Every finding on record at Life Care Center of Elkhorn

Licensure Reference Number 175 NAC 12-006.18(S)Based on observation and interview the facility failed to ensure a toilet safety arm support device (a bathroom aid that attaches around or directly to a toilet to provide stable armrests) was securely attached to the toilet in the bathroom of room [ROOM NUMBER] and failed to ensure a toilet was secured to the floor in the bathroom of room [ROOM NUMBER]. The facility had a census of 87. An observation on 6/10/2026 between 7:25am and 8:05AM of the following rooms, 101, 102, 103, 106, 107, 108, 114, 124, 212, 310, and 412, containing toilet safety arm supports attached to the toilet revealed the single safety arm support for the toilet in the bathroom of room [ROOM NUMBER] was not securely attached to the toilet.An observation of the toilet in the bathroom of room [ROOM NUMBER] revealed the toilet was not securely attached to the floor and moved in a lateral (sideways) direction when touched. An interview on 6/10/2026 at 7:45AM with Nurse Assistant (NA) F confirmed the resident in room [ROOM NUMBER] used the toilet. NA F confirmed the toilet safety arm support was not attached securely to the toilet. NA F confirmed this was unsafe. An interview on 6/10/2026 at 7:25AM with NA G confirmed the toilet in the bathroom of room [ROOM NUMBER] was not securely attached to the floor and the toilet moved in a lateral direction when touched. NA G confirmed that Resident 3 sometimes used the toilet. An interview on 6/10/2026 at 7:55AM with the Assistant Director of Nursing (ADON) confirmed the toilet was not secured to the floor and was unsafe for use.

Licensure Reference Number 175 NAC 12-006.10 Based on interviews and record review the facility failed to ensure that medications were administered as ordered for 1 (Resident 2) of 1 sampled resident. The facility identified a census of 87. Findings are:A.Record Review of the facility's Policy titled Administration of Medications with a revision date of 9/9/2025 revealed the following: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnosis and signs and symptoms. DefinitionsMedication Error- This means the observed or identified preparation or administration of medications or biologicals which is not in accordance with:1. The prescribers' order;2. Manufacturers specifications (not recommendations) regarding the preparation and administration of the medication or biological; or3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each state, and current commonly accepted health standards established by national organizations, boards, and councils.Significant medication error- This means one which causes the resident discomfort or jeopardizes his or her health and safety. B.Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03/16/2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 15 indicates a person is cognitively intact.-required total staff assistance with all self-care and mobility needs-had a diagnosis of Quadriplegia (inability to control movement in all four limbs). Record Review of Resident 2's Medication Administration Record (MAR) dated 5/1/2026 through 5/31/2026 revealed Resident 2's practitioner had ordered Cefepime (An antibiotic medication) 0.5 grams intramuscularly, twice a day for 10 day for a Urinary Tract Infection (UTI). Further review of Resident 2's MAR for May 21026 revealed the Cefepime medication not administered on the following dates: 05/08/2026 evening administration. 05/15/2026 evening administration. 05/16/2026 morning administration 05/16/2026 evening administration In an interview on 6/10/2026 at 8:47 AM, Resident 2 confirmed that the medication was not being administered by the facility staff as ordered by the provider. In an interview on 6/10/2026 at 10:12 AM, Registered Nurse (RN)- A confirmed the Cefepime medication was not documented as administered on the following dates: 05/08/2026 evening administration 05/15/2026 evening administration 05/16/2026 morning administration 05/16/2026 evening administration In an interview on 6/10/2026 at 10:36 AM, RN-A confirmed that not providing the ordered medication would be considered a medication error. RN-A confirmed that the provider should have been notified.In an interview on 6/10/2026 at 10:41 AM, RN-A confirmed that there was no evidence that the provider was notified that the Cefepime HCl Injection Solution Reconstituted (Cefepime HCl) was not administered for 5/8/2026, 5/15/2026 and 5/16/2026.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5). Based on record review and interview, the facility failed to notify the residents provider that medications were not administered for the prescribed duration for 1 (Resident 2) of 1 sample resident. The facility identified a census of 87. The findings are:Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03/16/2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 15 indicates a person is cognitively intact.-required total staff assistance with all self-care and mobility needs-had a diagnosis of Quadriplegia (inability to control movement in all four limbs). Record Review of Resident 2's Medication Administration Record (MAR) dated 5/1/2026 through 5/31/2026 revealed Resident 2's practitioner had ordered Cefepime (An antibiotic medication) 0.5 grams intramuscularly, twice a day for 10 day for a Urinary Tract Infection (UTI). Further review of Resident 2's MAR for May 21026 revealed the Cefepime medication not administered on the following dates: 05/08/2026 evening administration. 05/15/2026 evening administration. 05/16/2026 morning administration 05/16/2026 evening administration In an interview on 6/10/2026 at 8:47 AM, Resident 2 confirmed that the medication was not being administered by the facility staff as ordered by the provider. In an interview on 6/10/2026 at 10:12 AM, Registered Nurse (RN)- A confirmed the Cefepime medication was not documented as administered on the following dates: 05/08/2026 evening administration 05/15/2026 evening administration 05/16/2026 morning administration 05/16/2026 evening administration In an interview on 6/10/2026 at 10:36 AM, RN-A confirmed Resident 2's provider should have been notified that Resident 2 did not receive the medication for the ten days as ordered.In an interview on 6/10/2026 at 10:41 AM, RN-A confirmed that there was no evidence Resident 2's provider was notified the Cefepime medication was not administered on 05/8/2026, 05/15/2026 and 05/16/2026.

Licensure Reference Number NAC 175 12-006.05(G). Based on record review and interview the facility failed to ensure as needed psychotropic medications were re-evaluated by the medical practitioner for rationale and duration of continued use beyond 14 days for 1 (Resident 1) of 3 residents sampled. The facility census was 93. The findings are:A. Record review of the facility policy titled Pharmacy Services and Medication Regimen Review dated 09-15-2025 revealed the facility maintains the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director and the director of nursing. The pharmacist must report any irregularities to the attending physician and the facility's medical director and the director of nursing, and these reports must be acted upon. The facility must develop and maintain policies and procedures for the monthly drug regimen review that include time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.B. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 02-13-2026 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required limited assistance with bathing, lower body dressing and transfers. Record review of Resident 1's Order Summary (OS) printed on 05-12-2026 revealed an order dated 02-12-2026 for diazepam 10 milligram tablet give 1 tablet every 8 hours as needed for anxiety with no stop date. Record review of Resident 1's Medication Administration Record (MAR) for May 2026 revealed an order for diazepam 10 mg give 1 tablet every 8 hours as needed for anxiety without a stop date. Record review of Resident 1's Pharmacy Consultation Report (PCR) dated 03-25-2026 revealed the facility's pharmacist comment was Resident 1 has an order for as needed (prn) order for an anxiolytic, without a stop date: Diazepam 10 mg take 1 tablet every 8 hours prn for anxiety. The PCR also revealed the pharmacist recommended discontinuing the Diazepam prn and if the medication cannot be discontinued at this time, then provide and document the indication for use, the intended duration of therapy, and the rationale for the extended period.Further review of the PCR revealed at the bottom of the page a note was written declined by provider with no date, signature or notation. Record review of Resident 1's faxed signed copy of the PCR dated 03-25-2026 revealed Resident 1's provider had accepted the pharmacist's recommendation, please implement as written with the provider signature dated 04-14-2026, but did not indicate whether to discontinue the diazepam or provide the rationale and intended duration for continued use and the facility had faxed the PCR back to the provider for clarification. An interview with the Assistant Director of Nursing (ADON) and the Regional Nurse Consultant (RNC) confirmed the pharmacy recommendation did not provide the rationale and duration of the PRN diazepam and should have followed up with the provider in 3 to 5 days of not receiving clarification and didn't.

Licensure Reference Number 175 NAC 12-006.10(D). Based on record review and interview, the facility failed to ensure residents were free of significant medication errors for 1(Resident 2) of 3 residents sampled. The facility census was 93. The findings are:A. Record review of the facility policy titled Administration of Medications dated 09-09-2025 revealed the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnosis and signs and symptoms. A medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with:-the prescriber's order;-manufacturer's specifications regarding the preparation and administration of the medication or biological-accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each state, and current commonly accepted health standards established by national organizations, boards and councils. A significant error means one which causes the resident discomfort or jeopardizes his or her health and safety. B. Record review of the facility policy titled Medication Shortages/Unavailable Medications dated 08-01-2024 revealed upon discovery that the Facility has an inadequate supply of a medication to administer to a resident, the facility staff should immediately initiate action to obtain the medication from the Pharmacy. If the medication shortage is discovered at the time of medication administration, the facility staff should immediately notify the Pharmacy. If the medication is unavailable during normal Pharmacy hours: the facility nurse should call the pharmacy to determine the status of the order, if the medication has not been ordered, the facility nurse should place the order or reorder for the next scheduled delivery. If the next available delivery causes delay or a missed dose in the resident's medication schedule, the nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply (EMS), facility staff should notify the pharmacy and arrange for a STAT delivery, if medically necessary. If the medication is unavailable and discovered after normal pharmacy hours: a facility nurse should obtain the ordered medication from the Emergency Medication Supply. If the ordered medication is not available in the Emergency Medication Supply, the nurse should call the Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: emergency delivery or use of an emergency third party pharmacy. If an emergency delivery is unavailable the nurse should contact the attending physician to obtain new orders or directions for alternate administration. If the nurse is unable to obtain a response from the attending physician in a timely manner, the nurse should notify the nursing supervisor and contact the facility's Medical Director for alternate orders/directions. C. Record review of the facility's EMS formulary with an exchange date of 05-06-2026 revealed 8 tablets of Ciprofloxacin 500 milligram (mg) were available and 8 tablets of Ciprofloxacin 250 mg were available. C. Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-20-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored at a 13. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-required limited assistance bed mobility.-required extensive assistance with bathing and dressing.-required total assistance with toileting and transfers.-had a diagnosis of osteomyelitis (a serious infection and inflammation of the bone that can lead to bone death if untreated) of the left foot and ankle. Record review of Resident 2's Order Summary (OS) printed on 05-12-2026 revealed an order for Ciprofloxacin 250 mg tablet, give 1 tablet at bedtime for prophylaxis related to a chronic ulcer of the left heel and midfoot with necrosis (irreversible death of cells and living tissue caused by external factors such as infection, toxins or trauma) of the bone. Record review of Resident 2's Medication Administration Record for May 2026 revealed for the administration of Ciprofloxacin 250 mg, give 1 tablet at bedtime revealed the facility staff documented '7' on 05-02-2026 and the facility documented '10' on 05-03-2026 and 05-07-2026 and there was no documentation of administration on 05-05-2026 and 05-06-2026. Record review of Resident 2's Progress Notes (PN) dated 05-02-2026 revealed Ciprofloxacin 250 mg tablet was on order. Record review of Resident 2's PN dated 05-04-2026 revealed Ciprofloxacin 250 mg tablet was not available. Record review of Resident 2's PN dated 05-07-2026 revealed Ciprofloxacin 250 mg tablet awaiting arrival from the pharmacy. Record review of Resident 2's PNs revealed no notes regarding Ciprofloxacin 250 mg tablet administration on 05-03-2026, 05-05-2026 and 05-06-2026. An interview conducted on 05-13-2026 at 1:35 PM with the Regional Nurse Consultant (RNC) revealed when a medication is not available the facility staff should call the pharmacy to order the medication and obtain authorization to get the medication out of the EMS. If the medication is not available in the EMS then the attending provider should have been called and if unable to contact the attending provider then the Medical Director should be called. An interview conducted on 05-13-2026 at 2:25 PM with the Assistant Director of Nursing (ADON) and the RNC confirmed Resident 2's Ciprofloxacin 250 mg was not administered from 05-02-2026 through 05-07-2026 and the pharmacy should have been notified and either had the drug delivered or obtained the medication from the EMS. An interview conducted on 05-13-2026 at 3:55 PM with the ADON and the RNC confirmed the omission of Ciprofloxacin 250 mg was a medication error.

Licensure Reference Number 175 NAC 12-006.09(H). Based on interview and record review the facility failed to ensure pain medication was available for pain management for 1 (Resident 3) of 3 residents sampled. The facility census was 93. The findings are:A. Record review of the facility policy titled Medication Shortages/Unavailable Medications dated 08-01-2024 revealed upon discovery that the Facility has an inadequate supply of a medication to administer to a resident, the facility staff should immediately initiate action to obtain the medication from the Pharmacy. If the medication shortage is discovered at the time of medication administration, the facility staff should immediately notify the Pharmacy. If the medication is unavailable during normal Pharmacy hours: the facility nurse should call the pharmacy to determine the status of the order, if the medication has not been ordered, the facility nurse should place the order or reorder for the next scheduled delivery. If the next available delivery causes delay or a missed dose in the resident's medication schedule, the nurse should obtain the medication from the Emergency Medication Supply (EMS) to administer the dose. If the medication is not available in the EMS, facility staff should notify the pharmacy and arrange for a STAT delivery, if medically necessary. If the medication is unavailable and discovered after normal pharmacy hours: a facility nurse should obtain the ordered medication from the Emergency Medication Supply. If the ordered medication is not available in the EMS, the nurse should call the Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: emergency delivery or use of an emergency third party pharmacy. If an emergency delivery is unavailable the nurse should contact the attending physician to obtain new orders or directions for alternate administration. If the nurse is unable to obtain a response from the attending physician in a timely manner, the nurse should notify the nursing supervisor and contact the facility's Medical Director for alternate orders/directions. B. Record review of the Facility EMS formulary exchanged on 05-06-2026 revealed the EMS contained 8 oxycodone 5 milligram tablets. C. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 04-15-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required extensive assistance with bed mobility.-required total assistance with toileting, bathing, dressing and transfers.-had pain frequently that occasionally effected sleep and frequently interfered with therapy and almost constantly interfered with day-to-day activities. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 04-13-2026 revealed Resident 3 expresses pain and Resident 3 will express pain relief through the review date. Interventions listed on the care plan was to evaluate the effectiveness of pain interventions and to give pain medication as ordered. Record review of Resident 3's Hospital Discharge Orders (HDO) dated 04-13-2026 revealed Resident 3 had an order for a Butrans Transdermal Patch ( BTP: a 7-day patch used to treat severe, chronic pain requiring around-the-clock opioid treatment) 7.5 milligram (mg) apply 1 patch once a week and an order for oxycodone 2.5 mg tablet every 4 hours as needed (prn) for pain. Record review of Resident 3's Medication Administration Record (MAR) for May 2026 revealed the facility staff documented '7' on 05-09-2026 for the administration of the BTP 7.5 mg. Record review of Resident 3's Progress Notes (PN) dated 05-09-2026 revealed the BTP 7.5 mg was not available and contacted the pharmacy to reorder. An interview conducted with Resident 3 on 05-12-2026 at 11:00 AM revealed the facility had run out of Resident 3's BTP on 05-09-2026 and had run out of oxycodone 2.5 mg on 05-10-2026. An interview was conducted on 05-12-2026 at 2:45 PM with Licensed Practical Nurse (LPN) A confirmed that Resident had ran out of the BTP on Saturday and had ran out of oxycodone on Sunday and medications could not be obtained from the EMS because the pharmacy is closed on the weekend to obtain an authorization code to unlock the EMS. A follow-up interview was conducted with Resident 3 on 05-13-2026 at 9:30 AM and Resident 3 reported a pain level was a '9' on a scale from 0 to 10(0 being no pain and 10 being the worst pain ever) on Sunday and could tolerate a pain level at a 5-6 and revealed that (gender) thought the facility had an emergency medication kit but was not given anything for pain other than Tylenol. An interview was conducted on 05-13-2026 at 2:25 PM with the Assistant Director of Nursing (ADON) and the Regional Nurse Consultant (RNC) confirmed Resident 3 did not receive the BTP on 5-9-2026 and had ran out of oxycodone 2.5 mg on 5-10-2026 and confirmed the pharmacy is available on weekends and the nurse should have called the pharmacy and received authorization to obtain the medication from the EMS.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5). Based on record review and interview, the facility failed to notify the residents practitioner when pain and antibiotic medication were unavailable for 2 (Resident 2 and 3) of 3 residents sampled. The facility census was 93. The findings are: A. Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-20-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored at a 13. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-required limited assistance bed mobility.-required extensive assistance with bathing and dressing.-required total assistance with toileting and transfers.-had a diagnosis of osteomyelitis (a serious infection and inflammation of the bone that can lead to bone death if untreated) of the left foot and ankle.Record review of Resident 2's Order Summary (OS) printed on 05-12-2026 revealed an order for Ciprofloxacin 250 mg tablet, give 1 tablet at bedtime for prophylaxis related to a chronic ulcer of the left heel and midfoot with necrosis (irreversible death of cells and living tissue caused by external factors such as infection, toxins or trauma) of the bone. Record review of Resident 2's Medication Administration Record for May 2026 revealed for the administration of Ciprofloxacin 250 mg, give 1 tablet at bedtime revealed the facility staff documented '7' on 05-02-2026 and the facility documented '10' on 05-03-2026 and 05-07-2026 and there was no documentation of administration on 05-05-2026 and 05-06-2026. Record review of Resident 2's Progress Notes (PN) dated 05-02-2026 revealed Ciprofloxacin 250 mg tablet was on order. Record review of Resident 2's PN dated 05-04-2026 revealed Ciprofloxacin 250 mg tablet was not available. Record review of Resident 2's PN dated 05-07-2026 revealed Ciprofloxacin 250 mg tablet awaiting arrival from the pharmacy. Record review of Resident 2's PNs revealed no notes regarding Ciprofloxacin 250 mg tablet administration on 05-03-2026, 05-05-2026 and 05-06-2026. An interview conducted on 05-13-2026 at 3:30 PM with the Assistant Director of Nursing (ADON) and the Regional Nurse Consultant (RNC) confirmed Resident 2's practitioner was not notified when Ciprofloxacin supply ran out and should have been.B.Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 04-15-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-Brief Interview of Mental Status (BIMS) was scored at a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-required extensive assistance with bed mobility.-required total assistance with toileting, bathing, dressing and transfers.-had pain frequently that occasionally effected sleep and frequently interfered with therapy and almost constantly interfered with day-to-day activities. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 04-13-2026 revealed Resident 3 expresses pain and Resident 3 will express pain relief through the review date. Interventions listed on the care plan was to evaluate the effectiveness of pain interventions and to give pain medication as ordered. Record review of Resident 3's Hospital Discharge Orders (HDO) dated 04-13-2026 revealed Resident 3 had an order for a Butrans Transdermal Patch ( BTP: a 7-day patch used to treat severe, chronic pain requiring around-the-clock opioid treatment) 7.5 milligram (mg) apply 1 patch once a week and an order for oxycodone 2.5 mg tablet every 4 hours as needed (prn) for pain. Record review of Resident 3's Medication Administration Record (MAR) for May 2026 revealed the facility staff documented '7' on 05-09-2026 for the administration of the BTP 7.5 mg. Record review of Resident 3's Progress Notes (PN) dated 05-09-2026 revealed the BTP 7.5 mg was not available and contacted the pharmacy to reorder. An interview conducted with Resident 3 on 05-12-2026 at 11:00 AM revealed the facility had run out of Resident 3's BTP on 05-09-2026 and had run out of oxycodone 2.5 mg on 05-10-2026. An interview was conducted on 05-12-2026 at 2:45 PM with Licensed Practical Nurse (LPN) A confirmed that Resident had ran out of the BTP on Saturday and had ran out of oxycodone on Sunday and medications could not be obtained from the EMS because the pharmacy is closed on the weekend to obtain an authorization code to unlock the EMS. An interview conducted on 05-13-2026 at 3:35 PM with the ADON and RNC confirmed Resident 3's practitioner was not notified when the Resident 3's pain medications ran out and should have been.

