Every finding on record at Monument Healthcare and Nursing Center

Licensure Reference Number 175 NAC 12-006.04 Based on observations, interviews, and record review; the facility failed to have sufficient staff to ensure residents' call lights were being answered in a timely manner and to ensure resident meal trays were served in their rooms during the posted meal times. This had the potential to affect all residents. The facility identified a census of 90. Findings Are:An interview on 8/31/2026 at 3:04 PM with the Unit Manager confirmed allowing a resident's call light to go unanswered for more than 10 minutes was too long. A.An observation on 8/25/2026 at 8:11 AM revealed the call light had been activated in resident room [ROOM NUMBER]. At 8:30 AM the Registered Nurse working on the medication cart stopped in the doorway of room [ROOM NUMBER] and told the resident that someone should be coming to help them. At 8:39 AM a housekeeper stopped in the doorway of room [ROOM NUMBER] and conversed with the residents in the room but did not ask what they were needing help with. At 8:42 AM, 31 minutes after the call light was activated, two staff enter room [ROOM NUMBER] and close the door. The staff exited the room at 8:45 AM, one of them carrying a clear plastic trash bag which contained a wet incontinence brief. An interview on 8/25/2026 at 8:45 AM with Resident 28 in room [ROOM NUMBER] confirmed the resident had activated their call light because they were needing their incontinence brief changed. Resident 28 stated and yes, that was me that yelled out for help. I have a bad rectum because that is where my cancer originated, so I have pain there at times. The resident also stated they just prepare themselves in the mornings to have to wait for staff to answer the call light because the staff have so many other residents who also need help, so it takes time. An observation on 8/26/2026 at 7:16 AM revealed the call light was activated in resident room [ROOM NUMBER]. Two staff entered the room at 7:23 AM and turned off the call light. An observation on 8/26/2026 at 7:32 AM revealed Resident 28 in room [ROOM NUMBER] activated their call light again, there were no staff present in the room at this time. Staff entered the room [ROOM NUMBER] minutes later at 7:45 AM and closed the door. When staff exited the room at 7:48 AM, Resident 28 had been repositioned in their bed. B.A record review of Resident 54's undated Care Plan revealed the resident required assistance from staff for their transfers, ambulation, and locomotion. An observation on 8/27/2026 at 7:29 AM revealed Resident 54 sitting in their recliner and had just activated their call light in room [ROOM NUMBER]. Several minutes later, Resident 54 self-transferred to their wheelchair and wheeled self slowly down the hallway and toward the 200 hall. Staff did not attempt to assist or speak to Resident 54 at any point while they were wheeling self down the 100 hall from their room to the corner that turns toward 200 hall. At 7:43 AM, staff entered Resident 54's room and turned off the call light. C.An observation on 8/25/2026 at 12:45 PM revealed the call light was turned on for resident room [ROOM NUMBER]. Staff entered the room and turned off the call light 17 minutes later, at 1:02 PM. D.An observation on 8/25/2026 at 8:30 AM revealed the call light was activated in resident room [ROOM NUMBER]. Fifteen minutes later, nursing staff entered the room and turned off the call light. E.An observation on 8/27/2026 at 7:22 AM revealed the call light in resident room [ROOM NUMBER] had been activated. Staff entered the room [ROOM NUMBER] minutes later, at 7:37 AM, and turned off the call light. F.An observation on 8/24/2026 at 7:12 AM revealed the call light being activated in resident room [ROOM NUMBER]. Fourteen minute later, at 7:26 AM, staff entered the room and turned off the call light. G.An observation on 8/24/2026 at 6:42 AM revealed the call light being activated in resident room [ROOM NUMBER]. Eleven minutes later, at 6:53 AM, a nursing staff enters the room and turns off the call light. The staff can be heard telling the resident in the room, I have to go get people up. H.An observation on 8/26/2026 at 7:36 AM revealed the call light was activated in resident room [ROOM NUMBER]. Eleven minutes later, at 7:47 AM nursing staff entered the room and immediately went back out, got a second staff and re-entered the room with a Hoyer lift, closing the door behind them. I.A record review of an undated facility-provided document titled Meal times revealed Breakfast was to be from 7:30 AM until 9:00 AM, Lunch was from 11:30 AM until 1:00 PM, and Dinner was from 5:00 PM until 6:00 PM. An observation on 8/25/2026 at 8:24 AM of the bulletin board outside dining room which displayed the resident mealtimes revealed the following information:-Breakfast was from 7:30AM to 9:00 AM,-Lunch was from 11:30 AM to 12:30 PM, and -Supper was from 5:30 PM - 6:30 PM. An interview on 8/24/2026 at 1:25 PM with Resident 18 revealed they had received their lunch meal in their room just prior to the interview and that they routinely receive their lunch meal in their room around this same time. An observation on 8/25/2026 at 9:00 AM revealed Resident 18 lying in their bed, no breakfast meal had been provided to the resident. An observation on 8/25/2026 at 9:30 AM revealed Resident 18 lying in their bed as nursing staff entered their room with a meal tray. The nursing staff prepared the meal tray for Resident 18 as the resident sat themself up in bed and then began eating. An observation on 8/26/2026 at 12:39 PM revealed Resident 18 sitting in their wheelchair in their room with their eyes closed, they had not yet received their lunch meal. An observation on 8/26/2026 at 1:31 PM revealed Resident 18 sitting in their wheelchair in their room eating their lunch meal. An interview on 8/26/2026 at 1:31 PM with Resident 18 revealed the resident had just received their lunch meal at about 1:15 PM. J.An interview on 8/24/2026 at 9:01 AM with Resident 65 revealed they had not yet received their breakfast meal and they were hungry. An interview and observation on 8/24/2026 at 9:38 AM revealed Resident 65 had their breakfast meal, but it had not yet been uncovered, the resident stated, it just arrived a minute ago. An observation on 8/25/2026 at 1:06 PM revealed Resident 65 was lying in their bed with the lights off and they had not yet received their lunch meal. An observation on 8/25/2026 at 1:34 PM revealed Resident 65 was lying in their bed with the lights off and they had not yet received their lunch meal. An observation on 8/25/2026 at 1:38 PM revealed a nursing staff person delivered a lunch meal tray to Resident 65. An interview on 8/26/2026 at 8:00 AM with Resident 65 revealed they had received their supper meal tray late the evening prior. An observation on 8/27/2026 at 8:41 AM revealed Resident 65 had turned on their call light. Staff entered the room and answered the call light fourteen minutes later, at 8:55 AM. K.An observation on 8/24/2026 at 12:33 PM revealed the call light was turned on in Resident 9's room, staff answered the call light at 12:41 PM. An observation on 8/24/2026 at 1:20 PM revealed Resident 9 had not yet received their lunch meal; there was a meal tray distribution cart sitting in the hallway several rooms away. An observation on 8/24/2026 at 1:27 PM revealed staff entering Resident 9's room to deliver lunch trays to the resident and their roommate. An interview on 8/25/2026 at 8:12 AM with Resident 9 revealed the resident preferred to consume their meals in their room. The resident had not yet received their breakfast meal. An observation on 8/25/2026 at 9:13 AM revealed Resident 9 and their roommate were receiving their breakfast meals at that time. An observation on 8/25/2026 at 12:45 PM revealed Resident 9 lying in bed with their eyes closed. An observation on 8/25/2026 at 1:02 PM revealed a staff person delivering a lunch meal tray to Resident 9 in their room. An observation on 8/25/2026 at 1:05 PM revealed Resident 9 remained in their bed and their covered meal tray sitting on their bedside table. An observation on 8/25/2026 at 1:31 PM revealed Resident 9 remained in their bed with their eyes closed, their meal tray was still sitting covered on the bedside table. An observation on 8/25/2026 at 6:02 PM revealed Resident 9 lying in their bed with their eyes closed, their supper meal had not yet been delivered. An observation on 08/25/2026 at 6:20 PM revealed Resident 9 had received their supper meal tray and was sitting upright in bed eating tomato soup.

Licensure Reference Number 175 NAC 12-006.19(C)Based on record review and interviews, the facility failed to ensure there was enough linens for each shift for the residents to have a clean bed and washcloths or towels to ensure clean hygiene. This had the potential to affect all residents. The facility identified a census of 90.Findings are:Record review of Resident 44's admission Record, dated 8/31/2026, revealed Resident 44 was admitted to the facility on [DATE] with a diagnosis of osteoporosis (a bone disease that makes bones weak and fragile, so they break easily), mild cognitive impairment, and anxiety.Record review of Resident 44's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems), dated 7/29/2026, revealed the resident 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.Record review of a Grievance Complaint Form, dated 6/11/2026, revealed Resident 44 filed the grievance that their bedding had not been changed in about a week.Interview with Certified Nurse Aide (CNA)-C on 8/31/2026 at 2:10 PM confirmed that there are shifts where they don't have enough linens to change beds or to provide washcloths and towels to residents. CNA-C confirmed that it had been brought to management attention, but nothing had been done about it.Interview with Medication Aide (MA)-K on 8/25/2026 at 2:51 PM confirmed that they do not have enough supplies like towels and washcloths. MA-K said that there is only a few of those items when they get to the facility for day shift. MA-K confirmed that they don't have enough linens to be able to give all the residents to clean their faces in the mornings. MA-K confirmed that they have complained to management about the short supply of linens, and nothing had happened.

Licensure Reference Number 175 NAC 12-006.19 Based on observations and record review, the facility failed to ensure residents were not routinely served their meals on disposable dinnerware and with disposable cutlery. This had the potential to affect all residents. The facility identified a census of 90.Findings Are: A.An observation on 08/24/2026 beginning at 11:51 AM revealed the nursing staff in the Memory Care Unit (MCU) were serving the residents their meals from a cart that was wheeled from the kitchen. At 12:11 PM, nursing staff began serving the residents their drinks. All of the resident drinks were served in styrofoam cups. At 12:14 PM, a nursing staff entered the dining room with a handful of disposable plastic spoons, giving one to a resident who had a pureed meal. This resident began eating their food with the plastic spoon. Further observation of the residents' meal trays revealed all of the desserts had been served on disposable plates. An interview on 08/24/26 at 12:31 PM with Medication Aide (MA)-B revealed the MA did not know why the residents were served their meals on disposable dinnerware but stated this was a frequent occurrence. B.An observation on 08/24/2026 at 12:12 PM in the main dining room revealed a resident who was eating food out of a disposable bowl. There were 9 residents who had side dishes in disposable bowls. An observation on 08/25/2026 at 8:29 AM revealed the dietary staff had begun serving meal trays in the main dining room and were using disposable bowls for the residents' food. An observation on 08/25/2026 at 8:57 AM in the main dining room revealed 9 residents with styrofoam cups for their drinks. An observation on 08/26/2026 at 9:28 AM in the main dining room revealed there were several resident meal trays with disposable, black plastic utensils rather than silverware. An interview on 08/25/2026 at 1:10 PM with the Food Service Manager (FSM) revealed they were aware the facility was frequently utilizing disposable dinnerware and cutlery. The FSM stated the facility's bowls and silverware were items that frequently went missing and it had been a struggle to obtain more.

Licensure reference number 175 NAC 12-006.09(F)Based on interviews and record reviews the facility failed to involve Resident 2 or 26's representatives in the development of the residents' care plans; failed to revise Resident 54's care plan related to their need to utilize a wheelchair for mobility, and Resident 21's care plan related to their pressure wounds. The sample size was 19. The facility identified a census of 90. Findings Are: A record review of the facility policy Care Plans- Comprehensive with a revision date of April 2010 revealed the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The policy also stated the Care Planning/Interdisciplinary Team was responsible for the periodic review and updating of the care plan: -When there has been a significant change in the resident's condition; -When the desired outcome is not met; -When the resident has been readmitted from a hospital stay; and -At least quarterly. A. A record review of Resident 2's admission Record dated 8/27/2026 revealed the resident was admitted to the facility on [DATE] and had a diagnosis of 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)). An interview on 08/24/2026 at 9:47 AM with Resident 2's representative revealed the representative had not been contacted in a while about Resident 2's care planning or a care plan conference. The representative stated they were aware the facility had a change in ownership and wondered if this may be the reason. A record review of Resident 2's most recent 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) revealed it was completed on 6/29/2026. A record review conducted on 8/27/2026 of Resident 2's Progress Notes for the last 5 months revealed no evidence of the facility contacting the resident's representative to review or discuss Resident 2's care plan. Further record review of the remainder of Resident 2's medical records also revealed no evidence of the facility contacting the resident's representative to review or discuss Resident 2's care plan. An interview on 8/27/26 at 9:46 AM with the Social Services Director (SSD) revealed the SSD could not locate evidence of anyone contacting Resident 2's representative related to their quarterly or annual care plan or care plan meetings at any time over the prior 1.5 years. B. A record review of Resident 26's admission Record dated 8/31/2026 revealed the resident was admitted to the facility on [DATE] and had a diagnosis of cognitive communication deficit. An interview on 8/25/2026 at 12:34 PM with Resident 26's relative revealed the resident's representative had not been contacted for or included in the development of Resident 26's care plan. A record review of Resident 26's Progress Notes since their admission revealed no evidence of the facility contacting the resident's representatives to develop or discuss their care plan or to attend a care planning meeting. Further record review of the remainder of Resident 26's medical records also revealed no evidence of the facility contacting the resident's representatives to develop or discuss Resident 26's care plan or attend a care planning meeting. An interview on 8/27/2026 at 9:45 AM with SSD revealed SSD had attempted to locate evidence of Resident 26's representatives being invited to participate in the development of their care plan or to participate in their care planning meeting following the resident's admission and was not able to locate any evidence of being invited or otherwise participating in the development of Resident 26's care plan. C. A record review of Resident 54's admission Record dated 8/27/2026 revealed the resident was admitted to the facility on [DATE] and had diagnoses of other abnormalities of gait and mobility and weakness. An observation on 8/27/2026 at 7:29 AM revealed Resident 54 sitting in their recliner in their room and had just activated their call light. Several minutes later, Resident 54 self-transferred to their wheelchair and wheeled self slowly down the hallway and toward the 200 hall. A record review of Resident 54's quarterly MDS dated [DATE] revealed the resident utilized a walker and a wheelchair for mobility. A record review conducted on 8/27/2026 of Resident 54's undated Care Plan revealed the resident required supervision and limited assistance with cares and utilized a walker for mobility. There was no information regarding the resident's wheelchair use in the Care Plan An interview on 8/27/2026 at 11:31 AM with IP-I confirmed Resident 54's Care Plan had not been revised when the resident began using a wheelchair and should have been. D. Record review of Resident 21's admission record revealed an admission date of 7/10/2026. Record review of the resident's progress notes revealed the following: - 8/5/26 Licensed Practical Nurse (LPN)-J wrote Moisture-associated skin damage (MASD) noted to the bilateral buttocks. Area to the right buttocks measures approximately 0.5 cm × 0.5 cm. Area to the left buttocks measures approximately 0.5 cm × 1.8 cm. Wound edges are attached. No drainage, pain, odor, or signs and symptoms of infection noted. Peri-wound skin remains intact with blanchable erythema. Affected areas cleansed with wound cleanser. Xeroform applied to the wound beds and covered with an ABD pad per treatment order. -8/12/26 an unknown author wrote Previously identified moisture-associated skin damage (MASD) to the bilateral buttocks has been reclassified per the DON. The left buttocks is now staged as a Stage 2 pressure injury, and the right buttock is now staged as a Stage 3 pressure injury. Right buttocks (Stage 3): Measures approximately 0.5 cm × 0.8 cm. Left buttocks (Stage 2): Measures approximately 2.0 cm × 1.2 cm × 0.2 cm. Wound edges are attached. No drainage, pain, odor, or signs and symptoms of infection noted. Peri-wound skin remains intact with blanchable erythema. Affected areas cleansed with wound cleanser. Xeroform applied to the wound beds and covered with an ABD pad per treatment order. Resident tolerated the dressing change well Record review of Resident 21's care plan revealed a focus for: 'Resident 21 is at risk for skin breakdown related to (r/t) immobility' initiated on 7/14/26. This focus has the goal: 'Resident 21 will not develop any skin impairments initiated on 7/14/26. There are interventions listed with initiation dated as follows: -dietician as needed 7/14/26. -keep skin clean and dry 7/14/26. -provide pressure reducing mattress 7/14/26. -provide well balanced diet 7/14/26. There are no revisions to this section of Resident 21's care plan. During an interview at 10:14 AM on 8/27/26, IP-I confirmed that they use the medical diagnoses and the medication orders to build the care plan and when there are changes to a resident's care or needs that they will update the care plan within 24-48 hours. An interview at 11:01 Am on 8/31/2026 with LPN-J AND LPN-K confirmed that Resident 10 has wounds on his left and right buttock that have gotten progressively worse since their admission.

Licensure Reference Number 175 NAC 12-007.04(D) Based on observation, record review, and interview; the facility failed to ensure the bathroom ventilation system was functional for 6 (Residents 1, 2, 6, 63, 75, and 88) of 19 sampled residents. The facility identified a census of 90.Findings Are: A record review of Resident 6's Census List revealed the resident was admitted to room [ROOM NUMBER] on 8/7/2026. An observation on 8/24/2026 at 8:35 AM in room [ROOM NUMBER] revealed the bathroom vent would not pull up a 1-ply piece of toilet paper when held near the vent. A record review of Resident 88's Census List revealed the resident was admitted to room [ROOM NUMBER] on 12/26/2024. An observation on 8/24/2026 at 8:36 AM in room [ROOM NUMBER] revealed the bathroom vent would not pull up a 1-ply piece of toilet paper when held near the vent. A record review of Resident 75's Census List revealed the resident was admitted to room [ROOM NUMBER] on 2/15/2021. An observation on 8/24/2026 at 8:40 AM in room [ROOM NUMBER] revealed the bathroom vent would not pull up a 1-ply piece of toilet paper when held near the vent. A record review of Resident 2's Census List revealed the resident was admitted to room [ROOM NUMBER] on 3/3/2026. An observation on 8/24/2026 at 8:37 AM in room [ROOM NUMBER] revealed the bathroom vent would not pull up a 1-ply piece of toilet paper when held near the vent. A record review of Resident 1's Census List revealed the resident was admitted to room [ROOM NUMBER] on 6/10/2025. An observation on 8/24/2026 at 8:43 AM in room [ROOM NUMBER] revealed the bathroom vent would not pull up a 1-ply piece of toilet paper when held near the vent. A record review of Resident 63's Census List revealed the resident was admitted to room [ROOM NUMBER] on 8/20/2025. An interview and observation on 8/31/2026 at 9:15 AM with Maintenance Director (MD)-M confirmed the bathroom ventilation was not functioning in resident rooms [ROOM NUMBERS]. MD-M stated it appeared there was not a ventilation fan present in either bathroom's vent.

Licensure Reference Number 175 NAC 12-006.09(E) Based on observation, interview, and record review; the facility failed to ensure Resident 28 and 65's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) included information related to their toileting needs, Resident 18's preference for meals in their room, and Resident 67's hospice care goals and interventions. The sample size was 19 and the facility identified a census of 90. Findings Are: A record review of facility policy Care Plans-Comprehensive with a revision date of April 2010 revealed each resident's comprehensive care plan is designed to incorporate identified problem areas and risk factors associated with identified problems, and to reflect the resident's expressed wishes regarding care and treatment goals. A. A record review of Resident 18's admission Record dated 8/25/2026 revealed the resident was admitted to the facility on [DATE] and had diagnoses of morbid (severe) obesity due to excess calories and of unspecified protein-calorie malnutrition. An interview on 08/24/2026 at 1:25 PM with Resident 18 revealed they had received their lunch meal in their room just prior to the interview and that they routinely received their lunch meal in their room around this same time. An observation on 8/25/2026 at 9:30 AM revealed Resident 18 laying in their bed as nursing staff entered their room with a meal tray. The nursing staff prepared the meal tray for Resident 18 as the resident sat themself up in bed and then began eating. An observation on 8/26/2026 at 1:31 PM revealed Resident 18 sitting in their wheelchair in their room eating their lunch meal. An interview on 8/26/2026 at 1:31 PM with Resident 18 revealed the resident consumed their meals in their room because this was their preference. A record review of Resident 18's undated Care Plan revealed no evidence of the resident's preference to consume their meals in their room rather than in the dining room. An interview on 8/27/2026 at 11:28 AM with the Infection Preventionist (IP)-I confirmed they were the person responsible for updating residents' care plans and that Resident 18's preference for receiving their meals in their room had not been captured in their Care Plan. B. A record review of Resident 28's admission Record dated 8/26/2026 revealed the resident was admitted to the facility on [DATE] and had diagnoses of malignant neoplasm (cancer) of anal canal and urinary tract infection. An observation on 8/25/26 at 8:11 AM revealed Resident 28 was laying in their bed and had turned on their call light. Staff entered Resident 28's room at 8:42 AM and closed the resident's room door. At 8:45 AM, the staff exited the resident's room carrying a clear trash bag which contained a wet incontinence brief. An interview on 8/25/26 at 8:45 AM with Resident 28 confirmed the resident had turned their call light on because they were needing their incontinence brief changed. A record review of Resident 28'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 8/6/2026 revealed the resident was always incontinent of bladder and was not on a toileting program. A record review of Resident 28's undated Care Plan revealed there was no evidence of a focus, goals, or interventions related to their urinary incontinence and need for assistance with managing this. An interview on 8/27/2026 at 11:30 AM with IP-I confirmed there was no information in Resident 28's care plan about their incontinence needs and that this was an area that should have been in it. C. A record review of Resident 65's admission Record revealed they were admitted on [DATE] with diagnoses of cervical spondylosis (degenerative changes in the neck bones), muscle weakness, kidney failure, and benign prostatic hyperplasia (enlargement of the prostate gland which causes difficulty urinating and sudden urges to urinate). A record review of Resident 65's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 7/31/2026 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15, which indicated Resident 65 was cognitively intact. The resident utilized a wheelchair for mobility and was dependent with toileting hygiene. A record review of a facility-provided fall risk assessment dated [DATE] revealed Resident 65 fell on 6/25/26 at 3:10 PM in their room while trying to go to the bathroom unassisted. A record review of a facility-provided fall risk assessment dated [DATE] revealed Resident 65 fell on 6/26/26 at 4:17 AM in their room while trying to take the urinal to the bathroom to dump it out unassisted. A record review of a facility-provided fall risk assessment dated [DATE] revealed Resident 65 fell on 8/13/26 at 6:50 PM while attempting to get off the toilet. A record review of Resident 65's undated Comprehensive Care Plan revealed there was not a section describing Resident 65's toileting needs or preferences, including identifying whether the resident was continent or incontinent. An interview with the Unit Manager-A (UM-A) on 8/31/2026 at 12:05 PM confirmed toileting was not included on Resident 65's Comprehensive Care Plan and should have been. D. A record review of Resident 67's admission Record revealed they were admitted on [DATE] with diagnoses of rib fracture, falls, traumatic brain injury (a disruption in the normal function of the brain that can be caused by an external force), cervical (neck) vertebral fracture, and thoracic (mid-back) compression fractures. A record review of Resident 67's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 8/25/2026 revealed a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 5/15, which indicated Resident 65 was severely cognitively impaired. The resident utilized a wheelchair for mobility and hospice care (Section O, Item O0110K1B) was marked Yes. A record review of Resident 67's paper chart revealed they were admitted to hospice services on 8/12/26. No hospice care plan was in the paper chart. A record review of Resident 67's undated Comprehensive Care Plan revealed a section for hospice added on 8/24/26. A record review of a facility-provided document titled Plan of Care effective 8/12/26, revealed a Hospice care plan from the hospice provider printed on 8/27/26. An interview with the Unit Manager-A (UM-A) on 8/27/26 at 11:32 AM confirmed the hospice care plan was not on Resident 67's chart and should have been. An interview with the Director of Nursing (DON) on 8/27/26 at 9:41 AM confirmed hospice was not included on Resident 67's Comprehensive Care Plan and should have been.

Licensure Reference Number 175 NAC 12-006.09(I)Based on observations, record review and interviews, the facility failed to investigate falls and implement interventions based on root causes for 2 (Residents 65 and 67) of 5 sampled residents. The facility identified a census of 90. Findings are:A record review of the facility policy Falls and Fall Risk, Managing with a revision date of March 2018 revealed a Policy Statement, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. In the Resident-Centered Approaches to Managing Falls and Fall Risk section, it states: The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. In the Monitoring Subsequent Falls and Fall Risk section, it states: If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. The policy also revealed the staff and practitioner will begin to identify possible causes for the fall within 24 hours.A.A record review of Resident 65's admission Record revealed they were admitted on [DATE] with diagnoses of cervical spondylosis (degenerative changes in the neck bones), muscle weakness, kidney failure, and benign prostatic hyperplasia (enlargement of the prostate gland which causes difficulty urinating and sudden urges to urinate).A record review of Resident 65's admission 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) with an Assessment Reference Date of 7/2/2026 revealed the resident had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15 which indicated the resident was cognitively intact. The resident did have falls in the month prior to admission as well as in the 2-6 months prior to admission. The MDS also revealed that since their admission to the facility, the resident had two or more falls with no injuries and one fall with an injury that was not major. The resident was always continent of bladder and bowels. The resident was dependent on staff for transfers, toileting hygiene, and lower body dressing; and required partial staff assistance for upper body dressing and personal hygiene. A record review of facility-provided fall risk assessments for Resident 65 revealed the following:-Resident 65 fell on 6/25/26 at 3:10 PM while trying to go to the bathroom unassisted.-Resident 65 fell on 6/25/26 at 3:30 PM while trying to put their clothes on so they could leave the facility.-Resident 65 fell on 6/25/26 at 6:10 PM while trying to leave the facility but stated their legs didn't work and they couldn't find the call light.-Resident 65 fell on 6/26/26 at 4:17 AM in their room while trying to take the urinal to the bathroom to dump it out unassisted.-Resident 65 fell on 6/26/26 at 7:50 AM. Resident 65 stated they wanted to sit up so they sat up on the edge of the bed until they slipped out of bed. They stated they put their call light on and did not get any response, but staff stated the call light had not been turned on.-Resident 65 fell on 6/30/26 at 11:20 AM while trying to sit on the edge of the bed but slipped out of bed, right after their family left the room.-Resident 65 fell on 7/29/26 at 2:45 AM had an unwitnessed fall in their room. Resident 65 stated they were, trying to get out of this godforsaken place, and unplugged their bed alarm.-Resident 65 fell on 8/13/26 at 6:50 PM while attempting to get off the toilet. A record review of Resident 65's undated Care Plan revealed the resident was at risk for falls related to weakness, a history of falls, abnormal gait and mobility. This section of the care plan listed the following falls:-6/25/2026 fall in room at 3:10 PM,-6/25/2026 fall in room at 3:30 PM,-6/25/2026 fall in room at 6:10 PM,-6/26/2026 fall in room at 4:17 AM,-6/26/2026 fall in room at 7:50 AM,-6/30/2026 fall in room at 11:20 AM-7/29/2026 fall in room (no time listed),-7/29/2026 unwitnessed fall (no time or location listed), and-8/13/2026 fall in bathroom (no time listed).The interventions listed in the Falls section of Resident 65's Care Plan were:-On 6/25/2026 at 3:10 PM Educate resident on use of call light.-On 6/25/2026 at 3:30PM Provide resident with urinal at bedside.-On 6/25/2026 at 6:10 PM Encourage resident to utilize call light prior to transferring.-On 6/25/2026 Anticipate and meet the resident's needs.-On 6/25/2026 and revised on 6/26/2026 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.-On 6/25/2026 Ensure frequently used items are within reach.-On 6/26/2026 at 4:15 AM Place call don't fall signs in room.-On 6/26/2026 at 7:50 AM Provide 1:1 staffing.-On 6/30/2026 at 11:20 AM Ensure 1:1 staffing is present prior to family leaving.-On 7/1/2026 Trial 1:1 supervision to individualized activities to promote engagement and reduce unnecessary ambulation.-On 7/29/2026 Resident 65 is cognitively intact and able to make informed decision regarding safety. Resident 65 has been educated on fall risk and the importance of using recommended safety interventions but may choose to decline or not consistently follow these recommendations.-On 7/29/2026 Pharmacy review (gender) meds.-On 8/13/2026 Environmental Survey to be completed.-On 8/18/2026 Discontinue 1:1 and initial every 15-minute checks.Record review of Resident 65's progress notes revealed an interdisciplinary team (IDT) met on 8/24/26 to discuss the resident's unwitnessed fall which occurred on 8/13/26. Possible causes stated were, impulsive, self-transferring, poor safety awareness. New intervention was to have nursing complete an environmental survey. Record review of Resident 65's electronic medical records revealed no evidence of results of an environmental survey. B.A record review of Resident 67's admission Record dated 8/25/2026 revealed the resident was admitted to the facility on [DATE] with diagnoses of a fracture (break) of one rib on the right side, fractures of the 1st, 2nd, and 7th vertebra (the bones around the spinal column), repeated falls, unspecified focal traumatic brain injury without loss of consciousness, muscle weakness, other abnormalities of gait and mobility, and cognitive communication deficit.A record review of Resident 67's admission MDS with an ARD date of 7/21/2026 revealed the resident had a BIMS score of 10/15, indicating the resident had moderate cognitive impairment. The resident did have falls, including a fall with fracture prior to their admission to the facility. The resident was dependent on staff for their toileting hygiene, dressing, and personal hygiene; and required substantial assistance with transfers.A record review of facility-provided fall risk assessments for Resident 67 revealed the following:On 7/20/26 at 5:35 AM, Resident 67 had an unwitnessed fall, Resident unable to give description. Predisposing factors listed were: Confused, gait imbalance, impaired memory, weakness/fainted, no injuries were listed.On 7/26/26 at 7:50 AM, Resident 67 had an unwitnessed fall, Resident stated I don't know, I slid out. No injuries. Predisposing factors: Poor lighting, confused, impaired memory, weakness/ fainted during transfer.On 7/29/26 at 7:50 AM, Resident 67 had an unwitnessed fall. 'Resident stated, I don't know what happened, I guess I slid off the couch when I was trying to get in my chair. Wheelchair for resident was found next to couch'. No injuries. Predisposing factors: Poor lighting, furniture, confused, gait imbalance, impaired memory, ambulating without assist.On 8/3/26 at 2:12 AM Resident 67 had an unwitnessed fall, Resident was going to get his pants on to get up for the day. Predisposing factors: Poor lighting, impaired memory, during transfer. No injuries.On 8/20/26 at 8PM Resident 67 had an unwitnessed fall, Predisposing factors: confused, impaired memory, No injuries, and no description of what led to the fall.On 8/22/26 at 4:30 PM, Resident 67 had an unwitnessed fall, Resident was asking nurse if he could purchase a quart of milk, Predisposing factors: Poor lighting, confused, incontinent, impaired memory, improper footwear; No injuries.The interventions listed in the Falls section of Resident 67's Care Plan were:For fall 7/20/26: Ensure fall mat is in place while in bed. date Initiated: 7/29/2026.For fall 7/26/26: Ensure bed is in low position, date Initiated: 7/29/2026.For fall 7/29/26- Ensure appropriate footwear in place, date initiated: 8/04/2026.For fall 8/3/26: Follow up with neurosurgery, date Initiated: 8/04/2026.Anticipate and meet the resident's needs, date initiated 7/20/2026.Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, date Initiated: 7/20/2026.Ensure frequently used items are within reach, date Initiated: 8/22/2026.Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c, date Initiated: 8/22/2026.Encourage resident to ask for assistance when attempting to transfer, date Initiated: 7/15/2026.Keep call light within reach, date Initiated: 7/15/2026.Provide a clutter free environment, date Initiated: 7/15/2026.Provide a well lit environment, date Initiated: 7/15/2026.An interview on 08/27/2026 at 9:53 AM with the Unit Manager-A (UM-A) confirmed there were no additional root causes or investigations recorded outside the fall risk assessments care plans, and the IDT progress notes.An interview on 8/27/26 at 9:53 AM with the Director of Nursing confirmed the fall investigations and interventions were not effective for Resident 65 and 67.

Licensure Reference Number 175 NAC 12-006.05(S) Based on observation, interview, and record review; the facility failed to contain 4 (Residents 3, 6, 7, and 8) of 4 sampled residents' catheter bags within a dignity bag while in view of others. The facility identified a census of 82. Findings Are: A record review of facility policy Dignity with a revision date of February 2021 revealed demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents by helping the resident keep urinary catheter bags covered. A.A record review of Resident 3's admission Record dated 6/8/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 3's Order Summary Report dated 6/8/2026 revealed the resident had an order to monitor their foley catheter (a tube placed into the bladder to drain urine) output every shift, with a start date of 5/6/2026. An observation on 6/8/2026 at 8:42 AM revealed Resident 3 sitting in their wheelchair in the Golden Moments Activities room with other residents. Resident 3 had a catheter bag hooked to the underside of their wheelchair; there was no cover on the catheter bag and urine was visible within the bag from the hallway outside the room. An observation on 6/8/2026 at 10:00 AM revealed Resident 3 remained in the same room in their wheelchair with other residents listening to music. Their catheter bag continued to be hooked to the underside of their wheelchair with no cover on it and urine visible in it from the hallway. An observation on 6/8/2026 at 12:00 PM revealed Resident 3 sitting in their wheelchair at a table in the dining room with other residents. Their catheter bag continued to be hooked to the underside of their wheelchair with no cover on it and urine visible in it from several feet away. An observation on 6/9/2026 at 8:05 AM revealed Resident 3 sitting in their wheelchair at a table in the dining room with other residents. Their catheter bag was hooked to the underside of their wheelchair with no cover on it and urine visible in it from several feet away. An interview on 6/9/2026 at 8:15 AM with the facility Administrator confirmed Resident 3's urinary catheter bag was not contained within a dignity bag, and the urine was visible to others in the dining room. Administrator confirmed the catheter bag should have been concealed within a dignity bag. B.A record review of Resident 6's admission Record dated 6/8/2026 revealed the resident was admitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the bladder (nerve damage interrupts the communication between the brain and bladder causing the bladder unable to contract and release urine properly). A record review of Resident 6's undated Care Plan revealed the resident had an indwelling foley catheter related to their neurogenic bladder. An observation on 6/8/2026 at 8:49 AM revealed Resident 6 laying in their bed with their room door open. Their catheter bag was hooked onto the metal frame of the bed and did not have a cover on it. There was urine visible in the bag from the hallway. An observation on 6/8/2026 at 10:53 AM revealed Resident 6 laying in their bed talking with a staff person who was standing next to the bed. Their catheter bag remained hooked onto the metal frame of their bed without a cover on it and urine was visible within the bag from the hallway. An observation on 6/8/2026 at 12:57 AM revealed Resident 6 laying in their bed with the door to their room open. Their catheter bag remained in the same position as prior observations. C.A record review of Resident 7's admission Record dated 6/8/2026 revealed the resident was admitted to the facility on [DATE] with diagnoses of neuromuscular dysfunction of the bladder and retention of urine. A record review of Resident 7's undated Care Plan revealed the resident had an indwelling foley catheter related to neuromuscular bladder disfunction and urinary retention. An observation on 6/8/2026 at 8:54 AM revealed Resident 7 laying in their bed with the door to their room open. Their catheter bag was hooked onto the metal frame of the bed and did not have a cover on it. There was urine visible in the bag from the hallway. An observation on 6/8/2026 at 10:59 AM revealed Resident 7 laying in their bed with the door to their room open. Their catheter bag remained hooked onto the metal frame of the bed and did not have a cover on it. There was urine visible in the bag from the hallway. An observation on 6/8/2026 at 12:03 PM revealed Resident 7 sitting in their wheelchair at a table in the dining room with other residents. Resident 7's catheter bag was hooked to the underside of their wheelchair without a cover on it and there was urine in the bag visible from several feet away. An observation on 6/9/2026 at 7:37 AM revealed Resident 7 laying in their bed with the light off and the door to the hallway open. Their catheter bag was hooked onto the metal frame of the bed and did not have a cover on it. There was urine visible in the bag from the hallway. D.A record review of Resident 8's admission Record dated 6/8/2026 revealed the resident was admitted to the facility on [DATE] with a diagnosis of retention of urine. A record review of Resident 8's undated Care Plan revealed the resident had an indwelling foley catheter related to urinary retention. An observation on 6/8/2026 at 8:44 AM revealed Resident 8 had been sitting at a table in the dining room with other residents. Resident 8's catheter bag was hooked to the underside of their wheelchair without a cover on it and there was urine in the bag visible from several feet away. At this time, nursing staff approached Resident 8 and pushed them in their wheelchair to their room. An observation on 6/8/2026 at 10:02 AM revealed Resident 8 was being pushed out of their room and down the hallway by facility therapy staff. Their catheter bag remained hooked to the underside of their wheelchair without a cover on it and with urine visible from several feet away. An observation on 6/8/2026 at 12:50 PM revealed Resident 8 being pushed in their wheelchair from the dining room and through the hallway by nursing staff. Their catheter bag remained hooked to the underside of their wheelchair without a cover on it and with urine visible from several feet away. An observation on 6/9/2026 at 8:01 AM revealed Resident 8 sitting in their wheelchair at a table in the dining room with other residents. The resident's catheter bag was hooked to the underside of their wheelchair without a cover on it and there was urine in the bag visible from several feet away. An interview on 6/9/2026 at 8:15 AM with the facility Administrator confirmed Resident 8's urinary catheter bag was not contained within a dignity bag, and the urine was visible to others in the dining room. Administrator confirmed the catheter bag should have been concealed within a dignity bag.

