Every finding on record at Maple Crest Health Center

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 and monitor interventions to prevent the development of pressure ulcers and to promote wound healing for 3 (Resident 1,2 and 3) of 4 residents sampled. The facility census was 150. The findings are:A.Record review of the facility's policy titled Pressure Injury Prevention Guidelines revealed it is the policy of the facility to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Under the section, Policy Explanation and Compliance Guidelines revealed:-individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment such as moisture management, impaired mobility, and nutritional deficit. -the goal and preferences of the resident and/or authorized representative will be included in the plan of care.-interventions will be implemented in accordance with physician's orders, including the type of prevention devices to be used and, for tasks, the frequency of performing them. -in the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care and will notify the physician to obtain orders. -prevention devices will be utilized in accordance with the manufacturer's recommendations (e.g. heel floatation devices, cushions and mattresses).-interventions will be documented in the care plan and communicated to all relevant staff. -compliance with the interventions will be documented in the medical record. -the effectiveness of the interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: development of a new pressure injury, lack of progression towards healing or changes in the wound characteristics, changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. B.Record review of the National Library of Medicine article titled Nursing Assessment of Pressure Injury Risk with the Braden Scale dated 11-21-2022 revealed the Braden Scale is an evidence-based nursing tool to assess a patient's risk of developing pressure ulcers based on a score:-a score of 0 to 9 indicates a very high risk of pressure ulcer development.-a score of 10 to 12 indicates a high risk of pressure ulcer development.-a score of 13 to 14 indicates a moderate risk of pressure ulcer development.-a score of 15 to 18 indicates a mild risk of pressure ulcer development.-a score of 19 to 23 indicates no risk of pressure ulcer development. C.Record review of Resident 3's Electronic Medical Record (EMR) under the assessments section revealed Resident 3's Braden Scale Score (BSS) on 05-19-2026 was 17 indicating mild risk of pressure ulcer development. Record review of Resident 3's Skin Check Evaluation (SCE) dated 05-19-2026 revealed Resident 3 had bruising to the left and right forearms and left lateral leg, a surgical wound to the left shin, and general redness to the coccyx (tailbone). Record review of Resident 3's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 05-25-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE]-Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required touching assistance with bed mobility.-required partial assistance with bathing-required total assistance with lower body dressing and putting on and taking off footwear. -had a fractured left tibia/fibula (bones in the lower leg).-had surgical repair of fractures with surgical wounds. -was at risk for developing pressure ulcers/injuries.-had no unhealed pressure ulcers/injuries. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 05-21-2026 revealed Resident 3 was at risk of impaired skin integrity due to decreased mobility, bowel and bladder incontinence, and non-weight bearing status. The goal was for Resident 3's skin to remain intact, and interventions listed were:-air loss mattress (a specialized medical surface designed to treat and prevent pressure ulcers) make sure it's plugged in and functioning properly, weight-based alternating on a 15-minute cycle.-Braden skin risk evaluation to be completed on admission, every week for 4 weeks, quarterly and with any significant change. -Nurse aids to observe skin with morning and bedtime cares, report any abnormalities to the nurse.-Consult the dietician for nutritional assessment as needed. -maintain good skin hygiene, moisturize dry skin as needed. -observe for alteration in skin integrity and report to the healthcare practitioner. Skin is inspected by licensed staff weekly. -Provide adequate nutrition and hydration, nutritional supplements and vitamins as ordered.-provide rest periods throughout the day-record percentages of meal consumption. Record review of Resident 3's Progress Note (PN) dated 05-21-2026 revealed Resident 3 had Deep Tissue Injuries (DTI: According to the MDS Manual a DTI is a purple or maroon area of discolored intact skin due to damage of underlying soft tissue) to both heels and skin prep (premoistened towelettes that apply a protective breathable film to intact skin) and prevalon boots (a medical device designed to completely float and offload the heels to prevent and treat pressure injuries in non-ambulatory individuals) were started. Record review of Resident 3's PN dated 05-26-2026 revealed Resident 3 had a DTI to the right heel measuring 2.71 centimeters (cm) in length by 2.63 cm in width and the left heel had a DTI measuring 2.83 cm in length by 2.09 cm in width. Record review of Resident 3's EMR under the section weights and vitals revealed on 07-01-2026 Resident 3 weighed 125 pounds. An observation conducted on 07-07-2026 at 6:12 AM revealed Resident 3 was in bed with a air loss mattress in place on the bed set at 500 pounds with alternating 15-minute and 25-minute cycles. An interview conducted with Registered Nurse (RN) A on 07-07-2026 at 1:35 PM revealed the air loss mattress, Prevalon boots and the treatment of skin prep to the heels was implemented after the DTI were discovered to the bilateral heels. An interview conducted with the Director of Nursing (DON) on 07-07-2026 at 2:30 PM confirmed Resident 3's mattress should be set according to Resident 3's weight. D. Record review of Resident 1's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-had a diagnosis of Diabetes Mellitus, Dementia and Functional Quadriplegia. -cognitive skills for daily decision making were severely impaired.-required total assistance with eating, dressing, hygiene, bathing, toileting, bed mobility and transfers.-was at risk of developing a pressure ulcer.-had pressure ulcer to the sacral area (lower part of the back located at the base of the spine just above the tailbone and between the buttocks). Record review of Resident 1's CCP dated 09-28-2021 and revised 06-18-2026 revealed Resident 1 had an alteration in skin integrity related to having a history of pressure ulcers prior to admission, dementia, bowel and bladder incontinence, immobility, dependence on staff for repositioning, Further review revealed on 04-13-2026 Resident 1 sustained open areas to the coccyx. The goal was stabilization and/or improvement of skin integrity as evidenced by no further development of pressure injuries, and existing open areas to the coccyx showing signs of healing dated 04-21-2026. Interventions implemented on 04-21-2026 were:-air loss mattress in place, ensure it is plugged in and functioning properly.-leave brief open to air.-turn scheduleInterventions implemented prior to 04-21-2026 were:-cleanse perineal area with each incontinence episode-consult dietician for nutritional assessment as needed, nutrition/hydration interventions as ordered. -tilt wheelchair for pressure reduction and positioning-ensure special mattress is in place for pressure relief- pressure relieving Comfort M2 cushion for wheelchair-Prevalon boots at all times-provide rest periods throughout the day-record amount taken of nutritional supplement-record percentage of meal consumed-staff will turn or reposition the resident every 2 hours-weekly skin assessment, refer skin issues to the wound team and physician for evaluation and treatment orders. Record review of Resident 1's Skin Check Note (SCN) dated 04-11-2026 revealed the skin issue evaluated was on the buttocks and was described as scars and discoloration. Record review of Resident 1's SCN dated 04-13-2026 revealed Resident 1 had 3 new wounds to the left buttock identified as Skin Issue (SI) 2, 3 and 4. The SCN revealed Wound 2 measured 1.0 cm in length by 1.0 cm in width and 0.1 cm in depth, Wound 3 measured 1.5 cm in length by 1.5 cm in width and 0.1 cm in depth and Wound 4 measured 1.0 cm in length by 1.0 cm in width and 0.1 cm in depth. The SCN also revealed a new wound to the right buttock measuring 1.0 cm in length by 1.0 cm in width by 0.1 cm in depth. Record review of Resident 1's Tissue Analytics Evaluation ([NAME]) dated 04-14-2026 revealed Resident 1 had several stage 2 pressure ulcers (according to the MDS Manual a stage 2 pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister) to the buttocks, and the right and left buttocks ulcers were measured together as 7.68 cm in length by 4.95 cm in width by 0.1 cm in depth. Record review of Resident 1's April 2026 Documentation Report (DR) for turning and repositioning side to side every 2 hours revealed on 04-11-2026 and 04-12-2026 there was no documentation of turning and repositioning from 6:00 AM to 12:00 PM. Record review of Resident 1's [NAME] dated 04-21-2026 revealed Resident 1's wounds were evaluated and the stage 2 pressure ulcer measured 3.68 in length by 4.45 in width by 0.1 in depth and the wound looked less irritated. Record review of Resident 1's Treatment Administration Record (TAR) revealed no order for an air loss mattress and check for Record review of Resident 1's SCN dated 04-24-2026 revealed Resident 1's wound had deteriorated and a new treatment order was obtained. Record review of Resident 1's PN dated 04-24-2026 revealed Resident 1 can no longer be gotten early in the morning and is to only be out of bed for meals and then placed back in bed and positioned from side to side, 11 days after the stage 2 pressure ulcer was identified and the day the stage 2 pressure ulcer had deteriorated. Record review of Resident 1's Progress Note (PN) dated 04-24-2026 revealed Resident 1 was given a Roho cushion (a specialized, air-filled medical cushion designed for wheelchair users and individuals who sit for extended periods of time) for the wheelchair, 11 days after the stage 2 pressure ulcer was identified. Record review of Resident 1's Skin and Wound Progress Note (SWPN) dated 04-29-2026 revealed Resident 1 was seen by the Wound Nurse Practitioner (WNP) and Resident 1's pressure ulcer to the buttocks was a stage 3 pressure ulcer (According to the MDS Manual a stage 3 pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Dead tissue may be present but does not obscure the depth of tissue loss) measuring 10.91 cm in length by 5.24 cm in width and the wound bed contained dead skin tissue. Record review of Resident 1's PN dated 05-01-2026 revealed Resident 1 was sent to the hospital due to a high blood sugar level, and the pressure ulcer to the coccyx (tailbone). An interview conducted with the DON on 07-07-2026 at 2:00 PM confirmed the Roho wheelchair cushion was not implemented until 04-24-2026 and the pressure ulcer had already deteriorated and confirmed the absence of documentation of turning side to side every 2 hours on 04-11-2026 and 04-12-2026. E. Record review of Resident 2's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 5. According to the MDS Manual a score of 0 to 7 indicates severe cognitive impairment. - required set-up assistance with eating.-required total assistance with hygiene, toileting, bathing, dressing, bed mobility and transfers.-was frequently incontinent of bowel and bladder.- was at risk for pressure ulcer development. Record review of Resident 2's CCP dated 03-13-2022 revealed Resident 2 had the potential for altered skin integrity related to cognitive impairment and friction and sheer during bed mobility and transfers. The goal was Resident 2's will maintain intact skin integrity. Interventions listed on the CCP were: -air loss mattress, settings were reviewed and adjusted to the resident's weight-based pressure setting dated 05-18-2026. -complete a Braden assessment quarterly and with any significant change dated 03-13-2022-consult the dietician for a nutritional assessment as needed dated 03-13-2022-nutrition and hydration interventions per physician orders dated 03-13-2022.-provide rest periods throughout the day dated 03-13-2022-record percentage of meal consumption dated 03-13-2022-weekly skin evaluation, refer skin issues to wound team and the physician for evaluation and treatment orders dated 03-13-2022. Record review of Resident 2's Treatment Administration Record (TAR) for July 2026 revealed an order for Prevalon boot to left heel while in bed. An observation conducted on 07-06-2026 at 12:00 PM revealed Resident 2 was lying in bed on an air mattress that was set between 250 and 300 pounds, and the Prevalon boots were in the recliner. An observation conducted on 07-06-2026 at 1:25 PM revealed Resident 2 was sitting in the wheelchair; the air mattress was noted to be set between 250 and 300 pounds. An observation conducted on 07-06-2026 at 2:45 PM revealed Resident 2 was lying in bed with the air mattress set between 250 and 300 pounds and the Prevalon boots were in the recliner. An observation conducted on 07-07-2026 at 6:00 AM revealed Resident 2 was lying in bed with the air mattress set at 150 pounds and the Prevalon boots were in the recliner. An interview conducted with the DON on 07-07-2026 at 2:15 PM confirmed Resident 2's air mattress should have been set at 150 pounds and Resident 2 should have had Prevalon boots on while in bed.

Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to report an allegation of physical abuse to law enforcement within the required timeframe for 1 (Resident 6) of 3 sampled residents. Facility staff identified a census of 151.Findings are:A. Record review of facility policy entitled Abuse Reporting dated revised 08/08/2024 revealed in accordance with the Elder Justice Act, the facility administrator or designee would immediately notify, but not later than two hours after the allegation is made if the events that cause the allegation involved result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury the following persons or agencies of such an incident: the state licensing authority, the Ombudsman, the resident's representative; Adult Protective Services; law enforcement officials; the resident's attending physician; and the facility medical director. Further review of the abuse reporting policy identified if the allegations were true, the employee would be terminated from employment.B. Record review of Resident 6's Clinical Census showed the facility admitted the resident on 02/21/2019.Record review of Resident 6's Medical Diagnosis revealed Resident 6 had diagnoses of moderate vascular dementia with agitation (dementia of abrupt or gradual onset that is caused by cerebrovascular disease), generalized anxiety disorder (a condition characterized by excessive anxiety and worry about a variety of events or activities [e.g., work or school performance] that occurs more days than not, for at least 6 months), bipolar disorder (a condition characterized by dramatic shifts in mood, energy, and activity levels that affect a person's ability to carry out day-to-day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs that are experienced by everyone), and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 6's Quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 03/18/2026 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 Resident 6 had rejected care in four to six days of the assessment period. There were no other behavioral symptoms checked, including physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually).Record review of an e-mail from the Social Services Supervisor (SSS) to facility management revealed on 03/17/2026 between breakfast and lunch, a Nurse Aide (NA) entered Resident 6's room, placed a lift sling (sling used for mechanical lift transfers) under Resident 6, and informed Resident 6 that [gender] would be taking a shower. Resident 6 reported they refused the bath. Resident 6 reported to facility staff the situation then escalated, resulting in both Resident 6 and the NA exchanging punches. Resident 6 was observed by facility staff to have bruises on both arms.Record review of a Potential Resident Abuse Report Form with date of incident listed as 03/17/2026 at around 10:30 AM revealed no evidence law enforcement was notified of the allegation.Record review of Skin Check dated 03/16/2026 revealed Resident 6 had no bruising at the time of assessment.Record review of Skin Check dated 03/18/2026 revealed bruising in the following areas: -radial aspect of the right hand (above the thumb) measuring 2 centimeters (cm) by (x) 2.5 cm; -back of the right hand over the fifth metacarpal joint measuring 1 cm x 1.5 cm; -Forearm: most distal (furthest) bruise from the elbow measured 2.5 cm x 2.5 cm; second most distal bruise from elbow measured 2 cm x 1 cm; and bruise closest to elbow measured 4 cm x 4 cm. -dorsal side (back side) of the left hand measured 6.5 cm x 4 cm; -left radial (thumb side) of wrist measured 6 cm x 5 cm; -left mid-forearm measured 1 cm x 1 cm; second most distal bruise measured 1 cm x 1.2 cm; third most distal bruise measure 0.5 cm x 0.5 cm; and antecubital fossa (the fold in the elbow) measured 7 cm x 2 cm.Record review of Resident 6's Electronic Health Record (EHR) including progress notes and scanned documents revealed no evidence law enforcement was notified of the allegation of physical abuse.Interview on 04/29/2026 at 11:50 AM with the facility Administrator (ADM) confirmed law enforcement was not notified of the allegation of physical abuse. The ADM revealed the facility does not report bruising to the Police Department.Interview on 04/29/2026 at 12:36 PM with the SSS confirmed the allegation of physical abuse was not reported to law enforcement and should have been.

Based on record review and interview, the facility failed to update the 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) to reflect the current resuscitation status for 1 (Resident 10) of 15 sampled residents. The facility staff identified a census of 151.Findings are:A. Record review of facility policy entitled Comprehensive Care Plans dated reviewed/revised 09/02/2025 revealed the CCP would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set ((MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) assessment.B. Record review of Resident 10's MDS dated [DATE] revealed the facility admitted Resident 10 on 09/23/2024. Further review of the MDS revealed Resident 10 had a condition or chronic disease that may result in a life expectancy of less than six months, and Resident 10 was receiving hospice services.Record review of Resident 10's Do-Not-Resuscitate Order (DNR) dated 04/03/2026 revealed Resident 10's representative requested a DNR resuscitation status.Record review of Resident 10's Order Listing Report identified an order Do Not Resuscitate dated 04/22/2026.Record review of Resident 10's CCP printed 04/28/2026 at 9:18 AM revealed Resident 10 had a full code, do not resuscitate status dated 10/02/2024.Interview on 04/28/2026 at 3:33 PM with the Social Services Supervisor (SSS) revealed the facility had updated the care plan on 04/28/2026. The SSS further confirmed the code status should have been updated at the time of the code status change.

Licensure Reference Number 175 NAC12-006.09 Based on observation, interview and record review the facility failed to coordinate the provision of medication administration with dialysis services and failed to adhere to physician ordered fluid restriction for 1 (Resident 5) of 1 residents sampled. The facility census was 151. The findings are:A.Record review of the facility policy titled Guideline for Care of the Dialysis Resident dated 02-20-2022 revealed the purpose of the policy was to ensure dialysis residents would be provided care and services in a manner that promotes the resident's quality of life, and to attain or maintain the resident's highest possible physical, mental, and psychosocial well-being. The attending physician orders all diets served to dialysis residents. Dialysis residents are given fluid based on the fluid restriction as ordered by the physician. The nursing and dietary staff will organize the division and distribution of fluid. Medications will be administered as ordered prior to departure and after arrival from the dialysis center. These hours will not interfere with the hours designated for the dialysis treatment. The licensed nurse will obtain specific orders regarding administration or holding of medications. B.Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-24-2026 revealed the facility staff assessed the following about the resident:-Had a diagnosis of End Stage Renal Disease (ESRD)-dialysis dependent, Type 2 Diabetes Mellitus, Atrial Fibrillation (A-Fib), Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure. -Brief Interview of Mental Status (BIMS) was scored as a12. According to the MDS Manual a score of 12 indicates moderate cognitive impairment.-required set up and clean up assistance with eating.-required total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers.-was receiving dialysis services. Record review of Resident 5's After Visit Summary (AVS) dated 04-21-2026 revealed an order for a 1500 milliliter (ml) fluid restriction. Record review of Resident 5's Order Listing Report (OLR) printed on 04-28-2026 revealed an order for a Regular diet, thin consistency, no added salt, double protein at meals, avoid high potassium foods with a 1200 ml fluid restriction. Record review of Resident 5's Comprehensive Care Plan (CCP) revised 03-26-2026 revealed Resident 5 had a potential for altered nutrition and hydration and weight changes related to the therapeutic diet, fluid restriction, ESRD and dialysis treatments. The goal was Resident 5 would not have a significant weight change through the next review period and would not show signs or symptoms of dehydration through the review period. Interventions were:-confer with the dialysis Registered Dietician (RD) on an ongoing basis regarding diet, labs, weight and supplements.-diet as ordered: No added salt, Double protein, Low Potassium, regular texture, thin liquids and 1200 ml fluid restriction.-fluids offered within ordered daily fluid restriction of 1200 ml.-Monitor and record meal and fluid intake daily. -monitor for signs and symptoms of dehydration.-monitor weight and report any significant changes to the dietician.-no water pitcher in room. -resident attends dialysis 3 times a week. -supplements as ordered by the dialysis clinic. Record Review of Resident 5's Medication Administration Record (MAR) for April 2026 revealed an order for a fluid restriction 1200 ml per day give 240 ml with breakfast, 240 ml at lunch, 240 ml at dinner and 120 ml with each med pass. Record review of Resident 5's meal ticket revealed staff were to provide 240 ml fluid of choice. An observation conducted on 04-28-2026 at 10:00 AM revealed Resident 5 was in bed with the bedside table next to the bed and on the table was a 600 ml water pitcher that was full up to the 500 ml line on the pitcher. An observation conducted on 04-28-2026 at 12:15 PM revealed a lunch tray was delivered to Resident 5 containing a 240 ml carton of milk, a red plastic glass of juice and a white Styrofoam cup of ice and the 600 ml water pitcher was on the bedside table with the meal. An observation conducted on 04-29-3036 at 12:30 PM revealed Resident 5 had a lunch tray containing a 240 ml carton of milk, a red plastic cup of ice, and a white Styrofoam cup of juice. An interview conducted on 04-30-2026 with Registered Nurse (RN) E confirmed Resident 5 had a water pitcher in the room this morning and RN E had removed it because the Resident 5 was not to have a water pitcher in the room and confirmed Resident 5 was to have 240 ml of fluid with meals and had been offered more than 240 ml at the lunch meal. C. Record review of Resident 5's MAR for April 2026 revealed on 04-24-2026 a 3 indicating Resident 5 did not receive the medication due to being away from the facility without medications:-atorvastatin (a medication used to treat high cholesterol) 10 milligrams (mg) at 9 am.-Fluticasone nasal spray 1 spray both nares at 9 am.-linagliptin (a medication used to treat Type 2 Diabetes) 5mg 1 tablet at 9 am.-sennosides-docusate sodium 8.6-50 mg tablet at 9 am.-metoprolol tartrate (a medication that lowers the resting heart rate, reduces the hearts workload and lowers blood pressure) 25 mg tablet at 9 am.-mucinex extended release (a medication used for chest congestion) 600 mg at 9 am.-carboxymethycellulose sodium ophthalmic solution 0.5% (used for dry eyes) 1 drop in both eyes at 9 am.-ipratropium-albuteral inhalation solution (a medication used to open airways for COPD) 3 mg/ml 3ml inhaled at 9 am. An interview conducted with the Director of Nursing on 04-30-2026 at 3:00 PM confirmed the medications were omitted due to being out of the facility at dialysis and did not know the provision of medications should be scheduled around dialysis services.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5). Based on interview and record review the facility failed to notify the resident representative of a change of condition for 1(Resident 1) of 2 residents sampled. The facility census was 151. The findings are:A.Record review of the facility policy titled Change in Condition dated 05-21-2023 revealed it is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. The resident and/or their representatives will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Requirements for notification of resident, the resident representative and their physician:-an accident involving the resident, which results in injury and has the potential for requiring physician intervention. -a significant change in the resident's physical, mental, or psychosocial status.-a need to alter treatment significantly such as the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. B.Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 01-26-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had a diagnosis of Cerebral Vascular Accident (stroke) affecting the right side of the body.-Brief Interview of Mental Status (BIMS) was scored as a 5. According to the MDS Manual a score of 0-7 indicates a person has severe cognitive impairment. -required total assistance with toileting, hygiene, dressing, bed mobility, transfers and bathing.-was frequently incontinent of bladder.-was always incontinent of bowel. -did not have a pressure ulcer. Record review of Resident 1's Tissue Analytics Document (TAD) dated 03-03-2026 revealed Resident 1 had developed a new wound on the right ankle and a new Deep Tissue Injury to the left heel. Record review of Resident 1's Progress Notes revealed no indication Resident 1's representative was informed of the new wounds on the right ankle or left heel. An interview conducted with Licensed Practical Nurse (LPN) C on 04-30-2026 at 3:41 PM confirmed Resident 1's representative was not updated of the new wounds to the right ankle and left heel and should