Licensure Reference Number 175 NAC 12-006.04(H) Based on observation, interview and record review the facility failed to ensure staff were competent to operate the dishwasher. This had the potential to effect 85 of 86 residents who received foods from the kitchen. The Facility census was 86. The findings are:Record review of the facility's information from Ecolab on the dishwasher revealed the minimum operating temperature during the wash cycle is 120 degrees Fahrenheit (F) and the minimum operating temperature for the rinse cycle is 120 degrees F. An observation conducted on 12-03-2025 at 9:17 AM-10:00 AM revealed Dietary Aid (DA) K was doing dishes in the dishwasher. DA K placed 8 plates and 3 plate covers on a dish rack and put them into the dishwasher, the dishwasher temperature reached 100 degrees F during the wash cycle and 110 degrees F during the rinse cycle. After the dishwasher was done rinsing, DA K removed the dishes from the dishwasher and allowed them to dry. While the dishes were drying DA K placed several cups onto a tray and placed them into the dishwasher the dishwasher reached 100 degrees F during the wash cycle and 110 degrees F for the rinse cycle. DA K then took the plates and dish covers and put them away. DA K returns to the dish room and removes the tray of cups from the dishwasher and takes them from the dish room and places them on the rack under the food preparation table in the kitchen. Then returns to the dish room and places bowls and cups onto a dish rack and places them into the dishwasher. The dishwasher reached 100 degrees F during the wash cycle and 110 degrees F for the rinse cycle. An interview conducted on 12-03-2025 with DA K at 10:00 AM confirmed the dishwasher reached 100 degrees F for the wash cycle and 110 degrees F for the rinse cycle and revealed not knowing what to do if the dishwasher does not reach 120 degrees F. An interview with the Administrator (ADM) on 12-04-2025 at 1:50 PM confirmed DA K had not received training or competency completed for the use of the dishwasher and should have.

Licensure Reference Number: 175 NAC 12-006.04(B)(ii)(1)Based on record review and interview, the facility failed to ensure 3 [Nurse Aides (NA) C, D, and E] of 5 nurse aides had completed 12 hours of yearly required in-service education. This had the ability to affect all residents that resided in the facility. The facility had a total census of 86 residents.Findings are: A. Record review of a facility Employee list revealed NA C was hired on 5/28/24. Record review of NA C's Inservice education revealed that NA C had completed a total of 3.50 hours of training.B. Record review of a facility Employee list revealed NA D was hired on 5/28/24. Record review of in-service education for NA D had completed a total of 5 hours of training.C. Record review of a facility Employee list revealed NA E was hired on 4/25/23. Record review of in-service education for NA E revealed that NA E completed a total of 3 hours of training. D. Interview on 12/8/25 at 7:58 AM with the Director of Nursing [DON] confirmed that the 12-hour education training requirement had not been completed for NA's C, D, and E. The DON confirmed that the facility did not have an effective system to track the total number of hours to ensure that the 12 hours of education training were met by all staff.

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview and record review the facility failed to ensure the dishwasher reached the minimum required temperature of 120 degrees and failed to ensure the floor under the dish racks in the dish room were free of debris and dark, waxy build up; and the facility failed to ensure the double convection ovens were clean and free of food debris and hard water buildup. This had the potential to affect 85 of 86 residents who received food from the kitchen. The facility census was 86. The findings are: Record review of the facility's information from Ecolab on the dishwasher revealed the minimum operating temperature during the wash cycle is 120 degrees Fahrenheit (F) and the minimum operating temperature for the rinse cycle is 120 degrees F. Record review of the facility's dishwasher temperature log for October 2025 revealed no temperatures logged for breakfast and lunch after 10-11-2025 and no temperatures were logged for supper after 10-24-2025. Record review of the facility's dishwasher temperature log for November 2025 revealed no temperatures were logged for breakfast and lunch from 11-11-2025 to 11-21-2025, and 11-23-2025, 11-24-2025, and 11-26-2025 to 11-30-2025. The log also revealed no temperatures logged for supper from 11-11-2025 to 11-16-2025 and 11-18-2025, 11-25-2025 and 11-29-2025. A.An observation conducted on 12-03-2025 at 9:17 AM-10:00 AM revealed DA K was doing dishes in the dishwasher. DA K placed 8 plates and 3 plate covers on a dish rack and put them into the dishwasher, the dishwasher temperature reached 100 degrees F during the wash cycle and 110 degrees F during the rinse cycle. After the dishwasher was done rinsing, DA K removed the dishes from the dishwasher and allowed them to dry. While the dishes were drying DA K placed several cups onto a tray and placed them into the dishwasher the dishwasher reached 100 degrees F during the wash cycle and 110 degrees F for the rinse cycle. DA K then took the plates and dish covers and put them away. DA K returns to the dish room and removes the tray of cups from the dishwasher and takes them from the dish room and places them on the rack under the food preparation table in the kitchen. Then returned to the dish room and placed bowls and cups onto a dish rack and put them into the dishwasher. The dishwasher reached 100 degrees F during the wash cycle and 110 degrees F for the rinse cycle. An interview conducted on 12-03-2025 with DA K at 10:00 AM confirmed the dishwasher reached 100 degrees F for the wash cycle and 110 degrees F for the rinse cycle and revealed not knowing what to do if the dishwasher does not reach 120 degrees F. An observation conducted on 12-03-2025 at 10:30 AM with the Kitchen Manager (KM) confirmed the dishwasher temperature reached 110 degrees during the wash cycle and 118 during the rinse cycle and it should be 120 degrees F. B. An observation on 12-01-2025 at 7:21 AM revealed the floor under the dish shelves in the dish room had food debris and a dark waxy build up and the double convection ovens had a waxy build up on the outside where the control knobs were and there was a dark waxy build up and hard water build up around both the upper and lower double doors. An observation on 12-04-2025 at 12:05 PM revealed the floor under the dish shelves in the dish room had food debris and a dark waxy build up. An interview conducted on 12-04-2025 at 12:05 PM with DA K confirmed the dark waxy build up was present on the floor under the dish shelves in the dish room and confirmed the floor needed mopped. An observation on 12-04-2025 at 12:10 PM revealed the double convection oven had a waxy build up on the outside of the oven where the control knobs are and hard water build up and a dark waxy substance was present around both the upper and lower double doors. An interview conducted with the Administrator (ADM) on 12-08-2025 at 8:15 AM confirmed the floor in the dish room had a dark waxy build up and the double ovens had a waxy build up and hard water build up and needed to be cleaned and confirmed that cleaning logs were not retained to ensure consistent cleaning.

Licensure Reference Number 175 NAC 12-006.19(C), 12-006.18(B)Based on observation, record review and interview, the facility failed to ensure soiled linen did not come into contact with staff clothing for Residents 5 and 15, ensure nebulizer kits were cleaned after use for Residents 27 and 63, ensure Resident 6's PAP and PAP mask were clean and off the floor, and ensure Resident 6's PAP machine contained a filter; and the facility staff failed to wear enhanced barrier precautions when providing catheter care for Resident 12. The facility census was 86.Findings are: A. Record review of a facility policy dated 7/5/25 entitled Laundry Services revealed the following information: Facility staff should handle all laundry as potentially contaminated and use standard precautions with the appropriate Personal Protective Equipment. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling linen. -Never carry soiled linen against the body -Carefully roll up soiled linen to prevent contamination of air, surfaces and staff. -All soiled linen should be bagged or put into carts at the location used. B. Observation on 12/3/25 between 8:10 AM and 8:20 AM revealed Nursing Assistant [NA] D assisted Resident 5 to dress. NA-D assisted the resident to remove a soiled hospital gown, threw it on the floor and continued to assist the resident to don (put on) a clean shirt. After the resident was dressed and ready to leave the room, NA-D picked up the soiled gown from the floor, placed it underneath the NA's arm against [gender] clothing and assisted the resident to don a jacket. NA-D took the soiled unbagged hospital gown to the soiled utility room and placed into a laundry bin. Interview on 12/03/2025 at 8:20 AM with the NA-D confirmed that the soiled gown was picked up from the floor, placed under [gender] arm and was in contact with [gender] clothing while assisting the resident to don a jacket. NA-D confirmed the gown should have been bagged and should not have come into contact with the NA's clothing. Interview on 12/03/2025 at 1:29 PM with the Director of Nursing [DON] confirmed that soiled linen and clothing should have been bagged and not have come into contact with staff clothing. C. An observation on 12/01/2025 at 8:57 AM revealed NA-F exited room [ROOM NUMBER], Resident 15's room, and walked down the 300 hallway to the laundry hopper room carrying a bag of soiled clothing and a folded stack of soiled bedding directly on NA-F's left forearm. An observation on 12/04/2025 at 8:13 AM revealed NA-G exited the laundry room and walked down the 200 hallway to the bathhouse with uncovered linens directly against NA-G's left arm. In an interview on 12/04/2025 at 9:00 AM, the facility's Administrator confirmed the staff should not have carried soiled linens or clean towels against the staff's body. D. A record review of the facility's Cleaning and Disinfection of Non-Critical Patient Care Equipment with a reviewed date of 07/15/2025 revealed equipment should be cleaned daily and before and after reuse. An observation on 12/01/2025 at 11:24 AM revealed Resident 27 had a nebulizer (neb) on the bedside table and the nebulizer administration set with mask (neb kit) was draped over the top. The neb kit contained a residual (small, leftover) amount of medication in the cup and facial oils on the mask. An observation on 12/03/2025 at 7:07 AM revealed Resident 27 had a neb on the bedside table and the neb kit was draped over the top. The neb kit contained a full treatment worth of medication in the cup and facial oils on the mask. An observation on 12/03/2025 at 2:06 PM with the charge nurse, Licensed Practical Nurse (LPN)-H revealed Resident 27 had a neb on the bedside table and the neb kit was draped over the top. The neb kit contained a residual amount of medication in the cup and facial oils on the mask. In an interview on 12/03/2025 at 2:06 PM, the charge nurse, LPN-H confirmed Resident 27's neb kit was draped over the neb and had not been cleaned and should have been. E. A record review of the facility's Cleaning and Disinfection of Non-Critical Patient Care Equipment with a reviewed date of 07/15/2025 revealed equipment should be cleaned daily and before and after reuse. An observation on 12/03/2025 at 1:36 PM revealed Resident 63 was lying in bed with a neb on the bedside table and the neb kit was draped over the top. The neb kit contained a residual amount of medication in the cup and facial oils on the mask. An observation on 12/03/2025 at 1:55 PM with LPN-I revealed Resident 63 was lying in bed with a neb on the bedside table and the neb kit was draped over the top. The neb kit contained a residual amount of medication in the cup and facial oils on the mask In an interview on 12/03/2025 at 1:36 PM, Resident 63 confirmed the resident used the nebulizer regularly and just had a treatment that morning. In an interview on 12/03/2025 at 1:55 PM, LPN-I confirmed Resident 63's neb kit was draped over the bedside table and had not been cleaned following the nebulizer treatment that the resident had that morning. F. A record review of the facility's BIPAP (bilevel positive Airway Pressure) / CPAP (Continuous Positive Airway Pressure) Administration Policy with a reviewed date of 09/24/2025 revealed the facility would ensure each resident received respiratory care and services in accordance with professional standards of practice. The reservoir should be emptied daily and left to air dry and cleaned weekly with soap and water. The face mask should be cleaned as needed. A record review of ResMed's How to clean your CPAP equipment dated 2025 revealed CPAP mask cushions should be cleaned daily. The humidifier should be emptied and wiped thoroughly with a clean disposable cloth and allowed to dry daily and cleaned weekly with dishwashing soap or a vinegar water solution. https://www.resmed.com/en-us/sleep-health/resources/cleaning-cpap-equipment/ A record review of Resident 6's Clinical Physician Orders dated 12/02/2025 revealed the resident had an order for Clean CPAP/BIPAP mask with warm soapy water, rinse and air dry as needed and CPAP/BIPAP Clean reservoir with warm soapy water, rinse; set out to dry every day shift every 7 day(s). A record review of Resident 6's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated November and December 2025 revealed the resident wore the PAP every day. An observation on 12/01/2025 at 1:36 PM revealed Resident 6 had a ResMed Airsense 10 BiLevel ST on a tray table on the left side of the bed with water left in the humidifier. There was no filter in the machine. An observation on 12/02/2025 at 1:27 PM revealed Resident 6 had a ResMed Airsense 10 BiLevel ST and mask that was on the floor on the left side of the bed. The mask cushion had facial oils on it. There was water remaining in the humidifier and the machine did not have a filter. An observation on 12/03/2025 at 7:27 AM revealed Resident 6 had a ResMed Airsense 10 BiLevel ST that was on a tray table on the left side of the bed with a mask draped over the machine that contained facial oils. The humidifier still had water in it and there was not a filter in the machine. An observation on 12/03/2025 at 2:06 PM with the charge nurse, Licensed Practical Nurse (LPN)-H revealed Resident 6 had a ResMed Airsense 10 BiLevel ST that was on a tray table on the left side of the bed with a mask draped over the machine that contained facial oils. The humidifier still had water in it and the machine did not have a filter. In an interview on 12/01/2025 at 1:36 PM, Resident 6 confirmed the resident wore the PAP machine every night. In an interview on 12/03/2025 at 2:16 PM, Resident 6's family member was in the room and confirmed the staff does not clean the humidifier and supplies and the family member had talked to the facility and the problem had still not been resolved because the humidifier contained water and the humidifier was nasty. In an interview on 12/03/2025 at 2:06 PM, LPN-H confirmed Resident 6's BiPAP ST mask was draped over the machine, had facial oils on it, and it had not been cleaned. LPN-H confirmed the staff should clean the mask when they take it off in the morning and it had not been done and there was still water in the humidifier. LPN-H confirmed there was not a filter in the machine and should have been. G. Record review of the facility policy titled Enhanced Barrier Precautions (EBP) dated 08-19-2025 revealed the facility should use EBP as an additional strategy for residents that meet the following criteria, during high-contact resident care activities. EBP are indicated for residents with an indwelling medical device such as urinary catheters and feeding tubes. Examples of high-contact resident care activities requiring a gown and glove use include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as urinary catheters or feeding tubes, and wound care. Record review of Resident 12's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 10-17-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 14. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact. -required limited assistance with bed mobility. -required extensive assistance with dressing, bathing, and transfers -required total assistance with toileting. -had a urinary catheter. An observation conducted on 12-04-2025 at 9:25 AM of Licensed Practical Nurse (LPN) L and Nurse Aid (NA) M providing catheter care and incontinence care for Resident 12 revealed both the LPN L and the NA M did not utilize a gown during the provision of care. An interview with LPN L on 12-04-2025 at 9:30 AM confirmed Resident 12 had a urinary catheter and EBP should have been used and wasn't.

