Every finding on record at Life Care Center of Omaha

Based on record review and interview, the facility failed to ensure discharge planning was completed for 1 resident (Resident 1) of 4 residents surveyed. The facility claimed a census of 44.A record review of the Facility Discharge Planning Process dated 5/6/2019 and revised 8/18/2022, revealed the following:The discharge planning process will address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan.ProcedureIdentify the resident's needs and goals regarding discharge upon or as soon as practicable after admission.The discharge plan is incorporated into the interdisciplinary care plan. It originates on the baseline care plan and will be included on the resident's comprehensive care plan, once developed.Address the resident's goals and treatment preferences in the plan.Document the date and any updated information in the discharge plan.The discharge plan will identify the discharge destination, and ensure it meets the residents' health and safety needs as well as preferences.A record review of Resident 1's Clinical Resident Profile sheet revealed Resident 1 was admitted to the facility on [DATE] and discharged from the facility on 2/10/2026.A record review of Resident 1's Discharge Minimum Data Set (MDS - a federally mandated assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a resident's functional, medical, psychosocial and cognitive status) dated 2/10/2026 revealed Resident 1 had a Brief Interview for Mental Status (BIMS - a mandatory tool used to assess the cognitive status of residents) score of 15, indicating Resident 1 was cognitively intact.A record review of Resident 1's Care plan revealed the following diagnoses: Generalized muscle weakness, difficulty in walking, cognitive communication deficit ( a communication issue caused by disruptions in cognitive processes such as memory, attention and organization), Type 2 diabetes, Morbid obesity, high blood pressure and congestive heart failure (a chronic, progressive condition where the heart muscle is too weak to pump blood efficiently).A record review of Resident 1's undated care plan does not reveal a discharge plan was initiated.A record review of a rental application form for an independent living apartment revealed Resident 1 filled out and signed the form on 1/24/26.A record review of a Care Plan Conference Record Sheet, dated 0127/26 revealed Resident 1 had no discharge plans and did not attend the Care Plan Conference.A record review of an e-mail dated 2/5/2026 from the MDS Licensed Practical Nurse (LPN A) to the Social Services Director, Administrator, Director of Nursing and the Business Office Manager confirmed MDS LPN received confirmation Resident 1 was approved for independent living with a caregiver at the accepting facility and was working with the Office on Aging to set up caregiver services.A record review of a progress note by the Social Services Director (SSD) dated 2/10/2026 revealed Resident 1 discharged to an independent living facility and refused assistance from the SSD. SSD was unable to confirm transition to independent living.An interview on 3/10/2026 at 10:30 AM with LPN B confirmed Resident 1 was able to make their needs known and was cognitively intact.An interview on 3/10/2026 at 11:00 AM with NA C confirmed Resident 1 was able to make their needs known and was cognitively intact.An interview on 3/10/26 at 11:40 AM with SSD confirmed Resident 1 did not have an established discharge plan. Resident 1 contacted an independent living facility and set up their own discharge with Aged and Disabled waivers (A&D Waivers are Medicaid programs that allow individuals aged 65 or older or with disabilities to receive long-term care in their homes or communities rather than in nursing facilities). SSD confirmed they did not know about Resident 1's discharge plans until the day Resident 1 left the facility. SSD confirmed Resident 1 would not reveal who their caregivers were going to be to the SSD. SSD revealed the part-time Social Services assistant had been collaborating with Resident 1 in relation to their discharge. SSD was unable to provide documentation of a discharge plan for Resident 1and confirmed they could not prove the documentation had been completed.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) and 12-006.09 (H)(iii)(2). Based on observation, interview and record review, the facility failed to implement treatment and interventions to promote healing and prevent new pressure ulcers for 1 (Resident 3) of 1 residents sampled. The facility census was 94. The findings are:Record review of the facility policy titled Skin Integrity and Pressure Ulcer Prevention dated 06-11-2025 revealed the purpose of the policy was to provide staff and licensed nurses with procedures to manage skin integrity, prevent pressure ulcers, complete wound assessments and provide treatment and care of skin and wounds utilizing professional standards of the National Pressure Injury Advisory Panel and Wound, Ostomy, Continent Nurses Society. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) 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 upper body dressing.-required extensive assistance with bathing, bed mobility and lower body dressing.-required total assistance with transfers and toileting.-had a pressure ulcer. Record review of Resident 3's Admission/readmission Collection Tool (ARCT) dated 10-17-2025 revealed Resident 3 had been hospitalized for a urinary tract infection. Under the skin section of the assessment the facility staff noted an open wound to the coccyx measuring 7 by 5. The ARCT did not indicate what unit of measurement was used. Record review of Resident 3's Progress Note (PN) dated 10-17-2025 revealed Resident 3 returned from the hospital, a skin assessment had been completed, and a note was left for the Nurse Practitioner (NP) to update on the wound to the coccyx area (tailbone). Record review of Resident 3's Wound Observation Tool (WOT) dated 10-22-25 revealed Resident 3 had a stage 2 pressure ulcer (a shallow open wound involving the top 2 layers of skin) to the sacrum measuring 2.5 centimeters (cm) in length by 2.7 cm in width by 0.1 cm in depth. The WOT also revealed that the treatment plan for the wound to sacrum was to cleanse the wound with wound cleanser, rinse and pat dry and apply Hydrofera Blue (an antimicrobial wound dressing) with water resistant mepilex (a wound dressing that does not stick to the wound) change daily and as needed for soiling. Record review of Resident 3's Order Summary (OS) printed on 11-17-2025 revealed no order for treatment of the sacral wound dated on or before 10-22-2025.Record review of Resident 3's Treatment Administration Record (TAR) for October 2025 revealed an order dated 10-22-2025 to cleanse, rinse and pat dry coccyx, then apply triad paste and cover with a mepilex dressing every evening shift. Further review of the TAR revealed no orders for treatment to the coccyx before 10-22-2025.Record review of Resident 3's Nutrition: Assessment/Nutritional Data Collection dated 10-22-25 revealed the facility Registered Dietician (RD) had recommended Resident 3 to receive Prosource 30 milliliters (mls) twice a day for wound healing and to notify the RD of any significant changes or concerns. Record review of Resident 3's OS printed on 11-17-2025 revealed no order for Prosource.Record review of Resident 3's Medication Administration Record (MAR) for October 2025 revealed no order for Prosource 30 mls twice a day. Record review of Resident 3's WOT dated 10-28-2025 revealed the stage 2 pressure ulcer to the coccyx measured 7.25 cm in length by 7.66 cm in width by 0.0 depth and staged as a 2. The WOT also indicated the wound was declining and the treatment plan was to cleanse the wound with wound cleanser, rinse and pat dry and apply Hydrofera Blue with water resistant Mepilex change daily and as needed for soiling.Record review of Resident 3's Progress Notes (PN) dated 10-31-2025 revealed there was a decline in wounds to coccyx/sacral region and the wound nurse assessed the wounds and new treatment orders were obtained.Record review of Resident 3's Electronic Health Record (EHR) revealed no wound assessment on 10-31-2025.Record review of Resident 3's TAR for October 2025 revealed no new treatment orders for the wounds to the coccyx/sacral region.Record review of Resident 3's OS printed on 11-17-2025 revealed an order dated 11-04-2025 to Cleanse with wound cleanser, rinse, pat dry, and apply Hydrofera Blue, cut to fit wounds and cover with Duoderm (a wound dressing that provides a moist protective environment to promote wound healing) every other day for wound care.Record review of Resident 3's TAR for November 2025 revealed an order dated 11-01-2025 to cleanse with wound cleanser, rinse, pat dry and apply Hydrofera Blue, cut to fit wounds and cover with a water resistant Mepilex. Change daily and as needed for soiling.Record review of Resident 3's Tissue Analytics Wound Assessment ([NAME]) dated 11-11-2024 revealed the wound to the sacral/coccyx was staged as a 3 (a deep wound that has full thickness skin loss) and measured 2.86 cm in length and 2.90 cm in width and 0.0 cm depth. Record review of Resident 3's MAR for November 2025 revealed the absence of an order for Prosource 30 mls twice a day. Record review of Resident 3's TAR for November 2025 revealed an order dated 11-04-2025 to cleanse with wound cleanser, rinse, pat dry and apply Hydrofera Blue, cut to fit wounds and cover with Duoderm every other day.An observation 11-19-2025 at 1:30 PM of Registered Nurse (RN) A providing wound care to Resident 3's sacral/coccyx region revealed an open wound to the coccyx that was tear drop shaped and approximately 1.5 cm in length by 1 cm in width, another wound below the coccyx wound to the sacral area that was approximately 3 cm in length and 4 cm in width, and another wound to the right buttock that was round and approximately 3.5 cm by 3.5 cm. An interview conducted with RN A on 11-19-2025 at 1:40 PM during wound care revealed the wound to the coccyx and the right buttock were stage 2 pressure ulcers and the sacral wound was a stage 3 pressure ulcer. An interview conducted with RN A on 11-19-2025 at 3:30 PM confirmed a wound treatment was not provided for Resident 3's pressure ulcer to the coccyx until 10-22-2025, 5 days after the pressure ulcer was identified and also confirmed the recommendation for Prosource 30 mls twice a day was not implemented and Resident 3's wounds have increased in number and 1 of the pressure ulcers is now a stage 3.

Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3) and 12-006.09(J).Based on observation, interview and record review the facility failed to ensure a tube feeding was running continuously for 1 (Resident 2) of 3 residents sampled and failed to provide treatment to a feeding tube insertion site according to the practitioner's orders for 1 (Resident 7) of 3 residents sampled. The facility census was 94. The findings are:Record review of the facility policy titled Enteral Nutrition Therapy (Continuous) dated 09-05-2025 revealed the facility will provide continuous enteral nutrition therapy in accordance with physician's orders and professional standards of practice. Record review of the facility policy titled Treatment Orders dated 06-12-2025 revealed treatment orders are written per physician's orders. The physician orders are followed as are the manufacturer's instructions for use for each product ordered.A.Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tools used for care planning) revealed the facility staff assessed the following about the resident:-could rarely or never make themselves understood-required total assistance for eating, dressing, grooming, toileting, bathing, bed mobility and transfers.-had a feeding tube. Record review of Resident 2's Order Summary printed on 11-17-2025 revealed an order for Jevity 1.5 (a tube feeding formula) per feeding tube at 40 milliliters (ml) per hour for 24 hours a day. An observation conducted on 11-19-2025 at 2:32 PM revealed Resident 3 was lying in bed and the tube feeding pump was not administering the tube feeding. The pump was beeping and the screen on the pump said the pump had been idle for 10 minutes. An observation conducted on 11-19-2025 at 3:25 PM revealed Resident 3 was lying in bed, the feeding pump was beeping and not administering the tube feeding and screen on the pump said the pump had been idle for 10 minutes. An interview conducted on 11-19-2025 at 3:30 PM with Licensed Practical Nurse (LPN) B revealed (gender) was the nurse for Resident 2 and confirmed the tube feeding was not running and should have been running at 40 ml per hour and confirmed LPN B had not restarted the tube feeding pump in the last hour. B.Record review of Resident 7's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as 12. According to the MDS Manual a score of 8 to 12 indicates moderate cognitive impairment. -required total assistance with dressing, grooming, dressing, toileting, bathing, bed mobility and transfers.-had a feeding tube. Record review of Resident 7's Treatment Administration Record (TAR) for November 2025 revealed an order dated 05-19-2025 for feeding tube site care as follows:Cleanse site, apply Vaseline gauze follow by a split gauze two times a day for healing of the site. An observation on 11-18-2025 at 8:10 AM-8:30 AM of LPN C providing feeding tube site care for Resident 7 revealed when the old dressing was removed from the feeding tube site, Resident 7 grimaced. The observation also revealed the absence of Vaseline gauze on the old dressing and the presence of bright red blood around the feeding tube insertion site. An interview conducted with LPN C at 8:25 AM confirmed the absence of Vaseline gauze on the old dressing and confirmed Vaseline gauze should have been applied to the tube feeding site, and confirmed the old dressing had stuck to Resident 7's skin causing discomfort.

Based on record review and interview, the facility failed to ensure that the posted nurse staffing information contained the required information related to the total number of actual hours worked per discipline. This had the potential to affect all residents that resided in the facility. The facility staff identified a census of 98.Record reviews of 30 days of past posted nurse staffing between 8/10/25 and 9/10/25 revealed the daily posted nurse staffing did not contain the total number of actual hours worked for the different types of staff.An interview on 9/15/25 at 1:02 PM with the facility Administrator confirmed the nurse staff posting information did not contain the total number of actual hours worked per discipline and that the hours had not been calculated or documented on the posted nurse staffing and should have been.

Licensure Reference Number 175 NAC 12-006.09(H)Based on interview and record review, the facility failed to ensure behavior monitoring was completed for 1 (Resident 28) who received a psychotropic medications (drugs that alter mental processes, emotions, and behavior), failed to monitor for side effects for 1 (Resident 54) who received Depakote (a drug used to treat bipolar disorder, seizures, and prevent migraines) and Lexapro (a drug used to treat depression and anxiety), failed to ensure a sleep diary or test was completed for 1 (Resident 28) who received Zolpidem Tartrate (Ambien, a drug used to treat sleep disorders), failed to ensure as needed (PRN) antipsychotic medications (drugs used to treat mental health conditions) had a stop date of 14 days after first issuance for 1 (Resident 30), and failed to perform baseline and ongoing Abnormal Involuntary Movement Scale (AIMS) testing for the use of antipsychotics for 1 (Resident 71) for a total of 5 sampled residents. The facility census was 98. Findings are:A. A record review of the facility's Psychotropic Medication Use policy with a last revision date of 09/15/2024 revealed that psychotropic medications are drugs that affect mood, perception, or behavior, and include antipsychotic, antianxiety, antidepressant, mood stabilizers, and hypnotic (medications used to treat sleep disorders) medications. All medications used to treat behaviors should be monitored for efficacy (ability to produce desired result), risks, benefits, and adverse consequences (side effects). A record review of Resident 28's Clinical Census dated 09/11/2025 revealed the resident was admitted on [DATE] and had a medical record number of 8149. A record review of Resident 28's Medical Diagnosis dated 09/11/2025 did not reveal the resident had diagnoses of Anxiety, Depression, or a sleep disorder. A record review of Resident 28's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 06/30/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 14 which indicated the resident was cognitively aware. The resident needed setup or clean-up assistance for eating, oral hygiene (cleaning) and upper body dressing, needed partial/moderate assistance for bathing, and dependent of staff for toileting, lower body dressing, and personal hygiene. The resident was on antianxiety medications, antidepressant medications, and hypnotics. The resident did have depression symptoms but did not have behaviors in the lookback period. A record review of Resident 28's Care Plan with an admission date of 06/23/2025 revealed the resident had focus areas and interventions for the resident being on sedative/hypnotic therapy and antidepressant medications but did not reveal the staff should monitor for the target behaviors related to those medications. A record review of Resident 28's Order Summary Report dated 09/11/2025 revealed the resident had orders for 1 milligram (mg) tablet of Clonazepam (a seizure and antianxiety medication) two times a day (BID) for anxiety, one 30 mg capsule Duloxetine (an antidepressant medication) one time a day (Q-day) for depression, one 100 mg tablet of Trazadone (an antidepressant medication) at bedtime for depression, and Zolpidem Tartrate 5 mg tablet at bedtime for difficulty sleeping. The Order Summary Report included orders for side effect monitoring for the psychotropic medications but did not include orders for the target behavior monitoring of those medications. A record review of Resident 28's Electronic Medical Record dated 06/23/2025 – 09/11/2025 did not reveal specific target behavior monitoring for the resident's ordered psychotropic medications. In an email dated 09/11/2025, the facility's Regional Nurse Consultant (RNC)-A confirmed the facility did not have behavior monitoring for Resident 28's psychotropic medications. B. A record review of the undated American Association of Psychiatric Pharmacist's Medication Fact Sheet revealed Valproate (Depakote) is a mood stabilizer medication that works in the brain and is approved for the treatment of mania (abnormally elevated or expansive mood) associated with Bipolar disorder. https://www.nami.org/NAMI/media/NAMI-Media/Research/Valproate.pdf A record review of Resident 54's Clinical Census dated 09/11/2025 revealed the resident was admitted [DATE] and the resident's medical number was 7701. A record review of Resident 54's Medical Diagnosis dated 09/11/2025 did not reveal the resident had diagnoses of Bipolar Disorder (a serious mental illness that causes unusual shifts in mood) or Depression. A record review of Resident 54's MDS dated [DATE] revealed the resident had a BIMS of 15 which indicated the resident was cognitively aware. The resident was independent of staff for eating and oral hygiene, needed partial/moderate assistance for upper body dressing, needed substantial/maximal assistance with bathing, lower body dressing, and personal hygiene. The resident was on antidepressant medications, and an anticonvulsant (medications to treat seizures). The resident did not have mood symptoms but did exhibit a rejection of care behavior in the lookback period. A record review of Resident 54's Care Plan with an admission date of 03/18/2024 revealed the resident had a focus areas and interventions for the resident's target behaviors but did not reveal the staff should monitor for the side effects for the medications to be administered as ordered. A record review of Resident 54's Order Summary Report dated 09/11/2025 revealed the resident had orders for one 125 mg tablet Depakote Q-day for Bipolar disorder and one 10 mg tablet Lexapro Q-day for depression. The Order Summary Report did not included orders for side effect monitoring for the medications. A record review of Resident 54's Electronic Medical Record dated 11/29/2023 – 09/11/2025 did not reveal side effect monitoring for the resident's ordered Depakote or Lexapro. In an email dated 09/11/2025, the facility's Regional Nurse Consultant (RNC)-A confirmed the facility did not have any psychotropic side effect monitoring for Resident 54. C. A record review of the facility's Psychotropic Medication Use policy with a last revision date of 09/15/2024 revealed that psychotropic medications are drugs that affect mood, perception, or behavior, and include antipsychotic, antianxiety, antidepressant, mood stabilizers, and hypnotic (medications used to treat sleep disorders) medications. All medications used to treat behaviors must have a clinical indication and should be monitored for efficacy (ability to produce desired result), risks, benefits, and adverse consequences (side effects). The facility staff should monitor the resident's behavior using a behavior monitoring chart. A record review of Resident 28's Care Plan with an admission date of 06/23/2025 revealed the resident had a focus area of the resident is on a sedative/hypnotic therapy. An intervention was to evaluate other factors potentially causing insomnia (trouble falling and staying asleep) and attempt to modify and control the external factors before initiating hypnotic therapy. A record review of Resident 28's Order Summary Report dated 09/11/2025 revealed the resident had orders for Zolpidem Tartrate 5 mg tablet at bedtime for difficulty sleeping. A record review of Resident 28's Electronic Medical Record dated 06/23/2025 – 09/11/2025 did not reveal a sleep test or sleep diary had been completed to monitor the effectiveness of the Zolpidem Tartrate. In an email dated 09/11/2025, the facility's Regional Nurse Consultant (RNC)-A confirmed the facility did not have a sleep test or 3-day sleep for Resident 28's Zolpidem Tartrate. D.Record review of the facility's policy titled Psychotropic Medication Use dated 09-15-2024 revealed PRN orders for antipsychotic medications shall be limited to 14 days and cannot be renewed unless the attending physician or prescriber evaluates the resident for the appropriateness of that medication. The required evaluation of a resident before writing a new PRN order for antipsychotic entails the prescribing practitioner directly examining the resident and assessing the resident's current condition and progress to determine if the PRN antipsychotic medication is still needed. Record review of Resident 30's MDS 08-08-2025 revealed the facility staff assessed the following about the resident: -BIMS was scored as a 10. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment. -required limited assistance with bed mobility. -required extensive assistance with bathing -required total assistance with transfers, toileting, and wheelchair mobility. -was taking antipsychotic, antianxiety, and antidepressant medications. Record review of Resident 30's Medication Administration Record (MAR) for September 2025 revealed an order dated 08-05-2025 for Seroquel (an antipsychotic medication) 25 mg give one tablet by mouth every 6 hours PRN (as needed) for anxiety and aggression and an order dated 08-06-2025 for Haloperidol (an antipsychotic medication) 1 mg tablet give 2 tablets by mouth every 6 hours PRN agitation if not responsive for Seroquel. An interview with Regional Nurse Consultant (RNC) A conducted on 09-10-2025 at 10:45 AM confirmed the orders for PRN Seroquel and Haloperidol was not stopped after 14 days and should have been. E. Record review of the facility policy titled Tardive Dyskinesia (a chronic involuntary movement disorder that can develop as a side effect of antipsychotic medications) Assessment (AIMS) dated 08-29-2025 revealed each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug used without adequate monitoring or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Upon initiation of a medication with known extrapyramidal symptoms side effects the facility will complete a baseline AIMS (Abnormal Involuntary Movement Assessment) and then every 3 months and as needed thereafter for as long as the medication is being used. Record review of Resident 71's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 3. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. - required set up assistance with dressing, toileting and hygiene. -was independent with dressing, toileting and ambulation. - was taking an antipsychotic medication. Record review of Resident 71's Order Summary Report dated 09-09-2025 revealed an order for Risperidone (an antipsychotic medication) dated 06-10-2025 was to be given 0.125 mg in the morning every other day, and an order for Risperidone dated 06-10-2025 give 0.25 mg in the morning every other day. Record review of Resident 71's Electronic Medical Record revealed an in progress AIMS test dated 01-27-2025 that had not been completed and a incomplete initial AIMS test dated 10-02-2025. An interview was conducted with the RNC A on 09-10-2025 at 2:15 PM that confirms the AIMS tests were not completed for Resident 71 and should have been.

