the long term care area.During an interview on 01/14/25 at 10:50 AM the Quality Assurance Coordinator (QAC) confirmed that all staff should perform hand hygiene before putting on gloves and after removing gloves.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interview, the facility failed to notify the physician of a resident fall with the potential for requiring physician intervention. This affected 1 (Resident 17) out of 2 residents sampled for falls. The facility census was 33 at the time of survey.Findings are:Record review of the undated facility policy titled Fall Prevention and Investigation Policy and Procedure revealed to notify physician and family per facility notification policy. Injury is defined as physical harm.Record review of definitions from the Resident Assessment Instrument (RAI Manual instructs nursing homes on conducting standardized assessments) ([DATE] Updates) revealed: Injury (Except Major): Includes skin tears, abrasions, lacerations, superficial bruises, hematomas, sprains, or any fall-related complaint of pain.Record review of Resident 17's Quarterly Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 12/10/25 revealed the resident was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15, which indicated the patient is cognitively intact, no behaviors indicated, a diagnosis of heart failure, and no complaints of pain.Record review of Resident 17's Quarterly MDS dated [DATE] revealed that 1 fall with injury (except major) was marked and that included abrasions and fall related injury that caused the resident to complain of pain.Record review of Resident 17's Comprehensive Care Plan - (CCP- written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed the resident had a history of falls with a revision date of 11/18/2025, with a goal of the resident wished to have falls free of minor injuries with a revision date of 3/31/2025.Record review of facility provided incident report summary revealed that Resident 17 fell in the bath house, staff and resident reported that the resident fell on (gender's) right elbow and right hip, the resident was alert and oriented, the resident received an abrasion to right elbow and Tylenol (medicine used as needed to control pain) was given for complaints of pain at a 6 out of 10 (pain scale) for right hip pain.Review of Resident 17's progress note late entry dated 11/26/2025 and time of 1400 revealed staff reported resident fell on their right elbow and right hip. An abrasion noted to right elbow. Pain noted to right hip and Tylenol given.Review of facility provided incident report revealed that Resident 17 was currently receiving physical therapy regarding gait concerns due to fall history.Review of undated facility form titled Legacy Square revealed that Resident 17's doctor did not want to be notified of occurrences requiring no first aide or of occurrences requiring first aide.During an interview 01/15/2026 at 1:06 PM the Director of Nursing (DON) confirmed that the facility incident report had been reported to the state agency.During an interview on 01/15/2026 at 1:40 PM the DON confirmed that the physician was not notified of the fall immediately because the resident was not injured but maybe should have been due to the resident's hip pain.During an interview on 01/15/2026 at 4:18 PM the Assistant Administrator (AA) confirmed there was no facility notification policy.

Licensure Reference Number 175 NAC 12-006.09(I)Based on record review and interview, the facility failed to prevent an elopement which had the potential to cause harm on one resident (Resident 1) out of three residents sampled. This had the potential to affect six residents identified at risk for elopement. The facility census was 37. Findings:The facility was notified on 10/20/2025 at 5:02 PM of an Immediate Jeopardy (IJ represents a situation in which noncompliance by the facility has placed the health and safety of the residents in its care at risk for serious injury, serious harm, serious impairment, or death) which began on 10/13/2025. The IJ was removed on 10/20/2025 at 8:00 PM, as confirmed by the surveyor's onsite verification.A record review of the facility's undated Elopement Facility Wide policy revealed:- -Elopement is defined as any resident/patient who has left the campus without informing a member of the healthcare staff or a resident/patient who is found off campus that is not indicated or planned for. - -Staff will be knowledgeable regarding elopement procedures. A record review of the undated Facility's WanderGuard System Policy (an electronic system used in nursing homes to prevent residents with dementia [a syndrome characterized by a progressive decline in cognitive functions], Alzheimer's [a progressive and fatal brain disorder that causes gradual decline in cognitive abilities], or other cognitive impairments from wandering off and becoming lost or injured) revealed:- - Elopement defined as a resident who is cognitively impaired or otherwise at risk leaves a safe area or the facility without staff awareness and/or without necessary supervision. - - Documentation must include the elopement risk results, date and number on WanderGuard bracelet issued, system testing and results, and any incident, malfunctions, or corrective actions taken. A record review of the facility's Clinical Census revealed Resident 1 was admitted on [DATE]. A record review of the facility's Medical Diagnosis form with a print date of 10/20/2025 revealed Resident 1 had a diagnosis of Dementia with mood disturbance. A record review of Resident 1's Minimum Data Set (MDS, this comprehensive assessment evaluates each resident's functional capabilities) dated 7/23/2025 revealed a brief interview for mental status (BIMS a brief screener that aids in detecting cognitive impairment) score of four which indicated the resident had severe cognitive impairment. A record review of Resident 1's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) with an admission date of 10/18/2021 and a revision date of 12/3/2021, included a focus area of impaired cognitive function relating to a diagnosis of Dementia. An intervention included checking WanderGuard function every shift. This intervention was last updated on 1/17/2025. No other interventions relating to exit seeking or elopement risk were identified. A record review of the facility's Wandering Risk Scale dated 7/25/2025 revealed Resident 1 was identified as a high risk to wander (the act of a resident moving from place to place with or without a specific direction or purpose, that may or may not be aimless and could be a safety concern), and had wandered/exit seeking behaviors in the past month. A record review of the facility's Wandering Risk Scale dated 10/17/2025 revealed Resident 1 was identified as a high risk to wander. A record review of the facility's Incident Report Summary dated October 2025, revealed Resident 1 had an equipment failure on 10/13/2025 at 8:03 AM. The description of the event included: - - Staff member observed Resident 1 exiting the building and then immediately notified the Activity Coordinator (AC) who assisted Resident 1 back into the building. - - Resident 1 remained on facility property. - - Resident 1's WanderGuard checked at 7:04 AM and was working. - - Resident 1's WanderGuard checked at 8:30 AM and was no longer working. - - Registered Nurse- A (RN-A) replaced Resident 1's WanderGuard at 8:30 AM. - - Resident 1 was safely maintained. A record review of the facility's 24-Hour Report Sheet dated 10/13/2025 between the hours of 5:30 AM and 2:00 PM revealed no information regarding Resident 1 attempting to leave the facility or of equipment malfunction. A record review of the facility's 24-Hour Report Sheet dated 10/20/2025 revealed Resident 1 had an increase of exit seeking and trying to get out all night. A record review of the facility's undated Aide Care Plan (an informational document used by the nurse aides to assist in the care of the residents) revealed Resident 1 had a WanderGuard. No information regarding attempting to leave the facility or of equipment failure. A record review of a facility email dated 10/13/2025 at 1:06 PM revealed the Director of Nursing (DON) communicated information regarding charging the WanderGuard checking device (a handheld device used to test the WanderGaurd bracelets and door monitors). No information regarding Resident 1 attempting to leave the facility or equipment malfunction was located. During an interview on 10/20/2025 at 9:10 AM with the AC revealed:-AC was walking out of the building from the front door and was met by the Assistant Administrator (AA) outside the front door.-The AA informed the AC that Resident 1 was walking down the sidewalk around the northeast corner of the building.-AC walked through the building to the northeast exit door and observed Resident 1 on the sidewalk outside the gate of the northeast exit door.-AC redirected Resident 1 back through the northeast exit door and was let in by another staff member due to the exit door being locked.-AC confirmed Resident 1 was not to be outside unattended.-AC confirmed thinking this event should be reported and was told by the AA that it would be reported and handled. -AC confirmed Resident 1 wore a WanderGuard for safety. An observation on 10/20/2025 at 9:53 AM of Resident 1 revealed a WanderGuard bracelet on the right wrist. During an interview on 10/20/2025 at 10:14 AM the DON confirmed a call from the AA on 10/13/2025 at 8:00 AM reporting Resident 1 was outside. DON observed another staff member bringing Resident 1 back into the facility and was not aware how long Resident 1 was outside. During an interview on 10/20/2025 at 10:55 AM with the Plant Operations Director (POD) confirmed:- A motion detector was located by the northeast exit door but denied knowledge of the detector, how it worked, and how long it had been there.-The motion detector is not checked for functionality.-The exit doors only lock when activated by a WanderGuard bracelet, but the doors are always locked from the outside.-Confirmed that if the WanderGuard malfunctions, there is no way to keep the residents safe from elopement.-If a resident gets out the exit door unattended, the resident could not get back in due to the door locking.-POD unaware a resident had left the facility.- Door alarms are only checked if there is a reported problem and the doors have not been checked recently. An observation on 10/20/2025 at 11:00 AM with POD confirmed the motion detector located by the northeast exit door was shut off and not alarming when approaching the door. During an interview on 10/20/2025 at 11:55 AM with the AA confirmed:-No reportable incidents in the past month.-The new motion detector by the northeast exit door was added on 10/13/2025 after Resident 1 got out the door without staff knowledge.-No additional training was provided for staff regarding Resident 1 leaving the building.-No one is responsible for monitoring the new motion detector. AA stated I guess we should During an interview on 10/20/2025 at 12:15 PM Nurse Aide-D (NA-D, a healthcare professional who assists residents with their activities of daily living i.e. grooming, bathing, dressing, meals) confirmed no education, information relating to the new motion detector or additional elopement training had been received.During an interview on 10/20/2025 at 12:47 PM with the Licensed Practical Nurse-B (LPN-B a healthcare professional who provides basic nursing care under the supervision of a registered nurse) confirmed not receiving education or information relating to the new motion detector or additional elopement training. The only information received was regarding the charging of the WanderGuard checker.During an interview on 10/20/2025 at 12:50 PM with the Registered Nurse (RN-A ) on duty 10/13/2025 confirmed:-RN-A was not the nurse on the hallway that Resident 1 resided.-RN-A thought the incident should have been reported based on knowledge of situation. RN-A was told by the AA that the reporting was being handled.-RN-A was unaware if extra checks were being documented on Resident 1 since the incident of exiting the northeast door. An interview on 10/20/2025 at 12:57 PM with Resident 1's family confirmed not being aware that Resident 1 had exited the building on 10/13/2025. Family confirmed that the facility had called in the past to report exit seeking behavior. A record review of a facility Progress Note (a written record of the resident's health status, treatments, unusual occurrences) dated 10/13/2025 at 2:45 PM revealed at 8:03 AM, AA observed Resident 1 exiting the building and the AC was immediately notified and Resident 1 was assisted back into the building. Resident 1 remained on facility property and safety was maintained. The author was documented as AA. A record review of the facility Progress Notes dated 10/12/2025-10/20/2025 revealed no nursing assessment on Resident 1 and no follow up regarding the incident on 10/13/2025. During an interview on 10/20/2025 at 1:13 PM with AA revealed:- - On 10/13/2025, while driving to work on 17th street, AA observed Resident 1 exiting the northeast door of the facility.- - AA placed a phone call to the the DON and continued to drive around the building to the front entrance, losing direct sight of Resident 1. - Reported to the AC that Resident 1 was outside and to go and bring Resident 1 back into the building. - Confirmed no idea how Resident 1 got out the northeast door, and the gate or how long Resident 1 was outside unattended. -The motion detector was placed at the northeast door on the same day but after Resident 1 exited the door. - Confirmed all exit doors have WanderGuard alarms. - -Confirmed the exit doors and outside gates are not checked or monitored. - -Stated the outside gates are not locked. During an interview on 10/20/2025 at 2:35 PM NA-E confirmed the northeast exit door is usually locked but now it has the motion detector, and the motion detector is not working. During an interview on 10/20/2025 at 2:47 PM LPN-C confirmed not checking or monitoring the exit doors and only checking the WanderGaurd bracelets of the residents who wear them to insure they are functioning correctly. During an interview on 10/20/2025 at 2:53 PM with AA confirmed the facility had no elopements in the past year. The incident with Resident 1 was not considered an elopement since the resident did not leave the facility grounds. In addition, there was no resident assessment or report to the state documented. During an interview on 10/20/2025 at 3:11 PM with the DON confirmed being told by the AA that Resident 1 was witnessed exiting the northeast door and that AA continued to drive around the building to the front entrance losing visual sight of Resident 1. DON reported attempting to coordinate with other staff at the desk regarding who would watch the floor and who was going to get Resident 1 back into the facility. DON reported that while coordinating with the staff, the AC was bringing Resident 1 back into the facility. DON confirmed not knowing how long Resident 1 was outside of the building unattended. During an interview on 10/20/2025 at approximately 5:00 PM with the Administrator (ADM) confirmed the incident with Resident 1 was considered an equipment failure and was not investigated as an elopement, and was not reported. ADM confirmed not investigating the incident further was based on what was reported by the AA.A record review of the Facility's Abatement Statement dated 10/20/2025 revealed:Abatement Plan: Effective immediately, all staff on duty will be re-trained on the facility Elopement Policy and Procedure and our roles in these events/occurrences. All Legacy Staff (nursing, dietary, housekeeping, plant operations, activities, social services, administration) will be re-trained on the facility Elopement Policy and Procedure as they report to duty. Charge nurses will conduct focused huddles at the beginning of the shift for a week to ensure all questions are addressed and all precautions/interventions are well communicated. Once the re-training has been concluded, mock Elopement drills will be conducted on each shift. In addition, residents determined to be at risk for wandering/elopement will be placed on hourly rounding by staff to mitigate the risk. This will be added to each residents care plan and implemented immediately this evening. All exit doors will be checked each shift (starting immediately) to ensure the wanderguard mechanism engages the locking device on each door. This will be documented by the charge nurse. Any locking failure will be reported to the administration and plant operations manager and immediate interventions will be instituted until properly functioning. Additionally the latching mechanism on the patio doors will be checked each shift (starting immediately) to ensure the gates are properly latched. This will be documented by the charge nurse. Any latching failure will be immediately reported to administration and plant operations manager and immediate interventions will be instituted until properly functioning. The facility will conduct updated elopement risk assessments on all residents identified as a wandering/elopement risk by end of day tomorrow (10/21) to determine if additional, individualized interventions should be implemented. Care plans will revised as needed and staff educated on any changes through the 24 hour communication sheet and CNA care plans. Nursing staff will continue to monitor for any resident changes in condition (infection, medication changes, pain, etc) that may contribute to wandering as well. Facility will implement a debriefing with leadership and staff on duty when an incident occurs. Care plans may be revised and those changes will be communicated to the care team. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the immediacy of the IJ violation at 8:00 PM on 10/20/2025. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to a D Level.