Licensure Reference Number: 175 NAC 12-007.04(D)Based on observation and interview, the facility failed to ensure that ventilation systems were operational in resident bathrooms in 4 (Rooms 106, 108, 114 and 115) of 15 occupied resident rooms on the 100 hall of the facility. The facility census was 86. Findings are:Observation on 12/4/25 between 9:00 AM to 9:30 AM with the facility Maintenance Supervisor [MS] revealed that the ventilation system did not draw a 1 ply square of toilet paper to the surface of the ventilation cover in resident bathrooms in resident rooms 106, 108, 114 and 115. This indicated that the ventilation system was not working properly on the 100 hall of the facility at the time of the observation. Interview on 12/4/25 at 9:25 AM with the MS confirmed that the ventilation system did not draw a 1 ply square of toilet paper in resident bathrooms in rooms 106, 108, 114 and 115 which indicated that the ventilation system was not working properly on the 100 hall of the facility. The MS confirmed that no routine checks of the ventilation system had been completed to ensure the ventilation systems were operational.

Licensure Reference Number 175 NAC 12-006.02(H)Based on interview and record review, the facility failed to protect 1 of 1 resident surveyed (Resident 14) during the investigation of an abuse allegation. The facility had a census of 88.Findings are:A record review of Resident 14's undated care plan revealed the following diagnoses: Type 1 Diabetes Mellitus with hyperglycemia (consistently high blood sugar levels due to insufficient insulin production), Anxiety Disorder, Diabetes insipidus ( a kidney disorder causing excessive thirst and large amounts of urine), Chronic pain, Adrenocortical insufficiency (a condition where the adrenal glands do not produce enough hormones), spinal stenosis with claudication (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves causing pain, numbness or weakness), depression, suicidal ideation (thoughts of suicide), other speech and language deficits following cerebral infarction (stroke).A record review of Resident 14's Minimum Data Set (MDS - a federally mandated assessment tool that measures the health status in nursing home residents) revealed Resident 14 had a Brief Interview for Mental Status (BIMS - a quick screening tool used in long term care facilities to assess a patients basic cognitive function) of 15, indicating Resident 14 was cognitively intact.A record review of a facility Investigation Note, dated 11/7/2025 revealed the following:On 11/3/2025 around 1:00 PM the facility was made aware of a verbal abuse allegation from Resident 14 regarding a comment that was made to them from the Director of Nursing (DON). The resident felt like they were verbally abused and not wanted in the facility. The comment that was made according to Resident 14 was that the DON stated, you do not belong here, and you have upset all of my staff. The report stated that as an immediate intervention due to the allegation of the resident, the DON was suspended pending investigation. A record review of the facility's Abuse - Reporting and Response Policy and Procedure, issued 10/04/2022 and revised on 10/13/2023 revealed the following:12. If the accused individual is an employee, the alleged perpetrator will be removed from the resident care areas immediately and placed on suspension pending results of the investigation.An interview on 12/1/2025 at 1:45 PM Resident 14 reported the Director of Nursing (DON) publicly humiliated the resident by yelling at them in the hallway several times. Resident 14 reported they were afraid of the DON and of retaliation from staff members. Resident 14 reported these incident occurred on 11/03/25. Resident 14 reported they had filed more than one complaint of neglect and abuse against the DON.An interview on 12/2/25 at 3:20 PM with the DON confirmed they had never been formally suspended during an investigation.

Licensure Reference Number 175 NAC 12-006.2(H)Based on interview and record review, the facility failed to investigate an allegation of abuse for 1 of 1 residents surveyed (Resident 14). The facility had a census of 88.Findings are:A record review of Resident 14's undated care plan revealed the following diagnoses: Type 1 Diabetes Mellitus with hyperglycemia (consistently high blood sugar levels due to insufficient insulin production), Anxiety Disorder, Diabetes insipidus ( a kidney disorder causing excessive thirst and large amounts of urine), Chronic pain, Adrenocortical insufficiency (a condition where the adrenal glands do not produce enough hormones), spinal stenosis with claudication (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves causing pain, numbness or weakness), depression, suicidal ideation (thoughts of suicide) and other speech and language deficits following cerebral infarction (stroke).A record review of Resident 14's Minimum Data Set (MDS - a federally mandated assessment tool that measures the health status in nursing home residents) revealed Resident 14 had a Brief Interview for Mental Status (BIMS - a quick screening tool used in long term care facilities to assess a patients basic cognitive function) of 15, indicating Resident 14 was not cognitively impaired.A record review of the facility's Abuse Reporting and Response Policy and Procedure, revised 04/09/2024 and reviewed 05/07/2025, stated the facility will report alleged violations related to mistreatment, exploitation, neglect or abuse including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes.A record review of the facility's Abuse and Neglect Policy, issued 10/04/2022 and revised 10/13/2023 revealed the following:Reporting:4. (a) The facility should retain documentation of the report, including what was reported and the date and time the report was made to the State Agency (SA).A record review of the Abuse - Identification of Types Policy dated 10/04/2022 reviewed 5/6/2025 revealed the following: Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear shame, agitation, or degradation. Verbal abuse includes the use of oral, written, or gestured communications or sounds, to residents within hearing distance, regardless of age ability to comprehend or disability.a. Examples of mental and verbal abuse include, but are not limited to:(i) Yelling or hovering over a resident, with the intent to intimidateA record review of an Event note dated 11/13/2025 by the Social Services Director (SSD) revealed Resident 14 had come to the social services office in regard to an encounter with the DON and the ADON. Resident 14 stated they felt their life was in danger and the DON was bullying them. After Resident 14 left the social services office the SSD reported the incident directly to the Executive Director (ED).An interview on 12/1/25 at 5:40 PM with the ED confirmed they reported the first step they take when they receive an allegation is to talk to the resident concerned to clarify the situation. In this instance the ED did not investigate the allegation of abuse/bullying and did not report the allegation of abuse/bullying on 11/13/25. An interview on 12/1/2025 at 1:45 PM Resident 14 reported the Director of Nursing (DON) publicly humiliated the resident by yelling at them in the hallway several times. Resident 14 reported they were afraid of the DON and of retaliation from staff members. Resident 14 reported this incident occurred on 11/13/25. Resident 14 reported they had filed a complaint of neglect and abuse against the DON.

The facility failed to administer tube feeding as ordered by the physician for 1 (Resident 7) of 1 sampled residents. The facility staff identified a census of 86.Record review of facility policy entitled Enteral Nutrition Therapy (Continuous) dated reviewed 9/5/2025 revealed: - The facility will provide continuous enteral nutrition therapy in accordance with physician orders and professional standards of practice.Record review of Resident 7's admission Record revealed the facility admitted the resident on 7/24/2025. Further review of the admission record identified Resident 7 had diagnoses which included encephalopathy (brain dysfunction often caused by an underlying condition such as infections, toxins, liver or kidney failure, or nutritional deficiency) and severe protein-calorie malnutrition.Record review of Resident 7's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 11/13/2025 revealed the facility staff assessed the following about Resident 7: -the resident held food in cheek or residual food was left in the residents mouth after meals; -the resident had complaints of difficulty swallowing; -the resident had a feeding tube present on admission; -the resident had a mechanically altered diet; -the resident received 51 percent (%) or more of total calories through tube feeding, and; -the resident received 501 milliliters (mL) or more average fluid intake through the tube.Record review of Resident 7's Medication Administration Record (MAR) dated December 2025 revealed an enteral feed order for Osmolite (brand of tube feeding) 1.5 via G-tube at 55 mL per (/) hour (hr) for (x) 18 hours via pump for a total amount of 990 mL. Tube feed on from 4:00 PM to 10:00 AM dated 11/7/2025.Record review of Resident 7'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) revealed the following interventions related to tube feeding: -G-tube water flushes; monitor weight; monitor meal intake; regular easy to chew diet dated revised 11/19/2025. -Tube feed per MD. Osmolite 1.5 dated 11/12/2025.Observation on 12/1/2025 at 9:29 AM revealed Resident 7's Osmolite 1.5 was hanging on the pole but not running. The tube feeding was not labeled with the date and time the tube feeding was first hung.Observation on 12/2/2025 at 7:25 AM revealed Osmolite 1.5 was hanging and the tube feeding pump was in alarm. The tube feeding pump displayed infusion complete.Observation on 12/3/2025 at 10:00 AM revealed Licensed Practical Nurse (LPN)-N entered Resident 7's room to disconnect the tube feeding. After hand hygiene, LPN-N donned (applied) gown and gloves. LPN-N explained to Resident 7 that it was time to disconnect the tube feeding. LPN-N shut the tube feeding pump off, disconnected the tube feeding from Resident 7, and flushed the G-tube with 60 mL's of water for line maintenance. LPN-N performed g-tube cares and applied a split-sponge dressing. The tube feeding container was not labeled with time and date of when the tube feeding was hung.Observation on 12/3/2025 at 10:47 AM revealed LPN-N returned to Resident 7's room to check the total amount of tube feeding administered. The tube feeding pump displayed 645 mL of tube feeding had been administered.An interview on 12/3/2025 at 10:47 AM with LPN-N confirmed the tube feeding was not dated or timed for when it was hung and should have been. LPN-N further confirmed the tube feeding amount administered read 645 mLs and that the resident did not receive the total amount of tube feeding nutrition as ordered by the provider.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to obtain valid positive airway pressure (PAP) device (a machine used to treat sleep apnea) orders for 2 (Residents 6 and 63) of 3 sampled residents and oxygen orders for 1 (Resident 63) of 3 sampled residents. The facility census was 86. Findings are:A record review of the facility's BIPAP (bilevel positive airway pressure) / CPAP (continuous positive airway pressure) Administration Policy with a reviewed date of 09/24/2025 revealed the facility would ensure each resident received respiratory care and services in accordance with professional standards of practice. When a PAP was ordered, the mode, pressure setting, size and type of mask, liters of oxygen if ordered, and frequency of use must be included in the written order. A.A record review of Resident 6's Clinical Census dated 12/02/2025 revealed the resident was admitted [DATE]. A record review of Resident 6's Medical Diagnosis dated 12/04/2025 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure, and Obstructive Sleep Apnea. A record review of Resident 6's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 10/31/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 15 which indicated the resident was cognitively aware (able to think and comprehend). The resident required substantial/maximal assistance with oral and personal hygiene (cleaning), bathing, and lower body dressing and was dependent on staff for toileting, upper body dressing, and footwear. The resident was on a non-invasive ventilator. A record review of Resident 6's Care Plan with an admission date of 07/21/2025 revealed an intervention of CPAP per order. A record review of Resident 6's Clinical Physician Orders dated 12/02/2025 revealed the resident had an order for CPAP/BIPAP on resident while sleeping/napping and off while awake and Oxygen with CPAP/BIPAP: Pressure setting okay for home settings APPY WHEN SLEEPING/NAPPING AND AT HS (bedtime) 9hours of sleep. A record review of Resident 6's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated November and December 2025 revealed the resident wore the PAP everyday. An observation on 12/01/2025 at 1:36 PM revealed Resident 6 had a ResMed Airsense 10 BiLevel ST on a tray table on the left side of the bed. An observation on 12/02/2025 at 1:27 PM revealed Resident 6 had a ResMed Airsense 10 BiLevel ST that was on the floor on the left side of the bed. An observation on 12/03/2025 at 7:27 AM revealed Resident 6 had a ResMed Airsense 10 BiLevel ST that was on a tray table on the left side of the bed. An observation on 12/03/2025 at 2:06 PM with the charge nurse, Licensed Practical Nurse (LPN)-H revealed Resident 6 had a ResMed Airsense 10 BiLevel ST that was on a tray table on the left side of the bed. In an interview on 12/01/2025 at 1:36 PM, Resident 6 confirmed the resident wore the PAP machine every night but did not know what the settings were. In an interview on 12/04/2025 at 7:03 AM, the Director of Nursing (DON) confirmed the facility did not have a written order for Resident 6's PAP and the order in the electronic medical record did not contain the mode or pressure settings. In an interview on 12/04/2025 at 6:48 AM, LPN-J confirmed Resident 6's physician's order for the PAP did not contain the required elements to make it a valid order. The physician's order did not contain the mode, pressure settings, or route of administration. B.A record review of the facility's Oxygen Administration (Infection Control, Safety, & Storage) policy with a revised date of 09/30/2025 revealed oxygen orders should include the specific liter flow. A record review of Resident 63's Clinical Census dated 12/03/2025 revealed the resident was admitted [DATE]. A record review of Resident 63's Medical Diagnosis dated 12/03/2025 revealed the resident had diagnoses of Morbid Obesity (extremely overweight), Heart Failure, Hypoxemia (low oxygen in the blood), Guillain-Barre Syndrome (nerve disorder), Obstructive Sleep Apnea, and Need For Assistance With Personal Care. A record review of Resident 63's MDS dated [DATE] revealed the resident had a BIMS of 15 which indicated the resident was cognitively aware. The resident was independent with eating and personal and oral hygiene, required partial/moderate assistance with bathing and upper body dressing, required substantial/maximal assistance with lower body dressing, and was dependent on staff for toileting and footwear. The resident was on a non-invasive ventilator. A record review of Resident 63's Care Plan with an admission date of 08/20/2024 revealed the resident had a CPAP and the resident was on oxygen. There was an intervention of Oxygen Settings: Administer oxygen per orders. A record review of Resident 63s Clinical Physician Orders dated 12/03/2025 revealed the resident had an order for Oxygen with CPAP/BIPAP: Pressure setting okay for previous home settings and CPAP/BIPAP on while sleeping/napping and off while awake. The Clinical Physician Orders did not reveal an order for oxygen without the PAP or a setting. An observation on 12/03/2025 at 1:36 PM revealed Resident 63 was lying in bed with an oxygen nasal cannula on and the oxygen concentrator (a machine that makes oxygen) was set a 1 liter per minute (l/m). The resident had a ResMed Airsense 11 Average Volume-Assured Pressure Support (AVAPS) PAP device on the overbed table. The observation did not reveal there was oxygen tubing or a bleed-in adapter to bleed in the oxygen to the PAP. An observation on 12/03/2025 at 1:55 PM with LPN-I revealed Resident 63 was lying in bed with an oxygen nasal cannula on and the oxygen concentrator (a machine that makes oxygen) was set a 1 liter per minute (l/m). The resident had a ResMed Airsense AVAPS PAP device on the overbed table. The observation did not reveal there was oxygen tubing or a bleed-in adapter to bleed in the oxygen to the PAP. In an interview on 12/03/2025 at 1:36 PM, Resident 63 confirmed the resident used oxygen all the time, the resident used the PAP device every night when the nurse remembered to help the resident put it on, and the resident did not think (gender) used oxygen at night with the PAP device. In an interview on 12/03/2025 at 1:55 PM, LPN-I confirmed Resident 63 had a PAP device and the resident was wearing oxygen and the concentrator was set at 1 l/m. LPN-I confirmed the resident's PAP order did not contain a mode, pressure settings, and oxygen settings and should have. LPN-I confirmed there was not an order for the resident's oxygen when the resident was not on the PAP. In an interview on 12/04/2025 at 7:03 AM, the Assistant Director of Nursing (ADON) confirmed the facility did not have a written order for Resident 63's oxygen and the order she got from the resident's provider the evening of 12/03/2025 was for 2-4 liters per minute. The ADON confirmed the residents PAP order did not have the mode or pressure settings and should have had and the ADON fixed it the evening of 12/03/2025.