Licensure Reference Number 175 NAC 1-005.04Based on record review and interview, the facility failed to resolve grievances and provide grievance resolution response for 1 (Resident 10) of 2 sampled residents. The facility staff identified a census of 151.Findings are:A. Record review of facility policy entitled Grievances dated reviewed/revised 08/25/2026 revealed: - 9. Upon receipt of a written grievance/complaint, Social Services and Department Managers will investigate the allegations and submit a written report of such findings to the administrator. The investigation and report will include, as each may apply: -a. The date and time of the alleged incident; -b. The circumstances surrounding the alleged incident; -c. The location of the alleged incident; -d. The names of any witnesses and their account of the alleged incident; -e. The resident's account of the alleged incident; -f. The employee's account of the alleged incident; -g. Accounts of any other individuals involved (i.e., employee's supervisor, etc.); and -h. Recommendations for corrective action. -9. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. -10. The resident or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems in a timely manner. A written summary of the report will also be provided to the resident if requested, and a copy will be filed in the Social Services office.B. Record review of Resident or Family Concern/Grievance Report Form (grievance form) received from Social Worker (SW)-A on 04/28/2026 at 10:46 AM revealed Resident 10's family member had submitted a grievance on 03/02/2026 regarding a staff member's attitude towards Resident 10 and the family member. The rest of the grievance form including the resolution and administrator review were incomplete.Record review of a grievance form received on 04/28/2026 at 2:18 PM from the Social Services Supervisor (SSS) detailed the grievance received by the facility on 03/02/2026 revealed the grievance of a staff member's attitude towards Resident 10 and their family member. The form was completed to include resolution and follow up with Resident 10 and their family member via a one-to-one discussion dated 03/10/2026.Interview on 04/28/2026 at 10:45 AM with the SSS revealed the facility was in receipt of a grievance regarding a concern with a staff member's attitude. SSS further revealed the grievance was written and was being processed.Interview on 04/28/2026 at 10:46 AM with SW-A revealed the grievance form was incomplete because SW-A was awaiting the permanent interventions from the Director of Nursing or Assistant Director of Nursing.Interview on 04/28/2026 at 10:59 AM with the Assistant Director of Nursing (ADON) revealed the ADON spoke with the staff member in question regarding the grievance. The staff member denied the allegation. The ADON reported the staff member was removed from Resident 10's care and education was provided.Interview on 04/28/2026 at 11:05 AM with the facility Administrator (ADM) revealed the ADM was unaware of the grievance until 04/28/2026 due to the ADM was not at the facility at the time of the grievance.Interview on 04/28/2026 at 3:33 PM with SSS revealed the facility provided grievance resolution on 03/10/2026 to Resident 10 and their family member.Phone interview 04/29/2026 at 10:47 AM with Resident 10's family member revealed the grievance filed was related to a staff member's attitude. Resident 10's family member further revealed that [gender] had not been notified of the resolution of the grievance filed.Interview on 04/29/2026 at 11:50 AM with the ADM revealed a reasonable time frame for grievance resolution was within 10-14 days, which included the form completion and review.During a follow up interview on 04/30/2026 at 11:45 AM, SW-A confirmed the grievance form was not complete when originally provided to surveyors on 04/28/2026 because the permanent grievance resolution was unknown. SW-A reported they informed Resident 10 and the family member of resolution the facility would normally implement in these types of grievances, not the permanent and grievance-specific resolution provided for Resident 10. SW-A further confirmed the grievance was not completed until 04/28/2026.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3). Based on observation, interview and record review the facility failed to implement physician's orders to prevent altered skin integrity for 1 (Resident 5) of 3 residents sampled. The facility census was 151. The findings are:A. Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-24-2026 revealed the facility staff assessed the following about the resident:-Had a diagnosis of End Stage Renal Disease (ESRD)-dialysis dependent, Type 2 Diabetes Mellitus, Atrial Fibrillation (A-Fib), Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure. -Brief Interview of Mental Status (BIMS) was scored as a12. According to the MDS Manual a score of 12 indicates moderate cognitive impairment.-required set up and clean up assistance with eating.-required total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers.-was receiving dialysis services. Record review of Resident 5's Order Listing Report (OLR) printed on 04-28-2026 revealed an order for wound care for the buttocks and coccyx (tailbone) area as follows:-cleanse with foam soap and water and pat dry-apply preventative ointment up to 4 times a day and as needed for soiling-secure with a sacral mepilex dressing (according to the manufacturer Molnlycke Health Care, mepilex sacral dressing is a self-adherent, 5-layer, silicone foam dressing specifically shaped for the sacral area to treat and prevent pressure injuries). Record review of Resident 5's Nurse Administration Record (NAR) for April 2026 revealed no order for wound care to the buttocks and coccyx area. An observation conducted on 04-30-2026 at 10:40 AM during the provision of incontinence care for Resident 5 revealed pink skin discoloration to the sacral area and the absence of a mepilex dressing to the sacral and coccyx area.An interview conducted on 04-30-2026 at 2:30 PM with Licensed Practical Nurse (LPN) C confirmed Resident 5 was to receive wound care to the sacral and coccyx area, confirmed the treatment had not been provided and there must have been a glitch in the electronic medical record program because the order was not on the NAR to cue the staff to provide the treatment.

Licensure Reference Number 175 NAC 12-006.04. Based on interview and record review the facility failed to ensure timely response to call lights as evidenced by call light response times, greater than 30 minutes for 3 (Residents 4, 5 and 7) of 15 sampled residents. The facility census was 151. The findings are:A. An interview conducted with Resident 4 on 04-29-2026 at 9:00 AM revealed Resident 4 had been left on the toilet for a very long time in mid-January of this year. The interview further revealed on 04-26-2026 Resident 4 was left on the toilet for a long time, but not as long as in January.Record review of Resident 4's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 1/15/2026 revealed the facility staff assessed Resident 4's Brief interview for Mental Status (BIMS) as a 13. According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact.Record review of Resident 4's Alarm Average Response Time Report (AARTR) for 01-10-2026 to 01-17-2026 revealed on January 13, 2026 Resident 4's call light was on for 167 minutes and 51 seconds. Record review of Resident 4's AARTR for 04-17-2026 to 04-30-2026 revealed on April 26, 2026 at 8:59 AM Resident 4's call light was on for 46 minutes and 32 seconds, and at 1:05 PM Resident 4's call light was on for 73 minutes and 34 seconds. B. Record review of Resident 5's MDS dated [DATE] the facility staff assessed Resident 5's BOMS as a 12. According to the MDS [NAME] a score of 8 to 12 indicates a persons cognition is moderately impaired.An interview conducted on 4-28-2026 at 8:00 AM with Resident 5's family member revealed Resident 5 has had to wait an hour to be laid down after dialysis. Record review of Resident 5's AARTR for 04-17-2026 to 04-30-2026 revealed on 04-26-2026 at 1:13 AM Resident 5's call light was on for 61 minutes and 38 seconds, and on 04-26-2026 at 6:26 AM Resident 5's call light was on for 76 minutes and 33 seconds. C. An interview conducted on 04-28-2026 at 10:00 AM with Resident 7 revealed Resident 7 had waited as long as 2 hours for someone to answer the call light. Record review of Resident 7's MDS dated [DATE] revealed the facility staff assessed the residents BIMS as a 15.Record review of Resident 7's AARTR for 04-17-2026 to 04-30-2026 revealed on 04-25-2026 at 2:44 PM Resident 7's call light was on for 65 minutes and 18 seconds and at 8:01 PM Resident 7's call light was on for 63 minutes.An interview conducted with the Director of Nursing (DON) on 04-30-2026 revealed the goal for call light response was 7 minutes and confirmed call light times over 30 minutes were not timely.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) & 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to develop, implement and reevaluate interventions for the prevention of pressure ulcer development and to promote wound healing for 2 (Resident 1 and 7) of 3 residents sampled. The facility census was 151. The findings are:A. Record review of the facility policy titled Pressure Ulcer Prevention and Management dated 09-25-2025 revealed the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale Score, on all residents upon admission/re-admission, weekly for 4 weeks, then quarterly or whenever the resident's condition changes significantly. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. The effectiveness of current preventative and treatment modalities and processes will be discussed in accordance with the Quality Assurance Committee Schedule, and as needed when actual or potential problems are identified. Interventions on the resident's plan of care will be modified as needed. Considerations for needed modifications include: -changes in resident's degree of risk for developing a pressure injury.-new onset or recurrent pressure injury development-lack of progression towards healing-resident non-compliance-changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. Record review of the National Library of Medicine article titled Nursing Assessment of Pressure Injury Risk with the Braden Scale dated 11-21-2022 revealed the Braden Scale is an evidence-based nursing tool to assess a patient's risk of developing pressure ulcers based on a score:-a score of 0 to 9 indicates a very high risk of pressure ulcer development.-a score of 10 to 12 indicates a high risk of pressure ulcer development.-a score of 13 to 14 indicates a moderate risk of pressure ulcer development.-a score of 15 to 18 indicates a mild risk of pressure ulcer development.-a score of 19 to 23 indicates no risk of pressure ulcer development. B. Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 01-26-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had a diagnosis of Cerebral Vascular Accident (stroke) affecting the right side of the body.-Brief Interview of Mental Status (BIMS) was scored as a 5. According to the MDS Manual a score of 0-7 indicates a person has severe cognitive impairment. -required total assistance with toileting, hygiene, dressing, bed mobility, transfers and bathing.-was frequently incontinent of bladder.-was always incontinent of bowel. -did not have a pressure ulcer. Record review of Resident 1's Electronic Health Record (EHR) under the assessments section revealed Resident 1's Braden Scale score on admission [DATE] was a 13 indicating moderate risk of pressure ulcer development. Record review of Resident 1's Baseline Care Plan (BCP) dated 01-20-2026 revealed Resident 1 was to have a pressure relieving cushion to the wheelchair. Record review of Resident 1's Electronic Health Record (EHR) under the assessments section revealed Resident 1's Braden Scale score on admission [DATE] was a 11 indicating high risk of pressure ulcer development. Record review of Resident 1's Comprehensive Care Plan (CCP) dated 01-22-2026 revealed Resident 1 was at high risk for skin breakdown due to immobility, right-sided hemiplegia (paralysis), decreased sensation and incontinence. The right heel and other bony prominences are particularly vulnerable to pressure injury. The goal was Resident 1's skin would remain intact. Interventions listed to achieve the goal were:-Braden skin risk evaluation completed on admission, every week for 4 weeks, quarterly and with any significant change.-Nurse Aids to observe skin with morning and bedtime cares and report any abnormalities.-consult the dietician for a nutritional assessment as needed. -document on a flow sheet: if skin is intact; mark Y. If skin is reddened or has open areas; mark N. Report any new openings to Registered Staff.-ensure special mattress is in place for pressure relief-maintain good skin hygiene. Moisturize dry skin as needed.-maintain the head of the bed at the lowest degree of elevation possible.-monitor labs and weights as ordered.-observe for alteration in skin integrity and report to practitioner. Skin will be inspected by licensed staff weekly per schedule.-provide adequate nutrition and hydration. Nutritional supplements and vitamins as ordered. Record review of Resident 1's Skin Check (SC) dated 01-28-2026 revealed Resident 1 had no pressure ulcers. Record review of Resident 1's SC dated 02-04-2026 revealed Resident 1 had blanchable redness to the right heel. Record review of Resident 1's Nurse Administration Record (NAR) for February 2026 revealed an order for Prevalon boots (according to the manufacturer [NAME]/Sage Products, the boots prevent and treat heel pressure ulcers by completely floating the heel off of mattress to relieve pressure) to be worn when in bed. Further review of the NAR for February 2026 revealed on February 6, 7, 8 and 9 there was a 9 in the box indicating to see the progress notes. Record review of Resident 1's Progress Notes (PN) dated 02-06-2026 revealed the Prevalon boots on when in bed were not available. Record review of Resident 1's PN dated 02-07-2026 revealed the Prevalon boots on when in bed were not available. Record review of Resident 1's PN dated 02-08-2026 revealed the Prevalon boots on when in bed were not available. Record review of Resident 1's PN dated 02-09-2026 revealed no pressure relieving boots were available, heels are floating on a pillow. Record review of Resident 1's TAD dated 02-10-2026 revealed an order to protect heels at all times with Prevalon boots, floating the heels and repositioning. Record review of Resident 1's SC dated 02-11-2026 revealed Resident 1 had a pressure ulcer to the right heel measuring 2.5 centimeters (cm) in length by 0.8 cm in width. Record review of Resident 1's Tissue Analytics Document (TAD) dated 02-17-2026 revealed Resident 1's pressure ulcer to the right heel measured 5.81 cm in length by 5.06 cm in width. The TAD also revealed an order to protect heels at all times with Prevalon boots, pillows, floating and repositioning. Record review of Resident 1's NAR for February 2026 revealed the order for Prevalon boots was not changed to reflect the practitioner's order for Prevalon boots at all times dated 02-10-2026. Record review of Resident 1's TAD dated 03-03-2026 revealed Resident 1's right heel pressure ulcer had gotten larger with a new dark area indicative of a Deep Tissue Injury (DTI) measuring 6.56 cm in length by 4.16 cm in width. The TAD also revealed a new wound to the right ankle measuring 0.72 cm in length by 0.71 cm in width with an etiology of possible skin tear vs. pressure ulcer vs. straps from Prevalon boots rubbing on skin and a DTI was identified to the left heel measuring 0.85 cm in length by 0.41 cm in width. The TAD also revealed instructions from the wound care practitioner to protect heels at all times including when Resident 1 is out of bed and do not let Resident 1's feet rest on foot pedals. Record review of Resident 1's NAR for March 2026 revealed on 03-06-2026 the facility had changed the order for Prevalon boots from wear while in bed, to wear at all times, 25 days after the initial practitioner order. Record review of Resident 1's Dietary Progress Notes (DPN) dated 03-07-2026 revealed a nutritional evaluation was conducted for wound healing, 27 days after the first pressure ulcer was identified. The DPN also revealed the Registered Dietician (RD) recommended a nutritional supplement of Ensure Plus give one carton twice a day. Record review of Resident 1's Medication Administration Record (MAR) for March 2026 revealed Ensure Plus give 1 carton twice a day was not administered to Resident 1 until 03-11-2026, 4 days after the RD recommendation. Record review of Resident 1's TAD dated 03-10-2026 revealed Resident 1's right heel pressure ulcer was 1.28 cm in length and 1.87 cm in width, the right ankle worsened measuring 3.91 cm in length by 1.14 cm in width, and the left heel DTI measured 1.36 cm in length by 0.54 cm in width. Record review of Resident 1's EHR revealed a TAD was not completed on 03-17-2026. Record review of Resident 1's TAD dated 03-24-2026 revealed Resident 1's right heel pressure ulcer was 1.83 cm in length and 0.88 cm in width, the right ankle worsened measuring 4.82 cm in length and 1.56 cm in width, and the left heel DTI measured 0.81 in length by 0.77 cm in width. Record review of Resident 1's PN dated 03-24-2026 revealed Resident 1 was transferred to the hospital for evaluation of a change in condition. An interview conducted on 04-30-2026 at 1:45 PM with Registered Nurse (RN) D revealed Resident 1 was non-compliant with the Prevalon boots and could not recall if the Interdisciplinary Team (IDT) had re-evaluated Resident 1's interventions for pressure relief for the bilateral feet. The interview also revealed that Resident 1 was not on a turning schedule and the schedule should have been put into the tasks in the EHR to cue the staff to reposition Resident 1. An interview conducted on 04-30-2026 at 2:00 PM with LPN C confirmed the turning schedule for Resident 1 was not entered into the EHR to cue the staff to reposition Resident 1, confirmed the nutritional evaluation was not requested prior to 03-07-2026 and confirmed pressure relieving interventions for Resident 1's had not been re-evaluated and confirmed new interventions on Resident 1's care plan were dated 04-21-2026, 28 days after Resident 1 discharged . C. Record review of the Joerns DermaFloat LAL model air mattress dated 2015 revealed directions for setting up the air mattress to prevent bottoming out (providing greater than 1 inch of air between the resident's sacral area/buttocks and the lower safety mattress) as outlined:-begin by placing the head of the bed in the appropriate position based on the resident's clinical condition.-select the highest or most firm Comfort Adjust setting.-Hand Check: place a hand with 3 fingers (if the head of the bed is at 30 degrees or higher) and 4 fingers (if the head of the bed is lower than 30 degrees) stacked vertically beneath the cells of the mattress and above the safety mattress directly between the lowest point of the resident's sacral area/buttocks. The smallest finger should be resting on the safety mattress. -sequentially reduce the Comfort Adjust setting to the firmness level where the height of the 3 or 4 fingers can slide with minimal resistance between the resident's sacral area/buttocks and the lower safety mattress. This is the proper Comfort Adjust setting for the resident to assure proper inflation of the air cells and prevent bottoming out of the mattress.-document the resident's Comfort Adjust setting for future reference and re-evaluate with the Hand Check as the resident's condition warrants. D. Record review of Resident 7's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-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 total assistance with toileting, bathing, dressing, personal hygiene, bed mobility and transfers.-was always incontinent of bowel and bladder.-was at risk of developing a pressure ulcer.-had a stage 2 pressure ulcer. An observation conducted on 04-27-2026 at 1:30 PM revealed Resident 7 was lying in bed on a DermaFloat air mattress set at the firmest setting.An observation conducted on 04-28-2026 at 8:00 AM revealed Resident 7 was lying in bed on a DermaFloat air mattress set at the firmest setting.An observation conducted on 04-29-2026 at 4:50 AM revealed Resident 7 was lying in bed on a DermaFloat air mattress set at the firmest setting. An interview conducted with the Director of Nursing (DON) on 04-30-2026 at 3:30 PM confirmed the facility had not followed the DermaFloat air mattress manual for the set up of Resident 7's air mattress and could not confirm if the mattress was at the correct setting to prevent bottoming out as described in the manual.