Number of residents sampled: Number of residents cited: Based on observation and interview, the facility failed to ensure garbage and refuse were stored in a covered receptacle. In addition, the facility failed to ensure malodorous trash bags, debris, and supplies were not on the ground around the garbage and refuse receptacle. These failures created the potential for pest activity and had the potential to affect all residents residing in the facility. Findings included: A concurrent observation and interview on 08/14/2025 at 5:00 PM with the Dietary Manager (DM) revealed the garbage and refuse receptacle located outside and behind the facility was uncovered and filled with garbage/refuse. Two large malodorous trash bags, garbage/debris (used gloves, an opened pudding cup, paper, paper cups, and bags), 18 metal poles, and wood fencing supplies were observed on the ground around the garbage and refuse receptacle. The DM stated the metal poles had been on the ground for about a month and were part of a fencing project that the maintenance department was working on. The DM confirmed that the garbage and refuse receptacle was uncovered; he further stated the receptacle had been uncovered for the past year. The DM stated that staff who could not lift the trash bags into the receptacle left the trash bags on the ground and either he or maintenance staff put the trash bags in the receptacle during rounds. During an interview on 08/14/2025 at 5:30 PM, the Director of Maintenance (DOM) stated that he monitored the grounds around the garbage and refuse receptacle once a day in the morning. The DOM stated that if trash bags were observed on the ground during his rounds, he put them inside the receptacle. The DOM confirmed that the garbage and refuse receptacle did not have a lid or cover. He stated that the trash receptacle was a rented unit the facility used since their trash compactor broke about a year prior, and the rental company did not have another trash compactor to provide or a trash receptacle with a lid. During a phone interview on 08/15/2025 at 10:34 AM, Administrative Clerk (AC) I for the rental company stated that the company could provide another trash compactor that the facility could rent, but before the trash compactor could be provided to the facility, the facility needed to complete repairs to the enclosure where the compactor would be stored and repair the fence. AC I stated that the facility was made aware about a year prior that the repairs had to be completed before a trash compactor could be provided. AC I further stated that the facility could purchase a tarp to cover the trash receptacle until they were able to rent the trash compactor and open the door on the back to put the trash inside the receptacle. During an interview on 08/15/2025 at 10:42 AM, the Director of Nursing (DON) stated that she expected the facility to purchase a tarp or something similar to cover the trash receptacle and use the door of the dumpster to put trash in instead of throwing trash over the top. The DON further stated the facility should make the necessary repairs so that the facility could get their compactor replaced. During an interview on 08/15/2025 at 11:55 AM, the Administrator (ADM) stated that she was not aware that repairs were needed to allow the facility to get a trash compactor. She stated that she expected the maintenance department to make the repairs to accommodate the trash compactor, maintain the trash receptacle covered with a tarp, and the grounds around the trash receptacle should be maintained clean.

Number of residents sampled: Number of residents cited: Based on observation, interview, and facility document and policy review, the facility failed to ensure: 1. cold foods were maintained at 41 degrees Fahrenheit (F) or below during meal service; 2. cartons of milk were labeled with an expiration date; 3. food items were labeled with use-by-dates (UBDs); 4. expired food items were discarded; and 5. frozen food items were stored in sealed containers and off the freezer floor. These failures had the potential to affect all residents receiving meals from the dietary department. Findings included: A facility policy titled, Refrigerators and Freezers, revised November 2022, indicated, 7. All food is appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery are marked on cases and on individual items removed from cases for storage. 'Use by' dates are completed with expiration dates on all prepared foods in refrigerators. Expiration dates on unopened food are observed and 'use by' dates are indicated once food is opened. 9. Supervisors are responsible for ensuring food items in panty, refrigerators and freezers are not past 'use by' or expiration dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes on packaging. A facility policy titled, Food Receiving and Storage, revised November 2022, indicated, Policy Interpretation and Implementation, 3. Potentially Hazardous Food, (PHF) or Time/Temperature Control for Safety (TCS) Food, means food that requires time/temperature control for safety to limit the growth of pathogens (i.e. bacterial or viral organisms capable of causing a disease or toxin formation. Refrigerated/Frozen Storage, 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ('use by') date. 2. PHF/TCS foods are stored at or below 41 degrees F, unless otherwise specified by law. 7. Refrigerated foods are labeled, dated and monitored so they are used by their 'use by' date, frozen or discarded. 1. During a concurrent interview and observation of the lunch meal tray line on 08/13/2025 at 11:45 AM with Dietary [NAME] J, a large plastic container of Italian salad with dressing was observed on the tray line. Temperature monitoring was completed by Dietary [NAME] J at the request of the surveyor. The salad temperature was 44.7 degrees F. Dietary [NAME] J stated the salad was on the tray line for approximately 10 minutes, but he had not checked the temperature of the salad prior to the start of the lunch tray line. Dietary [NAME] J stated the salad temperature should be 40 degrees F or less. Dietary [NAME] J stated that a cold salad was served at lunch once per month and stored in a large tub on the tray line but was not stored in a manner to keep the salad at the proper temperature. During an interview on 08/13/2025 at 1:01 PM, the Dietary Manager (DM) stated he expected cold foods to be maintained at a temperature of 41 degrees F or below and that the cooks were trained to put cold food on ice during the tray line. The DM stated that he noticed the salad on the lunch tray line on 08/13/2025 was not on ice, but he did not instruct his staff to put the salad on ice. During an interview on 08/14/2025 at 11:17 AM, the Administrator (ADM) stated that she expected cold foods to remain 41 degrees F or below for meal service. During an interview on 08/14/2025 at 11:55 AM, Registered Dietitian (RD) H stated that she completed onsite facility sanitation inspections once per month. RD H stated she had previously identified concerns with cold foods not stored on the tray line in a manner to keep cold foods at the appropriate temperature, and she recommended to the facility to keep cold foods iced or stored on ice sheets. During an interview on 08/14/2025 at 4:02 PM, the Director of Nursing (DON) stated she expected cold items on the tray line to be kept on ice during the tray line service. 2. During a concurrent interview with the Dietary Manager (DM) and an observation of the walk-in refrigerator on 08/11/2025 at 9:39 AM, 25 eight-ounce cartons of two percent milk were observed not labeled with a date of storage, UBD, or expiration date by the facility or manufacturer. The DM stated that the facility's milk vendor delivered milk on Mondays and Thursdays, but he did not notice the cartons of milk did not have a manufacturer expiration date stamps. The DM stated the milk vendor had delivered cartons of milk before that did not have a manufacturer expiration date stamp. He further stated he did not contact the milk vendor to clarify the expiration date for the cartons of milk that were delivered without a manufacturer date stamp. An invoice dated 08/11/2025 revealed 100 cartons of two percent milk were delivered to the facility on [DATE]. During an interview on 08/14/2025 at 11:55 AM, Registered Dietitian (RD) H stated that she completed onsite facility sanitation inspections once per month. RD H stated she had not identified a concern related to cartons of milk delivered to the facility without a manufacturer date stamp, but that the expectation would be for all foods to have a date of storage and UBD. During an interview on 08/14/2025 at 4:02 PM, the Director of Nursing (DON) stated that if milk was delivered without an expiration date, she expected the facility to not serve the milk and either discard the milk or clarify the expiration date with the manufacturer. 3. During a concurrent observation of the walk-in refrigerator and an interview with the Dietary Manager (DM) on 08/11/2025 at 9:39 AM, the following items were observed not labeled with UBDs: a container of approximately three quarts of tomato sauce, a container with approximately 32 ounces of butterscotch pudding, a bag of approximately 12 ounces of cooked roast beef, a bag of three biscuits, a bag of approximately eight cooked hamburger patties, a bag of approximately nine cooked breaded chicken patties, and a pan of approximately seven uncooked hamburger patties. The DM stated each item should be labeled with a UBD. During an interview on 08/11/2025 at 9:45 AM, Dietary [NAME] J stated he usually monitored the walk-in refrigerator once a week. Dietary [NAME] J stated staff were supposed to record the UBD of each food item. During an interview on 08/11/2025 at 9:48 AM, Dietary [NAME] K stated each food item should be labeled with an expiration date. During an interview on 08/11/2025 at 9:50 AM, Dietary Director Assistant (DDA) L stated each food item should be labeled with an expiration date. During an interview on 08/14/2025 at 11:17 AM, the Administrator (ADM) stated that she expected the DM to make sure there was an expiration date on each food item. The ADM stated she expected the staff to record a UBD on all cold storage items and to monitor the cold storage units daily to ensure items were properly labeled, stored, and all expired foods removed. 4. During a concurrent observation of the walk-in refrigerator and an interview with the Dietary Manager (DM) on 08/11/2025 at 9:39 AM, the following items were observed stored beyond their UBDs: a pan of approximately three pounds of cooked apples labeled with a UBD of 08/08/2025 and two bags containing approximately fifteen cooked turkey patties each labeled with UBDs of 08/10/2025. The DM stated staff should check refrigerators daily for expired food, and leftover food should be discarded after three days or according to the UBD. During an interview on 08/11/2025 at 9:45 AM, Dietary [NAME] J stated he usually monitored the walk-in refrigerator once a week. He stated that he worked on Monday, Tuesday, Wednesday, Friday, and Saturday of the prior week but did not check the walk-in refrigerator for expired food items. He stated that he discarded outdated foods when he checked the walk-in refrigerator, but he did not check for outdated food items every time he worked. During an interview on 08/11/2025 at 9:48 AM, Dietary [NAME] K stated that he checked the walk-in refrigerator for expired foods when he was in the walk-in refrigerator. He stated the last time he checked the walk-in refrigerator for expired food was on 08/10/2025. He stated he looked around in the walk-in refrigerator, but he did not look at everything. Dietary [NAME] K stated each food item should be labeled with an expiration date. During an interview on 08/11/2025 at 9:50 AM, Dietary Director Assistant (DDA) L stated she tried to check for expired foods in the walk-in refrigerator daily. She stated that she removed some expired food items on 08/10/2025, but she did not get to check everything in the walk-in refrigerator. During an interview on 08/14/2025 at 11:17 AM, the Administrator (ADM) stated she expected the staff to record a UBD on all cold storage items and to monitor the cold storage units daily to ensure items were properly labeled, stored, and all expired foods removed. 5. During a concurrent interview and observation of the freezer on 08/11/2025 at 10:00 AM with the Dietary Manager (DM), one case of dinner rolls was stored with the box open (exposing the dinner rolls to air). In addition, multiple boxes of food were observed stored on the floor of the freezer, including two cases of pulled pork, two cases of chicken breasts, and one case of peas and pearl onions. The DM stated the dinner rolls should have been stored in a closed container. The DM further stated that the items stored on the floor were delivered to the facility four days prior and remained on the floor because staff had not had a chance to put all the food items away. The DM stated he should have made sure staff went to the freezer to put the items away. During an interview on 08/14/2025 at 11:17 AM, the Administrator (ADM) stated she expected frozen foods to be put away appropriately upon delivery and all frozen items to be sealed. During an interview on 08/14/2025 at 11:55 AM, Registered Dietitian (RD) H stated all cold/frozen foods were to be stored in closed containers and should not be stored on the floor of the refrigerator or freezer. During an interview on 08/14/2025 at 4:02 PM, the Director of Nursing (DON) stated she expected food items to be stored in closed containers and not left on the floor.

Number of residents sampled: Number of residents cited: Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff used the proper personal protective equipment (PPE) during the care of a resident on Enhanced Barrier Precautions (EBP) for 1 (Resident #48) of 1 resident observed for wound care. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 08/2022, indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. The policy continued, 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). The policy continued, 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: indicating, h. wound care (any skin opening requiring a dressing). The policy continued, 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devises regardless of MDRO colonization. An admission Record indicated the facility admitted Resident #48 on 11/01/2022. According to the admission Record, the resident had a medical history that included diagnoses of neuromuscular dysfunction of the bladder, retention of urine, and extended spectrum beta lactamase (ESBL) resistance. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2025, revealed Resident #48 had severe impairment in cognitive skills for daily decision-making and short-term and long-term memory problems per a staff assessment of mental status (SAMS). The MDS indicated the resident had a Stage 3 pressure ulcer that was present on admission and received ulcer treatment that included nonsurgical dressings and applications of ointments/medications within the seven-day look back period. Resident #48's Care Plan Report included a focus area revised 08/14/2025 that indicated the resident had a urinary catheter system as well as an open wound to the low back/sacrum and bilateral ischium requiring enhanced barrier precautions. Interventions directed staff to assess wounds for signs and symptoms of infection during wound care (initiated 06/26/2025), utilize proper PPE while performing wound care (initiated 06/26/2025), and use proper PPE, including a gown during catheter care if splashing was expected (initiated 06/26/2025). Resident #48's Order Summary Report for active orders as of 08/16/2025 contained a physician's order dated 06/26/2025 for enhanced barrier precautions related to the urinary catheter and open wound to the lower back/sacrum. During an observation on 08/15/2025 at 10:50 AM, Licensed Practical Nurse (LPN) Q and Certified Medication Aide (CMA) R entered Resident #48's room, put on gloves, then performed wound care without putting on gowns. LPN S entered the room to replace CMA R and assist LPN Q and did not put on a gown before assisting with the wound care. During an interview on 08/15/2025 at 2:07 PM, Infection Preventionist (IP) O stated Resident #48 was on EBP due to the wound and the catheter. IP O stated Resident #48 had signage on the door, a red bagged trash can in the room, and supplies in the hall. IP O stated staff should wear gloves, gown, and mask to provide care and a face shield for splatter with catheter care. During an interview on 08/15/2025 at 1:58 PM, LPN Q stated Resident #48 was on EBP and they all should have worn gloves, gown, and mask when providing wound care. She stated it had just crossed her mind that they did not use the proper PPE. During an interview on 08/15/2025 at 2:00 PM, CMA R stated it did not even cross her mind that she needed to put on PPE when assisting with the wound care. She stated staff should have worn a gown and mask along with the gloves. During an interview on 08/15/2025 at 2:02 PM, LPN S stated she was not aware that the resident was on EBP, and additional PPE should have been worn while in the room. She stated she did not notice the signage on the door and did not see the PPE outside the room. She stated she came in to replace the CMA and was just there to help. During an interview on 08/16/2025 at 10:57 AM, the Administrator stated staff should know if a resident required EBP because of the signage on the door, and staff should follow the EBP policy when providing care.

Number of residents sampled: Number of residents cited: Based on interview and facility document and policy review, the facility failed to consistently employ a qualified infection preventionist. The facility's failure to employ a qualified infection preventionist to be responsible for the infection prevention and control program had the potential to affect all 78 residents residing in the facility. Findings included: The facility policy titled, Infection Preventionist, revised 09/2022, indicated, 1. The infection preventionist is qualified by education, training, experience and/or certification and has sufficient knowledge to perform the role. An undated facility document titled, Infection Control Preventionist, indicated the facility's previous infection preventionist (IP) P was the facility's IP for the timeframe from 08/01/2024 through 12/06/2024, Registered Nurse (RN) Y was the facility's IP for the timeframe from 12/16/2024 through 02/09/2025, and IP O was the facility's IP for the timeframe from 02/10/2025 to present. An award certificate for IP P revealed they completed the Centers for Disease Control (CDC) Nursing Home Infection Preventionist Training Course on 10/04/2024. As such, IP P served in the IP role without the necessary training from 08/01/2024 through 10/03/2024. An award certificate for IP O revealed they completed the CDC Nursing Home Infection Preventionist Training Course on 06/17/2025. As such, IP O served in the IP role without the necessary training from 02/10/2025 to 06/16/2025. During an interview on 08/14/2025 at 2:09 PM, IP O stated they had been in the IP position since 02/2025, and there had not been another qualified IP on staff. During an interview on 08/15/2025 at 4:39 PM, the Director of Nursing (DON) stated the facility was required to have a qualified IP. The DON stated the last qualified IP was IP P, until IP O completed the CDC IP training in June 2025. The DON stated the expectation was for the facility to have a qualified IP in that position with the appropriate training to run the Infection Control program. During an interview on 08/15/2025 at 2:33 PM, the Administrator (ADM) stated the facility did not have a qualified IP during the timeframe from 12/06/2024 (when IP P left) until 06/17/2025, when IP O completed their CDC IP training. During a follow-up interview on 08/15/2025 at 4:48 PM, the ADM stated the expectation was to ensure a qualified IP was in the IP position before they were given the title of IP. The ADM further confirmed RN Y never completed the IP training.

Based on interview, record review, facility document, and facility policy review, the facility failed to ensure a complete and accurate medical record for 2 (Resident #76 and Resident #48) of 18 sampled residents. Findings included: A facility policy titled, Charting and Documentation, revised 07/2017, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, function or psychosocial condition, shall be documented in the resident's medical record. The policy also indicated, 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed. 1.An admission Record indicated the facility admitted Resident #76 on 02/01/2023. Per the admission Record, the resident had a medical history that included diagnoses that included unspecified schizophrenia, schizoaffective disorder, anxiety disorder, borderline personally disorder, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/2025, indicated Resident #76 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #76's Care Plan Report, included a focus area revised 06/23/2025, that indicated the resident used psychotropic medications including Invega, related to behavior management. Interventions directed staff to administer psychotropic medications as ordered by the physician (initiated 04/13/2023). Resident #76's February 2025 Medication Administration Record [MAR], contained an order entry for Invega Sustenna (an atypical antipsychotic) Intramuscular Suspension Prefilled Syringe 234 milligrams (mg)/1.5 milliliters (ml) with directions to inject 1.5 ml intramuscularly (IM) daily starting on the 11th and ending on the 12th every month. The MAR lacked documented evidence that the medication was administered to the resident. A document titled, Medical Director Report, for medication regimen reviews performed between 02/01/2025 and 02/19/2025 revealed a finding/recommendation that indicated Resident #76's Invega 1.5 ml IM once monthly injection was NOT charted that it was administered on the MAR. During an interview on 08/15/2025 at 2:39 PM, Resident #76 stated they got a shot every month. The resident stated they did not recall missing their monthly shot. During an interview on 08/15/2025 at 2:10 PM, Licensed Practical Nurse (LPN) S stated they documented all medications that were provided to the residents on the MAR. LPN S stated a blank space on the MAR indicated that medication was not administered or was not documented that it was given to the resident. LPN S stated that when a medication was held, nursing staff were to let the DON know and make the doctor aware in case they had further instructions. LPN S stated the nurse needed to write a progress note explaining why medication was not provided and indicate the doctor's instruction. During an interview on 08/15/2025 at 2:24 PM, LPN W stated all medications administered to residents were documented on the MAR with the nurse's initials. LPN W stated that when there were blank spaces, it indicated the nurse forgot to document or the medication was not provided. Per LPN W, when the medication was not provided there should be a progress note explaining why the medication was not administered, and they needed to make the DON and doctor aware and follow their recommendation. During an interview on 08/15/2025 at 12:11 PM, Unit Nurse Manager (UNM) F stated there was no documentation found regarding Resident #76 receiving their Invega shot or if the medication was held in February 2025. UNM F stated if medication was not available, they notified pharmacy and the provider to determine how to proceed. UNM F stated that when medication was available and not administered, it was documented in the resident's chart and the provider was notified of the missed medication. Per UNM F, they would proceed with the provider's recommendation and document the communication with the provider. UNM F stated the medication was provided to Resident #76 or they would have been notified by the nurse that the nurse forgot to document it. During an interview on 08/15/2025 at 12:09 PM, the Director of Nursing (DON) stated staff could not find any documentation that Invega was administered to Resident #76 in February 2025. The DON stated the resident received the medication, but the nurse did not document the administration. The DON stated the expectation was for staff to document all medications that were administered to residents and follow up with a progress note if medication was not provided and the reason the medication was not provided. The DON stated Licensed Practical Nurse (LPN) V, who was responsible for administration, no longer worked at the facility. A phone call was made to LPN V. No voicemail was set up and there was no answer on 08/15/2025 at 12:20 PM and 4:10 PM or 08/16/2025 at 8:30 AM. During an interview on 08/15/2025 at 4:38 PM, the Administrator stated they expected staff members to document all medications administered to residents. The ADM stated when Resident #76 received the shot in February 2025, it should have been documented on the MAR. 2. An admission Record indicated the facility admitted Resident #48 on 11/01/2022. According to the admission Record, the resident had a medical history that included diagnoses of neuromuscular dysfunction of the bladder, retention of urine, and extended spectrum beta lactamase (ESBL) resistance. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2025, revealed Resident #48 had severe impairment in cognitive skills for daily decision-making and short-term and long-term memory problems per a staff assessment of mental status (SAMS). The MDS indicated the resident had a Stage 3 pressure ulcer that was present on admission and received ulcer treatment that included nonsurgical dressings and applications of ointments/medications within the seven-day look back period. Resident #48's Care Plan Report included a focus area revised 08/14/2025 that indicated the resident had impaired skin integrity related to a Stage 3 pressure ulcer injury to the low back/sacrum. Interventions directed staff to provide wound care as ordered (initiated 08/06/2025). Resident #48's August 2025 Treatment Administration Record [TAR], included an order entry dated 08/06/2025 for Wound care: Lowback[sic]/sacrum- Cleanse wound with wound cleanser/NS [normal saline]. Apply [NAME] [sic]. Cover with sacral dressing. Per the TAR, the wound care was scheduled daily at 6:00 AM. The TAR lacked documented evidence that the wound care was completed on 08/08/2025. Resident #48's TAR also included an order entry for Wound care: Lowback[sic]/sacrum- Cleanse wound with wound cleanser/NS. Apply silvercel [type of dressing] to the wound bed. Secure dressing with sacral border dressing. Per the TAR, the wound care was scheduled for the evening at 7:00 PM each Tuesday and Friday, with an order date of 07/22/2025 and discontinue date of 08/06/2025. The TAR lacked documented evidence that the wound care was completed on Friday, 08/01/2025 and Tuesday, 08/05/2025. An additional review of the TAR revealed that Licensed Practical Nurse (LPN) T provided care for Resident #48 on the dates and times when the wound care was scheduled. During an interview on 08/15/2025 at 2:42 PM, LPN T stated if she was scheduled to do a treatment, it was done, she just may not have documented the treatment. She stated she did all the treatments ordered for Resident #48; she just did not document it. She stated it was not on purpose; she either forgot or did not have time. She stated she was not sure and could not remember specifically but knew that she completed the treatment. During an interview on 08/16/2025 at 10:57 AM, the Administrator stated if there were incomplete sections on a TAR, then they could not prove that the medication or treatment was completed. She stated the medical record was incomplete.

Number of residents sampled: Number of residents cited: Based on interview and facility document review, the facility failed to ensure that in the absence of a full-time registered dietitian (RD) or other clinically qualified nutrition professional, a qualified individual was designated to serve as the director of food and nutrition services. This had the potential to affect all residents receiving meals from the dietary department. Findings included: A document titled, Application for Employment, signed by the Dietary Manager (DM) on 01/23/2025, revealed the DM's work history included work as a cook/dietary aide. The application further revealed the DM received a high school diploma and completed one and a half years of education at a community college. The application did not reflect any food service education or previous employment as a food service director. The Dietary Manager's (DM) personnel file revealed the DM was originally hired by the facility as a cook on 1/23/2025. A document titled, Job Description and Performance Standards for the position of Food Service Director, signed by the Dietary Manager (DM) on 05/11/2025, revealed, The purpose of this position is to implement and maintain effective systems to operate the dietary department and provide foodservice to residents in a cost-effective efficient manner to safely meet residents' needs in compliance with federal, state and local requirements. The section titled, Education and/or Experience (to be completed by the facility) was left blank. A document titled, Information for Monthly Quality Assurance Performance Improvement (QAPI) Committee Meeting Minutes, dated 06/11/2025, revealed the Administrator (ADM) and RD H attended the meeting. The document indicated the facility had a new DM in place (specified the facility's current DM), and the facility would work with him on dietary items and continue training him on expectations. The document indicated the DM would start certified dietary manager (CDM) courses soon, which were expected to take a year for completion. During an interview on 08/11/2025 at 10:10 AM, the DM stated that he did not complete a certification course, he did not have a degree in food service, and he had not previously been employed as a dietary director or food service director. The DM stated he started at the facility in early 2025 as a cook and was promoted to DM in April 2025. The DM stated that prior to his employment at the facility, he was employed as a cook for over two years at two other nursing facilities. The DM stated that he planned to enroll in online CDM courses in a couple weeks but he was not currently enrolled. The DM stated that he did not have a food service certificate, and he did not have formal training as the food service director. He stated that he was not aware of the federal requirements for the role of director of the dietary department. During an interview on 08/14/2025 at 11:17 AM, ADM stated that she was aware the DM was not certified in food service when she started as the ADM on 06/01/2025. The ADM stated they discussed the DM's lack of food service certification during the June 2025 QAPI meeting, and the plan was for the DM to complete an online CDM course within a year. The ADM stated she was not aware of the federal requirements for the director of the dietary department, and her expectation was that the facility would employ a qualified food service director. During an interview on 08/14/2025 at 11:55 AM, RD H stated she provided onsite and remote consultation services to the facility for a total of eight to twelve hours of consultation per week. She stated she was not a full-time RD for the facility. She stated she was aware the DM was not certified, but a plan to get him certified was discussed during a QAPI meeting. RD H stated she expected all dietary employees to have the necessary qualifications to complete their assigned responsibilities. During an interview on 08/14/2025 at 4:02 PM, the Director of Nursing (DON) stated she was not aware of the federal requirements for the director of the dietary department, but she expected the DM to have the proper training to ensure the dietary department was managed appropriately.

Number of residents sampled: Number of residents cited: Based on observation, record review, interview, and facility policy review, the facility failed to implement an adequate pain management program by accurately assessing, monitoring, and treating pain, which affected 1 (Resident #90) of 3 residents reviewed for pain management. The failure resulted in Resident #90 experiencing uncontrolled pain. Findings included: A facility policy titled, Pain Assessment and Management, revised 10/2022, indicated, The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The policy revealed, 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. ‘Pain management' is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. The policy also indicated, Recognizing Pain included 1. Observe the resident (during rest and movement) for physiological and behavioral (non-verbal) signs of pain; and 5. Review the medication administration record to determine how often the individual requests and receives PRN [pro re nata; as needed] pain medication, and to what extent the administered medications relieve the resident's pain. The policy revealed, Assessing Pain included 1. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment; and 4. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The policy continued, 5. During the pain assessment gather the following information as indicated from the resident (or legal representative), which included c. Characteristics of pain; d. Impact of pain on quality of life; f. Factors and strategies that reduce pain; and h. Physical and psychosocial issues (physical examination of the site of the pain, movement, or activity that causes the pain, as well as any discussion with resident about any psychological or psychosocial concerns that may be causing or exacerbating pain). The Implementing Pain Management Strategies included 1. Establish a treatment regimen that is specific to the resident based on consideration of the following: a. The resident's medical condition; b. Current medication regimen; c. History of addiction or opioid use disorder; d. Nature, severity, and cause of the pain; e. Course of the illness; and f. Treatment goals. The policy continued, 2. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. The policy revealed, 5. The following are considered when establishing the medication regimen: a. Starting with lower doses and titrating upward as necessary; b. Administering medication around the clock rather than PRN; c. Combining long-acting medications with PRNs for breakthrough pain; d. Combining non-narcotic analgesics with narcotic (opioid) analgesics; and e. Reducing or preventing anticipated adverse consequences of medications. The policy revealed, Monitoring and Modifying Approaches included 5. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled, and 6. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. The policy revealed, Report the following information to the physician or practitioner, which included 4. Prolonged, unrelieved pain despite care plan interventions. An admission Record indicated the facility admitted Resident #90 on 08/05/2025. According to the admission Record, the resident had a medical history that included diagnoses of primary osteoarthritis of the left shoulder, the presence of a left artificial shoulder joint, aftercare following joint replacement surgery, pain in the left shoulder, low back pain, and chronic pain. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2025, revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident received or was offered PRN medication during the assessment timeframe. Resident #90's Care Plan Report included a focus area initiated 08/07/2025, that indicated the resident was at risk for pain related to the primary diagnosis of osteoarthritis and left shoulder surgery. Interventions initiated on 08/07/2025 directed staff to administer medications as ordered and to reposition the resident. The Care Plan Report revealed no other non-pharmacological interventions to address the resident's pain. Resident #90's hospital Post Acute Care Transition Report, dated 08/05/2025, revealed Active Medications included the following: -Acetaminophen (an analgesic) 500 milligrams (mg), two tablets (1,000 mg) by mouth every six hours PRN, with a maximum of 4,000 mg a day. -Hydrocodone-acetaminophen (a narcotic analgesic combination) 5-325mg, two tablets by mouth every four hours PRN for acute pain. Resident #90's hospital Post Acute Care Transition Report, dated 08/05/2025, revealed Discontinued Medications included tramadol (an opioid) 50 mg. Resident #90's Order Recap [Recapitulation] Report, for order dates from 08/01/2025 through 08/31/2025, included the following orders: -Pain monitoring every day and night shift, with an order to utilize an appropriate pain scale according to the resident's cognition, ordered on 08/05/2025. -Acetaminophen extra strength 500 mg, two tablets by mouth every six hours PRN for pain, with instructions to not exceed 4,000 mg per day, ordered on 08/05/2025. -Hydrocodone-acetaminophen 5-325 mg, two tablets by mouth every four hours PRN for acute pain, ordered on 08/05/2025 and discontinued on 08/12/2025. -Hydrocodone-acetaminophen 5-325, one tablet by mouth every six hours PRN for acute pain, ordered 08/12/2025. The Order Recap Report revealed no orders for non-pharmacological interventions for pain. Resident #90's Pain Evaluation, dated 08/05/2025, was incomplete. The evaluation indicated the resident was on a scheduled pain management regimen and received PRN and non-medication interventions for pain. The evaluation included a Pain Interview that indicated that the resident had almost constant pain over the previous five days that made it hard to sleep at night and limited their day-to-day activities. The evaluation revealed the sections for indicating the location of the pain, potential underlying causes of pain, pain intensity, pain relief, type of pain, timing and contributing factors, manner of expressing pain and associated symptoms, pain interference, laxatives ordered, and interventions were incomplete. The evaluation did not include the signature of the staff member who completed the evaluation. Resident #90's August 2025 Medication Administration Record [MAR], for the timeframe from 08/05/2025 (date of admission) through 08/15/2025 (the MAR report was printed on 08/15/2025 at 9:52 AM), revealed the following: - Staff documented monitoring the resident's pain each shift (6:00 AM shift and 6:00 PM shift), beginning on 08/05/2025. The record revealed that of the 18 times staff documented the resident's pain level, the resident's pain was a 10 (on a scale of 0-10, with 10 being the worst possible pain) 10 times; 9, one time; 8, two times; 6, two times; 5, two times; and 1, one time. - Staff documented Resident #90 received two tablets of hydrocodone-acetaminophen 5-325 mg one time on 08/05/2025, two times on 08/06/2025, four times on 08/07/2025, four times on 08/08/2025, four times on 08/09/2025, three times on 08/10/2025, three times on 08/11/2025, and three times on 08/12/2025. - Of the 24 administrations of two tablets of hydrocodone-acetaminophen 5-325 mg, staff documented the resident's pain level was rated 10, 12 times; 9, five times; 8, four times; and 4, one time. Two were not documented. - Hydrocodone-acetaminophen 5-325 mg was decreased from two tablets every four hours PRN to one tablet every six hours PRN on 08/12/2025. -Staff documented the resident received one tablet of hydrocodone-acetaminophen 5-325 mg three times on 08/13/2025, four times on 08/14/2025, and one time so far on 08/15/2025. - Of the eight administrations of the medication, staff documented the resident's pain level was rated 10, five times; 9, one time; 8, one time; and 2, one time. Resident #90's August 2025 MAR revealed staff documented Resident #90 received two tablets of hydrocodone-acetaminophen 5-325 mg on 08/07/2025 at 6:44 PM (pain level 9) with an unknown effectiveness, and the next administration was at 11:06 PM (pain level 9). Resident #90's Progress Notes revealed an Administration Note, dated 08/07/2025 at 6:44 PM, that indicated the resident received two tablets of hydrocodone-acetaminophen 5-325 mg and a follow-up note at 9:14 PM indicated the effectiveness was unknown, indicating that the resident stated that they had vomited their medication. The resident's Progress Notes revealed no documentation of other follow-up or intervention until 11:06 PM, when the resident was given two more tables of hydrocodone-acetaminophen 5-325 mg. Resident #90's August 2025 MAR revealed staff documented Resident #90 received two tablets of hydrocodone-acetaminophen 5-325 mg on 08/08/2025 at 2:06 PM (pain level 10) and the effectiveness was unknown. The MAR revealed the next administration was at 6:47 PM (pain level 10). Resident #90's Progress Notes revealed an Administration Note, dated 08/08/2025 at 2:06 PM, that indicated the resident received two tablets of hydrocodone-acetaminophen 5-325 mg and their follow pain level documented at 6:45 PM (over four hours after administration) was 10 and the effectiveness of the administration was unknown. The resident's Progress Notes revealed no other follow-up or intervention was provided until 6:47 PM, when the resident was given two more tables of hydrocodone-acetaminophen 5-325 mg. Resident #90's August 2025 MAR revealed staff documented the resident received two tablets of hydrocodone-acetaminophen 5-325 mg on 08/09/2025 at 10:22 AM (pain level 10) and was ineffective. The MAR revealed the next administration was at 5:04 PM (pain level 10), which was also documented as ineffective. Resident #90's Progress Notes revealed an Administration Note, dated 08/09/2025 at 10:22 AM, that indicated the resident received two tablets of hydrocodone-acetaminophen 5-325 mg and their follow-up pain level documented at 4:18 PM (over six hours later) was 9 and indicated the administration was ineffective. The resident's Progress Notes revealed no other follow-up or intervention was provided until 5:04 PM, when the resident was provided another two tablets of hydrocodone-acetaminophen 5-325 mg. Per the notes, the follow-up pain level documented at 7:31 PM was 10 and indicated the administration was ineffective. The notes indicated the resident was given two tables of acetaminophen extra strength 500 mg at 7:32 PM and their follow-up pain level documented at 8:32 PM was 3 and indicated the administration was effective. Resident #90's August 2025 MAR revealed staff documented Resident #90 received two tablets of acetaminophen extra strength 500 mg on 08/10/2025 at 5:37 AM (pain level 10) with an unknown effectiveness. Resident #90's Progress Notes revealed an Administration Note, dated 08/10/2025 at 5:37 AM, that indicated the resident received two tablets of acetaminophen extra strength 500 mg and their follow-up pain level documented at 9:51 AM (over three hours after administration) was 10 and the effectiveness was unknown. The Progress Notes revealed an Administration Note, dated 08/10/2025 at 9:51 AM, that indicated the resident received two tablets of hydrocodone-acetaminophen 5-325 mg and their follow-up pain level documented at 1:46 PM (over four hours after administration) was 10, but it was documented that the administration as effective. Resident #90's Nursing Daily Skilled Charting, dated 08/10/2025 at 10:58 AM, indicated the resident rated their pain a 10. The record indicated that the resident displayed non-verbal indicators of pain, indicating that the resident was tearful at times. Resident #90's Nursing Daily Skilled Charting, dated 08/11/2025 at 3:07 PM, indicated the resident rated their pain a 10. The record indicated that the resident displayed non-verbal indicators of pain, indicating that the resident was tearful at times. Resident #90's August 2025 MAR revealed staff documented the resident received two tablets of hydrocodone-acetaminophen 5-325 mg on 08/12/2025 at 2:22 PM (pain level 10) and the effectiveness was unknown. Resident #90's Progress Notes revealed an Administration Note, dated 08/12/2025 at 2:22 PM that indicated the resident received two tables of hydrocodone-acetaminophen 5-325 mg and their follow-up pain level documented at 7:23 PM (over five hours after administration) was unknown. The Progress Notes revealed no other follow-up or intervention was provided until 08/13/2025 at 3:57 AM (over seven hours later) when the resident was given one tablet of hydrocodone-acetaminophen 5-325 mg. Resident #90's Nursing Daily Skilled Charting, dated 08/12/2025 at 10:09 PM, indicated the resident rated their pain a 10. The record indicated that the resident displayed non-verbal indicators of pain, indicating that the resident was tearful at times. Resident #90's August 2025 MAR revealed staff documented the resident received one tablet of hydrocodone-acetaminophen 5-325 mg on 08/13/2025 at 5:04 PM (pain level 10) and the administration was ineffective. Resident #90's Progress Notes revealed an Administration Note, dated 08/13/2025 at 5:04 PM, that indicated that the resident received one tablet of hydrocodone-acetaminophen 5-325 mg and their follow-up pain level documented at 7:37 PM (over two hours later) was a 10 and indicated the administration was ineffective. The Progress Notes indicated that the resident received two tablets of acetaminophen extra strength 500 mg at 7:39 PM and their follow-up pain level documented at 9:47 PM was a 5 and indicated the administration was effective. Resident #90's August 2025 MAR revealed staff documented the resident received one tablet of hydrocodone-acetaminophen 5-325 mg on 08/14/2025 at 5:12 PM (pain level 10) and the administration was ineffective, and the next administration was at 11:40 PM (pain level 10). Resident #90's Progress Notes revealed an Administrative Note, dated 08/14/2025 at 5:12 PM, that indicated that the resident received one tablet of hydrocodone-acetaminophen 5-325 mg and their follow-up pain level documented at 8:27 PM (over three hours after the administration) was 10 and indicated the administration was ineffective. The resident's Progress Notes revealed no documentation of other follow-up or intervention until 11:40 PM when the resident was given another tablet of hydrocodone-acetaminophen 5-325 mg. Resident #90's record revealed no documented rationale for decreasing the resident's hydrocodone-acetaminophen. The record revealed no documentation of non-pharmacological interventions for pain offered or provided to the resident. During an interview and observation on 08/12/2025 at 2:47 PM, Resident #90 stated it took forever to get pain medications. The resident stated they had just gotten pain medication a few minutes earlier, but they had not had any since that morning. Resident #90 stated they had shoulder surgery and was supposed to get the staples out that Friday (08/15/2025). The resident grimaced in pain with the movement of the left arm. During an interview on 08/13/2025 at 10:06 AM, Resident #90 was lying in bed and stated the pain to their left shoulder was rated an 8 at that time, and they were unsure when they had last received pain medication but wished they could get something to help. During an interview on 08/14/2025 at 10:45 AM, Resident #90 stated they had increased shoulder pain that day. The resident stated the facility decreased their pain medication to one pill every six hours, and the resident did not know why. Resident #90 stated the physician had not come in and talked to them about their pain. The resident stated they were trying to work with therapy staff as much as they could but felt they (Resident #90) were limited due to the pain. Resident #90 grimaced when they moved their arm and was guarding it. During an interview on 08/14/2025 at 10:57 AM, Licensed Practical Nurse (LPN) Q stated they ran out of Resident #90's hydrocodone-acetaminophen 5-325 mg that was ordered for two tablets every four hours. They stated that they tried to get the pharmacy to refill the prescription on Tuesday (08/12/2025), and the physician sent the prescription for one tablet every six hours right before the end of their shift, so they were not the one to follow up on it. LPN Q stated the provider wanted to start weaning the resident off the pain medication since it had been a week since the resident's surgery. LPN Q stated the provider did not assess the resident prior to decreasing the resident's medication. LPN Q stated Resident #90 continued to rate their pain level at a 10. LPN Q stated the resident did not like to use ice, saying it made the pain worse. During an interview on 08/14/2025 at 11:50 AM, LPN Q stated they called the physician's office to follow up on the decrease in the pain medication and was told that it was their protocol to start decreasing the pain medications the further out from surgery that the resident got. LPN Q stated that the nurse practitioner was out at that time, but they would let them know to follow up with the resident the following morning since the resident was still complaining their pain level was 10 out of 10 most of the time. During an interview on 08/15/2025 at 4:44 PM, Unit Nurse Manager (UNM) U, who was the UNM where Resident #90 resided, stated residents should be assessed half an hour to an hour after receiving a PRN pain medication to see if it was effective. UNM U stated that if it was not effective, then other PRN medications or non-pharmacological interventions should be provided. They stated if there were still no positive results, the physician should be notified to get further orders on what to do. UNM U stated they had not been notified of Resident #90's pain levels and said it should have been followed up on prior to that day. UNM U stated that any time a resident had ineffective results from a pain medication, the nurse should follow up on it and do something more. UNM U stated they were not aware of Resident 90's pain levels. They stated it should have been reported and followed up on sooner. UNM U stated that even if the resident rated their pain 10 out of 10 every time, the staff should have used an alternate type of assessment to follow up on the resident's pain. During an interview on 08/14/2025 at 3:10 PM, the Director of Rehabilitation (DOR) stated Resident #90 was having a lot of muscle spasms that limited their range of motion (ROM). The DOR stated they tried to ensure the resident had been given pain medication prior to therapy. The DOR stated they were looking to see what they could do for the resident's pain and decreased ROM. During a concurrent interview on 08/15/2025 at 1:45 PM, Physical Therapist (PT) N, while providing ROM for Resident #90, stated the resident had been able to do more ROM in the previous two days than since they were admitted . PT N stated there was a concern about the swelling in the resident's arm, so the resident was going for an ultrasound at 2:00 PM. Resident #90 stated they spoke with a physician assistant (PA) about their pain, and the PA ordered an X-ray that was negative, an ultrasound, and some laboratory tests. The resident stated that the PA did not adjust their pain medication. PT N stated the resident's therapy had been limited due to the resident's staples and the limited ROM. PT N stated the resident's pain needed to be under control in order for therapy to be effective. During an interview on 08/15/2025 at 2:24 PM, Medical Assistant (MA) X, who was the MA for the resident's orthopedic PA, stated Resident #90 complained of pain at a level of 10 out of 10 pain before surgery and during the five days following the operation while they were in the hospital, even after getting intravenous (IV) pain medications. MA X stated that a nurse followed up with the resident 15 to 20 minutes after giving the pain medication, and the resident continued to rate their pain level at a 10 out of 10. MA X stated the resident did not know how to describe their pain. They stated the resident was seen by the orthopedic PA that morning due to the pain and swelling. They stated the X-ray was negative, and the PA ordered laboratory tests and an ultrasound to rule out deep vein thrombosis (a blood clot). MA X stated the resident had orders for hydrocodone-acetaminophen 5-325 mg, one tablet every six hours and could get acetaminophen in between. They stated that when the medication was decreased, they were not aware that the resident's pain was not controlled. MA X stated that all they knew was that the resident needed a new prescription for their pain medication and the PA followed the normal process of lowering the dose because of the amount of time that had passed since surgery. MA X stated the facility needed to be utilizing acetaminophen and trying other non-pharmacological interventions, like ice. The MA stated pain management was based on each individual patient. MA X stated if the resident felt that the tramadol would be more beneficial, they (MA X) could talk to the PA about it, but it would not be until Monday (08/18/2025), and if the facility needed something more for the resident before then, they needed to contact the resident's primary care physician. During a telephone interview on 08/15/2025 at 4:25 PM,the Medical Director (MD), who was the Resident #90's primary care physician, stated they expected the staff to contact a provider when a resident's pain was not being controlled within 24 hours. The MD stated Resident #90 always reported their pain level at a 10 but expected the resident 10 but pain after surgery. The MD stated the staff should offer ice packs, position changes, a lidocaine (an anesthetic) patch, distraction, and other activities. The MD stated they were not aware of the resident's complaint of uncontrolled pain or of the resident being sent for an ultrasound. The MD stated Resident #90 did have some cognitive impairment and it was difficult to assess their pain, and the staff needed to use a clinical assessment with the resident's input to determine what the resident's pain level was. The MD stated tramadol was not effective for Resident #90 in the hospital, but it may be effective going forward if the resident felt it would be beneficial. The MD stated the resident's pain level needed to be controlled for them to participate in therapy to make progress. Resident #90's Order Recap Report, for order dates from 08/01/2025 through 08/31/2025, contained an order, dated 08/15/2025 and started on 08/16/2025, for lidocaine 4% patch, to be applied to the left shoulder in the morning and removed at bedtime. During an interview on 08/16/2025 at 9:52 AM, Resident #90 was lying in bed with their arm elevated on a pillow. There was notable swelling observed to the upper arm. The resident stated their pain was 10 at that time and they were waiting for pain medication. Resident #90 stated they had not noticed a difference with the medication changes. They stated they had a patch on their shoulder and stated that it was not effective. Resident #90 stated it had been so long since they had not had any pain that they did not know what a tolerable level of pain would be. The resident stated they were old and tired of being in pain. The resident stated having to wait six hours for pain medication was too long. The resident stated they wanted to be able to get the pain medication more often and wanted to know why they could not have tramadol back. Resident #90 grimaced in pain with movement and held onto their arm, guarding it with any movement. During an interview on 08/15/2025 at 4:50 PM, the Director of Nursing (DON) stated if a resident indicated they were having uncontrolled pain, the nurse should be evaluating the resident's pain and administering anything that was ordered, and if that was not effective, they should contract the physician to get further orders, and it should be documented. The DON stated they were not aware of Resident #90's unrelieved pain and stated the nurses should have contacted the orthopedic physician for further orders, and if the nurse did not get a response, then they should have contacted the resident's primary care physician. The DON stated if a resident indicated their pain management was ineffective, the physician should be notified to get further orders. The DON stated if the physician could not be contacted, the resident should be sent to the emergency room for further evaluation and pain management. During an interview on 08/16/2025 at 10:57 AM, the Administrator stated nursing staff should follow physician orders when administering pain medication, assessing residents to ensure their pain was being managed, and if it was not, they should try other interventions. The Administrator stated that if the pain was still not controlled, they should contact the physician to see what other interventions they want to try. The Administrator stated they should try repositioning or moving the resident to a different setting, and the staff should document what was being tried.