Licensure Reference Number 175 NAC 12-006.07ABased on interviews and record review, the facility administrator failed to ensure the Quality Assessment and Assurance (QAA) committee included all of the required members. This had the potential to affect all of the residents in the facility. The facility census was 37 at the time of the survey.Findings are:Record review of the facility's Quality Assurance (QA) meeting records revealed no evidence of the facility's Medical Director had participated in the quarterly QA meetings in the facility for the past 4 quarters on December 17, 2024, March 18, 2025, June 17, 2025, and September 16, 2025.During an interview on 10/23/2025 at 10:28 AM the Assistant Administrator confirmed there was no documentation that the facility's Medical Director had participated in the quarterly QA meetings in the long term care facility and it was further confirmed that on March 18, 2025 the facility Director of Nursing services and the Administrator were not in attendance of the QA meeting. During an interview on 10/23/2025 at 10:58 AM the facility's Administrator confirmed that (gender) and the facility's Medical Director did not attend the quarterly QA meetings in the long term care facility and should have.

Licensure Reference Number 175 NAC 12-006.02(H)Based on interviews and record reviews, the facility failed to thoroughly investigate an incident related to elopement for 1 (Resident 1) of 3 residents sampled. This had the potential to affect 6 residents identified as at risk for elopement. The facility census was 37 at the time of the survey.Findings are:Record review of the facility's undated policy titled Elopement Facility Wide revealed the definition of elopement as any resident who has left the campus without informing a member of the staff or a resident who is found in a location off campus that is not planned.Record review of the facility's undated algorithm titled Elopements, revealed to complete an incident report and a detailed notation in the resident's medical records after the resident is found.Record review of the facility's reportable investigations for the past 12 months did not reveal any elopements.Record review of Resident 1's progress notes dated 10/13/2025 revealed the Resident was found outside the building.Record review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 7/23/2025 revealed that the resident originally admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 4, which indicated severe cognitive impairment, and a history of wandering.Record review of Resident 1's Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) revealed:-Focus dated last revision on 12/3/2021 that the resident has impaired cognitive function related to a diagnosis of dementia.-Intervention with a date initiated of 4/15/2024 that the resident has a Wanderguard (an alarm system that allows facilities to monitor exit doors to prevent wandering or high risk residents from leaving the facility without assistance). Record review of Resident 1's Wandering Risk Scale dated 7/25/25 revealed the resident has a diagnosis of dementia, is ambulatory, and has verbalized wanting to go home or to leave the facility. This Wandering Risk Scale also revealed a score of 14, which indicated a High Risk to wander.During an interview on 10/20/025 at 9:10 AM the Activities Coordinator confirmed that on the morning of 10/13/2025 Resident 1 was walking down the sidewalk next to the building and (gender) redirected the resident back inside. It was also confirmed that the resident should not be outside unattended.During an interview on 10/20/25 at 10:55 AM the Plant Operations Director confirmed that if the WanderGuard malfunctions, there is no way to keep the resident safe from elopement, and if a resident got outside unattended the doors would lock and they could not get back in.During an interview on 10/20/25 at 2:53 PM the Assistant Administrator confirmed that the elopement was not investigated because (gender) did not think it was an elopement and there was no assessment completed on the resident because there was no visible injury.During an interview on 10/20/25 at 3:11 PM the Director of Nursing was unaware of how long the resident was outside unattended, it was also confirmed that the resident should not be outside unattended.During an interview on 10/20/2025 at 5:01 PM the Administrator confirmed that the elopement was not investigated and it should have been.

Licensure Reference Number 175 NAC 12-006.02(H)Based on interviews and record review, the facility failed to report an incident related to elopement to Adult Protective Services (APS) and to the Department of Health and Human Services (DHHS) within the required timeframe for 1 (Resident 1) of 3 sampled residents. The facility census was 37.Findings are:Record review of the facility's undated algorithm titled Elopements, revealed to complete an incident report, a detailed notation in the resident's medical records after the resident is found and then to send the complete investigation to DHHS Investigations.Record review of Resident 1's progress notes dated 10/13/2025 revealed the Resident was found outside the building.Record review of the facility's reportable investigations for the past 12 months did not reveal any elopements.Record review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 7/23/2025 revealed that the resident originally admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function score of 4), which indicated severe cognitive impairment, and a history of wandering.During an interview on 10/20/25 at 2:53 PM the Assistant Administrator confirmed that the elopement was not investigated or reported because (gender) did not think it was an elopement and there was no assessment completed on the resident because there was no visible injury.During an interview on 10/20/25 at 3:11 PM the Director of Nursing was unaware of how long the resident was outside unattended, it was also confirmed that the resident should not be outside unattended.During an interview on 10/20/2025 at 5:01 PM the Administrator confirmed that the elopement was not reported to the State Agencies and it should have been.

Licensure Reference Number 175NAC 12-006.05(S) Based on observation, record review, and interview the facility failed to ensure that the rights of facility residents were maintained for 14 residents (14, 2, 27, 30, 22, 19, 15, 1, 18, 9, 134, 26, 8, and 3). The facility census was 32. Findings are: A. Record review of the undated facility Admission Agreement revealed the section titled Rules and Regulations. The section revealed that the resident agrees to follow the rules, regulations and guidelines for residents which are included in the Resident Policies. The resident has the right to voice concerns (grievances) about the care or treatment to the administrator and to expect a response. Resident acknowledges receipt of the Resident Rights. The section titled Facility's Grievance Procedure revealed that if a resident or resident representative believes that the resident is being mistreated in any way or resident rights have been or are being violated by staff or another resident, the resident or resident representative shall make a complaint to the facility's Director of Nursing, Administrator, or Director of Social Services. The facility will review and investigate the complaint and provide a response to the resident and/or resident representative. Record review of the facility Resident Rights dated 2023 revealed that state and federal law define rights within a nursing facility to protect the potentially vulnerable people who live in a nursing facility. The resident has the right to be treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The nursing facility must protect and promote the rights of the resident. The resident has the right to receive visitors of his or her choosing, subject to the resident's right to deny visitation, and in a manner that does not impose on the rights of another resident. The resident has the right to personal privacy including accommodations. The resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The nursing facility must provide a safe, clean, comfortable, and homelike environment. The nursing facility must exercise reasonable care for the protection of the resident's property from theft or loss. The nursing facility must ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, establish policies and procedures to investigate any such allegations, and include training. Record review of the Admission Record dated 8/29/24 for Resident 6 revealed that Resident 6 admitted into the facility on [DATE]. Diagnoses included Vascular Dementia with behavioral disturbance (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain); Unspecified Dementia with other behavioral disturbance (a non-specific dementia with behaviors that can include impaired concentration, apathy (lack of feeling or emotion), anxiety, and agitation); and Anxiety. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 6/19/24 for Resident 6 revealed that the Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) could not be completed for Resident 6. The MDS revealed that Resident 6 is rarely or never understood. Resident 6's cognitive skills for daily decision making are moderately impaired. The behavior section of the MDS assessment revealed that Resident 6 has a behavior of wandering. The assessment revealed that Resident 6's wandering significantly intrudes on the privacy or activities of others. Record review of the Care Plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) for Resident 6 dated 8/28/24 revealed that Resident 6 is able to transfer and walk independently. The care plan revealed that Resident 6 has impaired cognitive function and decision making skills due to dementia and has behaviors of wandering and exit seeking. Interventions included: -Be aware of Resident 6's whereabouts. Resident 6 may wander any time of the day or night but tends to wander more in the afternoon or evening. Distract Resident 6 from wandering by offering toileting, food/fluid, rest, TV show in family room. Initiated 12/29/2014 with revision on 7/15/24. -Document behaviors and attempted diversional interventions in the behavioral book along with a progress note. Initiated 7/15/24. -Resident 6 requires approaches that limit choices. Present just one thought, idea, question, or command at a time. If Resident 6 becomes agitated, leave Resident 6 alone if safe to do so and attempt interaction at a later time. Switch out staff if needed. Initiated 12/29/2014 with revision on 7/15/24. -Staff to monitor for possible interactions between Resident 6 and Residents 2 and 15. (discharged residents from room [ROOM NUMBER] and room [ROOM NUMBER] were also listed in the intervention). Staff to provide early interventions as soon as possible including redirection, distraction and/or remove Resident 6 from the situation and take to an alternate location. Intervene as necessary to protect the rights and safety of both Resident 6 and other residents. Approach Resident 6 from the front and speak in a calm manner. Initiated 7/15/24. Record review of the progress note for Resident 6 dated 12/5/23 at 7:09 PM revealed that Resident 6 was repeatedly entering other resident's rooms. Staff attempted to redirect Resident 6 out of resident rooms and Resident 6 continued to roam. Resident 6 entered the room of Resident 14 and took decorations from the room. Record review of the progress note for Resident 6 dated 12/5/23 at 8:21 PM revealed that a staff member saw Resident 6 take down the stop sign outside the room door of Resident 2. Resident 6 entered the room of Resident 2. The room door was locked and staff was unable to get Resident 6 out of the room. The staff member ran to get the charge nurse. The charge nurse unlocked the door and entered the room of Resident 2. The charge nurse saw Resident 2 standing by the bed in the room facing Resident 6. Resident 2 was hitting Resident 6 across the arms and chest, screaming at Resident 6 to get out of here. The charge nurse removed Resident 6 from the room and placed the stop sign back across the door to the room of Resident 2. Resident 6 was redirected to another area to do activities, 1 on 1, and have a snack. Record review of the progress note for Resident 6 dated 12/5/23 at 8:52 PM revealed that Resident 6 continued to enter other resident's rooms that were now sleeping. The nurse tried to have Resident 6 sit and watch the television with the nurse. Resident 6 sits but gets back up right away and continues to wander. Resident 6 was opening exit doors and then walking away. Record review of the progress note for Resident 6 dated 12/9/23 at 2:49 PM revealed that Resident 6 was wandering the halls and frequently entering other resident's rooms. Record review of the progress note for Resident 6 dated 12/9/23 at 8:43 PM revealed that Resident 6 was in and out of other resident rooms throughout the shift. Resident 6 started taking other resident's walkers and wheelchairs from their rooms and walking with them down the hallway. Staff tried 1 on 1, giving snacks, activities, watching tv in the living room. All interventions were ineffective. Record review of the progress note for Resident 6 dated 12/10/23 at 9:30 PM revealed that the nurse received complaints from 3 different residents about Resident 6 coming into their rooms and touching things. The nurse did remove Resident 6 from 2 of the rooms as the residents were yelling at Resident 6 loudly enough that the nurse could hear them. Resident 6 had been wandering throughout the facility as per their usual. Record review of the progress note for Resident 6 dated 12/10/23 at 9:32 PM revealed that the nurse did attempt to redirect Resident 6 from wandering in and out of rooms this evening as residents are wanting their doors locked to keep Resident 6 out. Record review of the progress note for Resident 6 dated 12/26/23 at 7:30 PM revealed that Resident 6 wandered into the room of Resident 2. Resident 2 yelled at Resident 6 and Resident 6 did not leave the room. Resident 2 cornered Resident 6 and started punching Resident 6 in the chest. Staff separated the residents and Resident 6 was removed from the room of Resident 2. Record review of the progress note for Resident 6 dated 12/30/23 at 1:34 AM revealed that Resident 6 wandered into other resident rooms until Resident 6 went to bed around 10:00 PM. Several residents yelled at Resident 6. The nurse tried to redirect Resident 6 but Resident 6 was very hard to redirect. Record review of the progress note for Resident 6 dated 12/31/23 at 8:48 PM revealed that