Licensure Reference Number 175 NAC 12-006.09(E)(i)Based on record review and interview, the facility failed to develop a Comprehensive Care Plan (CCP, a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) related to prophylactic antibiotic use for Resident 8 and anticoagulant [a blood thinner medication which can increase the risk of bleeding] for Resident 14. The facility sample size was 25. The facility census was 86.Findings are:A. Record review of Resident 8's Face Sheet revealed that Resident 8 was admitted on [DATE] with diagnoses that included urinary tract infection [UTI], chronic kidney disease, and bladder neck obstruction. Record review of Resident 8's significant change Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated 10/21/25 revealed that Resident 8 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 11 which indicated that Resident 8 was cognitively intact. The MDS identified that Resident 8 had a foley catheter with a diagnosis of obstructive uropathy.Record review of Resident 8's Electronic Medical Record [EMR] revealed that Resident 8 was hospitalized from [DATE] to 10/10/25 with UTI and bladder stones. Resident 8 was given Rocephin [an antibiotic] in the emergency room and the antibiotic was changed to Ertapenem [an antibiotic] while in hospital. Record review of Resident 8's EMR revealed that Resident 8 was admitted to Hospice Care on 10/15/25 on Bactrim DS [an antibiotic] 800milligrams [mg] -160mg twice a day for 7 days. Record review of Resident 8's Physician Orders dated 10/28/25 revealed an order from Hospice for Macrobid [an antibiotic] daily for UTI prevention.Record review of Resident 8's CCP dated 11/4/25 revealed no information related to the use of prophylactic antibiotic use for Resident 8. Interview on 12/04/2025 at 7:22 AM interview with Director of Nursing [DON] confirmed no CCP had been developed for the use of the prophylactic antibiotic for Resident 8. The DON confirmed that a CCP should have been developed for the use of antibiotics for Resident 8. B. Record review of Resident 14's Face Sheet revealed that Resident 14 was admitted on [DATE] with diagnoses that included unspecified atrial fibrillation and cerebral infarction [stroke].Record review of Resident 14's admission MDS dated [DATE] revealed that Resident 14 had a BIMS score of 15 which indicated that Resident 14 was cognitively intact. The MDS identified that Resident 14 used anticoagulant medications daily. Record review of Resident 14's Physician Orders dated 10/21/25 revealed an order for Apixaban Oral Tablet 5 mg, give 1 tablet by mouth two times a day related to unspecified atrial fibrillation. Resident 8's physician orders also revealed an order to monitor s/s [signs and symptoms] of bleeding; including black tarry stools, bleeding gums, bruising/nosebleed related to anticoagulant use every shift. Record review of Resident 14's CCP dated 11/3/25 revealed no information related to the use of anticoagulant medications or the risk for bleeding for Resident 14. Interview on 12/04/2025 at 7:22 AM with the DON confirmed no CCP had been developed for the use of anticoagulant medication or the risk for bleeding for Resident 14. The DON confirmed that a CCP should have been developed for the risk for bleeding and anticoagulant use for Resident 14.

Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview, the facility failed to ensure an anti-psychotic medication [a class of medications used to manage symptoms of psychosis such as delusions and hallucinations] was used to treat a medically accepted, diagnosed, specific condition for 1 (Resident 10) of 5 residents reviewed for unnecessary medications. The facility census was 86.Findings are:A. Record review of a facility policy dated 11/19/24 entitled Psychotropic Medication Management revealed the following information:A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:Anti-psychotic, Anti-depressant, Anti-anxiety, and Hypnotic.Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. With regards to psychotropic medications, the regulations additionally require:Giving psychotropic medications only when necessary to treat a specific diagnosed and documented condition. The residents' medical record must show documentation of adequate indications for medication use and the diagnosed condition for which the medication is prescribed. B. Record review of Resident 10's Face Sheet revealed an admission date of 2/18/25 with diagnoses that included: Major Depressive Disorder single episode, Dementia in other diseases, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.Record review of Resident 10's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 10/3/25 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 6 which indicated that Resident 10 had severe cognitive impairment. A score of 0-7 indicated severe impairment. The MDS identified diagnoses of Alzheimer's Dementia, Parkinson's and Depression and daily use of antipsychotic medications. Record review of Resident 10's Physician Orders revealed an order dated 10/2/25 for Quetiapine Fumarate [an antipsychotic medication, also named Seroquel] give 1 tablet by mouth at bedtime related to Parkinson's Disease without dyskinesia, without mention of fluctuations. Record review of Resident 10's November 2025 and December 2025 Medication Administration Records revealed that Resident 10 received Quetiapine Fumarate daily as ordered. Record review of a Progress Note for Resident 10 dated 11/21/25 revealed the following note: Patient is on Seroquel [Quetiapine Fumarate] for Dementia with behavioral disturbance. DON [Director of Nursing] to request DC [discontinue] due to no behavior at this time. Interview on 12/03/2025 at1:37 PM with DON confirmed that Resident 10's physician denied the request to discontinue the Quetiapine Fumarate. The DON confirmed that Parkinson's was not a medically accepted diagnoses for the continued use of the antipsychotic medication Quetiapine Fumarate. The DON confirmed that Resident 10 had no other documented, medically accepted diagnoses for the use of the Quetiapine Fumarate.

Licensure Reference Number 175 NAC 12-006-05(A)(B)(C)Based on record review and interview, the facility failed to provide notice of resident rights on admission for 1 (Resident 95) of 1 sampled resident. The facility staff identified a census of 86.The findings are:Record review of a facility policy entitled admission Policy dated reviewed 8/28/2025 revealed: - Resident Rights - Before or upon admission the facility will ensure that the resident and/or the resident's representative or interested family member has been informed of the resident's rights and all facility policies governing resident conduct and responsibilities in a language and manner they can understand. - 1. The resident's rights are communicated both orally and in writing with adaptations made to account for visual and hearing impairments (i.e., sign language, large print, Braille copies). - 2. The facility will provide language assistance services such as qualified interpreters for individuals with limited English proficiency, and appropriate auxiliary aids and services to comply with Section 1557. - 3. Written acknowledgement of the explanation of rights and responsibilities is obtained and documented in the admission agreement. - Resident Orientation - 2. Should the resident be medically incapable of understanding his/her rights, the legal guardian/representative for the resident will be required to undergo the orientation process.Record review of Resident 95's admission Record revealed the facility admitted the resident on 1/21/2025. Further review of the admission record identified Resident 95 had diagnoses which included osteomyelitis (an infection and inflammation of the bone, usually caused by bacteria which can cause pain, swelling, and redness), intracranial injury with loss of consciousness (traumatic brain injury), quadriplegia (one affected with partial or complete paralysis of both the arms and legs especially as a result of spinal cord injury or disease in the region of the neck), and depression.Record review of Resident 95's admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 1/24/2025 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 11. According to the MDS manual, a score of 11 indicated the resident had moderate cognitive impairment.Record review of Resident 95's Power of Attorney for Health Care (Surrogate) dated 1/14/2025 revealed Resident 95 had identified an individual as agent for health care if Resident 95 was unable to make health care decisions.Record review of Resident 95's electronic health record (EHR) which included progress notes and scanned documents showed the EHR lacked an acknowledgement of receipt of resident rights.An interview on 12/8/2025 at 8:55 AM and 9:20 AM with the Admissions Director (AD) revealed admission paperwork had not been completed at the time Resident 95 was admitted by the facility. The AD confirmed the resident's medical record lacked required documentation that the resident or resident representative received notice of rights on admission.

Licensure Reference Number 175 NAC 12-006.2(H)Based on interview and record review, the facility failed to ensure that an abuse allegation for 1 of 1 resident surveyed (Resident 14) was reported to officials within the required time limits. The facility claimed a census of 88.Findings are:A record review of Resident 14's undated care plan revealed the following diagnoses: Type 1 Diabetes Mellitus with hyperglycemia (consistently high blood sugar levels due to insufficient insulin production), Anxiety Disorder, Diabetes insipidus (a kidney disorder causing excessive thirst and large amounts of urine), Chronic pain, Adrenocortical insufficiency (a condition where the adrenal glands do not produce enough hormones), spinal stenosis with claudication (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves causing pain, numbness or weakness), depression, suicidal ideation (thoughts of suicide) and other speech and language deficits following cerebral infarction (stroke).A record review of Resident 14's Minimum Data Set (MDS - a federally mandated assessment tool that measures the health status in nursing home residents) revealed Resident 14 had a Brief Interview for Mental Status (BIMS - a quick screening tool used in long term care facilities to assess a patients basic cognitive function) of 15, indicating Resident 14 was cognitively intact.A record review of the facility's Abuse Reporting and Response Policy and Procedure, revised 04/09/2024 and reviewed 05/07/2025, stated the facility will report alleged violations related to mistreatment, exploitation, neglect or abuse including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes.A record review of the facility's Abuse and Neglect Policy, issued 10/04/2022 and revised 10/13/2023 revealed the following:Reporting:1. An individual (e.g., A resident, visitor, facility associate) who reports an alleged violation to facility staff does not have to explicitly characterize the situation as abuse, neglect, mistreatment, or exploitation in order to trigger the facility to investigate. Rather, if facility staff could reasonably conclude that the potential exists related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, then it would be considered reportable and require action.2. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin (e.g., bruising and skin tears) will be immediately reported to the administrator and/or director of nursing.a. All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative.b. All residents, families, resident representatives, and visitors are encouraged to immediately report incidents of suspected resident abuse and/or neglect to facility administration.A record review of the Abuse - Identification of Types Policy dated 10/04/2022 reviewed 5/6/2025 revealed the following: Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear shame, agitation, or degradation. Verbal abuse includes the use of oral, written, or gestured communications or sounds, to residents within hearing distance, regardless of age ability to comprehend or disability.a. Examples of mental and verbal abuse include, but are not limited to:Yelling or hovering over a resident, with the intent to intimidate.A record review of an Event note dated 11/13/2025 by the Social Services Director (SSD) revealed Resident 14 had come to the social services office in regard to an encounter with the DON and the ADON. Resident 14 reported they felt their life was in danger and the DON was bullying them. After Resident 14 left the social services office the SSD reported the incident directly to the Executive Director (ED).An interview on 12/1/2025 at 1:45 PM with Resident 14 revealed Resident 14 reported the Director of Nursing (DON) publicly humiliated the resident by yelling at them in the hallway several times. Resident 14 reported they were afraid of the DON and of retaliation from staff members. Resident 14 reported this incident occurred on 11/13/25. Resident 14 reported they had filed a complaint of neglect and abuse against the DON.An interview on 12/1/25 at 5:40 PM with the ED confirmed they reported the first step they take when they receive an allegation is to talk to the resident concerned to clarify the situation. In this instance the ED did not investigate the allegation of abuse/bullying and did not report the allegation of abuse/bullying on 11/13/25.