Based on observation, interview, record review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to accurately code the Minimum Data Set (MDS) for 5 (Residents #2, #5, #35, #37 and #76) of 8 residents reviewed for Preadmission Screening and Record Review (PASRR) requirements, smoking, unnecessary medications, or speech/communication concerns. Findings included: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed, A1500: Preadmission Screening and Resident Review (PASRR) included Coding Instructions, which included, Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. The manual revealed, B0600: Speech Clarity included Coding Instructions, which revealed, Code 0, clear speech: if the resident usually utters distinct, intelligible words, Code 1, unclear speech: if the resident usually utters slurred or mumbled words, or Code 2, no speech: if there is an absence of spoken words. The manual revealed, J1300: Current Tobacco Use included Coding Instructions, which included, Code 0, no: if there are no indications that the resident used any form of tobacco, or Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period. The manual revealed, N0450: Antipsychotic Medication Review included Coding Instructions for N0450A, which included, Code 1, yes: if antipsychotics were received on a routine basis only, Code 2, yes: if antipsychotics were received on a PRN [pro re nata; as needed] basis only, or Code 2, yes: if antipsychotics were received on a routine and PRN basis. 1. An admission Record indicated the facility admitted Resident #76 on 02/23/2023. According to the admission Record, the resident had a medical history that included diagnoses of unspecified schizophrenia, schizoaffective disorder, anxiety disorder, borderline personally disorder, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/2025, indicated Resident #76 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Section A1500 of the MDS indicated Resident #76 was not considered by the state Level II PASRR process to have a serious mental illness. The MDS revealed J1300 indicated Resident #76 did not use tobacco during the assessment timeframe. N0450A indicated the resident did not receive antipsychotic medication during the assessment timeframe. Resident #76's Care Plan Report revealed a focus area initiated 07/12/2023, that indicated Resident #76 was a smoker. The Care Plan Report also included a focus area initiated on 04/13/2023, that indicated the resident used psychotropic medications. Resident #76's PASRR Level II determination letter, dated 02/17/2023, indicated Resident #76 had a serious mental illness, and recommended nursing home placement with psychiatric medication management and social and recreational activities. Resident #76's February 2025 Medication Administration Record revealed staff the resident received olanzapine (an antipsychotic) on 02/14/2025 (during the assessment timeframe). Resident #76's Resident Smoking Agreement, dated 06/23/2025, revealed Resident #76 was determined to be safe to smoke. An untitled and undated facility document provided by facility staff as a list of residents who smoked revealed Resident #76's name on the list. During an interview on 08/13/2025 at 8:54 AM, Resident #76 stated they smoked cigarettes two to three times a day. During an interview on 08/14/2025 at 2:57 PM, the MDS Coordinator stated the resident's MDS would accurately reflect the resident's status and care. The MDS Coordinator stated Resident #76's 02/20/2025 annual MDS, Section A1500 PASRR was incorrect and should have been marked yes, as the resident had a positive Level II PASRR. The MDS Coordinator stated Section J1300 was incorrect and should have been marked yes, as the resident was an active smoker. The MDS Coordinator stated they were both errors and needed to be modified to accurately reflect the resident's status. During an interview on 08/15/2025 at 4:06 PM, the MDS Coordinator stated Resident #76's Section N, related to the use of antipsychotic medication, was incorrect and should have been marked yes to indicate the resident received antipsychotic medication. The MDS Coordinator stated the facility did not have a policy for accuracy of MDS assessments; the facility followed the Resident Assessment Instrument (RAI) manual. During an interview on 08/15/2025 at 12:09 PM, the Director of Nursing (DON) stated the expectation was for MDS assessments to accurately reflect a resident's plan of care. The DON stated Resident #76's PASRR status, tobacco use, and their use of antipsychotic medication were all marked incorrectly and needed to be corrected. During an interview on 08/15/2025 at 10:38 AM, the Administrator (ADM) stated the expectation was for the MDS Coordinator to look at the resident's electronic medical record (EMR) and use it to accurately reflect the PASRR, smoking, and medication status in the MDS. The ADM stated Resident #76's 02/20/2025 annual MDS was incorrect for the resident's PASRR status, smoking status, and their use of antipsychotic medication and required modification to correct them. 2. An admission Record indicated the facility admitted Resident #5 on 05/23/2025. According to the admission Record, the resident had a medical history that included diagnoses of unspecified bipolar disorder and encounter for orthopedic aftercare following surgical amputation. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/28/2025, indicated Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A1500 of the MDS indicated Resident #5 was not considered by the state Level II PASRR process to have a serious mental illness. Resident #5's PASRR Level II determination letter, dated 05/21/2025, indicated the resident had a serious mental illness, and recommendations included nursing home placement with psychiatric medication management, supportive counseling, and individual therapy. Resident #5's Care Plan Report included a focus area initiated 05/24/2025, that indicated Resident #5 had a PASRR Level II completed on 05/21/2025 and met the state definition for having a mental illness. During an interview on 08/14/2025 at 3:02 PM, the MDS Coordinator stated Resident #5's 05/28/2025 admission MDS, Section 1500 PASRR was incorrect and should have been marked yes, as the resident had a positive Level II PASRR. The MDS Coordinator stated it needed to be corrected. During an interview on 08/15/2025 at 10:38 AM, the Administrator (ADM) stated the expectation was for the MDS Coordinator to look at the resident's electronic medical record (EMR) and use it to accurately reflect the PASRR status in the MDS. The ADM stated Resident #5's 05/28/2025 admission MDS PASRR Section A1500 was incorrect and needed to be modified. During an interview on 08/15/2025 at 12:09 PM, the Director of Nursing (DON) stated the expectation was for MDS assessments to accurately reflect a resident's plan of care. The DON stated Resident #5's PASRR section was coded incorrectly and needed to be corrected. 3. An admission Record indicated the facility admitted Resident #35 on 01/04/2012. According to the admission Record, the resident had a medical history that included a diagnosis of bipolar disorder. Resident #35's Notice of PASRR Level II Outcome, dated 07/15/2019, indicated Resident #35 was approved for PASRR Level II determination and did not require specialized services. The document indicated that if the resident was currently in a Medicaid-certified facility, the facility would need to document the PASRR condition in the Minimum Data Set (MDS) assessment record. The document indicated that the facility should mark yes for question A1500 on the MDS. Resident #35's significant change MDS, with an Assessment Reference Date (ARD) of 08/24/2024, revealed the facility documented No to the question in section A1500, Is the resident currently considered by the state level II process to have a serious mental illness and/or intellectual disability or a related condition? During a telephone interview on 08/14/2025 at 2:55 PM, the MDS Coordinator stated that she completed section A1500 of the significant change MDS dated [DATE] for Resident #35. The MDS Coordinator stated to complete that section, she looked in the miscellaneous section of the medical record and reviewed the PASRR to see if the resident had a Level I or Level II PASRR. During the interview, the MDS Coordinator reviewed Resident #35's PASRR and stated she marked No for section A1500 in error. She stated Resident #35 did have an approved PASRR Level II determination, and she should have marked this section Yes. During an interview on 08/15/2025 at 10:22 AM, the Director of Nursing (DON) stated she expected staff to review the medical record to identify whether a PASRR had been completed, and if the resident had an approved PASRR Level II, the MDS should be coded accordingly. The DON stated she expected the facility to refer to the Resident Assessment Instrument (RAI) manual to ensure MDS assessments were completed accurately. During an interview on 08/14/2025 at 4:32 PM, the Administrator stated the facility did not have a PASRR policy but stated she also expected the MDS Coordinator to follow the RAI manual when completing an MDS assessment. 4. An admission Record revealed the facility admitted Resident #2 on 06/10/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, unspecified, post-traumatic stress disorder (PTSD), unspecified, mental disorder, not otherwise specified, and generalized anxiety disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/18/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was not currently considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition. The MDS indicated active diagnoses for psychiatric/mood disorder included anxiety disorder, schizophrenia, and PTSD. Resident #2's Care Plan Report included a focus area initiated 05/14/2025 that indicated the resident had a mood problem related to amnesia, schizophrenia, anxiety, and PTSD medications. Interventions directed staff to monitor mood and behaviors (initiated 05/14/2025). Resident #2's Nebraska PASRR Level II Summary of Findings Report, Level II determination date of 05/29/2024, revealed the resident met the federal definition of serious mental illness. During a telephone interview on 08/15/2025 at 4:09 PM, MDS Coordinator (MDS) G stated Resident #2's MDS assessment was inaccurate. MDS G reviewed the PASRR Level II and stated the resident had a serious mental illness and the MDS assessment should have been marked yes. During an interview on 08/15/2025 at 4:29 PM, Director of Nursing (DON) B stated Resident #2 had schizophrenia, PTSD, mental disorder, and anxiety. DON B stated the MDS assessment with an ARD of 06/18/2025 was not correct and it should have been marked yes for a serious mental illness or condition. DON B's expectation was the MDS assessment needed to be accurate for staff to be able to provide the residents with appropriate care and assistance. During an interview on 08/15/2025 at 5:04 PM, Administrator (ADM) A stated Resident #2 had a serious mental illness with a diagnosis of schizophrenia. ADM A stated the MDS assessment with an ARD of 06/18/2025 was not correct and should have been marked yes for a serious mental illness. ADM A stated the ADM's expectation was that the ADM and MDS G worked together for the PASRR section of the MDS to ensure it was coded correctly. ADM A stated the facility did not have a policy for accuracy of the MDS; they followed the Resident Assessment Instrument (RAI) manual. 5. An admission Record revealed the facility admitted Resident #37 on 07/23/2003 and readmitted on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of cerebral palsy and dysphagia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/04/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had unclear speech – slurred or mumbled words. An annual MDS, with an ARD of 03/06/2025, revealed Resident #37 had a BIMS score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had unclear speech – slurred or mumbled words. A quarterly MDS, with an ARD of 06/06/2025, revealed Resident #37 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had clear speech – distinct intelligible words. Resident #37's Care Plan Report included a focus area revised 03/18/2025 that indicated the resident had impaired communication due to unclear speech related to cerebral palsy with severe spasticity, mild intellectual disabilities, hearing deficits, and used hearing aids. Speech was unclear at times and staff needed to listen very close at times or have the resident repeat more slowly. Interventions directed staff to listen carefully and validate verbal and non-verbal expressions (initiated 02/10/2017). During a telephone interview on 08/15/2025 at 4:04 PM, MDS Coordinator (MDS) G stated Resident #37's previous MDS assessments indicated the resident did not have clear speech and it was MDS G's error for the assessment of 06/06/2025 indicating the resident had clear speech. During an interview on 08/15/2025 at 4:36 PM, Director of Nursing (DON) B stated Resident #37's speech was difficult to understand. DON B referred to the resident's MDS assessment of 06/06/2025 and stated it was not accurate; the resident did not have clear speech. During an interview on 08/15/2025 at 5:07 PM, Administrator (ADM) A stated Resident #37's speech was difficult to understand. ADM A referred to the resident's MDS assessment of 06/06/2025 and stated it was not accurate because Resident #37 had unclear speech, and it was coded as clear speech. ADM A stated the ADM's expectation was that MDS G had accurate information for coding and the staff that completed that portion of the MDS assessment had accurate information. ADM A stated MDS G completed the speech section of the MDS for Resident #37.

Number of residents sampled: Number of residents cited: Based on interview, record review, and facility policy review, the facility failed to provide a written notice of bed hold policies upon transferring a resident to a hospital and failed to send a copy of a notification of transfer/discharge to the Ombudsman for 1 (Resident #86) of 1 resident reviewed for hospitalizations. Findings included: A facility policy titled, Bed-Holds and Returns, revised 10/2022, indicated, Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. The policy revealed, 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g. [exempli gratia; for example] in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was emergency, within 24 hours). An admission Record revealed the facility admitted Resident #86 on 05/30/2025. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, pneumonia, acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body's tissues), acute and subacute infective endocarditis (an infection of the inner surface of the heart), and pleural effusion (a collection of fluid around the lungs). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2025, revealed Resident #86 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #86's Progress Notes revealed a Change of Condition note, dated 06/08/2025, that indicated the resident was assessed and had diminished wheezes, and indicated that the resident was sent to the emergency room for further evaluation. Resident #86's medical record revealed no documentation that a written notification of the bed hold policy had been provided to the resident or the resident's representative at the time of or following the resident's transfer on 06/08/2025. There was also no evidence that the Ombudsman had been provided with a copy of a notification of transfer/discharge for the resident. During an interview on 08/16/2025 at 8:59 AM, Licensed Practical Nurse (LPN) Q stated nursing staff issued notifications of the bed hold policies when a resident went out of the facility. They stated that if a resident was unable to sign the notification, they contacted the resident's Power of Attorney (POA) and asked them if they wanted a bed hold for the resident, and then they (LPN Q) let the unit manager know to complete the paperwork and document it in a progress note. During an interview on 08/16/2025 at 10:27 AM, Unit Nurse Manager (UNM) U stated the nurse sending a resident to the hospital asked the resident if they wanted a bed hold and had them sign the notification if they were able. They stated that if a resident refused to sign a notice of bed hold policies, then it should be documented on the notification of bed hold policies form. During an interview on 08/15/2025 at 1:38 PM, the Administrator stated they did not have any notification of bed hold policies or documentation of notification of bed hold policies from when Resident #86 went out to the hospital. The Administrator stated the Social Service Director (SSD) was responsible for the notification of bed hold policies and stated that it usually was completed verbally and then documented. The Administrator stated they did not have documentation that the Ombudsman was notified of Resident #86's discharge and stated that it had not been done. The Administrator stated the SSD was responsible for sending that information. During a telephone interview on 08/16/2025 at 9:16 AM, the SSD stated that they did not notify the Ombudsman when a resident was sent to the hospital. During an interview on 08/16/2025 at 10:57 AM, the Administrator stated nursing staff should get the notification of bed hold. The Administrator stated that when the nurse called the family to notify them of the transfer, the nurse asked them at that time if they wanted a bed hold, and it was documented in the progress notes. They stated they did not know why Resident #86 did not have a record of notification of bed hold policies. The Administrator stated there should have been one, and it should have been documented.

Number of residents sampled: Number of residents cited: Based on observation, interview, facility document review, and facility policy review, the facility failed to post notice of the availability of the most recent survey results in a prominent and accessible area for the public; failed to post the most recent survey results in a location that was readily accessible to residents and visitors; and failed to maintain reports with respect to any surveys, certifications, and complaint investigations from the preceding three years and have them available for any individual to review upon request. The deficiency affected 10 (Residents #1, #6, #15, #24, #28, #29, #63, #67, #80, and #83) of 10 residents interviewed during a Resident Council meeting and had the potential to affect all the residents in the facility. Findings included: A facility policy titled, Survey Results, Examination of, revised April 2007, revealed, Copies of survey results are maintained in the administrative office. The policy revealed, 1. Copies of all survey reports (e.g. [exempli gratia; for example], standard, complaint, and/or extended surveys, follow-up revisits, etc. [et cetera; and so on]), along with approved plans of correction (as applicable) for noted deficiencies, are on file in the administrative office. 2. A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. 3. Copies of previous survey reports and state approved plans of correction are available upon request to the public, residents or their legal representatives (sponsors), designated ombudsman representative, and staff members. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/15/2025, revealed the facility admitted Resident #1 on 04/16/2024. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 06/17/2025, revealed the facility admitted Resident #6 on 02/09/2025. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. An admission MDS, with an ARD of 07/17/2025, revealed the facility admitted Resident #15 on 07/11/2025. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. An admission MDS, with an ARD of 05/27/2025, revealed the facility admitted Resident #24 on 05/21/2025. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. An annual MDS, with an ARD of 07/04/2025, revealed the facility admitted Resident #28 on 06/30/2023. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 06/19/2025, revealed the facility admitted Resident #29 on 08/18/2023. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 08/03/2025, revealed the facility admitted Resident #63 on 04/24/2023. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. A significant change in status MDS, with an ARD of 07/18/2025, revealed the facility admitted Resident #67 on 02/17/2023. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. An admission MDS, with an ARD of 08/04/2025, revealed the facility admitted Resident #80 on 07/28/2025. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 06/19/2025, revealed the facility admitted Resident #83 on 09/14/2023. The MDS indicated the resident had a BIMS score of 15, which indicated the resident had intact cognition. An observation on 08/11/2025 at 8:30 AM of the lobby area of the facility and the facility postings around the 100-Hall nurse's station revealed no posting regarding the availability of survey results. An observation on 08/11/2025 at 3:45 PM of the 200-Hall revealed no posting of the availability of survey results. An observation on 08/11/2025 at 3:47 PM of the 400-Hall unit revealed no posting of the availability of survey results. During a Resident Council meeting on 08/13/2025 at 1:30 PM, Resident #67 stated that they were aware of the location of survey results. The resident stated that there was a book behind a reception desk, but they had to ask staff to provide it to them. The other 9 (Residents #1, #6, #15, #24, #28, #29, #63, #80, and #83) residents in attendance stated they were not aware the facility maintained a binder that included survey results or the location of the binder. During an interview on 08/11/2025 at 10:32 AM, the Director of Nursing (DON) stated they did not know the location of the survey results in the facility and asked the Administrator (ADM) to locate the survey results binder. During a concurrent observation and interview on 08/11/2025 at 10:34 AM, the ADM retrieved a binder titled, Survey Book from the top of a reception desk located in the lobby of the facility where multiple binders were located. The Survey Book was not accessible to a resident seated in a wheelchair or to a resident or visitor standing in front of the reception desk. The Survey Book revealed survey results for a complaint survey that was completed on 02/12/2024 were not included. The ADM stated the binder with the survey results was not accessible to residents or visitors without them having to ask for staff assistance to retrieve the binder. The ADM stated the survey binder should have been accessible to the residents and visitors without having to ask for assistance. During an interview on 08/14/2025 at 10:21 AM, the ADM stated the notice regarding the availability of the survey results binder used to be located on the reception desk, but they noticed about a week prior that the notice was no longer posted. The ADM stated that they did not locate the survey results for the 02/12/2024 complaint survey. The ADM stated that moving forward, they would make sure there was a sign posted in the main lobby that indicated that the survey results were readily accessible, ensure they maintained survey results from the previous three years, and they would designate a place for the survey results book.

Licensure Reference Number 175 NAC 12-006.02(H) State Statute 28-372 Based on record review and interview, the facility failed to submit an investigative report to the State Agency within 5 working days following a fall that resulted in significant injury for 1 (Resident 1) of 3 sampled residents. The facility identified a census of 88. Findings are: A record review of the facility's policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, with a last revised date of September 2022 revealed the facility would provide a follow-up investigative report of any allegation of abuse or incidents that resulted in serious bodily injury within 5 business days of the incident to the state agency. A record review of an admission Record revealed the facility admitted Resident 1 on 5/2/2025. Resident 1 had an admitting diagnosis of metabolic encephalopathy (problems with a person's metabolism that can cause brain dysfunction). A record review of an Un-witnessed Fall Report with a date of 6/28/2025 revealed Resident 1 had tripped and fallen. Resident 1 had bleeding from the nose and was transported to the hospital for treatment. A record review of Resident 1's Emergency Department Provider Notes with a date of 6/28/2025 revealed Resident 1 had a fractured nasal bone and required stitches to their nose and finger. A record review of the facility's provided records of their submitted investigative reports revealed no evidence that an investigative report had been submitted following Resident 1's fall with significant injury. An interview on 7/9/2025 at 10:30 AM with the Director of Nursing (DON) revealed Resident 1 had sustained a broken nose following their fall on 6/28/2025. The DON confirmed the facility had notified the State Agency within 2 hours of being made aware of Resident 1's significant injury, but did not submit a follow-up investigative report to the State Agency within 5 business days and should have.

Licensure Reference Number 175 NAC 12.006.09 (H) Based on observation, record review, and interviews; the facility failed to ensure that one (Resident 5) of three sampled residents were not over-medicated. The facility identified a census of 89. Findings are: A record review of an undated Psychotropic Medication Use Policy revealed the following: Residents receiving psychotropic medications are monitored for adverse consequences. If psychotropic medications are identified as possibly causing or contributing to adverse consequences, the prescriber will determine whether the medication(s) should be continued, and document the rationale for this decision. Situations which may prompt an evaluation or re-evaluation of the resident include: -A clinically significant change in condition/status; -A new, persistent, or recurrent clinically significant symptom or problem; -A worsening of an existing problem or condition; -An unexplained decline in function or cognition. A record review of physicians' orders revealed the following: -Risperidone (a type of antipsychotic medication that treats mental health conditions schizophrenia, bipolar disorder and some symptoms of autism) 0.25 milligrams (mg); give one tablet by mouth every 12 hours as needed (PRN) for behaviors. The order had no documented evidence of a stop date or duration and included instructions to follow up with Resident 5s' primary health care provider. The order had a start date of 1/12/25. -Oxycodone (an opioid medication used for the treatment of pain) 10 mg; give one tablet by mouth every 12 hours for chronic pain requiring long term opioid treatment. This order had a start date of 1/10/25 -Oxycodone-Acetaminophen (an opioid combined with a non-opioid medication used to treat pain) 10-325 mg; give one tablet by mouth every 5 hours for chronic pain. The order had a start date of 1/10/25. -Buprenorphine HCl (a partial opioid used to treat pain with less side effects) 2 mg, Give 0.5 tablet under the tongue twice a day. This medication had a start date of 1/20/25, was administered the month of February as a scheduled medication, and replaced the scheduled Oxycodone 10 mg order in an effort to decrease side effects. A review of a Federal Drug Administration (FDA) Drug Safety Communication released in 2016 revealed a Black Box Warning (the most serious level of warning the FDA can place on a prescription drug label, indicating a significant risk of serious, potentially life-threatening, adverse effects) had been issued related to the interaction between opioid medications and antipsychotic medications. The interaction was shown to cause increased respiratory depression (a condition where breathing becomes too slow or shallow, potentially leading to insufficient oxygen and carbon dioxide exchange) and increased sedation. A record review of Resident 5s' Admission Summary revealed an admitted [DATE] from a short-term general hospital. The summary revealed Resident 5s' pertinent diagnoses include: -Wedge compression vertebral fracture T7-T8- (a bone fracture located in the mid vertebral spine). -Scoliosis- (an abnormal curvature of the spine). -Osteoarthritis- (chronic inflammation and deterioration of the cartilage between joints). -Depression- (a mood disorder characterized by a sustained feeling of sadness and loss of interest). A record review of Resident 5s' Minimum Data Set (MDS- a federally mandated assessment tool for nursing homes) dated 01/14/2025 revealed the following: -Section C revealed Resident 5 had a Brief Interview for Mental Status (BIMS- a standardized assessment tool used to screen for cognitive impairment in long-term care facilities) score of 11/15 indicating Resident 5 had mild cognitive impairment. -Section D revealed Resident 5 had a Patient Health Questionnaire 2 (PHQ-2to9 - brief screening tool for depression; used to assess the severity of depressive symptoms) score of 4/27 indicating that Resident 5 suffered from minimal symptoms of depression. -Section E revealed Resident 5 exhibited no potential indicators of experiencing hallucinations or delusions. Section E further revealed that Resident 5 exhibited behavioral symptoms not directed at occurred daily and significantly disrupted care of living environment. -Section GG revealed Resident 5 required maximal to total dependent assistance with dressing, undressing, bathing, and hygiene. -Section I revealed Resident 5 had a psychiatric diagnosis of depression. -Section J revealed Resident 5 received scheduled pain medication and PRN pain medication. The section further revealed that Resident 5 had not received non-medication intervention for pain. The Pain Assessment Interview revealed Resident 5 acknowledged the presence of pain rarely and revealed that pain rarely effected the ability to sleep. A record review of a Progress Note for Resident 5 dated 1/10/15, Resident 5s' admission day, revealed Resident 5 was alert and oriented to person, place, time, and situation. Resident 5 was responsive to commands and questions. Resident 5 used a walker and staff assistance for transfers. A record review of a Progress Note for Resident 5 dated 1/12/25 at 5:41 PM revealed Resident 5 began yelling out about pain to their back, despite having both PRN and regularly scheduled pain medication given. The writer documented they entered the room and found Resident 5 sitting in wheelchair, appearing to be sleeping and offering no complaints. The writer documented they left the room and approximately 10 minutes later, Resident 5 began to yell out again, and stated ow, it hurts. The writer documented that they notified the on-call provider at that point due to nothing helping Resident 5 with pain and discomfort. The writer stated that Resident 5 had pain medication, was repositioned, was redirected, and still Resident 5 continued to yell out. The writer documented that the provider prescribed an order for Risperidone 0.25 mg, one tablet every 12 hours as needed. The provider then instructed the facility to follow up with Resident 5s' primary care physician. The writer documented that the medication was administered, and Resident 5 continued to yell out for approximately 30 minutes, then was calm and did not yell out in pain since. A record review of Resident 5s' Medication Administration Record from 1/12/25 to 1/31/25 revealed the as needed antipsychotic medication was administered 11 occasions in 20 days with no documented evidence regarding what behaviors were observed that indicated the use of the medication. A review of the follow-up documentation (documentation required when an as needed medication is administered, to determine its effectiveness) revealed the medication was documented as being effective, indicating that no further behaviors were observed. A record review of Resident 5s' Medication Administration Record from 1/12/25 to 1/28/25 revealed the opioid medication was administered 21 occasions in 16 days. The follow-up documentation revealed the medication was effective in treating Resident 5s' pain. A record review of A record review of Resident 5s' Medication Administration Record from 2/11/25 to 2/28/25 revealed the antipsychotic medication was administered 12 occasions in 18 days. A review of the follow-up documentation revealed three occasions that the medication was documented as ineffective. A record review of Resident 5s' Medication Administration Record from 2/11/25 to 2/28/25 revealed the Buprenorphine medication was administered daily, as ordered. A record review of Resident 5s' Medication Administration Record from 3/1/25 to 3/20/25 revealed the antipsychotic medication was administered 8 occasions in 20 days. A record review of Resident 5s' Medication Administration Record from 3/1/25 to 3/31/25 revealed the opioid medication was administered every day, three times a day, as ordered by the provider. A record review of Resident 5's Progress Notes from 1/12/25 to 3/24/25 revealed the following documentation: -On 1/20/25, a Progress Note revealed Resident 5 was seen at a pain clinic where the Provider documented that Resident 5 was too heavily medicated and discontinued Resident 5s' routinely scheduled Oxycodone, but left the PRN oxycodone order in place. In addition, an order for Buprenorphine HCl (a partial opioid used to treat pain with less side effects) 2 mg, Give 0.5 tablet under the tongue twice a day was initiated -On 1/23/25, Resident 5 was evaluated by their primary care physician. The progress note further stated that Resident 5 has had a decline in cognition and physical ability. There was no documented evidence of the provider addressing the need for continuation of the antipsychotic medication or acknowledging a potential interaction between pain medication regimen and antipsychotic medication. -On 1/24/25, Resident 5s' representative voiced concern over Resident 5s' decline to which the facility told them labs were drawn and results were pending. -On 1/25/25, a Progress Note stated Resident 5 continues to decline with mentation and physical ability. Resident 5 has trouble feeding self, transfers, working with Physical Therapy, communicating issues (eating, using restroom, pain, and hold a conversation). The writer further stated that a phone call was placed to a physician in regard to the decline, as, when Resident 5 was admitted , they were alert and oriented to person, place, time, and situation. Now Resident 5 is oriented to self only. The physician gave orders to send Resident 5 to the Emergency Department. -Resident 5 returned from the Emergency Department after a chest x-ray, brain scan, and lab work with no issues noted, per writer. -On 1/28/25 a Care Conference Note revealed that Resident 5s' representatives had concerns with Resident 5s' mentation and stated that Resident 5 is not confused at baseline. Resident 5s' representatives requested to have their medications reviewed. No documented evidence of a follow-up is noted in the Progress Notes regarding this request. -On 1/28/25 a Progress Note regarding a telephone call with the pain clinic regarding Resident 5 revealed an order to discontinue all orders for the oxycodone. -On 2/3/25 a Progress Note at 1:37 AM revealed that Resident 5 was screaming out in pain and pointed to [gender] upper left side and stated it radiated around [gender] back. Resident 5 was transported to the Emergency Department per an order from the Nurse Practitioner on-call. Resident was discharged from the hospital after having their pain treated with opioid medication. -On 2/3/25 a Progress note at 5:59 PM revealed Resident 5 was again sent to the Emergency Department regarding uncontrolled pain. -On 2/10/25 Resident 5 was discharged from the hospital with no new orders, per writer. Writer further revealed that per the hospital nurse nothing new was found during the hospitalization . -On 2/10/25 a Progress Note revealed Resident 5 had a fall in their room, per writer. -On 2/13/25 a Progress Note revealed Resident 5 was administered the as needed antipsychotic medication due to sporadic yelling during the night. Writer stated the medication was effective. -On 2/18/25 a Progress Note revealed that the in-house Nurse Practitioner saw Resident 5 and instructed the facility to follow up with primary provider and pain management provider. There was no documented evidence of the provider addressing the need for continuation of the antipsychotic medication or acknowledging a potential interaction between pain medication regimen and antipsychotic medication. -On 2/25/25 a Progress Note revealed the Director of Nursing (DON) left a message for Resident 5s' primary care provider regarding risperidone order stating Resident 5 currently has a PRN order for risperidone and utilizes it daily. The DON is requesting that it be scheduled as a routine medication. -On 2/28/25 a Progress Note revealed Resident 5 returned from the pain clinic with orders to discontinue the pain medication- Buprenorphine 2 mg and issued an order to re-start the Oxycodone-Acetaminophen 10-325 mg three times at day, scheduled. -On 3/21/25 a Progress Note revealed a call to Resident 5s' primary care provider revealing that Resident 5s' representatives would like the antipsychotic medication Risperidone discontinued. The note further stated that Resident 5 has an appointment with the physician 3/24/25 and that it would be addressed at that time. -On 3/24/25 a Progress Note revealed Resident 5 was evaluated by the Primary Care Provider who stated Resident 5 was not doing well. Has many issues. The Physician discontinued the antipsychotic and the buprenorphine. Resident 5 remained on the PRN oxycodone. An interview on 4/2/25 at 12:10 PM with Physical Therapy Director (PTD) revealed that Resident 5 was discharged from therapy on 3/13/25 related to inconsistencies with therapy. The PTD further describes Resident 5s' inconsistencies as They were alert, oriented, and able to follow commands one day; then would be nearly completely nonverbal the next day. This made any progress with therapy very difficult to achieve. An interview on 4/2/25 at 10:45 AM with Nurse Aide (NA)-G revealed that they have worked with Resident 5 since their admission to the facility. NA-G stated there was period of time after Resident was admitted that their cognition and physical abilities appeared to have declined. NA-G further revealed that within the last week they had noted an improvement in Resident 5's cognition and stated Resident 5 seems more with it, knows more about what they want, and are able to tell me. An interview on 4/2/25 at 12:30 PM with Resident 5's representative revealed they were not made aware that Resident 5 was placed on that medication until much later and stated they would have not agreed to it, had they been told. The representative revealed they voiced concern about Resident 5's decline on numerous occasions and knew that something was off. The representative revealed they requested it be discontinued immediately upon hearing that the medication was an antipsychotic. Resident 5's representative stated they visit Resident 5 up to three times a day and have noticed an improvement in Resident 5's cognition and physical abilities. An interview on 3/31/25 at 10:30 AM with Unit Manager (UM)-D revealed that new education has been provided to staff on using the on-call provider for the management of behaviors. UM-D revealed they thought each time a provider signed the order summary that the provider was essentially renewing the PRN order. UM-D confirmed that there were many missed opportunities to evaluate the potential of Resident 5 being over-medicated or a potential interaction between opioids and antipsychotics.