Resident 6 has continued to roam the building. Resident 6 continued to go into resident's rooms that have their doors shut and are sleeping. Staff has tried several attempts to redirect Resident 6 to anther activity. Resident 6 will not redirect. Staff have tried television shows, food, and having Resident 6 sit with them and Resident 6 would not do so. Record review of the progress note for Resident 6 dated 1/14/24 at 7:28 PM revealed that Resident 6 was in and out of resident rooms moving things and startling people. Resident 6 removed a family quilt from the room of Resident 27. Resident 27 was upset and the nurse tried to remove Resident 6 from the room of Resident 27 three times in the past 1.5 hours. Interview on 8/29/24 at 10:00 AM with Resident 27 revealed that Resident 27 gets irritated with Resident 6 coming into their room. Resident 27 revealed that staff have to remove Resident 6 from the room. Resident 27 revealed that Resident 6 keeps coming into their room and Resident 27 does not like it. Record review of the progress note for Resident 6 dated 1/17/24 at 8:05 PM revealed that Resident 6 was wandering into other resident rooms constantly this evening and was unable to be redirected. Resident 6 had been removed from rooms 15, 13, 18, 19, 20, 21, 4, 6, and 8 in the last 2 hours. That did not count the rooms on the other side ([NAME] Hills unit) or the other staff removing Resident 6 from rooms. The residents are very frustrated and some yell at Resident 6. Resident 6 does not redirect. Record review of the progress note for Resident 6 dated 2/3/24 at 2:16 PM revealed that Resident 6 had entered several other resident rooms and had been picking up their mail. Staff has redirected Resident 6 several times. Record review of the progress note for Resident 6 dated 2/6/24 at 7:52 PM revealed that Resident 6 entered the room of Resident 30 and took that resident's personal folding chair. Resident 6 drug the chair out of the room and placed it in the hallway. Resident 30 was very upset and said we shouldn't have people like Resident 6 in here. Record review of the progress note for Resident 6 dated 2/7/24 at 8:32 PM revealed that Resident 6 entered the room of Resident 30 and pushed a dining room chair into the room of Resident 30. Resident 30 was greatly upset. Resident 30 called and complained saying this is not the place for Resident 6. Interview on 8/29/24 at 9:30 AM with Resident 30 revealed that Resident 6 comes into their private room unannounced. Resident 30 explained that when Resident 6 came into their room one evening, Resident 6 threw their chair into the hallway, threw their pillows on the floor, then stood in their shower. Resident 30 revealed that they are not comfortable when Resident 6 enters their room. Resident 30 revealed that they must yell for a staff person to come in and get Resident 6 when it occurs. Record review of the progress note for Resident 6 dated 2/13/24 at 8:58 PM revealed that Resident 6 wandered in and out of resident rooms tonight. Two residents yelled at Resident 6 before staff were able to remove Resident 6 from their rooms. Resident 6 is becoming harder to redirect and gets visibly agitated when staff try to remove Resident 6 from other rooms. Resident 6 was in rooms 21, 20, 19, 14, 13, and 4 that the nurse had noticed tonight so far. Record review of the progress note for Resident 6 dated 3/10/24 at 8:20 PM revealed that Resident 6 had wandered the halls this evening entering multiple rooms. Resident 6 entered the room of Resident 22. Resident 22 is almost blind. Resident 6 took Resident 22 by the hand and was literally pulling Resident 22 down the hallway as Resident 22 tried to resist. The nurse intervened and took Resident 22 back to their room. The nurse tried to redirect Resident 6. Record review of the progress note for Resident 6 dated 3/16/24 at 8:35 PM revealed that Resident 6 was having increased behaviors. Resident 6 walked the halls taking off their top and then continued to get naked. Staff intervened. Resident 6 went into another resident's room several times setting of the resident's motion alarm and scaring the resident. Resident 6 went into another resident's room. The other resident was sleeping. Resident 6 walked over to the recliner and pulled their pants down and tried to urinate on the recliner. Staff removed Resident 6 from the room. Record review of the progress note for Resident 6 dated 3/28/24 at 9:35 PM revealed that Resident 6 had been wandering throughout the facility and in and out of multiple resident rooms walking in on residents in various stages of undress, upsetting them. Resident 6 is unable to be redirected and the behavior continues throughout the shift. Record review of the progress note for Resident 6 dated 4/3/24 at 6:30 PM revealed that Resident 6 entered the room of Resident 2. A nurse aide heard Resident 2 yelling. The nurse aide entered the room of Resident 2 to find Resident 2 with one hand around Resident 6's throat and slapping Resident 6 across the face with the other hand while yelling at Resident 6. Resident 6 backed up into the closet door in an attempt to get away. The nurse aide told Resident 2 to let Resident 6 go. Resident 2 let go of Resident 6 and grabbed onto the nurse aide. The nurse aide pried themselves away from Resident 2 and left the area with Resident 6. The nurse aide placed the stop sign over the door to the room of Resident 2 to deter Resident 6 from reentering the room. Record review of the progress note for Resident 6 dated 4/7/24 at 9:30 PM revealed that Resident 6 wandered the facility this past evening and entered rooms 8, 12 (the room of Resident 27), 13, 15, 19, 20, and 29 that the nurse had witnessed. Resident 6 sat off motion alarms in the room, picked up items, and sat on other resident's beds that upsets them. Record review of the progress note for Resident 6 dated 4/15/24 at 12:31 PM revealed that Resident 6 was found entering other resident's rooms 3 times this morning. Staff were able to redirect Resident 6 out of the other resident's rooms. Record review of the progress note for Resident 6 dated 4/25/24 at 8:03 PM revealed that the nurse heard Resident 19 screaming get out of here. The nurse entered the room of Resident 19 and found Resident 6 in the room. The nurse escorted Resident 6 from the room and redirected Resident 6. Record review of the progress note for Resident 6 dated 4/26/24 at 10:22 PM revealed that Resident 6 had been going in and out of rooms all evening. Resident 6 was taking things out of resident rooms like pillows and water pitchers. Resident 6 entered the room of Resident 19 and broke off leaves from Resident 19's plant and took Resident 19's candy. Record review of the progress note for Resident 6 dated 5/11/24 at 3:00 PM revealed that Resident 6 was in and out of other resident's rooms continually today. At one point, Resident 6 could not be found, and Resident 6 was sitting in another resident's recliner. Resident 6 was continually redirected out of rooms. Attempted to distract Resident 6 with TV and 1 on 1 interaction. Record review of the progress note for Resident 6 dated 5/19/24 at 10:05 PM revealed that Resident 6 wandered the halls with their walker this evening. Resident 6 entered various resident's rooms and was difficult to redirect. Resident 6 was ramming their walker into staff as they attempted to direct Resident 6 out of the room. It took various staff to redirect Resident 6 out of rooms. Record review of the progress note for Resident 6 dated 6/8/24 at 2:53 PM revealed that staff found Resident 6 sitting on the bed of another resident in room [ROOM NUMBER]. Resident 6 had knocked the phone off the hook. Record review of the progress note for Resident 30 dated 6/8/24 at 6:19 PM revealed that Resident 30 requested that their door remain locked throughout the evening as Resident 6 had entered their room. Resident 6 had squeezed themselves between the bed and the window of Resident 30's room. Resident 30 explained to the nurse at the time that Resident 6 entered the room and shut the door behind them, so when Resident 30 yelled for help, no one could hear. Resident 30 stated I was pretty scared. Record review of the progress note for Resident 6 dated 6/17/24 at 4:44 PM revealed that Resident 6 was entering other resident's rooms and taking items. Resident 6 was hard to redirect out of rooms and to give other resident's items back to the owners. Record review of the progress note for Resident 6 dated 7/14/24 at 10:31 PM revealed that Resident 6 wandered the halls this evening. Resident 6 had been taking the stop signs from resident room doors and attempting to enter other resident's rooms. When staff tried to intervene and redirect, Resident 6 pushed their walker into staff. Staff heard the alarm sound in the room of Resident 15. Staff entered the room and observed Resident 6 sitting on Resident 15's bed on top of Resident 15's legs. Staff was able to get Resident up and off of Resident 15. Record review of the progress note for Resident 6 dated 7/20/24 at 3:00 PM revealed that Resident 6 entered the room of Resident 1 without permission. Resident 1 started yelling at Resident 6 to get out. Staff redirected Resident 6 from the room and locked the door to the room of Resident 1 at the request of Resident 1. Record review of the progress note for Resident 6 dated 7/30/24 at 9:13 PM revealed that Resident 6 had been wandering about the facility this evening. Resident 6 was removed from rooms [ROOM NUMBER]. Resident 6 had been redirected from entering other rooms as well. Record review of the progress note for Resident 6 dated 8/10/24 at 4:02 PM revealed that Resident 6 had entered several other resident's rooms and has been difficult to redirect. Staff have offered Resident 6 food and fluids. Record review of the progress note for Resident 6 dated 8/18/24 at 5:03 PM revealed that Resident 6 wandered the hallways this afternoon. Resident 6 was banging on the exit door and staff was able to redirect the resident. Resident 6 entered several resident's rooms. Resident 6 opened the closet in one room. Resident 6 pushed a folding chair out of another room. Observation on 8/28/24 at 1:35 PM revealed that Resident 6 walked from the Palm Springs unit down the north hall past room [ROOM NUMBER]. Resident 6 continued through the north hall and continued to the exit door at the west end of the north hall. Resident 6 went to the door keypad and rubbed the left hand over the keypad 4 times. Resident 6 then turned around and walked down the west hallway past rooms 35 through 38. Resident 6 turned around and walked through the [NAME] Hills unit living room and stopped at the kitchen. Licensed Practical Nurse-C (LPN-C) approached Resident 6 and asked Resident 6 to follow LPN-C. Resident 6 followed LPN-C past rooms 28 through 23 and entered the Palm Springs unit. Resident 6 went to the door of the room of Resident 2. Resident 6 grabbed the door handle to open the door. LPN-C was approximately 10 feet past the room door. LPN-C turned around and redirected Resident 6 away from the room of Resident 2. LPN-C continued to have Resident 6 follow LPN-C to the Palm Springs unit living room. Record review of the progress note for Resident 6 dated 8/28/24 at 3:16 PM revealed that Resident 6 had wandered the hallways with their walker this morning. Interview on 8/29/24 at 9:58 AM with Resident 18 revealed that there are two residents that enter their private room. Resident 18 revealed the two residents either don't realize it or they just enter when no one lets them in. Resident 18 revealed it is Resident 6 and Resident 28, explaining, I told the head authority about the situation; however, it continues to happen. Resident 18 explained that they are afraid that those two residents might get COVID, because Resident 18 currently has it. Observation on 8/29/24 at 12:35 PM on the Palm Springs unit revealed that Resident 6 walked down the east hall. Resident 6 stopped at the room of Resident 134. Resident 6 walked past rooms [ROOM NUMBERS]. Licensed Practical Nurse-E (LPN-E) and the facility Director of Nursing (DON) redirected Resident 6 towards the Palm Springs unit living room. Resident 6 stopped at a chair in the living room and picked up a blanket from the chair. Resident 6 put the blanket back on the chair and then walked into the dining room. Record review of the progress note for Resident 6 dated 8/31/24 at 4:39 PM revealed that Resident 6 had been wandering in the hallways this afternoon and had entered several other resident's rooms. Staff has toileted, offered fluids and foods, and done 1 on 1 to redirect the resident. Observation on 9/03/24 at 1:31 PM on the [NAME] Hills unit revealed that Resident 6 walked down the north hall towards the Palms Spring unit. Resident 6 walked into the Palm Springs unit past the nurse's station using a walker. Resident 6 stopped outside the door of room [ROOM NUMBER] and looked into the doorway. No staff were in the area supervising Resident 6. Resident 6 walked past rooms [ROOM NUMBERS] towards the southeast exit door. Resident 6 stopped outside the oxygen room. Resident 6 pushed on the door several times trying to open the door to the oxygen room. Resident 6 turned around and walked back towards the Palm Springs unit dining room. Resident 6 picked up a yellow wet floor sign with the right hand. Resident 6 walked from the dining room towards the living room with the walker in their left hand and the wet floor sign in their right hand. Resident 6 came to another wet floor sign and knocked it over with the walker. Resident 6 let go of the walker and carried the wet floor sign into the living room. Interview on 9/3/24 at 4:00 PM with Resident 9 revealed that Resident 6 wanders into their private room in the middle of the night and was standing at the end of the bed. Resident 9 explained that they woke up and were frightened when this occurred. Resident 9 was asked if they can lock the door at night. Resident stated yes, but what would happen if I needed help, that extra minute for staff to unlock the door is necessary. Record review of the progress note for Resident 6 dated 9/3/24 at 9:09 PM revealed that Resident 6 had been in and out of multiple rooms this evening. Resident 6 had been removed from rooms 19, 15 (the room of Resident 15), 16 (room of Resident 134), and 13. Resident 6 had been encouraged to sit but continued to wander throughout the facility. Interview on 9/4/24 at 10:20 AM with Resident 134 revealed that other residents come into their room uninvited. Resident 134 revealed that the other residents usually leave the room when they see that Resident 134 is in the