Licensure Reference Number 175 NAC 12-006.09(G) Based on interview and record review, the facility failed to complete a discharge plan for 1 (Resident 102) of 2 sampled residents. The facility census was 98. Findings are:A record review of Resident 102's Progress Notes dated 09/11/2025 revealed the resident was discharged to home on [DATE]. A record review of Resident 102's Notice Of Resident Transfer Or Discharge dated 08/18/2025 revealed the resident discharged to home and the box was marked that the resident's health had improved sufficiently and no longer needed the services provided by the facility. A record review of Resident 102's Discharge Summary Information dated 08/18/2025 revealed the resident was discharged to home. The reason for discharge was patient request. The resident was educated on the discharge process and was not expected to return. A record review of Resident 102's Care Plan with an admission date of 08/08/2025 did not reveal a Focus area or interventions for the discharge plan. A record review of Resident 102's Baseline Care Plan dated 08/08/2025 revealed the box for Discharge Plan was not checked. In an interview on 09/10/2025 at 11:50 AM, the facility's Regional Nurse Consultant (RNC)-A confirmed there was not a discharge plan done for Resident 102 and it should have been done.

Licensure Reference Number 175 NAC 12-006.06(A) Based on interview and record review, the facility failed to provide a bed hold policy to 3 (Residents 7, 100, and 111) of 3 sampled residents on hospital transfer and failed to notify the State Long term Care (LTC) Ombudsman (an official appointed to investigate individuals complaints) of a facility-initiated transfer on 3 (Residents 7, 100, and 111) of 3 sampled residents. The facility census was 98. Findings are: A record review of facility's Bed-Hold Policy with a reviewed date of 09/05/2024 revealed the facility was obligated to provide two notices related to bed-holds. The first notice is given on admission well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State Plan or the facility's policy were to change. The second notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. A record review of facility's Ombudsman Program policy revised 10/06/2022 revealed Notice to the Office of the State LTC Ombudsman must occur before or as close as possible to the actual time of a facility-initiated transfer or discharge. In the case of emergency transfers the notice is sent as soon as practicable. The medical record must contain evidence that the notice was sent to the Ombudsman. A. A record review of Resident 100's Progress Notes dated 09/09/2025 revealed the resident was transferred to the emergency room (ER) for tachycardia (rapid heart rate) and low oxygen saturations (oxygen in blood) on 08/20/2025. A record review of the facility's Nursing Home to Hospital Transfer Form dated 08/20/2025 revealed Resident 100 was sent to the hospital for altered mental status. It did not reveal a bed-hold was given to the resident or the resident's representative. A record review of Resident 100's Electronic Medical Record (EMR) dated 08/06/2025 – 09/09/2025 did not reveal a bed-hold had been completed and given to the resident and/or the resident's representative at the time of or following the emergent transfer to the hospital. The EMR did not reveal the State LTC Ombudsman had been notified of the resident's hospital transfer on 08/20/2025. In an interview on 09/09/2025 at 12:23 PM, the facility's Regional Nurse Consultant (RNC)-A confirmed the facility did not complete a bed-hold for Resident 100's 8/20/2025 transfer to the hospital. In a telephone interview on 09/10/2025 at 11:10 AM, Resident 100's representative confirmed the facility did not give the resident's representative a bed-hold notice for the hospital transfer on 08/20/2025. In an interview on 09/10/2025 at 11:25 AM, RNC-A confirmed a bed hold was not given to the resident or the resident's representative for Resident 100's 08/20/2025 transfer to the ER and should have been. In an interview on 09/10/2025 at 12:05 PM, RNC-A confirmed that the facility did not notify the State LTC Ombudsman of Resident 100's 08/20/2025 transfer to the hospital and should have. B. A record review of Resident 111's Progress Notes dated 09/10/2025 revealed the resident was transferred to the ER for a psychiatric evaluation on 07/28/2025 following an attempt at self-harm. A record review of the facility's undated SBAR (Situation-Background-Assessment-Recommendation) Communication Form and the facility's eINTERACT Change in Condition Evaluation dated 07/28/2025 revealed Resident 111 was sent to the hospital for behavior symptoms on 07/28/2025 but did not reveal a bed-hold was given to the resident or the resident's representative. A record review of Resident 111's Electronic Medical Record (EMR) dated 06/06/2025 – 09/10/2025 did not reveal a bed-hold had been completed and given to the resident and/or the resident's representative at the time of or following the emergent transfer to the hospital. The EMR did not reveal the State LTC Ombudsman had been notified of the resident's hospital transfer on 08/20/2025. In an interview on 09/10/2025 at 12:38 PM, RNC-A confirmed that the facility did not notify the State LTC Ombudsman of Resident 100's 07/28/2025 transfer to the hospital and should have. In an interview on 09/10/2025 at 12:13 PM, RNC-A confirmed a bed hold was not given to the resident or the resident's representative for Resident 111's 07/28/2025 transfer to the ER and should have been. D. A review of Resident 7's census section of the electronic medical record revealed the following: -Resident 7 was on paid hospital leave from 91/25-9/5/25 -Resident 7 was on paid hospital leave from 7/14/25-7/18/25 -Resident 7 was on paid hospital leave from 6/10/25-6/11/25 A review of Resident 7's electronic medical record including progress notes did not reveal Resident 7 was provided information on facility bed hold policy or ombudsman was notified of hospital admission. In an interview on 9/10/25 at 12 PM, Registered Nurse Consultant A confirmed that bed hold information was not provided to the resident or family and ombudsman notification was not completed.

Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview and record review the facility failed to accurately code the Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) for 1 (Resident 13) of 1 residents sampled. The facility census was 98. The findings are:Record review of Resident 13's MDS dated [DATE] 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 15 indicates a person is cognitively intact.-required limited assistance with upper body dressing.-required extensive assistance with bed mobility and lower body dressing.-required total assistance with toileting, bathing, and transfers-oral and dental status including edentulous and loosely fitting dentures were not present. An observation on 09-08-2025 at 10:36 AM revealed Resident 13 was edentulous. During the observation a interview conducted with Resident 13 with Resident 13 reporting the dentures were to big. An interview conducted on 09-15-2025 at 10:15 AM with the Regional Director of Clinical Reimbursement confirmed the MDS was coded incorrectly for Resident 13's oral status.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(F)(iii)Based on record review and interview, the facility failed to revise the comprehensive care plan related to fluid restriction for 1 (Resident 1) of 22 residents sampled. The facility staff identified a census of 98.The findings are:Record review of a facility policy entitled Comprehensive Care Plans and Revisions dated reviewed 9/11/2024 revealed: -The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. -Procedure: -1. The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. -2. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery, this can include: -a. Additional interventions on existing problems, -b. Updating goal or problem statements -c. Adding a short-term problem, goal, and interventions to address a time limited condition.Record review of Resident 1's Clinical Census revealed the facility admitted the resident on 2/24/23.Record review of Resident 1's Medical Diagnoses revealed the resident had diagnoses which included end-stage renal disease and heart failure.Record review of Resident 1's Minimum Data Set, dated [DATE] (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 15. According to the MDS manual, a score of 15 indicated the resident was cognitively intact. Further review of the MDS identified the resident received hemodialysis (the process of removing blood from an artery, purifying it by dialysis, adding vital substances, and returning it to a vein).Record review of Resident 1's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) printed 9/10/2025 identified an intervention for sips of fluid only in between meals dated 3/6/2023.Record review of Resident 1's electronic health record (EHR) including physician's orders, progress notes, and scanned documents did not reveal an order for fluid restriction.An interview on 9/15/2025 with the Regional Director of Clinical Reimbursement (RDCR) confirmed Resident 1's fluid restriction ended in May of 2025. The RDCR further confirmed the care plan was not revised related to fluid restriction after completion of the 8/27/2025 MDS and should have been.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview the facility failed to complete neurological evaluations after an unwitnessed fall for 1 (Resident 71) of 3 residents sampled. The facility census was 98. The findings are: Record review of the facility policy titled Neurological Checks dated 08-29-2025 revealed a neurological check list shall be initiated when indicated by the resident assessment such as a head injury, post fall or neurological decompensation. Record review of Resident 71's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 08-22-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 3. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. - required set up assistance with dressing, toileting and hygiene.-was independent with dressing, toileting and ambulation.- was taking an antipsychotic medication.-had 2 or more falls in the last 3 months. Record review of the facility's incident log printed on 09-08-2025 revealed on 06-16-2025 Resident 71 had an unwitnessed fall. Record review of Resident 71's Electronic Medical Record revealed a neurological check assessment with entries completed for the initial check, the next three 15 minute checks, the next four 30 minute checks, the next four 2 hour checks and the next four 4 hour checks. The remaining four 8 hour checks and the last check 24 hours after the last 8 hour check were blank. An interview with the Director of Nursing on 09-15-2025 at 8:40 AM confirmed the neurological checks were not completed for the unwitnessed fall on 06-16-2025 and should have been.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to implement interventions to prevent the potential for accidents on 2 (Residents 9 and 111) of 7 sampled residents. The facility census was 98. Findings are:A. A record review of the facility's “Transportation Coordination and Services” policy with a reviewed date of 05/15/2025 revealed the facility would ensure safety and infection control procedures were followed in accordance with state and federal guidance. A record review of the facility's “Suicide Precautions” policy with a reviewed date of 09/06/2024 revealed that residents who made attempts should be transferred to an acute setting for evaluation and reported in accordance with state regulation. Provide one to one supervision (1:1)(one staff with the resident at all times) until resident was transferred to an acute inpatient setting (hospital). A record review of Resident 111's “Clinical Census” dated 09/10/2025 revealed the resident was admitted [DATE] and the resident's Point Click Care number was 7563. A record review of Resident 111's “Medical Diagnosis” dated 09/11/2025 revealed the resident had diagnoses of Schizoaffective Disorder (a mental health condition that combines symptoms of schizophrenia and mood disorders), Alcohol Abuse, Traumatic Subdural Hemorrhage Without Loss of Consciousness (bleeding between the brain and the inner layer of the [NAME]), and Other Speech And Language Deficits Following Cerebrovascular Disease (speech or language impairment after a stroke or other brain event). A record review of Resident 111's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 07/03/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 10 which indicated the resident was moderately cognitively impaired. The resident was independent for activities of daily living except the resident needed supervision or touching assistance with bathing. The resident was independent with all areas of mobility. The resident was on antipsychotic medications (medications used to treat psychotic disorders), antianxiety medications, and antidepressant medications. The resident did have inattention, disorganized thinking but did not have mood symptoms or behaviors in the lookback period. A record review of Resident 111's “Care Plan” with an admission date of 06/26/2025 revealed the resident had a focus area of at risk for behavior problem related to schizoaffective disorder and interventions of administer medications as ordered with a date initiated of 11/10/2023, anticipate and meet the residents needs with a date initiated of 11/10/2023, explain all procedures to the resident before starting and allow the resident time to adjust to changes with a date initiated of 11/10/2023. A record review of Resident 111's “Progress Note” dated 07/28/2025 at 2:30 PM by Registered Nurse (RN)-C revealed during a bingo activity Resident 111 placed an orange bingo cap in the resident's mouth with an attempt to swallow it. The nurse spotted it and it was removed. The resident “appeared tearful, was rocking back and forth and was emotionally distressed.” The resident was provided safety by providing a 1:1. A record review of Resident 111's “Progress Note” dated 07/28/25 at 14:55 PM by RN-C revealed a non-emergency medical transportation company would transport the resident to the hospital emergency room (ER) for evaluation. A record review of Resident 111's “Progress Note” dated 07/28/25 at 15:04 PM by RN-C revealed report was called to a nurse at the hospital ER and notified of the reasoning the resident would be seen in the ER. A record review of Resident 111's “Progress Note” dated 07/28/25 at 16:30 PM by Licensed Practical Nurse (LPN)-D revealed the hospital ER nurse called the facility to voice frustration that the resident was sent to the ER unaccompanied (no companion or escort). In a telephone interview on 09/10/2025 at 8:22 AM, RN-C confirmed RN-C was the nurse that took care of Resident 111 on 07/28/2025. RN - C reported Resident 111 was in the dining room playing bingo. The Activities Director (AD) came and got RN-C and reported Resident 111 was trying to make Resident 111 gag. RN-C took the resident to the resident's room and RN-C seen an orange cap about the size of a medicine bottle cap in the resident's mouth and removed it. RN-C went and got the Director of Nursing (DON). The DON instructed RN-C the resident needed 1:1 supervision so RN-C went and got the Bath Aide to do the 1:1. RN-C confirmed RN-C spoke to the resident and the resident confirmed the resident was trying to harm self. RN-C confirmed an attempt was made to transfer the resident with the facility van driver, but they were bust, so RN-C contacted the driver from the non-emergency transportation company to transport the resident to the ER and called the hospital ER to give report. RN-C confirmed RN-C told the driver to keep an eye on the resident, but confirmed RN-C did not make Driver-E aware that the resident had attempted self-harm. RN-C's reported their shift was ending, so RN-C gave report to Licensed Practical Nurse (LPN)-D and left for the day. RN-C confirmed when RN-C left, the resident was still at the facility and the Bath Aide was still doing 1:1 with Resident 111. RN-C confirmed it was RN-C's decision to call the non-emergency transport company's driver and not to call 911 since the cap was out and the Bath Aide was doing 1:1. In an interview on 09/10/2025 at 9:20 AM, Driver-E confirmed Driver-E recalled the transport to the ER of Resident 111 on 07/28/2025, but did not recall being given any special instructions or being given a packet to take to the ER. In an interview on 09/10/2025 at 3:04 PM, LPN-D confirmed Resident 111 had already left the facility when LPN-D started the shift on 07/28/2025. LPN-D recalled getting report from RN-C but did not know who transported the resident. LPN-D confirmed the Bath Aide did not go to the ER with the resident, but the resident was gone when LPN-D got there. In an interview on 09/10/2025 at 1:30 PM, the facility's RNC-A confirmed facility staff did not go with Resident 111 to the hospital ER on [DATE]. B. Record review of Resident 9's “Clinical Census” revealed the facility admitted the resident on 1/26/24. Record review of Resident 9's “Medical Diagnosis” printed 9/9/2025 revealed the resident had diagnoses which included muscle weakness, need for assistance with personal care, convulsions, and abnormal posture. Record review of Resident 9's MDS dated [DATE] revealed Resident 9 had a BIMS score of 13. According to the MDS manual, a score of 13 indicated the resident was cognitively intact. Further review of the MDS identified Resident 9 required supervision while eating and was dependent upon staff for all other activities of daily living including transfers and mobility. Record review of Resident 9's “Progress Notes” printed 9/9/2025 revealed: -7/8/2025: “Bath aide called nurse to show purple bruise to left front shoulder. Resident not sure how she got this, denies pain to area. Message left with family to return call to facility. NP [nurse practitioner], DON notified.” Record review of a facility provided document “Skin Related Injury” dated 7/8/2025 involving Resident 9 revealed after facility investigation, the determined cause of the bruise to the shoulder was related to wheelchair positioning. Further review of the document showed a note dated 7/9/2025 “therapy applied a wedge in between knees to assist with positioning.” Record review of Resident 9's CCP revealed interventions to place an abductor wedge between the knees and make sure wedge is in place between resident and armrest on right side while in wheelchair dated revised 5/8/2025. An observation on 9/11/2025 at 10:34 AM revealed a standard foam cushion in the seat of Resident 9's wheelchair. Nurse Aide (NA)-B utilized a gait belt, performed a stand pivot transfer with Resident 9, and seated Resident 9 in the wheelchair. No wedge was placed between the resident and the armrest of the wheelchair, nor was an abductor wedge placed between Resident 9's knees. An observation on 9/15/2025 at 11:45 AM revealed Resident 9 seated in the wheelchair in the main dining room. A standard foam cushion was in the seat of the wheelchair. No further positioning devices were present. An interview on 9/11/2025 at 10:34 AM with NA-B revealed [gender] works with Resident 9 approximately half of NA-B's scheduled shifts. NA-B further revealed that [gender] was never made aware that Resident 9 required positioning devices to prevent the potential for further injury. NA-B reported that [gender] has never seen cushions or wedges in use with Resident 9. An interview on 9/15/2025 at 11:50 PM with the Director of Nursing confirmed the resident did not have any wedge or abductor wedge in use for Resident 9. An interview on 9/15/2025 at 12:20 PM with the Director of Rehabilitation (DOR) confirmed Resident 9 should have an abductor wedge between the knees. The DOR reported that the wedge between the resident and the right side of the wheelchair was no longer an active intervention. Record review of a facility policy entitled “Incident and Reportable Event Management” dated reviewed 9/25/24 revealed: -The Five “I's” to Event Management: -Intervention -1. The licensed nurse should implement an appropriate immediate intervention, based on the conclusions of the initial investigation. -2. The licensed nurse should update the resident care plan and communicate the intervention to the staff caring for the resident. -3. The IDT will, as part of their review, determine if the initial intervention is sufficient or if a modification is needed. Any changes from the initial intervention will be documented on the resident's care plan and communicated to the staff caring for the resident.

Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to monitor lab values related to thyroid medication for 1 (Resident 30) of 5 residents sampled and failed to hold blood pressure medication when the blood pressure was outside of parameters for 1 (Resident 71) of 5 residents sampled. The facility census was 98. The findings are:A. Record review of the facility policy titled Unnecessary Medication dated 08-30-2022 revealed the facility will ensure only medications required to treat the resident's assessed condition are being used, reducing the need for and maximizing the effectiveness of medications. The facility's medication management process will support and promote the monitoring of medications for efficacy and adverse consequences. Record review of Resident 30's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 08-08-2025 revealed the facility staff assessed the following about the resident:-BIMS was scored as a 10. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-required limited assistance with bed mobility.-required extensive assistance with bathing-required total assistance with transfers, toileting, and wheelchair mobility. -was taking antipsychotic, antianxiety, and antidepressant medications. Record review of Resident 30's Pharmacy Consultation Report (PCR) dated 02-18-2025 through 02-20-2025 revealed Resident 30 receives a thyroid replacement medication and a Thyroid Stimulating Hormone (TSH) concentration was not located in the medical record for the last year and an order for a TSH concentration on the next convenient lab day and at least annually was requested. The physician's response dated 03-06-2025 was to have a TSH concentration drawn on the next laboratory day and every 6 months thereafter. Record review of Resident 30's PCR dated 04-22-2025 through 04-23-2025 revealed Resident 30 receives a thyroid replacement medication and an order for a TSH concentration on the next convenient lab day and at least annually was requested. The physician's response dated 05-05-2025 was to have a TSH concentration drawn on the next laboratory day. Record review of Resident 30's Electronic Medical Record revealed no TSH laboratory results from 03-06-2025 to 09-10-2025. An interview conducted on 09-10-2025 at 3:28 PM with the Regional Nurse Consultant (RNC) confirms the TSH concentration had not been done and should have been. B. Record review of Resident 71's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-BIMS was scored as a 3. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. - required set up assistance with dressing, toileting and hygiene.-was independent with dressing, toileting and ambulation.- was taking an antipsychotic medication. Record review of Order Summary Report dated 09-09-2025 revealed an order dated 12-30-2024 for hydralazine 25 milligram (mg) give a half a tablet every 8 hours for Hypertension (HTN: high blood pressure) and to hold the medication if the systolic blood pressure (SBP: the top number of a blood pressure reading) was below 110. Record review of Resident 71's Medication Administration Record (MAR) for August 2025 revealed the following for hydralazine 25m g give a half tab every 8 hours and hold if SBP less than 110. -08-11-2025 at 8:00 AM blood pressure was 102/60 and documented as administered. -08-15-2025 at 8:00 AM blood pressure was 103/66 and documented as administered. -08-23-2025 at 8:00 AM blood pressure was 102/50 and documented as administered. -08-24-2025 at 8:00 AM blood pressure was 103/78 and documented as administered. -08-29-2025 at 8:00 AM blood pressure was 98/68 and documented as administered. -08-29-2025 at 2:00 PM blood pressure was 98/68 and documented as administered. -08-21-2025 at 10:00 PM blood pressure was 94/56 and documented as administered. Record review of Resident 71's MAR for September 2025 revealed the following for hydralazine 25mg give a half tablet every 8 hours for HTN, hold if SBP less than 110.-09-05-2025 at 10:00 PM blood pressure was 109/64 and documented as administered. -09-08-2025 at 8:00 AM blood pressure was 102/64 and documented as administered. An interview conducted on 09-15-2025 at 8:40 AM with the Director of Nursing (DON) confirmed the medication hydralazine was not held on the dates identified and should have been.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview and record review the facility failed to ensure a medication error rate of 5% or less as evidenced by 2 medication administration errors out of 25 opportunities for error, resulting in an error rate of 8%. The facility census was 98. The findings are:Record review of the facility policy titled Medication Administered through an Enteral Tube (feeding tube) dated 11-15-2024 revealed medications are administered by authorized and qualified facility staff, as prescribed, in accordance with standard nursing principles and practices. Insert medication syringe into the appropriate port and pour each medication through the syringe. Medications should be prepared and given separately. Do not mix medications together in a medication syringe. Record review of Resdient 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) revealed the facility staff assessed the following about the resident:-required total assistance with eating, hygiene, bathing, dressing, toileting, transfers and bed mobility.-had a feeding tube (a tube inserted into the gastrointestinal tract to deliver nutrition, fluids and medications). An observation on 09-15-2025 at 1:37 PM was conducted of Licensed Practical Nurse (LPN) F administering medication to Resident 3 revealed hydralazine 75 milligram (mg) tablet and baclofen 5 mg tablet were to be administered. LPN F removed the tablets from the medication cards and placed both medications in a clear pouch and inserted the pouch into the pill crusher and crushed the medications together. After the medications were crushed the medications were poured out of the clear pouch and into a clear medicine cup. Then LPN F along with LPN G went to Resident 3's room to administer the medication. LPN F poured approximately 3 teaspoons of water into the cup with medications and stirred it with a plastic spoon until the medication had dissolved. Resident 3's tube feeding was placed on hold by LPN F and a feeding syringe was inserted into the resident feeding port and after checking placement, LPN F flushed the feeding tube with water and then administered both medications dissolved in water through the feeding tube followed by a water flush. LPN G was present during the observation and was training LPN F. An interview with LPN G on 09-15-2025 at 1:45 PM reveals Resident 3's physician had given an order for medications to be crushed and administered together through the feeding tube. An interview with the Director of Nursing on 09-15-2025 confirmed Resident 3 did not have an order for medications to be crushed and administered together through the feeding tube and confirmed medications should not have been crushed and administered together for Resident 3.

Based on record review and interview the facility failed to provide a report to the receiving healthcare institution after an emergent transfer from the facility for 2 (Resident 1 and 3) of 4 residents sampled. The facility census was 95. The findings are: A. Record review of Resident 1's admission assessment dated [DATE] revealed the facility staff assessed the following about the resident: -was alert and oriented to person, place and time. -was receiving dialysis. -required extensive assistance with transfers. -required limited assistance with bed mobility, dressing, toileting and hygiene. -had an active infectious disease that required transmission-based precautions. Record review of Resident 1's progress notes dated 05-24-25 revealed Resident 1 and spouse wanted to be sent to the hospital due to body pain and had declined treatment for this at the facility. Furthermore, the progress note reveals the on-call supervisor was notified and 911 was called and an ambulance arrived at the facility to take Resident 1 to the hospital. Record review of Resident 1's Electronic Medical Record including physician's orders, progress notes, and transfer forms revealed no notification to the receiving hospital on the care needs of the resident. An interview with Licensed Practical Nurse (LPN) E on 06-11-2025 at 10:00 AM revealed LPN E was the nurse that transferred Resident 1 to the hospital on [DATE] and confirmed that a report was not given to the hospital after Resident 1's transfer. B. Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 05-06-2025 revealed the facility staff assessed the following about the resident: -the resident is rarely understood. -required total assist with eating, hygiene, dressing, toileting, bathing, bed mobility and transfers -had a urinary catheter. Record review of Resident 3's progress notes dated 4-27-2025 revealed Resident 3 was unresponsive and the staff called 911 and sent the resident to the hospital. Record review of Resident 3's Electronic Health Record revealed no information on when the ambulance arrived and what information was communicated to the receiving hospital on the care and needs of the resident. An interview with the Director of Nursing on 06-11-20256 at 1:15 PM revealed the expectation was for the staff to call the hospital and provide a report on the resident that is being sent there and confirmed that a report was not given to the hospital after Resident 3's transfer.

Licensure Reference Number 175 NAC 12-006.04 Based on record review and interview the facility failed to train licensed staff on an external cardiac defibrillator, prior to providing care to 1 (Resident 1) of 1 residents sampled. The facility census was 95. The findings are: Record review of Resident 1's admission assessment dated [DATE] revealed the facility staff assessed the following about the resident: -was alert and oriented to person, place and time. -was receiving dialysis. -required extensive assistance with transfers. -required limited assistance with bed mobility, dressing, toileting and hygiene. -had an active infectious disease that required transmission-based precautions. Record review of Resident 1's discharge orders from the hospital revealed an order for a life vest (an external defibrillator designed to protect individuals at risk of Sudden Cardiac Arrest by monitoring heart rhythms and delivering a shock when abnormal rhythms are detected) was to be worn at all times. An interview with Licensed Practical Nurse (LPN) E on 06-10-2025 at 3:00 PM revealed LPN C had worked and who provided care for Resident 1 revealed LPN C had no prior training on the Life Vest. Furthermore, LPN C revealed there were no training materials for the staff to refer to if needed. An interview with LPN D on 06-11-2025 at 10:15 AM that revealed LPN D had provided care for Resident 1 and had no prior training on the Life Vest. An interview with LPN F on 06-11-2025 at 10:30 AM that revealed LPN F had provided care for Resident 1 and had no prior training at the facility on the Life Vest. An interview with the Director of Nursing (DON) on 06-11-2025 at 2:40 PM confirmed that training on the Life Vest had not occurred prior to admitting and providing care Resident 1 who had a Life Vest in use.

Licensure Reference Number 175 NAC 1-005.06(E & F), 12-006.18(B) Based on observation, interview and record review the facility failed to utilize contact precautions for 1(Resident 2) of 3 residents sampled and failed to utilize enhanced barrier precautions for 2 (Resident 3 and 4) of 2 residents sampled. The facility census was 95. The findings are: A. Record review of Resident 2's Minimum Data Set, (MDS: a federally mandated assessment tool used for care planning) dated 04-16-2025 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 indicate a person is cognitively intact. -was legally blind -had a C. Difficile infection (a bacterium that can cause inflammation of the colon and diarrhea) -was on isolation for an active infection. -required supervision and minimal assistance with toileting, bathing and transfers. -was occasionally incontinent of bowel and bladder. An observation on 06-10-2025 at 8:15 AM of Resident 2's room revealed a sign on the door that stated contact precautions staff must wear a gown and gloves upon entering the room. There was another sign on the door that indicated hand hygiene with soap and water only. There was a cart located on the outside of the room that contained gowns and gloves. An observation on 06-10-2025 at 12:50 PM revealed Housekeeper (HK) K mopping the floor in Resident 2's room, without wearing a gown. An interview with HK K on 06-10-2025 at 1:00 PM confirmed a gown was not worn to mop the floor and should have been worn based on the sign on the door. An interview with the Regional Nurse Consultant (RNC) on 06-11-2025 at 2:30 PM confirmed Resident 2 was on contact precautions and the HK K should have worn a gown and gloves while cleaning and mopping the room. Record review of the facility policy titled Contact Precautions dated 04-22-2025 revealed contact precautions should be used when a resident develops signs and symptoms of a transmissible infection or has a laboratory confirmed infection that requires use of contact precautions to prevent transmission of pathogens that are spread by direct person to person contact or indirect contact with the resident or environment and requires the use of personal protective equipment (PPE) including a gown and gloves. B. Record review of Resident 3's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -the resident is rarely understood. -required total assist with eating, hygiene, dressing, toileting, bathing, bed mobility and transfers -had a urinary catheter. An observation on 06-10-2025 at 9:30 AM of Resident 3's room revealed a sign that stated Enhanced Barrier Precautions (EBP) and the sign instructed the staff must wear a gown and gloves for the following high resident contact activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: such as urinary catheter, feeding tube, and wound care. An observation on 06-11-2025 at 9:10 AM of Nursing Assistant (NA) G and NA J providing care for Resident 3 without wearing a gown. Resident 3 had just returned from the shower and was transferred onto the bed. NA G had assisted Resident 3 to roll to the side, while NA J dried Resident 3's back and buttocks. Furthermore, Resident 3 had a dressing to the buttocks that had become loose, and NA J removed the loose dressing and dried the area. During the observation, Resident 3 had a bowel movement and NA J provided perineal care and placed a new brief under the resident. NA G then rolled Resident 3 to the back and assisted with Resident 3 with dressing. An interview conducted with NA J on 06-11-2025 at 9:25 AM revealed NA J did not wear a gown because (gender) was not aware a gown was required. An interview conducted with NA G on 06-11-2025 at 9:33 AM revealed a gown was not worn because (gender) was not aware of Resident 3 being on EBP. An interview with the RNC on 06-11-2025 at 2:30 PM confirmed Resident 3 was on EBP and the staff should have worn a gown while providing care for Resident 3. C. Record review of Resident 4's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored at a 15 indicating intact cognition. -had a multidrug resistant organism (MDRO; a germ that is resistant to many antibiotics). -required dialysis (a medical procedure that cleans blood when the kidneys are unable to so). -required total assistance with toileting, bathing, dressing, transfers, and bed mobility. An observation on 06-10-2025 at 1:00 PM of Resident 4's room revealed a sign that stated Enhanced Barrier Precautions (EBP) and the sign instructed the staff must wear a gown and gloves for the following high resident contact activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: such as urinary catheter, feeding tube, and wound care. An observation on 06-11-2025 at 11:00 AM revealed NA H and NA I transferring Resident 4 into bed from the electric wheelchair, without wearing a gown. After Resident 4 was on the bed, NA I left the room and NA H continued to provide care for the resident. NA H proceeded to perform a brief change and perineal care for Resident 4 without a gown. Furthermore, the observation revealed a vascular access port used for dialysis to the right upper chest. An interview with NA H on 06-11-2025 at 11:25 AM confirmed a gown was not worn while providing care even though there was an EBP sign on the door. An interview with Registered Nurse (RN) B at 11:35 AM revealed RN B was not aware of Resident 4 being on EBP. An interview with the RNC on 06-11-2025 at 2:30 PM confirmed Resident 4 was on EBP and the staff should have worn a gown while transferring and providing perineal care. Record review of the facility policy titled Enhanced Barrier Precautions dated 04-22-2025 revealed the facility should use EBP as an additional MDRO mitigation strategy for residents that meet the following criteria, during high-contact resident activities: -wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. -indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.

175 NAC 12-006.09(H)(vi)(3)(a) Based on observation, interview and record review the facility failed to administer enteral tube feedings and water flushes according to the practitioner's orders for 1 (Resident 5) of 1 residents sampled. The facility census was 99. The findings are: Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 12-24-2024 revealed the facility the following about the resident. -Brief Interview of Mental Status (BIMS) was scored as a 3. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -had a diagnosis of Protein Calorie Malnutrition -required total assistance with eating, hygiene, toileting, bathing, dressing, transfers and bed mobility. -had a feeding tube and was receiving 51% or more of the daily total calories through the feeding tube. Record review of Resident 5's order summary printed on 03-13-2025 revealed an order Nepro enteral feeding at 45 milliliters (ml) per hour through the feeding tube for 24 hours a day continuously. Additionally, the order summary did not have an order to flush the feeding tube with water. An observation on 03-13-2025 at 1:30 PM revealed Resident 5 sitting in the room with the tube feeding running at 45 ml per hour, the feeding bag was dated 03-12-2025 and the bag was labeled Isosource 45 ml per hour and another feeding bag with clear liquid in it with no label or date on the bag. An interview conducted on 03-13-2025 at 2:05 PM with Registered Nurse (RN) C confirmed the tube feeding infusing for Resident 5 was labeled Isosource 45ml per hour dated 03-12-2025 and the clear liquid in the other feeding bag was water and the pump was set at 300 ml of water every 6 hours. RN C further confirmed the order was for Nepro tube feeding. RN C reported not find an order to flush the feeding tube with 300 ml of water every 6 hours. An interview conducted on 03-17-2025 at 11:03 AM with the facility's Registered Dietician (RD) confirmed that Nepro tube feeding formula is not interchangeable with Isosource tube feeding formula and the Isosource should not have been administered to Resident 5. Record review of the facility policy titled Enteral Therapy (Continuous) dated 09-10-2024 revealed as the policy statement: -the facility will provide continuous enteral nutrition therapy in accordance with physician orders and professional standards of practice.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5%. Observation of 29 medications administered revealed 3 errors resulting in a medication error rate of 10.34%. The medication errors affect 2 (Resident 2 and 3) of 4 residents. The facility census was 99. Findings are: A. Record review of Resident 3's Medication Administration Record (MAR) printed on 03-13-2025 revealed the following medications to be administered for 8:00 AM: -Amlodipine Besylate (medication used for blood pressure management) 10 milligrams (mg) -Baclofen (muscle relaxant) 15 mg -Calcium Carbonate Chewable 500 mg -Culturelle Capsules 1 capsule -Donepezil (medication used to improve mental function) HCl 10 mg -Fluticazone Propionate Nasal Suspension 1 spray each nare -Gabapentin (anticonvulsant medication) 300 mg -Isosorbide mononitrate ( ER 30 mg -Refresh Tears Solution 0.5 % 1 drop in both eyes. An observation on 03-13-2025 at 7:35 AM of Registered Nurse (RN) B administering medications for Resident 3 revealed the Refresh Tears Solution was not administered. An interview on 03-13-2025 at 7:45 AM with RN B confirmed the Refresh eye drops for Resident 3 were unavailable therefore the eye drops were omitted from the administration. B. Record review of Resident 2's MAR printed on 03-13-2025 revealed the following medications to be at administered at 8:00 AM: -Certirizine HCL (medication used for allergies) 10 mg -Oxcarbazepine (anticonvulsant medication) 300mg -Atorvastatin Calcium ( medication used to manage cholesterol) F/C 20 mg -Lantus (Insulin Glargine) injection 15 units -Timolol Maleate gel forming solution 0.5% 1 drop both eyes An observation on 03-13-2025 at 8:15 AM with Licensed Practical Nurse (LPN) A administering medications to Resident 2 revealed the administration of Atorvastatin 20 mg and Oxcarbapine 300 mg and Lantus insulin 15 units. The Certirizine and the Timolol Maleate medications were not administered at the time of the observation. An interview was conducted on 03-13-2025 at 10:05 AM with LPN A which confirmed the Certirizine 10 mg was not administered for Resident 2 and the Timolol Maleate gel solution 0.5% was administered late at 10:00 AM. Record review of the facility policy titled Administration of Medications revealed the following: -The facility must ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. -Medication error- this means the observed or identified preparation and administration of medications or biological's which is not in accordance with: -the prescribe's order -Manufacturer's specifications (not recommendations) regarding the preparation or administration of the medication or biological; or -Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. -Staff who are responsible for medication administration will adhere to the 10 rights of Medication Administration including: -Right time and Frequency- check the order for when the medication should be given.

175 NAC 12-006.12(D)(iii) Based on observation, interview and record review the facility failed to ensure 10 insulin pens were labeled with the date opened for Residents 5, 6 and 8 during an observation of 1 medication cart sampled. The facility census was 99. The findings are: Record review of the facility policy Guidance for Using Insulin Products revealed the following information: -insulin products should not be used if they were frozen. -Before opening all unused vials, pens, and cartridges of insulin are best stored in a refrigerator between 36 and 46 degrees Fahrenheit and can be kept until the expiration date printed on the packaging. -Storage of unopened insulin products outside of the refrigerator is permissible but results in an earlier expiration date. -Upon opening all vials, cartridges, pens should be dated and stored away from direct heat or light. Insulin pens should not be refrigerated once opened. -Lantus insulin opened and stored at room temperature will expire in 28 days. -Lispro insulin opened and stored at room temperature will expire in 28 days. Observation on 03-17-2025 at 7:45 AM revealed the following 10 insulin pens were available for use without opened dates: -3 Lantus pens and 2 lispro pens did not have an opened date for Resident 8. - 3 Lispro pens did not have an opened date for Resident 5 -1 Lantus pen and 1 lispro pen did not have an opened date for Resident 6. An interview conducted with Registered Nurse (RN) C on 03-13-2025 at 7:50 AM confirmed that the 10 insulin pens did not have a date indicating when initial use began and that the insulin will expire 28 days after opening.

Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview; the facility staff failed to include the resident/ family member in the quarter care planning process for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 90. Findings are: Record review of a Order Summary Report printed on 10-28-2024 revealed Resident 2 admitted to the facility on [DATE]. Record review of Resident 2's Electronic Medical Record (EMR) under the section identified as census revealed Resident 2 discharge from the facility on 8-23-2024. Further review of Resident 2's EMR revealed the last quarter care planning process was completed on 10-24-2023. There was no indication a quarter care planning process was conducted as of 10-29-2024. On 10-28-2024 at 10:10 AM an interview was conducted with a Family Member (FM) of Resident 2's. During the interview Resident 2's FM reported not being invited or being aware of the quarterly care planning process. Resident 2's FM reported being involved in planning care for Resident 2. On 10-28-2024 at 3:42 PM an interview was conducted with the Social Services Director (SSD). During the interview the SSD confirmed Resident 2's record did not reflect the care planning process had been completed for the resident. The SSD reported not being aware that the quarterly care planning process had been completed for Resident 2.

Licensure reference: 175 NAC 12-006.09D7 Based on observation, interview, and record review, the facility failed to ensure monitoring of Wanderguard bracelet placement and function to prevent potential elopement from the facility for 1 [Resident 1] of 3 sampled residents at risk for elopement. The facility had a total census of 85. Findings are: A. A review of Admission Record revealed Resident 1 was admitted to the facility on [DATE] with a diagnoses of hemiplegia [severe or complete loss of strength or paralysis on one side of the body] and hemiparesis [mild or partial weakness or loss of strength on one side of the body] following cerebral infarction affecting right dominant side. Observations on 4/1/24 at 5:58 PM revealed Resident 1 with a Wanderguard bracelet [a bracelet worn by a resident that triggers an alarm if resident attempts to exit a facility] on right wrist. RN [Registered Nurse]-B checked the bracelet with the tester machine and the braclet was functioning. A review of MDS [Minimum Data Set; a comprehensive assessment used for care planning] dated 2/8/24 revealed Resident 1 had a BIMS [Brief Interview for Mental Status is used to get a quick snapshot of how well you are functioning cognitively at the moment] score of 3 suggesting severe cognitive impairment. A review of Resident 1's care plan revealed a problem of being at risk for elopement with history of attempts to leave facility unattended and impaired safety awareness dated 7/27/23 with the following interventions: -Add resident to the Elopement book dated 7/27/23, -Complete Elopement Risk assessment dated [DATE], -Document wandering behavior and attempted diversional interventions in behavior, -The resident will not leave facility unattended dated 7/27/23, -Encourage to participate in activities to divert from exit seeking behavior dated 12/19/23, -Frequent monitoring dated 7/27/23, -Provide for safe wandering-resident is an elopement risk dated 7/27/23, -Wanderguard dated 2/12/24. A review of Elopement Risk Evaluations completed for Resident 1 revealed the following: -2/9/2023 Resident 1 is not at risk for elopement. -5/9/2023 Resident 1 is not at risk for elopement. -7/26/2023 Resident 1 is at risk for elopement. -8/9/2023 Resident 1 is not at risk for elopement. -11/15/2023 Resident 1 is not at risk for elopement. -11/24/2023 Resident is at risk for elopement. -3/4/2024 Resident 1 not at risk for elopement. -4/1/2024 Resident 1 is at risk for elopement. A review of Progress Note for Resident 1 dated 7/26/23 at 1:20 PM revealed Resident 1 found walking up the hill. Staff drove and retrieved Resident 1. Resident 1 was drove back down to the facility. Resident 1 was noted not to have sustained any injuries. Wanderguard was placed on Resident 1. A review of Incident Report for Resident 1 dated 11/24/23 at 6:05 PM revealed housekeeping found Resident 1 walking outside on the front side of the building and informed nurse. Nurse rushed to the outside and found Resident 1 at the end of the building sidewalk returning back to the front door. Resident 1 reported Resident 1 was walking. A check of Resident 1's Wanderguard bracelet revealed it was working according to the Incident Report. In an interview on 4/1/24 at 3:40 PM, RN-B reported the Wanderguard did not sound when Resident 1 went out the door on 11/24/23 but it sounded when Resident 1 came back inside and was working when checked with the tester. A review of Progress Note for Resident 1 dated 12/30/23 at 8:32 AM revealed Resident 1 was attempting to leave the building. Resident 1 was redirected back to the common area. A review of Progress Note for Resident 1 dated 12/31/23 at 2 PM revealed Resident 1 dressed in coat and hat. Resident 1 was seeking exit and trying to get out front door as well as side exit door. Wanderguard was in place and functioning. Resident 1 was on 1:1 for an hour with a nurse aide until Resident agreed to go to room and rest. A review of Progress Note for Resident 1 dated 2/11/24 at 11:30 AM revealed Resident 1 was attempting to exit front door of the facility. Resident 1 became angry when attempting to re-direct. Resident 1's Wanderguard was not working properly or alarming. Resident 1's Wanderguard was replaced. In an interview on 4/1/24 at 10:31 AM, LPN [Licensed Practical Nurse]-A reported that [gender] had checked this morning and Resident 1's Wanderguard bracelet was functioning. LPN-A confirmed that Resident 1 will watch the door and attempt to leave. A review of Resident 1's TARs [Treatment Administration Records] for 7/2034, 8/2023, 9/2023, 10/2023, 11/2023, 12/2023, 1/2024, 2/2024, and 3/2024 revealed no documentation of Resident 1's Wanderguard bracelet being monitored for placement or function. A review of Resident 1's Order Summary Report revealed an order dated 4/1/2023 to check Wanderguard placement and function every shift. In an interview on 4/1/23 at 1:11 PM, the ADON [Assistant Director of Nursing] confirmed [gender] had added Wanderguard monitoring to Resident 1's TAR that day. In interviews on 4/1/24 at 1:11 PM and 2:35 PM, the ADON confirmed the Wanderguard bracelet was placed on Resident 1 on 7/26/23 and there was no evidence that monitoring of placement or function had been completed between 7/26/23 and today. The DON reported the process is to add to the care plan and TAR for monitoring when placed on resident. In a follow-up interview on 4/1/24 at 3:23 PM, the DON reported there was no policy on monitoring function of Wanderguard bracelets. A review of facility policy titled Area of Focus: Elopement reviewed 11/28/23 revealed the following: -Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. -The interdisciplinary team will review and revise the resident's unsafe wandering management care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS and upon an unsafe wandering or elopement event. B. The facility implemented the following interventions on 4/1/2024 to remove the immediacy of the situation and to protect the residents: Resident 1: Resident was immediately assessed to confirm placement and function of Wanderguard. The physician order for monitoring function daily and placement every shift has been written. The care plan has been updated to reflect the current status of the resident. The following interventions were implemented to protect other residents that may be at risk for elopement: -A one-time review of current resident population will be completed by 04.02.24 to validate residents have been assessed for elopement risk. -A one-time review of current residents identified at risk for elopement confirming they have a wander guard bracelet on their person. -A one-time review of residents identified as being at risk of elopement have been reviewed validating the monitoring orders are in place on the Treatment Administration Record. -A one-time review has been completed validating the elopement binder is up to date with the current list of residents identified at risk for elopement with resident characteristics and picture. -Going forward, the IDT [Interdisciplinary Team] will be responsible to review new admissions, readmissions, quarterly, and significant change assessments to validate the elopement assessments are completed accurately and the elopement process was followed weekly for 2 months, then monthly for 2 months. -An Ad hoc QAPI meeting has been completed with the Medical Director to review the plan. The medical director is in agreement with the plan. Education to staff: Facility staff on the PM shift have been re-educated on wander guard placement and function monitoring, documentation of monitoring process, and elopement prevention. Night shift will be educated 04.01.24. Day shift 04.02.24 at begin of shift. Following 4/2/24, staff re-education will be completed prior to the next shift scheduled for both facility associate and agency staff. Education on elopement prevention is completed with any new associate and/or agency staff hires during the orientation process or at the beginning of the shift for new agency staff. Auditing: The Director of Nursing/Designee will be responsible for monitoring wander guard function and placement completion and documentation on Treatment Records 5 times weekly for 2 weeks, weekly for 2 weeks, monthly for 3 months.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on observations, record reviews, interviews and facility policy review, the facility failed to thoroughly investigate an incident where a resident fell out of a mechanical lift requiring an ER visit and resulting in a laceration. This affected 1 of 3 (Resident 117) resident files reviewed for facility reported incidents and had the potential to affect all residents requiring an investigation. The facility census was 64. Findings are: The facility Clinical Services Manual titled, Event Management and Emergency Procedures, in effect at the time of the resident's fall was dated February 2018. The procedure included in part: Neglect - means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person. Possible indicators of abuse/neglect may include but are not limited to: An injury that is suspicious because the source of injury is not observed, or the extent or location of the injury is unusual. 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. The written summary of the investigation should include, but is not limited to: - A review of the Incident Report - An interview with person(s) reporting the incident - Interviews with any witnesses to the incident - An interview with the resident if appropriate - A review of the resident's medical record - An interview with employee(s), as needed - A review of the employee's file, as needed - Interviews with staff members on all shifts having contact with the resident at the time of the incident - Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident - Interviews (with) other residents who received care or services from the alleged perpetrator - A review (of) all circumstances surrounding the incident The Event Management and Emergency Procedures, document also indicated a report of abuse/neglect should be submitted to the State Agency within 24 hours of the incident, and the results of the investigation should be submitted within five working days from the date of the incident. Resident 117 was admitted with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 10/24/19, indicated Resident 117 was moderately cognitively impaired, and required limited to extensive assistance with transfers. The care plan, most recently updated on 12/21/19, revealed the resident was at risk for falls. On 12/21/19, a report was submitted to the State agency by the Director of Nursing (DON) and indicated Resident 117 had fallen from a mechanical lift on 12/21/19 at 6:45 PM. A second report dated 12/30/19, was submitted to the State Agency related to the facility's investigation of a fall with injury for Resident 117. The, Detailed Description of Event, stated that on 12/21/19 at approximately 6:45 PM, Resident 117 was transferred from wheelchair to bed via a mechanical lift with two staff assisting. While being lifted, one corner strap of the sling became disconnected from the lift causing the resident to slide head-first out of the sling. The resident's head hit the floor leg of the lift and the resident sustained [REDACTED]. The family and physician were notified of the fall with injury. New orders were received to send the resident to the emergency room (ER) for evaluation and treatment. The resident returned to the facility at approximately 11:30 PM on 12/21/19 with no further injuries noted. A computed tomography (CT) scan was negative for any acute trauma to the brain. The Immediate Interventions, observed in the report indicated the resident was assessed by the charge nurse, noted to have a laceration to the back of the head, and was sent to the ER for further evaluation. The mechanical lift was taken out of service for evaluation, and the facility determined the lift was in proper working order. The mechanical lift's sling (which held the resident during transfer) was evaluated and determined to be in good condition with no fraying or tears. The sling straps (which would be attached to the lift bars) were all intact. Staff were educated prior to next shift on the proper use of mechanical lifts and they completed a return demonstration. The Outcome of Investigation, stated that upon investigation, the facility determined staff did not correctly secure the mechanical lift's sling to the lift bars prior to lifting the resident. It concluded the fall was determined to be accidental. The facility was unable to substantiate abuse or neglect, and then listed the names of the Director of Nursing (DON) and Executive Director (ED). The documents submitted in the report consisted of Resident 117's identifying information, diagnoses, a statement from the Maintenance Supervisor attesting the mechanical lift was in working order, the hospital's ER discharge summary and five pages of staff education acknowledgement signatures. The report did not include the names or interviews from the staff members involved in the transfer and did not include the incident report or statement from the nurse who assessed the resident after the fall. An interview was conducted with the facility ED and DON on 09/08/20 at 6:25 PM. The ED stated the investigation had been left up to the DON. The DON was unable to provide interviews from the staff involved and when asked about the names of the Certified Nursing Assistants (CNAs) who did the transfer, the DON could not remember but was able to refer to the staffing on 12/21/19 to provide the names. During an interview on 09/09/20 at 8:50 AM, the DON provided the names of CNA-G and CNA-H but didn't know which CNA had failed to secure the right shoulder strap to the mechanical lift. The DON said, I interviewed them, and they didn't know what happened. On 09/09/20 at 1:40 PM, CNA-G was interviewed by phone about Resident 117's fall from the mechanical lift and was asked to describe the incident. CNA-G said, Yes, that was terrible. The other CNA didn't hook the strap properly. CNA-G went on to describe the incident saying, I put the strap on the lift by the head and the leg on one side and (CNA-H) put the straps on the right side. I went to the back of the machine to work the controls. (CNA-H) removed the wheelchair, and then the strap on the right, by the head came off the lift and (the resident) fell backwards out of the sling. (Resident 117's) head hit the leg of the lift. There was blood everywhere. When asked about training received on the mechanical lift, CNA-G said, Let's see .I don't remember a date or anything, but we had training all the time. I'm sure I had training on the (mechanical lift) at least once a year. CNA-H did not respond to multiple attempts for a phone interview. The facility was asked when CNA-G and CNA-H had received training for transfers with the mechanical lift. The DON provided an orientation checklist that specified CNA-H had mechanical lift transfer education on 10/07/19 as a new hire. The Administrator provided mechanical lift training dated November 2017, but it did not include CNA-G. The facility was unable to provide documentation of CNA-G's training for the mechanical lift. The mechanical lift used to transfer Resident 117, was observed on 09/14/20 at 12:59 PM. The lift had six hooks where sling straps could be attached. The DON was unsure if the sling used for Resident 117 had four 4-point straps to attach to the lift or 6-point straps. The Maintenance Director said he had checked with the mechanical lift company and was told it was okay to use a 4-point sling on a 6-point mechanical lift. The manual for the mechanical lift was reviewed but did not address the number of hooks to be used. The ED was interviewed on 09/14/20 at 3:09 PM, about what was expected regarding the content of reports to the State agency. The ED indicated interviews should be included in the investigations and staff were expected to be trained.

LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09D7 Based on observation, record review, interviews and facility policy review, the facility failed to prevent an accident when a resident fell backwards out of a mechanical lift onto the resident's head requiring an ER visit and resulting in a laceration The facility failed to ensure all staff had documented training and education on the use of the mechanical lifts. This affected 1 of 1 residents (Resident 117) in the sample reviewed for mechanical lift transfers and had the potential to affect 15 residents currently in the facility being transferred with the mechanical lift. The resident sustained [REDACTED]. The facility census was 64. Findings are: Resident 117 was admitted with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident 117 was moderately cognitively impaired, and required limited to extensive assistance with transfers. The care plan, most recently updated on [DATE], revealed the resident was at risk for falls. On [DATE], a report was submitted to the State Agency by the Director of Nursing (DON) and indicated Resident 117 had fallen from a mechanical lift on [DATE] at 6:45 PM. A second report dated [DATE] submitted to the State Agency related to the facility's investigation of a fall with injury for Resident 117. The Detailed Description of Event, stated on [DATE] at approximately 6:45 PM, Resident 117 was transferred from wheelchair to bed via a mechanical lift with two staff assisting. While being lifted, one corner strap of the sling near the resident's right shoulder became disconnected from the lift causing the resident to slide head-first out of the sling. The resident's head hit the base leg of the lift and the resident sustained [REDACTED]. The family and Personal Care Physician were notified of the fall with injury. New orders were received to send the resident to the emergency room (ER) for evaluation and treatment. The resident returned to the facility at approximately 11:30 PM on [DATE] with no further injuries noted. A computed tomography (CT) scan was negative for any acute trauma to the brain. Immediate Interventions, observed in the report indicated the resident was assessed by the charge nurse, noted to have a laceration to the back of the head, and was sent to the ER for further evaluation. The mechanical lift was taken out of service for evaluation, and the facility determined the lift was in proper working order. The mechanical lift's sling (which held the resident during transfer) was evaluated and determined to be in good condition with no fraying or tears. The sling straps (which would be attached to the lift bars) were all intact. Staff were educated prior to next shift on the proper use of mechanical lifts and they completed a return demonstration. The Outcome of Investigation, stated upon investigation, the facility determined staff did not correctly secure the mechanical lift's sling to the lift bars prior to lifting the resident. It concluded the fall was determined to be accidental. The facility was unable to substantiate abuse or neglect, and then listed the names of the Director of Nursing (DON) and Executive Director (ED). Review of the hospital ER summary dated [DATE], CT scan revealed: There is no [MEDICAL CONDITION] or mass effect. There is no hemorrhage, mass or cortical infarct. There is no [DIAGNOSES REDACTED] or shift of midline. There is no extra-axial fluid collection. The skull is normal. No acute trauma to the brain. The resident was not admitted to the hospital and returned to the nursing facility. Due to ongoing pain after the fall, a leg x-ray was ordered on [DATE]. The x-ray was negative- no fractures noted. A nursing note dated [DATE], stated Resident 117 was alert and oriented to familiar surrounding, a small hematoma with scab on the right side of the head and the resident denied pain. Nursing notes revealed between [DATE] and [DATE], the resident was treated with Tylenol and [MEDICATION NAME] for hip and back pain. Nursing notes on [DATE] indicated the resident complained of a severe headache that was unrelieved despite being given [MEDICATION NAME] for pain. The clinical record specified the resident's pain was no longer relieved by [MEDICATION NAME] on [DATE], and [MEDICATION NAME] was ordered at 10 milligrams (mg) every hour as needed for pain. [MEDICATION NAME] 1mg was also ordered for agitation and could be given every hour as needed. Due to ongoing complaints of unrelieved pain, a [MEDICATION NAME] spine x-ray was ordered and obtained on [DATE]. The results were negative for any injury. [MEDICATION NAME] and [MEDICATION NAME] continued to be given through [DATE] until on [DATE] at 9:50 AM when documentation included, Patient appears comfortable this shift, has not been yelling out for staff and remains calm. On [DATE] at 1:15 PM, the resident expired. A Health Status Late Entry note for [DATE] dated [DATE] included Resident followed due to weight loss. Resident had a recent decline, not getting out of bed, fall and decreased intake often. Received order for hospice consult on [DATE] and resident passed on [DATE]. An interview with the facility's ED and DON on [DATE] at 6:25 PM. The ED stated the investigation had been left up to the DON. The DON was unable to provide interviews from the staff involved and when asked about the names of the Certified Nursing Assistants (CNAs) who did the transfer, the DON could not remember but would be able to refer to the staffing on [DATE] for the names. The DON also could not provide documentation of any monitoring done to ensure staff were using the lift according to instructions. The DON stated there had not been any falls from the mechanical lift since Resident 117's fall. During an interview on [DATE] at 8:50 AM, the DON provided the names of CNA-G and CNA-H but didn't know which CNA had failed to secure the strap to the mechanical lift. The DON said, I interviewed them, and they didn't know what happened. On [DATE] at 1:40 PM, CNA-G was interviewed by phone about Resident 117's fall from the mechanical lift and was asked to describe the incident. CNA-G said, Yes, that was terrible. The other CNA didn't hook the strap properly. CNA-G went on to describe the incident saying, I put the strap on the lift by the head and the leg on one side and (CNA-H) put the straps on the right side. I went to the back of the machine to work the controls. (CNA-H) removed the wheelchair, and then the strap on the right, by the head came off the lift and (the resident) fell backwards out of the sling. (Resident 117's) head hit the leg of the lift. There was blood everywhere. CNA-H did not respond to multiple attempts for a phone interview. The facility was asked when CNA-G and CNA-H had received training for transfers with the mechanical lift. The DON provided an orientation checklist that specified CNA-H had mechanical lift transfer education on [DATE] as a new hire. The Administrator provided mechanical lift training dated [DATE], but it did not include CNA-G. The facility was unable to provide documentation of CNA-G's training for the mechanical lift. On [DATE] at 11:30 AM, Resident 117's primary care physician was interviewed. The physician stated the resident had also been losing some weight and refusing meals before the fall. The physician said, (Resident 117's) decline is more attributed to the dementia rather than the fall. The mechanical lift used to transfer Resident 117, was observed on [DATE] at 12:59 PM. The DON stated they currently used this kind of lift for 15 residents in the facility. The lift had six hooks where sling straps could be attached. The DON was unsure if the sling used for Resident 117 had 4-point straps to attach to the lift or 6-point straps. The Maintenance Director said he had checked with the mechanical lift company and was told it was okay to use a 4-point sling on a 6-point mechanical lift. The manual for the mechanical lift was reviewed but did not address the number of hooks to be used. The ED was interviewed on [DATE] at 3:09 PM, about what would be expected regarding training, monitoring and safe transfers. The ED said, My expectation is that staff would transfer according to how they are trained. The ED also said, I expect the training to be monitored and the training was monitored. Every day in our stand up we reviewed falls and we had no further issues with the (mechanical lift).