Licensure Reference Number 175 NAC ,d+[DATE].09 Based on record reviews and interviews; the facility failed to follow the advance directive for Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) or DNR (A type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops) for three residents (Residents 40, 32 and 46). The facility census was 75. The facility Administrator was notified on [DATE] at 9:00 PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Findings are: Record review of the facility policy titled Do Not Resuscitate Order with a revision date of [DATE]. The policy statement revealed, our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. A. A review of Resident 40's admission record dated [DATE] revealed under advance directive as a DNR. A review of Resident 40's physician orders in the electronic medical record (EMR, a digital collection of medical information about a person that is stored on a computer), for the month of July showed, the resident was listed as a DNR with an order date of [DATE]. A review of Resident 40's medical record revealed an advance directive choice to attempt resuscitation/CPR and to provide full treatment dated [DATE]. The document was signed by the resident and the physician. During an interview on [DATE] at 2:25 PM the Unit Manager-M (UM-M) revealed when the resident needs emergency assistance, the crash cart is retrieved, and the code listing report is located on the crash cart revealing a code status for every resident. Record review of the code listing report found at the crash cart containing a list of all current residents and their current code status dated [DATE] revealed the code status listed for Resident 40 as DNR. An interview on [DATE] at 2:34 PM with UM-M further revealed, Resident 40's code status in the code listing report found at the crash cart and the code status found in the medical record were not accurate. Review of Resident 40's medical record, UM-M verified the advance directive found in the chart revealed a signed advance directive order for CPR, full treatment. UM-M reported to this surveyor, an interview with Resident 40 on [DATE] at 2:40 PM revealed the resident confirms an advance directive choice for CPR, full treatment. Licensed Practical Nurse-O (LPN-O) was interviewed on [DATE] at 3:32 PM revealing in an emergency, to locate a code status on an individual in an emergency, they look at the orders in the EMR. Registered Nurse-A (RN-A) was interviewed on [DATE] at 3:42 PM revealing in an emergency, to locate a code status on an individual, they look in the medical record. 41938 B. Record review of the Admission Record dated [DATE] for Resident 32 revealed that Resident 32 admitted into the facility on [DATE]. Diagnoses included Diabetes, Hypertension (high blood pressure), and Hyperlipidemia (high levels of fat particles (lipids) in the blood that increases the risk of stroke or heart attack). Record review of the Resuscitation Orders form for Resident 32 dated [DATE] revealed that the resident chose to have No CPR (DNR-Do Not Resuscitate) in the event of cardiac and/or Respiratory Arrest. The form was signed by the resident's physician on [DATE]. Record review Resident 32's Care Plan dated [DATE] revealed that in the event of no pulse and absence of respirations Resident 32 chooses to be a DNR (Do Not Resuscitate). Record review of the facility Code Book (a listing of residents and their code status) dated [DATE] located on the facility emergency crash carts (a self-contained, mobile unit that contains virtually all of the materials and devices necessary to perform CPR) revealed that it listed Resident 32 as a Full Code. (This did not reflect the wishes of Resident 32 to have No CPR). 49382 C. A review of an Admission Record dated [DATE] revealed the facility admitted Resident 46 on [DATE]. Record review of the Resuscitation Orders form for Resident 46 dated [DATE] revealed that the resident chose to have No CPR (DNR-Do Not Resuscitate) in the event of Cardiac and/or Respiratory Arrest. The form was signed by the resident's physician on [DATE]. Record review of the care plan dated [DATE] for Resident 46 revealed that in the event of no pulse and absence of respirations Resident 46 chooses to be a DNR (Do Not Resuscitate). Record review of the facility Code Book (a listing of residents and their code status) dated [DATE] located on the facility emergency crash carts (a self-contained, mobile unit that contains virtually all of the materials and devices necessary to perform CPR) revealed that it listed Resident 46 as a Full Code. (This did not reflect the wishes of Resident 46 to have No CPR). Record review of Abatement Statement for F678 Cardiopulmonary Resuscitation dated [DATE] submitted by the Nursing Home Administrator on [DATE] and approved on [DATE] at 11:10 PM revealed the following: Residents identified that were affected or were identified at risk of serious injury, harm, impairment, or death were: Resident 40, Resident 32, Resident 46 -All residents' signed code status forms will be audited starting [DATE] to ensure physician orders match resident preferences. -Code status spreadsheet will be updated starting [DATE] to reflect accurate and current code statuses for each resident. -Starting [DATE], Social Services will contact residents without current code status preferences and discuss resident or representative wishes related to code status. -Starting [DATE], the Admissions Department will verify and obtain code statuses prior to admission with responsible party. -Starting [DATE], current code status forms will be placed in the code status binder and placed inside crash cart. -Director of Nursing (DON) will start in-services on [DATE] regarding: -Code status policy -Code status spreadsheet -Code status form: DNR/Full Code/Do Not Hospitalize (DNH) -Identifying a resident's code status -Education will be provided to all staff currently on duty and prior to any staff coming off duty. -Resident profile and code status icon on PCC will be audited and updated with current resident wishes related to code status by Unit Managers or designee weekly or upon admission or re-admit. -Starting [DATE], Social Services will audit code status book weekly to ensure code statuses for residents are accurate. -Starting [DATE], Admissions Department will audit code status forms received and obtained from hospital records weekly for new residents. -Starting [DATE], new admissions will be reviewed during clinical meetings to discuss and determine resident code statuses. -Auditing results will be submitted to Quality Assurance and Performance Improvement (QAPI) (a data driven and proactive approach to quality improvement) and addressed as appropriate. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17A(1) LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observations, record review, and interviews; the facility failed to have measures in place to prevent the spread of COVID-19 (a mild to severe respiratory illness that is caused by a coronavirus) related to hand hygiene, doffing (removing) Personal Protective Equipment (PPE), mask use, quarantine of COVID-19 positive residents and the use of disposable supplies for meal service. The facility also failed to implement a surveillance plan for tracking and monitoring incidents of communicable disease transmission including COVID-19; and the facility failed to provide staff education pertaining to infection control including mitigating the spread of COVID-19. This had the potential to affect all residents. The facility census was 77. Findings are: A. An observation on 3/26/23 at 6:03PM revealed on Unit 4 Medication Aide (MA)-A's N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) mask below MA-A's chin, with MA-A's nose and mouth exposed. In an interview on 3/26/23 at 6:03PM MA-A confirmed that MA-A's nose and mouth should be covered with MA-A's N95 mask. An observation on 3/27/23 at 9:37AM revealed on Unit 2 Licensed Practical Nurse (LPN)-B N95 mask below LPN-B's chin, with LPN-B's nose and mouth exposed. In an interview on 3/27/23 at 9:37AM LPN-B confirmed that LPN-B's nose and mouth should be covered with LPN-B's N95 mask. An observation on 3/27/23 at 10:48AM revealed on Unit 4 Registered Nurse (RN)-C N95 mask below RN-C's chin, with RN-C's nose and mouth exposed. In an interview on 3/27/23 at 9:37AM RN-C confirmed that RN-C's nose and mouth should be covered with RN-C's N95 mask. An observation on 3/27/23 at 12:33PM on Unit 1 revealed Nursing Assistant (NA)-D's, MA-E's, and LPN-F's N95 mask below NA-D's, MA-E's and LPN-C's chin, with NA-D's, MA-E's and LPN-C's nose and mask exposed. In an interview on 3/27/23 at 12:33PM NA-D confirmed that NA-D's, MA-E's and LPN-C's nose and mouth should be covered with NA-D's, MA-E's, and LPN-F's N95 mask. A review of the facility's COVID-19 Infection and Prevention and Control Recommendations for Healthcare Personnel, dated 9/23/22, revealed: -When SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. 45613 B. An observation on 03/27/23 at 10:01 AM revealed NA-G came out of a room with their N95 mask on with the bottom strap hanging under their chin and not around the back of their neck. NA-G came out of the resident's room with their PPE on and then removed their PPE while in the hall. In an interview with NA-G on 3/27/23 at 10:02 AM confirmed staff always removed their PPE in the hallway and not in the resident's room the trash cans are in the halls. C. An observation on 03/27/23 at 12:47 PM revealed MA-E took a lunch tray into a COVID positive resident's room, room [ROOM NUMBER], wearing PPE as well as a nondisposable food tray, nondisposable coffee cup and nondisposable juice cup. MA-E was wearing an N95 mask below their chin with MA-E's nose and mouth exposed. An interview on 3/27/23 at 12:48 PM with MA-E confirmed that MA-E's nose and mouth should be covered with the mask. An observation on 03/27/23 at 01:16 PM of NA-H coming out of room [ROOM NUMBER] holding 2 nondisposable room trays with nondisposable dishes. NA-H sat both trays down on the nightstand in the hall to remove PPE and put the PPE in the trashcan. NA-H then put the trays in the cart. NA-H wore an N95 mask with the bottom strap hanging under their chin and not around the back of their neck. Interview on 3/27/23 at 1:18 PM with NA-H confirmed both straps should have been secured around NA-H's head. A record review of 3M Particulate Respirator N95 mask picture instructions revealed that both straps must be secured around head. 39282 D. Observation at 4:05 PM on 3/26/23 revealed surgical masks and N95 mask setting directly on a table by the entrance door. Registered Nurse (RN-X) did not have a mask on and two other unidentified staff were wearing surgical masks. Interview with RN-X on 3/26/23 at 4:20PM revealed the facility had COVID 19. RN-X stated the administration had told RN-X that RN-X didn't need to wear a mask at the nurses station. At 4:24 PM on 3/26/23 NA-P answered the phone and their mask was below their nose. On 3/26/22 at 4:40 PM observation in the kitchen revealed DC-W (Dietary Cook) didn't have a mask on. The staff person using the dishwasher didn't have a mask on. DA- I (Dietary Aide) had their mask under their nose. On 3/27/23 at 7:00 AM observation of the kitchen revealed DC-U had their mask below their nose and DA-J had no mask on. On 3/28/23 at 10:34 AM LPN-N was observed talking on the phone with no mask on. Interview on 3/27/23 at 7:20 AM with the Dietary Manager revealed the administration had told the dietary department that they did not have to wear masks. On 3/27/23 at 7:20 AM observation revealed that DA-V was not wearing and mask and that the mask was in DA-V's uniform pocket. On 3/27/23 at 7:20 AM interview with DA-V revealed that all staff should be wearing masks in the facility. On 10:20 AM on 3/27/23, an interview with the DM revealed that the expectation of dietary staff was that the staff should be wearing an N95 mask at all times. Phone call interview on 3/28/23 at 1:18 PM with the ADM (Administrator) revealed the staff were expected to be wearing N95 masks and to be extra diligent in the times of a COVID 19 outbreak. E. On 3/26/23 at 6:00 PM observation revealed NA-D (Nursing Aide) passing trays on the 100 and 200 hallways from a cart. No hand hygiene was performed while picking up the supper trays from the different rooms. F. Observation on 3/26/23 at 6:00 PM of the kitchen staff; revealed the dietary staff using nondisposable dishes and silverware to serve the residents there meals. F. Use of disposable supplies. Use of disposable supplies Observation on 2/26/23 at 6 PM revealed the dietary personnel were putting food on nondisposable plates and trays and then placed these items onto carts and took the cart and trays to individual resident rooms. Observation of the nursing staff on 3/26/23 at 6:07 PM revealed the staff were passing supper trays and the food and drinks were not disposable dishes. The trays were being taken in and out of residents' rooms with the disinfecting the trays. G. Interview on 2/27/23 at 0810 AM, with the ADON (Assisted director of nurses) revealed that the Surveillance book kept by the Infection Control Person; was not up to date and did not have any information sited in the book of any past or current infection problems. Record review of the Infection Control book from the DON's (Director of Nursing) office revealed that the book didn't identify any type of surveillance for hand hygiene, donning and doffing of PPE (personal protective equipment), or any residents or staff that may have had an infectious disease. Monument Rehab infection control audit sheets from March 20, 2022 thru March 26, 2023 were blank and no information was on the sheets. 45484 H. Observation made on 3/26/23 at 4:37 PM revealed NA-O entered room [ROOM NUMBER] in full PPE (gown, gloves, N-95, and face shield). NA-O then exited room, still in full PPE, and removed gown and gloves in the hallway, discarding them in a trash can in the hallway. Observation made on 3/26/23 at 4:58 PM revealed NA-P and NA-Q entering room [ROOM NUMBER] in full PPE. At 5:03 PM both NAs exited them room, pushed the lift across the hall, removed gown and gloves and discarded them in the trash can in the hallway. A review of the CDC.gov (Centers for Disease Control website) Coronavirus disease 2019 (COVID-19) Factsheet dated 6/3/2020 revealed the steps for removing PPE as: Doffing (taking off the gear): 1. Remove gloves 2. Remove gown . 3. HCP [healthcare personnel] may now exit patient room. In a phone interview on 03/28/23 at 1:18 PM the ADM confirmed that PPE should not be removed in the hallway. I. On 3/26/23 at 6:30 PM, an observation was made of Unit Director (Unit Mgr) S testing self on entering the building. Unit Manager S stated this was a re-test as the first one was positive, and that Unit Manager S was asymptomatic (had no signs or symptoms of COVID-19). Unit Manager S further stated that this second test was showing as positive as well. On 3/26/23 at 7:00 PM, an observation was made of Unit Manager S seated at a desk in the ADON's office. Unit Manager S stated since I'm asymptomatic and vaccinated, I can be here as long as I don't have contact with residents. On 3/27/23 at 8:10 AM, Unit Manager S was observed seated at the desk in the ADON's office with their mask off. The ADON was also present in the office at the time. A review of the ICAP (Infection Control Assessment and Promotion Program) Summary of Recommendations for COVID-19 in a Long-Term Care Facility revised 10/19/22 revealed that Staff diagnosed with COVID-19 need to be restricted from work until 7 days have passed since symptoms first appeared (or from the date of positive test if asymptomatic) AND a negative viral test is obtained within 48 hours prior to returning to work. J. An interview with the Rehab Director (Rehab Dir) R on 3/26/23 at 4:45 PM revealed that the facility had 15 Residents (3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) who had tested positive for COVID-19, and that Resident 8 had been sent to the hospital earlier that day. A review of a list of COVID-19 positive residents provided by the facility on 3/27/23 revealed that Resident 6 tested positive 3/22/23, Residents 9, 10, 11, and 12 tested positive 3/24/23, and Residents 3, 4, 5, 7, 8, 13, 14, 15, 16, and 17 tested positive 3/26/23. The list further noted that Resident 8 had been hospitalized . A review of the facility's Midnight Census Report for 3/25/23 revealed that Resident 18 was Resident 15's roommate, Resident 19 was Resident 7's roommate, Resident 20 was Resident 9's roommate, Resident 21 was Resident 10's roommate, and Resident 22 was Resident 12's roommate. Prior to being hospitalized , Resident 8 was Resident 16's roommate. A review of Resident 19's Progress Notes from 3/26/2023 at 5:55 AM revealed that the resident's POA had been notified that Resident 19 had tested negative for COVID-19 that morning, but the resident's roommate had tested positive for COVID-19 on 3/26/23 at 3:00 AM, and the facility would keep family notified if anything changed. There was no indication that the option was given to the POA to separate the residents. A review of Resident 20's Progress Notes from 3/24/2023 at 1:23 PM revealed that the resident's POA had been notified that Resident 20 had tested negative for COVID-19 that day, but the resident's roommate had tested positive for COVID-19. There was no indication that the option was given to the POA to separate the residents. A review of Resident 21's Progress Notes from 3/24/2023 at 12:11 PM revealed that the resident's guardian (a person who looks after and is legally responsible for someone who is unable to manage their own affairs) was notified that Resident 21 had tested negative that day, but the resident's roommate had tested positive for COVID-19. There was no indication that the option was given to the POA to separate the residents. A review of ICAP Summary of Recommendations for COVID-19 in a Long-Term Care Facility. revised 10/19/22 revealed under Isolation of Resident Identified to Have COVID-19 (Red Zone) -Isolate the resident in a private room (can be the resident's own room) or in a designated isolation area if established. Resident door should be kept closed. -If the resident with COVID-19 has a roommate, the roommate should be moved to a separate private room if available within the same unit/hallway. (Do not move the resident into another area of the building where no cases of COVID-19 have been identified) -For larger outbreaks, if a facility has a separate unit or a walled off area in the building with empty rooms, a COVID-unit/red zone can be established in the area to move all the COVID-19 positive residents to one area. On 3/26/23 at 4:37 PM an interview with NA-O confirmed that Resident 7 tested positive for COVID on 3/25 and that the resident's roommate, Resident 19, was negative and had not been moved. An interview with the ADON on 3/27/23 at 8:53 AM revealed they did not know if the facility had been in communication with ICAP regarding COVID-19 outbreak, was unsure of when the first resident tested positive for this outbreak, and did not know if ICAP had provided guidance regarding keeping positive residents in the same room with their negative roommates. In an interview on 3/27/23 at 3:32 PM the ADON confirmed that residents who had tested negative for COVID-19 remained in the same room as residents who had tested positive for COVID-19, stated that if the resident's Power of Attorney (POA-a legal document that allows one person to make decisions for another person) wanted the resident who tested negative to remain in the room with a resident who had tested positive, that was their right, but was unsure whether or not that had been communicated with the resident representatives. K. A review of the Monument Rehabilitation and Care Center Annual Compliance Training packet provided by the ADON revealed no infection control education, and no COVID-19 specific education. This packet was accompanied by a signature list labeled All Staff and dated 11/17/22. The list had the Employee name on one side and a space for a signature on the other. The signatures were not dated. There were 44 empty spaces. An interview with the ADON on 3/28/23 at 12:30 PM revealed that the list was ongoing with employees signing it as they completed the training. An interview with the Director of Admissions (DoA) on 3/28/23 at 1:05 PM confirmed there was no information regarding infection control including COVID-19 in the training packet. An interview with the ADON on 3/28/23 at 1:55 PM confirmed the empty spaces on the signature sheet, and that empty spaces indicated that employee had not completed the training. An interview with the DoA on 3/28/23 at 2:12 PM confirmed that they were unable to find any COVID-19 specific education for the past year. On 3-28-2023 to abate the immediacy of the situation the facility provided the following plan which lowered the scope and severity to 'F': - Inserviced all staff including agency personnel on wearing proper PPE and hand hygiene. Education will be on going. Staff who have not completed education will not be allowed to work. - Inserviced all staff including agency personnel on appropriate donning and doffing of PPE, including disposal of PPE. - Inserviced all staff including agency personnel that all meal trays shall be served in disposable dining ware and staff must don PPE during delivery. - Inserviced all staff including agency on COVID Policies and Procedures. Staff who have not completed education will not be allowed to work the floor. - Placed PPE carts outside of COVID positive rooms and ensured all carts were stocked with appropriate supplies and checked every shift to be restocked. - Placed biohazard bins for trash and lined inside COVID positive resident rooms near door exit. - Placed hand sanitizers on PPE carts outside COVID positive rooms. - Placed visual signs for PPE requirements on all COVID positive rooms. - Placed visual signs for donning and doffing PPE on COVID positive rooms. - Ensured COVID positive residents were placed on isolation or transmission based precautions to prevent further spread. - Transferred COVID positive resident with current roommate to isolation room or may cohort with another COVID positive resident. - Residents exposed to COVID positive residents were monitored for symptom development. - All communal dining and activities were restricted.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observation, interview, and record review; the facility staff failed to implement interventions to ensure resident nutritional status was maintained including monitoring and preventing weight loss and implementing nutritional interventions to promote the healing of pressure ulcers for 3 of 12 sampled resident (Resident 52, Resident 56, and Resident 38). The facility identified a census of 85 at the time of survey. Findings are: A. Review of Resident 52's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 10/22/2021 revealed an admitted [DATE]. Resident 52 had a BIMS (Brief Interview for Mental Status) score of 6 which indicated severe cognitive impairment. Resident 52 required extensive assistance from staff for bed mobility, locomotion on and off unit, toilet use, and personal hygiene. Resident 52 required supervision and set up help from staff for eating. Resident 52's height was 66 inches and their weight was 167 pounds. No or unknown weight loss or gain was indicated. Observation of Resident 52 on 12/15/21 at 10:20 AM revealed they were resting in bed. At 10:21 AM, RN-V (Registered Nurse), completed a dressing change for Resident 52. Resident 52 was assisted to their right side in bed. After the soiled dressing was removed, Resident 52 was observed to have an open area on the coccyx and the left buttock. The area on the coccyx was approximately ½ cm in diameter and the area to the left buttock was oblong, approximately 6 cm long by 4 cm wide and had an appearance of a blister that had broken and the top layer of the skin was gone, exposing the skin underneath; the area was raw and white and was non-blanchable (skin that does not lose its redness with pressure). Both areas presented as Stage II upon observation (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.) Review of Resident 52's Order Summary Report dated 12/15/2021 revealed the following diet order: Regular diet Dysphasia (difficulty swallowing) texture, Nectar consistency, Level 2. Active 06/11/2020. There was no documentation Resident 52 was receiving a dietary supplement due to weight loss or skin breakdown. Review of Resident 52's Weights and Vitals Summary report dated 12/14/2021 revealed the following: -12/13/2021 at 10:56 137.0 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 11/11/2021, 151.0 Lbs., -9.3%, -14.0 Lbs.] MDS: -10.0% change over 180 day(s) [Comparison Weight 6/21/2021, 158.6 Lbs., -13.6%, -21.6 Lbs.] -3.0% change over 30 day(s) [Comparison Weight 11/11/2021, 151.0 Lbs., -9.3%, -14.0 Lbs.] -5.0% change [Comparison Weight 11/25/2021, 152.0 Lbs., -9.9%, -15.0 Lbs.] -7.5% change [Comparison Weight 9/16/2021, 173.0 Lbs., -20.8%, -36.0 Lbs.] -10.0% change [Comparison Weight 6/21/2021, 158.6 Lbs., -13.6%, -21.6 Lbs.] -12/2/2021 at 12:56 141.0 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 11/4/2021, 151.0 Lbs., -6.6%, -10.0 Lbs.] MDS: -10.0% change over 180 day(s) [Comparison Weight 6/5/2021, 158.6 Lbs., -11.1%, -17.6 Lbs.] -3.0% change from last weight [Comparison Weight 11/25/2021, 152.0 Lbs., -7.2%, -11.0 Lbs.] -3.0% change over 30 day(s) [Comparison Weight 11/4/2021, 151.0 Lbs., -6.6%, -10.0 Lbs.] -5.0% change [Comparison Weight 11/4/2021, 151.0 Lbs., -6.6%, -10.0 Lbs.] -7.5% change [Comparison Weight 9/9/2021, 172.4 Lbs., -18.2%, -31.4 Lbs.] -10.0% change [Comparison Weight 6/5/2021, 158.6 Lbs., -11.1%, -17.6 Lbs.] -11/25/2021 at 15:38 152.0 Lbs. -11/11/2021 at 13:18 151.0 Lbs. -11/4/2021 at 15:12 151.0 Lbs. -10/14/2021 at 14:18 167.0 Lbs. -3.0% change over 30 day(s) [Comparison Weight 9/16/2021, 173.0 Lbs., -3.5%, -6.0 Lbs.] 10/7/2021 15:49 167.0 Lbs. -3.0% change over 30 day(s) [Comparison Weight 9/9/2021, 172.4 Lbs., -3.1%, -5.4 Lbs.] -9/30/2021 at 15:23 171.0 Lbs. -9/16/2021 at 11:00 173.0 Lbs. -9/9/2021 at 13:34 172.4 Lbs. -9/2/2021 at 15:24 173.0 Lbs. -8/26/2021 at 15:24 171.0 Lbs. -8/19/2021 at 15:36 170.0 Lbs. -8/12/2021 at 18:14 169.0 Lbs. -8/5/2021 at 12:52 167.0 Lbs. -7/29/2021 at 14:44 168.0 Lbs. -7/22/2021 at 14:54 165.0 Lbs. -7/8/2021 at 14:17 164.0 Lbs. -6/24/2021 at 16:46 159.0 Lbs. -6/21/2021 at 11:55 158.6 Lbs. -6/5/2021 at 14:59 158.6 Lbs. -5/13/2021 at 15:23 158.2 Lbs. -5/11/2021 at 14:35 158.9 Lbs. -4/29/2021 at 12:49 159.2 Lbs. -4/8/2021 at 14:11 159.5 Lbs. -4/1/2021 at 13:56 169.7 Lbs. -3/4/2021 at 12:36 169.0 Lbs. -2/27/2021 at 16:05 168.0 Lbs. -2/25/2021 at 15:07 169.0 Lbs. -2/22/2021 at 13:59 168.0 Lbs. -2/11/2021 at 18:15 168.0 Lbs. -1/28/2021 at 15:51 175.6 Lbs. -1/21/2021 at 13:18 176.0 Lbs. -1/18/2021 at 10:16 175.6 Lbs. -12/17/2020 at 16:20 174.5 Lbs. Review of Resident 52's Care Plan revealed the following: -Nutritional risk Date Initiated: 06/30/2017 Created on: 03/13/2017 Revision on: 09/16/2021 -Resident 52 will consume at least 75% of 2 out of 3 meals daily through next review Date Initiated: 11/29/2019 Created on: 03/13/2017 Revision on: 11/11/2021 Target Date: 02/15/2022 -Food intake will be recorded each meal Date Initiated: 05/24/2020 Created on: 05/24/2020 Revision on: 07/08/2020 -Obtain and observe weight as ordered or per facility protocol. Weight may fluctuate due to use of a diuretic. Date Initiated: 06/30/2017 Created on: 03/13/2017 Revision on: 04/25/2019 -Provide cueing and/or assistance with meals as needed. Date Initiated: 06/30/2017 Created on: 03/13/2017 Revision on: 04/25/2019 -Provide divided plate and cups with lids during meals for ease of dining. Date Initiated: 06/30/2017 Created on: 03/13/2017 Revision on: 05/24/2020 -Provide food preferences as available. Resident likes meats, seafood, mashed potatoes and gravy. Date Initiated: 08/23/2018 Created on: 08/23/2018 Revision on: 04/25/2019 -Provide supplement as ordered. Magic cup BID 9/16/21 RD recommend to d/c r/t not consuming Magic cup d/c'd on 10/4/21 Date Initiated: 05/29/2019 Created on: 05/29/2019 Revision on: 10/29/2021 -Regular, Dysphagia (level 2), nectar thick fluid diet Date Initiated: 06/30/2017 Created on: 03/13/2017 Revision on: 06/14/2021 -Snacks at HS and PRN. Date Initiated: 06/30/2017 Created on: 03/13/2017 Revision on: 04/25/2019 -EATING: Resident 52 requires supervision by staff for participation to eat. Date Initiated: 04/14/2017 Created on: 04/14/2017 Revision on: 04/25/2019 Review of Resident 52's Nutrition Notes revealed the following: 11/18/2021 at 10:33 Nutrition: Resident has an interesting weight history. Their weight dropped 16 pounds in 3 weeks. Present weight is satisfactory with BMI of 24.4. Remains in dysphagia diet with nectar liquids. Intake varies widely. Will continue to monitor weight to determine if further interventions are appropriate. There was no documentation Resident 52 had a nutrition review since 11/18/2021 and there was no documentation Resident 52's medical provider had been notified of Resident 52's weight loss. Review of Resident 52's Documentation Survey reports for October, November, and December 2021 revealed Resident 52's meal intakes were not being documented for every meal: 12/5/21 no documentation of intake for breakfast, lunch, supper; 12/6 and 12/7 no documentation of supper; 12/8-no documentation of breakfast and lunch; 12/11- no documentation of breakfast, lunch, supper; 12/12 and 12/13-no documentation of breakfast and lunch intake. Review of Resident 52's Physician's Order Form dated 11/10/2021 revealed Resident 52 was seen by the MD for a 60 day recertification visit. There were no new orders. There was no weight documented on the form and no documentation the MD had been notified of Resident 52's weights. Review of Resident 52's Progress Notes revealed the following documentation: -11/18/2021 at 10:33 Nutrition: Resident has an interesting weight history. Their weight dropped 16 pounds in 3 weeks. Will continue to monitor weight to determine if further interventions are appropriate. -11/15/2021 at 18:44 Nursing: Received 60 day recertification visit from Dr. No new orders. -10/4/2021 at 16:01 Nursing: DC'd (discontinued) magic cup r/t RDN (Registered Dietician) recommendation and approval of PCP (Primary Care Provider). There was no documentation Resident 52 was out of the facility during the times their meal intake was not documented. B. Review of Resident 56's Quarterly MDS dated [DATE] revealed an admitted [DATE]. Resident 56 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident 56 required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. Primary medical condition: fractures and other multiple trauma; displaced spiral fracture shaft of right femur (upper leg bone). Resident 56 was at risk to develop pressure ulcers. Resident 56 had no unhealed pressure ulcers at the time of the assessment. Resident 56 required supervision and set up help for eating. Resident 56's height was 64 inches. No weight was recorded. Weight loss was marked no or unknown. Mechanically altered diet was received while a resident. Interview with Resident 56 on 12/13/21 at 2:02 PM revealed they had an open sore on their buttock and Resident 56 revealed they had lost quite a bit of weight. I think I am down to 116 pounds. Observation of Resident 56 on 12/14/21 at 2:06 PM; 12/14/21 at 3:05 PM; 12/15/21 at 7:19 AM; 12/15/21 at 12:30 PM; 12/15/21 at 1:05 PM; 12/15/21 at 1:55 PM revealed Resident 56 was resting in bed. Observation of Resident 56 on 12/14/2021 at 3:09 PM revealed RN-A (Registered Nurse) and RN-N entered the room of Resident 56. RN-A reported the open area to Resident 56's bottom was healed and they had a call out to the MD to get the treatment discontinued. RN-A pulled Resident 56's covers down as Resident 56 was in bed. Resident 56 was wearing a brief; RN-A lowered the brief and RN-N helped Resident 56 roll over to their left side in bed. There was white cream on Resident 56's bottom; RN-A wiped off the cream with pre-moistened wipes. There was an unhealed dark scabbed un-stageable (Unstageable Pressure Ulcers Related to Slough and/or Eschar-ESCHAR TISSUE Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound) area observed to Resident 56's left buttock about the size of a quarter. RN-A wiped Resident 56's bottom, applied barrier cream, and re-applied the brief. RN-A did not measure the pressure area on Resident 56's left buttock. Observation of Resident 56 on 12/15/2021 at 9:13 AM revealed they were resting in bed and did not have any food. Interview with RN-A at this time revealed Resident 56 never ate breakfast. Observation of Resident 56 on 12/15/21 at 1:05 PM revealed Resident 56 was resting in bed. There was a tray of food and drinks on the bedside table next to their bed. Resident 56 revealed they had not eaten anything. Review of Resident 56's Order Summary Report revealed the following: Regular diet Mechanical Soft texture, Regular consistency, Level 3. Pt must be in chair for all meals and snacks. Active 06/16/2020 06/16/2020. There was no documentation of nutritional supplement orders. Review of Resident 56's Weights and Vitals Summary report dated 12/14/2021 revealed the following weights listed by date: -11/18/2021 at 11:12 110.0 Lbs. -09/1/2021 at 13:40 105.7 Lbs. -06/5/2021 at 14:58 108.8 Lbs. -04/7/2021 at 14:32 107.5 Lbs. -01/18/2021 at 10:16 108.3 Lbs. -12/10/2020 at 09:03 110 Lbs. -10/09/2020 at 15:01 108.6 Lbs. -09/30/2020 at 11:36 109 Lbs. -08/01/2020 at 15:05 110.4 Lbs. -07/29/2020 at 20:26 108.5 Lbs. -07/22/2020 at 20:57 108.5 Lbs. -07/08/2020 at 20:08 109.2 Lbs. -07/01/2020 at 16:45 108.8 Lbs. -05/06/2020 at 20:09 109 Lbs. -05/05/2020 at 15:58 109.1 Lbs. -04/07/2020 at 12:10 110.5 Lbs. -03/26/2020 at 15:24 112.5 Lbs. -02/22/2020 at 22:25 114.5 Lbs. -02/11/2020 at 08:10 113.5 Lbs. -01/31/2020 at 13:14 112 Lbs. -01/09/2020 at 12:55 116.5 Lbs. -12/23/2019 at 12:17 120.7 Lbs. -10/17/2019 at 11:47 123.5 Lbs. -09/16/2019 at 15:15 127.5 Lbs. -08/09/2019 at 10:26 128.5 Lbs. -07/15/2019 at 11:39 131 Lbs. -06/13/2019 at 15:12 128.5 Lbs. -05/18/2019 at 14:58 130.5 Lbs. -05/14/2019 at 12:48 138.4 Lbs. -05/13/2019 at 16:23 132.5 Lbs. -05/13/2019 at 12:44 132.5 Lbs. -04/29/2019 at 12:57 132.5 Lbs. -04/09/2019 at 13:59 135 Lbs. -03/26/2019 at 13:59 135 Lbs. -03/22/2019 at 11:39 134 Lbs. -03/05/2019 at 13:59 139 Lbs. -02/21/2019 at 18:30 144.5 Lbs. -02/19/2019 at 14:06 142.5 Lbs. -02/19/2019 at 08:15 142.5 Lbs. -02/13/2019 at 15:52 134.5 Lbs. -01/10/2019 at 16:54 142.9 Lbs. -There was no documentation Resident 56 been weighed since 11/18/2021 to ensure Resident 56 had maintained their weight and to ensure they had not any further weight loss. Resident 56 had a 23% weight loss since they were admitted to the facility. Review of Resident 56's MDS schedule revealed Resident 56 had not been out of the facility since 10/22/2021 and was available to be weighed. Review of Resident 56's Consultation/Clinic Referral dated 12/10/2021 revealed Resident 56's weight was listed at 110 pounds. There was no documentation Resident 56's weight loss was documented on the form. Review of Resident 56's Care Plan dated 1/31/2019 revealed the following: -Staff will provide diet as ordered: regular mechanical soft. Date Initiated: 01/31/2019 Created on: 01/31/2019 Revision on: 04/25/2019 -Staff will report any difficulty chewing or swallowing food to dietician and primary care provider for further intervention. Date Initiated: 01/31/2019 Created on: 01/31/2019 Revision on: 04/25/2019 -Eating: independent with set-up. Per ST, Resident 56 must be sitting up for meals to promote safe swallowing. Resident 56 refuses to get out of bed for meals, but does allow staff to position their in bed with their head up. RCS NSG Date Initiated: 04/18/2019 Created on: 01/11/2019 Revision on: 04/17/2021 Resident 56 has nutritional problem Date Initiated: 01/11/2019 Created on: 01/11/2019 Revision on: 10/03/2020 -Resident 56 will consume at least 75% of 2 meals per day Date Initiated: 01/27/2020 Created on: 01/11/2019 Revision on: 09/26/2021 Target Date: 12/28/2021 -Resident 56 often declines to eat one meal per day per their preference. Date Initiated: 04/24/2020 Created on: 04/24/2020 -Food/fluid intake will be recorded each meal Date Initiated: 01/11/2019 Created on: 01/11/2019 Revision on: 07/02/2020 Provide food preferences as available. Resident 56 likes cream of wheat, oatmeal, and orange sherbet. Resident 56 dislikes spinach and peas. Date Initiated: 01/11/2019 Created on: 01/11/2019 Revision on: 04/25/2019 -Regular, mechanical soft (level 3), regular fluid diet Date Initiated: 01/11/2019 Created on: 01/11/2019 Revision on: 07/02/2020 -Snacks provided PRN and at HS. Date Initiated: 01/11/2019 Created on: 01/11/2019 Revision on: 04/25/2019 -Weight will be obtained and monitored per facility policy Date Initiated: 01/11/2019 Created on: 01/11/2019 Revision on: 07/02/2020 NSG Review of Resident 56's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] SEQUELAE OF UNSPECIFIED NUTRITIONAL DEFICIENCY Review of Resident 56's Documentation Survey Report for December 2021 revealed no documentation of meal intakes for the following dates: 12/5/2021-breakfast, lunch, supper; 12/6-lunch; 12/7-supper; 12/8-breakfast and lunch; 12/11-supper; 12/12 and 12/13-breakfast and lunch. Review of Resident 56's Progress Notes revealed the following documentation: 12/3/2021 at 09:49. Value: 110.0 Vital Date: 2021-11-18 11:12:00.0 Resident is weighed infrequently. Fluctuations in weight are common. Most recent weight is BMI of only 18.9. Food intake is erratic. Need to monitor weight and intake to see if nutritional interventions are warranted. There was no documentation Resident 56 was out of the facility during the times their meal intake was not documented. C. Review of Resident 38's admission MDS dated [DATE] revealed an admitted [DATE]. Resident 38 had severely impaired cognitive skills for daily decision making. Resident 38 was dependent upon staff for transfer and required extensive assistance from staff for dressing and eating. Resident 38's primary medical condition was stroke. Resident 38's height was 67 inches and their weight was 175 pounds. No or unknown weight loss or gain. [MEDICATION(S)]/IV feeding was received while a resident; feeding tube was used while a resident; mechanically altered diet was received while a resident; 51% or more and 500 cc/day or less received while a resident and during entire 7 days per [MEDICATION(S)]/IV feeding. Resident 38 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device and had 1 unhealed pressure stage 2 that was present upon admission/entry. Review of Resident 38's Weights and Vitals Summary report dated 12/16/2021 revealed the following: -12/16/2021 at 09:37 163.5 Lbs. -7.5% change [Comparison Weight 10/15/2021, 177.0 Lbs., -7.6%, -13.5 Lbs.] -12/15/2021 14:59 162.0 Lbs. -7.5% change [Comparison Weight 10/15/2021, 177.0 Lbs., -8.5%, -15.0 Lbs.] -12/14/2021 13:12 160.0 Lbs. -3.0% change over 30 day(s) [Comparison Weight 11/14/2021, 165.0 Lbs., -3.0%, -5.0 Lbs.] -7.5% change [Comparison Weight 10/1/2021, 175.0 Lbs., -8.6%, -15.0 Lbs.] -12/13/2021 14:03 163.5 Lbs. -7.5% change [Comparison Weight 10/15/2021, 177.0 Lbs., -7.6%, -13.5 Lbs.] -12/13/2021 10:56 163.8 Lbs. -12/12/2021 11:02 163.0 Lbs. -7.5% change [Comparison Weight 10/15/2021, 177.0 Lbs., -7.9%, -14.0 Lbs.] -12/11/2021 15:31 164.0 Lbs. -12/10/2021 10:05 162.4 Lbs. -7.5% change [Comparison Weight 10/15/2021, 177.0 Lbs., -8.2%, -14.6 Lbs.] -12/9/2021 10:42 164.8 Lbs. -12/8/2021 07:26 163.4 Lbs. -3.0% change over 30 day(s) [Comparison Weight 11/8/2021, 169.0 Lbs., -3.3%, -5.6 Lbs.] -7.5% change [Comparison Weight 10/15/2021, 177.0 Lbs., -7.7%, -13.6 Lbs.] -12/7/2021 07:11 161.0 Lbs. -3.0% change over 30 day(s) [Comparison Weight 11/8/2021, 169.0 Lbs., -4.7%, -8.0 Lbs.] -7.5% change [Comparison Weight 10/1/2021, 175.0 Lbs., -8.0%, -14.0 Lbs.] -12/6/2021 14:46 164.0 Lbs. -12/5/2021 15:09 164.0 Lbs. -12/4/2021 14:15 163.4 Lbs. -3.0% change over 30 day(s) [Comparison Weight 10/31/2021, 170.3 Lbs., -4.1%, -6.9 Lbs.] -7.5% change [Comparison Weight 10/15/2021, 177.0 Lbs., -7.7%, -13.6 Lbs.] 12/2/2021 12:16 164.5 Lbs. -3.0% change over 30 day(s) [Comparison Weight 10/31/2021, 170.3 Lbs., -3.4%, -5.8 Lbs.] -12/1/2021 at 08:20 164.0 Lbs. -11/29/2021 at 14:42 163.0 Lbs. -11/28/2021 at 15:18 165.0 Lbs. -11/27/2021 at 14:48 164.0 Lbs. -11/26/2021 at 15:14 165.0 Lbs. -11/25/2021 at 12:55 164.7 Lbs. -11/24/2021 at 13:26 164.8 Lbs. -11/24/2021 at 11:14 166.0 Lbs. -11/23/2021 at 09:27 165.2 Lbs. -11/22/2021 at 09:02 164.0 Lbs. -11/21/2021 at 14:18 166.6 Lbs. -11/20/2021 at 14:13 166.8 Lbs. -11/19/2021 at 11:59 166.5 Lbs. -11/18/2021 at 14:38 165.7 Lbs. -11/17/2021 at 12:13 159.0 Lbs. -11/16/2021 at 14:41 163.0 Lbs. -11/15/2021 at 15:04 165.0 Lbs. -11/14/2021 at 17:10 165.0 Lbs. -11/14/2021 at 15:19 165.0 Lbs. -11/13/2021 at 08:01 164.4 Lbs. -11/12/2021 at 14:54 168.0 Lbs. -11/11/2021 at 14:05 165.0 Lbs. -11/10/2021 at 09:59 164.0 Lbs. -11/9/2021 at 12:53 164.4 Lbs. -11/8/2021 at 14:40 169.0 Lbs. -11/5/2021 at 12:59 168.0 Lbs. -11/4/2021 at 11:11 164.0 Lbs. -11/4/2021 at 07:06 164.5 Lbs. -10/31/2021 at 07:58 170.3 Lbs. -10/30/2021 at 13:23 169.0 Lbs. -3.0% change over 30 day(s) [Comparison Weight 10/1/2021, 175.0 Lbs., -3.4%, -6.0 Lbs.] -10/29/2021 at 17:22 171.2 Lbs. -10/26/2021 at 12:34 172.5 Lbs. -10/21/2021 at 11:35 170.0 Lbs. -10/17/2021 at 13:54 169.6 Lbs. -3.0% change from last weight [Comparison Weight 10/16/2021, 177.0 Lbs., -4.2%, -7.4 Lbs.] -10/16/2021 at 10:24 177.0 Lbs. -10/15/2021 at 15:30 177.0 Lbs. -10/13/2021 at 16:11 175.0 Lbs. -10/12/2021 at 14:33 174.7 Lbs. -10/5/2021 at 10:03 175.0 Lbs. -10/1/2021 at 16:59 175.0 Lbs. Review of Resident 38's weights revealed on 10/01/2021, the resident weighed 175 lbs. On 12/13/2021, the resident weighed 164 pounds which was a -6.29 % Loss. Review of Resident 38's Order Summary Report dated 12/14/2021 revealed the following: Dysphagia diet Pureed texture, alternate bites with fluids Active 10/01/2021. There was no documentation of nutritional supplement orders. Review of Resident 38's Nutrition Notes revealed the following: 12/9/2021 at 10:38 Nutrition Note Text: Resident is no longer on tube feeding. Weight is relatively stable. Most recent weight is 163.5 with BMI of 25.6. To maintain weight staff must continue to encourage oral intake. Review of Resident 38's Nutrition Data Collection dated 10/8/2021 revealed the following: Height 67 inches. Weight 168. BIM 27.4. No change in weight. Current pressure ulcer Stage 2. Eating ability total dependence. Resident takes in food orally and enteral feeding. Diet/supplement/snack/fortified foods: dysphagia, Puree (level 1); regular fluids. new admission on a dysphagia diet with puree texture consumes approximately 25-50% of oral foods also receives tube feeding of 948 ml 4 times daily with 200 ml water every 4 hours She receives limited to total assist at meals and with tube feeding When eating orally she needs to alternate bites of food with drinks; No significant weight change noted. Review of Resident 38's Nutrition RD assessment dated [DATE] revealed the following documentation: NUTRIENT ESTIMATED NEEDS 1. Calories 1600 to 1700 kcal 2. Protein 65 grams (increased by skin issues) 3. Fluid 1300 cc. 1. PES Statement Resident has poorly controlled diabetes as well as cerebral infarction and dysphagia. 2. Nutrition Interventions Order is for dysphagia diet, pureed texture-- intake has been poor. Also order for tube feeding four times a day with volume of 482 cc. Recommend Glucerna 1.5, 500 cc. per day which would provide 41 grams protein 3. Nutrition Goals Providing enough tube feeding to meet nutritional needs since food by mouth has been limited. Review of Resident 38's Documentation Survey Report for December 2021 revealed no nutrition intake amount eaten documented on 12/5/2021 (all 3 meals); 12/7/2021-supper; 12/8 and 12/9-breakfast and lunch; 12/11-supper; 12/12 and 12/13-breakfast and lunch. Review of Resident 38's Progress Notes for 10/1/2021 to 12/13/2021 revealed Resident 38's feeding tube was removed on 12/8/2021. On 11/12/2021 a Weight Change WEIGHT WARNING was documented: Value: 165.0 Vital Date: 2021-11-11 14:05:55.0 MDS: -5.0% change over 30 day(s) [5.6%, 9.7] -3.0% change over 30 day(s) [5.6%, 9.7] -5.0% change [5.6%, 9.7] Weight loss is reported to be related to less food intake since resident is feeding self. More assistance at meals is appropriate. No recommendation to increase tube feeding at this time. There was no documentation Resident 38 was out of the facility during the dates the meal intake was not documented. There was no documentation Resident 38's medical provider was notified of Resident 38's weight loss or any nutritional supplementation was ordered. Review of Resident 38's Weekly Skin Review dated 12/10/2021 revealed the following: Continue to treat coccyx per orders. Interview with the DON on 12/16/21 at 7:52 AM revealed they expected the staff to weigh the residents weekly if there was a specific order to do so. The DON revealed some residents had daily weights due to diuretic (medication used to reduce the build up of excess fluid in the body)use. Otherwise, weights were to be done at least monthly; we try to get them by the 10th. The DON revealed the nursing staff were responsible for documenting meal intake when they picked up the meal trays from the residents' rooms. The DON revealed if a resident refused the meal, the staff were expected to document that. Interview with the CDM (Certified Dietary Manager Consultant) on 12/15/21 at 2:23 PM revealed they reviewed resident weights once a week. The CDM revealed residents had not been weighed regularly. Interview with the RD (Registered Dietitian) on 12/16/21 at 10:10 AM revealed the residents had not been getting weighed regularly. The RD revealed they expected the residents to be weighed regularly and accurately. The RD revealed at a minimum, residents who were not at nutritional risk were expected to be weighed monthly. The RD revealed they preferred the residents, especially the residents with nutritional risk, to be weighed weekly. The RD confirmed the meal intake documentation was incomplete and it was difficult to assess resident nutritional status when meal intakes weren't documented. The RD confirmed Resident 52 did not receive a nutritional supplement. The RD revealed Resident 56 had only been weighed 6 times in the past year and they expected the facility staff to weigh the residents more often. The RD revealed they had not been alerted to Resident 56's weight loss. Regarding Resident 38, the RD revealed their biggest concern with Resident 38 was that they needed assistance with meals. The RD revealed Resident 38 would be okay if the facility staff assisted Resident 38 with eating their meals. Interview with the CDM on 12/16/2021 at 10:11 AM revealed Resident 52 did not follow their diet well. The CDM confirmed Resident 52 did not receive a nutritional supplement. The CDM revealed Resident 52 was receiving a Magic Cup pudding supplement but it was DC'd because Resident 52 refused it. The CDM revealed Resident 52 had been maintaining their weight pretty well but Resident 52 had an 11 pound weight loss and then their weight went down some more from 11/25. The CDM revealed Resident 52 did not come out to the dining room for meals and their meal intake was sporadic. The CDM revealed they expected the facility staff to document resident intake every meal. The CDM revealed they were not receiving consistent alerts from the Electronic Health Record (EHR) as the facility staff were not entering weights into the system consistently. The CDM revealed Resident 56 often refused at least one meal a day. The CDM revealed Resident 56 was not receiving a nutritional supplement. The CDM revealed Resident 56 had not been weighed regularly so it didn't trigger and they didn't get an alert from the EHR so that was where Resident 56's weight loss had been missed. Review of the facility policy Weight Monitoring dated 5/2017 revealed the following: Policy: based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. Suggested Weight Schedule: weights should be recorded at the time obtained. Mathematical rounding should be utilized (i.e. if weight is X.5 pounds [lbs.] or more, round weight upward to the nearest whole pound. If weight is x.1 to x.4 [lbs.] round down to the nearest whole pound). Newly admitted residents or readmitted residents-on admission, 24 hours, 48 hours, and then weekly for 4 weeks. Residents with weight loss-weekly; if clinically indicated-more frequent than weekly; all others-monthly. Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: 5% change in weight in 1 month (30 days); 7.5 % change in weight in 3 months (90 days); 10% change in weight in 6 months (180 days). The following formula may be used to calculate the percentage of weight change: % of body weight loss= (usual weight-actual weight/usual weight) x 100. Though a significant weight change may not occur, the resident may be identified as below ideal body weight by the Registered Dietitian or designee. Documentation: The physician should be informed of a significant change in weight and may order nutritional interventions. The physician should be encouraged to document the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietitian, Dietary Manager, or the nursing department may initiate this process. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. The interdisciplinary plan of care communicates care instructions to staff. Review of the facility policy Weighing the Resident/Patient dated 4/2015 revealed the following: It is the policy of this facility to maintain accurate information about weight gain or loss. Weights will be recorded in electronic health record and /or paper record within 24 hours of admission, weekly times four weeks and/or monthly per protocol. Any unplanned weight loss/gain is to be reported to the physician, family/responsible party, dietitian, and nursing supervisor and addressed at the weekly At Risk Meeting. Re-weigh of resident/patient is required with fluctuation of 3 lbs. from previous weight, with Licensed Nurse observation/validation. Also with: 5% loss or gain in one month; 7.5% loss or gain in three months; 10% loss or gain in six months.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2a LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, interview, and record review; the facility failed to implement measures to prevent pressure ulcers for Resident 9 and to promote healing of facility acquired pressure ulcers (a pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful) for Residents 52 and 56. The facility also failed to document wound monitoring of an identified pressure ulcer for 3 residents (Residents 52, 56, and 9) which had the potential to affect the physician treatment decisions for any changes in the pressure ulcer This affected 3 of 9 sampled residents. The facility identified a census 85. Findings are: A. Review of Resident 52's Quarterly MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 10/22/2021 revealed an admitted [DATE]. Resident 52 had a BIMS (Brief Interview for Mental Status) score of 6 which indicated severe cognitive impairment. Resident 52 required extensive assistance from staff for bed mobility, locomotion on and off unit, toilet use, and personal hygiene. Resident 52 was at risk of developing pressure ulcers/injuries. Resident 52 had no unhealed pressure ulcers. Observation of Resident 52 on 12/15/21 at 7:19 AM, 12/15/21 at 8:30 AM, 12/15/21 at 9:06 AM, 12/15/21 at 9:30 AM, 12/15/21 at 10:20 AM, 12/15/21 at 12:49 PM, 12/15/21 at 12:59 PM, 12/15/21 at 1:57 PM, 12/15/21 at 2:22 PM, revealed Resident 52 was resting in bed on their back. Observation of Resident 52 on 12/15/21 at 10:20 AM revealed they were resting in bed. At 10:21 AM, RN-V (Registered Nurse), completed a dressing change for Resident 52. Resident 52 was assisted to their right side in bed. After the soiled dressing was removed, Resident 52 was observed to have an open area on the coccyx and the left buttock. The area on the coccyx was approximately ½ cm (centimeter) in diameter and the area to the left buttock was oblong, approximately 6 cm long by 4 cm wide and had an appearance of a blister that had broken and the top layer of the skin was gone, exposing the skin underneath; the area was raw and white and was non-blanchable (skin that does not lose its redness with pressure). RN-V did not measure the areas. Both areas presented as Stage II upon observation (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.) Review of Resident 52's Weekly Skin Reviews revealed they were completed on the following dates: 11/25/2021 10/13/2021 9/22/2021 9/15/2021 9/1/2021 8/25/2021 8/18/2021 8/4/2021 7/28/2021 7/21/2021 7/14/2021 6/30/2021 6/9/2021 6/2/2021 5/26/2021 There was no documentation the weekly skin reviews were completed weekly. Review of Resident 52's Weekly Skin Review dated 11/25/2021 revealed documentation of multiple open areas to right buttock. Full thickness, treating per orders. There was no documentation of measurements or characteristics including staging of the open areas. Review of Resident 52's Weekly Skin Review dated 0/13/2021 revealed documentation of Residents scrotum area continues to be red/excoriated, continue to treat per orders. No other areas of concern noted at this time. Skin is otherwise warm, dry and intact throughout. There was no documentation a weekly skin review had been completed since the open wounds were documented on Resident 52's right buttock on 11/25/2021 and no documentation of a weekly skin review regarding the open area to Resident 52's coccyx or left buttock. Review of Resident 52's Progress Notes revealed the following documentation: -On 12/14/2021 it was documented Resident 52 had a wound to the right buttock; -On 12/12/2021; 12/11/2021; 12/10/2021; 12/7/2021; 12/6/2021; 12/5/2021; 12/3/2021; 12/2/2021; 11/28/2021, and 11/27/2021; it was documented that Resident 52 had a wound to buttocks. There was no documentation of the size, stage, or description of the wound, or exact location. On 11/25/ it was documented Resident 52 had multiple open areas to right buttock, full thickness. There was no documented of the size, stage, or characteristics including depth and location other than to right buttock. It was documented a standing wound order was placed in the TAR (Treatment Administration Record). (Standing orders are written protocols that authorize designated members of the health care team (e.g., nurses or medical assistants) to complete certain clinical tasks without having to first obtain a physician order). -On 11/29/2021, 12/1/2021, 12/2/2021, 12/3/2021, 12/4/2021 it was documented Resident 52 had a wound to the coccyx. There was no documentation of size, stage, or characteristics of the wound. There was no documentation regarding the wound on the coccyx after 12/4/2021. -On 12/1/2021 and 11/30/2021 it was documented wounds remain unchanged at this time. There was no documentation of location, size, or characteristics of the wounds. -On 11/27/2021 it was documented wound continues to be open. On 11/28/2021, it was documented wounds continue to be open. There was no documentation of the location, size, or characteristics of the wounds. On 11/29/2021 it was documented Resident 52 had a wound on their bottom. There was no documentation of the size, characteristics, or location. Review of Resident 52's Progress Notes revealed no documentation the medical provider was notified of the pressure ulcers/open wounds to Resident 52's left buttock and coccyx. There was also no documentation of any measurements or characteristics of the pressure ulcers to determine if they were healing. There was also no documentation of the size or characteristics of the wounds on Resident 52's buttocks or coccyx. Review of Resident 52's Order Summary Report dated 12/15/2021 revealed the following orders: -[MEDICATION(S)] to open area to right scrotum TID three times a day -Wound Care: Cleanse area to right buttock with NS (Normal Saline), Pat dry, Apply [MEDICATION(S)] (ointment) and cover with foam dressing/boarding foam. Change BID (twice a day) and PRN (as needed) until resolved; every day and night shift for Wound care Active 11/25/2021. There was no documentation of a treatment order for the open area on Resident 52's coccyx or the left buttock. Review of Resident 52's Weekly Skin Review dated 11/25/2021 revealed the following documentation: Multiple open areas to right buttock. Full thickness, treating per orders 10/13/2021: Residents scrotum area continues to be red/excoriated, continue to treat per orders. There was no documentation of size, stage, or characteristics of the wounds. Review of Resident 52's Medical Record revealed no documentation of any other type of skin or wound assessment. Review of Resident 52's Care Plan revealed the following: -Resident 52 is at risk for altered skin integrity related to: decreased mobility, extensive assist with bed mobility, incontinence of B&B Refuses cares at times. Resident 52 gets redness/excoriation to scrotum at times. 12/9/21 -Resident 52 currently has open areas to buttocks Date Initiated: 04/14/2017 Created on: 04/14/2017 Revision on: 12/09/2021 -Affected area will heal without complications. Treatments will be applied as ordered until open areas to buttocks are resolved -Administer treatments per MD orders. Date Initiated: 05/20/2020 Created on: 05/20/2020 -Complete Braden Scale per facility policy Date Initiated: 04/14/2017 Created on: 04/14/2017 Revision on: 05/31/2019 -Conduct weekly skin inspection Date Initiated: 04/14/2017 Created on: 04/14/2017 -Float heels as Resident 52 allows. Date Initiated: 10/24/2017 Created on: 10/24/2017 Revision on: 05/13/2021 -Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings Date Initiated: 12/09/2021 Created on: 12/09/2021 -Provide pressure reducing wheelchair cushion Date Initiated: 04/14/2017 Created on: 04/14/2017 -Provide pressure reduction/relieving mattress Date Initiated: 04/14/2017 Created on: 04/14/2017 -Provide thorough skin care after incontinent episodes and apply barrier cream Date Initiated: 04/14/2017 Created on: 04/14/2017 -Treatments as ordered. Wound Care: Cleanse area to right buttock with NS, Pat dry, Apply [MEDICATION(S)] and cover with foam dressing/boarding foam. Change BID and PRN until resolved Date Initiated: 12/09/2021 Created on: 12/09/2021 Revision on: 12/09/2021 -Turning and reposition as Resident 52 will allow Date Initiated: 10/24/2017 Created on: 10/24/2017 Revision on: 05/31/2019 Review of Resident 52's Braden Assessments revealed they were completed on 9/2/2021, 6/2/2021, and 3/2/2021 and indicated Resident 52 had moderate risk. There was no documentation the Braden Scale had been completed since 9/2/2021. Review of Resident 52's Physician's Order Form dated 11/10/2021 revealed the following: 60 day recertification (visit). No new orders. There was no documentation Resident 52 had been seen by the medical provider since 11/10/2021 or that the medical provider was notified about the open areas to Resident 52's coccyx and left buttock. B. Review of Resident 56's Quarterly MDS dated [DATE] revealed an admitted [DATE]. Resident 56 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident 56 required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. Primary medical condition: fractures and other multiple trauma; displaced spiral fracture shaft of right femur (upper leg bone). Resident 56 was at risk to develop pressure ulcers. Resident 56 had no unhealed pressure ulcers at the time of the assessment. Interview with Resident 56 on 12/13/21 at 2:02 PM revealed they had an open sore on their buttock. Observation of Resident 56 on 12/14/21 at 2:06 PM; 12/14/21 at 3:05 PM; 12/15/21 at 7:19 AM; 12/15/21 at 12:30 PM; 12/15/21 at 1:05 PM; 12/15/21 at 1:55 PM revealed Resident 56 was resting in bed on their back. Observation of Resident 56 on 12/14/2021 at 3:09 PM revealed RN-A and RN-N entered the room of Resident 56. RN-A reported the open area to Resident 56's bottom was healed and they had a call out to the MD to get the treatment discontinued. RN-A pulled Resident 56's covers down as Resident 56 was in bed. Resident 56 was wearing a brief; RN-A lowered the brief and RN-N helped Resident 56 roll over to their left side in bed. There was white cream on Resident 56's bottom; RN-A wiped off the cream with pre-moistened wipes. There was an unhealed dark scabbed un-stageable (Unstageable Pressure Ulcers Related to Slough and/or Eschar- Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound) area observed to Resident 56's left buttock about the size of a quarter. RN-A wiped Resident 56's bottom, applied barrier cream, and re-applied the brief. RN-A did not measure the pressure area on Resident 56's left buttock. Review of Resident 56's Weekly Skin Review dated 11/28/2021 revealed the following documentation: skin intact. Review of Resident 56's Weekly Skin Review dated 12/5/2021 revealed the following documentation: Excoriated/Open area to coccyx, treating per orders. There was no documentation of wound measurements or characteristics of the wound. Review of Resident 56's Weekly Skin Review dated 12/12/2021 revealed the following documentation: continue to treat coccyx per orders. No other concerns noted at this time. There was no documentation of wound measurements or characteristics of the wound. There was no documentation of the un-stageable pressure ulcer/wound to Resident 56's left buttock. Review of Resident 56's Progress Notes for 1/10/2019 to 12/14/2021 revealed the following documentation: On 11/29/2021 it was documented Resident 56 had an open area to the coccyx. On 11/12/2021 it was documented Resident 56 had an open area to the coccygeal (tailbone) area about a quarter size. On 11/10/2021 it was documented Resident 56 had an open area to the right buttock cheek 2 cm in diameter with a depth of 0.1. There was no further documentation in Resident 56's Progress Notes of the open area to Resident 56's right buttock after 11/10/2021. There was no documentation of the open area to Resident 56's coccyx after 11/29/2021 or from 11/12/2021 to 11/29/2021 and there was no documentation of the un-stageable wound to Resident 56's left buttock. On 11/7/2021 it was documented Resident 56 had an excoriated/open area to top of gluteal cleft (groove between the buttocks). There was no documentation of measurements or characteristics of the open area. There was no documentation the medical provider was notified of the open areas to Resident 56's buttocks or coccyx. Review of Resident 56's Order Summary Report dated 12/14/2021 revealed the following orders: Apply moisture barrier cream to coccyx BID and PRN as needed for replenish dry skin area Active 04/03/2020 Apply moisture barrier cream to coccyx BID and PRN every morning and at bedtime for replenish dry skin area Active 04/03/2020 Weekly Skin Assessment every day shift every Sun for Skin Integrity Active 07/11/2021 07/18/2021 Review of Resident 56's Braden Scale for Predicting Pressure Sore Risk dated 10/22/2021 revealed Resident 56 was moderate risk. Review of Resident 56's Care Plan revealed the following: -Resident 56 is at risk for skin breakdown/pressure R/T Immobility, Incontinence of both bowel and bladder. History of diarrhea. History of pressure area to right buttock Date Initiated: 01/11/2019 Created on: 01/11/2019 Revision on: 04/17/2021 -Keep skin clean and dry. Date Initiated: 01/11/2019 Created on: 01/11/2019 -Staff will check Resident 56's skin weekly and report concerns to Resident 56's primary care provider. Date Initiated: 01/31/2019 Created on: 01/31/2019 Revision on: 04/25/2019 Interview with the DON on 12/16/21 at 7:51 AM revealed the expectation for completing skin assessments and documenting the wound characteristics was the skin assessments were to be conducted weekly. The DON confirmed the staff had not been doing Resident 52's Skin Reviews weekly. The DON revealed sometimes Resident 52 was not cooperative and would refuse the skin assessments but the nurses should have been documenting if Resident 52 had refused and the nurses were to try again if Resident 52 refused the skin assessment. The DON confirmed the nurses were not documenting that Resident 52 was refusing the skin assessments. The DON revealed the staff were expected to assess and document the areas. The DON revealed they would see if they could find documentation of measurements of Resident 52's open areas on the left buttock and coccyx. The DON revealed all of the residents were to have a weekly skin assessment that were usually done with their bath day. Interview with the DON on 12/16/2021 at 7:56 AM revealed the staff were expected to continue the treatment to Resident 56's bottom if there was still an area of breakdown. Review of the facility policy Prevention and Management of Wounds dated July 1, 2013 revealed the following: Purpose: To promote healing, prevent infections, and prevent new pressure ulcers from developing. Policy statement: Residents will receive appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . General information: A licensed nurse will assess the pressure ulcer weekly and keep the physician informed of progress with prescribed treatments. Procedure: The Wound Care Coordinator or licensed nurse that is responsible for the wound care will examine all wounds weekly to assess and document findings. The Wound Care Coordinator or license (sic) nurse will complete a weekly wound description in AHR wound care module. Daily documentation will reflect if dressing is intact, drainage noted, pain associated with the wound, any odor and condition of surrounding skin which is visual around dressing. The Wound Care Coordinator or licensed nurse will document progress of wound healing weekly using AHT wound module in AHR or on paper. Documentation should include length, width, and depth. Identify location of any tunneling using clock reference. Measure depth using sterile cotton-tipped applicator. Describe condition of wound at each dressing change. The Wound Care Coordinator may use the Treatment administration record when a dressing is changed daily or less frequently. The dressing must be assessed daily. The Wound Care Coordinator or licensed nurse will document if dressing is intact, skin surrounding dressing, drainage, odor and pain level daily. When documenting on a healing wound, the principles of reverse staging should not be followed. C. Record review of the undated facility policy titled Skin Integrity Guideline revealed that the purpose of the guideline was to provide a comprehensive approach for monitoring skin conditions, to decrease pressure ulcer and/or wound formation by identifying those residents who are at risk and implement appropriate interventions, and to promote healing of wounds of any etiology (cause) whether admitted (wound present on admission to the facility) or acquired (developed during the resident's stay in the facility). The Guideline revealed that the objectives were to decrease the prevalence and incidence of residents who develop pressure ulcers. The general guideline revealed that the facility develops a routine schedule to review residents with wounds, or at risk of developing wounds, on a weekly basis and will document findings. Wound status will be monitored on a weekly basis. The plan of care will address problems, goals, and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. The section titled Documentation and Care Interventions for Skin Integrity revealed that if identified at risk, the interventions will be documented in the comprehensive care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident). Reposition every two hours, or as needed and tolerated. Record review of the Admission Record (a document that gives a resident's information at a quick glance that can include contact details, a brief medical history and the patient's level of functioning) for Resident 9 revealed that Resident 9 admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the MDS for Resident 9 dated 4/20/21 revealed that Resident 9 was at risk for developing pressure ulcers. The MDS documented that Resident 9 did not have a pressure ulcer at the time of the assessment. The MDS revealed that Resident 9 required extensive assistance of 2 staff for bed mobility (how the resident turns side to side and positions the body while in bed or alternate sleep furniture) and transfers (how the resident moves between surfaces including to or from the bed, chair, wheelchair, and standing). Record review of the care plan for Resident 9 revealed that Resident 9 was at risk for skin breakdown (skin and tissue injury caused when tissue parts are pressed between two harder surfaces such as bone and whatever the resident is resting on) related to decreased mobility. The care plan directed that the nurse will check the skin weekly and report concerns to the primary care provider. Record review of the Braden Scale for Predicting Pressure Sore (ulcer) Risk (a resident assessment used to determine the amount of risk for development of pressure ulcers) for Resident 9 dated 6/23/21 revealed that the Braden Risk Scale Score for Resident 9 was 17 ( a score of 15-18 means the resident is at risk for developing pressure ulcers). Record review of the progress note for Resident 9 dated 6/30/21 at 3:54 AM revealed that the licensed nurse was called to the resident's room. Resident 9 was observed with an open area (pressure ulcer) on the coccyx measuring 1.6 centimeters (cm) by 0.6 cm. Await orders for wound treatment and continue to turn resident every 2 hours. Record review of the progress note for Resident 9 dated 6/30/21 at 3:01 PM revealed that a phone call was received from the physician's office with a new order for wound clinic consult due to the open area on the coccyx. Record review of the health record for Resident 9 from 4/2/21 through 12/16/21 revealed that the Weekly Skin Reviews documented for Resident 9 were completed on 4/2/21, 4/16/21 (2 weeks after the previous weekly skin review), 4/23/21, 4/30/21, 5/14/21 (2 weeks after the previous weekly skin review), 5/21/21, 5/28/21, 6/4/21, 6/11/21, 6/18/21, 6/25/21, 7/2/21, 7/9/21, 7/16/21, 8/6/21 (3 weeks after the previous weekly skin review), 8/20/21 (2 weeks after the previous weekly skin review), 9/3/21 (2 weeks after the previous weekly skin review), 9/17/21 (2 weeks after the previous weekly skin review), 10/15/21 (4 weeks after the previous weekly skin review), 10/31/21 (2 weeks and 2 days after the previous weekly skin review), and 11/10/21 (1 week and 3 days after the previous weekly skin review). The health record for Resident 9 contained no documentation of any Weekly Skin Reviews being performed for Resident 9 after 11/10/21. Record review of the health record for Resident 9 revealed that a Braden Scale for Predicting Pressure Sore Risk assessment for Resident 9 was performed on 8/23/21. The Braden Risk Scale Score for Resident 9 was now 13 (a score of 13-14 means the resident is at moderate risk for developing pressure ulcers). The resident was now assessed to be at higher risk for pressure ulcers than the previous assessment. The health record for Resident 9 contained no documentation of any Braden Scale for Predicting Pressure Sore Risk being performed after 8/23/21. Record review of the MDS for Resident 9 dated 8/31/21 revealed that Resident 9 required extensive assistance of 2 staff for bed mobility and was now dependent on the assist of 2 staff for transfers. The MDS documented that Resident 9 had a stage 3 (an identifier used to describe the type of skin tissues involved in the pressure ulcer wound) pressure ulcer and was receiving pressure ulcer care. Observation on 12/14/21 at 3:19 PM in the room of Resident 9 revealed that Resident 9 was lying on the resident's right side in the bed. RN-B and Licensed Practical Nurse-H (LPN-H) entered the room of Resident 9 to perform the ordered dressing change to the stage 3 pressure ulcer on the coccyx (bone at the base of the spine) of Resident 9. RN-B unhooked the resident's brief and lowered the brief to expose the wound on the coccyx. The pressure ulcer measured approximately 3 centimeters (cm) long by 2 cm wide with a depth of 0.3 cm per visual measurement. The skin around the wound was dark reddish-purple in color extending approximately 10 cm out from all edges of the wound. A scant amount of yellow colored slough (dead tissue) was noted in the upper portion of the open wound. Interview on 12/16/21 at 8:50 AM with the facility Director of Nursing (DON) in the DON office confirmed that the expectation for floor staff is to reposition a resident with a wound on the buttocks or coccyx at least every 1 to 2 hours to assist with healing of the wound. Observation on 12/15/21 at 10:11 AM in the room of Resident 9 revealed that Resident 9 was lying on the resident's back in the bed with the bed flat. Observation on 12/15/221 at 12:27 PM in the room of Resident 9 revealed that Nursing Assistant-G (NA-G) exited the resident's room carrying the meal tray. Resident 9 was lying on the resident's back in the bed with the head of the bed elevated approximately 70 degrees per visual measurement. Observation on 12/15/21 at 2:14 PM in the room of Resident 9 revealed that Resident 9 continued to lay on the resident's back. The head of the bed remained elevated at approximately 70 degrees per visual measurement. Observation on 12/15/21 at 2:25 PM revealed that Nursing Assistant-S (NA-S) and Nursing Assistant-T (NA-T) entered the room of Resident 9 and closed the door. NA-S and NA-T exited the resident room with a trash bag of soiled items at 2:33 PM. Observation on 12/15/21 at 2:34 PM in the room of Resident 9 revealed that Resident 9 was positioned lying on the resident's back in the bed with the head of the bed elevated approximately 25 degrees per visual measurement. Observation on 12/16/21 at 7:56 AM in the room of Resident 9 revealed that Nursing Assistant-I (NA-I) repositioned Resident 9 onto the resident's back. NA-I raised the head of the bed to approximately 45 degrees per visual measurement. Observation on 12/16/21 at 10:55 AM in the room of Resident 9 revealed that Resident 9 remained lying on the resident's back in the bed with the head of the bed elevated approximately 45 degrees per visual measurement. Interview on 12/15/21 at 2:28 PM with Medication Aide-F (MA-F) confirmed that Resident 9 has had the open area on the coccyx since at least June of 2021. MA-F revealed that Resident 9 has had the open pressure ulcer the whole time since MA-F started on the Memory Care unit. MA-F revealed that the MA-F was switched from the 100 hall to the Memory Care unit about 6 months ago. Interview on 12/15/21 at 8:05 AM with Nursing Assistant-I (NA-I) revealed that NA-I has worked on the Memory Care unit for about a year and 6 months. NA-I confirmed that Resident 9 has had the open pressure ulcer wound on the coccyx that has not healed for several months. Record review of the facility policy titled Wound Treatment Guidelines dated 05-17 revealed that to promote wound healing of various types of wounds, it is the facility policy to provide evidence-based treatments in accordance with current standards of practice and physician orders. Step 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Step 5. Treatment decisions will be based on: a. Etiology (cause) of the wound b. Characteristics of the wound: i. Pressure injury stage. ii. Size- including shape, depth, and presence of tunneling (a tunnel that extends from the wound base underneath the skin) and/or undermining (a large wound with a small opening at the skin wound surface). iii. Volume and characteristics of exudate (fluid that oozes out of a wound). iv. Presence of pain. v. Presence of infection. vi. Presence of non-viable tissue. vii. Condition of peri-wound skin (the skin surrounding the wound). Step 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound. Record review of the health record for Resident 9 revealed that the only facility Weekly Wound Evaluations completed for Resident 9 during 2021 were documented on 11/23/21 and 12/14/21. The Weekly Wound Evaluation documented on 11/23/21 occurred 20 weeks and 6 days after the stage 3 pressure ulcer on the resident's coccyx was identified. Record review of the Weekly Wound Evaluation dated 11/23/21 revealed that Resident 9 had a stage 3 pressure ulcer acquired while in the facility. The measurements of the pressure ulcer were documented as 2.5 cm in length and 2.5 cm in width with 0 cm depth. Record review of the Progress Notes for Resident 9 written after 6/30/21 (when the stage 3 pressure ulcer was first documented) revealed a Progress Note dated 8/14/21 at 3:42 PM. The Progress Note revealed that [NAME] (a moisture barrier to promote healing) was applied to the wound on the coccyx and a foam (dressing) was applied. Turning the resident on sides to keep pressure off of the coccyx. The note contained no measurements or description of the pressure ulcer. Record review of the Weekly Skin Review for Resident 9 dated 8/20/21 documented that Resident 9 had a 2 cm diameter sore on the coccyx. The assessment contained no other description of the pressure ulcer wound. Record review of the Progress Note for Resident 9 dated 8/29/21 at 11:35 AM revealed a stage 3 pressure ulcer on the resident's coccyx. The note revealed that a fax was sent to the medical provider requesting treatment orders. Resident positioned side to side to avoid further pressure to the area. The note contained no measurements or description of the pressure ulcer. Record review of the Weekly Skin Review for Resident 9 dated 9/3/21 documented only that the sore on the coccyx was 2 cm in diameter. Treatment was applied as ordered. The assessment contained no other description of the pressure ulcer wound. Record review of the Weekly Skin Review for Resident 9 dated 9/17/21 documented the open area to the coccyx covered with an intact bandage. The assessment contained no measurements or description of the pressure ulcer wound. Record review of the Progress Note for Resident 9 dated 10/5/21 at 12:32 AM revealed that the pressure ulcer was noted with minimal serous (pale yellow body fluid) drainage. The note contained no measurements of the pressure ulcer. Record review of the Progress Note for Resident 9 dated 10/7/21 at 3:12 AM revealed that the pressure ulcer is a stage 3 with moderate slough covering the wound. The note documented that the pressure ulcer measured approximately 4 cm by 4 cm. Record review of the Weekly Skin Review for Resident 9 dated 10/15/21 documented the pre-existing open area. The assessment documented that the open area on the coccyx was 4 cm (in length) by 4 cm (in width) x 1.5 cm (deep). The assessment documented an additional open area to the left of the first wound measuring 0.5 cm by 0.5 cm by 0.2 cm. The assessment contained no other description of the pressure ulcer wounds. Record review of the Progress Note for Resident 9 dated 10/26/21 at 4:27 PM revealed that Resident 9 had an on-going open area on the coccyx. The note contained no measurements or description of the pressure ulcer. Record review of the Progress Note for Resident 9 dated 10/31/21 at 12:18 AM revealed that Resident 9's coccyx was assessed. The note revealed that there was a 15.4 cm reddened non-blanchable (pressing one's finger on the area does not force blood out of the capillaries and make the skin [NAME] or white. This indicates injury to the tissue) with three 1.5 cm opened areas in the middle with yellow drainage. Record review of the Weekly Skin Review for Resident 9 dated 10/31/21 documented the pre-existing open area. The assessment documented that Resident 9's coccyx was noted to have a 15 cm by 15 cm bright red area. The assessment documented that open area number 1 was 1.2 cm by 1 cm and that the center contained yellow slough. Open area number 2 was 0.5 cm by 0.7 cm. The treatment to the open areas continue. Record review of the Weekly Skin Review for Resident 9 dated 11/10/21 documented that Resident 9's right hand little finger fingernail was falling off. The assessment contained no documentation of the resident's pressure ulcer on the coccyx . Record review of the Progress Note for Resident 9 dated 12/13/21 revealed that Resident 9 was seen at the wound clinic (The medical provider had ordered that Resident 9 have a [TRUNCATED]