room. Interview on 9/3/24 at 10:27 AM with Nurse Aide-D (NA-D) confirmed that Resident 6 wanders around the facility a lot. NA-D revealed that Resident 6 often goes into other resident's rooms. NA-D revealed that facility staff try to watch Resident 6 and redirect Resident 6 from other resident rooms. Interview on 9/3/24 at 1:08 PM with Nurse Aide-F (NA-F) revealed that several staff try to watch Resident 6 since Resident 6 wanders all the time and goes into other resident's rooms. NA-F revealed that staff try to provide 1 on 1 visits and encourage Resident 6 to watch tv to keep Resident 6 out of other resident rooms. Interview on 9/3/24 at 3:18 PM with Housekeeper-G (HSK-G) confirmed that Resident 6 goes into other resident rooms throughout the day. HSK-G revealed that staff get Resident 6 out of the resident rooms. Interview on 9/4/24 at 9:13 AM with Medication Aide-H (MA-H) confirmed that Resident 6 wanders into other resident rooms through the day. MA-H revealed that residents do not like it when Resident 6 comes into their rooms. MA-H confirmed that other residents will yell at Resident 6 or hit at Resident 6 when Resident 6 wanders into their rooms. MA-H revealed that staff try do 1 on 1 visits with Resident 6 or provide magazines to try to keep Resident 6 from going into other resident rooms. Interview on 9/4/24 at 11:46 AM with Nurse Aide-I (NA-I) confirmed that resident complain about Resident 6 going into their rooms. NA-I revealed that Resident 6 usually just wants to look out a window in the rooms. NA-I revealed that all staff are to keep an eye on Resident 6. NA-I confirmed that staff can not keep an eye on Resident 6 at all times. Interview on 9/4/24 at 12:45 PM with the facility Assistant Administrator (ADMIN-B) confirmed that the facility expectation is for resident rights to be upheld. ADMIN-B confirmed that resident rights include privacy and safety. ADMIN-B revealed that the facility has tried interventions to protect the rights of residents including stop signs, locked doors, redirecting, and 1 on 1 activities to keep wandering residents out of other resident's rooms. ADMIN-B confirmed that Resident 6 continues to go into other resident's rooms. ADMIN-B confirmed that it is a concern and that there is a potential for injury with resident to resident confrontations. ADMIN-B confirmed that Resident 6 wandering into other resident's rooms is a violation of their rights. Observation on 9/4/24 at 12:55 PM outside the [NAME] Hills unit dining room revealed that Resident 6 walked past the dining room into the Palm Springs unit. Resident 6 walked to the door of Resident 2. Resident 6 rubbed the door of the room and then turned and walked back to the [NAME] Hills unit. Resident 6 walked down the north hall of the [NAME] Hills unit past the dining room. Resident 6 continued to walk to the west exit door. Resident 6 touched the door and ran their hand along the edge and along the press bar of the door. Resident 6 then turned and walked back down the north hall of the [NAME] Hills unit past the dining room and into the Palm Springs unit. Resident 6 turned and went to the family room on the Palm Springs unit. Resident 6 left the family room and walked into the Palm Springs unit living room. The time was now 1:01 PM. No staff were in the area supervising Resident 6. B. Record review of the Admission Record dated 8/29/24 for Resident 28 revealed that Resident 28 admitted into the facility on [DATE]. Diagnoses included Vascular Dementia and Anxiety. Record review of the MDS assessment dated [DATE] for Resident 28 revealed that Resident 28 was unable to complete the Brief Interview for Mental Status. Resident 28 has a problem with short-term and long-term memory. The MDS revealed that Resident 28 has a behavior of wandering. The assessment revealed that Resident 28's wandering significantly intrudes on the privacy or activities of others. Record review of the care plan dated 8/28/24 for Resident 28 revealed that Resident 28 is independent with transfers. The care plan revealed that Resident 28 has a behavior problem with wandering and resisting cares. Interventions included: -Resident 28 sometimes wanders into other resident's rooms or personal space. Intervene as soon as possible to protect the rights and safety of others. Divert attention. Remove Resident 28 from the situation and take to an alternate location as needed. Initiated 8/5/24 with revision on 8/6/24. -Resident 28 wanders throughout the facility. Identify pattern of wandering. Intervene as appropriate. Distract Resident 28 from wandering by offering food, drink, talking with the resident, TV shows (especially sports shows), toileting, or walking with the resident inside or outside the facility. Initiated 8/5/24 with revision on 8/6/24. Record review of the progress note for Resident 28 dated 7/22/24 at 8:53 PM revealed that Resident 28 wandered the facility and staff was unable to settle the resident with multiple attempts to get the resident ready for bed and show the resident their room. All interventions were ineffective. Resident 28 continued to wander and check the exits. Record review of the progress note for Resident 28 dated 7/23/24 at 9:10 PM revealed that Resident 28 had wandered in and out of other resident's rooms tonight. Resident 28 went to the doors and tried to open the outside doors. Resident 28 began to walk faster as Resident 26 yelled at Resident 28. Record review of the progress note for Resident 28 dated 7/24/24 at 7:11 PM revealed that Resident 28 entered the room of Resident 8 (a room on the [NAME] Hills unit). Staff went to remove Resident 28 from the room. Staff told Resident 28 that was not their room. About 2 minutes later, Resident 28 again went into the room of Resident 8. Staff found Resident 28 on the toilet in the room. Staff assisted Resident 28 from the bathroom and back to the Park Place unit where Resident 28's room is located so aides could assist Resident 28 with using the bathroom. Record review of the progress note for Resident 28 dated 7/24/24 at 7:20 PM revealed that Resident 28 had just been toileted successfully by the nurse aide. Resident 28 walked into the room of Resident 15 and had to be led out by staff. Staff found Resident 6's shoehorn in Resident 28's back pocket. Resident 28 has wandered the halls tonight and was redirected multiple times as they wandered. Record review of the progress note for Resident 28 dated 8/6/24 at 4:33 PM revealed that Resident 28 had been redirected out of other resident's rooms. Resident 28 will open the door and enter even if doors are closed. Resident 28 will redirect with encouragement but then repeats the behavior. Record review of the progress note for Resident 28 dated 8/6/24 at 8:25 PM revealed that Resident 28 wandered the halls and was in and out of resident's rooms. Resident 28 was redirected easily but then goes right back in. Resident 28 went and started wandering the [NAME] Hills unit hallway. The fire alarm was activated. Medication Aide-K (MA-K) saw Resident 28 walk to the east exit door and pull the fire alarm. Record review of the progress note for Resident 28 dated 8/7/24 at 8:18 PM revealed that Resident 8 wandered the halls going in and out of other resident's rooms. Resident 28 went into room [ROOM NUMBER] and turned on all the lights, putting tennis shoes in the bathroom, and then setting off the motion alarm. Staff got Resident 28 and took Resident 28 back to their room. Record review of the progress note for Resident 28 dated 8/12/24 at 9:17 PM revealed that Resident 28 had been wandering into the room of Resident 27 multiple times this shift. Record review of the progress note for Resident 28 dated 8/17/24 at 4:54 AM revealed that Resident 28 was found in the room of Resident 27. Resident 28 had set off Resident 27's motion alarm. Resident 28 was wearing Resident 27's hat and sitting on Resident 27's toilet. Resident 28 had turned on th [TRUNCATED]

License Reference Number 175 NAC 12-006.10(D) Based on record review, observations, and interviews the facility failed to ensure that the medication error rate was less than 5% for 3 (Resident 3, 14, and 24) of 9 sampled residents. There were 6 errors during the administration of 31 medications which resulted in an error rate of 19.35%. The facility census was 32. Findings are: A. Record Review of Sanofi Kwikpen Instructions for administration of Lantus revised December 2020 while using an injection pen revealed the following: After priming the needle and dialing the correct dosage of insulin: -Insert the needle into the skin. -Deliver the dose by pressing the injection button in all the way until you reach the zero it is injected. - Keep the injection button pressed all the way in. Slowly count to 10 before withdrawing the needle from the skin to ensure the full dose is delivered. -https://products.sanofi.us/lantus/lantus.html Record Review of [NAME] Lilly Instructions for administration of Humalog revised August 2023 while using an injection pen revealed the following: After priming the needle and dialing the correct dosage of insulin: -Insert the Needle into your skin. -Push the Dose Knob (Injection Button) all the way in. -Continue to hold the Dose Knob in and slowly count to 5 before removing the needle from the skin. - https://uspl.lilly.com/humalog/humalog.html#ug4 Record Review of Novo-Nordisk instructions for the administration of Ozempic (semiglutide) revised October 2023 for using the injection pen revealed the following: After priming and dialing the correct dose of Ozempic: -Press and hold down the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. You may then hear or feel a click. Continue pressing the dose button while keeping the needle in your skin. -Count 6 seconds while keeping the dose button pressed. -If the needle is removed earlier, you may see a stream of OZEMPIC(R) coming from the needle tip. If this happens, the full dose will not be delivered. -https://www.novo-pi.com/ozempic.pdf#guide Record Review of the undated Facility Insulin Pen Administration Policy and procedure revealed insulin will be administered per the package instructions. Should the package instructions not be available the procedure will be followed. In paragraph 3, sentence 4 of the procedures to administer insulin it is stated hold the needle in place for 5 to 10 seconds. Record Review of Resident 3 Physician orders revealed the following orders: 1. Glargine (Lantus) subcutaneously (SQ) (under the skin) insulin pen injector. Give 30 units SQ twice a day. Start date 04/04/2024. 2. Humalog Kwikpen 14 units SQ three times daily. Start date 07/02/2024. 3. Semiglutide Pen Injector inject 0.5 milligrams (mg) SQ every Tuesday morning. Start date 08/19/2024. 4. Artificial Tears Ophthalmic Solution instill one drop in right eye two times a day. Start date 03/29/2024. Observed on 09/03/2024 at 8:20 AM Registered Nurse J (RN-J) administered Lantus insulin to Resident 3 using an insulin pen and did not hold the pen in the skin after pushing the injector button a minimum of 10 seconds. Next RN J gave Resident 3 Humalog insulin and did not leave this needle in the skin for a minimum of 5 seconds after pushing the injector button. Finally, RN J gave Resident 3 semiglutide with an injection pen and did not hold the need in the skin for a minimum of 6 seconds. After completing the injections, RN J gave Resident 3 the Artificial Tears Ophthalmic Solution in both eyes of Resident 3 instead of only in the Right eye as ordered. RN J then charted all the medications in the Electronic Medical Record for Resident 3 onto the September 2024 Medication Administration Record as given. RN J then proceeded to the next resident. Interview on 09/03/2024 at 2:30 PM with RN-J who confirmed that RN-J always just push the injection button of the injection pens and when I reach the zero on the dial, I pull the needle out. RN-J confirmed that is how the injections were given to Resident 3. RN-J admitted not knowing that the pen had to be held in place for a certain length of time when the injection button was pushed. RN-J then confirmed that the eye drops were given to Resident 3 in both eyes, and it was at that time that RN-J rechecked the orders for Resident 3 RN-J confirmed the eye drops were only ordered for the Right eye and not both. Observed on 09/03/2024 at 2:37 PM of RN-J who reviewed the medication insert from Glargine (lantus) insulin that belonged to Resident 3 and read the instructions for use of the Sanofi (a brand name) Insulin injection pen. RN-J pointed out that the Glargine insulin needle must be held in the skin for a total of 10 seconds. B. Record Review of Resident 14 Physician orders revealed the following order: 1. Lantus insulin 12 units SQ each morning. Observed on 09/03/2024 at 9:05 AM RN-J administered Lantus insulin via an insulin pen to Resident 14 and did not hold the insulin pen needle in the skin for a minimum of 10 seconds before removing the needle. Interview on 09/03/2024 at 2:30 PM with RN-J who confirmed the needle was not held in place for a minimum of 10 seconds. C. Record Review of National Eye Institute and the National Institute of Health website instructions for administering eye drops. Eye drops prescribed to treat glaucoma or another eye condition must be given correctly so all the medicine gets into your eye. If not used correctly, one could lose ones vision. Follow these steps to put in eye drops: 1. Tilt head back and look up. 2. With 1 hand, pull the lower eyelid down and away from the eyeball - to make a pocket for the eye drop. 3. With the other hand, hold the eye drop bottle upside down with the tip just above the pocket. Squeeze the prescribed number of eye drops into the pocket. For at least 1 minute, ask the resident to their close eye and press a finger lightly on the tear duct (small hole in the inner corner of your eye) - this keeps the eye drop from draining into your nose. 4. https://www.[NAME].nih.gov/Glaucoma/glaucoma-medicines/how-put-eye-drops updated: July 23, 2021 Record Review of Resident 24 Physician orders revealed the following order: 1. Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate) Instill 1 drop in both eyes two times a day Observed on 09/03/2024 at 9:32 AM Licensed Practical Nurse E (LPN-E) administered Dorzolamide eye drops to Resident 24. The eye drops were administered in the inner canthus of the eye (Area of the eye nearest the nose and tear duct) and then immediately wiped Resident14 eye with a Kleenex and did not hold pressure at the tear duct. Interview on 09/03/2024 2:57 PM Minimum Data Set Coordinator (MDS) confirmed the errors in administration of the medications as described.