Licensure Reference Number: 175 NAC 12-006.18E Based on observation, interview and record review, the facility failed to evaluate the safety and provide supervision for smoking for Residents 49 and 85 and failed to ensure that a stationary fireplace did not reach a temperature that had the potential to cause [MEDICAL CONDITION] 12 residents that were identified as self-mobile with poor safety awareness (Residents 64, 25, 43, 81, 67, 13, 65, 21, 34, 32, 23 and 62). The facility Census was 92. Findings are: A. Review of the facility policy dated as effective (MONTH) 2011 revealed the facility is a nonsmoking facility for residents. Residents may not smoke on the campus. The facility will provide residents with smoking cessation assistance such as Nicotine patches to assist in their smoking cessation efforts. Interview on 3/13/2018 at 10:00 AM with the administrator revealed the facility was a non-smoking facility and residents awee required to leave the property to smoke and were not monitored by staff. Review of Resident 85's medical record revealed Resident 85 was admitted to the facility on [DATE] . Review of Resident 85's medical record revealed Resident 85 had a [DIAGNOSES REDACTED]. Review of the Social Services admission assessment dated [DATE] revealed Resident 85 wanted to smoke. Resident 85 had a BIMS (Brief Interview for Mental Status-a tool used to measure cognitive function) score of 15/15 which indicates the resident is cognitively aware. Observation on 03/20/18 at 06:30 AM revealed Resident 85 sitting in a wheelchair just outside of the facility front door. Resident 85 was wearing a coat with a loose hood and cloth gloves smoking a cigarette. Resident 85 had an oxygen tank on the back of the wheelchair. Interview on 03/20/18 at 6:35 AM with Registered Nurse (RN) - J revealed Resident 85 was allowed to go outside to smoke but was not to be smoking on the facility grounds. RN-J stated Resident 85 would be educated but continued down the hall and did not address Resident 85's smoking. Review of Resident 85's care plan dated 2/27/2018 revealed a care plan for smoking. The problem statement was I frequently go outside to smoke. The goal was to not have injuries related to smoking and an intervention was to notify the doctor if Resident 85 sustained an injury while smoking. There was no mention of a smoking safety assessment. Review of Resident 85's medical record revealed no smoking assessment was completed to determine if Resident 85 was safe to smoke independently without supervision. Review of progress notes dated 3/6/2018 revealed Resident 85 did smoke and did not desire to stop smoking or use any type of smoking cessation assistance. Interview on 03/20/18 at 7:50AM with LPN-E (Licensed Practical Nurse) revealed Resident 85 went out to smoke was not supervised. Resident 85 smoked outside and LPN-E had educated Resident 85 not to smoke with oxygen. Interview on 3/20/2018 at 6:45 AM with LPN-E revealed the staff do not keep residents' smoking supplies and was not aware where they were kept. Observation on 3/20/2018 at 6:50 AM revealed Resident 85 in a wheelchair with oxygen on it returning inside the building from smoking outside. No staff had checked on Resident 85 while Resident 85 was outside smoking. Observation on 03/20/18 at 7:57 AM revealed Resident 85 was outside the front door smoking unsupervised. The resident was in a wheelchair with oxygen on it. No staff attempted to intervene. Interview on 3/20/2018 at 9:30 AM with the Administrator revealed the facility does not admit active smokers and the facility is not responsibility for those residents that want to continue to smoke off campus so smoking safety assessments are not completed. B. Record review of Resident 49's MDS (Minimum Data Set) dated 1-12-2018 revealed the facility staff assessed the following about the resident: -BIMS was a 15. -Required limited assistance with transfers with the assistance of 1 person physically assisting. -Required limited assistance off the unit with the assistance of 1 person physically assisting. On 3-20-2018 an interview was conducted with Registered Nurse (RN) I. During the interview RN I identified Resident 49 as a resident who smoked cigarettes at the facility. RN I reported the facility was a smoke free facility and if residents want to smoke, they had to go off facility grounds. When asked if Resident 49 was supervised or if there was a process to evaluate residents for safety, RN I stated no. On 3-20-2018 at 7:40 AM an interview was conducted with Licensed Practical Nurse (LPN) H. During the interview LPN H reported the facility was smoke free and those residents who want to smoke must go off of the facility grounds. When asked if residents were supervised when off the facility grounds, LPN H responded that residents were not supervised. On 3-20-2018 at 7:43 AM an interview was conducted with LPN G. During the interview LPN G identified Resident 49 as a resident who smoked cigarettes at the facility. LPN G further reported Resident 49 does own thing. LPN G reported there was no process to evaluate resident's safety for smoking and that staff did not supervise residents while smoking. On 3-20-2018 at 8:45 AM an interview was conducted with Resident 49. During the interview Resident 49 reported that (gender) smoked and goes out front to do it. Resident 49 reported staff do not supervise while Resident 49 was smoking. On 3-20-2018 at 10:05 AM an interview was conducted with the facility Administrator. During the interview; the Administrator reported the facility was a non-smoking facility and reported when residents who smoked were admitted to the facility, they were considered exsmokers. The Administrator reported evaluations were not completed for smoking safety for residents. As outlined by the Administrator of the facility on 3/21/2018 at 2:30 PM the facility initiated the following plan to address the immediacy of the situation. The facility educated all staff regarding the smoking policy prior to them working their next shift. All residents that leave the facility grounds to smoke will be assessed for safety with smoking and the ability to leave the facility grounds. All smoking material will be kept by the facility. All residents will be advised of the non-smoking policy prior to and at admission. The facility will offer smokers that wish to be admitted to the facility a smoking cessation program. Audits will be conducted on new admissions daily for 30 days and weekly for 90 days to assure the residents were educated on the facility non-smoking policy upon admission and sign a written agreement regarding the non-smoking policy. All current residents that want to smoke have been assessed for safe smoking and ability to safely leave the campus. With the above interventions initiated, the scope and severity of the deficiency was lowered to an E. C. Record review of an article http://www.forensic pathologyonline.com/E-Book/injuries/thermal injuries written by Dr. Dinesh Rao revealed that a burn is an injury which is caused by application of heat to the external or internal surfaces of the body, which causes destruction of tissues. The minimum temperature for producing a burn is about 44 degrees Celsius (C) (111 degrees Fahrenheit (F) for an exposure of 5 to 6 hours or about 65 degrees C ( 149 degrees F) for 2 seconds are sufficient to produce burns. A highly heated solid body, when applied to the body for a very short time, may produce only a blister and reddening corresponding in size and shape to the material used. It will cause destruction, or even charring of the parts, when kept in contact for some time. The epidermis (skin) may be found blackened, dry and wrinkled. Record review of Dr. Moritz and Dr Henriques Harvard medical School Temperature /Time Burn Chart revealed the following temperature versus time to produce 1st ( first [MEDICAL CONDITION] only the outer layer of skin, skin may be red and painful), second (The outer and the layer underneath has been damaged, skin will be bright red, swollen and may look wet and shiny and may be blistered) and third [MEDICAL CONDITION](all layers of the skin have been damaged as well as muscles, tendons, ligaments and possibly organs, there is serious damage to nerves): 131 degrees F: 17 seconds for a first degree burn, 30 seconds for a second-3rd degree burn 140 degrees F: 3 seconds for a first degree burn, 5 seconds for a 2nd-3rd degree burn 151 degrees F: instant for a first degree burn, 2 seconds for a 2nd to 3rd degree burn Observation on 03/14/18 at 07:28 AM revealed a stationary electric fireplace present in the main lobby area of the facility. The fireplace was on, blew out warm air and had no protective barrier in front of the fireplace. The temperature of the exterior surface of the fireplace was taken and read 163.8. Observation on 03/14/18 at 09:27 AM with the Director of Nursing (DON) confirmed that the fireplace was on, blew out warm air and had no protective barrier in front of the fireplace. The temperature of the exterior surface of the fireplace was taken and read 156.2. Interview on 03/14/18 at 09:28 AM with the DON confirmed the temperature of the fireplace read 156.2. The DON confirmed that the exterior of the fireplace was hot to the touch and did have the potential to cause a burn if a resident were to touch it or sit closely to it for an extended period of time. Record review of a document received on 03/14/18 at 09:19 AM revealed a list of self-mobile residents with poor safety awareness and wandering behavior. Interview on 3/14/18 at 9:20 AM with the DON confirmed and identified a total of 12 residents (Residents 64, 25, 43, 81, 67, 13, 65, 21, 34, 32, 23 and 62) that had poor safety awareness, exhibited wandering behavior and were self-mobile. The DON confirmed that those residents would be able to access the fireplace in the lobby and could potentially be burned if they were to touch the exterior of the fireplace.

Licensure Reference Number: 175 NAC 12-006.02 Based on observations, record review, and interviews; the facility administration failed to ensure effective management of facility resources to maintain the highest practical wellbeing of residents and the facility environment as evidenced by 1) failure to implement an effective plan of action to maintain correction for previously cited areas of deficient practice, 2) failure to ensure the facility identified and developed plans of action to identify multiple issues of deficient practice Facility Census was 92. Findings are: The facility was found to be deficient in multiple areas of regulatory compliance after the tasks of the standard annual survey were completed. Please refer to the Tag citations for specific detailed findings. - F550 (formerly F151) Resident Rights. Previously cited 1/2018. - F580 (formerly F157) Notification of change of condition. Previously cited 3/2017 - F609 (formerly F225) Complete and submit investigations in 5 working days. - F657 (formerly F280) Review and Revise the comprehensive care plan. Previously cited 10/2015 - F676 (formerly F312) Provide ADL assistance. - F689 (formerly F323) Accident Prevention Previously Cited 10/2015, 3/2017, 8/2017, 12/2017. - F692 (formerly F325) Nutrition-Weight loss prevention - F697 (formerly F309) Pain Management Previously Cited 1/2017 - F730 (formerly F497) Nursing Assistants 12 hours annual continuing education. - F755 (formerly F425) Medication Storage and labeling. - F758 (formerly F428) Behavior management for residents on antipsychotic medications. - F812 (formerly F317) Safe food handling and storage. Previously Cited 8/2017 - F835 (formerly F490) Administration. - F867 (formerly F520) Quality Assurance Plan - F880 (formerly F441) Infection Control - F881 (no former F tag) Antibiotic Stewardship Program Interview on 3/21/2018 at 3:40 PM with the administrator confirmed they had multiple deficient practice.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, record review, and interview; the facility failed to implement interventions for pain management for 1 resident (Resident 66) of 2 residents sampled. The facility census was 92. Findings are: Record review of Resident 66's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 2/19/2018 revealed the following about Resident 66. Section C identified the Brief Interview for Mental Status (BIMS) score of 10 (The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition. Scoring 9-12 points indicates the person is moderately impaired). MDS section J Pain Management revealed that Resident 66 should receive scheduled and PRN (as needed) medications along with non-medication interventions for pain. Resident 66 should had a pain assessment interview conducted and the results were in the last 5 days. Resident 66 has had pain frequently with the highest pain intensity of 6 out of 10. Record review of a facility investigation of a fall with injury dated 3/9/2018 at 9:50 PM revealed that on 3/8/2018 at 3:30 PM Resident 66 slid out of (gender) wheelchair in transport van Resident 66 was taken to Methodist ER (emergency room ) for further evaluation. Resident 66 was admitted with a [DIAGNOSES REDACTED]. Record Review of Physician order [REDACTED]. Record Review of a Pain Assessment form dated 3/12/2018 revealed Resident 66 was assessed to have acute pain at a moderate level. According to the Pain Assessment Resident 66 was assessed to have the following signs of pain - Severe vocalizations (e.g. whimpering, groaning, crying) -Moderate facial expressions (e.g. looking tense, frowning, grimacing, looking frightened) -Moderate behavioral change (e.g. increased confusion, refusing to eat, alteration in usual patterns) Record Review of Resident 66's Medication Administration Record [REDACTED]. Continuous observation of personal care on Resident 66 on 3/15/18 from 09:03 am to 11:00 am, revealed Nursing Assistant (NA) C entered Resident 66's room to assist with morning meal. Resident 66 requested pain medication at that time. NA C told Resident 66 that NA C would inform Resident 66's nurse about the request. NA C then helped Resident 66 eat the morning meal without alerting Resident 66's nurse of the request of pain medications. Following the morning meal NA C left the room. NA C located NA B and requested assistance with personal care of Resident 66, NA C did not inform Resident 66's nurse of request for pain medications. NA B and NA C returned to Resident 66's room to perform personal care. NA B explained they would be changing Resident 66's brief. NA B unfastened Resident 66's brief and frontal peritoneal cleansing was completed. NA B and NA C started to turn Resident 66, Resident 66 began to cry out wait a minute, wait a minute Resident 66 had a furrowed brow and started to grab toward right leg. NA B and NA C stopped and NA told Resident 66 'I'm sorry but this has to be done NA B and NA C immediately attempted to turn Resident 66 again. Resident 66 cried out Stop, Stop, My leg, My leg Resident 66 had a furrowed brow and was grabbing at right leg. NA B and NA C stopped and NA B told Resident 66 We stopped, but this has to be done NA B and NA C immediately began turning Resident 66 again. Resident 66 cried out My leg, my leg, stop my leg, NA B and NA C continued to turn Resident 66 positioning the resident on their left hip. The brief was removed and rear peritoneal cleansing care was completed. Resident 66 was then rolled back to a flat position, Resident 66 cried out my leg, my leg during this movement. NA B and NA C then attempted to roll Resident 66 to the right. Resident 66 refused to let NA B and NA C complete this movement. At that point NA B stated to NA C, we need to tell the nurse to get a pain pill for Resident 66. Frontal peritoneal cleansing was preformed again. NA B and NA C then rolled the resident back to the left while Resident 66 cried out my leg, my leg and placed the clean brief under the resident by pushing the left side of the brief under the left hip. NA B and NA C then rolled Resident 66 to a flat position on the back. Resident 66 cried out my leg my leg during the movement with a furrowed brow and grabbing toward the right leg. NA B said that they would find a nurse for pain medication. At 10:12 Both NA B and NA C left Resident 66's room, at no time did NA B or NA C inform Resident 66's nurse prior to entering the next resident's room. At 10:15 AM Resident 66 could be heard calling out for help from the south nurse's station, Registered Nurse (RN) I heard Resident 66 and responded to the calls for help. RN I inquired about Resident 66's needs, then informed Resident 66 of return with help. RN I then returned to the south nurse's station and informed Resident 66's Nurse (LPN E) that Resident 66 was requesting pain medication. At 10:46 LPN E entered the room and administered pain medication to Resident 66. On 03/21/18 at 2:35 PM an interview was conducted with LPN E. During the interview LPN E reported never being told that Resident 66 was experiencing pain. On 03/21/18 at 2:43 PM an interview was conducted with the Director of Nursing (DON). The DON reported that the expectation was, if a resident was showing signs and symptoms of pain, the cares should be stopped and the pain addressed immediately. The DON further reported that the NAs were expected to notify the nurse if a resident was in pain during cares . Record Review of the facility's Pain Management Policy dated 11/2016: Purpose of pain management was to promote the patient well-being by reducing their pain. The facility will implement a pain management system to help patients attain or maintain their highest practical level of well-being by preventing or managing pain. This will be completed by being proactive in identifying, care planning and monitoring the patient's pain indicators.