Licensure Reference Number 175 NAC 12-006.09(H). Based on observation, interview and record review, the facility failed to follow physician's orders, for daily weights and fluid restrictions for 1(Resident 1) of 3 residents sampled. The facility census was 83. The findings are:A. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 09-19-2025 revealed the facility staff assessed the following about the resident:-date of admission [DATE].-Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -required extensive assistance with dressing, hygiene and bed mobility.-required total assistance with transfers, toileting and bathing. -had a diagnosis of Heart Failure. Record review of Resident 1's Order Summary (OS) printed on 11-06-2025 revealed an order dated 06-18-2025 for daily weights. Record review of Resident 1's Medication Administration Record (MAR) for June 2025 revealed the following dates a weight was not obtained:-06-19-2025 no weight listed. -06-21-2025-no weight listed.-06-24-2025- no weight listed. Record review of Resident 1's Progress Notes (PN) for 06-24-2025 at 4:02 PM revealed Resident 1 had 3 plus edema (severe swelling that leaves a depression after applying pressure to the affected area) to bilateral lower extremities up to the hips. Record Review of Resident 1's PN dated 06-24-2025 at 5:52 PM revealed Resident 1 was seen by a medical practitioner and gave orders to send Resident 1 to the emergency room (ER). Record review of Resident 1's Nursing Home to Hospital Transfer Form (NHHTF) dated 06-24-2025 revealed the reason for the transfer to the ER was fluid overload. Record review of Resident 1's Continuum of Care Transfer Report (CCTR) dated 06-25-2025 revealed Resident 1 returned from the hospital for acute-on-chronic heart failure (a person with long-standing, chronic heart failure experiences a sudden and severe worsening of symptoms, requiring immediate medical attention). Record review of Resident 1's PN dated 07-08-2025 revealed Resident 1 went to the hospital for a planned surgery. Record review of Resident 1's PN dated 07-21-2025 revealed Resident 1 had returned from the hospital. Record review of Resident 1's After Visit Summary (AVS) dated 07-21-2025 revealed the reason for the hospitalization was a diagnosis of a nonhealing amputation stump. Record review of Resident 1's Physician's Visit Report (PVR) dated 08-01-2025 revealed orders for No Salt in food and daily weights. Record review of Resident 1's MAR for August 2025 revealed the following dates a weight was not obtained:-08-02-2025- no weight listed.-08-03-2025 - no weight listed.-08-07-2025- no weight listed.-08-08-2025- no weight listed. -08-09-2025-hospitalized Review of Resident 1's Medical record that included PN , faxes, weight list and nutritional notes revealed there was no indications the facility staff obtained the weight for the above dates. Record review of Resident 1's PN dated 08-08-2025 revealed Resident 1 was at an appointment, and the physician was sending Resident 1 to the hospital directly from their office. Record review of Resident 1's Emergency Department Provider Notes (EDPN) dated 08-08-2025 revealed Resident 1 was being admitted for Congestive Heart Failure (CHF), fluid volume overload, electrolyte disturbance, and pulmonary edema (swelling in the lungs). Record review of Resident 1's Clinical Census printed on 11-04-2025 revealed Resident 1 returned from the hospital on [DATE]. Record review of Resident 1's OS printed on 11-06-2025 revealed an order dated 08-28-2025 for daily weights call for any weight increase of 1-5 lbs Record review of Resident 1's MAR for September 2025 revealed an order dated 08-28-2025 for daily weights, call the physician for any weight increases of 1- 5 lbs. The September MAR also revealed the following weights:09-03-2025-weight 171.4 pounds (lbs.).09-04-2025-weight 180 lbs. (a gain of 8.6 lbs. in one day) 09-11-2025 hospitalized Record review of Resident 1's PN dated 09-11-2025 revealed Resident 1's family member requested Resident 1 be sent to the ER for evaluation and treatment of Covid and Pneumonia, as Resident 1 was out of it and needed help eating supper last night. Further review of the PN revealed Resident 1 was sent to the hospital. An interview with the Director of Nursing ( DON) on 11-06-2025 at 1:10 PM confirmed Resident 1's practitioner had not been notified of the weight increase of 8.6 lbs. between 09-03-2025 and 09-04-2025 and should have been. Record review of Resident 1's Continuum of Care Transfer Report (CCTR) dated 09-17-2025 revealed the reason for admission was acute-on-chronic respiratory failure, acute-on-chronic heart failure and Covid. Record review of Resident 1's OS printed on 11-06-2025 revealed an order dated 09-17-2025 for daily weight-Call with any weight increases of 1-5 lbs. Record review of Resident 1's MAR for September revealed an order dated 09-17-2025 for daily weights, call for any weight increase of 1 to 5 lbs. Further review revealed the following dates and weights:09-18-2025-weight 164.1 lbs.09-19-2025-weight 170.8 lbs. (a gain of 6.7 lbs.)09-22-2025-weight 166.8 lbs.09-23-2025-weight 170.7 lbs. (a gain of 3.9 lbs.)09-25-2025-weight 166.7 lbs.09-26-2025-weight 170.5 lbs. (a gain of 3.8 lbs.)09-28-2025-no weight listed09-30-2025-weight NA An interview with the DON on 11-06-2025 at 1:10 PM confirmed Resident 1's practitioner had not been notified of the 6.7 lbs. weight increase between 09-18-2025 and 9-19-2025, the 3.9 lbs. weight increase between 9-22-2025 and 09-23-2025 and the 3.8 lbs. increase between 09-25-2025 and 09-26-2025 and should have been. B. Record review of Resident 1's PN for 07-08-2025 revealed Resident 1 went to the hospital for a planned surgery. Record review of Resident 1's PN for 07-21-2025 revealed Resident 1 had returned from the hospital. Record review of Resident 1's After Visit Summary (AVS) dated 07-21-2025 revealed the reason for the hospitalization was a diagnosis of a nonhealing amputation stump. Record review of Resident 1's After Visit Summary (AVS) dated 07-21-2025 revealed orders for Meropenem (an antibiotic) 500 milligrams (mg) in 50 ml of normal saline administer into the vein (IV) every 6 hours for 16 days. Record review of Resident 1's Order Summary (OS) printed on 11-06-2025 revealed an order dated 07-28-2025 for a fluid restriction of 1000 milliliters (ml's) per day. According to the OS, dietary department was to provide 200 ml's with breakfast, lunch and dinner and nursing was to provide on 150 ml's on day and evening shift, and night shift 100 ml's. Record review of Resident 1's MAR for July 2025 revealed Meropenem 500 mg (an antibiotic) in 50 ml's of normal saline was administered every 6 hours (4 times a day) intravenously (IV) on 07-28-25, 07-29-2025, 07-30-2025 and 07-31-2025 for a total of 200 ml's of fluid per day. Review of Resident 1's MAR for July 2025 revealed Resident 1's practitioner ordered a fluid restriction of 1000 ml's per day. According to Resident 1's MAR for July 2025 the dietary department would provide 200 ml's of fluid for breakfast, lunch and dinner and the nursing department would provide 150 ml's on the day and evening shift and 100 ml's for the night shift. Further review of the MAR for July 2025 revealed the facility staff recorded Resident 1's fluid intake exceeded 1000 ml's for the following days: -07-29-2025 600 ml's provided by dietary and nursing provided on day shift 400 ml's, evening shift 120 ml's and night shift 80 ml's, taking into consideration the 200 ml's from the IV Meropenem for a total of 1400ml's.-07-30-2025 600 ml's provided by dietary and nursing provided on day shift 240 ml's, evening shift 200 ml's and night shift 120 ml's, taking into consideration 200 ml's from the IV Meropenem for a total of 1360 ml's. Record review of Resident 1's MAR for August 2025 also revealed Meropenem 500 mg in 50 ml's of normal saline was administered every 6 hours on 08-01-2025, 08-02-2025, 08-03-2025, 08-04-2025, 08-05-2025 for a total of 200 ml's a day and on 08-06-2025 Resident 1 received 3 doses to complete the course of antibiotics, for a total of 150 ml's. Resident 1's MAR for August 2025 revealed Resident 1's practitioner ordered a fluid restriction of 1000 ml's per day. According to Resident 1's MAR for August 2025 the dietary department would provide 200 ml's for breakfast, lunch and dinner and the nursing department would provide 150 ml's on the day and evening shift and 100 ml's for the night shift. Further review of the MAR for August 2025 revealed the facility staff recorded Resident 1's fluid intake exceeded 1000 ml's for the following days: -08-01-2025 600 ml's provided by dietary and nursing provided on day shift 240 ml's, evening shift 140 ml's, night shift 80 ml taking into consideration 200 ml's from IV Meropenem for a total of 1260 ml's.-08-03-2025 600 ml's provided by dietary and nursing provided on day shift 240 ml's, evening shift 100 ml's, night shift 160 ml's taking into consideration 200 ml's from IV Meropenem for a total of 1300 ml's.-08-04-2025 600 ml provided by dietary and nursing provided on day shift 100 ml, evening shift 120 ml and night shift 120 ml taking into consideration 200 ml's from IV Meropenem for a total of 1140 ml's.-08-05-2025 600 ml's provided by dietary and nursing provided on day shift 240 ml's, evening shift 120 ml's, night shift 120 ml's, taking into consideration 200 ml's from IV Meropenem for a total of 1280 ml's.-08-06-2025 600 ml's provided by dietary and nursing provided on day shift 120 ml's, evening shift 120 ml's and night shift 120 ml's, taking into consideration 150 ml's from IV Meropenem for a total of 1110 ml's.-08-07-2025 600 ml's provided by dietary and nursing provided on day shift 250 ml's, evening shift 100 ml's, night shift 100 ml=1050 ml's. Record review of Resident 1's PN dated 08-08-2025 revealed Resident 1 was at an appointment, and the physician was sending Resident 1 to the hospital directly from their office. Record review of Resident 1's Emergency Department Provider Notes (EDPN) dated 08-08-2025 revealed Resident 1 was being admitted for Congestive Heart Failure (CHF), fluid volume overload, electrolyte disturbance, and pulmonary edema (swelling in the lungs). Record review of Resident 1's Clinical Census printed on 11-04-2025 revealed Resident 1 returned to the facility from the hospital on [DATE]. Record review of Resident 1's AVS dated 08-15-2025 revealed orders for a 1000 milliliter's (ml) fluid restriction. Resident 1's MAR for August 2025 revealed Resident 1's practitioner ordered a fluid restriction of 1000 ml's per day. According to Resident 1's MAR for August 2025 the dietary department would provide 200 ml's for breakfast, lunch and dinner and the nursing department would provide 150 ml's on the day and evening shift and 100 ml's for the night shift. Further review of the MAR for August 2025 revealed the facility staff recorded Resident 1's fluid intake exceeded 1000 ml's for the following days: -08-18-2025 600 ml's provided by dietary and nursing provided on day shift 240 ml's, evening shift 240 ml, night shift 120 ml's for a total of 1200 ml. Review of the Resident 1's MAR for August 2025 also revealed the following dates that fluid intakes were not recorded:-08-17-2025 Day shift 240 ml's, evening and night shift had no fluids recorded.-08-19-2025 Day shift 240 ml's, evening shift no fluids recorded, night shift indicated Resident 1 was hospitalized . Record review of Resident 1's PN dated 08-19-2025 revealed Resident 1 was sent the ER for redness and vision loss in the right eye. Record review of Resident 1's Clinical Census printed on 11-04-2025 revealed Resident 1 returned from the hospital on [DATE]. Record review of Resident 1's Hospital Medicine Physician Daily Progress Note dated 08-20-2025 revealed under assessment and plan a diagnosis of acute-on-chronic congestive heart failure. Record review of Resident 1's PN dated 08-23-2025 revealed Resident 1 had been readmitted back to the facility on [DATE] with a diagnosis of CHF and fluid volume overload. Record review of Resident 1's OS printed on 11-06-2025 revealed an order dated 10-03-2025 for a 1440 ml's per day fluid restriction to receive from dietary 320 ml's for breakfast, lunch and dinner and from nursing for day and evening shift 200 ml's, and 80 ml's for night shift. An observation on 11-05-2025 at 7:20 AM revealed Resident 1 was in the dining room for breakfast and received a Styrofoam cup full of tomato juice. An observation on 11-05-2025 at 11:25 AM revealed Resident 1 was in the dining room for an activity and resident had a maroon-colored coffee cup that was empty. An interview conducted with the resident during the observation revealed the cup was full and Resident 1 had already drunk the coffee. An observation on 11-05-2025 at 12:50 PM revealed Resident 1 was in the dining room for lunch and was served a Styrofoam cup filled with water. An observation on 11-06-2025 at 3:50 AM revealed Resident 1 was in bed with eyes closed and there was a large blue cup with a white lid that was about half full of liquid, on the bedside table in Resident 1's reach. Resident 1 woke up during this observation and revealed the blue cup with a white lid was water that was brought to him in the night. An interview conducted with the Medication Aid (MA) D on 11-06-2025 at 4:05 AM revealed Resident 1 gets one of the blue cups with a white lid of water for the whole night shift every night. An interview conducted on 11-06-2025 at 4:10 AM with Registered Nurse (RN) B revealed RN B had not received report for Resident 1, was unaware of the fluid restriction for Resident 1, or how much fluid Resident 1 had received for the night shift. RN B also revealed (gender) was unaware of being assigned to the hall Resident 1 resided on until a couple hours prior to being interviewed. An interview conducted on 11-06-2025 at 9:10 AM with Licensed Practical Nurse (LPN) A revealed the amount of fluids documented on the MAR for November 2025 is the amount nursing provided to Resident 1 and dietary staff write down what their department provides. An interview conducted with the Dietary Aid (DA) E on 11-06-2025 at 9:15 AM revealed Resident 1 gets a white Styrofoam cup of fluids with each meal. When asked how much the Styrofoam cup holds, she replied 12 ounces (360 ml's). When asked how much the blue cup with the white lid holds DA E said it holds 12 ounces (360 ml's). DA-E also revealed the dietary staff do not record what fluids are provided by the dietary department. An interview with [NAME] F on 11-06-2025 at 9:20 AM revealed the dietary staff do not record or write down what fluids are provided from the dietary department. Record review of Resident 1's dietary meal ticket dated 11-6-2025 revealed Resident 1 was on a 1400 ml fluid restriction and was to receive 1 beverage only per meal for fluid restriction and heart failure. The ticket did not indicate the amount of fluids to be provided with each meal. Record review of Resident 1's MAR for November 2025 revealed Resident 1's practitioner had ordered on 10-03-2025 a 1440 ml's fluid restriction per day. The dietary staff was to provide 320 ml's for breakfast, lunch and dinner and nursing was to provide 200 ml's on day and evening shift and 80 ml's on night shift. An interview conducted on 11-06-2025 at 10:00 AM with the DON confirmed Resident 1's fluid restriction was not consistently monitored and should have been. An interview conducted on 11-06-2025 at 11:30 AM with RN G revealed the facility process was to record on the MAR what the resident received from dietary and nursing for the shift and then the total fluids are calculated for the entire 24-hour period, to ensure the fluid restriction was followed. An interview conducted with the DON on 11-06-2025 at 12:10 PM revealed the DON was not aware of how the IV fluids were included in the daily total fluid intake for Resident 1. The DON also confirmed the maroon-colored coffee cups hold 8 ounces (240 ml's) and the cup of coffee provided to Resident 1 on 11-05-2025 at 11:25 AM was not recorded and should have been. The DON reported (gender) would have to inform the activity staff not to provide fluids to Resident 1 during activities. An interview conducted with the DON on 11-06-2025 at 1:10 PM revealed the facility did not have a policy for the implementation of a fluid restriction. The facility was unable to provide additional information relative to the fluid restriction for Resident 1 prior to exit.

Licensure Reference Number 175 NAC 12.006.09(J)(i)(1) Based on observation, interview, and record review the facility failed to evaluate and implement interventions to prevent significant weight loss for 1 (Resident 37) of 1 resident sampled. The facility census was 86. The Findings are: Record Review of Resident 37's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 06-28-2024 revealed an admitted [DATE] following hospitalization for surgery of a diaphragmatic Hernia with Obstruction (is a protrusion of abdominal contents into the thoracic cavity due to a defect within the diaphragm), other diagnosis included Gastro Esophageal Reflux Disease (GERD, is a long-term condition that occurs when stomach acid flows back up into the esophagus), Barrett's Esophagus (is a condition in which the flat pink lining of the swallowing tube that connects the mouth to the stomach (esophagus) becomes damaged by acid reflux, which causes the lining to thicken and become red) with dysphagia (difficulty swallowing). The MDS also indicated Resident 37 had a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 15 and required set up assistance from staff for oral and personal hygiene, partial assistance for dressing, substantial assistance with bed mobility and was dependent on staff for bathing and transfers. The MDS also revealed Resident 14 weighed 120 pounds. An interview conducted with Resident 37 on 08-07-2024 at 11:54 AM revealed Resident 37 thought they had lost weight but did not know how much. Record Review of Resident 37's Electronic Health Record (EHR, is a digital version of a patient's paper chart) under weights and vitals revealed the following weights: -06-26-2024 weight 120.6 pounds taken on a wheelchair scale. -06-28-2024 weight 120.4 pounds taken on a wheelchair scale. -07-01-2024 weight 120.1 pounds taken on a wheelchair scale. -07-22-2024 weight 114.0 pounds taken on a wheelchair scale, a loss of 6.6 pounds or 5.47% compared to the weight on 6-26-2024. Record Review of Resident 37's Dietary Progress Notes (DPN) revealed on 07-08-2024 Registered Dietician (RD) had identified a current body weight of 120.1 and a Body Mass Index (BMI, is a calculation that estimates body fat and a person's relative weight for their height) of 20.6. The DPN dated 07-08-2024 further identified nutritional supplements had not been ordered, but since Resident 37 was at the low end of a healthy BMI the RD identified Resident 37 could benefit from added calories and recommended a Magic Cup (a nutritional supplement) twice a day at lunch and dinner. According to the DPN dated 07-08-2024, the RD would continue to follow Resident 37 for weight trends, orders/supplements, and to evaluate for further recommendations as needed. Record Review of an email from the facility RD to the facility Director of Nursing (DON) and the DFS on 07-08-2024 revealed a recommendation from the RD to add a Magic Cup to Resident 37's lunch and supper trays. Record Review of progress notes, assessments and care plan in Resident 37's EHR revealed no additional nutritional evaluation related to the significant weight loss on 7-22-2024. An observation conducted during the interview with Resident 37 on 08-07-2024 at 11:54 AM revealed Resident 37 had been served a lunch tray without a Magic cup or other nutritional supplement. An interview with the facility RD on 08-08-2024 at 10:30 AM revealed the RD was at the facility on 07-31-2024 and had not noticed and had not been notified of a weight loss of 6.6 pounds for Resident 37. The RD confirmed during the interview Resident 37 had unplanned weight loss was 5% of Resident 37's body weight within 30 days which was clinically significant. The RD also confirmed Resident 37's physician had not been updated on the significant weight loss and on 07-08-2024 a Magic Cup with lunch and dinner had been recommended. An observation on 08-08-2024 at 12:24 PM of Resident 37 eating lunch revealed the absence of a Magic Cup on the lunch meal tray, Further observation on 08-08-2024 at 12:24 PM revealed Resident 37's dietary slip on the tray did not direct the staff to give a Magic cup with lunch. A follow up interview was conducted with Resident 37 on 08-08-2024 at 12:24 PM. During the interview Resident 37 reported (gender) had received a frozen nutritional supplement for a couple of days and then it stopped. An interview with the Director of Food Service (DFS) on 08-08-2024 at 12:44 PM confirmed the Magic cup was not on the dietary slip for Resident 37. During the interview the DFS reported they were not aware the Magic cup was recommended for Resident 37. An interview with Licensed Practical Nurse (LPN) K on 08-08-2024 1:48 PM revealed LPN K was passing medication for Resident 37 and confirmed (gender) had not provided a Magic Cup at lunch. An interview with Registered Nurse (RN) J on 08-08-2024 at 1:50 PM confirmed (gender) had not provided a Magic Cup for Resident 37 at lunch. Record Review of the Facility Policy Hydration and Nutrition dated 08-24-2023 revealed the following: - Policy-each resident receives a sufficient amount of food and fluids to maintain acceptable parameters of nutritional and hydration status. Under the section Procedure: -1. A physician order is obtained for all regular and therapeutic diets, including those with modified textures. -2. A minimum of three meals are provided each day. If a meal or particular food is refused, the resident is offered a substitute of a similar nutritive value. -3. Snacks are given between meals and at bedtime according to resident desire and/or need. -4. Fluid is available to residents at all times. -5. The resident is positioned properly to consume meals and snacks. -6. An ongoing assessment of the ability to consume and assimilate food and fluid is conducted by nursing personnel and all concerns are reported to the nurse, to include -Positioning needs, -Environmental and social considerations -Ability of resident to feed self -Ability of resident to chew, drink and swallow -Amount of food lost in spillage -Nutritional balance or imbalance of intake -Weight loss or gain -Signs of dehydration -7. Consultation with dietary and therapy personnel is performed on admission and as needed. -8. The facility will document intake percentages. -9. The physician is notified of any concerns. The facility was not able to provide additional information related to the evaluation of Resident 37's significant weight loss prior to exiting the facility on 08-13-2024.