License Reference number 175 NAC 12-006.10 Based on record review, observations and interviews, the facility failed to ensure that residents were free of significant medication errors while administering insulins for 3 (Residents 3 and Resident 14) of 9 sampleted residents. Facility Census was 32. Findings are: A. Record Review of Sanofi Kwikpen Instructions for administration of Lantus revised December 2020 while using an injection pen revealed the following: After priming the needle and dialing the correct dosage of insulin: -Insert the needle into the skin. -Deliver the dose by pressing the injection button in all the way until you reach the zero it is injected. -Keep the injection button pressed all the way in. Slowly count to 10 before withdrawing the needle from the skin to ensure the full dose is delivered. -https://products.sanofi.us/lantus/lantus.html Record Review of [NAME] Lilly Instructions for administration of Humalog revised August 2023 while using an injection pen revealed the following: After priming the needle and dialing the correct dosage of insulin: -Insert the Needle into your skin. -Push the Dose Knob (Injection Button) all the way in. -Continue to hold the Dose Knob in and slowly count to 5 before removing the needle from the skin. -https://uspl.lilly.com/humalog/humalog.html#ug4 Record Review of Novo-Nordisk instructions for the administration of Ozempic (semiglutide) revised October 2023 for using the injection pen revealed the following: After priming and dialing the correct dose of Ozempic: -Press and hold down the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. You may then hear or feel a click. Continue pressing the dose button while keeping the needle in your skin. -Count 6 seconds while keeping the dose button pressed. -If the needle is removed earlier, you may see a stream of OZEMPIC(R) coming from the needle tip. If this happens, the full dose will not be delivered. -https://www.novo-pi.com/ozempic.pdf#guide Record Review of the undated Facility Insulin Pen Administration Policy and procedure revealed insulin will be administered per the package instructions. Should the package instructions not be available the procedure will be followed. In paragraph 3, sentence 4 of the procedures to administer insulin it is stated hold the needle in place for 5 to 10 seconds. Record Review of Resident 3 Physician orders revealed the following orders: 1. Insulin Glargine (Lantus) subcutaneously (SQ) (under the skin) insulin pen injector. Give 30 units SQ twice a day. Start date 04/04/2024. 2. Humalog Kwikpen 14 units SQ three times daily. Start date 07/02/2024. 3. Semiglutide Pen Injector inject 0.5 milligrams (mg) SQ every Tuesday morning. Start date 08/19/2024. Observed on 09/03/2024 at 8:20 AM Registered Nurse J (RN-J administered Lantus insulin to Resident 3 using an insulin pen and did not hold the pen in the skin after pushing the injector button a minimum of 10 seconds. Next RN J gave Resident 3 Humalog insulin and did not leave this needle in the skin for a minimum of 5 seconds after pushing the injector button. Finally, RN J gave Resident 3 semiglutide with an injection pen and did not hold the need in the skin for a minimum of 6 seconds. Interview on 09/03/2024 at 2:30 PM with RN-J who confirmed that RN-J always just push the injection button of the injection pens and when I reach the zero on the dial, I pull the needle out. RN-J confirmed that is how the injections were given to Resident 3. RN-J admitted not knowing that the pen had to be held in place for a certain length of time when the injection button was pushed. Observed on 09/03/2024 at 2:37 PM of RN-J who reviewed the medication insert from Glargine (lantus) insulin that belonged to Resident 3 and read the instructions for use of the Sanofi (a brand name) Insulin injection pen. RN-J pointed out that the Glargine insulin needle must be held in the skin for a total of 10 seconds. B. Record Review of Resident 14 Physician orders revealed the following order: 1. Lantus insulin 12 units SQ each morning. Observed on 09/03/2024 at 9:05 AM RN-J administered Lantus insulin via an insulin pen to Resident 14 and did not hold the insulin pen needle in the skin for a minimum of 10 seconds before removing the needle. Interview on 09/03/2024 at 2:30 PM with RN-J who confirmed the needle was not held in place for a minimum of 10 seconds.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C1 Based on observation, interview, and record review; the facility failed to ensure facility staff and visitors wore face masks and eye covering in resident care areas and screened visitors prior to entry into the facility which had the potential to affect all of the facility residents; the facility failed to ensure that the facility staff performed hand hygiene (hand washing using soap and water or an alcohol based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) between resident rooms for 9 residents (Residents 2, 10, 18, 17, 36, 15, 12, 34, and 7); and failed to ensure that facility staff handled laundry to prevent the potential for cross contamination for 8 residents (Residents 10, 18, 17, 36, 15, 12, 34, and 7). The facility census was 39. Findings are: A. Interview with the RD (Registered Dietitian) on 6/27/2022 at 9:00 AM revealed the facility was in outbreak status due to a Covid-19 positive staff member and all staff were required to wear an N95 face mask and protective eye wear while in the facility. Observation of the facility nurses' station on 6/27/22 at 12:31 PM revealed RN-A (Registered Nurse), was sitting in the nurses' station. It was not closed as there was no door to the area; it was enclosed on 3 sides with a window in front only. RN-A was documenting on the computer. RN-A's N95 face mask was down under their nose and their nose was exposed. RN-A had goggles on but no face shield. Resident 21 was standing right next to RN-A with no mask on. Observation of the Restorative Room on 6/27/22 at 1:40 PM revealed LPN-B (Licensed Practical Nurse) was sitting at the desk in the room eating food and drinking out of a large jug. LPN-B's N95 mask was down under their chin leaving their mouth and nose exposed. LPN-B was also talking to Resident 13 who was sitting on the Nu-Step in the therapy room. Resident 13 was not wearing a face mask. Observation of the facility nurses' station on 6/27/22 at 4:40 PM revealed Resident 29 was in the nurses' station on the unit. MA-F (Medication Aide) was standing at the medication cart in the nurses' station. MA-F was talking to Resident 29. MA-F's mask was down under their nose. MA-F then pulled their mask completely down and talked to Resident 29. MA-F's mouth and nose were uncovered and Resident 29 was not wearing a mask. MA-F was less than 6 feet away from Resident 29, approximately 3 feet away from Resident 29. Observation of the facility nurses' station on 6/27/22 at 4:55 PM revealed Resident 9 was standing in the nurses' station inside the entry way by the desk talking to RN-A who was seated at the desk. MA-F was at the medication cart in the nurses' station and was approximately 2 feet away, from Resident 9 who was not wearing a face mask. MA-F's mask was down under their chin and their mouth and nose were exposed. Observation of the facility on 6/28/22 at 12:21 PM revealed LPN-B came out of the room occupied by Resident 139 and Resident 19. LPN-B's protective eyewear was up on their head and their eyes were uncovered. Resident 139 and Resident 19 were observed in the room. Observation of the facility on 6/28/22 at 1:38 PM revealed Resident 2 was walking down the hall on the unit. Resident 2 was walking with a walker and had no face mask on. A visitor was walking right next to Resident 2 talking to them. The visitor had a surgical mask in their hand and no covering on their face. Facility staff were in the area. Observation of the facility on 6/28/22 at 4:22 PM revealed Resident 8 was observed sitting in the dining area playing cards with a visitor. They were both sitting at the table in the dining room that was a square table and there was no Plexiglas between them. The visitor was sitting in the place adjacent to Resident 8 on their left approximately 1 foot away from Resident 8. Resident 8 was not wearing a face mask or eye protection. The visitor had a face mask on that was under their nose leaving their nose exposed. Facility Staff were observed in the area. Observation of the facility on 6/28/22 at 5:07 PM revealed a local business employee (identified by the logo on their shirt) entered the facility through the double doors, bypassed the screening kiosk, and did not don a face mask. The employee walked into the facility and approached a facility staff person, talked to them, and continued to remain in the facility without a mask on. Resident 1 was sitting by the door when the employee walked in and remained in the area. Resident 1 had a surgical mask on but no eye protection. The employee was not directed back to the door to screen in or put a face mask on and there were facility staff observed in the area. Interview with the RD on 6/29/22 at 7:43 AM confirmed the employee who entered the facility without screening or donning a face mask was from a local business and was doing business in the facility. Observation of the facility on 6/29/22 at 7:57 AM revealed Resident 7 was sitting in the entry of the nurses' station in a chair. There was no door to the nurses' station and it was not a fully enclosed area. Resident 7 was not wearing a face mask. MA-C was standing not more than a foot away from Resident 7 and was talking to Resident 7. MA-C had an N95 mask on their face the mask was down under their nose and their nose was exposed. As MA-C was talking to Resident 7, MA-C pulled their face mask completely down twice and exposed their mouth and nose and talked to Resident 7. Observation of the facility on 6/29/22 at 10:12 AM revealed a visitor was sitting in the living room next to a resident in a recliner. There were 5 other unidentified residents in the living room. None of the residents had a face mask or eye covering. One unidentified resident was sitting in a wheelchair to the right of the visitor who was only a few feet away from them and the resident did not have a face covering on. Resident 23 was sitting in a recliner next to the visitor and Resident 23 did not have a face mask. The visitor had a surgical mask on and would lower the surgical mask to take a drink of soda and talk to Resident 23. Interview with the visitor at this time revealed they were not clear about when they had to wear a face mask in the facility and the facility staff had not explained to them what the expectation was. Observation of the facility on 6/30/22 at 8:00 AM revealed HK-J (Housekeeper) was standing in the door way of Resident 1's room. HK-J's housekeeping cart was in front of the door and HK-J was partially inside the room in the doorway. HK-J was facing the hall and did not have a mask or face shield on. HK-J was coughing and clearing their throat. HK-J was coughing out into the hallway adjacent to the dining room. HK-J continued to cough and clear their throat for 1-2 minutes facing the hall and turning and facing into Resident 1's room. Resident 19 was sitting at the dining room table closest to the hallway and there were other residents sitting in the dining room adjacent to the hall HK-J was facing when they were coughing. Review of the Covid-19 Staff Vaccination Status for Providers received 6/27/2022 from the RD on behalf of the ICC (Infection Control Coordinator) revealed MA-F, RN-A, and LPN-B, were Not Vaccinated for Covid-19 and had been granted exemptions. Review of the CMS Nursing Home Visitation Frequently Asked Questions (FAQs) dated March 10, 2022 revealed the following: CMS was providing clarification to recent guidance for visitation (see CMS memorandum QSO-20-39- NH REVISED 11/12/2021). While CMS cannot address every aspect of visitation that may occur, we provide additional details about certain scenarios below. However, the bottom line was visitation must be permitted at all times with very limited and rare exceptions, in accordance with residents' rights. In short, nursing homes should enable visitation following these three key points: · Adhere to the core principles of infection prevention, especially wearing a mask, performing hand hygiene, and practicing physical distancing; · Don't have large gatherings where physical distancing cannot be maintained; and · Work with your state or local health department when an outbreak occurs. States may instruct nursing homes to take additional measures to make visitation safer, while ensuring visitation can still occur. This includes requiring that, during visits, residents and visitors wear masks that were well-fitting, and preferably those with better protection, such as surgical masks or KN95. States should work with CMS on specific actions related to additional measures they were considering. 1. What was the best way for residents, visitors, and staff to protect themselves from the Omicron variant? A: The most effective tool to protect anyone from the COVID-19 Omicron variant (or any version of COVID-19) was to be up-to-date with all recommended COVID-19 vaccine doses. Also, we urge all residents, staff, and visitors to follow the guidelines for preventing COVID-19 from spreading, including wearing a well-fitting mask (preferably those with better protection, such as surgical masks or KN95) at all times while in a nursing home, practicing physical distancing, and performing hand hygiene by using an alcohol-based hand rub or soap and water. Residents do not have to wear a mask while eating or drinking, or in their rooms alone or with their roommate. Can residents have close contact with their visitor(s) during a visit and visit without a mask? A: Visitors, regardless of vaccination status, must wear masks and physically distance themselves from other residents and staff when in a communal area in the facility. Separately, while we strongly recommend that visitors wear masks when visiting residents in a private setting, such as a resident's room when the roommate isn't present, they may choose not to. Also, while not recommended, if a resident (or responsible party) was aware of the risks of close contact and/or not wearing a mask during a visit, and they choose to not wear a mask and choose to engage in close contact, the facility cannot deny the resident their right to choose, as long as the residents' choice does not put other residents at risk. This would occur only while not in a communal area. Prior to visiting, visitors should also be made aware of the risks of engaging in close contact with the resident and not wearing a mask during their visit. For additional information see the CDC website Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes. Review of the CMS Nursing Home Visitation - COVID-19 (REVISED) 3/10/2022 revealed the following: Indoor Visitation during an Outbreak Investigation An outbreak investigation was initiated when a new nursing home-onset of COVID-19 occurs (i.e., a new COVID-19 case among residents or staff). To swiftly detect cases, we remind facilities to adhere to CMS regulations and guidance for COVID-19 testing, including routine staff testing, testing of individuals with symptoms, and outbreak testing. When a new case of COVID-19 among residents or staff was identified, a facility should immediately begin outbreak testing in accordance with CMS QSO 20-38-NH REVISED and CDC guidelines. While it was safer for visitors not to enter the facility during an outbreak investigation, visitors must still be allowed in the facility. Visitors should be made aware of the potential risk of visiting during an outbreak investigation and adhere to the core principles of infection prevention. If residents or their representative would like to have a visit during an outbreak investigation, they should wear face coverings or masks during visits, regardless of vaccination status, and visits should ideally occur in the resident's room. Facilities may contact their local health authorities for guidance or direction on how to structure their visitation to reduce the risk of COVID-19 transmission during an outbreak investigation. Review of the CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities Updated Feb. 2, 2022 revealed the following: Key Points Older adults living in congregate settings were at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2. A strong infection prevention and control (IPC) program was critical to protect both residents and healthcare personnel (HCP). Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. Educate Residents, HCP, and Visitors about [CONDITION(S)]-CoV-2, Current Precautions Being Taken in the Facility, and Actions They Should Take to Protect Themselves Regularly review CDC's Interim Infection Control Recommendations for Healthcare Personnel during the COVID-19 Pandemic for current information and ensure staff and residents were updated when this guidance changes. Educate and train HCP about recommended practices to prevent spread of [CONDITION(S)]-CoV-2, including reminding them not to report to work when ill. Training should include facility-based and consultant personnel (e.g., rehabilitation therapy, wound care, podiatry, barber), ombudsmen, and volunteers who provide care or services in the facility. Including consultants was important since they commonly provide care in multiple facilities where they can be exposed to and serve as a source of [CONDITION(S)]-CoV-2. CDC has created training resources for front-line staff that can be used to reinforce recommended practices for preventing transmission of [CONDITION(S)]-CoV-2 and other pathogens. Educate residents and families through educational sessions and written materials on topics, including information about [CONDITION(S)]-CoV-2, actions the facility was taking to protect them and their loved ones from [CONDITION(S)]-CoV-2, and actions they should take to protect themselves and others in the facility, emphasizing when they should wear source control, physically distance, and perform hand hygiene. Implement Source Control Measures Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person ' s mouth and nose to prevent spread of respiratory secretions when they were breathing, talking, sneezing, or coughing. Source control options for HCP include: A NIOSH-approved N95 or equivalent or higher-level respirator OR A respirator approved under standards used in other countries that were similar to NIOSH-approved N95 filtering face piece respirators (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection was indicated) OR A well-fitting facemask. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they were used during the care of patient for which a NIOSH-approved respirator or facemask was indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator) during the care of a patient with [CONDITION(S)]-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned. Source control and physical distancing (when physical distancing was feasible and will not interfere with provision of care) were recommended for everyone in a healthcare setting. This was particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have: not up to date with all recommended COVID-19 vaccine doses; or have suspected or confirmed [CONDITION(S)]-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with [CONDITION(S)]-CoV-2 infection for 10 days after their exposure, including those residing or working in areas of a healthcare facility experiencing [CONDITION(S)]-CoV-2 transmission (i.e., outbreak); or have moderate to severe immunocompromise; or have otherwise had source control and physical distancing recommended by public health authorities. While it was generally safest to implement universal use of source control for everyone in a healthcare setting, the following allowances could be considered for individuals who were up to date with all recommended COVID-19 vaccine doses (who do not otherwise meet the criteria described above) in healthcare facilities located in counties with low to moderate community transmission. These individuals might choose to continue using source control if they or someone in their household was immunocompromised or at increased risk for severe disease, or if someone in their household was not up to date with all recommended COVID-19 vaccine doses. HCP who were up to date with all recommended COVID-19 vaccine doses: Could choose not to wear source control or physically distance when they were in well-defined areas that were restricted from patient access (e.g., staff meeting rooms, kitchen). They should wear source control when they were in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors). Patient Visitation: Indoor visitation (in single-person rooms; in multi-person rooms, when roommates were not present; or in designated visitation areas when others were not present): The safest practice was for patients and visitors to wear source control and physically distance, particularly if either of them were at risk for severe disease or were unvaccinated. If the patient and all their visitor(s) were up to date with all recommended COVID-19 vaccine doses, they can choose not to wear source control and to have physical contact. Visitors should wear source control when around other residents or HCP, regardless of vaccination status. Outdoor Visitation: Patients and their visitors should follow the source control and physical distancing recommendations for outdoor settings described on the page addressing Your Guide to Masks. Residents who were up to date with all recommended COVID-19 vaccine doses in Nursing Homes in Areas of Low to Moderate Transmission: Nursing homes were healthcare settings, but they also serve as a home for long-stay residents and quality of life should be balanced with risks for transmission. In light of this, consideration could be given to allowing residents who were up to date with all recommended COVID-19 vaccine doses to not use source control when in communal areas of the facility; however, residents at increased risk for severe disease should still consider continuing to practice physical distancing and use of source control Implement Universal Use of Personal Protective Equipment for HCP If [CONDITION(S)]-CoV-2 infection was not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: NIOSH-approved N95 or equivalent or higher-level respirators should be used for: All aerosol-generating procedures; All surgical procedures that might pose higher risk for transmission if the patient has [CONDITION(S)]-CoV-2 infection (e.g., that generate potentially infectious aerosols or involving anatomic regions where [CONDITION(S)] loads might be higher, such as the nose and throat, oropharynx, respiratory tract). NIOSH-approved N95 or equivalent or higher-level respirators can also be used by HCP working in other situations where additional risk factors for transmission were present such as the patient was not up to date with all recommended COVID-19 vaccine doses, unable to use source control, and the area was poorly ventilated. They may also be considered if healthcare-associated [CONDITION(S)]-CoV-2 transmission was identified and universal respirator use by HCP working in affected areas was not already in place. To simplify implementation, facilities in counties with substantial or high transmission may consider implementing universal use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP during all patient care encounters or in specific units or areas of the facility at higher risk for [CONDITION(S)]-CoV-2 transmission. Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Encourage Physical Distancing In situations when patients were not up to date with all recommended COVID-19 vaccine doses could be in the same space (e.g., waiting rooms, cafeterias, [CONDITION(S)] treatment room), arrange seating so that patients can sit at least 6 feet apart, especially in counties with substantial or high transmission. This might require scheduling appointments to limit the number of patients in waiting rooms, treatment areas, or participating in group activities. Interview with the ICC on 6/29/22 at 2:02 PM revealed facility staff were required to wear masks while they were in the facility and visitors were required to wear masks when they were in public areas of the facility. If visitors were in their loved ones room, they were allowed to remove their masks. The ICC revealed facility staff were allowed to take their masks off when they were eating at breaks in the employee break room or outside on a break. The ICC revealed if the staff were transporting residents or outside with a resident they still had to wear a mask. The ICC revealed the staff were expected to wear a mask when they were in a resident care areas. The ICC revealed in order to make sure visitors wore a mask the facility had signage at the door and there usually was someone sitting at the front desk so they could flag people down if they entered the facility without a mask on. The ICC revealed if a contractor or visitor entered the facility they were expected to screen and wear a mask when they came in the building, even if it was only for a few minutes. Review of the undated facility policy Occupational Health during Covid-19 Pandemic revealed the following: Respiratory Protection: Respiratory protection will be provided for all staff members working during the COVID-19 pandemic. Clinical staff and staff with patient interaction will be expected to wear a surgical procedure mask at all times while in a public area during their shift. Non-clinical staff and staff with no patient interaction were expected to wear either a surgical procedure mask or a cloth mask at all times while in a public area during their shift. Interview with the FA (Facility Administrator) on 6/29/22 at 5:21 PM confirmed the facility staff and visitors were expected to wear a face mask in resident care areas. The FA agreed there should not be any encroachment of residents into areas if staff aren't wearing their masks and if residents were going to go into the nurses' stations, etc. then staff needed to have their masks on. The FA revealed they usually tried to have someone at the front desk to catch people. B. Observation on 6/30/22 at 10:58 AM in the mini lounge just outside the double doors to the Park Place unit revealed that 2 unidentified persons with no face masks sat in the area. The 2 persons visited with each other. Interview on 6/30/22 at 11:02 AM in the mini lounge revealed that the 2 unidentified persons were visitors. One visitor revealed that we have parents here to visit. We don't see each other often so we are catching up. C. Record review of the undated facility policy titled Hand Hygiene revealed that the objective of the policy was to provide guidelines for effective hand hygiene in order to prevent the transmission of bacteria, germs, and infection. Proper and frequent hand washing is the healthcare worker's first line of defense against becoming infected or spreading infection to someone else. Indications for using an alcohol based hand rub or soap and water include when entering the room, after contact with objects in the immediate vicinity of the resident, and when exiting the room. Record review of the undated facility policy titled Environmental Cleaning/Disinfection-COVID-19 revealed that the laundry staff may deliver laundry directly into resident rooms without putting on any additional personal protective equipment (PPE). Staff should perform hand hygiene between each resident. Record review of the undated facility policy titled Laundry and Linen Policy/Procedures revealed that staff will practice proper hand washing techniques. Observation on 6/27/22 at 2:31 PM outside of the room of Resident 36 revealed that Laundry Assistant-G (LA-G) removed clothing on hangers from the uncovered laundry cart. LA-G carried the clothing into the room of Resident 36 and hung the clothing in the closet. Resident 29 propelled to the laundry cart in a wheelchair. Resident 29 grabbed a hanger with a blue jacket from the rack in the laundry cart with the bare hands. Resident 29 removed the hanger with the blue jacket from the laundry cart. Resident 29 attempted to hang the hanger with the blue jacket on the outside of the laundry cart. Resident 29 was unable to hang the jacket on the outside of the laundry cart. Resident 29 laid the hanger with the blue jacket on the resident's lap. LA-G exited the room of Resident 36 carrying used empty hangers. LA-G placed the empty hangers on the rack in the laundry cart. LA-G picked up the blue jacket on the hanger from Resident 29 and hung the blue jacket on the rack in the cart on the opposite end from the clean clothing. LA-G did not perform hand hygiene. LA-G removed clothing on hangers from the laundry cart and carried the clothing into the room of Resident 2. LA-G hung the clothing in the closet for Resident 2. LA-G exited the room of Resident 2 and returned to the laundry cart. LA-G did not perform hand hygiene. LA-G removed folded clothing items from the bottom of the laundry cart and held the clothing against LA-G's uniform. LA-G removed clothing on hangers from the laundry cart and carried the clothing into the room of Resident 10. LA-G continued to hold the folded clothing against LA-G's uniform. LA-G hung the clothing on hangers in the resident's closet and placed the folded clothing into a drawer. LA-G exited the room of Resident 10 and returned to the laundry cart. LA-G did not perform hand hygiene. LA-G moved the laundry cart to the adjoining hallway. LA-G removed folded clothing items from the bottom of the laundry cart and held the clothing against LA-G's uniform. LA-G removed clothing on hangers from the laundry cart and carried the clothing into the room of Resident 18. LA-G continued to hold the folded clothing against LA-G's uniform. LA-G hung the clothing on hangers in the closet and placed the folded clothing into a drawer. LA-G removed used empty hangers from the closet and exited the resident's room. LA-G returned to the laundry cart. LA-G placed the empty hangers on the rack in the laundry cart. LA-G did not perform hand hygiene. LA-G removed folded clothing items from the bottom of the laundry cart and held the clothing against LA-G's uniform. LA-G removed clothing on hangers from the laundry cart and carried the clothing into the room of Resident 17. LA-G continued to hold the folded clothing against LA-G's uniform. LA-G hung the clothing on hangers in the closet and placed the folded clothing into a drawer. LA-G returned to the laundry cart. LA-G did not perform hand hygiene. The time was now 2:40 PM. LA-G removed the blue jacket on the hanger from the laundry cart. The blue jacket had been handled with the bare hands by Resident 29. LA-G removed additional clothing on hangers from the laundry cart and carried the blue jacket and additional clothing into the room of Resident 36. LA-G hung the clothes in the closet of Resident 36. LA-G removed empty hangers from the closet and exited the resident's room. LA-G returned to the laundry cart. LA-G placed the empty hangers on the rack in the laundry cart. LA-G did not perform hand hygiene. LA-G removed folded clothing items from the bottom of the laundry cart and held the clothing against LA-G's uniform. LA-G removed clothing on hangers from the laundry cart and carried the clothing into the room of Resident 15. LA-G continued to hold the folded clothing against LA-G's uniform. LA-G hung the clothing on hangers in the closet and placed the folded clothing into a drawer. LA-G returned to the laundry cart. LA-G did not perform hand hygiene. LA-G removed folded clothing items from the bottom of the laundry cart and held the clothing against LA-G's uniform. LA-G removed clothing on hangers from the laundry cart and carried the clothing into the room of Resident 12. LA-G continued to hold the folded clothing against LA-G's uniform. LA-G hung the clothing on hangers in the closet and placed the folded clothing into a drawer. LA-G removed used empty hangers from the closet and exited the resident's room. LA-G returned to the laundry cart. LA-G placed the empty hangers on the rack in the laundry cart. LA-G did not perform hand hygiene. The time was now 2:46 PM. LA-G took the laundry cart through the double doors to exit the hallway and entered the facility lobby area. Observation on 6/28/22 at 11:20 AM near the Slate Dining Room revealed that LA-G removed a light-colored night gown on a hanger from the laundry cart. LA-G carried the clothing into the room of Resident 33. LA-G exited the resident's room and returned to the laundry cart. LA-G did not perform hand hygiene. LA-G removed a stack of folded laundry from the bottom of the laundry cart. LA-G held the stack of clothing against LA-G's uniform. LA-G carried the clothing against the uniform into the room of Resident 34. LA-G exited the resident's room and returned to the laundry cart. LA-G did not perform hand hygiene. LA-G moved the laundry cart up the hallway. Resident 14 walked up to LA-G and stated that the resident had sent a shirt to laundry. LA-G moved clothing on the rack in the laundry cart and found a shirt on a hanger. Resident 14 confirmed that it was the resident's shirt. LA-G informed Resident 14 that the shirt had not been marked with the resident's name. LA-G informed Resident 14 that LA-G would mark the shirt for Resident 14. LA-G hung the shirt back in the laundry cart. Resident 14 left the area. LA-G removed a stack of folded laundry from the bottom of the laundry cart. LA-G held the stack of clothing against LA-G's uniform. LA-G carried the clothing against the uniform into the room of Resident 7. LA-G exited the resident's room and returned to the laundry cart. LA-G did not perform hand hygiene. LA-G moved the laundry cart up the hallway. Interview on 6/29/22 at 2:07 PM with the facility Infection Control Coordinator (ICC) confirmed that staff are expected to perform hand hygiene between resident rooms at all times. The ICC confirmed that staff are expected to carry clean laundry away from the staff uniform to prevent potential cross contamination. The ICC confirmed that staff should not hold clean laundry against the staff uniform.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, interview, and record review; the facility staff failed to prevent a potential accident hazard by wheeling Resident 29 in the wheelchair without their feet supported and their feet dragging on the floor. This affected 1 of 5 sampled residents. The facility identified a census of 39 at the time of survey. Findings are: Review of Resident 29's Annual MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 5/15/2022 revealed an admitted [DATE]. Resident 29 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated severe cognitive impairment. Resident 29 required extensive assistance from 2 staff for bed mobility, transfer, and toilet use; limited assistance from 1 staff person for locomotion on the unit and eating; and extensive assistance from 1 staff person for locomotion off the unit, dressing, and personal hygiene. A wheelchair was used for a mobility device. Active diagnoses included arthritis and Alzheimer's disease. Resident 29 had 2 falls with no injury since prior assessment and Hospice care was received while a resident. Bed alarm, chair alarm, motion sensor alarm, and wander/elopement alarm were used daily. Observation of Resident 29 on 6/27/22 at 2:33 PM revealed NA-I (Nurse Aide), pushed Resident 29 down the hall which was carpeted. Resident 29 was in a wheelchair wearing shoes and there were no foot pedals on the wheelchair. Resident 29's feet were dragging on the floor as NA-I was pushing Resident 29 in the wheelchair. At one point Resident 29's right foot caught on the floor and NA-I stopped and backed up then continued to push Resident 29 in the wheelchair with their feet dragging on the floor. Observation of Resident 29 on 6/28/22 at 11:18 AM revealed LPN-B (Licensed Practical Nurse) wheeled Resident 29 down the hall in a wheelchair with no foot pedals and Resident 29's feet were dragging on the floor. Observation of Resident 29 on 6/29/22 at 4:35 PM revealed MA-C (Medication Aide) wheeled Resident 29 into the facility from the courtyard. There were no foot pedals on the wheelchair and Resident 29's feet were dragging on the ground. Observation of Resident 29 on 6/30/22 at 11:10 AM revealed Resident 29 was observed sitting in their wheelchair in the hall by the dining room. DA-H (Dietary Aide) placed a plate of food on the dining room table. DA-H went over to Resident 29 and said come over and eat. Resident 29 did not comply. DA-H pushed Resident 29 in the wheelchair toward the dining room and Resident 29's feet were dragging on the floor. DA-H said pick up your feet, but Resident 29 did not comply and DA-H continued to push Resident 29 to the table off the carpeted hallway onto the laminate dining room floor up to the table. There were no foot pedals on the wheelchair and Resident 29's feet were dragging on the floor. When they got to the dining room floor, Resident 29's feet continued to drag and skipped along the floor as Resident 29 was wearing rubber soled shoes which caused Resident 29's feet to catch on the dining room floor. Interview with the DON (Director of Nursing) on 6/29/22 at 3:56 PM revealed the expectation was for the facility staff to wheel facility residents in their wheelchairs with their feet supported and their feet were not to be dragging on the floor. The DON revealed the resident needed to have their feet on wheelchair pedals and if the resident could not propel themselves in the wheelchair then foot pedals were required. The DON revealed if a resident was being pushed in the wheelchair and their feet were dragging on the floor, wheelchair pedals were required to support the resident's feet. Review of the facility policy Consideration for residents with wheelchairs dated [DATE] revealed the following: Use leg pedals to prevent the resident's legs from catching on things. Remove or release when resident is able to self-propel themselves. Leg pedals may stay in place if resident desires/prefers.