Based on record review, observation, and interview, the facility staff failed to change gloves between residents during the provision of blood glucose monitoring, perform hand hygiene after doffing (removing) gloves, and handle glucose strips in a manner to prevent the potential for cross contamination for 2 (Residents 14 and 15) of 6 sampled residents; and the facility failed to use enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition [e.g., residents with wounds or indwelling medical devices]) to prevent the potential for cross-contamination for 1 (Resident 5) of 2 sampled residents. Facility staff identified a census of 151.Findings are:Record review of facility policy entitled Glucometer Cleaning dated revised 03/02/2020 revealed it was the facility's policy to clean meters before and after each use. Each resident had their own glucometer to provide adequate control. The facility staff would make sure the meter was powered off and wet the glucometer with a sani-wipe until the meter was visibly wet for a full 2 minutes. Record review of facility policy entitled Using Gloves updated 02/21/2020 revealed: -1. Wash your hands following procedure before putting gloves on. -4. Dispose of the gloves by placing them into the trash. -5. Wash your hands thoroughly for a minimum of 20 seconds. Reminders for gloves: -6. Discard gloves after use, never wash or reuse disposable gloves. A. Record review of Resident 14's Nurse Administration Record (NAR) dated April 2026 identified Resident 14 required blood glucose monitoring at 8:00 AM for monitoring related to Type 2 Diabetes Mellitus (T2DM, a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). B. Record review of Resident 15's NAR dated April 2026 identified Resident 15 required blood glucose monitoring each morning for T2DM. Continuous observation on 04/30/2026 from 7:02 AM to 7:10 AM revealed Licensed Practical Nurse (LPN)-B exited room [ROOM NUMBER] wearing gloves on both hands and carrying insulin supplies and a glucometer. LPN-B placed the insulin supplies in the cart and discarded the previous glucometer test strip. Without doffing gloves, without the benefit of hand hygiene, and without cleaning the glucometer, LPN-B placed fingers into the cannister of test strips, placed a strip in the glucometer, and retrieved a lancet, alcohol pad, and cotton ball. LPN-B entered Resident 14's room, poked Resident 14's finger, and obtained a blood glucose sample. LPN-B exited the room, wrote on a piece of paper and discarded the used test strip and lancet. LPN-B did not remove gloves, perform hand hygiene, or clean the glucometer after use. With the previously used gloves, LPN-B retrieved a test strip from the cannister, retrieved an alcohol swab, cotton ball, and lancet, and entered Resident 15's room. LPN-B reported to Resident 15 that a new lancet needed to be obtained. LPN-B exited the room, doffed (removed) gloves, and without the benefit of hand hygiene, obtained a new lancet. LPN-B donned (applied) new gloves and performed the blood glucose check. LPN-B exited the room, disposed of supplies, doffed gloves, and wrote on a piece of paper. Interview on 04/30/2026 at 7:17 AM with LPN-B confirmed the use of the same gloves between three different residents. LPN-B further confirmed the glucometer was not cleaned between uses and should have been, and hand hygiene was not performed when gloves were changed. Interview on 04/30/2026 at 12:23 PM with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed using the same gloves, not disinfecting the glucometer between uses, and the absence of hand hygiene presented the potential for cross-contamination. ADON/IP further confirmed gloves are single-use gloves and should be changed between residents. C. Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-24-2026 revealed the facility staff assessed the following about the resident: -Had a diagnosis of End Stage Renal Disease (ESRD)-dialysis dependent, Type 2 Diabetes Mellitus, Atrial Fibrillation (A-Fib), Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure. -Brief Interview of Mental Status (BIMS) was scored as a12. According to the MDS Manual a score of 12 indicates moderate cognitive impairment. -required set up and clean up assistance with eating. -required total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers. -was receiving dialysis services. Record review of Resident 5's Comprehensive Care Plan (CCP) dated 05-13-2024 revealed Resident 5 was on Enhanced Barrier Precautions (EBP) due to having a dialysis catheter. The goal was Resident 5 would have reduced risk of infection and maintain the integrity of the dialysis catheter site through the review period. Interventions were for staff to use barrier precautions, such as disposable gowns when providing care. An observation conducted on 04-27-2026 at 1:30 PM revealed an EBP sign on the wall outside of Resident 5's room that stated, EBP everyone must: clean their hands, including before entering and when leaving the room. Further review of the sign revealed providers, and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: -dressing -bathing and showering -transferring -changing linens -providing hygiene -changing briefs or assisting with toileting -during wound care for any skin opening requiring a dressing -during device or use, such as central lines, urinary catheters, feeding tubes and tracheostomy. An observation conducted on 04-30-2026 at 10:40 AM of Nursing Assistant (NA) F changing Resident 5's incontinence brief revealed no use of a gown during the brief change. An interview conducted on 04-30-2026 at 11:00 AM with NA F confirmed a gown should have been worn while changing Resident 5's brief and wasn't because I forgot.