Licensure Reference Number 175 NAC 12-006.09D8 and 12-006.09D9 Based on observations, interviews and record reviews, the facility failed to evaluate and implement interventions to prevent significant weight loss for 5 of 8 residents reviewed (Resident 7, 9, 17, 50, 65) and failed to ensure water was within reach for Resident 9 and 19. The facility census was 91. Findings are: A. Review of Resident 65's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - [CONDITION(S)] (weakness of one side of the body) related to [CONDITION(S)] (stroke) - Dysphagia (difficulty with swallowing) Review of the facility weight documentation revealed, on 03/17/2022 Resident 65 weighed 162 lbs. and on 06/15/2022 Resident 65 weight was down to 136 pounds which is a 16 percent loss in 3 months. Review of Resident 65's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 65's care plan dated 3/2/2022 revealed Resident 65 required extensive assist with meals. Observation on 6/22/2022 at 7:35 AM revealed Resident 65 in the facility dining room. Resident 65 was leaning to the left and having difficulty cutting pancakes with a knife and fork. No staff assisted Resident 65 to cut pancakes or assisted Resident 65 to eat. Resident 65 continued to attempt for 5 minutes to cut the pancake and eat. Resident 65 was unable to eat independently and dropped food on Resident 65's shirt while attempting to eat with right hand fingers. At 7:45 AM Resident 65 stopped attempting to eat and pushed the plate away. Resident 65 tried to eat oatmeal with a fork. No assistance was provided by the staff. Observation of Resident 65 on 06/22/22 at 12:34 PM revealed Resident 65 in the main facility dining room. Resident 65's plate was placed on the table in front of Resident 65. Resident 65 attempted to feed self. Staff were in the dining room assisting other residents. Resident 65 had a difficult time holding a regular fork. Resident 65 held fork by index finger and thumb at the top of the fork and attempted to stab at food. No staff in the dining area attempted to assist the resident during the entire meal service and no adaptive utensils were offered. Review of Resident 65's Nutrition/Dietary Note dated 5/9/2022 revealed Resident 65 was at 149 pounds with weight loss from 162.1 pounds in 1 month. The Dietician recommended adding 240 milliliters (ml- a unit of measure) Osmolyte 1.5 four times a day (QID) with 200ml H20 QID. Observation on 6/22/2022 at 9:31 AM revealed Registered Nurse (RN)-T gathered supplies for Resident 65's Tube feeding including a bottle of Osmolyte 1.5 237 ml. RN T revealed since Resident 65 ate over 50% of the breakfast meal as documented in Resident 65's intake sheet RN T will only give 100ml of osmolyte and the water flush. RN T accessed Resident 65's G-tube (Gastric Tube: a tube placed through the abdominal wall into the stomach to provide nutrition) and poured part of the bottle of osmolyte into tube without measuring. Review of Resident 65's Order Summary Report dated June 22,2022 revealed an order dated 5/16/2022 for Osmolyte 1.5 250 ml 4 times daily. Interview on 06/23/22 at 1:49 PM with the facility contracted Dietician revealed the osmolyte was to be given without being dependent on meal intake. Review of Resident 65's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 65's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 65's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 65's weight log revealed, on 05/25/2022, the resident weighed 142 pounds and on 06/15/2022, the resident weighed 136 pounds which is a 4.23 percent loss in less than 30 days. Review of Resident 65's progress note revealed no further review of Resident 65's continued weight loss was documented by the facility Dietician. Interview on 06/23/22 at 1:49 PM with the facility Dietician revealed the Dietician reviews weights from home and does not observe resident to make recommendations. Review of Resident 65's medical record revealed Resident 65 was placed on hospice care on 6/17/2022 and Resident 65 has not been weighed since 6/15/2022, therefore no available data to determine any further weight loss. Interview on 7/6/2022 at 11:58 AM with the Director of Nursing revealed Resident 65 should have been receiving the full amount of Osmolyte regardless of amount eaten, the resident should have been assisted with meals and the G-tube orders were not followed. B. Review of the Resident 50's NUTRITION: Assessment/Nutritional Data Collection Dated 5/11/2022 revealed Resident 50's weight is 192.2 pounds, estimated needs determined and met. Diet order consistent with nutrition needs. Will monitor for changes in weight, renal status, and tolerance to diet order. Review of an Alert Note dated 6/1/2022 revealed Resident 50 was admitted on [DATE] with bladder neck obstruction. Resident 50's current weight 219.4 pounds. Will discontinue from Risk Assessment Review (RAR) meeting. Review of Resident 50's weight log revealed Resident 50 gained 17 pounds to 219.4 pounds in the first 5 days in the facility and then lost 49.6 pound to 169.8 pounds in the next in 21 days. This is an overall weight loss of 23.6 pounds in 30 days or over 10% loss. No documentation was found in the Electronic Medical Record (EMR) that this weight loss was identified or reviewed. Review of Resident 50's progress notes revealed No Dietary notes related to weight loss on 6/2/2022. No further dietary assessments were found in the medical record. Interview on 06/23/22 at 02:55 PM with the Dietician revealed the Dietician looks up weights from home and, relies on calls from the facility with weight loss concerns and provides recommendations. The Dietician comes into the facility for quarterly reviews. The facility did not notify the Dietician of the weight loss. The Dietician revealed Resident 50 has not been assessed since the initial admission nutrition assessment. On 7/6/2022 interview with the Director of Nursing revealed Resident 50's weight loss was not identified and investigated. C. Review of Resident 7's Nutrition/Dietary Note dated 2/6/2022 revealed Resident 7 is at 145# (pounds) with weight loss from 184# over 5 months. Would continue regimen and monitor for supportive nutrition. On 12/07/2021, the resident weighed 145 lbs. On 06/02/2022, the resident weighed 130 pounds which is a 10.34% Loss. Review of Resident 7's Alert Note dated 3/30/2022 revealed the facility staff questioned the accuracy of Resident 7's weight. It revealed a 20-pound weight loss. Nursing staff were instructed to re-weigh Resident 7 the following day. Review of Resident 7's weight log revealed no additional weight was obtained until 6 days later and results revealed Resident 7's weight to be 129.8# on 4/5/2022 compared to weight on 3/29/2022 of 126.8. No documentation was found in the medical record to show the weight loss of 15 pounds in 23 days was reported to the facility dietician. Interview on 06/23/22 at 2:52 PM with the Dietician revealed Resident 7's weight fluctuates, and Resident 7 has been off and on supplements and diuretics. The Dietician has not reviewed Resident 7's weight since 2/6/2022 and was not aware of the further weight loss. There was no dietary assessment after 2/6/2022. The Dietician agreed Resident 7's weight loss was significant and should have been addressed. D. Record Review of Resident 17's weights revealed the following: -6/23/2022 10:42 101.8 Lbs -6/12/2022 13:32 101.8 Lbs -6/2/2022 06:16 101.8 Lbs -4/26/2022 09:45 108.8 Lbs -4/12/2022 07:08 107.8 Lbs -4/2/2022 16:27 108.2 Lbs -3/29/2022 10:08 106.7 Lbs -3/27/2022 20:29 106.7 Lbs -3/23/2022 06:57 108.8 Lbs -3/15/2022 06:17 107.6 Lbs -3/13/2022 18:51 107.6 Lbs -2/28/2022 12:07 105.6 Lbs -2/14/2022 17:07 104.0 Lbs -2/8/2022 17:39 104.2 Lbs -2/6/2022 13:39 104.2 Lbs -2/4/2022 08:40 103.2 Lbs -1/25/2022 17:30 95.6 Lbs -1/23/2022 13:13 95.6 Lbs -1/18/2022 14:47 96.0 Lbs -1/9/2022 13:48 100.4 Lbs -1/9/2022 13:34 100.4 Lbs -1/4/2022 12:19 98.2 Lbs -The documented weight of 108.8 on 04/26/22 to a weight of 101.8 on 06/02/22 indicated a 6.43% weight loss. Review of Weight Change Note on 6/23/2022 at 20:18 revealed Resident 17 is at 101.8# with weight gain from 99.8#. Would continue regimen and monitor for stable weight. Interview conducted with the (Director of Nursing) DON on 07/05/22 at 09:00 AM which confirmed a significant weight loss of 6.43% from 4/26-6/02/22. E. Observation on 6/21/22 at 10:00 AM revealed Resident 9 in bed being assisted to eat a regular consistency diet by Nursing Assistant [NA] U. The resident did not exhibit any signs of coughing or choking. The resident was able to grasp the glass of water and drink independently. Observation on 6/21/22 at 1:19 PM revealed Resident 9 seated at a table in the dining area with a regular consistency diet plate of food. Resident 9 ate the food independently with some spilling onto the clothing and occasionally coughed throughout the breakfast meal. The resident was able to grasp the glass of water and drink independently. NA C stopped and encouraged the resident to slow down and take smaller bites of food. The staff member did not sit down or assist Resident 9 with eating. Record review of Resident 9's Admission Minimum Data Set [MDS] [ a mandatory comprehensive assessment tool used for care planning] dated 12/21/21 revealed that Resident 9 was admitted to the facility on [DATE]. The resident had a Brief Inventory of Mental status [BIMS] score of 10 which indicated moderate cognitive impairment, was independent with eating, had a weight of 165 and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had no swallowing difficulties at the time of admission. Record review of a Transfer to the Hospital Summary Progress Note dated 2/8/22 revealed that Resident 9 was sent to the hospital and admitted for weakness on the right side. The Resident was admitted to the hospital for possible [CONDITION(S)] and possible Aspiration Pneumonia. The resident returned to the facility on [DATE] per the Census Report in Resident 9's Electronic Medical Record [EMR]. Record review of Resident 9's most recent MDS dated [DATE] revealed a BIMS score of 6 which indicated severe cognitive impairment. The resident required extensive assist with eating and had a weight of 140. These indicated that Resident 9 had a decline in cognition, weight and in the ability to eat since admission to the nursing facility on 12/21/22. Record review of Resident 9's weight records since admission revealed the following weights over time from 6/23/22 to the admitted [DATE]: -6/23/2022 131.4 Lbs -6/14/2022 125.2 Lbs -4/6/2022 140.2 Lbs -3/15/2022 140.2 Lbs -3/2/2022 138.1 Lbs -1/30/2022 145.4 Lbs -1/25/2022 145.2 Lbs -1/18/2022 144.6 Lbs -1/6/2022 152.4 Lbs -12/22/2021 165.0 Lbs -12/17/2021 164.2 Lbs Record review of the weight records for Resident 9 revealed that on 12/17/2021 Resident 9 weighed 164 lbs. On 06/14/2022, Resident 9 weighed 125 pounds which was a -23.78 % weight loss over 6 months. Record review of a Progress Health Note dated 6/23/22 for Resident 9 revealed the following: - 6/23/2022 13:46 Health Status Note reweighed wheelchair; only 87 not 98lbs. So re weight on resident this am; incorrect. WEIGHT is 131.4. Record review of Resident 9's current weights as of 6/23/22 revealed the following: On 12/17/2021, the resident weighed 164 lbs. On 06/23/2022, the resident weighed 131 pounds which is a -20.12 % loss over 6 months. Record review of Resident 9's Nutrition Resident at Risk [NAR/ RAR] Progress Notes revealed the following information: - 3/11/2022 13:08 written by Licensed Practical Nurse [LPN] K: RAR meeting held. Resident readmitted on ,d+[DATE] for stroke. Resident is on puree soft with nectar thick liquids. Current weight 138.1. Resident is working with PT/OT to improve current ADLs and mobility. - 2/6/2022 16:28 Nutrition/Dietary Note written by the Registered Dietician: Resident is at 145.4# with weight loss x 1 month from 164.2#. No skin breakdown noted. Rx Vitamin C, [MEDICATION(S)], [MEDICATION(S)], Zinc. Dx [CONDITION(S)], HLD, Dementia. Diet order remains appropriate. Receives Regular. Will continue to follow. Record review of Resident 9's Nutrition Assessment completed 1/16/22 by the Registered Dietician revealed the following: - Resident is a 145.4# with weight loss from 164.2#. Skin tx to right posterior knee. Rx Vitamin C, [MEDICATION(S)], Zinc. Dx [CONDITION(S)], HLD, Dysphagia, [CONDITION(S)], GERD. Estimated needs determined and met. Receives Regular Diet. Will monitor for stable weight. Would add 60ml Med Pass Supplement BID and d/c zinc and vitamin c. Will monitor. Record review of Resident 9's EMR revealed no other nutritional assessments had been completed between 2/6/22 and 6/23/22 by the Registered Dietician to address Resident 9's continued weight loss. On 6/23/22, the RD completed a Nutritional Assessment for Resident 9 after the start of the annual survey which revealed: Resident is at 131.2# with weight loss noted from 164.2#. hospitalized in February. Weight appears to have been previously in the range of 150#. Loss to 140#, now reweigh of 131.2#. Intake inadequate to maintain weight; however, kcal exceed needs. Previously tried med pass supplement but will request 60ml Med Pass Supplement BID and if resident accepts, will increase. Would also d/c Zinc and add MVI w/Minerals. Review of nutritional history, intake and progression of disease, unless intake improves, weight loss will likely continue regardless of increased kcal. Will follow for supportive nutrition. Record review of Resident 9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 06/23/22 at 08:16 AM with the Director of Nursing [DON] confirmed that Resident 9 had a significant weight loss and that no supplements or other interventions were implemented to prevent further weight loss. The DON confirmed that Resident 9 was reviewed for weight loss by the NAR team and that the RD had not been to the facility to assess the resident and the continued weight loss since a nutrition note was written on February 6th of 2022. The DON confirmed that there were no NAR notes documented after 3/17/22 for Resident 9 when the resident was identified with stable weight at 140 pounds and was discontinued from the NAR/ RAR meetings. Interview on 06/23/22 at 1:31 PM with the RD confirmed that Resident 9 had not been assessed for continued weight loss since February of 2022 and that supplements were started for one day but then stopped. The RD was unsure of why the supplements had been stopped. The RD stated that nutritional assessments are completed by offsite review by looking at lab values and the NAR notes which would include any weight changes or loss. The RD stated that Resident 9's labs had been reviewed offsite in March of 2022 and were within normal limits at that time. The RD confirmed that the last time Resident 9 was assessed by the RD was February 6th, 2022. The RD stated [gender] was just made aware of Resident 9's weight loss on 6/23/22. Interview on 7/6/22 at 2:23 PM with the DON revealed that the resident had undergone several weeks of speech therapy in March and April after he came back from the hospital and that the Med Pass was discontinued in February 2022 due to refusals. On April 1st 2022, after speech therapy had worked with Resident 9, the diet order was changed from thickened liquids and puree to thin liquids and regular consistency. The DON confirmed that Resident 9 should have been reassessed by the RD after the speech therapy and the diet change and this was not done. F. Record review of Resident 9's MDS dated [DATE] revealed that Resident 9 required extensive assist with eating. Observations of Resident 9 on 6/21/22 at 10:00 AM, 11:06 AM and 3:30 PM and on 6/22/22 at 6:15 AM and 9:05 AM, 9:30 AM and 2:55 PM revealed Resident 9 seated in a wheelchair in room with a water pitcher on a bedside table that was located across the room and not within the residents reach. Interview with the Director of Nursing on 6/22/22 at 2:55 PM confirmed that Resident 9's water pitcher was not in reach of the resident and should be. The DON confirmed that Resident 9 was able to grasp a glass of water and drink independently. G. Record review of Resident 19's MDS dated [DATE] revealed that Resident 19 required supervision with eating. Observations of Resident 19 on 6/21/22 at 9:10 AM, 11:10 AM and 3:30 PM, on 6/22/22 at 6:25 AM, and 9:00 AM and on 6/23/22 at 7:05 AM revealed Resident 19 seated in a wheelchair in room with a water pitcher on a bedside table that was located across the room and not within the residents reach. Interview with the Medication Aide [MA] S on 6/23/22 at 7:07 AM confirmed that Resident 19's water pitcher was not in reach of the resident and should be. MA S confirmed that Resident 19 was able to grasp a glass of water and drink independently. Record review of a facility policy entitled Hydration and Nutrition effective 7/14/21 revealed: - Residents are to be offered sufficient fluid intakes to maintain hydration and health. - 4. Fluid is available to residents at all times. A hydration cart may be utilized. - 5. The resident is positioned properly to consume meals and snacks. Assistance is provided as needed. - 6. An ongoing assessment of the ability to consume and assimilate food and fluids is conducted by nursing personnel and all concerns are reported to the nurse to include weight loss or gain, signs of dehydration. - 8. The facility will document the intake percentages. H. Record review of Resident 9 and 19's Electronic Medical record [EMR] revealed no documentation of fluid intake percentages or fluids consumed. Interview on 06/23/22 at 02:11 PM with the Registered Dietician confirmed that residents should have water in reach in their rooms and that fluid intakes are not recorded unless ordered by the physician.