Based on record review and interview, the facility failed to notify residents, representatives, and families of new confirmed COVID-19 (a mild to severe respiratory illness) infections by 5 PM the next calendar day. This had the potential to affect all residents in the facility. The facility census was 36. Findings are: Review of the undated COVID Tracking for Residents spreadsheet revealed new positive cases of COVID-19 in residents were identified on 10/26/20 and 11/02/20. Interview on 11/17/20 at 9:40 AM with the ADM (Administrator) revealed the last new positive case of COVID-19 in staff members was identified on 11/5/20. Review of Resident 1, 2, and 3's electronic health records revealed an absence of documentation related to resident, family, or representative notification after new cases of COVID-19 were identified in the facility. The facility was unable to provide documentation showing residents and representatives/families were updated after new cases of COVID-19 were identified in the facility. Interview on 11/17/20 at 3:05 PM with the ADM revealed weekly updates to residents and families were being completed when facility staff were reaching out to gather consent for COVID-19 testing, but notifications to residents and representatives/families were not completed after new positive COVID-19 cases were identified. The ADM revealed a system capable of sending mass text updates was developed and tested on [DATE], but the system was not used to send updates after the positive staff case on 11/5/20.

Based on record review and interview, the facility failed to notify the resident and the residents' legal representative of the reason for the transfer in writing for 3 of 4 sampled resident (Resident 4, Resident 33, and Resident 9). The facility census was 40 at the time of the survey. Findings Are: An interview on 8/12/19 at 4:03 PM with Resident 4's family revealed that resident was sent to the hospital about 2 months ago. Review of Resident 4's EHR (Electronic Health Record) revealed no bed hold policy or documentation that there was a bed hold policy sent with Resident 4 to the hospital. Review of Resident 4's Paper chart revealed on (MONTH) 30, 2019 was transferred to the hospital for [MEDICAL CONDITION] activity and returned to the facility on [DATE]. Review of the NOTIFICATION OF BED HOLD POLICY dated 4/30/19 revealed no documentation of the reason for the transfer. B. Review of the PN (Progress Notes) for Resident 9 revealed that the resident was transferred to the hospital on [DATE]. PN dated 6/7/19 revealed resident was complaining of not feeling well. The resident was lying in recliner and appeared flushed and lethargic. Resident had a fever of 101.3 and the primary physician was contacted. The physician chose to direct admit Resident 9 to the hospital. There was no documentation that the resident or resident representative was notified of the reason for the transfer. PN dated 6/8/19 stated that Resident 9 had been admitted for aspiration pneumonia and being lethargic. Review of the NOTIFICATION OF BED HOLD POLICY for Resident 9 revealed no documentation of the reason for the transfer. C. An interview with Resident 33 on 8/13/19 at 10:04 AM revealed that Resident 33 had been transferred to the hospital and was diagnosed with [REDACTED]. Review of Resident 33's EHR (Electronic Health Record) revealed no transfers from the facility since admission on 4/25/19. An interview on 8/15/19 at 12:32 PM with the DON (Director of Nursing) revealed that Resident 33 had been a resident in the facility prior to 4/25/19 admission and had been sent to the hospital. The resident was doing so poorly and was not expected to return so family did not want to hold the bed so Resident 33 had been discharged from the facility. Prior to the family deciding not to continue with the bed hold they did sign a bed hold policy. Resident was doing better and was returned and placed on Hospice services. Review of Resident 33's paper chart revealed a NOTIFICATION OF BED HOLD POLICY dated 4/16/19 with no documentation of the reason for the transfer. Interview on 8/15/19 at 1:00 PM with SSC (Social Service Coordinator) revealed when the resident goes to the hospital someone from the facility goes to the hospital so the family member can sign the bed hold policy. The Ombudsman was notified at the time of the discharge or monthly. The resident and/or the resident representative were not being notified in writing of the reason for the transfer.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1c Based on record reviews and interviews, the facility failed to update three residents' (Resident 27, 18, and 33) Care Plans out of 14 care plans reviewed. The facility failed to update Resident 27's Care Plan related to pressure ulcer care and treatment, failed to update Resident 18 for the amputated toe, and failed to update Resident 33 for fall interventions. The facility census was 40 at the time of the survey. Findings are: [NAME] Review of Resident 27's 'Admission Record' dated 1-30-18 revealed the date of admission of 1-16-13 with [DIAGNOSES REDACTED]. Review of the PN (Progress Notes) dated 7-25-19 revealed Resident 27 developed two pressure wounds under the brace on the resident's right forearm. The wounds were about 1 inch each in diameter of red tissue with a 1/2 inch center of white tissue with yellow drainage with a slight odor. A treatment was initiated. Review of the 'Non-Pressure Skin Condition Record' dated 7-25-19 revealed the form was initiated and weekly documentation with assessment was completed. The documentation revealed the wounds were pressure ulcers and daily treatments were performed. The last assessment was on 8-8-19 which revealed one pressure ulcer was healed and the other site was nearly healed. Observation on 8-14-19 at 9:50 AM with RN-A (Registered Nurse) of Resident 27's pressure wounds of the right forearm revealed one site the skin was intact, and the other site had a superficial scab remaining, but both sites were still bright red in color. The site had been covered with a dressing. Review of the undated Care Plan for Resident 27 revealed absence of documentation about the resident having or having had a pressure ulcer to the right forearm. Interview on 08/14/19 at 1:29 PM with ADON (Assistant Director of Nursing) revealed the ADON was the only person in the nursing department who updated the Care Plans since the facility went to completing them on the computer only. The ADON confirmed the Care Plan would not have been updated with the pressure ulcer because the ADON had been on vacation for the past 2 weeks and the ADON was not aware the resident had a pressure ulcer. The ADON confirmed there had not been another person to enter Care Plans while the ADON was on vacation. Interview on 08/15/19 at 11:09 AM with the DON (Director of Nursing) confirmed having one person to enter all Care Plans for the nursing department was not a good plan and they needed a backup. B. Review of Resident 18's admission status revealed an admission date of [DATE] Observation on 8/12/19 at 10:35 AM of Resident 18's feet revealed a coban and dressing to the right foot. An interview on 8/12/19 at 10:35 AM with Resident 18 revealed that the resident had the 2nd toe of the right foot amputated on 8/9/19. Review of the undated Care Plan for Resident 18 revealed absence of documentation about the resident having any skin issues or surgical removal of the toe on the right foot. Review of the PN (Progress Notes) dated 8/12/19 Resident had amputation of 2nd toe on right foot. Spoke with resident today to educate on importance of good protein intake and fruits and vegetables to promote wound healing. PN dated 8/9/2019 Weekly skin assessment completed. Had R) 2nd toe surgically removed 8/8/19, see skin assessment form for details. PN dated 8/8/2019 Resident's dressing was dry and intact. Resident does have the post op shoe on as the resident had been up and around. Review of Physician order [REDACTED]. Weekly Skin Assessment As needed *Document and provide follow up for any abnormal findings as needed* Review of the TAR (Treatment Administration Record) for Resident 18 for (MONTH) revealed no treatments or monitoring being documented for potential signs and symptoms of complications with surgery such as monitoring for infection. Review of an Office Referral Form dated 7/2/19 with a request: Resident had open area on right 2nd toe-great toe sits on top of it. (MONTH) we have an order for [REDACTED]. This treatment was not placed on the care plan or other interventions to assist with healing of the area. An interview on 8/15/19 at 10:22 AM with RN-A (Registered Nurse) revealed that nursing does nothing with the surgical site for Resident 18. The resident coming back with orders to not touch the foot or remove the dressing until Resident 18 goes back to the hospital on [DATE]. An interview with on 8/15/19 at 10:31 AM with the ADON (Assistant Director of Nursing) revealed that the concerns regarding skin issues was not on the care plan. The Care Plans are updated by the MDS Coordinator and LPN-B (Licensed Practical Nurse) who does the skin assessments. An interview on 8/15/19 at 10:35 AM with the DON (Director of Nursing) revealed the instruction given to monitor for possible complications during post-operative surgery were not on the Care Plan or TAR (Treatment Administration Record). DON stated there was a long list of things the Charge Nurses were supposed to do and it wasn't put on the Care Plan. The list was at the nurses' station for the Charge Nurse to follow. There was no place for the Charge Nurse to document that this was being completed. 08/15/19 10:57 AM Review of the POS [REDACTED]. The other interventions were to seek care immediately or call 911 if blood soaks through the bandage covering the incision, heart beats faster than normal, increased respirations or feeling short of breath and skin feels cool and clammy. Contact the health care provider if the resident develops fever or chills, redness, swelling or pain near the wound. These interventions were not on Residents 18's Care Plan. Review of the TAR (Treatment Administration Record) revealed that the orders to seek care immediately or call 911 if blood soaks through the bandage covering the incision, heart beats faster than normal, increased respirations or feeling short of breath and skin feels cool and clammy. Contact the health care provider if the resident develops fever or chills, redness, swelling or pain near the wound. There was no documentation to verify monitoring of the surgical area was being conducted on the TAR. C. Review of the PN (Progress Notes) for Resident 33 dated 5/23/2019 Resident 33 had slipped out of the bath chair in the bath house and slid onto the floor. Review of the undated Care Plan for Resident 33 revealed that there were no falls addressed on the Care Plan or interventions in place to decrease the risk of falls from reoccurring. An interview on 8/15/19 at 11:43 AM with the DON (Director of Nursing) revealed that the resident slid from the bath chair and there are to be two staff when this resident receives a bath. This day for some reason the aide was doing the bath alone. The straps were in place but the lift sling slid in the chair causing the resident to slide. Facility staff and hospice staff were competency checked for safety with lifts and lift slings. The DON confirmed that there were no interventions on the care plan to prevent the fall from reoccurring.