Licensure Reference Number: 175 NAC 12-006.09D7b (3) Based on record reviews and interview, the facility failed to implement interventions to prevent recurrent falls which required hospitalization for treatment for a head injury for one current sampled resident (Resident 2). The facility census was 87 with three current sampled residents with falls. Findings are: Review of the Admission Record revealed that Resident 2 was admitted to the facility on [DATE] with diagnoses including History of Fractured Skull and Traumatic Brain Hemorrhage with Loss of Consciousness, [CONDITION(S)] Disorder, History of Falls and Anxiety. Review of the Care Plan, goal date 5/5/20 and printed 2/27/20, revealed that the resident was at risk for falls related to history of falls, poor safety awareness, head injuries and medications. Further review revealed that the resident had recurrent falls including the following: - 1/22/20 fell near the nurses station and had no injuries; - 1/27/20 at 6:30 AM fell in room near the bed and had no injuries; - 1/27/20 at 12:00 PM fell in room behind the door and had no injuries; - 1/27/20 at 5:14 PM witnessed fall with no injuries; - 1/29/20 at 2:15 PM fell in room with no injuries; - 1/30/20 fell in the dining room, sustained a small bump on the head; - 2/5/20 witnessed fall, walking with two staff and a walker. Review of the Progress Notes, dated 2/5/20 at 12:00 PM, revealed that the resident was attempting to get out of the wheelchair in the hallway. The staff placed a gait belt (belt placed around the resident's waist and used to hold on to the resident for transfers or ambulation) on the resident and ambulated with the resident in the hallway. Another resident was in front of the resident and the resident turned quickly and fell . The resident complained of pain at the back of the head and at the left hip. The resident was transferred to the hospital for evaluation and treatment. Further review revealed that the resident returned to the facility on [DATE] after hospitalization and treatment for a brain bleed. Interview with the Director of Nursing on 2/27/20 at 3:45 PM confirmed that the resident was considered a high risk for falls and interventions were not implemented by the facility to prevent recurrent falls and a head injury.