LICENSURE REFERENCE NUMBER 175 Chapter 12-006.02 Based on observations, record review and interview, the administrative and consultant staff failed to ensure the facility resources were utilized in a manner to ensure provision of care and services for residents. This deficient practice provided the potential to affect all residents of the facility. The facility census was 91. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance which required an extended survey related to substandard quality of care. The following issues related to systems failure and or failure to follow standards of care resulted in patterns of failure in the facility related to weight loss and hydration needs. Review of the facility roster matrix (a report indicating care concerns for each resident) developed from the MDS (Minimum Data Set: a federally mandated tool used for care planning) provided on entrance to the facility for annual survey revealed no residents identified for significant weight loss. Observations, record review and interviews through the initial phase of the survey identified 8 residents as having a potential significant weight loss. After moving into the investigative stage of the survey 6 were identified for Nutrition/hydration deficiencies related to lack of identification of the significant weight loss and monitoring interventions for reversing weight loss. Interview on 06/23/22 at 1:49 PM with the facility Dietician revealed the Dietician reviews weights from home and does not observe residents except for at the quarterly reviews. Interview with the administrator on 7/7/2022 at 9:10 AM revealed the facility does not have someone designated to review all resident weights monthly to identify significant weight loss and the facility should utilize the contracted Dietician more frequently.

Licensure Reference Number 175 NAC12-006.07 Based on interviews and record reviews, the facility failed to ensure the quality assurance program addressed concerns related to deficient practice cited on the annual and extended survey. The facility census was 91. Findings are: Annual survey completed on 7/7/2022 revealed deficient practice at the following areas: F558- Accommodation of needs F561-Self Determination F584-Safe/Clean/ homelike environment F623-Notice requirements before transfer/discharge F625-Notice of Bed Hold Policy before transfer F684-Quality of Care F689-Free of accident hazards F690-Bowel/Bladder Incontinence, catheter care F692-Nutrition/hydration maintenance F695-Respiratory care F726-Competent Nurse staff F809-Frequency of meals F812-Food storage and kitchen sanitation F835-Administration F867-QApi/QAA improvement activities F880-Infection Prevention and Control F886-Covid 19 staff testing F923-Ventilation F947 -Required In-service training for Nurse aides The Director of Nursing provided the Performance Improvement Plans (PIP) for nursing. Review of the facility PIP revealed the facility had plans to include Infection Surveillance, ADL assistance, Room moves, Wounds, low risk bowel and bladder incontinence, and Antipsychotic use in the PIP. Review of the facility [NAME] reports (a federal report listing facility deficiency history) revealed repeat tags from the previous 3 annual surveys include: 584- safe clean comfortable/homelike environment 623- Notice before transfer 625- Bed hold policy 684-Quality of Care 880- Infection Control 812- Food Procurement, store/prepare/serve Sanitary 867-QAA/QAPI Activities Interview on 7/7/2022 at 9:10 AM with the facility Administrator revealed the facility QAPI committee had not identified the cited deficient practice except for F809 regarding the extended meal serving times. A performance improvement plan had been developed but had not been put in place.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.D7 Based on record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 1 (Resident 46) of 3 sampled residents. The facility staff identified a census of 99. Findings are: Record review of Resident 46's MDS (Minimum Data Set-a Comprehensive Assessment tool used to develop a resident's care plan) signed as completed on 11-06-2019 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) was a 15. According to the MDS Manuel, a score of 13 to 15 indicates a person is cognitively intact. -Supervision with locomotion on and off the unit and eating. -Limited assistance with personal hygiene. -Extensive assistance with bed mobility, transfers, dressing and toilet use with 2 persons physically assisting. Further review of Resident 46's MDS completed on 11-06-2019 revealed the information for bed mobility was how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture. Record review of Resident 46's Comprehensive Care Plan (CCP) dated 5-28-2019 revealed Resident 46 required extensive assistance with bed mobility, bathing and transfers. Record review of a Witness Fall (WF) sheet dated 11-21-2019 revealed Resident 46 fell out of Bed. According to the WF sheet dated 11-21-2019, a nursing assistant was changing and getting Resident 46 dressed in bed after a bath. Record review of a Facility Verification of Investigation (FVI) sheet dated 12-23-2019 revealed a facility Bath Aid was providing cares in bed when Resident 46 fell out of bed and onto the knees. Review of a order dated 12-17-2019 revealed Resident 46's practitioner order an X-ray of the right knee. On 12-17-2019 at 9:00 PM the X-ray results revealed an acute [MEDICAL CONDITION] knee. On 1-28-2020 at 11:56 AM an interview was conducted with Resident 46. During the interview Resident 46 reported falling out of bed and sustaining a fracture to the right knee. Resident 46 reported one staff was working with Resident 46 when the fall from bed occurred. Resident 46 reported usually 2 staff work with (gender) however, when short staffed, Resident 46 reported 1 Nursing Assistant works with Resident 46. On 1-30-2020 at 11:41 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON reported one Nursing Assistant was working with Resident 46 when Resident 46 feel from the bed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, record review and interview; the facility staff failed to evaluate significant weight loss for 1 (Resident 53) of 3 resident, failed to obtain monthly weight for 1 (Resident 54) of 3 sampled residents and failed to ensure drinking water was within reach for 1 (Resident 54) of 3 sampled residents. The facility staff identified a census of 99. Findings are: A. On 1-28-2020 at 1:40 PM a interview was conducted with Resident 53's Family Member (FM). During the interview Resident 53's FM expressed concerns about Resident 53 and weight loss and was not sure what the facility was doing about it. Record review of Resident 53's Comprehensive Care Plan (CCP) dated 9-18-2019 revealed Resident 53 was at risk for weight fluctuation. According to Resident 53's CCP dated 9-18-2019 the goal was for Resident 53 to maintain current weights. Record review of a Weights and Vitals Summary (WVS) sheet revealed Resident 53's weights were as follows: -9-18-2019, weight was 193.2 pounds (lbs). -9-20-2019, weight was 184.3 lbs,a loss of 8.9 lbs or 4.6% weight loss from the 9-18-2019 weight. -9-23-2019, weight was 181 lbs, a loss of 13 lbs or 6.72% from the 9-18-2019 weight. -10-04-2019, weight was 176.4 lbs, a loss of 16.8 lbs or 8.69% from the 9-18-2019 weight. -11-06-2019, weight was 173 lbs, a loss of 20.2 lbs or a loss of 10.45% from the 9-18-2019 weight. 12-16-2019, weight was 160.6 lbs, a loss of 32 lbs or a loss of 16.87% from the 9-18-2019 weight. On 1-30-2020 at 12:07 PM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed there was not evidence Resident 53's significant weight loss had been evaluated. B. Record review of Resident 54's medical record revealed weights for November 2019 and December 2019 were not available in the record. On 1-30-2020 at 12:00 PM an interview was conducted with the DON. The DON confirmed during the interview weights for November 2019 and December 2019 were not obtained for Resident 54. C. Record review of the facility Policy and Procedure for Weight Monitoring dated 07-23-2009 revealed the following information: -Practice Guidelines: -All residents , with the exception of new admission and new enterals, are weighed monthly unless their condition indicates more frequent weighing. -Height and weight information is used to assess the residents nutritional status, formulate an appropriate nutrition care plan and for tracking prevalence of significant weight changes (gain or loss). -Weight variances are reviewed for residents with a 5% weight change in 30 days, 7.5% weight change in 90 days, and a 10% weight change in 180 days. This includes gain or loss. -Each identified resident with a weight change has a current nutritional assessment/progress note. D. Record review of Resident 54's CCP dated 8-28-2019 revealed Resident 54 was maximum assist of 2 with bed mobility. Observation on 1-28-2020 at 10:50 AM revealed Resident 54's was in bed and Resident 54's drinking water was out of reach for Resident 54. Observation on 1-29-2020 at 5:16 AM revealed Resident 54 was in bed. Resident water was sitting on a tray table out of reach of the resident. On 1-29-2020 at 5:18 AM an interview was conducted with Licensed Practical Nurse (LPN) D. During the interview LPN D confirmed Resident 54's water was not within reach and should have been.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to identify the development of a pressure ulcer for 1 (Resident 54) of 3 sampled residents and failed to evaluate the nutritional requirements for pressure ulcer healing for 1 (Resident 51) of 3 sampled residents. The facility staff identified a census of 99. Findings are: A. Observation on 1-29-2020 at 9:08 AM of personal cares for Resident 54 revealed Nursing Assistant (NA) E and NA F removed an adult brief and cleaned the front area of Resident 54. NA E and NA F turned Resident 54 onto the left laying position revealing Resident 54 to have a dark purple area to the Sacrum(commonly known as the tail bone area) that measured approximately 1.50 centimeters (cm) roundish with multiple red spots to the right buttocks. Record review of Resident 54's Weekly Skin Integrity Data Collection sheet dated 1-22-2020 revealed Resident 54 was not evaluated as having skin breakdown. On 1-29-2020 at 9:22 AM an interview was conducted with Licensed Practical Nurse (LPN) G who was observing personal cares being provided to Resident 54 on 1-29-2020 at 9:08 AM. During the interview LPN G reported not being aware of Resident 54's skin breakdown to the tailbone area and right buttock. LPN G further reported the area to the tailbone and right buttocks did not look new. On 1-30-2020 at 9:46 AM Registered Nurse (RN) C, identified as the facility wound nurse, provided the following information dated 1-30-2020 for the wound to Resident 54's sacrum. According to RN C the area to Resident 54's sacrum was assessed as pressure area that measured 4 centimeters (cm) by 3 cm with a depth of 0.1 cm and was dark purple. B. Record review of a Wound Observation tool dated 1-28-2020 revealed Resident 51 was admitted to the facility with a pressure ulcer to the right buttocks that measured 0.5 cm by 0.5 cm with a depth of 0.1 cm. Review of Resident 51's record revealed there was no evidence the facility staff had evaluated Resident 51's nutritional requirements for pressure ulcer healing. On 1-30-2020 at 11:58 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON confirmed there was not evidence the facility had evaluated Resident 51's nutritional requirements for pressure ulcer healing.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assurance (QA) program failed to identify ongoing issues relevant to F580, F600, F684, F686, F690, F692, F726 and F730 and implement plans of action to identify and correct the deficient practice. The facility staff identified a census of 105. Findings are: Record review of the facility policy and procedure for Quality Improvement revised on 6-26-2009 revealed the following information: -Policy: This facility actively participates in a formal, written quality assessment, assurance and improvement process. The comprehensive process involves all facility departments. The process included monitoring, evaluation, and follow up action. -Committee Recommendation: -Recommendation may include, but are not limited to, the following: - Communication methods to disseminate information to resident, staff, family members, community organizations, and/or regulatory agencies. On 2-12-2019 at 7:45 AM an interview was conducted with Licensed Practical Nurse (LPN) G. During the interview when asked what the facility QA committee was working on, LPN G stated I'm not sure. On 2-12-2019 at 7:45 AM an interview was conducted with LPN H. During the interview when asked what the QA committee was working on, LPN H reported could not remember. On 2-12-2019 at 7:50 AM an interview was conducted with Nursing Assistant (NA) B. During the interview, NA B reported not sure what the QA committee was working on. On 2-12-2019 at 9:27 AM a interview was conducted with NA I. During the interview, NA I reported not being aware of what the QA committee was working on. On 2-12-2019 at 9:32 AM an interview was conducted with LPN [NAME] During the interview, LPN J reported not knowing what the QA committee was working on. On 2-12-2019 at 10:30 AM an interview was conducted with Registered Nurse (RN) K. During the interview RN K reported not being aware of what the QA committee was working on.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(9) Based on record review and interview; the facility staff failed to protect residents during an investigation of a sexual assault allegation. The facility failure had the potential to affect all residents residing in the facility. The facility staff identified a census of 105. Findings are: Record review of the facility Policy and Procedure for Protection of Residents: Reducing the Threat of Abuse & Neglect revised on 2-2018 revealed the following information: -Introduction: -To minimize the threat of abuse and/or neglect , nursing homes must incorporate clear cut policy and practices that demonstrate a hardline,zero tolerance approach to resident abuse. -Position Statement and Guidelines: - Residents must not be subjected to abuse by anyone. -It is the policy and practice of this facility that all residents will be protected from all types of abuse,neglect, misappropriation of resident property and exploitation. -Investigation and Protection: -It is the policy of this facility that reports of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. -Procedure: -1. Following identification of alleged abuse, the resident(s)receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent recurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation. -3. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence. Protection will be provided to the alleged victim and other residents, such as room or staffing changes as needed to protect the resident(s) from the alleged perpetrator. Record review of a Resident Transfer Record dated 2-03-2019 revealed Resident 100 was transferred to the hospital related to increased anxiety and difficulty breathing. Record review of a the facility preliminary investigation note dated 2-04-(2019) revealed the facility Director of Nursing (DON) and the facility Administrator were notified on 2-04-2019 at 12:30 PM of an allegation of sexual assault of 1 of the facility Residents (Resident 100) by the facility Advanced Registered Nurse Practitioner (ARNP) who was following up with Resident 100 in the hospital. Further review of the preliminary investigation note dated 2-04-2019 revealed the police were notified and at apprx (approximately) 1:55 PM returned a call to the facility and obtained the information of the allegation of Resident 100 being sexually assaulted. According to the preliminary investigation note dated 2-04-2019 a police officer followed up with a phone call to the facility on [DATE] at 4:27 PM reporting Resident 100 had injuries to the vaginal region and believed something happened at the facility. On 2-06-2019 at 3:18 PM an interview was conducted with the facility Administrator. During the interview when asked how the facility residents were being protected after the allegation of sexual assault for Resident 100, the facility Administrator reported being instructed not to discuss the issue with anyone and had not implemented interventions to protect the facility residents. The facility Administrator further reported the facility staff had not been educated on the allegation of a facility resident being sexually assaulted. On 2-06-2019 at 4:38 PM an interview was conducted with Detective [MI] During the interview,discussion protecting the facility residents and integrity of the investigation was completed. During the interview, Detective L reported the facility staff should be protecting the facility residents. On 2-06-2019 at 1:20 PM an interview was conducted with Registered Nurse (RN) [NAME] During the interview RN A reported not being aware of an allegation abuse or neglect currently in the facility. On 2-06-2019 at 1:25 PM an interview was conducted with Nursing Assistant (NA) B. During the interview NA B reported not aware of an allegation of abuse currently being investigated in the facility. On 2-06-2019 at 1:30 PM an interview was conducted with Housekeeping (HK) C. During the interview HK C reported not being aware of an allegation of abuse currently being investigated in the building. On 2-06-2019 at 1:35 PM an interview was conducted with LPN D. During the interview LPN D reported not being aware of an allegation of abuse currently being investigated in the building. On 2-06-2019 at 1:45 PM an interview was conducted with NA E. During the interview NA [NAME] reported not being aware of an allegation of abuse currently being investigated in the facility. B. Abatement Statement: Based on the information provided on 2-06-2019 to correct the immediacy of the situation, the facility staff provided the following information to protect residents: 1. No males associates may work unsupervised without female associate in resident care area assisting residents. All staff were to review the requirement prior to starting their next shift. 2. All staff must review and sign off as understanding prior to their next shift of the facility Reducing the Threat of Abuse &Neglect Policy and review of this abatement plan with focus to understand sexual abuse, identifying and reporting injuries of unknown origin. 3. The facility charge nurse must document the review of the policy and is accountable to ensure no males associates may work unsupervised without a female associate in resident care areas (non-public). 4. The facility Executive Director shall ensure a log is maintained of the staff member assigned and reviewing . The log will be verified with those staff members clocked into the facility. 5. All staff are to report immediately to the facility Executive Director any concerns following review of this policy and memo and follow the facility Protection of Residents: reducing the threat of Abuse&Neglect Policy. The immediacy had been removed, however, the deficient practice was not totally corrected. Therefore, the severity was lowered to an F level.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02 Based on observations, record review and interviews; the facility staff failed to utilize facility resources to ensure provision of care and services were provided to the facility residents. This had the potential to effect all residents who reside in the facility. The facility staff identified a census of 105. Findings are: Review of the facility during a survey revealed the following deficiencies: [NAME] F580. The facility staff failed to notify the practitioner of a new wound for a sampled resident. B. F600. The facility staff failed to protect the facility residents during an allegation and investigation of a sexual assault for a sampled resident. C. F684. The facility staff failed to obtain an treatment order for a new wound for a sampled resident. D. F686. The facility staff failed to evaluate a decline in pressure ulcer healing for a sampled resident. E. F690. The facility staff failed to evaluate a toileting program for a sampled resident. F. F692. The facility staff failed to obtain weights as order by the practitioner. G. 726. The facility staff failed to ensure facility nursing staff had competency reviews completed. H. F730. The facility staff failed to ensure all nursing assistants had 12 hours of education per year. I. The facility failed to have and effective Quality Assurance committee.