Based on record review and interview, the facility failed to ensure one resident (Resident 18) out of five residents had signed a consent form to either give or deny the right for the Influenza or Pneumococcal Vaccination. The facility census was 40 at the time of the survey. Findings are: Record review of Resident 18's Immunization Record revealed documentation of refused for the Influenza and the Pneumococcal Vaccination on 11-26-18. Record review revealed absence of a consent form revealing documentation by the POA (Power of Attorney) or the resident that education on the risk and benefits of the Influenza and the Pneumococcal Vaccinations was given and that the POA/resident denied the vaccinations. Interview on 8/15/19 at 2:36 PM with the DON (Director of Nursing) revealed the DON wrote the refused on the Immunization form because the POA had told the Doctor at the initial visit the resident did not want vaccinations and this was communicated to the DON. The DON confirmed the resident and/or the POA did not sign a consent form denying the vaccinations and it had not been the practice of the facility to obtain denials of vaccinations in writing.

Licensure reference: 175 NAC 12-006.04C3a(6) Based on interview and record review, the facility failed to ensure physician was notified of a change of condition of for one sample resident (Resident 41) of 22 sampled residents. The facility had a total census of 36 residents. Findings are: Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Nurses' Notes for Resident 41 revealed the following entries: -4/8/17 at 9 AM vital signs temperature 98.2, oxygen saturation 96% on room air, pulse 63, respirations 18, blood pressure 181/62. Resident 41 stated the Resident 41 did not feel well. Resident stayed in bed for breakfast but did get up and eat breakfast in recliner. -4/8/17 1130 Resident 41 up and dressed in wheelchair for lunch. Resident 41 reported feeling better. Vital signs 98.7 temperature, 96% oxygen saturation on room air, 62 pulse, 18 respirations, 192/72 blood pressure -4/9/17 1 PM vital signs 201/69 blood pressure, 93% oxygen saturation on room air, 69 pulse, 24 respirations; Resident 41 not forming words into sentences and et words that don't make sense. Power of Attorney, at bed side. Refuses to go to emergency room . -4/9/17 5 PM Resident 41 alert-speech is incoherent at times. Vital signs 98.6 temperature, 78 pulse, 20 respirations, 184/72 blood pressure, 95% oxygen saturation on room air. Family member here. Resident transferring poorly. Office Referral Form dated 4/10/17 for Resident 41 identified Resident had increase in confusion and decline in activity of daily living over weekend. Physician orders [REDACTED]. A review of 4/10/17 physician progress notes [REDACTED]. Family did not want any further evaluation completed. In an interview on 6/29/17 at 8:10 AM, Licensed Practical Nurse A reported had noticed a change in Resident 41's condition and was concerned about Resident 41's blood pressure. Licensed Practical Nurse A reported discussing concerns with Resident 41's family member and Resident 41's family had not wanted anything else done. Licensed Practical Nurse A reported offering to send Resident 41 to emergency room several times and family member had refused. Licensed Practical Nurse A reported being uncertain if physician or clinic had been called regarding Resident 41's condition. In an interview on 6/29/17 at 9:44 AM, Registered Nurse B reported noting a gradual change in condition of Resident 41 over the weekend. Registered Nurse B reported Resident 41 had not been eating and drinking and this may have contributed to this. Registered Nurse B reported family did not want anything done. In interviews on 6/29/17 at 8:51 AM and 9:56 AM, the Director of Nursing and Registered Nurse C reported Resident 41's blood pressure was high at times. The Director of Nursing and Registered Nurse C verified that speech not being understandable was not typical for Resident 41. The Director of Nursing and Registered Nurse C verified that there was no evidence of Resident 41's physician being notified of a change of condition until Resident 41 was seen on 4/10/17. They reported that family did not want anything done so Resident 41's physician may not have been notified. A review of facility policy titled Change of Condition dated 4/2/16 stated the following: -Dependent on resident or their representative wishes, emergency care will be offered. For Full Code residents in an acute physical change-the resident will be taken to ER for evaluation. Physician visits will be always be offered even though resident is a NO Code or Hospice status. -Documentation in narrative nurses notes should be made in addition to flow charts when changes of condition occur, and should include any notifications made.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B3 Based on observations and interview, the facility failed to ensure the ceiling vents were working in Resident Rooms 22 and 27 out of 7 resident rooms. Findings are: Observation on 4-27-16 at 10:00 AM with the Maintenance Staff revealed the ceiling vents in Resident Rooms 22 and 27 on the northeast hall were not working. Interview on 4-27-16 at 10:00 AM with the Maintenance Staff revealed Maintenance Staff was aware of the ceiling vents not working in the northwest hall and a motor had been ordered on 4-26-16. Maintenance Staff revealed they were not aware the ceiling vents were not working on the northeast hall which was operated by a different motor. The Maintenance Staff revealed if the ceiling vents were not working in the Rooms 22 and 27, then the motor was down for the entire northeast hall.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.12.B Based on observation, record reviews, and interview; the pharmacy failed to ensure the medication labels matched the physician orders [REDACTED]. The facility census was 36. Findings are: A. Observation on 4-26-15 at 8:07 AM revealed LPN-A (Licensed Practical Nurse) administered Artificial Tears 2 drops to both eyes to Resident 3. Review of the label on the Artificial Tears bottle for Resident 3 revealed the instructions were listed as use as directed. Review of the April 2016 MAR (Medication Administration Record) revealed Artificial Tears Solution 2 drops both eyes TID (three times a day). Review of the signed Medication Reconciliation orders dated 4-25-16 revealed Artificial Tears 2 drops in both eyes TID. Interview on 4-26-16 at 8:39 AM with the DON (Director of Nursing) confirmed the label on the MAR and the medication should match. B Observation on 4-27-16 at 8:46 AM revealed RN (Registered Nurse) -B administer Flonase Nasal Spray 1 spray to Resident 4. Review of Physician orders [REDACTED]. Review of the April 2016 MAR revealed Flonase Nasal Spray 1 spray daily. Review of label on Flonase Nasal Spray label revealed 1 spray BID. Interview on 4-27-16 at 1:35 PM with RN-B confirmed Flonase Nasal Spray container label revealed 1 spray BID. C. Observation on 4-25-16 at 11:19 AM revealed RN-B administered 9 units of Novolog Insulin to Resident 16. Review of the April 2016 MAR revealed -Novolog solution Insulin inject 16 units SQ (subcutaneously) one time a day for Diabetes. -Novolog solution Insulin inject 7 units SQ one time a day for Diabetes. -Novolog solution Insulin inject 9 units SQ one time a day for Diabetes. In the time slots for the Novolog insulin was written 0700 for the 7 units, 1130 for the 9 units and 1700 for the 16 units. Review of signed Physician orders [REDACTED]. The orders were: -Novolog solution Insulin inject 16 units SQ one time a day for Diabetes. -Novolog solution Insulin inject 7 units SQ one time a day for Diabetes. -Novolog solution Insulin inject 9 units SQ one time a day for Diabetes. Interview on 4-26-16 at 8:39 AM with the DON confirmed the signed Physician orders [REDACTED].

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 AND 12-006.09D7a Based on observation, interview, and record review; the facility failed to ensure one resident (Resident 18) was not left unattended while bathing in a whirlpool tub with water and failed to maintain the whirlpool tub bath belt free from rips, frayed areas, and peeling plastic pieces with rough edges affecting 37 out of 38 residents. The facility census was 38. Findings are: A. During the initial tour of the facility on 2/25/14 at 8:35 am, the facility bath house door was unlocked. There was no staff member in attendance and Resident 18 was in the whirlpool tub with water, Resident 18 was leaning forward. There was a bath belt around the resident's waist and between the resident's legs. The bath belt was loosely applied and had frayed edges. Approximately one minute later a staff member entered the bath house carrying clothing. B. Interview with BA (Bath Aide) A 2/25/14 at 8:37 am revealed that the staff member never left residents alone in the whirlpool. The BA A stated that the resident lived nearby and just went down the hall to get the resident's clothing. Interview with the DON on 2/25/14 at 9:35 am and revealed that Bath Aide A was the only staff member that bathed residents. There was only one resident that preferred showers. Interview with BA A on 2/27/14 at 9:45 am revealed that with Resident 18 (gender) always used the T- strap bath belt (belt through the legs). BA A stated the staff did not bring the resident's clothing with the resident. The BA stated unsure why left the bath house to get the clothing. BA A stated that the bath belts were the original bath belts that came with the whirlpool tub two years ago. If the BA had any trouble with the tub the BA would report it to the Maintenance department. Interview with Resident 18 on 2/26/14 at 9:05 am revealed that the resident stated that (gender) was left alone in the whirlpool tub once in a while when the resident forgot her clothing. The resident stated that the resident's room was close by and BA A would leave and get the clothing if forgotten. C. Review of Resident 18's Annual MDS (Minimum Data Set: a federally mandated comprehensive data collection tool used for care planning) dated 10/13/13 revealed that the resident's BIMS (Brief Interview for Mental Status) was a 10 (8-12 moderate cognitive impairment). The resident did not have any behaviors. The resident required extensive assistance with activities of daily living which included: transfers, bed mobility, walking in room, locomotion, dressing toilet use, personal hygiene, and bathing. The resident required hands on assistance with correction of all balance. The resident had limited range of motion in the upper and lower extremities on one side. The resident received restorative nursing program for active range of motion. Review of Resident 18's Quarterly MDS dated [DATE] revealed that the residents BIMS was a 10. The resident had a total mood score of 10. The resident did not have any behaviors. The resident required extensive assistance with activities of daily living which included: transfers, bed mobility, locomotion, dressing toilet use, personal hygiene, and bathing. The resident was non-ambulatory. The resident's balance activity required assistance from staff. The resident had limited range of motion in the upper and lower extremities on one side. The resident receive restorative nursing program for active range of motion. The resident had not fallen in the past three months. Review of Resident 18's Care Plan dated 2/4/10 and revised on 1/14/14 revealed that the resident had a self-care deficit related to hyponatremia (low levels of sodium in the bloodstream) and a mild stroke. The resident experienced weakness, fatigue, left sided weakness and an unsteady gait and balance. The resident's goal was to receive the necessary assistance needed to complete ADL (Activities of Daily Living) tasks to allow participation. The resident's interventions included: one to two physical assistance with ADLS; provide two staff assists with transfers using a gait belt; twice weekly whirlpool baths. Review of Resident 18's Fall Risk Assessment and Intervention dated 1/15/14 revealed that the resident had a score of 14. A score of "7+" was a higher risk. D. Observation of Resident 18's transfer from bed to chair on 2/27/14 at 10:35 am revealed NA (Nurses Aides) B and C assisted the resident from a lying position to a seated position on the edge of the bed. The resident required assistance to maintain seated balance. A gait belt was applied around the resident's waist. The resident was assisted to a standing position with extensive assistance of the two NAs and a pivot transfer was done. The resident was unable to move the resident's left foot. E. Interview on 2/25/14 at 8:55 am with the DON (Director of Nursing) revealed that the resident had a CVA - Cerbral Vascular accident (stroke) and was flaccid (weakness) on the resident's left side. The resident required 2 staff assistance with activities of daily living. The resident had poor balance from the resident's CVA. Interview with DON and ADM (Administrator) on 2/25/14 at 11:15 am revealed it had been reported to SS (Social Services) that BA A had left a resident unattended in the whirlpool tub. The staff member had received re-education on the bathing policy and procedure to never leave a resident unattended in the whirlpool. Observation of Resident 11 on 2/27/14 at 9:25 am Bath Aide A attached a ripped, frayed, peeling rough waist bath belt around the resident and lifted the resident approximately four feet up with the lift and lowered the resident into the Superior Aqua Aire Whirlpool Tub. The Bath Aide did not put the strap on between the resident's legs. The Bath Aide did not leave the resident alone during the observation. F. Interview with the DON and ADM on 2/27/14 at 10 am revealed that they acknowledged the peeling plastic, ripped edges, and frayed edges of the bath belt. The DON stated that a bath belt was ordered on [DATE] when it was reported it was frayed. The DON stated that the bath belt had not been on any checklist to monitor when worn for replacement. G. Review of the Facility Bathing Policy dated as revised on 5/2012 revealed that the bath aide was always to ensure the residents were attended to while in the bath. Review of the Penner Superior Aqua Aire whirlpool tub manual stated "Daily Safety Checklist" Penner Transfer Perform the following safety checks for the Penner Transfer: 1. Seat Belt- Check this is to insure the parts are secure and not missing." WARNING If during the safety checks you find parts are missing are excessively worn, do not function properly, do not operate the equipment until the maintenance department has taken the appropriate corrective action." H. The immediate jeopardy was abated to an E 2/27/14 when the facility provided information that the bath aide had been re-educated to not leave residents unattended in the whirlpool tub. The other nursing staff attended an in-service on 2/26/14 and were educated to not leave residents in the whirlpool unattended. The DON had an additional belt that was on the top of the chair switched to the waist. The DON had ordered a new whirlpool bath belt on 2/25/14 that had not arrived yet on 2/27/14.