Licensure Reference Number 175 NAC 12-006.10(D). Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident 5) of 1 residents sampled. The facility census was 151. The findings are:A.Record review of Medication Errors in Nursing Homes Fact Sheet from the Long-Term Care Community Coalition dated 01-2023 revealed a medication error means an observed or identified preparation or administration of medications which is not in accordance with the prescriber's order, the manufacturer's specifications, or accepted professional standards or principles. A significant medication error is an error which causes the resident discomfort or jeopardizes their health and safety. Common medication errors include taking medication dose late, omitted dose, dispensing the wrong medication, giving the medication through the wrong route, and a wrong or extra dose of medication.B.Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-24-2026 revealed the facility staff assessed the following about the resident:-Had a diagnosis of End Stage Renal Disease (ESRD)-dialysis dependent, Type 2 Diabetes Mellitus, Atrial Fibrillation (A-Fib), Chronic Obstructive Pulmonary Disease (COPD) and Chronic Heart Failure. -Brief Interview of Mental Status (BIMS) was scored as a12. According to the MDS Manual a score of 12 indicates moderate cognitive impairment.-required set up and clean up assistance with eating.-required total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers.-was receiving dialysis services. Record review of Resident 5's Comprehensive Care Plan (CCP) revised 04-13-2026 revealed Resident 5 needs dialysis related to ESRD and had dialysis appointments on Monday, Wednesday and Friday. Record review of Resident 5's Medication Administration Record (MAR) for April 2026 revealed on 04-24-2026 a 3 indicating Resident 5 did not receive the following medication due to being away from the facility without medications:-metoprolol tartrate (a medication that lowers the resting heart rate, reduces the hearts workload and lowers blood pressure) 25 milligram (mg) tablet at 9 AM. Record review of Resident 5's Progress Note dated 04-24-2026 revealed morning medications were not given due to being at dialysis that morning and the physician wrote an order to give metoprolol tartrate 25mg now due to Resident 5's heart rate was 116. An interview conducted with the Director of Nursing (DON) on 04-30-2026 at 3:00 PM confirmed Resident 5 did not receive the metoprolol and linagliptin on 04-24-2026 and a medication omission was an error.

No Licensure Reference Number Based on observation, 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 hours worked per discipline. This had the potential to affect all residents that resided in the facility. The facility census was 143. The findings are: Record review of a facility policy entitled Facility Posted Nurse Staffing dated 7/24 revealed the following information.Policy Explanation and Compliance Guidelines:1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information:a. Facility nameb. The current datec. Facility's current resident censusd. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides Observation on 08/27/25 at 10:00 AM, 08/28/25 at 10:40 AM, and 09/02/25 at 9:40 AM revealed the posted nursing staffing information for 08/27/25, 08/28/25 and 09/02/25 did not contain a calculation of the total number of hours worked per discipline. Record review of 30 days past posted nurse staffing between 08/01/25 - 09/01/25 revealed the daily posted nurse staffing did not contain the totaled number of hours for the different types of staff. Interview on 09/02/25 at 11:00 AM with the facility Administrator confirmed that the posted nurse staffing information did not contain the total number of hours worked per discipline and that those had not been calculated or documented on the posted nurse staffing information and should have been.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview; the facility staff 1) failed to utilize hand-washing and gloving techniques to prevent potential food contamination during food preparation and meal service and 2) store foods in a manner to prevent potential food borne illness. This practice had the potential to affect all residents in the facility who ate meals from the kitchen. The facility also failed to monitor refrigerator temperatures daily on resident personal refrigerators. This had the potential to affect all residents that used the unit refrigerator on [NAME] and [NAME] Units. The facility census was 143.Findings are: A. Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -2-301.14 Food employees shall wash hands and exposed portions of their arms immediately before engaging in food preparation:-after touching bare human body parts other than clean hands and clean, exposed portions of arms,-after handling soiled equipment or utensils,-during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when tasks are changed,-after handling soiled equipment; and-before donning gloves to work with food. -3-304.15 (A) Single use gloves should be used for only one task and should be discarded when soiled or when interruptions occur in the operation -3-305.11(A) Food shall be protected from contamination by storing the food where it is not exposed to splash, dust, or other contamination. Review of the facility policy Handwashing Guidelines for Dietary Employees implemented 8/16/24 revealed the following:-Handwashing was necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees should clean their hands in a handwashing sink.-Dietary employees should clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and:-Every time an employee enters the kitchen at the beginning of the shift, after returning from break and after using the toilet,-After hands have touched anything unsanitary (garbage, soiled utensils or equipment and dirty dishes).-After hands have touched bare human body parts other than clean hands (such as face, nose and hair) and -Before donning gloves for working with food. Review of the facility policy Food Safety Requirements with an implemented date of 3/25/25 revealed the following:-It was the policy of the facility that foods would be stored, prepared, distributed and served in accordance with professional standards for food service safety.-Food safety practices should be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to the residents. B. Observation on 8/28/25 at 10:50 AM to 11:25 AM revealed the following:- Prep Cook, (PC-D) without washing hands donned clean gloves, cut cucumbers into slices and placed them in a large bowl, removed the gloves, opened the refrigerator door and placed the bowl with cucumbers in the refrigerator. No handwashing was identified after removing the gloves.- PC-D then took 5 packages of Hawaiian King buns, donned gloves, removed the buns from the packages, separated the buns and put them in a large white colored rectangle shaped container.- PC-D removed the gloves, picked up the empty bun packages, lifted the lid to the garbage can and threw the bun containers away in the garbage. No handwashing was identified before donning or after removing gloves. -PC-D then opened the refrigerator, brought out a container of sliced cheese and a package of bread. Donned clean gloves, opened the cheese container and package of bread, spread butter on 1 side of 2 pieces of bread, placed a piece of cheese on 1 slice of bread, placed another slice of bread on top of cheese, put the sandwich in a sandwich bag and then put the cheese sandwich in the refrigerator next to the serving line. Gloves were removed, the cheese container was put back into the refrigerator and then closed the package of bread. No hand washing was identified before donning or after removing gloves.- At 11:29 AM Dietary Aide, (DA-E) without washing hands donned clean gloves picked up a plate, used tongs and placed brisket on the plate, picked up another set of tongs and placed a bun on the plate, picked up other tongs and put a baked potato on the plate, plate was put on the serving tray. -DA-E picked up a plate, opened the door to the heating unit and picked up a container of hamburgers, picked up a hamburger bun with the gloved hand, put it on the plate, used tongs to pick up the hamburger and put it on the hamburger bun, used tongs to pick up baked potato and placed the plate on the serving tray with out completing hand hygiene. -DA-E then opened the heating unit door and returned the container of hamburgers to the shelf. -At 12:08 PM DA-E touched a pair of glasses that they were wearing and rubbed the right side of their face. -At 12:38 PM DA-E picked up 2 plates, opened the door on the heating unit, took out the container of hot dogs and container of hamburgers, with the gloved hand picked up a hot dog bun and placed on 1 plate and 2 hamburger buns placed on a plate. DA-E used tongs to pick up a hot dog and placed them on the hot dog bun, then used tongs to pick up 2 hamburgers that were put on the hamburger buns. DA-E then opened the refrigerator next to the serving line and with gloved hand picked up 2 pieces of cheese and put them on the hamburgers. DA-E used tongs to put baked potato on 2 plates then placed the plates on the serving tray. The same pair of gloves was used through the meal service; no changing of gloves or handwashing was identified. C. On 8/28/25 at 11:00 AM an observation in the food prep area revealed the following; - There was a food rack that had 2 layers of bowls of watermelon that were not covered with a protective covering. The watermelon was for the noon meal on 8/28/25. Directly on the right side of the rack were 3 trash cans that PC-D had thrown garbage into while the watermelon was next to the trash cans. On the left side of the rack was soiled breakfast plates, cups and silverware that were being separated, and food and liquids were being dumped into a bucket next to the watermelon. -At 11:05 AM PC-D took the garbage bags out of the garbage cans that were by the uncovered watermelon.An interview with the Director of Dietary Services on 8/28/25 at 11:43 AM confirmed that dietary staff were to wash hands in between glove changes. An interview with the Registered Dietician on 8/28/25at 1:00 PM confirmed that:- Dietary staff were to wash their hands when entering the kitchen at the beginning of the shift, when coming back from break or using the bathroom, before donning clean gloves and after soiled gloves are removed. - Food was to be covered when waiting to be served and not kept next to hazardous material. - A clean pair of gloves would be worn whenever touching ready to eat food if gloved hands touched another surface.D. Review of the Log Fridge temperature sheet dated July 2025 at the [NAME] Unit revealed that no temperatures were completed on the following dates:-The morning temperatures were not logged on July 12th, 13th, 17th, 18th, 20th, 21st, 26th, 27th, 30th and 31st.-The evening temperatures were not logged on July 1st, 9th and 23rd. Review of the Log Fridge temperature sheet dated August 2025 at the [NAME] Unit revealed that no temperatures were completed on the following dates:-The morning temperatures were not logged on August 3rd, 4th, 5th, 6th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 26th, 27th, 28th, 29th, 30th and 31st.-The evening temperatures were not logged on August 2nd, 4th, 10th, 12th, 13th, 15th and 20th. Review of Log Fridge temperature sheet dated August 2025 at the [NAME] Unit revealed that no temperatures were completed on the following dates:-The morning temperatures were not logged on August 6th, 17th, 21st, 22nd, 25th, 26th and 27th.-The evening temperatures were not logged on August 3rd, 4th, 5th, 6th, 10th, 15th, 20th, 23rd and 29th. An interview on 9/2/25 at 10:30 AM with the Director of Nursing confirmed that temperatures are to be checked daily on the resident personal refrigerators on the separate units. Record review of the facility policy Resident Personal Refrigerators with a revised date of 6/14/24 revealed the following:-Each refrigerator must be equipped with a reliable thermometer, and it will be located so that the temperature can be easily read.-Refrigerators would be maintained at a temperature range between 34 to 40 degrees Fahrenheit or less.-The temperatures of all lounge refrigerators will be monitored and recorded daily.