Licensure Reference Number 175 NAC 12-006.05 (21) Based on observations, interviews, and record reviews; the facility failed to provide toileting assistance to Resident 33 in a manner to maintain dignity. Due to the facility staff's failure to answer the call light for Resident 33, the resident experienced incontinent episodes. 33 residents were sampled. The facility staff identified the census as 101. The findings are: A review of Resident 33's undated Face Sheet revealed Resident 33 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. An interview conducted on 2-20-18 at 12:08 PM with Resident 33 revealed that the resident was having difficulty with urinary incontinence that the resident reported was due to waiting to long for staff to assist with toileting. The resident reported that it was embarrassing for someone their age to urinate on themselves and that the resident had cried a few times when they had been incontinent. An observation conducted on 2-22-18 at 7:09 AM revealed Resident 33's call light was on. Resident 33 was lying in bed shaking and crying. There was a puddle of liquid under the resident's bed with a drip pattern under the edge of the bed. An interview conducted on 2-22-18 at 7:09 AM with Resident 33 revealed that the resident had been turning on their call light since 3:10 AM requesting to go to the bathroom, but the nursing staff had been shutting it off because the resident must have fallen asleep. The resident reported their current call light had been on since 6:45 AM. The resident reported that a nurse had brought in their early morning medications and that the resident refused to take one of the medications because they needed to go to the bathroom. The nurse left and did not return. The resident reported that they had not spilled anything on the floor and they thought the puddle may have been urine from wetting the bed 3 times since 3:10 AM. An observation conducted on 2-22-18 at 7:18 AM revealed Registered Nurse (RN) B cleaned up the puddle with towels. The liquid had a yellow tint when soaked up into the white towel and had a urine odor. RN B confirmed these observations. An observation conducted on 2-22-18 at 7:23 AM revealed Nursing Assistant (NA) C entered Resident 33's room and asked the resident what they needed help with. Resident 33 was in bed crying and shaking and told NA C that they needed to go to the bathroom and get cleaned up because they had urinated in their bed 3 times. NA C told Resident 33 that they had not had time to pay attention to the call lights on the 200 Hall, where Resident 33 lived, because the NA was also assigned to the 100 Hall. NA C explained to Resident 33 that they normally work on the 100 Hall and that the residents on the 100 Hall were more at risk for falls because they were more independent. NA C explained they did not want any of their 100 Hall residents to fall while the NA was helping the residents on the 200 Hall so they were not going to help any of the 200 Hall residents until the 100 Hall residents were all up for the day. An observation conducted on 2-22-18 at 7:27 AM revealed NA C, with the assistance of NA D, assisted Resident 33 to get dressed and cleaned up. The brief that Resident 33 had been wearing was saturated with urine. The protective pad on the bed was saturated. The bed sheet had a large area of wetness that extended to the outer edge of the sheet on the side of the bed that the drip pattern had been observed earlier. The outer edge of wetness on the sheet had a brown staining that suggested the sheet was starting to dry. NA D removed the sheet from the bed and revealed liquid standing in the creases of the mattress cover. NA D confirmed the above observations. An observation conducted on 2-22-18 at 3:53 PM of Resident 33 at the Resident Council meeting revealed the resident started crying as the resident expressed concerns about their call light not being answered that morning and urinating in the bed 3 times. A review of Resident 33's Minimum Data Set (MDS: A federally mandated comprehensive assessment tool used for care planning) dated 10-20-17 revealed Resident 33 had Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). The resident required extensive assistance with toileting and was continent of both bowel and bladder. A review of Resident 33's Comprehensive Care Plan dated 1-4-17 revealed that Resident 33 was usually continent and required extensive assistance with toileting. A review of Resident 33's Urinary Incontinence assessment dated [DATE] revealed the resident was continent of urine.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a Based on record review, observation and interview; the facility staff failed to evaluate nutritional need for pressure ulcer healing, evaluate casual factors for the development of pressure ulcers, obtain treatment orders and failed to monitor pressure ulcers for healing for 2 resident (Resident 1 and 2). The facility staff identified a census of 95. Findings are: A. Record review of an undated Face Sheet revealed Resident 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Initial Data Collection Tool/Nursing Service sheet dated 6-02-2014 revealed Resident 2's skin condition was evaluated with some bruising, surgical scars and the skin was warm and intact. There were no pressure ulcers or other skin breakdown identified for Resident 2. Record review of Resident 2's Braden Scale (tool used for predicting pressure ulcer risk) dated 6-02-2014 revealed Resident 2 score was a 19. According to the information on the Braden Scale form, a score of 19 did not indicate risk. Record review of Resident 2's Braden Scale evaluation dated 6-26-2014 revealed Resident 2 score was 12. According to the information on the Braden Scale form, a score of 12 placed the resident at high risk for the development of a pressure ulcer. Record review of a Weekly Skin Integrity data Collection sheet dated 7-06-2014 revealed Resident 2's skin was "intact". Record review of Resident 2's Comprehensive Care Plan (CCP) dated 6-02-2014 revealed Resident 2 was at risk for the development of pressure ulcers related to immobility, incontinence and disease condition. The goal for Resident 2 was not to develop any new areas of skin breakdown. Interventions listed on Resident 2's CCP included the following: -Assist as needed to reposition and shift weight to relieve pressure. -Complete weekly skin checks. -Float heels when in bed. -Notify the nurse immediately of any new areas of skin breakdown. -Observe effectiveness of response to treatment. -Provide incontinent care after incontinence episodes, apply barrier cream. Record review of Resident 2's Progress notes dated 6-30-2014 Revealed the Resident 2 "...has an open area on the left heel which measured 1 by 1 and was cleaned and Bernadine (sp, [MEDICATION NAME]) applied cover with a [MEDICATION NAME] (type of wound dressing). No c/o (complaints of) pain or discomfort. Dr. (Physician) called with new orders". The facility was not able to provide evidence of what the physician had ordered for a treatment. Observation on 7-30-2014 at 9:31 AM of the treatment to Resident 2's left heel revealed the area measured by Registered Nurse (RN) A was 1.4 cm by 0.6 cm with a darkish light purplish area that measured 1.2 cm by 1.6 cm. Record review of Resident 2's Progress Note dated 6-26-2014 revealed the facility IDT (Interdisciplinary team) met to review Resident weight loss. Resident 2's pressure ulcer was not identified as being reviewed at the IDT meeting. Review of Resident 2's medical record revealed there was not evidence the facility had evaluated the casual factors of why Resident 2's left heel developed a pressure ulcer. Further review revealed there was not an evaluation of Resident 2's nutritional requirements to ensure pressure ulcer healing. Record review of Progress Notes (PN) for Resident 2's physician dated 7-03-2014 revealed Resident 2 was at the physicians office for a follow up diabetic visit. According to the PN dated 7-3-2014, the physician identified Resident had a wound on the left heel that had opened up. Record review of a Physician visit report dated 7-03-2014 revealed the physician had ordered the facility staff to monitor the left heel on a daily basis. Record review of Resident 2's PN dated 7-03-2014 revealed Resident 2 had returned from the physician visit. According to the PN dated 7-03-2014, a fax was sent to Resident 2's physician requesting a treatment change to "...skin prep for left heel, boggy area, every shifty awaiting response". The facility was not able to provide evidence that a follow up had been completed related to the fax sheet sent to the physician on 7-03-2014. Record review of Resident 2's PN dated 7-06-2014 revealed the facility sent a fax requesting a "...treatment to the left heel". Resident 2's record did not contain evidence the physician had responded to the request for a treatment or the facility staff had followed up with the physician related for the treatment request. Record review of Resident 2's PN dated 7-13-2014 revealed the open area to the left heel measured 0.6 (centimeter) CM, by 1 cm with the Pressure ulcer " dry and intact". Record review of Resident 2's PN dated 7-17-2014 revealed Resident 2's open area remained to the left heel and had clear drainage on a sock. Record review of Resident 2's PN dated 7-22-2014 revealed the left heel ulcer was evaluated as 1 cm by 1 cm, open, the heel was boggy with undermining of 0.1 cm to 0.2 cm. Record review of a fax sheet dated 7-22-2014 revealed the facility staff informed Resident 2's physician of the status of the pressure ulcer and requested a treatment change. According to information on the fax sheet, the facility staff refaxed a request for treatment changes on 7-28-2014, 6 days later. Record review of Resident 2's PN dated 7-23-2014 revealed staff documented the current treatment as skin prep daily. Record review of a Pressure Ulcer Status Record (PUSR) dated 7-24-2014 revealed Resident 2's left lateral heel was a stage 2 ( Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion) pressure ulcer that measured 1.0 cm by 1.0 cm with undermining of 0.1 cm. According to the documentation, the would had deteriorated with slough (dead tissue) in the wound. Record review of Resident 2 PUSR dated 7-28-2014 revealed the pressure ulcer to the left heel measured 1.5 cm by 1.0 cm with response to treament as "deteriorated". On 7-30-2014 at 12:14 PM an interview was conducted with the facility Registered Dietician (RD) . During the interview, when asked if a nutritional evaluation had been completed for pressure ulcer healing, the facility RD stated "no". When asked if (gender) had been notified of Resident 2's pressure ulcer, the facility RD stated "no". An interview was conducted with RN B on 7-30-2014 at 4:53 PM. During the interview, RN B confirmed staff had not followed up on faxes sent to the physician for treatment changes. When asked what the facility considered responsible time frame to follow up, RN B stated 24 to 48 hours. RN B further confirmed an evaluation of casual factors for the development of the pressure ulcer had not been completed, weekly monitoring of the pressure had not been completed and treatment orders had not been obtained for Resident 2. B. Record review of an undated Face sheet revealed Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's Braden Scale sheet dated 5-15-2014 revealed a score of 16. According to the information on the Braden's Scale sheet, a score of 16 placed the resident at risk for the development of pressure ulcers. Record review of a Initial Data Collection Tool/Nursing Service sheet dated 5-15-2014 revealed Resident was admitted with multiple wound areas that included the right calf area and both heels. Record review of a PUSR dated 5-15-2014 revealed Resident 1 was admitted with a un-stageable pressure ulcer to the right calf. There were no measurements or condition of the pressure ulcer. Record review of a PUSR dated 5-27-2014 ( a 12 day span of time) revealed the pressure ulcer to the right calf measured 3.1 cm by 1.7 cm. The color was describe as "scabbed". Review of Resident 1's PUSR dated 6-04-2014 revealed the pressure ulcer measured 1.3 by 2.2 and remained "scabbed". Review of Resident 1's PUSR dated 6-23-2014 (a time span of 19 days) revealed the pressure ulcer to the right calf measured 3.0 cm by 1.5 cm and color remained "scabbed". Record review of Resident 1's PUSR dated 7-02-2014 revealed the area measured 4.0 cm by 4.0 cm with eschar (dead hard like tissue) with the response to treament as deteriorated. Record review of Resident 1's Non- Pressure Skin Condition Record (NPSCR) dated 5-15-2014 revealed Resident 1 had dry skin and "scabbed" areas to the heels. There were no measurements or an evaluation of the black areas. Record review of Resident 1's NPSCR dated 6-02-2014 ( a 17 day span of time) revealed the left heel had dry skin and the right heel had scant drainage, dry skin and a black area. There were no evaluation of the physical characteristics of the pressure ulcer. Record review of Resident 1's PN dated 6-08-2014 revealed the "...wound on (the) right heel is getting worse", and "wound on right heel with some eschar". Record review of a Physician's Visit Report dated 6-17-2014 revealed a new treatment order for the foot ulcers, a 9 day span of time. Record review of a Weekly Pressure Sore Tracking form signed on 6-26-2014 for the dates of June 19 through June 26, 2014 revealed Resident 1 had admitted to the facility with 3 un-stageable pressure ulcers to the right heel. Record review of Resident 1's medical record did not contain evidence of ongoing monitoring of the 3 pressure areas to the right heel. An phone interview was conducted on 8-04-2014 with RN B. During the interview, review of Resident 1's non-pressure and pressure skin sheets were completed with RN B. RN B confirmed, during the interview, the initial pressure ulcer sheet on admission did not contain measurement or description of the pressure area to the right calf. RN B confirmed the pressure areas to the right heel had not been monitored and confirmed the Weekly Pressure Sore Tracking form had identified Resident 1 had 3 pressure areas to the right heel. RN B confirmed pressure ulcer assessments had not been completed for Resident 1. RN B confirmed that according to the documentation, the pressure areas had declined. RN B confirmed weekly assessments for pressures had not been completed as required for Resident 1. Record review of the facility Pressure Ulcer Prevention policy and procedure identified by klb 0 revealed the following information: -Post-admission weekly Skin Assessments. -A complete assessment is essential to an effective ulcer prevention and treatment program. a comprehensive individualized evaluation helps the facility to identify the resident at risk of developing pressure ulcers, the level and nature of risks and the presence of pressure ulcers. -The weekly Pressure Ulcer status Record and the Non-pressure Skin Condition Record are used for weekly assessments of existing wounds. Record review of the facility Pressure Ulcer Care guide for the Assessment and Monitoring of Healing Policy and Procedure dated 10-07-2010 revealed the following; -Purpose: -To gather data for the purpose of planning and implementing wound care treatment procedures and to evaluate outcomes, rational and frequency. -Policy: -Pressure ulcers are assessed and monitored once a week to determine if the treatment plan is working or should be re-evaluated. In addition, if bone or tendon is exposed, if a resident had an infected wound, or if a wound cannot be assessed )i.e. is covered with necrotic tissue) the wounds are monitored and assessed daily and with each dressing change. -Procedure: -Measure the wound (surface area and depth). -#7. Assess the wound bed for moisture, and determine if it is to dry, moist, or wet. -#8. Assess the wound bed for devitalized tissue. Assess the percentage of wound bed that is covered with necrotic tissue. -16. Document your findings. include a narrative description of the wound, including its physical characteristic, in the medical record to avoid miscommunication or misinterpretation. The description should included: -Location, stage, size, tissue type, exudate, wound bed and peri wound condition, odor, wound edges, tunneling, presence or absence of granulation or [MEDICATION NAME], slough, undermining/sinus tracts and type of wound. Note Never back stage a wound.