Licensure Reference Number: 175 NAC 12-006.05(9) Based on record reviews and interview, the facility failed to ensure that 1) incidents of visitor to resident abuse idintified and reported to the Administrator immediately and interventions were in place to protect the resident from further abuse for one closed record sampled resident (Resident 10) and 2) interventions were in place to prevent recurrent episodes of resident to resident abuse for one current sampled resident (Resident 5) which involved two current sampled residents (Residents 4 and 11). The facility census was 82 with nine current sampled residents and six closed records reviewed. Findings are: A. Review of Resident 10's Progress Notes revealed the following including: - 12/15/19 at 4:49 PM The resident's significant other was in the room, staff heard the significant other tell the resident to just shut [gender] mouth and listen to [gender] or [gender] was not getting anymore chocolate milk. The nurse entered the room and told the significant other that it was not ok to talk to the resident like that. Further review revealed no evidence that the staff immediately notified the Administrator of the incident so that interventions could be put in place to protect the resident from further abuse. - 12/22/19 at 3:36 PM The nurse heard the resident holler very loudly from the nurses station and went to the resident's room to intervene. The resident's significant other was in the room. The nurse told the significant other that the resident yelled much more often when the significant other was present. - 12/27/19 at 5:15 PM The nurse noted that the resident's significant other was in the room, talking softly but in a discreetly aggressive manner. The only thing that the nurse could make out was that the significant other told the resident I'm done with you and the significant other left the facility. The resident stated [gender] don't like me no more and I'm scared and started crying. The significant other returned to the facility and the nurses intervened when the significant other started raising voice to the resident. The nurses told the significant other to leave if [gender] was going to continue to call the resident names, get angry, and upset the resident any more then had already done. The ADON (Assistant Director of Nursing) was notified. Further review revealed no documentation that the Administrator was immediately notified of the incidents or that interventions were in place to protect the resident from further abuse. Review of the Care Plan, printed 1/27/20, revealed that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed no care plan to address protection of the resident from verbal abuse from the significant other. Review of the facility Abuse, Neglect or Misappropriation report, dated 12/20/19 revealed that the Administrator/Director of Nursing was notified of the incident on 12/15/19 on 12/16/19 at 9:00 PM. The facility investigation concluded that no physical, verbal or any other type of abuse occurred. Further review revealed no investigation report for the incidents on 12/27/19. Interview with the Social Services Director on 1/28/20 at 1:35 PM revealed was not aware of the incidents described above with the resident's significant other. Further interview confirmed that the resident was discharged home with the significant other on 1/16/20. Interview with the Administrator on 1/28/20 at 2:30 PM confirmed was not immediately notified of the incident which occurred on 12/15/19 and was not notified of the incident on 12/27/19. Further interview confirmed that the staff did not follow the facility abuse policy and procedure to ensure that potential abuse was identified, reported and interventions were in place to prevent verbal abuse towards the resident. B. Review of Resident 5's Care Plan, printed 1/27/20, revealed that the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that the resident exhibited behaviors including urinating in inappropriate places, grabbing staff members, yelling at others and resident to resident altercations. The resident was not easily redirected, was easily agitated and wandered around the unit and into other residents rooms at times. Review of the facility Resident to Resident report, dated 12/4/19, revealed that on 11/26/19, staff observed the resident grab Resident 4's right arm. Staff separated the residents and there were no observed injuries for either resident. Review of the facility Resident to Resident report, dated 1/17/20, revealed that on 1/13/20 staff observed the resident and Resident 11 struggling outside the nurses station door. Resident 11 was holding on to the handrail and the resident was trying to get Resident 11's hands off of the handrail. The residents fell down before staff could reach them. Resident 11 bumped head on the grate on the wall during the fall and landed on the right side. Staff helped the residents get up and were separated. The resident had no apparent injuries. Resident 11 had a hematoma (swelling) to the outer corner of the left eye which measured 0.6 x 0.4 cm. [centimeters] and a dark purple bruise to the top of the left hand which measured 1.5 x 1.1 cm. C. Review of Resident 11's Progress Notes revealed the following including: - 1/14/20 at 8:07 AM Resident is still upset with Resident 5, was attacked and was scared because the resident was really strong. Staff reassured the resident that they would keep them apart. - 1/16/20 at 5:49 AM Bruises to the eye and arm remain and the resident was kept away from Resident 5. - 1/16/20 at 9:20 AM Resident is still upset, staff is working hard to keep the resident feeling safe. - 1/16/20 at 11:45 AM Social Services spoke with the resident's Power of Attorney regarding moving the resident to a different unit and the family agreed. Interview with the Director of Nursing on 1/28/20 at 3:45 PM confirmed that interventions were not in place to prevent Resident 5 from recurrent resident to resident altercations. Review of the facility Abuse, Neglect and Exploitation policy, dated November 2017, revealed the following including: Policy: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Policy Explanation and Compliance Guidelines: 1. Report allegations or suspected abuse, neglect or exploitation immediately to: - Administrator - Other Officials in accordance with State Law - State Survey and Certification agency through established procedures . 8. Resident Protection after Alleged Abuse, Neglect and Exploitation - The facility will make efforts to protect all residents after alleged abuse, neglect and/or exploitation.

Licensure Reference Number: 175 NAC 12-006.09D7 Based on observations, record reviews and interviews, the facility failed to ensure that 1) a safe transfer was provided for one current sampled resident (Resident 2) to prevent a fall with a scalp laceration and a skin tear to the arm, 2) one current sampled resident (Resident 1) was transferred with two staff assistance in a full mechanical lift as directed to ensure safe and comfortable transfers and 3) provide specific instructions for one current sampled resident (Resident 14) to ensure safe and consistent transfers. The facility census was 85 with 10 current sampled residents. Findings are: [NAME] Review of Resident 2's Care Plan, goal date 10/30/19, revealed that the resident was at risk for falls related to history of falls and had a physical functioning deficit related to mobility impairment, limitations in range of motion, history of a left knee fracture, and self care impairment. Interventions included 4/22/19 transfer assist of two with a sit to stand mechanical lift. Review of the facility report Fall During Staff, revealed that on 10/17/19 at 8:08 PM, the resident was in a sit to stand mechanical lift to transfer from the chair to the bed. The resident stated was feeling like (gender) was going to faint. As the nursing assistant lowered the bed the resident stated I'm going down. The resident fell through the sling and hit head on the bed. The resident had bleeding from a scalp laceration and a skin tear on the right forearm. Further review revealed that the skin tear at the right forearm measured 10 x 7 and the laceration to the back of the head measured 0.4 x 1.0. The resident also had multiple bruising on the upper extremities, abdomen, right arm and hand, and bilateral rib cages. Review of the Progress Notes, dated 10/17/19 at 8:14 PM, revealed that the resident was sent to the emergency room for evaluation of the injuries. Interview with NA (Nursing Assistant), who requested to remain anonymous, on 10/30/19 at 8:45 AM revealed that the resident had been transferred with a full body lift for a couple of days before the fall as the resident was too weak to stand safely in the sit to stand lift. Interview with LPN (Licensed Practical Nurse), who requested to remain anonymous, on 10/30/19 at 8:45 AM revealed that, before the fall, the resident was to be transferred with the full mechanical lift due to increased weakness and inability to stand in the sit to stand lift. The change in care was not passed on to the next shifts to ensure safe transfers for the resident. Interview with the DON (Director of Nursing) on 10/30/19 at 10:40 AM confirmed that the staff needed to communicate changes in resident care needs to the next shifts and update the care plan interventions when needed to ensure safe and consistent care. B. Review of Resident 1's Care Plan, goal date 12/30/19, revealed that the resident was at risk for falls related extensive assist with bed mobility, transfers using two assist and a full mechanical lift, history of falls and fracture and medication usage. Interventions included that staff will utilize two staff with transfers and the resident required a full mechanical lift for transfers. Interview with the resident on 10/29/19 at 1:30 PM revealed had been transferred in the lift with just one staff member and they are supposed to have two staff members transfer with the lift. Interview with the DON on 10/30/19 at 10:20 AM confirmed that the staff were to always use two staff to transfer residents in the mechanical lifts to reduce the risk for falls and injuries. C. Review of Resident 14's Care Plan, goal date 11/26/19, revealed that the resident required assistance with activities of daily living. Interventions included one assist transfers using a gait belt (belt placed around the resident's waist for staff to hold and guide the resident) and may require hoyer lift (full mechanical lift) at times. Observations on 10/29/19 at 11:50 AM revealed MA (Medication Aide) - D and MA - [NAME] transferred the resident from the wheelchair to the bed with the full mechanical lift. Interview with MA - D on 10/29/19 at 11:50 AM revealed that the resident had needed the full lift for transfers for a long time as the resident was not able to stand. Interview with the DON on 10/30/19 at 10:20 AM confirmed that the staff needed specific instructions for safe and consistent transfers.

Licensure Reference Number: 175 NAC 12-006.09D7a Based on observations, record reviews and interviews; the facility failed to ensure that 1) safety measures were in place to prevent one sampled resident (Resident 44) from falling during bathing. The failure resulted in the resident sustaining a fracture; 2) care plan interventions were in place to reduce the risk for recurrent falls for one current sampled resident (Resident 41); and 3) a loose grab bar was secured to the bed frame to reduce the risk for injuries for one current sampled resident (Resident 42). The facility census was 85 with 24 current sampled residents. Findings are: A. Interview with Resident 44 on 5/22/19 at 1:45 p.m. revealed the resident describing having sustained a fall and fracture requiring surgery and hospitalization about a month after being admitted . The resident described the incident by stating the fall occurred in the tub room after the bath was completed. The resident stated being in a bath chair and that Usually the staff strapped the resident in the chair and had a second person present during transfers. On this occasion, the staff did not apply the strap or have a second person present. The resident described tumbling out of the chair and fracturing a leg resulting in the need for surgery after being diagnosed with [REDACTED]. Record review of Resident 44's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessments revealed an Admission assessment was completed on 2/20/19. The assessment recorded the following items regarding the resident's condition: - The assessment recorded the resident was admitted from another nursing home on 2/14/19. - The assessment recorded a resident BIMS (Brief Interview for Mental Status) test score was 15 (cognitively intact memory). - The assessment recorded the resident's ability to transfer between surfaces (to and from bed, chair, wheelchair) required the assistance of Two (or more) and that the resident required Total dependence- full staff performance to complete transfer tasks. -The assessment recorded the resident required Two (or more) persons and Physical assist support for Bathing. - The assessment recorded the resident's weight at the time of the assessment was 355 pounds. - Under the fall history portion of the assessment the facility recorded the resident had a history of [REDACTED]. Record review of Resident 44's electronic Progress Notes revealed the following entry: - 3/6/19 at 5:50 p.m. the note recorded a Situation while the resident was transferring during bath and fell to floor. The note recorded the resident was being transferred during a bath and was in bath chair. Is a bariatric (obese) patient. The note recorded the resident was assessed and assisted to a comfortable position and that the resident complained of Left hip pain. The medical provider was called and an order received to transfer the resident to the emergency room for evaluation. Record review of a hospital History and Physical Reports form dated 3/6/19 revealed the resident's CC (chief complaint) at the time of admission was I fell getting out of the bathroom. The physical recorded the resident was sent from the facility today after falling getting out of the bathroom, landed on left side, and ER (emergency room found to have left displaced femur fracture. The physical assessment diagnosed : Left femur fracture. Record review of a facility undated New ownership investigation of Resident 44's fall on 3/6/19 revealed a nurse was called to the 100 wing tub room and observed resident on floor between tub and north wall. The resident was sitting up with head against the tub, left leg straight out and right leg was bent. The resident expressed pain to the left leg. An ambulance was called and the resident transferred to the emergency room . The BA (Bath Aide)-W was interviewed during the investigation and re-enacted the incident. The investigation recorded the resident bath was completed and BA-W took off the resident's strap to clean under the abdominal folds and then elevated the tub chair to get the resident's feet out of the tub and pulled the chair out of the whirlpool When getting the resident out of the tub chair to put the belt back on the resident leaned forward and fell out of the tub chair. The investigation report indicated the resident was interviewed and stated remembering the bath aide having to jerk the tub chair and I flew out of the chair. Interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 5/28/19 at 10:39 a.m. verified Resident 44 sustained a fall and fracture during the bathing process on 3/6/19. The DON and ADON verified there was only one staff member assisting the resident during the bath and the transfer out of the tub. The causal factor for the fall was verified as the removal of the seat belt strap by BA-W while assisting the resident out of the tub. The failure to apply the strap resulted in the resident falling forward and sustaining the injury. The DON and ADON stated that safety straps should not be removed during the bathing procedures. B. Review of Resident 41's Care Plan, goal date 6/3/19, revealed that the resident was at risk for falls due to history of falls and the resident was found on the floor by the bed on 4/16/19. Further review revealed interventions including staff will ensure that the resident's bed was left in the low position while the resident was in bed and the call light was within reach at all times when in the room. Observations on 5/22/19 at 5:00 AM revealed Resident 41 resting in bed with eyes closed. Further observations revealed that the bed was positioned approximately waist high and the call light was fastened to the connection on the wall and not within the resident's reach. Interview on 5/22/19 at 5:10 AM with LPN (Licensed Practical Nurse) - G, Charge Nurse, confirmed that the resident's bed was to be left in the low position and that the resident was to have the call light within reach to reduce the risk for falls. Interview with the DON (Director of Nursing) on 5/23/19 at 8:15 AM confirmed that the staff were to follow the care plan interventions to reduce the risk for falls. C. Review of Resident 42's Care Plan, goal date 6/18/19, revealed that the resident required staff assistance with bed mobility and that the resident utilized assist rails on the bed for repositioning. Observations on 5/20/19 at 9:10 AM revealed the assist rail on the open side of the bed was loose and presented a three to four inch gap between the assist rail and the airflow mattress. Interview with the DON on 5/21/19 at 3:50 PM confirmed that the assist rail needed to be tightened to the bed frame to reduce the risk for injuries.

Licensure Reference Number: 175 NAC ,[DATE].07 Based on observations, record reviews, and interviews, the facility Quality Assurance Program failed to identify, correct, and maintain regulatory required compliance resulting in multiple citations and repeat areas of non-compliance from prior surveys. Facility census was 89. Sample size included 24 current residents and three closed records. Findings are: Record review of the facility QAPI (Quality Assurance Program) plan developed on [DATE] revealed the purpose of the committee was to educate, support and encourage staff to increase their skills to provide quality care to all residents. To provide residents with a comfortable environment where they are involved in, and have a voice in, the daily activities of their home. The committee's plan is to review all data sources and other available data to identify, prioritize, and correct issues with performance. The QAPI committee will evaluate the effectiveness of actions taken for further recommendation. Observations, record reviews, and interviews during the survey processes from surveys conducted on [DATE] and the current survey from [DATE] through [DATE] revealed the following areas of repeated non-compliance: F578- ensuring facility staff had valid CPR (Cardiopulmonary Resuscitation) certifications. F583- providing privacy with resident personal cares. F622- documentation regarding discharges from the facility. F684- providing assessments and care for residents with skin abnormalities. F689- ensuring staff were performing safe transfer techniques preventing accidents with injury. F726- competency of staff. F732- posting staffing information daily. F757- ensuring medications were being monitored to rule out unnecessary medications. F880- infection control The current survey also identified patterns in five additional areas of non-compliance: F576- mail delivery on Saturdays. F584- environmental issues. F623- notice provision in writing for facility-initiated transfers and discharge. F625- written notice of bedhold policies when residents are transferred to the hospital. F725- provision of staffing to meet the needs of the residents. Failures at the following tasks resulted in negative outcomes: F626- facility denial of re-admission to Resident 89 following hospitalization . The failure resulted in a prolonged stay in an acute setting after the resident's condition was stabilized. F684- facility failed to assess and monitor Resident 41's bruising condition resulting in hospitalization for an adverse effect of medication. F686- facility failed to provide care and treatment to prevent the development and/or healing of pressure sores for Residents 42 and 48 F689- facility failed to ensure safety measures in place during bathing resulting in hospitalization and surgery for [REDACTED]. Interview with the Administrator on [DATE] at 10:39 a.m. discussed and confirmed the repeated areas of deficiency and current survey findings.

Licensure Reference Numbers 175 NAC 12- D2 175 NAC 12-006.09D2b Based on observations, record reviews and interviews; the facility failed to provide care to prevent pressure ulcers and to promote healing, including repositioning at least every two hours, pressure relieving seat cushions, dressing changes as ordered, aseptic technique for dressing changes and follow up with ongoing resident non compliance with interventions for two current sampled residents (Residents 42 and 48). The facility census was 85 with 24 current sampled residents. Findings are: A. Review of the Admission Record, printed 5/21/19, revealed that Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/18/19, revealed that the resident required assistance with activities of daily living including repositioning in bed, transfers and personal hygiene and cares. Further review revealed that the resident was at risk for pressure ulcers due to assistance required with bed mobility, diabetes, history of pressure ulcers and placed a pillow in the wheelchair. On 9/12/18, the resident had a pressure area to the coccyx and right buttock, on 1/17/19 the area to the coccyx was closed, on 2/22/19 the area was opened, and 5/17/19 the area was stable with 100% granulation tissue. Interventions included treatments as ordered, weekly skin assessments, pressure reducing wheelchair cushion and air mattress, the resident frequently sits on a pillow on top of the pressure reducing wheelchair cushion and staff will continue to educate the resident on the importance of not using a pillow on top of the pressure reducing device and to comply with treatment. Review of the Wound Evaluation Flow Sheet Multiple Weeks - V 4, dated 4/28/19, revealed the following including: - 2/22/19 Stage 4 pressure ulcer ( full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling) at the coccyx which measured 0.5 cm. (centimeters) wide, 1 cm. long and 0.5 cm. depth; - pressure ulcer acquired in the facility; - tunneling/undermining at 0.5 cm.; - moderate amount of drainage present; - peri wound with macerated (moist)/soft skin; - treatment order 3/28/19 honey fiber and foam dressing and skin prep peri- wound; - current preventative interventions are pressure redistribution mattress and wheelchair cushion; - current wound status/additional comments included maceration peri-wound (around the wound) is worse, resident is non-compliant with utilizing pressure reducing wheelchair cushion appropriately and puts a pillow on top of the cushion, education provided on the risks associated with non-compliance. Further review revealed the Wound Evaluation Week 3 on 5/17/19 including: - wound measured 0.7 cm. long, 1 cm. wide (larger) and 0.5 cm. depth; - no drainage; - 100% granulation tissue; - 4/18/19 treatment order of honey fiber and foam dressing, change daily; - education provided on putting pillow on top of the pressure reducing wheelchair cushion; - maceration around the wound is resolved at this time. Observations on 5/20/19 at 9:44 AM revealed the resident seated in the wheelchair with a pillow placed on the top of the wheelchair cushion and the Microair mattress set at 8 which is for 315 pounds. Further observations at 2:50 PM revealed the resident resting on the bed, air mattress set at 8 and a pillow placed at the resident's lower back. LPN (Licensed Practical Nurse) - L, Charge Nurse, applied disposable gloves, assisted the resident to turn onto side, removed the dressing at the coccyx area, noted brown and red colored drainage on the dressing, noted open area approximately 2 cm. and 1 cm. in depth and surrounding skin reddened and macerated. LPN - L, wearing the same disposable gloves, cleansed the ulcer with saline, wiped the area with gauze, applied skin prep to the surrounding skin, changed gloves with no hand washing, applied the honey fiber dressing to the inside of the wound, resident stated that hurts and the cover foam dressing was applied. Review of the MAR (Medication Administration Record) for (MONTH) 2019 revealed an order, dated 3/21/19, for LiquaCal two times a day for wound healing. Further review revealed no documentation that the medication was administered on 5/2/19 at 5:00 PM or on 5/8/19 at 9:00 AM and 5:00 PM. Review of the TAR (Treatment Administration Record) for (MONTH) 2019 revealed an order to cleanse the wounds to the coccyx, pat dry, apply honey fiber to the wound bed, cover with foam dressing, change daily until resolved, apply skin prep around the wound to macerated skin, for Stage 4 pressure area. Further review revealed that the resident refused the treatment on 5/2/19 and no documentation that it was done on 5/7/19 and 5/10/19. Interview with the DON (Director of Nursing) on 5/21/19 at 3:50 PM confirmed that the air mattress was not set at a therapeutic level for the resident. The DON set the air mattress at 5 based on the resident's weight of approximately 200 pounds. Interview with the DON on 5/23/19 at 9:20 AM confirmed that the resident continued to sit in the wheelchair with a pillow over the pressure reducing cushion which decreased the therapeutic benefits of the cushion. Further interview confirmed that the resident should not place a pillow over the air mattress as that also reduced the effectiveness of the pressure relieving mattress. The DON confirmed that wound care needed to be done as ordered and the protein supplement needed to be administered as ordered to promote healing of the pressure ulcer. Further interview confirmed that dressing changes, including the proper use of disposable gloves and hand washing, should be done to promote healing of the pressure ulcer. The DON confirmed that the disposable gloves were to be removed after the soiled dressing was removed and hand washing done before new gloves were donned to treat and apply the clean dressing to reduce the risk of cross contamination. B. Review of Resident 48's Care Plan, goal date 7/2/19, revealed that the resident required assistance of two staff for bed mobility and transfers, had impaired cognition due to confusion and [DIAGNOSES REDACTED]. Interventions included weekly skin inspection, pressure reducing wheelchair cushion and mattress, reposition side to side during the night, educate the resident on the importance of off loading pressure and repositioning side to side to reduce the risk for pressure and to improve current skin issues, respect the resident's right to refuse, encourage the resident to lay down and reposition to sides between meal times and treatments as ordered. Review of the Weekly Skin Review - V 3, dated 5/16/19, revealed that the resident had an open area at the left buttock which measured 0.5 cm. by 0.5 cm. and an open area (not measured) at the right gluteal fold. Observations on 5/20/19 at 9:15 AM, 10:00 AM, 11:00 AM, 12:15 PM and 1:30 PM revealed the resident seated in the wheelchair with a pillow over the wheelchair seat cushion and the canvas mechanical lift transfer sling. Further observations at 1:30 PM revealed MA (Medication Aide - C and MA - D transferred the resident to the bed with a full mechanical lift. MA - C and MA - D removed the resident's soiled disposable brief and provided skin care. Dressings were noted on the resident's right and left inner buttocks areas. The resident was positioned on back after cares were completed and remained positioned on back at 2:30 PM. Interview with MA - D on 5/20/19 at 1:45 PM revealed that the resident usually sat in the wheelchair all morning, usually got up around 5:00 AM, and would sometimes agree to lay down in bed for awhile in the afternoon. so that the disposable brief could be changed. Further interview revealed that the resident could not reposition self in the wheelchair. Observations on 5/21/19 at 7:00 AM, 11:45 AM and 1:20 PM revealed the resident seated in the wheelchair with a pillow and mechanical lift sling over the wheelchair cushion. Observations on 5/22/19 at 5:00 AM, 7:50 AM, 9:00 AM, 12:00 PM, 1:30 PM and 3:10 PM revealed the resident seated in the wheelchair with a pillow and mechanical lift sling over the wheelchair cushion. Further observations at 3:10 PM revealed MA - N and MA - S transferred the resident from the wheelchair to the bed with the full mechanical lift for skin care. MA - N and MA - S removed the soiled disposable brief, noted smeary bowel movement and urinary incontinence and provided skin care. The resident's anal, coccyx and scrotum were noted to be excoriated with some open areas. Interviews with MA - N and MA - S on 5/22/19 at 3:10 PM confirmed that the resident had been in the wheelchair all day until now and was not able to reposition self in the wheelchair due to bilateral [MEDICAL CONDITION]. Further interview revealed that the resident often refused to lay down during the day to check and change the disposable brief, wanted the pillow and the lift sling kept in the wheelchair and didn't want to be repositioned in the wheelchair. Observations on 5/22/19 at 3:15 PM revealed RN (Registered Nurse) - M, applied disposable gloves, removed the dressing at the left inner buttock area and with the same gloves, cleaned the open area (which measured approximately 4 cm. x 1.5 cm.) with saline, applied skin prep around the wound and a collogen dressing and a cover dressing. RN - M removed gloves and applied new gloves without hand washing in between, repositioned the resident to the other side, removed the dressing at the right inner buttock, noted brown colored drainage on the dressing, cleaned the open area with saline (area measured approximately 4cm. x 1.5 cm.), applied skin prep to the surrounding skin and applied a collogen and cover dressings. RN - M applied [MEDICATION NAME] to open and excoriated areas at the anal, coccyx area and scrotum and assisted MA - N to apply a disposable brief. RN - N removed the disposable gloves and gathered trash and supplies. Further observations revealed that the resident requested to get up into the wheelchair and MA - N and MA - S transferred the resident back into the wheelchair with a pillow and the mechanical lift sling on top of the wheelchair seat cushion. Review of the Treatment Administration Record, dated (MONTH) 2019, revealed an order dated 5/10/19 for Collagen and foam to left buttock three times a day until healed. Further review revealed no documentation that the treatment was done at 10:00 PM on 5/13/19, 6:00 AM on 5/14/19 and at 2:00 PM on 5/17/19. Further review revealed a treatment order, dated 5/18/19, for the right ischeal tuberosity daily until resolved. There was no documentation that the treatment was done on 5/19/19 at 8:00 PM as scheduled. Interview with the DON on 5/23/19 at 10:10 AM confirmed that the the pressure ulcers were facility acquired and interventions were not in place to promote healing, including repositioning at least every two hours and off loading at least every two hours while in the wheelchair. The DON confirmed that sitting in the wheelchair with a pillow and mechanical lift sling over the wheelchair pressure reducing cushion reduced the effectiveness of the seat cushion. Further interview confirmed that the treatments were to be done as ordered to promote healing as scheduled and skin assessments completed weekly to include all open areas to ensure healing without complications. The DON confirmed that disposable gloves were to be removed after soiled dressings were removed and hand washing done before clean gloves were donned to reduce the risk of cross contamination. Further interview revealed that the residents continued with non compliance with interventions to prevent and promote healing of pressure ulcers and further assessments needed to completed to determine the reasons and possible interventions to obtain compliance. Review of the facility policy Prevention and Management of Wounds, dated 5/21/19, revealed the Policy Statement An interdisciplinary approach to pressure ulcer treatment encourages nurses and therapists to work closely together to assess risk and intervene with preventative measures such as pressure relieving devices and proper positioning. The Wound Care Coordinator and/or licensed nurse shall be designated as being responsible for prevention and treatment of [REDACTED].

Licensure Reference Number 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) abnormal bleeding was assessed and follow up was completed to ensure care was provided promptly for one current sampled resident (Resident 41) on blood thinning medication, 2) low blood sugar readings were assessed and follow up care provided to ensure needs were met for one current sampled resident (Resident 42, 3) [MEDICAL CONDITION] were assessed and follow up completed to ensure healing without complications for one current sampled resident (Resident 48) and 4) a PICC (Peripherally Inserted Central Venous Catheter) line was monitored every shift and a heart monitor present on re-admission was monitored as indicated for one current sampled resident (Resident 73). The facility census was 85 with 24 current sampled residents. Findings are: A. Review of the Admission Record, printed 5/21/19, revealed that Resident 41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 6/3/19, revealed that the resident was at risk for bruising and bleeding related to the use of blood thinning medication. Interventions included that the staff were to inspect the resident's skin for bruising or unusual bleeding daily during care and report to the charge nurse and provider for further interventions. Further review revealed that the resident had both short term and long term cognitive deficits and had difficulty making self understood and understanding others. Review of the Progress Notes revealed the following including: - 2/25/19 at 4:30 AM This nurse noted a large bruise to the left side of the hip, bruise area was hardened, the resident grimaced when the area was touched, no reports of injury from the previous nurse, resident was unable to state the source of the injury due to cognitive impairment, will pass report to coming nurse to notify the primary care physician for evaluation; - 2/25/19 at 1:29 PM Nursing Late Entry Note: Was told in morning report that the resident had a bruise. Later in the day, during the skin assessment in the bath house, the bruise was assessed and appeared dark purple and spanned approximately 29 cm. (centimeters) across and 9 cm. wide. The resident was assessed by a Nurse Practitioner and orders were received to send the resident to the Emergency Department; - 2/25/19 at 9:23 PM Update from the hospital showed that the the resident's INR (International Normalized Ratio), a blood laboratory test for bleeding time, showed a critically high level at 6.16 ( a range of 2.0 - 3.0 generally considered a therapeutic range for people taking blood thinning medication such as [MEDICATION NAME]). Further review revealed that the resident was to be admitted to the Intensive Care Unit at least overnight. Interview with the DON (Director of Nursing) on 5/23/19 at 8:15 AM confirmed that the night shift nurse should have identified the resident's high risk for abnormal bleeding due to the use of blood thinning medication and completed a skin assessment including the size and characteristics of the bruising. Further interview confirmed that the nurse should have notified the provider right away to determine the need for further evaluation and treatment. The DON confirmed that the day shift nurse should also have identified the resident's high risk for abnormal bleeding, should have assessed and documented the bruise and followed up with the resident's provider for further evaluation and treatment to ensure that the resident's needs were met. B. Interview with Resident 42 on 5/20/19 at 9:40 AM revealed had a low blood sugar this morning and had to drink orange juice. Further interview revealed no follow up blood sugar was done. Review of the Care Plan, goal date 6/18/19, revealed that the resident had a [DIAGNOSES REDACTED]. Interventions included that the nursing staff would observe the resident for low blood sugar symptoms including flushed face, sweating, change in usual mental status, lethargy, irritability, fruity breath odor, nervousness, trembling and light headedness. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident's blood sugar was 64 on 5/16/19 at 6:59 AM and at 11:30 AM and the blood sugar on 5/1/19 at 7:30 AM was 61. Review of the Progress Notes, dated 5/20/19 and and 5/1/19 revealed no assessment of the resident, including symptoms of hypogylcemia (low blood sugar), treatment provided or a follow up assessment of symptoms or blood sugar obtained. Further review revealed that on 5/16/19 at 6:59 AM, the resident was given glucose for low sugar with no assessment of the resident's symptoms or follow up blood sugar. Interview with the DON on 5/23/19 at 9:20 AM confirmed that the blood sugar levels listed above were abnormally low for the resident. Further interview confirmed that the nurses were to assess and document the resident's symptoms of low blood sugar, interventions provided and the resident's response to the interventions, including a follow up blood sugar in about an hour, to ensure that the resident was stable and needs were met. C. Observations of Resident 48 on 5/20/19 at 3:50 PM revealed dried [MEDICAL CONDITION] and redness on face and arms and a bandage on the right outer neck area. Further observations at 1:30 PM revealed MA (Medication Aide) - C and MA - D provided skin care and applied [MEDICATION NAME] to excoriated areas on the coccyx and gluteal folds. Review of the Care Plan, goal date 7/2/19, revealed that the resident had altered skin integrity related to incontinent [MEDICAL CONDITION] and excoriation. Interventions included weekly skin inspection, thorough skin care and apply barrier cream after incontinent episodes. Review of the Weekly Skin Review, dated 5/16/19, revealed no assessment of the multiple [MEDICAL CONDITION], area covered with a bandage on the neck or the excoriation on the coccyx and gluteal folds. Interview with the DON on 5/23/19 at 10:10 AM confirmed that there was no documentation on weekly summaries or progress notes of the resident's current skin injuries including the [MEDICAL CONDITION] on the face and arms, area on the neck or excoriation. Further interview confirmed that these areas needed to be routinely assessed and documented to ensure healing without complications. D. Record review of Resident 73's MDS (Minimum Data Set, a federally mandated assessment tool utilized to develop resident care plans and tracking for admissions and discharges) records revealed the resident was initially admitted to the facility on [DATE]. The tracking MDS records indicated the resident was admitted to an acute care hospital on [DATE] and re-admitted to the facility on [DATE]. A Significant change in status MDS was completed on 4/29/19. The assessment revealed the was receiving IV (intravenous) therapy both during the hospital stay and during the reference period of the MDS (4/23/-4/29/19). Interview on 5/20/19 at 10:30 a.m. with MA (Medication Aide)-E revealed the unit where Resident 73 now resided was a unit designed for residents with minimal care needs. MA-E stated there was no charge nurse routinely staffed on the unit. Observation of Resident 73's PICC line dressing change on 5/20/19 at 2:40 p.m. revealed RN (Registered Nurse)-F and the facility DON assisting the resident during the dressing change. RN-F and the DON discovered the resident's surrounding area to the PICC line was bright red measuring 7 x 12 cm with some blistering areas alongside the insertion site. Both RN-F and the DON stated this was not present at the last changes. Also, during the observation, a heart monitor was observed in place. Interview with the DON following the observation 5/20/19 at 3:00 p.m. revealed Resident 73's PICC line was scheduled for weekly dressing changes and as needed. The DON also verified there was no licensed nurse assigned as a charge nurse on the 300 unit, but that licensed nurses from other halls come over and do the dressing changes when scheduled and LPN (Licensed Practical Nurse)-I (A restorative nurse) is on the unit some days. The DON was unaware of any orders or monitoring that should be done regarding the resident's heart monitor. Interview with LPN-I on 5/20/19 at 3:30 p.m. revealed LPN-I is not involved in the PICC line care and treatment for [REDACTED]. Interviews and observations of the night shift staff on 5/22/19 between 4:45 a.m. and 5:30 a.m. revealed MA-X was assigned to the unit where Resident 73 resided. MA-X described being the only staff member on the unit during from 6 p.m. to 6 a.m. and if needing a licensed nurse, the Alzheimer's unit charge nurse would come down to the unit. RN-T described working on the locked Alzheimer's units from 6 p.m. to 6 a.m. and confirmed there was no licensed charge nurse on the 300 unit where Resident 73 resided. RN-T described assisting with PICC line dressing changes for Resident 73 on the days scheduled for change, but does not make routine rounds or check the dressing on other days. Record review of Resident 73's current physician orders [REDACTED]. An order dated 4/22/19 for Change central Line dressing weekly and PRN (as needed) as needed for dislodgement or soiled. There were no instructions or orders related to the resident's heart monitor. Record review of Resident 73's Treatment Administration Record for (MONTH) 2019 revealed the facility was documenting weekly central line dressing changes every Monday. There was no documentation the line was changed on 5/13/19. There was no documentation on the resident's treatment records for (MONTH) 2019 that licensed nurses were monitoring the PICC line site other than on dressing change days. Record review of Resident 73's electronic progress notes revealed no documentation by licensed nurses that the PICC line site and heart monitor sites were being monitored except on days when the PICC line dressing was changed. Interviews with the DON and ADON (Assistant Director of Nursing) on 5/28/19 at 10:30 a.m. verified there was no supportive documentation that Resident 73's PICC line dressing was being monitored on every shift and there was no documentation or orders pertaining to the resident's heart monitor placed during the hospitalization in April. Source: University of Michigan Serious risks from common IV (intravenous) devices (MONTH) (YEAR). These (PICC lines) are not innocuous devices. The time has come to stop thinking of them as a device of convenience, and rather one with clear risks and benefits. Many studies and patient safety efforts have worked to reduce another clear risk associated with PICCs: infections often called CLABSIs, for central line associated bloodstream infections. But the risks of [MEDICAL CONDITION]'s ([MEDICAL CONDITION] clotting_ and the potentially lethal risk of a [MEDICAL CONDITION] embolism if the PICC clot breaks away, haven't gotten the kind of attention that a common device would warrant.