Licensure Reference Number 175 NAC 12-006.04(F)(i)Licensure Reference Number 175 NAC 12-006.09Licensure Reference Number 175 NAC 12-006.09(H)(iii) The facility failed to notify the physician and resident representative when ordered daily weights were not obtained or documented for 1 ( Resident 58) of 1 sampled resident and failed to notify physician of changes in skin condition for 1 (Resident 15) of 1 sampled resident. The facility census was 143.A. A record review of Resident 58's Weights & Vitals on August 28, 2025 revealed 86 missed daily weights from April 1 through August 26, 2025. No refusals or provider notifications were documented. A record review of facility's Change in Condition policy with, revised date April 2023 revealed staff are required to immediately notify the physician/resident representative of significant changes in condition or failure to implement treatment orders. No evidence of such notification was found. A record review of Resident 58's monthly weight logs for April through August 2025 revealed multiple gaps: April 2025: 17 missed days of daily weights (e.g., 04/03, 04/04, 04/06, 04/08, 04/10, 04/12, 04/16–04/22, 04/27, 04/30). May 2025: 14 missed days of daily weights (e.g., 05/01–05/03, 05/07–05/09, 05/12, 05/18–05/19, 05/27–05/30). June 2025: 25 missed days of daily weights (e.g., 06/02–06/06, 06/08–06/09, 06/12–06/29). July 2025: 19 missed days of daily weights (e.g., 07/01–07/05, 07/07–07/11, 07/14, 07/16, 07/18–07/19, 07/23–07/24, 07/27–07/29). August 2025 (through 8/26): 11 missed days of daily weights (e.g., 08/01, 08/04, 08/06, 08/08, 08/11, 08/14, 08/16, 08/20–08/21, 08/24–08/25). A record review of Resident 58's progress notes during this same period revealed that no documentation of refusals, no nursing notes explaining missed daily weights, and no evidence of provider notification. A record review of resident 58's care plan (last reviewed 08/11/2025) revealed that daily weights were an active intervention for management of congestive heart failure and lymphedema. No revisions were made to address the 86 missed days of daily weights. An Interview with the Director of Nursing on September 3, 2025 at 12:00 PM confirmed by stating The documentation regarding the residents weights is just not there, neither is the notification to the provider, though it should be. We will have to do some training going forward. B. Review of Resident 15's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/19/25 revealed the resident's cognitive skills for daily decision making were severely impaired. The resident was dependent on staff for personal hygiene, toileting hygiene, bathing, upper and lower extremity dressing, rolling left to right, going from sitting to lying position, chair/bed to chair transfer, tub transfer and wheelchair mobility and was always incontinent of bowel and bladder. The resident was also at risk for skin breakdown and staff applied ointment to skin. Review of the Skin Check documentation from 8/13/25 revealed Resident 15 had scratches to the buttocks, abdomen, right hip area, left hip area and upper right and left leg. Nursing documentation on 8/24/25 at 6:42 PM revealed that Resident 15 had scratched the right buttock when sitting in the shower chair after bathing, area measured 6 centimeters (cm) in length by 3 cm wide. Review of nursing documentation dated 8/28/25 at 1:02 PM revealed Resident 15 had scratched the right buttock, area measured 10cm in length by 10cm in width. Review of Nurse Administration Record for August 2025 revealed that the resident did not have an order for medication for itching or skin treatments for the scratched areas. An observation of provision of care on 8/28/25 at 1:20 PM revealed that Resident 15 had scratched at skin to the lower abdomen, buttocks and peri cares when perineal cares (washing and caring for the genital and rectal areas of the body) had been completed. Nursing Assistant (NA-H) and NA-G confirmed that resident scratched genital areas and abdomen when not covered with a brief or pants. NA-H and NA-G verified that no creams are applied to the skin by nursing assistants. An interview with the Director of Nursing (DON) on 9/2/25 at 12:10 PM confirmed that resident's hospice agency nor the resident's physician had not been notified of the resident itching and scratching and the resident did not have any skin treatments or creams applied to scratched skin areas. An interview with NA-L on 9/2/25 at 1:00 PM confirmed that the resident scratched buttocks and genital areas when received a bath and when skin is not covered by brief or pants. An interview with the Hospice Registered Nurse (HRN-I) on 9/2/25 at 2:00 PM confirmed that Resident 15 was admitted to hospice on 6/12/25 and hospice was not aware of the resident itching or scratching at the skin.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(H)Based on record review and interview, the facility failed to implement interventions to prevent the potential for verbal abuse for 2 (Resident 8 & 59) of 2 residents sampled. The facility staff identified a census of 143.The findings are:Record review of a facility policy entitled Abuse Prohibition Program dated revised 8/8/2024 revealed: -Policy Statement: residents have the right to be free from abuse, neglect, misappropriation of resident property, and involuntary seclusion by anyone, including by not limited to - facility staff, other residents, volunteers, staff of other agencies serving the resident, family members, legal guardians, and friends. Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, and systems to assist in preventing resident abuse. -2. Our abuse prevention/intervention program includes, but is not necessarily limited to the following: -b) The protection of residents during abuse investigations; -c) The implementation of changes to prevent future occurrences of abuse.Record review of Resident 8's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 5/20/2025 identified the facility admitted the resident on 2/14/2025. Further review of the MDS identified Resident 8 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a score of 14 indicated the resident was cognitively intact. The MDS identified Resident 8 had diagnoses which included dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]), anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), depression, bipolar disorder (a condition characterized by dramatic shifts in mood, energy, and activity levels that affect a person's ability to carry out day-to-day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs that are experienced by everyone), and psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions).Record review of Resident 59's admission MDS dated [DATE] identified the facility admitted the resident on 6/2/2025. Further review of the MDS revealed Resident 59 had a BIMS score of 14 and the resident had delusions (misconceptions, or beliefs that are firmly held, contrary to reality) during the review period. The MDS identified Resident 59 had diagnoses which included dementia, anxiety disorder, and depression.Record review of Resident 59's Progress Notes dated 7/4/2025 showed a note written by Licensed Practical Nurse (LPN)-C that Resident 59 was requesting to move into a different room because Resident 8 had called Resident 59 derogatory names several times. Resident 59 also reported to facility staff that Resident 8's television was too loud.Record review of Resident Abuse Investigation Report Form (investigation) dated 7/11/2025 revealed on 7/4/2025, Resident 59 requested to be moved to a different room due to Resident 8 calling (gender) derogatory names several times. Resident 59 told staff that the roommate would not work and that Resident 8's television was too loud. Resident 59 called a family member to advise them of what the roommate had said.Further review of the investigation revealed on 7/7/2025 at approximately 12:00 PM, Resident 59's Nurse Practitioner (NP) notified Social Worker (SW)-B of Resident 59's concerns with the television. SW-B began an investigation and identified the progress note dated 7/4/2025 and written by LPN-C in Resident 59's medical record. At approximately 3:30 PM on 7/7/2025 the facility moved Resident 59 to a different room.An interview on 8/28/2025 at 3:20 PM with SW-B revealed Resident 59's room move was not completed until 7/7/2025.An interview on 8/28/2025 3:23 PM with the Administrator (ADM) confirmed the verbal incident between Resident 8 and Resident 59 occurred on 7/4/2025. The ADM further confirmed an intervention was not immediately put in place to protect both residents from further potential verbal abuse and that the facility should have.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(H)Based on interview and record review, the facility staff failed to report an allegation of verbal abuse within the required timeframes for 2 (Resident 8 & 59) of 2 sampled residents. The facility staff identified a census of 143.The findings are:Record review of a facility policy entitled Abuse Reporting dated revised 8/8/2024 revealed: -3. All personnel, residents, family members, visitors, etc., are encouraged to report incident of resident abuse or suspected incidents of abuse. Such report may be made without fear of retaliation from the facility or its staff. -4. Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Administrator/Director of Nursing/Social Services director. -5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator/Director of Nursing/Social Services director. The following information should be reported: -a. The name(s) of the resident(s) to which the abuse or suspected abuse occurred; -b. The date and time that the incident occurred; -c. Where the incident took place; -d. The name(s) of the person(s) allegedly committing the incident, if known; -e. The name(s) of any witnesses to the incident. -f. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); -g. A written statement of the above information; and -h. Any other information that may be requested by management. 6. Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment of offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. It may also result in facility disciplinary action or termination. -7. Staff members and persons affiliated with this facility shall not knowingly: -b. Fail to report an incident of mistreatment or other offense. -8. The Administrator and the Director of Nursing must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing must be called at home and informed of such incident. -9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. -14. In accordance with the Elder Justice Act, the facility administrator or his/her designee will notify immediately, but not later than two hours after the allegation is made if the events that cause the allegation involved result in serious bodily injury or not later than 24 hour if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, the following persons or agencies of such incident as applicable: -a. The State licensing/certification agency responsible for surveying/licensing the facility; -b. The local/State Ombudsman; -c. The resident's representative; -d. Adult Protective Services; -e. Law enforcement officials; -f. The resident's Attending Physician; and -g. The facility Medical Director.Record review of Resident 8's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 5/20/2025 identified the facility admitted the resident on 2/14/2025. Further review of the MDS identified Resident 8 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 14. According to the MDS manual, a score of 14 indicated the resident was cognitively intact. The MDS identified Resident 8 had diagnoses which included dementia (a usually progressive condition marked by the development of multiple cognitive deficits [such as memory impairment, aphasia, and the inability to plan and initiate complex behavior]), anxiety disorder (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), depression, bipolar disorder (a condition characterized by dramatic shifts in mood, energy, and activity levels that affect a person's ability to carry out day-to-day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs that are experienced by everyone), and psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions).Record review of Resident 59's admission MDS dated [DATE] identified the facility admitted the resident on 6/2/2025. Further review of the MDS revealed Resident 59 had a BIMS score of 14 and the resident had delusions (misconceptions, or beliefs that are firmly held, contrary to reality) during the review period. The MDS identified Resident 59 had diagnoses which included dementia, anxiety disorder, and depression.Record review of Resident 59's Progress Notes dated 7/4/2025 showed a note written by Licensed Practical Nurse (LPN)-C that Resident 59 was requesting to move into a different room because Resident 8 had called Resident 59 derogatory names several times. Resident 59 also reported to facility staff that Resident 8's television was too loud.Record review of Resident Abuse Investigation Report Form (investigation) dated 7/11/2025 revealed on 7/4/2025, Resident 59 requested to be moved to a different room due to Resident 8 calling (gender) derogatory names several times. Resident 59 told staff that the roommate would not work and that Resident 8's television was too loud. Resident 59 called a family member to advise them of what the roommate had said.Further review of the investigation revealed on 7/7/2025 at approximately 12:00 PM, Resident 59's Nurse Practitioner (NP) notified Social Worker (SW)-B of Resident 59's concerns with the television. SW-B began an investigation and identified the progress note dated 7/4/2025 and written by LPN-C in Resident 59's medical record. At approximately 3:30 PM on 7/7/2025 the facility moved Resident 59 to a different room.An interview on 8/28/2025 3:23 PM with the Administrator (ADM) confirmed the verbal incident between Resident 8 and Resident 59 occurred on 7/4/2025. The ADM further confirmed that the allegation of verbal abuse was not reported within 24 hours and should have been.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(D)Based on record review and interview, the facility failed to complete the Quarterly Minimum Data Set (MDS, a federally mandated assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) within the required time frames for 2 (Resident 14 & 119) of 35 sampled residents. The facility staff identified a census of 143.The findings are:Record review of the Resident Assessment Instrument (RAI) Manual Version 1.18.11 effective 10/01/23 revealed a quarterly MDS must be completed and signed no later than 14 days from the assessment reference date.A. Record review of Resident 14's MDS with a reference date of 8/6/2025 revealed the MDS was not signed as completed until 8/26/2025 which is 20 days after the reference date.B. Record review of Resident 119's MDS with a reference date of 6/23/2025 revealed the MDS was not signed as completed until 7/24/2025 which is 31 days after the reference date.An interview on 9/3/2025 at 11:53 AM with MDS Coordinator (MDSC)-A confirmed the MDS's for Resident 14 and Resident 119 were late and should have been signed within 14 days of completion.An interview on 9/3/2025 at 11:59 AM with the Nurse Consultant (NC) revealed the facility follows the MDS manual for timeliness and completion.

Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on record review, observation and interview; the facility failed to ensure nail care was provided for Resident 15. The sample size was 1 and the facility census was 143. Findings are:Review of the facility policy titled Shower and Bathing with a revised date of 5/17/22 included the following:-The facility would provide routine personal hygiene for the residents and assess the condition of the resident's skin on a weekly basis. -The resident fingernails would be cleaned and trimmed on resident bath day. Review of Resident 15's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/19/25 revealed the resident's cognitive skills for daily decision making was severely impaired. The resident was dependent on staff for toileting hygiene, personal hygiene, bathing, upper and lower extremity dressing, rolling left to right, going from sitting to lying position, chair/bed to chair transfer, tub transfer and wheelchair mobility and was always incontinent of bowel and bladder. The resident was also at risk for skin breakdown and staff applied ointment to skin. Review of Resident 15's Care Plan with a revised date of 5/7/25 revealed an intervention of:-Activity of daily living problem had an intervention that resident preferred 2 whirlpools per week, the resident can no longer participate in showering tasks. The resident had lost the ability to follow instructions like putting soap on the washcloth. Review of the Skin Check documentation from 8/13/25 revealed the resident had scratches to the buttocks, abdomen, right hip area, left hip area and upper right and left leg. Nursing documentation on 8/24/25 at 6:42 PM revealed that the resident had scratched the right buttock when sitting in the shower chair after bathing, area measured 6 centimeters (cm) in length by 3 cm wide. An observation on 8/28/25 at 9:20 AM revealed the resident being pushed in the wheelchair to the TV area after whirlpool received. Fingernails to the right hand were jagged with sharp corners and fingernail to the little finger on the right hand was long and dirty under the nail. An interview with a nursing assistant (NA-F) that gave the resident the whirlpool confirmed that the resident's nails were not trimmed with the whirlpool and that the residents nails were to be trimmed with their bath weekly. NA-F stated that the residents nails would be trimmed with the resident's next bath. An interview on 9/2/25 at 12:10 PM with the Director of Nursing confirmed that the resident's nails were to be trimmed weekly with the bath.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(3)Licensure Reference Number 175 NAC 12-006.09 The facility failed to ensure physician orders were followed by not obtaining and documenting daily weights for Resident 58, and failed to perform weekly skin evaluations for Resident 15, and weekly wound evaluations for Resident 5, and failed to implement interventions to prevent skin breakdown for Resident 62. The facility census was 143. The findings are:A. A record review of Resident 58's Weights & Vitals on August 28, 2025 revealed 86 missed daily weights from April 1 through August 26, 2025. No refusals or provider notifications were documented. A record review of facility's Change in Condition policy with, revised date April 2023 revealed staff are required to immediately notify the physician/resident representative of significant changes in condition or failure to implement treatment orders. No evidence of such notification was found. A record review of Resident 58's monthly weight logs for April through August 2025 revealed multiple gaps: April 2025: 17 missed days of daily weights (e.g., 04/03, 04/04, 04/06, 04/08, 04/10, 04/12, 04/16–04/22, 04/27, 04/30). May 2025: 14 missed days of daily weights (e.g., 05/01–05/03, 05/07–05/09, 05/12, 05/18–05/19, 05/27–05/30). June 2025: 25 missed days of daily weights (e.g., 06/02–06/06, 06/08–06/09, 06/12–06/29). July 2025: 19 missed days of daily weights (e.g., 07/01–07/05, 07/07–07/11, 07/14, 07/16, 07/18–07/19, 07/23–07/24, 07/27–07/29). August 2025 (through 8/26): 11 missed days of daily weights (e.g., 08/01, 08/04, 08/06, 08/08, 08/11, 08/14, 08/16, 08/20–08/21, 08/24–08/25). A record review of Resident 58's progress notes during this same period revealed that no documentation of refusals, no nursing notes explaining missed daily weights, and no evidence of provider notification. A record review of resident 58's care plan (last reviewed 08/11/2025) revealed that daily weights were an active intervention for management of congestive heart failure and lymphedema. No revisions were made to address the 86 missed days of daily weights. An Interview with the Director of Nursing on September 3, 2025 at 12:00 PM confirmed by stating The documentation regarding the residents weights is just not there, neither is the notification to the provider, though it should be. We will have to do some training going forward. B. Record review of the facility policy titled Skin assessment dated [DATE] revealed it the facility policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. A full body, or head to toe, skin assessment will be conducted by a licensed nurse upon admission/readmission, for 3 days and weekly thereafter. Record review of the facility policy titled Documentation of Wound Treatments dated August 2024 revealed wound assessments are conducted on admission, weekly and as needed if the resident or wound condition deteriorates. The following elements of a complete wound assessment include: -type of wound -degree of skin loss -measurements -wound characteristics- type of tissue in the wound bed, condition of the skin around the wound, drainage, odors and pain. Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-14-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored at a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment. -Had a diagnosis for Diabetes Mellitus. -required limited assistance with bed mobility -required extensive assistance with upper body dressing -required total assistance with transfers and lower body dressing. An observation conducted on 09-02-2025 at 7:15 AM of Resident 5 revealed a round tan area approximately 1 centimeter (cm) in diameter area to the lateral (outside, furthest away from the middle) aspect of the left great toe. Record review of the Resident 5's Treatment Administration Record (TAR) for August 2025 revealed Resident 5 had a blister to the left lateral great toe and had an order for a skin evaluation weekly and with any open area measurements and a description of the wound was indicated. Record review of Resident 5's weekly skin evaluations revealed no wound evaluation of the blister to the left great toe from 07-07-2025 to 07-23-2025. An interview with the Director of Nursing (DON) on 09-03-2025 at 1:07 PM confirmed Resident 5 should have had a weekly wound evaluation conducted between 07-07-2025 and 07-23-2025 and confirmed a weekly wound evaluation was not done in between those dates. C. Review of Resident 15's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/19/25 revealed the resident's cognitive skills for daily decision making was severely impaired. The resident was dependent on staff for toileting hygiene, bathing, upper and lower extremity dressing, rolling left to right, going from sitting to lying position, chair/bed to chair transfer, tub transfer and wheelchair mobility and was always incontinent of bowel and bladder. The resident was also at risk for skin breakdown and staff applied ointment to skin. Review of Resident 15's Care Plan with a revision date of 5/7/25 revealed an intervention of: -Activity of daily living problem had an intervention to complete a skin inspection weekly, observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. -Potential alteration in skin integrity problem had an intervention to complete a weekly skin assessment with documentation. Refer skin issues to the wound team and physician or nurse practitioner for further evaluation and treatment orders. Review of Resident 15's Nurse Administration Record dated August 2025, revealed an order to complete a weekly skin check assessment, notify Physician and Clinical Manager of any skin concerns every Wednesday. Review of the Skin Check documentation from 8/13/25 revealed the resident had scratches to the buttocks, abdomen, right hip area, left hip area and upper right and left leg. Review of Resident 15's Nurse Administration Record dated August 2025 revealed that the order for weekly skin check assessment had been signed off on 8/20/25 and 8/27/25 on the night shift as being completed. Review of Resident 15's skin check documentation revealed that there was no weekly skin documentation for 8/20/25 and 8/27/25. Interview with the Director of Nursing (DON) on 9/2/25 at 12:10 PM confirmed that skin assessments were to be completed weekly with skin check documentation. The weekly skin assessment for Resident 15 had been signed off as being completed on 8/20 and 8/27 by agency nurse, AG-J. The DON confirmed that skin documentation had not been completed on 8/20/25 and 8/27/25. AG-J stated per phone conversation of being unaware of needing to complete documentation for the skin assessment when signing it off in the Nurse Administration Record. AG-J received and signed Maple Crest Health Center Agency Orientation Package on 8/8/25 with education on weekly skin assessments. D. Review of Resident 62's MDS dated [DATE] revealed the resident's cognitive skills for daily decision making were severely impaired, resident was dependent on staff for bathing, dressing, personal hygiene, rolling left and right, chair/bed to chair transfer. The resident was always incontinent of bowel and bladder and was at risk for skin breakdown. The resident had moisture associated skin damage, ointment had been applied, and the resident was on a turning program. Review of Resident 62's care plan with a revision date of 5/7/25 revealed in the special instructions that resident was to be laid down between meals. Review of nursing documentation on 7/25/25 revealed that Resident 62 had an open area to the left side of buttocks that measured 0.4 centimeters (cm) in length by 0.2 cm wide by 0.1cm in depth. Physician orders were received for Triad Cream (helps to maintain a moist wound to facilitate debridement [removal of dead skin]) to area, 2 times daily. Intervention had been put in place to lay the resident down in between meals to reduce pressure to the area. An observation on 8/28 at 10:10 AM revealed that the resident was at Bible Study, at 11:00 AM resident had returned to the unit, staff transferred resident to bed with a mechanical lift, completed incontinence cares and transferred resident from the bed into the wheelchair. The resident had not laid down for more than 10 minutes after breakfast. An observation on 9/2 at 9:25 AM revealed the resident sitting in a wheelchair in the TV area with eyes closed. At 10:30 AM the resident continued to be sitting in a wheelchair in TV area. An interview on 9/2 at 9:25 AM with nurse assistant (NA-L) and NA-H confirmed that the resident does not lay down after breakfast. An interview with Licensed Practical Nurse (LPN-K) on 9/2/25 at 11:30 AM verified that Resident 62 was to lay down between meals per the report sheet for the unit. The resident had skin breakdown to the buttocks area. An interview on 9/3/25 at 10:00 AM with the DON confirmed that Resident 62 was to lay down after meals due to skin breakdown to the buttocks.

Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) Based on record review and interview the facility failed to conduct weekly skin evaluations to prevent the potential for pressure ulcer development for 2 (Resident 5 and 12) of 2 residents sampled. The facility census was 143. The findings are: A.Record review of the facility policy titled Skin assessment dated [DATE] revealed it the facility policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. A full body, or head to toe, skin assessment will be conducted by a licensed nurse upon admission/readmission, for 3 days and weekly thereafter.Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-14-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored at a 12. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.-Had a diagnosis for Diabetes Mellitus.-was at risk of developing a pressure ulcer.-required limited assistance with bed mobility-required extensive assistance with upper body dressing-required total assistance with transfers and lower body dressing. Record review of Weekly Skin Evaluations (WSE) for Resident 5 revealed a skin evaluation conducted on 08-01-2025 and 08-23-2025 and no evidence of a skin evaluation completed for the 2 weeks in between. An interview with the Director of Nursing (DON) on 09-03-2025 at 11:46 AM confirmed skin evaluations were not conducted between 08-01-2025 and 08-23-2025 and should have been. B.Record review of Resident 12's MDS dated [DATE] revealed the facility staff assessed the following about the resident:-BIMS was scored at a 15. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact.-was at risk of developing a pressure ulcer.-required total assistance with toileting, bathing, dressing, bed mobility and transfers. Record review of the WSE for Resident 12 revealed a skin evaluation was conducted on 07-19-2025 and 08-09-2025 and no evidence of a skin evaluation completed for the 2 weeks in between. An interview conducted on 09-03-2025 at 12:19 PM confirmed skin evaluations were not conducted on Resident 12 between 07-19-2025 and 08-09-2025 and should have been.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on record review, observation and interview; the facility failed to implement interventions to prevent weight loss for 2 (Resident 66 and 125) of 7 sampled residents and failed to ensure water was available for 1 (Resident 141) of 2 sampled residents. The facility staff identified a census of 144. The findings are: A. Record review of the MDS (Minimum Data Set: a federally mandated assessment tool used for care planning) dated 2/21/22 for Resident 66 revealed a weight of 188 pounds and no weight loss was coded. In Section G of the MDS it was coded for extensive assistance of 1 staff for eating. Record review of the current CCP (Comprehensive Care Plan) for Resident 66 revealed the following: -A focus of a significant weight loss of 6.3% in 30 days and a potential for altered nutrition/hydration related to pressure areas, repair of left [CONDITION(S)], mechanically altered consistency, variable intake and need for assistance. -Interventions include: a. Diet as ordered. b. Monitor weights weekly and report significant changes to dietician. c. Provide set up assistance as needed at mealtimes. Record review of documented weights for Resident 66 revealed the following information: 3/30/2022 12:25 177.6 Lbs 3/2/2022 11:40 175.9 Lbs 2/9/2022 01:52 187.9 Lbs 1/18/2022 14:32 191.9 Lbs 12/25/2021 10:49 188.1 Lbs 12/11/2021 10:10 187.6 Lbs 11/23/2021 15:15 192.1 Lbs Further review of Resident 66 weights revealed they were not obtained weekly. No weights were obtained for the weeks of November 29th 2021, December 13, 2021, December 27th 2021, January (Jan) 3rd 2022, [DATE]th, [DATE]th, [DATE]st, February 14th and 21st, March 7th, 14th, 21st, and April 4th. Resident 66's weight on 2/9/22 was 187.9 lbs and on 4/14/22 Resident 66's weight was 173.0 lbs, a loss of 14.9 lbs or 7.92% indicating a significant weight loss. Record review of Nutrition/weight note dated 3/14/22 revealed the latest weight for Resident 66 was 175.9 on 3/2/22. Observation of Resident 66 on 4/13/22 from 12:00PM until 12:26 PM at the dining room table for lunch revealed that Resident 66 took 2 bites of food. There was staff present at the dining room table assisting another resident. At no time did the staff attempt to assist Resident 66 and did not give Resident 66 verbal cues to eat. Observation on 4/14/22 at 12:04 Resident 66 was sitting at the table for lunch. Resident 66 received a tray at 12:10PM. At 12:30 PM resident 66 was sitting at the table asleep. Resident 66's silverware had not been opened. Staff assisting another resident seated at the table. At no time from 12:10pm-12:30pm did Resident 66 receive assistance or verbal cueing from staff. Observation of weight obtained for Resident 66 on 4/14/22 at 1:18 PM by LPN (Licensed Practical Nurse) B and Nursing Assistant C was 173 pounds. Interview conducted with LPN B on 4/14/22 at 1:45 PM confirmed that Resident 66 required assistance with eating. The interview also confirmed that residents on the unit receive weekly weights. Interview with RD (Registered Dietician) F at 1:30 PM on 4/14/22 revealed that the dieticians are employed full time and they review weights weekly. If there is a weekly weight missing the dietician would request the weight from nursing. RD F confirmed weekly weights were not obtained and there was no weight for Resident 66 since 3/30/22. B. Record review of Resident 125's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -Required extensive assistance for bed mobility, dressing, transfers and toilet use. -Required limited assistance with eating. Record review of Resident 125's CCP last reviewed on 3-13-2022 revealed Resident 125 admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal for Resident 125 was to maintain a weight of 142 pounds, plus or minus of 4 pounds. Interventions identified on Resident 125's CCP included provided Resident 125 with the ordered diet and to provide 2.0 Med Pass ( nutritional supplement) 120 cubic centimeter (cc's), twice a day. Record review of Resident 125's weight summary sheet revealed the following information: -12-17-2021 weight was 174.8 pounds (lb) and on 1-17-2022 Resident 125's weight was 147.9 lbs. A loss of 26.9 lbs or 15.3%. Review of Resident 125's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident 125's RD D progress note dated 1-12-2022 revealed Resident 125 had significant weight loss related to use of the diuretic medication. Record review of Resident 125's weight summary sheet on 1-31-2022 revealed a weight of 143.4 and on 3-02-2022 Resident 125's weight was 135.2, a loss of 8 lbs or 5.71% from the weight on 1-31-2022. Record review of Resident 125's RD D progress note dated 2-16-2022 revealed RD D made recommendations that included increasing the 2.0 med pass supplement to 120 cc's 3 times a day. Record review of Resident 125's MAR for April 2022 revealed the start date of 2.0 med pass 120 cc's supplement 10-05-2021 and was being given twice a day. Record review of Resident 125's weight summary sheet on 3-28-2022 revealed a weight of 145.9 lbs and on 4-11-2022 Resident 135's weight was 138.4 a loss of 7.5 lbs or 5.14% from the weight on 3-28-2022. Record review of Resident 125's RD D progress note dated 4-13-2022 revealed RD D evaluated Resident 125's weight loss and recommended increasing the 2.0 med pass supplement of 120 cc's 3 times a day. On 4-13-2022 at 3:50 PM an interview was conducted with RD D. During the interview RD D confirmed the recommendation of 2-16-2022 had not been completed or clarified. RD D reported it was not clear if it was related to the use of a diuretic or not. RD D confirmed Resident 125 had lost additional weight and made a recommendation on 4-13-2022 to increase the 2.0 med pass supplement to 120 cc's 3 times a day. C. An observation on 4/12/22 at 2:09 PM revealed no water pitcher in Resident 141's room. A record review of Resident 141's orders revealed no order for fluid restriction. An observation on 4/13/22 at 12:00 revealed no water pitcher in the room. A record review of Resident 141's undated careplan revealed an intervention of water pitcher to be in room and Resident 141 having an indwelling catheter with a history of [CONDITION(S)] (bacteria in the blood stream) Urinary Tract Infection ([CONDITION(S)]). An observation on 4/14/22 at 09:33 AM of staff assisting Resident 141 with breakfast. Resident 141 was able to drink through a straw while staff held a cup of juice. There was no water pitcher noted in the room. An observation on 4/14/22 at 12:16 PM revealed no water pitcher in the room. An interview with a NA (Nurse Aide) on 4/14/22 at 09:52 confirmed that Resident 141 normally has a water pitcher in room.