LICENSURE REFERENCE NUMBER 175 NAC ,[DATE].09 Based on record review, observations and interviews; the facility failed to evaluate, monitor and prevent a decline related to pain management for 2 of 3 sampled residents (Residents 66 and 131), failed to communicate with the outpatient [MEDICAL TREATMENT] team to coordinate care for one sampled resident (Resident 141), and failed to evaluate, monitor and provide care related to bowel management to prevent constipation requiring a hospital visit for one sampled resident (Resident 141). The facility census was 85. Findings are: A. Review of Resident 131's face sheet revealed Resident 131 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation on [DATE] at 10:50 AM revealed Resident 131 in bed moaning when asked if Resident 131 was in pain, Resident 131 replied yes. An interview on [DATE] at 2:20 PM with Resident 131's daughter revealed that Resident 131 did have pain down Resident 131's legs and the daughter was not sure if Resident 131 ever had gotten relief from the pain. An observation on [DATE] at 7:25 AM revealed Resident 131 in bed moaning with a grimaced facial expression. Review of Resident 131's Pain care plan with an initiation date of [DATE] revealed that Resident 131 was at risk for pain related to a past stroke with right sided weakness. Listed approaches were: administer medications as ordered, assess and document pain using ,[DATE] pain scale (10= greatest pain 0= no pain) or faces scale every shift and as needed, monitor for nonverbal indications of pain such as crying, guarding, irritability, assess pain at least one hour after administering interventions, and notify physician of subtherapeutic pain management regimen. Resident 131's [DATE] MAR (Medication Administration Record) revealed the resident had gotten the following pain medications: [REDACTED] -Tylenol 650 mg (milligram) four times a day for Mild to severe pain -[MEDICATION NAME] (non-opioid pain medication) 25 mg four times a day for Mild to severe pain -[MEDICATION NAME] (opioid pain medication) 5 mcg/hr (micrograms/hour) transferal patch topically, change weekly for moderate to severe pain that was discontinued on [DATE] -[MEDICATION NAME] (opioid pain medication) 10 mg every 12 hours for pain -No as needed pain medications were documented as being given. Review of Resident 131's Medication Administration Records for [DATE] revealed Resident 131's pain was to be assessed every shift using the ,[DATE] pain scale. The documented pain for Resident 131 for December was: Date: Day Shift Evening Shift Night Shift 10th ,[DATE] ,[DATE] ,[DATE] 15th ,[DATE] ,[DATE] ,[DATE] 21st ,[DATE] ,[DATE] ,[DATE] 22nd ,[DATE] blank ,[DATE] 23rd ,[DATE] ,[DATE] ,[DATE] 24th ,[DATE] ,[DATE] ,[DATE] 25th ,[DATE] ,[DATE] ,[DATE] 26th ,[DATE] ,[DATE] ,[DATE] 29th ,[DATE] blank blank 30th ,[DATE] ,[DATE] ,[DATE] 31st ,[DATE] ,[DATE] ,[DATE] Resident 131's [DATE] MAR indicated [REDACTED] A Telephone physician order dated [DATE] for Resident 131 ordered staff to discontinue oxcycontin 10 mg when the supply was gone and change to [MEDICATION NAME] Extended Release 15 mg every 12 hours for pain control. Review of Resident 131's Nurses Notes on [DATE] revealed that at 2:20 PM Resident 131 was hollering out in pain, crying and guarding both legs. Staff notified the Physicians Assistant and an order was obtained to send Resident 131 to the emergency room . Review of the Emergency Department Physician Discharge note dated [DATE] revealed that Resident 131 presented with lower extremity pain and that the onset was one day ago. The duration of symptoms was constant with no relieving factors. An interview with the Director of Nursing (DON) conducted on [DATE] at 3:45 PM confirmed that the new order for Resident 131 obtained on [DATE] for [MEDICATION NAME] for pain control was not started until January and confirmed that staff should have called the physician to clarify the start date of the new pain medication due to Resident 131's pain being rated at a high level. Review of Resident 131's nurses notes revealed the resident returned to the facility on [DATE] from the emergency room . Review of Resident 131's nurses notes revealed that on [DATE] the residents pain was rated at ,[DATE], no relief with pain medication. Review of Resident 131's Medication Administration Records for [DATE] revealed Resident 131's pain was to be assessed every shift using the ,[DATE] pain scale. The documented pain for Resident 131 for January was: Date: Day Shift Evening Shift Night shift 2nd ,[DATE] ,[DATE] ,[DATE] 3rd ,[DATE] ,[DATE] ,[DATE] 4th ,[DATE] ,[DATE] ,[DATE] 5th ,[DATE] ,[DATE] ,[DATE] 6th ,[DATE] ,[DATE] ,[DATE] 7th ,[DATE] ,[DATE] Resident Expired Resident 131's [DATE] MAR indicated [REDACTED] [MEDICATION NAME] (non-opioid pain medication) 25 mg four times a day [MEDICATION NAME] 15 mg every 12 hours [DATE]-5th [MEDICATION NAME] 30 mg every 12 hours [DATE]th Review of Nurses Notes for Resident 131 revealed: -[DATE] Resident 131 continued to complain of pain, medications were given with little relief. -[DATE] Resident 131 continued to have pain all over. [MEDICATION NAME] inititiated this evening for better pain control (from physicians order on [DATE]) -[DATE] Resident 131 reported pain medication was not effective and not holding pain until the next dose. The Physician was to evaluate on rounds. -[DATE] Resident 131 was found crying in pain and the physician saw the resident and increased the [MEDICATION NAME] to 30 mg twice a day for pain control. -[DATE] at 1:22 PM Resident 131 was not able to swallow and was non verbal, would open eyes when Residents name was called. The Physician was informed that Resident 131 was not able to swallow and an order was given to hold all medications. A telephone order dated [DATE] at 7:45 PM revealed an order for [REDACTED]. A Nurses Note on [DATE] stated resident 131 passed away at 8:15 PM. An interview conducted on [DATE] with Licensed Practical Nurse (LPN) A at 2:40 PM revealed that Resident 131 had always had problems with pain control. An interview conducted on [DATE] with LPN O at 2:45 PM revealed that LPN O worked on [DATE] and recalled Resident 131 being in pain the day that the resident passed away. An interview conducted on [DATE] with LPN C at 2:56 PM revealed that LPN C had worked [DATE] and Resident 131 could not swallow pills that morning and the physician was called and the physician ordered to hold all medications. LPN C confirmed that Resident 131's pain medication was also held as Resident 131 could not swallow and nothing else was given or ordered to be given in place of it. Review of the MAR for [DATE] revealed on [DATE] Resident 131's pain on the ,[DATE] shift was rated at a ,[DATE]. An interview conducted with the DON on [DATE] at 3:45 PM revealed that if a resident was ever having pain at a 6 or greater the nurse should do some pain intervention of medication or other nonmedication intervention and then reassess to see if it was effective. The DON stated if the pain wasn't controlled then the physician should have been called. The DON confirmed that once Resident 131 was no longer able to take oral medications there should have been some other route of pain medications ordered to be given to keep the pain managed. LICENSURE REFERENCE NUMBER: NAC 175 12.006.09 D B) Record review of Resident 66's face sheet, dated [DATE], revealed that Resident 66 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 66's MDS (The Long-Term Care Minimum Data Set (MDS) a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and/or Medicaid-certified long-term care facility) dated [DATE] revealed that Resident 66's cognitive status score was 15 out of 15, indicating the resident was cognitively aware. The MDS revealed that the resident was assessed for pain. The resident required pain medication on a routine basis and as needed (prn). Pain had limited Resident 66's activities and was rated at an 8 on the scale from 1 to 10. Observation of Resident 66 on [DATE] at 10:32 AM revealed, Resident 66 was lying in bed, with the room dark, with the head of the bed elevated, and had grimacing facial expressions and arms crossed over the abdomen. Observation of Resident 66 on [DATE] at 11:06 AM revealed, Resident 66 was lying in bed, with the room dark, with the head of the bed elevated, and had grimacing facial expressions and arms crossed over the abdomen. Interview with Resident 66 on [DATE] at 11:06:AM revealed that the resident was having severe pain. Resident 66, had rated the pain a 9 out of 10 in severity. Resident 66 revealed that it was from the [MEDICAL CONDITION]'s disease and mostly in the left abdomen. Resident 66 revealed that the resident had not been able to sleep because of the pain. Observation of Resident 66 on [DATE] at 7:46 AM revealed Resident 66 in bed with face red, grimacing and restless. Interview with Resident 66 on [DATE] at 7:46:23 AM revealed that the resident was in and the pain was rated a 9 ,[DATE] on a 10 point scale. Resident 66 revealed that the pain had was so severe that the resident was unable to sleep last night. Resident 66 revealed that the resident had asked for additional pain medication or something to sleep. Resident 66 revealed that the facility physician had said that no increase in pain medication would be given. Resident 66 revealed that the pain had been so severe that was unable to participate in therapy,for the past few days, and unable to get out of bed for the past 2 days. Interview with Resident 66 on [DATE] at 7:05 AM revealed that prior to the current fractures, a pain management doctor had been working on controlling the pain. Resident 66 revealed that changes had been made during the hospital stay to decrease the oral pain medications, to utilize intravenous pain medication. The resident stated that the resident had been taking pain medication since age of 20 due to the [MEDICAL CONDITION]'s disease and does realize a tolerance had developed. The resident revealed that the resdient had requested an appointment be made to be seen by the pain management physician. The facility responded by telling the resident that the facility staff had told Resident 66 that when admitted to the facility, Resident 66 had signed up to use the facility doctor and that Resident 66 would not be able to see the pain management doctor or the psychiatrist due to the insurance company would not pay for it. Resident 66 revealed that the pain was and has remained a 9. Resident 66 revealed that an acceptable rate for pain that was controlled would be a 3. Record review of Resident 66 Hospital Discharge Summary, dated [DATE], under the section titled, Pending lab and Physician Follow-up, revealed that Resident 66 was to see a pain specialist with in a week. Record review of Physician's progress notes dated [DATE] revealed that Resident 66's was up in the hall and pain was controlled. Progress note revealed that Resident 66 was narcotic dependent. Record review of Resident 66's Comprehensive Plan of Care (CPC) dated [DATE] revealed that Resident 66 had the [DIAGNOSES REDACTED]. The Goal for Resident 66 was that pain would be minimized with medication and positioning. Resident 66 was to have relief or reduction in the pain intensity within one hour after receiving interventions through the next review date of [DATE]. The approaches developed for Resident 66 were as follows: Administer and observe for effectiveness and for possible side effects from the pain medication. Consultation as needed Occupational Therapy (OT) Physical Therapy (PT) Notify physician if resident does not state or demonstrate relief or reduction of pain after one hour of receiving the last intervention. Observe and report to nurse the signs and symptoms of pain, (crying, resist moving, resist cares, agitation, grimaces) Report changes in pain location and type with frequency and intensity to the physician. Record Review of Resident 66's Physician orders dated [DATE] revealed the following medication related to pain: Monitor for signs and symptoms of pain each shift. [MEDICATION NAME] 30 mg one tablet by mouth every 8 hours (opiod pain medication) [MEDICATION NAME] 300 mg take on tab by mouth two times per day for [MEDICAL CONDITION] pain (nerve pain medication) Morphing Immediate Release(IR) 30 mg , give ,[DATE] tablet by mouth every 4 hours prn for pain [MEDICATION NAME] IR 30 mg 1 tab po by mouth as needed every 4 hours prn for pain Record review of Resident 66's Medication Administration Record [REDACTED]. Record review of the MAR Pain flow Record for [DATE] at 9:15 AM, the resident rated the pain a 7 out of 10 and received prn pain medication. Record review of the MAR for the month of [DATE] revealed the resident had not received the [MEDICATION NAME] 30 IR 1 tablet during that month. Resident had received ,[DATE] tablet on [DATE] at 8 am, [DATE] at 3:30 PM, [DATE] at 5 PM, [DATE] at 5 PM, [DATE] at 9 am and then not again until [DATE] at 9:15 AM and 12:15 PM Record review of Rehabilitation Services Progress Note dated [DATE] at 2:00 PM revealed the resident did not want to participate in therapy on this date due to [MEDICAL CONDITION]'s disease pain. Record review of the Rehabilitation Services Progress Note dated [DATE] at 8:29 AM revealed OT was unable to work with the resident due to the resident having pain due to [MEDICAL CONDITION]'s disease. Interview on [DATE] at 8:48:04 AM with PT Q and with OTR R reveled that Resident 66 had been seen by both services. Resident 66 was unable to participate in the therapy because of the pain due to the [MEDICAL CONDITION]'s disease. Resident 66 had a decline. PT Q revealed that Resident 66 was not having severe pain with the fractures, but was not able to participate because of [MEDICAL CONDITION]'s pain. OTR R revealed that on [DATE] and on [DATE] Resident 66 was unable to participate in the therapy related to pain. OTR R revealed that the resident was unable to get out of the bed because the pain was so severe. PT Q and OTR agreed that when Resident 66 first came to the facility, progress was made but after Resident 66 had layed in bed and not particpated in therapy, the resident had a decline. Therapy note for [DATE] revealed Resident 66 had requested to stop therapy due to [MEDICAL CONDITION]'s disease pain. Interview on [DATE] at 1:42 PM with ADON K confirmed that the process for admission by the facility included reviewing the documents that were received from the hospital. Upon review of Resident 66's record and document titled, Hospital Discharge Summary, dated [DATE], under the section titled, Pending lab and Physician Follow-up, revealed that Resident 66 was to see a pain specialist with in a week. ADON K confirmed that this had not been completed by the facility. On [DATE] at 8:59:46 AM, interview with the DON confirmed that Resident 66 did not see a pain management physician since admission on [DATE]. The DON confirmed that if Resident 66's pain was controlled, participation in therapy would have been improved, therefore there would not have been a decline in the resident's progress. LICENSURE REFERENCE NUMBER: NAC 175 ,[DATE].09D3(5) C ) Record review of Resident 141's medical record, revealed that Resident 141 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 141's Minimum Data Set ( MDS, a federally mandated assessment tool used for care planning) dated [DATE] revealed that, Resident 141's cognitive status score was 15 out of 15. Resident 141 was continent of urine and bowel. Record review of the facility policy titled Bowel Protocol revealed: -Purpose: To proved effective interventions for signs and symptoms of constipation. Protocol: 1) Nursing staff to document the resident's bowel movements each shift. 2) The evening shift nurse is to assess the bowel movement data daily and responds according to the protocol and/or physicians orders. 3) If no bowel movement is recorded for two days: The nurse is to assess for signs and symptoms of constipation, If the resident is alert and oriented, ask about any unrecorded bowel movements and assess for constipation. If constipation is validated and no acute abdominal symptoms are present, give ,[DATE] ounces (oz) of prune juice or 1 oz of fruit butter with the evening meal or med pass. If Acute abdominal symptoms are present, contact the physician immediately. 4) If no bowel movement is recorded for 3 days: Assess for absence of acute abdominal symptoms, administer a as needed (prn) laxative or enema, as ordered by physician. If acute abdominal symptoms are present, contact the physician immediately. 5) After 4 days with no bowel movement or inadequate response to previous interventions contact the physician. Interview on [DATE] at 2:46 PM, with Resident 141 revealed, that the resident had gone to [MEDICAL TREATMENT] yesterday ([DATE]) and was miserable. The resdient stated that the resident had nausea and threw up twice. Resident 141 revealed that the facility had called 911 and the resident went to the emergency room (ER). Resident 141 revealed that at the ER an enema was administered, and the nausea and vomiting had improved. Resident 141 revealed that the nausea remained this am, improved this after noon after 3 more large bowel movements. Resident 141 revealed that the resident had been in discomfort and the resident fears of it re-occurring. Resident 141 revealed that due to all the pain medication required at this time, the resident had been having a trouble with constipation even with the medications received. Resident 141 revealed that no medications were given to take to the outpatient [MEDICAL TREATMENT] center to be taken and that those medications were missed for the day. Resident 141 revealed that if the resident had not had a bowel movement by the 3rd or 4th day, the resident became sick. Record review of Physician orders revealed that Resident 141 was ordered the following medications to treat constipation: 1) Ducosate Sodium 100 mg capsule by mouth two times daily for constipation 2) Naloxegol 12.5 mg by mouth daily for opioid induced constipation 3) Polyethylene [MEDICATION NAME] 3350 17 gram dose oral powder by mouth two times daily mixed in ,[DATE] ounces of fluid. 4) Senna Plus 8.6 mg -50 mg tablet 2 tabs two times by mouth prn for constipation 5) [MEDICATION NAME] 4 mg , delayed release two tabs daily by mouth prn for constipation 6) [MEDICATION NAME] 10 mg rectal suppository prn every other day as needed for constipation 7) Fleet Enema 19 gram- 7 gram 118 ml 1 enema per rectum prn daily as needed for constipation. Record review of Resident 141's Physician orders revealed that Resident 141 was to attend [MEDICAL TREATMENT] on Monday, Wednesday, and Friday at a outpatient facility. Resident may have Medications 2 hours before or 2 hours after [MEDICAL TREATMENT]. Record review of Resident 141's Medication Administration Record [REDACTED]. The following are the medications with the dates that Resident 141 did not receive the medications: [REDACTED] -Ducostate sodium 100mg po two times per day 8 am and 8 pm. The MAR indicated [REDACTED] -Naloxegol 12.5 mg by mouth daily at 8 am, The MAR indicated [REDACTED]`16, [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] -Polyethylene [MEDICATION NAME] 3350 17 gram dose oral powder by mouth two times daily. The MAR indicated [REDACTED] Resident 141's MAR indicated [REDACTED]. -[MEDICATION NAME] 10 mg rectal suppository prn [DATE], -[MEDICATION NAME] 5 mg tablet delayed release [DATE] -Ondasteron HCL 4 mg talbelt every 8 hours prn for nausea/vomiting [DATE] -Senna Plus 8.6 mg-50mg tablet 2 tabs [DATE] Record review of Resident 141's Monthly Flow Report ( record for recording bowel movements) for December revealed that Resident 141 had no documented bowel movements from [DATE] to [DATE]. Recorded on [DATE] was a small incontinent stool. The next bowel movement recorded was on [DATE] as a continent medium bowel movement. Record review of Resident 141's Monthly Flow Report for December/January revealed that Resident 141 had no recorded bowel movement from [DATE] to [DATE], and from [DATE] to [DATE]. Record review of Resident 141's Seven Day Look Back , Bowel Record printed [DATE] revealed the resident had 1 documented bowel movement from [DATE]- [DATE]. Record review of Resident 141's Comprehensive Plan of Care (CPC), dated [DATE] revealed, Resident 141 had a potential for complications related to [MEDICAL TREATMENT] for [DIAGNOSES REDACTED]. The goal for Resident 141, with the target date of [DATE], was for Resident 141 to receive [MEDICAL TREATMENT] as ordered with minimal complications through next review date. The approaches to meet this goal included: -To administer and observe for the effectiveness of medications as ordered by Resident 141's physician. -Communicate with the [MEDICAL TREATMENT] center regarding medications, diet, and lab results. Coordinate Resident 141's care in collaboration with the [MEDICAL TREATMENT] center. Record review of Resident 141's CPC dated [DATE] revealed Resident 141 was at risk for constipation related to impaired mobility and use of pain medications. The Goal that was set for Resident 141 was to be free from constipation through the next care plan review with a target date of [DATE]. The approaches to meet Resident 141's goal included: -Monitor bowel sounds prn -Monitor bowel movements -Administer laxative prn -Update physician prn Record review of Nursing note dated [DATE] at 3:06 PM by Licensed Practical Nurse (LPN) N revealed that Resident 141 had thrown up twice at [MEDICAL TREATMENT] and had called 911 and was being transported to the ER. Record review of Nursing note dated [DATE] at 5:32 PM by LPN N revealed that a call was received from the ER and that the resident would be returning. Resident 141 had a large bowel movement, which was the cause of the nausea and vomiting. Record review of Nursing note dated [DATE] at 8:53 PM by LPN N revealed that Resident 141 returned to the facility with no nausea or vomiting. Interview on [DATE] at 2:05 PM with LPN P revealed that Resident 141 had called, from the [MEDICAL TREATMENT] center, on [DATE] and revealed that nausea and vomiting had occurred. LPN P revealed that the plan was to administer medication upon return to the facility for nausea. LPN P confirmed that 8 am medications for Resident 141 had not been administered on the days of [MEDICAL TREATMENT] on Monday, Wednesday and Friday. LPN P confirmed that, no medications were sent with Resident 141 to be taken during outpatient [MEDICAL TREATMENT]. LPN P confirmed that there were 3 medications to treat constipation scheduled for 8 am and that they were not administered during out patient [MEDICAL TREATMENT] days. Interview with ADON K on [DATE] at 2:55 PM revealed that Resident 141's last bowel movement recorded was on [DATE]. ADON K confirmed that Resident 141's record had no documentation for the 7th , 8th, and 9th. ADON K confirmed that Resident 141 had required emergency room treatment for constipation after episodes of nausea and vomiting related to constipation, and that Resident 141 had not received the medications to treat constipation as ordered by the physician. LICENSURE REFERENCE NUMBER: NAC 175: ,[DATE].09D D ) Record review of Resident 141 medical record, revealed that Resident 141 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 141's MDS dated [DATE] revealed that Resident 141's cognitive status score was 15 out of 15. Record review of the facility's [MEDICAL TREATMENT] Policy, revised [DATE], revealed the purpose of the policy was to provide guidelines for the patient that received [MEDICAL TREATMENT] at another facility. The policy was based on comprehensive, assessment of a resident, to ensure that a resident who required [MEDICAL TREATMENT] received the service, consistent with professional standards of practice, and that resident goals and preferences were honored. The policy revealed that the [MEDICAL TREATMENT] resident would receive consistent care pre and post-[MEDICAL TREATMENT]. The policy revealed that the shunt site (A [MEDICAL TREATMENT] Arterial Venous Shunt is a connection between a vein and an artery, usually in the forearm or upper arm. This provides easy access to the vascular system for [MEDICAL TREATMENT], a procedure that performs the function of the kidney, in people whose kidneys have failed) would be checked on a daily basis with physician notification for any known or suspected problem. The policy revealed the following: Pre-[MEDICAL TREATMENT]: 1. The physician would have established an order and the amount of time required for the patient to be on [MEDICAL TREATMENT]. 2. Lab work, as ordered by the physician , would be monitored 3. Patient teaching would be done, regarding day and time of [MEDICAL TREATMENT], fluid restrictions as ordered by the physician (to be instructed by the dietitian). Day of [MEDICAL TREATMENT]: 3) If the receiving facility requires a form to be completed and sent with resident, it would be sent with that resident. 4) The receiving facility ([MEDICAL TREATMENT] center) would be advised of medications the resident was currently taking, and any special information or instructions particular to that resident. Post [MEDICAL TREATMENT]: 1) Obtain Vital signs of the Resident upon return from [MEDICAL TREATMENT] to the facility. 2) Follow routine [MEDICAL TREATMENT] instructions on the [MEDICAL TREATMENT] transfer form 3) Transcribe any diet, medication, and/or orders received with the resident from the [MEDICAL TREATMENT] facility. 4) Allow rest period for resident upon their return to the facility. 5) Monitor shunt site on a routine basis. Notify physician it any unusual problems are noted with shunt site (tenderness, bleeding). Maintain [MEDICAL TREATMENT] transfer form in the resident medical record- do not destroy. Record review of Resident 141's record revealed a form titled Pre/Post [MEDICAL TREATMENT] Communication. This form had 3 sections, Pre-[MEDICAL TREATMENT], [MEDICAL TREATMENT] Center (to be completed by the [MEDICAL TREATMENT] staff) and Post [MEDICAL TREATMENT]. The form included the following in all 3 sections. Vital signs, weights, lung sounds, condition of access site, bruit and thrill assessment (shunt assessment of a vibration and a pulse done by touch and auscultation), and a place for additional notes. Each has signature line with title, date, and time. The Pre-[MEDICAL TREATMENT] (to be done prior to resident leaving the facility) Ask if any medications were given to the resident to take at the [MEDICAL TREATMENT] center. It asked if there was a meal given to the resident to take to the [MEDICAL TREATMENT] center. Is the Resident presently on an antibiotic and if so what was the [DIAGNOSES REDACTED]. The [MEDICAL TREATMENT] Center section revealed the type of vascular access used and pre and post [MEDICAL TREATMENT] weights. The Post-[MEDICAL TREATMENT] section was for the facility to complete upon the resident return. Record review of Resident 141's Pre/Post [MEDICAL TREATMENT] Communication Records revealed that the facility failed to perform the assessment upon return to the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and on [DATE]. Record review revealed that the facility received the resident from the [MEDICAL TREATMENT] center with no documentation regarding, what occurred with Resident 141 during the [MEDICAL TREATMENT] treatments on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The communication tool had not been completed by the [MEDICAL TREATMENT] center. Interview on [DATE] at 11:55 AM with the facility DON confirmed that the communication forms were used to communicate with the [MEDICAL TREATMENT] facility, that they were transported with the resident in a 3 ring binder. The DON confirmed that the facility failed to perform the assessment, for Resident 141, upon return to the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and on [DATE]. The DON confirmed the facility failed to call the [MEDICAL TREATMENT] center for the information regarding Resident 141 ' s [MEDICAL TREATMENT] treatment at the [MEDICAL TREATMENT] center when the form returned without any information.