Licensure Reference Number: 175 NAC 12-006.05 (5b) Based on record reviews and interviews, the facility failed to allow one sampled resident (Resident 89) to return to the facility following hospitalization to stabilize the resident's condition. The failure resulted in an extended hospital stay for the resident who no longer required hospital level of care. Facility census was 85. Sample size included 7 residents discharged from the facility to an acute care hospital setting. Findings are: Record review of an Admission Record for Resident 89 printed on 5/8/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of a Discharge- return anticipated MDS (Minimum Data Set, a federally mandated assessment and tracking tool) completed on 1/29/19 revealed Resident 89 had been discharged to an Acute hospital on [DATE] and the facility expected the resident to return when stabilized. Record review of Resident 89's electronic Progress Notes revealed on 1/29/19 the resident's physician was notified at 10:11 a.m. regarding the resident's aggression and anxiety and informed the the resident was either going to be put under an EPC (Emergency Protective Custody) or admitted to an available behavioral facility. At 1:39 p.m. the facility phoned the local police department, resident's physician, and resident's psychiatrist to inform them the resident was being sent EPC from the facility. At 1:53 p.m. the resident was escorted off the unit by the police department. At 1:56 p.m. an attempt was made to notify the resident's Sibling-A. At 2:51 p.m. the facility received a call from the resident's psychiatrist who stated will let the psychiatrist know the resident was being EPC'd from the facility. An entry on 2/1/19 at 2:17 recorded by the facility SSD (Social Services Director) recorded an emergency contact, Sibling-B, was called and a message left that the resident was being admitted to a behavioral unit. There were no other progress notes regarding the resident after the admission to the behavioral health unit. Record review of Resident 89's closed record documents revealed: There was no discharge summary completed by the facility regarding Resident 89's discharge, nor was there any evidence the resident was notified in writing by the facility indicating the facility initiated discharge. Record review of a document dated 2/14/19 received by Certified Mail at the facility on 2/21/19 revealed a General Counsel attorney for the local hospital sent correspondence to the facility. The corresponding letter recorded Resident 89 was admitted to the hospital's Behavioral Health Unit at the request of the facility and law enforcement for short term care. The patient is now stabilized and ready for discharge back (to the facility). However when (the hospital) contacted (the facility) to make arrangements for discharge, we (the hospital) were advised by (the facility) that it would not accept the patient back from (the hospital) citing behavioral issues with the patient. The correspondence goes on stating: You (the facility) have advised on the telephone that you will not accept the patient back because of behavior issues. We hereby request copies of the medical records that document or substantiate these behavior issues . As you know, we (the hospital) are a short term Behavioral Health Unit. We are not a long-term behavioral health facility. We are not equipped to house nursing home residents on a long-term basis. Request is made for (the facility) to accept the patient back as a resident. Interviews with the hospital General Counsel attorney were conducted in person on 5/21/19 at 1:05 p.m. and by phone on 5/22/19 at 11:00 a.m. The General Counsel attorney verified that Resident 89 was admitted for acute care following an EPC request from the facility on 1/29/19. The resident's condition was stabilized and the facility informed the facility the resident was ready for re-admission. The facility denied the re-admission stating issues with the resident's behavior. The attorney stated the facility had not come to the hospital to evaluate the resident's stable condition at the time of the request. The denial of re-entry by the facility prompted the attorney's formal correspondence to the facility sent and verified as received on 2/21/19 by certified mail. The hospital never received any documentation as requested regarding the behavioral issues or medical records supporting the facility's decision not to re-admit the resident. Further interview by phone revealed the resident remained in the hospital's Behavioral Health acute care unit until 4/9/19 when the hospital found suitable placement for Resident 89 in a facility in Colorado. Record review of a facility policy entitled Transfer and Discharge from the Facility Policy, created in (MONTH) of (YEAR), included the following policy statements: - It is the policy of this facility that each resident has the right to remain in the facility and not transfer or discharge a resident. The policy identifies exceptions to this which included: . resident's needs cannot be met in the facility . - Should a resident's need (s) not be met by the services provided by the facility, the facility staff will reevaluate the resident's care plan to determine if changes to the care plan will help meet the resident's needs. If the facility cannot provide for the resident's needs, the resident may have to be transferred to another healthcare facility that can provide the services needed . - The resident and representative will receive timely notification, adequate preparation, orientation and information to make the transfer as orderly and safe as possible. The notice contain information about the transfer and information about resident's appeal rights . The resident will not be discharged during the appeal process. If the transfer is due to an emergency, the notice will be issued as soon as practicable . - The objective of the transfer/discharge policy is to ensure that the resident is informed of an impending discharge and their right to appeal the discharge . - Overview Of Regulatory Requirement Components for This Policy recorded Facility requirements The facility must permit each resident to remain in the facility and not transfer or discharge the resident unless-- (A) The transfer or discharge is necessary for the resident's welfare and the residents needs cannot be met in the facility . Record review of the facility's Facility Assessment Tool updated on 5/9/19 revealed the facility offered and was licensed for care in both an Advanced Alzheimer's unit of 22 beds and an Alzheimer's unit of 20 beds. The assessment identified Services and Care We offer Based on our Residents' Needs which included: Mental health and behavior- Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/[MEDICAL CONDITIONS], other psychiatric diagnoses, intellectual or developmental disabilities . Interview with the facility Administrator on 5/21/19 at 11:30 a.m. confirmed Resident 89 was admitted to the facility in (MONTH) of (YEAR) and resided in one of the locked Alzheimer's care units at the facility during the resident's stay. The Administrator verified the resident's behavioral episodes escalated and experienced nine episodes of aggression toward other residents in a short period of time. The facility attempted various interventions and involved both the resident's physician and psychiatrist in attempting to treat the resident. Due to failure in stabilizing the resident, the resident was EPC'd to an acute Behavioral Health facility on 1/29/19. The Administrator verified the facility determined it was not safe to allow the resident to return and the facility denied re-admission after the hospital had notified the facility the resident's condition stabilized and the resident was ready for discharge back to the facility. The Administrator verified the facility had no documentation supporting why they chose not to allow the resident to return. The resident was not given a notice of discharge or allowed an appeal to the decision. The resident's psychiatrist and medical practitioner had not been involved in the decision or provided any supportive documentation why the resident's needs could not be met by the facility. The Administrator verified that the facility does admit and care for both Alzheimer's residents and those with psychiatric [DIAGNOSES REDACTED]. The Administrator verified the decision to not re-admit the resident to the facility was based on the resident's condition at the time of transfer and not based on any evaluations of the resident at the time the hospital described the resident's condition was stable and appropriate for return to long-term care management.

Licensure Reference Number: 175 NAC 12-006.09D7a Based on observations, record reviews, and interviews, the facility failed to: 1) safely transfer residents between surfaces for 2 sampled residents (Residents 5 and 89) resulting in fractures for Resident 5 and skin tearing for Resident 89; 2) ensure oxygen concentrators were turned off when unattended for one sampled resident (Resident 80) increasing the risk for room oxygenation which increases the risk for fire; and 3) transport wheelchair residents using footrests for four sampled residents (Residents 81, 88, 65, and 74) increasing the risk of injury for these residents. Sample size was 26 current residents. Facility census was 93. Findings are: A. Record review of Resident 5's Admission Record printed on 7/4/18 revealed the resident was admitted to the facility on [DATE]. Among the medical [DIAGNOSES REDACTED]. Record review of a Physical Therapy Discharge Summary for Resident 5 signed by the therapist on 8/14/2017 revealed the PT provided resident and caregiver training and instruction and education to nursing staff on how to properly set-up the sit to stand lift and the pt (patient or Resident 5) in order to ensure safety was enhanced and pt knew how to perform transfer properly.: The summary identified outcomes at the time of discharge recorded Mobility for Chair or bed to chair transfer and Toilet Transfer required Substantial/Maximal Assistance from staff to perform the task. Record review of Resident 5's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) assessment completed on 4/6/2018 revealed the resident required Extensive assistance (resident involved in activity, staff provide weight bearing support) with Transfer- how the resident moves between surfaces including to or from bed, chair, wheelchair, standing position. The MDS recorded two or more staff persons provided physical assistance for the task. Regarding Balance during transitions the MDS recorded the resident was Not steady, only able to stabilize with human assistance. The assessment recorded the resident's weight at 253 pounds. Record review of a Fall document dated 6/9/18 at 1:15 p.m. revealed an incident occurred involving Resident 5 on 6/9/18. The description of the incident read: Nurse called to room, noted resident laying on floor in between sit to stand lift and motorized wheelchair. Staff states resident was unresponsive prior to alerting this nurse. Resident noted to be responsive and answering questions appropriately, resident states doesn't know what happened, passed out and woke up on floor. The form listed a witnesses statement which described the resident was standing up in the sit to stand lift while they were holder (holding) the bucket from the bedside commode under (the resident) . Resident then became weak, let go of the lift, fell through the sling and fell to the floor . Record review of a fax communication to Resident 5's physician on 6/9/18 recorded Resident became weak and let go of sit to stand lift while in use, slipped through harness et (and) fell to floor. Did hit back of head on leg rest of wheelchair . Record review of an Occupational Therapy updated plan of treatment for [REDACTED]. Record review of a Fall document involving Resident 5, dated 6/27/18 at 8:40 p.m., revealed a description of the incident documented a nurse aide was assisting resident with lift transfer when resident became weak and lost grip and legs gave out. Resident noted by this nurse hanging with just left hand and wrist in the sit to stand lift sling. Resident described I think I passed out. The nurse assisted the Nurse Aide in lowering the resident to the floor and noted a skin tear on the left wrist along with the resident complaining of a sore wrist. The resident was assisted onto the bed and the on-call medical practitioner was notified with orders to notify primary care doctor if wrist pain continues. A witness statement from the Nurse Aide involved during the incident documented on the form on 6/28/18 I was getting (the resident) transferred from the bath chair to (the resident's) bed in the sit to stand and (the resident) went limp. I think (the resident) passed out. The notes section of the form recorded Resident uses sit to stand for transfers . New interventions: Staff to utilize 2 staff with lift transfers. Record review of Resident 5's Progress Notes on 6/28/18 revealed at 10:32 a.m. a call was placed to the resident's physician reporting the left wrist was swollen and painful due to the fall the previous night. At 11:50 a.m. the physician returned call and ordered x-rays for the resident. At 4:28 p.m. the physician reported the x-ray indicated the resident sustained [REDACTED]. On 6/29/18 the resident went to orthopedics and returned with orders to keep cast clean and dry to left wrist with the cast to remain at least 6 weeks. Correspondence to the State Agency on 7/10/18, verified by phone interview with Resident 5's POA (Power of Attorney) on 7/17/18 at 8:00 a.m. revealed the POA contacted Res 5 by phone on 6/10/18 after the facility reported an incident/fall on 6/9/18. The resident described passing out from hanging out in the sit to stand lift too long. The POA stated the facility contacted the POA again on 6/28/18 and told about the resident having another incident in the lift. The POA contacted the facility DON (Director of Nursing) who returned a call at 4:19 p.m. The DON stated the resident passed out in the sit to stand lift and the Nurse Aide could not keep the resident from falling. The POA asked the DON if two persons performed the lift as the resident was supposed to be a two person lift transfer. The DON responded, confirming only one staff member attempted the resident's transfer. The POA reported coming to the facility on [DATE] and speaking with the DON around 11:30 a.m. about the concerns of Resident 5 being transferred with only one person and reported the resident had said this wasn't the first time one person did the transfers alone (prior to 6/27/18). The DON assured the POA the resident would be a two-person assist. Observation of Resident 5 on 7/2/18 at 3:50 p.m. revealed the resident had a cast on the left arm below the elbow extending across the forearm and hand. Interview with Resident 5 on 7/2/18 at 3:51 p.m. revealed the resident experienced two recent falls while being transferred with a mechanical lift. Resident 5 stated on the first occasion, the resident passed out while being assisted on a sit to stand lift with two staff members helping. The second occasion resulted in the resident's arm being fractured. The resident described being transferred with the sit to stand lift but only one staff member was assisting with the lift transfer. The resident stated having passed out and does not recall much until being assessed by the nurse. The resident described continued pain from the fall and was x-rayed and diagnosed with [REDACTED]. The resident stated the staff were supposed to have two persons assisting with mechanical lifts, but at the time of the second fall, the staff member attempted the lift by self. The resident also stated that other occasions prior to 6/27/18 staff members were transferring the resident with only one staff member instead of two. Interview with the facility PT (Physical Therapist) on 7/5/18 at 2:18 p.m. revealed the PT was familiar with Resident 5 and the resident's therapy plans and treatment. The PT confirmed OT (Occupational Therapy) began seeing the resident on 6/22/18 for alignment and functional skills and reviewed the use of the sit to stand lift. The PT verified the staff were transferring the resident at the time of falls on 6/9/18 and 6/27/18 with the use of a sit to stand lift due to previous recommendations by therapy. The resident was now using a sling lift due to the fractured wrist and cast and difficulty for the resident to hang on. The PT stated staff should be utilizing two persons for transfers with sit to stand and sling lifts especially with this resident due to the resident's size and inability to bear weight without staff assistance. Interview with LPN (Licensed Practical Nurse)- K, the Restorative Nurse Coordinator, on 7/9/18 at 4:00 p.m. confirmed Res 5 had passed out in the sit to stand lift on 6/9/18 during a transfer while being assisted with two staff. LPN-K confirmed a second incident occurred on 6/27/18 while a single staff member, NA (Nurse Aide)-T, was transferring the resident from a bath chair using the sit to stand lift without another staff member. LPN-K agreed that due to a similar incident and the size of the resident, the staff should have been aware of the resident's potential to pass out in the lift and should have had additional staff assisting with the transfer on 6/27/18. Interview with NA-T on 7/9/18 at 5:27 p.m. confirmed NA-T was present during the 6/27/18 incident involving Resident 5. NA-T stated having assisted the resident with a bath and returned the resident to the room to transfer the resident in the wheelchair. NA-T stated looking for additional help to transfer the resident but could not find anyone. NA-T confirmed transferring Resident 5 by self in the sit to stand lift and the resident blacked out and slumped during the transfer. NA-T then screamed for help and the charge nurse responded. NA-T stated Resident 5's left hand got caught in the lift and the resident sustained [REDACTED]. Record review of NA-T's employee files revealed NA-T was hired at the facility on 2/28/18. Further review of the file revealed there was no evidence of training or competency testing for NA-T regarding the use of mechanical lifts during resident transfers. Interview with the Business Office Manager/Human Resources Director on 7/10/18 at 9:18 a.m. confirmed NA-T's employee file had not included any training or competency testing regarding the use of mechanical lifts during resident transfers. B. Record review of Resident 89's Admission Record revealed the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident 89's MDS assessments revealed an Admission assessment was completed on 6/20/2018. Review of the assessment revealed the resident's functional status for Transfer recorded the resident received Extensive Assistance from two or more staff members to complete transfer tasks from bed to chair. The assessment recorded the resident received Extensive Assistance from two or more staff members when transferring onto the toilet. The MDS assessment recorded Balance during transitions and walking was Not steady, only able to stabilize with human assistance for surface to surface transfer. Record review of Resident 89's care plan printed on 7/4/18 revealed a focus problem initiated on 6/20/18 which described the resident Requires assistance with ADL functions and recorded in the interventions Two person assist with transfers. Record review of a Fall document dated 6/28/18 at 10:21 a.m. for Resident 89 revealed an incident description involving the resident which recorded: Resident lowered to floor by cna (Nurse Aide) after knees buckled in restroom. The resident described knees just gave out while holding the transfer bar in restroom. The form recorded skin tear injuries to the right and left elbow. In the Witnesses section of the form, NA-X described being present and transferring resident from the wheelchair to the toilet with a gait belt and transfer bar, when resident's knees began to buckle. NA-X lowered the resident to the floor and called for help. Further review of attached Progress Notes revealed a late entry recorded on 6/28/18 at 10:36 which read Recommendation: Resident is to be 2 person transfer with all transfers and gait belt . Interview with Resident 89 on 7/2/18 at 2:42 p.m. revealed the resident had fallen recently. The resident described being assisted in the bathroom by a nurse aide and lost balance and fell resulting in an injury to the elbow. The resident stated there were supposed to be two staff assisting with transfers, but on this occasion, only one staff member assisted the resident. Interview with the DON and ADON (Assistant Director of Nursing) on 7/10/18 at 2:13 p.m. confirmed Resident 89's care plan identified the resident was to be transferred with two person assistance. The ADON confirmed the resident had an incident of being lowered to the floor on 6/28/18 while only one staff member was assisting the resident with a toilet transfer and that the resident sustained [REDACTED]. Record review of NA-X's employee file revealed the staff member was hired by the facility on 5/9/18. Record review of NA-X's education file revealed there was no documentation the employee was trained or competency tested in safe resident transfer techniques. Interview with the Business Office Manager/Human Resources Director on 7/10/18 at 9:18 a.m. confirmed NA-X's employee file had not included any training or competency testing regarding transfer techniques for safe resident transfers. C. Observations of Resident 80's room on 7/3/18 at 7:40 AM and at 11:40 AM revealed the oxygen concentrator on while the resident was out of the room for meals. Further observations on 7/9/18 at 3:20 PM revealed the oxygen concentrator on while the resident was out of the room. Interview with LPN - B, Unit Coordinator, on 7/10/18 at 7:30 AM confirmed that the oxygen concentrator should be turned off while the resident was out of the room to reduce the risk of fire and injuries. D. Observations on 7/5/18 at 7:40 AM revealed NA - P propelled Resident 81, seated in a wheelchair, though the hallway to the dining room without utilizing footrests. Observations on 7/5/18 at 11:10 AM revealed LPN - B propelled the resident, seated in a wheelchair, in the hallway without utilizing footrests. E. Observations on 7/5/18 at 7:40 AM revealed Resident 83 pushing Resident 88, seated in a wheelchair, in the dining room without utilizing footrests. F. Observations on 7/5/18 at 11:15 AM revealed a family member pushing Resident 65, seated in a wheelchair, in the hallway without utilizing footrests. G. Observations on 7/5/18 at 11:30 AM revealed LPN - B transported Resident 74, seated in a wheelchair, in the hallway from the dining room to room without utilizing footrests. Interview with LPN - U, Assistant Director of Nursing, on 7/10/18 at 7:30 AM confirmed that resident were to be transported in wheelchairs and utilize footrests to support the residents' feet, reduce the risk of injuries and to promote comfort. H. Observation on 02/02/18 at 11:28 a.m. room [ROOM NUMBER]-A which belonged to Resident 11 had electrical cords plugged into the electrical sockets located next to the sink and cords were just dangling down. There was a box with a hair blow dryer, and electric razor, hair clippers and multiple electrical cords hanging out of the box located next to the sink. Observation on 07/09/18 at 2:50 p.m. revealed Resident 11 was sitting in the recliner in room [ROOM NUMBER]-A watching television. There were electrical cords that might have belonged to Resident 11's electric razor and or possibly a cell phone and they were plugged into the electric plug ins located next to the sink. One of the cords was dangling off to the side of the sink and the other cord was in the sink but were not attached to the electric razor or cell phone. Plug in by the sink did have a default reset located on it. Staff interview on 07/09/18 at 3:09 p.m. with LPN-G verified the resident had electrical cords that had been plugged into the electrical outlets along with a box full of electronics being stored on the sink counter top in Resident 11's room [ROOM NUMBER]-A. LPN-G reported this was not safe having these electric cords plugged in and hanging in and round the sink. LPN-G reported she would move these items immediately. Observation on 07-09-18 at 6:40 pm room [ROOM NUMBER]-A where Resident 11 resides, all electrical cords and box of electronics that had been on counter top next to the sink had all been removed. Staff interview on 07/10/18 at 3:29 p.m. with the Administrator, Director of Nursing and Assistant Director of Nursing verified Resident 11 had electronics stored next to the sink and had electrical cords plugged in to the electrical outlets which were hanging in and along the sink. Administrator identified that electrical cords should not be left plugged into the electrical outlets next to sinks in resident rooms as this could increase the risk of injury to residents.

Licensure Reference Number: 175 NAC ,[DATE].07C Based on observations, record reviews, and interviews, the facility's QA (Quality Assurance) committee failed to: 1) identify regulatory deficient practice in systems including: Advanced directives regarding employee CPR (Cardiopulmonary Resuscitation) documentation; environment and maintenance, Activities, prevention of accident/hazards; verifying nursing employee competencies, education, and performance evaluations; Posting of nurse staffing; dating opened multi dose vials and bottles to ensure efficacy of these medications, vaccines, and injectables; Dietary department sanitation; Infection control practices; and Pest control. Failure to identify and correct issues related to improper resident transfers resulted in a fracture for one sampled resident (Resident 5) and elbow skin tears for one sampled resident (Resident 89); and 2) failed to maintain compliance in areas previously cited for deficient practice at the [DATE] annual survey. Facility census was 93. Findings are: Record review of the facility's (YEAR) Quality Assurance & Performance Improvement Plan revealed from Guiding Principle #4 that Our organization focuses on systems and processes. Listed in the document's Plan recorded in the Feedback, Data Systems and Monitoring section that the committee will put in place systems to monitor care and services drawing data from multiple sources . It also includes tracking, investigation, and monitoring adverse events every time they occur. The monitoring section documented the QA committee will decide what data to monitor routinely including Clinical care areas, medications, hospitalization s . care plans . state survey results and deficiencies . Business and administrative processes Regarding QA Evaluation the plan recorded: The team will thoughtfully and thoroughly consider the progress made in the last year toward achieve . goals and current status of measurement in meeting and sustaining the performance indicators . Results of the survey observations, record reviews, and interviews conducted between [DATE] and [DATE] revealed the facility received citations for deficient practice at scopes of patterns (more than 3 residents but not all residents), widespread (affecting all residents), and an actual harm severity related to resident accidents involving Residents 5 and 89; and staff competency regarding transfer techniques used for Residents 5 and 89. Citations with scopes of pattern or widespread were as follows: - E-001 The facility's emergency preparedness plan failed to include 13 required components describing policies and procedures for those components. - F578- the facility failed to maintain CPR certification for three licensed nurses providing direct cares for residents. The failure could potentially have affected 17 current residents requesting CPR in the event of a [MEDICAL CONDITION]. - F584- the facility environment was cited regarding multiple clinical areas of halls and resident rooms requiring repair, cleaning, or replacement of walls and flooring. - F679- the facility was cited for failure to document activity responses and progress for one resident and failure to provide ongoing activities in the special care units. - F689- the facility was cited for accident/hazards. Two sampled residents were identified to have been improperly transferred. Resident 5 was transferred with one assistant in a mechanical standing lift and lost consciousness catching the left wrist in the lift resulting in a wrist fracture. Resident 89 was care planned to have two staff during transfers and was lowered to the floor when only one staff assisted the resident resulting in skin tears to the elbows. In addition, four sampled residents were observed being transported in wheelchairs without the use of footrests increasing the potential for injury during transport. One resident's oxygen concentrator was left on while unattended increasing the risk for room oxygenation and potential fire hazard. Employee files revealed the two staff members involved in transfers for Residents 5 and 89 had no evidence of competency testing in use of mechanical lift or pivot transfers. - F726- Sampled employee files for nurse aides and medication aides revealed no evidence of competency testing related to the provision of direct care skills to residents. - F730- Sampled employee files for staff employed for direct care to dementia residents residing on the Special Care Units revealed no evidence of education hours pertaining to dementia care and no required annual performance reviews for these employees was included in their employee files. - F732- Staff posting for review by residents, families, and visitors was not accurate. - F761- Injectable medications, eye drop containers, and vaccination multi-use vials on two clinical areas were not dated when opened to ensure efficacy of these medications, eye drops, and vaccines. - F812- Dietary sanitation was cited potentially affecting potential cross-contamination of meals served to all residents. - F880- infection control practices regarding isolation and hand hygiene were cited in different clinical areas. - F925- pest control was cited due to the presence of flies and millers/moths found in hallways and in a dining area; and dead bugs discovered in light fixtures in different hallways of the facility. Record review of the facility's survey inspection from an annual survey conducted from [DATE] through [DATE] revealed the following areas of repeat deficient practice during the current survey from [DATE] through [DATE]: - Environmental and maintenance issues were cited at a scope of pattern and the severity was cited with no actual harm with potential for harm. - Accident/hazards were cited at a scope of pattern and severity of actual harm. This citation included accident with fracture and issues of oxygen concentrators left on while unattended. - Infection control was cited at a scope of pattern and severity of no actual harm with potential for harm. - Staff posting was cited as being inaccurate. - Dietary sanitation was cited was cited at a scope of widespread and severity of no actual harm with potential for harm. - Medication labeling was cited at a scope of pattern and severity of no actual harm with potential for harm. - Pest control cited flies in the facility at a scope of widespread and severity of no actual harm with potential for harm. - Staff education was cited related to emergency preparedness at a scope of widespread and severity of no actual harm with potential for harm. Interview with the facility Administrator on [DATE] at 2:47 p.m. revealed the facility had multiple systems issues related to issues with the ownership leading to the facility being transitioned through a receivership. The Administrator confirmed there were multiple systems problems including the loss of records and assessments, employee file documents, and difficulties obtaining necessary supplies and equipment to maintain the facility. The Administrator stated the focus at the facility has been maintaining staff and residents in light of the receivership management taking over. The Administrator verified there are many issues needing resolution and correction.

Licensure Reference Number: 175 NAC 12-006.09D Based on observations, record reviews and interviews; the facility failed to ensure that 1) thorough skin assessments were completed at least weekly and dressings were changed as ordered to promote healing of open wounds with ongoing drainage for one current sampled resident (Resident 84), 2) pain was assessed and controlled during wound care for one current sampled resident (Resident 169), 3) ongoing severe pain was identified and managed for one current sampled resident (Resident 15), 4) pain rated severe was assessed and controlled for one closed record (Resident 173) and two current sampled residents (Resident 90 and 10), 5) a resident with an abnormal blood pressure reading was assessed and follow up completed to ensure that the resident didn't experience any adverse effects for one current sampled resident (Resident 84) and 6) a decline in behaviors was assessed and a plan to manage behaviors was developed for two current sampled residents (Residents 29 and 25). The facility census was 107 with 22 current sampled residents and three closed records. Findings are: A Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/8/17 at 11:00 AM revealed the resident seated in the wheelchair with ongoing foul odors noted from dressings at lower extremities. Interview on 8/8/17 at 11:00 AM with the resident revealed they don't change my dressings like they're supposed to. Observations on 8/9/17 at 9:30 AM revealed the resident seated in room in a wheelchair and noted a strong foul smelling odor in the room and the hallway by the resident's room. Interview with the resident on 8/9/17 at 9:30 AM revealed my legs are bleeding, they're supposed to change my dressings two times a day and put some cream on my legs and lucky to get it done every 2-3 days. Further observations revealed the resident removing the dressings from the right lower legs and noted leg swollen with clear, foul smelling weeping drainage dripping down the leg. Observations on 8/9/17 at 1:30 PM revealed the resident seated in the wheelchair in the room for the scheduled treatment and dressing changes to the legs. Noted the foul smelling drainage continued to weep from the lower legs bilaterally and the dressings were removed from the lower legs. The dressing/wraps were intact at the thighs. Further observations revealed LPN (Licensed Practical Nurse) - R, Charge Nurse (assisted by LPN - C, Unit Coordinator), while sitting on the floor in front of the resident, removed the wrap and dressings from the right thigh, cleansed the back of the thigh with a disposable washcloth and then the front of the thigh, applied [MEDICATION NAME] cream as ordered to the back and front of the thigh, wrapped gauze around the thigh and then an ace wrap. Noted that the back of the thigh was not visible to the nurse to assess the resident's skin as the treatment was done. LPN - R removed the ace wrap and dressing from the left thigh and performed the treatment in the same manner. The resident complained of soreness behind the left knee. LPN - R could not visualize the skin at the back of the thigh for an assessment. The resident stated my legs have been bleeding for two days. The resident also complained of pain at the left thigh and lower legs, moaning and grimacing, while the treatments were done at the left thigh and lower legs. Interview on 8/10/17 at 8:00 AM with LPN - R revealed that the resident often removed the dressings from the lower legs and often refused routine bathing. Observations on 8/10/17 at 8:00 AM revealed the resident seated in a recliner in room with legs elevated about ten inches, strong foul odor remained in room. Further observations at 11:00 AM and 2:15 PM revealed the resident seated in the wheelchair, legs not elevated and the strong foul odor remained in the room and into the hallway. Review of the Weekly Skin Check, dated 7/12/17, revealed that the resident had [MEDICAL CONDITION] at the right and left thighs (rear), right lower and left lower front legs, and right lower and left lower legs rear. [MEDICAL CONDITION] is a condition of abnormal accumulation of tissue fluid (potential lymph) in the interstitial spaces. The resident refused to have skin assessment completed. Review of the Weekly Skin Check, dated 7/19/17, revealed that the resident had bilateral lower [MEDICAL CONDITION], right and left thighs (rear), right and left lower legs (front and rear) and dressings were applied as ordered. The resident also had excoriation under both breasts and under the abdominal fold and a wound at the buttock which measured two by two centimeters. The resident had no other areas of concern. Review of the Weekly Skin Check, dated 8/9/17, (none received to review for 8/2/17), revealed that the resident had excoriation under both breasts and under the abdominal fold, and [MEDICAL CONDITION] to the right and left thigh (rear), right and left lower legs (front and rear). Further review revealed no measurements of the swelling to evaluate worsening or improvement. Review of the Treatment Administration Record, dated August 2017, revealed an order, dated 1/30/17, for compression wraps to both legs, change every 12 hours for [MEDICAL CONDITION] and [MEDICATION NAME] cream to bilateral legs every 12 hours. Further review revealed no documentation that the treatment was done on the day shift on 8/4/17, 8/5/17 and 8/6/19. The treatment was documented as refused on the day shift on 8/7/17 and on the evening shift on 8/2/17, 8/3/17, 8/4/17, 8/6/17, 8/7/17 and 8/8/17. Further review revealed an order, dated 6/6/17, to check buttocks and coccyx daily for skin breakdown and an order dated 7/20/17, for [MEDICATION NAME] cream to buttock every shift. Review of the Progress Notes, dated August 2017, revealed no documentation of the resident's ongoing refusal of thorough skin assessments or treatments to the legs. Further review revealed no documentation of the ongoing foul smelling weeping drainage from the legs or the status of the open area on the buttock. Interview on 8/15/17 at 9:00 AM with LPN - C, Unit Coordinator, confirmed that complete skin assessments were not completed at least weekly to determine whether or not the treatments were effective. LPN - C confirmed that a complete assessment of the resident's skin condition could not be done while the resident was seated in a wheelchair. Further interview confirmed that the ongoing foul smelling drainage from the legs was not documented or addressed. B. Observations on 8/9/17 at 1:00 PM revealed Resident 169 resting on the bed, positioned on back for wound care. Further observations revealed LPN - Q lifted the resident's right foot to remove the protective boot and the resident complained of pain as the foot was lifted up. The resident said ouch, that is so tender and the resident grimaced and had labored breathing. The resident continued to complain of pain when the right foot was moved for the treatment on the pressure ulcer at the heel with continued verbal complaints of pain, facial grimacing and labored breathing. LPN - Q continued with the treatment and encouraged the resident to take deep breaths. LPN - Q and RN (Registered Nurse) - P turned the resident to left side to continue treatments to pressure ulcers at the right buttock and sacral area. The resident groaned again with pain when the right foot was lifted while repositioned to side. The resident also complained of hip pain when repositioned, when the treatment was done to the sacral area and when positioned again on back. Interview on 8/9/17 at 2:00 PM with the resident revealed that those treatments are so painful. Review of the Medication Administration Record, [REDACTED]. Interview on 8/15/17 at 10:00 AM with LPN - C, Unit Coordinator, confirmed that the resident should have been offered pain medication before the wound care in anticipation of pain. LPN - C confirmed that the nurses should have stopped the treatment when the resident complained of pain, medicated the resident and then continue with the treatment to promote comfort for the resident. C. Interview with Resident 15 on 8/8/17 at 11:20 AM revealed that the resident had back and neck pain. The resident stated that takes pain medications but it still hurts. Observations during the interview revealed that the resident had pained facial expressions and a clenched jaw. Observations on 8/9/17 at 9:45 AM revealed the resident seated in the wheelchair in room with tears in eyes. Further observations revealed dried dark red colored matter on the rim of the urinal on the edge of the garbage container. Interview with the resident on 8/9/17 at 9:45 AM revealed my bladder, back and kidneys hurts so bad. The resident also stated that it has been hurting for several days now with no relief from the pain pills. The resident stated pain pills don't help at all, it hurts so bad that I want to cry, having blood in my urine and I'm supposed to see a doctor. Interview on 8/9/17 at 10:00 AM with RN (Registered Nurse) - P, Charge Nurse, revealed that the resident had chronic neck pain and usually requested a pain pill in the morning. RN - P did not mention the resident's back pain or blood in urine. Observations on 8/9/17 at 11:15 AM revealed the resident seated on the toilet and complains of really bad pain. The resident stated may be passing a kidney stone or something. Further observations revealed the resident had bright red blood in the toilet. Interview on 8/9/17 at 11:30 AM with RN - P revealed that no urology appointment had been made yet to evaluate the resident. Further interview revealed would have the Nurse Practitioner check the resident. Review of the MAR (Medication Administration Record), dated August 2017, revealed that the resident had a routine [MEDICATION NAME] (narcotic [MEDICATION NAME]). Further review revealed that the resident received [MEDICATION NAME] (Opioid [MEDICATION NAME]), ordered as needed for pain, on 8/7/17 at 8:22 AM, on 8/8/17 at 8:38 AM and 7:12 PM and on 8/9/17 at 8:43 AM for pain rated 9 (severe) on the 1-10 pain scale. Further review revealed documentation that the 8/8/17 at 8:38 AM and the 8/9/17 at 8:43 AM doses were ineffective in relieving the resident's pain. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Interview with the LPN - C, Unit Coordinator, on 8/15/17 at 10:30 AM confirmed that the medical provider should have been notified of the resident's ongoing unrelieved pain and blood with urination sooner to relieve the resident's pain. D. Review of the Admission Record, printed 8/9/17, revealed that Resident 173 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed that the resident received the first dose on 7/11/17 at 1:00 AM for pain rated 7 (on a pain scale of 1-10 with 10 as the worst possible pain) for right shoulder pain per the Progress Notes. The resident received the next doses at 7:34 AM for right shoulder pain rated 8 and at 4:44 PM for all over pain rated 9. The resident received the pain medication again on 7/12/17 at 4:51 AM for pain rated 7 for right shoulder and right arm pain, at 1:11 PM for right shoulder pain rated 10 and at 9:09 PM for right shoulder pain rated 7. Review of the Progress Notes, dated 7/12/17 at 9:55 AM, revealed that the resident complained on continuous pain to the left upper extremity and the right lower extremity and pain medication offered as needed was effective for a short amount of time, but then the pain returned. The resident was to have an x-ray of the right ankle today due to severe pain. Review of the Progress Notes, dated 7/13/17 at 2:36 PM revealed a new order for [MEDICATION NAME] 10/325 milligrams every 6 hours for pain. Review of the Medication Administration Record, [REDACTED]. Further review of the Medication Administration Record [REDACTED]. Further review revealed no documentation on 7/14/17 or 7/15/17 of how the resident rated the pain. Review of the Progress Notes, dated 7/15/17 at 4:10 PM, revealed that the resident was continuously pulling on the call light cord screaming in sleep, noted body tremors, when the resident was awake was confused and hallucinating about chickens. The on call provider was notified of the resident's change in condition and stated it is probably the dosage increase of [MEDICATION NAME] and new orders were received to discontinue the routine scheduled [MEDICATION NAME] and change back to every eight hours as needed for pain. Further review revealed that at 8:00 PM, the resident continued to have episodes of twitching with [MEDICAL CONDITION] off and on during the day, was unresponsive and grimaced with pain during movement. The provider was notified and orders were received to transport the resident to hospital emergency room for evaluation and then admission. Interview on 8/15/17 at 3:00 PM with LPN - C, Unit Coordinator, confirmed that further assessments of the resident's ongoing pain should have been completed, including causal factors and non- pharmacological interventions in place to control the resident's pain. Further interview confirmed that pain assessments should have continued when the [MEDICATION NAME] was changed to routine dosing to ensure that pain was managed effectively for the resident's comfort. E. Review of the Admission Record, printed 8/9/17, revealed that Resident 90 was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview on 8/9/17 at 10:00 AM with the resident revealed that the right shoulder continued to hurt and rated pain at 7 as it still hurts a lot. Interview on 8/10/17 at 7:15 AM with the resident revealed that the right shoulder and right leg hurt and the resident was rubbing the shoulder and leg. The resident stated that the pain pills help some, but it still hurts. Review of the Medication Administration Record, [REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed that orders were received on 8/8/17 for routine [MEDICATION NAME] every bedtime. Interview on 8/15/17 at 10:40 AM with LPN - C, Unit Coordinator, confirmed that further assessments of the resident's ongoing pain should have been completed to include potential causal factors and non - pharmacological interventions to manage the resident's pain. F. Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record, [REDACTED]. Further review revealed the resident's blood pressure was 195/75 on 7/28/17. Review of the medical record, including the progress notes, revealed no assessment of the resident on 7/28/17 or follow up blood pressure until 8/2/17 with a reading on 163/73. Interview on 8/14/17 at 1:30 PM with LPN - D, Unit Coordinator, confirmed that an assessment and follow up vital signs should have been completed and documented with the abnormally high blood pressure reading on 7/28/17. Further interview confirmed that the resident's condition should have been monitored closely to ensure that the resident's needs were met. G. Review of Resident 29's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 6/10/17, revealed that the resident had no behaviors. Review of the MDS, dated [DATE], revealed that the resident had physical behaviors directed towards others one to three days during the assessment period. Interview on 8/14/17 at 2:30 PM with LPN - Z, MDS Coordinator, revealed that the resident had a documented episode of hitting and kicking staff in the nursing assistant documentation during the assessment period. Further interview confirmed that there was no documentation that the care plan team reviewed the incident, considered the potential causal factors related to the behaviors or developed a plan to reduce the risk for further behaviors. H. Review of Resident 25's MDS, dated [DATE], revealed that the resident had no behaviors. Review of the MDS, dated [DATE], revealed that the resident had physical behaviors directed towards others one to three days during the assessment period. Interview on 8/14/17 at 2:30 PM with LPN - Z, MDS Coordinator, revealed that the care plan team did not address the resident's decline in behaviors, identify potential causal factors or develop a plan to manage any further behaviors directed towards others. I. Interview with Resident 10 revealed the resident had pain that would not go away and the facility hadn't intervened to assist in alleviating the pain. Observation on 8/8/17 at 10:20 a.m. revealed the resident grimaced throughout the interview. Record review of the MDS (Minimal Data Set, a federally mandated comprehensive assessment tool utilized to develop care plans) revealed the resident was assessed with [REDACTED]. Record review of the resident's care plan revealed the resident had right knee pain. Record review of Nurses notes revealed Resident 10 had knee injections for pain on 8/9/17 at the physician's clinic. Record review of facility documentation revealed no pain assessments for Resident 10 were completed before and after knee injection on 8/9/17. Record review of Resident 10's Medication Administration Record [REDACTED]. Record review of Resident 10's electronic medical record revealed there were no formal pain assessments completed since 6/30/17. Interview with LPN (Licensed Practical Nurse)-C on 8/15/17 at 3:00 p.m. revealed LPN-C was the unit coordinator and worked routinely with Resident 10. LPN-C confirmed there were no follow up formal pain assessments or documentation for Resident's pain since 6/30/17.