Licensure Reference Number 175 NAC ,d+[DATE].09D7 Based on observation, record review and interview; the facility failed to ensure supervision in the dining room to provide emergency services for a resident that was coughing and/or choking while eating for 1 resident (Resident 1). The facility census was 134. Findings are: Observations on [DATE] at 6:00 PM on the secured unit revealed 1 nurse and 2 NA's (nurse aide) were in the dining area with 10 residents eating in the area. Several residents exhibited wandering during meal and after the meal requiring the nurse to assist them leaving 2 NA to supervise the remaining residents. Interview on [DATE] at 6:10 PM with NA A revealed the residents can have wandering behaviors during and after the meal. At times the Nurse is in the main dining room outside the secure unit to supervise, leaving only two NA on the unit. Interview on [DATE] at 2:30 PM with the Director of Nursing revealed Resident 1 had been living on the secure unit related to a diagnosis of dementia requiring closer monitoring. Review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment used to develop a care plan) dated [DATE] revealed a Brief Interview for Mental Status (BIMS: an assessment used to assess cognitive function) score of 08 indicating moderate cognitive impairment. Review of the facility investigation revealed on [DATE] prior to 6:25 PM, NA-A left the secure unit for a meal break and Resident 1 was still eating. NA-B was on the unit assisting with toileting needs and supervising Resident 1 eating in the dining area. At approximately 6:25 to 6: 30 PM, NA B heard Resident 1 coughing and asked if Resident 1 was alright and Resident 1 indicated yes by nodding head. NA B then left Resident 1 in the dining area and assisted other residents with toileting needs and on return to the dining area found Resident 1 had stopped coughing and was not breathing. Resident 1 was sent to the hospital with CPR in progress. Interview on [DATE] at 3:00 PM with the Administrator revealed the unit should not be staffed with only one NA when residents are eating.

LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09D2a and 12-006.09D2b Based on observation, record review, and interview; the facility failed to prevent development of a pressure ulcer for Resident 208 and failed to implement treatment for [REDACTED]. Record review of the facility policy, dated revised 12/07, revealed the following: -Provide catheter care at least every eight hours. -Be sure that the catheter remains secured. -When a stat lock is used, please ensure that it is at the right distance so it is not pulling on the meatus. -Report unsecured catheters to the supervisor. Be observant of skin irritation. Record review of the Face Sheet for Resident 208 revealed that, Resident 208 was admitted to the facility on [DATE]. Resident 208's [DIAGNOSES REDACTED]. Morbid (Severe) Obesity Due to Excess Calories, and Foley Catheter for [MEDICAL CONDITION]. Observation on 11/01/17 from 1:49 PM to 2:15 PM , staff members Registered Nurse (RN) and Nursing Assistant (NA) O were present in the room of Resident 208. NA O began performing Foley Catheter Care ( Foley catheter is a tube that is placed into the bladder thru the opening in the Penis called the Meatus). Resident 208 was observed to have a stat lock (Stat lock is a securement device to hold the catheter in place to prevent repeated motion found to cause increased risk of Urinary Tract Infections). Resident 208 was observed to have the stat lock to the left inner thigh, and it was observed to be secured in a manner that pulled the tubing taunt. During the cleansing performed by NA O, it was found that where the Foley catheter was pulled taunt against the skin, the skin had developed an open area. RN N observed the new area and confirmed, at that time, that the catheter had been secured too tightly causing a pressure area to open on the foreskin of the residents penis. RN N then went and returned with Staff nurse P. Staff nurse P confirmed that the stat lock was pulling the tubing taunt, and that the area that was now open was new and had not been noted before. Interview with Resident 208's family member, present, on 11/1/17 at 2:26 PM, confirmed that there had not been an open area present prior to today. B. Record review of an Admission Record sheet printed on 11-01-2017 revealed Resident 143 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident 143 Progress Notes sheet (PNS) dated 9-23-2017 revealed Resident 143 was evaluated with having .two darken spots,(on each heel) on the back bottom of (gender) heels. There was no evidence the facility had evaluated the sizes of the dark areas on Resident 143's heels. Record review of a Skin Risk Data sheet dated 9-26-2017 revealed the facility staff had assessed Resident 143's heel wounds as a stage 2 (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer. There was no evidence the facility staff had evaluate the sizes of the pressure ulcers. Record review of a PNS dated 9-26-2017 revealed Resident 143's practitioner was notified of the pressure ulcers. According to the PNS dated 9-26-2017. Resident 143's practitioner had ordered a treatment for [REDACTED]. Record review of Resident 143 October 2017 Treatment Administration Record (TAR) revealed the ordered treatment was not started. Record review of a Mobile Wound Solutions (MWS) sheet dated 10-02-2017 revealed Resident 143 was assessed with [REDACTED]. According to the MWS sheet dated 10-02-2017 the Right Heel measured 2.50 centimeters (cm) by 1.80 cm and was unable to determine pre-depth and the Left Heel measured 1.50 cm by 2.50 cm and was unable to determine pre-depth. The practitioner ordered a treatment that was to be completed daily and as needed. The practitioner further ordered that Resident 143 wear specialty boots when Resident 143 was in bed or sitting in a recliner. According to the MWS sheet dated 10-02-2017, the quality of the tissue and the status of the pressure ulcers to the Right and Left heels had deteriorated. Record review of an undated Skin Monitoring Report (SMR) provided by the facility Administrator revealed Resident 143 had developed the pressure ulcers to the Left and Right heels at the facility. Observation on 11-01-2017 at 11:36 AM of the pressure ulcer treatments with Registered Nurse (RN) J revealed Resident 143 had dark black areas that measured approximately 1.5 cm roundish. RN J reported at the time of the treatment, the areas to Resident 143's heels were hard to touch. Observation on 11-01-2017 at 12:32 PM revealed Resident 143 was sitting in a recliner without heel boots on. Observation on 11-01-2017 at 12:43 PM revealed Resident 143 was sitting in a recliner without heel protecting boots on. 11-01-2017 at 1:01 PM revealed Resident 143 was sitting in a recliner and did not have the heel protecting boots on. On 11-01-2017 at 1:13 PM an interview was conducted with RN J. During the interview, RN J confirmed Resident 143 was not wearing the heel boots and should have been. On 11-02-2017 at 12:20 PM an interview was conducted with Licensed Practical Nurse (LPN) K. During the interview, LPN K confirmed an order for [REDACTED].

175 NAC 12-006.09D7 Based on record review, observations, and interviews, the facility failed to implement care planned fall alarm interventions to prevent falls for 1 (Resident 9) of 10 sampled residents. The facility had a total census of 124 residents. Findings are: Resident 9 was admitted to the facility on [DATE] according to admission record. Resident 9's 8/29/11 history and physical included a [DIAGNOSES REDACTED]. Resident 9's care plan included a problem dated 7/12/11 of potential risk for falls. Interventions listed included use of a bed alarm when in bed. Occurrence Report for Resident 9 dated 8/28/11 at 11:15 PM stated "Dr. White' called; noted res outside of room in hallway laying flat on (gender) back." On occurrence checklist alarm and alarm activated were both checked no. In an interview on 9/8/11 at 7:45 AM, RN D reported Resident 9's bed alarm was on Resident 9's bed and not attached to Resident 9 when Resident 9 was found on floor in hallway. Radiology Report dated 8/29/11 for Resident 9 stated Resident had an acute right hip fracture. A review of acute care plan dated 8/29/11 for Resident 9 revealed Resident 9 was to have bed and chair alarms and floor mats down when in bed. Observations of Resident 9 in wheelchair in room at 7:45 AM on 9/8/11, in wheelchair in dining room at 8:05 AM and in wheelchair in resident lounge at 9 AM revealed Resident 9's chair alarm was not hooked up. In an interview on 9/12/11 at 11:45 AM, the DON (Director of Nursing) confirmed Resident 9 was to have sit stand alarm in place.