LICENSURE REFERENCE NUMBER 175 NAACP 12-006.09 Db Based on record review, observation, and interview; the facility failed to evaluate and ensure functioning of respiratory equipment for one resident (Resident 1). The facility census was 104 Findings are: A review of Resident 1's face sheet revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's physician orders [REDACTED]. A review of a list of interviewable residents in the facility provided by the Director of Nursing on 6-28-16 at 4 PM revealed Resident 1 was interviewable. An interview conducted on 6-28-16 at 4:20 PM with Resident 1 revealed that prior to Resident 1's hospitalization on [DATE], Resident 1 was to wear a [MEDICAL CONDITION] while sleeping. Resident 1 stated that the [MEDICAL CONDITION] machine had been broken for weeks. Resident 1 reported that multiple staff were made aware that it was broken, however the staff just kept saying the company that owned the [MEDICAL CONDITION] would have to come out and fix it but no one ever came. Resident 1 stated the settings were not correct on the [MEDICAL CONDITION] and it would shoot out a very high pressure of air and then it would just turn off and stay off. Resident 1 stated that upon return to the facility after the hospitalization Resident 1 received a new [MEDICAL CONDITION] and Resident 1 has had no problems with the new [MEDICAL CONDITION] machine. Review of Resident 1's Treatment Administration Record (TAR) for March 2016 revealed Resident 1 was to have the [MEDICAL CONDITION] on at bedtime and off in the AM. The documentation showed that the [MEDICAL CONDITION] was not put on Resident 1 from March 19 th to April 1st, with documentation on the back of the TAR that stated the [MEDICAL CONDITION] did not work. Review of Resident 1's TAR for April 2016 revealed Resident 1 was to have the [MEDICAL CONDITION] on at bedtime. The documentation showed that the [MEDICAL CONDITION] was not put on Resident 1 from April 1st to April 21st and the documentation on the back of the TAR stated the [MEDICAL CONDITION] did not work. A review of Resident 1's progress notes revealed that on 4-21-16 the resident was short of breath. The physician was contacted and Resident 1 was ordered to be sent to the hospital for evaluation. Review of Resident 1's hospital physician note dated 4-21-16 stated Resident 1 presented to the hospital with acute chronic [MEDICAL CONDITION] with hypercapnia (excessive carbon [MEDICATION NAME] (CO2) in the blood from difficulty breathing) and respiratory acidosis (a condition when the lungs cant remove all the CO2 in the lungs and becomes acidic). The physician note stated that Resident 1 was above baseline pCO2 (lab value showing the amount of CO2 in the blood) which was consistent with Resident 1's symptomology. Resident 1 was to be transferred to the ICU (Intensive Care Unit) for [MEDICAL CONDITION] (a machine to help with breathing while sleeping), etiology likely multifactoral with noncompliance with [MEDICAL CONDITION] as it was apparently broken. Review of Resident 1's progress notes dated 4-27-16 revealed that Resident 1 was readmitted to the facility from the hospital. An interview with the Administrator on 6-28-16 at 5:15 PM revealed that the Administrator spoke with the company that owned Resident 1's [MEDICAL CONDITION] machine and they reported they had been out to check the mask and tubing but had never checked Resident 1's machine or turned it on to see if it was functioning and did not recall staff informing them that Resident 1's [MEDICAL CONDITION] was not functioning. An interview conducted on 6-28-16 at 5:40 PM with Medication Aide (MA) A revealed that MA A had worked with Resident 1 many times in the evening. MA A stated that Resident 1's [MEDICAL CONDITION] machine was not working right prior to the resident's hospitalization in the end of April, 2016. MA A stated that the [MEDICAL CONDITION] machine was putting out too much pressure and Resident 1 reported the resident couldn't breathe with the [MEDICAL CONDITION] machine on and it would sometimes just turn off. MA A revealed that MA A had reported it once to one of the nurses, but could not remember whom or when. An interview on 6-28-16 at 5:51 PM with the Director of Nursing (DON) revealed that the DON was never made aware the Resident 1's [MEDICAL CONDITION] was not functioning until the day that Resident 1 was sent to the hospital. The DON revealed that if a MA or any other staff knew that Resident 1's [MEDICAL CONDITION] was not functioning the staff should have notified the nurse and the nurse should inform the DON and get someone to come out and look at the machine.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on record review and interview; the facility staff failed to evaluate skin condition under a splint and failed to evaluate nutritional requirements for pressure ulcer healing for 1 resident (Resident 15). The facility staff identified a census of 99. Findings are: A. Record review of a undated Face Sheet revealed Resident 15 was admitted to the facility on [DATE]. Record review of Resident 15's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated 9-05-2015 revealed the facility staff assessed the following about the resident: - Brief Interview for Mental Status (BIMS) score was 14. According to the MDS Manuel, a score of 14 indicates cognitively intact. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. - Active [DIAGNOSES REDACTED]. Record review of an Initial Data Collection Tool/Nursing Service (IDCT/NS) dated 8-29-2015 revealed Resident 15 was admitted to the facility with a left ankle fracture and had an above the knee amputation. Resident 15 was assessed to not have any pressure ulcers. Review of Resident 15's Admission Care Plan dated 8-31-2015 revealed Resident 15 was admitted to the facility with a splint to the left foot. Record review of Resident 15's Braden Scale (tool used for predicting pressure ulcer risk) dated 8-29-2015 revealed a score of 20 indicating low risk. Record review of Resident 15's medical record that included Treatment Administration Records (TARS), Skin sheets, Admission Care Plan and progress notes revealed there was not evidence the facility staff had been monitoring Resident 15's skin condition under the splint. Record review of Resident 15's Physical Therapy (PT) note dated 9-02-2015 revealed Resident 15's splint had been removed temporarily as Resident 15 had reported pain. According to the information in the PT note dated 9-02-2015, when the splint was removed, Resident 15 was assessed with [REDACTED]. Record review of a Pressure Ulcer Status Record (PUSR)'s dated 9-2-2015 revealed Resident 15 had the following pressure ulcers: -Left dorsal ( back) Foot Proximal (closest to midline of the body) unstageable pressure ulcer that measured 1.2 centimeters (CM) by 1.0 cm. -Left dorsal foot- distal (furthest away from the mid line of the body) unstageable pressure ulcer that measured 2.7 cm by 2.1 cm. -Left lateral (side) of foot that was assessed as a Suspected Deep Tissue Injury (SDTI, A purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) that measured 2.5 cm by 0.3 cm. -Left dorsal middle foot, SDTI that measured 2.4 cm by 1.7 cm. Record review of Resident 15's Interim Care Plan dated 8-31-2015 revealed Resident 15 was at risk for a break in skin integrity with the use of the splint. The goal for Resident 15 was to maintain intact skin with no breaks within 21 days. The Interim Care Plan did not identify staff were to monitor Resident 15's skin under the splint. An interview with the Director of Nursing (DON) was conducted on 10-06-2015 at 7:23 AM. During the interview, when asked if the facility should have called the physician and requested orders to inspect Resident 15's skin under the splint, the DON stated Yes. The DON further confirmed Resident 15 was at risk for pressure ulcer development. B. Record review of a Nutritional Data Collection/assessment tool signed on 9-5-2015 by the facility Registered Dietician revealed there was not an evaluation of Resident 15's nutritional requirements for pressure ulcer healing. An interview with the DON on 10-06-2015 at 7:23 AM revealed that the DON reported that if a resident had a pressure ulcer, there should be a nutritional assessment. An interview with the facility Regional Director of Clinical Services (RDCS) was conducted on 10-06-2015 at 2:10 PM. During the interview the RDCS confirmed a nutritional evaluation for the pressure ulcer had not been completed.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7 Based on observation, record review and interview; the facility staff failed to re-evaluate and implement additional interventions to prevent hot liquid burns for 1 resident (Resident 71). The facility staff identified a census of 99. Findings are: Record review of an undated Face Sheet revealed Resident 71 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 71's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 7-08-2015 revealed the facility staff assessed the following about Resident 71: -Brief Interview for Mental Status (BIMS) score was 1. According to the MDS Manuel, a score of 1 would indicate severe cognitive impairment. -Required supervision with eating. -Required extensive assistance with Bed mobility, transfers, dressing, toilet use and personal hygiene. Record review of Resident 71's Comprehensive Care Plan (CCP) dated 8-06-2012 revealed revealed Resident 71 was to use clothing protectors and was to use a maroon cup with lid for hot liquids. Record review of an Incident/Accident Data Entry Questionnaire (IADEQ) form dated 10-4-2015 revealed Resident 71 had received a burn. According to the IADEQ form, Resident 71 removed (the) plastic lids from cocoa and spilled (the) liquid on (gender) self. According to the information on the IADEQ form, Resident 71 was taken out of the Dining room and the residents clothing was changed. Record review of a Non-Pressure Skin Condition Record (NPSCR) dated 10-05-2015 revealed Resident 71 received 4 burn areas. The 4 burn areas identified on the NPSCR form identified the following: -Site A, Left Forearm, measured 15.0 cm (centimeters) by 14.2 cm, the color was red and no depth. -Site B, Left Breast area, measured 1.5 cm by 1.5 cm, had a depth of 0.1 cm. -Site C. Left Abdomen area measured 5.1 cm by 12.0 cm, the skin was red. -Site D, Left Knee, area measured 7.2 cm by 8.1 cm and the skin was red and no depth. According to the information at www.mayoclinic.org a first degree burn involves only the outer layer of skin and may cause redness, swelling and pain. A second degree burn may cause red, white or splotchy skin, swelling, pain and blisters. Observation on 10-06-2015 at 7:54 AM of a treatment to the burn areas with Licensed Practical Nurse (LPN) C revealed Resident 71 had a red area to the left fore arm that measured approximately 7.5cm, by 3.5 cm, Left abdomen area that measured approximately 4.5 cm by 7.9 cm. The breast area was covered with a dressing and the Left knee area was pink. On 10-06-2015 at 9:05 AM an interview was conducted with the facility administrator. During the interview the facility Administrator reported Resident 71 would remove the lid from the hot liquid cup. The Administrator stated Resident 71 . would remove the lid all the time. when asked who knew that Resident 71 was removing the lid from hot liquids the Administrator stated all the management team knew. The Administrator confirmed no new interventions had been attempted to prevent hot liquid burns for Resident 71. On 10-06-2015 at 9:16 AM an interview was conducted with the Housekeeping Supervisor (HS). During the interview, when asked if Resident 71 would remove the lid from (gender) hot liquids prior to being burned on 10-04-2015, the HS stated all the time. On 10-06-2015 at 9:17 AM an interview was conducted with the Dietary Services Manager (DSM). When asked if Resident 71 would remove the lid to (gender) hot liquids, the DSM stated yes. When asked if any changes to interventions were attempted to prevent a burn, the DSM reported (gender) was not aware of any new intervention. An interview on 10-06-2015 at 9:48 AM was conducted with LPN C. During the interview, when asked if Resident 71 removed the lid to hot liquids prior to being burned on 10-04-2015, LPN C stated (gender) . would remove it all the time, almost daily. An interview was conducted with Nursing Assistant (NA) B on 10-06-2015 at 9:50 AM. During the interview, NA B reported Resident 71 would remove the lid to (gender) hot liquids almost daily. When asked how long Resident 71 had been doing this, NA B reported a long time. Record review of the undated Corporation Inservice Training Manual for Reducing the Risk of burns to Residents from hot Beverages revealed the following: -Hot beverages should be available to residents only in areas that are supervised at all times. -Evaluate each resident's ability to manage hot beverages, and provide needed assistance. -Use ice or milk to cool the hot beverage, if the resident was agreeable. Record review of the Facility Specific Policy for Reducing the Risk of burns to Residents from hot beverages dated 1-2013 revealed the following: -Covered maroon cups will be used for residents who are at high risk for spilling beverages. -Residents who are high risk for spilling (have a covered cup) will be provided with two clothing protectors.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observation, record review and interview; the facility staff failed to re-evaluate and implement interventions to manage pain for 1 resident (Resident 170). The facility staff identified a census of 97. Findings are: A. Record review of a undated Face Sheet revealed Resident 170 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 170's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 10-06-2014 revealed the facility staff assessed the following about the resident: -Brief Interview for Mental Status (BIMS) score was 15. According to the MDS Manuel, a score of 13-15 indicates cognitively intact. -Resident 170 required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. -Occasionally incontinent of bladder and frequently incontinent of bowel. -Occasionally had pain. Record review of Resident 170's MDS dated [DATE] revealed Resident 170 had pain indicators with the frequency identified as Occasionally. The pain level was a 7 on a scale of 0 to 10 ( 10 being the worst). Record review of Resident 170's admission order dated 9-29-2014 revealed Resident 170's physician had ordered medications that included Lidocain 5% (700 mg (milligram) patch) to be placed onto the skin and removed every 24 hours for pain and [MEDICATION NAME] (commonly known as [MEDICATION NAME]) 50 mg 1 to 2 tabs every 6 hours as needed for pain. Record review of Resident 170 Medication Administration Record [REDACTED]. Record review of Resident 170's Comprehensive Care Plan (CCP) dated 10-11-2014 revealed Resident 170 had pain. The goal for Resident 170 was to report a reduction in pain within 60 minutes and pain would not prevent Resident 170 from progressing in therapy. Interventions listed on the CCP included the following: -Assess for pain every shift using a 0 to 10 scale. -Medications and labs as ordered. -Observe and report to the nurse signs and symptoms of pain. -Consult therapy for pain modalities. -Quarterly and as needed pain assessment, with revision of interventions as indicated. Record review of Resident 170's Pain Flow Sheet revealed 17 entries of pain. The Pain Flow Sheet had intensity levels identified at the top of the page that indicated 0 (no pain) to 10 (hurts the worst). Further review of the Pain Flow Sheet revealed that, for 15 of 17 entries, movement was the cause of pain. Six had the intensity of level 6 (hurts even more), 8 at a level 7 and 3 at a level 8 (hurts whole lot). Resident 170's pain flow sheet revealed the following additional information: -10-7-2014, Pain level was a 7. Resident 170 was medicated for pain and after 30 minutes and 1 hour, Resident 170's pain remained at a 7. -10-10-2014, Pain level 8, Resident 170 was given pain medication and after 15 minutes Resident 170's pain remained an 8. -10-11-2014, Pain level was a 6, Resident 170 was given pain medication and a resulting pain level was a 4 (Hurts a little more). -10-23-2014, Pain level an 8, Resident 170 medicated for pain, 15 minutes later, pain remained an 8, 30 minutes later, pain was a 7 and 1 hour later pain was a 4. -10-25-2014, pain was a level 7, Pain medication was given and 1 hour later, pain remained a 7. 10-26-2014, Pain level was a 7, medication was given and after 1 hour the pain level was a 6. 10-29-2014, Pain was a 6, medication was given after the pressure ulcer treatment and after 1 hour was a 4. Record review of Resident 170's Physical Therapy Treatment Notes dated 10-17-2014 revealed The Physical Therapist Assistant had documented Resident 170's "L. (left) LE ( lower extremity) was swollen and pain was reported in the L (left) heel going all the way up into LE. Pt (patient) was perseveration on pain and about not knowing what happened to (gender) to put (gender) in such a bad position". Observation on 10-29-2014 at 6:23 AM of pressure ulcer treatments revealed Licensed Practical Nurse (LPN) D obtained the required supplies for wound treatment. LPN D explained to Resident 170 (gender) would be starting the treatment. Resident 170 reported to LPN D that both of (gender) heels were painful. LPN D lifted and began to remove the soiled dressing when Resident 170 started to moaned in pain. LPN D cleansed the wound area, applied the ointment and dressing. LPN D lifted Resident 170's right leg and began to wrap the leg with [MEDICATION NAME] dressing. Resident face indicated pain and Resident 170 started to moan in pain. LPN D started the treatment to the left heel. LPN D began the treatment to the left heel. Resident 170 moaned and yelled out as LPN D lift the left leg to remove the soiled dressing. LPN D cleansed the wound to the left heel. Resident 170 moaned and yelled out "oh my God that hurts" with the treatment. LPN D stated "(gender) has a lot of pain, (gender) should have had a pain pill, (gender) pain has increased". LPN D did not stop the treatment to obtain pain medication for Resident 170. LPN D instructed and assisted Resident 170 onto a left side position for wound treatment to the coccyx area. LPN D removed the soiled dressing and began to cleanse the coccyx area. Resident 170 moaned and yelled out "holy cow that hurts". LPN D completed the treament and repositioned Resident 170 in bed. An interview was conducted with LPN D on 10-29-2014 at 7:16 AM. During the interview when asked if Resident 170 had been medicated for pain prior to the treatment, LPN D stated "no". When asked if Resident 170 should have been premedicated for pain prior to the treatment, LPN D stated "yes, it should be scheduled". An interview was conducted on 10-29-2014 at 11:45 AM with Resident 170. During the interview when asked about (gender) pain level, Resident 170 reported that (gender) was always in pain. When asked about repositioning in bed, Resident 170 reported it was difficult to reposition due to pain and the boots Resident 170 wore on the feet. Resident reported the "pain is bad, the pain, oh boy it's bad". A follow up interview was conducted with LPN D on 10-29-2014 at 11:51 AM. When asked if Resident 170 was able to communicate needs and was accurate, LPN D stated "yes". An interview was conducted with the Director of Nursing (DON) on 10-30-2014 at 10:30 AM. During the interview, when asked if Resident 170 pain should have been re-evaluated and pain medication scheduled prior to Resident 170's treatment, the DON stated "yes".