Based on observations, record review and interviews; the facility failed to ensure that 1) interventions were in place to prevent recurrent falls and a subsequent fractured finger for one current sampled resident (Resident 26) and 2) oxygen concentrators were turned off when not in use to reduce the risk of fires for five current sampled residents (Residents 25, 66, 40, 15 and 71). The facility census was 107 with 22 current sampled residents. Findings are: Licensure Reference Number: 175 NAC 12-006.09D7b (3) A. Review of the Admission Record, printed 8/9/17, revealed that Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident also had [DIAGNOSES REDACTED]. Review of the Care Plan, goal date 11/3/17, revealed that the resident was at risk for falls related to poor safety awareness and self-determination related to transfers. Further review revealed that the resident fell getting out of the wheelchair on 4/24/17, slid self out of the wheelchair to the floor on 6/29/17 and had an unwitnessed fall out of the wheelchair on 7/25/17. Review of the Progress Notes, dated 7/25/17 at 1:49 PM, revealed that the resident was found to be on the floor next to the wheelchair in the dining room and no injuries were noted. Further review revealed at 2:09 PM, bruising which measured 5 cm. (centimeters) by 2 cm. was noted on the 3rd digit. At 6:14 PM, swelling was noted at the finger. On 7/27/17 at 2:45 PM, an x ray showed that the resident had a fractured right third finger and orders for a splint were received. Observations on 8/9/17 at 7:40 AM revealed the resident resting in bed and a splint in place at the right third finger. Review of the Treatment Administration Record, dated August 2017, revealed an order, dated 7/26/17, for Epsom salt treatment two times a day for swelling and bruising of the right hand. Review of the Medication Administration Record, dated August 2017, revealed an order, dated 8/1/17, to take the splint off and check skin daily and reapply the splint daily until 9/7/17. Review of the Medication Administration Record, dated July 2017, revealed that the resident received Hydrocodone - Acetaminophen (narcotic analgesic) for pain on 7/24/17 and 7/26/17. Interview on 8/14/17 at 1:45 PM with LPN (Licensed Practical Nurse) - D, Unit Coordinator, confirmed that the care plan interventions were not effective to prevent further falls from the wheelchair and the subsequent fractured finger. Licensure Reference Number: 175 NAC 12-006.09D7 B. Observations on 8/8/17 at 8:30 AM revealed Resident 15 (Room 104 B) and Resident 17 (Room 215 B) oxygen concentrators on while the residents were out of the room. Observations on 8/14/17 at 7:45 AM revealed Resident 25 (Room 220 B), Resident 66 (219 B) oxygen concentrators on while the residents were out of the room. Observations on 8/14/17 at 8:00 AM revealed Resident 40 sleeping in bed with the oxygen concentrator on and the mask on the bed. Interview on 8/14/17 at 8:15 AM with the Interim Director of Nursing confirmed that the oxygen concentrators were to be turned off when not in use to reduce the risk of accidental fires and to promote safety.

Licensure Reference Numbers 175 NAC 12-006.09D2a 175 NAC 12-006.09D2b Based on observations, record reviews and interviews; the facility failed to ensure that 1) a turning/repositioning schedule was developed and implemented, a pressure relieving mattress was provided and set at a therapeutic and comfortable level, a nutrition assessment was completed to obtain a supplement to promote wound healing, the recommendation made for a supplement was ordered and administered timely, ongoing diarrhea was managed to reduce the risk of cross contamination at the pressure ulcers, linens and clothing layers were minimized to ensure the therapeutic benefits of the pressure relieving mattress and interventions were evaluated and changed when the pressure ulcers deteriorated and before more pressure ulcers developed for one current sampled resident (Resident 169)admitted with pressure ulcers and subsequently developed more pressure ulcers and 2) a turning/repositioning schedule was developed and implemented, a larger bed was provided to enhance self repositioning in bed, a nutrition evaluation was completed to evaluate the need for a supplement to promote healing of a facility acquired pressure ulcer, layers of linens and clothing between the resident's skin and the mattress was minimized to ensure the therapeutic pressure relieving properties of the mattress and treatments were evaluated and changed when the pressure ulcer worsened for one current sampled resident (Resident 37). The facility census was 107 with 22 current sampled residents and three closed records reviewed. Findings are: A. Review of the Admission Record, printed 8/9/17, revealed that Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 7/14/17, revealed that the resident was at risk for the development of pressure ulcers. Review of the Admission Nursing Assessment, dated 7/7/17, revealed that the resident had a Stage 2 pressure ulcer at the right buttock which measured 4 cm. (centimeters) length x 4.5 cm. width x 0.1 cm. depth. Review of the Care Plan, goal date 9/25/17, revealed that the resident required extensive assistance of two staff members for bed mobility and transfers. Further review revealed that the resident was admitted with a Stage 2 pressure ulcer at the right buttock related to assistance required in bed mobility and the presence of [MEDICAL CONDITION] (swelling). Interventions included turning and repositioning schedule and weekly skin assessments. Review of the Weekly Wound Assessment, dated 7/27/17, revealed that the pressure ulcer at the right buttock was identified on 7/7/17. Further review revealed that the ulcer measured 6 cm. length; 9 cm. width, and 0.1 cm. depth, with a moderate amount of serosanguinous (serum and blood) drainage, painful and 10 % necrotic (dead) tissue. Interventions in place included a pressure redistribution mattress and wheelchair cushion. Interventions did not include a specific turning or repositioning program, nutritional supplements, positioning devices, protein supplements or heel boots or the need for a pressure relieving mattress. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that the pressure ulcer at the right buttock measured 8 cm. length, 4.2 cm. width, depth not marked and Stage is now Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray green or brown) and/or eschar (tan, brown, or back) in the wound bed). Further review revealed that the ulcer contained a moderate amount of serosanguinous, foul smelling drainage with 100% slough (dead matter or necrotic tissue separated from living tissue or an ulceration). Review of the Weekly Wound Assessment, dated 7/26/17, revealed that a Suspected Deep Tissue Injury at the right heel (facility acquired) was identified on 7/25/17 which measured 3.5 cm. length, 3 cm. width with a small amount of serosanguinous drainage and no odor and painful. Current preventative interventions included pressure redistribution mattress, wheelchair cushion and heel boots. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that the pressure ulcer at the right heel was Unstageable and measured 3.5 length and 3 cm width, with a moderate amount of foul smelling serosanguinous drainage, painful, with 100% black slough with maceration (softening from fluid) at the surrounding skin. Interventions added included nutritional and protein supplements. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that an Unstageable pressure ulcer was identified on 8/2/17 at the coccyx which measured 4.0 cm. length by 3.7 cm. width, with a moderate amount of foul smelling serosanguinous drainage, painful and 100% slough. Further review of the Care Plan, goal date 9/25/17, revealed interventions added on 7/25/17 including air mattress (pressure relieving) set at weight for comfort, protective boots or float heels with a pillow, wound clinic consult. Interventions added on 8/2/17 included treatments as ordered and to see wound clinic. Review of the Progress Notes, dated 8/3/17, revealed that the resident went to a wound clinic and new treatment orders were received for the heel and sacral wounds. Observations on 8/9/17 at 1:00 PM revealed the resident resting on the bed, boot on the right foot, airflow mattress set at 4 (175 pounds) and noted a sheet and blanket between the resident's skin and the airflow mattress. LPN (Licensed Practical Nurse) - Q stated that the resident's dressings at the right buttock and coccyx were removed earlier as the resident had been incontinent of stool which saturated the dressings. LPN - Q removed the protective boot from the right foot, the resident complained of pain when the boot was removed and began breathing harder because of the pain. The resident repeatedly complained of pain throughout the treatment when the right foot was moved with facial grimacing and labored breathing. LPN - Q noted increased swelling on the foot and lower leg, removed the dressing from the right heel and noted reddish brown colored foul smelling drainage on the dressing. LPN - Q continued with the treatment as ordered. Further observations revealed LPN - Q and RN (Registered Nurse) - P repositioned the resident on the left side for the treatments to the pressure ulcers at the right buttock and coccyx. The resident stated that bottom hurts, too. LPN - Q removed the resident's slacks and disposable brief and continued with the treatment and dressings as ordered. LPN - Q and RN - P performed perineal care to remove feces from skin. LPN - Q and RN - P applied a disposable brief, pulled up the resident's slacks and positioned the resident on back. Observations on 8/10/17 at 7:00 AM revealed the resident resting in bed, positioned on back and the air mattress set at 4. Interview with the resident on 8/10/17 at 2:00 PM revealed that was not able to reposition self, those treatments are so painful, the mattress was not very comfortable and continued to have diarrhea stools. Review of the resident's admission weight was 152 pounds and weight on 8/4/17 was 149 pounds. Interview on 8/14/17 at 9:00 AM with RN - P, Charge Nurse, revealed was not aware that the air mattress was set at 4 for a resident who weighed 175 pounds. RN - P confirmed that the resident did not weigh 175 pounds so the air mattress was not set at the therapeutic weight for pressure relief. Interview on 8/14/17 at 9:15 AM with LPN - Y, Restorative Care Nurse, confirmed that the air mattress was set at 4. Further interview revealed would lower the rate to 3 (145 pounds) which was closer to the resident's weight to achieve the therapeutic benefits of the air mattress and to promote comfort. Interview on 8/15/17 at 7:30 AM with the resident revealed that the mattress was now more comfortable and not so hard. Review of the Documentation Survey Report v2, dated July 2017, revealed that the resident repositioned self on the day shift on 7/20, 7/21, 7/25, 7/27 and 7/28; repositioned self on the evening shift on 7/20, 7/21, 7/24 and 7/25; and repositioned self on the night shift on 7/8, 7/13, 7/14 and 7/29. Further review revealed no documentation that the resident was repositioned every two hours while in bed on the evening shift on 7/10 - 7/14, 7/17 - 7/19 and 7/26 and on the night shift on 7/10, 7/22, 7/24, 7/26 and 7/31. Review of the Documentation Survey Report v2, dated August 2017, revealed that the resident repositioned self on the day shift on 8/1, 8/4 and 8/6, on the evening shift on 8/1 - 8/5, 8/7 - 8/9 and 8/13 - 8/14, and on the night shift on 8/5, 8/12 and 8/14. Review of the Nutrition Assessment described as Admission, dated 7/26/17, (Resident admitted [DATE]) revealed that the resident had a surgical wound and a stage 2 pressure ulcer and a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). Further review revealed that the resident's [MEDICATION NAME] (protein) level was low on 7/15/17 and recommendation was made for 2 cal supplement two times a day to promote wound healing. Review of the Nutrition Assessment, dated 8/10/17, revealed that the resident had a weight loss, surgical wound and pressure ulcers to coccyx and right heel. Recommendations were made to increase the 2 cal supplement to four times a day to increase calories and promote wound healing. Review of the physician Order Summary Report, printed 8/15/17, revealed an order, dated 7/31/17, for 2.0 calorie supplement three times a day related to a pressure ulcer at the right heel. Review of the MAR (Medication Administration Record), dated July 2017 and printed 8/9/17, revealed that the resident did not receive any nutritional supplement until 7/31/17. Further review revealed that the air mattress was initiated on 7/19/17. Review of the MAR, dated August 2017 and printed 8/9/17, revealed an order, dated 8/2/17 for Prostat supplement two times a day for wound healing and the 2 calorie supplement remained at three times a day. Interview on 8/15/17 at 10:00 AM with LPN - C, Unit Coordinator, confirmed that care plan interventions were effective to promote healing of the pressure ulcer on the right buttock or to evaluated and changed to prevent the development and to promote healing of the pressure ulcers at the right heel and the coccyx area. Further interview confirmed that the pressure ulcers contributed to the resident's pain, a turning and repositioning schedule was not developed or implemented consistently, the pressure relieving air mattress was not implemented until the pressure ulcer at the right heel developed, the air mattress was not set at the therapeutic level based on the resident's weight and comfort and layers of linens and clothing were not minimized to ensure the therapeutic benefits of the mattress. LPN - C confirmed that a nutrition assessment was not completed on admission and RD (Registered Dietician) recommendations were delayed in being ordered and administered to promote healing of the pressure ulcers. Further interview confirmed that ongoing diarrhea was not controlled to reduce the risk of cross contamination of the pressure ulcers on the right buttock and coccyx area. B. Review of the Admission Record, printed 8/9/17, revealed that Resident 37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that the resident was readmitted from the hospital on [DATE] post treatment for [REDACTED]. Review of the MDS, dated [DATE], revealed that the resident had no pressure ulcers. Review of the Care Plan, goal date 10/22/17 and printed 8/9/17, revealed that the resident required extensive assistance with activities of daily living including bed mobility, toileting and personal cares and transferred with a mechanical lift. Further review revealed a care plan, dated 7/17/17, for a stage 2 pressure ulcer at the coccyx. Interventions included pressure reducing wheelchair seat cushion, pressure reduction/relieving mattress and treatments as ordered. Observations on 8/9/17 at 2:30 PM revealed the resident seated in the wheelchair in room. Interview on 8/9/17 at 2:30 PM with the resident revealed had been up in the wheelchair since 7:30 AM. The resident stated will usually try to lay down in bed in the mornings. The resident also stated that the staff don't reposition me at night, the bed is too narrow for me to turn over by myself and my bottom hurts so bad in the morning because I've been on my back all night. Further interview revealed I have sores on my bottom. Review of the Progress Notes, dated 7/15/17, revealed that the resident had a wound at the coccyx which measured approximately 3 x 1 cm and a wound to the inside cleft of the right buttock which measured 2 x 2.5 cm. Further review revealed that [MEDICATION NAME] cream was applied to the areas. Review of the Weekly Wound Assessment, dated 7/26/17, revealed that the resident had a Stage 2 pressure ulcer at the coccyx which measured 1.0 cm. length, 0.3 cm. width and 0.1 cm. depth with a small/minimal amount of serosanguinous drainage. Further review revealed that current pressure redistribution mattress and wheelchair cushion. Specific turning/repositioning program, nutritional supplements, positioning devices or protein supplements not checked. Review of the Weekly Wound Assessment, dated 8/2/17, revealed that the Stage 2 pressure ulcer at the coccyx measured 1.5 cm. length, 0.5 cm. width and 0.1 cm. depth with the same drainage. Interventions added included a protein supplement but no specific turning/repositioning program. Review of the Nutrition Assessment, dated 7/27/17, revealed that the resident had two, Stage 2 pressure ulcers and the RD (Registered Dietician) recommended Prostat supplement daily. Review of the TAR (Treatment Administration Record), dated July 2017, revealed an order, dated 7/25/17, for [MEDICATION NAME] three times a day coccyx cleft wound and left lower buttock. Further review revealed no previous treatment orders for the pressure ulcers and no orders for a nutritional supplement. Review of the TAR, dated August 2017, revealed an order, dated 8/8/17, for Prostat supplement daily for wound healing. Review of the Documentation Survey Report v2, dated July 2017, revealed that the resident repositioned self on the day shift on 7/19, 7/26 and 7/30 and on the night shift on 7/6, 7/11, 7/12, 7/14 and 7/25. Further review revealed no documentation that the resident was repositioned on the day shift on 7/6, 7/14, and 7/23; evening shift on 7/22, 7/23 and 7/30; and on the night shift on 7/16, 7/27 and 7/29. Review of the Documentation Survey Report v2, dated August 2017, revealed that on the day shift the resident repositioned self on 8/6 and 8/7 and on the night shift on 8/3 and 8/12. Observations on 8/10/17 at 1:00 PM revealed the resident on bed positioned on back for wound care. LPN - R, Charge Nurse, stated that the resident's disposable brief was just changed due to urinary incontinence and skin care was done. LPN - R positioned the resident on right side and noted that the bed was too narrow and the resident's face was inches from the wall when repositioned. Further observations revealed LPN - R cleansed the open area at the coccyx with saline, noted red drainage from the wound, and applied [MEDICATION NAME] cream to the ulcer and reddened skin at the left buttock area. LPN - R and LPN - C turned the resident from side to side to apply the disposable brief and then positioned the resident on back. Further observations revealed that the resident was placed on top of two sheets, a quilted bedspread and the disposable brief which was four layers of material between the resident's skin and the therapeutic mattress. The resident was in the same position at 4:00 PM. Interview on 8/15/17 at 9:30 AM with LPN - C, Unit Coordinator, confirmed that the resident developed a facility acquired pressure ulcer and interventions were not in place to prevent the development of the pressure ulcer. Further interview confirmed that the resident required assistance with repositioning and should be repositioned at least every two hours which wasn't consistently done. LPN - C stated that the resident often refused to lay down during the day and often sat in the wheelchair all day. Further interview confirmed that there was a delay in receiving orders to treat the pressure ulcer and no nutrition assessment was completed until 7/27/17 and the recommendations for a supplement received that day was not ordered and administered to the resident until 8/8/17 to promote wound healing. LPN - C confirmed that layers of linen and clothing and the resident's skin should be minimized to enhance the therapeutic benefits of the pressure reducing mattress and the resident should have had a larger bed to allow more independence with repositioning. Review of the facility Skin Integrity Guideline, not dated, revealed the following including: Purpose: To provide a comprehensive approach for monitoring skin conditions, to decrease pressure ulcer and/or wound formation by identifying those residents who are at risk and implementing appropriate interventions, to promote healing of wounds of any etiology, whether admitted or acquired. Documentation and Care Interventions for Skin Integrity included: - interventions will be documented in the care plan; - pressure redistribution mattresses will be in place and will be reviewed for appropriateness is there is a decline in skin integrity; - reposition every two hours, or as needed and tolerated; - positioning schedule to minimize concentrated pressure to skin; - minimal linen under prone skin areas; - nursing notifies dietary of any resident admitted with pressure ulcers or newly identified pressure ulcers; - nutritional assessment determines the need for nutritional interventions.

Licensure Reference Number 175 NAC 12-006.04C3a (6) Based on observations, record reviews and interviews; the facility failed to notify 1) the medical practitioner of a change of condition for three current sampled residents (Residents 15, 84 and 169) to ensure that medical care was provided to meet the needs of the residents and 2) the resident's POA (Power of Attorney) of a change in condition for one closed record (Resident 50). The facility census was 107 with 22 current sampled residents and three closed records reviewed. Findings are: A. Review of the Admission Record, printed 8/9/17, revealed that Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with the resident on 8/8/17 at 11:20 AM revealed that the resident had back and neck pain. The resident stated that the resident took pain medications but it still hurts. Observations during the interview on 8/8/17 at 11:20 AM revealed that the resident had pained facial expressions and a clenched jaw. Observations on 8/9/17 at 9:45 AM revealed the resident seated in the wheelchair in room with tears in eyes. Further observations revealed dried dark red colored matter on the rim of the urinal on the edge of the garbage container. Interview with the resident on 8/9/17 at 9:45 AM revealed my bladder, back and kidneys hurt so bad. The resident also stated that it has been hurting for several days now with no relief from the pain pills. The resident stated pain pills don't help at all, it hurts so bad that I want to cry, having blood in my urine and I'm supposed to see a doctor. Interview on 8/9/17 at 10:00 AM with RN (Registered Nurse) - P, Charge Nurse, revealed that the resident had chronic neck pain and usually requested a pain pill in the morning. RN - P did not mention the resident's back pain. Further interview at 10:10 AM revealed that an order was just received for a urology consult. Observations on 8/9/17 at 11:15 AM revealed the resident seated on the toilet and complaining of really bad pain. The resident stated may be passing a kidney stone or something. Further observations revealed the resident had bright red blood in the toilet. Interview on 8/9/17 at 11:30 AM with RN - P revealed that no appointment had been made yet for the resident to be seen by a medical practitioner. Further interview revealed that RN-P would have the Nurse Practitioner check the resident today. Review of the MAR (Medication Administration Record), dated August 2017, revealed that the resident had a routine [MEDICATION NAME] (narcotic [MEDICATION NAME]). Further review revealed that the resident received [MEDICATION NAME] (Opioid [MEDICATION NAME]), ordered as needed for pain, on 8/7/17 at 8:22 AM, on 8/8/17 at 8:38 AM and 7:12 PM and on 8/9/17 at 8:43 AM for pain rated 9 (severe) on the 1-10 pain scale. Further review revealed documentation that the 8/8/17 at 8:38 AM and the 8/9/17 at 8:43 AM doses were ineffective in relieving the resident's pain. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Interview with the LPN (Licensed Practical Nurse) -C, Unit Coordinator, on 8/15/17 at 10:30 AM confirmed that the medical provider should have been notified of the resident's ongoing unrelieved pain and blood with urination sooner to evaluate the resident and consider further orders to relieve the resident's pain. B. Review of the Admission Record, printed 8/9/17, revealed that Resident 84 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/7/17 at 9 AM, during the initial tour of the facility, on 8/8/17 at 11:00 AM and 2:30 PM and on 8/9/17 at 9:30 AM and 1:30 PM revealed a strong, foul odor in the resident's room and into the hallway. Further observations on 8/9/17 at 9:30 AM revealed the resident seated in the wheelchair in room removing the ace wraps and dressings from lower legs to show the bleeding from legs. Noted clear, foul smelling drainage from both lower extremities. Observations of skin care at 1:30 PM revealed that the clear, foul smelling drainage continued from the resident's lower extremities. Review of the Progress Notes, dated 8/1/17 - 8/14/17, revealed no notes related to the ongoing, foul smelling drainage or indication that the medical practitioner was notified. Interview with LPN - C, Unit Coordinator, on 8/15/17 at 10:30 AM confirmed that there was no documentation that the medical provider was notified of the ongoing, foul smelling drainage at the lower extremities. C. Review of the Admission Record, printed 8/9/17, revealed that Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on 8/9/17 at 1:00 PM with LPN - Q, Charge Nurse, revealed that the resident's dressings at the coccyx area were removed as the resident had diarrhea stools. LPN - Q stated that the diarrhea may be caused from new medications that the resident is taking. Observations on 8/9/17 at 1:00 PM revealed the resident on the bed for wound care. Further observations revealed LPN - Q provided skin care due to diarrhea. Interview on 8/14/17 at 7:45 AM with the resident revealed that diarrhea continued through the weekend. The resident stated had two diarrhea episodes yesterday and one again this morning. Interview on 8/14/17 at 9:00 AM with RN - P, Charge Nurse, revealed that the resident's routine morning dose of Senna (laxative) was not held this morning. RN -P stated would notify the Nurse Practitioner today of the resident's ongoing diarrhea. Interview on 8/15/17 at 10:00 AM with LPN - C, Unit Coordinator, confirmed that the Nurse Practitioner was not notified of the resident's ongoing diarrhea until 8/14/17. Further interview revealed that a new order was received on 8/14/17 to change the Senna to as needed rather than daily. D. Review of the Admission Record, printed 8/15/17, revealed that Resident 50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated 7/21/17 at 9:37 AM revealed that the resident's blood pressure was 103/45 and at 3:48 PM the resident's blood pressure was 79/48. Further review revealed no documentation that the resident's POA was notified of the low blood pressure. The POA was notified of the resident's death at 4:49 PM. Interview on 8/15/17 at 2:15 PM with LPN - C, Unit Coordinator, confirmed that there was no documentation that the resident's POA was notified of the resident's low blood pressure reading.

Licensure Reference Number 175 NAC 12-006.09D8b Based on observations, interviews and record reviews, the facility failed to ensure that one sampled resident (Resident 120) did not experience unplanned, significant weight loss. The facility census was 114. Findings are: Review of the Admission Record for Resident 120 revealed that the resident had an admission date of [DATE] to the facility. Further review revealed [DIAGNOSES REDACTED]. Review of the Nutrition Data collected on 10/20/15 for Resident 120 revealed an admission weight to the facility of 272 pounds and a current weight of 261 pounds. Weight status identified as weight loss. Further review revealed that the resident was overweight and did have swallowing issues. Review of the MDS (Minimal Data Set, a federally mandated comprehensive assessment tool utilized to develop resident care plans) for Resident 120 revealed weights on: - 9/6/16 of 229, - 8/7/16 of 236, - 6/8/16 of 238, - and 3/10/16 of 245. Review of the Care Plan dated 7/22/16 for Resident 120 revealed that the resident had a physical functioning deficit related to self care impairment. Further review of the Care Plan revealed that Resident 120 was Obese with a BMI(Body Mass Index) of greater than 30. The goal was that the resident's weight would not exceed 242 pounds. Review of a fax sent to the physician on 8/2/16 by the Registered Dietician revealed that, Speech therapy has seen the resident in the past and when the diet is changed the resident doesn't want to follow it. Resident 120 is a significant weight loss of 13 pounds in one month. Further review revealed that the resident voiced chewing and swallowing difficulties. Review of a 60 day Recertification visit with the physician on Resident 120 revealed no oral exam or documentation of any exam completed in regards to chewing and swallowing difficulty. The history of present illness revealed that the resident had requested a pureed diet a few months ago due to difficulty with chewing, swallowing and felt like there was something in the throat. Interview on 9/7/16 at 10:00 AM with the Director of Nursing revealed that the facility did not have any residents on planned weight loss. Interview on 9/7/16 at 11:AM revealed that Resident 20 had missing and broken teeth and stated, I would like teeth to chew my foods. Interview with the Resident on 9/19/16 at 9:30 AM revealed that the resident did have a few teeth on the bottom left side of the mouth. The resident stated would like to see the dentist for some teeth so that would be able to chew some foods, and eat better. Continued interview revealed that the resident stated, The foods taste better when I am able to chew them. Interview with the Registered Dietician on 9/20/16 at 9:00 AM revealed that the RD had been following the resident. Further interview revealed that the RD was aware of Resident 120's chewing and swallowing difficulty. The RD did reveal that the initial weight loss on the resident was thought to be a mental issue or not liking a tablemate. Further interview revealed that the resident was moved to another table. Continued interview verified that the resident continued to lose weight after the table move. Further interview revealed that the RD (gender) did not complete of do any dental assessments and only worked with the diet if the person had a chewing or swallowing issue with significant weight loss. Interview on 9/20/16 at 10:20 AM with LPN (Licensed Practical Nurse) - B, the Nurse Manager for Resident 120 verified that the the resident was an unplanned weight loss. Continued interview verified that the resident had a significant weight loss recently. Further interview revealed that LPN- B was aware that the resident did have chewing and swallowing difficulties and had complained of the difficulties since 10/20/15. Continued interview verified that the LPN- B felt that the significant weight loss of this resident could have been due to the lack of teeth to chew foods well and to be able to swallow the chewed foods better. Interview on 9/20/16 at 4:15 PM with the Administrator and the Director of Nursing confirmed that Resident 120 was a significant weight loss that was unplanned. Continued interview verified that the resident did have dental issues with chewing and swallowing and that this resident should have had a dental appointment set up to address the missing, broken teeth, chewing and swallowing difficulties. Further interview confirmed that a dental appointment should have been made when the resident first complained of chewing/swallowing problems and the unplanned weight loss could have been avoided.

Licensure Reference Number 175 NAC 12-006.09D2b Based on observations, interviews and record reviews; the facility failed to provide treatments and cares to prevent and promote wound healing for one sampled resident (Resident 4) identified at high risk for pressure ulcer reoccurrence. The facility census was 126. Finding are: Observation on 9/17/15 at 3:15 PM of Resident 4 asleep in bed. Further observation revealed the resident to be lying on a standard facility mattress. Review of a History and Physical/Postadmission Physician Evaluation dated 12/1/14 revealed that Resident 4 had sustained a pressure-induced tissue necrosis (tissue death) to the perineal area and gangrene to the area from prolonged sitting. Further review revealed that the resident had a long series of surgical debridements to include 15 over the time of hospitalization . Continued review revealed that the resident had [DIAGNOSES REDACTED]. Review of the Progress Notes for Resident 4 revealed on: - 9/12/15 at 12:18 PM a weekly skin assessment completed with notes, buttocks wound site is closed and healing area measures 2 cm(centimeters) by 5 cm. - 9/4/15 at 1:37 PM the resident was seen by physician for sacral wound. - 9/14/15 at 1:55 PM weekly skin assessment . wound to buttocks healed. Review of the Care Plan dated 8/24/15 for Resident 4 revealed a focus of: The resident had an actual pressure ulcer and was at high risk for pressure ulcers due to bed mobility, has [MEDICAL CONDITION], occasionally incontinent of bladder .skin fragile, is on an air mattress .is at risk for further pressure areas. Interview with the Resident 4's family member on 9/21/15 at 11:30 AM revealed that the family member was not happy with the resident not being on the speciality air mattress and that the physician had ordered it because the resident had a great potential for the area to break down again due to pressure. Further interview revealed that the facility had made several room changes with the resident and every time the room was changed the speciality air mattress was left in the old room and the bed had not been moved with the resident. The family member reported that the resident had not been on the specialty air mattress for a couple of weeks now. Observation on 9/21/15 at 11:30 AM of Resident 4 awake and lying in bed. Further observation revealed that the mattress was a standard facility mattress. Interview on 9/21/15 at 12:00 PM with the (Director of Nursing) DON revealed that Resident 4 had been on a speciality air mattress. Further interview verified that the resident was on a standard facility pressure relieving mattress and not the speciality air mattress. Interview on 9/21/15 at 12:35 PM with (Nursing Assistant) NA- D and (Medication Aide) MA- E revealed that Resident 4 had been on a speciality air mattress for pressure relief. Further interview verified that the resident was no longer on the speciality air mattress. Continued interview verified that the speciality air mattress had been left in the room that the resident was moved from and the staff thought it was broke. Review of Resident 4's medical chart revealed no written documentation to support that he speciality air mattress had been discontinued by the physician. Further review revealed no written order for the speciality air mattress. Interview on 9/21/15 at 12:30 PM with the Administrator and the DON verified that Resident 4's medical chart did not contain a written order to discontinue the speciality air mattress. Further interview confirmed that the resident was no longer on the speciality air mattress. Continued interview revealed that an intervention for air mattress for pressure relief was on the current care plan for Resident 4. Further interview verified that Resident 4 should have been on the speciality air mattress until it had been discontinued by the physician or requested to discontinue by the facility.

Licensure Reference Number 175 NAC 12-006.07C Based on interviews and record reviews, the facility failed to ensure that the QA&A (Quality Assessment and Assurance) Committee identified quality of care issues and developed a plan of action to ensure quality of cares issues identified during the facility's annual survey on 8/13/15 had been corrected. The facility census was 126. Findings are: Review of the Annual survey note dated 8/13/15 revealed that the F 312 had been cited for the lack of bathing care to 2 residents during that visit. Continued review of the notes revealed that the Administrator and the (Director of Nursing) DON were aware of the issue. Further review revealed that the facility had been notified of baths not being completed as scheduled on 8/13/15 and 40 days later the identified problem had not been corrected to the resident's satisfaction. Interview on 9/21/15 at 12:30 PM with the Administrator and the DON verified that the lack of scheduled bathing was still a problem at the facility. Further interview verified that it had been 29 days since the annual survey and that an exit conference had taken place on 8/13/15 with the bathing issues identified at that time. Continued interview confirmed that the facility should have put a plan of action in place as soon as possible to correct the identified issues with bathing.