LICENSURE E REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to evaluate, monitor, implement interventions and evaluate casual factors for the development of pressure ulcers for 2 residents (Resident 170 and 188). The facility staff identified a census of 97. Findings are: A. Record review of a undated Face Sheet revealed Resident 170 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 170's Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) dated and signed as completed on 10-06-2014 revealed the facility staff assessed the following about the resident: -Required extensive assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. -Occasionally incontinent of bladder and frequently incontinent of bowel. -1 unstageable pressure ulcer (according to the National Pressure Ulcer Advisory Panel (NPUAP), an unstageable pressure ulcer is a full thickness tissue loss with the depth unknown visually obscured by slough (dead tissue)). -1 stage 1 pressure ulcer (stage 1 pressure ulcers intact skin, non-blanchable redness of a localized area usually over bony prominence). Record review of a Braden Scale ( tool used for predicting pressure ulcer risk) dated 9-29-2014 revealed Resident 170 score was 16. According to the Braden Scale form, a score of 15 to 18 placed Resident 170 at risk for developing pressure ulcers. Record review of Resident 170's Initial Data Collection Tool/Nursing service sheet dated 9-29-2014 revealed the facility staff had identified 1 pressure ulcer to the left heel. Record review of Resident 170's Physical Therapy (PT) daily Treatment Note dated 10-04-2014 revealed a "CNA (Nursing Assistant) pointed out to PTA (Physical Therapist Assistant) that pt (patient) has redness on (gender) coccyx area due to being in bed...". Record review of Resident 170's Weekly Skin Integrity Data Collection (WSIDC) sheet revealed 1 entry on the sheet that was dated 9-30-2014. The information on the WSIDC did not identify the left heel pressure ulcer. The WSIDC contained information that Resident 170's skin was intact and had new bruising. Record review of a Pressure Ulcer Status Record (PUSR)sheet dated 10-24-2014 revealed Resident 170 had a pressure ulcer to the right coccyx area. According to the documentation on the PUSR, the pressure ulcer was a stage 3 (according to the NPUAP, a stage 3 pressure ulcer is a full thickness loss. Subcutaneous fat may be visual . Slough may be present but does not obscure the depth of tissue loss). The Right Upper Coccyx pressure area measured 4.2 cm (centimeter) by 2.0 cm by 0.2 cm with 75 percent of yellow slough. Observation on 10-29-2014 at 6:23 AM of the treatment to Resident 170's pressure ulcers revealed Resident 170 had a area on the coccyx that measured approximately 2.7 cm roundish with an approximately 0.7 cm black area. The bed of the wound was covered in yellowish slough. On 10-29-2014 at 1:15 PM an interview was conducted with the Director of Nursing (DON). During the interview, review of Resident 170's WSIDC sheet dated 10-24-2014 was completed with the DON. The DON confirmed the wound base was not visible and should have been evaluated as a unstageable pressure ulcer. The DON confirmed the red area to Resident 170's coccyx had not been monitored when identified on 10-04-2014 and "should have been". The DON confirmed the pressure ulcer was "avoidable". The DON did not provide an evaluation of casual factors related to the development of the pressure ulcer to the coccyx's area. B. Record review of an undated Face Sheet revealed Resident 188 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Initial Data Collection Tool/Nursing Services (IDCTNS) dated 10-01-2014 revealed Resident 188 was identified with a surgical incision to the lower back. There were no pressure ulcers identified. Record review of Resident 188's Comprehensive Care Plan (CCP) dated 10-15-2014 revealed Resident 188 had a pressure ulcer to the right heel. The CCP had been updated to reflect new interventions after Resident 188 had developed the pressure ulcer. The additional interventions were to complete the treatment as ordered and to have Resident 188 wear Prevalon Boots (boots that protect heels from additional pressure ulcers and promote pressure relief off current pressure ulcer) in the chair or bed and have off for transfers. Observation revealed Resident 188 was seated in a reclining chair and did not have the Prevalon boots on for: - 10-28-14 at 11:20 PM, - 10-28-2014 at 12:40 PM and - 10-28-2014 at 1:14 PM An interview was conducted on 10-28-2014 at 1:58 PM with the DON. During the interview, when asked if Resident 188 was to wear the Prevalon boot when in a chair, the DON stated "yes". Observation with the DON of Resident 188 seated in the room confirmed Resident 188 was not wearing the Prevalon boots.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and staff interview, the facility Quality Improvement (QI) plan failed to identify ongoing issue relevant to F156, F247, F311, F312, F313, F314, F318, F431, F517 and F520 and implement effective plans of action to identify and correct the deficient practice. The Quality Improvement plan failed to ensure the repeated deficiencies at F253, F309, F280, F315 and F242 were corrected and the correction maintained. The facility staff identified a census of 97. Findings are: A. Record review of the facility Quality Improvement Plan revised on 11-23-2009 revealed the following information: -Standard: -The facility implements and maintains an ongoing program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care, and resolve identified problems. -Purpose: -To provide a means whereby negative outcomes related to resident care and safety can be identified and resolved through an interdisciplinary approach, and effective systems of service and positive care measures rendered are reinforced and expanded to improve the care given. -To develop plans of action and evaluate corrective actions taken to obtain the desired results. -To assist departments, consultants, and ancillary services that provide direct or indirect care to residents to delineate lines of authority, responsibility, and accountability so that open lines communication and negative outcomes resolutions are archived for optimum resident care on a continuous basis. B. An interview was conducted with Nursing Assistant (NA) H on 10-30-2014 at 11:18 AM. During the interview when asked if NA H was aware of the QI program, NA H stated " I have worked here for 4 yeas and don't know". C. An interview was conducted with Licensed Practical Nurse (LPN) K on 10-30-2014 at 11:23 AM. During the interview LPN K stated "I'm not really sure" when asked what the QI committee had been working on. D. An interview was conducted on 10-30-2014 at 11:32 AM with NA L. During the interview when asked what the QI program was, NA L reported (gender) was not aware of the committee or who was on it. E. An interview was conducted with the Assistant Director of Nursing (ADON) on 10-30-2014 at 11:03 AM. During the interview when asked what the QI committee was working on, The ADON stated : I'm not sure. I don't go".

Licensure Reference: 175 NAC 12-006.09D7 Based on observation, record review, and staff interview, the facility failed to implement interventions to prevent falls for 1 (Resident 11) of 11 sampled residents and failed to transfer residents using a mechanical lift in accordance with manufacturer's instructions for 2 (Resident 8 and 10) of 11 sampled residents. The facility had a total census of 99 residents. Findings are: A. Resident 11 was admitted to the facility on [DATE] according to a Progress Note dated 1/12/13 at 3:33 PM. A fall risk assessment completed 1/12/13 revealed Resident 11 was at high risk for falls. The fall risk assessment stated Resident 11 was at risk for fall due to "sundowners" (decrease in cognitive status late in the day), cognitive changes, cancer, decreased mobility and impaired mobility. Resident 11's Care Plan included a problem dated 1/12/13 of Resident 11 being at risk for physical injury from falls. The Care Planned interventions included the following: 1 assist for transfers and ambulating, chair alarm when in wheelchair or chair, bed alarm when in bed, mat on the floor, and physical therapy to evaluate and treat. A review of Resident 11's Care Directive revealed Resident 11 was to have a pad alarm in bed and chair. A Progress Note dated 1/20/13 stated Resident 11 was to have 1 assist but did ambulate independently with activities of daily living. A facility incident report dated 1/21/13 at 12:45 AM stated Resident 11 was found sitting on the hallway floor outside of the resident's room with feet out in front. A Progress Note dated 1/21/13 at 11:36 AM revealed Resident 11 was admitted to the hospital with [REDACTED]. A review of Education Acknowledgement Form dated 1/21/13 revealed 3 staff members were educated on making rounds twice per shift to ensure that fall prevention items were in place. Nurse Aide (NA) A documented that NA A didn't know Resident 11 was to have an alarm. In an interview on 1/29/13 at 1:45 PM, the DON (Director of Nursing) confirmed Resident 11 did not have a fall alarm on at the time that the incident occurred. The DON reported Resident 11 was assessed at risk for falls on admission. Resident 11 had been receiving therapy and was walking independently in the room but alarms where still an interventions on the care plan at the time of the fall. The DON reported care guides were available at the nurse's stations for staff to look at and inform themselves of resident care needs. B. A review of Resident 8's Care Plan revealed Resident 8 was to be transferred using a Hoyer lift (mechanical lift) with 2 person assist. A Hoyer lift transfer of Resident 8 was observed at 3:33 PM on 1/28/13. Observations revealed the legs of the Hoyer lift were not opened wide by NA B when Resident 8 was lifted up. The Hoyer lift was locked by RN (Registered Nurse) C when Resident 8 was lowered into the wheelchair. In an interview after the transfer, NA B confirmed Hoyer lift legs were not opened as far as they could be when Resident 8 was lifted up. In an interview on 1/29/13 at 2:29 PM, RN C confirmed RN C had locked Hoyer lift when lowering Resident 8 into wheelchair. A review of Safety Instructions for the Midline lift used to transfer Resident 8 revealed that during lifting and lowering, the base of the lift was to be in the widest position with the caster unlocked. C. A review of Resident 10's Care Plan revealed Resident 10 was to be transferred with a Hoyer lift. A Hoyer lift transfer of Resident 10 was observed at 11:07 AM on 1/29/13. Observations revealed Resident 10 was lifted with the legs of the lift together and the wheels locked. In an interview after the transfer, NA D confirmed legs of Hoyer lift need to open when lifting a resident and the wheels locked. A review of Vander-Lift instructions, the lift used for Resident 10, revealed the base was to open to its widest position when lifting. The caster brakes were to be unlocked when lifting the patient as it allowed the lift to center itself over the patient's center of gravity as it raised. D. In an interview on 1/29/13 3:33 PM, RN C, Staff Educator, reported being trained to lift resident with Hoyer legs in closed position and brakes locked. After reviewing lift instruction, RN C confirmed lifts were not operated in accordance with manufacturer's instructions.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.18 LICENSURE REFERENCE NUMBER 175 NAC 12-006.18B Based on observation, record review and interview; the facility staff failed to implement the plan of care for safety of toilet use for 1 (Resident 3), failed to ensure toilet seat riser were secured for 2 (Resident 1 and 3) and failed to ensure safety of transfers for 1 (Resident 6) of 9 sampled and 3 non-sampled residents. The facility identified a census of 104. Findings are: A. Record review of a Face Sheet dated 9/23/2011 revealed Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 3's Minimum Data Set ( MDS, A federally mandated comprehensive assessment tool used for care planning) dated 7/11/2011 revealed the facility staff assessed the following about the resident: -Resident 3 had cognitive problems. -Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. -Not steady, only able to stabilize with human assistance when moving from a seated position to standing position, when moving on and off toilet and surface to surface transfers. -Occasionally incontinent of bladder and continent of bowel. Record review of a Fall Risk Evaluation sheet dated 6/30/2011 revealed Resident 3 scored a 12. According to the information on the sheet, a resident who scores a 10 or higher is at risk for falls. Record review of a Incident Follow-Up & Recommendation Form dated 7/13/2011 revealed Resident 3 had fallen off the toilet with a toilet seat riser. Record review of the facility Final Report of the investigation revealed Resident 3 needed to use the toilet and was placed on the toilet by Nursing Assistant (NA) G. The report contained information that a toilet seat riser was in use for Resident 3. According to the information, the resident's roommate had requested assistance and NA G left the bathroom door open and assisted Resident 3's roommate "and at that time (gender) heard a thump in the bathroom and found (Resident 3) on the floor with the toilet seat riser next to (gender)''. The report contained documentation that Resident 3 had been assessed and did not complain of pain until 7/14/2011. The MD (Physician) was informed and an X-ray was ordered revealing Resident 3 had a fracture of the left wrist. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 7/06/2011 revealed Resident 3 was "...at risk for injuries r/t (related to) falls due to decreased in strength and endurance, impaired sit/stand balance..." The goal on the CCP was that Resident 3 would "remain free from injury due to falling...". Interventions identified on the CCP included, "do not leave unattended in bathroom". A interview with the Director Of Nursing (DON) was conducted on 10/17/2011 at 8:30 AM. During the interview, Resident 3's CCP was reviewed with the DON. The DON confirmed the CCP instructions were not to leave Resident 3 alone in the bathroom. The DON confirmed Resident 3 fell when alone in the bathroom. B. Review of the Final Report dated 7/19/2011 identified the toilet seat riser as the potential cause of the fall for Resident 3. "Initially the toilet seat riser was replaced with a bed side commode and on 7/14/2011, a new framed toilet seat riser that fits over the toilet was installed" Review of Final Report dated 7/19/2011, interventions to prevent the accident/ incident from occurring was, "the staff has been educated to check all toilet seat risers prior to seating a resident on the toilet". An interview with Registered Nurse (RN) H was conducted on 10/13/2011 at 2:45 PM. During the interview, RN H stated "no" when asked if (gender) had been educated on the use of the toilet seat risers". An interview with NA I was conducted on 10/13/2011 at 3:00 PM. During the interview, NA I stated "no" when asked if (gender) had been in-serviced on the use of the toilet seat risers. When asked if the toilet seat risers are to be checked prior to placing resident on them, NA I stated" I am not sure, I don't think so". Inspection of Resident 3's toilet seat riser was conducted on 10/13/2011 at 3:07 PM with the Director of Nursing (DON). When asked if the toilet seat riser was secured, the DON lifted on the toilet seat riser and was able to remove it without difficulty. When asked if the toilet seat riser had been secured, the DON stated "no". An interview with the DON was conducted on 10/17/2011 at 7:10 AM. When asked if the education for the staff on the use of the toilet seat risers had been completed, the DON state" no". Observation on 10/17/2011 at 9:32 AM of a transfer from a wheelchair to the toilet revealed NA M wheeled Resident 3 into the bathroom and placed a gait belt around Resident 3. NA M cued Resident 3 on the task of transferring from the wheelchair to the toilet with the toilet seat riser in place. NA M completed the transfer and placed Resident 3 onto the toilet with the riser. NA M did not check the toilet seat riser to ensure it was secured to the toilet. NA M asked Resident 3 if Resident 3 wanted NA M to leave the room. Resident 3 stated "no". Resident 3 completed using the bathroom and after assisting Resident with with cleaning, transferred Resident 3 into a wheelchair. An interview with NA M was conducted on 10/17/2011 at 9:52 AM. When asked if NA M had been educated on the need to check the toilet seat risers prior to placing a resident onto them, NA M stated "yes". When asked if NA M had checked the security of the toilet seat riser prior to placing Resident 3 onto it, NA M stated "no, I forgot". C. Record review of a Face Sheet dated 7/06/2011 revealed Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 1's CCP dated 8/18/2011 revealed Resident 1 required a mechanical lift for transfers and needed assistance with toileting. Observation on 10/13/2011 at 8:20 AM of a transfer to the toilet revealed NA J and NA L used a mechanical lift and transferred Resident 1 onto the toilet that had a toilet seat riser attached. NA J and NA L did not check the security of the toilet seat riser prior to placing Resident 1 onto it. A interview with Nursing Assistant (NA) J and NA L on 10/13/2011 at 8:30 AM was conducted related to being educated on the use of toilet seat risers. During the interview, Both, NA J and NA L stated "no" when asked if they had been educated on the use of the toilet seat risers and what to do before placing a resident onto them. When asked if staff were to check the toilet seat risers to make sure they were secured, NA J and NA L stated"no, no one has ever told us that". D. Record review of a Face Sheet dated 9/28/2011 revealed Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of a Accident report form dated 9/18/2011 revealed Resident 6 was being transferred by NA N "from the toilet to bed utilizing a sit/stand (mechanical lift)". According to the report form, Resident 6 "slid out of the sling" and fell to the floor. Resident 6 complained of pain and was sent to the hospital. Record review of a Consultation sheet from the hospital revealed Resident 6 had a fracture to the left hip. Record review of Resident 6's CCP dated 6/14/2011 revealed Resident 6 was at risk for falls. The goal identified for Resident 6 was Resident 6 would be free of injury from falls. Interventions for staff to utilize included using 2 people with a transfer belt or a sit stand. Record review of a unsigned form revealed there are to be 2 people at all times for the use of Mechanical lifts. A interview with the Assistant Director of Nursing (ADON) was conducted on 10/13/2011. During the interview, the ADON report that (gender) had held the position of Staff Development and had recently became the ADON. When asked how long the policy for 2 people were to use the mechanical lifts had been in place, the ADON stated "I've been here over 2 yes and it's been like that". Record review of a Final Report sheet dated 9/21/2011 revealed Resident 6 had been transferred using the sit/stand and NA N. A interview with the DON was conducted on 10/17/2011 at 9:20 AM. during the interview, the DON confirmed the use of a mechanical requires 2 staff and that this was the policy prior to Resident 6's fall. The DON confirmed Resident 6 was transferred with 1 staff assisting resulting in a fracture.